ECG Interpretation:

Learning the Basics

Presented by:

12400 High Bluff Drive

San Diego, CA 92130

This course has been awarded eight (8.0) contact hours.

This course expires on June 7, 2010.

Copyright © 2002 by RN.com.

All Rights Reserved. Reproduction and distribution
of these materials are prohibited without the
express written authorization of RN.com.

First Published: August 8, 2002 Revised: August 8, 2004 Revised: June 7, 2007
Acknowledgements............................................................................................................... 3
Purpose & Objectives ........................................................................................................... 4
Introduction............................................................................................................................ 5
Section 1: Anatomy and Physiology.................................................................................... 6
Heart Chambers and Normal Blood Flow ............................................................................ 6
Heart Valves ........................................................................................................................... 6
Correlation to Heart Sounds................................................................................................. 7
Atrial Kick............................................................................................................................... 7
Section 2: Basic Electrophysiology..................................................................................... 8
Electrical and Mechanical Properties .................................................................................. 8
Depolarization and Repolarization....................................................................................... 9
Section 3: The Conduction System ................................................................................... 10
Sinoatrial (SA) Node............................................................................................................ 10
Atrioventricular (AV) Node and AV Junction .................................................................... 11
Bundle of His ....................................................................................................................... 11
Purkinje Fibers..................................................................................................................... 12
Summary of Pacemaker Functions.................................................................................... 12
Section 4: Electrode Placement and Lead Selection........................................................ 13
Overview .............................................................................................................................. 13
Electrodes ............................................................................................................................ 13
Leads .................................................................................................................................... 14
ECG Deflections: Isoelectric, Upright, Negative, and Biphasic....................................... 14
Isoelectric Line .................................................................................................................... 14
Upright Deflections ............................................................................................................. 14
Downward Deflections ........................................................................................................ 15
Biphasic Deflections ........................................................................................................... 15
Lead I .................................................................................................................................... 15
Lead II ................................................................................................................................... 16
Lead III .................................................................................................................................. 16
MCL 1 or Modified V1 .......................................................................................................... 16
5 Lead Set Up....................................................................................................................... 17
Section 5: The ECG Paper .................................................................................................. 18
Section 6: ECG Waveforms ................................................................................................ 19
P Wave.................................................................................................................................. 19
PR Interval............................................................................................................................ 20
QRS Complex....................................................................................................................... 20
ST Segment.......................................................................................................................... 21
The T Wave........................................................................................................................... 21
Summary .............................................................................................................................. 22
Section 7: Rate Measurement............................................................................................. 23
The Six Second Method ...................................................................................................... 23
Large Box Method ............................................................................................................... 24
Small Box Method ............................................................................................................... 24
Section 8: Format for ECG Interpretation.......................................................................... 25
Step 1: Rate.......................................................................................................................... 25
Step 2: Regularity (or the Pattern of the Rhythm) ............................................................ 26
Step 3: P Wave Examination............................................................................................... 27
Step 4: P to R Interval ......................................................................................................... 27
Step 5: QRS Complex.......................................................................................................... 28
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ST – T Wave ......................................................................................................................... 28
Step 6: Rhythm Interpretation ............................................................................................ 29
Nursing Priorities and Potential Treatments..................................................................... 29
Section 9: The Sinus Rhythms ........................................................................................... 31
Normal Sinus Rhythm ......................................................................................................... 31
Description........................................................................................................................... 31
Sinus Bradycardia ............................................................................................................... 32
Description........................................................................................................................... 32
Sinus Tachycardia............................................................................................................... 33
Description........................................................................................................................... 33
Section 10: Atrial Dysrhythmias......................................................................................... 34
Premature Atrial Contractions (PACs)............................................................................... 34
Description........................................................................................................................... 34
Other Types of PACs........................................................................................................... 35
Atrial Flutter ......................................................................................................................... 36
Description........................................................................................................................... 36
Atrial Fibrillation .................................................................................................................. 37
Description........................................................................................................................... 37
Section 11: Junctional Rhythms ........................................................................................ 39
Junctional Escape Rhythm................................................................................................. 39
Description........................................................................................................................... 39
Accelerated Junctional Rhythm/Junctional Tachycardia ................................................ 40
Section 12: Atrioventricular Blocks ................................................................................... 42
First Degree AV Block......................................................................................................... 42
Description........................................................................................................................... 42
Second Degree AV Block- Type I or Mobitz I or Wenckebach ......................................... 43
Description........................................................................................................................... 43
Second Degree AV Block- Type II or Mobitz II .................................................................. 45
Description........................................................................................................................... 45
Third Degree or Complete Heart Block.............................................................................. 46
Description........................................................................................................................... 46
Section 13: Ventricular Rhythms ....................................................................................... 49
Premature Ventricular Contractions .................................................................................. 49
Description........................................................................................................................... 49
Ventricular Tachycardia...................................................................................................... 52
Description........................................................................................................................... 52
Ventricular Fibrillation ........................................................................................................ 53
Description........................................................................................................................... 53
Asystole ............................................................................................................................... 55
Description........................................................................................................................... 55
Section 14: Types of ECG Recording Interference........................................................... 56
Conclusion ........................................................................................................................... 57
Practice Rhythm Strips ....................................................................................................... 58
Practice Rhythm Strips Answer Key.................................................................................. 61
Resources ............................................................................................................................ 62
Appendix - Bundle Branch Blocks..................................................................................... 63
Post Test Viewing Instructions .......................................................................................... 64

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 Acknowledgements
RN.com acknowledges the valuable contributions of…

...Tanna R. Thomason, RN, MS, CCRN, is the primary author of ECG Interpretation:
Learning the Basics. Tanna has over 27 years of experience as a clinician in the hospital
setting. After completing her Master’s Degree as a Clinical Nurse Specialist from San Diego
State University in 1993, Tanna functioned as a critical care Clinical Nurse Specialist for
Sharp Memorial Hospital in San Diego, CA. In addition to her Clinical Nurse Specialist role,
Tanna has been teaching nursing students since 1998 in an adjunct faculty position at Point
Loma Nazarene University. In 2001, Tanna became President of Smart Med Ed, an
educational consulting business. Before taking her current positions, Tanna worked in the
role of Cardiac Surgical Case Manager at Sharp Grossmont Hospital and as a Clinical Nurse
Specialist at Sharp Cabrillo Hospital. Tanna’s publications center on research in caring for
the acute myocardial infarction, congestive heart failure, interventional cardiology patient
populations along with best practices for orientation & training of nurses. Tanna is a member
of the American Association of Critical Care Nurses (AACN) and has served in various
leadership roles for the San Diego Chapter of AACN. Other memberships include Sigma
Theta Tau and the Cardiovascular Council of the American Heart Association.
 Purpose & Objectives
The purpose of ECG Interpretation: Learning the Basics is to give the healthcare professional
the tools to perform basic electrocardiogram (ECG) interpretation. This course is designed
for the healthcare professional who has limited or no previous ECG experience. Key basic
rhythms will be taught along with nursing priorities and initial treatment strategies for each
rhythm. To facilitate learning, a systematic approach for interpretation will be used
throughout this course.

You will need limited supplies and tools to make this learning opportunity a success. To
enhance ECG strip analysis we recommend you purchase hand calipers to determine heart
rate, regularity, and all ECG intervals. If you do not own calipers already, they can
typically be purchased for approximately $10.00 at most medical book and uniform stores.

After successful completion of this continuing education self-study course,

participants will be able to:
1. Describe the flow of blood through the normal heart and lungs specifically focusing on
valvular function and the correlation with the atrial and ventricular contraction.
2. State the differences between electrical and mechanical cells within the heart.
3. Describe the location and function of the following structures:
♦ Sinoatrial (SA node)
♦ Atrioventricular (AV) junction
♦ Bundle of His
♦ Bundle branches
♦ Purkinje fibers
4. Name the three cardiac pacemakers, their locations and intrinsic heart rates of pacing.
5. Describe the correct electrode placement for leads I, II, III and MCL1 or V1.
6. Define and describe the significance of each of the following as they relate to the cardiac
electrical activity:
♦ P wave
♦ PR Interval
♦ QRS complex
♦ ST segment
♦ T wave
♦ QRS Interval
7. State one method of heart rate calculation.
8. Describe ECG characteristics, nursing priorities, and initial treatment options for the
following rhythms:
♦ Normal sinus rhythm ♦ Second degree heart block, type II
♦ Sinus bradycardia ♦ Third/Complete heart block
♦ Sinus tachycardia ♦ Premature ventricular contraction
♦ Atrial fibrillation (PVC)
♦ Atrial flutter ♦ Ventricular tachycardia
♦ Junctional rhythm ♦ Ventricular fibrillation
♦ First degree heart block ♦ Asystole
♦ Second degree heart block, type I

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 Introduction
Interpretation of ECGs (Electrocardiograms; also known as EKGs) is one of the building
blocks of critical care nursing. Before the actual ECG interpretation can occur, a significant
base of cardiac knowledge must be built. This groundwork will include the topics such as the
normal conduction system, electrode placement, lead selection, ECG paper, and specific
ECG waveforms.

Because this information is complex and potentially confusing, you might want to re-read the
sections you find more challenging. You do not need to finish this course in one sitting. The
course encourages you to stop and practice at your own pace. Throughout this course, you
will be asked to participate in “Question and Answer” sections, along with actual ECG strip
practice. This is to help you gauge your progress. For continuing education credits, the post
test at the conclusion of this course must be completed. Enjoy your ECG adventure!!

IMPORTANT NOTE: This is NOT a course that can be done in one

sitting or with only one reading! Be prepared to spend some time and
review the materials more than once in order to learn the material and
pass the post test.

Disclaimer
RN.com strives to keep its content fair and unbiased.
The author(s), planning committee, and reviewers have no conflicts of
interest in relation to this course. There is no commercial support being
used for this course. There is no "off label" usage of drugs or products
discussed in this course.

You may find that both generic and trade names are used in courses
produced by RN.com. The use of trade names does not indicate any
preference of one trade named agent or company over another. Trade
names are provided to enhance recognition of agents described in the
course.

Note: All dosages given are for adults unless otherwise stated. The
information on medications contained in this course is not meant to be
prescriptive or all-encompassing. You are encouraged to consult with
physicians and pharmacists about all medication issues for your patients.

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 Section 1: Anatomy and Physiology

Heart Chambers and Normal Blood Flow

The heart is a four-chambered structure made up of two receiving chambers called atria and
two pumping chambers called ventricles. The right atrium receives oxygen-depleted blood
returning from the body through the
superior and inferior vena cava. The
right ventricle pushes the oxygen poor Aorta
blood to the lungs through the pulmonary
arteries. The blood is oxygenated in the
Pulmonary Arteries
lungs. The left atrium receives oxygen-
rich blood returning from the lungs through Right Atrium
pulmonary veins. The left ventricle Left Atrium

pushes the oxygen-rich blood out through

the aorta, which directs the blood to all
parts of the body. The left ventricle is a Left Ventricle
high-pressure chamber that is
Right Ventricle
approximately three times thicker than the
right ventricle. The right and left atria and
ventricular chambers are separated by a
septal wall or septum.

Heart Valves
When blood flows through the heart, it
follows a unidirectional pattern. There are Aortic Valve
four different valves within the myocardium
and their functions are to assure blood
flows from the right to left side of the heart
and always in a “forward” direction. Pulmonic Valve (hidden)

The two valves found between the atria

and ventricles are appropriately called Mitral Valve
atrioventricular (A-V) valves. The
tricuspid valve separates the right atrium Tricuspid Valve
from the right ventricle. Similarly, the
mitral valve separates the left atrium from
the left ventricle.

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The two remaining valves are called semilunar valves (because they look like half moons).
The valve located where the pulmonary artery meets the right ventricle is called the
pulmonic valve. The aortic valve is located at the juncture of the left ventricle and aorta.
Both semilunar valves prevent backflow of blood into the ventricles.

