Orientation EKGII Study

Guide
Handout & Practice Strips

10/1/2014

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 Key Concept

 Interpreting Dysrhythmias = interpretation of electrical impulses of the heart

 Electrical activity represented by the rhythm assists us to evaluate mechanical function of the heart

Patients at Risk for Developing Dysrhythmias:

Cardiac disease/ischemia
Hypoxia
Electrolyte disturbances
Acid-Base disturbances
Medications
Elderly
Cardiac Surgery/Congenital heart defects
Chest trauma
Pulmonary diseases
Recovering from anesthesia

Cardiac Cells
Four characteristics make the cardiac cell different
Automaticity: ability to spontaneously produce an impulse
Excitability: ability to respond to an impulse
Conductivity: ability to transmit an impulse
Contractility: ability to respond to impulse by muscle contraction

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 Cardiac Cycle
Diastole Systole
Heart relaxed Active contractile phase
Coronary perfusion occurs Blood is pumped
Ventricles fill
2/3 of total cardiac cycle From RV into the pulm artery to
Early Diastole: Ventricles fill passively the lungs
Late Diastole: Atria contract
“top-off” ventricles From the LV into the aorta and
“atrial kick” systemic circulation
10-30% of volume in ventricle

Cardiac Output (CO)

Total volume of blood ejected from the heart each minute
Normal = 4 to 8 liters per minute

Stroke Volume x Heart Rate

quantity ejected each beat number of cardiac cycles/minute
approx. 60-135ml/beat usually 60-100 bmp

Signs & Symptoms of Decreased CO:

 Dizziness
 Decreased LOC, Confusion, Restlessness
 Decreased BP
 Decreased UO
 Decreased or absent peripheral pulses
 Cool, clammy skin

Electrical States of Cells

Polarized Depolarization Repolarization

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Sinus Node (Sinoatrial node, SA Node)  Intrinsic rate 40 - 60 beats per minute
 Normal pacemaker of heart
 Located on posterior wall of the right atrium Ventricular Conduction (R and L Bundle
 Intrinsic rate 60 - 100 beats per minute Branches + Purkinje Fibers)
 Rapid conduction
Junctional Area (AV Node + Bundle of His)  Purkinje fibers are small fingerlike
 Back up pacemaker projections of the conduction system into
 Gate-keeper to the ventricles the myocardium
 Located on the floor of right atrium near  Last back-up pacemaker if SA and AV
tricuspid valve nodes fail
 Bundle of His is bridge between atria &  Intrinsic rate 20 - 40 beats per minutes
ventricle

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 EKG Leads

 Flow of electricity through the heart is sensed by electrodes placed on skin

 Different combinations of electrodes are referred to as a “lead”
 The monitor assigns each electrode to be + , - ,or ground based on the lead chosen
 Each different lead looks at the heart from a different angle
 Lead selection depends on what you are looking for and wanting to monitor

Electricity Rules:

If electricity travels toward the positive

electrode the shape/morphology will be upright
/positive

If electricity travels away from a positive

electrode the shape/ morphology will be
downward/negative

If electricity travels perpendicular to the

positive electrode the shape/morphology will
be biphasic

Wave Forms and Intervals

 A single cycle on the EKG begins with the initiation of an impulse at the SA node
 Includes all electrical signals that course through the heart, until the ventricles repolarize to a resting state,
awaiting another signal

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P Wave
 Represents atrial depolarization
 P wave forms as electrical signal spreads across atria
 simultaneous wave of atrial contraction follows
 Usually small (2mm), rounded, and upright

PR Interval (PRI)
 Atrial depolarization & electrical delay at the AV node
 Measured from beginning of P wave to beginning of
QRS complex
 Delay allows atria to contract adding filling volume to
ventricles
 Normal PRI is 0.12 to 0.20 seconds

QRS Complex
 Represents ventricular depolarization
 QRS is measured where it leaves and returns to
baseline
 Normal duration is < 0.12 seconds
 The term QRS complex is an umbrella term that
describes the components representing ventricular
depolarization
 Morphology depends on lead choice and electrical path
through the ventricle
Q Wave
 First negative deflection after P wave but before R wave
 Represents beginning of ventricular depolarization
 Not present in all leads
R Wave
 First positive wave following P wave, or first positive
wave of the QRS complex
 Represents continuing ventricular depolarization
S Wave
 Negative deflection following the R wave
 Completion of ventricular depolarization

