Basics of

Electrocardiography

What is an ECG?
An ECG is the recording (gram)
of the electrical activity(electro)
generated by the cells of the heart(cardio)
that reaches the body
surface.

Recording ECG
William Einthoven
Nobel prize 1924

Recording an ECG

An isoelectric line is recorded when:

A.There is no depolarization wave
B.There are two oposing depolarisation
waves
C.There is no repolarisation wave
D.There are two oposing repolarisation
waves
E.When the patient is dead

In ECG recording the vector of a wave

means:
A.The direction of propagation independent
of the initial polarity of the membranes
B.The vector oriented from negative to
positive areas
C.The vector oriented from positive to
negative areas

In bipolar leads a positive wave is recorded

when:
A.The vector is oriented towards the positive
electrode of the lead
B.The vector is oriented towards the negative
electrode of the lead
C.The vector is oriented contrary to the
positive electrode of the lead
D.The vector is oriented contrary to the
negative electrode of the lead

The characteristics of an wave are:

A.Axis depends on the electrode position
B.Amplitude increases in the presence of
emphysema
C.Duration depends on calibration
D.Axis can shift with breathing
E.Amplitude increases in the presence of
pericardial efusion

Basics
ECG graphs:
1 mm squares
5 mm squares
Paper Speed:
25 mm/sec standard
Voltage Calibration:
10 mm/mV standard

ECG Paper: Dimensions

5 mm
1 mm

0.1 mV

0.04 sec
0.2 sec

Speed = rate

Voltage
~Mass

Ventricular depolarization is going from left to

right and caudo-cranial if the QRS complex
is:
A.+DI, +DII
B.-DI, -DII
C.-DI, +DII
D.+DI, -DII

In relationship with the triangle formed by

leads I, II and III the unipolar leads
represent:
A.bisectors
B.mediators
C.medians

ECG Leads
The standard ECG has 12 leads:

3 Standard Limb Leads

3 Augmented Limb Leads
6 Precordial Leads

The axis of a particular lead represents the viewpoint from

which it looks at the heart.

Summary of Leads

Bipolar

Limb Leads

Precordial Leads

I, II, III

(standard limb leads)

Unipolar

aVR, aVL, aVF

(augmented limb leads)

V1-V6

Interpretation of an ECG

Steps involved
Heart Rate
Rhythm
Axis
Wave morphology
Intervals and segments analysis
Chamber enlargement
Specific changes

Cardiac Conduction: Cycle

Initiation

Cardiac Conduction: P Wave

Cardiac Conduction: AV Node

Cardiac Conduction: Bundle

Branches

Cardiac Conduction: Purkinje

Fibers

Cardiac Conduction: QRS

Complex

Cardiac Conduction: Plateau

Phase

Cardiac Conduction: T-Wave

Label the ECG

P Wave:

Atrial Depolarization.

Can be positive, biphasic, negative.

QRS Complex: Ventricular Depolarization.

Q Wave: 1st negative deflection wave before R-Wave.
R Wave: The positive deflection wave.
S Wave: 1st negative deflection wave after R wave.

T Wave:

Ventricular Repolarization.

Can be positive, biphasic, negative.

Calculating Heart Rate

1) Measure Cycle Length (CL).
1) (# small boxes from R R) (40ms) = CL .
2) Calculate HR
60,000/CL = x BPM
(20)(40ms) = 800ms
60,000/800 = 75 bpm

(25)(40ms) = 1000ms
60,000/1000 = 60 bpm

(12)(40ms) = 480ms
60,000/480 = 125 bpm

Calculating the Heart Rate

The Rule of 300
# of big
boxes

Rate

300

150

100

75

60

50

The QRS Axis

The QRS axis represents the
net overall direction of the
hearts electrical activity.
Abnormalities of axis can hint
at:
Ventricular enlargement
Conduction blocks (i.e.
hemiblocks)

The QRS Axis

By near-consensus, the
normal QRS axis is defined
as ranging from -30 to +90.

