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Normal:
o How tall? 0.5-2.5 mm
o How wide? 0.10 sec
Is the PR interval
short (<0.12
sec)?
o YES: Bypass of
the AV node
PR interval
Look at your
measurements
Is the PR interval
long (>0.20 sec)?
o YES: First
degree AV Block
Q wave
Q wave is present when
the first QRS deflection
is downward
Observed in each lead
o YES: Infarction
Q wave
If:
o Pathological Q wave
o No ST segment depression
o Normal T wave
V1, V2 Septal
V3, V4 Anterior
(left main artery)
V5, V6 Lateral
Q wave
If:
o Pathological Q wave
o ST segment depression
o T wave inversion
V1, V2 Septal
V3, V4 Anterior
(left main artery)
V5, V6 Lateral
R and S waves
Are any R or S waves
too big?
o YES: Left
ventricular
hypertrophy
Check using:
o Sokolow-Lyon index:
SV1 + (RV5 or RV6) >3.5
mV
o Cornell voltage criteria:
SV3 + RavL 2.8 mV
(men)
SV3 + RavL 2.0 mV
(women)
R and S waves
Look at leads V1 to V6
Normal:
o R wave increases in height from V1 to V6
o S wave decreases in depth from V1 to V6
R and S waves
Look at leads V1 to V6
Are the R waves persistent in sizes (<5 mm)?
o YES: Poor R wave progression
R and S waves
Look at leads V1 to V6
Are the S waves persistent in sizes?
o YES: Persistent posterobasal forces
QRS complex
Normally varies in
different ECG leads
Normal:
o < 0.12 sec
o < 3 small squares
If:
o Wide QRS complex
o M sign or rSR in V1
YES: Right Bundle
Branch Block (RBBB)
If:
o Wide QRS complex
o srS in V1
o M sign in the peak of R
YES: Left Bundle
Branch Block (LBBB)
If:
o Normal QRS complex
o BBB morphology
YES: Incomplete BBB
ST segment
Isoelectric ( Lies at
the same level as the
baseline)
Normal:
o Deviate between -0.5 and +1
mm from the baseline
ST segment
Are the ST segments
elevated (raised
above level of
baseline)?
o YES: Acute MI to normal
variant
ST segment
ST segment
Are the ST segments
depressed ( > 2 small
squares below level of
baseline)?
o YES: Myocardial ischemia
ST segment
ST segment
Does the J point ensue early at repolarization?
o YES: Early Repolarization Pattern
ST segment
Is there flattening of T waves?
o YES: Non-specific ST wave changes (NSSTWC)
T wave
Normal:
o Not clearly defined
o Guide:
Should not be > size of
the preceding QRS
complex
T wave is usually not
above 10 mm in any
precordial leads
T wave
Look at V2, V3, V4
Are the T waves too tall (>10 mm)?
o YES: Peak T waves (Hyperkalemia or AMI)
T wave
Is the T wave inverted
(> 1 mm)?
o YES: Myocardial Ischemia
U wave
Prominent in V3
Normal:
o Not >1 mm amplitude
U wave
Do the U waves
appear too
prominent?
o YES: Prominent U waves
(Hypokalemia,
Hypercalcemia,
Hyperthyroidism)
RHYTHM
Sinus Rhythm
Presence of P wave
Followed by QRS complex
Regular rate
Normal:
o 60-100 bpm
Sinus Arrhythmia
Presence of P wave
Followed by QRS complex
Irregular sinus rhythm at rate <100 bpm
Cycle vary by 10% or more
Premature Atrial Complex (PAC)
Regular Irregular
Sinus Bradycardia
BRADYCARDIA
Type 2
TACHYCARDIA
RR > 100 bpm
Flutter waves;
P wave; 100-140 No P wave; 150
No P wave saw tooth; >300
bpm bpm
bpm
Sinus
SVT AF Atrial flutter
tachycardia
BRADYCARDIA
Sinus Tachycardia
BRADYCARDIA
SVT
BRADYCARDIA
AF
BRADYCARDIA
Atrial flutter
BRADYCARDIA
V-tach
AXIS
Left Anterior Fascicular Block
(LAFB)
Mean QRS axis of -45 to -90 degrees
o > -30 degrees is the hallmark