ECG WORKSHOP

Heart Anatomy
Heart Anatomy Heart Anatomy Flash Cards

How to read an ECG strip

ECG paper is a grid where time is measured along

the horizontal axis. Each small square is 1 mm in length and represents 0.04 seconds. Each larger square is 5 mm in length and represents 0.2 seconds. Voltage is measured along the vertical axis. 10 mm is equal to 1mV in voltage. The diagram in next slide illustrates the configuration of ECG graph paper and where to measure the components of the ECG wave form

ECG graph paper configuration

Heart rate calculation

Heart rate can be easily calculated from the

ECG strip: When the rhythm is regular, the heart rate is 300 divided by the number of large squares between the QRS complexes.
For example, if there are 4 large squares

between regular QRS complexes, the heart rate is 75 (300/4=75).

The second method can be used with an

irregular rhythm to estimate the rate. Count the number of R waves in a 6 second strip and multiply by 10.
For example, if there are 7 R waves in a 6

Instant Feedback
On a typical ECG grid, 5 small squares, or 1

large square, represent 0.20 seconds of time

True False

Normal components of the ECG waveform

P wave Indicates atrial depolarization, or contraction of

the atrium. Normal duration is not longer than 0.11 seconds (less than 3 small squares) Amplitude (height) is no more than 3 mm No notching or peaking

Normal components of the ECG waveform

QRS complex Indicates ventricular depolarization, or

contraction of the ventricles. Normally not longer than .10 seconds in duration Amplitude is not less than 5 mm in lead II or 9 mm in V3 and V4 R waves are deflected positively and the Q and S waves are negative

Normal components of the ECG waveform

T wave Indicates ventricular repolarization Not more that 5 mm in amplitude in standard

leads and 10 mm in precordial leads Rounded and asymmetrical

Normal components of the ECG waveform

ST segment Indicates early ventricular repolarization Normally not depressed more than 0.5 mm May be elevated slightly in some leads (no

more than 1 mm)

Normal components of the ECG waveform

PR interval Indicates AV conduction time Duration time is 0.12 to 0.20 seconds

Normal components of the ECG waveform

QT interval Measured from the Q to the end of the T. Represents ventricular depolarization and

repolarization (sodium influx and potassium efflux) V3, V4 or lead II optimize the T-wave. QT usually less than half the R-R interval

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Normal QRS duration is 0.15 - 0.25 seconds.

True False The normal QRS is no more than two small boxes or 0.10 seconds.

Sinus Bradycardia

Sinus Bradycardia
Rate 40-59 bpm P wave sinus QRS normal (.06-.12) Conduction P-R normal or slightly prolonged

at slower rates Rhythm regular or slightly irregular This rhythm is often seen as a normal variation in athletes, during sleep, or in response to a vagal maneuver. If the bradycardia becomes slower than the SA node pacemaker, a junctional rhythm may occur.

Instant feedback
Sinus bradycardia is always abnormal and

must be treated. True False

This rhythm is often seen in athletes, during sleep, or in response to a vagal maneuver.

Sinus Tachycardia

Sinus Tachycardia
Rate 101-160/min P wave sinus QRS normal Conduction normal Rhythm regular or slightly irregular Underlying causes include: CHF, hypoxia,

increased temperature, stress, response to pain

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Sinus tachycardia is a normal response to pain.

True False

Premature Atrial Contraction

Premature Atrial Contraction

Rate normal or accelerated P wave usually have a different morphology than

sinus P waves because they originate from an ectopic pacemaker QRS normal Conduction normal, however the ectopic beats may have a different P-R interval. Rhythm PAC's occur early in the cycle and they usually do not have a complete compensatory pause. PAC's occur normally in a non diseased heart. However, if they occur frequently, they may lead to a more serious atrial dysrhythmias. They can also result from CHF, ischemia and COPD.

Instant feedback
With PACs, all the P waves look identical.

