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ECG tracings are recorded on grid paper. The horizontal axis of the
EKG paper records time, with black marks at the top indicating 3 second intervals.
Each second is marked by 5 large grid blocks. Thus each large block equals 0.2 second. The
vertical axis records EKG amplitude (voltage). Two large blocks equal 1 millivolt (mV). Each small
block equals 0.1 mV.
Within the large blocks are 5 small blocks, each representing 0.04 seconds.
Normal EKG tracings consist of waveform components that indicate electrical events during one
heart beat. These waveforms are labeled P, Q, R, S, T and U. The following descriptions are with
respect to Lead II.
P wave is the first deflection and is normally a positive (upward) waveform. It indicates atrial
depolarization.
QRS complex follows the P wave. It normally begins with a downward deflection, Q; a larger
upward deflection, R; and then a downward S wave. The QRS complex represents ventricular
depolarization and contraction.
T wave is normally a modest upward waveform, representing ventricular repolarization.
U wave indicates the recovery of the Purkinje conduction fibers. This wave component may not be
observable.
Rhythm
For ventricular rhythms, examine the R to R intervals on the EKG strip. Calipers or paper
marks can be used to fix the distance for one R-R interval and then this distance can be
compared to other R-R pairs. Within this web site, you will also be able to use virtual calipers.
Are they regular, meaning that each heart beat's R-R interval is equal? Small variations of up
to 10% are considered equal. Is the rhythm regularly irregular? For example is there a pattern,
such as increasing R-R durations? Or perhaps groups of similar intervals as illustrated on the
right? Or are R-R intervals completely irregular?
For atrial rhythm, observe the P-P intervals. Are they regular (minor variations can be caused
by the breath cycle)? If P-P intervals are irregular, is there a pattern?
Heart Rate
There are several methods for determining heart rate. Our first method is simple. Count the
number of QRS complexes over a 6 second interval. Multiply by 10 to determine heart rate.
This method works well for both regular and irregular rhythms. In the first image, we can
count 7 QRS complexes, so the heart rate is 70.
The second method uses small boxes. Count the number of small boxes for a typical R-R
interval. Divide this number into 1500 to determine heart rate. In the second image, the
number of small boxes for the R-R interval is 22.5. The heart rate is 1500/21.5, which is
69.8.
P Wave
The P wave represents atrial depolarization. In a normal EKG, the P-wave precedes the QRS
complex. It looks like a small bump upwards from the baseline. The amplitude is normally
0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is 0.06-0.11 seconds (1.5 to 2.75
small boxes). The shape of a P-wave is usually smooth and rounded.
P-wave questions:
PR Interval
QRS Complex
Does the QRS interval fall within the range of 0.08-0.12 seconds?
Are the QRS complexes similar in appearance across the ECG tracing?
T Wave
QT Interval
The QT interval represents the time of ventricular activity including both depolarization and
repolarization.
It is measured from the beginning of the QRS complex to the end of the T wave. Normally, the
QT interval is 0.36 to 0.44 seconds (9-11 boxes). The QT interval will vary with patient gender,
age and heart rate. Another guideline is that normal QT Intervals is less than half of the R-R
Interval for heart rates below 100 bpm.
ST Segment
The ST segment is the line that from the end of the QRS complex to
beginning of the T wave. Normally the ST segment is flat relative to
the baseline.