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PrintversionofKnowledgebytesusedinthislesson.
Closethewindowtoreturntothelessonafterprinting.

Therateofpaper(i.e.ofrecordingoftheEKG)is25mV/swhichresultsin:
1mm=0.04sec(oreachindividualblock)
5mm=0.2sec(orbetween2darkverticallines)
DistancebetweenTickmarks=3seconds(intherhythmstrip)
Thevoltagerecordedfromtheleadsisalsostandardizedonthepaperwhere1mm=1mV(orbetweeneachindividual
blockvertically)Thisresultsin:
1mm=0.1mV
5mm=0.5mV(orbetween2darkhorizontallines)
10mm=1.0mV

Heartratecalculation:
Normalrangeatrestisbetween60100beatsperminute(bpm).

Thebasicwaytocalculatetherateisquitesimple.Youtakethedurationbetweentwoidenticalpointsofconsecutive
EKGwaveformssuchastheRRduration.Takethisdurationanddivideitinto60.Theresultingequationwouldbe:
Rate=60/(RRinterval)
Aquickerwaytoobtainanapproximaterateis

1. togobyRRorPPinterval.Ifitis1bigbox(0.2secs)thentherateis60/0.2=300bpm.Therestof
thesequencewouldbeasfollows.
1bigbox=300beats/min(duration=0.2sec)
2bigboxes=150beats/min(duration=0.4sec)
3bigboxes=100beats/min(duration=0.6sec)
4bigboxes=75beats/min(duration=0.8sec)
5bigboxes=60beats/min(duration=1.0sec)

2. CountthenumberofRRintervalsbetweentwoTickmarks(6seconds)intherhythmstripand
multiplyby10togetthebpm.Thismethodismoreeffectivewhentherhythmisirregular.

Rhythmcanbequitevariable.Itcouldbe
Regular:RRintervalconstant
Basicallyregular
Prematureectopicbeat
Escapeectopicbeat
Regularlyirregular:RRintervalvariablebutwithapattern.Normalandectopicbeatsgroupedtogetherand
repeatingoverandover.
Irregularlyirregular.RRintervalvariablewithnopattern,totallyirregular
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Normal:
Normalsinusrhythm(NSR):indicatesthattherateisbetween60and100,inclusive,and
thatthePwavesareidentifiableandareofthesamemorphologythroughout.TheRR
intervalorPPintervalsbetweenbeatsaresame.
Sinusarrhythmia:Thereisacyclicalaccelerationofheartratewithinspirationand
slowingwithexpiration.Thebeattobeatintervalisslightlydifferent.Therhythmis
regularlyirregular,inthesensethatthereisapatterntoirregularity.Thisistermedsinus
arrhythmia.

Pwave
RepresentsdischargeofSAnodeanddepolarizationofbothatria
Normal:
ThebestleadtolookatthePwaveisV1.
NormalPwaveisuprightandrounded
ThePwaveingeneralshouldnotbemorethan1boxwide
ThePwaveingeneralshouldnotbemorethan1boxtall.
Thepwaveisbiphasicin
ThePwavecontourisconstant
Abnormal:
IfPwaveexceedsthenormalrangefordurationorvoltage,itgenerallymeansthateitheror
bothatriaisenlarged(hypertrophied)
IfPwavecontour
PeakingofPwave(Voltageincrease)suggestsRightatrialhypertrophy
Broadslurred(increasedduration)suggestsLeftatrialhypertrophy
WhenbiphasictheinitialpositivewaveisprominentwithRAhypertrophyandthe
negativedeflectionisprominentwitLAhypertrophy
IfthePwavecontourchangesbetweenbeatsitcouldmeanthatthereisanectopicatrial
focus

QRS
QRScomplexisaseriesofwaveformsfollowingPwave.
Namingconvention:
Qwave:firstdownstrokeoftheQRScomplex.Usuallyverysmallorabsent.
Rwave:firstupwarddeflectionoftheQRScomplex.UpwarddeflectionsoccurringafteranSwavearenotedby
a"primemark"suchasR'
Swave:thefirstdownwarddeflectionoccurringaftertheRwave.
AmonophasicnegativeQRScomplexiscalledQS.
Normal
Duration:0.080.12seconds(23horizontalboxes)
Contourissamebetweenbeats
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Abnormal
Duration:
DelayinconductionthroughtheventriclesleadstoprolongationofQRScomplex
Prolonged:Bundlebranchblocks,drugtoxicity,electrolyteimbalance
Shortened:WPW
Contour
Changeofcontourbetweenbeatssuggestsectopicfoci
Abnormalbutconstantcontoursuggests
Bundlebranchblocks
Drugtoxicity
Electrolyteimbalance

Qwave
Normal:
Usuallyverysmallorabsent
NormalinIIIandAVR.
Abnormal:
AQwaveissignificantifitisgreaterthan1boxwide(0.04secs)inleadsotherthanIIIand
AVR
Greaterthan1/3theamplitudeoftheQRScomplex.
Greaterthan1/4thofRwave
AbnormalQwaves:indicatepresenceofinfarct

