Basic

ECG
Rhythm
Interpretation
Textbook for OSU Medical Center
Basic ECG Dysrhythmia Course

Published by: Department of Educational

Development & Resources
The Ohio State University Medical Center

© OSU revised May 2007

 The Department of Educational Development and Resources at the Ohio State University
Medical Center would like to acknowledge Sandra Walden MS, RN for her original creation of
the Basic ECG Course and manual (1988; Revised 2002).

This manual is intended to be used as a reference only-it does not supersede OSUMC policy or
physician orders.

Applicable Policies:

1. Pain and Symptom Management

2. ECG Monitoring, Continuous
3. Defibrillation, AED and Emergency Response
4. Pacemakers
5. Telemetry Beds, Adult Divisional Standards of Practice

2
 Basic ECG Rhythm Interpretation

Objectives

At the completion of this course the learner will be able to:

1. Identify the sequence of normal electrical activation of the heart.

2. Describe the physiology of cardiac muscle contraction.

3. Given a rhythm strip, identify Sinus, Atrial, Junctional and Ventricular dysrhythmias, and
Atrioventricular Blocks.

4. Identify the appropriate nursing and medical interventions, and first line medications for
ECG rhythms.

5. Score at least 85% competency on the posttest.

3
 GLOSSARY

Aberrant Conduction - Term applied to abnormal (slowed) intraventricular conduction of

supraventricular (above the ventricles) impulses caused by a transient functional delay or
block (slowed conduction) in one or more of the conducting fascicles (conduction system)
causing a wide QRS.
Arrhythmia - Absence of heart rhythm
Artifact - Man-made disturbance in the EKG tracing; due to poor electrode contact or muscle
activity originating outside the heart.
Dysrhythmia - A disturbance in the heart rhythm (abnormality)
Ectopic Focus - A site that initiates an electrical impulse other than the SA Node (usually
prematurely due to irritability of the part of the myocardium)
Escape Pacemaker - (Backup) An alternate site capable of initiating an electrical impulse to
ultimately stimulate a heart beat when the SA Node fails to do so.
Electrodes -Sensing devices placed on the chest (or extremities) for the purpose of detecting
electrical impulses traveling through the heart.
Focus - Site of impulse formation
Infranodal - Adjective referring to focus below the AV Node.
Isoelectric Line - The imaginary line on which the ECG waves are drawn; also called the
baseline or PR Line.
Multifocal - Adjective describing ectopic foci that originates from multiple sites, thereby
causing configurations (shapes) different from each other.
Multiformed – Adjective describing multiple morphology (shape) of the qRs in a rhythm.
The shapes vary therefore the likelihood is increased that the ectopic foci originate from
multiple sites. (Multiformed is preferred over multifocal).
Retrograde Conduction - An electrical impulse travels the opposite direction from normal.
It is usually associated with an ectopic focus that occurs in the Junction, forming a
retrograde P wave. The P wave will be inverted and either is seen before or after the QRS
or is not seen at all.
Supraventricular - Adjective referring to a dysrhythmia originating above the ventricles (SA
Node or Atria), usually characterized by a qRs complex of normal width.
Unifocal - Adjective describing an ectopic focus that originates from one focus. The
complexes seen are uniform.
Uniform – Adjective describing the uniform shape of the qRs complexes in a rhythm

Frequently Used Abbreviations

AV Atrioventricular PAC Premature Atrial Contraction (APC)
ECG Electrocardiogram PJC Premature Junctional Contraction (JPC)
EKG Electrocardiogram PVC Premature Ventricular Contraction (VPC)
NSR Normal Sinus Rhythm SVT Supraventricular Tachycardia
PAT Paroxysmal Atrial Tachycardia SA Sinoatrial

4
 Contents

Chapter Content Pages

Chapter One Basic Principles 5 - 27

Chapter Two Sinus Rhythms 28 - 40

Chapter Three Atrial & SVT Rhythms 41 – 60

Chapter Four Junctional Rhythms 61 - 70

Chapter Five Ventricular Rhythms 71 - 92

Chapter Six Pulseless Electrical Activity 93 – 96

Chapter Seven AV Blocks 97 - 111

Chapter Eight Temporary Ventricular Pacers 112 - 124

Appendix Practice Strips

Appendix Integrated Practice

5
Chapter One

Basic Principles

Published by: Department of Educational

Development & Resources
The Ohio State University Medical Center

© OSU revised May 2007

6
 Chapter One

BASIC PRINCIPLES
OBJECTIVES

1. Review anatomy of the heart.

2. Describe two myocardial cell types.

3. Describe four properties of cardiac cells.

4. Discuss the process of depolarization and repolarization.

5. Describe the sequence of electrical activation of the heart.

6. Correctly label the ECG complex.

7. Demonstrate computation of the heart rate on a rhythm strip, using two different methods.

8. Identify four potential pacemakers in the heart.

9. Analyze a rhythm strip in a systematic fashion.

7
BASIC CARDIAC ANATOMY AND PHYSIOLOGY

CARDIAC ANATOMY:

The heart is a muscular pump. The left side of the heart is the larger and thicker side. It does
more work because it pumps oxygenated blood into the aorta and then throughout the entire
body. The thinner, right side of the heart pumps the same amount of blood, but only has to send
it a short distance into the lungs via the pulmonary arteries. Each side of the heart consists of two
chambers, an atrium and a ventricle. The thick walled ventricles are the larger pumping
chambers that expel blood from the heart with each beat (contraction or systole.) The relatively
thin-walled atria function as collecting and loading chambers. The atria hold blood being
returned to the heart during ventricular systole. In between contractions, the ventricles are
relaxed (diastole). During diastole, blood flows into the ventricles from the atria, at first
passively, and then propelled by atrial contraction (atrial systole). Strategically located valves
prevent backflow of blood. The mitral valve is between the left atrium and ventricle, the aortic
valve between the aorta and left ventricle, the tricuspid valve between the right ventricle and
right atrium and the pulmonary valve between the main pulmonary artery and the right ventricle.

The endocardium is a layer of smooth lining cells. These cells are found not only in the heart but
also on the inside of all the blood vessels of the body, where they are called endothelium. The
myocardium is the mass of heart muscle cells whose coordinated contraction causes the
chambers of the heart to contract and pump blood. The myocardium is thin in the atria, thicker in
the right ventricle and thickest in the left ventricle. The epicardium is a fatty layer on the outer
surface of the myocardium. The major coronary blood vessels, the vessels that supply blood to
the heart itself, run through the epicardium. The outermost layer is the pericardium, actually two
layers with a small amount of lubricating fluid between them, forming the pericardial sac, which
encloses the entire heart.

Coronary Vein Coronary Artery

Pericardium

Epicardium

Myocardium

Endocardium
CORONARY CIRCULATION

The heart is always in continuous action. In order to maintain aerobic metabolism and
contractile activity, the heart must be able receive oxygen and nutrients and have carbon
dioxide and other wastes removed. This is accomplished through coronary circulation. The
heart is supplied by 2 major coronary arteries: the right coronary artery (RCA) and the left
coronary artery (LCA). These arteries arise from the aorta immediately distal to the aortic
valve. Coronary perfusion occurs during diastole. The RCA supplies the right atrium, right
ventricle, and a portion of the posterior and inferior surfaces of the left ventricle. The RCA
supplies the AV node and bundle of His in 90% of hearts and the sinus node in 55% of
hearts. The LCA is the main coronary artery that passes between the left atrial appendage
and the pulmonary artery and then divides into two major branches, the left anterior
descending artery (LAD) and the left circumflex artery (LCA). The LAD is responsible for
supplying portions of the left and right ventricular myocardium and the majority of the
interventricular septum. The (LCA) supplies the lateral wall and posterior wall of the left
ventricle, SA node (45%), AV node (10%), and posterior inferior portion of the LBB.