ST Segment
 Represents time from the end of the QRS to the onset
of the T wave
 Beginning of ventricular repolarization
 Usually flat or isoelectric, (within 1 sm. box of the
isoelectric line)
 May become elevated or depressed due to cardiac
disease/ischemia or drugs

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 T Wave
 Rounded wave that follows QRS complex
 Represents continued ventricular repolarization
 Very tall, peaked T waves, low flat T waves or inverted
T waves require further evaluation by physician

QT Interval
 Represents total time for ventricular depolarization &
repolarization
 Changes with HR; should be 0.30 - 0.40 seconds
 Serial QT measurements used to evaluate patient
response to antiarrhythmics
 Lengthened QT interval means more time to repolarize
& puts patient at risk for developing lethal dysrhythmias

Refractory Periods
 As cardiac cell repolarizes & returns to the resting state,
there is a period of time during which the cells are
refractory or unresponsive to electrical stimuli
 There are two periods of time during which the
myocardial cells considered refractory:
Absolute Refractory Period: No electrical signal can
stimulate a contraction
Relative Refractory Period:
 Cells can respond to strong electrical signal
 Response of cells may be incomplete or follow
the wrong pathway resulting in potentially lethal
rhythm
 “R-on-T” phenomenon
Basic Steps for Interpreting EKGs
Basic Steps for Interpreting EKG’s Normal Range
1. Regularity –measure regularity or rhythm of R waves. Any variation beyond Regular
0.12seconds is considered irregular
2. Rate –Calculate heart rate 60-100 beats/minute
3. P/QRS Ratio –Is there a P wave for every QRS? If not, what is their ratio? 1:1
4. P wave and PR Interval –measure the interval from the beginning of the P wave 0.12-0.20 seconds
to the beginning of the QRS complex. Is P wave upright?
5. QRS Duration –measure the interval from the first upstroke or downstroke of <0.12 seconds
the QRS to the end of the S wave
6. QT Interval –measure from the beginning of the QRS complex to the end of the 0.30-0.40 seconds
T wave
7. Interpretation ???

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Determining Heart Rate
1. Six Second Method
Examine a six second strip, count the number of QRS complexes and multiply by 10.
2. Dubin’s Method
Find an R wave that falls on a heavy line. Starting with the next heavy line, count off each heavy line to
the next R Wave with this sequence:
300-150-100-75-60-50-43-37

3. Division/Small Squares Method

Count the number of small boxes between 2 consecutive R waves and divide that number into 1500.
Considered the most accurate method, but most time consumingZ
SINUS RHYTHMS

Normal Sinus Rhythm (NSR) = rate 60-100 bpm

Sinus Bradycardia = rate < 60 bpm

Sinus Tachycardia = rate 100-150 bpm

Sinus Arrhythmia = irregular sinus rhythm

 These rhythms all originate in the SA node and conduct normally to the ventricles

NORMAL SINUS RHYTHM (NSR)

Regularity Rate P waves P/QRS PRI

Regular 60-100 Present, upright 1:1 0.12-0.20
Summary:
 Describes a rhythm that starts in the SA node and follows the normal electrical pathway through the heart.
Significance:
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 Allows for normal atrial & ventricular contraction in an organized way.
Interventions:
 None
SINUS BRADYCARDIA

Regularity Rate P waves P/QRS PRI

Regular <60 Present, upright 1:1 0.12-0.20
Summary:
 A sinus rhythm but a rate less than 60 beats per minute
Precipitating Factors:
 Sleep, athletic heart, vagal stimulation, medicines (digoxin, beta-blockers, calcium channel blockers,
morphine, or anticholinesterase), Inferior MI, hypoxia.
Significance:
 In athletes, sinus bradycardia frequently develops because the well-conditioned heart can maintain stroke
volume with less effort
 Marked sinus bradycardia may severely decrease cardiac output
 Usually not treated unless there is hemodynamic compromise.
Interventions:
 Assess for how well the patient tolerates the slow rhythm
o Slow rates often drop cardiac output
o May lead to premature beats
 If symptomatic (chest pain, shortness of breath, altered level of consciousness):
o Atropine
o Transcutaneous / temporary pacing

