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ELECTROCARDIOGRAPHY
FOR HEALTHCARE PROFESSIONALS

Fourth Edition

Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS

Total Care Programming, Inc.
Palm Coast, Florida

Thomas O’Brien, AS, CCT, CRAT, RMA

Remington College
Allied Health Programs Chair
ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS, FOURTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2016 by
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Library of Congress Cataloging-in-Publication Data

Booth, Kathryn A., 1957- author.

Electrocardiography for healthcare professionals / Kathryn A. Booth, Thomas
E. O’Brien. — Fourth edition.
p. ; cm.
Includes index.
ISBN 978-0-07-802067-4 (alk. paper) — ISBN 0-07-802067-0 (alk. paper)
I. O’Brien, Thomas E. (Thomas Edward), 1959- author. II. Title.
[DNLM: 1. Electrocardiography—methods—Problems and Exercises.
2. Arrhythmias, Cardiac—diagnosis—Problems and Exercises. WG 18.2]
RC683.5.E5
616.1’207547—dc23
2014019157

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Dedication
To the individuals using this book, you have chosen a worthwhile and
rewarding career. Thank you; your skills and services are truly needed.
To my youngest grandaughter, Harper Kathryn, so happy you are in my life.
Kathryn Booth
I want to thank my beautiful wife, Michele, and our wonderful children,
Thomas, Robert, and Kathryn. Without their love and support, I would have
nothing. They inspire me every day to make a difference in people’s lives. I
also want to express my sincere thanks to the faculty, staff, and students of
Remington College for their encouragement and guidance. Today’s students
are the difference makers of tomorrow!
Thomas O’Brien
About the Author
Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS, is a registered
nurse (RN) with CPR and ACLS training as well as a master’s degree in educa-
tion and certifications in phlebotomy, pharmacy tech, and medical assisting.
She is an author, educator, and consultant for Total Care Programming, Inc.
She has over 30 years of teaching, nursing, and healthcare work experience
that spans five states. As an educator, Kathy has been awarded the teacher of
the year in three states where she taught various health sciences. She serves
on the American Medical Technologists registered Phlebotomy Technician
Examinations, Qualifications, and Standards Committee. She stays current in
the field by practicing her skills in various settings as well as by maintaining
and obtaining certifications. In addition, Kathy volunteers at a free healthcare
clinic and teaches online. She is a member of advisory boards at two educa-
tional institutions. Her larger goal is to develop up-to-date, dynamic health-
care educational materials to assist other educators as well as to promote the
healthcare professions. In addition, Kathy enjoys presenting innovative new
learning solutions for the changing healthcare and educational landscape to
her fellow professionals nationwide.

Thomas E. O’Brien, AS, CCT, CRAT, RMA, is the Allied Health Program chair-
person at Remington College, Fort Worth, Texas. Tom also works as an author
of CME activities and editor with Practical Clinical Skills (www.practical
clinicalskills.com). He is also on the Board of Trustees and Exam Chair for the
Certified Cardiographic Technician and Certified Rhythm Analysis Technician
Registry Examinations working with Cardiovascular Credentialing Interna-
tional (CCI). His background includes over 24 years in the U.S. Air Force and
U.S. Army Medical Corps. Tom’s medical career as an Air Force Independent
Duty Medical Technician (IDMT) has taken him all over the United States and
the world. He has several years’ experience working in the Emergency Ser-
vices and Critical Care arena (Cardiothoracic Surgery and Cardiac Cath Lab).
He was awarded Master Instructor status by the U.S. Air Force in 1994 upon
completion of his teaching practicum. He now has over 15 years of teaching
experience; subjects include Emergency Medicine, Cardiovascular Nursing,
Fundamentals of Nursing, Dysrhythmias, and 12-Lead ECG Interpretation. His
current position provides challenges to meet the ever-changing needs of the
medical community and to provide first-rate education to a diverse adult edu-
cation population.

iv
Brief Contents
Preface xi

CHAPTER 1 Electrocardiography 1
CHAPTER 2 The Cardiovascular System 28
CHAPTER 3 The Electrocardiograph 54
CHAPTER 4 Performing an ECG 82
CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121
CHAPTER 6 Atrial Dysrhythmias 147
CHAPTER 7 Junctional Dysrhythmias 166
CHAPTER 8 Heart Block Dysrhythmias 186
CHAPTER 9 Ventricular Dysrhythmias 204
C H A P T E R 10 Pacemaker Rhythms and Bundle Branch Block 234
C H A P T E R 11 Exercise Electrocardiography 253
C H A P T E R 12 Ambulatory Monitoring 282
C H A P T E R 13 Clinical Presentation and Management of the
Cardiac Patient 307
CHAPTER 14 Basic 12-Lead ECG Interpretation 334
APPENDIX A Cardiovascular Medications A-1
APPENDIX B Standard and Isolation Precautions B-1

v
 APPENDIX C Medical Abbreviations, Acronyms, and Symbols C-1
APPENDIX D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1

vi Brief Contents
Contents
Preface xi

CHAPTER 1 Electrocardiography 1

1.1 The ECG and Its History 2

1.2 Uses of an ECG 3
1.3 Preparing for an ECG 11
1.4 Safety and Infection Control 15
1.5 Vital Signs 18

CHAPTER 2 The Cardiovascular System 28

2.1 Circulation and the ECG 29

2.2 Anatomy of the Heart 29
2.3 Principles of Circulation 34
2.4 The Cardiac Cycle 36
2.5 Conduction System of the Heart 38
2.6 Electrical Stimulation and the ECG Waveform 41

CHAPTER 3 The Electrocardiograph 54

3.1 Producing the ECG Waveform 54

3.2 ECG Machines 59
3.3 ECG Controls 64
3.4 Electrodes 67
3.5 ECG Graph Paper 69
3.6 Calculating Heart Rate 71

vii
 CHAPTER 4 Performing an ECG 82

4.1 Preparation for the ECG Procedure 83

4.2 Communicating with the Patient 84
4.3 Identifying Anatomical Landmarks 86
4.4 Applying the Electrodes and Leads 88
4.5 Safety and Infection Control 91
4.6 Operating the ECG Machine 94
4.7 Checking the ECG Tracing 95
4.8 Reporting ECG Results 100
4.9 Equipment Maintenance 101
4.10 Pediatric ECG 102
4.11 Cardiac Monitoring 103
4.12 Special Patient Considerations 104
4.13 Handling Emergencies 107

CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121

5.1 Rhythm Interpretation 121

5.2 Identifying the Components of the Rhythm 122
5.3 Rhythms Originating from the Sinus Node 129
5.4 Sinus Bradycardia 132
5.5 Sinus Tachycardia 134
5.6 Sinus Dysrhythmia 135
5.7 Sinus Arrest 137

CHAPTER 6 Atrial Dysrhythmias 147

6.1 Introduction to Atrial Dysrhythmias 147

6.2 Premature Atrial Complexes 148
6.3 Wandering Atrial Pacemaker 150
6.4 Multifocal Atrial Tachycardia 152
6.5 Atrial Flutter 153
6.6 Atrial Fibrillation 155

CHAPTER 7 Junctional Dysrhythmias 166

7.1 Introduction to Junctional Dysrhythmias 166

7.2 Premature Junctional Complex (PJC) 168
7.3 Junctional Escape Rhythm 169

viii Contents
 7.4 Accelerated Junctional Rhythm 171
7.5 Junctional Tachycardia 173
7.6 Supraventricular Tachycardia (SVT) 175

CHAPTER 8 Heart Block Dysrhythmias 186

8.1 Introduction to Heart Block Dysrhythmias 186

8.2 First Degree Atrioventricular (AV) Block 187
8.3 Second Degree Atrioventricular (AV) Block, Type I (Mobitz or
Wenckebach) 188
8.4 Second Degree Atrioventricular (AV) Block, Type II (Mobitz II) 191
8.5 Third Degree Atrioventricular (AV) Block (Complete) 193

CHAPTER 9 Ventricular Dysrhythmias 204

9.1 Introduction to Ventricular Dysrhythmias 205

9.2 Premature Ventricular Complexes (PVCs) 205
9.3 Agonal Rhythm 210
9.4 Idioventricular Rhythm 211
9.5 Accelerated Idioventricular Rhythm 213
9.6 Ventricular Tachycardia 215
9.7 Ventricular Fibrillation 217
9.8 Asystole 220