With knowledge of coronary anatomy, we can anticipate complications of various coronary

artery blockages. Since the RCA supplies the SA Node in 55% of hearts and the AV Node in
90% of hearts, we can anticipate problems that would arise with a compromise of these
primary pacemakers such as sinus bradycardia, sinus arrest, junctional rhythms and AV
Block rhythms. Since the LCA perfuses the anterior wall of the heart, we can anticipate
problems that would result from a lack of pump function, such as congestive heart failure,
cardiogenic shock, and ventricular irritability. It is important to understand which areas of the
heart are perfused by which coronary artery, and to anticipate the possible complications of
an occlusion.

CARDIAC CYCLE

Blood is propelled to the body by the sequential activation of the cardiac chambers through
electrical and mechanical factors. The cardiac cycle is divided into two major phases,
ventricular systole and diastole.
Ventricular Systole:
Ventricular contraction follows the ventricular depolarization reflected by the
electrocardiographic QRS wave. Ventricular pressure increases rapidly. This
results in the opening of the pulmonic and aortic valves. At the onset of this
period, pressures in the atrium and ventricle are approximately equal, but atrial
pressure decreases with atrial muscle relaxation and repolarization. The tricuspid
and mitral valves are closed as the atria fill with blood.
Ventricular Diastole:
Ventricular muscle relaxation begins, pressure decreases, ventricular filling
occurs as the tricuspid and mitral valves open and blood flows from the atria into
the relaxed ventricles. During diastole, approximately 75% of blood flows
passively from the atria through the open tricuspid and mitral valves into the
ventricles even before the atria contract. Atrial contraction (atrial kick)
contributes an additional 25% to ventricular filling.

9
CARDIC OUTPUT

Cardiac output is the amount of blood the left ventricle pumps into the aorta per minute. This is a
systolic event. The stroke volume times the number of cardiac cycles per minute (heart rate)
equals the cardiac output. The ejection fraction (EF) is the percentage of total ventricular volume
injected during each contraction. Normally it is greater than 55% and usually is approximately
65%. Three factors affect or determine stroke volume:

Preload: is the degree of stretch, or tension, on the muscle fibers when they begin to
contract.

Afterload: is the load or amount of pressure the left ventricle must work against to eject
blood during systole and corresponds to the systolic pressure. The greater the resistance
is, the greater the heart’s workload. Afterload is sometimes called systemic vascular
resistance.

Contractility: is the ventricles’ ability to contract, which is determined by the degree of

muscle fiber stretch at the end of diastole. The more the muscle fibers stretch during
ventricular filling, up to an optimal length, the more forceful the contraction.

Frank-Starling law of the heart

This law defines the fundamental principle of cardiac behavior which states that the force of
contraction of the cardiac muscle is proportional to its initial length. The energy set free at each
contraction is a simple function of cardiac filling. When the diastolic filling of the heart is
increased or decreased with a given volume, the displacement of the heart increases or decreases
with this volume.

BASIC ANATOMY OF THE CONDUCTION SYSTEM

Stimulation of the heart originates in the Sympathetic and Parasympathetic branches of the
Autonomic Nervous System.

The impulse travels first to the Sinoatrial Node (SA Node) located in the posterior wall of the
right atrium. The SA Node is the main cardiac pacemaker from which wave-like impulses are
sent through the atria stimulating first the Right and then the Left Atrium. The SA Node is richly
supplied with both Vagal and Sympathetic nerve fibers and the former are derived mainly from
the right Vagus Nerve.

Under normal circumstances the SA Node will initiate electrical impulses at the rate of 60 to
100 times per min.

Physiologic and Anatomic studies indicate that the Sinus impulse spreads in the Atria and to the
AV Node through the three (3) Atrial internodal tracts.

10
 1. The anterior internodal tract divides into two parts, one going to the left atrium
and known as Bachman's Bundle, the other descending to the upper margin of
the A-V node.

2. The middle internodal tract, or Wenckebach Bundle, which descends within the
interatrial septum to enter the upper part of the A-V node.

3. The Posterior Internodal Tract--or Thorel's tract reaches the interatrial septum
and enters the posterior margin of the AV node.

As soon as the Atria have been stimulated, the impulse slows as it passes through the
Atrioventricular (AV) Node, which lies in the inferior posterior portion of the Right Atrium. The
AV node has two vital functions in serving the heart.
1. The AV Node has the ability to protect the ventricles from excessively fast rates
that may originate in the atria.
2. The area just above and just below the AV Node (AV Junction) like the SA
node, may also serve as the pacemaker for the heart, should the SA node or atrial
tissue fail to initiate impulses or should the impulse fail to reach the AV node.

The AV Junction will normally initiate impulses at 40 to 60 times per minute when
functioning as the pacemaker. (AV Junction includes the A-N region, the AV Node and the
N-H region- see AV Junction figure on Page 11). The AV node itself is totally devoid of
pacemaking cells.

The wave of excitation then spreads to the Bundle of HIS (common bundle) which is continuous
with the AV node and reaches the interventricular septum where it divides into the right and left
bundle branches.

The right bundle branch runs along the right side of the interventricular septum, and reaches the
base of the anterior papillary muscle of the right ventricle where it divides into a network
supplying the right ventricular myocardium.

The left bundle branch runs along the left side of the interventricular septum and divides almost
immediately into an anterior (superior) division and an inferior (posterior) division. The anterior
division, a relatively long and thin pathway reaches the base of the anterior papillary muscle and
supplies the anterior superior part of the left ventricle. The posterior division, a relatively short
and thick structure, passes to the base of the posterior papillary muscle and supplies the inferior
posterior aspect of the left ventricle. The intraventricular conduction system is therefore
composed of three conduction pathways, also called fascicles; the right bundle branch, the
anterior division of the left bundle branch, and the posterior division of the left bundle branch.

The right bundle branch and both the anterior and posterior divisions of the left bundle branch
divide into a complex network of fibers, called the Purkinje fibers, which is distributed to the
ventricular myocardium. The fibers are more abundant in the subendocardial layers and are
longer than the common myocardial fibers. The Purkinje fibers in the human heart are believed
to lack nerve supply entirely.

11
The ventricles also have the ability to function as a backup pacemaker (escape mechanism),
should they not receive impulses from the S-A node, atrial tissue or AV node.
The ventricles may be considered a much less efficient backup system, for the rate at which
they normally initiate impulses (inherent rate) is 20-40 times per minute.

Electrical Conduction System

SA Node Atrial Tracts

Bundle of HIS

AV Node

Left Bundle
Branch
Right Bundle
Branch
Purkinje
Fibers

AV Junction
A-N Region Pacemaker Inherent Rate

SA Node 60-100

AV Node
Atrial Tissue 75

N-H Region
AV Junction 40-60
HIS Bundle
Ventricles 20-40

12
 ELECTROPHYSIOLOGICAL PROPERTIES

PROPERTIES of CARDIAC CELLS

Cardiac cells have three electrical properties:
1. Automaticity
2. Excitability
3. Conductivity

AUTOMATICITY: The heart has the property of initiating and maintaining rhythmic activity
without the help of its neurological supply. The myocardial cells that possess the property of
automaticity are called pacemaking cells.

Under normal circumstances the pacemaking cells with the highest degree of automaticity and
more rapid discharge rate are located in the Sinus Node, the primary pacemaking focus of the
heart. Pacemaking cells with a lesser degree of Automaticity and slower inherent or natural
discharge rate are present in the atria, in the AV Junction and in the ventricles; forming auxiliary
ectopic pacemaking foci (sites). The more peripheral the site of the pacemaking focus from the
SA Node, the slower its automaticity and inherent discharge rate.

