Block 9 Week 6

Krishnan EKG Basics Lecture Notes

Einthovens Triangle

Lead
I
II
III

Lead perpendicular to it
aVF
aVL
aVR

Note: Leads II, III and aVF look at the inferior portion of the heart while leads I and aVL look at the lateral portion of the
heart
An EKG
P wave atrial depolarization
QRS complex ventricular depolarization
T wave ventricular repolarization
Note: r wave is a small R wave, q wave is a small Q wave, s is a small S wave

Genesis of EKG Normal Complexes

o Atrial depolarization (P wave)
o The right atrium (RA) is activated first, then the left atrium (LA) is activated
o This registers as a P wave
o Because the electrical impulse is going downward and to the left, the P waves are upright in leads I, II, V5
and V6
o The RA activation is directed anteriorly and then the LA activation is directed posteriorly biphasic P
wave in lead V1 (positive deflection, then negative deflection)
o Ventricular depolarization (QRS complex)
o Q wave is the first downward deflection after the P wave
o R wave is the first upward deflection after the R wave
o S is the first negative deflection after the R wave
o Note that if another R shows up after one R, we add an to it and call it R prime; the same thing can be
done for S waves as well
o Electrical impulse travels from interventricular septum from septum His-Purkinje fibers arising from the
left bundle positive r wave in V1, small q wave in V5 and V6
o Activation in apical region of ventricles with a leftward direction
o Simultaneous activation of right and left ventricles

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Block 9 Week 6
Krishnan EKG Basics Lecture Notes

Wide
QRS

Narrow QRS

How to analyze EKGs

1. Heart rate
a. Tachycardia > 100 bpm
b. Bradycardia < 60 bpm
c. 1 small box is 40 msec (0.04 sec), 1 big box is made of 5 small boxes and is 200 msec (0.20 sec)
d. Heart rate = 300 / (number of large boxes between R waves)
2. P wave
a. The P wave is most prominent in lead II
b. Regular duration: 100 msec (half of a big box)
c. LA enlargement leads to widening of the P wave in lead II
d. RA enlargement leads to an increase in amplitude of the P wave in lead II
3. Origin of rhythm atrial and ventricular
EKG reading
Association
P wave precedes QRS complexes and P waves are
Sinus rhythm
upright in leads II, aVF and V5
P wave precedes QRS complex, but P wave is
Ectopic atrial rhythm (atrial fibrillation)
inverted in lead II
P wave follows QRS complex
Junctional rhythm
No P waves
Junctional rhythm, supraventricular tachycardia
Regular sawtooth P waves
Atrial flutter (rates exceeding 250/minute)
More QRS waves than P waves or no P waves at all Ventricular rhythm
Irregular and alternating polarity
Polymorphic ventricular tachycardia (Torsade de
Pointes)
Chaotic irregular oscillations
Ventricular fibrillation
Note: Widened QRS bundle branch block because myocyte to myocyte conduction is taking place
4. PR interval
a. Normal PR interval: 0.12 to 0.21 sec (half to one big box)
EKG reading
Association
Prolonged PR First degree AV block, second degree AV block, atrial ectopic beats
Short PR
WPW syndrome, ectopic atrial rhythm, junctional rhythm, normal variant
5. QRS morphology
a. Duration
i. Normally less than 0.10 sec (half of a big box)
EKG reading
Association
Increased QRS duration (0.10 to 0.12 sec)
Incomplete bundle branch block
Increased
rsR in V1 with secondary down-sloping ST and
Complete RBBB
QRS
inverted T; slurred in V5/V6 (bunny ears)
duration
Broad monophasic R in V5/V6 which is notched; Complete LBBB
(> 0.12
QS complex in V1; secondary down sloping ST
sec)
and inverted T in V5/V6 (bunny ears)
Widening of the first part of the QRS complex (delta wave)
WPW syndrome
b. Axis
i. Look for the smallest QRS complex
ii. Identify the lead at a right angle to it
1. If this lead has a positive deflection, then the
QRS axis is within 10-15 degrees of its positive
pole
2. If this lead has a negative deflection, then the
QRS axis is within 10-15 degrees of its negative
pole
iii. Look back at the lead with the smallest QRS complex
1. If it is exactly equal both ways dont need to
change QRS axis
2. If it is more positive or negative correct the
QRS axis by 10-15 degrees

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Block 9 Week 6
Krishnan EKG Basics Lecture Notes
c.

d.

e.

f.

g.

h.

Voltage
EKG reading
Low voltage QRS

Association
Obesity, emphysema, pericardial effusion,
cardiomyopathy, extensive infarction
Left ventricular hypertrophy
Right ventricular hypertrophy

Tallest R and deepest S in chest leads

R/S ratio > 1 in V1 or R/S ratio < 1 in V5/V6
Abnormal Q waves
i. Normal Q waves are less than 0.04 sec (one little box); seen in all leads except in leads V1, V2,
and V3
EKG reading
Association
Q in II, III and aVF Inferior infarction
Q in V1-V3
LBBB, LVH, WPW type B
Q in I, aVL, V4-V6 Hypertrophic cardiomyopathy
ST segment
EKG reading
Association
Concave upward and generalized
Pericarditis, normal variant
Concave upward in II, III, aVF
Inferior wall MI
ST
Concave upward in V1-V3
Anteroseptal MI
elevation Concave upward in V2-V4
Anterior wall MI
Concave upward in V4-V6
Anterolateral MI
With Q waves
Ventricular aneurysm
In V1-V3 with absence of infarction
LBBB, LVH
ST depression
Ischemia, digitalis, LVH, LBBB, RVH, RBBB
T wave
i. Normal T wave is upright in I, II, V3-V6 and inverted in aVR
EKG reading
Association
Tall T waves
Hyperkalemia, hyperacute MI
Deeply inverted T waves NSTEMI, intracranial bleed, hypertrophic cardiomyopathy
QT interval
i. Measured from beginning of QRS to end of the T wave
ii. Normal QT interval: ~0.40 seconds (2 big boxes)
EKG reading
Association
Short QT interval
Hypercalcemia
Prolonged QT interval
Hypocalcemia, hypokalemia, hypomagnesemia,
congenital, Class Ia and III anti-arrhythmics,
intracranial bleed
U wave
i. Represent repolarization of Purkinje fibers
ii. Prominent in hypokalemia

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