EKG Part 1

My name is Bruce Addison D.O. and I have taught a primer for

EKGs for many years. This course is designed to help you
recognize arrhythmias. We will briefly touch on some
information about reading 12 lead EKGs as well but the primary
emphasis of these units is to recognize arrhythmias. Some of
you have had this material in the past and for you it will be a
review and some of you have never really seen much of this.
Either way I think you can get something out of a quick and easy
way to look at EKGs.
I would like to get this started early in your career as a nurse or
it will serve as a nice review for those of you who are already
nurses. This will not serve to teach you to do 12 lead EKG
interpretations but rather will work to help you recognize
arrhythmias that you will see on a common monitor or rhythm
strip. We have already had a little bit of this material but now we
are going to go into it in depth over several units. At the end
you should be able to answer some easy questions about ekgs
and recognize some simple arrhythmias.
Lets go back and review a few things to start with.
In the normal heart beat, the impulse will begin in the SA (sinoatrial) node (the normal pacemaker in the heart) and will travel
through the atria to the AV (atrio-ventricular node. From there it
travels down the bundle of His to the left and right bundle
branches of which there are 2 in the left ventricle and 1 in the
right. The bundles each divide out into the Purkinje fibers which
actually innervate the ventricle myocardium.
Each area has an intrinsic normal rate of depolarization and if
needed any can serve as the pacemaker for the heart:
SA node = 60-100 per minute.
AV node = 40-60 per minute.
Ventricles = 20-40 per minute.

Remembering of course that we are relating this electrical

impulse to an event on the EKG we see that:
P wave equals to the SA node depolarization and in the normal
heart the electrical depolarization of the rest of the atria. It is
usually about 80 ms.
PR interval (from start of P wave to start of QRS) is the delay as
the impulse travels through the AV node and the bundle of His. It
is normally 120-200 ms or 3-5 small blocks on the EKG paper.
QRS equals to ventricular depolarization, both bundles as well
as the purkinje fibers and the myocardium. If there is an
abnormal depolarization here we will see a wide QRS. It is
normally 80-120 ms.
J point is the point that marks the end of the QRS complex and
the beginning of the following part that merges into the T wave.
ST segment is from the J point to the start of the T wave.
The T wave is the last event in the cycle and represents
repolarization of the ventricles. The first 2/3rds of the T wave is
considered to be in an absolute refractory state in which it is not
ready for the ventricles to fire again. The last 1/3rd of the T wave
is considered to be a relative refractory state. Some of the
ventricle is ready to fire again and some is not. This is the
danger period in the T wave in which an abnormal impulse at
this time in the ventricles could cause ventricular fibrillation.

When we say EKG complex we are referring to the entire P QRS

and T wave group. By convention when we say QRS we are
talking about the ventricular electrical activity. This may be a
true QRS complex or it may be just an upward deflection (R
wave) or it may be a QS or completely downward deflection.
Anything above the baseline or the isoelectric line is considered
to be a positive deflection and anything below the isoelectric
line is considered a negative deflection. It is recorded as
positive or negative because the electrical signal is going
towards (results in a positive deflection) or away from (results in
a negative deflection) the electrode considered by that lead to be
the primary electrode. Please refer to the following site so that
you can see the different placement patterns for EKG leads as
well as a nice history and explanation of EKGs in general:
http://en.wikipedia.org/wiki/Electrocardiography

Please note in the above QRS complexes that lead II results in

an almost totally positive complex. This is the normal pattern
but you may not always see this depending on any underlying
pathology. The positive nature of lead II means that the electrical
signal is going to the primary lead for lead II which is the left leg
electrode. The QRS will appear different depending on where the
3

lead is and what direction the electrical signal is going. As you

can see on aVR, it almost entirely negative so in that case the
signal is almost completely going away from that lead.
Complexes that are equidistant above and below the isoelectric
line (such as in v4 above) part of the signal is going towards the
lead and part is going away from it. I know this all sounds
complicated right now but we will pull it all together later in the
lecture series. Right now I just want you to realize that we are
seeing electrical activity traveling through a 3 dimensional
object and it is this pathway that gives us the QRS complexes
we see when we look at an EKG.
By convention the first downward deflection of the QRS complex
is called the Q wave. It may or may not be present. If there is
only a downward deflection it is called a QS complex. If it is
strictly positive it is called an R wave. If there are 2 upward
deflections the second one is called an R' and the entire
complex is called an rSR' complex.
One of the hardest things for us to remember is that the EKG is
just an electrical event. I have seen many cases in which the
heart was dead still and had NO mechanical activity at all but
still had electrical activity that was represented on the monitor.
We hope that mechanical events will go along with the electrical
events we see on the EKG and in fact the electrical events we
see are usually directly related to certain mechanical events in
the heart. In fact it is the need for these mechanical events to
occur that makes the EKG look like it does. For instance, there is
a pause in the normal EKG complex in which the electrical event
actually slows to allow a mechanical event to occur. This is the
time from the start of atrial contraction to the start of ventricular
contraction. Without the pause, the ventricles would not fill
completely and the heart beat would be inefficient. Remember
now I am referring to the normal events since we need to know
what normal is before we start getting into the abnormal stuff.
The EKG is a 2 dimensional representation of what a 3
dimensional object is doing electrically. I say 2 dimensional
because not only is the complex we see showing us the
4

