Basic ECG

The Electrocardiogram
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Chapter 1
What isinthischapter
TheECG
Thenormal ECG
Theheart
Conduction system
Waveformdirection
ECGpaper
ECGleadsI, II, III

AugmentedlimbleadsaVR,
aVL,andaVF
Precordial (chest) leadsV ,V,
1 2
V3,V4,V5,andV6
Modified chest leads(MCL)
The ECG
ECG tracing
Identifiesirregularitiesin heart
rhythm.
Revealsinjury, death, or other
physical changesin heart muscle.
Usedasanassessment and
diagnostic tool in prehospital,
hospital, andother clinical
settings.
Canprovidecontinuous
monitoringof heartselectrical
activity.
Figure 1-1
The electrocardiograph is the device that detects, measures, and records the
ECG.
Chapter 1
Chapter 1
QRS
QRS
QRS
QRS
QRS
QRS
QRS
Figure 1-2
The electrocardiogram is the tracing or graphic representation of the hearts electrical activity.
Thenormal ECG
Upright, roundPwaves occurring at regular intervals at arate of 60to 100beatsper minute.
PRinterval of normal duration (0.12to 0.20seconds) followed byaQRScomplex of normal upright
contour, duration (0.06to 0.12seconds), andconfiguration.
FlatSTsegment followed byanupright, slightly asymmetrical Twave.
The heart
About the samesizeasits
ownersclosed fist.
Locatedbetweenthe two
lungsin mediastinum
behind the sternum.
Liesonthe diaphragmin front
of the trachea, esophagus, and
thoracic vertebrae.
About two thirds of it issituatedinthe left sideof the chest
cavity.
2nd rib
Base of
the heart
Sternum
Apex of
the heart
5th rib
Diaphragm
Chapter 1
Hasafront-to-back
(anterior- posterior)
orientation.
Its baseis directed posteriorly
andslightly superiorly at the
level of the second intercostal
space.
Its apexis directed anteriorly
andslightly inferiorly at the
level of the fifth intercostal
spacein the left midclavicular
line.
In this position the right ventricle iscloser to the front of the
left chest, while the left ventricle
is closer to the left sideof the
chest.
The Electrocardiogram 6
Chapter 1
Knowing the position and orientation of the heart will help
you to understand why certain ECG waveforms appear as they
do when the electrical impulse moves toward a positive or
negative electrode.
Posterior
Lung
s Thoracic
vertebra
Left
ventricle
Base of
the
heart
Sternum
B
Apex of
the heart
Right ventricle
Anterior
Figure 1-3
(a) Position of the heart in the chest.
(b) Cross section of the thorax at the level of the
heart.
Conductionsystem
Sinoatria
l node
Sinoatrial (SA)nodeinitiatesthe
heartbeat.
Impulsethenspreadsacrossthe right
andleft atrium.
Atrioventricular (AV)nodecarriesthe
impulsefromthe atria to the
ventricles.
Fromthe AVnodethe impulseiscarried
throughthe bundleof His, which then
divides into the right andleft bundle
branches.
Theright andleft bundlebranches
spreadacrossthe ventricles andeventually terminateinthe Purkinjefibers.
Inherent rate
60100 beats
per minute
Left atrium
1
Atrioventricula
r node
Inherent rate
4060 beats
per minute
Bundl
e of
His
Left and right
bundle
Left ventricle
Inherent rate
2040 beats
per minute
branches
Apex
Purkinje
fibers
Figure 1-4
Electrical conductive system of the heart.
Chapter 1
Chapter 1
Waveform
direction
Direction anECG
waveformtakes
dependsonwhether
electrical currents are
traveling toward or
away fromapositive
electrode.
Impulses traveling
perpendicular to the
positive electrode
may produce a
biphasic waveform
(one that has both a
positive and negative
deflection).
Impulses
traveling away
from a positive
electrode and/or
toward a
negative
electrode will
produce
downward
deflections.
Negative
electrode
Figure 1-5
Direction of electrical impulses and
waveforms.
Impulses traveling
toward a positive
electrode produce
upward deflections.
Positive
electrode
ECGpaper
Voltage
Heated
writing tip
Vertical
Grid layout on ECGpaper consists of horizontal and vertical

lines.
Allows quick determination
of duration andamplitude
of
waveforms, intervals, andsegments.
Vertical lines represent
amplitude in electrical
voltage(mV)or millimeters.
Horizontal linesrepresent
time.
Time
Moving
stylus
Horizontal
Figure 1-6
Recording the
ECG.
Chapter 1
Chapter 1
10
3 seconds
Voltage
Eachsmall square= 0.04

sec in duration and0.1mV
in amplitude.
Fivesmall squares= one
largebox and0.20seconds
in duration.
Horizontal
measurements
determineheart rate.
15largeboxes= 3seconds.
30largeboxes= 6seconds.
Onthe top or bottomof the
printout there areoften
vertical markingsto represent
1-, 3-, or
Time
Figure 1-7
ECG paper
values.
0.2
seconds
0.5 mV
(5 mm)
0.04
seconds
0.1 mV
(1 mm)
ECGleads
I, II, III
To properly position the electrodes, use the lettering located

on the top of the lead wire connector for each lead; LL
stands for left leg, LA stands for left arm, and RA stands for
right arm.
Bipolar leads
LeadI
Positiveelectrodeleft arm(or
under left clavicle).
Negativeelectroderight arm
(or belowright clavicle).
Groundelectrodeleft leg(or
left sideof chest in midclavicular line just beneathlast rib).
Waveforms arepositive.
view
or
RA
view
LA
Impulse
s moving
toward
=
the
positive
lead
= Upright
waveforms
LL
Lead I
Chapter 1
11
Chapter 1
LeadII
Positiveelectrodeleft leg (or on
left sideof chest in midclavicular
line just beneathlast rib).
Negativeelectroderight arm(or
below right clavicle).
Groundelectrodeleft arm(or
below left clavicle).
Waveforms arepositive.
or
RA
LA
Impulse
s moving
toward
= the
positive
lead
= Upright
waveforms
+
LL
Lead II
LeadIII
or
RA
LA
view
Positiveelectrodeleft leg (or left

sideof the chest in midclavicular
line just beneathlast rib).
Negativeelectrodeleft arm(or
below left clavicle).
Groundelectroderight arm
(or belowright clavicle).
Waveforms arepositive or
biphasic.
12
LL +
+
Figure 1-8 (a) Lead I. (b) Lead II. (c) Lead

III.
Impulse
s
intersect
= with
negative
to
ECG
positive
leadsof
layout
Lead III
= Upright or
biphasic
waveforms
Augmentedlimb
andaVF
Unipolar leads.
EnhancedbyECGmachine becausewaveformsproducedbytheseleadsare normallysmall.
Impulse
s moving
away
from the
positive
lead
= Downward
waveforms
LeadaVR
Positiveelectrode placedonright arm.
Waveforms havenegativedeflection.
Views baseof the heart, primarily the atria.
Lead aVR
Chapter 1
13
Chapter 1
LeadaVL
Positiveelectrode placedon
left arm.
Waveforms havepositive
deflection.
Views the lateral wall of the
left ventricle.
Impulses
moving
toward
the
positive
lead
= Upright or
biphasic
waveforms
moving
toward
the
positiv
e lead
= Upright
waveforms
Lead aVL
LeadaVF
left leg.
Waveforms haveapositive
deflection.
Views the inferior wall of the
left ventricle.
+
C
Lead aVF
Figure 1-9 (a) Lead aVR. (b) Lead aVL. (c) Lead
aVF.
14
Precordial (chest)
leadsV1, V2, V3, V4,
V5, andV6
LeadV1 electrode is placed onthe right sideof

the sternumin the fourth intercostal space.
LeadV2 is positionedonthe left sideof the
sternumin the fourth intercostal space.
LeadV3 is located betweenleadsV2 andV4.
LeadV4 is positionedat the fifth intercostal
spaceat the midclavicular line.
LeadV5 is placedin the fifth intercostal space
at the anterior axillaryline.
LeadV6 is located level with V4 at the
midaxillaryline.
V6
V1
V5
V2
V3
V1
V2
V3
V4
V4
V5
V6
Figure 1-10 Precordial leads.

Chapter 1
15
Chapter 1
Modified chest leads(MCL)

MCL1 andMCL6 providecontinuous
cardiac monitoring.
For MCL1, place the positive electrode
in sameposition asprecordial leadV1
(fourth intercostal spaceto the right
of the sternum).
For MCL6, place the positive electrode
in sameposition asprecordial leadV6
(fifth intercostal spaceat the midaxillary line).
= Downward
waveforms
G
RA
LA
Impulse
s moving
away
from the
positive
lead
LL
MCL1
G
RA
LA
=
Upright
Impulse waveforms
s moving
toward
the
positive
lead
+
LL
MCL6
Figure 1-11 MCL leads. (a) MCL1 and (b)

MCL6.
16
Analyzingthe ECG
Chapter 2
What is in thischapter
Five-step (and nine-step)
process
Methods for determining the
heart rate
Analyzing the ECG 18
Dysrhythmias by heart rate

Determining regularity
Methods used to determine
regularity
ECGwaveforms
Five-step (andnine-step) process
Thefive-step process(andnine-step) is alogical andsystematicprocess for analyzing

