Basic EKG for Dummies
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Basic EKG For Dummies
R. Javelosa, Jr., MD. FPCP. FPCCSection of Cardiology
Department of MedicineUERMMMC
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Cardiac Anatomy
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Cardiac Cycle
Step 1: Rapid filling of ventricles
• Ventricular pressure drops below atrial pressure
• AV valves are open, semilunar valves are closed
• Rapid ventricular filling occurs
• 70-90% of the ventricles fill with blood
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Cardiac Cycle
Step 2: Atrial systole
• P wave occurs
• Atrial contraction
• Pushed 10-30% more blood into ventricle
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Cardiac Cycle
Step 3: Isovolumetric contraction
• QRS just occurred
• Contraction of the ventricles causes ventricular pressure to rise above atrial pressure,
• AV valves close
• Ventricular pressure is still less than aortic pressure
• Semilunar valves are closed
• Volume of blood in the ventricle is EDV
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Cardiac Cycle
Step 4: Ejection
• Contraction of the ventricles causes ventricular pressure to rise above aortic pressure,
• Semilunar valves open
• Ventricular pressure is still greater than atrial pressure
• AV valves are still closed
• Volume of blood ejected by the ventricles: stroke volume (SV)
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Cardiac Cycle
Step 5:
• T-wave occurs
• Ventricular pressure drops below aortic pressure
• Back pressure causes semilunar valves to close
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Cardiac Cycle
Step 6: Isovolumetric relaxation
• AV valves are still closed
• Semilunar valves are still closed
• Volume of blood in ventricles: ESV
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P
QRS
T
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The Limb Leads
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The Precordial Leads
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The Precordial Leads
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Sequence of ECG Interpretation
1. Rate2. Rhythm3. Axis4. Hypertrophy5. Infarction6. Injury7. Ischemia
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Interpretation Sequence
• Check the patient details - is the ECG correctly labelled?
• What is the rate? • Is this sinus rhythm? If not, what is going on? • What is the mean frontal plane QRS axis (You may
wish at this stage to glance at the P and T wave axes too)
• Are the P waves normal (Good places to look are II and V1)
• What is the PR interval?
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Interpretation Sequence• Are the QRS complexes normal? Specifically, are
there: – significant Q waves? – voltage criteria for LV hypertrophy? – predominant R waves in V1? – widened QRS complexes?
• Are the ST segments normal, depressed or elevated? Quantify abnormalities.
• Are the T waves normal? What is the QT interval? • Are there abnormal U waves?
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What is the Rate?• Identify an R wave that falls on the marker of a `big block' • Count the number of big blocks to the next R wave. • 300 / # of big squares or 300, 150, 100, 75, 50 sequence• 1500 / # of small squares
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What is the Rate?
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What is the Rate?
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Step 2. What is the Rhythm?
• Sinus?• Junctional?• Ventricular?• Pacemaker?• AF?• VF?
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Junctional or AV Nodal Rhythm
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Step 3. What is the QRS Axis?
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Frontal QRS Axis
Extreme RAD Left axis NW axis deviation
Right axis Normal axisdeviation
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Using leads I and aVF the axis can be calculated to within one of the four quadrants at a glance.
