EKG interpretation should be performed using a standard procedure.

For this course, we

are using an eight step procedure:

Rhythm

Rate

P Wave

PR Interval

QRS Interval
 T Wave

QT Interval

ST Segment

P Wave
The P wave represents atrial depolarization. In a normal EKG, the P-wave precedes the QRS complex. It looks like a small bump upwards
from the baseline. The amplitude is normally 0.05 to 0.25mV (0.5 to 2.5 small boxes). Normal duration is 0.06-0.11 seconds (1.5 to 2.75
small boxes). The shape of a P-wave is usually smooth and rounded.

P-wave questions:
 Are they present?

Do they occur regularly?

Is there one P-wave for each QRS complex?

Are the P-Waves smooth, rounded, and upright?

Do all P-Waves have similar shapes?

Following the steps below will allow ease with interpretation of arrhythmias. Analyzing strips in this
order and reviewing these 5 aspects will allow for correct identification of cardiac rhythms.

Rate

P Waves

P:QRS

QRS

PR Interval
Rate
 What is the ventricular rate?

o On a six second strip count the R waves and multiply by 10

o Alternatively, you can divide 300 by the number of large squares between R waves or P
waves. This method is less reliably if the rate is irregular.

P Waves

Are there P Waves?

What is the rate of the P wave?

What is the morphology of the P wave (upward, smooth, rounded)?

Okay so the next thing we have to do is look at NSR (normal sinus rhythm) because we have to base
every other interpretation off what SHOULD be happening.

While referring to the image above lets work through the 5 steps.
Rate

60 100 bpm

P Waves

Are there P Waves?

 o Yes

What is the rate of the P wave?

o 60 100

What is the morphology of the P wave (is it positive, smooth, round)?

o Yes

P:QRS

Is there a 1:1 relationship between P wave and QRS complex?

o Yes

QRS

Are there QRS complexes?

o Yes

Is the QRS width 0.06 0.12 seconds (1.5 3 small boxes)?

o Yes

PR Interval

Is the PRI between 0.12 0.20 seconds (3 5 small boxes)?

 o Yes

Explanation:
Normal sinus rhythm is the result of the electrical conduction following the intended course without
deviation or alteration in rate. Slight variations in rhythm regularity may be noted with the respiratory
cycle.

Bradycardia, or sometimes called Brady, is defined as a heart rate under 60 beats per minute (BPM).

There are two types of bradycardia:

1. Sinus bradycardia

2. Atrioventricular (AV) block

First degree

Second degree

Type 1 (Wenckebach)

Type 2 (Mobitz)

Third degree (complete)

Sinus Bradycardia EKG
Interpretation
When looking at an EKG that is sinus brady, all PQRST waves are within normal measurements
meaning that the PR, QRS, and QT intervals are all meat criteria for sinus rhythm. However, when you
count out the heart rate it is less than 60 bpm.

What causes Sinus

Bradycardia?
Sinus bradycardia can be seen in healthy adults if they are athletic and/or they are asleep! Other
common causes of sinus brady include:
 Heart tissue damage

Hypertension

Myocarditis

Hypothyroidism

Lupus

Common with inferior wall MI

Increased ICP

Increased vagal tone from vomiting

Bearing down to have a bowel movement

Hemochromatosis

Medications:

o Heart rhythm/Hypertensive medications

Beta blockers

Metoprolol (Lopressor)

Propranolol (Inderal)
 Calcium channel blockers

Amlodipine (Norvasc)

Diltiazem (Cardizem)

Digoxin

Opiates

Opium

Codeine

Morphine

Dilaudid

Methadone (Dolophine)

Heroin

Psychosis medications

Clozapine (Clozaril)

Amitriptyline (Elavil)

Haloperidol (Haldol)
 Thioridazine

In case you are a fan of mnemonics, there is one for causes of bradycardia:

PACED

o Propranolol or Poppies (Opiates)

o Anticholinesterase drugs

o Clonidine or Calcium Channel Blockers

o Ethanol

o Digoxin

What could happen to

someone in sinus
bradycardia?
Patients with sinus bradycardia will likely be asymptomatic, however, it makes sense for patients to
exhibit signs and symptoms of cardiac compromise such as:

Altered LOC
 Hypotension

Respiratory distress/failure

Delayed capillary refill

Syncope

Shortness of breath (SOB)

How do you
treat bradycardia?
Medications:

o First line:

Atropine

o Second line:

Dopamine

Epinephrine
Transcutaneous pacing should be used if the patient is exhibiting signs and symptoms of poor
profusion.