Twave
FirstupwarddeflectionafterQRScomplex.Represents:ventricularrepolarization
Normal:
Ingeneral,TwavesareinthesamedirectionasthelargestdeflectionoftheQRS(normally
theRwave).
NegativeinAVR
InvertedTwavesinprecordialleadsV1,V2,V3canbeseeninnormal,youngathletes
LowTvoltagechangesmayoccurintheabsenceofanyheartdiseaseatall.
Abnormal:
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Twavechangescanbeprimaryorsecondary.
PrimaryTwavechangerefertoabnormalrepolarization
SecondaryTwavechangesarecausedbyQRSchanges.Twavechanges
causedbybundlebranchblockorventricularhypertrophyaresecondary.
TallpeakedTwaves
Electrolyteimbalance=HyperkalemiacausestallpeakedTwaves.overall
maximumof15mVbutthisisnotsensitive.Twavelookslikeanisosceles
triangle.
LowvoltageTwaves
HypokalemiacauseslowvoltageTwavesandprominentUwaves.
Twaveslessthan1mVinthelimbleadsandlessthan2mVinthe
precordialleads.
lowTvoltageandsaggingorflattenedSTsegments.thesechanges
mayoccurintheabsenceofanyheartdiseaseatall.
InvertedTwaves
InvertedTwavesthataresymmetrical,"roundshouldered"canbecausedby
coronaryischemia.especiallywhenitoccursinapatternaspreviouslydescribedfor
STsegmentchanges..
InvertedTwavesinprecordialleadsV1,V2,V3canbeseeninnormal,young
athletes,aswellasCNSdiseases.

Uwave
Whatitrepresentsisnotcertain.
Thisuprightwave,whenpresent,followstheTwave.
Abnormal:
ThepresenceofUwavesmayindicateHypokalemia.
HypokalemiaisassociatedwithflatTwaves,Uwaves.UwavestallerthanTwaves.

PRinterval
Represents:atriatoventricularconductiontime(throughHisbundle)ItincludesPwaveandPRsegment.
Normalduration:0.122.0seconds(35horizontalboxes).ThisismeasuredfromtheonsetofthePwavetotheonsetof
theQRScomplexregardlessiftheinitialwaveisaQorRwave.

Abnormalduration:
Prolonged:

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IfthePRintervalisgreaterthan0.2sec,thenanAVblockispresent.ThereareseveraltypesofAVblocks:
1stdegreeAVBlock:PR>0.20sec.
2nddegreeAVBlock:2types:
1. TypeI(MobitzIorWenckeback):increasingPRintervaluntilaQRScomplexisdropped.
Itisusuallybenign.
2. Type2(MobitzII):QRSdroppedwithoutanyprogressiveincreaseinPRinterval(i.e.,PR
intervalisconstantbutstill>0.20sec).
3rddegreeAVBlock:atriaandventriclesareelectricallydissociated.Therefore,PwavesandQRS
complexeswilloccurindependentofeachother.Asalways,usetheQRScomplexestodetermine
heartrate.
Shortened:
APRintervalthatis<0.12sec(whenassociatedwithaprolongedQRS)shouldpromptevaluationfor
WolffParkinsonWhiteSyndrome(WPW).
<0.12secwhenassociatedwithprolongedQRSshouldpromptevaluationforWolffParkinsonsyndrome
(WPW).

STsegment
Representsearlyphaseofrepolarizationofventricles.
BeginsattheendofSwaveandendsatthebeginningofTwave.
Innormalsituations,itservesastheisoelectriclinefromwhichtomeasuretheamplitudesoftheotherwaveforms.
STsegmentsareusuallyisoelectricandnormal.
WhenexaminingtheSTsegment,evaluateelevationsordepressions0.06secondsaftertheJpoint(sincetheSTsegment
canattimesbesloping).
Abnormal:
Thissegmentisimportantinidentifyingpathologysuchasmyocardialinfarctions(elevations)and
Ischemia(depressions).
STsegmentelevation
Ingeneral,anSTsegmentelevationindicatesinfarction.
STsegmentelevationisacurrentofinjurycanbeseeninpericarditisaswellas
Prinzmetal'sangina.
EarlyrepolarizationcausesSTsegmentelevationintheleadofnormalEKG's.
ThelocationoftheSTelevationsontheEKGcanhelptoidentifyalocationoftheinfarct:
AnteriorWallInfarct(correspondingtoLeftAnteriorDescendingArtery):V1,V2
LateralWallInfarct(CircumflexArtery):V3,V4
InferiorWallInfarct(canbecombinationofCircumflexorRightCoronaryArtery):
V5,V6,I,avl
wheninallleadssuggestsPericarditis
STsegmentdepression

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Ingeneral,anSTsegmentdepressionindicatesIschemia
STsegmentdepressioncanbeIschemiaasinexerciseEKG'sorsubendocardial
injurycurrent.
DigitaliscausesSTsegmentsaggingandshortenstheQTinterval.

QTandQTc(correctedQT)interval
QTrepresentsthedurationofactivationandrecoveryoftheventricularmuscle.
Thisdurationvariesinverselywiththeheartrate
SincethedurationofQTvariesinverselywiththeheartrate,theQTisnotused,butratherthecorrectedQTis.
QTcinterval
QTc=QT+1.75(ventricularrate60)
Normal:
ThenormalQTcisapproximately0.41seconds.Ittendstobeslightlylongerforfemales
andincreasesslightlywithage.
Abnormal:
ProlongedQT
QuinidineToxicity
Hypocalcemia
ShortenedQT
Maybeshortenedinhypocalcemia.

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