Valve Type Valve Name Location

Tricuspid Separates right atrium and right ventricle
Atrioventricular (AV)
Mitral Separates left atrium and left ventricle
Pulmonic Between right ventricle and pulmonary artery
Semilunar
Aortic Between left ventricle and aorta

Correlation to Heart Sounds

The first heart sound called S1 (or “Lub” of the “Lub-Dub” sound) is the result of closure of the
tricuspid and mitral valves during ventricular contraction. The second heart sound called S2
(or “Dub”) occurs at the end of ventricular contraction due to the closure of the aortic and
pulmonic valves.

Atrial Kick
About 2/3 of the atrial blood flows passively from the atria into the ventricles. When atrial
contraction occurs (and the AV valves are open), the atrial blood is pushed down into the
ventricles. This atrial contribution is called atrial kick and accounts for approximately 30% of
the cardiac output (the amount of blood ejected by the left ventricle into the aorta in one
minute). This concept will be discussed in detail, as it relates to specific rhythms, later in this
module.

Question 1.0
When you hear the “lub” sound of lub-dub (or S1), you are
actually hearing the closure of the _____________ and the
________________ valves.

Answer 1.0
When you hear the “lub” sound of lub-dub (or S1), you are
actually hearing the closure of the Tricuspid and the Mitral
valves.

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 Section 2: Basic Electrophysiology
To understand and interpret ECG rhythms, it is necessary for you to understand the electrical
activity, which is occurring within the heart. The term electrocardiography literally means the
recording of the electrical activity of the heart muscle.

Electrical and Mechanical Properties

Two distinct components must occur for the heart to be able to contract and pump blood.
These components are A) an electrical impulse and B) a mechanical response to the
impulse.
♦ The electrical impulse tells the heart to beat. This
property is called automaticity. Automaticity Question 2.1
means that these specialized cells within the heart
After the ___________ cells initiate
can discharge an electrical current without an
the impulse and conduct through
external pacemaker, or stimulus from the brain via
the heart, the _____________ cells
the spinal cord.
respond and initiate the cells
♦ The mechanical beating or contraction of the heart
response by contracting and
occurs after the electrical stimulation. When the
pumping blood.
mechanical contraction occurs, the person will have
(See next page for answer.)
both a heart rate and a blood pressure.

In summary, the heart has both an electrical and a mechanical property.

Question 2.2
As part of our assessment of mechanical function, we use blood pressure, pulse, and
other perfusion parameters to determine whether or not the heart is pumping adequately.
We must also look for evidence of electrical impulses. To do this, we look at the ECG.
The ECG tracing is used to evaluate the ______________ activity of the heart, while the
mechanical activity is evaluated by assessing ______________ and ________________.
(See next page for answer.)

The heart also has two distinct types of cells. There are electrical (conductive) cells, which
initiate electrical activity and conduct it through the heart. There are also mechanical
(contracting) cells, which respond to the electrical stimulus and contract to pump blood.

The contracting or myocardial “working cells” contain Question 2.3

contractile filaments. When these cells are The ability of cardiac pacemaker
electrically stimulated, these filaments slide together cells to spontaneously initiate an
and the myocardial cell contracts and the atria or electrical impulse without being
ventricular chambers contract. This is how we get stimulated from another source is
our pulse and blood pressure. called ______________.
(See next page for answer.)

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An ECG tracing is designed to give a graphic display of the electrical activity in the heart.
The pattern displayed on the ECG is called the heart rhythm. However, an ECG cannot tell
you about the mechanical activity of the heart. You will have to assess the patient’s blood
pressure and pulse to determine this.

Answer 2.1: After the electrical cells initiate the impulse and conduct through the heart,
the mechanical cells respond and initiate the cells response by contracting and pumping
blood.
Answer 2.2: The ECG tracing is used to evaluate the electrical activity of the heart, while
the mechanical activity is evaluated by assessing the pulse and blood pressure.
Answer 2.3: The ability of cardiac pacemaker cells to spontaneously initiate an electrical
impulse without being stimulated from another source is called automaticity.

Depolarization and Repolarization

Na+
In a cardiac cell, two primary chemicals provide the +
electrical charges: sodium (Na+) and potassium +
(K+). In the resting cell, the potassium is mostly on Polarization

+
K+ + (cell at rest)
the inside, while the sodium is mostly on the outside.
This results in a negatively charged cell at rest (the +
interior of the cardiac cell is mostly negative or +
polarized at rest). When depolarized, the interior Na
cell becomes positively charged and the cardiac cell
will contract. Depolarization
K (cell will contract)

In summary, the polarized or resting cell will carry a

negative charge on the inside. When depolarized,
the opposite will occur. This is due to the movement K
of sodium and potassium across the cell membrane.
Depolarization moves a wave through the Repolarization
myocardium. As the wave of depolarization (return to baseline)
Na
stimulates the heart’s cells, they become positive
and begin to contract. This cell-to-cell conduction of
depolarization through the myocardium is carried by
the fast moving sodium ions.

Repolarization is the return of electrical

charges to their original state. This
process must happen before the cells can
be ready conduct again. Even though we
have not yet introduced the ECG
Atrial
Ventricular waveforms to you, simply look at the
repolarization
depolarization diagram below and note the depolarization
and repolarization phases as they are
Ventricular represented on the ECG.
depolarization

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You are probably wondering how does all of this relate to what is happening in the heart and
how is it reflected on the ECG? The electrical cells in the heart are arranged in a system of
pathways called the conduction system

Section 3: The Conduction System

The specialized electrical cells in the heart are arranged
in a system of pathways called the conduction system.
These specialized electrical cells and structures guide the
wave of myocardial depolarization.

The physical layout of the conduction system is shown in

the picture to the right. It is important that you understand
the sequence of events within this conduction system.
This is something that you will need to memorize because
it will help you to understand normal and abnormal
rhythms.

The conduction system consists of the Sinoatrial node (SA node), Atrioventricular Node
(AV node), Bundle of His (also called the AV Junction), Right and Left Bundle Branches,
and Purkinje Fibers. Let us now discuss each structure in more detail.

Sinoatrial (SA) Node

The Sinoatrial node (also called the SA node or sinus node) is a group of specialized cells
located in the posterior wall of the right atrium. The SA node normally depolarizes or paces
more rapidly than any other part of the conduction system. It
sets off impulses that trigger atrial depolarization and
contraction. Because the SA node discharges impulses SA Node
quicker than any other part of the heart, it is commonly
known as the natural pacemaker of the heart. The SA node
normally fires at a rate of 60-100 beats per minute.
AV Node
After the SA node fires, a wave of cardiac cells begin to
depolarize. Depolarization occurs throughout both the right
and left atria (similar to the ripple effect when a rock is
thrown into a pond). This impulse travels through the atria by
way of inter-nodal pathways down to the next structure, Atrial polarization
which is called the AV node.

Remember the term mentioned before called “atrial kick”? Atrial kick occurs when the atria
contract and dump their blood down into the ventricles. This atrial contraction contributes up
to 30% of the cardiac output, which is obviously an important element toward maintaining our
blood pressure. So remember... the SA node is not only the primary pacemaker of the heart
but also triggers atrial depolarization and the contribution of the atrial kick.

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The heart is truly an amazing organ. Not only does it have one dominant pacemaker (the SA
node) it also has two back-up pacemakers. A back-up pacer is located in the area of near
the Bundle of His. The final back-up pacer is located in the ventricles along the Purkinje
fibers. More interesting information on this later...

Atrioventricular (AV) Node and AV Junction

The next area of conductive tissue along the conduction pathway is at the site of the
atrioventricular (AV) node. This node is a cluster of specialized cells located in the lower
portion of the right atrium, above the base of the tricuspid valve. The AV node itself
possesses no pacemaker cells.

The AV node has two functions. The first function is to DELAY the electrical impulse in order
to allow the atria time to contract and complete filling of the ventricles. The second function is
to receive an electrical impulse and conduct it down to the ventricles via the AV junction and
Bundle of His.

Bundle of His
After passing through the AV node, the electrical impulse
enters the Bundle of His (also referred to as the Right and Left Bundle Branches
common bundle). The bundle of His is located in the
upper portion of the interventricular septum and connects
the AV node with the two bundle branches. If the SA
node should become diseased or fail to function properly,
the Bundle of His has pacemaker cells, which are capable
of discharging at an intrinsic rate of 40-60 beats per
minute. This back-up pacemaker function can really
come in handy!

The AV node and the bundle of His are referred to

collectively as the AV junction. The Bundle of His
conducts the electrical impulse down to the right and left
bundle branches.

The right bundle branch spreads the wave of depolarization to the right ventricle. Likewise,
the left bundle branch spreads the wave of depolarization to both the interventricular septum
and the left ventricle. The left bundle further divides into 3 branches or fascicles. The bundle
branches further divide into Purkinje fibers.

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Purkinje Fibers
We are now coming to the end of this amazing cardiac conduction system. At the terminal
ends of the bundle branches, smaller fibers distribute the electrical impulses to the muscle
cells, which stimulate contraction. This web of fibers is called the Purkinje fibers. The
Purkinje fibers penetrate about 1/4 to 1/3 of the way into the ventricular muscle mass and
then become continuous with the cardiac muscle fibers. The electrical impulse spreads
rapidly through the right and left bundle branches and Purkinje fibers to reach the ventricular
muscle, causing ventricular contraction, or systole.

These Purkinje fibers within the ventricles also have intrinsic pacemaker ability. This third
and final pacemaker site of the myocardium can only pace at a rate of 20-40 beats per
minute. You have probably noticed that the further you travel away from the SA node, the
slower the backup pacemakers become. As common sense tells you, if you only have a
heart rate of 30 (from the ventricular back-up pacemaker), your blood pressure is likely to be
low and you might be quite symptomatic.

Summary of Pacemaker Functions

The heart is designed with a system of one dominant and two back-up pacing systems.

Summary of Pacemaker Function

Pacemaker Hierarchy Location Pacing Rate
Level 1 (normal) SA Node 60-100
beats/minute
Level II (back-up system) Bundle of His/ AV Node/ Junction 40-60
beats/minute
Level III (lowest back-up Purkinje Fibers within Ventricles (typically 20-40
system) called the Ventricular Pacemaker) beats/minute

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 Section 4: Electrode Placement and Lead Selection

Overview
There are many types of cardiac monitoring systems,
but they all generally consist of a monitor screen on Nursing Tip: You may note that
which the ECG is displayed, along with a printer for many night shift nurses change all
rhythm strip interpretation and documentation. Some ECG electrodes before the patient
monitoring systems are stationary where the leads and goes to sleep. It is frustrating to
cable are mounted into the fixed monitor. This type of have a patient finally asleep and
system requires the patient to be confined to a bed or have the quality of the ECG
chair. Other monitoring systems are portable with the become poor due to either dried
transmission of the ECG signal through a telemetry or up electrode conductive jelly or an
antennae system, thereby allowing the patient to be unsecured or loose electrode.
ambulatory.

Each monitoring system can be set with customized parameters (e.g. the monitor will
automatically print a strip if the heart rate drops below 50 or is above 120 beats/min). Some
work areas have only one lead monitoring choice, while others are able to monitor in two or
more simultaneous leads. Please become familiar with the equipment in your work setting.

Electrodes
The ECG records the electrical activity of the heart by using skin sensors called electrodes.
Electrodes are adhesive pads that contain a conductive gel and are attached to the patient’s
skin.

Having both good skin contact and

adequate conductive jelly in the center
of the electrode will help assure a good
ECG signal is received. The ECG
electrode conductive jelly typically
dries up within two to three days.
When in doubt, replace all electrodes
and write the date on the topside of the
electrode.

