Ecg Basics Help

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So I'm trying to learn the basics in reading ecg's. My biggest problem is that I don't know what is normal in each lead. For example should xwave be upright or down in xlead, etc.

I've searched a number of texts and maybe I'm missing something but I can't find these answers.

Can someone please help, and tell me what normal morphology is for the pwave, qrs complex, t wave, etc for each lead.

Thank You very much

 

[lookleft]

So I'm trying to learn the basics in reading ecg's. My biggest problem is that I don't know what is normal in each lead. For example should xwave be upright or down in xlead, etc.

I've searched a number of texts and maybe I'm missing something but I can't find these answers.

Can someone please help, and tell me what normal morphology is for the pwave, qrs complex, t wave, etc for each lead.

Thank You very much

 

[grendelsdragon]

So I'm trying to learn the basics in reading ecg's. My biggest problem is that I don't know what is normal in each lead. For example should xwave be upright or down in xlead, etc.

I've searched a number of texts and maybe I'm missing something but I can't find these answers.

Can someone please help, and tell me what normal morphology is for the pwave, qrs complex, t wave, etc for each lead.

Thank You very much

This is too much material to cover in a forum post, but there is already a bunch of material already out there that does a fantastic job of teaching how to read ecg's. The problem is trying to choose from a host of different guides and references. If I was learning form scratch, I would recommend the following:

First, read Dale Dubin's "Rapid Interpretation of EKG's". It is VERY basic and easy reading. It does an excellent job of getting you to first base.

After you get the hang of basics, you need to learn the nuances by learning while reading actual ECG's. One of the best books for this is James O'Keefe's "The Complete Guide to ECGs", but it is now out of print (you may find one used). The next version of this book is due to come out shortly.

 

[grendelsdragon]

So I'm trying to learn the basics in reading ecg's. My biggest problem is that I don't know what is normal in each lead. For example should xwave be upright or down in xlead, etc.

I've searched a number of texts and maybe I'm missing something but I can't find these answers.

Can someone please help, and tell me what normal morphology is for the pwave, qrs complex, t wave, etc for each lead.

Thank You very much

I've commented on this in the Cardiology thread. Please don't double post. 😀

 

[sacrament]

So I'm trying to learn the basics in reading ecg's. My biggest problem is that I don't know what is normal in each lead. For example should xwave be upright or down in xlead, etc.

I've searched a number of texts and maybe I'm missing something but I can't find these answers.

Can someone please help, and tell me what normal morphology is for the pwave, qrs complex, t wave, etc for each lead.

Thank You very much

Maybe I'm not understanding your question, but... every textbook will have an example of a normal ECG, and if you look at those... well, that's what's normal in each lead. (There are many normal variations which exist, but for a beginner I wouldn't worry about that.)

 

[Gas4Life]

I have to disagree with the Dubin's recommendation. The only good that book ever did me was to help build strength carrying it around. When I really learned the basics of EKG's was on a fourth year cardiology rotation that was basically setting down and reading EKG's all day for an entire month. I read right around 2000 EKG's with an absolutely amazing cardiologist on that rotation and it has been more useful to me than any other rotation of my entire medical training. This particular cardiologist was able to DIAGNOSE a case of pancreatitis from a freakin' EKG, I kid you not. The dude looked at the EKG, got a kinda funny look on his face, said to me and the other student that he figured this guy had a case of pancreatitis. The other student and I just kinda snickered, figuring the old codger was joking. So, we looked up the medical record for this patient and, I kid you not, this patient by God had pancreatitis. Needless to say, my jaw hit the floor and I then realized what an opportunity I had been given to learn from this incredible attending cardiologist. I later tried to put it all together and it actually made sense, the changes on the EKG were reflective of the disease state of pancreatits. It is absolutely incredible the amount of information you can glean from an EKG if you have the knowledge and time. It is second to none in the right hands (for example this attending cardiologist) as far as providing information about the patient.

