Advanced EMT A Clinical-Reasoning Approach 2nd Edition

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Appendix 2
Advanced ECG
Recognition

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Advanced EMT
Education Standard
• ECG recognition is supplemental to the Advanced
EMT Education Standards. The information in this
appendix is provided for programs that choose to
teach advanced ECG recognition.

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Objectives (1 of 2)
1. Identify the indications, purpose, and limitations of
continuous ECG monitoring.
2. Relate the waves, segments, and intervals of the ECG to
events in the cardiac cycle.
3. Explain the clinical significance of common dysrhythmias.
4. Demonstrate lead placement to obtain a Lead II ECG.
5. Use the rules for identifying normal sinus rhythm as the
basis for comparison of ECGs.
6. Recognize and identify a variety of ECG tracings and the
characteristics of each.

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Objectives (2 of 2)
7. Describe the purpose of prehospital 12-lead ECGs.
8. Demonstrate lead placement to obtain a 12-lead ECG.

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Figure A2-1
Placement of electrodes to monitor Lead II.

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Figure A2-3
Using graph paper markings to measure voltage and time.

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Table A2-1
Normal Cardiac Cycle
ECG Feature Normal Duration Action Within the Heart
P wave 0.04–0.08 sec Atrial depolarization
P–R interval 0.12–0.20 sec “Pause” created by the
atrioventricular node to
allow full atrial contraction
QRS complex Less than 0.12 sec Ventricular depolarization
T wave Not defined Ventricular repolarization

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• Regularity: Regular
• Rate: 60–100 bpm
• P-waves: Uniform, upright
• P–R interval: 0.12–0.20 seconds
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
Normal Sinus Rhythm

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Figure A2-4
Rhythm strip: Normal sinus rhythm.

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• Regularity: Regular
• Rate: 100–150 bpm
• P-waves: Uniform, upright
• P–R interval: 0.12–0.20 seconds
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
Sinus Tachycardia

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Figure A2-5
Rhythm strip: Sinus tachycardia.

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• Regularity: Regular
• Rate: Less than 60 bpm
• P-waves: Uniform, upright
• P–R interval: 0.12–0.20 seconds, may be slightly
slower at slower heart rates
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
Sinus Bradycardia

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Figure A2-6
Rhythm strip: Sinus bradycardia.

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• Regularity: Irregular (regularly irregular)
• Rate: Varies but averages between 60–100 bpm
• P-waves: Uniform, upright
• P–R interval: 0.12–0.20 seconds
• QRS complex width: Usually less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
Sinus Dysrhythmia

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Figure A2-7
Rhythm strip: Sinus dysrhythmia.

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• Regularity: Regular
• Rate: Greater than 150 bpm
• P-waves: May be present; not discernible in very rapid
rates
• P–R interval: Not discernible
• QRS complex width: Less than 0.12 seconds
• P–QRS relationship: Not reliable
Supraventricular Tachycardia

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Figure A2-8
Rhythm strip: Supraventricular tachycardia.

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• Regularity: Irregular (irregularly irregular)
• Rate: Varies
• P-waves: Absent; “wavering baseline”
• P–R interval: None
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: None
Atrial Fibrillation

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Figure A2-9
Rhythm strip: Atrial fibrillation.

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• Regularity: Usually regular, may be regularly irregular
• Rate: Varies upon conduction
• P-waves: Absent; flutter waves
• P–R interval: None
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: None
Atrial Flutter

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Figure A2-10
Rhythm strip: Atrial flutter.

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• Regularity: Irregular; isolated PAC interrupts the
rhythm regularity
• Rate: Varies
• P-waves: Usually upright and uniform; consistent with
underlying rhythm
• P–R interval: Consistent with underlying rhythm;
0.12–0.20 seconds
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
Premature Atrial Complex (PAC)

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Figure A2-11
Rhythm strip: Premature atrial complex (PAC).

