EKG Crash Course

The QRS Interval

ECG Graph Paper
Horizontal= time
Vertical= voltage

Each tiny box is
equal to 0.04
seconds, therefore
every large box is
equal to 5 times
that- 0.20 seconds.
Another view
Waveforms
P wave
P-R interval
QRS complex
ST segment
T wave
QT interval
U Wave
Steps to Analyzing Rhythms
1- Determine regularity
2- Calculate rate
3- Identify P waves
4- Measure PR interval
5- Identify P:QRS ratio
6- Measure QRS duration
7- Measure the QT interval
Step 1: Determine Regularity

Step 2: Calculate Heart Rate

Count the number of QRS complexes in a 6
second strip

6 QRS complexes x 10 = 60 beats per minute
Step 3: Identify P Wave
Find the P wave that precedes the QRS
Look at several of the P waves

The P waves should be identical in shape, size
and position
Step 4: Measure the PR interval
Beginning of P to the beginning of the QRS

Count the number of small boxes x 0.04 seconds

Normal PR interval is 0.12 - 0.2
Step 5: Identify P:QRS Ratio
Determine how many P waves precede each QRS
Normal is 1:1
there should be a P for every QRS, or else rhythm is irregular

Step 6: Measure the QRS Duration
Beginning of the QRS to the end of QRS
(when ST begins)
Normal < 0.12 seconds

Step 7: Measure the QT Interval
Measure from start
of the QRS to the
end of the T wave
Count boxes and
multiply by 0.04
seconds
Normal QT Interval
is 0.32 to 0.44
(dependent on HR)

Lead Choice
determines direction of deflections
Normal Sinus Rhythm
Rhythm: Regular
Rate: 60-100
P waves: Normal, each P wave precedes each QRS
PR interval: 0.12-0.2 sec
QRS ratio: 1:1
QRS duration: 0.04-0.1(0.12) sec
QT interval: 0.32 to 0.44 sec
Sinus Bradycardia
Rhythm: Regular
Rate: < 60
P waves: Normal, each P wave precedes each QRS
PR interval: 0.12-0.2 sec
QRS ratio: 1:1
QRS duration: 0.04-.1(0.12) sec
QT interval: 0.32 to 0.44 sec

Sinus Tachycardia
Rhythm: Regular
Rate: > 100
P waves: Normal, each P wave precedes each QRS
PR interval: 0.12-0.20 sec
QRS ratio: 1:1
QRS duration: 0.04-.10 sec
QT interval: 0.32 to 0.44 sec

Sinus Dysrhythmia
Rhythm: Irregular
Rate: 60-100
P waves: Normal, each P wave precedes each QRS
PR interval: 0.12-0.2 sec
QRS ratio: 1:1
QRS duration: 0.04-.1 sec

You will see strips that are not this obvious; this is why you must measure the R
to R interval each time!

Sinus Arrest

Rhythm: Irregular
Rate: 60-100. Often less than 60 bpm
P waves: Normal but absent during pause
PR interval: 0.12-0.20 sec

Wandering Atrial Pacemaker
Rhythm: Regular or irregular
Rate: 60-100
P waves: Vary in size and shape. This is a distinct
characteristic.
PR interval: May vary
QRS duration: 0.04-.10 sec

Atrial Fibrillation
Rhythm: Irregular
Rate: Ventricular rate varies but atrial rate is > 400 (atrial
rate is calculated by counting the number of bumps you
see between the QRS complexes).
P waves: Absent
PR interval: Not measurable
QRS duration: 0.4-.10 sec

Atria Fibrillation
May convert without treatment
May receive:
Anticoagulation
Medications to reduce Ventricular
response: Beta Blockers
Nondihydropyridine CCB
digitalis



Atrial Flutter
Rhythm: Regular or irregular
Rate: Atrial rate which are the bumps between the R
wave is between 250-400
P waves: Flutter waves saw tooth pattern
PR interval: Not measured
QRS duration: 0.4-.10 sec

Flutter
Chest pain, SOB low BP
Electrical cardioversion
Anticoagulation
Medications to reduce Ventricular
response: Beta Blockers
Nondihydropyridine CCB
(diltiazem & verapamil)
Digitalis

Cardio Version
Defibrillator in synchronized mode
Cardiac monitor
Anticoagulated
NPO
Sedation
Gel pads/paddles Anterior and Posterior
AmbuBag
Volatge measured in Joules 50 - 360



Cardio Version
Electrical Cardioversion


NO Beta-Blocker for Asthmatics
NO verapamil (CCB) for impaired
Ventricles
NEITHER with AV BLOCK
???
Is this regular or irregular?

Premature Ventricular Contraction
(PVC)
Rhythm: Regular except for the PVC
P waves: Normal with basic rhythm
PR interval: 0.12-0.20 sec
QRS duration: 0.04-.10 sec

Ventricular Tachycardia
Rhythm: regular
Rate: >100
P waves: None
PR interval: None
QRS duration: > 0.10 sec

Supraventricular Tachycardia
(SVT)
Rhythm: Regular
Rate: >160
P waves: May be hidden or present

Some causes of SVT are various medication medications (broncodialators) and caffeine
Patient might have chest pain, feel palpitations and feel numbness in various body
parts.


Torsades de pointes
Means twisting of the points in French
Rhythm: Irregular
Rate: >100
P waves: None
PR interval: None
QRS duration: > 0.10 sec

Ventricular Fibrillation
Rhythm: Chaotic
Rate: 0
P waves: None
PR interval: None
QRS duration: None

coarse
fine
Defibrillation
Txt of Choice for
V fibrillation
Pulseless VT
NOT for those who have LOC or Pulse!!!!
Defibrillation
Mono phasic & Biphasic



Cardio Version


Defibrillation

Good contact c conductive gel
NO one in contact with patient or bed
CLEAR x 3
Bundle Branch Block
Easy to recognize
Notched QRS
QRS duration is > 0.12 seconds
First Degree Heart Block
Rhythm: Regular
P waves: Normal
PR interval: > 0.20 sec ELONGATED
QRS duration: 0.04-.10 sec

Second Degree Heart Block Type 1
(Mobitz 1 or Wenckebach)
1. PR progressively lengthens until beat is
dropped.
2. Regular atrial rhythm, irregular ventricular
rhythm.

Second Degree Heart Block Type 2
(Mobitz 2)
1. PR constant
2. QRS wide block involves both branches
3. P:QRS ratio 2:1 3:1 4:1
4. Regular atrial rhythm,
5. Irregular ventricular rhythm

Third Degree Heart Block Type 3
1. PR varies
2. P waves have no constant relationship to QRS
3. Regular atrial rhythm
4. regular ventricular rhythm
Pulseless Electrical Activity
(PEA)

Nursing Assessment is critical..
Why?
Asystole
Nursing Action ??
What do you see?


































































































































































































12 Lead EKG
Cardiac Leads - Einthovan's Triangle


Lead II
Lead III
The View from 12 leads
Pacemakers.. An introduction


Atrial Pacing
Pacing spike
Response ??
V pacing
Pacing spike with generated beat P

Patient generated beat C