 

[grendelsdragon]

I have to disagree with the Dubin's recommendation. The only good that book ever did me was to help build strength carrying it around. When I really learned the basics of EKG's was on a fourth year cardiology rotation that was basically setting down and reading EKG's all day for an entire month. I read right around 2000 EKG's with an absolutely amazing cardiologist on that rotation and it has been more useful to me than any other rotation of my entire medical training. This particular cardiologist was able to DIAGNOSE a case of pancreatitis from a freakin' EKG, I kid you not. The dude looked at the EKG, got a kinda funny look on his face, said to me and the other student that he figured this guy had a case of pancreatitis. The other student and I just kinda snickered, figuring the old codger was joking. So, we looked up the medical record for this patient and, I kid you not, this patient by God had pancreatitis. Needless to say, my jaw hit the floor and I then realized what an opportunity I had been given to learn from this incredible attending cardiologist. I later tried to put it all together and it actually made sense, the changes on the EKG were reflective of the disease state of pancreatits. It is absolutely incredible the amount of information you can glean from an EKG if you have the knowledge and time. It is second to none in the right hands (for example this attending cardiologist) as far as providing information about the patient.

Sounds like you had a great experience! Everyone has a different way of learning the basics of ECG reading--some people like didactics, books, journal review, whatever. Dubin does a good job of teaching the bare essentials in principles of ECGs, but most any other source will do.

But as you mentioned (and I mentioned as well in my initial post), mastering ECGs takes practice reading actual ECGs. For those who do not have the benefit of training first-hand with a cardiologist, a book of unmarked ECGs with lessons and interpretations on a different page is a great tool.

As for the pancreatitis, I would assume the ECG demonstrated the hallmark findings of hypocalcemia (prolonged QTc with normal T wave morphology), attributable to retroperitoneal saponification. ECG findings for hypocalcemia may also be seen in someone who has had multiple blood transfusions (because the citrate in stored blood chelates calcium). These are actually amongst a number of systemic states with ECG findings that we are supposed to know for the cardiology boards (eg. hyperkalemia with rhabdo crush injury, Parkinson's disease causing tremor artifacts, hypothermia, etc.). This stuff is so much fun!

 

[Gas4Life]

Sounds like you had a great experience! Everyone has a different way of learning the basics of ECG reading--some people like didactics, books, journal review, whatever. Dubin does a good job of teaching the bare essentials in principles of ECGs, but most any other source will do.

But as you mentioned (and I mentioned as well in my initial post), mastering ECGs takes practice reading actual ECGs. For those who do not have the benefit of training first-hand with a cardiologist, a book of unmarked ECGs with lessons and interpretations on a different page is a great tool.

As for the pancreatitis, I would assume the ECG demonstrated the hallmark findings of hypocalcemia (prolonged QTc with normal T wave morphology), attributable to retroperitoneal saponification. ECG findings for hypocalcemia may also be seen in someone who has had multiple blood transfusions (because the citrate in stored blood chelates calcium). These are actually amongst a number of systemic states with ECG findings that we are supposed to know for the cardiology boards (eg. hyperkalemia with rhabdo crush injury, Parkinson's disease causing tremor artifacts, hypothermia, etc.). This stuff is so much fun!

What actually tipped him off to the idea of pancreatitis in that patient was the combination of hypocalcemia (with the prolonged QTc as mentioned) along with a mild but noticeable hyperkalemia (evidenced by peaked but symmetric t waves) if I remember correctly. At least, I think that is what he said. I have never been more impressed by an attending than I was with this particular cardiologist.

 

[JayneCobb]

Dubin does a good job of teaching the bare essentials in principles of ECGs

The key here is BARE essentials. Personally, I think Dubin's is a waste of time and really is only good for strip interpretation.

I've used Garcia's The art of 12-lead interpretation, and a few 12 lead practice books, and learned far more from that and actually reading EKGs with cardiologists than anything else.

 

[grendelsdragon]

The key here is BARE essentials. Personally, I think Dubin's is a waste of time and really is only good for strip interpretation.

I've used Garcia's The art of 12-lead interpretation, and a few 12 lead practice books, and learned far more from that and actually reading EKGs with cardiologists than anything else.

