Arrythmias interpreted by medical professionals to

 Problem with rate or rhythm in your understand the following:

heartbeat  Heart rate
 Tachycardia  Heartbeat regularity
 Bradycardia  Strength and timing of the electrical
 Irregular rhythm signals
 Any possible abnormal conditions
Cause:
 changes in heart tissue or activities
 Problem with electrical signals that
control heartbeat

Diagnosis:
 Check using ECG –
electrocardiogram

12 lead ECG
 10 electrodes
 Remaining 2 are combination of
other electrodes
th
V14 intercostal space to the right of the
sternum

V2 4th ICS to the left of the sternum

V3 directly between the leads V2 and V4

V4 5th intercostal space at midclavicular line

V5 level with V4 at the left anterior axillary

line

V6 level with V5 at midaxillary line (directly

under the midpoint of the armpit)

Basic ECG Interpretations

❖ An EKG, also called an ECG or
electrocardiogram, is a recording of the
hearts electrical activity. It is a quick and
painless procedure. EKGs captures a tracing
of cardiac electrical impulse as it moves
from the atrium to the ventricles. These
electrical impulses cause the heart to
contract and pump blood. EKGs are
CONDUCTION PATHWAYS
1. SA (sino-atrial) node down to
2. AV (atrio-ventricular) node
a. Bachman’s Bundle ()
3. To Bundle branches in ventricles that
divides into right then left [bundle]
branches
4. To Purkinje fibers
Normal PR: 60-100 bpm (SA node)
 AV Node contributes: 40-60 bpm
 Bundle Branches (divided by 2 (L and R)
 Purkinje Bundle contributes: 20-40 BPM
* Bachmann’s Bundle – alsoknown as
the interatrial bundle, passes signal from SA
node (right atrium) to to the left atrium
GRAPH PAPER
Straight line: ISO electric line
Depolarization = Contraction
Small boxes: each small box is 0.04 seconds
Repolarization = Relaxation
Big boxes: 0.2 seconds
Wave above ISO electric line: positive
deflection
Wave below ISO electric line: negative
deflection

OVERVIEW
PR Interval = important to determine if px
has heart block
Normal: 0.12-0.20 seconds

QRS complex = important to determine size

Normal: less than .12 seconds

ST segment = important for patients with

M.I.; should always be straight

ABERRATION= Term used for abnormalities

in the patient’s rhythm
1 cardiac cycle:
First positive deflection = P wave; due to
atrial depolarization (contraction)
Atrial Repolarization is not noted, because
….
Ventricular depolarization (contraction) =
QRS Complex
1. First negative positive = Q wave
2. Second positive deflection = R wave
3. Second negative deflection = S wave
4. Third positive deflection = T wave;
relaxation
5. Then back to cycle
 2. SVT (Supraventricular Tachycardia)
3. Atrial Fibrillation
4. Atrial Flutter
C. VENTRICULAR ABERRATIONS
1. PVCs (Premature Ventricular
Contractions)
2. Ventricular Tachycardia
a. Monomorphic
b. Polymorphic
c. Torsade de pointes
D. ATRIOVENTRICULAR BLOCKS
1. 1st Degree
o Normal Sinus Rhythm 2. 2nd Degree
o Sinus Arrhythmia 3. 3rd Degree
o Sinus Bradycardia
BASE RHYTHMS
o Sinus Tachycardia
SINUS RHYTHM
o Sinus Exit Block
SINUS BRADYCARDIA
o Sinus Arrest
SINUS TACHYCARDIA
IF WITH ECTOPY
SINUS RHYTHM
SINUS RHYTHM W/ PAC
 A normal sinus rhythm refers to both a
SINUS RHYTHM W/ PVC IN BIGEMINY
normal heart rate and rhythm
 Normal Heart rates are from 60 to 100 SINUS BRADYCARDIA W/ PAC COUPLET
beats per minute IF WITH RUN
 With normal sinus rhythms, the heart SINUS TACHYCARDIA W/ 4 BEATS OF
beat’s electrical impulse originates in VENTRICULAR TACHYCARDIA
the sinoatrial node (SA) SINUS RHYTHM W/ 5 BEATS OF
 The P waves are upright and appear SUPRAVENTRICULAR RUN
before each QRS and have the same ATRIAL ABERRATION (NO NEED TO USE
shape. BASE RHYTHM FOR THESE)
READING ATRIAL FIBRILLATION
 The shape of the electrocardiogram ATRIAL FIBRILLATION W/ RVR
(EKG) tracing will exhibit certain key VARIABLE ATRIAL FLUTTER
attributes to be considered normal 2:1 ATRIAL FLUTTER
VENTRICULAR ABERRATION (NO NEED TO
CLASSIFICATION USE BASE RHYTHM FOR THESE)
 The intervals between the P waves are MONOMORPHIC VENTRICULAR
regular although some variations can TACHYCARDIA
occur with respiration. Sinus rhythms VENTRICULAR FIBRILLATION
are classified as: POLYMORPHIC VENTRICULAR TACHYCARDIA
HEART BLOCKS
 SINUS RHYTHM CATEGORIES SINUS RHYTHM W/ 1ST DEGREE AVB (NEEDS
1. Normal Sinus Rhythm
BASE RHYTHM)
2. Sinus Bradycardia
MOBITZ TYPE 1 AVB
3. Sinus Tachycardia
3RD DEGREE AVB
B. ATRIAL ABERRATIONS
1. PACs (Premature Atrial Contraction)
NCM 118 – ECG

