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David W. Woodruff, MSN, RN, CNS, CCRN
5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses, Inc. www.ed4nurses.com
5 Steps to Rhythm Strip Interpretation
As patient acuity increases, more patients are being placed on telemetry and nurses are being expected to be able to read EKG rhythm strips. However, this skill need not be difficult to learn. It is best accomplished by a systematic method of analysis. The 5 Steps to Rhythm Strip Interpretation systematically reviews the major components of a rhythm strip to help determine the type of rhythm and the appropriate course of treatment. The 5 Steps are listed below: Step 1. Step 2. Step 3. Step 4. Step 5. Is the speed of the rhythm between 60-100? Is it regular? Is the complex narrow? Is it preceded by a P-wave? Do all the complexes look the same?
Step 1 evaluates the speed of the rhythm to determine if it is normal, too slow or too fast. A speed between 60-100 maintains the best hemodynamic stability. Rates less than 60 or greater than 100, can lead to hemodynamic instability and become symptomatic. Step 2 asks if the rhythm is regular. Rhythms originating from the normal pacemakers in the heart will be regular. Irregular rhythms indicate extra beats or abnormal rhythms. Step3 assesses the shape of the complex. A narrow complex is normal. A wide complex indicates conduction abnormalities. Step 4 asks if a P-wave precedes the QRS complex. This represents normal conduction from the atria to the ventricles. If the P-wave is absent, the impulse is being generated from elsewhere in the heart. Step 5 assesses whether all the complexes look the same. Normal conduction follows the same pathway with each beat. Different looking complexes indicate the some impulses are following alternative or aberrant pathways. If the nurse can answer all of the questions asked by the 5-steps affirmatively, the patient has a sinus rhythm. The greater the number of questions answered negatively, then the greater the abnormal conduction through the heart. This usually indicates myocardial irritability. Spend a few moments to reacquaint yourself with the normal EKG complex, and its components.
Repolarization: In order for the heart to fire again. The delay is seen on the EKG as the P-R interval. generating a P-wave. it generates the QRS complex.ed4nurses.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. it needs to re-load. Inc. As the impulse travels down the perkinge fibers in the ventricles. The impulse travels through the electrical pathways to the Atrio-Ventricular (AV) node. The AV node delays the impulse. www. Figure 1 3 . so that the atria and ventricles don’t fire at the same time.com Normal conduction Depolarization: Impulses begin at the Sinoatrial (SA) node. Electrical re-loading of the heart is called repolarization and is represented by the T-wave on the EKG.
He would hook up a voltmeter to determine if it’s “got power. look at the lead selection dial or on an EKG tracing. but will use another as a ground. The EKG machine doesn’t look at all 12 leads at once. By reading the electrical energy of the heart. Inc. 4 . it reads electrical energy from the body. In figure 2. Why do we need all those different leads? Each lead looks from a different perspective. the nurse can tell if it is generated and conducted correctly. it may not work. In other words. To understand this concept. then an appliance repairman might be called to attempt to repair it. the machine can change its view or perspective on the heart. www.ed4nurses. What lead does my monitor at work use? Figure 2 To identify which lead your monitor is reading. V1 indicates the first chest lead. The EKG and the patient If a washing machine is not working. the EKG machine will be looking in the direction of the arrow. The EKG machine “takes pictures” of the heart. The motor or a relay may be broken. This gives the machine perspective for its view. How an EKG is obtained An EKG machine is a voltmeter.” Even if it’s powered up. instead it chooses one at a time to view. and gives a different view of the heart. and each view we call a lead on the resulting tracing.com The EKG Complex: Keep in mind that the EKG complex represents electrical activity of the heart and does not assure mechanical activity (contraction). II indicates lead II.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. What do all the different leads mean? The EKG machine looks at only one sensor (lead) at a time. The heart uses electrical energy to cause muscle cells to contract. An EKG is obtained by placing electrical sensors (leads) on the patient’s chest. think of the process of taking a picture with a camera. By using different leads. The EKG machine “looks” from the positive (+) lead to the negative (-) lead. Usually 12 leads are used to look at the heart from many angles. Where you stand to take the picture is equally as important as what direction you face when taking it. For example. Loss of contraction associated with continued electrical activity is called “pulseless electrical activity” (PEA). The lead will be identified by its abbreviation. Using different leads allows the nurse to watch electrical activity in many different parts of the heart.
