ECGs MADE EASY

NORMAL ECG
 ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic

recording of the electrical potentials produced
by the cardiac tissue.
– Electrical impulse formation occurs within the
conduction system of the heart.
– Excitation of the muscle fibers throughout the
myocardium results in cardiac contraction.
The ECG is recorded by applying electrodes to
various locations on the body surface and
connecting them to a recording apparatus.
 ELECTROCARDIOGRAM

Clinical Value of the ECG

– Atrial and ventricular hypertrophy
– Myocardial ischemia and infarction
– Pericarditis
– Systemic diseases that affect the heart
– Determination of the effect of cardiac drugs
– Disturbances in electrolyte balance
– Evaluation of function of cardiac pacemakers
 ELECTROCARDIOGRAM

Considerable diagnostic value

– Conduction delay of atrial and ventricular electrical
impulses
– Determination of the origin and behavior of
dysrhythmias
 ELECTROCARDIOGRAM

Value of ECG in the following clinical conditions

– Prediction of sudden cardiac death
– Prediction of ischemic pre-conditioning
– Prediction of adverse states in AMI, post-MI and
silent ischemia cases
– Progression/regression of LV mass
 RECORDING AND MONITORING AN ECG

Lead Configurations
– Bipolar Leads
• Two electrodes placed at 2 different sites
• Register the difference in potential between these 2
leads
– Unipolar leads
• Measure the absolute electrical potential at one site
• Requires a reference site
• Reference site formed by the limb leads
 12 LEAD ECG

Limb Leads
RA Red Right arm
LA Yellow Left arm
LL Green Left leg
RL Black Right leg
Chest Leads
V1 Red 4th ICS RPSB
V2 Yellow 4th ICS LPSB
V3 Green Midway between V2 and V4
V4 Brown 5th ICS LMCL
 ELECTROPHYSIOLOGY OF THE HEART

Four Electrophysiologic Events Involved in the

Genesis of the ECG
– Impulse formation
– Transmission of the impulse
– Depolarization
– Repolarization
TRANSMEMBRANE ACTION POTENTIAL
REFRACTORINESS
 LAYERS OF THE HEART WALL

Epicardium
– Coronary arteries are
found in this layer

Myocardium
– Responsible for
contraction of the heart

Endocardium
– Lines the inside of the
myocardium
– Covers the heart valves
CONDUCTION SYSTEM OF THE HEART

SA Node

Atrial Muscle
AV Node

Bundle of His
Bundle Branches
Purkinje Fibers
Ventricular Muscle
 MYOCARDIAL CELL TYPES

Kinds of Where Primary Primary

Cardiac Cells Found Function Property

Myocardial cells Myocardium Contraction and Contractility

Relaxation

Specialized cells
of the electrical Electrical Generation and Automaticity
conduction conduction conduction of Conductivity
system system electrical
impulses
 TERMINOLOGY

Chronotropic Effect
– Refers to a change in heart rate
– A positive chronotropic effect refers to an increase in heart rate
– A negative chronotropic effect refers to a decrease in heart rate
Dromotropic Effect
– Refers to a change in the speed of conduction through the AV
junction
– A positive dromotropic effect results in an increase in AV
conduction velocity
– A negative dromotropic effect results in a decrease in AV
conduction velocity
Inotropic Effect
– Refers to a change in myocardial contractility
– A postive inotropic effect results in an increase in myocardial
contractility
– A negative inotropic effect results in a decrease in myocardial
 TERMINOLOGY

Waveform
– Movement away from the baseline
in either a positive or negative
direction
Segment
– A line between wave forms
Interval
– A waveform and a segment
Complex
– Consists of several waveforms
ECG PAPER
 ELECTROGRAM

Upward deflection
- +

Downward deflection
- +

Diphasic deflection - +
 AVL

AVR

AVF
 THE NORMAL ELECTROCARDIOGRAM

P wave
– Generated by activation of the atria
PR segment
– Represents the duration of atrioventricular (AV)
conduction
QRS complex
– Produced by activation of both ventricles
ST-T wave
– Reflects ventricular recovery
 STANDARD 12 LEAD ECG

The P wave
– Atrial activation
– Height < 0.2 mV (2 mm)
– Duration < 0.12 sec
 STANDARD 12 LEAD ECG

