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QUICK EKG REFERENCE

NORMAL SINUS RHYTHM

EKG Criteria
Rate: 60-100 bpm.
Rhythm: Regular.
P wave: look the same
PRI: .12-.20 seconds
QRS: .08-.12 seconds
narrow unless effected by underlying anomoly

SINUS BRADYCARDIA

EKG Criteria
Rate: <60 bpm.
Rhythm: Regular generally.
Pacemaker: SA node
P wave: Present, all originating from SA node, all look the same.
PRI: <.20 seconds and constant.
QRS: Normal, .08-.12 seconds

SINUS TACHYCARDIA

EKG Criteria
Rate: >100 bpm.
Rhythm: Regular, generally.
Pacemaker: SA node.
P wave: Present and normal,
may be buried in T waves in rapid tracings.
PRI: .12-.20 seconds, generally closer to .12
QRS: Normal.

SINUS ARRHYTHMIA
SINUS EXIT BLOCK

R-R irregular
P-P irregular
P before & for every QRS
PRI: .12-.20 seconds
QRS: .04-.12 seconds

SINUS ARREST
R-R irregular
P-P irregular
P before & for every QRS
PRI: .12-.20 seconds
QRS: .04-.20 seconds
Missing PQRS complex

SICK SINUS SYNDROME

Electrocardiogram exhibiting alternating patterns


of bradycardia and tachycardia as seen in patients with sick sinus syndrome

ATRIAL RHYTHMS
PREMATURE ATRIAL CONTRACTION
EKG Criteria
Rate: Underlying rhythm.
Rhythm: Irregular with PACs.
Pacemaker: Ectopic atrial pacemaker outside SA node.
P wave: Ectopic P wave present,
generally different than normal SA P wave.
PRI: Generall normal range 120-200 msec,
but differ from underlying rhythm.
QRS: Same as underlying rhythm

ATRIAL FIBRILLATION

EKG Criteria
Undulating baseline replaces P waves
Rhythm: Irregularly irregular

ATRIAL FLUTTER

EKG Criteria Rate: 250 - 350 bpm (atrium)


Rhythm: Atrial rate regular,
ventricular conduction 2:1 to 8:1
Pacemaker: Reentrant circuit rhythm located in the right atrium
P wave: Saw-tooth or picket fence
PRI: Constant onset

CARDIOVERSION

Cardioversion was done to convert Atrial Flutter to Sinus Rhythm

ATRIAL TACHYCARDIA
P before & every QRS
PRI: .12-.20 seconds
QRS: .08-.12
Can come in runs or bursts

MULTIFOCAL ATRIAL TACHYCARDIA-MAT-WAP


R-R may be a little irregular due to different foci in atrial conduction
P-P may be a little irregular due to different foci in atrial conduction
P before & for every QRS of underlying rhythm
Different shaped P waves due to changes in conduction foci
PRI: usually within .12-.20 seconds
QRS: 04.-.12 seconds
Different shaped P waves due to changes in conduction foci

JUNCTIONAL RHYTHMS
JUNCTIONAL RHYTHM

EKG Criteria
Rate: 40 - 60 bpm
Rhythm: Regular
Pacemaker: Atrioventricular junction
P wave: If present, negative in lead 2
PRI: .12 seconds or less
QRS: .08-.12 seconds, unless prolonged by aberrant conduction

JUNCTIONAL TACHYCARDIA
R-R regular; rate >100
P-P regular; rate >100 (may or may not have visable P at fast rate
P wave inverted, my come before, during or after QRS
If P is with T, it will NOT peak the T

PREMATURE JUNCTIONAL CONTRACTION

EKG Criteria
Rate: Underlying rhythm
Rhythm: Irregular with PJC's
Pacemaker: Ectopic junctional pacemaker
P wave: If present, negative in Lead 2
PRI: .12 seconds or less
QRS: .08-.12 seconds, unless prolonged by aberrant conduction
HEART BLOCKS
FIRST DEGREE AVB

EKG Criteria
Rhythm: Regular
PRI: >.20 seconds

SECOND DEGREE-MOBITZ II
EKG Criteria
PRI: Constant on conducted complexes until a sudden block of AV conduction.
That is, a P wave is abruptly not followed by a QRS

SECOND DEGREE-WENCHEBACH-MOBITZ I

EKG Criteria
Rhythm: Irregular
PRI: Progressive lengthening of PRI until dropped beat.
A clue to Wenckebach is that the QRS's appear to occur in groups

THIRD DEGREE AVB

AV DISSOCIATION
There is no fixed temporal relationship between P waves and QRS complexes
due to the existence of two independent pacemakers,
one in the SA node (or in the atria) which controls the beating of atria
and other in the AV junction (or in the ventricles) which controls the beating of ventricles.
When the atria are beating faster than the ventricles,
AV dissociation is due to complete AV block;
when the ventricles are beating faster than the atria,
AV dissociation is due to ectopic tachycardia (junctional or ventricular).
In complete AV dissociation no atrial impulse is conducted to the ventricles;
in incomplete AV dissociation some atrial impulses may be conducted to the ventricles
resulting in ventricular captures.

