Electrocardiography for Health Care Professionals

Chapter 5: ECG Interpretation and Clinical Significance Part B

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Learning Outcomes   



Summarize the process of evaluating ECG tracings and determining the presence of dysrhythmias. Identify criteria used for classification of dysrhythmias. Describe various rhythms and dysrhythmias. Identify the dysrhythmias using the criteria for classification.
Chapter 5 2

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Learning Outcomes (Cont¶d) 
  

Explain how dysrhythmias may affect the patient. Discuss basic patient care and treatment for dysrhythmias. Describe an electronic pacemaker, its function, and the normal pacemaker rhythm characteristics. Identify the steps in evaluating electronic pacemaker function on an ECG tracing.
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Presentation Topics Part B 
  

Heart Block Rhythms Bundle Branch Block Dysrhythmias Rhythms Originating from the Ventricles Electronic Pacemaker Rhythms

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Permission required for reproduction or display.Copyright © The McGraw-Hill company. Mobitz II 3rd degree block Chapter 5 5 . Inc. Heart Block Rhythms    Occur when electrical activity has difficulty traveling along normal conduction pathway Ventricular depolarization is delayed or absent Three levels of heart blocks     1st degree heart block 2nd degree AV block. Mobitz I (Wenckebach) 2nd degree AV block.

Copyright © The McGraw-Hill company. First Degree AV Block   Delay in electrical conduction around the AV node Electrical stimulus is prevented from traveling to ventricular conduction system Chapter 5 6 . Inc. Permission required for reproduction or display.

Permission required for reproduction or display. Rate ± normal. First Degree AV Block Criteria    Rhythm ± regularity between P-P interval and R-R interval is constant. Inc. 60-100 beats per minute P wave configuration   Same configuration and shape P wave occurs before each QRS complex Chapter 5 7 .Copyright © The McGraw-Hill company.

20 second QRS duration ± normal 0.Copyright © The McGraw-Hill company.10 second Chapter 5 8 . First Degree AV Block Criteria (Cont¶d)   PR interval ± greater than 0. Inc. Permission required for reproduction or display.06-0.

Inc. Permission required for reproduction or display. First Degree AV Block What You Should Know  Patient will maintain normal cardiac output  No change in the patient will occur with this rhythm  Monitor and report further degeneration and development of other heart blocks Chapter 5 9 .Copyright © The McGraw-Hill company.

Permission required for reproduction or display. Mobitz I (Wenckebach)    Some electrical impulses are blocked/non-conducted at AV junction region AV node conducts electrical impulse to ventricular conduction pathway until it fails. Inc. then resets in a repetitious pattern The ventricular rhythm is irregular Chapter 5 10 .Copyright © The McGraw-Hill company. Second Degree AV Block.

Inc. Mobitz I (Wenckebach) Chapter 5 11 .Copyright © The McGraw-Hill company. Permission required for reproduction or display. Second Degree AV Block.

Second Degree AV Block. Mobitz I Criteria  Rhythm   P-P interval regular R-R interval irregular due to blocked impulses Atrial rate within normal limits Ventricular rate slower than atrial rate Chapter 5 12  Rate   . Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.

gets progressively longer until QRS wave is dropped.10 second Chapter 5 13 . Second Degree AV Block. upright One P wave for every QRS. Inc.Copyright © The McGraw-Hill company.06-0. then cycle is restarted QRS duration ± normal 0. with additional P waves   PR interval ± varies. Mobitz I Criteria (Cont¶d)  P wave configuration   Normal size. starts short. Permission required for reproduction or display.

Permission required for reproduction or display. Mobitz I What You Should Know   Patient may not exhibit signs of low cardiac output until rate decreases to 40 beats per minute or lower Condition usually results from inflammation around AV node and is often temporary Chapter 5 14 . Second Degree AV Block.Copyright © The McGraw-Hill company. Inc.

notify licensed practitioner If no low cardiac output signs are exhibited. Second Degree AV Block.Copyright © The McGraw-Hill company. Permission required for reproduction or display. Mobitz I What You Should Know (Cont¶d)   If patient exhibits signs of low cardiac output. Inc. monitor patient for progression to third degree heart block Chapter 5 15 .