Additional tips for good electrode to skin connections include:

♦ Remove hair prior to applying the electrode
♦ Clean perspiration and any bodily fluids from skin
♦ Use a dry towel to mildly “roughen up” or abrade the skin before electrode application

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Leads
A lead is a record of electrical activity between two electrodes. There are three types of
leads: standard limb leads, augmented leads, and precordial leads. This module will focus
on the standard limb leads and will not explore the 12 lead ECG which makes use of the
augmented and precordial leads.

Each lead has a positive (+) and a negative (-) electrode. When you move the “lead selector”
on the ECG machine, you are able to change the polarity of electrodes and thus obtain
different lead selections without actually moving the electrodes or lead cables.

ECG Deflections: Isoelectric, Upright, Negative, and Biphasic

Isoelectric Line
Each waveform produced is related to a specific electrical event within the heart. When
electrical activity is not detected, a straight line is recorded. This is called the electrical
baseline or isoelectric line. Although this only occurs in short intervals within the cardiac
cycle, we do see an isoelectric line on the ECG when the heart is polarized and awaiting its
next contraction.

Isoelectric
Isoelectric
Line
Line

Upright Deflections
A basic rule of electrocardiology refers to the flow of electricity through the heart and out to
the skin electrodes. The rule states that if the electricity flows toward the positive electrode,
the patterns produced on the graph paper will be upright.

- Electrical Current
+ =
ECG Recording

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Downward Deflections
Based on the above principle, when the flow if electricity through the heart is away from a
positive electrode, it produces a negative deflection on the ECG.

- Electrical Current
+ =
ECG Recording

Biphasic Deflections
When some of the electricity or conduction current is traveling toward and some travels away
from the positive electrode, the ECG recording will have a QRS complex, which are both up
and down. This is called a biphasic waveform.

- Electrical Current
+ =
ECG Recording

The placement of electrodes for monitoring the ECG allows you to see a single view of the
electrical pattern of the heart. Monitoring systems typically have either a 3-lead or a 5-lead
system. The 5-lead system has a standardized electrode set-up (electrodes and leads are
placed according to the visual illustration provided by the manufacturer). The five lead
systems have the benefit of allowing the healthcare provider to monitor in two or more
concurrent leads. The 3-lead system allows for monitoring in only one lead at a time.
Electrode and lead placement for the 3-cable system is described below:

Lead I
In Lead I, the negative electrode is under the right clavicle. The
positive electrode is under the left clavicle. When the heart
depolarizes, the + electrode senses electrical movement coming
toward it. Lead I is therefore an upright tracing.

15
Lead II
In Lead II, the positive electrode is below the left pectoral muscle and
the negative is below the right clavicle. Since the left side of the heart
has a larger muscle mass (remember the left ventricle is much thicker
than the right ventricle), the positive electrode in Lead II senses the
current traveling toward the electrode. Lead II is an upright tracing
and is therefore a popular lead for monitoring by most healthcare
providers. Due to the large upright deflection and ease in
“synchronizing” with the “R” wave, Lead II is also the recommended
lead of choice for electrical cardioversion.

Lead III
Lead III is displayed by attaching the positive electrode beneath the left
pectoral muscle and the negative below the left clavicle. Again, the
positive electrode senses electrical current traveling towards it, thereby
recording an upright waveform or deflection.

MCL 1 or Modified V1
Another popular monitoring lead is the MCL1 lead (or modified V1).
To connect this lead, the negative electrode is placed near the left
shoulder, usually under the outer third of the left clavicle, and the
positive electrode is placed to the right of the sternum in the fourth
intercostal space.

Nursing Tip: With a 3-Lead monitoring system, the ECG cables are often color-coded for
ease of application and to reduce confusion about electrode to lead location. The negative
lead is usually white, the positive lead is red, and the ground lead is black, green, or brown.
For a Lead II set up, a popular phrase is: “white-to-right, red-to-ribs, and black left over.”
Another phrase is “smoke over fire.” This little phrase reminds us that the black lead should
be on the upper chest (i.e. smoke), while the red lead is on the same side but on the lower
chest near the rib area (i.e. “fire” is the red lead).

16
5 Lead Set Up
The placement of electrodes for monitoring the ECG allows you to see a single view of the
heart’s electrical pattern. Newer monitoring systems typically have a 5-lead system. The 5-
lead system has a standardized electrode set-up (electrodes and leads are placed according
to the visual illustration provided by the manufacturer). The five lead systems have the
benefit of allowing the healthcare provider to monitor in two or more concurrent leads. (Note:
The 3-lead system allows for monitoring in only one lead at a time).

RA LA

RL LL

Nursing Tip: With a 5 Lead System, the two upper electrodes are placed below the right
and left clavicles on the upper chest. The two lower electrodes are placed below the right
and left ribs. Precise placement of these electrodes is not required; placement in these
general areas will be fine. The “C” or “chest” electrode, however, is different. The “C”
electrode (often times brown in color) must be precisely placed at the 4th intercostal space
to the right of the sternum. Many healthcare providers are not familiar with the importance
of finding this anatomical location. Correct electrode placements for the “C” electrode
will ensure an accurate recording of V1. Remember the V1 recording is used to assist
with differentiation of SVT vs. VT, BBB and the continued assessment of potential anterior
wall ischemia & injury.

17
 Section 5: The ECG Paper
The ECG paper is graph paper that is made up of small and larger, heavy-lined squares. The
smallest squares are one millimeter wide and one millimeter high. There are five small
squares between the heavier lines.

The ECG paper comes out of the printer at constant and standardized speed. On the ECG
graph paper, time is measured in seconds along the horizontal axis. Each small square is 1
mm in length and represents 0.04 seconds. This is something that you will need to
memorize. Each larger square is 5 mm in length and therefore represents 0.20 seconds.

Voltage or amplitude is measured along the vertical axis. Question 5.0

The size or amplitude of a waveform is measured in
millivolts or millimeters. The ECG machine is sensitive Using your calipers, you
and may require periodic calibration. One small square measure an ECG complex to
on the vertical axis is equal to 1 millimeter (mm). When be four boxes in width. What
properly calibrated, a one millivolt electrical signal will is the measurement of this
produce a deflection measuring exactly 10 mm in height. complex in seconds?

The diagram below illustrates the configuration of ECG graph paper and where to measure
the components of the ECG waveform:

ECG Graph Paper and the ECG Wave Form Components

To evaluate an ECG rhythm strip, it is standard practice to print a strip of at least a 6 second
duration. This type of ECG print out will be adequate for the majority of rhythm
interpretations. A continuous strip can always be printed especially when unusual rhythms
present and require a closer inspection.

Answer 5.0
.04 seconds (1 small box) x 4 small boxes wide = 0.16 seconds

18
 Section 6: ECG Waveforms
The ECG is a recording of the electrical impulses produced by
the heart. The term arrhythmia literally means the “absence Question 6.1
of” or “without a rhythm.” The term dysrhythmia is used when
there is abnormal cardiac electrical impulses and conduction. The______ wave is
Healthcare professionals use both terms interchangeably. Do indicative of atrial
not let this confuse you. depolarization.

The body acts as a giant conductor of electrical currents. As you remember, any two points
on the body may be connected by electrical leads (electrodes) to register an ECG or to
monitor the rhythm of the heart. The tracing recorded from the electrical activity of the heart
forms a series of waves and complexes that have been arbitrarily labeled (in alphabetical
order) the P, Q, R, S, and T waves. These waves or deflections occur in regularly occurring
intervals in the healthy individual.

Normal ECG Waveforms and

P Wave
Electrical impulses originating from the SA node are
represented on the ECG with a waveform called a P wave. The Answer 6.1
P wave is generated after the SA node fires and depolarizes the
right and left atria. The beginning of the P wave is recognized The P wave is
as the first upward deflection from the baseline. It resembles a indicative of atrial
small upward “hill” or “bump” and once completed, returns to depolarization.
the ECG baseline. Locate the P wave in the Normal ECG
Waveforms and Intervals figure above.

19
PR Interval
When the impulse leaves the atria and travels to the AV node, it encounters a slight delay.
The tissues of the node do not conduct impulses as fast as
the other cardiac electrical tissues. This means that the wave Nursing Tip: A normal
of depolarization will take a longer time to get through the AV PR Interval is less than or
node. On the ECG, this is represented by a short period of equals 0.20.
electrical inactivity called the PR interval (PRI).

The PR interval extends from the beginning of the P wave (the

beginning of atrial depolarization) to the onset of the QRS Question 6.2
complex (the beginning of ventricular depolarization). It should The PR interval is
not exceed 0.20 seconds as measured on ECG graph paper, indicative of the delay in
where each small square represents 0.04 seconds. In other the _____________.
words, the PR interval should not exceed five little boxes in
width. This is an important interval to memorize.

Changes in conduction through the AV node are the most common cause of changes in the
PR interval. The P to R interval is important in identification of heart blocks. We will cover
this topic later.

QRS Complex
The ventricular depolarization is shown on the ECG by a large complex of three waves: the
Q, the R, and the S waves. Together, these
three waves are called the QRS complex. QRS Complex
The QRS complex represents the electrical R Wave
depolarization of the ventricles. Identify the
QRS complex in the previous Normal ECG
Waveforms and Intervals figure. Note how
the QRS voltage or amplitude is much higher Q wave
than the height of the P wave. This is S wave
because ventricular depolarization involves a
greater muscle mass and creates a larger
complex.

R Following the P wave, the Q wave is the first negative, or

downward deflection. The R wave is the first positive or upward
deflection following the P wave. The negative wave following the
R wave is known as the S wave.

Each QRS complex can look a bit

Q S different. In fact, some QRS complexes Answer 6.2
Measure width from are lacking a Q wave or others may lack The PR interval is
start of Q to end of S the S wave. Regardless of the indicative of the
appearance, they are always generically delay in the AV
called the “QRS” and still indicate Node.
depolarization of the ventricles.

20
Several different configuration of the QRS complex are shown in the figure below. Can you
identify the Q, R, and S components in the figure below?

Different Configurations of the QRS

R R R

Q S Q S
R
R

Q S
Q S

The upper limit of normal duration of the QRS complex

is less than 0.12 seconds or three small boxes. Place Question 6.3
one leg of your caliper on the beginning of the Q wave The QRS complex reflects
and place the other leg of the caliper on the S wave depolarization of the
where it meets the ST segment. A wide QRS complex _________________.
(more than 0.12 seconds) may signify delayed
conduction in one or more of the bundle branches.

ST Segment
The ST segment begins at the end of the S complex
and ends with the onset of the T wave. The ST
segment represents the early part of repolarization of
the ventricles. The ST segment normally sits on the
baseline or isoelectric line. It is also normal if the ST
segment is slightly elevated or below the isoelectric
line (no greater than one millimeter in either direction).
Greater than 1 mm ST segment elevation or
depression can be indicative of myocardial ischemia
or injury.

The T Wave
Ventricular repolarization is represented on the ECG by a T wave. The beginning of the T
wave is identified at the point where the slope of the ST segment appears to become abruptly
or gradually steeper. The T wave ends when it returns to the isoelectric baseline.

21
Summary
The key to rhythm interpretation is analysis of
various waveforms and interrelations of the P wave, Answer 6.3
the PR interval, and the QRS complex. The ECG
should be analyzed with respect to its rate, rhythm, The QRS complex reflects
site of the dominant pacemaker, and the depolarization of the ventricles.
configuration of waveforms. These skills require
repeated practice.

Practice Exercise

Analyze the above strip. Look at the P waves. Note the QRS complex is really only a Q
and an R wave. The ST segment is below the isoelectric line. The T wave is upright.
♦ Circle all of the P waves
♦ Measure the PR interval. Using your calipers, measure from the beginning of the P
wave upstroke to the point where the P wave joins the Q wave. The PR interval is
______ seconds.
♦ Measure the QRS width. Measure from the beginning of the Q wave down slope to the
end of the R wave (remember there is no “S” wave in this tracing, but we still call it a
QRS). The QRS width is ________ seconds.
♦ Circle all T waves. Do the T waves follow the direction of the R waves? Yes or No?

