SlideShare a Scribd company logo
1
Learning objectives
• Develop a method for reading EKGs
• Know how to determine rate, rhythm, axis
• Know the normal intervals for the parts of an
EKG
• Introduce ST segment elevation and
depression
ECG tracing
How to measure an ECG
tracing
EKG Leads
• The standard EKG has 12 leads:
• 3 Limb leads
• 3 Augmented leads
• 6 Pre-cordial leads
How does it work
Department Name | Month X,
201X
How does it work
|
Precordial Leads
Anatomic Groups
(Summary)
ECG Interpretation
What is your approach to reading an ECG?
•Rate
•Rhythm
•Axis
•Hypertrophy
•Intervals
•P wave
•QRS complex
•ST segment – T wave
Rate
Square Counting: 300-150-100-75-60-50-42A
Count QRS in 10 second rhythm strip x 6  use this method to
determine rate when rhythm is irregular (e.g., atrial fibrillation)
Rhythm
Look at the rhythm strip below and answer the questions
• Are P waves present?
• yes
• Is there a P wave before every QRS complex and a QRS complex after
every P wave?
• yes
• Are the P waves and QRS complexes regular?
• yes
• Is the PR interval constant?
• yes
Yes to all these
questions, so this is
normal sinus rhythm!
Axis
Department Name | Month X,
201X
Lead I and AVF – look at the QRS complex. Is it mostly upgoing or downgoing?
Lead I
Lead AVF
Deviation nml Left Right (leaving)
(reaching)
Practice!
Department Name | Month X,
201X
4. P Wave
Lead II and aVR
Positive in II
Negative in aVR
< 2.5 mm in amplitude
< 0.12 sec. in width
P Waves
•Left atrial enlargement (P mitrale) = wide, bifid P wave: >0.12s in
lead II or biphasic P in lead V1 with largely negative terminal portion
•Right atrial enlargement (P pulmonale) = peaked P: amplitude
>2.5mm in inferior leads (II, III, avF) or >1.5mm in V1, V2
•If multiple morphologies  Wandering pacemaker or
Multifocal atrial tachycardia (common in COPD)
PR interval
Department Name | Month X,
201X
-Less than one big box (5 small boxes)!
-Bigger than one small box
-Too long means
you got the
heart block
AV Nodal Blocks
• Delay conduction of impulses from
sinus node
• If AV node does not let impulse
through, no QRS complex is seen
• AV nodal block classes:
1st, 2nd, 3rd degree
1st Degree AV Block
• PR interval constant
• >.2 sec
• All impulses conducted
2nd Degree AV Block Type 1
• AV node conducted each impulse
slower and finally no impulse is
conducted
• Longer PR interval, finally no QRS
complex
2nd Degree AV Block Type 2
• Constant PR interval
• AV node intermittently conducts
no impulse
• AV node conducts no impulse
• Atria and ventricles beat at intrinsic
rate (80 and 40 respectively)
• No association between P waves and
QRS complexes
3rd Degree AV Block
• Caused by bypass
tract
• AV node is bypassed,
delay
• EKG shows short PR
interval <.11 sec
• Upsloping to QRS
complex (delta wave)
Another Consideration:
Wolfe-Parkinson-White (WPW)
• Delta wave, short PR interval
WPW
QRS Duration
• Normal QRS is < 120 ms
• Prolonged QRS duration (>120ms) is seen in
bundle branch blocks (BBB).
• This is a result of abnormal conduction through the
bundle branches or fascicles in the electrical
conduction system
• Different criteria for left and right bundle branch
blocks but know the general morphology of each.
QRS complex
Poor R Wave Progression in V1 to V6: possible prior anterior
MI
•Pathologic Q wave = previous MI.
-Q wave amplitude 25% or more of the subsequent R wave OR
- Q wave > 0.04 s in width + > 2 mm in amplitude in more than one lead
Left and right bundle
branch blocks
• Left BBB –
• Dominant S wave in V1 (‘W’-shaped)
• Broad, notched (‘M’-shaped) R wave in V6
• Right BBB –
• Tall R wave in V1 (‘M’-shaped)
• Wide, slurred S wave (‘W’-shaped) in V6
QT interval
• Visual estimate, end of T wave is before the mid way R
to R point
• Use calculated QTc for accurate measurements (look to
the top)
• Male: <450 msec
• Female: <460 msec
Hypertrophy
RVH:
V1 R/S ratio >1
OR
V6 S/R ratio >1
LVH: 2 commonly used criteria (use either)
1. Sokolow criteria:
S in V1 or V2 + R in V5 or V6 ≥ 35 mm.
2. Cornell criteria:
S in V3 + R in aVL > 28 mm (men)
S in V3 + R in aVL > 20 mm (women)
Precordial Leads
Anatomic Groups
(Summary)
ST segment and MI
ST elevation may indicate STEMI if the following are met:
• At least 1 mm (0.1 mV) elevation in the limb leads (I, II, III, AVL, AVR)
• At least 2 mm elevation in the precordial leads (V1-V6)
• Elevation must be in at least 2 anatomically contiguous leads (see upcoming slides
on “grouping leads”)
ST depression may indicate NSTEMI if the following are met:
• Downsloping ST depression ≥ 0.5 mm
• Must be in at least 2 anatomically contiguous leads
Problem solving
What is the heart rate?
(300 / 6) = 50 bpm
www.uptodate.com
What is the heart rate?
(300 / ~ 4) = ~ 75 bpm
www.uptodate.com
Thankyou…

