ECGs MADE EASY

NORMAL ECG

ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic recording of the electrical potentials produced by the cardiac tissue.
Electrical impulse formation occurs within the conduction system of the heart. Excitation of the muscle fibers throughout the myocardium results in cardiac contraction.

The ECG is recorded by applying electrodes to various locations on the body surface and connecting them to a recording apparatus.

ELECTROCARDIOGRAM

Clinical Value of the ECG

Atrial and ventricular hypertrophy Myocardial ischemia and infarction Pericarditis Systemic diseases that affect the heart Determination of the effect of cardiac drugs Disturbances in electrolyte balance Evaluation of function of cardiac pacemakers

ELECTROCARDIOGRAM

Considerable diagnostic value

Conduction delay of atrial and ventricular electrical impulses Determination of the origin and behavior of dysrhythmias

ELECTROCARDIOGRAM

Value of ECG in the following clinical conditions

Prediction of sudden cardiac death Prediction of ischemic pre-conditioning Prediction of adverse states in AMI, post-MI and silent ischemia cases Progression/regression of LV mass

RECORDING AND MONITORING AN ECG

Lead Configurations
Bipolar Leads
Two electrodes placed at 2 different sites Register the difference in potential between these 2 leads

Unipolar leads
Measure the absolute electrical potential at one site Requires a reference site Reference site formed by the limb leads

12 LEAD ECG

Limb Leads
RA LA LL RL V1 V2 V3 V4 Red Yellow Green Black Red Yellow Green Brown Right arm Left arm Left leg Right leg 4th ICS RPSB 4th ICS LPSB Midway between V2 and V4 5th ICS LMCL

Chest Leads

ELECTROPHYSIOLOGY OF THE HEART

Four Electrophysiologic Events Involved in the Genesis of the ECG

Impulse formation Transmission of the impulse Depolarization Repolarization

TRANSMEMBRANE ACTION POTENTIAL

REFRACTORINESS

LAYERS OF THE HEART WALL

Epicardium
Coronary arteries are found in this layer

Myocardium
Responsible for contraction of the heart

Endocardium
Lines the inside of the myocardium Covers the heart valves

CONDUCTION SYSTEM OF THE HEART

SA Node Atrial Muscle AV Node Bundle of His Bundle Branches Purkinje Fibers Ventricular Muscle

MYOCARDIAL CELL TYPES

Kinds of Cardiac Cells

Myocardial cells Specialized cells of the electrical conduction system

Where Found
Myocardium

Primary Function
Contraction and Relaxation Generation and conduction of electrical impulses

Primary Property
Contractility

Electrical conduction system

Automaticity Conductivity

TERMINOLOGY
Chronotropic Effect
Refers to a change in heart rate A positive chronotropic effect refers to an increase in heart rate A negative chronotropic effect refers to a decrease in heart rate

Dromotropic Effect
Refers to a change in the speed of conduction through the AV junction A positive dromotropic effect results in an increase in AV conduction velocity A negative dromotropic effect results in a decrease in AV conduction velocity

Inotropic Effect
Refers to a change in myocardial contractility A postive inotropic effect results in an increase in myocardial contractility A negative inotropic effect results in a decrease in myocardial

TERMINOLOGY Waveform
Movement away from the baseline in either a positive or negative direction

Segment
A line between wave forms

Interval
A waveform and a segment

Complex
Consists of several waveforms

ECG PAPER

ELECTROGRAM

Upward deflection

Downward deflection

+ + +

Diphasic deflection

AVL

AVR

AVF

THE NORMAL ELECTROCARDIOGRAM

P wave
Generated by activation of the atria

PR segment
Represents the duration of atrioventricular (AV) conduction

QRS complex
Produced by activation of both ventricles

ST-T wave
Reflects ventricular recovery

STANDARD 12 LEAD ECG

The P wave
Atrial activation Height < 0.2 mV (2 mm) Duration < 0.12 sec

STANDARD 12 LEAD ECG

P-R Interval
Intraatrial, internodal, His purkinje conduction Duration 0.12 to 0.20 or 0.22 sec

STANDARD 12 LEAD ECG

The QRS Complex

Ventricular activation Duration of 100 msec

STANDARD 12 LEAD ECG

The ST-segment
Phase 2 of transmembrane potential Isoelectric in normal subjects

STANDARD 12 LEAD ECG

The T wave
Upright after the age of 16 Juvenile T wave

STANDARD 12 LEAD ECG

The U wave
Surface reflection of negative after potential Repolarization of Purkinje fibers Ventricular relaxation

STANDARD 12 LEAD ECG

The QT Interval
From beginning of QRS to end of T wave Reflects the duration of depolarization and repolarization Bezett: Q-Tc Interval = Q-T/ R-R

ANALYZING A RHYTHM STRIP

Rate Rhythm Axis P wave PR Interval QRS Complex T wave Q-T Interval

ANALYZING A RHYTHM STRIP

What is the rate?