Practice Exercise Answers

PR interval is 4 small boxes or .16 seconds (normal is <.20 seconds).

QRS width is 2-2.5 boxes or .08 - .10 seconds (normal is < .12 seconds).

Yes, the T waves are upright and follow the direction of the R wave (which is normal).

22
 Section 7: Rate Measurement
The patient’s heart rate reveals a great deal of information. If the rate is slow (under 60 beats
per minute), we call it bradycardia. If the heart rate is fast (over 100 beats per minute), then it
is called tachycardia.

ECG monitors display the heart rate. When an ECG strip is printed, most printers provide
heart rate information at the top of the strip. Never the less, you might be in a situation where
you must calculate the heart rate from the ECG recording. There are numerous methods and
formulas, which can be used to calculate a heart rate from the ECG. Three methods for heart
rate calculation are presented below.

The Six Second Method Six Second ECG Strip

Paper Recording
This method can be used with either regular or irregular
rhythms and provides a rough estimate (but not precise) of ♦ Look for markers (or
heart rate. Print a 6 second strip (see text box if you are not hatch-marks) on the top
sure how to do this). Count the number of R waves in a 6 bar of the ECG paper
second strip and multiply by 10. For example, if there are ♦ Most markers are
seven (7) R waves in a 6 second strip, the heart rate is automatically printed
approximately 70 or (7x10=70). Let’s give it a try. Look at every 1 or 3 seconds
the rhythm below and count all the R waves. ♦ Print a 6 second strip
♦ Add up the number of R
waves and multiply by
10.

Question 7.0
What is the approximate heart rate of the ventricles?

Answer 7.0
There are 8 R waves, so our patient’s rate is 8 X 10
or 80 beats per minute. Wasn’t that easy?

23
Large Box Method
Count the number of large squares between two consecutive R waves. Divide this number
into 300 for a ventricular rate. For example, if there are four large squares between regular
QRS complexes, the heart rate is 75 (300/4=75).

For an atrial rate, count the number of large boxes between two consecutive P waves and
also divide into 300.

Small Box Method

This method also uses an “R to R” or “P to P” measurement, but is more precise because we
use the smaller ECG boxes to help us calculate the heart rate. To calculate the ventricular
rate, count the number of small boxes between two consecutive R waves and divide by 1500.
To calculate the atrial rate, count the number of large boxes between two consecutive P
waves and divide by 1500.

Practice using all three types of calculation methods until you find the one you like best.
Remember, if you only have a short rhythm strip (<.06 seconds), you will need to use either
Method #2 or #3.

24
 Section 8: Format for ECG Interpretation
The ECG tracing provides a variety of clues as to what is happening within the heart. These
clues include heart rate, regularity or irregularity of the rhythm, interval measurements and
characteristics of each individual waveform. Think of the ECG strip as a unique fingerprint in
which you are the detective conducting the investigation. Like a detective, you will need to
pay attention to details.

In addition to a detailed analysis, you will also need a “recipe” for ECG interpretation, just like
a cook needs a recipe for a complex dessert. If you follow the interpretation “recipe” each
time you analyze a strip, your skills will grow and your interpretations will be consistently
accurate.

Remember to print a 6 second strip (or longer) and to use your calipers for measurements
each time you begin an interpretation. Follow the six basic steps (your recipe) for rhythm
interpretation.

Six Basic Steps for Rhythm Interpretation

1. Rate (Calculate the heart rate (HR) or note the HR from the
monitor)
2. Regularity (Measure the regularity or rhythm of the R waves)
3. P-wave Examination. Is there one P wave before each QRS?
(there should be)
4. P to R interval (Measure the P to R interval - Is it within normal
limits? It is consistent?)
5. QRS width (Measure the duration of the QRS complex)
6. Rhythm interpretation

Step 1: Rate
Calculate both the atrial and ventricular rates. Normally the atrial rate is the same as the
ventricular rate. Is this true in the ECG strip you are analyzing? Remember the normal heart
rate for most individuals falls between the range of 60-80 beats/minute.

Normal Findings: Abnormal Findings:

♦ The HR should be between 60-80 ♦ Heart rates less than 60 beats/minute
beats/minute. are typically labeled as slow or
bradycardic.
♦ The atrial rate should be the same as
the ventricular rate. ♦ Heart rates greater than 100
beats/minute are typically labeled fast
or tachycardic.

25
Step 2: Regularity (or the Pattern of the Rhythm)
Step 2 is the assessment of the regularity of the rhythm. Is the rhythm regular or is it
irregular?

To assess the regularity, you will need to place the legs of your calipers on two consecutive R
waves. This is your “R to R” or “R-R” interval. Without moving the width of the calipers,
march through the rhythm as you travel from R wave to R wave. Do the R waves follow a
regular pattern? If so, the ventricular rhythm is called regular rhythm. Normal ECG rhythms
are regular in their pattern.

If the R-R interval varies in the number of ECG small boxes between them, you are dealing
with an irregular rhythm. Do the same type of assessment with the atrial rhythm. Put your
calipers at the beginning (or upslope) of a P wave. Put the other end of your caliper at the
beginning of the next P wave. This is the P-P interval. Lift your calipers and begin marching
through the strip looking for the pattern of regularity of the P waves. If the SA node is firing at
a constant beat, the P-P interval will be regular.

Normal Findings: Abnormal Findings:

♦ The R-R intervals are regular. ♦ The R-R intervals are irregular.
♦ The P-P intervals are regular. ♦ The P-P intervals are irregular.
♦ There is one P for every QRS. ♦ There is more than one P for each
QRS.

Very few rhythms are irregular. For example, Nursing Tip: Many healthy
atrial fibrillation is always irregular (more on this individuals have heart rates below 60
rhythm later). Therefore, if your rhythm is regular beats/minute, especially athletes.
it cannot be atrial fibrillation. Look at the strips Always check the patient’s blood
below. Note that the R-R intervals are regular in pressure to assess the hemodynamic
the first tracing. The second tracing has an response to a slow or fast heart rate,
irregular pattern with the R-R intervals. This is a especially when there is a rise or fall
helpful clue in your interpretation process. of greater than 20 beats/minute.

Regular Rhythm Irregular rhythm

26
Step 3: P Wave Examination
Step 3 is the examination of the P wave. First, you must go on a “P hunt” and find the P
waves. Once you have identified them, assess their characteristics.

Normal Findings
♦ P waves should be regular (march out the P-P intervals with your calipers).
♦ P waves have a symmetrical shape, usually upright and rounded.
♦ P waves should all look alike (uniform) and should point in the same direction.
♦ There should be one P for every QRS (or a 1:1 relationship).

Abnormal Findings Nursing Tip:

♦ A P wave is not followed by a QRS complex. Remember that the P
♦ There are more P waves than QRS complexes. wave represents atrial
depolarization.
Step 4: P to R Interval
Remember that the P to R interval represents the time it takes an impulse to travel from the
atria through the AV node. The P to R interval is measured from the beginning of the P wave
to the beginning of the QRS complex. This is a bit confusing
as you might think it is a measurement from the beginning of Nursing Tip: Normal PR
the P wave to the beginning of the R wave.... but it is actually Interval is 0.12-0.20
only measured from the beginning P to the beginning of the seconds (3-5 small boxes).
Q wave. Think of it as a “P to Q measurement” despite the
fact that it is called a PR interval.

Normal Findings: Abnormal Findings:

♦ The PR interval (or time travel from SA ♦ The PR interval is > .20 seconds (this
to AV nodes) is between 0.12 to 0.20 might indicate delayed travel time from SA
seconds. to AV node).
♦ The PR intervals are constant ♦ The PR interval is irregular in
throughout the rhythm. measurement (irregular or varying PR
intervals may indicate some type of SA-AV
conduction problem and possible
conduction heart block).

27
Step 5: QRS Complex
The QRS complex represents ventricular depolarization. The QRS complex consists of three
waves: the Q wave, the R wave, and the S wave. It is measured from the beginning of the Q
wave to the end of S wave. Normal ventricular conduction and depolarization takes no more
than .12 seconds.

Normal Findings: Abnormal Findings:

♦ All the QRS complexes have uniformity ♦ The QRS complexes vary in shape,
throughout (the same size, shape and width and direction.
direction). ♦ The QRS complex is >.12 seconds
♦ All QRS complexes are of equal wide.
duration or width. ♦ The R to R interval between each QRS
♦ The R to R interval between each QRS is irregular.
is regular.

ST – T Wave
The ST segment and T wave represent ventricular repolarization. The cells are returning
back to their polarized status and the heart is getting ready for yet another contraction.

Normal Findings: Abnormal Findings:

♦ The ST segment should be electrically ♦ There is > 1mm ST segment elevation
neutral (or near neutral) and should be or depression from the isoelectric line.
sitting on the isoelectric baseline (no ♦ The T wave is in the opposite direction
greater than 1 mm above or below the than the R wave.
isoelectric line is normal).
♦ The T wave is upright whenever the R
wave is upright. The T wave deflects
downward when the R wave is
downward.

Bundle Branch Blocks

Do you hear this term a lot, but are not quite sure what it is all about? Bundle branch
blocks are outside the scope of this course. Since there is such a high level of interest
in them, and some ECG learners may be ready to tackle this concept, a short
description of bundle branch blocks is included in Appendix I. Bundle branch blocks will
not be included on the post test.

28
Step 6: Rhythm Interpretation
Believe it or not, after completing Step 5, you are ready to make an educated decision on
naming the correct rhythm. Remember to correlate information obtained in Steps 1-5 along
with your understanding of the heart’s electrophysiology. Rather than pure memorization, if
you can integrate the electrophysiology with the rhythm interpretation your patient care
priorities and potential treatments will make a lot more sense.

Nursing Priorities and Potential Treatments

Interpreting the actual ECG rhythm is only the beginning of the assessment and care for your
patient. You cannot be successful in your practice if you only know how to interpret ECG. As
healthcare providers, you must be able to respond with appropriate priorities and understand
initial treatments. Comprehensive treatments for each type of ECG rhythm are beyond the
scope of this module, however, initial or “first steps” will be discussed.

29
 Practice Exercises

Look at the following 6-second rhythm strip and begin to answer the questions below:

1. Heart Rate: ___________ Circle one: Normal/Fast/Slow

2. Regularity of the rhythm:

♦ Are the P to P intervals regular? Circle one: Yes/No
♦ Are the R to R intervals regular? Circle one: Yes/No

3. P Waves:
♦ Are P waves present? Circle one: Yes/No
♦ Is there one P proceeding each QRS? Circle one: Yes/No

3. PR Interval: ________ Circle one: <.20 seconds (normal) or > .20 seconds

4. QRS Width: _________ Circle one: <.12 seconds (normal) or >.12 seconds

5. Rhythm Interpretation: ____________________________________

Practice Exercise Answers

1. Heart Rate: Approximately 80 beats/min (8 R waves in a six second strip x 10).
Normal
2. Regularity of the rhythm: The P to P intervals are regular. The R to R intervals
are regular.
3. P waves: The P waves are present. There is one P preceding each QRS.
4. PR Interval: 4 sm boxes x .04 sec = .16 seconds <.20 seconds (normal)
5. QRS Width: 2 sm boxes x .04 sec = .08 seconds <.12 seconds (normal)
6. Rhythm Interpretation: We are not ready for this yet, but a sneak preview will
indicate this is a Normal Sinus Rhythm. (More on this soon!!)

30
 Section 9: The Sinus Rhythms

Normal Sinus Rhythm

Description
Normal sinus rhythm (NSR) is also simply called sinus rhythm (both terms are used
interchangeably). NSR is the result of the dominant pacer function from the SA node. In
addition to the healthy SA nodal function, all of the conduction pathways are working normally
(the AV node, junction, bundle of His, right and left bundles and the Purkinje fibers). The
sinus node is firing at a regular rate of 60-100 times per minute. Each beat is conducted
normally through to the ventricles.