More Related Content

Similar to ECG Basics.pptx

Basics of ECG.pptx
Basics of ECG.pptxBasics of ECG.pptx
Basics of ECG.pptx
doctor / pediatrician
 
ECG-2 RAMA.pptx
ECG-2 RAMA.pptxECG-2 RAMA.pptx
ECG-2 RAMA.pptx
manishadya
 
Basic ecg
Basic ecgBasic ecg
Ecg easy to learn
Ecg easy to learnEcg easy to learn
Ecg easy to learn
sanjeev vishwakarma
 
Electrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKGElectrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKG
Fuad Farooq
 
ECG Analysis
ECG AnalysisECG Analysis
ECG Analysis
SCGH ED CME
 
ECG lecture
ECG lectureECG lecture
ECG lecture
Alric Mondragon
 
Ecg in children
Ecg in childrenEcg in children
Ecg in children
NiveditaMishra17
 
ECG easy way
ECG easy way ECG easy way
ECG easy way
mohammed shakir
 
Ecg easy way
Ecg easy wayEcg easy way
normalecginterpretation in human heart ppt
normalecginterpretation in human heart pptnormalecginterpretation in human heart ppt
normalecginterpretation in human heart ppt
VAIBHAVBHASTANA
 
Ecg
EcgEcg
Ecg power point
Ecg power pointEcg power point
Ecg power point
Pradeep Indurkar
 
All info about ecg
All info about ecgAll info about ecg
All info about ecg
Ghaidaa Sadeq
 
base-110816084037-phpapp02.pdf
base-110816084037-phpapp02.pdfbase-110816084037-phpapp02.pdf
base-110816084037-phpapp02.pdf
ssuser61d4e0
 
QRS INTERVAL IN ECG AND ITS ABNORMALITIES
QRS INTERVAL IN ECG AND ITS ABNORMALITIESQRS INTERVAL IN ECG AND ITS ABNORMALITIES
QRS INTERVAL IN ECG AND ITS ABNORMALITIES
DR Venkata Ramana
 
Basic of ecg_dr nazmun
Basic of ecg_dr nazmunBasic of ecg_dr nazmun
Basic of ecg_dr nazmun
Nazmun Ara
 
How to read ecg (basic ecg findings)
How to read ecg (basic ecg findings)How to read ecg (basic ecg findings)
How to read ecg (basic ecg findings)
Hajira Nisar
 
