ECG for Interns

UCI Internal Medicine Mini-Lecture

Learning Objectives

Basics of EKG

Establish Consistent Approach to

Interpreting ECGs
Rate, rhythm, axis, identifying ischemia

Review Essential Cases for New Interns

Provide Additional Resources for Future

Learning
 Basics of EKG: Einthovens Triangle
and Vectors

+AVR +AVL

Why is lead II often so

important?
->you can see the
hearts depolarization
vector is in the same
axis as lead II!
->this means that in +AVF
normal conduction, the
QRS should be upright
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
Yes to all these
Is the PR interval constant? questions, so this is
yes normal sinus
rhythm!
 Axis
Axis is the general flow of electricity as it passes
through the heart
Look at the main direction of the QRS complex
in leads I and AVF I AVF Axis

+ + normal

+ - LAD

- + RAD
 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.
 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
 QRS complex
Poor R Wave Progression in V1 to V6: suggests prior
anterior MI

hologic 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
 Hypertrophy
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 > 28mm (men)
S in V3 + R in aVL > 20mm (women)

RVH:
V1 R/S ratio >1
OR
V6 S/R ratio >1
 Intervals
What is the normal PR interval?
0.12 to 0.20 s (3 - 5 small squares).
Short PR Look for Wolff-Parkinson-White.
Long PR 1st Degree AV block

What is the normal QRS?

< 0.12 s duration (3 small squares).
Long QRS - look for bundle branch block, ventricular pre-
excitation, ventricular pacing or ventricular tachycardia

What is the normal QTc (QT/square root of RR)?

< 0.42 s.
Long QTc can lead to torsades to pointes.
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)
 ST segment and MI

ST elevation may indicate STEMI if the following are met:

At least 1mm (0.1 mV) elevation in the limb leads (I, II, III, AVL, AVR)
At least 2mm 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 2anatomically contiguous leads
Evolution of an MI:
Patterns on EKG
 First thing you should do when
looking for ischemia: Group leads
by region!
 EKG Grouped Leads
correspond to area of injury
LETS DO SOME
PRACTICE CASES
Case #1

70 year old male with history of diabetes

mellitus and hypertension occasionally feels
lightheaded. He recently fainted while
standing.
Case #1 ECG
Case #2

58 year old female with no significant past

medical history presents with fatigue,
lightheadedness and shortness of breath.
Case #2 ECG
Case #3

78 year old female with history of HTN, DM,

HL, CAD admitted for syncope complains of
palpitations and lightheadedness.
Case #3 ECG
Case #4

67 year old male with history of diabetes,

hypertension, COPD presents with chest pain.
Case #4 ECG
Case #5

60 year-old man with history of HTN, HL, CAD

presents with nausea, shortness of breath and
chest pain.
Case #5 ECG
Additional Resources
Websites:
http://en.ecgpedia.org/
http://ecg.utah.edu
http://ecg.bidmc.harvard.edu/maven/

Apps:
ECG Guide by QxMD (iPad and iPhone)
ECG Interpret (iPhone)

Books:
12-Lead ECG: The Art of Interpretation, Tomas Garcia
(perhaps the best book on ECGs with detailed
explanations and physiology.)
Arrhythmia Recognition, Tomas Garcia
Summary

Learned the basics of EKG

Learned how to have a consistent approach

to EKGs
Reviewed essential cases for new interns

Equipped with resources for continued

learning