Labeling of the EKG waveform Look at the waveform below to reaquaint yourself to the various parts of the EKG waveform. Isoelectric Line - The "base line". The line that starts when the "T* wave ends ‘and finishes where the *P* wave begins. ~p" wave - This is the frst wave you see on the cardiac cycle. Its indicative of atrial depolarization. "Q” wave - This isthe first negative deflection after the "P" wave "R™ wave ~ This s the first positive defelction following the "P* wave "S" wave ~ First negative deflection after the "R" wave. ‘The "QRS" together signifies ventricular depolarization. ST" Segment - The line between the end of the "S* wave and the beginning of the" wave. "3" Point - This Is the point used to determine If there has been any changes in the ST segment. To determine the J point, find where the "S* turns towards the “T" wave. Look at the picture below. 2.5 Hotter 20"7" wave - Represents ventricular repolarization. "This is a very vulnerable thme during the cardiac cycie. U" wave - Small low amplitude wave that follows the "T", When present, could be indicative of hypokalemia. RHYTHM REVIEW When approaching an EKG for the purposes of interpretation It's important to do it ina systematic fashion. Ask yourself the following questions: Is the rate fast or slow? ‘Are the atrial and ventricular rates the sarne? ‘Are the P-P Interval and the R-R interval reguiar or irregular? fits regular, fs it irregularly imequiar? Is there a P- wave before every QRS? ‘Are the P-waves and QRS complexes identical and normal in configuration? ‘Are the P-R and QRS Intervals within ormel limits? $0.5 Hank 21First Determine the Rate ‘There are a couple of different ways to determine the heart rate. Count the number of "RT waves in a 6 - second strip and then multiply by 10. “This method is not very accurate but can be used to get a quick estimate. ‘You can determine « six-seuond sip by looking at the EKG paper end finding the time marking on the top as shiown below. On standard paper, the interval between two time markings represents 3 seconds. Count the number of large squares between two consecutive R waves and divide into 300. Or you can memorize the following scale: Large ‘Square ra ary 1 large square 2 large squares 3 large squares 4 large squares 5 large squares Glarge squares 300 bpm 150 bpm 100 bpm 75 bpm 60 bpm 50 bpm Large Square ‘Small Square pets Hane 22“This method ts also very quick but can only be used when the rhythm is regular and Is not very accurate when the rates very fast. 1» The last method that can be used to determine rate is the one that is most accurate but very time consuming. Count the number of small ‘squares bebveen two consecutive "R waves and divide into 1500. Now that we have determined the overall RATE, next we need to look at the various parts ofthe EKG waveform for normalcy. Normal Time Intervals PRinterval- 0.12 - 0.20 seconds QRS Duration- 0.06 - 0.10 seconds QT Interval 0.40 (dependent on the heart rate) Second Determine the Rhythm Look at the rhythm strip from left to right and get a feel for whether ft is regular ‘oF not. It will help if you take an index card oF calipers and mark from "R" wave to "R” wave and see ifthe distance Is constant. If Its, then the rhythm is considered regular. If it varies by 0.12 seconds or three squares on the EKG paper then itis considered irregular. Third Identify and Examine the "P" Waves Look at the "P* waves, There should be one in front of every "QRS" complex. {All "P* waves should look the same in size, shape, and position, Fourth Measure the "PR" Interval ‘Measure from the beginning of the "P* wave to the beginning of the "QRS" ‘complex. A normal "PR" Interval is 0.16 seconds or 4 small squares. Ac1s Heed 3Fifth Measure the "QRS" Complex ‘Measure from the beginning of the "QRS" complex until the end of ft. Count the ‘number of squares. 