EXCITABILITY: Both pacemaking and non-pacemaking myocardial cells have the property
of responding to a natural or artificial electrical stimulus. This ability to respond to an impulse
or stimulus is called excitability.

CONDUCTIVITY: Conductivity is the property that allows the myocardial cell to propagate an
impulse to a neighboring cell. An impulse of adequate strength originating in any area of the
heart during its resting period creates a wave of excitation that is propagated over the whole
tissue.

The cardiac cells also have one mechanical property:

1. Contractility

CONTRACTILITY: Contractility is the ability of the cardiac muscle to respond to an electrical

impulse with pump action. (the ability of the muscle to shorten and contract).

DYSRHYTHMIAS
The terms dysrhythmia and arrhythmia are used interchangeably in the literature. Since
dysrhythmia means an abnormality in rhythm, whereas arrhythmia indicates an absence of
rhythm, the former term will be used in this text.

Cardiac dysrhythmias may result from one of the following mechanisms:

 Disturbances in automaticity
 Disturbances in conductivity
 Combinations of altered automaticity and conductivity.

13
 ELECTRICAL ACTIVITY OF THE HEART

In order to better understand disturbances in the electrical activity of the heart, it is important to
have a basic knowledge of the electrical properties of the working and electrical system cells.

MYOCARDIAL CELL TYPES: There are two basic groups of cells within the myocardium
which are important for cardiac function:

1. Working Myocardial Cells - possess the property of contractility, or the ability to

shorten and then return to their original length.

2. Electrical System Cells - Cells belonging to the electrical system that are
responsible for conduction of the electrical stimulus to the working cells of the
myocardium.

Working Cells (Contraction of the Myocardial Cells) - Cardiac muscle cells are polarized during
the resting state. During resting the cells have a negative charge inside the cell membrane and a
positive charge outside the cell membrane. When the cell membrane is electrically stimulated a
process called depolarization occurs. Electrical stimulation of the cell results in a change in the
electrical properties of the cell (depolarization) by causing the flux of positive ions into the cell
and negative ions outside the cell membrane. Once depolarized, the cell shortens and contracts.
Next the cell repolarizes returning the negative ions inside the cell membrane and positive ions
outside the cell. Once repolarized, the cell returns to the resting state ready for depolarization and
repolarization to occur again.

+ + + + + + + + +
- - - - - - - - -
SA
Node

Cell at Rest
- - - - - - - - - - - - - - - - - -
+ + + + + + + + + + + + + + + + + +

Depolarized Cell Shortens &

Contracts

14
Electrical System Cells – The electrical wave is propagated from cardiac cell to cell and fiber to
fiber through the heart via the electrical system. The rate at which the impulse travels
(conduction velocity) varies. The conduction velocity is the slowest through the AV Node;
Ventricular muscle conducts 6 times the speed of the AV Node; Atrial muscle at 20 times the
speed of the AV Node velocity; and the Bundle Branches and Purkinje Fibers conduct at 40
times the rate of the AV Node. This rapid conduction through the entire electrical system occurs
normally and contributes toward an organized and efficient contraction.

Should a site outside the electrical system initiate an impulse (for example, a ventricular site), a
different mechanism of depolarization occurs. Because the impulse occurs outside the
specialized electrical system cells, asynchronous activation of the right and left ventricle occurs
and in addition the conduction velocity is slowed through the myocardial cells. This results in a
wide bizarre qRs.
THE ELECTROCARDIOGRAM

An electrocardiogram is a graphic tracing of voltage produced by depolarization and

repolarization of the heart muscle. It is important to remember that the ECG shows you only the
electrical activity of the heart – it shows nothing related to the mechanical function of the heart
muscle.

When no current is flowing, the stylus (writing point) of the electrocardiograph does not move,
and a straight line is recorded. A current flow causes a deflection (movement) of the stylus, so
that a wave is inscribed on the ECG paper. Normal movements from the baseline are called
waves and are designated P, q, R, s, T and U. The spaces between the waves, which usually
appear as straight lines, are called segments and are named by the waves they separate (for
example, ST segment between the S and T waves). Intervals are also named by the waves at their
beginning and end, for example, PR interval, but their measurement is from the beginning of the
first wave, unlike the segments whose measurement starts at the end of the first wave. An
interval ends with the start of the wave at its end just like a segment does, with one exception;
the qT interval is measured from the start of the q wave to the end of the T wave. A complex
includes more than one wave (qRs complex).

Each wave recorded on the electrocardiogram corresponds to a particular event in the cardiac
cycle. Although the heart consists of several layers, it is only the heart muscle cell layer
(myocardium) that generates currents large enough to be recorded by the electrocardiograph.

The current recorded by the electrocardiograph at any moment is the sum of all the currents
flowing in cells throughout the heart at the particular instant.

Deflections that emanate above the isoelectric line are called positive deflections. Deflections
that radiate below the isoelectric line are considered negative deflections.
Positive
Isoelectric

Negative
15
 ELECTRODE PLACEMENT

Electrodes are small patches which are placed on the chest to transmit electrical activity from the
heart to the telemetry system. Correct electrode placement is critical in order to correctly identify
cardiac rhythms and rhythm disturbances. “Research has shown that when an electrode is
misplaced by 1 intercostal space, the morphology of the qRs can change dramatically and missed
…diagnosis may occur… There are certain leads that are appropriate for specific dysrhythmias.
For example, leads V1 and V6 are the leads of choice to differentiate Ventricular Tachycardia
from SVT” (AACN Practice Alert: Dysrhythmia Monitoring, 2004). Telemetry devices can be
portable and fit into the pocket of a gown, or they can be hardwired to the central nursing station
or a bedside monitor. There are 3, 5 and even 12-lead bedside systems. If you have the capability
with your monitoring system, it is always wise to display two leads from two different areas of
the heart to maximize your ability to capture ectopy or ECG changes.
Skin preparation is another important factor in the quality of an ECG. The skin should be cleaned
with soap and water or alcohol and allowed to dry. Gentle abrasion of the electrode sites with a
washcloth aids with impulse transmission. It may be necessary to shave the sites. Before
applying the electrodes, ensure that the conductive gel is moist and intact, and attach the lead
wires. Avoid bony prominences.
2nd ICS Right Mid-
Clavicular Line
2nd ICS Left Mid-
Clavicular Line

8th
ICS Right Mid-Clavicular
Line

2nd ICS Right Mid-

Clavicular Line

2nd ICS Left Mid-Clavicular Line

4th ICS Right Sternal Border

8th
ICS Left Mid-Clavicular Line

16
 Normal ECG Complex
The wave of depolarization spreading through the heart can be recorded on paper. This is called
the electrocardiogram ECG (EKG). The electrical stimulus originating from the SA Node
proceeds away from the node concentrically in all directions in an enlarging circular wave. This
electrical impulse spreads across the atria and yields a P Wave on the ECG. The P wave
represents atrial depolarization electrically.

P Waves

Normal Inverted Notched Peaked

The impulse then reaches the AV Node, where conduction is the slowest. The impulse takes
1/10 second to travel through the node, allowing blood to enter the ventricles. This time frame is
shown on the ECG as the P-R interval, which is measured from the onset of the P wave to the
beginning of the QRS complex.
The normal P-R interval is 0.12 - 0.20 seconds

PR Interval

17
After the 1/10 second pause, the AV Node is stimulated, initiating an electrical impulse that
starts down the AV bundle into the Bundle Branches, to the Purkinje fibers and into the
myocardial cells, causing ventricular depolarization. The electrical activity of the stimulation of
the ventricles is represented by the qRs complex. The q wave is the first downward stroke of the
qRs complex and is followed by the upward R wave. The q wave is often not present. The
upward R wave is followed by a downward s wave. This total complex duration represents the
electrical activity of ventricular depolarization and contraction.
Normal duration of the qRs is .04 – 0.10 seconds

R = first
positive
deflection
R = first positive
deflection

s = negative
q = negative deflection
deflection following R
preceding R q = negative s = negative
deflection deflection
preceding R following R

Variation of qRs Complexes

R R
R R R
R
r
QS S
s qs
S
S S
There is a pause after ventricular depolarization that is represented by the ST segment, which
normally is on the isoelectric (flat) line having no voltage from the end of the S wave to the
beginning of the T wave.

