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 I 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 .

22 sec .12 to 0.20 or 0. internodal. His purkinje conduction – Duration 0.STANDARD 12 LEAD ECG P-R Interval – Intraatrial.

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. The slower the heart rate. – Generally. measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-r intervals. – For atrial rhythm. the more acceptable the variation.12 seconds (3 small boxes) is acceptable. . measure the distance between 2 consecutive P-P intervals. a variation of up to 0.

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 I } 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 0.20 second. – Is the PR interval of conducted beats constant or does it vary? .12 or more than 0. conduction followed an abnormal pathway or the impulse was delayed in the area of the AV node.

– Do the QRS’s occur uniformly throughout the strip? . it is presumed to be supraventricular in origin. it is probably ventricular in origin.12 second (wide).ANALYZING A RHYTHM STRIP Is the QRS narrow or wide? – What is the duration of the QRS complex? • If it is 0. • If it is greater than 0.10 second or less (narrow).

the mechanism (bradycardia).ANALYZING A RHYTHM STRIP Interpret the rhythm – Specifying the site where the dysrhythmia originated (sinus). and the vetnricular rate. “sinus bradycardia with a ventricular response (rate) of 38/min.” . – For example.

III. AVL – High lateral II.ANALYZING RHYTHM STRIP Localization I. AVF – Inferior I AVL AVR AVF .

V2 – Septal V3.V6 – Apicolateral V1-V3 or V4 – Anteroseptal V3 or V4-V6 – Anterolateral .V5.V4 – Anterior V1-V6 – Extensive anterior I.AVL.V6 .Lateral V5.ANALYZING THE RHYTHM STRIP Localization V1.

ANALYZING A RHYTHM STRIP How is the rhythm clinically significant? .

.

normal shape. . 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. upright.10 second or less.20 second QRS 0. one preceding each QRS complex PR interval 0.12-0.NORMAL SINUS RHYTHM Rate Rhythm 60-100 beats per minute Atrial regular Ventricular regular P waves Uniform in appearance.

.

one preceding each QRS complex 0. If greater than 0. normal shape.12-0.20 second 0. upright.10 second or less. 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.10 second in duration. .Sinus Rhythms Normal Sinus Rhythm Rate Rhythm P waves PR interval QRS 60-100 beats per minute Atrial regular Ventricular regular Uniform in appearance.

.

20 second Usually 0. one preceding each QRS complex 0. upright.12-0.10 second or less . normal shape.Sinus Rhythms Sinus Bradycardia Rate Rhythm P waves PR interval QRS Less than 60 beats per minute Atrial regular Ventricular regular Uniform in appearance.

.

normal shape. upright.Sinus Rhythms Sinus Tachycardia Rate Rhythm P waves PR interval QRS Usually 100-160 beats per minute Atrial regular Ventricular regular Uniform in appearance. one preceding each QRS complex 0.10 second or less .20 second Usually 0.12-0.

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 .

.

one preceding each QRS complex 0.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.20 second Usually 0.10 second or less . normal shape.12-0.

.

12-0.20 second Usually 0.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. one preceding each QRS complex 0.10 second or less . normal shape.

.

one preceding each QRS complex 0.12-0. Uniform in appearance.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.10 second or less . normal shape.20 second Usually 0. upright.

.

flattened. • 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. The early P wave may or may not be followed by a QRS complex . notched or pointed 3.Atrial Rhythms Premature Atrial Complexes 1. 2. partly negative).

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

.

12 second when the pacemaker site is nearer the AV junction Usually less than 0. . biphasic. The QRS of the PAC is similar to those of the underlying rhythm unless the PAC is abnormally conducted. or lost in the preceding T wave Varies from 0.12-0.10 second but may be prolonged. pointed. notched.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.20 second when the pacemaker site is near the SA node. 0.

Atrial Rhythms Vagal Maneuvers Vagal maneuvers – are methods used to stimulate baroreceptors in the internal carotid arteries and the aortic arch. . bilateral carotid pressure should never be performed. 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. Acetylcholine slows conduction in the AV node. Stimulation of these receptors results in reflex stimulation of the vagus nerve and release of acetylcholine.

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 .

.

Usually not measurable because the P wave is difficult to distinguish from the preceding T wave.20 second. P waves are usually identifiable at the lower end of the rate range but are seldom identifiable at rates above 200. the RR interval will usually measure 0. pointed. May be lost in the preceding T wave.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. or biphasic).12-0. PR interval QRS . notched.10 second unless an intraventricular conduction defect exists. Less than 0. If P waves are seen.

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 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 rhythm is termed multifocal (or chaotic) atrial tachycardia. and direction may change from beat to beat.Atrial Rhythms Wandering Atrial Pacemaker (Multiformed Atrial Rhythm) Rate Rhythm P waves 60-100. Atrial – irregular Ventricular . At least three different P waves are required for a diagnosis of wandering atrial pacemaker Variable Usually less than 0. shape. If the rate is greater than 100 beats per minute.irregular Size.10 second unless an intraventricular conduction defect exists PR interval QRS .

.

Rhythm P waves PR interval QRS .10 second but may be widened if flutter waves are buried in the QRS complex or if an intraventricular conduction defect exists.Atrial Rhythms Atrial Flutter Rate Atrial rate 250-350 beats per minute. The ventricular rate will usually not exceed 180 beats per minute due to the intrinsic conduction rate of the AV junction. ventricular rate variable – determined by AV blockade. saw-toothed “flutter waves” Not measurable Usually less than 0. Atrial regular Ventricular may be regular or irregular Not identifiable P waves.