"Waste of time" seems pretty dogmatic to me (especially coming from a moderator). From a cardiologist's perspective, rhythm interpretation is usually the most challenging and informative aspect of ECG reading. In fact, it is generally the first element of an ECG I ask my students, housestaff and fellows to comment upon (also usually the first feature of an ECG cardiologists address as well). ST changes are a cakewalk by comparison.

I am sure there are plenty of excellent books on learning ECG interpretation, and Garcia's sounds great. Personally, it doesn't really matter which book you choose, so long as it works for you in getting the absolute basics in the shortest possible amount of time. I usually recommend Dubin's for this purpose primarily because it reads like a children's book (big pictures and big simple writing), and most people can get through it cover-to-cover in less than 3 hours. If Garcia's reads easily and a reader can get through it in less than a day, then it sounds great!

Then, the meat of learning ECG interpretation is actually reading unmarked ECG's (preferably with a short blurb on clinical presentation to give it context) with useful feedback. This feedback can be provided by a friendly cardiologist (probably not easily accessible) or in a workbook. O'Keefe is pretty decent for this purpose. It was the study aid of choice for cardiology fellows about to take the ECG portion for the cardiology boards. Too bad it's out of print, but the newer version is due to be released soon.

 

[JayneCobb]

"Waste of time" seems pretty dogmatic to me (especially coming from a moderator). From a cardiologist's perspective, rhythm interpretation is usually the most challenging and informative aspect of ECG reading. In fact, it is generally the first element of an ECG I ask my students, housestaff and fellows to comment upon (also usually the first feature of an ECG cardiologists address as well). ST changes are a cakewalk by comparison.

When you consider how much they charge apiece for Dubin and Thalers books, it seems apt to say waste of time, especially for what you are getting for each. When you can get more for the same amount of money, it is a waste of money. These books have little utility in being carried in a white coat for reference, they don't have adequate amounts of examples to use as a work book and really only offer the bare basics of EKGs to barely get you started. Sure, for rhythm interpretation, they are great, and that is the first thing I look at in an EKG, but it's only the first and to me and my non-cardiology aspect, interpreting 12 rhythm strips doesn't help me tie the big picture of an EKG together.

O'Keefe is a good book, I still kick myself that I got rid of mine, but Walraven and Purdie's workbooks are very good basic 12 lead interpretations for non-cardiologists.

And don't think of this as coming from a moderator, but a book snob extraordinar.

 

[grendelsdragon]

When you consider how much they charge apiece for Dubin and Thalers books, it seems apt to say waste of time, especially for what you are getting for each. When you can get more for the same amount of money, it is a waste of money. These books have little utility in being carried in a white coat for reference, they don't have adequate amounts of examples to use as a work book and really only offer the bare basics of EKGs to barely get you started. Sure, for rhythm interpretation, they are great, and that is the first thing I look at in an EKG, but it's only the first and to me and my non-cardiology aspect, interpreting 12 rhythm strips doesn't help me tie the big picture of an EKG together.

O'Keefe is a good book, I still kick myself that I got rid of mine, but Walraven and Purdie's workbooks are very good basic 12 lead interpretations for non-cardiologists.

And don't think of this as coming from a moderator, but a book snob extraordinar.

"Book snob extraordinaire"... hehe. I like it! 👍

In all honesty, it has been a long time since I have even purchased an ECG book (well over a decade. even my O'keefe was a pharma present), so the whole concept of value is completely lost on me. I will have to defer to you on that.

I generally would not recommend carrying any ECG book in a white coat as reference (most residents have enough to carry around already), unless you want your residents to have the weight distribution of a bowling pin.

Oh, I forgot to mention. There is a fun and free online tool to practice ECG interpretation. Not as good as O'Keefe, but it IS free:

http://ecg.bidmc.harvard.edu/maven/mavenmain.asp

 

[DrWBD]

Gas4Life is correct - the only way to become proficient with EKGs is to read a lot of them - real ones, not the idealized ones in the Dubin and Thaler books. While both books are highly regarded to help you get the basics of EKGs down, you won't master reading them without real world experience.

The key is to do a Cardiology rotation and find the semi-retired attending who trained about 40 years ago when all they had was the EKG and physical exam - you'll learn the most from those guys.