Electrocardiography

Overview
 Introduction
 Basic Principles

 Rate

 Axis

 Rhythm

 Intraventricular Conduction Defects

 Hypertrophy

 Ischemia, Infarction, and Pericarditis

 Putting It All Together

Electrocardiography

Learning Objectives
1. Interpret a 12-lead EKG using a systematic
approach. This interpretation should include:
a. Rate
b. Rhythm
c. Intervals
d. QRS axis
e. Conduction
f. Atrial abnormality
g. Ventricular hypertrophy
h. Extra or abnormal waves
i. ST segment and T wave changes
Electrocardiography

Putting It All Together

 When faced with the task of
interpreting a 12-lead EKG or a
rhythm strip, the best way avoid
missing an important finding is to
use the same systematic approach
every time!
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Identification
 Name, age, gender, date
 Calibration
 Paper speed, amplitude
 Technician’s comments
 “Right-sided chest leads”
 “Arm leads transposed”
 “During chest pain”
 Interpretation
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Important:
Always compare the EKG that you’re
interpreting to that patient’s previous
EKGs when possible (especially the most
recent previous EKG).
 Caution:
 Not all 12-lead EKGs are formatted the same.
 Don’t confuse “lead change lines” with QRS
complexes!
Electrocardiography
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Rate
 Ventricular
 Atrial
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Rhythm
 Regularity
 QRS complex width
 P wave polarity in leads II and aVR
 Explain missing or extra beats
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Intervals
 PR (normal: 120 – 200 msec)
 QT (correct for rate) (normal: 360 - 460 msec)
 QRS duration (normal: <120 msec)
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 QRS axis
 Frontal plane
 Horizontal plane
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Conduction
 AV
 Ratio of P waves to QRS complexes
 PR interval

 Intraventricular
 QRS duration

 QRS pattern
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Atrial abnormality
 P wave size and shape in leads II and V1
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Ventricular hypertrophy
 QRS amplitude (if patient’s age > 40 years)
 QRS axis (frontal plane for RVH)
 ST and T changes (ventric. strain pattern)
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 Extra or abnormal waves
 Delta waves
 Flutter waves
 Significant Q waves
 Prominent or inverted U waves
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Interpretation (cont.)
 ST segment and T wave changes
 ST elevation
 ST depression
 ST segment shape
 T wave inversion
 T wave shape (including symmetry)
 T wave size
 Compare to previous EKGs if available
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Systematic approach (cont.)
 Basic information
 Interpretation
 Rate
 Rhythm
 Intervals
 QRS axis
 Conduction
 Atrial abnormality
 Ventricular hypertrophy
 Extra or abnormal waves
 ST segment and T wave changes
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Interpret this:
Electrocardiography

Putting It All Together (cont.)

Interpret this: