ECG INTERPRETATION

(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

NORMAL
1. P WAVE
a. Represents: atrial depolarization (contraction)
b. Conduction site: SA node (generator or pacemaker)
c. Duration: <0.11 seconds (less than 3 small boxes)
i. 1 box = 0.04

2. PR INTERVAL
a. Measurement: beginning of the P WAVE to the beginning of QRS
b. Conduction sites: SA node -> AV node -> Bundle of His
c. Duration: 0.12 - 0.20 seconds (3 – 5 small boxes)

3. QRS COMPLEX
a. Represent: ventricular depolarization (contraction)
b. Conduction site: Purkinjie Fibers
c. Duration: less than 0.10 – 0.12 seconds (does not go beyond 3 boxes)

4. ST SEGMENT
a. Represents: early repolarization (relaxation)
b. Measurement: end of QRS to beginning of the T wave

5. T WAVE
a. Represents: ventricular repolarization
b. Relaxation or resting mode

6. QT INTERVAL
a. Represents: whole cycle of contraction and relaxation
b. Measurement: beginning of QRS to the end of T wave

CONDUCTION SYSTEM
1. SA NODE
a. Impulse originated – generator or pacemaker
b. Site: superior vena cava (junction of the superior vena cava and right atrium)
c. Rate: 60 – 100

2. AV NODE
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

a. Travelling of the impulse: gate way to the ventricles

3. BUNDLE OF HIS
a. Route of the purkinjie fibers

4. PURKINJIE FIBERS
a. Site: ventricular muscles -> “contract”

INTERPRETATION OF ECG
§ STEPS:

1. RHYTHM
a. Measures R wave to R wave
b. Determine: regular or irregular

2. RATE
a. Determine: Normal, Tachycardic or Bradycardic?
i. Method: Count the number of R waves on a six second strip and multiply
by 10
ii. Results:
1. Normal: 60 – 100
2. Sinus Bradycardia: below 60
a. Drug of choice: Atropine Sulfate
i. Considered as an SNS drug
ii. Action: increases the heart rate
iii. Dosage: 0.5 mg
3. Sinus Tachycardia: more than 100
a. Drug of choice:
i. BETA – BLOCKERS
1. Action: decreases heart rate
ii. CALCIUM – CHANNEL BLOCKERS
1. Examples: Verapamil and Diltiazem
iii. Action of both drugs: decreases the heart rate
3. P WAVE
a. Identify the P WACE
b. Ask:
i. Is there P wave before each QRS complex?
ii. Are the P waves similar in size, shape and position?
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

iii. Are they normal in appearance?

4. PR INTERVAL
a. Normal duration: 0.12 – 0.20 seconds
i. IF less than 0.20 = “AV Block”
b. How many boxes? 3 – 5 boxes only
c. Ask:
i. Is the PRI consistently the same length?

5. QRS
a. Normal duration: less than 0.10 or 0.12 seconds
b. If more than 0.12 seconds or widened in the strip -> “ventricular problem”

PROBLEM
Atrial P WAVE + NORMAL QRS
Ventricular QRS Sometimes absent P wave

ATRIAL DYSRHYTHMIAS
1. Premature Atrial Contraction
a. Problem: early P WAVE (non-continuous)
b. Management: does not require treatment
i. Rest
ii. AVOID caffeine: coffee, tea, chocolates and cola

2. Atrial Tachycardia
a. Problem: fast P WAVE (early but continuous)
b. Atrial rate: 150 – 250 beats per minute
c. Management:
i. Vagal stimulation
1. Examples:
a. Carotid massage
i. Action: stimulates the vagus nerve (Cranial nerve 9)
ii. Result: decrease HR and decreases BP
ii. Drugs:
1. Class 2 Drugs
a. Beta Blockers: propranolol, atenolol and more
b. Action: decreases HR
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

2. Class 4 Drugs
a. Calcium Channel Blockers: Verapamil and diltiazem
b. Action: decreases HR
3. Atrial Flutter
a. Problem: P wave -> (has a pattern: “SAW TOOTH PATTERN”)
b. QRS is normal
c. Atrial rate: 250 – 350
d. Management:
i. If stable:
1. Class 2
a. Beta blockers
b. Action: decreases heart rate
2. Class 4
a. Calcium Channel Blockers
b. Action: decreases heart rate
3. Digoxin (Lanoxin)
a. Miscellaneous
b. Action:
i. (+) inotrophy => increase force of contractions
ii. (-) cHRonotrophy => decreases HR
ii. Prolong Relaxation:
1. Class 3
a. Examples:
i. Amiodarone
ii. Ibutilide
b. Action: prolongs relaxation (T wave)
2. Class 1
a. Examples:
i. Procainamide
ii. Quinidine
b. Action: slows down conduction or activity of the heart

4. Atrial Fibrillation
a. Problem: P wave
i. Disorganize/chaotic
ii. Irregular rhythm
iii. Rapid, wavy lines
b. Atrial rate: more than 350 – 400 beats per minute
c. Signs and symptoms:
i. Pulse rhythm -> irregular
ii. Decreased cardiac output = decreased BP
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

d. Management:
i. CARDIOVERSION = SAFETY
1. Set mode: synchronous / synchronized
2. Shock: during patient’s R wave
ii. Drugs:
1. All classes EXCEPT Class 1-B
a. Class 1B – Lidocaine = this is for ventricular problem
2. Anticoagulants
a. Examples: Heparin and Warfarin
b. Patient is high risk for: clot formation or thrombus
formation (Deep Vein Thrombosis)
c. Action: prevents clot development

VENTRICULAR DYSRHYTHMIAS
1. Premature Ventricular Contraction
a. Problem: QRS -> early (not continuous or consecutive) instead of P wave
iii. QRS is widened
iv. P wave is ABSENT
b. Management:
i. Drug of choice: CLASS 1 – B (Lidocaine)
ii. Action: slows conduction of the heart / impulses of the heart
1. Initial IV bolus: 50 mg
2. Continuous IV: 2 mg/min
iii. ALERT!!!
1. If more than 6 PVCs per minute, you must NOTIFY the doctor.
2. Then give your Lidocaine.

