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Interpretation of an ECG Strip

Step 1: Heart Rate.
Step 2: Heart Rhythm.
Step 3: P – Wave.
Step 4: PRI.
Step 5: QRS ...
How to calculate heart rate from ECG?
Calculating the heart rate when the rhythm is regular
• There are 300 large squares per minute
• If the rhythm is regular ...
6-Second Method: Have a six second strip, count the QRS
complexes and multiple by 10.
To accurately determine the
regularity of the rhythm,
measure the R-R interval
across the entire strip .

 Is the distanc...
P – Wave

5 Keys: Questions:

-

Are P-wave presents?
Are P-wave occurring Regularly ?
Is there a P-wave for each QRS comp...
PR Interval
• Normal length of the PR Interval is
•
•
•

(0.12 – 0.20 Seconds , 3-5 small
squares).
Are PRI greater than 0...
• Normal Duration: less than 0.12 seconds (less than 3 small
boxes).

• Are QRS same in shape?
• Are QRS Greater than 0.12...
Dysrhthmias
Causes:
6 H’s & 5 T’s are mostly common:
6 H’s

5 T’s

Hypoxia

Toxins (Drugs).

Hypothermia

Tamponade

Hypo...
Normal Sinus Rhythm

Implies normal sequence of conduction, originating in the sinus node and
proceeding to the ventricles...
Bradycardia

• HR< 60 bpm; every QRS narrow, preceded by p wave
• Can be normal in well-conditioned athletes
Bradycardia-Etiology
•
•
•
•
•
•

Increased Vagal tone.
Hypothermia.
Hypothyroidism.
Seizures.
Increased intracranial
pres...
ACLS – Bradycardia Drugs
•
•
•

Atropine.
Epinephrine.
Dopamine.
Junctional Rhythm

•
•
•
•

Heart rate: 40 – 60 bpm.
QRS Narrow complex less than 0.12 seconds.
Electrical impulse come fr...
Accelerated Junctional Rhythm

•
•
•
•

Heart rate: 60- 100 bpm.
QRS Narrow complex less than 0.12 seconds.
Electrical imp...
Junctional Tachycardia

•
•
•
•

Heart rate: above 100 bpm.
QRS Narrow complex less than 0.12 seconds.
Electrical impulse ...
Premature Ventricular Complex PVC

•
•
•
•
•

Rate: within normal range
Rhythm: Regular.
Narrow QRS complex, less than 0.1...
Bigeminy PVCs
• Premature Ventricular beats occurring after
every normal beat.
Trigeminy PVCs
• PVCs occur at intervals of 2 normal beats to 1
PVC 
Quadrigeminy PVCs
• PVCs occur at intervals of 3 normal beats to 1
PVC 
Premature Atrial contraction
PACs occur when another region of the atria
depolarizes before SA Node and thus triggers a
pr...
Premature Junctional Contraction
1st Degree AV Block

• P – wave present.
• Narrow QRS Complex
• Prolonged PRI, More than 0.2 seconds (5 small boxes)
2nd Degree AV Block Mobitz type I
(Wenckebach)

•
•
•
•
•

Rhythm - Regularly irregular
Rate - Normal or Slow
QRS Duration...
2nd Degree block Type II (Mobitz 2)

•
•
•
•
•
•

Rhythm - Regular
Rate - Normal or Slow
QRS Duration - Prolonged
P Wave -...
3 rd Degree AV Block (Complete Heart
Block)

•
•
•
•
•
•
•
•

Complete AV disassociation, HR is a ventricular rate
Rhythm ...
Idioventricular
•
•
•

P – Wave : Absent.
QRS: > 0.12 Seconds.
Rate : 20 – 40
•
•

HR > 100 bpm, regular
Often difficult to distinguish p and t waves
Tachycardia-Etiology
•
•
•
•
•

Fever
Hyperthyroidism
Anxiety
Sepsis
Anemia

•
•
•
•
•
•

Hypotension and shock
Pulmonary ...
ACLS – Tachycardia Drugs
•
•
•
•
•
•
•

Adenosine.
Diltiazem.
Beta Blockers.
Amiodarone.
Digoxin.
Verapamil.
Magnesium Sul...
Atrial Fibrillation

•
•
•
•

Irregularly irregular rhythm
Absence of definite p waves
Narrow QRS, less than 0.12 seconds
...
Atrial Flutter – Saw Teeth

Rate: 250 – 350 bpm.
Rhythm: Usually Regular.
No True P-waves are presents – saw teeth.
PRI – ...
Supraventricular Tachycardia