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The QRS Axis
• Normal axis : both I and aVF (+)
• Right axis deviation : lead I (-) and aVF (+)
• Left axis deviation: lead I (+) and aVF (-)
• Northwest Territory : both I and aVF (-)
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Causes of left axis deviation• Left ventricular hypertophy• Inferior myocardial infarction • Artificial cardiac pacing • Emphysema • Hyperkalemia • Wolff-Parkinson-White syndrome - right sided accessory
pathway • Tricuspid atresia • Ostium primum ASD
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Causes of right axis deviation
• Normal finding in children and tall thin adults • Right ventricular hypertrophy • Chronic lung disease even without pulmonary hypertension • Anterolateral myocardial infarction • Left posterior hemiblock • Pulmonary embolism• Wolff-Parkinson-White syndrome - left sided accessory
pathway • Atrial septal defect • Ventricular septal defect
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Causes of a Northwest axis • Emphysema • Hyperkalemia • Lead transposition • Artificial cardiac pacing • Ventricular tachycardia
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Step 4. Check the P-R Interval for AV blocks
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Second Degree AV Block
• Mobitz Type I (Wenckebach)• Mobitz Type II
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Causes of AV Blocks
• Autonomic Carotid sinus
hypersensitivity
• Metabolic/endocrine Hyperkalemia Hypothyroidism Hypermagnesemia Adrenal insufficiency
• Drug-related Beta blockers Adenosine Ca channel blockers Antiarrhythmics (class I & III) Digitalis Lithium
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Causes of AV Blocks
• Infectious Endocarditis Tuberculosis Lyme disease Diphtheria Chagas disease Toxoplasmosis Syphilis
• Heritable/congenital Congenital heart disease Maternal SLE Kearns-Sayre syndrome Emery-Dreifuss MD Myotonic dystrophy Progressive familial heart block
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Causes of AV Blocks• Inflammatory SLE MCTD Rheumatoid arthritis Scleroderma • Infiltrative Amyloidosis Hemochromatosis Sarcoidosis • Coronary artery disease Acute MI
• Neoplastic/traumatic Lymphoma Radiation Mesothelioma Catheter ablation Melanoma • Degenerative Lev disease Lenègre disease
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Step 5. Look for Ectopic beats
• Atrial?• Ventricular?
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Step 6. Is there Chamber Enlargement?
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Left atrial enlargement
a. P wave duration equal or more than 0.12 sec.
b. Notched, slurred P wave in lead I and II (P mitrale).
c. Biphasic P wave in lead V1 with a wide deep and negative terminal component.
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Right atrial enlargementa. P wave duration equal or
less than 0.11 sec. b. Tall, peaked T wave equal
or more than 2.5 mm in amplitude in lead II,III or aVF (P pulmonale).
c. Mean P wave axis shifted to the right (more than +70 degrees).
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Ventricular Hypertrophy
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Left Ventricular Hypertrophy
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Left ventricular enlargementa. "Voltage criteria":
1. R or S wave in limb lead equal or more than 20mm 2. S wave in V1,V2 or V3 equal or more than 30mm 3. R wave in V4,V5 or V6 equal or more than 30mm.
b. Depressed ST segment with inverted T waves in lateral leads(strain pattern ;more reliable in the absence of digitalis therapy.
c. Left axis of -30 degree or more.
d. QRS duration equal or more than 0.09 sec. e. Time of onset of the intrinsicoid deflection ( time from the beginning of the QRS
to the peak of the R wave ) equal or more than 0.05 sec in lead V5 or V6.
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Right ventricular enlargementa. Tall R waves over the right precordium and deep S waves
over the left precordium ( R:S ratio in lead V1 > 1.0) b. Normal QRS duration (if no bundle branch block) c. Right axis deviation. d. ST-T "strain" pattern over the right precordium. e. Late intrinsicoid deflection in lead V1 or V2.
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Step 7. Examine QRS Duration
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Left bundle branch block
a. QRS duration equal or more than 0.12 sec. b. Broad , notched or slurred R wave in lateral leads( I,
aVL , V5,V6 ) c. QS or rS pattern in the anterior precordium.d. Secondary ST-T wave changes ( ST and T wave
vectors are opposite to the terminal QRS vectors). e. Late intrinsicoid deflection in lead V5 and V6.
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Right bundle branch block
a. QRS duration equal or more than 0.12 sec. b. Large R' wave in lead V1( rsR' ). c. Deep terminal S wave in lead V6. d. Normal septal Q wave. e. Inverted T wave in lead V1 ( secondary T wave
changes ). f. Late intinsicoid deflection in lead V1 and V2.
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Step 8. Look for ST Segment Abnormalities
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Localization of Infarction
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Localization of MI with the help of EKG
• Anterior wall V1 through V6
• Anteroseptal V1 through V3
• Inferior II, III, aVF
• Right ventricular V4R, V3R
• Posterior wall V7 through V9 V1 through V3 ( ST depression)
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Thank you for not sleeping!