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NORMAL SINUS RHYTHM
EKG Criteria Rate: 60-100 bpm. Rhythm: Regular. P wave: look the same PRI: .12-.20 seconds QRS: .08-.12 seconds narrow unless effected by underlying anomoly
EKG Criteria Rate: <60 bpm. Rhythm: Regular generally. Pacemaker: SA node P wave: Present, all originating from SA node, all look the same. PRI: <.20 seconds and constant. QRS: Normal, .08-.12 seconds
EKG Criteria Rate: >100 bpm. Rhythm: Regular, generally. Pacemaker: SA node. P wave: Present and normal, may be buried in T waves in rapid tracings. PRI: .12-.20 seconds, generally closer to .12 QRS: Normal.
SINUS EXIT BLOCK
R-R irregular P-P irregular P before & for every QRS PRI: .12-.20 seconds QRS: .04-.12 seconds
R-R irregular P-P irregular P before & for every QRS PRI: .12-.20 seconds QRS: .04-.20 seconds Missing PQRS complex
SICK SINUS SYNDROME
Electrocardiogram exhibiting alternating patterns of bradycardia and tachycardia as seen in patients with sick sinus syndrome
PREMATURE ATRIAL CONTRACTION
EKG Criteria Rate: Underlying rhythm. Rhythm: Irregular with PACs. Pacemaker: Ectopic atrial pacemaker outside SA node. P wave: Ectopic P wave present, generally different than normal SA P wave. PRI: Generall normal range 120-200 msec, but differ from underlying rhythm. QRS: Same as underlying rhythm
Undulating baseline replaces P waves Rhythm: Irregularly irregular
EKG Criteria Rate: 250 - 350 bpm (atrium) Rhythm: Atrial rate regular, ventricular conduction 2:1 to 8:1 Pacemaker: Reentrant circuit rhythm located in the right atrium P wave: Saw-tooth or picket fence PRI: Constant onset
Cardioversion was done to convert Atrial Flutter to Sinus Rhythm
P before & every QRS PRI: .12-.20 seconds QRS: .08-.12 Can come in runs or bursts
MULTIFOCAL ATRIAL TACHYCARDIA-MAT-WAP
R-R may be a little irregular due to different foci in atrial conduction P-P may be a little irregular due to different foci in atrial conduction P before & for every QRS of underlying rhythm Different shaped P waves due to changes in conduction foci PRI: usually within .12-.20 seconds QRS: 04.-.12 seconds Different shaped P waves due to changes in conduction foci
EKG Criteria Rate: 40 - 60 bpm Rhythm: Regular Pacemaker: Atrioventricular junction P wave: If present, negative in lead 2 PRI: .12 seconds or less QRS: .08-.12 seconds, unless prolonged by aberrant conduction
R-R regular; rate >100 P-P regular; rate >100 (may or may not have visable P at fast rate P wave inverted, my come before, during or after QRS If P is with T, it will NOT peak the T
PREMATURE JUNCTIONAL CONTRACTION
EKG Criteria Rate: Underlying rhythm Rhythm: Irregular with PJC's Pacemaker: Ectopic junctional pacemaker P wave: If present, negative in Lead 2 PRI: .12 seconds or less QRS: .08-.12 seconds, unless prolonged by aberrant conduction
FIRST DEGREE AVB
EKG Criteria Rhythm: Regular PRI: >.20 seconds
SECOND DEGREE-MOBITZ II
EKG Criteria PRI: Constant on conducted complexes until a sudden block of AV conduction. That is, a P wave is abruptly not followed by a QRS
SECOND DEGREE-WENCHEBACH-MOBITZ I
EKG Criteria Rhythm: Irregular PRI: Progressive lengthening of PRI until dropped beat. A clue to Wenckebach is that the QRS's appear to occur in groups
THIRD DEGREE AVB
There is no fixed temporal relationship between P waves and QRS complexes due to the existence of two independent pacemakers, one in the SA node (or in the atria) which controls the beating of atria
and other in the AV junction (or in the ventricles) which controls the beating of ventricles. When the atria are beating faster than the ventricles, AV dissociation is due to complete AV block; when the ventricles are beating faster than the atria, AV dissociation is due to ectopic tachycardia (junctional or ventricular). In complete AV dissociation no atrial impulse is conducted to the ventricles; in incomplete AV dissociation some atrial impulses may be conducted to the ventricles resulting in ventricular captures.