CHAPTER 10 Pacemaker Rhythms and Bundle Branch Block 234

10.1 Introduction to Pacemaker Rhythms 234

10.2 Evaluating Pacemaker Function 236
10.3 Pacemaker Complications Relative to the ECG Tracing 241
10.4 Introduction to Bundle Branch Block Dysrhythmias 243

CHAPTER 11 Exercise Electrocardiography 253

11.1 What Is Exercise Electrocardiography? 253

11.2 Why Is Exercise Electrocardiography Used? 255
11.3 Variations of Exercise Electrocardiography 257
11.4 Preparing the Patient for Exercise Electrocardiography 260
11.5 Providing Safety 264
11.6 Performing Exercise Electrocardiography 265
11.7 Common Protocols 267
11.8 After Exercise Electrocardiography 270

Contents ix
 CHAPTER 12 Ambulatory Monitoring 282

12.1 What Is Ambulatory Monitoring? 282

12.2 How Is Ambulatory Monitoring Used? 284
12.3 Functions and Variations 285
12.4 Educating the Patient 290
12.5 Preparing the Patient 292
12.6 Applying an Ambulatory Monitor 293
12.7 Removing an Ambulatory Monitor and Reporting Results 296

CHAPTER 13 Clinical Presentation and Management

of the Cardiac Patient 307

13.1 Coronary Arteries 308

13.2 Cardiac Symptoms 310
13.3 Atypical Patient Presentation 312
13.4 Acute Coronary Syndrome 314
13.5 Heart Failure 316
13.6 Cardiac Patient Assessment and Immediate Treatment 318
13.7 Treatment Modalities for the Cardiac Patient 324

CHAPTER 14 Basic 12-Lead ECG Interpretation 334

14.1 The Views of a Standard 12-Lead ECG and Major Vessels 334
14.2 Ischemia, Injury, and Infarction 339
14.3 Electrical Axis 343
14.4 Bundle Branch Block 345
14.5 Left Ventricular Hypertrophy 347

Appendix A Cardiovascular Medications A-1

Appendix B Standard and Isolation Precautions B-1
Appendix C Medical Abbreviations, Acronyms, and Symbols C-1
Appendix D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1

x Contents
Preface
Healthcare is an ever-changing and growing field that needs well-trained indi-
viduals who can adapt to change. Flexibility is key to obtaining, maintain-
ing, and improving a career in electrocardiography. Obtaining ECG training
and certification, whether it be in addition to your current career or as your
career, will make you employable or a more-valued employee. This fourth edi-
tion of Electrocardiography for Healthcare Professionals will prepare
users for a national ECG certification examination, but most importantly
provides comprehensive training and practice for individuals in the field of
electrocardiography.
The fact that you are currently reading this book means that you are
willing to acquire new skills or improve the skills you already possess. This
willingness translates into your enhanced value, job security, marketability,
and mobility. Once you complete this program, taking a certification exami-
nation is a great next step for advancing your career.
This fourth edition of Electrocardiography for Healthcare Profes-
sionals can be used in a classroom as well as for distance learning. Check-
point Questions and Connect exercises correlated to the Learning Outcomes
make the learning process interactive and promote increased comprehension.
The variety of materials included with the program provides for multiple
learning styles and ensured success.

Text Organization
The text is divided into 14 chapters:
● Chapter 1 Electrocardiography includes introductory information about
the field as well as legal, ethical, communication, safety, and patient edu-
cation information. In addition, basic vital signs and troubleshooting are
addressed.
● Chapter 2 The Cardiovascular System provides a complete introduction
and review of the heart and its electrical system. The information focuses
on what you need to know to understand and perform an ECG. Specific top-
ics include anatomy of the heart, principles of circulation, cardiac cycle,
conduction system and electrical stimulation, and the ECG waveform.
● Chapter 3 The Electrocardiograph creates a basic understanding of the
ECG, including producing the ECG waveform, the ECG machine, elec-
trodes, and ECG graph paper.
● Chapter 4 Performing an ECG describes the procedure for performing
an ECG in a simple step-by-step fashion. Each part of the procedure is
explained in detail, taking into consideration the latest guidelines. The
chapter is divided into the following topics: preparation, communica-
tion, anatomical landmarks, applying the electrodes and leads, safety

xi
 and infection control, operating the ECG machine, checking the trac-
ing, reporting results, and equipment maintenance. Extra sections are
included regarding pediatric ECG, cardiac monitoring, special patient
circumstances, and emergencies. Procedure checklists are included to
practice performing both an ECG and continuous monitoring.
● Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms introduces
the five-step criteria for classification approach to rhythm interpretation
that will be utilized throughout Chapters 5 to 10. With updated, realistic
rhythm strip figures, explanations, and Checkpoint Questions, the user
learns to interpret the sinus rhythms, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 6 Atrial Dysrhythmias provides an introduction to and inter-
pretation of the atrial dysrhythmias, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 7 Junctional Dysrhythmias provides an introduction to and inter-
pretation of the junctional dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 8 Heart Block Dysrhythmias provides an introduction to and
interpretation of the heart block dysrhythmias, including criteria for
classification, how the patient may be affected, basic patient care, and
treatment.
● Chapter 9 Ventricular Dysrhythmias provides an introduction to and inter-
pretation of the ventricular dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 10 Pacemaker Rhythms and Bundle Branch Block provides an
introduction to pacemaker rhythms, evaluation of pacemaker function,
and complications related to the ECG tracing. An introduction to bundle
branch block dysrhythmias, including criteria for classification, how the
patient may be affected, basic patient care, and treatment, is also included.
● Chapter 11 Exercise Electrocardiography provides the information nec-
essary to assist with the exercise electrocardiography procedure. The
competency checklist provides the step-by-step procedure for practice
and developing proficiency at the skill.
● Chapter 12 Ambulatory Monitoring includes the latest information
about various types of ambulatory monitors and includes what you need
to know to apply and remove a monitor. A procedure checklist is also
provided for this skill.
● Chapter 13 Clinical Presentation and Management of the Cardiac
Patient expands on the anatomy of the coronary arteries and relates them
to typical and atypical cardiac symptoms. STEMI, non-STEMI, and heart
failure are introduced. The chapter includes a section about sudden car-
diac death as compared to myocardial infarction and finishes with assess-
ment, immediate care, and continued treatment of the cardiac patient.
● Chapter 14 Basic 12-Lead ECG Interpretation provides an introduction
to 12-lead ECG interpretation. It includes anatomic views of the coronary
arteries and correlates the arteries with the leads and views obtained
on a 12-lead ECG. It also identifies the morphologic changes in the trac-
ing that occur as a result of ischemia, injury, and infarction. Axis devia-
tion, bundle branch block, and left ventricular hypertrophy round out the
chapter concepts. The last section helps users put all of these concepts
together for 12-lead interpretation.

xii Preface
These chapters can be utilized in various careers and training programs. Fol-
lowing are some suggested examples:
● Telemetry technicians (Chapters 1–12, depending on requirements)
● EKG/ECG technicians (the entire book, depending on requirements)
● Medical assistants (the entire book, depending on where they work)
● Cardiovascular technicians working in any number of specialty clinics,
such as cardiology or internal medicine (the entire book)
● Remote monitoring facilities personnel (transtelephonic medicine) (Chap-
ters 1–10, 12–14)
● Emergency medical technicians (Chapters 2, 5–10, 14, possibly more depend-
ing on where they work)
● Paramedics (Chapters 2–14)
● Nursing, especially for cross-training or specialty training (Chapters 2–14)
● Patient care tech or nursing assistant (Chapters 2–4, 12, perhaps more de-
pending on job requirements)
● Polysomnography technologist (Chapters 2–10)
● Echocardiography technologist (Chapters 2, 5–11)
● Cardiac cath lab technologist (Chapters 2–10, 14)

New to the Fourth Edition

● Over 25 new photos and revised figures for an improved, up-to-date, and
realistic look that also provides additional student practice.
● Complete revision of Chapter 1 including new and expanded sections on
safety and infection control and basic vital signs.
● Modified Bloom’s specific learning outcomes providing one learning out-
come per level 1 heading and corresponding questions to ensure student
understanding and success.
● Added and updated content about the following essential topics: cardiac
anatomy, lead descriptions, law and ethics, cardiac output, vagal tone,
stroke volume, premature complexes, Wolff-Parkinson-White syndrome,
Torsades de Pointes, pacemakers, exercise electrocardiography (includ-
ing a new table for common stress test chemicals), and ambulatory
monitoring.
● Modified and simplified descriptions of arrhythmias; changed the term
configuration to morphology when appropriate for accuracy.