P-R Interval
– Intraatrial, internodal, His purkinje conduction
– Duration 0.12 to 0.20 or 0.22 sec
 STANDARD 12 LEAD ECG

The QRS Complex

– Ventricular activation
– Duration of 100 msec
 STANDARD 12 LEAD ECG

The ST-segment
– Phase 2 of transmembrane potential
– Isoelectric in normal subjects
 STANDARD 12 LEAD ECG

The T wave
– Upright after the age of 16
– Juvenile T wave
 STANDARD 12 LEAD ECG

The U wave
– Surface reflection of negative after potential
– Repolarization of Purkinje fibers
– Ventricular relaxation
 STANDARD 12 LEAD ECG
The QT Interval
– From beginning of QRS to end of T wave
– Reflects the duration of depolarization and
repolarization
– Bezett: Q-Tc Interval = Q-T/ R-R
 ANALYZING A RHYTHM STRIP

Rate
Rhythm
Axis
P wave
PR Interval
QRS Complex
T wave
Q-T Interval
 ANALYZING A RHYTHM STRIP

What is the rate?

– To determine the ventricular rate,measure the
distance between 2 consecutive R-waves (R-R
interval)
– To determine the atrial rate, measure the distance
between 2 consecutive P-waves (P-P interval)
 What Is The Rate?

Ventricular Rate
– Small squares (R-R Interval) / 1500
– Big squares (R-R Interval) / 300
 What Is The Rate?

Sinus rhythm

Atrial Fibrillation
– QRS complexes in 6-sec strip X 10
 ANALYZING A RHYTHM STRIP

Is the rhythm regular or irregular?

– To determine if the ventricular rhythm is regular or
irregular, measure the distance between 2
consecutive R-R intervals and compare that
distance with the other R-r intervals.
– For atrial rhythm, measure the distance between 2
consecutive P-P intervals.
– Generally, a variation of up to 0.12 seconds (3
small boxes) is acceptable. The slower the heart
rate, the more acceptable the variation.
 ANALYZING A RHYTHM STRIP

What Is The Axis?

Normal
– 0 – (+90)
Left axis AVL

– 0 – (-90) I

Right axis
AVR
– (+90) – (+180)
Extreme axis AVF

– (-90) – (-180)
 What Is The Axis?

} 10

AVL

I
Lead I

}
AVR
10

AVF

AVF
 ANALYZING A RHYTHM STRIP

Is there 1 P wave before each QRS?

– Are P waves present and uniform in appearance?
– Is there a P wave before each QRS or are there P
waves that are not followed by QRS complexes?
– Is the atrial activity occurring so rapidly that there
are more atrial beats than QRS complexes?
 ANALYZING A RHYTHM STRIP

Is the PR interval within normal limits?

– If the PR interval is less than 0.12 or more than
0.20 second, conduction followed an abnormal
pathway or the impulse was delayed in the area of
the AV node.
– Is the PR interval of conducted beats constant or
does it vary?
 ANALYZING A RHYTHM STRIP

Is the QRS narrow or wide?

– What is the duration of the QRS complex?
• If it is 0.10 second or less (narrow), it is
presumed to be supraventricular in origin.
• If it is greater than 0.12 second (wide), it is
probably ventricular in origin.
– Do the QRS’s occur uniformly throughout the
strip?
 ANALYZING A RHYTHM STRIP

Interpret the rhythm

– Specifying the site where the dysrhythmia
originated (sinus), the mechanism (bradycardia),
and the vetnricular rate.
– For example, “sinus bradycardia with a ventricular
response (rate) of 38/min.”
 ANALYZING RHYTHM STRIP

Localization
I, AVL
– High lateral
II, III, AVF AVL

– Inferior
I

AVR

AVF
 ANALYZING THE RHYTHM STRIP

Localization
V1,V2
– Septal V1-V6 – Extensive anterior
V3,V4 I,AVL,V5,V6 - Lateral
– Anterior
V5,V6
– Apicolateral
V1-V3 or V4
– Anteroseptal
V3 or V4-V6
– Anterolateral
 ANALYZING A RHYTHM STRIP

How is the rhythm clinically significant?

