ELECTROCARDIOGRAPHY
GENERAL INFORMATION

 
 
Sinus Dysrhythmias Atrial Dysrythmias Junctional Dysrythmias Ventricular Dysrythmias
Atrio-Ventricular Blocks 12 lead EKG Axis Hypertrophy
Bundle Branch Blocks Hemi-Blocks Bifascicular Blocks Myocardial infarction

 

Large EKG grids represent 0.20 seconds and small EKG grids represent 0.04 seconds,
therefore 5 large squares represent 1 second.

Triplicates:  300, 150, 100, 75, 60, 50, 43, 37, 33, 30




Normal Sinus Rhythm

Rate:  60 - 100;   PR interval:  0.12 - 0.20 seconds;   QRS interval:  0.04 - 0.12 seconds
QT interval:  0.36 - 0.44 seconds;  Regular

 

 


CHARACTERISTICS OF DYSRHYTHMIAS

Sinus Dysrhythmias
Sinus Tachycardia:  Rate:  101 - 160
Sinus Bradycardia:  Rate:  40 - 59
Sinus Arrhythmia:  Irregular;  difference between shortest R-R interval and longest R-R interval is at least .12 sec.
Sinus Exit Block: Irregular;  length of the pause is the same as 1 cycle, or  multiples of cycles; the same rate resumes after the pause; measure the P - P interval
Sinus Arrest: Irregular;  the length of the pause is not a multiple of the normal cycle; the rate differs after the pause; measure the P - P interval; document the length of the pause



Atrial Dysrhythmias
Wandering Atrial Pacemaker:   Irregular;  P waves vary;  PR interval varies, rate ? 100
Multifocal (Chaotic) Atrial Tachycardia: Rate:  101 - 250;  irregular;  P waves of several different shapes, ifpresent, with varying PR intervals
Atrial Tachycardia:  Rate:150 - 250;  regular;  P waves are all the same (if no P waves       present, then referred to as Supraventricular Tachycardia)
Paroxysmal Atrial Tachycardia:  Rate: 150 - 250;  abrupt onset and termination (if no P waves present,  then Paroxysmal Supraventricular Tachycardia)
Premature Atrial  Complexes:  Premature;  incomplete compensatory pause;  P waves present, but    different, or hidden in the T waves
Atrial Flutter: Saw tooth or picket fence pattern P waves;  regular; variable block may
be irregular;  document the conduction rate
Controlled Atrial Ventricular Fibrillation:  rate: 70 - 110;  irregular;  no discernible P waves
Uncontrolled Atrial Ventricular Fibrillation:  rate:  110 - 220;  irregular;  no discernible P waves



Junctional Dysrhythmias
Junctional Rhythm: Rate:  40 - 60;  regular;  inverted or biphasic P waves before, during (not visible), or after the QRS
Accelerated Junctional  Rate: 61 -100;  regular;  inverted or biphasic P waves before, during  Rhythm: (not visible), or after the QRS

Junctional Tachycardia:
 Rate:  101 - 180;  regular;  inverted or biphasic P waves before, during (not visible), or after the QRS
Premature Junctional Complexes: 
 Premature;  incomplete compensatory pause;  inverted or biphasic P waves before, during (not visible), or after the QRS

 



Ventricular Dysrhythmias
Ventricular Rhythm: Rate:  20 - 40;  P waves may be present;  wide QRS; usually regular, but may be irregular
Idioventricular Rhythm: Rate:  20 - 40;  absent P waves;  wide QRS;  usually regular, but may be     irregular
Accelerated Idioventricular Rhythm:  Rate:  41 - 99;  absent P waves;  wide QRS;  usually regular, but may be irregular
Ventricular Tachycardia: Rate:  101 - 200+;  QRS wide and bizarre;  same configuration as PVC; usually regular but may be irregular;  3 or more PVCs in a row
Coarse Ventricular Fibrillation: Rapid, irregular, wide QRS without specific pattern; larger     undulations
Fine Ventricular Fibrillation: Rapid irregular QRS without specific pattern;  smaller undulations
Ventricular Asystole: Straight or wavy line;  no QRS;  may be P waves
Torsades de Pointes: Rate:  150 - 300;  may be initiated by a PVC occuring on a prolonged QT interval; 
R - R interval is irregular;  has spindle effect