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 SINUS TACHYCARDIA

Regularity Rate P waves P/QRS PRI

Regular 100-150 Present, upright 1:1 0.12-0.20
Summary:
 A sinus rhythm with a rate over 100, but less than 150 beats per minute.
Precipitating Factors:
 Fever, pain, exercise, heightened emotions, stimulant drugs, anemia, hypoxemia, hypovolemia, CHF,
hyperthyroidism
Significance:
 Sinus tachycardia occurs as the normal cardiac response to an increased oxygen demand
 Commonly occurs in normal healthy individuals, usually with no adverse effects
 Sinus tachycardia increases heart’s oxygen requirements
 Sinus tachycardia may cause or worsen ischemia (↓ O2 supply to heart muscle because of ↓ coronary
perfusion time)
 Sinus tachycardia may worsen Congestive Heart Failure (CHF)
 Could be a compensatory mechanism for decreased cardiac output

Interventions:
 Treatment is seldom required unless the patient is symptomatic
 Identify the underlying cause and treat accordingly

SINUS ARRHYTHMIA

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Regularity Rate P waves P/QRS PRI
Irregular 60-100 Present, upright 1:1 0.12-0.20
Summary:
 Sinus arrhythmia is just like Sinus Rhythm except it is irregular & varies with respirations
 Difficult to identify from a 6 sec. strip. Should be interpreted at the bedside while observing respirations of
off of a 60 sec. strip.
Precipitating Factors:
 Digitalis toxicity, increased ICP, inferior wall MI
Significance:
 Occurs normally in healthy persons, most commonly in children, the elderly, & athletes
 Results from changing vagal tone in response to changes in intrathoracic pressure associated with
respirations.
Interventions:
 No treatment indicated unless patient is symptomatic
 If sinus arrhythmia is not related to respirations, the underlying cause may be treated.
Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION ___________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION ___________________________________________________________________

ATRIAL RHYTHMS

Atrial Tachycardia

Atrial Flutter

Atrial Fibrillation (A-Fib)

 Atrial rhythms start in the atria, but not at the SA node.

o An ectopic focus in the atria assumes responsibility for pacing the atria
o An ectopic focus is one that originates outside the SA node
 Supraventricular rhythms start above the ventricles
o QRS duration should be normal

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 ATRIAL TACHYCARDIA /
SUPRAVENTRICULAR TACHYCARDIA

Regularity Rate P waves P/QRS PRI

Regular 150-250 Usually present, upright, 1:1 if visible 0.12-0.20 If P
may be lost in T wave wave seen
Summary:
 Atrial tachycardia / supraventricular tachycardia is an ectopic atrial rhythm that is the result of rapid firing of
an atrial ectopic focus.
 It may be paroxysmal (means sudden onset and ending of the dysrhythmia).
Precipitating Factors:
 Stress, fear, anxiety, excessive use of caffeine or other stimulants, digitalis toxicity, hypoxia, coronary
artery disease, hyperthyroidism, Wolf-Parkinson-White syndrome.
Significance:
 The fast heart rate shortens diastole which decreases the coronary perfusion time and ventricular filling
(also increases myocardial oxygen demand).
 Atrial tachycardia / supraventricular tachycardia may occur as brief episodes or may last for hours.
Interventions:
 Treatment depends on the patient’s response to the dysrhythmia
 Vagotonic maneuvers, either mechanical or pharmacological, may be used
o Valsalva maneuver
o Carotid massage (physicians only)
o Adenosine
o Amiodarone
o Synchronized cardioversion
ATRIAL FLUTTER

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 Regularity Rate P waves P/QRS PRI
Regular or A=250-350 Flutter waves UTA None
Irregular V=60-100
May be faster
Summary:
 Atrial flutter is an atrial dysrhythmia characterized by a rapid atrial rate.
 The atria are beating too rapidly for the ventricles to respond, so the AV node acts as a “gate-keeper” or
filter and blocks some of the impulses.
 May be described as a 4:1, 5:1, etc. based on number of flutter waves to each QRS

Precipitating Factors:
 Acute MI, chronic cardiac disease, mitral or tricuspid valve disease, sick sinus syndrome, electrolyte
imbalance, hyperthyroidism, hypoxia, hypertension, digitalis toxicity, pericarditis, pulmonary embolism.

Significance:
 Significance is related to the ventricular rate associated with it.
 If the ventricular response is too slow or too fast, decreased coronary output may result.