ECG Criteria:
1. Heart Rate: 60 – 100 bpm
2. Rhythm: Atrial regular. Ventricular regular
3. P waves: Upright and uniform (all of the P waves look alike). One P precedes every QRS
4. PR Interval: .12 - .20 seconds (less than one big box on the graph paper)
5. QRS Width: ≤ .12 seconds

Nursing Priorities:
There are no nursing priorities.

Potential Treatments:
There are no potential treatments.

Important Self-Assessment Note

NSR is the standard against which all other rhythms are compared.

If you are not clear on this rhythm, do not advance in this module. To have your
questions answered and to clear up any confusion, please re-read the above sections
and consult with a colleague BEFORE continuing with this module.

31
Sinus Bradycardia

Description
Sinus bradycardia (SB) is characterized by a decrease in the rate of atrial depolarization
due to slowing of the SA node. The sinus node is the pacemaker, firing regularly at a rate of
less than 60 times a minute. Each impulse is conducted normally through to the ventricles.

Possible Causes:
♦ Increased vagal (parasympathetic) tone (vomiting, carotid sinus massage)
♦ Hyperkalemia
♦ Increased intracranial pressures
♦ Possible result of inferior MI
♦ Side effects from beta-adrenergic blockers, sympatholytic drugs, Digoxin, or morphine
♦ Normal effect, especially in athletes

ECG Criteria:
1. Heart Rate: less than 60 bpm
2. Rhythm: Atrial regular. Ventricular regular
3. P waves: Upright and uniform. One P precedes every QRS
4. PR Interval: .12 - .20 seconds
5. QRS Width: ≤ .12 seconds

Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope, and SOB.
♦ You patient may need to lie down to prevent potential falls.
♦ Keep in mind that it may be normal for some individuals to have sinus bradycardia (e.g.
athletes).

Potential Treatments:
♦ Asymptomatic: Observation.
♦ Symptomatic: Oxygen, atropine, transcutaneous pacing, dopamine (if hypotensive).

Nursing Tip: This course is only addressing the basic treatments for arrhythmias.
Your unit/facility may have different or more complex treatments.

32
Sinus Tachycardia

Description
Sinus tachycardia (also called Sinus Tach) is characterized by a rapid (> 100 bpm) rate of
discharge of the SA node. The sinus node is discharging at a rate > 100 and the remainder
of the conduction follows the normal pathway.

Possible Causes:
♦ Normal cardiac response to demands for increased oxygen need during pain, fever,
stress, dehydration and exercise
♦ Caffeine, nicotine ingestion
♦ Hyperthyroidism
♦ Post MI or early sign of heart failure

ECG Criteria:
1. Heart Rate: ≥ 100 bpm to 160 bpm
2. Rhythm: Regular
3. P waves: Upright and normal. One P precedes every QRS
4. PR Interval: .12 - .20 seconds
5. QRS Width: ≤ .12 seconds

Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope, palpitations, or SOB.
♦ Your patient may need to lie down to prevent potential falls.
♦ Patient may have lower B/P due to decreased diastolic ventricular filling time associated
with the tachycardia.

Potential Treatments:
♦ Asymptomatic: Observation.
♦ Symptomatic: Treat the underlying cause (dehydration, anxiety, etc). Drugs such as
beta blockers may be given to slow the HR.

33
 Section 10: Atrial Dysrhythmias

Premature Atrial Contractions (PACs)

As described above, the intrinsic pacemaker of the heart is the sinus (SA) node, and normally
it initiates each beat. Pacemaker stimuli can also arise from other parts of the heart – the
atria, the AV junction, or the ventricles. The terms “ectopy” or “ectopic beat” are used to
describe these non-sinus beats. Ectopic beats are often premature; that is, they come in
early or before the next sinus beat is due.

Description
A premature atrial contraction results from an ectopic stimulus that arises from somewhere in
either the left or the right atrium, but not in the sinus node. The atria are depolarized from the
ectopic stimulus, but the remainder of the conduction is typically normal through the AV
Node-Junction and downward into the bundle branches (i.e. normal PR and QRS morphology
and intervals).

Possible Causes:
PACs are very common and may occur in persons with a normal heart or in persons with
virtually any type of organic heart disease. PACs do not imply that a person has cardiac
disease and may be seen with caffeine intake and with emotional stress. Other causes
include:
♦ Administration of sympathomimetic ♦ Digoxin toxicity
agents (epinephrine, theophylline) ♦ Hyperthyroidism
♦ Electrolyte abnormalities
♦ Myocardial ischemia or injury

ECG Criteria:
1. Heart Rate: Typically normal
2. Rhythm: Underlying rhythm is typically regular with early premature beats
3. P waves: Atrial depolarization is premature, occurring before the next normal P wave.
Since the impulse originates outside the SA node, the P wave may have a different
shape - often notched, peaked or buried in the proceeding T wave
4. PR Interval: Maybe normal, shorter or longer than normal PR interval, depending on
origin of the PAC
5. QRS Width: typically normal but may be prolonged if the PAC is aberrantly conducted
through the ventricles

34
Other Types of PACs
There are a few variations from the above description. On occasion, a PAC may not conduct
into the ventricles or the PAC may conduct into the ventricles in an abnormal way.
Nonconducted PACs: If the PAC occurs very prematurely (or close to the preceding T
wave), the early atrial depolarization might be too early for the right and left bundles to
conduct the impulse. This type of PAC cannot be conducted down into the ventricles. In this
situation, look for an early P wave (which might also be buried in the preceding T wave). The
early PAC does not conduct into the ventricles, thus there is no QRS for this one cardiac
cycle.
Aberrantly conducted PACs: If the impulse should happen to travel abnormally through the
ventricles, the QRS may be prolonged. This can happen if either the right or left bundle
branches are not ready to depolarize and result in a temporary block. If the QRS is wide
following a PAC, it will be called an aberrantly conducted PAC.

Nursing Priorities:
♦ Intervention not typically required
♦ Heart rate may be irregular during episodes of PACs so assess the pulse for one full
minute

Potential Treatments:
♦ Asymptomatic:
• Observation and ECG monitoring for frequency and trends.
• Explore potential underlying causes (caffeine intake, stress reduction, myocardial
abnormalities, etc).
♦ Symptomatic:
• Treatment is typically centered around observation and monitoring for increased
frequency.
• Be aware that individuals may complain of palpitations or feeling a “skipped” heart
beat with an irregular pulse. Explain to them the reason for these feelings.
• Increased number of PACs may be a forerunner of the development of atrial
fibrillation or other atrial dysrhythmias.

35
Atrial Flutter

Description
Atrial Flutter is a dysrhythmia, which is the result of a flawed reentry circuit within the atria.
It is often described as resembling a sawtooth or picket fence. These flutter waves should
not be confused for P waves. The AV node is a wonderful protective mechanism. Imagine
the atria depolarizing at a rate of 250 to 350 bpm. If all of these atrial depolarizations were
conducted down into the ventricle, the patient’s ventricles would likely begin to fibrillate.
Think of the AV node as the central train station where numerous train tracks merge. The
central station only lets some of the trains through to avoid congestion. The AV node helps
to protect the ventricles by only allowing some of the atrial depolarizations to conduct down
through the bundle of His into the bundle branches and on to the ventricles.

When the ventricular rate is < 100 bpm, we call this “controlled atrial flutter.” If the ventricular
rate is > 100 bpm, it is labeled “uncontrolled atrial flutter.” Since the ventricles always have
more time to fill during diastole when the HR is under 100, our goal is to have controlled atrial
flutter. This can often be accomplished with drug therapy.

In the setting of atrial flutter, coordinated contraction of the atria is absent. The patient has
therefore lost their atrial kick with potential loss of cardiac output and lower blood pressure.

Possible Causes:
♦ Acute or chronic cardiac disorder, mitral or tricuspid valve disorder, cor pulmonale,
pericarditis
♦ Post MI complication (usually transient)
♦ Hyperthyroidism
♦ Alcoholism
♦ Post cardiac surgery (usually transient)

ECG Criteria:
1. Heart Rate: Atrial rate is 250-350 bpm. Ventricular rate varies according to AV node
conduction.
2. Rhythm: Atrial regular; ventricular may be regular or irregular (again, depending on AV
node conduction).
3. P waves: Absent. Only flutter or saw tooth looking waveforms
4. PR Interval: Not applicable
5. QRS Width: ≤ .12 seconds

36
Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope, palpitations, or SOB.
♦ Your patient may need to lie down to prevent potential falls.
♦ Patient may have lower B/P due to loss of atrial kick.

Potential Treatments
♦ Asymptomatic: Observation and rate control.
• Normal heart function: control ventricular rate by
administering beta blockers (esmolol) or calcium Nursing Tip: Before
channel blockers (diltiazem or verapamil). electrical cardioversion is
attempted, consider
• Impaired heart function: control ventricular rate by anticoagulation to prevent
administering digoxin, diltiazem, or amiodarone. embolic complications.
♦ Symptomatic: If hemodynamically unstable,
synchronized cardioversion at 100-200 monophasic joules.

Atrial Fibrillation

Description
Atrial fibrillation (often called “a. fib” or “atrial fib”) may result from multiple areas of re-entry
within the atria or from multiple ectopic foci. The atrial electrical activity is very rapid
(approximately 400 bpm), but each electrical impulse results in the depolarization of only a
small islet of atrial myocardium rather than the whole atrium. As a result, there is no
contraction of the atria as a whole. Since there is no uniform atrial depolarization, there is no
P wave. The chaotic electrical activity does produce a deflection on the ECG, referred to as
a fibrillatory wave.

Fibrillatory waves vary in size and shape and are irregular in rhythm. Fibrillatory waves look
different from the sawtooth waves of atrial flutter. Transmission of these multiple atrial
impulses into the AV node is thought to occur at random, resulting in an irregular rhythm.
Some impulses are conducted into but not through the AV node (they are blocked within the
AV node). Remember that the ventricular rhythm is always irregular in atrial fibrillation.

When the ventricular rate is < 100 bpm, we call this “controlled atrial fibrillation.” If the
ventricular rate is > 100 bpm, it is labeled “uncontrolled atrial fibrillation.” Since diastolic filling
is enhanced when the HR is under 100, our goal is to have controlled atrial fibrillation. This
can often be accomplished with drug therapy.

37
Possible Causes:
♦ Mitral valve disorders
♦ Rheumatic heart disease, MI, hypertension, coronary artery disease (CAD), heart failure,
pericarditis
♦ Chronic obstructive pulmonary disease (COPD)
♦ Digoxin toxicity
♦ Post cardiac surgery (usually transient)

ECG Criteria:
1. Heart Rate: Atrial rate 350-400 bpm. Ventricular rate is variable
2. Rhythm: Ventricular rate is irregular (one of the hallmark signs of atrial fibrillation)
3. P waves: Absent. Only atrial fibrillatory waves (or small looking bumps) are seen
4. PR Interval: Not applicable
5. QRS Width: ≤ .12 seconds

Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope or SOB.
♦ Palpitations are commonly felt as a result of the irregular, and often rapid, heart rate.
♦ Your patient may have lower B/P due to loss of atrial kick.

Potential Treatments:
♦ Asymptomatic: Observation and rate control.
• Normal heart function: control ventricular rate by administering beta blockers
(esmolol) or calcium channel blockers (diltiazem or verapamil).
• Impaired heart function: control ventricular rate by administering digoxin, diltiazem or
amiodarone.
♦ Symptomatic: If hemodynamically unstable, synchronized cardioversion at 100-200
monophasic joules.

Nursing Tip: Before electrical cardioversion is

attempted, consider anticoagulation to prevent
embolic complications.