Inc. Permission required for reproduction or display.Copyright © The McGraw-Hill company. Second Degree AV Block. Mobitz II     Referred to as the classical heart block AV node selects which electrical impulses to block No pattern or reason for dropping QRS complex exists Frequently progresses to third degree AV block Chapter 5 16 .

Copyright © The McGraw-Hill company. Inc. Mobitz II Chapter 5 17 . Permission required for reproduction or display. Second Degree AV Block.

Mobitz II Criteria  Rhythm   P-P interval is regular R-R interval is irregular Atrial rate is within normal limits Ventricular rate is slower than atrial rate  Rate   Chapter 5 18 . Inc. Permission required for reproduction or display.Copyright © The McGraw-Hill company. Second Degree AV Block.

Second Degree AV Block. Permission required for reproduction or display.06-0. 0. Inc. Mobitz II Criteria (Cont¶d)  P wave configuration    Normal size Upright One P wave for every QRS complex. but additional P waves   PR interval ± constant. even after QRS drop occurs QRS duration ± normal.Copyright © The McGraw-Hill company.10 second Chapter 5 19 .

Permission required for reproduction or display. the interval is constant Both rhythms should be reported Chapter 5 20 . Troubleshooting    In second degree type I. Inc. the PR interval in front of the dropped QRS complex is longer than the PR interval behind the dropped QRS complex In second degree type II.Copyright © The McGraw-Hill company.

Copyright © The McGraw-Hill company. Inc. Second Degree Mobitz II What You Should Know   Observe patient for signs of low cardiac output Condition can progress quickly to third degree AV block or complete heart block Chapter 5 21 . Permission required for reproduction or display.

Third Degree AV Block    Also known as complete heart block (CHB) All electrical impulses originating above the ventricles are blocked No correlation exists between atrial and ventricular depolarization Chapter 5 22 .Copyright © The McGraw-Hill company. Inc. Permission required for reproduction or display.

Inc. Permission required for reproduction or display. Third Degree AV Block Chapter 5 23 .Copyright © The McGraw-Hill company.

but different from P-P interval Atrial rate is 60 to 100 beats per minute Ventricular is 20 to 40 beats per minute Chapter 5 24  Rate   .Copyright © The McGraw-Hill company. Permission required for reproduction or display. Inc. Third Degree AV Block Criteria  Rhythm   P-P interval is regular R-R interval is regular.

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Third Degree AV Block Criteria (Cont¶d) 

P wave configuration   

Normal size and shape, but may be buried in QRS complex Number of P waves does not correlate to number of QRS complexes P waves outnumber QRS complexes

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Third Degree AV Block Criteria (Cont¶d) 

PR interval 


Intervals will vary A long PR interval followed by a short PR interval indicates complete heart block Constant May be within normal limits or wider depending on the location of the block
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QRS duration 


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Third Degree AV Block What You Should Know 
  

Patient will show signs of low cardiac output and may be unconscious Initiate Code Blue when patient shows first signs of low cardiac output Immediate medical intervention may be required ± temporary pacemaker Rhythm strips should be mounted and identified in patient¶s record
Chapter 5 27

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Apply Your Knowledge
Identify this type of AV block:

ANSWER: Second degree AV block type I
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Permission required for reproduction or display.Copyright © The McGraw-Hill company. Inc. Apply Your Knowledge Identify this type of AV block: ANSWER: First degree AV block Chapter 5 29 .

Bundle Branch Block (BBB) Dysrhythmias    Occur when one or both ventricular pathways are damaged Ventricle with damaged pathway receives current one cell at a time Longer contraction time reflected in wider QRS complex Chapter 5 30 . Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.

then moves to the right side Chapter 5 31 .Copyright © The McGraw-Hill company. Bundle Branch Block Dysrhythmias (Cont¶d)  Right bundle branch block (RBBB)   Right side of the conduction pathway is blocked after the His bundle Conduction travels to left ventricle first. Permission required for reproduction or display. Inc.