Interventions:
 If possible, remove the precipitating cause(s)
 Drug therapy includes:
o Beta blockers
o Calcium channel blockers (e.g. – diltiazem)
o Amiodarone
o Digoxin
o Synchronized cardioversion

ATRIAL FIBRILLATION (A-Fib)

Regularity Rate P waves P/QRS PRI

Irregular A= >350 Fibrillatory waves UTA None

V =varies (100-150)
Summary:
 Atrial fibrillation is an atrial rhythm characterized by disorganized atrial activity without discernable P
waves.
 Atria are fibrillating

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 Controlled rate refers to a ventricular rate less than 100 bpm.
 Uncontrolled refers to a ventricular rate greater than 100 bpm
Precipitating Factors:
 Acute MI, cardiomyopathy, CHF, congenital heart disease, pericarditis, COPD, electrolyte imbalance

Significance:
 Because the atria quiver rather than contract:
o There is no atrial kick (about 10-30% of normal end-diastolic volume)
o Blood is not “squeezed” from the atria into the ventricles, causing the atria to have a tendency to
develop mural thrombi.

Interventions:
 Stable Patient
o Goals: (Patients in A-Fib. > 48 hours usually need to be anticoagulated)
 Rate control with medications (calcium channel blockers, beta blockers, Amiodarone)
 Convert the rhythm to NSR with meds or synchronized cardioversion
 Chronic A-Fib : control rate with drug therapy
 Unstable Patient
o Synchronized cardioversion
Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

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P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION ___________________________________________________________________

JUNCTIONAL RHYTHMS

 Depolarization begins in the Junctional area

 The atria are depolarized by retrograde conduction
 The ventricles will be depolarized in a normal manner
 Possible appearances of P waves:
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 o Inverted & before the QRS
o Inverted & after the QRS
o Absent or hidden in the QRS

JUNCTIONAL RHYTHM

Junctional
Rhythms
Junctional Regular 40-60 Inverted/hid If present, 1:1 <0.12 if before QRS; not measured if
Rhythm den in QRS absent or after QRS
Accelerated Regular 60-100 Inverted/hid If present, 1:1 <0.12 if before QRS; not measured if
Junctional den in QRS absent or after QRS
Junctional Regular >100 Inverted/hid If present, 1:1 <0.12 if before QRS; not measured if
Tachycardia den in QRS absent or after QRS
Summary:
 Junctional Rhythm = a dysrhythmia originating in the AV/Junctional tissue at a rate of its inherent
pacemaker (40-60 bpm).
 Accelerated Junctional (rate of 60 – 100 bpm)
 Junctional Tachycardia (rate > 100 bpm)
 Occurs as an escape or safety mechanism when higher pacemakers are not functioning, or if their
impulses are not getting through the AV node
Precipitating factors:
 Damage to the SA node, increased vagal tone (parasympathetic stimulation), medications (digoxin, beta
blockers, calcium channel blockers), myocardial ischemia or infarction, electrolyte disorders
Significance:
 Patient’s may be asymptomatic or symptomatic
 Underlying cause needs to be determined (even if asymptomatic)
Interventions:
 If symptomatic (heart rate too slow):

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 o Fix the underlying cause
o Atropine
o Pacing
 If symptomatic (heart rate too fast):
o Fix the underlying cause
Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

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P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

5. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

6. INTERPRETATION ___________________________________________________________________

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 VENTRICULAR RHYTHMS

Idioventricular Rhythm
Accelerated Idioventricular
Ventricular Tachycardia (VT)
Torsade de Pointes
Ventricular Fibrillation (V-Fib)
Asystole

 Ventricular dysrhythmias are the most serious because the heart is less effective and is functioning on its
last backup support.
 All beats of ventricular origin will have a QRS wider than 0.12 sec.
o Exception: supraventricular rhythms with a conduction delay in the ventricles (aberrant conduction)
will also have a QRS > 0.12

Rate Terminology

20 - 40 Idioventricular Rhythm

40 - 100 Accelerated Idioventricular

Rhythm
> 100 Ventricular Tachycardia

IDIOVENTRICULAR RHYTHM

Regularity Rate P waves P/QRS PRI

Idioventricular Often regular 20-40 None UTA None
Accelerated Often regular 40-100 None UTA None
Idioventricular

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Summary:
 Idioventricular rhythm is an escape rhythm originating in the ventricle that takes over when all other higher
pacemaker sites have failed
Precipitating Factors:
 Loss of pacemaker generating ability from the sinus node & AV node
 Acute MI
 Digitalis toxicity
Significance:
 Patient’s symptoms are due to decreased cardiac output from:
o Loss of atrial kick and
o Slow heart rate
 High risk for ventricular standstill
Interventions:
 Therapies are directed at enhancement of normal pacemaker
 Cardiac pacing
 Caution: Lidocaine is contraindicated for this rhythm. It will suppress the escape rhythm leading to
asystole
VENTRICULAR TACYCARDIA (VT)