• Rate: Atrial Rate 150 – 250 bpm, Ventricular Rate 150- 250
•
•
•
•

bpm.
Rhythm: Regular.
...
Ventricular Tachycardia

•
•
•
•
•

Rhythm: regular.
Rate: 100 – 220 bpm
P - wave: non associated with QRS, Some time visi...
Non-sustained Ventricular tachycardia

• Defined as 3 or more consecutive ventricular beats
• Rate of >120 bpm, lasting le...
Ventricular Fibrillation

Rhythm - Irregular
Rate - 300+, disorganized
QRS Duration - Not recognizable
P Wave - Not seen

...
ACLS – VF & VT Drugs
•
•
•
•

Epinephrine.
Vasopressin.
Amiodarone.
Lidocaine
Torsade's De Pointes

• QRS morphology of V Tach keeps
changing
A Systole

•
•
•
•
•

Rhythm - Flat
Rate - 0 Beats per minute
QRS Duration - None
P Wave - None
Carry out CPR!!
PEA – Pulseless Electrical Activity
It is a rhythm appear on monitor but without
sensible pulse
All rhythms without pulse called PEA
EXCEPT:
1- VF
2- Pulseless VT.
3- A systole.
4- Torsade's De Pointes
Thank You
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
Cardiac arrythemia - ACLS Course
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Cardiac arrythemia - ACLS Course

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Cardiac arrythemia - ACLS Course