Features of the Text

● Key Terms and Glossary: Key terms are identified at the beginning of
each chapter. These terms are in bold, color type within the chapter and
are defined both in the chapter and in the glossary at the end of the book.
● Checkpoint Questions: At the end of each main heading in the chapter
are short-answer Checkpoint Questions. Answer these questions to make
sure you have learned the basic concepts presented.
● Troubleshooting: The Troubleshooting feature identifies problems and
situations that may arise when you are caring for patients or perform-
ing a procedure. At the end of this feature, you are asked a question to
answer in your own words.

Preface xiii
 ● Safety & Infection Control: You are responsible for providing safe
care and preventing the spread of infection. This feature presents tips
and techniques to help you practice these important skills relative to
electrocardiography.
● Patient Education & Communication: Patient interaction and educa-
tion and intrateam communication are integral parts of healthcare. As
part of your daily duties, you must communicate effectively, both orally
and in writing, and you must provide patient education. Use this feature
to learn ways to perform these tasks.
● Law & Ethics: When working in healthcare, you must be conscious of
the regulations of HIPAA (Health Insurance Portability and Accountabil-
ity Act) and understand your legal responsibilities and the implications
of your actions. You must perform duties within established ethical prac-
tices. This feature helps you gain insight into how HIPAA, law, and ethics
relate to the performance of your duties.
● Real ECG Tracings: Actual ECG tracings, or rhythm strips, have been
provided for easy viewing and to make the task of learning the various
dysrhythmias easier and more realistic. Use of these ECG rhythm strips
for activities and exercises throughout the program improves compre-
hension and accommodates visual learners.
● Chapter Summary: Once you have completed each chapter, take time
to read and review the summary table. It has been correlated to key con-
cepts and learning outcomes within each chapter and includes handy
page number references.
● Chapter Review: Complete the chapter review questions, which are pre-
sented in a variety of formats. These questions help you understand the
content presented in each chapter. Chapters 4, 11, and 12 also include Pro-
cedure Checklists for you to use to practice and apply your knowledge.

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Electrocardiography for Healthcare Professionals
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xiv Preface
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Preface xv
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representative. CXG is available Sunday through Friday.

Additional Instructor Resources

● Instructor’s Manual with course overview, lesson plans, answers to
CheckPoint and End-of-Chapter Review questions, competency correla-
tions, sample syllabi, and more.
● PowerPoint Presentations for each chapter, containing teaching notes
correlated to learning outcomes. Each presentation seeks to reinforce
key concepts and provide an additional visual aid for students.
● Test Bank and answer key for use in class assessment. The comprehen-
sive test bank includes a variety of question types, with each question
linked directly to a learning outcome from the text. Questions are also
tagged with relevant topic, Bloom’s Taxonomy level, difficulty level, and
competencies, where applicable. The test bank is available in Connect,
and Word and EZ Test versions are also available.
● Conversion Guide with a chapter-by-chapter breakdown of how the
content has been revised between editions. The guide is helpful if you are
currently using Electrocardiography for Healthcare Professionals
and moving to the new edition, or if you are a first-time adopter.
● Instructor Asset Map to help you find the teaching material you need
with a click of the mouse. These online chapter tables are organized by
Learning Outcomes and allow you to find instructor notes, PowerPoint
slides, and even test bank suggestions with ease! The Asset Map is a
completely integrated tool designed to help you plan and instruct your
courses efficiently and comprehensively. It labels and organizes course
material for use in a multitude of learning applications.
All of these helpful materials can be found within your Connect course
under the Instructor Resources.

Preface xvii
Guided Tour
Features to Help You Study and Learn

The
Electrocardiograph
Learning Outcomes and Key Terms, and an Learning Outcomes 3.1 Explain the three types of leads and how each is recorded.
3.2 Identify the functions of common ECG machines.
Introduction begin each chapter to introduce 3.3
3.4
Explain how each ECG machine control is used.
Recognize common electrodes.

you to the chapter and help prepare you for the 3.5
3.6
Describe the ECG graph paper.
Calculate heart rates using an ECG tracing.

information that will be presented. Key Terms artifact

augmented lead
millimeter (mm)
millivolt (mV)
bipolar lead multichannel recorder
bradycardia output display
Einthoven triangle precordial lead
electrodes serial ECG comparison
gain signal processing
hertz (Hz) speed control
input tachycardia
lead unipolar lead
limb lead

3.1 Producing the ECG Waveform

In this chapter, we discuss the electrocardiograph and the equipment needed

Copyright © 2016 by McGraw-Hill Education

to perform an ECG and record the ECG waveform. You will discover how the
12-lead system works and how to read the measurements on the ECG graph
paper. Learning the equipment and lead system thoroughly and correctly will
prepare you to record your first ECG.
The electrical impulse that is produced by the heart’s conduction system
is measured with the ECG machine. The ECG machine interprets the impulse
and produces the ECG waveform. The waveform indicates how the heart is
functioning electrically.
A single heart rhythm tracing views the heart from one angle. Because
the heart is three-dimensional, it is necessary to view the electrical impulse
from different sides to obtain a complete assessment of its electrical activity.
A 12-lead ECG provides a complete picture, not of the heart’s structure, but of
its electrical activity. It records the heart’s electrical activity from 12 different

54

boo20670_ch03_054-081.indd 54 02/09/14 3:43 pm

Sinus Arrest
Troubleshooting exercises identify problems A patient is in sinus arrest that lasts longer than 6 seconds. This indicates
that no electrical current is traveling through the cardiac conduction system

and situations that may arise on the job. You asystole When no rhythm
or electrical current is
traveling through the cardiac
and is known as asystole. What should you do?

conduction system.
may be asked to answer a question about the
situation.
Check Point 1. Using the criteria for classification, select the rhythm that most
Question closely resembles sinus arrest.
(LO 5.7)
A.

Checkpoint Questions are provided at the end of B.

each section in the chapter to help you understand

Copyright © 2016 by McGraw-Hill Education

the information you just read.

Which distinguishing feature(s) led you to make the selection?

Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 139

boo20670_ch05_121-146.indd 139 02/09/14 4:26 pm

xviii
“I have been examining textbooks for approximately
eight years now and this ECG text provides students
with the most complete and accurate information
without overwhelming them.”
Donna Folmar, Belmont Technical College
Patient Education & Communication boxes
give you helpful information for communicating
effectively—both orally and written—with patients.
Interpret-TIP features throughout
Chapters 5–10 provide simple and easy
guidelines to help you recognize each of
the ECG rhythms presented.
Safety & Infection Control boxes
present tips and techniques for you to apply
on the job.
boo20670_ch09_204-233.indd 218
Law & Ethics boxes help you gain insight into
necessary information related to the performance of
your duties.
4.1 Preparation for the ECG Procedure
Now that you understand how the ECG is used, the anatomy of the heart, and
the electrocardiograph, the next step is to record an ECG. The ECG experi-
ence should be pleasant for the patient and not produce anxiety. The ECG
procedure must be done correctly, and the tracing must be accurate.
Prior to performing the ECG, you will need to prepare the room. Cer-
tain conditions in the room where the ECG is to be performed should be con-
sidered. For example, electrical currents in the room can interfere with the
tracing. If possible, choose a room away from other electrical equipment and
x-ray machines. Turn off any nonessential electrical equipment that is in the
room during the tracing. The ECG machine should be placed away from other
sources of electrical currents, such as wires or cords.
An ECG must be ordered by a physician or other authorized personnel,
and an order form must be completed prior to the procedure. This form may
be called a requisition or consult and should be placed in the patient’s record.
It should include why the ECG was ordered and the following identifying
information:
● Patient name, identification number or medical record number, and birth
●
date
Location, date, and time of recording
● Patient age, sex, race, and cardiac and other medications the patient is
●
currently taking
Weight and height
● Any special condition or position of the patient during the recording
If this information is not included on the requisition or consult, you should
ask the patient or find the information in the patient’s record.
Most facilities now have computerized systems. The ECG order is fre-
quently entered through this system. Entering the patient’s identifying infor-
mation into the computer will produce the order form and generate patient
charges. Without a computer system, the information should be handwritten
on the order form, consult, or requisition, whichever your facility uses.
Cardiac Medications
Certain cardiac medications can change the ECG tracing. Prior to the ECG
Copyright © 2016 by McGraw-Hill Education
procedure, determine if your patient is on any cardiac medications and, if
so, inform the physician and write the names of the medications on the ECG
report. See the appendix Cardiovascular Medications for examples of com-
mon cardiac medications.
The patient’s identifying information should also be entered through the
LCD panel on the ECG machine prior to the recording. If the ECG machine
does not allow you to enter the information or there isn’t time due to an emer-
gency situation, you should write it on the completed ECG. Most importantly,
all information should be written or entered accurately no matter what type
of ECG machine or order system you are using.
Figure 9-7 Ventricular fibrillation.
boo20670_ch04_082-120.indd 83 02/09/14 4:20 pm
Interpret-TIP Ventricular Fibrillation
Ventricular fibrillation is the absence of organized electrical activity. The
tracing is disorganized or chaotic in appearance.
How the Patient Is Affected and What You Should Know
What appears to be ventricular fibrillation on the monitor may not be ventric-
ular tachycardia at all. Remember to always check your patient first. Fibril-
latory waveforms may be caused by a variety of different things, like poorly
attached or dried out electrodes, broken lead wires, and excessive patient
movement. If your patient is talking to you, the patient is not in ventricular
apnea The absence of
breathing.
fibrillation.
In true ventricular defibrillation, patients will be unresponsive when the
advanced cardiac life sup-
port (ACLS) A set of clinical
interventions for the urgent
ventricles are quivering without contracting. This will always be an emer-
gency situation. Check your patient first, then initiate CPR and activate EMS
or in a healthcare institution follow the protocol for the emergency. Every
treatment of cardiac arrest patient experiencing ventricular fibrillation will be unconscious, apneic
and other life-threatening (apnea means not breathing), and pulseless. CPR and emergency measures
medical emergencies, as should begin immediately. It is recommended that appropriate personnel
well as the knowledge begin the advanced cardiac life support (ACLS) to regain normal cardiac
and skills to deploy those function. Rhythm strips are maintained and used as documentation in the
interventions. patient’s medical record.
Copyright © 2016 by McGraw-Hill Education
Crash Cart
Emergency equipment found on the crash cart must be ready when a code
situation occurs. It is important that the cart be well stocked and the emer-
crash cart A cart or tray gency equipment functioning properly. Each facility has a policy that
containing emergency medi- requires regular checking and documentation of all emergency equipment
cation and equipment that and crash carts.
can be easily transported to
the location of an emergency
for life support.
Interpret
p TIP Supraventricular
Supravent
tricular Dysrhythmias
Supraventricular
Supraventrricular tachycardia describes a group of dysrhythmias
d that
218
present with a normal-to-narrow QRS compl
complex rate of greater than
lex and a ra
150 beats per
per minute.
29/08/14 10:01 am
How the Patient Is Affected and What You Should Know
There are various supraventricular dysrhythmias, all of which may cause the
patient to exhibit the same signs and symptoms. The patient may be in either
a stable or an unstable condition. The stable patient (one without signs and
symptoms of decreased cardiac output) may complain only of palpitations and
state, “I’m just not feeling right” or “My heart is fluttering.” When the patient’s
condition is unstable, he or she may experience any symptom of low cardiac
output because the heart is not pumping effectively to other body systems.
Many patients may present initially with a stable condition and then a few min-
utes later experience unstable symptoms.
Copyright © 2016 by McGraw-Hill Education
Observe the patient for signs and symptoms of low cardiac output.
Signs, symptoms, and rhythm changes need to be communicated quickly to a
licensed practitioner for appropriate medical treatment. Because tachycardia
significantly increases myocardial oxygen demand, treatment should begin
as early as possible. It is difficult to predict how long a patient’s heart can
beat at a rapid rate before it begins to affect the other body systems.
Scope of Practice
Your role regarding evaluation of the rhythm strip and assessment of the
patient will depend on your training and place of employment. Working out-
side your scope of practice is illegal, and you could be held liable for per-
forming tasks that are not part of your role as a healthcare professional.
Chapter 7 Junctional Dysrhythmias 177
boo20670_ch07_166-185.indd 177 28/08/14 9:28 pm
xix
 Criteria for Classification
● Rhythm: P-P interval cannot be determined; the R-R interval is regular.

ECG Rhythm Strips make the task of learning the ● Rate: Atrial rate cannot be determined due to the absence of atrial depo-
larization. The ventricular rate is 40 to 100 beats per minute.
● P wave morphology: The P wave is usually absent; therefore, no analy-
various dysrhythmias easier and more realistic. Over ●
sis of the P wave can be done.
PR interval: The PR interval cannot be measured because the P wave

200 strips are included within the textbook. ●

cannot be identified.
QRS duration and morphology: The QRS duration and morphology
measure 0.12 second or greater and have the classic ventricular wide and
bizarre appearance.

Interpret-TIP Accelerated Idioventricular Rhythm

“Practice ECG rhythm strips are key tools for prac- The accelerated idioventricular rhythm has an absence of P waves, a
ventricular rate of 40 to 100 beats per minute, and wide and bizarre QRS

Copyright © 2016 by McGraw-Hill Education

ticing rhythm recognition. An excellent comprehen- complexes.

sive textbook for the Electrocardiography student.” Figure 9-4 Accelerated idioventricular rhythm.

Stephen Nardozzi, Westchester Community College

Chapter 9 Ventricular Dysrhythmias 213

Key Points correlated to the learning

outcomes in each Chapter Summary help you Second
ond degree type II
boo20670_ch09_204-233.indd 213

Missing QRS
RS
S Complex
Co
C omplex Missing QRS
Mi
Missing QRS
Third degree (Complete)
29/08/14 10:01 am

Missing QRS
Mi
Missing QRS Missing QRS
Mi
Missing QRS Mi
M ssing QRS
Missing QRS Mi
Missing QRS
Missing QRS

review what was just learned.

PRI remains PRI remains PRI remains PRI remains P wave is partialy P wave is partialy P wave is partialy
the same the same the same the same buried within the T wave buried within the QRS buried within the T wave

Chapter Summary
Learning Outcomes Summary Pages

8.1 Describe the various heart block In heart block rhythms, the electrical current has difficulty 186
dysrhythmias. traveling along the normal conduction pathway, causing
a delay in or absence of ventricular depolarization. The
degree of blockage depends on the area affected and the
cause of the delay or blockage. The P-P interval is regular
with all heart blocks. There are three levels of heart blocks.

8.2 Identify first degree atrioventricular (AV) First degree AV block is a delay in electrical conduction 187–188
block using the criteria for classification, and from the SA node to the AV node, usually around the AV
explain how the rhythm may affect the patient, node, which slows the electrical impulses as they travel to
including basic patient care and treatment. the ventricular conduction system.

8.3 Identify second degree atrioventricular Second degree heart block type I has some blocked or 188–190
(AV) block, Mobitz I, using the criteria for nonconducted electrical impulses from the SA node to
classification, and explain how the rhythm the ventricles at the atrioventricular junction. The impulses

Copyright © 2016 by McGraw-Hill Education

may affect the patient, including basic patient coming from the atria are regular, but the conduction
care and treatment. through the AV node gets delayed.

8.4 Identify second degree atrioventricular Second degree atrioventricular block, Mobitz II, is 191–193
(AV) block, Mobitz II, using the criteria for often referred to as the “classical” heart block. The
classification, and explain how the rhythm atrioventricular node selects which electrical impulses
may affect the patient, including basic patient it will block. No pattern or reason for the dropping of
care and treatment. the QRS complex exists. Frequently this dysrhythmia
progresses to third degree atrioventricular block.

8.5 Identify third degree atrioventricular (AV) Third degree atrioventricular block is also known as third 193–196
block using the criteria for classification, and degree heart block or complete heart block (CHB). All
explain how the rhythm may affect the patient, electrical impulses originating above the ventricles are
including basic patient care and treatment. blocked and prevented from reaching the ventricles. There is
no correlation between atrial and ventricular depolarization.
In third degree atrioventricular block, the P-P and R-R
intervals are regular (constant) but firing at different rates.

