STUDY GUIDE

FOR ECG EXAM

Saint Peter’s University Hospital

The EKG complex represents the electrical activity of the
heart.

The path of normal electrical

conduction in the heart

SA Node to AV Node.

AV Node to Bundle of His.

Bundle of His to Bundle

Branches. Bundle Branches to
Purkinje Fibers. Purkinje Fibers to
Free Muscle.

With normal conduction of the heart, the impulse begins at the SA node
generating a P wave.

The impulse travels through the electrical pathway to the AV node

The AV node delays the impulse and is seen as the PR Interval.

The impulse travels down the perkinge fibers in the ventricles which is seen as
the QRS.
 Intrinsic Adult heart rates:

SA NODE-60-100 AV JUNCTION-40-60 VENTRICLE- 20-40

Waves, Segments,
Intervals and Complexes

PR Interval is important in the

differential diagnosis of AV Block.

ST Segment is important in the

differential diagnosis of Ischemia
infarction and pericarditis.

Waveform: Movement away from the baseline in either a positive or negative direction.

Segment: A line between waveforms; named by the waveform that precedes or follows it.

Interval: A waveform and a segment.

Complex: Several waveforms.

A 12- Lead EKG shows several views or pictures of the electrical activity of the
heart.
 Proper skin prep is essential for accurate ECG monitoring. Changing electrodes
every 24 hours and PRN helps assure a clear ECG reading.

ECG “Artifact” is an electrical interference or ‘noise’ that is recorded from sources

other than the electronic signals of the heart. Some causes are: Excessive patient
movement, loose or disconnected lead wires, poor electrode contact.
Determining Rate
.

Each large box on ECG paper equals 0.20 seconds.

Each small box on ECG paper equals 0.04 seconds.

If the complexes fall on the big boxes of an ECG strip, divide the
number of big boxes between two complexes into 300

If the complexes do not fall on the big boxes of an ECG strip, divide the
number of small boxes between two complexes into 1500.

To determine the Atrial or Ventricular rate divide the number of small boxes
between the P waves (atrial) and R waves (ventricular) into 1500
OR
divide the big boxes between P waves (atrial) and R waves (ventricular) into 300.
 Six Second-Method

The ECG paper is marked with 1 or 3 second markers at the top or bottom of the
paper. To determine the Ventricular rate count the number of QRS complexes in a 6
second strip and multiply by 10.
This method is more accurate in irregular heart rhythms.

There are 8 QRS Complexes in this 6 second strip 8x10=80 Rate= 80

5 Steps for ECG interpretation

1. Determine the Rhythm (regularity).
2. Calculate the Rate.
3. Examine the P wave.
4. Measure the PR Interval.
5. Measure the QRS Complex.

SINUS RHYTHMS
Normal Sinus Rhythm: Rate 60 to 100
Sinus Bradycardia: Rate less than 60
Sinus Tachycardia: Rate101 to 180

NORMAL SINUS RHYTHM (NSR)

Rate: 60-100 beats per minute
Rhythm: P-P interval regular, R-R interval regular
P waves: Positive (upright) in lead II, one precedes each QRS complex. All look
alike
PR interval: 0.12-0.20 second and constant from beat to beat
QRS duration: 0.10 second or less unless an intraventricular conduction delay
exists.
 SINUS BRADYCARDIA
Rate: Less than 60
Rhythm: P-P interval regular, R-R interval regular
P waves: Positive (upright) in lead II, one precedes each QRS complex, P waves
look alike
PR interval: 0.12-0.20 second and constant from beat to beat
QRS duration: 0.10 second or less unless an intraventricular conduction delay
exists.

SINUS TACHYCARDIA
Rate: 101-180
Rhythm: P-P interval regular, R-R interval regular.
P waves: Positive (upright) in lead II, one precedes each QRS complex, all
look alike. At very fast rates it may be hard to tell the difference between a P wave
and a T wave.
PR Interval: 0.12-0.20 second (may shorten with faster rates) and constant from
beat to beat.
QRS Duration: 0.10 second or less unless an intraventricular conduction delay
exists.

SINUS ARRHYTHMIA
Rate: Usually 60-100 ,but may be slower or faster.
Rhythm: Irregular, phasic with respiration; heart rate increases gradually during
Inspiration (R-R intervals shorten) and decreases with expiration
(R-R intervals lengthen).
P waves: Positive (upright) in lead II, one precedes each QRS complex,
P waves look alike.
PR Interval: 0.12-0.20 second and constant from beat to beat.
QRS Duration: 0.10 second or less unless an intraventricular conduction delay
exists.