True False Ectopic beats arise from sites outside of the SA node. Therefore they have a different shape.

Sinus Arrest

Sinus Arrest

Rate normal P wave those that are present are normal QRS normal Conduction normal Rhythm The basic rhythm is regular. The length of the pause

is not a multiple of the sinus interval. This may occur in individuals with healthy hearts. It may also occur with increased vagal tone, myocarditis, MI, and digitalis toxicity. If the pause is prolonged, escape beats may occur. The treatment of this dysrhythmia depends on the underlying cause. If the cause is due to increased vagal tone and the patient is symptomatic, atropine may be indicated.

Instant Feedback
Atropine should never be used to treat sinus

arrest.

True False Atropine may be prescribed if the patient is symptomatic and the underlying cause is increased vagal tone.

Atrial Fibrillation

Atrial Fibrillation
Rate atrial rate usually between 400-650/bpm. P wave not present; wavy baseline is seen

instead. QRS usually normal, a wide QRS may indicate conduction by accessory pathway. Conduction variable AV conduction; if untreated the ventricular response is usually rapid. Rhythm irregularly irregular with abscence of P waves. (This is the hallmark of this dysrhythmia). Symptoms palpitations, chest pain, dyspnea, fatigue, lightheadedness, or syncope.

Atrial Fibrillation cont

Atrial fibrillation (AF) is the most common

sustained cardiac arrhythmia. Signs of acute atrial fibrillation are: hypotension, myocardial ischemia, decreased perfusion of vital organs and acute congestive heart failure (CHF). Chronic atrial fibrillation increases the risk of atrial thrombus and embolus. Some conditions associated with atrial fibrillation are: mitral stenosis, lung disease, heart disease, sepsis, hyperthyroidism and cardiac surgery.

Instant Feedback
The hallmark sign of atrial fibrillation is:

An abscence of P waves and an irregulary irregular ventricular rate A sawtooth pattern

Atrial Flutter

Atrial Flutter
Rate atrial 250-350/min; ventricular conduction

depends on the capability of the AV junction (usually rate of 150-175 bpm). P wave not present; usually a "saw tooth" pattern is present. QRS normal Conduction 2:1 atrial to ventricular most common. Rhythm usually regular, but can be irregular if the AV block varies. Symptoms palpitations, rapid heart rate, chest pain, shortness of breath, lightheadedness, fatigue, and low blood pressure.

Atrial Flutter cont

Atrial flutter is the second most common

tachyarrhythmia, after atrial fibrillation. It is usually confined to tissue of the right atrium, only rarely passing through the atrial septum to effect the left atrium. It results from an aberrant conduction circuit typically located in the tissue between the inferior vena cava and the tricuspid valve, an area known as the cavotricuspid isthmus.

Atrial Flutter cont

Atrial flutter almost always occurs in diseased

hearts but it can occur in otherwise asymptomatic hearts. The incidence of atrial flutter increases with age and medical conditions including: congestive heart failure, rheumatic valve disease, congenital heart disease, lung disease such as emphysema, or high blood pressure.

Instant Feedback
In atrial flutter, instead of P waves there is

commonly a "sawtooth" pattern seen.

True False

Ventricular Fibrillation

Ventricular Fibrillation
Rate unattainable P wave may be present, but obscured by

ventricular waves QRS not apparent Conduction chaotic electrical activity Rhythm chaotic electrical activity This dysrhythmia results in the absence of cardiac output. Almost always occurs with serious heart disease, especially acute MI. The course of treatment for ventricular fibrillation includes:immediate defibrillation and ACLS

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The P wave is never present during Ventricular

Fibrillation

True False The P wave may be present, but obscured by ventricular waves

Artifact

Artifact
Artifact occurs when something causes a

disruption in monitoring.
Some common causes are: AC interference -causes 60 cycle artifact Muscle tremors Respiratory artifact-wandering baseline Loose electrode Broken lead wire