196 Chapter 8 Heart Block Dysrhythmias

Chapter Review
boo20670_ch08_186-203.indd 196 28/08/14 10:12 pm

Multiple Choice
Circle the correct answer.
1. Which heart block rhythm is the one with the distinguishing feature of a PR interval that measures
greater than 0.20 second and measures the same duration each time? (LO 8.2)
a. First degree heart block
b. Second degree type I
c. Second degree type II
d. Third degree heart block
2. Which of the following heart block dysrhythmias is identified by a repetitious prolonging PR interval

Chapter Reviews consist of various methods of pattern after each blocked QRS complex? (LO 8.3)
a. First degree heart block
b. Second degree type I

quizzing you. True/false, multiple choice, matching, c. Second degree type II

d. Third degree heart block

and critical thinking questions, among others, appeal 3. Which of the following heart block dysrhythmias is identified by missing QRS complexes and a
consistent PR interval measurement? (LO 8.4)
a. First degree heart block

to all types of learners. b. Second degree type I

c. Second degree type II
d. Third degree heart block
4. Which of the following heart block dysrhythmias is identified by regular P-P and R-R intervals that
are firing at two distinctly different rates? (LO 8.5)
At the end of each chapter, you will be directed to visit a. First degree heart block
b. Second degree type I
c. Second degree type II
the Internet to experience more interactive activities
Copyright © 2016 by McGraw-Hill Education

d. Third degree heart block

5. P-P intervals are with all heart block dysrhythmias. (LO 8.2–8.5)
about the information you just learned. a. irregular
b. absent
c. regular
d. progressively prolonged
6. QRS complexes that measure 0.12 second or greater with a rate between 20 and 40 beats
per minute indicate that the impulses causing ventricular depolarization are coming from
the . (LO 8.5)
a. SA node
b. interatrial pathways
c. AV node
d. Purkinje fibers (ventricles)

Chapter 8 Heart Block Dysrhythmias 197

boo20670_ch08_186-203.indd 197 28/08/14 10:12 pm

xx
Procedure Checklists help you learn and apply the PROCEDURES CHECKLIST 12-1
Applying and Removing an Ambulatory (Holter) Monitor
knowledge presented. Practice Practice Performed Mastered
Procedure Steps (Rationale) Yes No Yes No Yes No Date Initials

Preprocedure

1. Gather supplies and equipment.

• Prep razor

• Alcohol

• Electrodes

• Gauze pads

• Skin rasp

• Tape

• Holter unit with strap and case

• Fresh batteries

• Digital disk (SD card)

• Pen and patient diary

2. Review patient instructions per facility policy

(to ensure accuracy and prevent problems
during the testing procedure).

• Documentation (diary), activities of daily living

(ADLs), when symptoms occur.

• Medications.

• Physical restrictions such as new activities

(should maintain normal routine), bathing,
showers, swimming while wearing the device.

• How to operate the event marker.

Copyright © 2016 by McGraw-Hill Education

• How to reapply an electrode if one comes
loose or falls off.

• Must return with the Holter and diary to

complete the test.

• Must wear loose-fitting garments on the

upper body to reduce artifact.

• Provide facility phone number, copy of

instructions, and “point of contact” if the
patient has questions, problems, or concerns.

• Provide picture of electrode locations,

extra electrodes, and adhesive tape per
clinic policy.

(Continued)

Chapter 12 Ambulatory Monitoring 303

boo20670_ch12_282-306.indd 303 30/08/14 8:48 pm

Critical Thinking Application Rhythm Identification

Review the dysrhythmias pictured here and, using the criteria for classification provided in the chapter as
clues, identify each rhythm and explain what criteria you used to make your decision. (LO 5.3 to 5.7)
Review and Practice Rhythm 23.

Identification throughout textbook

activities provide ample practice
opportunities.
Rhythm (regular or irregular): PR interval:
Rate: QRS:
P wave: Interpretation:

24.
Copyright © 2016 by McGraw-Hill Education

Rhythm (regular or irregular): PR interval:

Rate: QRS:
P wave: Interpretation:

Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 143

boo20670_ch05_121-146.indd 143 02/09/14 4:27 pm

xxi
Acknowledgments
Authors
Kathryn Booth: Thanks to all the reviewers who have spent time helping to
make sure this fourth edition is up-to-date. In addition, I would like to acknowl-
edge McGraw-Hill for supporting this book into its fourth edition and Jody
James for being my right hand through the process.
Additionally, I would like to acknowledge Patricia Dei Tos and the members
of the Inova Health system, who help to create and support the development
of this textbook, and the Inova Learning Network, which provided encourage-
ment and lab space for photo opportunities. Also, I would like to acknowledge
the members of the Inova Heart and Vascular Institute and Inova eICU for
their assistance in obtaining photographs and video selections.
Thomas O’Brien: I would like to acknowledge Mr. David Rubin, president
& CEO of Aerotel Medical Systems (1998) Ltd., 5 Hazoref St., Holon 58856,
Israel. I would like to express my sincere appreciation to a pair of former
students and Central Florida Institute graduates: Rebecca Walton, CCT, for
her contribution of Interpret-Tips and Jamie Merritt, CCT, for “bunny branch
block.” I would also like to give a special thank-you to the staff members of
the Non-Invasive Cardiology Departments at the Pepin Heart Hospital, Mor-
ton Plant Hospital, All Children’s Hospital, and Palms of Pasadena Hospital for
their inputs and generous donation of their time and expertise.
Additionally I would like to thank my co-workers and the leadership at CFI:
Rose Lynn Greene, Director; Susan Burnell, DOE; Steve Coleman, NCMA, Edu-
cation Supervisor; Amanda L. Jones, MBA, NR-CMA, NCPT, CPC, Medical Assis-
tant Program Director (CFI); and Nicholas R. Senger, RMA, Medical Assistant
Program Instructor (CFI). Additionally I would like to thank my former col-
leagues at Central Florida Institute: Mr. Jimmy Smith, DOE; Mr. John Michael
Maloney, RCIS; Mrs. Kathy Hellums, RCS; and Mr. Steve Coleman, NCMA.
Finally, a very special thank-you to my son Rob for his hours devoted to
scanning many of the cardiac rhythms in this text.