ECG REview.pdf
ECG REview.pdfECG REview.pdf
ECG REview.pdf
Jagan53828
 
44 E C G
44 E C G44 E C G
44 E C G
kdiwavvou
 

Similar to ECG Basics.pptx (20)

Basics of ECG.pptx
Basics of ECG.pptxBasics of ECG.pptx
Basics of ECG.pptx
 
ECG-2 RAMA.pptx
ECG-2 RAMA.pptxECG-2 RAMA.pptx
ECG-2 RAMA.pptx
 
Basic ecg
Basic ecgBasic ecg
Basic ecg
 
Ecg easy to learn
Ecg easy to learnEcg easy to learn
Ecg easy to learn
 
Electrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKGElectrocardiogaram - ECG EKG
Electrocardiogaram - ECG EKG
 
ECG Analysis
ECG AnalysisECG Analysis
ECG Analysis
 
ECG lecture
ECG lectureECG lecture
ECG lecture
 
Ecg in children
Ecg in childrenEcg in children
Ecg in children
 
ECG easy way
ECG easy way ECG easy way
ECG easy way
 
Ecg easy way
Ecg easy wayEcg easy way
Ecg easy way
 
normalecginterpretation in human heart ppt
normalecginterpretation in human heart pptnormalecginterpretation in human heart ppt
normalecginterpretation in human heart ppt
 
Ecg
EcgEcg
Ecg
 
Ecg power point
Ecg power pointEcg power point
Ecg power point
 
All info about ecg
All info about ecgAll info about ecg
All info about ecg
 
base-110816084037-phpapp02.pdf
base-110816084037-phpapp02.pdfbase-110816084037-phpapp02.pdf
base-110816084037-phpapp02.pdf
 
QRS INTERVAL IN ECG AND ITS ABNORMALITIES
QRS INTERVAL IN ECG AND ITS ABNORMALITIESQRS INTERVAL IN ECG AND ITS ABNORMALITIES
QRS INTERVAL IN ECG AND ITS ABNORMALITIES
 
Basic of ecg_dr nazmun
Basic of ecg_dr nazmunBasic of ecg_dr nazmun
Basic of ecg_dr nazmun
 
How to read ecg (basic ecg findings)
How to read ecg (basic ecg findings)How to read ecg (basic ecg findings)
How to read ecg (basic ecg findings)
 
ECG REview.pdf
ECG REview.pdfECG REview.pdf
ECG REview.pdf
 
44 E C G
44 E C G44 E C G
44 E C G
 

More from Abhijith Puttananickal

Coagulation Cascade with primary and secondary.pptx
Coagulation Cascade with primary and secondary.pptxCoagulation Cascade with primary and secondary.pptx
Coagulation Cascade with primary and secondary.pptx
Abhijith Puttananickal
 
Cardiac health
Cardiac healthCardiac health
Cardiac health
Abhijith Puttananickal
 
Antepartum fetal surveillance
Antepartum fetal surveillanceAntepartum fetal surveillance
Antepartum fetal surveillance
Abhijith Puttananickal
 
Physiology of menopause And Post Menopausal Bleeding
Physiology of menopause And Post Menopausal BleedingPhysiology of menopause And Post Menopausal Bleeding
Physiology of menopause And Post Menopausal Bleeding
Abhijith Puttananickal
 
Scrub typhus spm seminar
Scrub typhus spm seminarScrub typhus spm seminar
Scrub typhus spm seminar
Abhijith Puttananickal
 
Cholera Diagnosis, Management, Treatment and Control
Cholera Diagnosis, Management, Treatment and ControlCholera Diagnosis, Management, Treatment and Control
Cholera Diagnosis, Management, Treatment and Control
Abhijith Puttananickal
 

More from Abhijith Puttananickal (6)

Coagulation Cascade with primary and secondary.pptx
Coagulation Cascade with primary and secondary.pptxCoagulation Cascade with primary and secondary.pptx
Coagulation Cascade with primary and secondary.pptx
 
