BASIC ELECTROCARDIOGRAPHY

INTERPRETATION AND MANAGEMENT

THE ECG waveforms P, QRS, and T

THE ECG segments and intervals PR interval,

QRS duration, ST segment, QT interval.

VARIOUS QRS
CONFIGURATIONS

RATE MEASUREMENT

The horizontal axis represents time. The vertical axis

represents amplitude or voltage
1. Six-second method
a. Most ECG paper in use today is printed with 1-sec or 3-sec
markers on the top or bottom of the paper
b. To determine the ventricular rate, count the number of R-R
intervals within a period of 6 seconds and multiply that number
by 10 to find the number of complexes in 1 minute

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Method 1:

Method 2:
Small
boxes

Calculating heart rate. Method 1: Number of R-R intervals

in 6 seconds x 10 (e.g., 8 x 10 = 80/min. Method 2: Number of
large boxes between QRS complexes divided into 300 (e.g., 300
divided by 4 = 75/min). Method 3: Number of small boxes
between QRS complexes divided into 1500 (e.g., 1500 divided by
18 = 84/min

MONITORING AND LEAD

PLACEMENT

Hardwire monitoring
TYPES OF INTERFERENCE

Muscle Tremors

Patient Movement

TYPES OF INTERFERENCE

Loose Electrode

60-Cycle Interference

Straight Line

Loss of reception Bio-Telemetric Interference

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CHARACTERISTICS OF SINUS RHYTHM

Rate
60 to 100 beats/min
Rhythm
Regular
P waves
Uniform in appearance, positive (upright) in lead II, one
precedes
each QRS complex
PR interval
0.12 to 0.20 sec and constant from beat to beat
QRS duration
.10 sec or less

Sinus rhythm at 70 beats/min

SINUS BRADYCARDIA

Rate
54 beats/minute
Rhythm
Regular
P waves
Sinus
PR interval
0.20 second
QRS duration 0.06 to 0.08 second
Note
A notched P wave is usually indicative of left
atrial
hypertrophy

CHARACTERISTICS OF SINUS
TACHYCARDIA

Rate
101 TO 180 beats/min
Rhythm
Regular
P waves
Uniform in appearance, positive (upright) in lead II, one
precedes
each QRS complex; at very fast rates, it may be difficult
to
distinguish a P wave from a T wave
PR interval
0.12 to 0.20 sec and constant from beat to beat
QRS duration 0.10 sec or less

Sinus tachycardia at 129 beats/min

SINUS ARRHYTHMIA
Rate
60 beats/min
Rhythm
irregular
P waves
Normal in configuration; precede each QRS
PR interval
0.12 to 0.14 second
QRS duration 0.06 to 0.08 second

NORMAL SINUS RHYTHM WITH SINUS

ARREST
R-R regularity
R-R
REGULARIT
Y
INTERRRUP
TED;
rhythm
does not
resume on
time after
pause

Rate
Basic rhythm 94 beats/minute
Rhythm
Basic rhythm regular, irregular during pause
P waves
Normal in normal in basic rhythm; absent during pause
PR interval
0.16 to 0.18 second in basic rhythm; absent during
pause
QRS duration 0.06 to 0.08 second in basic rhythm; absent during
pause

NORMAL SINUS RHYTHM WITH SINUS

BLOCK

Rate
Basic rhythm 84 beats/minute
Rhythm
Basic rhythm regular, irregular during pause
P waves
Normal in normal in basic rhythm; absent during pause
PR interval
0.16 to 0.18 second in basic rhythm; absent during
pause
QRS duration 0.08 to 0.10 second in basic rhythm; absent during
pause
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JUNCTIONAL RHYTHM
Rhythm
Rate:
P waves
PR interval
QRS complex:

: Regular
: 50 beats/minute
: Hidden in QRS complex
: Not measurable
:Normal 0.06 to 0.08 second

JUNCTIONAL TACHYCARDIA
Rhythm
Rate:
P waves
PR interval
QRS complex:

: Regular
: 65 beats/minute
: Hidden in QRS complex
: Not measurable
:Normal 0.06 to 0.08 second

CHARACTERISTICS OF ATRIAL FLUTTER

Rate
ventricular
will
conduction
Rhythm

Atrial rate 250 to 450 beats/min, typically 300 beats/min;

rate variable --- determined by Av blockage; the ventricular rate
usually not exceed 180 beats/min because of the intrinsic
rate of the AV junction.
Atrial regular, ventricular regular or irregular depending on AV
conduction/blockage
P waves
No identifiable P waves; saw-toothed flutter waves are present
PR interval
Not measurable
QRS duration Usually less than 0.10 sec but may be widened if flutter waves
are
buried in the QRS complex or an intraventricular conduction
delay
exists

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CHARACTERISTICS OF ATRIAL
FIBRILLATION