ECGtracings
1. Determinethe rate. (Isit normal, fast, or slow?)
2. Determinethe regularity.(Isit regular or irregular?)
3. Assessthe Pwaves. (Isthere auniformPwave precedingeachQRScomplex?)
4. Assessthe QRScomplexes. (AretheQRScomplexeswithin normal limits?Dothey
appearnormal?)
5. Assessthe PRintervals. (Arethe PRintervals identifiable? Within normal limits?
Constant in duration?)
Four more steps can be added to the five-step process making it a nine-step process.
6. Assessthe STsegment. (Isit aflat line?Isit elevatedor depressed?)
7. Assessthe Twaves. (Isit slightly asymmetrical?Isit of normal height?Is it oriented in
the samedirection asthe precedingQRScomplex?)
8. Lookfor Uwaves. (Aretheypresent?)
9. Assessthe QTinterval. (Isit within normal limits?)
Chapter 2
Analyzing the ECG
19
Chapter 2
Five-step process
Assess
Rate
Regularity
P waves
QRS complexes
PR intervals
A
Nine-step process
Assess
Rate
Regularity
P waves
QRS
PR
ST
QT
complexes
intervals
segments
waves
waves
intervals
Figure 2-1 (a) The five-step process. (b) Nine-step

process.
Methods for determining the heart rate

Usingthe6-second! 10method
Multiply by10the number of QRScomplexes(for the ventricular rate)andthe Pwaves (for the atrial
rate)foundin a6-secondportion of ECGtracing. Theratein the ECGbelow isapproximately70beats
per minute.
1
Multiply the number of QRS complexes or P waves by 10

3-second
marks
3-second interval
Figure 2-2 6-second interval! 1 0

method.
3-second interval
6-second interval
Chapter 2
Analyzing the ECG
21
Usingthe300, 150, 100, 75, 60, 50

method
Beginbyfinding an
Rwave (or Pwave)
located onaboldline
(thestart point).
Thenfind the next
consecutiveRwave.
R
Theboldline it falls wave
on(or isclosest to) is
the endpoint and
representsthe
heart rate.
If the second Rwave
doesnot fall onabold
line the heart rate must
beapproximated.
Chapter 2
The heart rate in the ECG below is

approximately 100 beats per minute.
Start
point
End
point
Figure 2-3 300, 150, 100, 75, 60, 50

method.
Usingthe thinlines todetermine the heart rate

Tomoreprecisely determinethe heart ratewhen the second Rwave fallsbetween
two boldlines, youcan usethe identifiedvaluesfor eachthin line.
Start
point
300
150
250
100
136
214
188
167
75
94
125
115
107
60
72
88
68
84
79
50
58
56
65
63
43
48
47
54
52
38
42
41
45
44
33
37
36
40
39
35
34
Figure 2-4 Identified values shown for each of the thin

lines.
Analyzing the ECG
Chapter 2
23
Chapter 2
Usingthe1500method
Beginbycounting number of small squaresbetweentwo consecutiveRwaves anddivide 1500by
that number. Remember,this method cannot beusedwith irregular rhythms.
Start
point
1500 divided by 38 small boxes = 40 beats per minute
38 small
boxes
End
point
Figure 2-5 The 1500

method.
Dysrhythmias byheart rate

Averageadult hasaheart rate of 60-100beatsper minute(BPM).
Ratesabove100BPMor below60BPMareconsideredabnormal.
Aheart ratelessthan60BPMis calledbradycardia.
It mayor maynot haveanadverseaffect oncardiac output.
In the extremeit can leadto severereductions in cardiac output andeventuallydeteriorateinto
asystole(anabsenceof heart rhythm).
Aheart rategreater than100BPMis calledtachycardia.
It hasmanycausesandleadsto increased myocardial oxygenconsumption, which can
adverselyaffect patients with coronaryarterydiseaseandother medical conditions.
Extremelyfast rates can haveanadverseaffect oncardiac output.
Also, tachycardia that arisesfromthe ventricles mayleadto achaotic quiveringof the ventricles
called ventricular fibrillation.
Analyzing the ECG
Chapter 2
25
Chapter 2
Heart rate
Slow
Sinus bradycardia
Sinus arrest*
Junctional escape
Idioventricular rhythm
AV heart block
Atrial flutter or
fibrillation with slow
ventricular
response
Normal
Normal sinus rhythm

Sinus dysrhythmia
Wandering
atrial
pacemaker
Accelerated
junctional rhythm
Atrial flutter or
fibrillation with
normal ventricular
response
Fast
Sinus tachycardia
Junctional tachycardia
Atrial tachycardia,
SVT, PSVT
Multifocal atrial
tachycardia
(MAT)
Ventricular tachycardia
Atrial flutter or
fibrillation with fast
ventricular
response
*Heart rate can also be normal
Figure 2-6 Heart rate

algorithm.
Determiningregularity
Equal R-RandP-Pintervals
Normallythe heart beatsin aregular,rhythmic fashion. If the distance of the R-Rintervals
andP-Pintervals is the same, the rhythmis regular.
21
21
21
21
21
Figure 2-7 This rhythm is regular as each R-R and P-P interval is 21 small
boxes apart.
Chapter 2
21
Analyzing the ECG
27
Chapter 2
Unequal R-RandP-Pintervals
If the distance differs, the rhythmis irregular.
Irregular rhythmsareconsideredabnormal.
Usethe Rwave to measurethe distance betweenQRScomplexesasit istypically the tallest
waveformof the QRScomplex.
Remember,anirregular rhythmis consideredabnormal. Avariety of conditions can produce
irregularitiesof the heartbeat.
21
15
25
22
21 1/2
21 1/2
Figure 2-8 In this rhythm, the number of small boxes differs between some of the R-R and P-P
intervals. For this reason it is considered irregular.
Methods usedtodetermine regularity

Usingcalipers
PlaceECGtracing onaflat surface.
Place one point of the caliper on a
starting point, either the peakof an
Rwave or Pwave.
Openthe calipers bypulling the
other leg until the point is
positioned onthe next Rwave or P
wave.
With the calipers openin that
position, andkeepingthe point
positionedover the second Pwave or
Rwave, rotate the calipers across to
the peakof the next consecutive (the
third) Pwave or Rwave.
Peak of
first R or
P wave
Peak of
Peak of
second R or third R or
P wave
P wave
Peak of
fourth R or
P wave
Peak of
fifth R or
P wave
Figure 2-9 Use of calipers to identify

regularity.
Chapter 2
Analyzing the ECG
29
Chapter 2
Usingpaperandpen
Placethe ECGtracing onaflat
surface.
Positionthe straight edgeof apiece
of paper abovethe ECGtracing so
that the intervals are still visible.
Identify astarting point, the peakof
anRwave or Pwave, andplace amark
onthe paper in the corresponding
position aboveit.
Findthe peakof the next consecutive
Rwave or Pwave, andplace amark
onthe paper in the corresponding
position aboveit.
Move the paper across the ECGtracing, aligning the two marks with succeedingR-Rintervals or P-Pintervals.
Figure 2-10 Use of paper and pen to identify

regularity.
Countingthesmall squaresbetween eachR-Rinterval

Count the number of small squaresbetweenthe peaksof two consecutive Rwaves (or Pwaves)
andthencompare that to the other R-R(or P-P) intervals to reveal regularity.
This R-R interval is 21
small boxes in duration.
1+ 5 + 5 + 5 + 5 = 21
21
Figure 2-11 Counting the number of small squares to identify

regularity.
Chapter 2
Analyzing the ECG
31
Typesofirregularity
Chapter 2
Irregularitycan becategorizedas:
occasionally irregular or veryirregular.
slightly irregular.
suddenacceleration in the heart rate.
patterned irregularly.
irregularly(totally) irregular.
variable conduction ratio.
Eachtypeof irregularity is
associatedwith certain dysrhythmias. Knowing which
irregularity isassociated
with which dysrhythmias
makesit easier to later interOccasional
pret agivenECGtracing.
or very
Evaluating regularity
Regular
Slightly
Sudden
acceleration
in heart rate
Irregular
Patterned
Figure 2-12 Algorithm for regular and irregular

rhythms.
Totally
Variable
conduction
ratio
Occasionally irregular
The dysrhythmia is mostly regular but from time to time you see an area of irregularity.
Shorter
Area where
R-R interval it is irregular
21
15
25
Area where
it is regular
21
21
21
Figure 2-13 An occasionally irregular

rhythm.
Chapter 2
Analyzing the ECG
33
Chapter 2
Frequentlyirregular
Avery irregular dysrhythmia has many areas of irregularity.
Area where
it is irregular
Shorter
R-R interval
Area where
it is regular
Area where
it is irregular
Shorter
R-R interval
Shorter
R-R interval
Underlying rhythm against

which the regularity of the
rest of rhythm is measured.
Figure 2-14 A frequently irregular rhythm.
Slightly irregular
Rhythmappears to change only slightly with the P-Pintervals and R-Rintervals
varying somewhat.
Area where it is
regular
Area where it is
slightly irregular
Area where it is
regular
Figure 2-15 A slightly irregular

rhythm.
Analyzing the ECG
Chapter 2
35
Chapter 2
Paroxsymally irregular
Anormal rate suddenly accelerates to a rapid rate producing an irregularity
in the rhythm.
Area where it is
regular
Figure 2-16 A paroxsymally irregular

rhythm.
Area where the heart rate

suddenly accelerates
Patterned irregularity
The irregularity repeats in a cyclic fashion.
Area where it is
patterned irregular
Figure 2-17 A patterned irregular

rhythm.
Analyzing the ECG

Chapter 2
37
Chapter 2
Irregular irregularity
No consistency to the irregularity.
Entire tracing is
irregular
Figure 2-18 An irregularly irregular

rhythm.
Variable irregularity
The number of impulses reaching the ventricles changes, producing
an irregularity.
Figure 2-19 Variably irregular

rhythm.
Chapter 2
Areas where
the conduction
ratio changes
Analyzing the ECG
39
Chapter 2
Normal sinus rhythm

