Rhythm Packet
Normal ECG Criteria
Part Time (sec.) Description Abnormal
P wave < 0.10 Atrial depolarization Atrial hypertrophy: amplitude
or width
PR Interval 0.12-0.20 Time required for atrial Diseased AV node
depolarization and conduction Ischemia
through AV node Drug effects
Vagal tone
QRS Complex 0.06-0.10 Entire ventricular depolarization Intraventicular conduction
Atrial repolarization occurs, but is delays
obstructed by QRS WPW syndrome
Hyperkalemia
ST Segment Isoelectric Initial ventricular repolarization Hypocalcemia; prolonged
Pericarditis, injury, infarction;
elevated
Subendocardial injury or
ischemia, electrolyte
disturbances, drugs;
depressed
T Wave Ventricular repolarization Infarctions, ischemia, injury,
hypertrophy; inverted
Hyperkalemia, acute injury; tall-
peaked
QT Interval Corrected for Ventricular depolarization and Ischemia, electrolyte
heart rate repolarization imbalances, hypertrophy,
< 0.44 males antiarrhythmic drugs;
< 0.45 prolonged
females Acute ischemia, hypercalcemia,
drugs; shortened
Lead Selection
Leads with ECG Injury/Infarct Related Area of Damage Associated Complications
Changes Artery
V1-V2 Left coronary artery: left Septum, His Infranodal block and bundle branch
anterior descending bundle, bundle blocks
septal branch branches
V3-V4 Left coronary artery: left Anterior Left ventricle dysfunction, CHF, bundle
anterior descending branch blocks, complete heart block,
diagonal branch PVCs, ventricular septum rupture
V5-V6, I, aVL Left coronary artery: High lateral Left ventricle dysfunction, AV nodal
circumflex branch block in some
II, III, aVF Right coronary artery: Inferior, Posterior Conduction disturbances; if hypotension
posterior descending occurs, suspect right ventricular MI
branch
V1-V4 Either left coronary artery Posterior wall Left ventricular dysfunction
– circumflex OR right
coronary after – posterior
descending branch
V4 right (II, III, Right coronary artery: Right ventricle, Usually accompanies inferior MI,
aVF) proximal branches inferior and hypotension, sensitivity to nitroglycerin
posterior wall left and morphine sulfate, jugular venous
ventricle distension with clear lung fields
supranodal and AV nodal blocks, atrial
fibrillation/flutter, PACs
Sinus Rhythm
Rate: 60 to 100
P waves: Precede each QRS
PR Interval: Normal, 0.12-0.20
QRS Complex: Usually normal, 0.40-0.10
Conduction Conduction through atria, AV node,
and ventricles is normal
Rhythm: Regular
Causes: Normal
Treatment: Usually nothing
Sinus Bradycardia
Rate: 40-60
P waves: Precede each QRS,
PR Interval: Usually normal
QRS Wave: Usually normal
Conduction Usually normal
Rhythm: Regular
Causes: Vagal stimulation
Hypoxia
Reduced cardiac output
Drugs
Treatment: Determine if symptomatic or normal
If symptomatic give Atropine, if
ineffective consider
Transcutaneous Pacing
Dopamine infusion
Epinephrine infusion
Consider expert consultation and
transvenous pacing
Sinus Tachycardia
Rate: 100-150
P waves: Precede each QRS. May be buried
in the preceding T wave.
PR Interval: Usually normal
QRS Complex: Usually normal
Conduction Usually normal
Rhythm: Regular
Causes: Pain
Sympathetic stimulation
Cardiac
Noncardiac
Drugs
Treatment: Treat underlying cause
Calcium channel blockers
Beta blockers
SR First Degree AV Block
Rate: 60-100 minute
P waves: Precede each QRS
PR Interval: > 0.20 seconds and constant
QRS Complex: Usually normal
Conduction: Prolonged through AV node, usually
normal through bundle branches
Rhythm: Usually regular, rate may be variable
Causes: Drugs that slow conduction (digitalis)
Ischemia, MI
Increase parasympathetic tone
Treatment: Usually none
Watch for further block
SR Second Degree AV Block Type 1
SR Second Degree AV Block
Type 1 (Wenckebach)
Rate: 60-100 minute
P waves: Precede each QRS, until an atrial
impulse is blocked.
PR Interval: Progressively longer until a P wave
fails to conduct.
QRS Complex: Usually normal
Conduction: Progressive increase in conduction
time through the AV node until an
atrial impulse is blocked
Rhythm: “Group beating” appearance
Causes: MI, drugs, Post CABD, electrolyte
imbalance
Treatment: Monitor, usually temporary. Treat if
symptomatic
SR Second Degree AV Block Type 2
SR Second Degree AV Block
Type II
Rate: 30-55
P waves: Precede each QRS until sudden
blockage of atrial beat.
PR Interval: May be prolonged, constant
QRS Complex: May be prolonged if also bundle
branch block
Conduction: Consistent conduction times through
the AV node until an atrial impulse is
blocked.
Frequently associated with a bundle
branch block.
Rhythm: Irregular
Causes: Indicates pathology below the AV
node.
MI, ischemia, coronary artery
disease, cardiomyopathy
Treatment: Pacemaker, atropine
Third Degree AV Block
Complete Heart Block
Rate: Usually less than 40
P waves: Regular P-P interval, no correlation
to QRS.
PR Interval: Non-existent
QRS Complex: Regular R-R interval, no correlation
to P waves. May be wide.