04 seconds. 5 . The EKG paper is marked in time. Blood pressure determines whether a rhythm is stable. so remember to turn the lead selector back to its original position. Validating EKGs Sometimes a wire is cracked. However. and the QRS duration. Usually normal EKG activity will correlate with normal mechanical activity (cardiac output).20 seconds. These are the most helpful in analyzing rhythm strips. Using a sixsecond strip is helpful in determining heart rate. see figure 3. or the lead is dried up and a poor connection is made. www. There is no direct correlation between the type of EKG rhythm and the blood pressure. and another would be in shock with the same heart rate. The blood pressure can be measured to assess mechanical activity (cardiac output). Measuring intervals The duration of the waveforms on the EKG should be short. the tracing will be marked with hash-marks at the top to designate each six-second increment. A heart rate of 50 may be perfectly normal for one patient. Intervals can be measured by comparing the distance on the tracing to the markings on the EKG paper. it is possible that the patient can have normal EKG activity and be hemodynamically unstable. Inc. This is usually a simple procedure of turning the lead selector dial to another lead. and each large box represents 0. Each small box represents 0.ed4nurses. the EKG should be validated by checking it in more than one lead. the intervals can be measured. Count the number of complexes in six seconds and multiply it by ten for the heart rate per minute. Most monitoring floors have policies about which lead is suppose to be monitored. There are two measurements that we will use with the 5-steps: the PR-interval.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. In these situations the EKG machine may not be able to read accurately. To assess for changes. Keep in mind that the EKG only represents the electrical activity of the heart and does not measure mechanical activity. A large box contains five small boxes. Figure 3 There are 30 large boxes in each six-second strip. Whenever possible. Fortunately.com An EKG is helpful in the same way. The EKG tracing indicates electrical activity of the heart.
The QRS duration indicates how long it takes for the impulse to travel through the ventricles. The purpose of measuring the PR-interval is to determine if the impulse from the SA node is conducted to the ventricles through the normal conduction pathways. Wide complexes are associated with aberrant conduction. Figure 4 The normal PR-interval is 0.ed4nurses. A normal QRS duration is 0.20 seconds.04-0.com The PR-interval is the distance between the beginning of the P-wave and the beginning of the QRS complex. Inc. Figure 4 shows where to measure the PR-interval. 6 . or ventricular rhythms.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Longer intervals indicate slowing of the impulse in the AV-node. The QRS duration is measured at the beginning of the QRS complex until the end of the complex (figure 5). Figure 5 QRS duration determines whether we have a narrow complex or not. www.12 to 0.08 seconds.
Regular Step 3. Rate: 60-100 Step 2. www. therefore this is a normal sinus rhythm. Normal conduction indicates that the myocardium is not irritable or injured. Use the 5-Step approach to identify the rhythm: Step 1.16 sec) Step 4. but the blood pressure should be taken to validate stability.com Identifying normal rhythms Sinus Rhythm A heart rhythm that originates in the sinoatrial node and is normally conducted is called a Normal Sinus Rhythm (NSR). The real test to determine whether a patient is hemodynamically stable is to check his blood pressure.06 seconds) Step 5. 7 . So.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Narrow complex (QRS duration 0. preceded by a P-wave where all the complexes look the same. All complexes look the same All five questions were answered with a “yes”. vital signs should be taken. The characteristics of a normal sinus rhythm are a regular rate between 60-100 beats per minute. A normal sinus rhythm is usually associated with normal hemodynamics. P-wave precedes QRS (PR interval 0. a narrow complex. Inc.ed4nurses. There is no treatment necessary if the patient’s blood pressure is normal.
