The Pre-brief
Reading 12-lead electrocardiograms (ECG/EKGs) is a skill found in various nursing and healthcare specialties. It can be tricky, but this is meant to be a basic walkthrough on reading ECGs.Â
Let’s start with the anatomy of an ECG!
Small boxes (1mm) = 0.04 seconds
Large box (5mm) = 0.2 seconds
Large boxes X 5 = 1 second
There are 50 large boxes per standard EKG print out, 10 seconds total.
P wave – Represents right and left atrial depolarization/contraction
QRS Complex – Represents right and left ventricular depolarization/contraction
T wave – Represents ventricular repolarization/electrical recovery
U wave – Represents after-repolarization of ventricles, rarely present >95 bpm
Normal Intervals (important ones in bold):Â
P wave: 0.08 – 0.11s
PR interval: 0.12 – 0.20s
Q wave: <0.04sÂ
QRS complex: 0.07 – 0.10s
ST segment: 0.08 – 0.12s
T wave: 0.10 – 0.25sÂ
QT interval: 0.36 – 0.44s
QTc (rate-corrected QT interval): <0.44s in men and <0.46s in women
What is sinus rhythm?
- P wave before EVERY QRS complex
- Positive/upright P wave in leads I and II
- Negative/inverted P wave in lead aVR
- P waves are round and uniformly shaped throughout the ECG
- Fixed and within normal measurement PR intervals
When interpreting an ECG, it is important to assess each one strategically and the same way each time. Here are the steps to take when walking through an ECG:
- Rate – Normal 60 – 100 bpm
Bradycardia <60 bpm
Tachycardia >100 bpm
- Rhythm – Normal sinus rhythm (see above)? Sinus bradycardia/tachycardia?
- Regular or irregular? Map out R-R and P-P for ventricular and atrial regularity, respectively.
- Is the QRS wide or narrow?
- Is the PR interval within 0.12-0.20s?Â
- A prolonged PR indicates a delay through the AV node and thereby a heart block, and an abnormally narrow PR can be associated with Wolff Parkinson White (WPW) Syndrome.
- ST-segment – elevated, depressed, or isoelectric?
- T wave upright and following each QRS? Any biphasic or inverted T waves?
The Debrief:
- Know the definition of sinus rhythms
- Follow the same algorithm every time you assess an ECG. Make it habitual!
- Walk yourself through as many ECGs as possible, practice makes improvement.
References
- ECG waves (2021). Clinical ECG Interpretation. https://ecgwaves.com/course/the-ecg-book/
- Harris PR. The Normal Electrocardiogram: Resting 12-Lead and Electrocardiogram Monitoring in the Hospital. Crit Care Nurs Clin North Am. 2016 Sep;28(3):281-96. doi: 10.1016/j.cnc.2016.04.002. Epub 2016 Jun 22. PMID: 27484657.
- Hornick J, Costantini O. The Electrocardiogram: Still a Useful Tool in the Primary Care Office. Med Clin North Am. 2019 Sep;103(5):775-784. doi: 10.1016/j.mcna.2019.04.003. Epub 2019 Jul 1. PMID: 31378324.
- Kligfield P, Gettes LS, Bailey JJ, Childers R, Deal BJ, Hancock EW, van Herpen G, Kors JA, Macfarlane P, Mirvis DM, Pahlm O, Rautaharju P, Wagner GS; American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; American College of Cardiology Foundation; Heart Rhythm Society, Josephson M, Mason JW, Okin P, Surawicz B, Wellens H. Recommendations for the standardization and interpretation of the electrocardiogram: part I: The electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2007 Mar 13;115(10):1306-24. doi: 10.1161/CIRCULATIONAHA.106.180200. Epub 2007 Feb 23. PMID: 17322457.
- Woodrow P. An introduction to electrocardiogram interpretation: part 2. Nurs Stand. 2009 Dec 2-8;24(13):48-56; quiz 58, 60. doi: 10.7748/ns2009.12.24.13.48.c7420. PMID: 20069816.