-30 to -90 is referred to as a

left axis deviation (LAD)

+90 to +180 is referred to as

a right axis deviation (RAD)

Determining the Axis

The Quadrant Approach
The Equiphasic Approach

Determining the Axis

Predominantly
Positive

Predominantly
Negative

Equiphasic

The Quadrant Approach

1. Examine the QRS complex in leads I and aVF to determine
if they are predominantly positive or predominantly
negative. The combination should place the axis into one
of the 4 quadrants below.

Example 1

Negative in I, positive in aVF RAD

Example 2

Positive in I, negative in aVF

Predominantly positive in II

Normal Axis (non-pathologic LAD)

Marked RAD

-90
-120

-60
LAD

aVR

-30

-150

aVL
0

180

I
150

30
120

III

RAD

60
90 aVF

II
Normal Axis
-30 to +100

Example 1

Equiphasic in aVF Predominantly positive in I QRS axis 0

Example 2

Equiphasic in II Predominantly negative in aVL QRS axis +150

Common causes of LAD

May be normal in the elderly and very
obese
Due to high diaphragm during pregnancy,
ascites, or ABD tumors
Inferior wall MI
Left Anterior Hemiblock
Left Bundle Branch Block
WPW Syndrome
Congenital Lesions
RV Pacer or RV ectopic rhythms
Emphysema

Common causes of RAD

Normal variant
Right Ventricular Hypertrophy
Anterior MI
Right Bundle Branch Block
Left Posterior Hemiblock
Left Ventricular ectopic rhythms or
pacing
WPW Syndrome

The Normal ECG

In normal sinus rhythm:

A.The left atrium is depolarised postero
anterior
B.The right atrium is depolarised posteroanterior
C.There are no preferential bundles

Normal Sinus Rhythm

Originates in the sinus node
Rate between 60 and 100 beats per min
P wave axis of +45 to +65 degrees, ie.
Tallest p waves in Lead II
Monomorphic P waves
Normal PR interval of 120 to 200 msec
Normal relationship between P and QRS
Some sinus arrhythmia is normal

Normal P wave
Atrial depolarisation
Duration 80 to 100 msec
Maximum amplitude 2.5 mm
Axis +45 to +65
Biphasic in lead V1
Terminal deflection should not exceed 1
mm in depth and 0.03 sec in duration

Normal P wave

PR interval
AV node conduction
From the beginning of P wave to the
beginning of q wave
120-200 ms

The PR interval :
A.Deacreases with tachycardia
B.Is longer in older patients
C.Is increased in AV nodal PACs

Normal QRS complex

Completely negative in lead aVR , maximum
positivity in lead II
rS in right oriented leads and qR in left oriented
leads (septal vector)
Transition zone commonly in V3-V4
RV5 > RV6 normally
Normal duration 50-110 msec, not more than
120 msec
Physiological q wave not > 0.03 sec

ECG showing qR pattern in lead III

,disappears on deep inspiration q wave
not significant
Mech:shift in the QRS axis

Amplitude of QRS
Depends on the following factors
1.electrical force generated by the ventricular
myocardium
2.distance of the sensing electrode from the
ventricles
3.Body build;a thin individual has larger
complexes when compared to obese
individuals
4.direction of the frontal QRS axis

QRS-T angle
The normal t wave axis is similar to the
QRS axis
Normally the QRS-T angle does not
exceed 60 deg

Why can the ST segment be elevated in V1,

V2 in normal individuals?

ST segment
Merges smoothly with the proximal limb of
the T wave
No true horizontality

Why does the T wave have the same polarity

as the QRS segment?

Normal T wave
Same direction as the preceding QRS
complex
Blunt apex with asymmetric limbs
Height < 5mm in limb leads and <10 mm
in precordial leads
Smooth contours
May be tall in athletes

What is the significance of U wave?