Regularity Rate P waves P/QRS PRI

Often regular 100-250 None UTA None
Summary:
 Ventricular tachycardia (VT) is a rhythm originating in the ventricle.
Precipitating Factors:
 Myocardial ischemia/MI, electrolyte disturbance (hypomagnesemia, hypokalemia), hypoxia, myocardial
irritability, cardiomyopathy, R-on-T, sympathetic stimulants, drug toxicity, mitral valve prolapse.
Significance:
 VT is a life threatening dysrhythmia
o Patient response may range from asymptomatic to pulseless (CHECK THE PATIENT !!)
 Patient’s symptoms are due to decreased cardiac output from:
o Loss of atrial kick and
o Fast heart rate
 Sustained VT usually deteriorates to ventricular fibrillation
Interventions:
 Stable Patient
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 o Drug therapy (amiodarone)
o Synchronized cardioversion if drugs fail
 Unstable Patient
o Synchronized cardioversion
 Pulseless
o Defibrillation & CPR

TORSADE de POINTES

Summary:
 “Twisting of the points”
 A variant of polymorphic V-Tach
Precipitating Factors:
 Caused by prolonged QT interval:
o Congenital: Long QT syndrome
o Drug induced
o Hypomagnesemia or hypocalcemia
o Acute MI or ischemia
Significance:
 Is a life-threatening dysrhythmia
Interventions:
 Magnesium
 Defibrillation
VENTRICULAR FIBRILLATION (V-Fib)

Regularity Rate P waves P/QRS PRI

Chaotic None None UTA None

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Summary:
 Ventricular fibrillation is a rapid, disorganized depolarization of the ventricles
 Individual muscle fibers depolarize but the ventricles do not contract
 Course V-Fib: large fibrillatory waves
 Fine V-Fib: small fibrillatory waves
Precipitating Factors:
 Myocardial ischemia, MI, untreated VT, hypomagnesemia, hypokalemia, hypoxia, R-on-T, sympathetic
stimulants, hypothermia, acid/base disturbance, electrical shock, drug toxicity.
Significance:
 Patient is PULSELESS
 Because the ventricles quiver rather than contract, no cardiac output occurs
 Continuation of V-Fib eventually leads to ventricular standstill (asystole)
Interventions:
 The only effective treatment for V-Fib is defibrillation
 If no defibrillator is available, call for help & maintain CPR until a defibrillator becomes available
 Treat the underlying cause
 Other concurrent therapies include: oxygen, epinephrine (or vasopressin), amiodarone
ASYSTOLE

Regularity Rate P waves P/QRS PRI

Flat Line None None UTA None
Summary:
 Ventricular asystole (ventricular standstill) is a total absence of ventricular electrical activity.
 Some activity may be present in the atria (only P waves seen).
 The EKG will show a flat (isoelectric) line.
Precipitating Factors:
 Pulmonary embolus, air embolus, hemorrhage, heart failure, cardiac rupture, MI, cardiac tamponade,
hyperkalemia, hypokalemia, drug overdose, hypoxemia, severe acidosis, tension pneumothorax.
Significance:
 There is no ventricular electrical activity and therefore, no ventricular contraction (cardiac output)
Interventions:
 ALWAYS confirm this rhythm in 2 leads
o To differentiate asystole from fine V-Fib.

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 o Asystole may be seen when a patient’s electrodes fall off or when the monitor is not operating
properly)
 CPR and determine the cause of the arrest.
 Medications:
o Epinephrine
o Atropine
Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

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P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION ___________________________________________________________________

PREMATURE COMPLEXES
Premature Atrial Contractions (PAC’s)
Premature Junctional Contractions (PJC’s)
Premature Ventricular Contractions (PVC’s)

Steps to Interpret Strips with Ectopic Beats

1. Identify the underlying rhythm
2. Identify the type of ectopic beat (PAC, PJC, PVC)
3. Describe the ectopic beat(s):
1. “Looks” (unifocal vs. multifocal)
2. “Groupings” (couplets)
3. “Patterns” (bigeminy, trigeminy, etc.)

