SummaryofEKGInterpretationbyDHKim

1.Electrophysiology
Depolarization Repolarization
Approachingtothelead:positivedeflection Approachingtothelead:negativedeflection

2.EKGLeadReferenceSystem
Lead Position
Limbleads(LA/RA/LL/RL) Ineachextremity,atleast10cmfromtheheart
V1 4thintercostalspace,justtotherightofthesternum
V2 4thintercostalspace,justtotheleftofthesternum
V3 MidwaybetweenV2andV4
V4 Midclavicularline,5thintercostalspace
V5 Anterioraxillaryline,samelevelasV4
V6 Midaxillaryline,samelevelasV4andV5
HexaxialSystem PrecordialSystem

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SummaryofEKGInterpretationbyDHKim

3.EKGWaveformsandIntervals

Waveforms/Intervals Meaning NormalRange

Pwave Depolarizationofatria 0.080.11sec
SinusPwaveisuprightinIIandinvertedinaVR.
PRsegment Depolarization of AV node, His bundle, bundle
branch,andthepurkinjesystem
PRinterval Pwave+PRsegment 0.080.20sec
QRScomplex Depolarizationofventricles 0.080.10sec
Qwave:thefirstnegativedeflectionafterPwave
Rwave:thefirstpositivedeflectionafterPwave
Swave:thefirstnegativedeflectionafterRwave

SignificantQwave:eitherofthefollowingcriteria
(1)Qwaveduration>0.04sec
(2)Qwaveheight>1/4ofthetotalheightoftheQRS

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STsegment Electrically neutral period between depolarization

andrepolarizationofventricles
Twave Repolarizationofventricles
NormalTwaveisasymmetric

QTinterval QRScomplex+STsegment+Twave QTc<0.44sec
Ventriculardepolarizationandrepolarization
CorrectedQT(QTc)(NormalQTc 0.44seconds)
=QTmeasured(sec)/SquarerootofRRinterval(sec)
Uwave Drugs(Quinidine,Procainamide,Disopyramide)
Hypokalemia

4.EKGPaper
EKGpaperspeed=25mm/sec

The red line represents time ;

events that touch the red line
occurredsimultaneously.

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5.InterpretationofEKG
(1)Calibration
OneSmall OneSmall
VerticalBox HorizontalBox
A.Standard 0.1mV 0.04sec(25mm/sec)
B.Halfstandard 0.2mV 0.04sec(25mm/sec)
C.Doublespeed 0.1mV 0.02sec(50mm/sec)

(2)Rate:Useoneofthefollowingthreemethods
1500/(numberofmmbetweenbeats):onlyapplicabletoregularrhythm
Countoffmethod:300150100756050:onlyapplicabletoregularrhythm
Numberofbeatsin12secondstrip(theentireEKGlength)X5:applicabletoirregularrhythm

(3)Rhythm:Sinusrhythmispresent,if:
(1)eachPwaveisfollowedbyQRS
(2)eachQRSispreceededbyaPwave
(3)thePwaveisuprightinleadsI,II,&IIIandinvertedinleadaVR
(4)thePRintervalis0.120.20sec(35smallboxes)
(5)Ifrate60100:normalsinusrhythm;Ifrate>100:sinustachycardia;Ifrate<60:sinusbradycardia
Ifthesecriteriaarenotmet,determinethetypeofarrhythmia.

(4)Interval
Interval Normal Decreasedin Increasedin
0.120.20sec Preexcitationsyndrome
PR FirstdegreeAVblock
(35smallboxes) Junctionalrhythm
Bundlebranchblocks
0.10sec Ventricularectopicbeat
QRS
(2.5smallboxes) Toxicdrugeffect(e.g.,quinidine)
Severehyperkalemia
Hypocalcemia
Hypokalemia(dueto Uwave)
Hypercalcemia Hypomagnesemia
QT QTc 0.44sec
Tachycardia Myocardialischemia
CongenitalprolongationofQT
Toxicdrugeffect(e.g.,quinidine)

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(5)MeanQRSAxis
NormalQRSaxis:30degreesto90degrees
IfQRSispositiveinleadsIandII,normalQRSaxis
Ifnot,(1)findtheisoelectriclead;(2)examinetheperpendicularleadtotheisoelectriclead.