 NORMAL SINUS RHYTHM

Rate 60-100 beats per minute

Rhythm Atrial regular
Ventricular regular
P waves Uniform in appearance, upright,
normal shape, one preceding each
QRS complex
PR interval 0.12-0.20 second
QRS 0.10 second or less. If greater than
0.10 second in duration, the QRS is
termed “wide” since the existence of
a bundle branch block or other
intraventricular conduction defect
cannot be accurately detected in a
single-lead.
 Sinus Rhythms
Normal Sinus Rhythm
Rate 60-100 beats per minute
Rhythm Atrial regular
Ventricular regular
P waves Uniform in appearance, upright, normal shape, one preceding
each QRS complex
PR interval 0.12-0.20 second
QRS 0.10 second or less. If greater than 0.10 second in duration,
the QRS is termed “wide” since the existence of a bundle
branch block or other intraventricular conduction defect
cannot be accurately detected in a single-lead.
 Sinus Rhythms
Sinus Bradycardia
Rate Less than 60 beats per minute
Rhythm Atrial regular
Ventricular regular
P waves Uniform in appearance, upright, normal shape, one preceding
each QRS complex
PR interval 0.12-0.20 second
QRS Usually 0.10 second or less
 Sinus Rhythms
Sinus Tachycardia
Rate Usually 100-160 beats per minute
Rhythm Atrial regular
Ventricular regular
P waves Uniform in appearance, upright, normal shape, one preceding
each QRS complex
PR interval 0.12-0.20 second
QRS Usually 0.10 second or less
 Sinus Rhythms
Normal Heart Rates in Children
Age Awake Heart Rate Sleeping Heart Rate
(per minute) (per minute)
Neonate 100-180 80-160
Infant (6 mos) 100-160 75-160
Toddler 80-110 60-90
Preschooler 70-110 60-90
School-aged 65-110 60-90
Adolescent 60-90 50-90
 Sinus Rhythms
Sinus Dysrhythmia (Arrhythmia)
Rate Usually 100-160 beats per minute but may be faster or slower
Irregular (R-R intervals shorten during inspiration and
Rhythm lengthen during expiration)
Uniform in appearance, upright, normal shape, one preceding
P waves each QRS complex
0.12-0.20 second
PR interval Usually 0.10 second or less
QRS
 Sinus Rhythms
Sinoatrial (SA) Block
Rate Usually normal but varies because of pause
Rhythm Irregular – the pause is the same as (or an exact multiple of)
the distance between two other P-P intervals
Uniform in appearance, upright, normal shape, one preceding
P waves each QRS complex
0.12-0.20 second
PR interval Usually 0.10 second or less
QRS
 Sinus Rhythms
Sinus Arrest
Rate Usually normal but varies because of the pause
Rhythm Irregular – the pause is of undetermined length (more than
one PQRST complex is omitted) and is not the same
distance as other P-P intervals.
P waves Uniform in appearance, upright, normal shape, one preceding
each QRS complex
PR interval 0.12-0.20 second
QRS Usually 0.10 second or less
 Atrial Rhythms
Premature Atrial Complexes
1. Early (premature) P waves
2. Upright P waves that differ in shape from normal sinus P waves in Lead II
• P waves may be biphasic (partly positive, partly negative), flattened, notched
or pointed
3. The early P wave may or may not be followed by a QRS complex
 Atrial Rhythms
Compensatory vs. Non-compensatory Pause
To determine whether or not the pause following a premature complex is
compensatory or non-compensatory, measure the distance between three
normal beats. Compare that distance between three beats, one of which
includes the premature complex.

Non-compensatory (incomplete) – if the normal beat following the premature

complex occurs before it was expected (i.e., when the distance is not the
same)

Compensatory (complete) – if the normal beat following the premature complex

occurs when expected (i.e., when the distance is the same).
 Atrial Rhythms
Premature Atrial Complexes (PACs)
Rate Usually normal but depends on underlying rhythm
Rhythm Essentially regular with premature beats
P waves Premature
Differ from sinus P waves – may be flattened, notched, pointed,
biphasic, or lost in the preceding T wave
PR interval Varies from 0.12-0.20 second when the pacemaker site is near
the SA node; 0.12 second when the pacemaker site is nearer
the AV junction
QRS Usually less than 0.10 second but may be prolonged. The QRS of
the PAC is similar to those of the underlying rhythm unless the
PAC is abnormally conducted.
 Atrial Rhythms
Vagal Maneuvers
Vagal maneuvers – are methods used to stimulate baroreceptors in the internal
carotid arteries and the aortic arch. Stimulation of these receptors results in reflex
stimulation of the vagus nerve and release of acetylcholine. Acetylcholine slows
conduction in the AV node, resulting in slowing of the heart rate
• Coughing
• Bearing down
• Squatting
• Breath-holding
• Carotid sinus pressure (massage)
• Immersion of the face in ice water
• Stimulation of the gag reflex