Sinus bradycardia
Sinus tachycardia
Atrial tachycardia
Junctional escape
Accelerated junctional
Occasionally
or very
Sinus arrest
Premature
beats (PACs,
PJCs,
PVCs)
Atrial flutter/constant
1st & 3rd degree AV block
2nd (Type II)
Slightly
Wandering
atrial
pacemake
r
Figure 2-20 Algorithm showing which

dysrhythmias display which type of
irregularity.
Sudden
acceleration
in heart rate
PSVT,
PAT, PJT
Irregularity algorithm
Regularity
Regular
Patterned
Sinus
dysrhythmi
a
Premature
beats
(bigeminy,
trigeminy,
quadrigemin
y
2nd degree AV
block, Type I
Irregular
Totally
Atrial
fibrillatio
n
Variable
conductio
n ratio
Atrial flutter
2nd degree AV
heart block,
Type II
ECGwaveforms
Beginswith its movement away fromthe baseline andendsin its returnto the baseline.
Characteristicallyroundandslightlyasymmetrical.
ThereshouldbeonePwave precedingeach
QRScomplex.
In leadsI, II, aVF,andV2 throughV6,its deflection
is characteristicallyupright or positive.
In leads III, aVL, and V1, the P wave is usually
upright but maybenegative or biphasic (both
positive andnegative).
In leadaVR,the Pwave isnegativeor inverted.
Height/amplitude (energy)
Pwave
One P
wave
precedes
each QRS
Usually
rounded and
upright
Amplitude is
0.5 to 2.5 mm
P
Duration is 0.06
to 0.10 seconds
Time (duration, rate)
Figure 2-21 P wave.
Chapter 2
Analyzing the ECG
41
QRScomplex
Chapter 2
Follows PRsegment andconsists of:

QRS
complex
Q
wavefirst
negativedeflection
fol
lowing PRsegment. It isalwaysnegative.
R
In somecasesit is absent. Theamplitude
is normallylessthan25%of the amplitude of the Rwave in that lead.
R wavefirst positive triangular
deflection following Qwave or PR
Q
S
segment.
Duration is 0.06 to
0.12 seconds
S wavefirst negativedeflection
Time
(duration, rate)
that extendsbelow the baselinein the
Figure 2-22 QRS
QRScomplex following the Rwave.
complex.
In leadsI, II, III, aVL,aVF, andV4 to V6,the deflection
of the QRScomplex is characteristically positive or upright.
In leadsaVR andV1 to V3,the QRScomplex is usually
negativeor inverted.
In leadsIII andV2 to V4 the QRScomplex mayalsobebiphasic.
Differing formsof QRScomplexes

QRScomplexescan consist of positive (upright) deflections called Rwaves andnegative
(inverted) deflections called QandSwaves: all three waves arenot always seen.
If the Rwave is absent, complex is calledaQScomplex. Likewise, if the Qwave is absent,
complex is calledanRScomplex.
Waveforms of
normal or greater
thannormal
amplitudeare denoted
R
R
with a largecaseletter,
R
R
R'
whereaswave- forms
r
r
r
lessthan5mm
q
q
amplitudeare denoted
Q
S
S
S
Q
S
QS
with a small caseletter
(e.g., q, r, s).
R'
r r'
Figure 2-23 Common QRS

complexes.
Chapter 2
Analyzing the ECG
43
Chapter 2
MeasuringtheQRScomplex
First identify the QRScomplex with the longest duration and
most distinct beginningandending.
Start byfinding the beginningof the QRScomplex.
Thisisthe point wherethe first wave of the complex (where
either the Qor Rwave) beginsto deviatefromthe baseline.
Thenmeasureto the point wherethe last
wave of the complex transitions into the
R
R
STsegment (referredto asthe J point).
J point
J point
Typically,it is wherethe Swave or R
wave (inthe absenceof anSwave)
QS
beginsto level out (flatten) at, above,
or belowthe baseline.
S
0.08 seconds
0.08 seconds
Thisisconsideredtheendof the
in duration
in duration
B
QRScomplex.
R
J point
Q
S
J point
0.14 seconds
in duration
R J point
0.12 seconds
in duration
0.10 seconds
in duration
J point
J point
S
0.18
seconds 0.22 seconds
S in duration in duration
Figure 2-24 Measuring the QRS complex. (a) These two QRS complexes have easy to see J points. (b) These QRS
complexes have less defined transitions making measurement of the QRS complex more challenging.
Extendsfromthe beginningof the

Pwave to the beginningof the
Qwave or Rwave.
Consistsof aPwave andaflat
(isoelectric) line.
It is normallyconstant for each
impulseconductedfromthe
atria to the ventricles.
ThePRsegment isthe isoelectric
line that extendsfromthe endof the
Pwave to the beginningof the Q
wave or Rwave.
PRinterval
PR segment
PR interval
Duration is
0.12
to 0.20 seconds
Figure 2-25 PR interval.
Chapter 2
Analyzing the ECG
45
Chapter 2
MeasuringthePRinterval
Start
measuremen
t here
End
measuremen
t here
Tomeasurethe width (duration) of a

PRinterval, first identify the interval
with the longest duration andthe
most distinct beginningandending.
Start by finding the beginning of the
interval. This is the point where the
Pwave begins to transition fromthe
isoelectric line.
Then measure to the point where the
isoelectric line (following the P wave)
transitions into the Qor Rwave (inthe
absenceof anSwave).
Thisis consideredthe endof the
PRinterval.
This PR interval 0.16 seconds in duration
Figure 2-26 Measuring PR

intervals.
STsegment
Theline that follows the QRScomplex and

ST
connects it to the Twave.
segment
Beginsat the isoelectric line extendingfromthe
Swave until it graduallycurvesupward to the
Twave.
Under normal circumstances, it appearsasaflat
T wave
line (neither positive nor negative), althoughit
mayvaryby0.5to 1.0mmin someprecordial leads.
QT interval
The point that marks the end of the QRSand
J point
the beginning of the ST segment is known as
the J point.
ThePRsegment isusedasthe baselinefrom
Figure 2-27 ST segment, T wave, and QT
which to evaluatethe degreeof displacement
interval.
of the STsegment fromthe isoelectric line.
Measure at apoint 0.04seconds(onesmall box) after theJ point. TheSTsegmentis considered
elevatedif it is abovethe baselineandconsidereddepressedif it is below it.
Chapter 2
Analyzing the ECG
47
Chapter 2
Twave
Larger,slightly asymmetrical waveformthat follows the STsegment.
Peakiscloser to the endthanthe beginning, andthe first half hasamoregradual slopethan
the second half.
Normallynot morethan5mmin height in the limbleadsor 10mmin anyprecordial lead.
Normallyoriented in the samedirection asthe precedingQRScomplex.
Normallypositive in leadsI, II, andV2 to V6 andnegativein leadaVR.Theyarealsopositive in
aVL andaVF but maybenegativeif the QRScomplex is lessthat 6mmin height. In leadsIII and
V1,the Twave maybepositive or negative.
QTinterval
QRS
Distancefromonset of QRScomplex until endof Twave.

Measures timeof ventricular depolarizationandrepolarization.
Normal duration of 0.36to 0.44seconds.
QRS
T U P
wave
Uwave
Small upright (except in leadaVL)waveformsometimes seenfollowing the Twave, but before the next Pwave.
Figure 2-28 U
waves.
Abnormal Pwaves
Evaluate P waves
Pwaves seenwith impulsesthat originate in the SA nodebut travel

throughaltered or damagedatria (or atrial conduction pathways) appear
tall androundedor peaked, notched, wide andnotched or biphasic.
Absent
Present
Pwaves appear different thansinusPwaves when
the impulsearisesfromthe atria insteadof the sinus
node.
Normal,
Unusua
Inverted
round
l
Sawtooth appearingwaveforms (flutter waves) occur
looking
when anectopic sitein the atria firesrapidly.
Achaotic-looking baseline(nodiscernible Pwaves)
More P
One
waves than
for
occurs when manyectopic atrial sitesrapidlyfire.
QRS
every
QRS
Pwaves are inverted, absent, or follow the QRScomplexwhen the impulsearisesfromthe left atria, low
Peaked,
Differing
Chaotic
notched, morphology Sawtooth
in the right atria, or in the AVjunction.
baselin
enlarge
e
More Pwaves thanQRScomplexesoccur when
d
impulsesarisefromthe SA node, but donot all reach
Figure 2-29 Algorithm for normal and
abnormal P waves.
the ventricles dueto ablockage.
Chapter 2
Analyzing the ECG
49
Chapter 2
F
waves
P'
P
Tall, rounded
Tall, peaked
Notched
Wide, notched
Biphasic
f
waves
P'
more P waves than

QRS complexes
P'
Figure 2-30 Types of waveforms: (a) abnormal sinus P waves, (b) atrial P wave associated with a PAC, (c)
flutter waves,
(d) no discernible P waves, (e) inverted P wave, (f) absent P wave, (g) P wave that follows QRS, and (h) P
waves that are not all followed by a QRS complex.
Abnormal QRScomplexes
Abnormallytall dueto ventricular
hypertrophy or abnormallysmall dueto
obesity,hyperthy- roidism, or pleural effusion.
Slurred(deltawave) dueto ventricular
preexcitation.
Varyfrombeingonlyslightly abnormal to
extremelywide andnotched dueto bundle
branchblock, intraventricular conduction
distur- bance, or aberrant ventricular
conduction.
Widedueto ventricular pacing byacardiac
pacemaker.
Wideandbizarrelookingdueto electrical
impulsesoriginating fromanectopic or escape
pacemaker sitein the ventricles.
Evaluate
QRS
complexes
Present
Absent
More P
waves
than
complexes
QRS
Follow
each
P wave
Normal
0.060.12
seconds
Tall, low
voltage
Figure 2-31 Algorithm

for
normal
and
abnormal QRS
complexes.
Unusua
l
looking
Notched
Wide
(greater than
0.12
seconds),
bizarre
appearance
Chapter 2
Inverted
Analyzing the ECG
Chaotic
51
Delta
wave
Chapter 2
H
Figure 2-32 Types of QRS complexes: (a) tall, (b) low amplitude, (c) slurred, (d) wide due to intraventricular
conduction defect,
(e) wide due to aberrant conduction, (f) wide due to bundle branch block, (g) wide due to ventricular cardiac
pacemaker, and
(h) various wide and bizarre complexes due to ventricular origin.
Abnormal PRintervals
Abnormallyshort or absent dueto impulsearising
fromlow in the atria or in the AVjunction.
Abnormallyshort dueto ventricular
preexcitation.
Absent dueto ectopic sitein the atriafiring rapidly or manysitesin the atria firing chaotically.
Absent dueto impulsearising fromthe ventricles.
Longer thannormal dueto adelayin AV
conduction.
Varydueto changing atrial pacemaker site.
Progressivelylonger dueto aweakenedAVnode
that fatigues moreandmorewith eachconductedimpulseuntil finallyit issotired that it failsto
conduct animpulsethroughto the ventricles.
Absent dueto the Pwaves havingno relationship
to the QRScomplexes.
Evaluate
PR
intervals
Present
Normal
0.12
0.20
seconds
Shorter
than
0.12
seconds
Absent
Abnormal
Longer
than
0.20
seconds
Absent
Vary in
duratio
n
Figure 2-33 Algorithm for normal and abnormal