38
 Section 11: Junctional Rhythms

Junctional Escape Rhythm

As you probably remember, the AV node is a group of specialized cells and its main function
is to delay impulses coming from the atria to ventricles, thereby allowing the atria more time
to completely contract. Between the AV node and the right and left bundle branches lies the
Bundle of His. The area around the Bundle of His is also called the AV junction (where the
AV node and the bundles junction together).

Description
This AV junction can function as a pacemaker. It initiates impulses at a rate of 40 to 60 beats
per minute. Under normal circumstances, the sinus node pacemaker is faster and
predominates. If the AV node is not depolarized by the arrival of a sinus impulse within
approximately 1.0 to 1.5 seconds, it will initiate an impulse of its own from this junctional area.
This is called a junctional escape complex. It occurs because of failure of the sinus node
to initiate an appropriately timed impulse or because of a conduction problem between the
sinus node and the AV junction. A repeated series of such impulses is referred to as a
junctional escape rhythm.

Unusual or Absent P waves:

If the AV junction paces the heart, the atria may or may not be stimulated. The electrical
impulse must travel in a backward (retrograde) direction to activate the atria. In Leads II, III,
and aVF, the P wave will be negative (inverted) if the atria are stimulated. Depending on how
the atria responds to the junctional pacemaker, the patient could have a) no P waves; b) an
inverted P wave (upside down just preceding the QRS); or c) an inverted P wave after the
QRS (if atrial depolarization occurs after the QRS).

Possible Causes:
♦ Post MI (damage to SA node)
♦ Digoxin toxicity

ECG Criteria:
1. Heart Rate: 40-60 bpm
2. Rhythm: Ventricular rhythm is regular
3. P waves: may be absent or may occur before, during or after the QRS (due to retrograde
conduction)
4. PR Interval: None (impulses are originating from the AV junction, not the SA node)
5. QRS Width: ≤ .12 seconds (the impulse is traveling down the normal pathways of the
right and left bundles

39
Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope, palpitations, or SOB.
♦ Lower blood pressure may result from loss of atrial kick and bradycardic heart rate.

Potential Treatments:
♦ Asymptomatic: Observation.
♦ Symptomatic: Atropine, dopamine, transcutaneous pacing.

Accelerated Junctional Rhythm/Junctional Tachycardia

Can the AV junctional area ever “speed up” and pace at a rate faster than 40-60 beats per
minute? The answer is “yes, it can.” For all of the same reasons a person might experience
a junction escape rhythm, a person might also experience enhanced automaticity of the AV
junction area. The result is a junctional rhythm, which depolarizes at a rate of 60-100 bpm.
This is an Accelerated Junctional Rhythm. If the rate is greater than 100 bpm the rhythm
is called Junctional Tachycardia (see above). It might be tempting to call the ECG tracing a
normal sinus rhythm, but make note that uniform looking P waves are absent along with a
constant PR interval. The SA node is not working and the junction has taken over as the
pacer, only a bit faster than its normal intrinsic rate of 40-60 bpm.

Possible Causes of Accelerated Junctional Rhythm:

♦ Digoxin toxicity (most common cause)
♦ Hypoxia
♦ Cardiomyopathy
♦ MI
♦ Valve replacement surgery

ECG Criteria of Accelerated Junctional Rhythm:

1. Heart Rate: 60-100 bpm (Remember: if Heart Rate is > 100 it is called Junctional
Tachycardia)
2. Rhythm: Ventricular rhythm is regular
3. P waves: may be absent or may occur before, during or after the QRS (due to retrograde
conduction)
4. PR Interval: None (impulses are originating from the junction, not the SA node)
5. QRS Width: ≤ .12 seconds (the impulse is traveling down the normal pathways of the
right and left bundles

40
Nursing Priorities:
♦ Check your patient’s blood pressure, assess for syncope, palpitations, or SOB.
♦ Lower blood pressure may result from loss of atrial kick.

Potential Treatments:
♦ Asymptomatic: Observation.
♦ Symptomatic: Discontinue digoxin therapy. Check potassium levels. If heart rate
becomes faster (100-180 bpm) the rhythm is called Junctional Tachycardia. Now
consider treatment with IV amiodarone, beta-adrenergic blockers (Esmolol, Labetalol,
Metoproplol), or calcium channel blockers.

TAKE A BREAK!!!!
If you have been working at this course without a
break, we suggest you take one now. Let some of
the information “simmer” in your head. Come back
fresh and ready to tackle even more information
about interpreting ECGs!

41
 Section 12: Atrioventricular Blocks
Atrioventricular blocks (otherwise known as heart blocks)
can be divided into three degrees. First-degree heart blocks Nursing Tip: A hint for
are characterized by P to R intervals longer than 0.20 seconds. separating the heart
Second-degree heart blocks are characterized by some P blocks into degrees is
waves being blocked at the AV node. This results in some P that first- and third-
waves occurring without following QRS complexes. Third- degree blocks usually
degree heart block is characterized by a complete dissociation have regular QRS rates.
between P waves and QRS complexes.

First Degree AV Block

Description
First-degree AV block is simply a delay in passage of the impulse from atria to ventricles.
Unlike its name (which can be confusing), first-degree AV block is not an actual “block,” but
rather a delay in conduction. This conduction delay usually occurs at the level of the AV
node.

Remember that in normal sinus rhythm, the time it takes the SA node to fire, depolarize the
atria and transmit to the AV node is ≤ 0.20 seconds. In first degree AV block the patient has
a PR interval of ≥ .20 seconds. If the patient’s underlying rhythm is sinus bradycardia, but
the PR interval is .24 seconds, the interpretation would be “sinus bradycardia with a first-
degree AV block.”

Possible Causes:
♦ Drug therapy (digoxin, beta-adrenergic blockers or calcium channel blockers, or
antiarrhythmic drugs such as amiodarone)
♦ Post MI
♦ Chronic degenerative disease of the atrial conduction system (seen with aging)
♦ Hypo- or hyperkalemia
♦ Increased vagal tone

42
ECG Criteria:
1. Heart Rate: Varies depending on the underlying rhythm
2. Rhythm: Atrial and ventricular regular
3. P waves: Upright and normal. One P precedes every QRS
4. PR Interval: ≥ .20 seconds and is constant
5. QRS Width: ≤ .12 seconds

Nursing Priorities:
♦ Observe for lengthening PR intervals or development of more serious heart blocks.

Potential Treatments:
♦ Treatment for first-degree heart block is usually unnecessary as it is typically
asymptomatic.
♦ Treatment typically aims to correct the underlying cause.
♦ Consult with physician if PR interval is lengthening. Discuss holding medications which
slow A-V conduction.

Second Degree AV Block- Type I or Mobitz I or Wenckebach

There are two categories of second-degree heart block. One is called Wenckebach (Type I)
and the other is called Type II. In both types, the impulse originates in the sinus node, but is
conducted through the AV node in an intermittent fashion. Simply stated, not every P wave
will be followed by QRS complex. In second-degree heart blocks, some impulses are
conducted and others are not. The cause of the non-conducted P waves is related to
intermittent AV nodal block. The difference between the two-second degree blocks is related
to the pattern in which the P waves are blocked.

Description
Second-degree AV block- Type I is unique in that it has three different names, and all three
are used interchangeably (just to keep us all on our toes!). Second degree AV Block- Type I
is also called Mobitz I or it can be referred to as Wenckebach. Do not let this confuse you as
all three names mean the SAME rhythm.

For simplicity, we will call this rhythm “Wenckebach.” Wenckebach is characterized by a

progressive prolongation of the PR interval (so the key to diagnosing this rhythm is by
careful examination of each PR interval). The SA node is healthy and fires on time, thus the
P to P intervals are regular. Impulses traveling through the AV node take longer and longer
to fully conduct until one impulse is completely blocked. The SA node continues to fire right
on time (regular P to P intervals) and the cycle of prolongation of PR intervals continues as
the pattern is repeated.
43
The repetition of this pattern results in “group beating,” (e.g. three conducted sinus beats with
progressively lengthening PR intervals and a fourth sinus beat that is NOT followed by a
QRS). Beats that are successfully conducted have a normal QRS width. Because QRS
complexes are periodically dropped, the ventricular rhythm is irregular.

This block almost always occurs at the level of the AV node (rarely at His bundle or bundle
branch level), is typically a transient rhythm, and prognosis is good.

Possible Causes:

♦ Drug therapy (digoxin, beta-adrenergic blockers, calcium channel blockers, amiodarone)

♦ CAD
♦ New MI – seen more commonly with acute inferior wall infarctions
♦ Rheumatic fever
♦ Increased vagal tone
♦ Hyperkalemia
♦ Myocarditis

ECG Criteria:

1. Heart Rate: Atrial regular; Ventricular rate is slightly slower. Typically between 60-90
bpm
2. Rhythm: Atrial regular. Ventricular irregular
3. P waves: Upright and normal. Some P’s are not followed by a QRS (more Ps than
QRSs)
4. PR Interval: Progressively longer until one P wave is not followed by a QRS complex.
After the blocked beat, the cycle starts again
5. QRS Width: ≤ .12 seconds

Nursing Priorities:

♦ Check the patient’s blood pressure and other patient vital signs (often they are normal).
♦ Assess the patient for possible causes.

Potential Treatments:

Treatment is not typically required.

♦ Asymptomatic: Observation and monitoring only. If PR interval is lengthening, consult
with physician for holding drugs that can slow AV node conduction.
♦ Symptomatic: On a rare occasion, atropine and/or temporary pacing may be considered.

44
Second Degree AV Block- Type II or Mobitz II

Description
Second degree AV block Type II is also referred to as Mobitz II (only two names this time ☺).
This form of conduction delay occurs below the level of the AV node, either at the bundle of
His (uncommon) or the bundle branches (common). A hallmark of this type of second-degree
AV block is that there is a pattern of conducted P waves (with a constant PR interval),
followed by one or more non-conducted P waves. The PR interval does not lengthen before
a dropped beat. Remember that the P waves that are successful in conducting through have
a constant PR interval. Since the SA node is firing in a regular pattern, the P to P intervals
again march through in a regular pattern (P-P is regular). Since not all P waves are
conducted into the ventricles, the R to R intervals will be irregular and the ventricular
response (HR) may be in the bradycardia range.

When the block occurs at the bundle of His, the QRS may be narrow since ventricular
conduction is not disturbed in beats that are not blocked. If the blockage occurs at the level
of the bundle branches, conduction through the ventricles will be slower therefore creating a
wider QRS complex (>.12 seconds).

Mobitz II is associated with a poorer prognosis, and complete heart block may develop.
Causes are usually associated with an acute myocardial infarction, severe coronary artery
disease or other types of organic lesions in the conduction pathway. The patient’s response
to the dysrhythmia is usually related to the ventricular rate.

Possible Causes:
♦ Age related degenerative changes in the conduction system
♦ New MI- seen more commonly with acute anterior wall infarctions
♦ Post cardiac surgery or complication arising with cardiac catheterization
♦ Note: not typically a result of increased vagal tone or drug effects

ECG Criteria:
1. Heart Rate: Atrial regular. Ventricular rate is typically ¼ to ½ the atrial rate (depending on
the amount of blockage in conduction)
2. Rhythm: Atrial regular (P-P is regular). Ventricular irregular
3. P waves: Upright and normal. Some Ps are not followed by a QRS (more Ps than QRS)
4. PR Interval: The PR interval for conducted beats will be constant across the strip
5. QRS Width: ≤ .12 seconds for conducted beats

45
Nursing Priorities:
♦ Check the patient’s blood pressure.
♦ Assess the patient’s symptoms.
♦ Note: Mobitz II has the potential to suddenly progress to complete heart block or
ventricular standstill; have a temporary pacemaker nearby!