Leftaxisdeviation Rightaxisdeviation
Normalvariant(inchildrenandyoungadults)
RVH
LVH(sometimes) AcuteorchronicRVoverload
Leftanteriorfascicularblock (e.g.massivepulmonaryembolism)
InferiorwallMI Leftposteriorfascicularblock
Normalvariant LateralwallMI
Dextrocardia
Leftpneumothorax

(6)Pwave
Lookforatrialenlargement

LeadII V1

Normal NoteslightlybiphasicPinV1

Ppulmonale
Rightatrialabnormality(RAA)
PinleadII2.5mm

Pmitrale
Leftatrialabnormality(LAA) BiphasicPinV1
Broad,oftennotchedPinleadII

(7)QRSComplex
Lookforventricularhypertrophy
Lookforbundlebranchblockandfascicularblock
Lookforinfarction
LookforpoorRwaveprogression

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V1 MainQRSvector V6

Rightventricularhypertrophy
R SinV1
Rightaxisdeviation

Leftventricularhypertrophy
SinV1+RinV5orV6 35mm
RinV5orV6 25mm
RinI 15mm
RinaVL 1113mm

RinaVF 20mm
RinI+SinIII 25mm

Rightbundlebranchblock Leftbundlebranchblock
1.QRS 0.12sec 1.QRS 0.12sec
2.Deep,slurredSwaveinIandV6 2.Broad,monomorphicRinI/V6,withnoQwaves
3.RSRpatterninV1 3.Broad,monomorphicSinV1

Leftanteriorfascicularblock Leftposteriorfascicularblock
1.RADwiththeaxisat90to180
1.LADwiththeaxisat30to90
2.rScomplexinI,aVL
2.qRcomplexinI,aVL
3.qRcomplexinII,III,aVF
3.rScomplexinII,III,aVF
4.ExclusionofRAEand/orRVH

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AnatomicSite ChangesonEKG CoronaryArtery

Inferior II,III,aVF RCAorLCx

Anteroseptal V1,V2 LAD
Anteroapical V3,V4 LAD(distal)
Anterolateral V5,V6,I,aVL LCx
Posterior tallRinV1,V2 RCAorLCx

AnteroseptalMI AnteroseptalMIwithLateralExtension

LateralMI InferiorMI

PosteriorMI RV+InferiorMI

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EKGProgressioninMI

(8)STandTchanges
Baseline:TPsegment

STelevation:Injuryandischemia STdepression:Ischemia

ExamplesofSTchanges ExamplesofTchanges

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SummaryofEKGInterpretationbyDHKim

Conditions EKGchange Features

Tall,peakedandnarrowTwave
Wideningofintervals
Hyperkalemia
LossofPwave
Sinewavepattern
ProminentUwave
Hypokalemia MildSTdepression
FlattenedTwave

Hypercalcemia ShorteningofSTQTc

Hypocalcemia ProlongationofSTQTc

Osbornwave:adistinctive
Hypothermia
convexelevationofJpoint

Intracranialbleeds MarkedQTprolongation
(SAH) Deep,wideTinversions

ShortenedQTinterval
Digoxin
ScoopingoftheSTTwave

Drugs(increase the duration of the action potential): Type IA
antiarrhythmics (quinidine, disopyramide, procainamide), TCAs, ProlongationofQT
phenothiazines,typeIIIantiarrhythmics(amiodarone,sotalol)

REFERENCES
1.GarciaTB,HoltzNE.12leadECG:Theartofinterpretation.Sudbury,JonesandBarlettPublishers,2001

2.WagnerGS.Marriottspracticalelectrocardiography,10thedition.Philadelphia,LippincottWilliams&Wilkins,

2001

3.GoldbergerAL.Electrocardiography,inHarrisonsprinciplesofinternalmedicine,15thedition,EBraunwaldetal

(eds).NewYork,McGrawHill,2001

4. Lilly LS et al. The electrocardiogram, in Pathophysiology of heart disease, 2nd edition, Lilly LS et al (eds).

Philadelphia,LippincottWilliams&Wilkins,1997

5.ThalerMS.TheonlyEKGbookyoulleverneed,3rdedition.Philadelphia,LippincottWilliams&Wilkins,1999

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