  1. 1. Interpretation of an ECG Strip Step 1: Heart Rate. Step 2: Heart Rhythm. Step 3: P – Wave. Step 4: PRI. Step 5: QRS Complex
  2. 2. How to calculate heart rate from ECG?
  3. 3. Calculating the heart rate when the rhythm is regular • There are 300 large squares per minute • If the rhythm is regular count the number of large squares between two QRS complexes and divide it into 300.
  4. 4. 6-Second Method: Have a six second strip, count the QRS complexes and multiple by 10.
  5. 5. To accurately determine the regularity of the rhythm, measure the R-R interval across the entire strip .  Is the distance between R-R interval is constant?
  6. 6. P – Wave 5 Keys: Questions: - Are P-wave presents? Are P-wave occurring Regularly ? Is there a P-wave for each QRS complex? Are p-waves upright or converted? Are they all similar in appearance?
  7. 7. PR Interval • Normal length of the PR Interval is • • • (0.12 – 0.20 Seconds , 3-5 small squares). Are PRI greater than 0.12 seconds? Are PRI smaller than 0.12 seconds? Are the PRI’s constant across the ECG Strip?
  8. 8. • Normal Duration: less than 0.12 seconds (less than 3 small boxes). • Are QRS same in shape? • Are QRS Greater than 0.12 seconds? • Are QRS Less than 0.12 seconds?
  9. 9. Dysrhthmias Causes: 6 H’s & 5 T’s are mostly common: 6 H’s 5 T’s Hypoxia Toxins (Drugs). Hypothermia Tamponade Hypoglycemia Tension Pneumothorax Hypo/hyper kalemia Thrombosis (coronary, pulmonary) Hypovolemia Trauma Hydrogen Ion (Acidosis)
  10. 10. Normal Sinus Rhythm Implies normal sequence of conduction, originating in the sinus node and proceeding to the ventricles via the AV node and His-Purkinje system. ECG Characteristics: Regular narrow-complex rhythm Rate 60-100 bpm Each QRS complex is proceeded by a P wave
  11. 11. Bradycardia • HR< 60 bpm; every QRS narrow, preceded by p wave • Can be normal in well-conditioned athletes
  12. 12. Bradycardia-Etiology • • • • • • Increased Vagal tone. Hypothermia. Hypothyroidism. Seizures. Increased intracranial pressure. Aging • • • • Sleep. Intrinsic disease of SA Node (e.g. sick sinus syndrome). Side effect of some drugs like digitalis, calcium channel blockers Result of complication of some diseases like rheumatic fever, viral myocaditis, diphtheria •• Bradycardia is Normal to Athletic people Bradycardia is Normal to Athletic people
  13. 13. ACLS – Bradycardia Drugs • • • Atropine. Epinephrine. Dopamine.
  14. 14. Junctional Rhythm • • • • Heart rate: 40 – 60 bpm. QRS Narrow complex less than 0.12 seconds. Electrical impulse come from the AV Node (Junctional). P – Wave: Absent or Inverted or after QRS, or come shorter than PR Interval (less than 0.12 Seconds
  15. 15. Accelerated Junctional Rhythm • • • • Heart rate: 60- 100 bpm. QRS Narrow complex less than 0.12 seconds. Electrical impulse come from the AV Node (Junctional). P – Wave: Absent or Inverted or after QRS, or come shorter than PR Interval (less than 0.12 Seconds
  16. 16. Junctional Tachycardia • • • • Heart rate: above 100 bpm. QRS Narrow complex less than 0.12 seconds. Electrical impulse come from the AV Node (Junctional). P – Wave: Absent or Inverted or after QRS, or come shorter than PR Interval (less than 0.12 Seconds
  17. 17. Premature Ventricular Complex PVC • • • • • Rate: within normal range Rhythm: Regular. Narrow QRS complex, less than 0.12 seconds. P-wave normal. PRI Is normal.
  18. 18. Bigeminy PVCs • Premature Ventricular beats occurring after every normal beat.
  19. 19. Trigeminy PVCs • PVCs occur at intervals of 2 normal beats to 1 PVC 
  20. 20. Quadrigeminy PVCs • PVCs occur at intervals of 3 normal beats to 1 PVC 
  21. 21. Premature Atrial contraction PACs occur when another region of the atria depolarizes before SA Node and thus triggers a premature heartbeat.
  22. 22. Premature Junctional Contraction
  23. 23. 1st Degree AV Block • P – wave present. • Narrow QRS Complex • Prolonged PRI, More than 0.2 seconds (5 small boxes)
  24. 24. 2nd Degree AV Block Mobitz type I (Wenckebach) • • • • • Rhythm - Regularly irregular Rate - Normal or Slow QRS Duration - Normal P Wave rate - Normal but faster than QRS rate P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped
  25. 25. 2nd Degree block Type II (Mobitz 2) • • • • • • Rhythm - Regular Rate - Normal or Slow QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 P Wave rate - Normal but faster than QRS rate P-R Interval - Normal or prolonged but constant
  26. 26. 3 rd Degree AV Block (Complete Heart Block) • • • • • • • • Complete AV disassociation, HR is a ventricular rate Rhythm - Regular Rate - Slow QRS Duration - Prolonged P Wave - Unrelated P Wave rate - Normal but faster than QRS rate P-R Interval - Variation Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm
  27. 27. Idioventricular • • • P – Wave : Absent. QRS: > 0.12 Seconds. Rate : 20 – 40
  28. 28. • • HR > 100 bpm, regular Often difficult to distinguish p and t waves
  29. 29. Tachycardia-Etiology • • • • • Fever Hyperthyroidism Anxiety Sepsis Anemia • • • • • • Hypotension and shock Pulmonary embolism Acute coronary ischemia and myocardial infarction Heart failure Chronic pulmonary disease Hypoxia
  30. 30. ACLS – Tachycardia Drugs • • • • • • • Adenosine. Diltiazem. Beta Blockers. Amiodarone. Digoxin. Verapamil. Magnesium Sulphate
  31. 31. Atrial Fibrillation • • • • Irregularly irregular rhythm Absence of definite p waves Narrow QRS, less than 0.12 seconds Can be accompanied by rapid ventricular response
  32. 32. Atrial Flutter – Saw Teeth Rate: 250 – 350 bpm. Rhythm: Usually Regular. No True P-waves are presents – saw teeth. PRI – Usually constant QRS Complex usually normal less than 0.12 seconds
  33. 33. Supraventricular Tachycardia • Rate: Atrial Rate 150 – 250 bpm, Ventricular Rate 150- 250 • • • • bpm. Rhythm: Regular. Narrow QRS complex, less than 0.12 seconds. P-wave usually is discernable. PRI usually is discernable.
  34. 34. Ventricular Tachycardia • • • • • Rhythm: regular. Rate: 100 – 220 bpm P - wave: non associated with QRS, Some time visible. PRI: None. QRS: Wide complex, greater than 0.12 seconds Shock this rhythm if the patient is unconscious and without a pulse
  35. 35. Non-sustained Ventricular tachycardia • Defined as 3 or more consecutive ventricular beats • Rate of >120 bpm, lasting less than 30 seconds • May be discovered on Halter, or other exercise testing
  36. 36. Ventricular Fibrillation Rhythm - Irregular Rate - 300+, disorganized QRS Duration - Not recognizable P Wave - Not seen This patient needs to be defibrillated!! QUICKLY
  37. 37. ACLS – VF & VT Drugs • • • • Epinephrine. Vasopressin. Amiodarone. Lidocaine
  38. 38. Torsade's De Pointes • QRS morphology of V Tach keeps changing
  39. 39. A Systole • • • • • Rhythm - Flat Rate - 0 Beats per minute QRS Duration - None P Wave - None Carry out CPR!!
  40. 40. PEA – Pulseless Electrical Activity It is a rhythm appear on monitor but without sensible pulse
  41. 41. All rhythms without pulse called PEA EXCEPT: 1- VF 2- Pulseless VT. 3- A systole. 4- Torsade's De Pointes
  42. 42. Thank You

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