SINUS RHYTHM CATEGORIES

To dissect/interpret ECGs:
1. Locate both P wave and QRS complex
2. Measure both by counting boxes
PRI (PR Interval) = 0.12-0.20 seconds
QRS (QRS Complex) = 0.06-0.10 seconds (<0.12)
3. Determine if Rhythm is regular or irregular
4. Determine the HR
Regular: Marching; Difference allowed = 1=2 small boxes between R waves
a. Big boxes method: 300 / number of big boxes = x bpm
b. Small boxes method:1,500 / number of small boxes = x bpm
Irregular:
c. 6 second method (can also be used for regular): R waves number * 10 = x bpm
5. Interpret rhythm (if regular, irregular)

NORMAL BRADYCARDIA TACHYCARDIA ARRHYTHMIAS

Rhythm Regular Regular Regular Irregular, varying
with respiration
Rate Normal (60-100 Slow (<60 bpm) Fast (>100 bpm) Normal 60-100
bpm) >59 bpm bpm); rate may
increase during
inspiration
P wave Normal (positive & Normal Normal; may Normal
precedes each QRS merge with T wave
at very fast rates
PR Normal (0.12-0.20 Normal (0.12-0.20 Normal (0.12-0.20 Normal (0.12-0.20
Interval sec) sec) sec) sec)
QRS Normal (0.6-0.10 Normal (0.6-0.10 Normal (0.6-0.10 Normal (0.6-0.10
sec) sec) sec) sec)
*QT interval
shortens with
increasing heart
rate
NCM 118 – ECG

NORMAL SINUS RHYTHM

 Is the normal rhythm of the heart. The electrical impulse originates within the SA node
and travels through the atria to the AV node. After a brief delay, the impulse travels
down the bundle branches, through the Purkinje fibers to the ventricles

NORMAL
Rhythm Regular
Rate Normal (60-100 bpm)
P wave Normal (positive & precedes each QRS
PR Interval Normal (0.12-0.20 sec)
QRS Normal (0.6-0.10 sec)

STRIP above shows normal sinus rhythm because

1. R to R is regular; marching; same distance and interval
a. 4 big boxes; small difference of 1-2 small boxes
2. Rate within 60-100 bpm
3. P wave is upright; coming right before QRS
4. PR interval is .12 seconds (normal)
5. QRS is not less than .12 seconds
NCM 118 – ECG

SINUS Bradycardia (insert screenshot)

 A sinus rhythm with a rate of 59 bpm and below

BRADYCARDIA
Rhythm Regular
Rate Slow (<60 bpm) >59 bpm
only difference
P wave Normal
PR Interval Normal (0.12-0.20 sec)
QRS Normal (0.6-0.10 sec)

SINUS Tachycardia
 Is a normal sinus rhythm but with a heart rate over 100 bpm. It is a normal response to
exercise, excitement, and some illnesses

