ECG Interpretation &

Dysrhythmia Identification
By naaim ali
Physiology of the Heart: Conductive System (Electrical
Pathway)
 Physiology of the Heart: Electrophysiology

1) Atria begin to contract

2) Atria contract

atria relax
3) Ventricles begin to contract at
apex;

4) Ventricles contract
5) Ventricles begin to relax at apex

6) Ventricles relax
Physiology of the Heart: Electrophysiology

Positive Deflection
(P & R & T)

Isoelecrtical
Line

Negative Deflection
(Q & S)
 Electrocardiogram (ECG): Relation between
ECG Leads & Heart Surfaces

Lateral surface of the

left ventricle

Anterior surface of
inferior surface the left ventricle
of the left
ventricle Interventricular septum
Localizing Pathology on the ECG
ECG Paper (Grid)

Paper used in recording ECGs has a grid to

permit the measurement of:
• Duration or Time in seconds (sec),
• Distance in millimeters (mm) along the
horizontal lines and
• Voltage (amplitude) in millimeters (mm)
along the vertical lines.

Each large box (square) = 5

small boxes (squares) = 0.5 mV
Each small box = 1mm = 0.1
mV
 ECG Interpretation: How to Read ECG
 Regularity of the Rhythm

© Estimating the R-R intervals: counting the small squares between every R –
R intervals.
© Measuring them using ECG callipers or, if callipers are not available, a
pencil and paper. Comparing the R-R intervals to each other.
© A rhythm is considered “REGULAR OR CONSTANT” when:
 The distance between R - R is either the same or varies by 1 ½ small
boxes or less from one R wave to the next R wave
 There is one P for every QRS
ECG Interpretation: How to Read ECG
 Regularity of the Rhythm
 ECG Interpretation: How to Read ECG
 Calculate the Heart Rate
Normal – 60-100 bpm - Tachycardia > 100 bpm - Bradycardia < 60 bpm
© Calculating of heart rate in REGULAR RHTHYM
© Method 1:
1) Counting the number of large boxes between two consecutive R waves.
2) Then Divide 300 by this number to calculate the heart rate.
 ECG Interpretation: How to Read ECG
 Calculate the Heart Rate

Calculating of heart rate in REGULAR RHTHYM

© Method 2:
© Sometimes it is necessary to count the number of small boxes between two
consecutive R waves for fast heart rates. That number is divided into 1500 to
calculate bpm.
© Example. If there are ten small boxes between two R waves: 1500/10 =150 bpm.
R R
 ECG Interpretation: How to Read ECG
 Calculate the Heart Rate
© Calculating of heart rate in IRREGULAR RHYTHYM
© Method 3: Six-Seconds ECG Rhythm Strip
© The best method for measuring rates in irregular rhythm with varying R-R intervals is to
count the number of R waves in a 6-sec strip (30 large squares) and multiply by 10. This
gives the average number of rate bpm.
© For example: 7 R 10= 70 bpm

R R R R R R
R
ECG Interpretation: How to Read ECG
 P-wave Examination Wave

1 Are P waves present?

2 Are P waves occurring regularly?

3 Is there one P wave present for every QRS complex

present?
4 Are the P waves smooth, rounded, and upright in
appearance, or are they inverted?
5 Do all P waves look similar?
Features of Normal Sinus Rhythm
Normal ECG Strip
Abnormal Rhythm - Dysrhythmias
 Dysrhythmias/Arrhythmias

© Dysrthymia is an abnormal heart rate/and or  Drugs Commonly Associated with

rhythm. Cardiac Arrhythmias
© Causes of Dysrhythmias include:  Digoxin.

 Ischemic heart diseases, cardiomyopathy &  Antiarrythmic drugs, especially

valvular heart disease quinidine.

 Autonomic nervous system imbalance  Cocaine.