Rate
Atrial rate usually greater than 400-600 beats/min;
ventricular rate
variable
Rhythm
Ventricular rhythm usually irregularly irregular
P waves
No identifiable P waves; fibrillatory waves present.
Erratic,
wavy baseline
PR interval
Not measurable
QRS duration Usually less than 0.10 second but may be widened if
an
intraventricular conduction delay exists

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CHARACTERISTICS OF FIRST-DEGREE AV
BLOCK

Rate
Usually within normal range but depends on underlying
rhythm
Rhythm
Regular
P waves
Normal in size and shape; one positive (upright) P wave
before
each QRS in leads II, III, and aVF
PR interval
Prolonged (greater than 0.20 sec) but constant
QRS duration Usually 0.10 sec or less unless an intraventricular
conduction
delay exists

CHARACTERISTICS OF FIRST-DEGREE AV
BLOCK
The AV node holds each sinus impulse longer than normal
before conducting if through to ventricles. Each impulse is
eventually conducted . Once into the ventricles, conduction
proceeds normally.

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FIRST DEGREE AV BLOCK

Rhythm interpretation:
Usually regular
Rate:
That of underlying sinus rhythm; atrial and ventricular
rates
will be the same
P waves:
Sinus; one P wave to each QRS complex
PR interval:
Prolonged (greater than 0.20 second
QRS complex:
Normal (0.10 second or less)

SECOND-DEGREE AV BLOCK (MOBITZ I)

Rhythm interpretation:
Atrial:
Regular
Ventricular:
Irregular
Rate:
Atrial:
That of underlying rhythm
Ventricular:
Depends on number of impulses
conducted though AV node;
less than atrial rate
P waves:
Sinus origin
PR interval:
Varies; progressively lengthens until a P
wave is not
conducted (P wave occurs
without a QRS complex); a pause
follows the dropped QRS
complex
QRS complex:
Normal (0.10 second or less)

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SECOND-DEGREE AV BLOCK (MOBITZ II)

Rhythm interpretation:
Atrial:
Ventricular:
Rate:
Atrial:
Ventricular:
P waves:
PR interval:
QRS complex:
block in bundle

Regular
Usually regular but may be irregular if AV conduction ratios vary
That of the underlying rhythm
Depends on number of impulses conducted though AV node;
less than atrial rate
Sinus; two or three P waves (sometimes more) before each QRS
complex
May be normal or prolonged; remains constant
Normal is block at AV node or bundle of His; wide if
branches

THIRD-DEGREE AV BLOCK (COMPLETE HEART

Rhythm interpretation:
BLOCK)
Atrial:
Regular
Ventricular: Regular

Rate:
Atrial:
That of the underlying rhythm
Ventricular: 40 to 60 beats/minute if paced AV junction; less than 40
beats/minute of paced by ventricles; ventricular rate
less than atrial rate
P waves:
Sinus P waves present with no constant relationship to QRS
complex (P waves found marching through QRS
complexes and T waves)
PR interval:
Varies greatly
QRS complex:
Normal if block at AV node or bundle of His; wide if
block in bundle
branches

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PACEMAKERS

100% Ventricular-paced rhythm

Atrial pacing

Ventricular pacing

AV sequential pacing

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CHARACTERISTIC OF PREMATURE VENTRICULAR

COMPLEXES (PVCs)
Rate
Rhythm
interpolated
P waves

Usually within normal range but depends on underlying rhythm

Essentially regular with premature beats; if the PVC is an
PVC, the rhythm will be regular
Usually absent or, with retrograde conduction to the atria, may
appear
after the QRS (usually upright in the ST-segment of T

wave)
PR interval
None with the PVC because the ectopic originates in the
ventricles
QRS duration
Greater than 0.12 sec, wide and bizarre, T wave
frequently in
opposite
direction of the QRS complex

Sinus tachycardia with frequent uniform PVCs

Sinus tachycardia with multiform PVCs

Sinus rhythm with a run of VT and one episode of couplets

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CHARACTERISTICS OF MONOMORPHIC
VENTRICULAR TACHYCARDIA
Rate
Rhythm
P waves

101 to beats/min
Essentially regular
May be present or absent; if present, they have no set
relationship to the QRS complexes appearing between
the
QRSs at a rate different from that of the VT
PR interval
None
QRS duration Greater than 0.12 sec, often difficult to differentiate
between
the QRS and T wave

Polymorphic Ventricular Tachycardia or Torsades de pointes

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CHARACTERISTIC OF VENTRICULAR
FIBRILLATION (VF)
Rate
waves or

Cannot be determined because there are no discernible

complexes to measure
Rhythm
Rapid and chaotic with no pattern or regularly
P waves Not discernible
PR interval
Not discernible
QRS
Not discernible

Fine VF

COARSE
VF

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