1. ECG Paper A. horizontal--time .04 sec. Each vertical line.2 sec. each bold line B.

To count rate if regular: 300/# of bold lines between each QRS.(i.e. 2 = 150; 3 = 100; 4 = 75; 5 = 60) also--count number of QRS's in two 3 second marks at top of paper X 10 = HR C. Vertical lines--mV (millivoltage of electrical activity Quick review of normal Electrical activity of the heart 2. Leads 12 lead EKG 6 limb leads (1, 2, 3, AVR, AVL, AVF) Lead 1- right arm is -; left arm is positive 2 right arm is -; left leg is positive --most common lead, since all waves are normally positive (cause upward deflections on EKG) 3 - left arm is -; left leg is positive 6 chest leads (V1 thru V6) V1- 4th intercostal space, just right of sternum V2- 4th intercostal space, just left of sternum V3 - half way between V2 and V4 V4 - 5th intercostal space; mid-clavicular line V5 - half way between V4 and V6 V6 - 5th intercostal space; mid axillary line Chest leads, (FOR PATIENT MONITORING) 1, 2, and 3 and MCL1 (left arm -; rt. chest +) 3. To interpret an EKG: a. Determine the rate of QRS activity b. Determine the pattern of the rhythm (regular, irregular etc.) c. Measure the width of the QRS d. Determine atrial activity and relationship of P's to QRS's e. Measure PR interval f. You are now ready for an overall interpretation of the rhytm strip Anatomic diagram of conduction system of heart 3. Normal Sinus rhythm A. rate 60-100 B. P wave precede each QRS C. QRS- .08 to .12 sec. D. PR interval- .12 - .2 seconds E. R to R intervals constant Normal 12 lead EKG 4. Sinus Arrhythmia A. Same as NSR except R to R interval not constant

B. Often described as a regularly irregular rhythm C. Usually benign and associated with respiration (slower on expiration) D. No treatment usually necessary Example of sinus arrhythmia 5. Sinus bradycardia A. exactly like NSR except the rate is less than 60. B. Can be normal in well-conditioned athletes. C. Can also be caused by hypoxemia D. Rx.- only if it is associated with hypotension; give atropine or perhaps epinephrine Exampe of sinus brady 6. Sinus tachycardia A. Exactly like NSR except the rate is between 100-150. B. Causes include hypoxemia, anxiety, stimulant drugs, hypovolemia, MI and others C. Treat underlying cause Example of sinus tach 7. Atrial or supraventricular tachycardia (SVT) A. heart rate 150-250 minute B. P waves present and look similar though they may be on preceeding T-wave C. QRS normal configuration and duration D. R to R intervals regular E. Runs of atrial tachycardia called paroxysmal atrial tachycardia (PAT) F. Causes--stress, caffiene, tobacco, drugs G. Rx--carotid massage or adensone or verapamil Example of atrial tachycardia 8. Artifact A. 60 cycle interference--wide baseline B. Patient movement--wavering baseline and other artifacts C. Faulty leads 9. Premature atrial contractions (PAC's) A. P-wave present though it may look different than normal P-wave and it comes sooner or more prematurely than normal P. B. QRS usually appears normal although there can be PAC's with aberrant conduction C. P-wave originates from an ectopic focus in the atria, rather than the S-A node D. Usually next regular beat occurs slightly early (non- compensatory pause) E. Causes: caffeine, stress, alcohol, sympathetic nervous stimulation, example of PAC 10. Atrial Flutter A. P waves are present but fast; 250 to 350/minute. B. P waves take on a sawtooth pattern C. Not every P-wave is conducted thru AV junction; ventricular rate usually slower; i.e. 2 P's

to 1 QRS , or 3:1 or 4:1 D. QRS's are within normal limits E. R to R interval usually regular F. Rx. Cardioversion (if patient hemodynamically unstable) example of atrial flutter 11. Atrial Fibrillation A. P waves are absent, though there is a wavy pattern due to extremely fast atrial firing rates (> 350 minute) B. Rhythm is very chaotic and irregular-(R to R intervals irregular) C. A-V conduction system impaired by extremely fast rates, only some of the ectopic atrial impulses are transmitted to the ventricles. D. QRS complexes usually normal, indicating that there are a supraventricular rhythm. E. If many impulses are transmitted, the patient is tachycardic F. Also can have a normal HR, if slowed AV conduction exists G. Many causes, usually not life threatening. Chronic Atrial fibrillation can lead to CHF. H. Rx.--digitalis to slow AV conduction to convert a fast A-fib to a slow A-fib (with normal HR) I. Sometimes cardioversion used if severe hypotension exists Example of a-fib 12. First degree heart block A. Regular rhythm that is like a normal sinus rhythm except that the PR interval is longer than .2 seconds. B. Caused by a delay in conduction at the AV node or the bundle of His. C. No Rx except the patient must be watched that it doesn't progress to a more serious block. Example of 1sr degree block 13. Type 1 Second degree block. (Wenchebach) A. P waves present and regular B. QRS complexes normal but the R to R interval changes C. PR interval progressively lengthens until a P wave is not followed by a QRS complex. D. Atrial rate usually 60-100 but the ventricular rate is less depending on how many P waves are not conducted E. This condition is usually transient, caused by drugs (verapamil, digitalis, or Inderal). F. Rx- None unless bradycardia exists in which atropine is given Example of Type 1 Second degree block 14. Type II second degree block. 1. The P-waves are present and regular 2. The PR interval may be normal or prolonged but it is constant if the P waves are conducted to the ventricles. 3. QRS's will be normal if block at Bundle of His, it will be > .12 if the block is in the