Premature Ventricular Complexes:
Premature;  wide and bizarre QRS;  T wave deflection is opposite that  :   of the complex;  pause following the PVC is fully compensatory; (R - PVC - R = R - R - R)



Atrio-Ventricular Blocks
First Degree Block:  1 P wave for each QRS complex;  PR interval is greater than 0.20 seconds;  normal QRS;  document the underlying rhythm

Second Degree AV Block 
 More P Waves than QRS complexes;  PR interval increases Type I progressively until a P is blocked;  group beating (Mobitz I or Wenckebach)

Second Degree AV Block

  More P waves than QRS complexes;  PR interval is normal or prolonged, Type II  but constant;  note the conduction ratio of P:QRS and document (Mobitz II):
Third Degree Block  More P waves than QRS complexes;  P - P interval is regular;  R - R  (Complete    interval is usually regular, but may be irregular;  P waves and QRS  Heart Block):  complexes are not related to one another; complete AV dissociation



THE 12 LEAD EKG

When analyzing the 12 lead, use a systematic approach:

1) Rate (any lead),

2) Rhythm (lead II),

3) Intervals (PR, QRS, QT),

4) Axis (leads I & AVF),

5) Hypertrophy (lead V1 & V5),

6) Infarct (QRST changes).
 



Axis
Normal Axis: positive QRS in both leads I and AVF
Left Axis Deviation: positive QRS in lead I, but negative QRS in lead AVF
Right Axis Deviation: negative QRS in lead I, but positive QRS in lead AVF

Extreme Right Axis Deviation:
negative QRS in both leads I and AVF



Hypertrophy
Right Atrial Enlargement: larger initial component of a biphasic P wave in lead V1 or P wave > 2.5 mm in height in any limb lead
Left Atrial Enlargement: wide or ģMī shaped P wave in lead II or larger terminal component of a biphasic P wave in lead V1

Right Ventricular Hypertrophy:
R:S ratio > 1 in V1 (R wave > S wave in V1)

Left Ventricular Hypertrophy: 
the depth of the S wave in lead V1 + the height of the R wave in lead   V5 > 35 mm (if patient is * age 35)

 



Bundle Branch Blocks
Complete RBBB: wide QRS, notched R (RRķ) in leads V1 or V2
Incomplete RBBB: normal QRS, notched R (RRķ) in leads V1 or V2
Complete LBBB: wide QRS, notched R (RRķ) in leads V5 or V6
Incomplete LBBB: normal QRS, notched R (RRķ) in leads V5 or V6



Hemiblocks
Left Anterior Hemiblock:  normal QRS, left axis deviation, Q1 - S3 (Q wave in lead I, S wave in lead III)
Left Posterior Hemiblock: normal QRS, right axis deviation, S1 - Q3 (S wave in lead I, Q wave in lead III)



Bifascicular Blocks

RBBB + Left Anterior Hemiblock:
wide QRS, notched R (RRķ) in lead V1, left axis deviation

RBBB + Left Posterior Hemiblock:
wide QRS, notched R (RRķ) in lead V1, right axis deviation



Myocardial Infarction
 

The Classic Triad of EKG Characteristics of Myocardial Infarction

ST Segment Elevation - concave down (the earliest change)
at least 2 mm of elevation in 2 contiguous pre-cordial (chest) leads
at least 1 mm of elevation in 2 contiguous frontal (limb) leads

T wave Inversion especially in leads V2 - V6

Presence of Q waves
at least .04 sec. wide, depth at least 25% of R wave
or
one-third of the entire QRS amplitude


Inferior MI  QRST changes in leads II, III, and AVF
Anterior MI QRST changes in leads V1, V2, and V3
Lateral MI  QRST changes in leads I & AVL or V5 & V6
Posterior MI                      QRST changes in leads V1 & V2 (in this case look for large R waves and often associated ST segment depression)with Inferior MI