Cardiac health
Cardiac healthCardiac health
Cardiac health
 
Antepartum fetal surveillance
Antepartum fetal surveillanceAntepartum fetal surveillance
Antepartum fetal surveillance
 
Physiology of menopause And Post Menopausal Bleeding
Physiology of menopause And Post Menopausal BleedingPhysiology of menopause And Post Menopausal Bleeding
Physiology of menopause And Post Menopausal Bleeding
 
Scrub typhus spm seminar
Scrub typhus spm seminarScrub typhus spm seminar
Scrub typhus spm seminar
 
Cholera Diagnosis, Management, Treatment and Control
Cholera Diagnosis, Management, Treatment and ControlCholera Diagnosis, Management, Treatment and Control
Cholera Diagnosis, Management, Treatment and Control
 

Recently uploaded

一比一原版(UO毕业证)渥太华大学毕业证如何办理
一比一原版(UO毕业证)渥太华大学毕业证如何办理一比一原版(UO毕业证)渥太华大学毕业证如何办理
一比一原版(UO毕业证)渥太华大学毕业证如何办理
aqzctr7x
 
Challenges of Nation Building-1.pptx with more important
Challenges of Nation Building-1.pptx with more importantChallenges of Nation Building-1.pptx with more important
Challenges of Nation Building-1.pptx with more important
Sm321
 
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
zsjl4mimo
 
Palo Alto Cortex XDR presentation .......
Palo Alto Cortex XDR presentation .......Palo Alto Cortex XDR presentation .......
Palo Alto Cortex XDR presentation .......
Sachin Paul
 
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
nuttdpt
 
Influence of Marketing Strategy and Market Competition on Business Plan
Influence of Marketing Strategy and Market Competition on Business PlanInfluence of Marketing Strategy and Market Competition on Business Plan
Influence of Marketing Strategy and Market Competition on Business Plan
jerlynmaetalle
 
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
Timothy Spann
 
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
Timothy Spann
 
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdfUdemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
Fernanda Palhano
 
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
bopyb
 
Analysis insight about a Flyball dog competition team's performance
Analysis insight about a Flyball dog competition team's performanceAnalysis insight about a Flyball dog competition team's performance
Analysis insight about a Flyball dog competition team's performance
roli9797
 
DSSML24_tspann_CodelessGenerativeAIPipelines
DSSML24_tspann_CodelessGenerativeAIPipelinesDSSML24_tspann_CodelessGenerativeAIPipelines
DSSML24_tspann_CodelessGenerativeAIPipelines
Timothy Spann
 
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
v7oacc3l
 
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data LakeViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
Walaa Eldin Moustafa
 
My burning issue is homelessness K.C.M.O.
My burning issue is homelessness K.C.M.O.My burning issue is homelessness K.C.M.O.
My burning issue is homelessness K.C.M.O.
rwarrenll
 
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
74nqk8xf
 
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
74nqk8xf
 
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
nuttdpt
 
Experts live - Improving user adoption with AI
Experts live - Improving user adoption with AIExperts live - Improving user adoption with AI
Experts live - Improving user adoption with AI
jitskeb
 
Global Situational Awareness of A.I. and where its headed
Global Situational Awareness of A.I. and where its headedGlobal Situational Awareness of A.I. and where its headed
Global Situational Awareness of A.I. and where its headed
vikram sood
 

Recently uploaded (20)

一比一原版(UO毕业证)渥太华大学毕业证如何办理
一比一原版(UO毕业证)渥太华大学毕业证如何办理一比一原版(UO毕业证)渥太华大学毕业证如何办理
一比一原版(UO毕业证)渥太华大学毕业证如何办理
 
Challenges of Nation Building-1.pptx with more important
Challenges of Nation Building-1.pptx with more importantChallenges of Nation Building-1.pptx with more important
Challenges of Nation Building-1.pptx with more important
 
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
一比一原版(Harvard毕业证书)哈佛大学毕业证如何办理
 
Palo Alto Cortex XDR presentation .......
Palo Alto Cortex XDR presentation .......Palo Alto Cortex XDR presentation .......
Palo Alto Cortex XDR presentation .......
 
