ECG for Interns

UCI Internal Medicine Mini-Lecture

Learning Objectives
Establish Consistent Approach to
Interpreting ECGs
Review Essential Cases for New Interns
Provide Additional Resources for Future
Learning

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

Rhythm
Are P waves present?
Is there a P wave before every QRS complex
and a QRS complex after every P wave?

Are the P waves and QRS complexes

regular?
Is the PR interval constant?

Axis
Left or right axis deviation?
Look at limb leads I and aVF.
Normal: I +, aVF +
LAD: I +, aVF
RAD: I -, aVF +

Hypertrophy
LVH: S in V1 or V2 + R in V5 or V6 35 mm.

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 1 st 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
Evaluate the shape, height and width of P
waves.
Multiple morphologies Wandering pacemaker
or Multifocal atrial tachycardia

Notched (M-shaped) P-wave in I and II, > 0.12 s

P-mitrale seen in severe left atrial
enlargement

QRS complex
Poor R Wave Progression in V1 to V6: suggests prior
anterior MI

Pathologic Q wave: previous MI. Q wave amplitude

25% or more of the subsequent R wave, OR > 0.04 s in
width + > 2 mm in amplitude in more than one lead

ST segment & T wave

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
38 year old female with history of DM, HTN,
CKD presents with 2 days of nausea and
abdominal pain.

Case #5 ECG

Case #6
60 year-old man with history of HTN, HL, CAD
presents with nausea, shortness of breath and
chest pain.

Case #6 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
Always keep a consistent approach.
Do not rely upon machine reads.
Practice makes perfect.