There are three degrees of AV block, in the second degree, there are two types. I personally have
found these to be very confusing and still to this day, I do not recognize these heart blocks at first
glance, I have to slow down and take my time reading the EKG strip to get the right type of block.
 First degree:

o This is the mildest form of the heart blocks and is rarely symptomatic. There are very few
times this rhythm will receive treatment. The electrical signals from the atria to the
ventricles are delayed, causing long PR intervals.

Second degree:

o In second degree AV block, not all electrical signals reach the ventricles causing some
beats to drop as well as causing an irregular rhythm., There are two types of second
degree block:

Type 1 which is also called Wenckebach

In second degree type 1 AV block, the atria are pumping at a regular rate but
ventricles are pumping slower causing prolonged regular PR intervals.

Type 2 which is also called Mobitz

In second degree type 2 AV block, the conduction delay is below the AV node.
Thus, the SA node is firing regularly causing regular P to P waves but either
bundle of his or bundle branches are not receiving the action potential every
time causing skipped QRS complexes.

Third degree which is also called complete

o In third degree AV block, the atria and ventricles are not communicating at all
Communication is blocked you might say! The atria are using their pacemaker,
the Sinoatrial (SA) node, which beats at 60-80 bpm, but since the conduction pathways for
the electrical signal to pass on to the ventricles are blocked, the ventricles use their own
 intrinsic pacemaker. This can either be the junction (40-60 bpm) or bundles (20-40 bpm).
This chaotic messaging system can cause P waves to happen in the middle of a QRS
complex. Because the P waves represent the atria pumping and the QRS complex
represent the ventricles pumping and the atria are receiving almost double the amount of
signals, there will be more P waves than QRS waves.

Recognizing AV block
bradycardia on an EKG
First degree

o PR interval consistently greater than 20

o Less than 60 bpm

o Regular rate
 Second degree

o Type 1 (Wenckebach)

P to P intervals are regular

PR intervals become progressively longer

Eventually a QRS complex is skipped

 Type 2 (Mobitz)

o P to P intervals are regular

 o Extra P waves (no QRS complex to follow)

o PR intervals are regular when there is a QRS complex following that P wave

o Has the potential to progress to complete heart block

Third degree (complete)

o P waves continue to be 60-80 bpm

o QRS complexes are at the rate of either 40-60 bpm or 20-40 bpm
What causes AV block?
First degree AV block, second degree type 1 AV block, and third degree AV block can be caused by the
following issues:

Acute inferior MI

Right Ventricular infarction

Increased vagal tone

Ischemic heart disease

Digitalis toxicity

Beta blockers

Amiodarone
 Calcium channel blockers

Electrolyte imbalances

Rheumatic heart disease

myocarditis

Second degree type 2 (Mobitz), however, is caused by damage to the bundle branch system following
an acute anterior Myocardial infarction. It is important to note that second degree type 2 AV block is
NOT caused by medications or increased vagal tone.

What can happen to a patient

in AV block?
AV blocks are usually asymptomatic. However, a patient may experience the following:

Fainting/syncope

Heart failure

Cardiac arrest and death

Hypotension
How do you treat AV block?
The main goal of treating AV block usually depends on if the patient is symptomatic or not. If they are
not symptomatic and their heart rate is sustaining appropriate profusion, then the goal is to monitor
PR intervals and make sure that the heart block conduction system does not worsen. In each specific
degree of heart block, you will want to follow the following:

In first degree AV block, you want to holding medications that cause slow AV conduction and
monitor for lengthening PR intervals

In second degree AV block type 1, also called Wenckebach, if the patient is too bradycardic,
you will give them atropine and possibly use pacing, but only temporarily. The best outcome is if
the cause of the heart block is discovered and that underlying cause can be treated. It is
important to monitor for progression into higher forms of block

In second degree type 2 AV block, also called Mobitz, if the patient is symptomatic, you will
use a transcutaneous pacer and dopamine for hypotension. If the patient is asymptomatic but
not maintaining proper profusion, you will have the transcutaneous pacer nearby and ready to
use. You will also want to hold all drugs that slow the AV node conduction.

In third degree AV heart block, also called complete heart block,a symptomatic patient
who is bradycardic will need to receive atropine as well as being paced by a transcutaneous
pacer.