SINUS PAUSE
Sinus Exit Block & Sinus Arrest - Shared Characteristics

Rate: The heart rate is usually 60 to 100 beats per minute but may be less.
Rhythm: Irregular when sinus arrest or SA exit block is present.

P waves: The pacemaker site is the SA node. The sinus P waves of the underlying
rhythm are identical and precede each QRS complex.

If an electrical impulse is not generated by the SA node (sinus arrest) or if it is

generated by the SA node but blocked from entering the atria (sinoatrial exit block),
atrial depolarization does not occur and, consequently, neither does a P wave
(dropped P wave).

PR Interval: The P-R intervals are those of the underlying rhythm and may be
normal or abnormal.

R to R Interval: The R-R intervals are unequal when sinus arrest or SA exit block is
present.

QRS Duration: The QRS complexes are normal unless a preexisting bundle branch
block is present. A QRS complex normally follows each P wave.

A QRS complex is absent when a P wave does not occur.

 ATRIAL RHYTHMS
WANDERING ATRIAL PACEMAKER (WAP)
MULTIFORMED ATRIAL RHYTHM (MAR)
CHAOTIC ATRIAL TACHYCARDIA (CAT)

Rate: Usually 60-100 , but may be slow; if the rate is greater than 100 , the rhythm
is termed multifocal (or chaotic) atrial tachycardia: MAT or CAT
Rhythm: May be irregular as the pacemaker site shifts from the SA node to ectopic
atrial locations and the AV junction Size, shape, and direction may change from
beat to beat.
P waves: Variable
PR Interval: Irregular
QRS Duration: 0.10 second or less unless an intraventricular conduction delay
exists

AV NODAL REENTRY CHARACTERISTICS/SVT

Rate: 150-250
Rhythm: Ventricular rhythm is usually very regular.
P waves: P waves are often hidden in the QRS complex.
PR Interval: P waves are not seen before the QRS complex; therefore the PR
interval is not measurable.
QRS Duration: 0.10 second or less unless an intraventricular conduction delay
exists.

ATRIAL FLUTTER

Rate: Atrial rate 250-450 . Ventricular rate variable—determined by AV blockade,

the ventricular rate will usually not exceed 180 due to the intrinsic conduction rate
of the AV junction.
Rhythm: Atrial regular, ventricular regular or irregular depending on AV
conduction/blockade.
P waves: No identifiable P waves; saw-toothed “flutter” waves are present.
PR Interval: Not measurable
QRS Duration: 0.10 sec or less but may be widened if flutter waves are buried in
the QRS complex or an intraventricular conduction delay exists.

ATRIAL FIBRILLATION
Rate: Atrial rate usually 400-600 . Ventricular rate variable
Rhythm: Ventricular rhythm usually irregularly irregular
P waves: No identifiable P waves, fibrillatory waves present; erratic, wavy
baseline
PR Interval: There are no P waves.
QRS Duration: 0.10 sec or less but may be widened if an intraventricular
conduction delay exits.

PREMATURE BEATS CAN OCCUR FROM

DIFFERENT AREAS OF THE HEART

PAC’s
PREMATURE ATRIAL CONTRACTIONS

Rate: Usually within normal range, but depends on underlying rhythm.

Rhythm: Regular with premature beats
P waves: Premature (occurring earlier than the next expected sinus P wave), one
before each QRS complex, often differ in shape from sinus P waves-may be
flattened, notched, pointed, biphasic, or lost in the preceding T wave PR interval.
PR Interval: May be normal or prolonged depending on the prematurity of the
beat.
QRS: Usually 0.10 sec or less the QRS of the PAC is similar in shape to those of the
underlying rhythm unless the PAC is abnormally conducted.
 PJCs
PREMATURE JUNTIONAL CONTRACTIONS

Rate: Usually within normal range, but depends on underlying rhythm.

Rhythm: Regular with premature beats
P waves: May occur before, during, or after the QRS. If visible the P wave is
inverted in II, III, and AVF.
PR Interval: May be normal or prolonged depending on the prematurity of the
beat.
QRS: Usually 0.10 sec or less the QRS of the PJC is similar in shape to those of the
underlying rhythm unless the PJC is abnormally conducted.

PVC’s
PREMATURE VENTRICULAR CONTRACTIONS

Rate: Usually normal but PVC may occur at any rate.

