Method for Reading EKGs

Standardization. Make sure the standardization mark on the EKG paper is 10 mm high so that 10 mm = 1 mV. Also make sure that the paper speed is correct (25mm/s). Heart rate. Box method (300, 150, 100, 75, 60, 50) 2-tick method (2 ticks on bottom of EKG = 6 seconds so rate = # of beats x 10) Rhythm. Are there normal P waves present? Are the QRS complexes wide or narrow (<0.12s)? What is the relationship between the P waves and QRS complexes? Is the rhythm regular or irregular? QRS axis. Axis Lead I Normal axis + LAD + RAD Extreme RAD (superior or northwest axis) Isoelectric method o Find isoelectric lead o Identify perpendicular lead to isoelectric lead to approximate axis Intervals. PR interval (0.12-0.20 seconds) QT interval (<0.42 seconds; <40% RR interval) o QTc = QT / RR (>440 ms when corrected) QRS complex (<0.10 seconds) Enlargement & Hypertrophy Atrial Enlargement Look at the P waves in leads II and V1 o Right Atrial enlargement (commonly caused by severe lung disease): P waves >2.5 boxes tall in II, III, or AVF Is not associated with change in duration of P wave Possible with RAD o Left atrial enlargement (commonly caused by mitral valve disease): P in V1 with negative portion > 1 box deep, 1 box wide duration of P wave Ventricular hypertrophy Look at the QRS complexes in all leads o Right ventricular hypertrophy (commonly caused by COPD, uncorrected congenital heart disease) RAD of >100 (QRS in I more negative than positive) R>S in V1 and S>R in V6 Left ventricular hypertrophy (commonly caused by systemic HTN, valvular disease) Precordial criteria: R in V5 or V6 + S in V1 or V2 >35mm R in V5 >26mm R in V6 >18mm R in V6 > V5 Limb lead criteria: R in AVL >13mm Lead AVF + + -

AV Block. First degree: The PR interval is greater than 0.2 seconds; all beats are conducted through to the ventricles. Second degree: Only some beats are conducted through to the ventricles. o Mobitz type I (Wenckebach): Progressive prolongation of the PR interval until a QRS is dropped. o Mobitz type II: All-or-nothing conduction, in which the QRS complexes are dropped without PR interval prolongation.

R in AVF >21mm R in I >14mm R in I + S in III >25mm

Third degree: No beats are conducted through to the ventricles. There is complete heart block with AV dissociation, in which the atria and ventricles are driven by independent pacemakers.

Bundle Branch Block or Hemiblock. Bundle Branch Blockslook at width and configuration of the QRS complex o RBBB QRS complex widened to greater than 0.12 seconds. RSR in V1 and V2 (rabbit ears) with ST segment depression and T wave inversion. Reciprocal changes in leads V5, V6, I, and AVL. o LBBB QRS complex widened to greater than 0.12 seconds. Broad of notched R wave with prolonged upstroke in leads V5, V6, I, and AVL with ST segment depression and T wave inversion. Reciprocal changes in V1 and V2. LAD may be present. Hemiblockslook for LAD or RAD o Left Anterior Hemiblock Normal QRS duration and no ST segment or T wave changes. Left axis deviation greater than -30. No other cause of LAD is present. o Left Posterior Hemiblock Normal QRS duration and no ST segment or T wave changes. RAD. No other cause of RAD is present. Bifascicular block o RBBB combined with Left Anterior Hemiblock: RBBB QRS wider than 0.12 seconds. RSR in V1 and V2. Left Anterior Hemiblock LAD o RBBB combined with Left Posterior Hemiblock: RBBB RS wider than 0.12 seconds. RSR in V1 and V2. Left Posterior Hemiblock RAD Coronary artery disease. Look for Q waves and ST segment and T wave changes. Remember that not all such changes reflect coronary artery disease. During an acute infarction, the EKG evolves through 3 stages: o The T wave peaks, then inverts. o The ST segment elevates.

o Q waves appear. Criteria for Q Wave infarctions. o The Q wave must be greater than 0.04 seconds in duration. o The depth of the Q wave must be at least 1/3 the height of the R wave in the same QRS complex. Criteria for Non-Q Wave infarctions. o T wave inversion. o ST segment depression persisting for more than 48 hrs in the appropriate setting. What the artery supplies RA, RV, usually AV node LV, in 10% also AV node Anterior wall of heart, most of septum, LV Anterior wall of heart, most of septum, LV RA, RV, usually AV node EKG leads involved II, III, avF Reciprocal changes in anterior & left lateral leads. I, aVL, V5, V6 Reciprocal changes in inferior leads. V1-V6 Reciprocal changes in inferior leads V1, V2 Reciprocal changes in V1 (ST-segment depression, tall R wave)

Localizing the infarct. Location of Artery Involved Infarct Inferior R coronary a. or its descending branch Lateral L circumflex a. Anterior Septal Posterior L anterior descending a. L anterior descending a. R coronary a.

The ST Segment o ST segment elevation may be seen: With an evolving infarction. In Prinzmetals angina. o ST segment depression may be seen: With typical exertional angina. In a non-Q wave infarction. ST depression is also one indicator of a positive stress test.

Miscellaneous EKG Changes. Electrolyte Disturbances o Hyperkalemia: Evolution of peaked T waves, PR prolongation, P wave flattening, and QRS widening. Ultimately, the QRS complexes and T waves merge to form a sine wave, and ventricular fibrillation may develop. o Hypokalemia: ST depression, T wave flattening, U waves. o Hypocalcemia: Prolonged QT interval o Hypercalcemia: Shortened QT interval Hypothermia o Osborne waves, prolonged intervals, sinus bradycardia, slow atrial fibrillation; beware of muscle tremor artifact. Drugs o Digitalis: Therapeutic levels associated with ST segment and T wave changes in leads with tall R waves; toxic levels associated with tachyarrhythmias and conduction blocks; PAT with block is most characteristic. o Sotalol, quinidine, procainamide, amiodarone, TCAs, erythromycin, the quinolones, the phenothiazides, various antifungal medications, some antihistamines: Prolonged QT interval, U waves. Other Cardiac Disorders o Pericarditis: Diffuse ST segment and T wave changes. A large effusion can cause low voltage and electrical alternans. o HOCM: Ventricular hypertrophy, left axis deviation, septal Q waves. o Myocarditis: Conduction blocks. Pulmonary Disorders o COPD: Low voltage, right axis deviation, poor R wave progression. Chronic cor pulmonale can produce P pulmonale and right ventricular hypertrophy with repolarization abnormalities.

o Acute pulmonary embolism: Right ventricular hypertrophy with strain, RBBB, S1Q3. Sinus tachycardia and atrial
fibrillation are the most common arrhythmias. CNS Disease o Diffuse T wave inversion, with T waves typically wide and deep; U waves. The Athletes Heart o Sinus bradycardia, nonspecific ST segment and T wave changes, left and right ventricular hypertrophy, incomplete BBB, first-degree of Wenckebach AV block, occasional supraventricular arrhythmia.