Sinus Tachycardia, also called tachy, is when the heart is beating more than 100 beats per minute
(bpm) due to rapid firing of of the sinoatrial (SA) node. All wave forms are present on the EKG making
this a fast but steady arrhythmia.
Sinus Tachycardia EKG
Interpretation
On the EKG, all PQRST wave forms present and the rhythm is regular, just very fast.

What causes Sinus

Tachycardia?
Heart tissue damage

o Heart attack

o Heart failure
 Abnormal vital signs:

o Fever

o Hypertension

o Pain

Stress/anxiety/fear

Alcohol, caffeine, nicotine

Cocaine

Electrolyte imbalance

Hyperthyroidism

Anemia

Hemorrhage
What could happen to
someone in Sinus
Tachycardia?
Sinus Tachycardia causes decreased cardiac output due to inadequate ventricular filling as well as an
increased oxygen demand for the myocardial cells. A patient with sinus tachycardia may have the
following signs and symptoms:

Dizziness

Lightheadedness

Syncope

Chest Pain

Fast heart rate

Palpitations

Shortness of breath
How do you treat Sinus
Tachycardia?
The best treatment for sinus tachycardia is to treat the underlying cause. If a patient has a fever,
administer antipyretics such as Motrin or Tylenol, or if they have anxiety give them an antianxiety
medication such as Xanax, Valium or Ativan. If the patient has a narrow QRS complex, then treat them
with the following:

Vagal maneuvers

Adenosine

Beta blockers

Calcium channel blocker

Synchronized cardioversion

If the patient has a wide QRS complex, then treat them with an antiarrhythmic such
as Procainamide, Amiodarone, or Sotalol.
Closer Look at Atrial
Rhythms
Lets look even closer at Atrial Rhythms. When the sinoatrial (SA) node is not generating proper
electrical activity, the hearts atrial tissues or even other tissues of the heart will attempt to generate
electrical action potential. This can cause issues with the heart not beating properly, completely, or
rhythmically.

Supraventricular Tachycardia (SVT) series of rapid heartbeats that originate from the atria. It is an
umbrella term to cover multiple types of tachycardia, however, people often will refer to paroxysmal
supraventricular tachycardia (PSVT) as SVT. The heartbeats can be inconsistent or consistent and are
always fast. Two major types of SVT are Atrial Fibrillation (Afib), Paroxysmal Supraventricular
Tachycardia (PSVT) and Atrial Flutter (AFlutter).

What is PSVT?
Paroxysmal Supraventricular Tachycardia (PSVT) is a rapid heartbeat that originates in the atria. It is
called paroxysmal because it happened intermittently and lasts various lengths of time.
PSVT is often just called SVT.
Recognizing PSVT on an EKG
The EKG will show a fast heart rate anywhere from 100 to up to 300 bpm!
The QRS is narrow at a regular rhythm.
Sometimes the P waves are inverted, this is referred to as retrograde P waves.

What causes PSVT?

A patient can be genetically inclined to have PSVT; Their electrical conduction doesnt fire normally.
It can also be drug induced; Digoxin and Theophylline can cause PSVT.
However, certain behaviors such as alcoholism, caffeine, drug use, or smoking can put you at risk as
well.
 Signs and symptoms:

o Anxiety

o Shortness of breath

o Tachycardia

o Palpitations

o Dizziness

o Syncope

What could happen to

someone in PSVT?
Patients who have sustained PSVT can have adverse effects such as hypotension due to the inevitable
incomplete heartbeats from the fast beating of the heart. As well as over time, the heart will enlarge
(Cardiomegaly) and eventually fail (heart failure).

How do you treat PSVT?

Because PSVT can be treated by the patient by themselves, the first line of treatment involves
performing the Valsalva maneuver where the patient holds their breath and bear down as if they were
having a bowel movement, or cold water on the face (splashing or submerging). Coughing while
positioned sitting forward can also bring someone out of PSVT.
In the hospital, a patient may get a carotid massage by a physician, medications such as adenosine
(Adenocard) and cardioversion.
[faq question="Atrial Fibrillation Afib"]
Atrial Fibrillation, commonly called Afib, is the most common heart arrhythmia. The atria beat very
fast, irregularly and out of sync with the ventricles. The atria are often getting such confusing signals
that they will quiver.
Patients can have 3 types of Afib:

Paroxysmal Afib (early)

o Usually when first diagnosed

o Periods of Afib that come and go

o Afib usually goes away on its own

Persistent Afib

o Medications are needed to correct Afib (we will talk about medications later)

o Longer and more frequent episodes of Afib

Permanent Afib (late)

o Have had Afib for a long time and the heart is unable to return to Normal Sinus Rhythm
(NSR).