18
 Elevated Depressed

Normal ST Segment
S-T segments

Recent studies have shown the importance of continuous ST segment monitoring, especially in
patients with “acute coronary syndromes presenting to the ED, patients undergoing a catheter-
based procedure, patients with a cardiac history undergoing a surgical procedure and patients in
the ICU following cardiac surgery…” (AACN Practice Alert: ST Segment Monitoring, 2004).
Continuous ST segment monitoring allows for “…continuous monitoring of ST segment for
changes associated with ischemia to allow early indications of ischemia even in the absence of
chest pain” (Dennison, 2000, p.56). It is important to realize that elevation or depression of just
1mm is considered significant. Just as with dysrhythmia detection, in which leads V1 and V6
were optimal, leads III and V3 are optimal to detect ST segment deviations. However, if the
patient has had a 12-lead ECG, you can determine which lead will be the most appropriate based
on their individual ischemic event.
Typically, ST segment elevation represents injury or severe ischemia, and ST segment
depression represents ischemia.

The repolarization of the ventricles then occurs so that heart cells can regain the negative charge
and, thus, may depolarize again. Final repolarization is represented by the T wave.

T Waves

Normal T Inverted Peaked

19
The q-T interval is measured from the onset of the qRs complex to the completion of the T wave.
The normal duration of the q-T (with a normal rate 60-100) is generally 0.35-0.45 seconds.
The typical qT interval should not exceed more than one-half of the preceding R-R interval.

Count the number of small boxes between two consecutive R waves and divide by 2.
Count the number of small boxes in the qT interval. If the qT is longer than ½ of the R-R
measurement, the qT is prolonged. This method is called the qTc (or the qT calculated to take
heart rate into account) and is the most accurate method of determining the length of the qT
interval. The Corrected qT (qTc) equation is qT/sqrt (RR).
The qT interval should be calculated with each rhythm interpretation according to
hospital or unit policy (see policy ECG Monitoring, Continuous), and be monitored for trends. A
prolonged qT interval shows that there is a delay in ventricular repolarization. This means that
the relative refractory period (the most vulnerable part of the cardiac cycle) is prolonged and this
can place the patient at risk for Torsades de Pointe. Some references site a qTc of > 0.50 seconds
as a risk for Torsades de Pointe. Specific risk factors include certain medications such as
Amiodarone, hypokalemia, low magnesium and calcium levels, bradydysrhythmias, and
hypothermia.

q-T interval

20
A U wave, a small wave of low voltage, is sometimes seen following the T wave. It is often best
discerned in lead V3. It is rendered more prominent by potassium deficiency, and its polarity is
often reversed in myocardial ischemia and left ventricular strain. The U Wave's precise
significance is uncertain. In the cardiac cycle it coincides with the phase of supernormal
excitability during ventricular recovery, and in this connection it is interesting to note that most
ventricular premature beats occur at about the U wave. It is important to distinguish U waves
from a second P wave.

U Wave

21
 P-QRS-T-U Waves Summary
P Waves
♦ Represent atrial depolarization
♦ Should be smooth and round
♦ Should be upright in all leads except aVR
♦ May be diphasic or biphasic (both positive and negative components)
♦ May be notched or peaked
♦ Should be one P for every qRs complex

PR Interval
♦ Normal duration = 0.12 – 0.20 seconds
♦ Measured from the beginning of the P to the beginning of the qRs
♦ Represents atrial depolarization + delay through the AV Node

qRs Complex
♦ Normal duration 0.10 seconds or less
♦ Measured from the beginning of the qRs complex to the end of the S (the J-point)
♦ Represents ventricular depolarization
♦ Atrial repolarization is hidden within the qRs
♦ q = first downward deflection before the R wave
♦ R = first initial upward deflection following the P wave
♦ s = first downward deflection following the R wave; the J-point is the point at which the s wave
returns to baseline

ST Segment
♦ Period between the completion of ventricular depolarization and beginning of final ventricular
repolarization.
♦ Normally found on the isoelectric line; may be elevated or depressed

T Wave
♦ Represents recovery phase
♦ Normally upright in all leads except aVR
♦ Round and asymmetrical

U Wave
♦ Occurs after the T wave (not always present)
♦ Important to distinguish from second P wave

QT Interval
♦ Measured from the beginning of the qRs complex to the end of the T wave
♦ Normal interval is dependent on rate and gender (normal 0.35-0.45 seconds)

22
 R PR
interval

P T

q
s

qRs
interval

qT
Interval

23
Each rhythm strip should be analyzed in a systematic fashion. It is helpful to
consider the Five Steps of ECG Rhythm analysis.

The Five Steps of ECG 5. Identify the Rhythm

Rhythm Analysis
4. Measure Intervals

3. Examine P-qRs-T waves

2. Calculate Heart Rate

1. Determine regularity

Step 1 Determine Regularity

RHYTHM
The rhythm is said to be regular when there is a constant distance between similar waves
(P-P or R-R). To determine whether the rhythm is regular or irregular place the straight edge of
a piece of paper along the baseline of the rhythm strip. Then, move the paper up slightly so that
the straight edge is near the top peak of the P waves. With your pencil, make a dot on the paper
at each of two consecutive P waves; this is the P-P interval. Now, move the paper across the
strip from left to right lining up the dots with each consecutive P wave. If each distance
between all the P waves is the same, the atrial rhythm is regular, if the distance varies, the atrial
rhythm is irregular. Next, using the same method, measure the distance between consecutive R
waves (the R-R interval) to determine whether the ventricular rhythm is regular or irregular.

24
 Calipers may also be used to achieve measurement (a more accurate technique).

The rhythm is considered regular if all the R-R measurements are consistent. If the rate is within
a normal range of 60-100 beats per minute, and the R-R interval varies no more than 3 small
boxes (0.12 sec), the rhythm is considered essentially regular (even though it is slightly
irregular). This 0.12 second leeway in regularity does not apply to rates above 100.

25
Step 2 Calculate the Heart Rate

ECG PAPER
The ECG is recorded on ruled paper. The smallest divisions are one millimeter squares (one mm
long and one mm high). There are five small squares between the heavy black lines. The height
and depth of a wave is measured in millimeters and represents a measure of voltage.

Time
The horizontal axis represents time. The amount of time represented by the distance between the
heavy black lines is 0.20 seconds. There are five small squares between the heavy black lines.
Therefore each small square represents 0.04 seconds. By measuring along the horizontal axis the
duration of any part of the cardiac cycle can be determined.

One Large Square

1 small box = .04 sec
(1mm)
0.04 x 5 = 0.20
seconds 5 mm or 5 small
boxes =
0.20 sec
3 Second Lines
Time

0.20 x 5 = 1 second

0.20 x 10 = 2 seconds

0.20 x 15 = 3 seconds

6 seconds = 30 Large or 150 Small Boxes

26
 Step 2 Calculate the Heart Rate

The rate of any cardiac rhythm can be quickly determined from an ECG strip. Once you
understand the layout and measurement of the graph paper, rate calculations become easy. Most
ECG recorders in North America run ECG paper at 25mm/sec. (Remember Large boxes = 0.20
seconds in time and small boxes = 0.04 seconds in time). Three methods for determining heart
rates will be discussed. The method used for rate measurement is determined by whether the
rhythm is regular or irregular. If the rhythm is regular the Grid or Ruler Method can determine
the rate accurately. If the rhythm is irregular the best means for determining the rate is the Scan
Method.

