HOUSTON METHODIST HOSPITAL

CENTER FOR PROFESSIONAL EXCELLENCE

BASIC EKG SELF-STUDY GUIDE

Objectives

1. Understand the basic anatomy of the heart.

2. Describe the normal physiology of cardiac conduction.
3. Identify normal EKG waveform morphology.
4. Differentiate between basic dysrhythmias.
5. Describe the physiological consequences and treatments of basic dysrhythmias.

EKG Review Guide

 50 questions
 1 hour
 Rhythm Strip Recognition
 Nursing Interventions
 Medication Interventions
http://www.skillstat.com/tools/ecg-simulator
http://www.practicalclinicalskills.com/ekg.aspx

SR: Sinus Rhythm

SB: Sinus Bradycardia
ST: Sinus Tachycardia
PVC: Premature Ventricular Contractions
Bigeminy
Trigeminy
Supraventricular Tachycardia
A-Fib: Atrial Fibrillation
Atrial Flutter
IVR: Idioventricular Rhythm
VT: Ventricular Tachycardia
VFib: Ventricular Fibrillation
Asystole
AV Pacer: Atrial Ventricular Pacemaker
V Pacer: Ventricular Pacemaker
Heart Blocks: First Degree, Second Degree Type I, Second Degree Type II, Third Degree
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ELITE Orientation Revised 7.18.2017/ LO

 Anatomy of the Heart

The heart contains four chambers- two atria and two ventricles. The right and left atria serve
as volume reservoirs for blood being sent into the ventricles. The right atrium receives
deoxygenated blood returning from the body through the inferior and superior vena cavas and
from the heart through the coronary sinus. The left atrium receives oxygenated blood from the
lungs through the four pulmonary veins. The interatrial septum divides the chambers and
helps them contract. Contraction of the atria forces blood into the ventricles below.

The right and left ventricles serve as the pumping chambers of the heart. The right ventricle
receives blood from the right atrium and pumps it through the pulmonary arteries to the lungs,
where it picks up oxygen and drops off carbon dioxide. The left ventricle receives oxygenated
blood from the left atrium and pumps it through the aorta and then out to the rest of the body.
The interventricular septum separates the ventricles and also helps them to pump.

The heart contains four valves- two atrioventricular valves (AV valves) called the tricuspid
and mitral valves, and two semilunar valves called the pulmonic and aortic valves. The valves
open and close in response to changes in pressure within the heart chambers and serve as one-
way doors that keep blood flowing through the heart in a forward direction. When the valves
close, they prevent backflow, or regurgitation, of blood from one chamber to another. The
closing of the valves creates the heart sound heard through a stethoscope during a physical exam.

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 Blood Flow through the Heart

During diastole, the ventricles relax, the atria contract and blood is forced through the open
tricuspid and mitral valves. The aortic and pulmonic valves are closed.

During systole, the atria relax and fill with blood. The mitral and tricuspid valves are
closed. Ventricular pressure rises and forces open the aortic and pulmonic valves. The
ventricles then contract and blood flows through the circulatory system.

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 Cardiac Blood Supply

Like the brain and all other organs, the heart needs an adequate supply of blood to survive.
The coronary arteries, which lie on the surface of the heart, supply the heart muscle with
blood and oxygen.

The coronary ostium, an opening in the aorta that feeds blood to the coronary arteries, is
located near the aortic valve. During diastole, when the left ventricle is filling with blood,
the aortic valve is closed and the coronary ostium is open, enabling blood to fill the coronary
arteries.

The heart has veins like other parts of the body. Cardiac veins collect deoxygenated blood
from the capillaries of the myocardium. The great cardiac vein, thebesian veins and other
cardiac veins, along with the coronary sinus, return blood to the right atrium, where it
continues through the circulation.

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 Cardiac Conduction System

In an adult with a healthy heart, the heart rate is usually about 72 beats per minute.

The excitatory and electrical conduction system of the heart is responsible for the contraction and
relaxation of the heart muscle. The sinoatrial node (SA node) is the pacemaker where the
electrical impulse is generated. This node is located along the posterior wall of the right atrium
right beneath the opening of the superior vena cava. It is crescent shaped and about 3 mm wide
and 1 cm long.

The impulse travels from the SA node through the internodal pathways to the atrioventricular
node (AV node). The AV node is responsible for conduction of the impulse from the atria to the
ventricles. The impulse is delayed slightly at this point to allow complete emptying of the atria
before the ventricles contract. The impulse continues through the AV bundle and down the left
and right bundle branches of the Purkinje fibers. The Purkinje fibers conduct the impulse to
all parts of the ventricles, causing contraction.