PR intervals.
Chapter 2
Analyzing the ECG
53
Chapter 2
P'
0.18
0.30
0.10
Premature
atrial
complex
0.42
absent
0.19
P'
P'
P'
P'
0.20
0.16
0.12
0.14
0.35
Figure 2-34 Types of PR intervals: (a) shortened, (b) absent, (c) longer than normal, (d) progressively longer in a
cyclical manner, (e) varying, and (f) absent due to an absence in the relationship between the atrial impulses and
ventricular impulses.
Sinus Dysrhythmias
Chapter 3
Normal sinus rhythm
characteristics
Sinus bradycardia
characteristics
Sinus Dysrhythmias
Sinus tachycardia
characteristics
Sinus dysrhythmia
characteristics
Sinus arrest characteristics
Characteristics commontosinusdysrhythmias
Arise from SA node.

Normal Pwave precedes each QRScomplex.
PRintervals are normal at 0.12to 0.20seconds in duration.
QRScomplexes are normal.
56
Normal sinus rhythm characteristics
Rate:
60 to 100 beats per minute
Regularity:
It is regular
P waves:
QRS complexes:
Present and normal; all the P waves are followed by a QRS

complex
Normal
PR interval:
Within normal range (0.12 to 0.20 seconds)
QT interval:
Figure 3-1
Summary of characteristics of normal sinus
rhythm.
Chapter 3
Sinus Dysrhythmias
57
Chapter 3
Sinus Dysrhythmias
Normal sinus rhythm arises from the SA node. Each impulse travels down through the
conduction system in a normal manner.
Figure 3-2
Normal sinus
rhythm.
58
Sinus bradycardia characteristics
Rate:
Less than 60 beats per minute
Regularity:
It is regular
P waves:
QRS complexes:

complex
Normal
PR interval:
QT interval:
Within normal range (0.36 to 0.44 seconds) but may be

prolonged
Figure 3-3
Summary of characteristics of sinus
bradycardia.
Chapter 3
Sinus Dysrhythmias
59
Chapter 3
Sinus Dysrhythmias
Sinus bradycardia arises from the SA node. Each impulse travels down through the conduction
system in a normal manner.
Figure 3-4
Sinus
bradycardia.
60
Sinus tachycardia characteristics
Rate:
Regularity:
It is regular
P waves:
QRS complexes:

complex
Normal
PR interval:
QT interval:
Within normal range (0.36 to 0.44 seconds) but commonly

shortened
Figure 3-5
tachycardia.
Chapter 3
Sinus Dysrhythmias
61
Chapter 3
Sinus Dysrhythmias
Sinus tachycardia arises from the SA node. Each impulse travels down through the
conduction system in a normal manner.
Figure 3-6
Sinus
tachycardia.
62
Sinus dysrhythmia characteristics
Rate:
Typically 60 to 100 beats per minute
Regularity:
QRS complexes:
It is regularly irregular (patterned irregularity); seems to speed

up, slow down, and speed up in a cyclical fashion
complex
Normal
PR interval:
QT interval:
May vary slightly but usually within normal range (0.36 to 0.44
seconds)
P waves:
Figure 3-7
dysrhythmia.
Chapter 3
Sinus Dysrhythmias
63
Chapter 3
Sinus Dysrhythmias
Sinus dysrhythmia arises from the SA node. Each impulse travels down through the conduction
system in a normal manner.
Figure 3-8
Sinus
dysrhythmia.
64
Sinus arrest characteristics
Rate:
Typically 60 to 100 beats per minute, but may be slower
QRS complexes:
depending on frequency and length of arrest

It is irregular where there is a pause in the rhythm (the SA node
fails to initiate a beat)
complex
Normal
PR interval:
QT interval:
Within normal range (0.36 to 0.44 seconds); unmeasurable

during a pause
Regularity:
P waves:
Figure 3-9
arrest.
Chapter 3
Sinus Dysrhythmias
65
Chapter 3
Sinus Dysrhythmias
Sinus arrest occurs when the SA node fails to initiate an

impulse.
SA node fails
to initiate
impulse
Figure 3-10
arrest.
66
Atrial Dysrhythmias
Chapter 4
Premature atrial complexes
(PACs) characteristics
Wandering atrial pacemaker
characteristics
Atrial tachycardia characteristics
Atrial Dysrhythmias
Multifocal atrial tachycardia

characteristics
Atrial flutter characteristics
Atrial fibrillatrion characteristics
Characteristics commontoatrial dysrhythmias

Arise from atrial tissue or internodal pathways.
P waves (if present) that differ in appearance from normal sinus Pwaves
precede each QRScomplex.
PRintervals may be normal, shortened, or prolonged.
QRScomplexes are normal (unless there is also an interventricular
conduction defect or aberrancy).
68
Wandering atrial pacemaker characteristics
Rate:
Usually within normal limits
Regularity:
Slightly irregular
P waves:
Continuously change in appearance
QRS complexes:
Normal
PR interval:
Varies
QT interval:
Usually within normal limits but may vary
Figure 4-1
Summary of characteristics of wandering atrial
pacemaker.
Chapter 4
Atrial Dysrhythmias
69
Chapter 4
Atrial Dysrhythmias
Wandering atrial pacemaker arises from different sites in the

atria.
Figure 4-2
Wandering atrial
pacemaker.
70
Premature atrial complexes (PAC) characteristics
Rate:
Depends on the underlying rhythm
Regularity:
May be occasionally irregular or frequently irregular (depends

on the number of PACs present). It may also be seen as patterned irregularity if bigeminal, trigeminal, or quadrigeminal
PACs are seen.
May be upright or inverted, will appear different than those of
the underlying rhythm
Normal
P waves:
QRS complexes:
PR interval:
Will be normal duration if ectopic beat arises from the upper- or

middle-right atrium. It is shorter than 0.12 seconds in duration
if the ectopic impulse arises from the lower right atrium or in
the upper part of the AV junction. In some cases it can also be
prolonged
QT interval:
Figure 4-3
Summary of characteristics of premature atrial
complexes.
Chapter 4
Atrial Dysrhythmias
71
Chapter 4
Atrial Dysrhythmias
Premature atrial complexes arise from somewhere in the

atrium.
Figure 4-4
Premature atrial
complexes.
72
The
pause
that
follows
a premature
beat
is
called a
noncompensatory
pause if the space
between the complex
before and after the
premature beat is less
than the sum of two
R-R intervals.
No n - c ompensat o r
y pauses are typically
seen with
premature
atrial and
junctional
complexes
(PACs,
PJCs).
When the tip of

the right caliper
leg fails to line up
with the next R
wave it is
considered a
noncompensatory
pause
Measure first
R-R interval
that
precedes the
early beat
Rotate or
Rotate or
slide the
slide the
calipers over
calipers over
until the left
until
linedleft
upleg
with
up
the
is
legwith
is lined
your the second first mark
R wave
mark the
point where
Figure 4-5
the tip of the
Premature beats with a noncompensatory
right leg falls
pause.
Chapter 4
Atrial Dysrhythmias
73
Chapter 4
Atrial Dysrhythmias
When the tip of the

right caliper leg lines
up with the next R
wave it is considered a
compensatory pause
Measure first R-R

interval that
precedes the early
beat
Rotate or slide the
calipers over until the left
leg is lined up with the
second
R wave mark the
point where the tip of
the right leg falls
Rotate or slide the calipers
over until the left leg is
lined up with your first
mark
Figure 4-6
Premature beats with a compensatory
pause.
Compensatory pauses are typically

associated with premature
ventricular complexes
(PVCs)
74
Premature beats occurringin a pattern

One way to describe PACs is how they are intermingled among the normal beats. When every
other beat is a PAC, it is called bigeminal PACs, or atrial bigeminy. If every third beat is a PAC, it
is called trigeminal PACs, or atrial trigeminy. Likewise, if a PAC occurs every fourth beat, it is
called quadrigeminal PACs, or atrial quadrigeminy. Regular PACs at greater intervals than every
fourth beat have no special name.
Normal
PAC
Normal
PAC
Normal
PAC
Normal
PAC
a)
Figure 4-7
Premature atrial complexes: (a) bigeminal PACs, (b) trigeminal PACs, and (c)
quadrigeminal PACs.
Chapter 4
Atrial Dysrhythmias
75
Chapter 4
Normal
PAC
Normal
Normal
PAC
Normal
Atrial Dysrhythmias
Normal
PAC
b)
Normal
Normal
PAC
Normal
Normal
Normal
c)
PAC
76
Atrial tachycardia characteristics
Narrow
complex
tachycardia
that has a
sudden,
witnessed
onset and
abrupt
termination is
called paroxysmal
tachycardia.
Rate:
Regularity:
Regular unless the onset is witnessed (thereby

producing paroxysmal irregularity)
P waves:
May be upright or inverted, will appear different than those of the underlying rhythm
QRS complexes: Normal