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• Regularity: Regular
• Rate: Bradycardic; usually 40–60 bpm
• P-waves: May be concealed by QRS; may appear
inverted either before or after QRS
• P–R interval: If discernible, short (greater than 0.12
seconds)
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: If discernible, P wave for every
QRS, QRS for every P wave
Junctional Escape Rhythm

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Figure A2-12
Rhythm strip: Junctional escape rhythm.

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• Regularity: Irregular
• Rate: Varies; ectopic beat
• P-waves: May be concealed by QRS; may appear
inverted either before or after QRS
• P–R interval: If discernible, short (greater than 0.12
seconds)
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: If discernible, P wave for every
QRS, QRS for every P wave
Premature Junctional Complex (PJC)

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Figure A2-13
Rhythm strip: Premature junctional complex (PJC).

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• Regularity: Usually regular
• Rate: Less than 40 bpm
• P-waves: Absent
• P–R interval: None
• QRS complex width: 0.12 seconds or greater; bizarre
• P–QRS relationship: None
Idioventricular Rhythm (IVR)

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Figure A2-14
Rhythm strip: Idioventricular rhythm (IVR).

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• Regularity: Irregular
• Rate: Varies; ectopic beat
• P-waves: Absent
• P–R interval: None
• QRS complex width: Wide, 0.12 seconds or greater;
bizarre
• P–QRS relationship: None
Premature Ventricular Complex (PVC)

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Figure A2-15
Rhythm strip: Premature ventricular complex (PVC).

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• Regularity: Regular
• Rate: 150–250 bpm
• P-waves: Absent
• P–R interval: None
• QRS complex width: Wide, 0.12 seconds or greater;
bizarre
• P–QRS relationship: None
Ventricular Tachycardia (VT)

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Figure A2-16
Rhythm strip: Ventricular tachycardia (VT).

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• Regularity: Cannot be determined
• Rate: Cannot be determined
• P-waves: None
• P–R interval: None
• QRS complex width: None
• P–QRS relationship: None
Ventricular Fibrillation (VF)

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Figure A2-17
Rhythm strip: Ventricular fibrillation (VF).

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• Regularity: Cannot be determined
• Rate: Cannot be determined
• P-waves: None
• P–R interval: None
• QRS complex width: None
• P–QRS relationship: None
Asystole

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Figure A2-18
Rhythm strip: Asystole.

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• Regularity: Regular
• Rate: Depends on underlying sinus rate
• P-waves: Present; upright and uniform
• P–R interval: Prolonged; greater than 0.20 seconds
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P wave for every QRS, QRS for
every P wave
First-Degree A-V Block

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Figure A2-19
Rhythm strip: First-degree A-V block.

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• Regularity: Regularly irregular
• Rate: Atrial rate usually 60–100 bpm (may be slower);
ventricular rate usually bradycardic (always less than
atrial)
• P-waves: Present; upright and uniform
• P–R interval: May be normal or prolonged where it
exists
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: P waves consistent; QRS
periodically missing from blocked conduction
Second-Degree A-V Block―Type I

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Figure A2-20
Rhythm strip: Second-degree A-V block Mobitz Type I.

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• Regularity: Irregular
• Rate: Depends on underlying sinus rate
• P-waves: Present; upright and uniform
• P–R interval: Varies; increasing in length until R-wave
drops, then repeats pattern
• QRS complex width: Normally less than 0.12 seconds
• P–QRS relationship: Inconsistent; more P waves that
QRS due to R wave periodically blocked
Second-Degree A-V Block―Type II

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Figure A2-21
Rhythm strip: Second-degree A-V block Mobitz Type II.

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• Regularity: Atrial and ventricular are regular
• Rate: Bradycardic; atrial near-normal to as low as 30
bpm; ventricular consistent at 30–40 bpm or lower
• P-waves: Present; upright and uniform
• P–R interval: None discernible
• QRS complex width: Usually wide (0.12 seconds or
greater) and bizarre
• P–QRS relationship: No correlation
Third-Degree A-V Block

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Figure A2-22
Rhythm strip: Third-degree A-V block.