To determine the ventricular rate,measure the distance between 2 consecutive R-waves (R-R interval) To determine the atrial rate, measure the distance between 2 consecutive P-waves (P-P interval)

What Is The Rate?

Ventricular Rate
Small squares (R-R Interval) / 1500 Big squares (R-R Interval) / 300

What Is The Rate?

Sinus rhythm

Atrial Fibrillation
QRS complexes in 6-sec strip X 10

ANALYZING A RHYTHM STRIP

Is the rhythm regular or irregular?

To determine if the ventricular rhythm is regular or irregular, measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-r intervals. For atrial rhythm, measure the distance between 2 consecutive P-P intervals. Generally, a variation of up to 0.12 seconds (3 small boxes) is acceptable. The slower the heart rate, the more acceptable the variation.

ANALYZING A RHYTHM STRIP

What Is The Axis? Normal

0 (+90)

Left axis
0 (-90)
I

AVL

Right axis
(+90) (+180)
AVR

Extreme axis
(-90) (-180)

AVF

What Is The Axis?

}
Lead I

10
AVL

}
AVF

10
AVF

AVR

ANALYZING A RHYTHM STRIP

Is there 1 P wave before each QRS?

Are P waves present and uniform in appearance? Is there a P wave before each QRS or are there P waves that are not followed by QRS complexes? Is the atrial activity occurring so rapidly that there are more atrial beats than QRS complexes?

ANALYZING A RHYTHM STRIP

Is the PR interval within normal limits?

If the PR interval is less than 0.12 or more than 0.20 second, conduction followed an abnormal pathway or the impulse was delayed in the area of the AV node. Is the PR interval of conducted beats constant or does it vary?

ANALYZING A RHYTHM STRIP

Is the QRS narrow or wide?

What is the duration of the QRS complex? If it is 0.10 second or less (narrow), it is presumed to be supraventricular in origin. If it is greater than 0.12 second (wide), it is probably ventricular in origin. Do the QRSs occur uniformly throughout the strip?

ANALYZING A RHYTHM STRIP

Interpret the rhythm

Specifying the site where the dysrhythmia originated (sinus), the mechanism (bradycardia), and the vetnricular rate. For example, sinus bradycardia with a ventricular response (rate) of 38/min.

ANALYZING RHYTHM STRIP

Localization I, AVL
High lateral

II, III, AVF

Inferior
I

AVL

AVR

AVF

ANALYZING THE RHYTHM STRIP Localization V1,V2

Septal

V3,V4
Anterior

V1-V6 Extensive anterior I,AVL,V5,V6 - Lateral

V5,V6
Apicolateral

V1-V3 or V4
Anteroseptal

V3 or V4-V6
Anterolateral

ANALYZING A RHYTHM STRIP

How is the rhythm clinically significant?

NORMAL SINUS RHYTHM

Rate Rhythm

60-100 beats per minute Atrial regular Ventricular regular P waves Uniform in appearance, upright, normal shape, one preceding each QRS complex PR interval 0.12-0.20 second QRS 0.10 second or less. If greater than 0.10 second in duration, the QRS is termed wide since the existence of a bundle branch block or other intraventricular conduction defect cannot be accurately detected in a single-lead.

Sinus Rhythms
Normal Sinus Rhythm
Rate Rhythm P waves PR interval QRS 60-100 beats per minute Atrial regular Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second 0.10 second or less. If greater than 0.10 second in duration, the QRS is termed wide since the existence of a bundle branch block or other intraventricular conduction defect cannot be accurately detected in a single-lead.