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Abnormal heart rhythms occur for several reasons.

1. The vagal stimulation of the parasympathetic nervous system can cause a decrease in the
rate at the SA node and can also decrease the excitability of the AV junction fibers. This
causes a slowing of the heart rate, and in severe cases, a complete blockage of the
impulse through the AV junction.
2. Sympathetic stimulation also affects cardiac rhythm and conduction. It increases the
rate at the SA node and increases the rate of conduction and excitability throughout the
heart. It also increases the force of myocardial contraction. Subsequently, the overall
workload on the heart is increased.
3. A small area of the heart can become more excitable than normal, which causes abnormal
heart beats called ectopy. Ectopic foci are usually caused by an irritable area in the heart.
This irritability can be caused by ischemia, stimulants such as nicotine and caffeine, lack
of sleep or anxiety.

Intrinsic rates of pacemaker cells located in three critical areas of the heart:

SA node- 60 to 100

AV junction- 40-60

Purkinje fibers- 20-40

As impulses are transmitted, cardiac cells undergo cycles of depolarization and

repolarization. Cardiac cells at rest are considered polarized, meaning that no electrical
activity takes place. Cell membranes separate different concentrations of ions, such as
sodium and potassium, and create a more negative charge inside the cell. This is called the
resting potential. Once a stimulus occurs, ions cross the cell membrane and cause an action
potential, or cell depolarization.

When a cell is fully depolarized, it attempts to return to its resting state in a process call
repolarization. Electrical charges in the cell reverse and return to normal. The cycle then
repeats itself with each impulse.

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 How to Read an EKG Strip

EKG paper is a grid where time is measured along the horizontal axis.

 Each small square is 1 mm in length and represents 0.04 seconds

 Each larger square is 5 mm in length and represents 0.20 seconds

Voltage is measured along the vertical axis.

 10 mm is equal to 1mT in voltage

 The diagram below illustrates the configuration of ELG graph paper and where to
measure the components of the EKG wave form

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 Calculating the Rate:

When the rhythm is regular

 Count the number of R waves in a 6 second strip and multiply by 10.

For example, if there are 8 R waves in a 6 second strip, the heart rate is 80 (8 x
10=80 bts).

Alternative R to R Method
 Count the number of small squares between 2 R waves and divide that into 1500.
 32 small boxes from R to R
 1500 ÷ 32 = Rate 46 beats/min
 R to R or P to P rates should be the same for NSR
Reminder: 1 small box =0.04 seconds

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 Normal Components of the EKG Waveform

P wave
 Indicates atrial depolarization, or contraction of the atrium.
 Normal duration is not longer than 0.11 seconds (less than 3 small squares)
 Amplitude (height) is no more than 3 mm
 No notching or peaking

QRS complex
 Indicates ventricular depolarization, or contraction of the ventricles.
 Normally between 0.06 - 0.12 seconds in duration
 Amplitude is not less than 5 mm in lead II or 9 mm in V3 and V4
 R waves are deflected positively and the Q and S waves are negative

T wave
 Indicates ventricular repolarization
 Not more that 5 mm in amplitude in standard leads and 10 mm in precordial leads
 Rounded and asymmetrical

ST segment
 Indicates early ventricular repolarization
 Normally not depressed more than 0.5 mm
 May be elevated slightly in some leads (no more than 1 mm)

PR interval
 Indicates AV conduction time
 Duration time is 0.12 to 0.20 seconds

QT interval
 Indicates repolarization time. General rule: duration is less than half the preceding R-R
interval

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 Systematic Approach to Arrhythmia Interpretation

REGULARITY PR INTERVAL
(ALSO CALLED Rhythm)
• Are all the PRIs constant?
• Is it regular? • Is the PRI measurement within normal range?
• Is it irregular? • If the PRI varies, is there a pattern to the
• Are there any patterns to the irregularity? changing Measurement?
• Are there any ectopic beats; if so, are they
early or late?
QRS COMPLEX

• Are all the QRS complexes of equal duration?

RATE • What is the measurement of the QRS
complex?
• Is the QRS measurement within normal limits?
• What is the exact rate? • Do all the QRS complexes look alike?
• Is the atrial rate the same as the • Are the unusual QRS complexes associated with
ventricular rate? ectopic beats?

P WAVES

• Are the P waves regular?

• Is there one P wave for every QRS?
• Is the P wave in front of the QRS or
behind it?
• Is the P wave normal and upright in
Lead II?
• Are there more P waves than QRS
complexes?
• Do all the P waves look alike?
• Are the irregular P waves associated
with ectopic beats?