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
一比一原版(UCSB文凭证书)圣芭芭拉分校毕业证如何办理
 
Influence of Marketing Strategy and Market Competition on Business Plan
Influence of Marketing Strategy and Market Competition on Business PlanInfluence of Marketing Strategy and Market Competition on Business Plan
Influence of Marketing Strategy and Market Competition on Business Plan
 
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
 
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
06-04-2024 - NYC Tech Week - Discussion on Vector Databases, Unstructured Dat...
 
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdfUdemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
Udemy_2024_Global_Learning_Skills_Trends_Report (1).pdf
 
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
一比一原版(GWU,GW文凭证书)乔治·华盛顿大学毕业证如何办理
 
Analysis insight about a Flyball dog competition team's performance
Analysis insight about a Flyball dog competition team's performanceAnalysis insight about a Flyball dog competition team's performance
Analysis insight about a Flyball dog competition team's performance
 
DSSML24_tspann_CodelessGenerativeAIPipelines
DSSML24_tspann_CodelessGenerativeAIPipelinesDSSML24_tspann_CodelessGenerativeAIPipelines
DSSML24_tspann_CodelessGenerativeAIPipelines
 
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
在线办理(英国UCA毕业证书)创意艺术大学毕业证在读证明一模一样
 
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data LakeViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
ViewShift: Hassle-free Dynamic Policy Enforcement for Every Data Lake
 
My burning issue is homelessness K.C.M.O.
My burning issue is homelessness K.C.M.O.My burning issue is homelessness K.C.M.O.
My burning issue is homelessness K.C.M.O.
 
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
一比一原版(牛布毕业证书)牛津布鲁克斯大学毕业证如何办理
 
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
一比一原版(Coventry毕业证书)考文垂大学毕业证如何办理
 
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
一比一原版(UCSF文凭证书)旧金山分校毕业证如何办理
 
Experts live - Improving user adoption with AI
Experts live - Improving user adoption with AIExperts live - Improving user adoption with AI
Experts live - Improving user adoption with AI
 
Global Situational Awareness of A.I. and where its headed
Global Situational Awareness of A.I. and where its headedGlobal Situational Awareness of A.I. and where its headed
Global Situational Awareness of A.I. and where its headed
 