Permission required for reproduction or display. Inc. then moves to the left side Chapter 5 32 . Bundle Branch Block Dysrhythmias (Cont¶d)  Left Bundle Branch Block (LBBB)   Left conduction pathway is blocked Conduction travels to right ventricle first.Copyright © The McGraw-Hill company.

Copyright © The McGraw-Hill company. Inc. Permission required for reproduction or display. Branch Bundle Block Dysrhythmias Criteria   Specific characteristics of left or right BBB identifiable in leads V1 to V6 Rhythm   May be regular or irregular Depends on underlying rhythm  Rate ± atria and ventricles depend on basic rhythm Chapter 5 33 .

20 second QRS duration ± 0. and coordination with QRS complex depend on basic rhythm PR interval ± normal. configuration. Inc.Copyright © The McGraw-Hill company.12-0. Permission required for reproduction or display. deflection.12 second or greater Chapter 5 34 . Branch Bundle Block Dysrhythmias Criteria (Cont¶d)    P wave configuration ± shape. 0.

Inc. Permission required for reproduction or display. Bundle Branch Blocks What You Should Know    Patient exhibits normal effects of basic rhythm Widening of QRS complex must be reported to a licensed practitioner immediately Condition may require pacemaker or Code Blue Chapter 5 35 .Copyright © The McGraw-Hill company.

Apply Your Knowledge Will the QRS complex be of normal duration or widened in a bundle branch block? ANSWER: Widened. 0. Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.12 second or greater Chapter 5 36 .

12 second or greater. Inc. Permission required for reproduction or display. Rhythms Originating from the Ventricles    Rate of automaticity is 20-40 beats per minute Current initiated in Purkinje fibers QRS duration and configuration will be 0. suggesting cell-by-cell stimulation Chapter 5 37 .Copyright © The McGraw-Hill company.

Rhythms Originating from the Ventricles (Cont¶d)        Premature ventricular contractions (PVC) Idioventricular rhythm Accelerated idioventricular rhythm Ventricular tachycardia (V tach) Agonal rhythm Ventricular fibrillation (V fib) Asystole Chapter 5 38 .Copyright © The McGraw-Hill company. Permission required for reproduction or display. Inc.

Premature Ventricular Complex (PVC)  Caused by an ectopic beat that occurs early in the cycle and originates from the ventricles Chapter 5 39 . Permission required for reproduction or display.Copyright © The McGraw-Hill company. Inc.

Premature Ventricular Complex Criteria  Rhythm   P-P and R-R intervals are regular with early QRS complexes Early complex has full compensatory pause Atrial and ventricular rates are the same for the underlying rhythm Early complexes make ventricular rhythm faster than normal rhythm Chapter 5 40  Rate   . Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.

Inc. Permission required for reproduction or display. Premature Ventricular Complex Criteria (Cont¶d)  P wave configurations   Shape is that of the underlying rhythm P waves not identified on early ventricular complex Follows underlying rhythm P wave not present in early complex Chapter 5 41  PR interval   .Copyright © The McGraw-Hill company.

Copyright © The McGraw-Hill company. Premature Ventricular Complex Criteria (Cont¶d)  QRS duration    Follows underlying rhythm Duration of early complex greater than 0. with T wave in opposite direction from QRS wave Chapter 5 42 .12 second QRS shape is bizarre. Inc. Permission required for reproduction or display.

suggesting only one irritable focus present) Multifocal ± varied shapes and forms of the PVCs Interpolated ± PVC occurs during the normal R-R interval without interrupting the normal cycle. Occasional ± more than one to four PVCs per minute Frequent ± more than five to seven PVCs per minute Chapter 5 43 . Permission required for reproduction or display. Inc.Copyright © The McGraw-Hill company. Types of Premature Ventricular Complexes      Unifocal ± early beat (has similar shape.

Inc. Permission required for reproduction or display.Copyright © The McGraw-Hill company. Types of Premature Ventricular Complexes (Cont¶d)      Bigeminy ± every other beat is a PVC Trigeminy ± every third beat is a PVC Quadrigeminy ± every fourth beat is a PVC R on T PVCs ± PVC occurs on the T wave or the vulnerable period of the ventricular refractory period Coupling ± two PVCs occur back to back Chapter 5 44 .