Normal u wave
Best seen in midprecordial leads
Height < 10% of preceding T wave
Isoelectric in lead aVL (useful to measure
QTc)
Rarely exceeds 1 mm in amplitude
May be tall in athletes (2mm)

QT interval
Normally corrected for heart rate
Bazetts formula
Normal 350 to 430 msec
With a normal heart rate (60 to 100), the
QT interval should not exceed half of the
R-R interval roughly

Measurement of QT interval
The beginning of the QRS complex is best
determined in a lead with an initial q wave
leads I,II, avL ,V5 or V6
QT interval shortens with tachycardia and
lengthens with bradycardia

Prolonged QTc
During sleep
Hypocalcemia
Ac myocarditis
AMI
Drugs like quinidine,procainamide,tricyclic
antidepressants
Hypothermia
HOCM

Advanced AV block or high degree AV

block
Jervell-Lange Neilson syndrome
Romano-ward syndrome

Shortened QT
Digitalis effect
Hypercalcemia
Hyperthermia
Vagal stimulation

Normal Variants in the ECG

Sinus arrhythmia
Persistent juvenile pattern
Early repolarisation syndrome
Non specific T wave changes

Persistent juvenile pattern

Features of ERPS
Vagotonia / athletes heart
Prominent J point
Concave upwards, minimally elevated ST segments
Tall symmetrical T waves
Prominent q waves in left leads
Tall R waves in left oriented leads
Prominent u waves
Rapid precordial transition
Sinus bradycardia

Early Recognition Prevents Streptokinase infusion !

Reporting an ECG

1. Patient Details
Whose ECG is it ?!

2. Standardisation and lead

placement
Is it properly taken ?

3. Analysis of Rate, Rhythm and

Axis

4. Segment and wave form

analysis

Final Impression
Does the ECG correlate with
the clinical scenario ?

CHAMBER ENLARGEMENT

Chamber Enlargement
The ECG criteria for diagnosing right or left
ventricular hypertrophy are very insensitive (i.e.,
sensitivity ~50%, which means that ~50% of
patients with ventricular hypertrophy cannot be
recognized by ECG criteria). However, the
criteria are very specific (i.e., specificity >90%,
which means if the criteria are met, it is very
likely that ventricular hypertrophy is present).

LVH - 1
S in V1 + R in V5 or V6 > 35 mm
R in aVL >11 mm or, if left axis deviation,
R in aVL >13 mm plus S in III >15 mm
CORNELL Voltage Criteria for LVH
(sensitivity = 22%, specificity = 95%)
S in V3 + R in aVL > 24 mm (men)
S in V3 + R in aVL > 20 mm (women)

LVH - 2
ESTES Criteria for LVH
("diagnostic", >5 points;
"probable", 4 points)

ECG Criteria

Points

R or S in limb leads
> 20mm
S in V1 or V2 > 30mm
R in V5 or V6 > 30mm

Any criteria positive

3 points

ST T abnormalities
Without digoxin
With digoxin

3 points
1 point

Left Atrial Enlargement

inV1

3 points

Left Axis Deviation

2 points

QRS duration 0.09sec

1 point

Delayed intrinsicoid
deflection in V5 or V6
> 0.05SEC

1 point

RVH
V1 Lead:
- R/S ratio > 1 and negative T wave
- R > 6 mm, or S < 2mm,
- rSR' with R' >10 mm
R in V1 + S in V5 (or V6) > 10 mm
V5 or V6
- R/S ratio in V5 or V6 < 1
- R in V5 or V6 < 5 mm
- S in V5 or V6 > 7 mm

LAE
Sensitivity = 50%; Specificity = 90%

P wave duration > 0.12s in frontal plane (usually

lead II)
Terminal P negativity in lead V1 (i.e., "P-terminal
force") duration >0.04s, depth >1 mm.

RAE
P wave amplitude >2.5 mm in II and/or >1.5 mm
in V1 (Sensitivity = 50%; Specificity = 90%)

QRS voltage in V1 is <5 mm and V2/V1

voltage ratio is >6 (Sensitivity = 50%;
Specificity = 90%)
Criteria derived from the QRS complex are
due to both the high incidence of RVH
when RAE is present, and the RV
displacement by an enlarged right atrium.