ECG Basics.pptx

  • 1. 1 Learning objectives • Develop a method for reading EKGs • Know how to determine rate, rhythm, axis • Know the normal intervals for the parts of an EKG • Introduce ST segment elevation and depression
  • 3. How to measure an ECG tracing
  • 4. EKG Leads • The standard EKG has 12 leads: • 3 Limb leads • 3 Augmented leads • 6 Pre-cordial leads
  • 5. How does it work Department Name | Month X, 201X
  • 6. How does it work |
  • 7.
  • 8.
  • 9.
  • 12. ECG Interpretation What is your approach to reading an ECG? •Rate •Rhythm •Axis •Hypertrophy •Intervals •P wave •QRS complex •ST segment – T wave
  • 13. Rate Square Counting: 300-150-100-75-60-50-42A Count QRS in 10 second rhythm strip x 6  use this method to determine rate when rhythm is irregular (e.g., atrial fibrillation)
  • 14. Rhythm Look at the rhythm strip below and answer the questions • Are P waves present? • yes • Is there a P wave before every QRS complex and a QRS complex after every P wave? • yes • Are the P waves and QRS complexes regular? • yes • Is the PR interval constant? • yes Yes to all these questions, so this is normal sinus rhythm!
  • 15. Axis Department Name | Month X, 201X Lead I and AVF – look at the QRS complex. Is it mostly upgoing or downgoing? Lead I Lead AVF Deviation nml Left Right (leaving) (reaching)
  • 17. 4. P Wave Lead II and aVR Positive in II Negative in aVR < 2.5 mm in amplitude < 0.12 sec. in width
  • 18. P Waves •Left atrial enlargement (P mitrale) = wide, bifid P wave: >0.12s in lead II or biphasic P in lead V1 with largely negative terminal portion •Right atrial enlargement (P pulmonale) = peaked P: amplitude >2.5mm in inferior leads (II, III, avF) or >1.5mm in V1, V2 •If multiple morphologies  Wandering pacemaker or Multifocal atrial tachycardia (common in COPD)
  • 19.
  • 20. PR interval Department Name | Month X, 201X -Less than one big box (5 small boxes)! -Bigger than one small box -Too long means you got the heart block
  • 21. AV Nodal Blocks • Delay conduction of impulses from sinus node • If AV node does not let impulse through, no QRS complex is seen • AV nodal block classes: 1st, 2nd, 3rd degree
  • 22. 1st Degree AV Block • PR interval constant • >.2 sec • All impulses conducted
  • 23. 2nd Degree AV Block Type 1 • AV node conducted each impulse slower and finally no impulse is conducted • Longer PR interval, finally no QRS complex
  • 24. 2nd Degree AV Block Type 2 • Constant PR interval • AV node intermittently conducts no impulse
  • 25. • AV node conducts no impulse • Atria and ventricles beat at intrinsic rate (80 and 40 respectively) • No association between P waves and QRS complexes 3rd Degree AV Block
  • 26. • Caused by bypass tract • AV node is bypassed, delay • EKG shows short PR interval <.11 sec • Upsloping to QRS complex (delta wave) Another Consideration: Wolfe-Parkinson-White (WPW)
  • 27. • Delta wave, short PR interval WPW
  • 28. QRS Duration • Normal QRS is < 120 ms • Prolonged QRS duration (>120ms) is seen in bundle branch blocks (BBB). • This is a result of abnormal conduction through the bundle branches or fascicles in the electrical conduction system • Different criteria for left and right bundle branch blocks but know the general morphology of each.
  • 29. QRS complex Poor R Wave Progression in V1 to V6: possible prior anterior MI •Pathologic Q wave = previous MI. -Q wave amplitude 25% or more of the subsequent R wave OR - Q wave > 0.04 s in width + > 2 mm in amplitude in more than one lead
  • 30. Left and right bundle branch blocks • Left BBB – • Dominant S wave in V1 (‘W’-shaped) • Broad, notched (‘M’-shaped) R wave in V6 • Right BBB – • Tall R wave in V1 (‘M’-shaped) • Wide, slurred S wave (‘W’-shaped) in V6
  • 31. QT interval • Visual estimate, end of T wave is before the mid way R to R point • Use calculated QTc for accurate measurements (look to the top) • Male: <450 msec • Female: <460 msec
  • 32. Hypertrophy RVH: V1 R/S ratio >1 OR V6 S/R ratio >1 LVH: 2 commonly used criteria (use either) 1. Sokolow criteria: S in V1 or V2 + R in V5 or V6 ≥ 35 mm. 2. Cornell criteria: S in V3 + R in aVL > 28 mm (men) S in V3 + R in aVL > 20 mm (women)
  • 33.
  • 36. ST segment and MI ST elevation may indicate STEMI if the following are met: • At least 1 mm (0.1 mV) elevation in the limb leads (I, II, III, AVL, AVR) • At least 2 mm elevation in the precordial leads (V1-V6) • Elevation must be in at least 2 anatomically contiguous leads (see upcoming slides on “grouping leads”) ST depression may indicate NSTEMI if the following are met: • Downsloping ST depression ≥ 0.5 mm • Must be in at least 2 anatomically contiguous leads
  • 37.
  • 38.
  • 39.
  • 40.
  • 42. What is the heart rate? (300 / 6) = 50 bpm www.uptodate.com
  • 43. What is the heart rate? (300 / ~ 4) = ~ 75 bpm www.uptodate.com
  • 44.
  • 45.
  • 46.
  • 47.
  • 48.
  • 49.
  • 50.
  • 51.
  • 52.
  • 53.
  • 54.
  • 55.