Sinus Rhythms
Sinus Bradycardia
Rate Rhythm P waves PR interval QRS Less than 60 beats per minute Atrial regular Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Sinus Rhythms
Sinus Tachycardia
Rate Rhythm P waves PR interval QRS Usually 100-160 beats per minute Atrial regular Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Sinus Rhythms
Normal Heart Rates in Children
Age Neonate Infant (6 mos) Toddler Preschooler School-aged Adolescent Awake Heart Rate (per minute) 100-180 100-160 80-110 70-110 65-110 60-90 Sleeping Heart Rate (per minute) 80-160 75-160 60-90 60-90 60-90 50-90

Sinus Rhythms
Sinus Dysrhythmia (Arrhythmia)
Rate Rhythm P waves PR interval QRS Usually 100-160 beats per minute but may be faster or slower Irregular (R-R intervals shorten during inspiration and lengthen during expiration) Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Sinus Rhythms
Sinoatrial (SA) Block
Rate Rhythm P waves PR interval QRS Usually normal but varies because of pause Irregular the pause is the same as (or an exact multiple of) the distance between two other P-P intervals Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Sinus Rhythms
Sinus Arrest
Rate Rhythm P waves PR interval QRS Usually normal but varies because of the pause Irregular the pause is of undetermined length (more than one PQRST complex is omitted) and is not the same distance as other P-P intervals. Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second Usually 0.10 second or less

Atrial Rhythms
Premature Atrial Complexes
1. 2.

Early (premature) P waves Upright P waves that differ in shape from normal sinus P waves in Lead II
P waves may be biphasic (partly positive, partly negative), flattened, notched or pointed

3.

The early P wave may or may not be followed by a QRS complex

Atrial Rhythms
Compensatory vs. Non-compensatory Pause
To determine whether or not the pause following a premature complex is compensatory or non-compensatory, measure the distance between three normal beats. Compare that distance between three beats, one of which includes the premature complex. Non-compensatory (incomplete) if the normal beat following the premature complex occurs before it was expected (i.e., when the distance is not the same) Compensatory (complete) if the normal beat following the premature complex occurs when expected (i.e., when the distance is the same).

Atrial Rhythms
Premature Atrial Complexes (PACs)
Rate Rhythm P waves PR interval QRS Usually normal but depends on underlying rhythm Essentially regular with premature beats Premature Differ from sinus P waves may be flattened, notched, pointed, biphasic, or lost in the preceding T wave Varies from 0.12-0.20 second when the pacemaker site is near the SA node; 0.12 second when the pacemaker site is nearer the AV junction Usually less than 0.10 second but may be prolonged. The QRS of the PAC is similar to those of the underlying rhythm unless the PAC is abnormally conducted.

Atrial Rhythms
Vagal Maneuvers
Vagal maneuvers are methods used to stimulate baroreceptors in the internal carotid arteries and the aortic arch. Stimulation of these receptors results in reflex stimulation of the vagus nerve and release of acetylcholine. Acetylcholine slows conduction in the AV node, resulting in slowing of the heart rate Coughing Bearing down Squatting Breath-holding Carotid sinus pressure (massage) Immersion of the face in ice water Stimulation of the gag reflex Carotid pressure should be avoided in older patients. Simultaneous, bilateral carotid pressure should never be performed.

Atrial Rhythms
The Unstable Patient
Signs and Symptoms Shock Chest pain Hypotension Shortness of breath Pulmonary congestion Congestive heart failure Acute myocardial infarction Decreased level of consciousness

Atrial Rhythms
Supraventricular Tachycardia
Rate Rhythm P waves 150-250 beats per minute Regular Atrial P waves may be seen which differ from sinus P waves (may be flattened, notched, pointed, or biphasic). P waves are usually identifiable at the lower end of the rate range but are seldom identifiable at rates above 200. May be lost in the preceding T wave. Usually not measurable because the P wave is difficult to distinguish from the preceding T wave. If P waves are seen, the RR interval will usually measure 0.12-0.20 second. Less than 0.10 second unless an intraventricular conduction defect exists.

PR interval

QRS

Atrial Rhythms
ELECTRICAL THERAPY Synchronized Countershock
Description and Purpose Synchronized countershock reduces the potential for delivery of energy during the vulnerable period of the T wave (relative refractory period). A synchronizing circuit allows the delivery of a countershock to be programmed. The machine searches for the peak of the QRS complex (R wave deflection) and delivers the shock a few milliseconds after the highest part of the R wave. Indications: Supraventricular tachycardia Atrial fibrillation Atrial flutter Unstable ventricular tachycardia with pause