TACHYCARDIA
Rhythm Regular
Rate Fast (>100 bpm)
P wave Normal; may merge with T wave at very fast rates
PR Interval Normal (0.12-0.20 sec)
QRS Normal (0.6-0.10 sec)
*QT interval shortens with increasing heart rate
NCM 118 – ECG

 Rhythm = regular

SINUS Arrhythmia
 Looks normal except for slight irregularities. A frequency cause of sinus arrhythmia can
be rhythm variations caused by respiration

ARRHYTHMIAS
Rhythm Irregular, varying with respiration
Rate Normal 60-100 bpm); rate may increase during inspiration
P wave Normal
PR Interval Normal (0.12-0.20 sec)
QRS Normal (0.6-0.10 sec)
NCM 118 – ECG

ATRIAL ABERRATIONS

PACs (Premature atrial contraction)

 There are problems in the atria
 There is an ECTOPY (next cycle comes in early)
 P wave looks strange
o There is a problem with atrial depolarization (contraction) reflected in P wave
 there is a COMPENSATORY PAUSE in the ISO line

Interpretations:
1. Get base rhythm (PR)
2. Check p wave

 PRI and QRI Normal

 Irregular Rhythm
o Use 6 second method
 SINUS RHYTHM WITH P.A.C.s =SINUS rhythm (PR: 80 bpm) but has ECTOPY (2 PCAs=
red circles)
 2nd strip is SINUS Tachycardia

PAC in Bigeminy

Interpretation: SINUS TACHYCARDIA with PAC in Bigeminy

 1 normal cycle + PAC
NCM 118 – ECG

o There is a pattern
o There is ectopy – as there is partially buried P wave (touching T wave)
o There is compensatory pause
 HR (using 6 sec method) = 120 bpm
 Base rhythm: SINUS TACHICARDIA
 There is PAC in Bigeminy

PAC in Trigeminy

Interpretation:
a. (center part only)SINUS BRADYCARDIA with PAC in TRIGEMINY
 Every third cardiac cycle, there is an aberration
 HR (shown) = 58 bpm
 Base rhythm: SINUS BRADYCARDIA
 There is PAC in Trigeminy

b. (end parts)
 INTERPRET THE WHOLE STRIP!!!
 There are only 2 cycles of bigeminy on both sides
 Hence, we cannot count these as bigeminy

FINAL INTERPRETATION: SINUS BRADYCARDIA with PAC in Trigeminyand PACs

ATRIAL FIBRILLATION
 impulses from SA node gabalikbaliksaagisaatria
 chaotic
 HR will not matter (within normal range or 101 up)
o If 101 up, the term is RAPID VENTRICULAR RESPONSE (R.V.R.)
 Irregular Rhythm
 there are fibrillatory waves= Small F waves
 No P waves = cannot determine PRI
 QRS exists because ventricles are not affected
NCM 118 – ECG

Interpretation: ATRIAL FIBRILLATION with Rapid Ventricular Response

1. locate P wave and QRS complex
NO P WAVE, QRS complex exists
2. PRI = cannot be measured because no P wave
3. QRS = normal, unaffected because this commonly affects only the atria
(gwapa lang daw sha)
4. HR = 110 bpm (RVR)

* AFIB may coexist with PVC

Atrial Flutter
 Problems in atria (balikbalikna impulses)
 No P waves, but with QRS since ventricles are not affected
 Rhythm varies

Interpretation: 2:1 Atrial Flutter

 2 big F waves in 1 QRS

Interpretation: Variable Atrial Flutter

 No specific pattern
NCM 118 – ECG

VENTRICULAR ABERRATIONS

PVCs – Premature Ventricular Contractions

Reflects in ECG if there are ventricular contractions = QRS complex

 QRS complex is wide and bizarre
o ventricle has a problem with ventricular depolarization

Interpretation: SINUS RHYTHM with PVCs

1. Locate P and QRS complex
2. PRI = 12 seconds
3. QRS = 0.08 (not normal, there is ectopy (or early nanigawasna wave))
4. HR is 80 (regular) = SINUS RHYTHM (base rhythm)
5. but there are problems
6. 2 PVCs (wide and bizarre PVCs)

BIGEMINY

Interpretation: SINUS RHYTHM with PVCs in Bigeminy

1. no P or T wave distinction
a. but some patients have P wave
2. PRI = ____ (normal)
3. Rhythm is regular
4. HR is 80 (regular) = SINUS RHYTHM
TRIGEMINY

