# ECG Rhythm Interpretation

ECG Basics NUR 222

Waveforms and Intervals

Normal ECG findings
Waveform/Interval P PR QRS T ST QT Less than ½ R-R interval .12 - .20 seconds .08 - .12 seconds Normal Duration Correlation to conduction system Sinus node/atrial firing Depolarization of atria Depolarization of ventricles Repolarization of ventricles Indicator of ischemia or injury Prolonged- May be side effect of antiarrhythmics; May cause V-Tach

The ECG Paper • Horizontally – One small box .0.5 mV .0.04 s – One large box .20 s • Vertically – One large box .0.

. NOTE: the following strips are not marked but all are 6 seconds long.The ECG Paper (cont) 3 sec 3 sec • Every 3 seconds (15 large boxes) is marked by a vertical line. • This helps when calculating the heart rate.

ECG Rhythm Interpretation How to Analyze a Rhythm .

Rhythm Analysis • • • • • Step 1: Step 2: Step 3: Step 4: Step 5: Calculate rate. Assess the P waves. . Determine PR interval. Determine regularity. Determine QRS duration.

Determine QRS duration.Rhythm Analysis • • • • • Step 1: Step 2: Step 3: Step 4: Step 5: Calculate rate. Assess the P waves. Determine PR interval. Determine regularity. .

Systematic Approach • Rate – Fast or slow ? • Rhythm – Regular or Irregular ? • P waves – Present? – P wave for every QRS • Intervals – PR & QRS .

Interpretation? 9 x 10 = 90 bpm . – Reminder: all rhythm strips in the Modules are 6 seconds in length. then multiply by 10.Step 1: Calculate Rate 3 sec 3 sec – Count the # of R waves in a 6 second rhythm strip.

Step 2: Determine regularity R R • Look at the R-R distances (using a caliper or markings on a pen or paper). • Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular? Interpretation? Regular .

Step 3: Assess the P waves • Are there P waves? • Do the P waves all look alike? • Do the P waves occur at a regular rate? • Is there one P wave before each QRS? Interpretation? Normal P waves with 1 P wave for every QRS .

5 boxes) Interpretation? 0.Step 4: Determine PR interval • Normal: 0.20 seconds.12 seconds .0. (3 .12 .

(1 .04 .Step 5: QRS duration • Normal: 0.0.08 seconds .12 seconds.3 boxes) Interpretation? 0.

08 s Normal Sinus Rhythm .12 s 0.Rhythm Summary • Rate • Regularity • P waves • PR interval • QRS duration Interpretation? 90-95 bpm regular normal 0.

ECG Rhythm Interpretation Normal Sinus Rhythm .

Rhythms that do not conduct via the typical pathway are called arrhythmias.Normal Sinus Rhythm (NSR) • Etiology: the electrical impulse is formed in the SA node and conducted normally. • This is the normal rhythm of the heart. .

sinus bradycardia or an arrhythmia .100 bpm • Regularity regular • P waves normal • PR interval 0.12 .0.20 s • QRS duration 0.04 .0.NSR Parameters • Rate 60 .12 s Any deviation from above is sinus tachycardia.

Arrhythmia Formation Arrhythmias can arise from problems in the: • Sinus node • Atrial cells • AV junction • Ventricular cells .

SA Node Problems The SA Node can: • fire too slow • fire too fast Sinus Bradycardia Sinus Tachycardia Sinus Tachycardia may be an appropriate response to stress. .

Atrial Cell Problems Atrial cells can: • fire occasionally from a focus Premature Atrial Contractions (PACs) • fire continuously due to a looping re-entrant circuit Atrial Flutter .

Atrial Cell Problems Atrial cells can also: • fire continuously Atrial Fibrillation from multiple foci or Atrial Fibrillation fire continuously due to multiple micro re-entrant “wavelets” .

AV Junctional Problems The AV junction can: • fire continuously Paroxysmal due to a looping Supraventricular re-entrant circuit Tachycardia • block impulses AV Junctional Blocks coming from the SA Node .

Ventricular Cell Problems Ventricular cells can: • fire occasionally Premature Ventricular from 1 or more foci Contractions (PVCs) • fire continuously Ventricular Fibrillation from multiple foci • fire continuously Ventricular Tachycardia due to a looping re-entrant circuit .

ECG Rhythm Interpretation Sinus Rhythms and Premature Beats .

10 s Interpretation? Sinus Bradycardia .Rhythm #1 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 30 bpm regular normal 0.12 s 0.

Rate < 60 bpm • SA Node depolarizes slower than normal: otherwise normal conduction .Sinus Bradycardia • Deviation from NSR .