Permission required for reproduction or display. Inc.Copyright © The McGraw-Hill company. Premature Ventricular Complexes What You Should Know      Significance depends on their frequency Can occur in normal hearts May feel dizziness or other symptoms of low cardiac output R on T PVCs and coupling increase risk of a more serious dysrhythmia Notify practitioner if symptoms of low cardiac output develop Chapter 5 45 .

Idioventricular Rhythm   Impulse created by the ventricular pacemaker Presents with the classic wide QRS complex.Copyright © The McGraw-Hill company. Permission required for reproduction or display. slow ventricular rate and absent P waves Chapter 5 46 . Inc.

Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.12 seconds or greater with a wide. bizarre appearance Chapter 5 47 . P-P interval cannot be determined Ventricular rate is 20-40 beats per minute     Rate  P wave is absent PR interval cannot be measured QRS duration and configuration  0. Idioventricular Rhythm Criteria  Rhythm  R-R interval is regular.

Copyright © The McGraw-Hill company. Idioventricular Rhythm What You Should Know     Profound loss of cardiac output The patient will likely be unconscious Notify health care practitioner immediately Likely to require medication and/or pacing Chapter 5 48 . Inc. Permission required for reproduction or display.

Accelerated Idioventricular Rhythm    Impulse created by the ventricular pacemaker The heart rate is faster than an idioventricular rhythm QRS complex is wide and bizarre and P waves are absent Chapter 5 49 . Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.

P-P interval cannot be determined Ventricular rate is 40-100 beats per minute     Rate  P wave is absent PR interval cannot be identified QRS duration  Wide. Accelerated Idioventricular Rhythm Criteria  Rhythm  R-R interval is regular.Copyright © The McGraw-Hill company. bizarre appearance and 0. Inc.12 second or greater Chapter 5 50 . Permission required for reproduction or display.

Copyright © The McGraw-Hill company. Accelerated Idioventricular Rhythm What You Should Know     Decrease in cardiac output due to slow ventricular rate Patient may be unconscious Notify health care practitioner May require medication and/or pacing Chapter 5 51 . Inc. Permission required for reproduction or display.

Copyright © The McGraw-Hill company. Inc. Permission required for reproduction or display. Ventricular Tachycardia (V tach)   Three or more PVCs occur in a row Ventricles are in continuous state of contraction-relaxation Chapter 5 52 .

Permission required for reproduction or display. Ventricular Tachycardia Criteria  Rhythm   P-P interval usually not identifiable R-R interval usually regular. can be slightly irregular at times Atrial rate cannot be determined Ventricular rate 100-200 beats per minute Chapter 5 53  Rate   .Copyright © The McGraw-Hill company. Inc.

Ventricular Tachycardia Criteria (Cont¶d)    P wave configurations ± usually absent PR interval cannot be determined QRS duration   Greater than 0. Inc.12 second T wave in opposite direction (usually down) from QRS complex Chapter 5 54 . Permission required for reproduction or display.Copyright © The McGraw-Hill company.

Ventricular Tachycardia What You Should Know    Lost atrial kick and decreased ventricular filling time results in decreased cardiac output Approximately 50% of patients become unconscious immediately Notify licensed practitioner Chapter 5 55 . Inc.Copyright © The McGraw-Hill company. Permission required for reproduction or display.

issue Code Blue.Copyright © The McGraw-Hill company. Inc. use emergency equipment Mount rhythm strips in patient¶s medical record If patient is responsive. Ventricular Tachycardia What You Should Know (Cont¶d)    If patient is unresponsive. licensed practitioner may initiate treatment plan Chapter 5 56 . Permission required for reproduction or display. begin CPR.

Permission required for reproduction or display. Troubleshooting   Heart rates less than 60 beats per minute can cause ³escape beats´ Often PVCs occur in response to bradycardia Chapter 5 57 .Copyright © The McGraw-Hill company. Inc.

