12-Lead ECG Rules of Interpretation I. II. III. IV. V. VI. VII. VIII.

General Impression Measurements Underlying Rhythm QRS Axis Atrial Enlargement/Ventricular Hypertrophy Bundle Branch Blocks Myocardial Infarction Miscellaneous Good Milfs Use Quality Ass Butter Merrily and Mightily

I. General Impression R-Wave Progression aVR Deflection II. Measurements Rate # of small boxes between concurrent R-Waves divided into 1500 Rhythm PRI 0.12sec-0.20sec QRS <0.12sec QTc <0.44sec with HR 60-100 k = 0.397 for men k = 0.415 for women

III. Underlying Rhythm P:R Ratio = 1:1 P-Wave Morphology Round & Upright R-Wave Morphology IV. QRS Axis Lead I & aVF: Positive, Negative, Equiphasic Lead I & aVF Positive: Normal Axis Lead I Positive & aVF Negative: Left Axis Deviation (LAD) Lead I Negative & aVF Positive: Right Axis Deviation (RAD) Lead I Negative & aVF Negative: Extreme Right Axis Deviation (ERAD) Out of All Limb Leads Find the one that is Isoelectric Lead I: 180 to 0 Lead II: -120 to 60 Lead III: 120 to -60 aVR: -150 to 30 aVL: 150 to -30 aVF: 90 to -90 Find the Lead that is Perpendicular to the Isoelectric Lead

Lead I & aVF Perpendicular Lead II & aVL Perpendicular Lead III & aVR Perpendicular

V. Atrial Enlargement/Ventricular Hypertrophy Atrial Enlargement Right Atrial Enlargement (RAE) Lead II P-Waves >2.5mm & Peaked V1 First half of P-Wave >1mm in height and width & larger than second half Left Atrial Enlargement (LAE) Lead II P-Waves notched and >.11sec in duration V1 Second half of P-Wave >1mm in height and width & larger than first half Ventricular Hypertrophy Right Ventricular Hypertrophy V1 R-Wave is equal or greater than size of S-Wave V1-V6 Reversal in R-Wave Progression and RAD Left Ventricular Hypertrophy (a.) R -Wave height in aVL >11mm (b.) {R-Wave height in Lead I + the SWave depth in Lead III} > 25mm (c.) {S-Wave depth in V1 + the height in V5} > 35mm VI. Bundle Branch Block Right Bundle Branch Block (RBBB) V1 & V2 QRS Complex has two R-Waves; double peaked rSR-Wave Lead I, V5, & V6 S-Wave is slurred and does not return sharply to the isoelectric line Left Bundle Branch Block (LBBB) Lead I, V5, & V6 QRS Complex >.12sec QRS Complex Upright T-Wave Inversion V1-V3 QRS Complexes Mostly Negative (e.g. Big Q-Waves) T-Waves are Upright VII. Myocardial Infarctions What youre looking for Significant Q-Wave At least 1mm wide and one third the height of the R-Wave ST-Segment Elevation Elevation > 1mm from the isoelectric line Start Lateral

High Lateral Lead I aVL V5 V6 Then Inferior Lead II Lead III aVF Lastly Anterior Septal (Normally has elevated ST-Segments) V1 V2 Anterior V3 V4 Posterior V1 & V2: Tall R-Waves without a RAD

Lead I LATERAL (High) Lead II INFERIOR Lead III INFERIOR

avR aVL LATERAL (High) aVF INFERIOR

V1 ANTERIOR (Septal) V2 ANTERIOR (Septal) V3 ANTERIOR

V4 ANTERIOR V5 LATERAL (Low) V6 LATERAL (Low)

VIII. Miscellaneous Electrolyte Imbalances Potassium Hyperkalemia Tall peaked T-Waves Wide flat P-Waves Widening of QRS Disappearing ST-Segments Merging QRS and T Hypokalemia Flat T-Waves Increasingly Prominent U-Waves Calcium Hypercalcemia Short QTc Hypocalcemia Prolonged QTc Digitalis Toxicity Sloping ST-Segments ST depression Diphasic or inverted T-Wave Short QT Interval

Pericarditis Elevated, concave ST-Segment Diffuse ST changes not correlated to coronary vessels