PR interval:
Will be normal duration if ectopic beat arises

from the upper- or middle-right atrium. It
is shorter than 0.12 seconds in duration
if the ectopic impulse arises from the
lower-right atrium or in the upper part of
the AV junction
QT interval:
Usually within normal limits but may be

shorter due to the rapid rate
Narrow complex
tachycardia
that cannot be
clearly identified as atrial
or junctional
tachycardia is
referred to as
supraventricul
ar tachycardia.
Figure 4-8
Summary of characteristics of atrial
tachycardia.
Chapter 4
Atrial Dysrhythmias
77
Chapter 4
Atrial Dysrhythmias
Atrial tachycardia arises from a single focus in the

atria.
Figure 4-9
Atrial
tachycardia.
78
Multifocal atrial tachycardia characteristics

Rate:
120 to 150 beats per
Regularit
minute Irregular
y: P
P waves change in morphology (appearance) from beat

to beat (at least three different shapes)
waves:
QRS
Norma
complexes:
PR interval:
Varies
QT interval:
Figure 4-10
Summary of characteristics of multifocal atrial
tachycardia.
Chapter 4
Atrial Dysrhythmias
79
Chapter 4
Atrial Dysrhythmias
In multifocal atrial tachycardia, the pacemaker site shifts between the SA node,
atria, and/or the AV junction.
Figure 4-11
Multifocal atrial
tachycardia.
80
Atrial flutter characteri stics
Rate:
Ventricular rate may be slow, normal, or fast; atrial rate is
QRS complexes:
between 250 and 350 beats per minute

May be regular or irregular (depending on whether the
conduction ratio stays the same or varies)
Absent, instead there are flutter waves; the ratio of atrial
waveforms to QRS complexes may be 2:1, 3:1, or 4:1. An
atrial-to-ventricular conduction ratio of 1:1 is rare
Normal
PR interval:
Not measurable
QT interval:
Not measurable
Regularity:
P waves:
Figure 4-12
flutter.
Chapter 4
Atrial Dysrhythmias
81
Chapter 4
Atrial Dysrhythmias
Atrial flutter arises from rapid depolarization of a single focus in the atria.
Figure 4-13
Atrial flutter.
82
Atrial fibrillation characteristics
Rate:
Ventricular rate may be slow, normal, or fast; atrial rate is
Regularity:
greater than 350 beats per minute

Totally (chaotically) irregular
P waves:
Absent; instead there is a chaotic-looking baseline
QRS complexes:
Normal
PR interval:
Absent
QT interval:
Figure 4-14
fibrillation.
Unmeasurable
Chapter 4
Atrial Dysrhythmias
83
Chapter 4
Atrial Dysrhythmias
Atrial fibrillation arises from many different sites in the

atria.
Figure 4-15
Atrial fibrillation.
84
Junctional
Dysrhythmias
Chapter 5
Premature junctional complexes (PJCs)
characteristics
Junctional escape rhythmcharacteristics
Junctional Dysrhythmias
Accelerated junctional rhythm

characteristics
Junctional tachycardia characteristics
Characteristics commontojunctional dysrhythmias

Arise from theAVjunction, the area around theAVnode, or the bundle of His.
P wave may be inverted (when they would otherwise be upright) with a short PRinterval
(less than 0.12seconds in duration).
Alternatively, the P wave may be absent (as it is buried by the QRScomplex), or it may
follow the QRScomplex. If the P wave is buried in the QRScomplex it can change the
morphology of the QRScomplex.
If present, PRintervals are shortened.
QRScomplexes are normal (unless there is an interventricular conduction defect or
aberrancy).
86
Premature junctional complexes (PJCs) characteristics
Rate:
Regularity:

on the number of PJCs present). It may also be seen as patterned
irregularity if bigeminal, trigeminal, or quadrigeminal PJCs are
seen.
Invertedmay immediately precede, occur during (absent), or
follow the QRS complex
Normal
P waves:
QRS complexes:
PR interval:
Will be shorter than normal if the P wave precedes the QRS

complex and absent if the P wave is buried in the QRS; referred
to as the RP interval if the P wave follows the QRS complex
QT interval:
Figure 5-1
Summary of characteristics of premature junctional complexes
(PJCs).
PJCs are typically followed by a non-compensatory

pause.
Chapter 5
87
Chapter 5
Premature junctional complex arises from somewhere in the AV

junction.
Figure 5-2
Summary of characteristics of premature junctional complexes
(PJCs).
88
Junctional escape rhythm characteristics
Rate:
Regularity:
Regular
P waves:

Normal
QRS complexes:
PR interval:
Will be shorter than normal if the Pwave precedes the QRS

QT interval:
Figure 5-3
Summary of characteristics of junctional escape
rhythm.
Chapter 5
89
Chapter 5
Junctional escape rhythm arises from a single site in the AV junction.
Junctional escape
rhythm 40 to 60 beats
per minute
rhythm 60 to 100 beats per
minute
minute
Figure 5-4
Junctional escape
rhythm.
90
Accelerated junctional rhythm characteristics
Rate:
Regularity:
Regular
P waves:

Normal
QRS complexes:
PR interval:

QT interval:
Figure 5-5
Summary of characteristics of accelerated junctional
rhythm.
Chapter 5
91
Chapter 5
Accelerated junctional rhythm arises from a single site in the AV

junction.
Junctional escape
per minute
minute
minute
Figure 5-6
rhythm.
92
Junctional tachycardia characteristics
Rate:
Regularity:
Regular
P waves:

Normal
QRS complexes:
PR interval:
QT interval:
Figure 5-7
Summary of characteristics of junctional
tachycardia.

Chapter 5
93
Chapter 5
Junctional tachycardia arises from a single focus in the AV junction.
Junctional escape
per minute
minute
minute
Figure 5-8
Junctional
tachycardia.
94
Ventricular
Dysrhythmias
Chapter 6
Premature ventricular complexes (PVCs)
characteristics
Idioventricular rhythm characteristics
Ventricular Dysrhythmias
Accelerated idioventricular rhythm

characteristics
Ventricular tachycardia characteristics
Characteristics commontoventricular dysrhythmias
Arise from the ventricles below the bundle of His.

QRScomplexes are wide (greater than 0.12seconds in duration) and bizarre looking.
Ventricular beats have Twaves in the opposite direction of the Rwave.
Pwaves are not visible as they are hidden in the QRScomplexes.
96
Premature ventricular complexes (PVCs) characteristics
Rate:
Regularity:
P waves:

on the number of PVCs present). It may also be seen as patterned irregularity if bigeminal, trigeminal, or quadrigeminal
PVCs are seen.
Not preceded by a P wave (if seen, they are dissociated)
QRS complexes:
Wide, large, and bizarre looking
PR interval:
Not measurable
QT interval:
Usually prolonged with the PVC
Figure 6-1
Summary of characteristics of premature ventricular complexes.
PVCs are followed by a compensatory pause.

Sometimes, PVCs originate from only one location in the ventricle. These beats look the same
and are called uniform (also referred to as unifocal) PVCs. Other times, PVCs arise from different sites
in the ventricles. These beats tend to look different from each other and are called multiformed
(multifocal) PVCs.
97
Chapter 6
Chapter 6
Premature ventricular complexes arise from somewhere in the

ventricle(s).
Figure 6-2
Premature ventricular complexes
(PVCs).
98
PVCs that occur

one after
the
other
(two PVCs
in a row) are
called a couplet,
or pair.
Figure 6-3
Couplet of PVCs.
Three
or
more
PVCs in a row at a
ventricular rate of
at least 100 BPM
is
called
ventricular tachycardia.
It may be called a
salvo, run, or burst
of
ventricular
tachycardia.
Figure 6-4
Chapter 6
99
Chapter 6
An
interpolated
PVC occurs when
a PVC does not
disrupt the normal
cardiac
cycle. It
appears
as
a
PVC
squeezed
between two regular
complexes.
Figure 6-5 Interpolated

PVC.
PVC that occurs on or near the T wave can

precipitate ventricular tachycardia or
fibrillation
A PVC occurring
on or
near
the
previous T
wave
is called an R-onT PVC.
Figure 6-6 R-on-T

PVC.
100
Idioventricular rhythm characteristics
Rate:
20 to 40 beats per minute (may be slower)
Regularity:
Regular
P waves:
QRS complexes:
Not preceded by a P wave (if seen, they are dissociated and

would therefore be a 3rd-degree heart block with an idioventricular escape)
PR interval:
Not measurable
QT interval:
Usually prolonged
Figure 6-7
Summary of characteristics of idioventricular
rhythm.
Chapter 6
101
Chapter 6
Idioventricular rhythm arises from a single site in the ventricles(s).

Idioventricular rhythm arises from a single site in the ventricles.
Rate is 20 to
40 beats per
minute
Rhythm is
regular
P waves are not visible as

they are hidden in the QRS
complexes
QRS complexes are

wide and bizarre in
appearance, have T
waves in the
opposite direction of
the R wave

PR intervals
are absent
Figure 6-8
Idioventricular
rhythm.
102
Accelerated idioventricular rhythm characteristics
Rate:
Regularity:
Regular
P waves:
Not preceded by a P wave
QRS complexes:
PR interval:
Not measurable
QT interval:
Usually prolonged
Figure 6-9
Summary of characteristics of accelerated idioventricular
rhythm.
Chapter 6
103
Chapter 6
Accelerated idioventricular rhythm arises from a single site in the

ventricles(s).

Figure 6-10
Accelerated idioventricular
rhythm.
104
Ventricular tachycardia characteristics
Rate:
Regularity:
Regular
P waves:
Not preceded by a P wave (if seen, they are dissociated)
QRS complexes:
PR interval:
Not measurable
QT interval:
Not measurable
Figure 6-11
Summary of characteristics of ventricular
tachycardia.
Ventricular tachycardia may be monomorphic, where the appearance of each QRS complex is
similar, or polymorphic, where the appearance varies considerably from complex to complex.
Chapter 6
105
Chapter 6
106
Ventricular tachycardia arises from a single site in the ventricles(s).