1 ~ 3 squares fs normal. pets HannoRhythm identification Sinus Rhythms “These are a class of rhythms that originate in the SA node. They travel through ‘out the entire conduction system. ‘The Sinus Rhythms are characterized by the folowing: Acconducted P-wave, This means that there is a P-wave before every QRS. '¢ The P-R interval is between 0.12 and 0.20 seconds or between 3 small boxes and 5 small boxes on the EKG paper. The QRS width should be 0.04 to 0.12 seconds or between 1 small box and 3 small boxes on the EKG paper. Normal Sinus Rhythm: “The criteria for @ Normal Sinus Rhythm Is: ’ Regular ’ {60 ~ 100 beats per minute ’ ‘one before every "QRS" ¢ "PR" Interval - 0.12 -0.20 seconds © QRS~ 0.04 - 0.12 seconds Acts Hentosk 25Sinus Bradycardia ‘¢ Allof the intervals are the same as with Normal Sinus Rhythm, the only difference isthe rate. ‘© The rate for Sinus Bradycordia is less than 60 beats per minute Sinus Tachycardia © Allof the intervals are the same as with Normal Sinus Rhythm, the only difference is the rate. The rate for Sinus Tachycardia Is 100 - 160 beats per minute. ets Heeboo 25Atrial Arrhythmias [Atrial arthytimmias come from ectopic stes in the atria, The "P" wave is not the ‘same as the "P" wave in a sinus rhythm. In slower atrial rhythms, the "P" weve ‘2ppears small, pointed; upright or ft can also be inverted ifthe origination of the impulse is lower in the atrla. In faster atrial rhythms, the "P* wave can be superimposed on the preceding "T™ wave, It can appear: as @ sawtooth or it can be seen as a wavy baseline. Atrial Flutter ++ Rhythm Is regular or irregular ‘+ Atrlal Rate ~ 250 ~ 400 beats per minute (count the “P* waves) Ventricular rete ~ varies ‘+ "P* waves - "V" shaped in a saw tooth pattern "PR" interval - not measurable > "QRS" normal Snel 6.8 Hanan 27Atrial Fibrillation © Rhythm Very irregular Rate Atrial rete: 400 or more but not measurable because unable to discern "P* waves. Ventricular rate varies “pr waves Irregular wavy deflections -fibrilatory waves (F waves) “PRM interval - Not measurable "QRS" Normal pousHeeeteo28AV Junctional Arrhythmias and AY Blocks AV Junctional Archythmia ‘AV 3unctional arrhythmias originate from the area around the AV node. The AV nade can act as the secondary pacemaker in the event the SA node is not functioning. Inherenty, the junctional pacemaker will have a rate of 40 - 60 beats per minute. Junctional Rhythm + Rhythm: Regular # Rate: 40-60 ® "P*vives- Inverted in lead IL. Can occur immeciately before, afer or hidden within the "QRS" complex. ‘+ "PRY interval - Short (0.10 seconds or less) 2 "ORS Norma (010 seconds or less) pets Hatton 29AV Heart Blocks ‘A heart block is an arrhythmia where there is a delayed oF falled conduction of ‘supraventricular impulses through the AV node into the ventricles. ‘The ‘conduction problem can be permanent or it can be temporary. AV Heart Blocks dare classified into First Degree, Second Degree, Types I and Ii, and Third Degree. This dassfication system is based on the area in which the block is located, For example, in First Degree Heart Block, the electrical impulse & delayed in the AV node longer than normal, but all impulses are conducted to the Ventiiles. In second dogree AV Blocks, some impulses are conducted, some are rot. And in Third Degree AV Block, no impulses are conducted from the atria to the ventries. When looking at AV Blocks, use this systematic approach: ‘Assess the regularity ofthe rhythm both atrial and ventricular. Tdentify the *P* waves. ‘Assess the "QRS" complex. Look at width, is it narrow or wide? ‘Assess the relationship between the "P" waves and the "QRS" complex. Ts the "pR” Interval consistent or does it vary? First Degree AV Block @ Rhythm: Regular © Rate: Underiying Rhythm, Usually Sinus ‘+ "P" Waves: Sinus; one "P" wave for every "QRS* ‘© "PR" Interval: Prolonged - greater the 0.20 seconds but does remain constant = "ORS" ‘Normal (0.10 seconds or less) pcxsananet 30Second Degree AV Block, Type I (Weneckebach or Mabitz IZ) © Rlnythm: ¢ Rate: ¢ "P" waves: @ "PR" Interval: © QRS: Atrial ~ Regular Ventricular ~ irregular ial - Underlying Rhythm, Usually Sinus Ventricular - Rate depends on how many impulses are conducted through the AV node, will be less than the atrial rate Sinus PR Interval varies. It progressively lengthens until a "P* wave occurs without @ QRS. ‘Normal (0.10 seconds) pexsttettet 31Second Degree AV Block, Type 1 (Mobitz IX) © Rhythm: Atrial - Regular Ventricular - Regular, unless the AV conduction ratio varies Rater Atrial - Unceriying Rhythm usuelly sinus ‘Ventricular - Depends on number of impuises are conducted through the AV node - will be fess than the atrial rate 8 -"P' Waves: Sinus; two or three "P* waves before each ORS © "PR" Interval: May be normai or prolonged but does remain constant © "QRS": Normal (if block is located in the bundle of Fis) ‘Wide (IF block fs located in the bundle branches) pes Manan 32‘Third Degree AV Block (Complete Heart: Block) © Rhythm: Atrial - regular Ventricular - regular © Rater Arial - usually sinus ‘Ventricular - Usually between 40 - 60 beats per minute if paced by the AV node. Can be 2s low as 30 ~ 40 if paced by the ventricles. ‘2 "P* waves: Sinus "P* waves but no constant relationship between "P* ‘waves and "QRS". @ "PR" Interval: Varies 2 "ORS": Normal (if block is located at level of AV node or bundle of His) Wide (if block fs located at the level of the bundle branches) poxs Hetton 33~ AV Block Comparisons R Interval Constant PR interval Varying First Degree ‘Second Degree, Type T © PR Constant PR Varies ‘8 PR Prolonged PR progressively gets longer unt a ‘2 One P wave to each QRS QRS is dropped ‘¢ Regular atial and ventricular Regular atrial rhythm and irregular rhythm, ventricular rhythm ‘Second Degree Type Tr Third Degree | ¢ PR Constant PR Varies ‘PR normal or prolonged P waves have no constant 3 Two, three, four P waves (or more) | relationship to QRS (found hidden ‘to each QRS: in QRS complexes and T waves) 4 Reguiar atrial rhythm, regular Regular atrial rhythm and reguiar ventricular rhythm (unless ventricular rhythm ‘conduction ratios vary) pctsHettook34Ventricular Arrhythmias, Ventricular arrhythmias originate below the bundle of His in the right or left venir. The electrical impulse arises from the ventricular tissue and spreads through the ventricle in an abnormal way. ‘These types of arrhythmias include Premature Ventricular Contractions (PVC), Ventricular Tachycardia, Ventricular Fibrilation, and Idioventricular Rhythm, Premature Ventricular Contraction (PVC) Rhythm ~ Underiying rhythm is usually regular » Rate= “That of the underlying rhythm 2 "PT waves None associated with the PVC © PRinterval~ Not measurable © QRS Premature, wide (0.12 seconds or greater) and abnormal, looks different than the QRS from the underiying rhythm. PVC's can be unifocal, from the same area ofthe ventricle or be multifocal, from Various areas of the ventricle. “The above example is mutbfocal because the PVCs look diferent (one is upright and one has a negative deflection.) When looking at PYC's you also want to note how often they occur. When they ‘occur every other beat its called bigeminy, when they occur every third beat, its pcxsHebek 3S‘sigeminy. Also, IF the PVC’s occur together as below, they are referred to as a ‘couplet. Tt s important to note these differences because PVC's occurring close together and/or in couplets have a greater chance of turning into Ventricular ‘Tachycardia which can be life threatening. ‘Ventricular Tachycardia Rhythm - Regular + Rate~ 140 ~ 250 beats per minute @ Pwaves - No P waves ¢ PRinterval- Not measurable © QRS- Wide ( greter than or equal to 0.12 seconds) pcisHanoor36‘Torsades de Pointes (Polymorphic VT) © Rhythm~ Regular @ Rate 140 - 250 @ Pwave- None identified % PRInterval- Not measurable 2 QRS- treater than or equal to 0.12 seconds, but it varies from one complex to the next. “The name Torsades de pointes means "Twists of Points". tis called this because it appears as Ifthe rhythm is bwisting around the isoelectric ine. Tt ‘changes from a negative to @ positive polarity with no reguiarity. ial aor \ “Torsades de Pointes seus Hobe 37Ventricular Fibrillation Rhythm- Chaotic - irregular Rate ~ 0 Pwaves- Absent PR Interval- Not Measurable Rs Absent “The deflections that are seen are very chaotic and iregular. They vary in size, shape and height. They may be small which is referred to as fine v-ib or large, which is coarse v-fib. Acts Haack 38Idioventricular Rhythm (also town 2s Ventricutar Escape Beats) Rhythm = Usually regular Rate - 30 ~ 40 beats per minute "pt waves- Absent "PR" Interval Not measurable “ORS ‘Wide (0.12 seconds or greater) ASYSTOLE © Rhythm Absent Rhythm not distinguishable * Rate- ‘Absent @ "Pwaves- None ‘¢ "PR interval - None © "ORS" None ES es Ht 39Pulseless Electrical Activity (PEA) pulseless Electrical Activity is the absence of a palpable pulse but with the | presence of organized electrical activity. PEA is not an actual rhythm Dut fepresents a clinical condition in which the patient is clinically dead, despite the fect that there is an organized rhythm on the monitor. pos ener 40