Recognizing Normal ECG

Cardiac Circulation
Cardiac Conduction
 Sinoatrial (SA)Node
 Intaatrial Nodal
Pathways
 Atrioventricular
(AV) Node
 Bundle of His
 Left Bundle Branch
 Right Bundle Branch
 Purkinje Fibers
Action Potentials
 The heart’s electrical activity results from
ion shifts across the cell membrane.
 Polarized
 Resting State: no electrical activity take place
 Normal ionic balance – slightly negative inside the
cell.
 Depolarization
 Creating a positive charge within the cell
 The electricity gets “turned on”…like a large
wave…..contraction of the myocardium….Lub Dub !!
 Repolarization
 Inside the cell returning to a negative charge;
returning to the resting state.
Cardiac Pacemakers
 SA Node
 “Normal” pacemaker
 Intrinsic rate 60-100
beats/min
 AV Node
 Intrinsic rate 40-60
beats/min
 Purkinje Fibers
 Intrinsic rate 20-40
beats/min
Electrocardiography
 Abbreviated as EKG or ECG
 Depicts the electrical activity of the
heart
 Shows Dysrhythmias
 Conduction Abnormalities
 Electrolyte Imbalances
 Chamber Abnormalities (i.e. hypertrophy)
 Drug effectiveness
 Myocardial Ischemia or Infarction
Bedside Monitoring

 Lead Placement
 Three Leadwire System
 White: Right Arm (RA)
 2nd intercostal
space, right

midclavicular line
 Black: Left Arm (LA)
 2nd intercostal
space, left

midclavicular line
 Red: Left Leg (LL)
 Placed on the left
lower rib cage
 8th intercostal
space, left
midclavicular line
Bedside Monitoring Cont.,
 Lead Placement
 Five Leadwire Systems
 White: Right Arm (RA)
 Black: Left Arm (LA)
 Red: Left Leg (LL)
 Green: Right Leg (RL)
 Placed at the 8th
intercostal
space, Right
midclavicular line
 Brown: chest lead (C)
 Usually placed 4th
intercostal space,
right sternal border
Components of ECG / EKG
 Complexes / Waves
 P wave
 QRS complex
 T wave
 Intervals
 Measured including a wave
 PR interval
 QT interval
 Segments
 Measured between waves
 ST segment
P Wave
 Indicates atrial
depolarization, or
contraction of the
atrium.
 First positive deflection
 Simultaneous
contraction of the
atria forces blood
through the AV valves
(tricuspid and mitral)
between the atria and
ventricles.
PR Interval
 Represents the time
required for atrial
depolarization, the impulse
delay through the AV node
and travel time to the
Purkinje fibers.
 Duration time is 0.12 to
0.20 seconds
 Measured from the
beginning
of the P wave
to the beginning

of the QRS complex

QRS Complex
 Indicates ventricular
depolarization, or
contraction of the ventricles.
 Q wave negative
deflection (Most don’t
have !!)
 R wave positive
deflection
 S wave negative
deflection
 Duration time is < 0.10
seconds
 Measured from the beginning of
QRS complex to the end of the S
wave
ST Segment
 Isoelectric line
representing the early
ventricular
repolarization or
ventricular resting.
 Measured from the
end of the
QRS complex
to the beginning
of
the T wave.
T Wave

 Indicates
ventricular
repolarization or
resting of the
ventricles

 Positive Deflection
QT Interval
 Indicates total time
required for
ventricular
depolarization and
repolarization.

 Measured from the

beginning of the
QRS complex to the
end of the T wave
EKG Paper
 Vertical Axis
Amplitude (Voltage)

 Small Boxes= 0.04 seconds

 Horizontal Axis  Large Boxes= 0.20 seconds
 Time(in seconds
 5 large boxes = 1second
How To Read An EKG
 Determine:
 Rate
 Rhythm
 Configuration / Conduction
 P Wave
 PR Interval
 Relationship between P waves & QRS
complexes
 QRS Complex
 T Wave
 Evaluate Any Other Components
Determining Rhythm
 Calipers
 Piece of Paper
Calculating Rate Cont.,
 10-Times Method
 Obtain a six second strip (30 large boxes)
 Count the number of R waves and multiple by
10.
 Good for irregular rhythms; less precise
Calculating Rate Cont.,
 Sequence Method
 Find R wave on heavy black line; start counting
with the next heavy black line in sequence until
you’re the next R wave.
 Only good for regular rhythms, less precise
Normal Sinus Rhythm (NSR)

