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ECG review – ACLS Program Ohio State University Medical Center

Rhythm ECG Characteristics Example

Normal Sinus Rhythm Rate: 60-100 per minute


Rhythm: R- R =
(NSR)
P waves: Upright, similar
P-R: 0.12 -0 .20 second
& consistent
qRs: 0.04 – 0.10 second
P:qRs: 1P:1qRs

Sinus Tachycardia Rate: > 100


Causes: Rhythm: R- R =
Exercise P waves: Upright, similar
Hypovolemia P-R: 0.12 -0 .20 second
Medications & consistent
Fever qRs: 0.04 – 0.10 second
Hypoxia P:qRs: 1P:1qRs
Substances
Anxiety, Fear
Acute MI
Fight or Flight
Congestive Heart Failure

Sinus Bradycardia Rate: < 60


Causes: Rhythm: R- R =
intrinsic sinus node P waves: Upright; similar
disease P-R: 0.12 -0 .20 second
increased & consistent
parasympathetic tone qRs: 0.04 – 0.10 second
drug effect. P:qRs: 1P:1qRs

Published by: Department of Educational Development and Resources, OSU Medical Center 1
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Premature Atrial Rate: usually < 100,


Contractions (PAC) dependant
On underlying rhythm
♦ ♦ ♦
Causes:
Rhythm: irregular
normal
P waves: Early & upright,
excessive use of caffeine,
different from Sinus
tobacco, or alcohol
CHF
PR: 0.12 – 0.20 second;
different from Sinus
PAC = ♦
Myocardial ischemia or
qRs: 0.04 – 0.10 second
injury
P:qRs = 1:1
Hypokalemia, Dig
toxicity
COPD

Atrial Flutter Rate: Atrial rate 250-350


Causes: Vent 150 common
ischemic heart disease Rhythm: Atrial = Regular
Hypoxia Vent = Reg. or irreg
Acute MI P waves: Not identifiable
Dig Toxicity F waves: Uniform (sawtooth
Mitral or Tricuspid valve or picket fence )
disease PRI: not measurable
Pulmonary embolism qRs: 0.04 – 0.10 second

Atrial Fibrillation Rate: Atrial: 400-700


Ischemic heart disease Vent. 160-180/minute
Hypoxia Rhythm: Atrial: irregular;
Acute MI Vent.: irregular
Digitalis toxicity P waves: No identifiable Ps
Mitral or tricuspid f waves: may be seen.
disease PRI: unable to measure
(No identifiable P)
qRs: usually normal

Published by: Department of Educational Development and Resources, OSU Medical Center 2
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Paroxysmal Atrial Rate: usually 160-220


Rhythm: Regular
Tachycardia
P waves: differ in shape from
Causes:
Sinus Ps; usually difficult
Same as PACs
to identify (rate related)
PR Interval: Normal when the Ps
can be identified;
short if WPW present
qRs: usually normal
Other: Onset sudden, often
initiated by a PAC

Premature Junctional Rate: usually < 100,


dependant on the
Contraction (PJC)
underlying rhythm
Causes:
Rhythm: irregular
Same as PACs
P waves: Inverted before or after
qRs or not visible
PR interval: < 0.12 second when
inverted P is before
qRs
qRs: 0.04 – 0.10 second
P:qRs = 1:1 if Ps are visible

Published by: Department of Educational Development and Resources, OSU Medical Center 3
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Junctional escape Rate: 40-60


61 – 100 (accelerated)
Rhythm
Rhythm: Regular
Causes:
P waves: Inverted before or after
healthy athlete at rest
qRs or not visible
related to medications-
PR interval: < 0.12 second when
Beta Blockers, Calcium
inverted P is before
Channel Blockers, Dig
qRs
Toxicity
qRs: 0.04 – 0.10 second
or increased
P:qRs 1:1 if Ps are visible
parasympathetic tone
Acute Inferior Wall MI
Rheumatic Heart Disease
Post-Cardiac Surgery
Valvular Disease
SA Node Disease
Hypoxia

Junctional Tachycardia Rate: 101-200


Causes:
Same as Paroxysmal Same as Junctional Escape
Atrial Tachycardia (PAT) Rhythms.