Copyright © The McGraw-Hill company. Agonal Rhythm   Occurs when all of the pacemakers in the heart have failed Ventricular rate is less than 20 beats per minute Chapter 5 58 . Permission required for reproduction or display. Inc.

bizarre appearance Chapter 5 59 . Permission required for reproduction or display.12 second or greater with a wide. Agonal Rhythm Criteria      Rhythm  R-R interval may or may not be regular Rate is less than 20 beats per minute P wave is absent PR interval cannot be determined QRS duration and configuration  0.Copyright © The McGraw-Hill company. Inc.

Agonal Rhythm What You Should Know     Profound loss of cardiac output Patient will be unconscious Notify health care practitioner immediately This is a medical emergency. Inc. BLS and ACLS interventions will be initiated Chapter 5 60 . Permission required for reproduction or display.Copyright © The McGraw-Hill company.

Safety  Follow facility¶s guidelines on stocking of ³crash cart´ for Code Blue emergencies Chapter 5 61 .Copyright © The McGraw-Hill company. Inc. Permission required for reproduction or display.

Inc. Ventricular Fibrillation (V fib)  Chaotic asynchronous electrical activity within ventricular tissue results in no cardiac output Chapter 5 62 . Permission required for reproduction or display.Copyright © The McGraw-Hill company.

if identifiable.Copyright © The McGraw-Hill company. if able to determine. Permission required for reproduction or display. Inc. Ventricular Fibrillation Criteria  Rhythm  R-R interval. will be greater than 300 beats per minute  Rate     P wave configurations ± not identifiable PR interval ± not identifiable QRS duration ± cannot be determined Chapter 5 63 . will be irregular Ventricular rate.

Copyright © The McGraw-Hill company. Permission required for reproduction or display. Ventricular Fibrillation What You Should Know      If patient is conscious and talking. leads are loose or detached Patient will be unresponsive Code Blue situation is present Begin CPR and emergency measures immediately Advanced cardiac life support (ACLS) should begin immediately Chapter 5 64 . Inc.

Permission required for reproduction or display.Copyright © The McGraw-Hill company. Asystole   Often called straight line or flat line No electrical activity is present in the myocardium Chapter 5 65 . Inc.

Inc. Permission required for reproduction or display. Asystole Criteria      Rhythm ± no waveforms are present Rate ± no atrial or ventricular rates are present P wave configurations ± no P waves are present PR interval ± none. no waveforms are present Chapter 5 66 . since no waveforms are present QRS duration ± not measurable.Copyright © The McGraw-Hill company.

Permission required for reproduction or display. initiate emergency procedures Chapter 5 67 . Asystole What You Should Know   Situation is life-threatening Patient is in cardiac arrest. Inc.Copyright © The McGraw-Hill company.

Permission required for reproduction or display.Copyright © The McGraw-Hill company. Patient Education and Communication for Emergency  If family/friends are present. explain that there is an emergency and escort them out of immediate area Chapter 5 68 . Inc.

Apply Your Knowledge How is an accelerated idioventricular rhythm differ from an idioventricular rhythm? ANSWER: Rate. Chapter 5 69 . Accelerated idioventricular rhythm occurs at a rate of 40 to100 beats per minute while an idioventricular rhythm occurs at a rate of 20 to 40 beats per minute. Permission required for reproduction or display. Inc.Copyright © The McGraw-Hill company.

Inc.Copyright © The McGraw-Hill company. Apply Your Knowledge Identify this rhythm. Permission required for reproduction or display. ANSWER: Ventricular tachycardia Chapter 5 70 .

Apply Your Knowledge What is the ventricular rate in a patient suffering from an agonal rhythm? ANSWER: Less than 20 beats per minute Chapter 5 71 .Copyright © The McGraw-Hill company. Inc. Permission required for reproduction or display.

or both Usually implanted under the skin Chapter 5 72 .Copyright © The McGraw-Hill company. Permission required for reproduction or display. ventricles. Inc. Electronic Pacemaker Rhythms     Also known as artificial pacemakers Deliver electrical impulse to myocardium. causing cells to depolarize Can pace the atria.