Consultants
Cynthia T. Vincent, MMS, PA-C
Alderson Broaddus College, Philippi, WV
Jennifer Childers, MS PAC
Alderson Broaddus College, Philippi, WV
Susan Hurley Findley, RN, MSN
Houston, TX
Lynn M. Egler, RMA, AHI, CPhT
St. Clair Shores, MI
Kimberly Speiring, MA
St. Clair Shores, MI
xxii
Reviewers
Stephanie Bernard, BA, NCMA
Sanford–Brown Institute
Jacksonville, FL
Gayle Carr, CPFT, RRT, MS
Illinois Central College
East Peoria, IL
Cyndi Caviness, CRT, CMA
(AAMA), AHI
Montgomery Community College
Troy, NC
Harvey Conner, NRP, AHA
Oklahoma City Community College
Oklahoma City, OK
Mary Hewett, BSEMS, MEd,
NREMTP
University of New Mexico
Albuquerque, NM
Charles Hill, Paramedic
North Georgia Technical College
Clarksville, GA
Cynthia Hill, MBA, CPT, CEHRS,
CMA
NewBridge Cleveland Center for Arts
& Technology
Cleveland, OH
Scott Jones, BS, MBA, EMT-P
Victor Valley College
Apple Valley, CA
Konnie King Briggs, CCT, CCI; PBT,
ASCP; CPCI, ACA
Houston Community College
Houston, TX
Joyce Lockwood, NREMTP
Prince George’s Community College
Largo, MD
Previous Edition Reviewers
Emil P. Asdurian, MD
Bramson ORT College
Forest Hills, NY
Vanessa J. Austin, RMA, CAHI
Clarian Health Sciences Center,
Medical Assistant
Indianapolis, IN
Rhonda J. Beck, NREMT-P
Central Georgia Technical College
Macon, GA
David Martinez, Medical Assistant/
EMT
Vista College
Richardson, TX
John McBryde, Nationally
Registered Paramedic
East Mississippi Community College
Mayhew, MS
Cheryl McQuay, CPT, CMA, CPI, CEKG
Star Career Academy
Brick, NJ
Sheri Melton, PhD, ACSM Certified
Exercise Specialist, ACSM
Certified Health Fitness Specialist
West Chester University
West Chester, PA
Bharat Mody, MD
Star Career Academy
Clifton, NJ
Nicole Palmieri, RN, AHI
Advantage Career Institute
Eatontown, NJ
Stephen Smith, MPA, RT, RRT
Stony Brook University
Stony Brook, NY
Scott Tomek, Paramedic
Century College
White Bear Lake, MN
Suzanne Wambold, RN, PhD
The University of Toledo
Toledo, OH
Andrew Wood, MS, NREMT-P
Emergency Medical Training
Professionals, LLC
Lexington, KY
Nia Bullock, PhD
Miller-Motte Technical College
Cary, NC
Jesse A. Coale, PA-C
Philadelphia University
Philadelphia, PA
Stephen Coleman
Central Florida Institute
Palm Harbor, FL
Acknowledgments xxiii
 Harvey Conner, AS, REMT-P Elizabeth Laurenz
Oklahoma City Community College National College
Oklahoma City, OK Columbus, OH
Barbara S. Desch, LVN, CPC, AHI Sheri A. Melton, PhD
San Joaquin Valley College Inc. West Chester University
Visalia/Hanford Campus West Chester, PA
Visalia, CA
Stephen J. Nardozzi
Melissa L. Dulaney Westchester Community College
MedVance Institute of Baton Rouge Valhalla, NY
Baton Rouge, LA
David James Newton, NREMT-P
Mary Patricia English Dalton State College
Howard Community College Dalton, GA
Columbia, MD
R. Keith Owens
Michael Fisher, Program AB-Tech Community College
Director Asheville, NC
Greenville Technical College
Greenville, SC Douglas A. Paris, BS,
NREMT-P
Donna L. Folmar Greenville Technical College
Belmont Technical College Department of Emergency Medical
St. Clairsville, OH Technology
Anne Fox Greenville, SC
Maric College
David Rice, AA, BA, MA
Carson, CA
Career College of Northern Nevada
James R. Fry, MS, PA-C Reno, NV
Marietta College
Marietta, OH Dana M. Roessler, RN, BSN
Southeastern Technical College
Michael Gallucci, MS, PT
Glennville, GA
Assistant Professor of Practice,
Program in Physical Therapy Wayne A. Rummings, Sr.
School of Public Health, New York Lenoir Community College
Medical College Kingston, NC
New York, NY David Lee Sessoms, Jr., MEd, CMA
Jonathan I. Greenwald Miller-Motte Technical College
Arapahoe Community College Cary, NC
Littleton, CO Mark A. Simpson, NREMT-P, RN,
Grace Haines CCEMTP
National College Director of EMS
Dayton, OH Northwest-Shoals Community College
Linda Karp Muscle Shoals, AL
Atlantic Cape Community College Linda M. Thompson, MS, RRT
Mays Landing, NJ Madison Area Technical College
Deborah Kufs, MS, BSN, CEN, Madison, WI
EMT-P Dyan Whitlow Underhill, MHA, BS
Hudson Valley Community College Miller-Motte Technical College
Troy, NY Cary, NC
Susie Laughter, BSN, RN Eddy van Hunnik, PhD
Cambridge Institute of Allied Health Gibbs College Boston
Longwood, FL Boston, MA

xxiv Acknowledgments
Suzanne Wambold, PhD, RN First Edition
RDCS, FASE Civita Allard
The University of Toledo Mohawk Valley Community College
Toledo, OH Utica, NY
Danny Webb Vicki Barclay
Milan Institute West Kentucky Technical College
Visalia, CA Paducah, KY
Danielle Schortzmann Wilken Nina Beaman
Goodwin College Bryant and Stratton College
East Hartford, CT Richmond, VA
Stacey F. Wilson, MT/PBT Cheryl Bell
(ASCP), CMA Sanz School
Cabarrus College of Health Washington, DC
Sciences Lucy Della Rosa
Concord, NC Concorde Career Institute
Fran Wojculewicz, RN, BSN, MS Lauderdale Lakes, FL
Maricopa Community College Myrna Lanier
Glendale, AZ Tulsa Community College
Roger G. Wootten Tulsa, OK
Northeast Alabama Community Debra Shafer
College Blair College
Rainsville, AL Colorado Springs, CO

Acknowledgments xxv
 Electrocardiography

Learning Outcomes 1.1 Describe the history and the importance of the ECG.
1.2 Identify the uses of an ECG and opportunities for an electro-
cardiographer.
1.3 Troubleshoot legal, ethical, patient education, and communication
issues related to the ECG.
1.4 Perform safety and infection control measures required for the ECG.
1.5 Compare basic vital sign measurements related to the ECG.

Key Terms auscultated blood pressure ethics

automatic external healthcare providers
defibrillator (AED) hypertension
body mechanics hypotension
cardiac output isolation precautions
cardiopulmonary law
resuscitation (CPR) libel
cardiovascular disease (CVD) medical professional liability
cardiovascular technologist myocardial infarction (MI)
Code Blue personal protective equipment
coronary artery disease (CAD) (PPE)
defibrillator slander
diastolic blood pressure standard precautions
Copyright © 2016 by McGraw-Hill Education

dysrhythmia stat
ECG monitor technician systolic blood pressure
electrocardiogram (ECG) telemedicine
electrocardiograph vital signs
electrocardiograph (ECG)
technician

1
cardiovascular disease
(CVD) Disease related to
the heart and blood vessels
(veins and arteries).
coronary artery disease
(CAD) Narrowing of the
arteries around the heart,
causing a reduction of blood
flow.
myocardial infarction
(MI; heart attack) Damage
to the heart muscle caused
by lack of oxygen due to a
blockage of one or more of
the coronary arteries.
electrocardiograph An
instrument used to record
the electrical activity of the
heart.
electrocardiogram
(ECG) A tracing of
the heart’s electrical
activity recorded by an
electrocardiograph.
1.1 The ECG and Its History
The number one cause of death in the United States every year since 1918 is
cardiovascular disease (CVD), or a disease of the heart and blood vessels.
Approximately 2,500 Americans die every day because of coronary artery
disease (CAD), which is narrowing of the arteries of the heart, which causes
a reduction of blood flow. Unbelievably, one out of every three American
adults has some form of CAD. You may know someone who has hypertension
(high blood pressure) or other heart conditions. Maybe someone you know
has had a myocardial infarction (MI) or heart attack.
An instrument known as an electrocardiograph allows the heart’s
electrical activity to be recorded and studied. It is used to produce an electri-
cal (electro) tracing (graph) of the heart (cardio). This tracing is known as an
electrocardiogram (ECG).
Scientists have known since 1887 that electrical currents are produced
during the beating of the human heart and can be recorded. An English physi-
cian, Dr. Augustus D. Waller (1856–1922), showed that electrical currents are
produced during the beating of the human heart and can be recorded. Willem
Einthoven (1860–1927) invented the first electrocardiograph, which resulted
in a Nobel Prize in Physiology or Medicine in 1924. Advancements in this tech-
nology have brought about today’s modern ECG machines (see Figure 1-1).
Computer technology continues to improve the availability and speed of com-
puter interpretation and quickly communicates this information to a health-
care professional. Digital communication allows healthcare professionals to
monitor patients from remote locations miles away.

Figure 1-1 Today’s 12-lead ECG machine

is attached to the patient’s chest, arms,
and legs using electrodes and lead wires.
It records a tracing of the electrical activity
of the heart.