BUNDLE BRANCH BLOCKS

Left Bundle Branch Block

Electrocardiographic Criteria
1.The QRS duration is >/- 120 ms
2.Leads V5,V6 and AVL show broad and notched
or slurred R waves
3.With the possible exception of lead AVL, the Q
wave is absent in left-sided leads
4.Reciprocal changes in V1 and V2
5.Left axis deviation may be present

Right Bundle Branch Block

The diagnostic criteria include
1.QRS duration is >/- 120 ms
2.An rsr,rsR or rSR pattern in lead V1 or
V2 and occasionally a wide and notched R
wave.
3.Reciprocal changes in V5,V6,I and AVL

12 Lead ECG Basics

Bundle Branch Block
Step 1. Determine that the rhythm is
supraventricular in origin and has a QRS
that is > 0.12 secs in lead V1 or MCL1 .
Step 2. Locate the J point in the ECG cycle
(end of the QRS and beginning of the ST).
Step 3. Draw a line backward into the
terminal component of the QRS.
Step 4. Shade in the triangle created by this
line and the terminal component of the
QRS.

12 Lead ECG Basics

Bundle Branch Block
Shade this area

Step 5. If the triangle

points up then it is
a Right BBB.

12 Lead ECG Basics

Bundle Branch Block
Shade this area

Step 6. If the
triangle points
down then it is a
Left BBB.

Left Anterior Fascicular Block

Left axis deviation , usually -45 to -90 degrees
QRS duration usually <0.12s unless coexisting RBBB
Poor R wave progression in leads V1-V3 and deeper S
waves in leads V5 and V6
There is RS pattern with R wave in lead II > lead III
S wave in lead III > lead II
QR pattern in lead I and AVL,with small Q wave
No other causes of left axis deviation

Left Posterior Fascicular Block

Diagnostic Criteria include
1.QRS duration 100- <120 ms
2.No ST segment or T wave changes
3.Right axis deviation (100 degree)
4.QR pattern in inferior leads (II,III,AVF) small q
wave
5.RS patter in lead lead I and AVL(small R with
deep S)
6.No other causes of right axis deviation

Bifascicular Bundle Branch

Block
RBBB with either left anterior or left posterior
fascicular block
Diagnostic criteria
1.Prolongation of the QRS duration to 0.12 second
or longer
2.RSR pattern in lead V1,with the R being broad
and slurred
3.Wide,slurred S wave in leads I,V5 and V6
4.Left axis or right axis deviation

Trifascicular Block
The combination of RBBB, LAFB and long
PR interval
Implies that conduction is delayed in the
third fascicle

ST Elevation and non-ST Elevation MIs

When myocardial blood supply is abruptly
reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.
The ECG changes over time with each of
these events

INFARCTION

INJURY

ISCHAEMIA

INFARCTED MYOCARDIUM
(STEMI)
myocardium electrically dead
The electrode lying over the area of
infarction has the effect of looking through
the infarcted area as a window. This
therefore will detect and record potentials
from the myocardium directly opposite.

INJURED MYOCARDIUM
myocardium is never completely polarized
The electrode lying over the area of injury
will record ST Segment elevation on the
ECG because of the myocardium retaining
its polarity.

ISCHAEMIC MYOCARDIUM
myocardium exhibits impaired
repolarisation
The electrode lying over the area of
ischaemia will record T wave changes on
the ECG

STAGE 1
ACUTE STAGE - HOURS OLD
Acute stage of injury The myocardium is
not yet dead and unless rapid intervention
is possible then death of the affected area
of muscle will certainly follow. In the case
of rapid intervention then the area of death
may be reduced although even with
treatment some necrosis will take place

The typical shape of the ECG leads which are

positioned directly over the injured area of
myocardium will show significant ST segment
elevation of greater than 2 mm, there may also
be a reduction in the size of the R wave.
There will be ST segment depression in the
areas of myocardium opposite the injured area
these are known as RECIPROCAL CHANGES

STAGE 2
LATER PATTERN - DAYS OLD
In stage 2 the injured myocardium is now
starting to necrose and this results in Q
waves beginning to appear on the ECG
which are representations of
depolarization on the opposite wall of the
heart, this is due to the window effect over
the area of dead myocardium

The electrode is looking through the

electrical window where no electrical activity
occurs
The ST segment elevation will lessen as the
area of injury either becomes Ischaemic or
dies
T waves now begin to appear representing
the area of ischaemia which is surrounding
the infarcted muscle

STAGE 3
LATE PATTERN - WEEKS OLD
In stage three, the zone of injury has now
evolved into infarcted myocardium
There is a pathological Q wave seen on the
ECG due to the electrical window being
present
The ST segment has now returned to
normal/Iso-electric line because the injured
area has now necrosed or become ischaemic
There is now a symmetrically inverted T wave
present on the ECG which represents
persistent ischaemia surrounding the area of
infarct