Inc. Permission required for reproduction or display. Electronic Pacemaker Rhythms (Cont¶d)    Performing ECG on patient with pacemaker may require additional training Each pacemaker is individually set for the desired heart rate and electrical current Atrial pacing is used alone when the AV node and ventricular conduction are performing correctly Chapter 5 73 .Copyright © The McGraw-Hill company.

Inc. Permission required for reproduction or display.Copyright © The McGraw-Hill company. Electronic Pacemaker Rhythms (Cont¶d) Chapter 5 74 .

Pacemaker Safety  Electrical current from pacemaker cannot be transmitted to those who encounter the patient Chapter 5 75 . Permission required for reproduction or display.Copyright © The McGraw-Hill company. Inc.

Inc. Evaluating Pacemaker Function  Pacing spike   Thin spike on ECG tracing indicating electrical current from pacemaker After spike. Permission required for reproduction or display.Copyright © The McGraw-Hill company. either a P wave or QRS complex will appear Chapter 5 76 .

Permission required for reproduction or display.Copyright © The McGraw-Hill company. measure from beginning of P wave to ventricular spike Chapter 5 77 . Evaluating Pacemaker Function (Cont¶d)  AV delay     Similar to PR interval on normal rhythm tracing Measured from atrial spike to ventricular spike Normally 0.20 second If patient has normal P wave and pacerinduced ventricular complex. Inc.12-0.

Inc. Seven Steps To Evaluating Pacemaker ECG Tracing     Step 1 ± What are the rate and regularity of the paced rhythm? Step 2 ± What are the rate and regularity of the intrinsic rhythm? Step 3 ± Is the atrial lead sensing appropriate? Step 4 ± Is atrial capture present? Chapter 5 78 . Permission required for reproduction or display.Copyright © The McGraw-Hill company.

Permission required for reproduction or display.Copyright © The McGraw-Hill company. Chapter 5 79 . steps 3 through 5 can be eliminated. Seven Steps To Evaluating Pacemaker ECG Tracing (Cont¶d)     Step 5 ± Is AV delay appropriate? Step 6 ± Is ventricular sensing appropriate? Step 7 ± Is ventricular capture present? Note: If patient does not have an AV sequential pacemaker. Inc.

Inc. Permission required for reproduction or display. Complications of Pacemaker in Relationship to ECG Tracing  Weak battery complications    Slow firing rates Less effective sensing capabilities Less than predetermined electrical current Sensing capability too low for pacemaker to see normal contractions Chapter 5 80  Program complication  .Copyright © The McGraw-Hill company.

Permission required for reproduction or display. Complications Visible on ECG Tracings     Malfunctioning ± failure to pace Malsensing ± failure to sense Loss of capture ± failure to depolarize Oversensing ± perceiving sources other than the heart Chapter 5 81 .Copyright © The McGraw-Hill company. Inc.

Copyright © The McGraw-Hill company. Your Responsibility  To recognize normal pacemaker rhythms and possible complications! Chapter 5 82 . Permission required for reproduction or display. Inc.

Apply Your Knowledge A pacemaker can provide stimulation to which regions of the heart? ANSWER: Atria. Permission required for reproduction or display.Copyright © The McGraw-Hill company. Inc. or both Chapter 5 83 . ventricles.

Permission required for reproduction or display. P wave configuration. and QRS duration and configuration Sinus rhythm is a normally functioning rhythm Dysrhythmias are abnormal rhythms Chapter 5 84 . Inc. Chapter 5 Summary     Evaluating an ECG requires basic knowledge of the components of the rhythm The process of evaluating an ECG tracing includes determining the rhythm. PR interval. rate.Copyright © The McGraw-Hill company.

Chapter 5 Summary (Cont¶d)     Many dysrhythmias can result in low cardiac output Each of the dysrhythmias may affect the patient with varying degrees of severity Pacemakers can pace the atria. ventricles or both and are seen as a spike on the ECG Evaluating a pacemaker involves seven steps. Inc. similar to a non-paced rhythm Chapter 5 85 . Permission required for reproduction or display.Copyright © The McGraw-Hill company.

. Inc.END OF CHAPTER FIVE ECG Interpretation and Clinical Significance Copyright © The McGraw-Hill company. Permission required for reproduction or display.

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