Interpretation: SINUS RHYTHM with PVCs in Trigeminy

1. Upright P wave, precedes QRS complex
2. PRI = 0.16 (normal)
3. QRS = 0.08 (normal)
4. 6-sec-method = 90 (normal) = SINUS RHYTHM as base rhythm
5. every 3rd cardiac cycle, there is PVC (premature or early nigawas)
6. compensatory pause
NCM 118 – ECG

VENTRICULAR TACHYCARDIA

Interpretation:SINUS RHYTHM with 5 beats of Ventricular Tachycardia

1. P wave preceeds QRS complex, is upright
2. PRI = .12
3. QRS = .08
4. Way of calculation is in VTach is in the run
Manual: 6-sec-method
HR is 10 bpm = SINUS RHYTHM
5. count how many consecutive PVCs (5 beats)

NOTE: If there are:

2 consecutive beats = COUPLETs (SINUS RHYTHM with PVC couplet)
* there are also PAC Couplet
3 consecutive beats = VENTRICULAR RUN (SINUS RHYTHM with x beats of Ventricular
Tachycardia)

VENTRICULAR TACHYCARIDIA: MONOMORPHIC

 QRS Complexes in monomorphic VT have the same shape and amplitude

HR = 160 bpm

Rate: 100-250 bpm

Rhythm: Regular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (0.10 sec), bizarre appearance
NCM 118 – ECG

VENTRICULAR TACHYCARIDIA: POLYMORPHIC

 QRS complexes in Polymorphic VT vary in shape and amplitude
 The QT interval is normal or long

Rate: 100-250 bpm

Rhythm: Regular or irregular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (0.10 sec), bizarre appearance

TORSADE DE POINTES (torsa de pwah)

Rate: 200-250 bpm

Rhythm: irregular
P Waves: None
PR Interval: None
QRS: Wide (0.10 sec), bizarre appearance
NCM 118 – ECG

VENTRICULAR FIBRILLATION (VF)

 Chaotic electrical activity occurs with no ventricular depolarization or contraction
 The amplitude and frequency of the fibrillatory activity can be used to define the type of
fibrillation as coarse, medium, or fine

Rate: indeterminate
Rhythm: chaotic
P Waves: None
PR Interval: None
QRS: None

Supra ventricular tachycardia (SVT)

 Under ATRIAL aberrations
 “above” “ventricles”
 Sometimes interpreted as sinus tachycardia
 P wave are partially blurred
 RHYTHM is regular

This arrythmia has such a fast rate that the P waves may not be seen.

HR = 190 bpm

Rate: 150-250 bpm

Rhythm: regular
P Waves: Frequently buried in preceding T waves and difficult to see
PR Interval: Usually not possible to measure
QRS: Normal (0.06-0.10 sec) but may be wide if abnormally conducted through ventricles
NCM 118 – ECG

ATRIOVENTRICULAR (AV) BLOCKS

FIRST-DEGREE AV BLOCK
 RATE: depends on rate of underlying rhythm
 RHYTHM: regular
 P waves: normal (upright and uniform)
 PR Interval: Prolonged (0.20 sec)
 QRS: Normal (0.06-0.10 sec)

 PRI measurement should be constant (same measurement of PR intervals)

1st DEGREE HEART BLOCK

NCM 118 – ECG

SECOND-DEGREE AV BLOCK
Type 1 (Mobitz I or Wenckebach)
 P-R intervals become progressively longer until one P wave is totally blocked and
produces no QRS. After a pause, during which the AV node recovers, this cycle is
repeated

2ndDEGREE HEART BLOCK

TYPE 1:
 prolonging PRI
 There are drop beats (P wave nganasaag)
 No QRS complex

Type 2:
 PRI doesn’t matter
 Series of drop beats (missing QRS complexes)
NCM 118 – ECG

3rd DEGREE HEART BLOCK

 No correlation between P wave and QRS (no synchronization)

 Atria and ventricles fire simultaneously
 Marching R waves(regular R to R)
 Marching P waves (regular P to P) but some may be buried with QRS complex
o For buried, use FINGER METHOD / USE RULER since the interval is
constant