.

10 second but may be widened if an intraventricular conduction defect exists. fibrillatory waves present. Not measurable Usually less than 0. No identifiable P waves. a regular ventricular rhythm may occur because of digitalis toxicity. ventricular rate variable Ventricular rhythms usually very irregular.Atrial Rhythms Atrial Fribrillation Rate Rhythm P waves PR interval QRS Atrial rate usually greater than 350-400 beats per minute. . Erratic wavy baseline.

.

12 second. Slurred upstroke of the QRS complex (delta wave) is often seen in one or more leads) . Regular unless associated with atrial fibrillation Normal and upright unless WPW is associated with atrial fibrillation If P waves are seen. the rate is usually 60-100 beats per minute.12 second Usually greater than 0.Atrial Rhythms Wolff-Parkinson-White (WPW) Syndrome Rate Rhythm P waves PR interval QRS If the underlying rhythm is sinus in origin. less than 0.

.

.

.

or after the QRS If visible. QRS .Junctional Rhythms Premature Junctional Complexes Rate Rhythm P waves PR interval Usually normal. III. If no P wave occurs before the QRS. there will be no PR interval.12 second.10 second or less unless an intraventricular conduction defect exists. the PR interval will be usually less than or equal to 0. AVF If the P wave occurs before the QRS. Usually 0. but depends on the underlying rhythm Essentially regular with premature beats May occur before. the P wave is inverted in leads II. during.

.

or after the QRS If visible. the PR interval will be usually less than or equal to 0.12 second. but depends on the underlying rhythm Essentially regular with LATE beats May occur before. QRS .10 second or less unless an intraventricular conduction defect exists. If no P wave occurs before the QRS. Usually 0. during.Junctional Rhythms Junctional Escape Beat Rate Rhythm P waves PR interval Usually normal. III. the P wave is inverted in leads II. AVF If the P wave occurs before the QRS. there will be no PR interval.

.

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. QRS . during. AVF If the P wave occurs before the QRS. the P wave is inverted in leads II. or after the QRS If visible. Usually 0.12 second. If no P wave occurs before the QRS. the PR interval will be usually less than or equal to 0.10 second or less unless an intraventricular conduction defect exists. there will be no PR interval. III.

.

12 second. the PR interval will be usually less than or equal to 0. there will be no PR interval. the P wave is inverted in leads II. If no P wave occurs before the QRS. or after the QRS If visible. III.10 second or less unless an intraventricular conduction defect exists.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. QRS . during. Usually 0. AVF If the P wave occurs before the 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 .

.

there will be no PR interval.10 second or less unless an intraventricular conduction defect exists. Usually 0. If no P wave occurs before the QRS. III. AVF If the P wave occurs before the QRS. the P wave is inverted in leads II. QRS . or after the QRS If visible. during. the PR interval will be usually less than or equal to 0.12 second.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.

.

12 second. Wide and bizarre. There is no P wave associated with the PVC None with the PVCs because the ectopic beat originates in the ventricle Greater than 0. If the PVC is an interpolated PVC. .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. the rhythm will be regular. T wave frequently in opposite direction of the QRS complex.

5.Ventricular Rhythms Patterns of PVCs 1. 4. 2. 3. 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 .

.

.

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

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) .

.

Greater than 0. Irregular. There is no P wave associated with escape beat. None with the escape beat because the complex originates from the ventricles.Ventricular Rhythms Ventricular Escape Beat Rate Rhythm P waves PR interval QRS Atrial and ventricular rate dependent upon the underlying rhythm.12 second. The ventricular escape beat occurs LATE. . T wave deflection is opposite that of the QRS complex. after the next expected sinus beat.

.

T wave deflection is in the opposite direction of the QRS.12 second.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. .

.

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

.

Ventricular Rhythms Ventricular Tachycardia (VT) Rate Rhythm P waves Atrial rate not discernible. Often difficult to differentiate between the QRS and the T wave. if present they have no set relationship to the QRS complexes – appearing between the QRS’s at a rate different from that of the VT. None Greater than 0. PR interval QRS .12 second. ventricular rate 100-250 beats per minute Atrial rhythm not discernible Ventricular rhythm is essentially regular May be present or absent.

amphetamines) .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.Ventricular Rhythms VENTRICULAR TACHYCARDIA .

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

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

.

12 second. ventricular rate 150-250 beats per minute Atrial not discernible Ventricular may be regular or irregular None None Greater than 0.Ventricular Rhythms Torsades de Pointes (TdP) Rate Rhythm P waves PR interval QRS Atrial rate not discernible. 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 .

Indications: • Unstable ventricular tachycardia with a pulse • Pulseless ventricular tachycardia • Ventricular fibrillation • Sustained Torsades de Pointes . Defibrillation is a random delivery of energy – there is no relation of the discharge of energy to the cardiac cycle.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.

.

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

.

digitalis) .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. beta-blockers. calcium channel blockers.

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 (P’s plot through) Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more P’s than QRS’s). 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

.

10 second or greater. Normal in size and shape. Atrial regular (P’s plot through) Ventricular irregular. Usually 0. QRS . Ventricular rate is often slow. Some P waves are not followed by a QRS complex (more P’s than QRS’s). Within normal limits or prolonged but always constant for the conducted beats. Type II (Mobitz) Rate Rhythm P waves PR interval Atrial rate is greater than the ventricular rate. periodically absent after P waves. There may be some shortening of the PRI that follows a nonconducted P wave.Atrioventricular Blocks Second-Degree AV Block.

.

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

.

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