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 Sinus Rhythm

EKG Characteristics:

Rate: 60-100 beats per minute

Rhythm: regular
P wave: normal shape and size
PR interval: normal 0.12 to 0.20 seconds
QRS complex: normal 0.08-0.12 seconds
(Complexes are the same size and shape)
T Wave: normal shape

Nursing Intervention:
No nursing intervention is needed

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 Sinus Bradycardia (SB)

EKG Characteristics:

Rhythm: regular
Rate: less than 60 beats/minute
P Wave: normal size and shape
QRS Complex: normal 0.08-0.12 seconds
T Wave: normal

Common Causes:
Vagal stimulation, ischemia to the SA node, beta-blockers, digitalis toxicity, increased ICP. It
can also be seen as a normal variation in athletes.

Nursing Intervention:
Notify the doctor. Anticipate oxygen administration, atropine or pacing for symptomatic
bradycardia.

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 Sinus Tachycardia (ST)

EKG Characteristics:

Rhythm: regular
Rate: Greater than 100 beats/minute
P Wave: Normal or (may be buried in the T wave)
QRS Complex: Normal
T wave: Normal

Common Causes:
Exercise, infection, increased temperature, response to pain, hypovolemia, hypoxia, fever, stress,
pulmonary emboli, myocardial infarction, increased circulating catecholamines and responses to
stimulant drugs.

Nursing Intervention:
Notify the doctor if this is a new occurrence. Determine and treat the cause. The clinical
significance will depend upon the underlying cause.

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 PVC: Premature Ventricular Contractions

Definition: Is a premature ectopic beats that originates in the ventricles. A wide bizarre QRS
complex is the result. Pattern of ectopic can be unifocal, paired, multifocal, bigeminy, and
trigeminy. Three or more PVCs in a row and/or PVCs lasting more than 30 seconds are
considered a run of ventricular tachycardia (VT).

EKG Characteristics:

Rhythm: Irregular during PVC’s

Rate: Normal underlined intrinsic rate
P Wave: Normal on the underlined rhythm
QRS Complex: PVC’s will be early, wide and bizarre,
greater than 0.12 seconds. (The underlined rhythm will have normal QRS complexes)
T-wave: Normal on the underlined rhythm

Common Causes:
Possible causes include electrolyte imbalances, hypoxia, ischemia, acute myocardial infarction
and medical toxicity.

Nursing Intervention:
Notify the doctor if this is a new event. Administer oxygen,
determine the underlined cause of the PVC’s and treat the cause.

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 Bigeminy and Trigeminy

Definition: Bigeminy is a premature ventricular contraction that is followed by a normal

QRS complex (PVC every other beat). Trigeminy is PVC followed by two normal QRS
complexes in an alternating pattern (PVC every third beat).

EKG Characteristics:

Rhythm: Irregular
Rate: Usually normal 60-100 beats/minute
P-wave: may be absent with each ectopic beat
(normal with the underlined rhythm)
QRS Complex: Normal complex followed by a wide QRS complex.
T-wave: may appear in the opposite direction of the QRS after each ectopic beat
(normal with the underlined rhythm)

Common Causes:
Possible causes include electrolyte imbalances such as (low K+, Mg+), hypoxia, ischemia,
medication toxicity, and acute infarction.

Nursing Intervention:
Notify the doctor if this is a new arrhythmia, administer oxygen. Determine underlying cause
and treat accordingly. Treat the arrhythmia if the patient is symptomatic.

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 Supraventricular Tachycardia (STV)

Definition: SVT is a rapid regular heartbeat that originates above the ventricles, it is known as
supraventricular. It is caused by a rapid firing of ectopic beats.

EKG Characteristics:

Rhythm: regular
Rate: 150-250 beats/minute
P Wave: Unable to visualize P wave due to rapid rate
PR Interval: none
QRS Complex: normal

Common Causes:
Possible causes include stimulants, anxiety, atrial enlargement, medication toxicity, and
hyperthyroidism.

Nursing Intervention:
Notify the doctor and oxygen administration. Vagal maneuvers (cough and valsalva) can be
used. Cardioversion may be needed for unstable patients. Medical management includes calcium
channel blockers or beta blockers. Prepare for a code if the rhythm does not convert.