Conduction: Normal through atria, all impulses
blocked at the AV node, no
conduction to ventricles. May be
wide, especially if ventricular escape
rhythm.
Rhythm: May appear regular
Causes: MI; poor prognosis if anterior MI,
damage or ischemia to AV node or
bundle branches; drugs
Treatment: If symptomatic. Atropine will be
ineffective as it will speed up the
atrial rate, but still no conduction to
the ventricles. Need a pacemaker.
Bundle Branch Block
Rate: Usually normal
P waves: Usually normal
PR Interval: Usually normal
QRS Wide due to the activation of one
complex: ventricle before the other. _ The
blocked ventricle spreads the
impulse cell to cell and is slower.
Conduction: Delay of excitation to one ventricle
- I
Rhythm: Usually regular
Causes: CAD/MI, scarring of conduction
system, trauma, cardiomyopathy,
severe aortic stenosis.
R·ight: V1: rS·R'
V6: qRS
Left: V1: rS or QS
V6, AVL,· I·: slurred·-- notched··R· wave
Treatment If symptomatic, pacemaker
Atrial Flutter
Rate: Atrial rate 250-350, ventricular rate is
2:1 to 4:1.
P waves: Saw tooth, picket fence patterns.
PR Interval: Unable to measure.
QRS Complex: Usually normal.
Conduction: Normal through ventricles, impulses
blocked through AV node.
Rhythm: Regular or irregular.
Causes: Heart disease, acute cor pulmonale,
heart failure, MI.
Treatment: Treat underlying cause.
Synchronized cardioversion, beta
blockers, calcium channel blockers.
Consider expert consultation.
Atrial Fibrillation
Rate: Atrial rate 350-600, ventricular rate
120-200
P waves: Difficult to detect
PR Interval: Unable to measure
QRS Complex: Usually normal
Conduction: Normal through the ventricles.
Circular reentry of impulses in the
atria.
Rhythm: Irregular
Causes: Heart failure, heart disease, acute
cor pulmonale.
Treatment: Need to treat because rapid
ventricular response leads to
decrease ventricular filling time.
Loss of atrial kick (25-30%) of
cardiac output.
Synchronized cardioversion, vagal
maneuvers, treat underlying cause.
beta blockers, calcium channel
blockers.
Consider expert consultation.
Supraventricular Tachycardia
Rate: 150-250
P waves: Variable
PR Interval: Variable
QRS Complex: Usually normal
Conduction: Normal from AV node to ventricles.
Rhythm originates from above the
bundle of His.
Rhythm: Regular or Irregular
Causes: Digitalis toxicity, pulmonary disease,
emotions, tobacco, caffeine, alcohol
Treatment: Vagal maneuvers, synchronized
cardioversion, beta blockers, calcium
channel blockers.
If regular, consider adenosine
Consider expert consultation
Junctional Escape
Rate: 40-60
P waves: May be inverted and occur before,
during, or after the QRS.
PR Interval: If P wave occurs before the QRS,
the interval is shortened.
QRS Complex: Usually normal
Conduction: Occurs when SA node fails to fire
and junctional fibers take over as the
pacemaker.
Rhythm: Regular
Causes: Digitalis toxicity, inferior MI, ischemic
SA node.
Treatment: If symptomatic, pacing. Treat
underlying cause.
Consider expert consultation.
Ventricular Tachycardia
Rate: 100-200
P waves: Usually buried in the QRS
PR Interval: Non-existent
QRS Complex: Wide, bizarre, T wave in opposite
direction.
Conduction: Originates in the ventricle, with
possible retrograde conduction to the
junction and atria.
Rhythm: Regular or irregular
Causes: Heart disease, myocardial irritability
Treatment: Defibrillation, CPR if no pulse,
amiodarone, epinephrine,
vasopressin, treat reversible causes.
If pulse consider antiarrhythmic
drugs and/or infusion and expert
consultation
Torsades de Pointe
Rate: 100-200
P waves: Usually buried in the QRS
PR Interval: Non-existent
QRS Complex: Wide, bizarre, T wave in opposite
direction, twisting of the points.
Conduction: Originates in the ventricle, with
possible retrograde conduction to the
junction and atria.
Rhythm: Regular or irregular
Causes: Uneven delay in ventricular
repolarization, prolonged QT, drugs,
electrolyte imbalances.
Treatment: Defibrillation, drugs that shorted the
refractory period, CPR, Magnesium
Sulfate.
Treat reversible causes.
Ventricular Fibrillation
Rate: Rapid
P waves: None
PR Interval: None
QRS Complex: Coarse, quivering pattern
Conduction: Originates in the ventricle from
multiple foci, with no organized
conduction
Rhythm: Irregular
Causes: Heart disease, myocardial irritability
Treatment: Defibrillation, CPR, amiodarone,
epinephrine, vasopressin, treat
reversible causes
Ventricular Escape
Rate: 20-40
P waves: None
PR Interval: Non existent
QRS Complex: Wide, bizarre, T wave in opposite
direction
Conduction: Ventricles take over as primary
pacemaker
Rhythm: Regular or irregular
Causes: Heart disease, bundle branch blocks
Treatment: CPR, Epinephrine, Vasopressin
Treat underlying cause
Asystole
Rate: None
P waves: None
PR Interval: None
QRS Complex: None
Conduction: None
Rhythm: None
Causes: Cessation of mechanical and
electrical activity of the heart.
Treatment: CPR, Epinephrine, Vasopressin
Treat underlying cause