STAGE 4
OLD INFARCT -MONTHS TO YEARS
In stage 4 the zone of ischaemia has recovered
and the ECG returns to almost normal
However there are changes which allow us to
identify a previous infarct on the ECG
The pathological Q wave is considered the
finger print for life of a previous myocardial
infarction
The R wave height is reduced in the leads
positioned directly over the area of infarct

ST Elevation Infarction
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion
results in ST depression (not shown) and
peaked T-waves
C. Infarction from ongoing ischemia results in
marked ST elevation
D/E. Ongoing infarction with appearance of
pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Qwaves, but normal ST segment and Twaves

ST Elevation Infarction
Heres an ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF).
Question:
What ECG
changes do
you see?
ST elevation
and Q-waves

Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!

ST Elevation Infarction
Heres an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?

ST elevation,
Q-waves and
T-wave
inversion

Non-ST Elevation Infarction

The ECG changes seen with a non-ST elevation infarction are:

Before injury Normal ECG

Ischemia

ST depression & T-wave inversion

Infarction

ST depression & T-wave inversion

Fibrosis

ST returns to baseline, but T-wave

inversion persists

Non-ST Elevation Infarction

Heres an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.

Question:
What area of
the heart is
infarcting?

Anterolateral

ECG

ECG

ECG

ECG

ECG

ECG

ECG

ECG

Rhythm disorders

Normal Sinus Rhythm

Rate

60-100bpm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Bradycardia

Rate

Less than 60bpm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal, gradually lengthens with HR decrease

QRS Width

Normal

Sinus Tachycardia

Rate

Greater than 100bpm, Gradual onset

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal, gradually shortens with HR increase

QRS Width

Normal

Sinus Arrhythmia

Rate

60-100bpm

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Pause/Arrest

Rate

Varies

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, except during pause

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Node Exit Block

Rate

Varies

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, except during dropped beats

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Normal

Sinus Rhythm w/ PAC

(Premature Atrial Contraction)

Rate

Depends on underlying sinus rate

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

Present, may be different morphology during PAC

P:QRS Ratio

1:1, associated

PR Interval

Normal, varies during PAC

QRS Width

Normal

Atrial Tachycardia

Rate

100-180bpm, Sudden onset

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Morphology will differ from sinus p-wave

P:QRS Ratio

1:1, associated

PR Interval

Interval of ectopic focus will differ from sinus PR

QRS Width

Normal, but can develop aberrant (wide) complexes

Multifocal Atrial Tachycardia

Rate

Greater than 100bpm

P-P Regularity

Irregularly irregular

R-R Regularity

Irregularly irregular

P wave

At least 3 different p-wave morphologies

P:QRS Ratio

1:1, associated

PR Interval

Varies

QRS Width

Normal

Atrial Flutter

Atrial Rate
Ventricular Rate

Atrial Rate commonly 250-350bpm

Ventricular Rate will vary with conduction

P-P Regularity

Regular

R-R Regularity

Usually regular, but may be variable

P wave

Saw-tooth p-wave morphology

P:QRS Ratio

Varies, can be 1:1, 2:1, 3:1, 4:1, etc.

PR Interval

Varies

QRS Width

Normal

Atrial Fibrillation

Rate

Varies, ventricular response can be fast or slow

P-P Regularity

Chaotic atrial activity

R-R Regularity

Irregularly irregular

P wave

No discernable p-waves

P:QRS Ratio

None

PR Interval

None

QRS Width

Normal, but can develop aberrant (wide) complexes

Junctional Rhythm

Rate

40-60bpm

P-P Regularity

None, or Regular if antegrade or retrograde

R-R Regularity

Regular

P wave

Variable (none, antegrade, or retrograde)

P:QRS Ratio

None, or 1:1 if antegrade or retrograde

PR Interval

None, short, or retrograde

QRS Width

Normal

Accelerated Junctional Rhythm

Supraventricular Tachycardia
(SVT)

Rate

60-100bpm (Accelerated Junctional Rhythm)