Atrial Rhythms
Wandering Atrial Pacemaker (Multiformed Atrial Rhythm)
Rate Rhythm P waves 60-100. If the rate is greater than 100 beats per minute, the rhythm is termed multifocal (or chaotic) atrial tachycardia. Atrial irregular Ventricular - irregular Size, shape, and direction may change from beat to beat. At least three different P waves are required for a diagnosis of wandering atrial pacemaker Variable Usually less than 0.10 second unless an intraventricular conduction defect exists

PR interval QRS

Atrial Rhythms
Atrial Flutter
Rate Atrial rate 250-350 beats per minute; ventricular rate variable determined by AV blockade. The ventricular rate will usually not exceed 180 beats per minute due to the intrinsic conduction rate of the AV junction. Atrial regular Ventricular may be regular or irregular Not identifiable P waves; saw-toothed flutter waves Not measurable Usually less than 0.10 second but may be widened if flutter waves are buried in the QRS complex or if an intraventricular conduction defect exists.

Rhythm P waves PR interval QRS

Atrial Rhythms
Atrial Fribrillation
Rate Rhythm P waves PR interval QRS Atrial rate usually greater than 350-400 beats per minute; ventricular rate variable Ventricular rhythms usually very irregular; a regular ventricular rhythm may occur because of digitalis toxicity. No identifiable P waves; fibrillatory waves present. Erratic wavy baseline. Not measurable Usually less than 0.10 second but may be widened if an intraventricular conduction defect exists.

Atrial Rhythms
Wolff-Parkinson-White (WPW) Syndrome
Rate Rhythm P waves PR interval QRS If the underlying rhythm is sinus in origin, the rate is usually 60-100 beats per minute. Regular unless associated with atrial fibrillation Normal and upright unless WPW is associated with atrial fibrillation If P waves are seen, less than 0.12 second Usually greater than 0.12 second. Slurred upstroke of the QRS complex (delta wave) is often seen in one or more leads)

Junctional Rhythms
Premature Junctional Complexes
Rate Rhythm P waves PR interval Usually normal, but depends on the underlying rhythm Essentially regular with premature beats May occur before, during, or after the QRS If visible, the P wave is inverted in leads II, III, AVF If the P wave occurs before the QRS, the PR interval will be usually less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction defect exists.

QRS

Junctional Rhythms
Junctional Escape Beat
Rate Rhythm P waves PR interval Usually normal, but depends on the underlying rhythm Essentially regular with LATE beats May occur before, during, or after the QRS If visible, the P wave is inverted in leads II, III, AVF If the P wave occurs before the QRS, the PR interval will be usually less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction defect exists.

QRS

Junctional Rhythms
Junctional Escape Rhythm
Rate Rhythm P waves PR interval 40 to 60 beats per minute Atrial and ventricular rhythm very regular May occur before, during, or after the QRS If visible, the P wave is inverted in leads II, III, AVF If the P wave occurs before the QRS, the PR interval will be usually less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction defect exists.

QRS

Junctional Rhythms
Accelerated Junctional Rhythm
Rate Rhythm P waves PR interval 60 to 100 beats per minute Atrial and ventricular rhythm very regular May occur before, during, or after the QRS If visible, the P wave is inverted in leads II, III, AVF If the P wave occurs before the QRS, the PR interval will be usually less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction defect exists.

QRS

Junctional Rhythms
The Unstable Patient
Signs and Symptoms Shock Chest pain Hypotension Shortness of breath Pulmonary congestion Congestive heart failure Acute myocardial infarction Decreased level of consciousness

Junctional Rhythms
Junctional Tachycardia
Rate Rhythm P waves PR interval 100 to 180 beats per minute Atrial and ventricular rhythm very regular May occur before, during, or after the QRS If visible, the P wave is inverted in leads II, III, AVF If the P wave occurs before the QRS, the PR interval will be usually less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction defect exists.

QRS

Ventricular Rhythms
Premature Ventricular Complexes
Rate Rhythm P waves PR interval QRS Usually normal but depends on the underlying rhythm Essentially regular with premature beats. If the PVC is an interpolated PVC, the rhythm will be regular. There is no P wave associated with the PVC None with the PVCs because the ectopic beat originates in the ventricle Greater than 0.12 second. Wide and bizarre. T wave frequently in opposite direction of the QRS complex.