 Rate: 60-100 beats /min

 Rhythm: Regular
 Pacemaker: SA Node
 P wave: Same Morphology (shape & size)
 PR Interval: Normal (0.12 - 0.20)
 QRS Complex: Normal (< 0.10)
 P to QRS Ratio: 1:1 (One P wave in front of each
QRS complex)
 Treatment: None
Sinus Dysrhythmias

 Sinus Bradycardia
 Sinus Tachycardia
 Sinus Arrhythmia
Sinus Bradycardia ++

 Rate: < 60 beats /min

 Rhythm: Regular
 Pacemaker: SA Node
 P wave: Same Morphology
 PR Interval: Normal
 QRS Complex: Normal
 P to QRS Ratio: 1:1
Sinus Tachycardia ++

 Rate: >100 beats/min (150 upper limit)

 Rhythm: Regular
 Pacemaker: SA Node
 P wave: Same Morphology
 PR Interval: Normal
 QRS Complex: Normal
 P to QRS Ratio: 1:1
Sinus Arrhythmia ++

 Rate: 60-100 beats /min (variable)

 Rhythm: Slightly Irregular
 Respiratory variation: ↑ rate: inspiration & ↓rate:
expiration
 P wave: Same Morphology
 Pacemaker: SA Node
 PR Interval: Normal
 QRS Complex: Normal
 P to QRS Ratio: 1:1
 Treatment: None
Atrial Flutter +

 Rate:
 Atrial: 250-400 beats/min & Ventricular: 60-150
beats/min
 Rhythm: Both Atrial & Ventricular Regular
 Pacemaker: Ectopic Atrial Focus / AV block
 P wave: “Sawtooth” pattern (F waves)
 PR Interval: Difficult to Determine
 QRS Complex: Normal
 P to QRS Ratio: 2:1, 3:1 or 4:1
Atrial Fibrillation (A-Fib)+

 Rate:
 Atrial: 350-600 beats/min & Ventricular: 100-200
beats/min
 Rhythm: Both Atrial & Ventricular Irregular
 Pacemaker: Numerous Ectopic Atrial Foci
 P wave: No Identifiable P waves
 PR Interval: Unable To Determine
 QRS Complex: Normal
 P to QRS Ratio: Many:1
Junctional Dysrhythmias

 Premature Junctional Contraction

 Junctional / Idionodal Rhythm

Premature Junctional Contraction

 Rate: Depends on underlying rhythm

 Rhythm: Irregular- due to the early complex
 Pacemaker: Early beat - Ectopic Junctional Focus
 P wave:
 Absent (obscured by QRS)
 Inverted before or after the QRS complex
 PR Interval: Normal; early beats maybe different
 QRS Complex: Normal
 P to QRS Ratio: 0:1 or 1:1
PJC Cont.,
 Junctional Rhythm + Junctional
Rhythm + PJC Cont.,

 Rate: 40-60 beats /min (intrinsic rate of AV node)

 Rhythm: Regular
 Pacemaker: AV Node
 P wave:
 Absent (obscured by QRS)
 Inverted before or after the QRS complex
 PR Interval: Normal or Unable To Determine
 QRS Complex: Normal
 P to QRS Ratio: 0:1 or 1:1
Supraventricular Tachycardia +

 Rate: 150-250 beats /min

 Rhythm: Regular
 P wave: Difficult to identify if present; hidden in T
wave
 Pacemaker: Ectopic Atrial Focus or Junctional Focus
 PR Interval: Normal
 QRS Complex: Usually Normal
 P to QRS Ratio: 1:1
 *SVT with sudden onset and cessation is termed
“paroxysmal”
AV Conduction Abnormalities

 First Degree AV Block

 Second Degree AV Block
 Mobitz Type I / Wenckebach
 Mobitz Type II
 Third Degree AV Block
First Degree AV Block +

 Rate: Depends on underlying rhythm

 Rhythm: Depends on underlying rhythm
 P wave: Same morphology
 Pacemaker: Abnormal delay at AV Node
 PR Interval: Prolonged > 0.20 & Constant
 QRS Complex: Usually Normal
 P to QRS Ratio: 1:1
Second Degree AV Block:
Mobitz Type I / Wenckebach +

