ECG PUZZLER

A new feature of the American Journal of Critical Care, the ECG Puzzler addresses ECG interpretation for clinical practice. We welcome letters to
the Editors regarding this feature.

INVERTED P WAVES
Michele M. Pelter, RN, PhD, and Mary G. Adams, RN, MS. From the Department of Physiological Nursing,
University of California, San Francisco, Calif.

Scenario: The patient is a 52-year-old woman
who presents to her physician’s office with complaints
of general malaise and a low-grade fever. The patient
presented to an acute care clinic 3 weeks prior for a
sore throat, which was diagnosed as strep throat
(streptococcal pharyngitis). Appropriately, she was
started on oral penicillin but admitted to not finishing
the prescription since she “felt better after 4 days of
taking the antibiotic.”

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Examine this ECG and the following 9 fea- 5. QRS complex duration in lead V1
tures, and check all that apply: ❏ Normal (≤0.12 seconds)
❏ Wide (>0.12 seconds)
1. Rate
❏ Normal (60-90 beats per minute) 6. QRS complex morphology in lead V1
❏ Bradycardia (<60 beats per minute) ❏ Negative and ≤0.12 seconds (normal)
❏ Tachycardia (>90 beats per minute) ❏ Negative and >0.12 seconds (left bundle branch
block)
2. Rhythm
❏ Regular ❏ Positive and >0.12 seconds (right bundle branch
❏ Irregular block)
❏ Irregular-regular
❏ Irregular-irregular 7. ST segment
❏ Normal
3. P waves ❏ Elevated (≥2 mm)
❏ One P wave for every QRS complex ❏ Depressed (≥2 mm)
❏ Too many
❏ Missing 8. T Wave
❏ Inverted (opposite direction as QRS complex
❏ Normal
using lead II)
❏ Inverted
4. PR interval
❏ Normal (≤0.20 seconds) 9. QTc
❏ Short (<0.08 seconds) ❏ Normal for this heart rate
❏ Lengthened (>0.20 seconds) ❏ Lengthened (>0.47 seconds)

AMERICAN JOURNAL OF CRITICAL CARE, March 2002, Volume 11, No. 2 173

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 I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

ANSWER 5. QRS complex duration in lead V1

1. Rate x Normal (≤0.12 seconds)
❏
x Normal (60-90 beats per minute)
❏ ❏ Wide (>0.12 seconds)
❏ Bradycardia (<60 beats per minute)
❏ Tachycardia (>90 beats per minute)
6. QRS complex direction lead V1
x Negative and ≤0.12 seconds (normal)
❏
2. Rhythm
x
❏ Regular ❏ Negative and >0.12 seconds(leftbundlebranch block)
❏ Irregular ❏ Positive and >0.12 seconds(leftbundlebranch block)
❏ Irregular-regular
❏ Irregular-irregular 7. ST segment
x Normal
❏
3. P waves ❏ Elevated (≥2 mm)
x
❏ One P wave for every QRS complex ❏ Depressed (≥2 mm)
❏ Too many
❏ Missing 8. T Wave
x
❏ Inverted (opposite direction as QRS complex using x Normal
❏
lead II)
❏ Inverted
4. PR interval
❏ Normal (<0.20 seconds) 9. QTc
x Short (<0.12 seconds)
❏ x Normal for this heart rate
❏
❏ Lengthened (>0.20 seconds) ❏ Lengthened (>0.47 seconds)

Interpretation: Nonparoxysmal junctional The causes of nonparoxysmal junctional tachycar-

tachycardia at 65 bpm.
Rationale: Nonparoxysmal (gradual-onset) junc-
tional tachycardia is a supraventricular rhythm with
narrow QRS complexes and a regular rate, usually
between 60-140 bpm. The distinguishing feature of
this ECG is retrograde conduction of the atrium caus-
ing an inverted P wave, best observed in lead II. In
this case, the P waves are also inverted in multiple
leads (III, aVF, V3 through V6). Although lead V1, a
commonly selected monitoring lead, is not helpful for
observing retrograde P-wave conduction, the PR
interval is short (0.10 seconds), which suggests a
junctional rhythm.
dia include underlying heart disease such as inferior
myocardial infarction, myocarditis as a result of rheu-
matic fever, or after open heart surgery. In addition, an
important cause of nonparoxysmal junctional tachy-
cardia is digitalis toxicity. Given this patient’s sce-
nario, which included a recent streptococcal infection,
myocarditis is a likely cause of this rhythm.
Nursing Actions to Consider
This ECG rhythm is regular, and cardiovascular
status in not compromised. However, given the diag-
nosis of rheumatic fever causing the myocarditis, this
patient should be admitted to the hospital for bed rest,
anti-inflammatory agents, and antibiotic therapy.

174 AMERICAN JOURNAL OF CRITICAL CARE, March 2002, Volume 11, No. 2

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Inverted P Waves
Michele M. Pelter and Mary G. Adams
Am J Crit Care 2002;11 173-174
Copyright © 2002 by the American Association of Critical-Care Nurses
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