Supraventricular Rhythm: Absolutely regular


Tachycardia (SVT) Rate: > 150 per minute
P Waves: Not visible
An umrella term used
(PRI not measurable)
when unable to qRs: normal 0.04 – 0.10 sec
distinguish which
rhythm is present.
Causes:
Same as Sinus, Atrial, and
Junctional Tachycardia, and Atrial
Flutter

Published by: Department of Educational Development and Resources, OSU Medical Center 4
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Premature Ventricular Rate: Dependent upon


underlying rhythm
Complex (PVC)
Rhythm: R – R ≠
Causes:
Gastric overload P waves: Usually absent, if
PVC PVC
present, not associated
Stress
Caffeine, Alcohol, with PVC
Nicotine qRs: 0.12 second or greater;
Heart Disease bizarre and notched
Acid-Base Imbalance ST & T: Often opposite in
Electrolyte Imbalance direction to the qRs.
Cyclic Antidepressants Timing
Hypoxia One on a strip = Rare
Acidosis One in a row = Isolated
Acute MI Two in a row = Pair, couplet
Three in a row = V Tachycardia
Pattern
Every other = Bigeminy
Every third = Trigeminy
Morphology
Similar shape = Uniformed
Different shape = Multiformed
Location
R – on – T = PVC falls on the T
wave of the complex before the
PVC

Published by: Department of Educational Development and Resources, OSU Medical Center 5
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Ventricular Rate: > 100 per minute and


usually not > 220
Tachycardia
Rhythm: Usually regular
Causes:
P Waves: ∅ P waves or if
Same as PVCs
present, not
R on T Phenomenon
associated with qRs
qRs: Wide (≥ 0.12 sec),
bizarre
ST/T wave: Opposite direction
of qRs

A group of three PVCs in a row or


more at a rate greater than 100/
minute or more constitutes
Ventricular Tachycardia.

Ventricular Fibrillation Rate: ∅


Causes: Rhythm: ∅ regularity,
Acute Myocardial chaotic undulating
Infarction waves
Untreated Ventricular P Waves: ∅
Tachycardia qRs: ∅
Hypothermia ST/T Wave: ∅
R-on-T PVCs Organized activity: ∅
Electrolyte imbalance
Electrical shock No Cardiac Output or Pulse

Published by: Department of Educational Development and Resources, OSU Medical Center 6
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

Idioventricular Rate: 20-40 per minute


Rhythm: R – R =
Rhythm
P waves: No P waves associated
Causes:
to qRs
Myocardial Infarction
qRs: > 0.12 sec, notched,
Digitalis toxicity
bizarre appearance
Metabolic imbalances
ST/T : Opposite direction of qRs
Post resuscitation rhythm

Rate > 40 to 100 = Accelerated

Asystole Rate: Ventricular rate = 0


Causes: Rhythm: ∅ unless Ps are present,
Extensive myocardial then regular or irregular
damage P waves: may be present
Acute respiratory failure qRs: ∅
Ischemia or Infarction P:qRs ∅
Traumatic cardiac arrest
Ventricular aneurysm
Countershock
Hypoxia, Hypothermia
Hyperkalemia,
Hypokalemia
Preexisting acidosis
Drug overdose

Published by: Department of Educational Development and Resources, OSU Medical Center 7
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

1st degree AV Block 1P : 1 qRs


Prolonged PRI
(> 0.20 sec not > 0.40 sec)

2nd degree AV Block, More P waves than qRs


PRI progressively increases
Type I in a cycle until P appears
w/o qRs.
Cyclic pattern reoccurs
R–R≠ = non-conducted P wave

2nd degree AV Block, More P waves than qRs


PRI consistent
Type II qRs normal or wide (bundle
branch block)
R - R≠ or R – R =

= non-conducted P wave

Published by: Department of Educational Development and Resources, OSU Medical Center 8
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved
ECG review – ACLS Program Ohio State University Medical Center
Rhythm ECG Characteristics Example

3rd degree AV Block More P waves than qRs


P not r/t qRs
(P too close, P too far)
PRI varies greatly
qRs normal or wide
R–R=
= non-conducted P wave

Published by: Department of Educational Development and Resources, OSU Medical Center 9
 December 2001 by The Ohio State Univeristy Medical Center All Rights Reserved