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 Atrial Fibrillation (A-Fib)

Definition: The atria discharge impulses at rates greater than 400 beats/minute due to many
ectopic impulses in the atria. It can be chronic or intermittent. A-Fib is considered controlled if
the rate is less than 100 beats/minute and uncontrolled for rates greater than 100 beats/minute

EKG Characteristics:

Rate: Atrial rate is no measurable

Rhythm: Very Irregular
P Wave: No P waves are present
PR Interval: is not measurable (P waves are not visible)
QRS Complex: Normal 0.08-0.12 seconds.
T Wave: No visible

Common Causes: hypertension, ischemia, myocardial disease, pericardial disease,

hyperthyroidism, chronic congestive heart failure, chronic obstructive pulmonary disease, edema
associated with status post heart surgery, and the aging heart

Nursing Intervention: Notify MD, oxygen administration, calcium channel blockers, beta-
blockers, anticoagulants, and digoxin. If drug treatment fails to treat this arrhythmia,
cardioversion may be used

If this rhythm has been present for greater than 48 hours, you cannot try to convert the rhythm.
The fibrillating atrium allow clot formation and converting the patient to a normal sinus rhythm
after 48 hours can send clots out into the blood stream leading to an embolism The rare is
controlled with antiarrhythmic agents such as diltiazem along with anticoagulants

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 Atrial Flutter (A-Flutter)

Definition: A-flutter is a single atrial ectopic beat that is conducted in a repetitive pattern
resulting in a series of atrial waves also know as flutter or F waves.

EKG Characteristics:

Rhythm: Atrial rhythm is regular. Ventricular rhythm could be regular or irregular.

Rate: Atrial rare: 250-400beats/minute. Ventricular rate varies
P Wave: A "saw tooth” shape or flutter waves are present.
QRS Complex: Normal 0.08-0.12 seconds.
T Wave: Not visible

Common Causes: enlarged atria, chronic obstructive pulmonary disease, valve disease and
pericarditis.

Nursing Intervention: Notify MD if this is a new rhythm, oxygen. Calcium channel blockers,
beta-blockers, anticoagulants, and digoxin. Cardioversion may also be used if drug treatment is
not successful.

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 IVR: Idioventricular Rhythm

Definition: IVR originates from the ventricles. IVR is characterized by a wide QRS complex
that is regular. It may be transient or continuous. Continuous IVR is generally a terminal event,
occurring just before the patient enters an agonal rhythm, and then asystole.

EKG Characteristics:

Rhythm: Usually regular

Rate: Atrial rate can’t be determined. Ventricular rate is regular
IVR: 30-40 beats per minute
Accelerated IVR: 40-60 beats per minute
P waves: None
QRS Complex: Wide, being greater than 0.12 seconds.
T waves: abnormal (usually in a negative deflection)

Common causes:
It is caused by increased vagal stimulation, and heart disease.

Nursing Interventions: Check vital signs, notify the doctor. Administer oxygen and atropine per
hospital protocol. Possibly initiate transcutaneous pacing, and start dopamine infusion if the
patient is hyportensive. Prepare for code situation.

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 VT: Ventricular Tachycardia

Definition: VT is a rapid deadly rhythm originating from the ventricles. They are often wide and
bizarre with a QRS of 0.12 seconds or greater. Patients can have VT with a pulse (a beating
heart) or pulseless. It can be sustained or nonsustained.

EKG Characteristics:

Rhythm: Atrial rate cannot be determined. Ventricular rate may be regular or

irregular
Rate: Ventricular: 100-250 beats per minute
P waves: None
QRS Complex: Greater than 0.12 seconds. QRS complex and wide and bizarre
T waves: None

Common Causes:
It is often found in patients with myocardial ischemia or infarction, cardiomyopathy, congestive
heart failure, hypokalemia, hypomagnesaemia, reperfusion following thrombolytic therapy, or
medication toxicity.

Nursing Intervention:
Start oxygen, obtain vital signs. If there is a pulse, synchronized cardioversion is your first line
action. Amiodarone, magnesium or lidocaine can also be used to treat VT. If there is no pulse,
call a code, defibrillation immediately, starts CPR/ACLS per hospital protocol.

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 VFib: Ventricular Fibrillation

Definition: In VFib many ectopic beats take over the ventricles and produce a disorganized,
chaotic rhythm. The patient is considered pulseless, with no blood pressure and requires
immediate intervention. This is a deadly rhythm.

EKG Characteristics:

Rhythm: No pattern just fibrillatory waves

Rate: None
P Waves: None
QRS Complex: None
T-wave: None

Common Causes: Coronary artery disease, myocardial ischemia, myocardial infarction,

cardiomyopathy, cardiac trauma, drug toxicity, hypoxia, and electrolyte imbalance.

Nursing Intervention: Call a code. “Defib V-Fib”, starts ACLS (advanced cardiac life support),
establish an IV line access, intubate. Epinephrine, vasopressin and amiodarone are some of the
medications used to treat V-Fib. The patient may need to be transport to Intensive Care Unit.

