EKG Basics

S. Parvez Quadri
Chief Resident
Advocate Christ Medical Center
White on Right, Smoke over Fire
I
II
aVF
III
aVL
aVR
One small box = 0.04 s
One large box = 0.2 s
Systematic Approach!
Rate
Rhythm
Axis
Intervals
Hypertrophy
Ischemia/Infarction

Rate
Normal = 60 100 beats/min
Tachycardia > 100 beats/min
Bradycardia < 60 beats/min
Count the number of QRS complexes in a 6 second interval and multiple by 10
You MUST memorize these numbers!
Or rate = 300/number of large boxes
Rhythm
Sinus Rhythm
P before every QRS
QRS after every P
Upright P in lead II
If your EKG does not
meet these criteria, it
is not sinus rhythm
Axis
Normal axis =
-30 to 90 degrees
Is it positive in I and aVF?
Where is the QRS biphasic?

I
II
aVF
III
aVL
aVR
Segments and Intervals
PR < 0.2 s (< 5 small
boxes)
QRS < 0.12 s (< 3 small
boxes
QT eyeball to make
sure < RR
QTc < 0.45s
Why do we need to correct the QT interval?
Atrial Hypertrophy
Lead II characteristics
Prolonged P wave > 120s = LAE
Peaked P wave > 0.25 mV = RAE
V1
II
Ventricular Hypertrophy
Right ventricular enlargement
R > S in V1
Left ventricular enlargement
many criteria
Bigger of S in V1 or V2 + R
in V5 or V6 > 35 mV
R in aVL > 11 mV

Hypertrophy
V1
II
II
Ischemia/Infarction
ST abnormalities
ST elevation or
depression
T wave abnormalities
Q waves

Practice EKGs!!!
Sinus tachycardia-PE, anemia, pain
Rate = 110
Rhythm = nl sinus
Axis = normal (around 60)
Intervals = nl
Hypertrophy = none
Ischemia/Infarction = none

Prolonged QT interval
Rate-60
Rhythm-normal sinus
axis = normal ( around 60)
intervals = QT prolongation
hypertrophy = none
ischemia = none

Congenital (hereditary) long QT syndrome. The ECG demonstrates sinus rhythm with a very
prolonged QT interval of 0.6 second. Note the broad T waves with notching (or possibly U
waves) in the precordial leads. This characteristic may identify patients with long QT
syndrome at increased risk for torsade de pointes and syncope and sudden death. Low
ampitude, but prolonged T waves may lead to underestimation by eye or computer.

Left atrial abnormality, LVH


Rate = 80
rhythm = nl sinus
axis = almost left axis (-30)
intervals = nl (QRS = 110, upper limit of normal)
hypertrophy = LVH (V2 + V5 > 35, aVL > 11)
Ischemia/Infarction = non-specific ST-T abnormalities)
Pt had cardiomyopathy secondary to anthracycline chemotherapy for her history of breast
cancer

A fib with RVR
Rate = 110
Rhythm = atrial fibrillation with RVR
Axis = nl, 30
Intervals = nl
Hypertrophy = nl
Ischemia/infarction= non-specific ST-T
changes in II, III, aVF
RAE, RVH, RV strain pattern
Rate = 110
Rhythm nl sinus
Axis = right axis (120)
intervals = nl
hypertrophy = RAE (P in II), RVH (R>S in V1)
ischemia = ST depression/Twave inversion consistent with strain

The patient had a complex combination of problems, including congenital heart disease with
partial anomalous pulmonary venous return and a sinus venosus atrial septal defect. In
addition, there was severe pulmonary artery thromboembolic disease.

NSR with repolarization
abnormality ( normal)
Rate = 90
Rhythm = nl sinus
Axis = normal (around 60)
intervals = nl (PR = 120, QRS = 80, QT = nl)
Hypertrophy = none
Ischemia/Infarction = none