Carotid pressure should be avoided in older patients. Simultaneous, bilateral carotid

pressure should never be performed.
 Atrial Rhythms
The Unstable Patient
Signs and Symptoms
• Shock
• Chest pain
• Hypotension
• Shortness of breath
• Pulmonary congestion
• Congestive heart failure
• Acute myocardial infarction
• Decreased level of consciousness
 Atrial Rhythms
Supraventricular Tachycardia
Rate 150-250 beats per minute
Rhythm Regular
P waves Atrial P waves may be seen which differ from sinus P waves (may
be flattened, notched, pointed, or biphasic). P waves are
usually identifiable at the lower end of the rate range but are
seldom identifiable at rates above 200. May be lost in the
preceding T wave.
Usually not measurable because the P wave is difficult to
PR interval distinguish from the preceding T wave. If P waves are seen,
the RR interval will usually measure 0.12-0.20 second.
Less than 0.10 second unless an intraventricular conduction
defect exists.
QRS
 Atrial Rhythms
ELECTRICAL THERAPY – Synchronized Countershock
Description and Purpose
Synchronized countershock reduces the potential for delivery of energy during the
vulnerable period of the T wave (relative refractory period). A synchronizing
circuit allows the delivery of a countershock to be “programmed”. The
machine searches for the peak of the QRS complex (R wave deflection) and
delivers the shock a few milliseconds after the highest part of the R wave.
Indications:
• Supraventricular tachycardia
• Atrial fibrillation
• Atrial flutter
• Unstable ventricular tachycardia with pause
 Atrial Rhythms
Wandering Atrial Pacemaker (Multiformed Atrial Rhythm)
Rate 60-100. If the rate is greater than 100 beats per minute, the
rhythm is termed multifocal (or chaotic) atrial tachycardia.
Atrial – irregular
Rhythm Ventricular - irregular
Size, shape, and direction may change from beat to beat. At
P waves least three different P waves are required for a diagnosis of
wandering atrial pacemaker
Variable
Usually less than 0.10 second unless an intraventricular
PR interval conduction defect exists
QRS
 Atrial Rhythms
Atrial Flutter
Rate Atrial rate 250-350 beats per minute; ventricular rate variable
– determined by AV blockade. The ventricular rate will
usually not exceed 180 beats per minute due to the intrinsic
conduction rate of the AV junction.
Atrial regular
Rhythm Ventricular may be regular or irregular
Not identifiable P waves; saw-toothed “flutter waves”
P waves Not measurable
Usually less than 0.10 second but may be widened if flutter
PR interval waves are buried in the QRS complex or if an
QRS intraventricular conduction defect exists.
 Atrial Rhythms
Atrial Fribrillation
Rate Atrial rate usually greater than 350-400 beats per minute;
ventricular rate variable
Rhythm Ventricular rhythms usually very irregular; a regular ventricular
rhythm may occur because of digitalis toxicity.
No identifiable P waves; fibrillatory waves present. Erratic
P waves wavy baseline.
Not measurable
PR interval Usually less than 0.10 second but may be widened if an
QRS intraventricular conduction defect exists.
 Atrial Rhythms
Wolff-Parkinson-White (WPW) Syndrome
Rate If the underlying rhythm is sinus in origin, the rate is usually
60-100 beats per minute.
Rhythm Regular unless associated with atrial fibrillation
P waves Normal and upright unless WPW is associated with atrial
fibrillation
PR interval If P waves are seen, less than 0.12 second
QRS Usually greater than 0.12 second. Slurred upstroke of the
QRS complex (delta wave) is often seen in one or more
leads)
 Junctional Rhythms
Premature Junctional Complexes
Rate Usually normal, but depends on the underlying rhythm
Essentially regular with premature beats
Rhythm May occur before, during, or after the QRS
P waves If visible, the P wave is inverted in leads II, III, AVF
If the P wave occurs before the QRS, the PR interval will be
PR interval usually less than or equal to 0.12 second. If no P wave
occurs before the QRS, there will be no PR interval.
Usually 0.10 second or less unless an intraventricular
conduction defect exists.
QRS
 Junctional Rhythms
Junctional Escape Beat
Rate Usually normal, but depends on the underlying rhythm
Essentially regular with LATE beats
Rhythm May occur before, during, or after the QRS
P waves If visible, the P wave is inverted in leads II, III, AVF
If the P wave occurs before the QRS, the PR interval will be
PR interval usually less than or equal to 0.12 second. If no P wave
occurs before the QRS, there will be no PR interval.
Usually 0.10 second or less unless an intraventricular
conduction defect exists.
QRS
 Junctional Rhythms
Junctional Escape Rhythm
Rate 40 to 60 beats per minute
Rhythm Atrial and ventricular rhythm very regular
P waves May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III, AVF
PR interval If the P wave occurs before the QRS, the PR interval will be
usually less than or equal to 0.12 second. If no P wave
occurs before the QRS, there will be no PR interval.