RIGHT BUNDLE BRANCH BLOCK

When the right bundle branch is blocked,


activation of the right ventricle begins when electrical activity “spills over” from the left
ventricle.
Depolarization of the right ventricle is delayed.
The QRS is prolonged (over 0.1 sec) in right bundle branch block (RBBB).
This extra length of the QRS is caused by late activation of the right ventricle,
which is then seen after the left ventricle activity.
Normally, right ventricle activity is not seen,
as it is overshadowed by the larger left ventricle.
In RBBB, a typical RsR’ wave occurs in lead V1.
Also, a wide S wave is seen in leads I, V5, and V6, along with a broad R in lead R.
When RBBB occurs in a patient with old or new septal infarction,
the initial septal R wave may not be seen in lead V1.
Instead, a wide QR complex is seen.
When the typical RsR’ wave is seen in V1 without widening of the QRS complex,
this is called “right ventricular conduction defect” rather than RBBB

LEFT BUNDLE BRANCH BLOCK


LBBB usually indicates widespread cardiac disease.
When the left bundle is blocked,
activation of the left ventricle proceeds through the muscle tissue,
resulting in a wide (.12 msec) QRS complex.
In left bundle branch blockage (LBBB),
the QRS usually has the same general shape as the normal QRS,
but is much wider and may be notched or deformed.
Voltage (height of the QRS complex) may be higher.
In LBBB, look for wide (possibly notched) R waves in I, L, or V5-V6,
or deep broad S waves in V1-V3.
There is left axis deviation.
“Septal Q waves” sometimes seen in I, L, and V5-V6 disappear in LBBB.
T waves in LBBB are usually oriented opposite the largest QRS deflection.
That is, where large R waves are seen,
T waves will be inverted.
ST segment depression may occur.

SUPRAVENTRICULAR TACHYCARDIA(SVT)
EKG Criteria
Rate: 140 - 220 bpm
Rhythm: Regular
Pacemaker: Reentry circuit
Accessory pathway: Normal or short (if down accessory pathway)
A-V nodal reentry: Hidden in or at end of QRS
PRI: Depends on location of circuit
QRS: Normal if accessory pathway used - prolonged (>120 msec) with delta wave

QRS ETIOLOGY SVT vs VT


VENTRICULAR RHYTHMS
PREMATURE VENTRICULAR CONTRACTION

EKG Criteria
Rhythm: Irregular
QRS: Is not normal looking. Broadened, greater than 0.12 seconds.
P waves are usually obscured by the QRS, ST segment, or T wave of the OVC.
The P wave may sometimes be seen as notching during the ST segment or T wave.

BIGEMINY

EKG Criteria QRS: Normal QRS complex followed by (PVC) in patterns of 2

VENTRICULAR ESCAPE BEAT


VENTRICULAR TACHYCARDIA

EKG Criteria
No normal looking QRS complexes, often bizzare with notching.
Width of QRS>0.12 sec. ST segment and T wave are opposite polarity to the
QRS.
Sinus node may be depolarizing normally.
There is usually complete AV dissociation.
P waves are sometimes seen between QRS complexes.
They have no impact on the QRS complexes.
Rate: Generally 100 to 220 bpm
Rhythm: Generally regular, on occassion can be modestly irregular.

TORSADES
P wave obscured if present
QRS wide and bizarre morphology
Conduction as with PVCs
Rhythm Irregular
Paroxysmal–starting and stopping suddenly
The upward and downward deflection of the QRS complexes around the
baseline.
The term Torsade de Pointes means "twisting about the points."

ASYSTOLE

EKG Criteria
Complete absence of ventricular electrical activity.
Occasional P waves or erratic ventricular beats may be seen.
These patients will be pulseless.
Treatment must be immediate if the patient is to have any chance at
resusctiation.
Rate: None
Rhythm: None
Sometimes there is a few or more seconds of Asystole
as in the above strip of over 5 seconds.

IDIOVENTRICULAR

EKG Criteria
Rate: 40 bpm
Rhythm: Regular
P wave: Regular if present
PRI: If present, varies (no relationship to QRS complex [AV dissociation])
QRS: QRS interval >.12 seconds wide and bizarre

VENTRICULAR FIBRILLATION
EKG Criteria
Rate: Very rapid, too disorganized to count.
Rhythm: Irregular, waveform varies in size and shape
No normal QRS complexes.
Absent ST segments, P waves, T waves.

PACERS & ICD


VENTRICULAR PACED

Note the pacemaker spikes before the QRS complexes.

ATRIAL PACED

Pacemaker spikes are seen before each QRS complex


and initiate a tiny P wave

MVP OPERATION
NON-CAPTURED PACED

Paced rhythm with single failure to capture

PACER FAILURE
ATRIAL-VENTRICULAR PACED

ICD
Below are 2 ways for Ventricular Tachycardia
to be terminated having a ICD.
Ventricular Tachycardia with ICD pacer
overriding the VT rate to convert back to sinus rhythm
Ventricular Tachycardia with ICD firing
(without the pacer override) conversion.

AGONAL RHYTHM

Hyperkalemia with Agonal Rhythm


The QRS complexes here are ventricular escape beats
as noted by the severe bradycardia (inherent ventricular rate in the 40s),
wide complex indicating origin is in the ventricle, and lack of a preceding p-wave