Figure 6-12
Ventricular tachycardia.
Two other conditions to be familiar with:

Ventricular fibrillation (VF)results from chaotic firing of multiple sites in the ventricles. This causes
the heart muscle to quiver, much like a handful of worms, rather than contracting efficiently. On the
ECG monitor it appears like a wavy line, totally chaotic, without any logic.
Asystoleis the absense of any cardiac activity. It appears as a flat (or nearly flat) line on the monitor
screen.
AVHeart Blocks
Chapter 7
1st-degreeAVheart block characteristics
2nd-degreeAVheart block, Type I
(Wenckebach) characteristics
AV Heart Blocks
108
2nd-degreeAVheart block, Type II

characteristics
3rd-degreeAVheart block characteristics
Characteristics commontoAVheart blocks

Pwaves are upright and round. In 1st-degreeAVblock all the Pwaves are followed by
a QRScomplex. In 2nd-degreeAVblock not all the Pwaves are followed by a QRS
complex, and in 3rd-degree block there is no relationship between the Pwaves and
QRScomplexes.
In 1st-degreeAVblock PRinterval is longer than normal and constant. In 2nd-degree
AVblock, Type I, in a cyclical manner the PRinterval is progressively longer until a
QRScomplex is dropped. In 2nd-degreeAVblock, Type II, the PRinterval of the conducted beats is constant. In 3rd-degree block there is no PRinterval.
QRScomplexes may be normal or wide.
1st-degree AV heart block characteristics
Rate:
Underlying rate may be slow, normal, or fast
Regularity:
Underlying rhythm is usually regular
P waves:
Present and normal and all are followed by a QRS complex
QRS complexes:
Should be normal
PR interval:
Longer than 0.20 seconds and is constant (the same each time)
QT interval:
Figure 7-1
Summary of characteristics of 1st-degree AV
block.
Chapter 7
AV Heart Blocks
109
Chapter 7
AV Heart Blocks
In 1st-degree AV heart block impulses arise from the SA node but their passage through the
AV node is delayed.
Delay
Delay
Delay
Delay
Delay
Delay
Figure 7-2
1st-degree AV
block.
110
2nd-degree AV heart block, Type I (Wenckebach) characteristics
Rate:
Ventricular rate may be slow, normal, or fast; atrial rate is within
Regularity:
normal range
Patterned irregularity
P waves:
QRS complexes:
PR interval:
Present and normal; not all the P waves are followed by a QRS
complex
Should be normal
Progressively longer until a QRS complex is dropped; the cycle
then begins again
QT interval:
Figure 7-3
Summary of characteristics of 2nd-degree AV block,
Type I.
Chapter 7
AV Heart Blocks
111
Chapter 7
AV Heart Blocks
In 2nd-degree AV heart block, Type I (Wenckebach), impulses arise from the SA node but their
passage through the AV node is progressively delayed until the impulse is blocked.
Delay
Impulse is blocked
Even more delay
More delay
Delay
Figure 7-4
2nd-degree AV block, Type
I.
112
2nd-degree AV heart block, Type II characteristics
Rate:
QRS complexes:
normal range
May be regular or irregular (depends on whether conduction
ratio remains the same)
Present and normal; not all the P waves are followed by a QRS
complex
Should be normal
PR interval:
Constant for all conducted beats
Regularity:
P waves:
QT interval:
Figure 7-5
Summary of characteristics of 2nd-degree AV block,
Type II.
Chapter 7
AV Heart Blocks
113
Chapter 7
AV Heart Blocks
In 2nd-degree AV heart block, Type II, impulses arise from the SA node but some are
blocked in the bundle of His or bundle branches.
Figure 7-6
2nd-degree AV block, Type
II.
114
3rd-degree AV heart block characteristics
Rate:
PR interval:
normal range
Atrial rhythm and ventricular rhythms are regular but not related to one another
Present and normal; not related to the QRS complexes; appear to
march through the QRS complexes
Normal if escape focus is junctional and widened if escape focus
is ventricular
Not measurable
QT interval:
May or may not be within normal limits
Regularity:
P waves:
QRS complexes:
Figure 7-7
Summary of characteristics of 3rd-degree AV
block.
Chapter 7
AV Heart Blocks
115
Chapter 7
AV Heart Blocks
In 3rd-degree AV heart block there is a complete block at the AV node resulting in the
atria being depolarized by an impulse that arises from the SA node and the ventricles
being depolarized by an escape pacemaker that arises somewhere below the AV node.
Escape
Figure 7-8
3rd-degree AV
block.
116
Electrical Axis
Chapter 8
Direction of ECGwaveforms
Mean QRSVector
Methods for Determining
QRSaxis
Lead I
Lead aVF
Axis Deviation
Electrical Axis
118
Direction of ECGwaveforms
Depolarization and repolarization of
the cardiac cells produce many small
electrical currents called instantaneous vectors.
The mean, or average, of all the
instantaneous vectors is called the
mean vector.
When an impulse is traveling toward
a positive electrode, the ECGmachine
records it as a positive or upward
deflection.
When the impulse is traveling away
from a positive electrode and toward
a negative electrode, the ECG
machine records it as a negative or
downward deflection.
Impulses
traveling away
from a positive
electrode and/or
toward a negative
electrode
produce
downward
deflections
Impulses
traveling toward a
positive electrode
produce an
upward deflection
Negative
electrod
e
Figure 8-1
Direction of ECG waveforms when the electrical
current is traveling toward a positive ECG
electrode or away from it.
Chapter 8
Positive
electrod
e
Electrical Axis
119
Chapter 8
Mean QRSVector
The sumof all the small vectors of ventricular
depolarization is called the mean QRSvector.
Because the depolarization vectors of the
thicker left ventricle are larger, the mean QRS
axis points downward and toward the patients
left side.
Changes in the size or condition of the heart
muscle and/or conduction system can affect
the direction of the mean QRSvector.
If an area of the heart is enlarged or damaged,
specific ECGleads can provide a view of that
portion of the heart.
While there are several methods used to
determine the direction of the patients electrical axis, the easiest is the four-quadrant
method.
Electrical Axis
Impulse originates in SA
Figure 8-2
Direction of of the mean QRS
axis.
120
Method for determining QRSaxis
90
120
The four-quadrant method works in the following

manner:
150
An imaginary circle is drawn over the patients
chest; it represents the frontal plane.
+180
Within the circle are six bisecting lines, each
M
ean
representing one of the six limb leads.
The intersection of all lines divides the circle
+150
into equal, 30-degree segments.
The mean QRSaxis normally remains
+120
between 0and +90 degrees.
+90
As long as it stays in this range it is
Lead aVF
considered normal.
Figure 8-3
If it is outside this range, it is considered
Normal direction of the mean QRS
abnormal.
axis.
Leads I and aVF can be used to determine
if the mean QRSis in its normal position.
Chapter 8
60
30
Lead I
+30
+60
Electrical Axis
121
122
Electrical Axis
Chapter 8
LeadI
Lead I is oriented at 0 (located at
the three oclock position).
Apositive QRScomplex indicates
the mean QRSaxis is moving from
right to left in a normal manner and
directed somewhere between 90
and +90 (the right half of the circle).
If the QRScomplex points down
(negative), then the impulses are
moving from left to right; this is
considered abnormal.
Lead I
90
Left arm electrode
Right
+
+
+
Vno M
ean
QRS
+
+
+
+
Left
+
QRS
in lead I
+90
Figure 8-4
A positive QRS complex is seen in lead I if the mean QRS
axis is directed anywhere between 90 and +90.
LeadaVF
Lead aVF is oriented at +90 and is
located at the six oclock position.
If the mean QRSaxis is directed anywhere between 0 and 180 (the
bottomhalf of the circle), you can
expect aVF lead to record a positive
QRScomplex.
If the mean QRSis directed toward the
top half of the circle, the QRScomplex
points downward.
Top
+180
+
+
+
+
Bottom
+
Lead aVF
Figure 8-5
A positive QRS complex is seen in lead aVF if the
mean QRS axis is directed anywhere between 0 and
180 degrees.
Chapter 8
Electrical Axis
QRS
in
lead
aVF
123
Chapter 8
Axis deviation
Positive QRScomplexes in lead I and aVF indicate a normal QRSaxis.
Anegative QRScomplex in lead I and an upright
QRScomplex in lead aVF indicates right axis
deviation.
An upright QRScomplex in lead I and a negative QRScomplex in lead aVF indicates left axis
deviation.
Negative QRScomplexes in both lead I and lead
aVF indicates extreme axis deviation.
Persons who are thin, obese, or pregnant can
have axis deviation due to a shift in the position
of the apex of the heart.
Myocardial infarction, enlargement, or hypertrophy of one or both of the hearts chambers, and
hemiblock can also cause axis deviation.
Electrical Axis
90
I
60 aVF
120
aVF
150
30
Extrem
e axis
deviation
Left axis
deviatio
n
Lead I
0
+180
+150
Right
axis
deviation
Normal
axis
+30
+60
+120
I
124
+90
Lead aVF +
aVF
I
aVF
Figure 8-6
Direction of QRS complexes in lead I and aVF
indicate changes in size or condition of the heart
muscle and/or conduction system.
Hypertrophy, Bundle
BranchBlock, and
Preexcitation
Chapter 9
Right atrial enlargement

Right ventricular hypertrophy
Right bundle branch block
Left atrial enlargement
Left ventricular hypertrophy
Hypertrophy, Bundle Branch Block, and Preexcitation
Left bundle branch block

Left anterior hemiblock
Left posterior hemiblock
Wolff-Parkinson-White (WPW)
syndrome
Lown-Ganong-Levine (LGL) syndrome
126
Right atrial enlargement

Leads II and V1 provide the necessary information to assess atrial enlargement.
Indicators of right atrial enlargement
include:
An increase in the amplitude of the first
part of the Pwave.
The Pwave is taller than 2.5mm.
If the Pwave is biphasic, the initial
component is taller than the terminal
component.
The width of the Pwave, however, stays
within normal limits because its terminal
part originates from the left atria, which
depolarizes normally if left atrial enlargement is absent.
P pulmonale
II, III, and
aVF
Right atrial
enlargemen
t
Biphasic P
wave V1
Lea
d
V1
Figure 9-1
Right atrial enlargement leads to an increase
in the amplitude of the first part of the P wave.
Chapter 9
Lead II
+
127
Chapter 9
Left atrial enlargement