 Electrolyte or Metabolic Disorders include:  Genetic Disorders

Hypokalemia (low potassium levels).  Aging
Hyperkalemia (high potassium levels).
 Anesthesia
Hypomagnesemia (low magnesium levels).
Hypocalcemia (low calcium levels).
 Cardiac Trauma
Acidosis (blood too acidic).  Idiopathic
Alkalosis (blood too alkaline).
Classifications of Dysrhythmias
 Sinus Dysrhythmias

Types of Sinus Ds

Sinus Sinus Pause

Sinus
Bradycatdia or Arrest
Tachycardia
 Sinus Dysrhythmias: Sinus Bradycardia

Rate: Slow (60 bpm)

Rhythm: Regular
P Waves: Normal (upright and
uniform)
PR Interval: Normal (0.12–
0.20 sec)
QRS: Normal (0.06–0.12 sec)
 Sinus Dysrhythmias: Sinus Tachycardia

Rate: Fast (100 bpm)

Rhythm: Regular
P Waves: Normal (upright &
uniform)
PR Interval: Normal (0.12–
0.20 sec)
QRS: Normal (0.06–0.10 sec)
 Sinus Dysrhythmias: Sinus Arrest or Pause

© A sinus pause or arrest is defined as the transient absence of sinus P waves on the

electrocardiogram (ECG) that may last from two seconds to several minutes.
©Regularity: Irregular
QRS
©Heart rate: Varies
© P wave: Present, Normal
©QRS Width: Normal or Narrow
© PR interval is Normal or Prolonged
© Dropped Beats: Yes
 Atrial Dysrhythmias

© When the sinoatrial (SA) node fails to

generate an impulse; atrial tissues or
internodal pathways may initiate an
impulse.

© Most common atrial arrhythmias that

could affect the critically ill patients are:
1) Atrial Flutter (rate varies; usually
regular; saw-toothed)
2) Atrial Fibrillation (rate varies, always
irregular)
 Atrial Dysrhythmia: Atrial Flutter (A-flutter)
© When the SA node fails to deliver impulse, many other sites inside the atrium start to
deliver impulses called ectopic foci.
© These electrical impulses that are propagated by these abnormal ectopic foci travel
in a circle pattern inside the atriums and continue to move in a circle again, etc
leading to firing of the atria & making the atriums to contract so quickly (250 – 300
b/m).
© Not all the electrical impulses come from the ectopic foci are reached to the AV
node, so the AN node contracted only 150 b/m.
© AV node has no abnormality so, the QRS complex is normal.
© there is no P wave but many sawtooth pattern called F wave.
© The rhythm is irregular.
 Atrial Dysrhythmia: Atrial Fibrillation (A-fib)

© Multiple atrial ectopic foci.

© No organized atrial contractions are detectable.
© The ventricles do not receive regular impulses
and contract out of rhythm, and the heartbeat
becomes uncontrolled and irregular.
© One of the hallmark AFib symptoms is this so-
called FLUTTERING OR FIBRILLATION.

©Rate: Atrial: 350 bpm or greater;

Sinus rhythm A – (fib)
ventricular: slow or fast
©Rhythm: Irregular
©P Waves: No true P waves; chaotic atrial
activity
©PR Interval: None
©QRS: Normal (0.06–0.12 sec)
 Ventricular Dysrhythmias

