Mastering ECG
Interpretation
For Nurses
A Step-by-Step Guide to Analyze ECG Rhythms
Dr. Seif Alislam Ebada
Senior GP-A ER Physician
MOH, Kuwait
1 Understand the Basics of ECG
• P Wave: Atrial depolarization.
• QRS Complex: Ventricular depolarization.
• T Wave: Ventricular repolarization.
• PR Interval: the time from the onset of the
P wave to the start of the QRS complex
• QT Interval: Total time from the
beginning of the QRS complex to
the end of T wave.
2 Check the Rhythm
• Regular vs. Irregular: Assess the spacing between R-R intervals.
• Identify P Waves: Are they present before each QRS? This indicates atrial activity.
3 Determine Heart Rate
Count R Waves:
300 method: 300 / (number of large squares between R waves)
6-seconds method (count R waves in a 6-second strip and multiply by 10).
4 P Waves
• Presence: Are they present and uniform?
• Morphology: Look for abnormalities that may indicate atrial enlargement or other
issues.
5 PR Interval
• Normal Range: 120-200 ms (3-5 small squares).
• Prolonged PR Interval: Indicates possible first-degree AV block.
• Short PR Interval: Could indicate pre-excitation syndromes (e.g.,
Wolff-Parkinson-White syndrome).
6 QRS Complex
Width: Normal is <120 ms (3 small squares).
A wider QRS may indicate a bundle branch block or other conduction
issues.
Morphology: Look for abnormal shapes or patterns.
7 ST Segment
Elevation or Depression: ST segment elevation may indicate myocardial
infarction, while depression may suggest ischemia.
J Point: The junction between the end of the QRS complex and the
beginning of the ST segment.
8 T Wave
Shape and Direction: T waves should be upright in most leads. Inversion may
indicate ischemia or other conditions.
Peaked T Waves: May suggest hyperkalemia.
9 QT Interval
Normal Range: Generally <440 ms in men and <460 ms in women.
Prolonged QT Interval: Can increase the risk of arrhythmias.
10 Identify Any Abnormalities
Look for signs of ischemia, infarction, hypertrophy, or other cardiac conditions.
Use specific criteria for recognizing conditions such as STEMI, NSTEMI, atrial
fibrillation, etc.
11 Consider Clinical Context
Always correlate ECG findings with patient symptoms and history for accurate
interpretation
12 Practice Regularly
Familiarize yourself with different ECG strips and practice interpreting them
to enhance your skills
In Basic Life Support (BLS) algorithms, the two primary
shockable rhythms are:
1- Ventricular Fibrillation (VF)
2- Ventricular Tachycardia (VT)
1- Ventricular Fibrillation (VF)
2- Ventricular Tachycardia (VT)
CRITERIA FOR PRIORITIZING ECGS IN ER ATTENDEES:
Chest Pain or Discomfort
Shortness of Breath
Palpitations
Syncope or Near-Syncope
Signs of Heart Failure
Abnormal Vital Signs
Risk Factors for Cardiovascular Disease
Critical ECGs
Not to miss in
ER
Role of ER nurses regarding ECG
1. Patient Preparation: Proper positioning / Skin preparation
2. ECG Monitoring: Application of electrodes / ECG acquisition
3. ECG Interpretation (Initial Analysis): Recognizing
abnormalities such as arrhythmias, ST-segment elevation or
depression / Alerting the physician
4. Continuous Monitoring
5. Documentation
6. Patient Education and Comfort: Explaining the procedure /
Emotional support
7. Collaboration with the Healthcare Team: Team
communication / Assisting with treatment decisions
8. Post-ECG Care
When a nurse reviews an ECG in the Emergency Room (ER), there are
several emergent changes that should prompt immediate attention,
further investigation, and rapid intervention.
These changes could indicate life-threatening conditions, such as
a myocardial infarction, arrhythmias, or electrolyte imbalances.
Nurses should be vigilant for the following key emergent ECG findings:
EMERGENT ECG CHANGES
1. ST Segment Elevation
2. ST Segment Depression
3. T Wave Inversion
4. Ventricular Tachycardia (VT)
5. Ventricular Fibrillation (VF)
6. Complete Heart Block (Third-Degree AV
Block)
7. Atrial Fibrillation / Atrial Flutter / SVT
8. Prolonged QT Interval
9. Hyperkalemia Changes
10. Bundle Branch Blocks
ST-SEGMENT
1 ELEVATION
1. STEMI
2. Pericarditis
3. Early Repolarization
4. Left Ventricular Aneurysm
5. Brugada Syndrome
6. Hyperkalemia
1. STEMI
2. Pericarditis
3- Early
repolarization
4- Left
Ventricular
Aneurysm
5- Burgada
syndrome
6-
Hyperkalaemia
ST-SEGMENT
2 DEPRESSION
1. Myocardial
Ischemia
2. Ventricular
Hypertrophy
3. Digitalis Effect
4. Hypokalemia
5. Aortic Stenosis
Myocardial
Ischemia
Ventricular Hypertrophy
Digitalis Effect
Hypokalemi
a
Aortic Stenosis
T WAVE
3 INVERSION
VENTRICULAR
4 TACHYCARDIA (VT)
VENTRICULAR
5 FIBRILLATION (VF)
Complete Heart Block (Third-
6 Degree AV Block)
Atrial Fibrillation / Atrial
7 Flutter / SVT
Atrial Fibrillation
Atrial Flutter
SVT
Prolonged QT
8 Interval
QTc range from 350 to 450 ms
each small box (1 mm) is
equivalent to 0.04 seconds (40
milliseconds), and each large
box (5 mm) is equivalent to 0.2
seconds (200 milliseconds)
Hyperkalemia
9 Changes
include peaked T waves, shortened QT interval, and ST-
segment depression
Bundle Branch
10
Blocks
RBBB
LBBB
Training Your Eyes
for Emergency ECG Interpretations
Heart rate 43 bpm
