Introduction to

Electrocardiography
& Dysrhythmias


Janet Smith, RN, MPH
Objectives
To gain a basic knowledge of cardiac
electrophysiology
To understand the representations of the
cardiac cycle on the ECG
To master techniques used for learning the
characteristics of the different dysrhythmias
To learn measurement and count techniques
essential for dysrhythmia interpretation

Definitions
Tachycardia
Bradycardia
Intrinsic Firing Rate


Isoelectric Line
Rate of > 100
Rate if < 100
The normal firing rate for
the rhythm of a certain
pacemaker
The baseline of a rhythm
where no electrical
activity is present

Definitions
Depolarization


Repolarization

Refractory period
The complete electrical
firing of the cells of the
heart
The time during which the
cells recharge after
depolarization
The time during the
repolarization when cells
rearm
Definitions
PR Interval




The distance between the beginning
of innervation of the sinus node
to the beginning of ventricular
depolarization

Cardiac Conduction
Cardiac Conduction
P
Q
R
S
T
Cardiac Conduction
PR
.12 - .20 s
Q
R
S
<.12 s
ST
Seg.
EKG Paper
Measures time horizontal in seconds
Measures amplitude vertical in milliamps
Uses the Metric system
Is very good for accuracy
EKG Paper
1 mm
.04 sec.
.2 sec.
Rate Measurement

300 divided by number of big blocks
between R R interval (must be a
regular rhythm)
i.e. 300/4 = 75
Rate Measurement

Memorization and counting backward
between R R interval (must be regular)
300 150 100 75 60 50 43 37 33 30
Dysrhythmia
Characteristics
Normal Sinus Rhythm
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
60-100 BPM
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)
Sinus Bradycardia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
< 60 BPM
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)

Sinus Tachycardia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
> 100 and < 160 BPM
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)
Sinus Dysrhythmia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular
60-100 BPM
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)
Sinus Arrest
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular
Normal - slow
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)

Premature Atrial Contractions
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular (PACs);Non-compensatory
Depends on underlying rhythm
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)

(Paroxysmal) Atrial Tachycardia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
> 150-250 BPM
Upright/Normal
.12-.20 s (120-200 ms)
.04-.12 s (40-120 ms)
Supraventricular Tachycardia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
> 150-250 BPM
Indiscernible
None seen
.04-.12 s (40-120 ms)
Atrial Flutter
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Atrial: Regular; Ventr.: Varies
Atrial: 250-300; Ventr.: Varies
Big F-Waves Saw tooth pattern
Normally constant may vary
.04-.12 s (40-120 ms)

Atrial Fibrillation
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregularly irregular ventricular
Atrial: 350-750; Ventr.: Varies
Little F-Waves no pattern
No discernable P waves
.04-.12 s (40-120 ms)

Junctional Rhythm
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
40-60 BPM
Inverted prior to or after; absent
< .12s if present
.04-.12 s (40-120 ms)
First Degree AV Block
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular; can be irregular
Usually 60-100 BPM; Rhythm dep.
Upright/Normal
> .20 s (200 ms); Constant
.04-.12 s (40-120 ms)
Second Degree AV Block
(Type I)
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Atrial: Reg.; Ventr.: Regularly irreg.
Atrial: Normal; Vent.: Norm./Slow
Normal: extra P waves
Not constant; Lengthens - drops beat
Usually .04-.12 s (40-120 ms)
Second Degree AV Block
(Type II) Classical
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Atrial: Reg.; Ventr.: Regular or irreg.
Atrial: Normal; Ventricular: Slow
Normal; extra P waves
Constant on conducted beats
Usually .04-.12 s (40-120 ms)
Second Degree AV Block
(Type II) Variable
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Atrial: Reg.; Ventr.: Regular or irreg.
Atrial: Normal; Ventricular: Slow
Normal; extra P waves
Constant on conducted beats
Usually .04-.12 s (40-120 ms)
Third-Degree AV Block
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Atrial & Ventricular: Regular
Atrial: Normal; Vent.: 40-60; < 40
Normal: extra P waves
No Atrial/Ventricular Relationship
<.12 s (120 ms) Junct.;> .12 Ventr.

Pacemaker Rhythm
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Paced: Reg.; Demand: Irregular
Varies with pacemaker rate
May be present
No relationship
> .12 s (120 ms);Ventricular
Premature Ventricular
Contractions
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular (PVCs); Compensatory
Depends on underlying rhythm
None on premature beat
None on PVCs
> .12s (120 ms) on PVC
Ventricular Tachycardia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Usually Regular
100-250 BPM
If present, not associated
None
> .12s (120 ms)
Ventricular Fibrillation
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Chaotic;no set rhythm;fine/coarse
None
Absent
Absent
No discernable; medium F-waves

Asystole
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

No electrical activity
No electrical rhythm
Absent
Absent
Absent

Idioventricular Rhythm
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Usually Regular
15-40 BPM
None
None
> .12 s (120 ms);exaggerated

TIME FOR
SOME
REMEMBER!!!
Use a systematic approach
Go through all the steps
Take your time!
Compare with your characteristics list
Interpret the dysrhythmia
Atrial Flutter
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular
70
Big F (Flutter) Waves
.20 s
Normal; .04-.12 s
Sinus Dysrhythmia
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular
60 BPM
Normal; upright
.16 s
Normal
Third Degree Heart Block
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regular
37 BPM
Normal; upright; extra
Non-constant; No relationship
Normal
Sinus Tachy with PVCs (UF)
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular (due to ectopics)
110 BPM
Present underlying; none ectopics
.16 s
Normal; .16 for ectopics
Sinus Arrest
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Regularly Irregular; loses complexes
40 BPM
Normal; upright
.16 s
Normal
Sinus Rhythm with PAC
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular (due to ectopics)
60
Normal; upright; present for ectopic
.18 s; .14 s for ectopic
Normal for all complexes

Sinus Rhythm with V-Tach
Rhythm:
Rate:
P Waves:
P-R Interval:
(Q)RS Complex:

Irregular (due to ectopics)
80 BPM
Normal; upright none for ectopics
.14 s; none on ectopics
Normal; .14 s on ectopics
Acute Anterior MI
Summary
You need to learn the definitive
characteristics
Use a complete, systematic approach to
dissect the rhythm
Take your time
Mistakes are made when steps are skipped
Practice! Practice! Practice!