Basic EKG

CR 黃祺元
The principles
The principles
The principles
The conduction
The conduction
 Outlines
✓ Rate ✓Rhythm ✓Interval ✓ Axis ✓ Chamber
Approach ✓ ST segment

✓Atrial
Arrhythmia
✓Ventricular

Conduction ✓Atrial-ventricular conduction block

system ✓Bundle branch block

Infarction ✓ Territory of ischemia

Ischemia ✓ Infarction equivalent

Practice
round
Rate
• Bradycardia: < 60 bpm

• Tachycardia: >100 bpm

Rhythm
• Regularity

• Irregular
PR interval
• The normal PR interval lasts 0.12 to 0.2 seconds.
QRS complex: Septal Q
• Pathologic:
• > 40 ms (1 mm) wide
• > 2 mm deep
• > 25% of depth of QRS
QRS complex
QRS complex
QRS complex

QRS widening
(>120ms)

Deep Q wave
(Septal Q)
Axis
Axis
Chamber size: P wave
Atrial enlargement:
Chamber size
Left axis deviate: Right axis
LVH deviate : RVH
Chamber size:
Right Ventricular hypertrophy
• RAD
• In lead V1, R>S In lead V6, S>R
• Rt axis deviation
 Chamber size:
Left Ventricular hypertrophy

SV1-2 + RV5-6 > 35

RaVL + SV3 > 20 - 28

RaVL > 11
RaVF > 20

RLead I + SLead III > 25

ST segment

ST segmental
elevation

ST segmental
depression

T wave inversion
 Outlines
✓ Rate ✓Rhythm ✓Interval ✓ Axis ✓ Chamber
Approach ✓ ST segment

✓Atrial
Arrhythmia
✓Ventricular

Conduction ✓Atrial-ventricular conduction block

system ✓Bundle branch block

Infarction ✓ Territory of ischemia

Ischemia ✓ Infarction equivalent

Practice
round
Atrial arrhythmia
Atrial arrhythmia: junction
Atrial arrhythmia
• P wave?
• Narrow/wide QRS?
• P-QRS (A:V 1:1)
• Regularity(RR interval)
Atrial ectopic/re-entry arrhythmia
Arrhythmia Characteristics

AVNRT Regular
Retrograde P?
Rate: 150–250 bpm
Carotid massage: slows or
terminates

Atrial Flutter Regular, saw-toothed

Atrial rate: 250–350 bpm
Carotid massage:
increases block

Atrial Fibrillation Irregular

Atrial rate: 350–500 bpm
Carotid massage: may
slow ventricular rate

Paroxysmal atrial Regular

tachycardia Rate: 100–200 bpm
Carotid massage: eqivocal

Multifocal atrial Irregular

tachycardia At least three different P
Rate: 100–200 bpm;
Carotid massage: (-)
Ventricular arrhythmia
• QRS> 120ms
• VPC

• Accelerated JT
Ventricular arrhythmia
• VT(> 3 consecutive VPCs)

• Short run VT (3~6 beats)

• Non-sustain (> 6 beats, <30 seconds)
Ventricular arrhythmia
• Ventricular fibrillation(polymorphic VT)
 Outlines
✓ Rate ✓Rhythm ✓Interval ✓ Axis ✓ Chamber
Approach ✓ ST segment

✓Atrial
Arrhythmia
✓Ventricular

Conduction ✓Atrial-ventricular conduction block

system ✓Bundle branch block

Infarction ✓ Territory of ischemia

Ischemia ✓ Infarction equivalent

Practice
round
Conduction block
1’ degree AV block: PR>200ms
Bundle branch block
Right bundle branch block
Right bundle branch block

右小左大
VT or RBBB?
Hemiblock
• Left Anterior Hemiblock
• Normal QRS duration and no ST-segment or T-wave
changes.
• Left axis deviation between −30° and −90°.
• No other cause of left axis deviation is present.
• Left Posterior Hemiblock
• Normal QRS duration and no ST-segment or T-wave
changes.
• Right axis deviation.
• No other cause of right axis deviation is present.
Bi-fascicular block
• RBBB + LAFB?
• RBBB + LPFB?
Bi-fascicular block
Pacemaker rhythms
Pacemaker rhythms
Pacemaker rhythms
Coronary
sinus
Pre-excitation (accessory
pathway)
• Short PR (no delta wave)

•
• SVT/AF with delta wave
Bundle of
Kent
VT or AF with accessory path?
Brugada criteria for VT
Brugada criteria: VT morphology
Brugada criteria: VT morphology
 Outlines
✓ Rate ✓Rhythm ✓Interval ✓ Axis ✓ Chamber
Approach ✓ ST segment

✓Atrial
Arrhythmia
✓Ventricular

Conduction ✓Atrial-ventricular conduction block

system ✓Bundle branch block

Infarction ✓ Territory of ischemia

Ischemia ✓ Infarction equivalent

Practice
round
ST-T change: Chronic/acute
coronary syndrome in EKG
ST depression
Chronic:
ST depress
T wave invert

T wave inversion

ST elevation
Stages of acute myocardial infarct
• T-wave peaking followed by T-wave inversion
• ST-segment elevation
• The appearance of new Q waves

Reciprocal
change
RV infarct
 Outlines
✓ Rate ✓Rhythm ✓Interval ✓ Axis ✓ Chamber
Approach ✓ ST segment

✓Atrial
Arrhythmia
✓Ventricular

Conduction ✓Atrial-ventricular conduction block

system ✓Bundle branch block

Infarction ✓ Territory of ischemia

Ischemia ✓ Infarction equivalent

Practice
✓ Practice makes perfect
round