Time Small boxes (1 = 0.04 seconds) Large Boxes (1 = 0.20 seconds)

0.04 seconds 1 small box
0.20 seconds 5 small boxes 1 large box
1 second 25 small boxes 5 large boxes
3 seconds 75 small boxes 15 large boxes
6 seconds 150 small boxes 30 large boxes
60 seconds 1500 small boxes* 300 large boxes*
* = Number of small and large boxes in a minute

1. Grid Method
The rate can be determined by counting the number of boxes, small or large, between R waves
and then dividing that number into 1500 or 300 respectively. (See example strips below)

1 2 3 4 5 6

6 Large Boxes between R Waves Rate = 50

300 ÷ 6 = 50

5 10 15 20 25 30

30 Small Boxes between R Waves Rate = 50

1500 ÷ 30 = 50

27
1. The Grid Method is done by either dividing 1500 (1500 smaller, 1mm, squares in one
minute) by the number of small boxes between 2 R waves or by dividing 300 (300 large, 5mm,
squares in one minute) by the number of large boxes between 2 R waves. The Grid method is
the most accurate, yet very time consuming to calculate and impractical when trying to get a
quick estimate of the heart rate. The large box method can be completed quickly by
memorization. The Grid Method is limited to regular rhythms.

Large Squares Rate

Between R Waves Per Minute
1 Large Square 300
2 Large Squares 150 Memorize
3 Large Squares 100
4 Large Squares 75
5 Large Squares 60
6 Large Squares 50
7 Large Squares 42

2. The Scan Method is done by counting the number of R waves in a 6 second strip and then
multiplying by 10 (6 seconds x 10 = 60 seconds; therefore the number of R waves per 6 second
strip multiplied by 10 gives the rate/minute). The scan method is the most practical and
commonly used because calculations can be determined for both regular and irregular rhythms
quickly.

6 Seconds

3 Seconds

5 R waves/6 second strip = 5 x 10

Rate = 50/minute

28
3. Three Beat Ruler Method – is done by using a commercially developed ruler. Place
the first qRs complex on the “0”. Next, count three complexes over; the rate on the ruler
corresponds with the third complex.

Rate = 50

“0” 1st 2nd 3rd

Mark Complex Complex Complex

Step 3 Examine P-qRs-T Waves

P WAVES
After assessing the rate and rhythm, the next step is to examine the P waves. Determine the
following:
 Are P waves present and in front of all qRs complexes?
 Does a P wave follow the qRs complex?
 Is there 1P:1qRs relationship?
 Are the P waves all a similar shape?
 Are the P waves all upright (positive) in all leads except aVR?

qRs complexes
Next determine the following:
• Are the qRs complexes present with each p wave?

29
Step 4 Measure PR Intervals and qRs Complexes

PR INTERVAL
The next step is to measure the
PR Interval. The PR interval
J Point
begins with the initiation of the P
wave (where the slope of the P
wave first leaves the isoelectric
line) and ends with the first
deflection of the qRs complex.
 Are PR Intervals within
normal limits (0.12 seconds
– 0.20 seconds)?
 Are PR Intervals consistent
(constant)?

qRs Duration PR
The qRs should measure interval
between 0.04 seconds up to 0.10 = 0.16
seconds (not equal to or greater seconds
than 0.12 seconds). The qRs
begins at the point where the complex begins (either with a q or R) and ends with the J point
(sometimes referred to as the J junction). The J point is defined as the point at which the s wave
returns to baseline and the ST segment begins.

 Normal qRs duration is 0.04 seconds – 0.10 seconds

QT Intervals – The Q-T interval is measured from the first initiation of the qRs complex to the
end of the T wave. Normal Q-T intervals are based on rate and gender. The Q-T grows shorter
as the rate increases. (See chart on next page)

qT Interval=
0.40 seconds

30
 Normal Q-T Intervals
Heart Rate Men & Children Women
40 0.45-0.49 seconds 0.46-0.50 seconds
50 0.41-0.45 seconds 0.43-0.46 seconds
60 0.39-0.42 seconds 0.41-0.43 seconds
71 0.36-0.38 seconds 0.37-0.41 seconds
100 0.31-0.34 seconds 0.32-0.35 seconds
150 0.25-0.28 seconds 0.26-0.28 seconds
172 0.23-0.26 seconds 0.24-0.26 seconds

Step 5 Identify the Rhythm

Once all of the steps have completed and the information examined, a correct and complete
interpretation can be made. The steps are summarized below, along with normal ranges noted.

 Rate = 60 – 100 per minute

 Rhythm = Regular

 P waves = Present, similar, 1 and only 1 P for each qRs

 PRI = 0.12 – 0.20 seconds and consistent

 qRs = 0.04 – 0.10 seconds

 P: qRs = One P for each qRs

31
 Chapter Two

Rhythms
Originating
from the
Sinus Node

Published by: Department of Educational

Development & Resources
The Ohio State University Medical Center

© OSU revised May 2007

28
Objectives Chapter Two

1. Identify normal Sinus Rhythm.

2. Compare and contrast Normal Sinus Rhythm, Sinus Bradycardia and Sinus
Tachycardia.

3. Differentiate normal Sinus Rhythm from Sinus Arrhythmia and Sinus Pause
or Sinus Arrest.

29
The Sinus Complex

The salient point for identifying a complex from the Sinus Node is the presence of a normal P
wave. In lead II normal P waves will have a shape that is rounded, upright and similar to each
other. A normal P wave in Lead aVr will be inverted; and in V1 may be biphasic (have both a
negative and positive component.

Normal P Wave
Lead II Normal P Wave
Normal P Wave
Lead aVr
Lead V1

The normal qRs will also vary from lead to lead. It

should be upright or positive in Lead II. Most normal
qRs complexes in Lead II will not have a visible
q Wave, while a normal q wave may be present in
Leads I, aVl, V5 & V6.
Normal qRs
Lead I

Therefore any complex that has originated from the SA

Node will have this normal P-qRs-T configuration.

30
If the impulse from the SA Node is normally conducted down through the atrial tracts, the AV
Node, the Bundle of HIS, the bundle branches and the purkinje system, the sinus complex will
have normal PR interval (0.12-0.20 second) and qRs duration (0.04-0.10 second). Every
complex arising from the SA node that is conducted normally will have similar morphology.

Sinus rhythms have the following ECG characteristics in common: One Sinus P wave for each
qRs and similar to each other, PR and qRs intervals normal and constant PR intervals. ECG
characteristics that vary are rate and rhythm. Sinus rhythms include:

™ Normal Sinus Rhythm

™ Sinus Tachycardia
™ Sinus Bradycardia
™ Sinus Dysrhythmia
™ Sinus Pause (Arrest)

Sinus Rhythms ECG Summary

™ Rate: 60-100, >100 or < 60 per minute
™ Rhythm: R- R = or ≠
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 -0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

31
 Normal Sinus Rhythm (NSR)

Normal sinus rhythm represents a regular discharge of the sinus node with subsequent atrial
depolarization at a rate between 60-100 per minute. The rhythm is regular (or slightly irregular-
no more than 3 small boxes or 0.12 seconds difference in R-R intervals when the rate is 60-100).