Ventricular Rhythms
Patterns of PVCs
1. 2. 3. 4. 5. Pairs (couplets) two sequential PVCs Runs or bursts three or more sequential PVCs are called vntricular tachycardia (VT) Bigeminal PVCs (ventricular bigeminy) every other beat is a PVC Trigeminal PVCs (ventricular trigeminy) every third beat is a PVC Quadrigeminal PVCs (ventricular quadrigeminy) every fourth beat is a PVC

Ventricular Rhythms
Common Causes of PVCs
Normal variant Anxiety Exercise Hypoxia Digitalis toxicity Acid-base imbalance Myocardial ischemia Electrolyte imbalance (hypokalemia, hypocalcemia, hypercalcemia, hypomagnesemia) Congestive heart failure Increased sympathetic tone Acute myocardial infarction Stimulants (alcohol, caffeine, tobacco) Drugs (sympathomimetics, cyclic antidepressants, phenothiazines)

Ventricular Rhythms
Warning Dysrhythmias

Six or more PVCs per minute PVCs that occurred in pairs (couplets) or in runs or three or more (ventricular tachycardia) PVCs that fell on the T wave of the preceding beat (R-on T phenomenon) PVCs that differed in shape (multiformed PVCs)

Ventricular Rhythms
Ventricular Escape Beat
Rate Rhythm P waves PR interval QRS Atrial and ventricular rate dependent upon the underlying rhythm. Irregular. The ventricular escape beat occurs LATE, after the next expected sinus beat. There is no P wave associated with escape beat. None with the escape beat because the complex originates from the ventricles. Greater than 0.12 second. T wave deflection is opposite that of the QRS complex.

Ventricular Rhythms
Idioventricular (Ventricular Escape) Rhythm
Rate Rhythm P waves PR interval QRS Atrial not discernible, ventricular 20-40 beats per minute Atrial not discernible Ventricular essentially regular Absent None Greater than 0.12 second. T wave deflection is in the opposite direction of the QRS.

Ventricular Rhythms
Accelerated Idioventricular Rhythm
Rate Rhythm P waves PR interval QRS Atrial not discernible, ventricular 40-100 beats per minute Atrial not discernible Ventricular essentially regular Absent None Greater than 0.12 second. T wave deflection is in the opposite direction of the QRS.

Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate Rhythm P waves Atrial rate not discernible, ventricular rate 100-250 beats per minute Atrial rhythm not discernible Ventricular rhythm is essentially regular May be present or absent; if present they have no set relationship to the QRS complexes appearing between the QRSs at a rate different from that of the VT. None Greater than 0.12 second. Often difficult to differentiate between the QRS and the T wave.

PR interval QRS

Ventricular Rhythms
VENTRICULAR TACHYCARDIA - CAUSES
Hypoxia Exercise R-on T PVCs Catecholamines Digitalis toxicity Myocardial ischemia Acid-base imbalance Electrolyte imbalance Ventricular aneurysm Coronary artery disease Rheumatic heart disease Acute myocardial infarction CNS stimulants (cocaine, amphetamines)

Ventricular Rhythms
LONG QT INTERVAL - CAUSES
Drug induced Cyclic antidepressants Phenothiazines Type 1A antidysrhythmics (quinidine, procainamide, disopyramide) Organophosphate insecticides Eating disorders (bulimia, anorexia) Electrolyte abnormalities (hypomagnesemia, hypokalemia, hypocalcemia)

Ventricular Rhythms
ANTIDYSRHYTHMIC CLASSIFICATIONS
Group I Primarily inhibit the fast sodium channel in cardiac tissue, resulting in an increased refractory period 1A - increased conduction velocity and prolong the action potential (Quinidine, Procainamide, Disopyramide) 1B - Either increase or have no effect on conduction velocity (Lidocaine, Phenytoin, Tocainide, Mexiletine) 1C - Decrease conduction velocity (Flecainide, Encainide) Beta-adrenergic blockers (Propranolol) Prolong repolarization (Bretylium, Amiodarone) Block slow calcium channels, resulting in decreased automaticity, and depression of myocardial and smooth muscle contraction (Verapamil, Nifedipine, Diltiazem)

Group II Group III Group IV

Ventricular Rhythms
Torsades de Pointes (TdP)
Rate Rhythm P waves PR interval QRS Atrial rate not discernible, ventricular rate 150-250 beats per minute Atrial not discernible Ventricular may be regular or irregular None None Greater than 0.12 second. Gradual alteration in the amplitude and direction of the QRS