Indicators of left atrial enlargement include:
The amplitude of the terminal portion of the
Pwave may increase in V1.
The terminal (left atrial) portion of the P
wave drops at least 1mmbelow the isoelectric line (in lead V1).
There is an increase in the duration or
width of the terminal portion of the Pwave
of at least one small square (0.04seconds).
Often the presence of ECGevidence of left
atrial enlargement only reflects a nonspecific
conduction irregularity. However, it may also
be the result of mitral valve stenosis causing
the left atria to enlarge to force blood across
the stenotic (tight) mitral valve.
128
P wave
Broad Notched P wave Biphasic

P wave
P wave
(P mitrale)
I, II, and V4V6 V1V2
Left atrial
enlargement
Lead V1
+
Lead II
+
Figure 9-2
Left atrial enlargement leads to an increase in the
amplitude and width of the terminal part of the P wave.
Right ventricular hypertrophy
Lead I
Key indicators of right ventricular hypertrophy include:

The presence of right axis deviation
(with the QRSaxis exceeding +100).
The Rwave larger than the Swave in lead
V1, whereas the Swave is larger than the
Rwave in lead V6.
Right ventricular
hypertrophy
90
+
+180
+90
Left ventricular hypertrophy
Lead aVF
Key ECGindicators of left ventricular

hypertrophy include:
Increased Rwave amplitude in those
leads overlying the left ventricle.
The Swaves are smaller in leads overlying the left ventricle, but larger in
leads overlying the right ventricle.
aVF
Figure 9-3
In right ventricular hypertrophy the QRS axis moves to
between +90 and +180 degrees. The QRS complexes
in right ventricular hypertrophy are slightly more
negative in lead I and positive in lead aVF.
Chapter 9
129
Chapter 9
130
The mean QRS axis moves

farther leftward resulting in
left axis deviation
90Left ventricular
hypertrophy
S
V1
V2
V3
V4
V5
V6
+180
Right ventricular
hypertrophy
Starting with V1, the waveforms take an
upward deflection but then moving toward
V6 the waveforms take a downward
deflection
+90
R
S
S
V1
V1
V2
V3
V2
V3
V4
V5
V6
V4
Figure 9-4
The thick wall of the enlarged right ventricle
causes the R waves to be more positive in the
leads that lie closer to lead V1.
Figure 9-5
The thick wall of the enlarged left ventricle causes the R waves
to be more positive in the leads that lie closer to lead V6 and
the S waves to be larger in the leads closer to V1.
Right bundlebranchblock
The best leads for identifying right bundle
branch are V1 and V2.
Right bundle block causes the QRScomplex to have a unique shape its appearance has been likened to rabbit ears or the
letter M.
As the left ventricle depolarizes, it produces the initial Rand Swaves, but as
the right ventricle begins its delayed
depolarization, it produces a tall Rwave
(called the R).
In the left lateral leads overlying the left
ventricle (I, aVL, V5, and V6), late right ventricular depolarization causes reciprocal
late broad Swaves to be generated.
V1
R'
R R'
r'
S
V5
Block
QRS
configuratio
n in V1, V2
V6
+
QRS
configuration
in V5, V6, I, aVL
Different M-shaped configurations

that may be seen
Late broad S waves
Figure 9-6
In right bundle branch block, conduction through
the right bundle is blocked causing depolarization
of the right ventricle to be delayed; it does not
start until the left ventricle is almost fully
depolarized.
131
Chapter 9
V2
Chapter 9
132
Left bundlebranchblock
Leads V5 and V6 are best for identifying left
bundle branch block.
QRScomplexes in these leads normally
have tall Rwaves, whereas delayed left
ventricular depolarization leads to a
marked prolongation in the rise of those
tall Rwaves, which will either be flattened on top or notched (with two tiny
points), referred to as an R, R wave.
True rabbit ears are less likely to be seen
than in right bundle branch block.
Leads V1 and V2 (leads overlying the right
ventricle) will show reciprocal, broad, deep
Swaves.
V1
V2
Block
V5
+
QRS
configuration
in V1, V2
V6
+
QRS
configuration
in V5, V6
R'
R R'
R'
R R'
QS
Deep S
Different configurations
that may be seen
Figure 9-7
In left bundle branch block, conduction through the left
bundle is blocked causing depolarization of the left ventricle
to be delayed; it does not start until the right ventricle is
almost fully depolarized.
Left anterior hemiblock

With left anterior hemiblock, depolarization of the left ventricle occurs progressing in an inferior-to-superior and
right-to-left direction.
This causes the axis of ventricular depolarization to be redirected
upward and slightly to the left, producing tall positive Rwaves in the
left lateral leads and deep Swaves
inferiorly.
This results in left axis deviation with
an upright QRScomplex in lead I and
a negative QRSin lead aVF.
QRS
configuration
in lead I
Small Q
Block
90
Left axis
deviation
+180
0
Lead aVF
QRS
configuration
in lead III
Small R
+90
Deep S
Figure 9-8
With left anterior hemiblock, conduction down the left anterior
fascicle is blocked resulting in all the current rushing down the
left posterior fascicle to the inferior surface of the heart.
133
Chapter 9
Lead I
Tall R
Chapter 9
Left posterior hemiblock

In left posterior hemiblock, ventricular
myocardial depolarization occurs in
a superior-to-inferior and left-to-right
direction.
This causes the main electrical axis
to be directed downward and to the
right, producing tall Rwaves inferiorly and deep Swaves in the left
lateral leads.
This results in right axis deviation.
With a negative QRSin lead I and a
positive QRSin lead aVF.
In contrast to complete left and right
bundle branch block, in hemiblocks,
the QRScomplex is not prolonged.
134
QRS
configuration
in lead I
Small
R
+
Deep S
Block
QRS
configuration
in lead III
Right axis
Tall R
deviation
Lead aVF
Small Q
Figure 9-9
With left posterior hemiblock, conduction down the
left posterior fascicle is blocked resulting in all the
current rushing down the left anterior fascicle to the
myocardium.
Wolff-Parkinson-White
(WPW) syndrome
WPW is identified through the
following ECGfeatures:
Rhythmis regular.
Pwaves are normal.
QRScomplexes are widened due to a characteristic
called the delta wave.
PRinterval is usually shortened (less than 0.12seconds).
WPW can predispose the
patient to various tachydysrhythmias; the most common
is PSVT.
Bundle of Kent
Instead of
the
impulse traveling
through the AV
node,
travels down
to the itventricles
an
Delta
wave
Delta
wave
Delta
wave
Delta
wave
Delta
wave
Delta
wave
Figure 9-10
In WPW, the bundle of Kent, an accessory pathway, connects the atrium to
the ventricles, bypassing the AV node. The QRS complex is widened due to
premature activation of the ventricles.
135
Chapter 9
Chapter 9
Lown-Ganong-Levine
(LGL) syndrome
LGLis identified through the
following ECGfeatures:
Rhythmis regular.
Pwaves are normal.
The PRinterval is less than
The QRScomplex is not
widened.
There is no delta wave.
WPW and LGLare called
preexcitation syndromes and
are the result of accessory
conduction pathways between
the atria and ventricles.
136
Impulse
travels down
through the
atria
James fibers
Instead of traveling
through the AV node,
the impulse is
carried to the
ventricles by
accessory pathway
Figure 9-11
In LGL, the impulse travels through an intranodal accessory pathway,
referred to as the James fibers, bypassing the normal delay within the AV
node. This produces a shortening of the PR interval but no widening of
the QRS complex.
Myocardial Ischemia
andInfarction
10
Chapter 10
Myocardial Ischemia and Infarction
ECGchanges associated with
ischemia, injury, and infarction
Identifying the location of myocardial ischemia, injury, and
infarction
Anterior
Septal
Lateral
Inferior
Posterior
138
ECGchanges associated with ischemia,

injury, andinfarction
The ECGcan help identify the presence of ischemia,
injury, and/or infarction of the heart muscle.
The three key ECGindicators are:
Changes in the Twave (peaking or inversion).
Changes in the STsegment (depression or
elevation).
Enlarged Qwaves or appearance of new Qwaves.
STsegment elevation is the earliest reliable sign that
myocardial infarction has occurred and tells us the
myocardial infarction is acute.
Pathologic Qwaves indicate the presence of irreversible myocardial damage or past myocardial infarction.
Myocardial infarction can occur without the development of Qwaves.
Chapter 10
T wave
change
s
Tall,
Inverted
peaked
Depressed
T wave
T wave
ST segment
Elevated
Ischemia ST segment
changes
Injury
ST
segment
Infarction
Q wave
change
s
Figure 10-1
Key ECG changes with ischemia,
injury, or infarction
139
Chapter 10
140
Identifying the location of myocardial