Greater than 100bpm (Supraventricular
Tachycardia)

P-P Regularity

None, or Regular if antegrade or retrograde

R-R Regularity

Regular

P wave

Variable (none, antegrade, or retrograde)

P:QRS Ratio

None, or 1:1 if antegrade or retrograde

PR Interval

None, short, or retrograde

QRS Width

Normal

Sinus Rhythm w/ PVC

(Premature Ventricular Contraction)

Rate

Depends on underlying sinus rate

P-P Regularity

Irregular

R-R Regularity

Irregular

P wave

No P-waves with the PVC

P:QRS Ratio

No P-waves with the PVC

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Ventricular Rhythm

Rate

20-40bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Accelerated Ventricular Rhythm

Rate

40-100bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Ventricular Tachycardia

Rate

100-200bpm

P-P Regularity

Variable

R-R Regularity Regular

P wave

Dissociated atrial rate

P:QRS Ratio

Variable

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Fast VT (Ventricular Flutter)

Rate

200-300bpm

P-P Regularity

None

R-R Regularity

Regular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide complex (>/= 0.12sec).

Polymorphic VT (Torsades)

Rate

200-250bpm

P-P Regularity

None

R-R Regularity

Irregular

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

Variable with wide complexes

Ventricular Fibrillation

Rate

Indeterminate

P-P Regularity

None

R-R Regularity

Chaotic Rhythm

P wave

None

P:QRS Ratio

None

PR Interval

None

QRS Width

None

Sinus Rhythm
w/ 1st Degree AV Block

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present, Normal

P:QRS Ratio

1:1, associated

PR Interval

Prolonged, > 0.20sec

QRS Width

Normal

Sinus Rhythm

w/ 2nd Degree AV Block Type I (Wenckebach)

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity

Regularly irregular

P wave

Present

P:QRS Ratio

Variable; 2:1, 3:2, 4:3, etc

PR Interval

Variable, gradually lengthens until dropped

QRS Width

Normal

Sinus Rhythm

w/ 2nd Degree AV Block Type II

Rate

Depends on underlying rhythm

P-P Regularity

Regular

R-R Regularity Regularly irregular

P wave

Present

P:QRS Ratio

Variable; 2:1, 3:2, 4:3, etc

PR Interval

Normal for conducted beats

QRS Width

Normal

Sinus Rhythm

w/ 3rd Degree AV Block (Complete Heart Block)

Atrial Rate
Ventricular Rate

Atrial rate is the underlying rhythm (i.e, Sinus, Atrial Fib, etc.)
Ventricular rate is from the dissociated escape rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

Variable, dissociated

PR Interval

Variable, No pattern

QRS Width

Normal (Junctional escape rhythm)

Wide (Ventricular escape rhythm)

Sinus Rhythm w/ BBB

(Bundle Branch Block)

Rate

Depends on the underlying sinus rhythm

P-P Regularity

Regular

R-R Regularity

Regular

P wave

Present

P:QRS Ratio

1:1, associated

PR Interval

Normal

QRS Width

Wide (>0.12ms)

Atrial Fib w/ BBB

(Bundle Branch Block)

Rate

Depends on the underlying Atrial Fibrillation,

Ventricular rate can be fast or slow.

P-P Regularity

Chaotic atrial activity

R-R Regularity

Irregularly irregular

P wave

Present

P:QRS Ratio

None

PR Interval

None

QRS Width

Wide (>0.12ms)

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.
Complete Heart Block
D.
Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete
Complete Heart Block
D.Atrial
Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

Knowledge Checkpoint
Identify the Rhythm:

A.Ventricular Tachycardia
B.Sinus Bradycardia
C.Complete Heart Block
D.Atrial Fibrillation
E.Ventricular Fibrillation

PRACTICE RHYTHM STRIPS

Practice Rhythm
Strips
On the following rhythm strips in subsequent slides,
determine rhythm presented.
Consider the following:

What is the atrial and ventricular rate? Is it normal?

What is the regularity (P-P and R-R)
Are any AV and/or Bundle branch blocks present?
Does the rhythm have a clinical significance?

Answers can be found in the notes section of the slides.

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Practice Rhythm Strips

Thank you !