UNDERSTANDING

ECG

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 NORMAL ECG WAVE FORM DIAGRAM

A normal ECG waveform contains these components:-

• P wave – Represents atrial depolarization
• PR interval – Represents the activity from the
beginning of atrial depolarization to
the beginning of ventricular
depolarization
 NORMAL ECG WAVE FORM DIAGRAM

A normal ECG waveform contains these components:-

• QRS complex - Represents ventricular
depolarization
• ST segment - Represents the end of ventricular
depolarization and the beginning of
ventricular repolarization
• T wave - Represents ventricular repolarization
 ANALYZING ECG
• STEP 1 – DETERMINE THE RHYTHM (IS THE
RHYTHM REGULAR)
• STEP 2 – DETERMINE THE RATE
• STEP 3 – EVALUATE THE P WAVE (ASK YOURSELF)
• STEP 4 – DETERMINE THE DURATION OF PR
INTERVAL
• STEP 5 – DETERMINE THE DURATION OF QRS
COMPLEX
• STEP 6 – EVALUATE THE T WAVE
• STEP 7 - EVALUATE THE ST SEGMENT
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 DETERMINE THE RYTHM

• For atrial rhythm, measure the P-P

intervals—the intervals between
consecutive P waves.
• To determine the ventricular rhythm,
measure the intervals between two
consecutive R waves in the QRS complexes.
 Methods of measuring rhythm
1. Paper-and-pencil
method

2. Caliper method
 DETERMINE THE RATE
Times ten Method
• Simples, quickest and useful if patient heart
rhythm is irregular.
• For this method obtain a 6 second rhythm
strip, then the number of P waves on the strip,
multiply by 10 to get the atrial rate (ten 6 sec
strips = 10 minute).
• Calculate the ventricular rate in the same
manner but count the number of R waves
within the 6 second strip.
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1,500 method
• For regular rhythm
• 1,500 small squares represent 1 minute.
• Count the small squares between identical
points on two consecutive P waves and then
divide 1,500 by that number to get the atrial
rate.
• To obtain the ventricular rate, use the same
method with two consecutive R waves.
Sequence method
• To get the atrial rate, find
a P wave that peaks on a
heavy black line and assign
the following numbers to the next six heavy
black lines: 300, 150, 100, 75, 60, and 50.
• Then find the next P wave peak and estimate the
atrial rate, based on the number assigned to the
nearest heavy black line. Estimate the
ventricular rate the same way, using the R wave.
 P WAVE
P-wave questions:
Are they present?
Do they occur regularly?
Is there one P-wave for
each QRS complex?
Are the P-Waves smooth,
rounded and upright?
Do all P-Waves have similar shapes?
 PR INTERVAL
• Measure the interval from
where the P wave begins
until the beginning of the
QRS complex.
• PR Interval questions:
 Does the PR-Interval fall within the norm of 0.12-
0.20 seconds?
 Is the PR-Interval constant across the ECG tracing?
 QRS COMPLEX
• Measure the QRS interval
from the end of the PR
interval to the end of the
S wave.
• QRS questions:
 Does the QRS interval fall within the range of 0.08-0.12
seconds?
 Are the QRS complexes similar in appearance across the
ECG tracing?
 T Wave
• The T wave question :
It is follows the QRS complex?
Is it round and smooth?
Take note if the waveform is downward
(negative) deflection or of T waves with tall,
pointed peaks.
 ST SEGMENT
• The ST segment is the line that from the end
of the QRS complex to beginning of the T
wave.
• Question on ST segment :
Is it is flat, being neither positive or negative
and relative to the baseline ( isoelectric)?
NORMAL SINUS RYTHM
NSR Rhythm

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Sinus Bradycardia Rhythm

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 MANAGEMENT OF BRADYCARDIA
• This rhythm is often seen as a normal variation in
athletes, during sleep, or in response to a vagal
maneuver or patient on cardiac drug eg digoxin
• If the bradycardia is asymptomatic, vital sign
stable – no treatment needed.
• If the bradycardia symptomatic with
hemodynamically compromised, treat the
underlying cause and give :
Transcutaneous pacing if patient is or
Epinephrine or
Atropine.
Sinus Tachycardia Rhythm

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MANAGEMENT OF SINUS TACHYCARDIA
• Normal response to sympathetic nervous system
stimulation or any condition that produces an
increase in metabolic rate
• Medical conditions – anemia, hemorrhage, fever,
hypotension, pain, shock
• Medications – central nervous system stimulants
• Eliminate the cause of the tachycardia
• Medications e.g Calcium channel blockers,
Digoxin
Ventricular Tachycardia

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 MANAGEMENT OF VENTRICULAR
TACHCARDIA
• Management depends upon severity
• If stable – continue monitoring, obtain 12 lead
electrocardiogram, consider synchronized
cardioversion on IV Amiodarone
• Unstable- unconscious / without a pulse –
treat as ventricular fibrillation – immediate
CPR and DEFIBRILLATION
• Medication – IV adrenaline 1 mg bolus (repeat
every 3-5 minute)
V. Fibrillation

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 MANAGEMENT OF VENTRICULAR
FIBRILLATION
• Immediate CPR
• DEFIBRILLATION
• Medication – IV adrenaline 1 mg bolus (repeat
every 3-5 minute)
Asystole

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 MANAGEMENT OF ASYSTOLE
• Confirm asystole rhythm (‘true asystole’) by :
Check the rhythm in multiple leads to rule out
ventricular fibrillation
Check lead –loose leads or not connected to
patient or defibrillator / monitor
Increase lead size
• CPR
• IV Epinephrine I mg / Vasopressin40 u
• Advanced airway
ACUTE ANTEROSEPTAL MI

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MANAGEMENT OF MYOCARDIAL INFARCTION
1. Monitor & support ABC
2. Administer
• Morphine – for relief chest discomfort or no
response to nitrates
• Oxygen if SPO2 < 94%
• Nitroglycerin (GTN) – 1 sublingual every 3-5 min,
if patient hemodynamically stable
• Aspirin – if not taken
3. Obtain 12 lead ECG
4. Consider fibrinolytics therapy or PCI
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EXCERCISE

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 PREPARED BY:
EDUCATION SERVICE

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