2. Ventricular Tachycardia
a. Problem: fast QRS (early – consecutive)
i. 3 or more consecutive PVCs
ii. Widened -> duration: >0.12 seconds
iii. P wave: absent
b. Management:
i. Treatment:
1. If conscious: ASSESS level of consciousness
a. Drugs:
i. L – idocaine (DOC)
ii. A – miodarone
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

iii. P – rocainamide
b. Cough CPR
i. Inhale deeply and cough forcefully
2. If unconscious and no pulse: pulseless V-Tach
a. Treatment: defibrillator

3. Ventricular Fibrillation
a. Cause: untreated V-Tach
i. To treat V tach, give lidocaine.
b. QRS is:
i. Disorganized
ii. Chaotic
iii. Irregular
iv. (+) coarse wavy lines
v. V – RATE: 350
c. Treatment:
i. Defibrillation: only management
1. 1st shock: 200 joules
2. 2nd shock: 300 joules escalating
3. 3rd shock: 360 joules
ii. If no defibrillator: CPR

CARDIOVERSION DEFIBRILLATION
Synchronous
MODE Asynchronous
“Set mode”
(+) -> so patients must be
CONSCIOUS (-)
sedated
HIGH
st
LOW <200 1 shock: 200 joules
ENERGY
50 to 100 joules 2nd shock: 300 joules
3rd shock: 360 joules
Ventricular Tachycardia
INDICATED Atrial fibrillation
Ventricular Fibrillation

NURSING MANAGEMENT:
1. Advance Directives
2. NOT DNR -> ensure
3. Apply conductive agents:
a. Gels
b. Paints
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

4. Say “CLEAR” = 3 times

5. Correct placement:
a. 1st pad: 2nd ICS, right sternal border
b. 2nd pad: 5th ICS, left MAL, MCL and anterior axillary line
6. Pressure: 20 – 25 pounds
a. 10 – 12 something

ATRIAL AND VENTRICULAR DYSRHYTHMIAS

1. AV BLOCK
a. Impaired conduction between atria to ventricles
b. Blocked or interrupted: impulses
i. If partial: 1st and 2nd degree
ii. If complete or total: 3rd degree
c. Cause: decreased oxygen to muscles => MI (+) necrosis

2. 1st Degree AV block

a. Impulse: slow (delayed) but still makes it
b. PR interval: prolonged = 0.20
i. Prolonged -> consistent = 0.24 -> 0.24 -> 0.24
c. Signs and symptoms:
i. Asymptomatic

3. 2nd Degree AV block

a. Type 1: (Mobitz 1 / Wenchebach)
i. PR interval: progressively longer until blocked completely
1. 0.22 -> 0.25 -> 0.27 -> 0.28
ii. Signs and symptoms:
1. Light headedness / “LUTAW”
2. Dizziness
3. Fainting (syncope)
b. Type 2: (Mobitz 2)
i. PR interval: no progressive lengthening (constant) and intermittent
(blocked completely)
ii. Constant
1. 0.24 -> blocked -> 0.24 -> blocked
iii. Signs and symptoms:
1. Light headedness / “LUTAW”
2. Dizziness
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

3. Fainting (syncope)
4. Dyspnea
5. Chest pain
c. Type 3: (Mobitz 3)
i. Impulse or signal: completely blocked or interrupted
ii. No pulse to the ventricular muscles or the Purkinjie fibers
iii. Heart rate: less than 60
iv. Signs and symptoms:
1. Light headedness / “LUTAW”
2. Dizziness
3. Fainting (syncope)
4. Dyspnea
5. Chest pain

NURSING MANAGEMENT FOR AV BLOCK:

1. Identify underlying cause

2. Treatment:
a. Atropine
i. Action: increases Heart Rate
b. Transcutaneous Pacing
i. Emergency cases
ii. Through: electrodes on skin -> temporary
c. Permanent Pacing
i. Pacemaker: device implanted

v PACEMAKER

1. Indicated for:
a. AV Block (Heart Block)
b. Bradycardia
2. Minor surgery
3. Actions:
a. Control abnormal heart rhythm
b. Uses electrical impulse
4. Parts:
a. Battery (5-15 years)
b. Computerized generators
c. Wires with sensor
5. Health teachings
a. Avoid vigorous exercises -> AVOID lifting -> 3 pounds
 ECG INTERPRETATION
(Intensive Review)
Kaithlene Yapha Alfar
COMMON IN BOARD EXAM | BOOK | REVIEW

b. Report malfunction signs and symptoms:

i. Irregular pulse = check pulse daily
1. Decreased urine output
2. Edema
3. Dyspnea
ii. Hiccups
c. Avoid close contact with strong magnetic fields devices
i. AVOID MRI
ii. Cellphones are OKAY but:
1. If pacemaker is at the right, use phone on the left.
2. If pacemaker is at the left, use phone on the right.
iii. Microwaves are OKAY
1. Not damaged