EKG Basics

Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Irregular Rhythms Sinus Arrhythmia irregular rhythm; considered normal

varies with
inhalation. P waves
are all the same!

Wandering irregular rhythm; P

Pacemaker waves CHANGE
shape (bc
pacemaker location
changes). Rate is
LESS than 100bpm

Multifocal Atrial exactly like

Tachycardia (MAT) wandering
pacemaker except
rate is GREATER
than 100bpm

Atrial Fibrillation “irregularly

irregular” ventricular
rhythm, eratic atrial
spikes with no P
waves

Escape Rhthms Atrial Escape pause before Automaticity focus

Rhythm escape beat; can in atria, but NOT SA
see P waves (i think node; rate is 60-80
those are p bpm
waves?)

Idiojunctional/ pause before Automaticity focus

Junctional Escape escape beat; just above AV node;
Rhythm narrow QRS, less P rate is 40-60 bpm
wave (?)

Idioventricular/ pause before Automaticity focus

Ventricular escape beat; wide in ventricles; rate is
Escape rhythm QRS 20-40 bpm

Premature Beats Premature Atrial For all 3 premature

Beat beats: due to
irritable automaticity
This pt
focus suddenly
also
discharging
has
prematurely
RBBB
(embarrassing…)
……………………
……………………

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Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Premature
Junctional Beat

Premature Can be multifocal

Ventricular (different
Contraction morphology to
waves), couplet
(same morphology,
2 right together), or
in runs or multiples

Tachyarrhythmias Paroxysmal Atrial Rate of 150-250 Also called a

Tachycardia (PAT) bpm, irritable atrial Supraventricular
focus discharges at tachycardia
this rate, produces
normal sequence,
sometimes P’
waves visible

PAT with block Rate of 150-250 Also called a

bpm, same as PAT, Supraventricular
but only every other tachycardia
P’ (or more) wave
produces a QRS
complex

Paroxysmal Rate of 150-250 Also called a

Junctional bpm, AV junctional Supraventricular
Tachycardia focus produces a tachycardia
rapid squence of
QRS-T cycles. QRS
complexes may be
a little widened.

Paroxysmal Rate of 150-250

Ventricular bpm from
Tachycardia ventricular focus.
PVC-like, wide
complexes

Atrial Flutter Rate of 250-350

bpm, classic “saw-
tooth” pattern from
rapid atrial firing.
Need many P
waves to get
ventricular
response.
Ventricular Flutter Rate of 250-350 Can lead to v. fib!
bpm from a rapid-
firing ventricular
focus.

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Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Atrial Fibrillation erratic rapid

discharges from
multiple atrial foci
leading to rate of
350-450 bpm. Spiky
baseline. QRS
response is
irregular.
Ventricular erratic rapid Needs IMMEDIATE
Fibrillation discharges from treatment!
multiple ventricular
foci leading to a
rate of 350-450
bpm.

Heart Blocks SA Block SA node misses Looks like escape

one or more cycle; rhythm; be careful
there will be a
pause and then it
will resume normal
pacing.

1st degree AV Prolonged PR Usually doesn’t

Block intervals (more than require tx
0.2s)

2nd degree AV PR interval

Block Type 1 gradually lengthens
(Wenckebach) until there is a
dropped beat (no
QRS)

2nd degree AV PR Interval is the

Block Type 2 same length
(Mobitz) consistently, but
there are dropped
beats (no QRS)

3rd degree/ P waves from SA

Complete AV node. QRS’s from
Block either junctional
(rate would be
40-60 and QRSs
would be narrow)
focus or from
ventricular (rate
would be 20-40 and
QRSs would be
wide) focus

Right Bundle RSR’ with wide

Branch Block QRS in V1 or V2
This is a left
posterior
hemiblock

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Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Left Bundle RSR' with wide Difficult to

Branch Block QRS in V5 or V6 determine infarction
on EKG with LBBB

Anterior axis shifts leftward

Hemiblock to LAD, look for
Q1S3

Posterior Axis shifts rightward

Hemiblock to RAD, look for
S1Q3

Hypertrophy Right Atrial Large diphasic P

Hypertrophy wave with TALL
INITIAL component

Left Atrial Large, diphasic P

Hypertrophy wave with a WIDE
TERMINAL
component

Right Ventricular R wave >> S in V1.

Hypertrophy RAD with widened
QRSs.

Left Ventricular (S wave in V1) + (R

Hypertrophy wave in V5) = more
than 35mm. LAD
with widened
QRSs. Inverted T
waves that slant
downward
gradually, but up
rapidly

Infarction Necrosis Significant Q waves Significant Q waves

ONLY. remain for lifetime
even with old
infarcts.

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Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Injury ST segment ST elevation with

elevation. significant Qs
signifies an ACUTE
process (how you
can tell if it’s an old
infarct or not)

Ischemia T wave inversion. Usually in same

Normally, leads that show
concordant (T wave acute infarction
is up with QRS is
up and v.v.) but not
the case here

Early ST elevation in left

Repolarization chest leads (V5/V6)

Electrolytes Hyperkalemia Wide, flat P waves,

wide QRS complex,
PEAKED T WAVES

Hypokalemia Flat T waves,

Prominent U wave

Hypercalcemia Short QT

Hypocalcemia Prolong QT

Drugs Digitalis T waves depressed

or inverted, QT
interval shortened.
Think “Dali’s
mustache”

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Category Type of “rhythm” Look for: What it looks like: Clinical Pearls?

Quinidine Wide, notched Ps, Can lead to

Wide QRS, long QT Torsades de
interval, deep ST, U pointes!!! (any drug
wave that blocks
potassium
channels, or even
low serum
potassium)