AFib EKG Interpretation

The waves are more chaotic and random, the beat is irregular and you can see the atria quivering
between the QRS (ventricles pumping). No discernible P waves. The ventricular rate is often 110-160
bpm and the QRS complexes is usually less than 120 ms.
What causes Afib?
The actual cause of Afib is unknown but research suggests many risk factors that are commonly seen
with patients with Afib.

Risk factors

o Age

o Family history

o Smoking

o Hypertension

o Obesity

Conditions increasing risk

o Heart failure
 o Diabetes

o Coronary heart disease

What could happen to

someone in Afib?
Due to the pooling of blood from incomplete contractions and the quivering of the atria, a patient is
likely to form a clot. If the blood clot breaks free it can cause a stroke or pulmonary embolism (PE) and
increased the risk of heart failure and death.
A patient with Afib may not have any signs or symptoms at all (about 60% do not), however, a
patient may feel lightheaded, dizzy, short of breath, as well as experience chest pains, palpitations
and/or weakness. Afib also causes the heart to undergo a process called remodeling where the walls
thicken and the heart size increases.

How do you treat Afib?

The two main goals of treating Afib is controlling the rate and rhythm and prevention of
stroke/pulmonary embolism (PE).
Medications can be used to control a patients rate and rhythm. The most commonly used medication
for the rate is adenosine. The two most commonly used medications for rhythm control is diltiazem
(Cardizem) and amiodarone (Cordarone). Cardizem is better at controlling the rhythm but can
cause hypotension in the patient, whereas amiodarone is better for hemodynamically
compromised patients.
Anticoagulants are used for stroke and pulmonary emboli prevention. Heparin is the first line,
however Lovenox and warfarin (Coumadin) are also used.
If medication has not been successful in controlling rate or rhythm, the patient may have a medical
procedure to correct this arrhythmia.

Cardioversion

o Electrical current is used to restore electrical heart rhythm

Surgical ablation

o Destroys the cells that are causing abnormal heart rhythm

Catheter ablation (radio frequency ablation)

o Stops the heart from setting off the faulty electrical signals

Atrial Pacemaker

o Placed under the skin to generate electrical signals to regulate heart beat

Atrial Flutter, commonly called Aflutter or AFL, is very similar to Afib except that the heart still is
beating at a regular rhythm. The Sinoatrial Node (SA node) sends electrical impulses through the atria
at a very fast rate, sometime the electrical impulse is so fast it circulates around the atria. The
Atrioventricular Node (AV Node) receives this electrical impulse and with the combination of slowing
down the rate as well as the intrinsic beat for the AV Node (40-60 bpm), the ventricles still beat at a
regular rate and rhythm.
Recognizing AFlutter on an
EKG
This was always the easiest rhythm for me to pick out because it is so unique. The jagged edges are
similar to that of a saw blade, and people refer to it as a saw tooth pattern. The rate is regular, but
fast.
What causes AFlutter?
Heart conditions:

o Rheumatic or ischemic heart disease

o Heart failure

o Previous heart attack

o Pericarditis

o Septal defects

o Hypertension

o Pre-excitation syndromes

o Atrioventricular (AV) valve disease

Non-cardiac conditions:

o Thyroid dysfunction (hyperthyroidism, thyrotoxicosis)

Too much thyroid hormones cause electrical changes within atrial myocytes,
shortening the action potential

o Diabetes
 Fluctuations of serum glucose can cause increased size of the atria, leading to
electrical conduction problems.

o Alcoholism

Shortens the right atrial effective refractory period (AERP)

What could happen to

someone in AFlutter?
Signs and symtpoms

o Palpitations

o Fast steady heart beat

o Shortness of breath (especially upon exertion)

o Anxiety/Nervousness

o Chest pain

o Dizziness

o Lightheadedness
 o Syncope

If untreated can lead to cardiomyopathy, heart failure, and Afib.

How do you treat AFlutter?

Generally speaking, AFlutter itself isnt life threatening, however, long term, it can cause complications
similar to Afib. The most common treatment for Aflutter is cardioversion and medications.

Medications

o Ibutilide (Corvert)

Give to patients before cardioversion

o Amiodarone (Coradarone)

o Diltiazem (Cardizem)

Severely compromised

o Cardioversion (treatment of choice)

o Rapid atrial overdrive pacing

o Radiofrequency catheter ablation