 Rate: Depends on underlying rhythm

 Rhythm: Depends on underlying rhythm
 P wave: Same morphology; intermittently not
conducted
 Pacemaker: Block at AV Node
 PR Interval: Progressively increases until a p wave
until appears without a QRS complex; “longer,
longer, drop!”
 QRS Complex: Usually Normal
 P to QRS Ratio: More p waves than QRS complexes
Second Degree AV Block:
Mobitz Type II +

 Rate: Depends on underlying rhythm

 Rhythm: Depends on underlying rhythm
 P wave: Same morphology; intermittently not
conducted
 Pacemaker: Block below the AV Node
 PR Interval: When present constant; may be
prolonged
 QRS Complex: Usually Normal
 P to QRS Ratio: More p waves than QRS complexes
 Third Degree AV Block / Complete
Heart Block +

 Rate: Depends on underlying rhythm; Atrial rate

faster than ventricular rate
 Rhythm: Depends on underlying rhythm
 P wave: Same morphology; intermittently not
conducted
 Pacemaker: Two separate impulses atria & ventricle
 PR Interval: Very Irregular
 QRS Complex: Usually Abnormal
 P to QRS Ratio: No relationship between p waves
and QRS complexes; more p waves that QRS
complexes
Ventricular Dysrhythmias
 Premature Ventricular Contraction
 Ventricular Tachycardia
 Ventricular Fibrillation
 Idioventricular Rhythm
 Asystole: Ventricular Standstill
Premature Ventricular Contraction
(PVC) +

 Rate: Depends on underlying rhythm

 Rhythm: Irregular- due to early complex
 Pacemaker: Early complex - ectopic ventricular
focus
 P wave: Absent in early complex
 PR Interval: Normal; early complex may be
different
 QRS Complex: Early, Wide and Bizarre !!
 P to QRS Ratio: 0:1 or 1:1
PVC: Configurations

 Bigeminy
 PVC every other
beat

 Trigeminy
 PVC every third beat
PVC: Configurations Cont,

 Couplet*
 Two PVC’s in a row

 Triplet*
 Three PVC’s in a row
 AKA “Run of V-Tach”
* More dangerous !!
 PVC: More Dangers
 R on T Phenomenon *
 The superimposition of an ectopic beat on
the peak of the preceding T wave, which
could result in ventricular tachycardia or
ventricular fibrillation.
PVC: Configurations Cont.,
 Unifocal PVC
 PVC’s are identical (same shape)

 Multifocal PVC*
 PVC’s with different shapes; more dangerous
!!
Ventricular Tachycardia (VT) +

 Rate: >100 beats/minute

 Rhythm: Regular
 Pacemaker: Ectopic Ventricular Focus
 P wave: None
 PR Interval: Unable to Determine
 QRS Complex: Wide and Bizarre
 P to QRS Ratio: Unable to Determine
 Ventricular Fibrillation (VF) +
Coarse
“early”

Fine
“late”

 Rate: > 300 beats/minute

 Rhythm: Extremely Irregular
 Pacemaker: Ectopic Ventricular Foci
 P Wave: None
 QRS Complex: Undulations; No Identifiable QRS
Idioventricular Rhythm+

 Rate: Ventricular = 20 - 40 beats /min

 Rhythm: Regular
 Pacemaker: Purkinje Fibers
 P Wave: None
 PR Interval: Unable To Determine
 QRS Complex: WIDE & BIZZARE !!
 Asystole:
Ventricular Standstill +

 Rate: NONE
 Rhythm: NONE
 Pacemaker: NONE
 P wave: NONE
 QRS Complex: NONE
 Treatment (ACLS):
 Immediate Cardiopulmonary resuscitation (CPR)
 Medications: i.e. epinephrine, atropine
 Emergency cardiac pacing
 Treat or remove underlying cause !!
Pacemaker Strips
 Atrial Pacemaker

 Ventricular Pacemaker
 Nursing: Temporary Pacemakers
 Nursing Considerations
 Potential for microshock and infection
 Nursing Education
 Explain device & why it is needed
 Care of Device
 Notify nurse if dressing is loose or wet
 Minimize lead handling

 Not to touch or manipulate generator settings

 Symptoms to Report
 i.e. SOB or lightheadedness
Thank you