Potential Treatments:
♦ Asymptomatic: Observation and monitoring only. Hold drugs that can slow AV node
conduction. Notify physician. Obtain supplies for pacing should this become necessary.
♦ Symptomatic: If symptomatic bradycardia is present, apply transcutaneous pacemaker
and collaborate with physician for insertion of transvenous pacer wire. Administer a
dopamine infusion if patient is hypotensive.
♦ Note: Atropine must be used with great caution (if at all) with this rhythm. Atropine will
increase the sinus note discharge, but does not improve conduction through the AV
node, (the location of this block is lower in the conduction system). Acceleration of the
atrial rate may result in a paradoxical slowing of the ventricular rate, thereby decreasing
the cardiac output.

Third Degree or Complete Heart Block

Description
Third-degree AV block is also called complete heart block. This type of dysrhythmia
indicates complete absence of conduction between atria and ventricles (the atria and the
ventricles are not communicating with one another). The atrial rate is always equal to or
faster than the ventricular rate in complete heart block. The block may occur at the level of
the AV node, the bundle of His, or in the bundle branches. As in second-degree AV block,
this distinction is not merely academic since pathogenesis, treatment, and prognosis may
vary considerably, depending on the anatomic level of block.

When third-degree AV block occurs at the AV node, a junctional escape pacemaker

frequently will initiate ventricular depolarization. This is usually a stable pacemaker with a
rate of 40 to 60 beats per minute. Since it is located above the bifurcation of the bundle of
His, the sequence of ventricular depolarization usually is normal, resulting in a normal QRS.
This type of third-degree AV block can result from increased parasympathetic tone
associated with inferior infarction, from toxic drug effects (e.g., digitalis, propranolol), or from
damage to the AV node.

46
When third-degree AV block occurs below the junction, it is most often due to a block
involving both bundle branches. The only escape mechanism available is in the ventricle
distal to the site of block. Such a ventricular escape pacemaker has an intrinsic rate that is
slow, less than 20-40 beats per minute. Like any depolarization originating in a ventricle,
the QRS complex will be wide. It is not a stable pacemaker, and episodes of ventricular
asystole are common.

Remember that the rhythm strip reflects two separate processes that are taking place. The
SA node continues to control the atria and typically fires at a rate of 60-80 bpm. Since the
atria and the ventricles are not communicating, one of the two remaining back-up intrinsic
pacemakers will take over. Either the junction will pace the ventricles (rate 40-60 bpm) or the
back-up ventricular pacer will discharge (rate 20-40 bpm).

When there are two separate pacemakers controlling the upper and lower chambers of the
heart without regard to each other, the situation is called AV disassociation (this is not a
“rhythm” but a “condition” and the umbrella term AV disassociation is often used).

On the ECG, you will see normal P waves marching regularly across the strip. The P-P
intervals are regular. You will also see QRS complexes at regular intervals. The unique
feature is that the P waves and the QRS complexes will not be “talking to each other.” There
is no relationship between the P and the QRS waveforms. The PR interval will be totally
inconsistent and you may even see P waves superimposed in the middle of QRS complexes.
There will be more P waves than QRS complexes (because the intrinsic rate of the sinus
node is faster than either the junctional or ventricular rates).

Possible Causes:
♦ Drug therapy (digoxin, beta-adrenergic blockers, calcium channel blockers, amiodarone),
♦ New MI – seen more commonly with acute inferior wall infarctions
♦ Increased vagal tone
♦ Hyperkalemia
♦ Myocarditis or rheumatic heart fever
♦ Post cardiac surgery or complication arising with cardiac catheterization

ECG Criteria:
1. Heart Rate: Atrial rate is normal. Ventricular rate is slower. 40-60 bpm if back-up pacer
is from the junction or 20-40 bpm if back-up pacer is from the ventricles
2. Rhythm: P-P is regular; R-R is regular (but the two are independent functions)
3. P waves: Upright and normal.
4. PR Interval: No relationship between the P and the QRS waves. No PR interval
5. QRS Width: ≤ .12 seconds if controlled by the junction; >.12 seconds if paced by the
ventricle

Nursing Priorities:
♦ Check the patient’s blood pressure, assess for syncope, palpitations, or SOB.
♦ Your patient may need to lie down to prevent syncope and/or potential falls.
♦ Patient may have lower B/P due to low ventricular rate.

47
Potential Treatments:
♦ Asymptomatic: Notify physician. Observation and monitoring only. Hold drugs that can
slow AV node conduction. Obtain supplies for pacing should this become necessary.
♦ Symptomatic: Notify physician. If symptomatic bradycardia is present, administer
atropine and apply transcutaneous pacemaker. Atropine may be effective if the QRS is
narrow (AV node level of block) but has little or no effect on wide QRS (bundle-branch
level) third-degree block rhythms. Administer a dopamine infusion if patient is
hypotensive.

48
 Section 13: Ventricular Rhythms
All of the dysrhythmias which you have learned thus far are classified as supraventricular
dysrhythmias, because they originate from above the ventricles. When a rhythm originates
from above the ventricles (and thereby travels down the normal right and left bundles to the
Purkinje fibers) the QRS is .12 seconds or less. When rhythms originate in the ventricles,
they generally have a QRS >.12 seconds because they are coming from an area outside the
right and left bundle branches. This is an important concept to remember.

Ventricular rhythms are of great importance and can be very dangerous. Our hearts were
designed to conduct and contract from the top down (atria to ventricle). When this
mechanism is disrupted, we lose our atrial kick and the heart’s efficiency is greatly reduced.

The first dysrhythmia is not an actual rhythm, but an occasional ectopic (abnormal) beat
originating from an irritable cluster of cells somewhere in either the right of left ventricle.

Premature Ventricular Contractions

Description
A premature ventricular contraction (PVC) is a depolarization that arises in either ventricle
before the next expected sinus beat, and is therefore labeled “premature.” They are
generally easy to detect because the QRS is wide and bizarre looking. Since PVCs originate
in the ventricle, the normal sequence of ventricular depolarization is altered. For example,
instead of the two ventricles depolarizing simultaneously, a PVC will cause the ventricles to
depolarize at different times or sequentially. In addition, conduction occurs more slowly
through the myocardium than through specialized conduction pathways. This results in a
wide (0.12 second or greater) and bizarre-appearing QRS. The sequence of repolarization is
also altered, usually resulting in an ST segment and T wave in a direction opposite to the
QRS complex. After the PVC occurs, you may find a short pause before the next QRS. This
is called a compensatory pause. The compensatory pause may or may not be present.

Unifocal PVCs:
When a PVC originates from a single focus, its morphology or waveform characteristics look
the same each time. When a PVC looks the same each time, it is called a unifocal PVC
(because it originates from one area). All of the PVCs from a unifocal source are identical in
appearance. The strip below is an example of a unifocal PVC.

49
Multifocal PVCs:
In cases of greater irritability, several ventricular foci might begin to initiate ectopic beats.
Multifocal PVCs will occur if more than one ectopic area begins to initiate early ventricular
beats. For example, if three ectopic ventricular sites began initiating PVCs, each site would
produce a slightly different looking PVC waveform. The ECG criteria are basically the same
as unifocal PVCs. Multifocal PVCs are considered more dangerous when compared to
unifocal PVCs, as this represents a greater amount of myocardial irritability. Below is a
sample of a patient in NSR with a couplet of PVCs from two foci (multifocal).

PVCs may also occur in succession. When this happens, the PVCs are called a Couplet.
(The strip above also shows a couplet.) The term Ventricular Bigeminy is used for a
grouped beating pattern when every other beat is a PVC (despite the underlying rhythm). For
example, ventricular bigeminy is a when you see a pattern of one PVC, then one normal
beat, then one PVC, followed by a normal beat.

If every other beat is a PVC, ventricular bigeminy is present. If every third beat is a PVC, the
term Ventricular Trigeminy is used; if every fourth beat is a PVC, Ventricular
Quadrigeminy is present; and so forth. The strip below is an example of ventricular
trigeminy.

Keep in mind, PVCs may occur as isolated complexes, or they may occur repetitively in pairs
(two PVCs in a row). When three or more PVCs occur in a row, whether unifocal or
multifocal, Ventricular Tachycardia (VT) is present. When VT lasts for more than 30
seconds, it is arbitrarily defined as Sustained Ventricular Tachycardia.

50
R on T Phenomenon:
The T wave is a sensitive or vulnerable area in the cardiac electrical cycle. Remember that
the heart is now repolarizing and does not like to be stimulated at this time. If an early
ventricular beat comes in on top of or near the T wave, the early beat could throw the heart
into an uncontrollable repetitive pattern called ventricular tachycardia. The term “R on T
phenomenon” is used whenever an early ventricular beat lies near the vulnerable T wave.
Consult with MD if you see early R waves coming in near the T wave. Early detection can
help prevent your patient from developing a life-threatening rhythm.

Possible Causes of PVCs:

♦ Caffeine, tobacco, alcohol
♦ Digoxin toxicity
♦ Exercise
♦ Hypocalcemia
♦ Hyperkalemia
♦ New MI
♦ Proarrhythmic effect of antiarrhythmic agents

ECG Criteria:
1. Heart Rate: Depends on the underlying rhythm
2. Rhythm: Depends on the underlying rhythm. The PVC beats are premature, so this will
make the R to R interval a bit irregular
3. P waves: Not applicable (there are no P waves associated with PVCs)
4. PR Interval: Not applicable
5. QRS Width: > .12 seconds, wide and bizarre in appearance. T wave may be opposite
direction of QRS complex

Nursing Priorities:
♦ Assess the patient’s response.
♦ Many patients are asymptomatic, while others may feel palpitations or light-headed.

Potential Treatments:
Treatment is required only when PVCs are frequent or the patient has intolerable symptoms.
♦ Asymptomatic: Observation. Rule out hypokalemia and hypoxemia (both can trigger
PVCs). Oxygen. Correct electrolyte imbalances.
♦ Symptomatic: In the setting of an acute myocardial infarction, PVCs indicate the need to
aggressively treat the ischemia/infarction with oxygen, nitroglycerin, morphine, and
potential antiarrhythmic agents.

51
Ventricular Tachycardia

Description
Ventricular Tachycardia (VT) is defined as three or more consecutive PVCs in a row at a
rate greater than 100 beats per minute. VT is generally caused by single foci in either
ventricle that fire at a rapid rate to override the SA node and thereby take control of the
heart’s rhythm. A short run of consecutive PVCs is often called a “burst” of VT.

ECG characteristics include a rapid, regular rhythm with a wide QRS. The QRS is wide since
the origin of the rhythm is outside the bundle branches, thereby taking a longer time to
conduct cell to cell within the ventricle. Ventricular tachycardia may be monomorphic (all
QRSs with the same shape) or polymorphic (varying QRS shapes during the tachycardia).

Atrioventricular dissociation is present, but not always noticeable. This means that the sinus
node is depolarizing the atria in a normal manner at a rate either equal to or slower than the
ventricular rate. Thus sinus P waves sometimes can be recognized between QRS
complexes but do not conduct down into the ventricles.

This arrhythmia may be either well tolerated or associated with life-threatening hemodynamic
compromise. The hemodynamic consequences of VT depend largely on the presence or
absence of myocardial dysfunction (such as might result from ischemia or infarction) and on
the rate of VT (the faster the rate, the less well tolerated).

Possible Causes:
♦ Myocardial irritability
♦ Acute MI
♦ CAD
♦ Drug toxicity
♦ Electrolyte imbalance
♦ Heart failure

ECG Criteria:
1. Heart Rate: 100-250 bpm
2. Rhythm: Ventricular rhythm regular.
3. P waves: P waves may or may not be seen. If present, they are not associated with the
QRS complex. (AV disassociation occurs with this rhythm, but P waves are not always
seen)
4. PR Interval: Not applicable
5. QRS Width: >.12 seconds, wide and bizarre in appearance. Difficult to differentiate
between the QRS and the T wave.