PREMATURE ATRIAL CONTRACTIONS (PACs)

Summary:
 Premature atrial contractions (PACs) are ectopic beats that occur earlier than the next expected beat and
originate in the atria, but not the SA node.
 P wave may appear different from other p-waves in the rhythm
 PRI usually is within normal limits

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 QRS usually within normal limits
 The rhythms with ectopy must have an analysis of the underlying rhythm.
Precipitating Factors:
 Stress, fatigue, stimulants, ischemic heart disease, MI, electrolyte imbalance, hypoxia, CHF,
hyperthyroidism, digitalis toxicity.
Significance:
 PACs are observed in both normal and diseased hearts
o Significance is related to the clinical condition that precipitates them
 Frequent PACs may herald the onset of more serious atrial dysrhythmias
Interventions:
 Most patients do not require treatment
 Removal of the underlying cause will usually result in elimination of the PACs.

PREMATURE JUNCTIONAL CONTRACTIONS (PJCs)

Summary:
 Premature junctional contractions (PJCs) are ectopic beats that occur earlier than the next expected beat
and originate in the junctional area (AV node & Bundle of His).
 P wave will be inverted before or after QRS or absent
 PRI if measurable is usually <0.12sec
 QRS usually < 0.12sec
 The rhythms with ectopy must have an analysis of the underlying rhythm.
Precipitating Factors:
 Excessive caffeine, amphetamine ingestion, MI, electrolyte imbalance (hypokalemia, hypomagnesemia),
hypoxia.
Significance:
 Relatively rare
 Related to the clinical condition that precipitates them
 Frequent PJCs may herald the onset of more serious junctional dysrhythmias.
Interventions:
 Identify the cause
 Removal of the cause will usually eliminate the PJCs.

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PREMATURE VENTRICULAR CONTRACTIONS (PVCs)

Summary:
 Premature ventricular contractions (PVCs) are ectopic beats that occur earlier than the next expected beat
and originate in the ventricles (below the Bundle of His).
 No P wave; no PRI; QRS wide & bizarre >0.12sec
 Rhythms with ectopy must have an analysis of the underlying rhythm.
 “Looks”:
o Unifocal PVCs: look the same and originate from the same irritable focus
o Multifocal PVCs: look different and originate from multiple foci
 Multifocal PVCs are more serious than unifocal PVCs and indicate a greater degree of
myocardial irritability
 “Groupings”:
o Couplets: a pair of PVCs
o 3 or more PVC’s in a row = VT.
 “Patterns”:
o PVCs may also occur in grouped beats:
 Bigeminy – every other beat
 Trigeminy – every third beat
 Quadrigeminy – every fourth beat
o These terms for patterns of grouped beats may also be used to describe PACs and PJCs.
Precipitating Factors:
 Myocardial ischemia, sympathetic stimulants, hypoxia, electrolyte imbalance (hypomagnesemia,
hypokalemia)
Significance:
 A decrease in cardiac output may occur, especially if the PVCs are sustained or frequent.
 They may precipitate a serious ventricular dysrhythmia.
 R-on-T phenomenon: if the PVC occurs during the down slope of the T wave (relative refractory period), it
can cause a lethal dysrhythmia.
Interventions:
 Identify the underlying cause if possible and treat.
 No interventions may be necessary if the patient is asymptomatic.
 If symptomatic & medications necessary:
o Amiodarone
o Lidocaine

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Comparison of premature atrial, premature junctional and premature ventricular beat:

PAC PJC PVC

Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

5. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

6. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

7. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

8. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

9. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

10. INTERPRETATION ___________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

11. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

12. INTERPRETATION __________________________________________________________________

HEART BLOCKS

1ST Degree Heart Block

2nd Degree Heart Block – Type I (Mobitz I or Wenckebach)
2nd Degree Heart Block – Type II (Mobitz II or Classical Heart Block)
3rd Degree Heart Block (Complete Heart Block)

Heart blocks are caused by a delay or block in transmission of electrical impulses in the
conduction system.
FIRST DEGREE HEART BLOCK

Regularity Rate P waves P/QRS PRI

Regular Usually 60-100 Present, upright 1:1 >0.20
Summary:
 1° Heart block is a conduction disturbance in which electrical impulses flow normally from the SA node
through the atria, but are delayed at the AV node.
Precipitating Factors:
 Beta blockers or calcium channel blockers, digitalis toxicity, rheumatic fever, chronic degeneration of the
conduction system, inferior wall MI, ischemia.
Significance:
 1° Heart Block may occur in healthy persons

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 It can result from any of the factors listed above
Interventions:
 If not associated with an MI/ischemia:
o Usually no interventions are needed except to treat the underlying cause, unless the patient is
symptomatic from the underlying rhythm.
 If associated with an MI/ischemia:
o Monitor closely because it may progress to a higher degree heart block.