16 s 0.08 s Interpretation? Sinus Tachycardia .Rhythm #2 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 130 bpm regular normal 0.

not a primary arrhythmia.Sinus Tachycardia • Deviation from NSR . impulse is conducted normally. . • Response to physical or psychological stress.Rate > 100 bpm • SA node is depolarizing faster than normal.

Premature Beats • Premature Atrial Contractions (PACs) • Premature Ventricular Contractions (PVCs) .

08 s Premature Atrial Contractions Interpretation? .Rhythm #3 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 70 bpm occasionally irreg. 2 premature beats 0.14 s (except 2) 0.

the PR interval. and the timing are different than a normally generated pulse from the SA node. therefore the contour of the P wave.Premature Atrial Contractions • Deviation from NSR – These ectopic beats originate in the atria (but not in the SA node). .

Atrial Impulses • When an impulse originates anywhere in the atria (SA node.0.12 s). . the QRS will be narrow (0. AV node.04 . atrial cells. Bundle of His) and then is conducted normally through the ventricles.

14 s 0.Rhythm #4 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 60 bpm occasionally irreg.08 s (7th wide) Interpretation? Sinus Rhythm with 1 PVC . none for 7th QRS 0.

they are called “multifocal PVC’s”. – Multiple premature beat s that all look alike-are called “unifocal PVC’s”.PVCs • Deviation from NSR – Ectopic beats originate in the ventricles resulting in wide and bizarre QRS complexes. When they look different. .

conduction through the ventricles will be inefficient and the QRS will be wide and bizarre. .Ventricular Impulses • When an impulse originates in a ventricle.

Ventricular Conduction Normal Signal moves rapidly through the ventricles Abnormal Signal moves slowly through the ventricles .

ECG Rhythm Interpretation Supraventricular and Ventricular Arrhythmias .

Supraventricular Arrhythmias • Atrial Fibrillation • Atrial Flutter • Paroxysmal Supraventricular Tachycardia .

06 s Interpretation? Atrial Fibrillation .Rhythm #5 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 100 bpm irregularly irregular none none 0.

Atrial Fibrillation • Deviation from NSR – No organized atrial depolarization. so no normal P waves (impulses are not originating from the sinus node). up to 5-10% if > 80 years old . – Commonly affects 2-4%. – Atrial activity is chaotic (resulting in an irregularly irregular rate).

Rhythm #6 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 70 bpm regular flutter waves none 0.06 s Interpretation? Atrial Flutter .

– Only some impulses conduct through the AV node (usually every other impulse).350 bpm.Atrial Flutter • Deviation from NSR – No P waves. . Instead flutter waves (note “sawtooth” pattern) are formed at a rate of 250 .

08 s Paroxysmal Supraventricular Tachycardia (PSVT) Rate? Regularity? P waves? PR interval? QRS duration? Interpretation? .Rhythm #7 • • • • • 74 148 bpm Regular  regular Normal  none 0.16 s  none 0.

often triggered by a PAC (not seen here) and the P waves are lost.PSVT • Deviation from NSR – The heart rate suddenly speeds up. .

Ventricular Arrhythmias • Ventricular Tachycardia • Ventricular Fibrillation .

12 sec) Interpretation? Ventricular Tachycardia .Rhythm #8 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 160 bpm regular none none wide (> 0.

Ventricular Tachycardia • Deviation from NSR – Impulse is originating in the ventricles (no P waves. at other times no pulse can be felt . wide QRS) • V T can sometimes generate enough cardiac output to produce a pulse.

Rhythm #9 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? none irregularly irreg. none none wide. if recognizable Interpretation? Ventricular Fibrillation .

Ventricular Fibrillation • Deviation from NSR – Completely abnormal. .

conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.Remember • When an impulse originates in a ventricle. .

There will ALWAYS be extra P waves .AV Nodal Blocks • 1st Degree AV Block – PR is longer than .20 sec – All other blocks.

Rhythm #10 • • • • • Rate? Regularity? P waves? PR interval? QRS duration? 60 bpm regular normal 0.08 s Interpretation? 1st Degree AV Block .36 s 0.

20 s .1st Degree AV Block • Deviation from NSR – PR Interval > 0.

1st Degree AV Block • Etiology: Prolonged conduction delay in the AV node or Bundle of His. .

Name that Rhythm .

Normal Sinus Rhythm .

Name that Rhythm .

What’s the Rhythm? .

Sinus Tachycardia .

What’s this Rhythm .

Premature Atrial Contraction .

Name this Rhythm .

Atrial Flutter .

What is this Rhythm? .

Atrial Fibrillation .

What’s this Rhythm? .

Multifocal PVC’s .

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Ventricular Tachycardia .

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Ventricular Fibrillation

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Asystole

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First Degree AV Block .

Questions • ???? .

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