ECG Summary
™ Rate: 60-100 per minute
™ Rhythm: R- R = (no more than 0.12 seconds
difference in R-R when the rate is 60-100)
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 -0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

Normal Sinus Rhythm

= P Waves

= R Waves

= T Waves

Rate: 80 Rhythm: R – R = PRI: 0.16 - 0.18 seconds qRs: 0.08 seconds

32
 Sinus Tachycardia

Sinus Tachycardia represents an increase in the rate of discharge of the sinus node. It may be
secondary to multiple factors and is a physiologic response to a demand for a higher cardiac
output.

ECG Summary
™ Rate: > 100 (usually not > 150)
™ Rhythm: R- R =
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 -0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

Causes of Sinus Tachycardia:

♦ Exercise ♦ Hypovolemia ♦ Medications

♦ Fever ♦ Hypoxia ♦ Substances
♦ Anxiety, Fear ♦ Acute MI
♦ Fight or Flight ♦ Congestive Heart Failure

Therapy:

♦ None specific for this dysrhythmia

♦ Assess patient to determine stability and notify the physician if new rhythm and/or
unstable
♦ Treat underlying cause
6 Seconds

3 Second Mark

▼ ▼ ▼

1 Second Marks

Rate = 120
Sinus Tachycardia

33
Sinus Bradycardia

Sinus Bradycardia is a decrease in the rate of atrial depolarization subsequent to a slowing of the
sinus node. It may be secondary to intrinsic sinus node disease, increased parasympathetic tone,
or drug effect.

ECG Summary
™ Rate: < 60 (usually 40-59)
™ Rhythm: R- R =
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 - 0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

Causes:
♦ Healthy Athlete ♦ Sinus Node Disease
♦ Sleep ♦ Medications
♦ Increased Vagal Tone ♦ Increased Intracranial Pressure
♦ Valsalva maneuver, Vomiting, Suctioning

Therapy:
♦ Stable – Assess patient; notify physician if new rhythm; 12-lead ECG; observe
♦ Unstable – Notify physician, 12-lead ECG, support ABCs/determine need for oxygen,
confirm or initiate IV, Monitor, Atropine 0.5mg IVP, pacemaker (see page 35 for
unstable parameters)
♦ See OSUMC or unit-specific policy regarding oxygen administration

▼ ▼ ▼

Rate - 38 Sinus Bradycardia

34
 Unstable
Four basic parameters classify a patient as unstable. They are:

™ Hypotension – Systolic blood pressure ↓ 90 mmHg, signs of shock

™ Altered mental status
™ Shortness of breath – pulmonary congestion
™ Ischemic chest pain

Sinus Dysrhythmia (Sinus Arrhythmia)

Sinus Dysrhythmia is a normal variation of Normal Sinus Rhythm and in most cases is
considered a normal rhythm. The rhythm has slight irregularities. A rhythm strip may appear
normal but when measured, the P-P and R-R intervals will reveal a variation of the rhythm (to be
considered irregular the R-R must vary more than 0.12 seconds). The most common type of
Sinus Dysrhythmia is found in children and is usually associated with respiration; that is the rate
speeds up with inspiration and slows with expiration. There are also non-respiratory versions.
Some Sinus Dysrhythmias may be bradycardic, if so then the rhythm name would be Sinus
Bradydysrhythmia. (A tachycardic rate would be called Sinus Tachydysrhythmia).
It is important to differentiate Sinus Dysrhythmia from a Normal Sinus Rhythm with ectopy.
With Sinus Dysrhythmia, all the complexes and waveforms are identical because they originate
in the same focus (the SA Node). Ectopic complexes will differ in appearance from the
underlying rhythm which is how you know they came from a different focus (atrial tissue, AV
Junction, etc.).

ECG Summary
™ Rate: 60 – 100 (may also be < 60 or > 100)
™ Rhythm: R- R ≠ ( > 0.12 seconds difference)
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 - 0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

Causes:

35
 ♦ Normal in children, young adults & the elderly
♦ Coronary Artery Disease
♦ Medications

Treatment:
♦Assess patient to determine stability; 12-lead ECG, notify physician if new rhythm or
unstable
♦ Generally no treatment is required. If the patient is unstable, it is due to a bradycardic
rate

Sinus Dysrhythmia

R-R = 0.60 R-R = 0.78

seconds seconds
Rate = 90-100

Sinus Pause

Occasionally, the SA Node will fail momentarily and will not initiate an impulse. This might be
due to increased vagal stimulation, pharyngeal irritation, carotid sinus massage or deep
inspiration. In the case of severely delayed or even permanent cessation, alternative or secondary
pacemakers may takeover and maintain the heart rhythm. Two rhythms fall under the Sinus
Pause category: Sinus Arrest and Sinus Exit Block.

Sinus Arrest

Sinus Arrest is a failure of the SA Node to initiate an impulse. This is a disorder of automaticity.
The rhythm will be slightly irregular as the SA Node will not resume “on time” after the arrest.

Sinus Exit Block

36
In Sinus Exit Block, the SA Node initiates impulses in a regular rhythm; however, some of the
impulses are blocked as they leave the SA Node and therefore do not reach the atria. This is a
disorder of conductivity. This rhythm will have P waves that “march out”.

Clinically, it is not necessary to distinguish between a Sinus Arrest and a Sinus Exit Block. If the
underlying rhythm is irregular (Sinus Dysrhythmia) then differentiation is impossible, and the
general term of Sinus Pause is used.

Sinus Pause ECG Summary

™ Rate: Usually < 60 due to the pause
™ Rhythm: R- R ≠ due to the pause
™ P Waves: Upright (except AVR); similar
™ P-R interval: 0.12 -0 .20 seconds & consistent
™ qRs: 0.04 – 0.10 seconds
™ P to qRs: 1P:1qRs

Causes:

♦ Vagal Stimulation – overeating, caffeine, nicotine

♦ Pharyngeal irritation -Intubation
♦ Valsalva maneuver - Carotid Sinus Massage, deep inspiration
♦ Sick Sinus Node
♦ Medications
♦ Coronary Artery Disease, Myocardial Infarction

Treatment:
♦ Stable – Assess patient to determine stability; 12-lead ECG, determine need for
oxygen, ensure adequate IV access, notify physician if new, observe
♦ Unstable – Ensure ABCs/determine need for oxygen; notify physician; initiate or
confirm IV access, Atropine 0.5mg IVP; pacemaker

37
 Normal Sinus Rhythm with a 2.44 Second Sinus Pause .

R – R = Before and
After Pause

Sinus Arrest interval =

Measure from the start of the P before the
pause to the start of the P after the pause =
2.44 Second Sinus Pause

It is imperative to measure and document the length of the pause and assess the patient’s
tolerance of the pause. Does the patient complain of dizziness, shortness of breath or chest pain?
Is the blood pressure stable? With any dysrhythmia, the nurse needs to begin to assess the
possible causes of the rhythm disturbance and have that information ready to discuss with the
physician and health-care team. As you will see, there are several common causes of the various
dysrhythmias such as hypoxia, cardiac ischemia, electrolyte imbalance and acidosis just to name
a few. It is pointless to simply medicate for the dysrhythmia if the underlying cause is not
corrected.

Clinical Picture

It is just as imperative for the nurse or healthcare provider to notice and document trends in the
clinical picture. Trends in vital signs, physical assessments or patient complaints can assist the
healthcare provider in anticipating untoward clinical events. When these signs are not
recognized, this is known as “Failure to Rescue”. It has been shown that patients will exhibit
signs and symptoms as far out as 24 to 48 hours prior to full cardiac arrest. The ECG is just one
tool that, if used correctly, can provide clues to the patient’s underlying disease process or
injury.

38
Electrocardiographic Artifact

Electrocardiographic artifact or electrical noise can be seen on the ECG strip as a result of
patient body movement, muscle tremor, electrical current near the patient, or poor skin-to-
electrode contact. It is important to recognize artifact as such and not to confuse it with other
rhythms such as Atrial Fibrillation or Ventricular Tachycardia.