Sinus tachycardia is caused by fever. Treatment would be for the underlying condition. Rate: >100 Step 2. it is just too fast. pain. All complexes look the same Four of the five questions were answered affirmatively. 8 . anxiety. or you can estimate it by counting the number of QRS complexes on a six-second strip. Use the 5-Steps to identify the rhythm below: Step 1. You will see the rate displayed on your monitor. Narrow complex (QRS duration 0. dehydration. Regular Step 3.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Inc.com Sinus Tachycardia A rhythm that originates in the SA node and is conducted normally.12) Step 4. This is a sinus rhythm (has a P-wave). The above strip is cut off prematurely.04 seconds) Step 5.ed4nurses. The only negative answer was for the rate. so the rate from the monitor will be used. P-wave precedes QRS (PR interval 0. www. but that exceeded 100 beats-per-minute is called Sinus Tachycardia (ST). or hypoxemia. The rate in the above strip is approximately 120.
Persistent rhythms may require a pacemaker.ed4nurses. To summarize the findings from the 5-step analysis: Step 1.com Sinus Bradycardia A rhythm that originates in the SA node (P-wave) but is less than 60 beats per minute is called Sinus Bradycardia (SB). like athletes. The rate for this strip is about 40. Calcium-channel blocker and beta-blocker medications can cause bradycardia. but slow rates can lead to hypotension. Assess your patient to see if he takes these medications. Regular Step 3. www. P-wave precedes QRS (PR interval 0. the blood pressure should be taken. Inc. normally have a sinus bradycardia.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. 9 .16 seconds) Step 4. Therefore. This rhythm is not showing a lot of myocardial irritability. Rate: <60 Step 2. Some patients. If the blood pressure is low. then treatment would include administration of atropine or epinephrine. Narrow complex (QRS duration 0. All complexes look the same The only question answered negatively was for the rate.04 seconds) Step 5.
All complexes look the same In step 3 the flutter wave was discovered so that atrial flutter could be diagnosed.com Identifying abnormal rhythms Atrial Flutter The rhythm strip below has a regular ventricular rhythm. www. 10 . or diltiazem would help to slow the ventricular rate. Rate: 60-150 Step 2. If every flutter wave were conducted. or flecainide would be used to chemically convert the rhythm back to sinus rhythm. Using the 5-step analysis. There are three flutter (F-waves) for every QRS complex. Treatment with digoxin.ed4nurses. but has a saw-tooth wave preceding the QRS instead of a P-wave. In the strip above. saw-tooth flutter waves (F-waves).5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.12) Step 5. the ventricular rate would increase to 180 and the patient would probably develop hypotension. This pattern is consistent with atrial flutter. Narrow complex (QRS duration 0. Note the difference in morphology between a rounded P-wave and the sharp. verapamil. a 1:3 ratio. Amiodarone. our findings would be: Step 1. the ventricular rate (QRS) is relatively slow at 60 beats per minute. Always check the blood pressure to assess the patient’s stability. sotalol. Regular Step 3. Inc. Several F-waves precede QRS Step 4.
www. This is consistent with fibrillation waves (f-waves). This happens because of an irregular pattern of atrial impulses conducting to the ventricles. no F-waves are present.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.ed4nurses. Treatment for atrial fibrillation would be to control the rate from becoming too fast with digoxin. a P-wave is lacking again. or to convert it back to sinus rhythm with cardioversion. Several f-waves precede QRS d.com Atrial Fibrillation In the following rhythm. sotalol. However. If the patient has persistent atrial fibrillation he should be anticoagulated to prevent blood clots from developing in the atria. verapamil.08 seconds) e. All complexes look the same The hallmark of atrial fibrillation is an irregularly-irregular rhythm. flecainide. or chemically with amiodarone. diltiazem. Irregular c. there is a wavy or “noisy” baseline. Rate: 70 (can be abnormal with a-fib) b. Inc. Narrow complex (QRS duration 0. Instead. a. There is no pattern to the irregularity. 11 . Using our 5-steps atrial fibrillation (A-fib) can be identified.