ischemia, injury, andinfarction
Leads V1, V2, V3, and V4 provide the best view for identifying anterior myocardial infarction.
Leads V1, V2, and V3 overlie the ventricular septum, so
ischemic changes seen in these leads, and possibly in
the adjacent precordial leads, are often considered to
be septal infarctions.
Lateral infarction is identified by ECGchanges such as ST
segment elevation; Twave inversion; and the development of significant Qwaves in leads I, aVL, V5, and V6.
Inferior infarction is determined by ECGchanges such as
STsegment elevation; Twave inversion; and the development of significant Qwaves in leads II, III, and aVF.
Posterior infarctions can be diagnosed by looking for
reciprocal changes in leads V1 and V2.
Anterior infarction
V1
+
V2
+
V3
+
V4
+
V1
V2
V3
V4
Figure 10-2
Leads V1, V2, V3, and V4 are used to identify
anterior myocardial infarction.
Figure 10-4
Leads I, aVL, V5, and V6 are used to
identify lateral myocardial infarction.
Septal infarction
V1
+
I
+
V2
V3
Lateral infarction
V5
V6
V1
V2
V3
V5
V6
aVL
Figure 10-3
Leads V1, V2, and V3 are used to identify
septal myocardial infarction.
Chapter 10
aVL
141
Chapter 10
142
Posterior view of heart
Inferior infarction
Posterior infarction
V1
V2
II
III
II
III
V3
+
aVF
+
aVF
V1
Figure 10-5
Leads II, III, and aVF are used to identify
inferior myocardial infarction.
V2
V3
Figure 10-6
Leads V1 and V2 are used to identify posterior myocardial
infarction.
Other Cardiac
Conditions
11
Chapter 11
Pericarditis
Pericardial effusion with lowvoltage QRScomplexes
Pericardial effusion with electrical alternans
Other Cardiac Conditions
Pulmonary embolism
Pacemakers
Electrolyte imbalances
Digoxin effects seen on the ECG
144
Pericarditis
Effects of pericarditis on the heart
Initially with pericarditis the Twave is upright

and may be elevated. During the recovery
phase it inverts.
The STsegment is elevated and usually flat or
concave.
While the signs and symptoms of pericarditis
and myocardial infarction are similar, certain
features of the ECGcan be helpful in differentiating between the two:
The STsegment andTwave changes in
pericarditis are diffuse resulting in ECG
changes being present in all leads.
In pericarditis, Twave inversion usually
occurs only after the STsegments have
returned to base line. In myocardial infarction, Twave inversion is usually seen before
STsegment normalization. (continued)
Enlarged view
Normal
pericardium
Inflamed
pericardiu
m
Effects on ECG
Elevated ST segment is flat or concave
ST segments and T waves are off the baseline,

gradually angling back down to the next QRS
complex
Figure 11-1
Pericarditis and ST segment elevation.
Chapter 11
145
Chapter 11
In pericarditis, Qwave development does not

occur.
Pericardial effusion is a buildup of an abnormal

amount of fluid and/or a change in the character of
the fluid in the pericardial space.
The pericardial space is the space between the
heart and the pericardial sac.
Formation of a substantial pericardial effusion dampens the electrical output of the heart, resulting in
low-voltage QRScomplex in all leads.
However, the STsegment and Twave changes of
pericarditis may still be seen.
Figure 11-2
Pericardial effusion with low-voltage QRS
complexes.
Pericardial effusion
Pericardia
l sac
Pericardial effusion with low-voltage

QRScomplexes
I
146
Normal pericardium
Collectio
n of
fluid
Dampened
electrical
output
aVR
II
aVL
III
aVF
Pericardial effusion with

electrical alternans
If a pericardial effusion is large
enough, the heart may rotate freely
within the fluid-filled sac.
This can cause electrical alternans, a
condition in which the electrical axis
of the heart varies with each beat.
Avarying axis is most easily recognized on the ECGby the presence of
QRScomplexes that change in height
with each successive beat.
This condition can also affect the
Pand Twaves.
Pericardial effusion
Pericardia
l sac
Collection
of fluid
II
Figure 11-3 Pericardial effusion with electrical alternans.

Chapter 11
147
Chapter 11
148
Pulmonaryembolism
ECGchanges that suggest the development of a
massive pulmonary embolus include:
Tall, symmetrically peaked Pwaves in leads
II, III, and aVF and sharply peaked biphasic
Pwaves in leads V1 and V2.
A large S wave in lead I, a deep Qwave in
lead III, and an inverted T wave in lead III.
This is called the S1 Q3 T3 pattern.
STsegment depression in lead II.
Right bundle branch block (usually subsides
after the patient improves).
The QRSaxis is greater than
+90 (right axis deviation).
The Twaves are inverted in leads V1V4.
Qwaves are generally limited to lead III.
Embolus
Large S
wave in
lead I
ST segment
depression
in lead II
S1Q3T3
Large Q wave
in lead III with
T wave
inversion
Right bundle branch

block in leads V1
V4
V1
V2
T wave
inversion in
leads V1V4
V3
Figure 11-4
ECG changes seen with pulmonary
embolism.
V4
Pacemakers
Apacemaker is an artificial device
that produces an impulse from a
power source and conveys it to the
myocardium.
It provides an electrical stimulus for
hearts whose intrinsic ability to
generate an impulse or whose ability to conduct electrical current is
impaired.
The power source is generally
positioned subcutaneously, and the
electrodes are threaded to the right
atrium and right ventricle through
veins that drain to the heart.
The impulse flows throughout the
heart causing the muscle to depolarize and initiate a contraction.
Impulses initiated
by the SA node
do
not reach the ventricles
Pacemaker
Pacemaker initiates
impulses that stimulate
the ventricles to
contract
Pacemake
r spike
Figure 11-5
Pacemakers are used to provide electrical stimuli for hearts
with an impaired ability to conduct an electrical impulse.
Chapter 11
149
Chapter 11
150
Pacemaker impulses
Figure 11-6
Location of pacemaker
spikes on the ECG tracing
with each type of
pacemaker.
Atrial pacing
Ventricular pacing
Atrial and ventricular pacing
Pacemaker spikes
An atrial pacemaker will produce a spike trailed by a Pwave and a normal QRScomplex.
With anAVsequential pacemaker, two spikes are seen, one that precedes a Pwave and one
that precedes a wide, bizarre QRScomplex.
With a ventricular pacemaker, the resulting QRScomplex is wide and bizarre. Because the
electrodes are positioned in the right ventricle, the right ventricle will contract first, then the
left ventricle. This produces a pattern identical to left bundle branch block, with delayed left
ventricular depolarization.
Electrolyte
imbalances
Depressed
ST segment U wave
Hyperkalemia
Hypokalemia
ECGchanges seen
with serious hypokaSTsegment
depression.
Flattening of the
Twave.
Appearance of
Uwaves.
Prolongation of
the QTinterval.
Figure 11-7
ECG effects seen with
hypokalemia.
Figure 11-8
hyperkalemia.
T wave
flattens (or is
inverted)
Depressed
ST segment U wave
U wave becomes
more prominent
ECGchanges seen with

hyperkalemia include:
Peaked, narrow T waves

in all leads
Flattened Pwaves.
Prolonged PRinterval (1stdegreeAVheart block).
T wave peaking increases,

P waves flatten and QRS
Deepened Swaves and

merging of Sand Twaves.
Concave up and down
slope of the Twave.
Widened QRS complexes and
peaked T waves become almost
Sine-wave pattern.
indistinguishable, forming what

described as a sine-wave pattern
are
Chapter 11
151
Chapter 11
Hypercalcemia/
Hypocalcemia
152
Digoxin effects seen onthe ECG
Alterations in serum
calcium levels mainly
affect the QTinterval.
Hypocalcemia prolongs the QTinterval
while hypercalcemia
shortens it.
Torsades de pointes, a
variant of ventricular
tachycardia, is seen
in patients with prolonged QTintervals.
Figure 11-9
hypocalcemia and
hypercalcemia.
Short QT interval
Prolonged QT interval
Digoxin produces a characteristic gradual downward

curve of the STsegment (it looks like a ladle).
The Rwave slurs into the STsegment.
Sometimes the Twave is lost in this scooping effect.
The lowest portion of the STsegment is depressed
below the baseline.
When seen, the Twaves have shorter amplitude and
can be biphasic.
The QTinterval is usually shorter than anticipated,
and the U
waves are
more visible.
Also, the PR
interval may
be prolonged.
Gradual downward curve of the ST segment
Figure 11-10
Effects of digoxin on the
ECG.

Basic ECG

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Basic ECG

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The Electrocardiogram

ECGleadsI, II, III

Grid layout on ECGpaper consists of horizontal and vertical

Eachsmall square= 0.04

To properly position the electrodes, use the lettering located

Positiveelectrodeleft leg (or left

Figure 1-8 (a) Lead I. (b) Lead II. (c) Lead

LeadV1 electrode is placed onthe right sideof

Figure 1-10 Precordial leads.

Modified chest leads(MCL)

Figure 1-11 MCL leads. (a) MCL1 and (b)

Analyzing the ECG 18

Dysrhythmias by heart rate

Five-step (andnine-step) process

Thefive-step process(andnine-step) is alogical andsystematicprocess for analyzing

Analyzing the ECG

Analyzing the ECG 20

Figure 2-1 (a) The five-step process. (b) Nine-step

Methods for determining the heart rate

Multiply the number of QRS complexes or P waves by 10

Figure 2-2 6-second interval! 1 0

Analyzing the ECG

Usingthe300, 150, 100, 75, 60, 50

Analyzing the ECG 22

The heart rate in the ECG below is

Figure 2-3 300, 150, 100, 75, 60, 50

Usingthe thinlines todetermine the heart rate

Figure 2-4 Identified values shown for each of the thin

Analyzing the ECG 24

Figure 2-5 The 1500

Dysrhythmias byheart rate

Analyzing the ECG 26

Normal sinus rhythm

*Heart rate can also be normal

Figure 2-6 Heart rate

Analyzing the ECG

Analyzing the ECG 28

Methods usedtodetermine regularity

Figure 2-9 Use of calipers to identify

Analyzing the ECG

Analyzing the ECG 30

Figure 2-10 Use of paper and pen to identify

Countingthesmall squaresbetween eachR-Rinterval

Figure 2-11 Counting the number of small squares to identify

Analyzing the ECG

Analyzing the ECG 32

Figure 2-12 Algorithm for regular and irregular

Figure 2-13 An occasionally irregular

Analyzing the ECG

Analyzing the ECG 34

Underlying rhythm against

Figure 2-14 A frequently irregular rhythm.

Figure 2-15 A slightly irregular

Analyzing the ECG 36

Figure 2-16 A paroxsymally irregular

Area where the heart rate

Figure 2-17 A patterned irregular

Analyzing the ECG

Analyzing the ECG 38