R
P T

Normal Sinus Rhythm with Artifact

Documentation & Housekeeping

The monitor ECG strip should be placed in the Nursing and Allied Health Professions Notes. A
note immediately following the strip should include the patient’s name, date, time, rhythm
interpretation, heart rate, PR interval, qRs interval, QT interval, any wave abnormalities and RN
signature. Rhythm interpretation documentation should include a full description such as
“Normal Sinus Rhythm with 2.44 second Sinus Pause”. Do not write directly on the rhythm
strip! Rhythm strips should be obtained at least every 8 hours (or per unit-specific policy) and
with any significant change in rhythm. Monitor recall should be done per unit policy. The alarm
limits should be set at 50 – 150 bpm (unless physician order dictates otherwise), and telemetry
batteries should be changed q24 hours (Policy: ECG Monitoring, Continuous).

39
 Bradycardia
Assess patient to determine stability
Stable or Unstable?

Stable Unstable

Yes No
Notify MD if new Ensure ABCs/determine need for oxygen
rhythm Notify MD
12-lead ECG Initiate or confirm IV access (at least 2 sites)
Ensure IV access Remain with patient and continually reassess
Observe and Reassess

‹ Atropine 0.5mg IVP (total dose of 3mg)

‹ TCP or Transvenous pacer

‹ Dopamine or Epinephrine drips (Hypotension)

Sinus Rhythms Causes and Treatments

40
 Rhythm Causes Treatment

Sinus Tachycardia ♦ Exercise ♦ Treat or remove cause

♦ ↑ Temperature ♦ MI – Beta Blockers
♦ Hypovolemia, Dehydration
♦ Stress, Anxiety, Fight or Flight
♦ Hypoxia, CHF, Acute MI
♦ Sympathetic Stimulation
♦ Meds or Substances

Sinus Bradycardia ♦ Normal ♦ Stable – Notify MD if new

♦ Increased Vagal Tone rhythm; 12-lead ECG; Observe &
♦ Medications Reassess
♦ Diseased SA Node ♦ Unstable
♦ Hypothermia ™ Notify MD
™ Ensure ABCs/determine
need for oxygen
™ Ensure IV Access
™ Atropine 0.5mg IV
™ Pacemaker

Sinus Dysrhythmia ♦ Normal ♦ Assess

♦ Coronary Artery Disease ♦ Notify MD if new rhythm
♦ Myocardial Infarction
♦ Medications

Sinus Pause (Arrest) ♦ Increased Vagal Tone ♦ Stable – Notify MD if new

♦ Coronary Artery Disease rhythm; 12-lead ECG; Observe &
♦ Rheumatic Heart Disease Reassess
♦ Myocarditis ♦ Unstable
♦ Medications ™ Notify MD
™ Ensure ABCs
™ O2 at 2L/NC
™ Ensure IV Access
™ Atropine 0.5mg
™ Pacemaker

41
 ECG Rhythm Characteristics Ohio State University Medical Center

Rhythm P waves qRs Notes

Round, upright, 0.04-0.10 Rate: 60-100 bpm
Normal Sinus Rhythm similar
PRI: 0.12-0.20 Rhythm: R
(NSR) P:qRs 1:1

Round, upright, 0.04-0.10 101-150 bpm

Sinus Tachycardia similar
PRI: 0.12-0.20 Rhythm: R
P:qRs 1:1

Round, upright, 0.04-0.10 ≤ 59 bpm

Sinus Bradycardia similar
PRI: 0.12-0.20 Rhythm: R
P:qRs 1:1
Sinus Dysrhythmia Round, upright, 0.04-0.10 Rate: variable
similar
PRI: 0.12-0.20 Rhythm: I
P:qRs 1:1

PAC Varies from 0.04-0.10 Rate: Variable

sinus Ps; small,
peaked or Rhythm: I (d/t
notched; may PAC)
be buried in
preceding Timing: Early
sinus T wave;
PRI may be
different than
sinus PRI

©OSU June 2006 1

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center
Rhythm P waves qRs Notes
0.04-0.10 Rate: ≥ 150 bpm
Supraventricular Not visible
Rhythm: R
Tachycardia (SVT) PRI: N/A

N/A 0.04-0.10 Rate: Variable

Atrial Flutter “F” or “flutter”
waves Rhythm: R or I
PRI: N/A
Saw tooth pattern
N/A 0.04-0.10 Rate: Varies
Atrial Fibrillation Fibrillating
baseline Rhythm: I

PRI: N/A
PJC No P wave, or 0.04-0.10 Rate: Varies
inverted P
wave before or Rhythm: I (d/t
after qRs PJC)

PRI: ≤0.12 if Timing: Early

present before
qRs
No P wave, or 0.04-0.10 Rate: 40-60 bpm
Junctional escape inverted P
wave before or Rhythm: R
Rhythm after qRs

PRI: ≤0.12 if
present before
qRs

©OSU June 2006 2

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center
Rhythm P waves qRs Notes
Accelerated Junctional No P wave, or 0.04-0.10 Rate: 61-100 bpm
inverted P
wave before or Rhythm: R
after qRs

PRI: ≤0.12 if
present before
qRs
No P wave, or 0.04-0.10 Rate: 101-150
Junctional Tachycardia inverted P bpm
wave before or
after qRs

PRI: ≤0.12 if
present before
qRs
PVC None >0.12 Rate: Variable
Rhythm: I (d/t
PVC)
Timing: Early
Pattern: Bigeminy-
every other beat;
Trigeminy-every
third beat;
Multiformed-
different shapes;
Couplet-two in a
row

©OSU June 2006 3

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center
Rhythm P waves qRs Notes
>0.12 Rate: 20-40 bpm
Idioventricular None
Rhythm Rhythm: R
PRI: N/A

Accelerated None >0.12 Rate: 41-100 bpm

Idioventricular
PRI: N/A Rhythm: R

None >0.12 Rate: >100 bpm

Ventricular Tachycardia
PRI: N/A Rhythm: R

N/A Rate: N/A

Ventricular Fibrillation None
Rhythm: Chaos
PRI: N/A

©OSU June 2006 4

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center
Rhythm P waves qRs Notes
May be N/A
Asystole present; round, Rate: 0
upright &
similar Rhythm: R (if P
waves present)
PRI: N/A

Any organized rhythm

that should perfuse but
patient is PULSELESS =
“Rhythm Name with
PEA”

Round, upright, 0.04-0.10 Only block that

st
1 degree AV Block similar does not drop
qRs
PRI: >0.20 but
<0.40 Consistent PRI
P:qRs 1:1
Round, upright, 0.04-0.10 Consistent PRI
nd
2 degree AV Block, similar OR when P conducts
Type II ≥ 0.12 to qRs;
PRI: normal or unpredictable
long; consistent drop of qRs
across strip

#P > #qRs

©OSU June 2006 5

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center
Rhythm P waves qRs Notes
Round, upright, 0.04-0.10 Cyclic pattern
nd
2 degree AV Block, similar
Type I Inconsistent
PRI: PRI
progressive
lengthening Predictable drop
until drop of
of qRs after
qRs
lengthening PRI
#P > #qRs

Round, upright, 0.04-0.10 Inconsistent

3rd degree AV Block similar OR PRI
≥0.12
PRI: N/A No relationship
qRs “march between P and
#P > #qRs out”
qRs
Ps “march out”

©OSU June 2006 6

Revised August 07
 ECG Rhythm Characteristics Ohio State University Medical Center

Drugs Defib Synch Cardiovert TCP

Atropine

Adenosine

Amiodarone

Lidocaine

Epinephrine

©OSU June 2006 7

Revised August 07
 CONDUCTION SYSTEM IN RELATION TO
HEART STRUCTURES

SA Node
Intrinsic Rate
60-100

Atrial Rhythms

AV Junction
Intrinsic Rate
40-60

Ventricular Rhythm
Intrinsic Rate
20-40
Sinus Rhythms

The SA Node is the only place that gives you the perfect, “normal” sinus rhythm.
The rhythms are characterized by round, upright, similar-appearing P waves,
followed by a normal PR Interval. There is one narrow QRS that follows each P
wave. The rhythms may differ in their rate (≤60 bpm to between 100-150 bpm).
All other characteristics will remain the same.