© When the sinoatrial (SA) node and the AV Junctional tissues fails to
generate an impulse the ventricles will assume the role of pacing the
heart.
© There is an absence of P waves because there is no atrial activity or
contraction.
© Ventricular rhythms will display QRS complexes that are wide
(greater than or equal to 0.12 seconds) and bizarre in appearance.
© Life – Threatening Ventricular Dysrhythmias include:
 Supraventricular Tachycardia
 Premature Ventricular Contraction
 Ventricular Tachycardia
 Torsade de Pointes
 Ventricular Fibrillation
Ventricular Dysrhythmias: Supraventricular Tachycardia
 Ventricular Dysrhythmias: Premature Ventricular Contraction
(PVC)
© A PVC is not a rhythm, but an ectopic beat that arises from an
irritable site in the ventricles.
© PVCs appear in many different patterns and shapes, but are
always wide and bizarre compared to a “normal” beat.
© Because ventricular contraction does not come from the atria,
PVCs are not preceded by P wave.
© Depending on the location of ectopic site, the result is QRS
may be taller or deeper than usual.
© SA node is not affected so P wave is normal.
© There are 3 mechanisms that which PVC may occur:
1) Increased automaticity
2) Re – entry circuit in damaged heart muscle (scar)
3) Triggered beat or extra beats
Ventricular Dysrhythmias: Premature Ventricular Contraction
(PVC)
Ventricular Dysrhythmias: Premature Ventricular Contraction
(PVC)
Ventricular Dysrhythmias: Premature Ventricular Contraction
(PVC)
 Ventricular Dysrhythmias: Torsade de Pointes
© In French the term means “twisting of the points
© The QRS reverses polarity and the strip shows a spindle
effect.
Rate: 200–250 bpm
© This rhythm is an unusual variant of polymorphic VT with Rhythm: Irregular
normal or long QT intervals..” P Waves: None
PR Interval: None
© Torsade de pointes may deteriorate to VF or asystole.
QRS: Wide (0.10 sec), bizarre
© Frequent causes are drugs that prolong QT interval and appearance
electrolyte abnormalities such as hypomagnesemia.
 Ventricular Dysrhythmias: Ventricular Tachycardia (VT) &
Ventricular Fibrillation

© Ventricular tachycardia is a serious condition & always

occurs in diseased hearts (MI).
© There are multiple ectopic foci propagate impulses at the
same time making electrical firing in the ventricles leading
to very fast ventricular contractions.
© QRS wide and has bizarre shape.

© Rhythm in which three or more PVCs arise in sequence at a

rate greater than 100 beats per minute.
© V-tach can quickly deteriorate into ventricular fibrillation in
which the ventricles become exhausted from the fast
contractions & start to FIBRILLATE.
 Ventricular Dysrhythmias: Ventricular Tachycardia (VT) &
Ventricular Fibrillation

© As long as the ventricles are not contracted, only

FIBRILLATE, no cardiac output will be delivered
from the heart to the body.
© Within seconds the may be completely stop and
defibrillation and CPR will be a must.
 Ventricular Dysrhythmias: Ventricular Tachycardia (VT)

Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None Ventircular
QRS: None

Ventricular Fib
 Ventricular Dysrhythmias: Asystole

© Electrical activity in the ventricles is

completely absent.
Rate: None
Rhythm: None
P Waves: None
PR Interval: None
QRS: None
 Conductive Dysrhythmias: AV Block/Heart Block

© Partial or complete interruption of impulse transmission from the atria to the ventricles. 
© The commonest cause of AV block overall is idiopathic fibrosis and sclerosis of the
conduction system.
© There are different types of heart block:

 First-degree AV block
 Second-degree AV block (type 1)
 Second-degree AV block (type 2)
 Third-degree (complete) AV block
 Conductive Dysrhythmias: AV Block/Heart Block

© First-degree AV Block
Consistent prolongation of the PR interval (defined as >0.20 seconds) due to delayed
conduction via the atrioventricular node.
 Every P wave is followed by a QRS complex (i.e. there are no dropped QRS
complexes, unlike some other forms of AV block discussed later).
 First-degree AV block is relatively common and can often be an incidental finding.

© ECG findings
 Rhythm: regular

 P wave: every P wave is present and followed by a QRS complex

 PR interval: prolonged >0.2 seconds (5 small squares)

 QRS complex: normal morphology and duration (<0.12 seconds) Normal PR interval is 0.12–0.20
seconds = (3-5 small squares)
Conductive Dysrhythmias: AV Block/Heart Block
© First-degree AV Block
 Conductive Dysrhythmias: AV Block/Heart Block

© Second – Degree Heart Block (Type 1)