electrical event as it goes through the heart but it also is

measuring the time in which it takes to occur.
Lets go back for just a bit and review the way the heart works.
http://en.wikipedia.org/wiki/Electrical_conduction_system_of_th
e_heart has a very good map of the electrical conduction of the
heart as well as a very good write up on how it all occurs. Please
read that before going on with this lecture. On this site there is a
great breakdown of the QRS complex as well as animation of the
impulse traveling through the heart and matching with the same
event on the QRS. For those of you who are visual learners this
will really help you to visualize what I might not be able to
adequately express here.

Here is a standard piece of monitor paper which for convenience

we are going to call EKG paper from here on out. You will notice
that it is divided into small one mm blocks and that they are
grouped into sections of 5 blocks each. Each of the small one
mm blocks is equivalent to 0.04 seconds. From heavy red line to
heavy red line is 5 small 1 mm blocks which when put together
equals 0.2 seconds. So with a little simple addition we can see
that 5 large 0.2 second blocks together equals 1 second.
At the top of the lines you can see 2 small red lines that protrude
upwards above all the other lines. For convenience sake, all ekg
paper will have these marks so that you can see easily 3 second
intervals.
So each small block is 0.04 seconds.
Each set of 5 small blocks equals one large block which equals
0.2 seconds.
Each set of 5 large blocks equals 1 second.
15 large blocks equals 3 seconds.
5

Now that you have all of that in your head, the very easiest way
to figure out the rate is to count the number of beats (QRS
complexes or cardiac cycles) in 6 seconds (30 large blocks) and
multiply x 10 to get the rate in one minute.
There is another way to do the same thing but it really only
works good with regular rhythms (we will talk about rhythms
next time.)

Here is a normal cardiac cycle. I have put this here so that you
can see the R wave. You can actually use any part of the QRS
complex to decide the next rate method but I have found the R
wave if present to be the easiest. To calculate the rate with this
method you need to memorize the following sequence:
300, 150, 100, 75, 60, 50, 43, 37, 33, 30
Find an R wave on a heavy line (large box) and count off the
above sequence for each large box you see until you reach the
next R wave. If you are lucky then the R wave will fall on a heavy
line. If it does then you have the rate.
For example, if you count 3 heavy lines and then the R wave falls
on the third line your rate is 100.
If it falls on the 4th heavy line then the rate is 75 and so on.

If it doesnt then you have to do just a little calculation. When

using this method, you just have to remember that the little
boxes mean different things for each interval.
Between 300-150 there are 5 small blocks, each would be worth
30 beats.
Between 150-100 there are 5 small blocks, each would be worth
10 beats.
Between 100-75 there are 5 small blocks, each would be worth 5
beats.
Between 75-60 there are 5 small blocks, each would be worth 3
beats.
Between 60-50 there are 5 small blocks, each would be worth 2
beats.
So you can see that if you count 3 heavy lines over (300, 150,
100) and the R wave falls on the 3rd small line (2 before you get
to 75) then the rate is going to be 85.
Really once you get past the first part of this, it gets pretty easy.
The next way to calculate the rate is the 6 second method. On
the top or bottom of each EKG or rhythm strip there will be a
vertical mark every 3 seconds. If you count the number of QRS
complexes between 3 marks you will have the total number in 6
seconds (or 30 large boxes) and multiple x 10.
Some people will like to use the 10 second method and that is
the number of QRS complexes found in the space between 50 of
the large blocks and then multiply x 6.
I prefer the first method myself; it is quick and easy when the
rhythm is pretty close to regular.
The first step is always to know the rate. This will help you to
decide what you are seeing and what to call it. If the rate is less
than 60 we consider it a bradycardia. If the rate is over 100 then
we consider that a tachycardia. So for right now, lets just worry
about one simple little thing and that is figuring out what the rate
is.
7

Here is a great general site that covers lots of material and I

really recommend you look at it:
http://www.fammed.wisc.edu/sites/default/files/webfmuploads/documents/med-student/ekg-interpretation.pdf
http://www.skillstat.com/ecg_sim_demo.html
http://www.monroecc.edu/depts/pstc/backup/prandekg.htm
http://www.unm.edu/~lkravitz/EKG/ekgwebsites.html
So this time we have talked about rate. We have talked about
the cardiac cycle and the paper that it is printed out on. And we
have talked about 3 ways to quickly calculate rate. Read it
through a couple of times and we will go to Rhythm next unit.
The key to this is practice practice practice and there are lots of
sites on the net that will give you that opportunity.
Dr. A.