Ventricular Rhythms
Ventricular Fibrillation
Rate Rhythm P waves PR interval QRS Cannot be determined since there are no discernible waves or complexes to measure Rapid and chaotic with no pattern or regularity Not discernible Not discernible Not discernible

Ventricular Rhythms
Defibrillation (Unsynchronized Countershock)
Description and Purpose: The purpose of defibrillation is to produce momentary asystole. The shock attempts to completely depolarize the myocardium and provide an opportunity for the natural pacemaker centers of the heart to resume normal activity. Defibrillation is a random delivery of energy there is no relation of the discharge of energy to the cardiac cycle. Indications: Unstable ventricular tachycardia with a pulse Pulseless ventricular tachycardia Ventricular fibrillation Sustained Torsades de Pointes

Ventricular Rhythms
Asystole
Rate Rhythm P waves PR interval QRS Ventricular usually indiscernible but may see some atrial activity. Atrial may be discernible. Ventricular indiscernible. Usually not discernible Not measurable Absent

Ventricular Rhythms
Causes of Pulseless Electrical Activity (MATCHx4ED)
Myocardial infarction (massive acute) Acidosis Tension pneumothorax Cardiac tamponade Hypovolemia (most common cause) Hypoxia Hyperkalemia Hypothermia Embolus (massive pulmonary) Drug overdoses (cyclic antidepressants, calcium channel blockers, beta-blockers, digitalis)

Atrioventricular Blocks
Classification of AV Blocks
Degree of block Partial (incomplete) blocks First-degree AV block Second-degree AV block type I Second-degree AV block type II Second-degree AV block 2:1 conduction Third-degree AV block Complete block Site of block AV node First-degree AV block Second-degree AV block type I Third-degree AV block Bundle of His Bundle branches Second-degree AV block type II (uncommon) Third-degree AV block Second-degree AV block type II (more common) Third-degree AV block

Infranodal

Atrioventricular Blocks
First Degree AV Block
Rate Rhythm P waves PR interval QRS Atrial and ventricular rates the same; dependent upon underlying rhythm. Atrial and ventricular regular Normal in size and shape Only one P wave before each QRS Prolonged (greater than 0.20 second) but constant Usually 0.10 second or less unless an intraventricular conduction exists

Atrioventricular Blocks
Second-Degree AV Block, Type I (Wenckebach)
Rate Rhythm P waves PR interval Atrial rate is greater than the ventricular rate. Both are often within normal limits. Atrial regular (Ps plot through) Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs). Lengthens with each cycle (although lengthening may be very slight), until a P wave appears without a QRS complex. The PRI after the nonconducted beat. Usually 0.10 second or less but is periodically dropped.

QRS

Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate Rhythm P waves PR interval Atrial rate is greater than the ventricular rate. Ventricular rate is often slow. Atrial regular (Ps plot through) Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs). Within normal limits or prolonged but always constant for the conducted beats. There may be some shortening of the PRI that follows a nonconducted P wave. Usually 0.10 second or greater, periodically absent after P waves.

QRS

Atrioventricular Blocks
Second-Degree AV Block, 2:1 Conduction
Rate Rhythm P waves PR interval QRS Atrial rate is greater than the ventricular rate. Atrial regular (Ps plot through) Ventricular regular. Normal in size and shape; every other P wave is followed by a QRS complex (more Ps than QRSs) Constant Within normal limits if the block occurs above the bundle of His (probably type I); wide if the block occurs at or below the bundle of His (probably type II); absent after every other P wave.

Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate Rhythm P waves PR interval QRS Atrial rate is greater than the ventricular rate. The ventricular rate is determined by the origin of the escape rhythm. Atrial regular (Ps plot through). Ventricular regular. There is no relationship between the atrial and ventricular rhythm. Normal in size and shape. None the atria and ventricles beat independently of each other, thus there is no true PR interval. Narrow or broad depending on the location of the escape pacemaker and the condition of the intraventricular conduction system. Narrow = junctional pacemaker; wide = ventricular pacemaker.

Atrioventricular Blocks
Classification of AV Blocks
Second-Degree AV Block Type I Ventricular Rhythm PR Interval QRS Width Irregular Lengthening Usually narrow Second-Degree AV Block, 2:1 Conduction Ventricular Rhythm PR Interval Regular Constant Second-Degree AV Block Type II Irregular Constant Usually wide Complete (Third-Degree) AV Block Regular None no relationship between P waves and QRS complexes May be narrow or wide

QRS Width May be narrow or wide