 Second-degree AV block (type 1) is also known as Mobitz type 1 AV block or Wenckebach
phenomenon.
 Typical ECG findings in Mobitz type 1 AV block include progressive prolongation of the PR
interval until eventually the atrial impulse is not conducted and the QRS complex is dropped.
 AV nodal conduction resumes with the next beat and the sequence of progressive PR interval
prolongation and the eventual dropping of a QRS complex repeats itself.
© ECG findings
 Rhythm: irregular
 P wave: every P wave is present, but not all are followed by a QRS complex
 PR interval: progressively lengthens before a QRS complex is dropped
 QRS complex: normal morphology and duration (<0.12 seconds), but are occasionally
dropped
 Conductive Dysrhythmias: AV Block/Heart Block

© Second – Degree Heart Block (Type 1)

 Conductive Dysrhythmias: AV Block/Heart Block

© Second – Degree Heart Block (Type 2)

 Second-degree AV block (type 2) is also known as Mobitz type 2 AV block.
 Typical ECG findings in Mobitz type 2 AV block include a consistent PR interval
duration with intermittently dropped QRS complexes due to a failure of conduction.
 The intermittent dropping of the QRS complexes typically follows a repeating cycle of
every 3rd (3:1 block) or 4th (4:1 block) P wave.
© ECG findings
 Rhythm: irregular (may be regularly irregular in 3:1 or 4:1 block)
 P wave: present but there are more P waves than QRS complexes
 PR interval: consistent normal PR interval duration with intermittently dropped QRS
complexes
 QRS complex: normal (<0.12 seconds) or broad (>0.12 seconds)
 The QRS complex will be broad if the conduction failure is located distal to the bundle of
 Conductive Dysrhythmias: AV Block/Heart Block

© Second – Degree Heart Block (Type 2)

 Conductive Dysrhythmias: AV Block/Heart Block

© Third-degree (Complete) AV Block

 Third-degree (complete) AV block occurs when there is no electrical
communication between the atria and ventricles due to a complete failure of conduction.
 Typical ECG findings include the presence of P waves and QRS complexes that have no
association with each other, due to the atria and ventricles functioning independently.
 Cardiac function is maintained by a junctional or ventricular pacemaker.
 Narrow-complex escape rhythms (QRS complexes of <0.12 seconds duration)
originate above the bifurcation of the bundle of His. A typical heart rate would be
>40bpm.
 Broad-complex escape rhythms (QRS complexes >0.12 seconds duration) originate
from below the bifurcation of the bundle of His. These escape rhythms produce slower,
less reliable heart rates and more significant clinical features (e.g. heart failure, syncope).
 Conductive Dysrhythmias: AV Block/Heart Block

© Third-degree (Complete) AV Block Complete Dissociation between Atrial

& Ventricular Activity
© ECG findings
 Rhythm: variable
 P wave: present but not associated with QRS complexes
 PR interval: absent (as there is atrioventricular dissociation)
 QRS complex: narrow (<0.12 seconds) or broad (>0.12 seconds)
 Depending on the site of the escape rhythm (see introduction)
 References

© Jordan M Prutkin, MD, MHS, FHRS. ECG tutorial: Basic principles of ECG analysis. Literature
review current through: Mar 2020.
© American Heart Association Advanced Cardiac Life Support. (2017). 

© Harmon K.G.,  Asif I.M., Maleszewski J.J., et al. (2015) Incidence, etiology, and comparative

frequency of sudden cardiac death in NCAA Athletes: a decade in review. Circulation 132:10–19.
© Finocchiaro G.,  Papadakis M.,  Robertus J.L., et al. (2016) Etiology of sudden death in sports: insights
from a United Kingdom Regional Registry. J Am Coll Cardiol 67:2108–2115.
© Calo L., Sperandii F., Martino A., et al. (2015) Echocardiographic findings in 2261 peri-pubertal
athletes with or without inverted T waves at electrocardiogram. Heart 101:193–200.
© ACLS Algorithms. (2012). Learn and master. Retrieved from http://acls-algorithms.com/

© E-Medicine Health. (2012). Retrieved from http://www.emedicinehealth.com/script/main/hp.asp

 Thank You
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