Regular Step 3.ed4nurses. adenosine. treatment is necessary and includes vagal maneuvers. Inc. www. All complexes look the same The rate in this strip is about 260. The 5-steps will identify this rhythm as a very fast. P-wave may precede QRS Step 4. It is referred to as supraventricular because it is too fast to see Pwaves. betablockers. Therefore. or cardioversion. Step 1. Narrow complex (QRS duration 0. 12 . due to inadequate diastolic time for ventricular filling. but regular rhythm with a narrow complex is called supraventricular tachycardia (SVT). Rates exceeding 150 are often accompanied by hypotension.04 seconds) Step 5. Rate: 140-300 Step 2.com Supraventricular Tachycardia A very fast. and may be coming from somewhere other than the SA-node.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. regular rhythm with a narrow complex. verapamil.
ed4nurses. or it may be absent entirely. 13 .06 seconds) Step 5. Rate: 40-60 (accelerated 60-100) Step 2. Symptomatic junctional rhythms are treated with atropine or a pacemaker. Narrow complex (QRS duration 0. Inc. The 5-steps would identify the following characteristics: Step 1. The rate in this strip is 50. The characteristic signs are a slow rhythm without a P-wave. P-wave absent or inverted Step 4. the blood pressure should be assessed to determine stability. www.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Regular Step 3. All complexes look the same In a junctional rhythm the P-wave may be inverted and very close to the QRS because it is being generated by the AV node.com Junctional Rhythm A rhythm originating in the AV-node is called a junctional rhythm.
Our 5-step analysis will identify the following characteristics: Step 1. www. Narrow complex (QRS duration 0.06 seconds) Step 5. It is important to observe the patient for development of a greater degree of AV blockage. Inc. Regular Step 3. A first-degree block can progress to a second-degree or third-degree block.com First-degree AV-Block The AV node can function as a pacemaker in junctional rhythms as well as act to delay the impulse from the SA-node. treatment is not necessary. P-wave precedes QRS: long PR-interval (0.ed4nurses. Rate: 60-100 Step 2. All complexes look the same As long as the blood pressure is normal. Sometimes the AV-node may delay the impulse too long and this is called a first-degree AV-block.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.38 seconds) Step 4. 14 . so that the atria and ventricles don’t contract at the same time.
Rate: varies Step 2. The cardinal signs are that the rhythm is irregular and that more than one P-wave precedes the QRS. A pacemaker may be necessary if the rate is slow and the blood pressure drops. www. the blood pressure should be assessed to determine if the patient is stable. Notice in the strip below that there is a long space between the second and third complexes.08 seconds) Step 5.ed4nurses.com Second-degree AV-Block A greater degree of AV blockage is called a second-degree block. 15 . Using the 5-stap method.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. P-wave precedes QRS (PR interval varies) Step 4. Narrow complex. but some dropped (QRS duration 0. Digoxin can cause this rhythm and should be discontinued. with one P-wave immediately after the T-wave and another preceding the third QRS complex. the following characteristics are identified: Step 1. Irregular Step 3. All complexes look the same Again. Inc.
In this type of block the PR-interval becomes progressively longer. Rate: varies Step 2. so check the blood pressure. www. In the strip below. Step 4.com Mobitz Type I Block Another type of second-degree block is called Mobitz Type I.32 seconds) and longer yet in the second (0. P-wave precedes QRS: PR-interval becomes progressively longer. Atropine or a pacemaker will be necessary if the patient is symptomatic. 16 . Narrow complex (QRS duration 0. Inc.ed4nurses. All complexes look the same Digoxin can slow conduction through the AV-node and cause this type of block.42 seconds). The characteristics of a Mobitz Type I second-degree block can be found in the 5-step analysis: Step 1.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. or Wenckebach. A P-wave is in the T-wave of the second complex and a third complex is not conducted causing the delay between complex two and complex three.10 seconds) Step 5. Therefore digoxin should be held. notice how the PR-interval is long in the first complex (0. until a QRS is dropped. until a QRS complex is dropped. Irregular Step 3.