bundle branches. 4. Ventricular rate is slower than atrial rate with pauses when the P wave is not conducted. 5. Cause: usually a lesion and may progess to a third- degree block 6. Rx: Permanent pacemaker Example of Type II second degree block Diagram to show difference of Type I and Type II above 15. Third degree block (complete) 1. P waves present but bear no relationship whatsoever with QRS 2. PR intervals are irregularly irregular 3. QRS wide if idioventricular rhythm (< 40) (block is at bundle branches) or normal if junctional or nodal rhythm(block is at AV node) 4. Complete absence of conduction between atria and ventricles 5. Causes a. if nodal block(digitalis toxicity, increased parasympathetic tone or node damage) b. if complete bundle branch block (anterior wall MI which caused irreversible bundle block damage 6. Rx. permanent pacemaker Example of third degree block Example of a pacer rhythm 16. Junctional or nodal rhythms 1. P waves are absent or negative (retrograde)in front of the QRS 2. No PR interval 3. QRS's usually normal since impulse is still originating above the ventricles; however can be wide if a ventricular conduction problem is also present) 4. R to R rhythm usually normal with a rate of 40 to 60 5. Rate may be faster however (junctional tachycardia) 6. Rx. Sometimes isoproterenol to increase HR; Temporary or permanent pacemaker inserted, depending on compromise of cardiac output and permanence of condition Ventricular Dysrhythmmias 17. Premature ventricular complexes (PVC) 1. P waves are absent in front of complex (usually buried in abnormal complex. 2. QRS is wide and different from other complexes and appears earlier in cycle than regular beat. 3. Full compensatory pause present. Next regular beat is exactly two times (between previous normal QRS complex and QRS complex that follows the PVC) the normal single beat R to R interval. This is true if patient in underlying regular rhythm. 4. PVC caused by an irritable focus in the ventricle 5. Multifoval PVC's caused by more than one ectopic focus. 6. R on T PVC, if PVC occurs during ventricular repolarization (on T-wave) it can be very dangerous and lead to a more dangerous ventricular dysrhythmmia such as V-tach or V-fib 7. If every other beat is a PVC, called bigeminy; every third beat--trigeminy. 2 in a row are called "back to back"'s. 3 in a row is a run of V-tach.

8. Causes include hypoxia and sympathomimetic drugs 9. RX --ventricular anti-dysrhythmic (i.e. lidocaine, procaineamide, bretylium.) 18. Ventricular tachycardia 1. 3 or more beats of ventricular origin with a rate in excess of 100/min. 2. Rhythm is usually regular 3. P-waves generally not seen but may be present. 4. QRS is wide 5. Rate is 100-250/min 6. Usually will degenerate into a V-fib. 7. Rx--if Hemodynamically stable--IV anti-ventricular dysrhythmic agents if unstable-precordial thump; if unsuccessful initiate cardiac compressions then immediate cardioversion Example of V-tach 19. Ventricular fibrillation 1. Completely disorganized cardiac activity which produces no cardiac output 2. Rate--too rapid and disorganized to count 3. no discernible organized waves at all. 4. Coarse--means V-fib is more recent onset. Amplitude of disorganized waves > than in fine V-fib 5. Death is imminent unless treated immediately 6. Rx--CPR, Immediate defibrillation; give lidocaine, and epinephrine to optimize chances of conversion to a cardiac output producing rhythm. Example of v-fib 20. Idioventricular rhythms (also called ventricular escape beats) 1. Wide QRS's present at a rate of 20-40/min 2. If p-waves present, they bear no relationship to QRS's (third degree block) 3. Produce little or no cardiac output 4. Usually bad sign and often progress to asystole. CPR usually must begin and Pacemaker insertion necessary Example of idioventricular rhythm 21. Asystole 1. Complete absence of cardiac activity 2. Prognosis for CPR very poor (CPR, epineprine, atropine, possibly bicarbonate. Example of asystole