RIGHT BUNDLE BRANCH BLOCK
When the right bundle branch is blocked, activation of the right ventricle begins when electrical activity “spills over” from the left ventricle. Depolarization of the right ventricle is delayed. The QRS is prolonged (over 0.1 sec) in right bundle branch block (RBBB). This extra length of the QRS is caused by late activation of the right ventricle, which is then seen after the left ventricle activity. Normally, right ventricle activity is not seen, as it is overshadowed by the larger left ventricle. In RBBB, a typical RsR’ wave occurs in lead V1. Also, a wide S wave is seen in leads I, V5, and V6, along with a broad R in lead R. When RBBB occurs in a patient with old or new septal infarction, the initial septal R wave may not be seen in lead V1. Instead, a wide QR complex is seen. When the typical RsR’ wave is seen in V1 without widening of the QRS complex, this is called “right ventricular conduction defect” rather than RBBB
LEFT BUNDLE BRANCH BLOCK
LBBB usually indicates widespread cardiac disease. When the left bundle is blocked, activation of the left ventricle proceeds through the muscle tissue, resulting in a wide (.12 msec) QRS complex. In left bundle branch blockage (LBBB), the QRS usually has the same general shape as the normal QRS, but is much wider and may be notched or deformed. Voltage (height of the QRS complex) may be higher. In LBBB, look for wide (possibly notched) R waves in I, L, or V5-V6, or deep broad S waves in V1-V3. There is left axis deviation. “Septal Q waves” sometimes seen in I, L, and V5-V6 disappear in LBBB. T waves in LBBB are usually oriented opposite the largest QRS deflection. That is, where large R waves are seen, T waves will be inverted. ST segment depression may occur.
EKG Criteria Rate: 140 - 220 bpm Rhythm: Regular Pacemaker: Reentry circuit Accessory pathway: Normal or short (if down accessory pathway) A-V nodal reentry: Hidden in or at end of QRS PRI: Depends on location of circuit QRS: Normal if accessory pathway used - prolonged (>120 msec) with delta wave
QRS ETIOLOGY SVT vs VT
PREMATURE VENTRICULAR CONTRACTION
EKG Criteria Rhythm: Irregular QRS: Is not normal looking. Broadened, greater than 0.12 seconds. P waves are usually obscured by the QRS, ST segment, or T wave of the OVC. The P wave may sometimes be seen as notching during the ST segment or T wave.
EKG Criteria QRS: Normal QRS complex followed by (PVC) in patterns of 2
VENTRICULAR ESCAPE BEAT
EKG Criteria No normal looking QRS complexes, often bizzare with notching. Width of QRS>0.12 sec. ST segment and T wave are opposite polarity to the QRS. Sinus node may be depolarizing normally. There is usually complete AV dissociation. P waves are sometimes seen between QRS complexes. They have no impact on the QRS complexes. Rate: Generally 100 to 220 bpm Rhythm: Generally regular, on occassion can be modestly irregular. TORSADES
P wave obscured if present QRS wide and bizarre morphology Conduction as with PVCs Rhythm Irregular Paroxysmal–starting and stopping suddenly The upward and downward deflection of the QRS complexes around the baseline. The term Torsade de Pointes means "twisting about the points." ASYSTOLE
EKG Criteria Complete absence of ventricular electrical activity. Occasional P waves or erratic ventricular beats may be seen. These patients will be pulseless. Treatment must be immediate if the patient is to have any chance at resusctiation. Rate: None Rhythm: None
Sometimes there is a few or more seconds of Asystole as in the above strip of over 5 seconds. IDIOVENTRICULAR
EKG Criteria Rate: 40 bpm Rhythm: Regular P wave: Regular if present PRI: If present, varies (no relationship to QRS complex [AV dissociation]) QRS: QRS interval >.12 seconds wide and bizarre VENTRICULAR FIBRILLATION
EKG Criteria Rate: Very rapid, too disorganized to count. Rhythm: Irregular, waveform varies in size and shape No normal QRS complexes. Absent ST segments, P waves, T waves.
PACERS & ICD
Note the pacemaker spikes before the QRS complexes. ATRIAL PACED
Pacemaker spikes are seen before each QRS complex and initiate a tiny P wave MVP OPERATION
Paced rhythm with single failure to capture PACER FAILURE
ICD Below are 2 ways for Ventricular Tachycardia to be terminated having a ICD.
Ventricular Tachycardia with ICD pacer overriding the VT rate to convert back to sinus rhythm
Ventricular Tachycardia with ICD firing (without the pacer override) conversion.
Hyperkalemia with Agonal Rhythm The QRS complexes here are ventricular escape beats as noted by the severe bradycardia (inherent ventricular rate in the 40s), wide complex indicating origin is in the ventricle, and lack of a preceding p-wave
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