P-waves will be regular and flow through the strip. Be prepared to administer ACLS if the patient decompensates. but are not coordinated with the ventricles (QRS). but a pacemaker may be required to increase the heart rate. but they are not conducted to the ventricles and there is no relationship between the P-wave and the QRS complex. All complexes look the same The patient will probably be symptomatic due to the slow ventricular response and loss of the atrial kick. Regular Step 3. Treatment includes administering atropine. 17 . The atria may be contracting (P-wave present). The 5-step analysis would identify the following characteristics: Step 1. www. No coordination between P-wave and QRS Step 4. Wide complex (QRS duration 0. Rate: <60 Step 2.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.ed4nurses. The QRS complex is originating in the ventricle and typically has a very slow rate. Inc.16 seconds) Step 5.com Third-degree AV-Block Loss of all communication between the atria and ventricles is called a third-degree AV-block.
procainamide. Wide complex (QRS duration 0. and sotalol are used to convert v-tach. or procainamide. and administration of epinephrine. If the patient has a pulse and a stable blood pressure the rhythm will be converted using medications. Rate: 100-220 Step 2. amiodarone. cardiopulmonary resuscitation. call a code! Treatment includes immediate defibrillation. The rhythm will be fast (>100 beats per minute). All complexes look the same Treatment depends on whether there is a pulse. If the patient does not have a pulse. www.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.12 seconds) Step 5.ed4nurses. 18 . Inc. If the patient has a pulse. No P-waves Step 4. and have a wide QRS complex. but the blood pressure is unstable then cardioversion is performed and followed by lidocaine.com Ventricular Tachycardia A rapid rate that comes from the ventricles is called ventricular tachycardia (Vtach). The 5-step analysis would identify: Step 1. regular. Regular Step 3. Lidocaine.
Rate: none detectable Step 2. Immediate treatment with defibrillation is associated with improved outcomes. procainamide. Complexes look different There is no coordinated activity of the heart during V-fib. Characteristics from the 5-step analysis include: Step 1. or wavy pattern to the baseline without QRS complexes.ed4nurses. and the patient will have no pulse or blood pressure. Irregular Step 3. amiodarone. The rhythm strip will show a saw-tooth. Lidocaine. Inc. If defibrillation does not convert the patient back to a stable rhythm. or magnesium may be helpful pharmacologic agents to convert V-fib. then cardiopulmonary resuscitation should be started and epinephrine should be administered.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Wide. www. 19 . No P-wave or QRS Step 4.com Ventricular Fibrillation Loss of all coordinated activity of the heart results in ventricular fibrillation (V-fib). bizarre. chaotic complexes Step 5.
P-waves may be present Step 4. www.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.ed4nurses. therefore asystole should be confirmed in two leads. Inc. The characteristics of asystole are: Step 1. Cardiopulmonary resuscitation should be started at once. A flat-line EKG strip can also be obtained if the lead wires are not properly connected. Rate: none Step 2. This patient will have neither pulse nor blood pressure. QRS complexes absent Step 5. The EKG strip will show a flatline. as illustrated in the strip below. Flat line Step 3. followed by epinephrine and atropine. No electrical or mechanical activity Loss of electrical activity corresponds to loss of mechanical activity. Turn the dial on your monitor to a different lead to confirm asystole.com Asystole No electrical activity of the heart is called asystole. 20 . A pacemaker may also be helpful in stimulating contraction.