SECOND DEGREE HEART BLOCK TYPE I

(Mobitz I or Wenckebach)

Regularity Rate P waves P/QRS PRI

Often Usually <60 Present, upright Some P’s don’t Usually normal; may be prolonged
Irregular have QRS Constant for conducted beats

Summary:
 2° Heart Block Type I is a conduction disturbance in which the AV node progressively delays conduction
and then blocks it completely.
 This results in PRI getting progressively longer and longer until one QRS is “dropped”.
 Then the cycle starts all over again.
Precipitating Factors:
 Inferior wall MI, ischemic heart disease, medications (beta blockers, calcium channel blockers, digitalis
toxicity), rheumatic fever, post-cardiac surgery, electrolyte imbalance.
Significance:
 2°Heart Block Type I is often transient.
Interventions:
 Treatment is based on patient tolerance of the dysrhythmia and is directed toward the underlying cause.
 If symptomatic bradycardia is present: atropine or temporary pacing may be required.

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 SECOND DEGREE HEART BLOCK TYPE II
(Mobitz II or Classical Heart Block)

Regularity Rate P waves P/QRS PRI

Often Usually <60 Present, upright Some P’s don’t Usually normal; may be prolonged
Irregular have QRS Constant for conducted beats
Summary:
 2° Heart Block Type II is an intermittent block of sinus impulses at or below the Bundle of His.
 The dropped beats occur without warning as some P waves fail to conduct.
 What is seen on the EKG is a fixed PRI and non-conducted P waves with no subsequent QRS.
Precipitating Factors:
 MI, ischemic heart disease, medications (digitalis toxicity, beta blockers, calcium channel blockers),
myocardial disease.
Significance:
 2° Heart Block Type II reflects heart disease and frequently progresses to a higher form of block.
Interventions:
 Treatment is based on the patient’s signs and symptoms.
 If symptomatic: increase the heart rate
o Temporary pacing
o Atropine may not be as effective at increasing the ventricular rate
 If asymptomatic
o Standby pacing may be indicated
o Determine underlying cause & monitor closely for progression to 3° Heart Block.
THIRD DEGREE HEART BLOCK
(Complete Heart Block)

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Regularity Rate P waves P/QRS PRI
Regular A =faster than V Present, upright. May be P>QRS Variable, inconsistent; no
V = <60 hidden in QRS or T wave relationship between P & QRS
Summary:
 3° Heart Block, also referred to as Divorced Heart Syndrome, is a complete block of all supraventricular
impulses.
 There is no relationship of P waves to QRS complexes.
 It may result from a block at the level of the AV node, within the Bundle of His, or distal to it in the
ventricles.
 The ventricles can be controlled by either a junctional or a ventricular escape rhythm.
 The pacemaker site can be identified by the width of the QRS and the ventricular rate.
Precipitating Factors:
 MI, severe digitalis toxicity, calcium channel &/or beta blocker overdose, degenerative conduction system
disease.
Significance:
 Significance relates to the patient’s response to the decreased cardiac output.
 Can deteriorate to asystole.
Interventions:
 Treatment is based on the patient’s signs and symptoms.
 If symptomatic: increase the heart rate
o Temporary pacing
o Atropine may not be effective at increasing ventricular rate
 If asymptomatic
o Standby pacing is indicated
 If underlying cause is irreversible, a permanent pacemaker is indicated
Review Strips:

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

5. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

6. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

7. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

8. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

9. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

10. INTERPRETATION __________________________________________________________________

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 REVIEW STRIPS

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

1. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

2. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

3. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

4. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

5. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

6. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

7. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

8. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

9. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

10. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

11. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

12. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

13. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

14. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

15. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

16. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

17. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

18. INTERPRETATION __________________________________________________________________

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Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

19. INTERPRETATION __________________________________________________________________

Regularity__________________ Atrial Rate_______________ Vent. Rate __________________

P waves ______________ PR Interval ________________ QRS ______________________

20. INTERPRETATION __________________________________________________________________

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