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 Asystole

Definition: In Asystole is the last stage of a dying heart where there is no electrical activity.
There is no cardiac output; therefore patients will not have a blood pressure. This is a code
situation.

EKG Characteristics:

Rhythm: None (generally asystole is a flat line)

Rate: None
P Waves: None
QRS Complexes: None

Nursing Intervention: Check the pulse and rapidly assess the patient. Check the rhythm in a
second lead and increase the gain to ensure it is not a fine ventricular fibrillation. This is not a
shockable rhythm. Start CPR, establish an IV line, and intubate the patient. Consider using
trancutaneous pacing early. Transport to the Intensive Care Unit.

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 AV Pacer: Atrial Ventricular Pacemaker

Definition: An AV Pacer is when the heart rhythm is completely produced from the implanted
pacemaker. The pacemaker is a device that delivers electrical stimulus that depolarizes the
myocardium producing a mechanical contraction. The AV Pacer delivers an impulse to the atria
and ventricle.

EKG Characteristics:

Rate: Usually 60-100 beats per minute, but it can vary according to the rate at which it has been
programmed
Rhythm: Pacemaker spikes are one atrial spike followed by a P wave, then one ventricular spike
followed by a wide QRS complex and T wave
P Wave: P waves may be present or absent or they may be dissociated from the QRS Complex
QRS complex: Usually wide
T Wave: Usually wider than usual

Nursing Intervention: There are no nursing interventions for a normally functioning AV paced
rhythm. However continue to monitor for failure to capture and failure to sense in patients
who have a slow underlined rhythm or 100% paced.

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 V Pacer: Ventricular Pacemaker

Definition: A ventricular pacemaker is a device that electronically depolarizes the ventricles and
produces a mechanical contraction. Pacemakers are used when a patient's own heart is too slow.
(Ex: Sinus arrest, sick sinus syndrome, symptomatic sinus bradycardia, slow atrial fibrillation,
ventricular standstill or asystole, 2nd degree heart block type 2 (Mobitz II), and third degree heart
block).

EKG Characteristics:

Rate: Usually 60-100 beats per minute, but may vary according to the programmed rate, or
demand of the patient
Rhythm: There is one pacemaker spike before the QRS complex, initiating and followed by the
QRS complex
P Wave: There may be a P wave present, absent, or it may be dissociated from the QRS complex
QRS complex: depends upon the intrinsic rhythm

Nursing Interventions: There are no nursing interventions for a normally functioning V paced
rhythm. However continue to monitor for failure to capture and failure to sense in patients who
have a slow underlined rhythm or 100% paced.

Cardioversion

 Cardioversion is used on a beating heart.

 Much less energy is used (50, 75, 100 joules)
 Joule setting will be ordered by the doctor
 Used in treatment of tachy-dysrhythmias
o Super Ventricular Tachycardia (SVT), Symptomatic rapid A-fib / F-flutter or VT
with a pulse.
 Press the Sync button on the zoll
 The R wave will be “mark”

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 o The energy will deliver on the R wave (ventricular depolarization)
 If it is a planned procedure, obtain consent and give sedation,

Defibrillation

 Can deliver energy anytime in cardiac cycle to stop fibrillation.

 This allows heart to re-organize electrically (rhythm, automatic, conductive)
 Monophasic 360j or Biphasic 200j
 Verify if “Hands free defibrilation” is used at your facility
 The pictures on each pads acts as a guide for the operator to ensure correct placement on
the chest.
 If gel pads are used, 25 lbs paddle pressure must be applied. (keep the elbows straight!)
 Before administering a shock the operator must say.
 “I’m clear, you’re clear, everybody’s clear”
 Check monitor for memory and recording of discharge of energy

AED Sequence

 The correct sequence for operating the AED:

o Turn the AED On and follow the instructions
o Apply Pads to the patient’s chest.
o Analyze the rhythm.
o Deliver shock if needed.

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Rhythm: Regular
Rate: That of the underlying rhythm
PRI is > 0.2 seonds

Nursing Interverntions: Continue to monitor patient

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Nursing Interventions: If patient symptomatic, Atropine or Temporary Pacing

1. P waves are punctual and similar (at the same time)

2. The Ventricular rhythm is irregular
3. The Atrial rhythm is regular
4. PRI is normal or prolonged
5. QRS can be abnormal

Nursing Interventions: PACEMAKER Placment of permanent pacemaker

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Rhythm: Regular
NO Association between the atria and ventricles
Nursing Interventions: PACEMAKER !!!! Placment of permanent pacemaker

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