52
Nursing Priorities:
♦ Check your patient’s pulse and blood pressure to determine if this is stable, unstable (B/P
<90) or pulseless VT.
♦ Notify physician
♦ Treatment depends on the patient’s response to the VT rhythm.

Potential Treatments:
♦ Asymptomatic or stable:
• Oxygen, obtain 12-lead ECG, consider Lidocaine or Amiodarone. Check electrolytes
such as potassium and magnesium. Apply multifunction pads as cardioversion may
be necessary if patient becomes unstable.
♦ Symptomatic: If unstable, prepare for immediate synchronized cardioversion. Consider
amiodarone bolus and infusion. If pulseless, administer one defibrillation shock followed
by CPR. Activate your code resuscitation team and follow ACLS guidelines.

Ventricular Fibrillation

Description
Ventricular fibrillation (VF) is the result of highly irritable ventricle(s), which begin to send
out rapid electrical stimuli. The stimuli are chaotic resulting in no organized ventricular
depolarization. The ventricles do not contract because they never depolarize. For you visual
learners... just imagine shaking a bowl full of Jell-O. Gently shake the bowl and watch the
Jell-O quiver or “fibrillate.” This is similar to what is happening within the heart. Because the
ventricles are fibrillating and never contracting, the patient does not have a pulse, cardiac
output, or blood pressure.

The terms coarse and fine have been used to describe the amplitude of the waveforms in
VF. With Coarse VF, the fibrillatory waves are more easily seen and are usually greater than
3mm in height (3 small boxes tall). Coarse VF usually indicates a more recent onset of VF,
which could be more easily converted by prompt defibrillation. The presence of fine VF
(which looks a bit like asystole and is less than 3mm in height) often means there has been a
considerable delay since collapse, and successful resuscitation is more difficult.

53
Possible Causes:
♦ Acute MI
♦ Untreated ventricular tachycardia
♦ Underlying heart disease
♦ Acid-base imbalance
♦ Electrolyte imbalances such as hypokalemia, hyperkalemia, and hypercalcemia

ECG Criteria:
1. Heart Rate: None. No discernable P waves or QRS complexes
2. Rhythm: Chaotic wavy recording. No discernable rhythm.
3. P waves: None
4. PR Interval: Not applicable
5. QRS Width: Not applicable

Nursing Priorities:
Check for an airway, breathing, and pulse per Basic Life Support (BLS) standards. Call for
help. The patient will be apneic, pulseless, and unresponsive. Begin CPR. VF treatment
requires electrical therapy (defibrillation). Resuscitation requires defibrillation and often
requires emergency drugs per ACLS VF guidelines. The sooner the patient is defibrillated,
the more likely of achieving spontaneous circulation. The longer the patient is in VF, the
more difficult it is to convert the rhythm.

Potential Treatments:
Initial treatment is always defibrillation. Only defibrillation provides definitive therapy. Other
priorities include securing an airway, making sure the patient has IV access, and
administering medications per guidelines.

54
Asystole

Description
Asystole represents the total absence of electrical activity. Since depolarization does not
occur, there is no ventricular contraction and a straight line will appear on the ECG. To
assure there is no electrical activity, check the rhythm in a second lead and make sure your
monitor is working properly. Asystole may occur as a primary event in cardiac arrest, or it
may follow VF.

In addition, the distinction between very fine VF and asystole may be very difficult. If it might
be VF, it should be treated, like VF, with defibrillation. If no organized QRS complex is seen
and the patient has a pulse, then the ECG is improperly connected, turned off, or improperly
calibrated.

Possible Causes:
♦ Severe metabolic deficit
♦ Acute respiratory failure
♦ Extensive myocardial damage or ruptured ventricular aneurysm

ECG Criteria:
1. Heart Rate: None Nursing Tip: Assess
2. Rhythm: None your patient! Treat
3. P waves: None the patient and not
4. PR Interval: None the monitor!!
5. QRS Width: None

Nursing Priorities:
Check rhythm in a second lead (make sure a lead has not fallen off). If your patient has a
pulse, they are obviously NOT in asystole. If the patient is pulseless, initiate CPR and call for
help

Potential Treatments:
Continue CPR and secure airway and IV access. Search for possible causes. Implement
medication therapy per ACLS guidelines.

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 Section 14: Types of ECG Recording Interference
Because the complexes seen on the ECG recording are a reflection of electrical activity,
other interfering factors can distort the quality of the tracing. The term artifact is used when
an ECG recording is distorted by non-cardiac factors. Common causes of interference or
artifact include:
♦ Muscle movement, shivering or seizure activity
♦ Loose electrodes
♦ Patient movement
♦ 60 cycle interference (the influence of other equipment in the room which is
improperly grounded)

60 cycle Interference

Patient Movement

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 Conclusion
This module has taught the anatomy, physiology, and basic electrophysiologic knowledge
needed to understand basic ECG interpretation. A six-step process of rhythm identification
has been taught as a framework for the interpretation of rhythms originating in the sinus,
junctional, ventricular areas. Heart blocks and life threatening rhythms have also been
discussed. Beyond interpretation, all rhythms include nursing priorities and potential
treatment strategies.

Every attempt has been made to provide information that is consistent with current literature
including the American Heart Association guidelines. Mastery of this complex topic requires
several months to years of practice in the clinical setting. Many first time learners need to re-
review sections of this module as their learning develops and when new questions arise.

For further information, the following web sites offer you the opportunity to practice ECGs
with strips from their websites. Keep in mind that with ECG interpretation “practice, practice,
practice” is key to making this information “stick.”

University of Utah-School of Medicine.

Alan E. Lindsay ECG Learning Center
http://medstat.med.utah.edu/kw/ecg/ecg_outline

ECG Library
Jenkins, J & Gerrend, S. (2002)
http://www.ecglibrary.com/ecghome.html

www.ecglibrary.com

www.americanheart.org

Please Read:
This publication is intended solely for the use of healthcare professionals taking this course, for credit, from
RN.com. It is designed to assist healthcare professionals, including nurses, in addressing many issues
associated with healthcare. The guidance provided in this publication is general in nature, and is not designed
to address any specific situation. This publication in no way absolves facilities of their responsibility for the
appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a
part of their own orientation processes should review the contents of this publication to ensure accuracy and
compliance before using this publication. Hospitals and facilities that use this publication agree to defend and
indemnify, and shall hold RN.com, including its parent(s), subsidiaries, affiliates, officers/directors, and
employees from liability resulting from the use of this publication. The contents of this publication may not be
reproduced without written permission from RN.com.

57
 Practice Rhythm Strips
The following rhythm strips are for your practice. The answers are on the following page.
We suggest you practice with these prior to taking the post test. (All strips are six-second
strips unless otherwise indicated.)

Rhythm Strip #1
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #2
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #3
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #4
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

58
 Rhythm Strip #5
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #6
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #7
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #8
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval:__________
QRS Width: __________
Interpretation: ________
The strip below is approximately 4 seconds long

Rhythm Strip #9
APPROX. 4 SECOND STRIP
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

59
 Rhythm Strip #10
ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #11

ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #12

ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #13

ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

Rhythm Strip #14

ECG Criteria:
Heart Rate: __________
Rhythm: _____________
P waves: ____________
PR Interval: __________
QRS Width: __________
Interpretation: ________

60
 Practice Rhythm Strips Answer Key

Rhythm Strip #1: Normal Sinus Rhythm with 1st degree AV block

Rhythm Strip #2: Sinus Tachycardia (rate 102, so if you put sinus rhythm you were very close)

Rhythm Strip #3: Sinus Bradycardia with ventricular bigeminy (unifocal)

Rhythm Strip #4: Controlled Atrial Flutter

Rhythm Strip #5: 2nd degree Heart Block – Mobitz II

Rhythm Strip #6: Uncontrolled Atrial Fibrillation

Rhythm Strip #7: 2nd degree Heart Block – Mobitz I - Wenckebach

Rhythm Strip #8: Complete Heart Block

Rhythm Strip #9: Ventricular Tachycardia

Rhythm Strip #10: Sinus Rhythm into Ventricular Tachycardia into Ventricular Fibrillation

Rhythm Strip #11: Asystole

Rhythm Strip #12: Sinus Rhythm with 1st degree Heart Block

Rhythm Strip #13: Sinus Rhythm with ventricular couplet and then 4 beat run of V-Tach

Rhythm Strip #14: Sinus Bradycardia

61
 Resources
Aehlert, B. (2005). ECGs Made Easy (3nd Ed). St. Louis, MO: Mosby.

Advanced Cardiovascular Life Support: www.americanheart.org/cpr

American Heart Association. Guidelines 2006 CPR and ECC. Philadelphia: Lippincott,
Williams & Wilkins.

Conover, M. (2003). Understanding Electrocardiography (8th Ed). Mosby, St. Louis.

Dubin, D. (2000). Rapid ECG Interpretation (6th Ed). Tampa, Florida: Cover Publishing.

Gertsch, M. (2004). ECG: A Two-step Approach to Diagnosis. Springer Verlag, New York.

Houghton, A., & Gray, D. (2003). Making Sense of the ECG. Edward Arnold, London.

Huff, J. (2006). ECG Workout (5th Ed). Lippincott, Williams & Wilkins; Philadelphia.

Kastor, J. (2000). Arrhythmias (2nd Ed). Philadelphia: W.B. Saunders.

McCann, J.A. (2007) ACLS review made incredibly easy. Lippincott, Williams & Wilkins:
Philadelphia.

© 2002 AMN Healthcare, Inc.

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 Appendix - Bundle Branch Blocks
In the healthy heart, the right bundle branch quickly conducts the stimulus of depolarization to
the right ventricle and the left bundle branch conducts to the left ventricle. The depolarization
stimulus is nearly simultaneous and conduction to both ventricles occurs at nearly the same
time. This simultaneous conduction is recorded in a QRS complex that is ≤ .12 seconds.

A block in one of the bundle branches produces a delay of depolarization to its ventricle. The
unblocked bundle branch will depolarize before the blocked side. Since the blocked bundle
branch can no longer conduct an impulse, this ventricle must depolarize in a slower, cell-to-
cell method (the ventricle does eventually depolarize, but the cell-to-cell method is less
efficient and slower). Due to this slowed process, the QRS width is greater than .12 seconds
in the setting of a bundle branch block. Some physicians and nurses call the widened QRS
an “intraventricular conduction delay (IVCD)” which is a term used interchangeably with the
term “bundle branch block.”

Characteristics of the QRS may vary a bit. Have you ever heard the saying “rabbit ears”? As
you know, the widened QRS represents the non-simultaneous depolarization of both
ventricles. The ECG might record this delay with one wide R wave or with two separate R
waves. Two separate R waves might be called “rabbit ears” as they resemble two pointed
ears on a rabbit head. The two separate R waves are really just a recording of the left and
right ventricles depolarizing at different times.

If the right bundle is blocked, it is termed a Right Bundle Branch Block. If the left bundle is
blocked, it is called a Left Bundle Branch Block. Bundle branch blocks (BBB) are reflective
of damage to one of the bundles. It is most often associated with coronary artery disease.
Once a person develops a widened QRS, they are likely to keep this for life. Most BBB are
stable and often do not require treatment other than observation and measurement of the
QRS width. Notify the MD if the width is increasing. In the setting of an acute MI, a new
bundle branch block (or widening QRS) may reflect newly damaged myocardium and the
potential need for a temporary pacemaker.

Caution… Do not let the wide QRS fool you for ventricular ectopy. The person with a BBB
will have a P wave before the widened beat AND the QRS width will always be wide. The
person with ventricular ectopy will not have a P wave preceding the widened beat and only
the ectopic beats will be >.12 seconds.

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 Post Test Viewing Instructions

In order to view the post test you may need to minimize this window and click “TAKE TEST.”
You can then restore the window in order to review the course material if needed.

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