Practice using the system on every strip you can.com Pulseless Electrical Activity When there is electrical activity of the heart. 21 . Immediate cardiopulmonary resuscitation. there will be no pulse or blood pressure. Rate: varies Step 2. This happens in cardiac tamponade. In PEA there is electrical activity of the heart but no mechanical activity. P-waves may be present Step 4.ed4nurses. Treatment of any abnormal rhythm depends on whether the patient is symptomatic. However. Monitor his blood pressure to find out. it is often a ventricular rhythm. The characteristics from our 5-step analysis will show: Step 1. If the patient has cardiac tamponade. It is also important to correct the mechanical cause. This phenomenon is called pulseless electrical activity (PEA). May be regular or irregular Step 3. though. followed by administration of epinephrine and atropine is the treatment of choice. That way the abnormal findings will really stand out when you see them. but no mechanical activity. QRS complex present Step 5. but there is no pulse. Inc. The EKG will look OK. tension pneumothorax. Be sure to notify the physician of any changes in cardiac rhythm. and chest trauma. Even with an abnormal rhythm he may still maintain his perfusion and no treatment will be immediately necessary. Summary The 5-steps to Rhythm Strip Interpretation is a simple and accurate system to help you rapidly identify abnormal rhythm strips. No detectable pulse or B/P with electrical activity Treatment is necessary because there is no mechanical activity and therefore no pulse or blood pressure. Any type of EKG rhythm could be present.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. PEA can be caused by compression of the heart by fluid. CPR and medications will not deliver a stable blood pressure until the tamponade is corrected. www.
Slowed conduction d. No conduction 3. 6 seconds 5. Long PR interval 7. Hypokalemia 2. Missed beats d. Indicates conduction through pacemakers c. Why is it important that all the QRS complexes look the same? a. PR interval 22 . Indicates abnormal conduction 4. Rhythm b. 0. www. Hypertension b. Rapid conduction c. Indicates conduction through normal pathways b.22 seconds d. Long QRS duration b. A wide QRS complex indicates: a.02 seconds b. Rate c. PR interval d. A normal PR-interval is: a. Fast rate c. The primary characteristic of supraventricular tachycardia (SVT) that makes it unstable is: a. Inc.com Post-test 1. A first-degree heart block may result in: a. Shape of complex d.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses.18 seconds c.ed4nurses. Indicates that the monitor is working d. 0. Shape of complex c. Rhythm b. In sinus tachycardia which of the following variables is abnormal? a. Rate 6. Normal conduction b. EKG rhythms with a rate of greater than 100 or less than 60 may be associated with: a. Hyperkalemia c. 0. Hypotension d.
c 2. d 6. The condition that will result in a EKG rhythm on the monitor. Wrong lead selected c. Disconnected lead d. www. CPR d. but no pulse or blood pressure is called: a. a 7. What common complication can imitate asystole on the monitor? a. Initial emergent treatment for ventricular fibrillation is: a. Lidocaine 9. Third-degree block c. Asystole b. a 9. 10. c.ed4nurses. a 4. Dead battery in monitor 10. c 3. d 23 . Ventricular fibrillation (VF) d. Unplugged monitor b.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. Pulseless electrical activity (PEA) Answers: 1. Defibrillation b. A flat-line on the monitor may be asystole. Epinephrine c.com 8. b 8. b 5. Inc.
2004. Inc.ed4nurses. Thank you for using 5-Steps to Rhythm Strip Interpretation! Brought to you by: Supercharge your career at www.5 Steps to Rhythm Strip Interpretation © 2003 Ed4Nurses. 2004. timesavers and updates at: www. Accessed February 22.ed4nurses. On-line: The EKG Site: http://www.com Additional Resources Book: McPhee. T.edu/cardiacep/CardiacEP2003_files/frame.com.the-ekg-site.asp.com. 2004. www. ECG interpretation made incredibly easy. and support you! Get FREE nursing news. EKG rounds: http://www. motivate.com/ekg/ekg.uvm.com with programs designed to inspire. (1997).mdchoice. tips. 24 . EKG presentation: http://physioweb.nurses-newswire. Accessed January 6.htm. Accessed January 6.med. Springhouse: Springhouse. A.