Usually 0.10 second or less unless an intraventricular
QRS conduction defect exists.
 Junctional Rhythms
Accelerated Junctional Rhythm
Rate 60 to 100 beats per minute
Rhythm Atrial and ventricular rhythm very regular
P waves May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III, AVF
PR interval If the P wave occurs before the QRS, the PR interval will be
usually less than or equal to 0.12 second. If no P wave
occurs before the QRS, there will be no PR interval.
Usually 0.10 second or less unless an intraventricular
QRS conduction defect exists.
 Junctional Rhythms
The Unstable Patient
Signs and Symptoms
• Shock
• Chest pain
• Hypotension
• Shortness of breath
• Pulmonary congestion
• Congestive heart failure
• Acute myocardial infarction
• Decreased level of consciousness
 Junctional Rhythms
Junctional Tachycardia
Rate 100 to 180 beats per minute
Rhythm Atrial and ventricular rhythm very regular
P waves May occur before, during, or after the QRS
If visible, the P wave is inverted in leads II, III, AVF
PR interval If the P wave occurs before the QRS, the PR interval will be
usually less than or equal to 0.12 second. If no P wave
occurs before the QRS, there will be no PR interval.
Usually 0.10 second or less unless an intraventricular
QRS conduction defect exists.
 Ventricular Rhythms
Premature Ventricular Complexes
Rate Usually normal but depends on the underlying rhythm
Essentially regular with premature beats. If the PVC is an
Rhythm interpolated PVC, the rhythm will be regular.
There is no P wave associated with the PVC
None with the PVCs because the ectopic beat originates in
P waves the ventricle
PR interval Greater than 0.12 second.
Wide and bizarre.
QRS T wave frequently in opposite direction of the QRS complex.
 Ventricular Rhythms
Patterns of PVCs
1. Pairs (couplets) – two sequential PVCs
2. Runs or bursts – three or more sequential PVCs are called vntricular
tachycardia (VT)
3. Bigeminal PVCs (ventricular bigeminy) – every other beat is a PVC
4. Trigeminal PVCs (ventricular trigeminy) – every third beat is a PVC
5. Quadrigeminal PVCs (ventricular quadrigeminy) – every fourth beat is a PVC
 Ventricular Rhythms
Common Causes of PVCs
• Normal variant
• Anxiety
• Exercise
• Hypoxia
• Digitalis toxicity
• Acid-base imbalance
• Myocardial ischemia
• Electrolyte imbalance (hypokalemia, hypocalcemia, hypercalcemia,
hypomagnesemia)
• Congestive heart failure
• Increased sympathetic tone
• Acute myocardial infarction
• Stimulants (alcohol, caffeine, tobacco)
• Drugs (sympathomimetics, cyclic antidepressants, phenothiazines)
 Ventricular Rhythms
Warning Dysrhythmias
• Six or more PVCs per minute
• PVCs that occurred in pairs (couplets) or in runs or three or
more (ventricular tachycardia)
• PVCs that fell on the T wave of the preceding beat (R-on T
phenomenon)
• PVCs that differed in shape (multiformed PVCs)
 Ventricular Rhythms
Ventricular Escape Beat
Rate Atrial and ventricular rate dependent upon the underlying rhythm.
Irregular. The ventricular escape beat occurs LATE, after the next
Rhythm expected sinus beat.
There is no P wave associated with escape beat.
P waves None with the escape beat because the complex originates from
PR interval the ventricles.
Greater than 0.12 second.
QRS T wave deflection is opposite that of the QRS complex.
 Ventricular Rhythms
Idioventricular (Ventricular Escape) Rhythm
Rate Atrial not discernible, ventricular 20-40 beats per minute
Atrial not discernible
Rhythm Ventricular essentially regular
Absent
P waves None
PR interval Greater than 0.12 second.
QRS T wave deflection is in the opposite direction of the QRS.
 Ventricular Rhythms
Accelerated Idioventricular Rhythm
Rate Atrial not discernible, ventricular 40-100 beats per minute
Atrial not discernible
Rhythm Ventricular essentially regular
Absent
P waves None
PR interval Greater than 0.12 second.
QRS T wave deflection is in the opposite direction of the QRS.
 Ventricular Rhythms
Ventricular Tachycardia (VT)
Rate Atrial rate not discernible, ventricular rate 100-250 beats per
minute
Rhythm Atrial rhythm not discernible
Ventricular rhythm is essentially regular
P waves May be present or absent; if present they have no set
relationship to the QRS complexes – appearing between
the QRS’s at a rate different from that of the VT.
None
PR interval Greater than 0.12 second.
QRS Often difficult to differentiate between the QRS and the T
wave.
 Ventricular Rhythms
VENTRICULAR TACHYCARDIA - CAUSES
• Hypoxia
• Exercise
• R-on T PVCs
• Catecholamines
• Digitalis toxicity
• Myocardial ischemia
• Acid-base imbalance
• Electrolyte imbalance
• Ventricular aneurysm
• Coronary artery disease
• Rheumatic heart disease
• Acute myocardial infarction
• CNS stimulants (cocaine, amphetamines)
 Ventricular Rhythms
LONG QT INTERVAL - CAUSES
Drug induced
• Cyclic antidepressants
• Phenothiazines
• Type 1A antidysrhythmics (quinidine, procainamide, disopyramide)
• Organophosphate insecticides