Copyright © 2016 by McGraw-Hill Education

2 Chapter 1 Electrocardiography
Another random document with
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 C’est une des caractéristiques du génie de Henri Poincaré qu’il
réunit un prodigieux esprit d’invention à un esprit critique
extrêmement aiguisé. Sa critique semble même aller parfois
jusqu’au scepticisme; il contemplait sans tristesse les ruines des
théories. Alors que d’autres constatent avec regret que certaines
idées ne s’accommodent plus aux faits, et commencent par penser
que ceux-ci ont été mal vus ou mal interprétés, Poincaré a plutôt une
tendance contraire, bien qu’elle se soit peut-être atténuée dans les
dernières années. Ainsi un jeune physicien ayant cru jadis pouvoir
s’inscrire contre la célèbre expérience de Rowland, d’après laquelle
une charge électrique en mouvement produit un champ magnétique
conformément à la théorie de Maxwell, cette annonce ne parut pas
étonner Poincaré. Nul n’eut moins que lui la notion statique d’une
science se reposant sur quelques conquêtes définitives, et c’est ce
qui explique que plusieurs se soient crus autorisés à tirer de certains
de ses écrits, où il poussait sa tendance critique presque jusqu’au
paradoxe, des conclusions sur la vanité de la Science contre
lesquelles il dut protester.
Quelques Préfaces des Leçons de Poincaré ont vivement attiré
l’attention. Dans l’Introduction du Livre Électricité et Optique, il
discute ce qu’on doit entendre par «interprétation mécanique d’un
phénomène». Cette interprétation est ramenée d’après lui à la
possibilité de la formation d’un système d’équations de Lagrange
avec un certain nombre de paramètres que
l’expérience atteint directement et permet de mesurer. Dans ces
équations figurent l’énergie cinétique et une fonction des forces
. Cette possibilité étant supposée, on pourra toujours déterminer
masses (masses visibles ou cachées) et leurs coordonnées (
) fonctions des (en prenant assez grand), de manière
que la force vive de ce système de masses soit égale à l’énergie
cinétique figurant dans les équations de Lagrange.
L’indétermination est ici très grande, et c’est précisément là qu’en
veut venir Poincaré, dont la conclusion est que, s’il y a une
explication mécanique, il y en a une infinité. Il faut avouer, dirons-
nous, que cette indétermination est même trop grande, car on perd
complètement de vue les corps en présence. Ainsi, suivant les
formes qu’auront l’ensemble des masses partiellement
indéterminées , on n’aura pas nécessairement dans la suite les
mêmes mouvements; il pourra, par exemple, y avoir ou non des
chocs. Que devient aussi la répartition des forces réelles dans les
systèmes en partie fictifs auxquels on est ainsi conduit?
Dans la Préface de sa Thermodynamique, Poincaré, voulant
descendre en quelque sorte jusqu’au fond du principe de la
conservation de l’énergie, conclut que «la loi de Meyer est une forme
assez souple pour qu’on puisse y faire rentrer presque tout ce qu’on
veut». Il semble à la vérité un peu effrayé de sa conclusion, car il
ajoute plus loin qu’il ne faut pas «pousser jusqu’à l’absolu». Nous
retrouverons cet esprit hypercritique, si j’ose le dire, clans certains
écrits philosophiques de Poincaré.
Poincaré, sans cesse curieux de nouvelles théories et de
nouveaux problèmes, ne pouvait manquer d’être attiré par
l’Électromagnétisme qui tient une si grande place dans la Science de
notre époque. On ne saurait trop admirer avec quelle sûreté et
quelle maîtrise il repense les diverses théories, les faisant ainsi
siennes. Il leur donne parfois une forme saisissante, comme quand,
dans l’exposition de la théorie de Lorentz, il distingue entre les
observateurs ayant les sens subtils et les observateurs ayant les
sens grossiers. La considération, bien personnelle à Poincaré, de ce
qu’il appelle «la quantité de mouvement électromagnétique», la
localisation de celle-ci dans l’éther et sa propagation avec une
perturbation électromagnétique sont venues rétablir d’importantes
analogies. Le Mémoire sur la dynamique de l’électron, écrit en 1905,
restera dans l’histoire du principe de la relativité; le groupe des
transformations de Lorentz, qui n’altèrent pas les équations d'un
milieu électromagnétique, y apparaît comme la clef de voûte dans la
discussion des conditions auxquelles doivent satisfaire les forces
dans la nouvelle dynamique. La nécessité de l’introduction dans
l’électron de forces supplémentaires, en dehors des forces de liaison
est établie, ces forces supplémentaires pouvant être assimilées à
une pression qui régnerait à l’extérieur de l’électron. Poincaré
montre encore quelles hypothèses on peut faire sur la gravitation
pour que le champ grafivique soit affecté par une transformation de
Lorentz de la même manière que le champ électromagnétique.
 On sait l’importance qu’a prise aujourd’hui le principe de la
relativité, dont le point de départ est l’impossibilité, proclamée sur la
foi de quelques expériences négatives, de mettre en évidence le
mouvement de translation uniforme d’un système au moyen
d’expériences d’optique ou d’électricité faites à l’intérieur de ce
système. En admettant, d’autre part, que les idées de Lorentz et ses
équations électromagnétiques sont inattaquables, on a été conduit à
regarder comme nécessaire le changement de nos idées sur
l’espace et sur le temps; espace et temps ( ) n’ont plus
leurs transformations séparées et entrent simultanément dans le
groupe de Lorentz. La simultanéité de deux phénomènes devient
une notion toute relative; un phénomène peut être antérieur à un
autre pour un premier observateur, tandis qu’il lui est postérieur pour
un second. Les mathématiciens, intéressés par un groupe de
transformations qui transforment en elle-même la forme quadratique
( = vitesse de la lumière) se sont livrés à
d’élégantes dissertations sur ce sujet et ont sans doute contribué à
la popularité du principe de relativité. A d’autres époques, on eût
peut-être, avant de rejeter les idées traditionnelles de l’humanité sur
l’espace et le temps, passé au crible d’une critique extrêmement
sévère les conceptions sur l’éther et la formation des équations de
l’électromagnétisme; mais le désir du nouveau ne connaît pas de
bornes aujourd’hui. Les objections ne manquent pas cependant, et
d’illustres physiciens, comme Lord Kelvin et Ritz, sans parler des
vivants, ont émis des doutes très motivés. La Science assurément
ne connaît point de dogmes, et il se peut que des expériences
positives précises nous forcent un jour à modifier certaines idées
devenues notions de sens commun; mais le moment en est-il déjà
venu?
Poincaré voyait le danger de ces engouements, et, dans une
conférence sur la dynamique nouvelle, il adjurait les professeurs de
ne pas jeter le discrédit sur la vieille Mécanique qui a fait ses
preuves. Et puis, il a vécu assez pourvoir les principaux
protagonistes des idées nouvelles ruiner partiellement au moins leur
œuvre. Dans tout ce relativisme, il reste un absolu, à savoir la
vitesse de la lumière dans le vide, indépendante de l’état de repos
ou de mouvement de la source lumineuse. Cet absolu va
probablement disparaître, les équations de Lorentz ne représentant
plus qu’une première approximation. Les plus grandes difficultés
viennent de la gravitation, au point que certains théoriciens de la
Physique croient ne pouvoir les lever qu’en attribuant de l’inertie et
un poids à l’énergie, d’où en particulier la pesanteur de la lumière. Si
Poincaré avait vécu, il eût sans doute été conduit à rapprocher des
vues actuelles son essai de 1905 sur la gravitation. Au milieu des
incertitudes qui se présentent aujourd’hui en électro-optique, son
esprit lumineux va nous manquer singulièrement. Il faut avouer que
dans tout cela les bases expérimentales sont fragiles, et peut-être
Poincaré eût-il suggéré des expériences apportant un peu de
lumière dans cette obscurité.
Un des derniers travaux de Poincaré a été une discussion
approfondie de la théorie des quanta, édifiée par Planck, d’après
laquelle l’énergie des radiateurs lumineux varierait d’une manière
discontinue. De ce point de vue «les phénomènes physiques, dit
Poincaré, cesseraient d’obéir à des lois exprimables par des
équations différentielles, et ce serait là sans aucun doute la plus
grande révolution et la plus profonde que la philosophie naturelle ait
subie depuis Newton». Quelque grande, en effet, que doive être
cette révolution, il est permis toutefois de remarquer que des
circonstances plus ou moins analogues se sont déjà présentées.
Ainsi, dans un gaz à la pression ordinaire, ou peut parler de pression
et l’on peut appliquer les équations différentielles de la dynamique
des fluides; il n’en est plus de même dans un gaz raréfié, où il n’est
plus possible de parler de pression. Il faudra peut-être nous résigner
à faire usage, suivant les limites entre lesquelles nous étudions une
