Basics of EKG Interpretation

Basics of EKG
Interpretation
Waveforms and Intervals
EKG Leads
The standard EKG has 12 leads: 3 Standard Limb Leads
3 Augmented Limb Leads
6 Precordial Leads
The axis of a particular lead represents the viewpoint from

which it looks at the heart.
Precordial Leads
Adapted from: www.numed.co.uk/electrodepl.html

Standard Limb Leads
All Limb Leads
Precordial Leads
Anatomic Groups
(Summary)
Systematic Approach
► Rate
► Rhythm
► Axis
► Wave Morphology
 P, T, and U waves and QRS
complex
► Intervals
 PR, QRS, QT
► ST Segment
Rate
► Rule of 300
► 10 Second Rule
Rule of 300
Take the number of “big boxes” between
neighboring QRS complexes, and divide this
into 300. The result will be approximately
equal to the rate
Although fast, this method only works for

regular rhythms.
What is the heart rate?
www.uptodate.com
(300 / 6) = 50 bpm
www.uptodate.com
(300 / ~ 4) = ~ 75 bpm
(300 / 1.5) = 200 bpm

The Rule of 300
It may be easiest to memorize the following table:
# of big Rate
boxes
1 300
2 150
3 100
4 75
5 60
6 50
10 Second Rule
As most EKGs record 10 seconds of rhythm per

page, one can simply count the number of beats
present on the EKG and multiply by 6 to get the
number of beats per 60 seconds.
This method works well for irregular rhythms.

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
33 x 6 = 198 bpm
The QRS Axis
By near-consensus, the
normal QRS axis is defined
as ranging from -30° to +90°.
-30° to -90° is referred to as a

left axis deviation (LAD)
+90° to +180° is referred to as

a right axis deviation (RAD)
Determining the Axis
► The Quadrant Approach
► The Equiphasic Approach

Determining the Axis
Predominantly Predominantly Equiphasic

Positive Negative
The Quadrant Approach
1. Examine the QRS complex in leads I and aVF to determine
if they are predominantly positive or predominantly
negative. The combination should place the axis into one
of the 4 quadrants below.
The Quadrant Approach
2. In the event that LAD is present, examine lead II to
determine if this deviation is pathologic. If the QRS in II is
predominantly positive, the LAD is non-pathologic (in other
words, the axis is normal). If it is predominantly negative, it
is pathologic.
Quadrant Approach: Example 1
The Alan E. Lindsay

ECG Learning Center
http://medstat.med.utah
.edu/kw/ecg/
Negative in I, positive in aVF  RAD

Quadrant Approach: Example 2
The Alan E. Lindsay

ECG Learning Center
http://medstat.med.utah
.edu/kw/ecg/
Positive in I, negative in aVF  Predominantly positive in II 
Normal Axis (non-pathologic LAD)

Rhythms/Arrhythmias
► Sinus
► Atrial
► Junctional
► Ventricular
Sinus Rhythms: Criteria/Types
►P waves upright in I, II, aVF

► Constant P-P/R-R interval
► Rate
► Narrow QRS complex

► P:QRS ratio 1:1
► P-R interval is normal and constant
Normal Sinus Rhythm
• Rate is 60 to 100
Sinus Bradycardia
• Can be normal variant

• Can result from medication
• Look for underlying cause
Sinus Tachycardia
• May be caused by exercise, fever,

hyperthyroidism
• Look for underlying cause, slow the rate
Atrial Arrhythmias: Criteria/Types
►P waves inverted in I, II and aVF

► Abnormal shape
 Notched
 Flattened
 Diphasic
► Narrow QRS complex
Atrial Flutter
• Regular ventricular rate 150 bpm

• Varying ratios of F waves to QRS
complexes, most common is

4:1
Atrial Flutter
• Tracing shows 6:1 conduction

Atrial Fibrillation
• Tracing shows irregularly irregular

rhythm with no P waves
• Ventricular rate usually > 100 bpm
Atrial Fibrillation
• Tracing shows irregularly irregular
rhythm with no P waves

• Ventricular rate is 40
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
2 Degree AV Block Type 1
nd
• AV node conducted each impulse

slower and finally no impulse is
conducted
• Longer PR interval, finally no QRS
complex
2 Degree AV Block Type 2
nd
• Constant PR interval
• AV node intermittently conducts
no impulse
3 Degree AV Block
rd
• AV node conducts no impulse

• Atria and ventricles beat at intrinsic
rate (80 and 40 respectively)
• No association between P waves
and QRS complexes
Ventricular Arrhythmias:
Criteria/Types
► Premature Ventricular
► Wide QRS Contractions
complex ► Idioventricular Rhythm

► Accelerated IVR
► Rate:
variable ► Ventricular Tachycardia
► No ► Ventricular Fibrillation
P waves
Premature Ventricular Contraction
• Occurs earlier than sinus beat

• Wide, no P wave
Ventricular Tachycardia
• Rate is > than 100 bpm

Ventricular Tachycardia/Fibrillation
• Unorganized activity of ventricle

Ventricular Fibrillation
Ischemia and Infarction
Normal Complexes and Segments
Ischemia
• T wave inversion, ST segment depression

• Acute injury: ST segment elevation
• Dead tissue: Q wave
Measurements

Basics of EKG Interpretation

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Basics of EKG

The axis of a particular lead represents the viewpoint from

Adapted from: www.numed.co.uk/electrodepl.html

Although fast, this method only works for

(300 / 1.5) = 200 bpm

As most EKGs record 10 seconds of rhythm per

This method works well for irregular rhythms.

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

-30° to -90° is referred to as a

+90° to +180° is referred to as

► The Quadrant Approach

► The Equiphasic Approach

Predominantly Predominantly Equiphasic

The Alan E. Lindsay

Negative in I, positive in aVF  RAD

The Alan E. Lindsay

Positive in I, negative in aVF  Predominantly positive in II 

Normal Axis (non-pathologic LAD)

►P waves upright in I, II, aVF

► Narrow QRS complex

• Can be normal variant

• May be caused by exercise, fever,

►P waves inverted in I, II and aVF

• Regular ventricular rate 150 bpm

complexes, most common is

• Tracing shows 6:1 conduction

• Tracing shows irregularly irregular

• Tracing shows irregularly irregular

rhythm with no P waves

• Delay conduction of impulses from

• AV node conducted each impulse

• AV node conducts no impulse

complex ► Idioventricular Rhythm

• Occurs earlier than sinus beat

• Rate is > than 100 bpm

• Unorganized activity of ventricle

• T wave inversion, ST segment depression

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