Eating disorders (bulimia, anorexia)

Electrolyte abnormalities (hypomagnesemia, hypokalemia, hypocalcemia)

 Ventricular Rhythms
ANTIDYSRHYTHMIC CLASSIFICATIONS
Group I Primarily inhibit the fast sodium channel in cardiac tissue, resulting
in an increased refractory period
1A - increased conduction velocity and prolong the action potential
(Quinidine, Procainamide, Disopyramide)
1B - Either increase or have no effect on conduction velocity
(Lidocaine, Phenytoin, Tocainide, Mexiletine)
1C - Decrease conduction velocity (Flecainide, Encainide)
Beta-adrenergic blockers (Propranolol)
Prolong repolarization (Bretylium, Amiodarone)
Block slow calcium channels, resulting in decreased automaticity,
Group II and depression of myocardial and smooth muscle contraction
Group III (Verapamil, Nifedipine, Diltiazem)
Group IV
 Ventricular Rhythms
Torsades de Pointes (TdP)
Rate Atrial rate not discernible, ventricular rate 150-250 beats per
minute
Rhythm Atrial not discernible
Ventricular may be regular or irregular
P waves None
PR interval None
QRS Greater than 0.12 second.
Gradual alteration in the amplitude and direction of the QRS
 Ventricular Rhythms
Ventricular Fibrillation
Rate Cannot be determined since there are no discernible waves or
complexes to measure
Rhythm Rapid and chaotic with no pattern or regularity
P waves Not discernible
PR interval Not discernible
QRS Not discernible
 Ventricular Rhythms
Defibrillation (Unsynchronized Countershock)
Description and Purpose:
The purpose of defibrillation is to produce momentary asystole. The shock
attempts to completely depolarize the myocardium and provide an opportunity
for the natural pacemaker centers of the heart to resume normal activity.
Defibrillation is a random delivery of energy – there is no relation of the
discharge of energy to the cardiac cycle.