catégorie de phénomènes, de représentations analytiques
différentes, si pénible que puisse être cette sorte de pluralisme pour
ceux qui rêvent d’unité. Mais c’est là encore le secret de l’avenir, et il
serait imprudent d’affirmer qu’on ne trouvera pas quelque biais
permettant de rétablir dans nos calculs la continuité.
 V.
Les nombreux écrits de Poincaré, sur ce qu’on appelle la
philosophie des sciences, ont fait connaître son nom à un public très
étendu. Nous entrons ici dans un autre domaine que celui des
recherches proprement scientifiques, et je n’ai pas l’intention
d’étudier à fond cette partie de son œuvre. Il y est tout d’abord
singulièrement difficile de se rendre compte de l’originalité de telle
ou telle étude; ainsi, dans ses écrits sur l’hypothèse dans la Science,
Poincaré s’est rencontré plus d’une fois avec divers auteurs, mais
l’illustration de son nom, consacrée par tant de découvertes
mathématiques, donnait à ses opinions une autorité particulière. La
forme en ces questions est aussi de grande importance. La phrase
concise de Poincaré, allant droit au but, parfois avec une légère
pointe de paradoxe, produit une singulière impression; on est un
moment subjugué, même quand on sent qu’on n’est pas d’accord
avec l’auteur. Mainte page de Poincaré a produit sur plus d’un
lecteur un vif sentiment d’admiration en même temps qu’une sorte
d’effroi et d’agacement devant tant de critique.
On a parlé quelquefois de la philosophie de Poincaré. En fait,
penseur indépendant, étranger à toute école, Poincaré ne chercha
jamais à édifier un système philosophique, comme un Renouvier, un
Bergson ou même un William James. Il a écrit des livres de
«Pensées», où savants et philosophes trouvent ample matière à
réflexions. Il n’est esclave d’aucune opinion, pas même de celle qu’il
a émise antérieurement, et il sera un jour intéressant de suivre
certaines variations de la sa pensée, où l’on voit quelque peu
s’atténuer ce qu’on a appelé son nominalisme. Il fut ainsi conduit à
expliquer certaines affirmations qui, prises trop à la lettre, avaient été
mal comprises et utilisées dans un dessein dont il n’avait aucun
souci.
 Si l’on voulait toutefois caractériser d’un mot les idées de
Poincaré, on pourrait dire que sa philosophie est la philosophie de la
commodité. Dans quelques unes de ses pages, le mot commode
revient constamment et constitue le terme de son explication.
D’aucuns pensent qu’il faudrait donner les raisons de cette
commodité, et, parmi eux, les plus pressants sont les biologistes
toujours guidés par l’idée d’évolution. La commodité résultera pour
eux d’une longue adaptation, et, ainsi approfondie, deviendra un
témoignage de réalité et de vérité. A l’opposé des évolutionnistes,
d’autres ne voient que l’esprit humain tout formé et sa fonction la
pensée. A certaines heures au moins, Poincaré fut de ces derniers,
et cet idéalisme lui a inspiré des pages d’une admirable poésie qui
resteront dans la littérature française; telle cette dernière page de
son Livre sur la valeur de la Science, qui débute par ces mots «Tout
ce qui n’est pas pensée est le pur néant». Entre des doctrines si
différentes toute communication est impossible, et l’on arrive à se
demander si l’on peut discuter de l’origine des plus simples notions
scientifiques, sans avoir à l’avance une foi philosophique à la
formation de laquelle auront d’ailleurs concouru d’autres éléments
que des éléments proprement scientifiques.
Pour ne pas rester uniquement dans les généralités, arrêtons-
nous un moment sur les principes de la Géométrie. Poincaré part
d’un esprit humain, dans lequel l’idée de groupe préexiste et
s’impose comme forme de notre entendement. L’esprit, après un
travail d’abstraction aboutissant aux premiers concepts de la
Géométrie (point, droite, etc.), cherche à exprimer les rapports de
position des corps; il le fait au moyen de l’idée de groupe, prenant le
groupe le plus commode et le plus simple qui est le groupe de la
géométrie dite euclidienne. Les propriétés géométriques ne
correspondent, pour Poincaré, à aucune réalité; elles forment un
ensemble de conventions que l’expérience a pu suggérer à l’esprit,
mais qu’elle ne lui a pas imposées. L’évolutionniste dont je parlais
plus haut voit là de grandes difficultés, non pas seulement pour la
raison banale que la dualité ainsi posée entre l’esprit et le milieu
extérieur est contraire à sa doctrine, mais parce que, cherchant à
retracer la genèse des origines de la Géométrie dans l’espèce
humaine, il lui paraît impossible de séparer l’acquisition des notions
géométriques et celles des notions physiques les plus simples, la
Géométrie ayant dans des temps très anciens fait partie de la
Physique. Sans changer l’ensemble de ces notions, on ne peut,
semble-t-il, remplacer le groupe euclidien par un autre, et les
exemples cités de transport d’un homme dans un autre milieu (où
cet homme commencerait par mourir) sont plus pittoresques que
probants. On retombe ainsi, sous un autre point de vue, sur les
idées de Gauss qui considérait comme un fait expérimental que la
courbure de notre espace est nulle, et regardait, contrairement à
Poincaré, que la géométrie euclidienne est plus vraie que les
géométries non euclidiennes. Il y a sans doute bien des hypothèses,
ne disons pas des conventions, en Géométrie. C’en est une par
exemple, oubliée quelquefois, que notre espace est simplement
connexe. Peu importe quelle est la connexité de l’espace, quand on
se borne à envisager une partie assez petite, celle-ci s’étendît-elle
jusqu’aux lointaines nébuleuses, mais il pourrait en être autrement
quand on considère l’espace dans son ensemble.
Tous les esprits élevés trouveront, dans l’œuvre philosophique et
littéraire de Poincaré, matière à longues réflexions, soit qu’ils se
laissent convaincre par sa dialectique, soit qu’ils cherchent des
arguments contraires. Certaines pages sont d’une austère grandeur,
comme celle où la pensée est qualifiée d’«éclair au milieu d’une
longue nuit». Non moins suggestive est la parenthèse ouverte un
peu avant «étrange contradiction pour ceux qui croient au temps»,
où l’on est presque tenté de voir un demi-aveu. Les inquiétudes
qu’on peut concevoir au sujet de la notion même de loi furent-elles
jamais exprimées avec plus de profondeur que dans l’étude sur
l’évolution des lois? J’ai déjà fait allusion au prétendu scepticisme de
Poincaré. Non, Poincaré ne fut pas un sceptique; à certaines heures,
il fut pris, comme d’autres, d’angoisse métaphysique, et il sut
éloquemment l’exprimer. Mais tournons le feuillet, et le savant,
confiant dans l’effort de l’esprit humain pour atteindre le vrai, nous
apparaît dans des pages admirables sur le rôle et la grandeur de la
Science. Les plus belles peut-être forment cet hymne à l’Astronomie
qu’il faudrait faire lire aux jeunes gens à une époque où tend à
dominer le souci exclusif de l’utile. Aucune des préoccupations de
notre temps ne fut d’ailleurs étrangère au noble esprit de Poincaré;
c’est ce dont témoigne une de ses dernières études sur la morale et
la science, où l’argumentation est irréprochable, si par morale on
entend la morale impérative de Kant.
On ne ferme pas sans tristesse ces volumes d’un contenu si riche
et dont quelques parties auraient été l’objet de nouveaux
développements, si la plume n’était tombée des mains de leur
auteur. Tous ceux qui ont le culte de la Science pure et
désintéressée ont été douloureusement émus par sa mort
prématurée, mais ce sont surtout les sciences mathématiques qui
sont cruellement frappées par cette disparition. Poincaré fut, avant
tout, un profond mathématicien, qui, pour la puissance d’invention,
est l’égal des plus grands. L’heure n’est pas venue de porter un
jugement définitif sur son œuvre que le temps grandira encore, ni de
le comparer aux plus célèbres géomètres du siècle dernier: peut-être
Henri Poincaré fût-il encore supérieur à son œuvre?
[1] On sait qu’un savant Finlandais M. Sundmann vient de donner
une solution complète du problème des trois corps. Il serait injuste
de ne pas reconnaître que les travaux antérieurs de Poincaré ont
eu une grande influence sur les recherches de l’astronome
d’Helsingfors. J’ai fait une étude des Mémoires de M. Sundmann
dans un article récent de la Revue générale des Sciences (15
octobre 1913) et dans le Bulletin des Sciences Mathématiques
(octobre 1913).
[2] C’est en approfondissant cette idée, et en ne craignant pas de
comprendre dans son analyse le cas des chocs que M.
Sundmann est arrivé à une solution du problème de trois corps
(voir la note ci-dessus).

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Augustins.

AU LECTEUR
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corrigées.
Une table des matières a été ajoutée pour faciliter la tâche du lecteur.
 *** END OF THE PROJECT GUTENBERG EBOOK L'ŒUVRE DE
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