Junctional Rhythms

The AV Junction or Node is able to take over as an “escape” pacemaker for the
heart in the absence of a functioning SA Node. Since the junction lies superior to
the ventricles, the rhythms maintain a narrow QRS complex, and are regular.
However, Junctional rhythms are differentiated from SA Node rhythms by the P
wave. The P wave may have one of three characteristics: absent; inverted before
the QRS; inverted following the QRS. The inherent rate of the junction is 40-60
bpm. Again, the Junctional rhythms may differ in their rate (40-60 bpm, 60-100
bpm or 100-150 bpm), but all other characteristics will remain the same.

Ventricular Rhythms

The ventricular myocardium is able to take over as an “escape” pacemaker for

the heart in the absence of upper-level functioning pacemakers. Since the
ventricles deliver their impulses across the myocardium (no intact pathways), the
QRS is wide and bizarre in appearance. There are no associated P waves (the P
waves only come from superior to the ventricles, and since the impulse is
initiated in the ventricles, no P waves are present). Ventricular rhythms are
hallmarked by the wide, bizarre-appearing QRS complex. The inherent rate of
the ventricles is 20-40 bpm. Again, the ventricular rhythms may differ in their rate
(20-40 bpm, 40-100 bpm, 100-220 bpm), but all other characteristics will remain
the same.
Ventricular Fibrillation is a chaotic rhythm that does not produce a pulse and is
not compatible with life. The heart is simply “quivering” , and does not produce an
organized contraction. The patient in “V Fib” requires immediate life support
measures.
Ventricular Asystole is a rhythm that does not produce a pulse and is not
compatible with life. The heart is motionless, and does not produce a contraction.
There may be P waves on the rhythm strip, but this signifies atrial depolarization,
which does not produce a pulse. The patient in “Asystole” requires immediate life
support measures.
PAC (Premature Atrial Complex)

A PAC is a complex that falls early in the cardiac cycle. It is produced by an

ectopic site that fired from the atrial myocardium. It is similar in appearance to a
normal sinus complex, but it will be identified in one of three ways: 1. There will
be a change in the P wave (the PAC’s P wave may be smaller or more peaked
than the other “normal” sinus P waves on the rhythm strip). 2. There will be a
change in the PR Interval (the PAC’s PR interval will be different from the
“normal” sinus PR intervals across the rhythm strip). 3. There will be a change in
the T waves (the T wave of the preceding sinus complex before the PAC will be
larger in size than all other sinus complex T waves-this shows a buried P wave
inside the sinus complex T wave).

PJC (Premature Junctional Complex)

A PJC is a complex that falls early in the cardiac cycle. It is produced by an

ectopic site that fired from the AV Junction or Node. It maintains the fundamental
characteristics of a Junctional complex (narrow QRS and either no P wave, an
inverted P wave before the QRS or an inverted P wave following the QRS).

PVC (Premature Ventricular Complex)

A PVC is a complex that falls early in the cardiac cycle. It is produced by an

ectopic site that fired from the ventricular myocardium. It maintains the
fundamental characteristics of a Ventricular complex (no P wave and a wide,
bizarre-appearing QRS).
PVCs are described according to their number or pattern on the rhythm strip
(rare, occasional, frequent; bigeminal or trigeminal) and their shape (uniformed or
multiformed). It is important to thoroughly describe PVCs as their shape, number
and pattern become clinically significant (increasing numbers of PVCs
demonstrate ventricular instability, and PVCs of different shapes demonstrate
multiple ectopic sites that are firing from the ventricles).

SVT (Supraventricular Tachycardia)

SVT is a name assigned to a group of rhythms that originate from above the
ventricles (“supraventricular” ), with a rate of ≥150 bpm (tachycardia), and are
regular. At this rate, it is not possible to accurately determine if a P wave is
present, however, the clinician knows that this rhythm originated above the
ventricles due to the narrow QRS complex. Until the rhythm is slowed via medical
interventions, the clinician is unable to determine the exact origin of the
tachycardia (sinus, atrial or Junctional).
Atrial Flutter

Atrial Flutter is a rhythm that originates in the atrial myocardium, at rates between
250-350 bpm. The atrial rate is regular, and instead of P waves, F waves are
present. F waves create a baseline that resembles a picket fence or the blades of
a saw (saw tooth pattern). The AV Node will “filter” the atrial impulses to the
ventricles, so that not all impulses reach the ventricles to cause contraction. The
“filtering” can be consistent or inconsistent (every 3rd atrial beat is allowed
through, versus a random pattern of beats allowed through), which is what
makes the overall rhythm regular or irregular. Since the rhythm originates above
the ventricles, the QRS complex is narrow.

Atrial Fibrillation

Atrial Fibrillation is a rhythm that originates in the atrial myocardium, at rates

greater than 350 bpm. At this rate, no discernible waves are able to be seen, so
a “wavy” or “fibrillating” baseline is present. The AV Node cannot “filter” atrial
beats with any regularity at these rates, so the overall rhythm is always irregular.
Since the rhythm originates above the ventricles, the QRS complex is narrow.

1st Degree AV Block

First Degree AV Block is similar in appearance to a “normal” sinus rhythm. The

key difference is a prolonged PR Interval. The impulse leaves the SA Node, but
is slowed at the AV Node, creating a prolonged PR Interval. Once the impulse
passes the AV Node, conduction proceeds normally. Since the rhythm originates
in the SA Node, there are upright, similar “normal” sinus P waves, and a narrow
QRS complex that follows each P wave.

2nd Degree AV Block Type 2

Second Degree AV Block Type 2 is characterized by P waves that conduct to

QRS complexes, but without warning, the atrial impulse is not conducted through
to the ventricles, and a QRS complex is dropped. The PR Interval of the
conducted beats is usually normal, but may be prolonged. In either case, the PR
Interval is consistent across the rhythm strip. The QRS complexes may be
narrow if the escape pacemaker is in the Junction, or wide if the escape
pacemaker is in the ventricular myocardium. The hallmark of a Second Degree
AV Block Type 2 is that when the P wave is conducted to the QRS, the PR
Interval is consistent; when the QRS complex is dropped, it is dropped without a
change to the PR Intervals.
2nd Degree AV Block Type 1

Second Degree AV Block Type 1 is characterized by a progressive lengthening

of the PR Interval until a QRS complex is dropped. This is a cyclic pattern, which
regularly repeats throughout the rhythm strip. Each cycle is identical to the
others, and would match up perfectly if placed atop one another. This rhythm is
usually transient.

3rd Degree AV Block

Third Degree AV Block is a complete lack of communication between the atria

and ventricles. The atria will initiate regular impulses that are not conducted
through to the ventricles. The P waves are upright and similar throughout the
rhythm strip. Since there is no communication between the atria and ventricles,
there is no PR Interval. The QRS complexes may be narrow if the escape
pacemaker is in the Junction, or wide if the escape pacemaker is in the
ventricular myocardium. The heart rate is also dependent upon the location of
the escape pacemaker (other factors may play a role as well). The overall rhythm
is irregular, but taken individually, the atrial and the Junctional or ventricular
impulses are regular and “march out” .