Indications:
• Unstable ventricular tachycardia with a pulse
• Pulseless ventricular tachycardia
• Ventricular fibrillation
• Sustained Torsades de Pointes
 Ventricular Rhythms
Asystole
Rate Ventricular usually indiscernible but may see some atrial
activity.
Rhythm Atrial may be discernible.
Ventricular indiscernible.
P waves Usually not discernible
PR interval Not measurable
QRS Absent
 Ventricular Rhythms
Causes of Pulseless Electrical Activity (MATCHx4ED)
Myocardial infarction (massive acute)
Acidosis
Tension pneumothorax
Cardiac tamponade
Hypovolemia (most common cause)
Hypoxia
Hyperkalemia
Hypothermia
Embolus (massive pulmonary)
Drug overdoses (cyclic antidepressants, calcium channel blockers, beta-blockers,
digitalis)
 Atrioventricular Blocks
Classification of AV Blocks
Degree Partial First-degree AV block
of block (incomplete) Second-degree AV block type I
blocks Second-degree AV block type II
Second-degree AV block 2:1 conduction

Third-degree AV block
Complete block
First-degree AV block
Site of AV node Second-degree AV block type I
block Third-degree AV block

Second-degree AV block type II – (uncommon)

Infranodal Bundle Third-degree AV block
of His
Second-degree AV block type II – (more
common)
Bundle Third-degree AV block
branches
 Atrioventricular Blocks
First Degree AV Block
Rate Atrial and ventricular rates the same; dependent upon
underlying rhythm.
Rhythm Atrial and ventricular regular
P waves Normal in size and shape
Only one P wave before each QRS
PR interval Prolonged (greater than 0.20 second) but constant
QRS Usually 0.10 second or less unless an intraventricular
conduction exists
 Atrioventricular Blocks
Second-Degree AV Block, Type I (Wenckebach)
Rate Atrial rate is greater than the ventricular rate. Both are often
within normal limits.
Rhythm Atrial regular (P’s plot through)
Ventricular irregular.
P waves Normal in size and shape. Some P waves are not followed by
a QRS complex (more P’s than QRS’s).
Lengthens with each cycle (although lengthening may be very
PR interval slight), until a P wave appears without a QRS complex. The
PRI after the nonconducted beat.
Usually 0.10 second or less but is periodically dropped.

QRS
 Atrioventricular Blocks
Second-Degree AV Block, Type II (Mobitz)
Rate Atrial rate is greater than the ventricular rate.
Ventricular rate is often slow.
Rhythm Atrial regular (P’s plot through)
Ventricular irregular.
P waves Normal in size and shape. Some P waves are not followed by
a QRS complex (more P’s than QRS’s).
Within normal limits or prolonged but always constant for the
PR interval conducted beats. There may be some shortening of the PRI
that follows a nonconducted P wave.
Usually 0.10 second or greater, periodically absent after P
waves.
QRS
 Atrioventricular Blocks
Second-Degree AV Block, 2:1 Conduction
Rate Atrial rate is greater than the ventricular rate.
Atrial regular (P’s plot through)
Rhythm Ventricular regular.
P waves Normal in size and shape; every other P wave is followed by a
QRS complex (more P’s than QRS’s)
Constant
PR interval Within normal limits if the block occurs above the bundle of
QRS His (probably type I); wide if the block occurs at or below
the bundle of His (probably type II); absent after every other
P wave.
 Atrioventricular Blocks
Complete (Third-Degree) AV Block
Rate Atrial rate is greater than the ventricular rate. The ventricular
rate is determined by the origin of the escape rhythm.
Atrial regular (P’s plot through). Ventricular regular. There is
Rhythm no relationship between the atrial and ventricular rhythm.
Normal in size and shape.
None – the atria and ventricles beat independently of each
P waves other, thus there is no true PR interval.
PR interval Narrow or broad depending on the location of the escape
pacemaker and the condition of the intraventricular
QRS conduction system.
Narrow = junctional pacemaker; wide = ventricular
pacemaker.
 Atrioventricular Blocks
Classification of AV Blocks
Second-Degree AV Block Second-Degree AV Block
Type I Type II
Ventricular Rhythm
PR Interval Irregular Irregular
QRS Width Lengthening Constant
Usually narrow Usually wide

Second-Degree AV Block, Complete (Third-Degree)

2:1 Conduction AV Block
Ventricular Rhythm
PR Interval Regular Regular
Constant None – no relationship between P
waves and QRS complexes
QRS Width May be narrow or wide
May be narrow or wide