Rhythm: Regular with premature beats.
P waves: None on ectopic beat. PR Interval: None with the PVC because the ectopic
originates in the ventricles.
QRS Duration: Usually 0.10 sec or less unless it is aberrantly conducted or an
intraventricular conduction delay exists.
QRS Complex of ectopic beat: Greater than 0.12 sec, wide and bizarre; T wave
usually in opposite direction of the QRS
 Bigeminy - any ectopic beat occurring every other beat.
Trigeminy – any ectopic beat occurring every third beat.
Quadrigeminy – any ectopic beat occurring every forth beat

JUNCTIONAL ESCAPE RHYTHM (JER)

Intrinsic AV Nodal Rhythm
Rate: 40-60
Rhythm: Very regular.
P waves: May occur before, during, or after the QRS; if visible, the P wave is
inverted in leads II, III, and AVF.
PR Interval: If a P wave occurs before the QRS, the PR interval will usually be
<0.12 sec; if no P wave occurs before the QRS, there will be no PR interval.
QRS Duration: Usually 0.10 sec or less unless it is aberrantly conducted or an
intraventricular conduction delay exists (IVCD).

IDIOVENTRICULAR ESCAPE RHYTHM

Intrinsic Ventricular Rhythm
Rate: 20-40
Rhythm: Usually regular
P-wave: Usually absent with SA arrest and block
PR Interval: Not measurable
QRS Duration: Greater than 0.12 second, wide, bizarre morphology
 VENTRICULAR RHYTHMS
The contours of the QRS complexes may all look alike (monomorphic) or may vary
(polymorphic) because of shifting sites of impulse origin or different exit paths from
the same origin.

VENTRICULAR TACHYCARDIA: MONOMORPHIC/UNIFOCAL

When the same QRS electrocardiographic wave repeats itself, the VT is considered
monomorphic. This implies that the sequence of electrical activation within the
ventricle is repetitive.
Monomorphic VT is most commonly due to repetitive activation of the same
reentrant circuit within the ventricle.
Rate: 101-250.
Rhythm: Regular
P waves: Usually buried within QRS Complex, but may be normal. Independent of
ventricular rhythm
PR Interval: None
QRS Duration: 0.10 sec or greater. It may be difficult to differentiate between the
QRS and T wave.

VENTRICULAR TACHYCARDIA: POLYMORPHIC TORSADE DE

POINTES.
A type of ventricular tachycardia characterized by QRS complexes of changing
amplitude that appear to twist around the isoelectric line.
Usually, the QRS complexes deflect downward for a few beats, then change to a
positive deflection for a few beats, and so on.
The twisting pattern continues throughout the tachycardia, giving it a spiral
appearance.
Rate: 150-300
Rhythm: Ventricular rate may be regular or irregular P waves: None
PR Interval: None
QRS: None

VENTRICULAR FIBRILLATION
Ventricular fibrillation is a chaotic rhythm that begins in the ventricles. There is no
organized depolarization of the ventricle. The ventricular muscle quivers as a result
there is no effective myocardial contraction and no pulse.

The rhythm looks chaotic with deflections that vary in shape and amplitude.

Rate: Cannot be determined as there is no discernible complexes to measure

Rhythm: Rapid and chaotic with no pattern or regularity.
P waves: None
PR Interval: None
QRS: None

COARSE VENTRICULAR FIBRILLATION

 FINE VENTRICULAR FIBRILLATION

VENTRICULAR STANDSTILL
Ventricular standstill and asystole are both a total absence of ventricular electrical
activity. There is no ventricular rate or rhythm, no pulse, and no cardiac output. If
atrial activity is present the rhythm is called ventricular standstill.

Rate: No Ventricular rate atrial activity may be present.

Rhythm: Ventricular rate not discernible atrial rate may be.
P waves: Usually not discernible
PR Interval: Not measurable
QRS: None

ASYSTOLE
Rate: No Ventricular rate atrial activity may be present.
Rhythm: Ventricular rate not discernible atrial rate may be.
P waves: Usually not discernible
PR Interval: Not measurable
QRS: None
 PULSELESS ELECTRICAL ACTIVITY (PEA)
PEA is a clinical situation (not a specific arrhythmia) in which an organized
cardiac rhythm is observed on the monitor but no pulse is palpated.
Causes and treatment of PEA are the same as asystole but any rhythm
may appear on the cardiac monitor. REMEMBER: Any rhythm which is
pulseless
(excluding pulseless VT) should be treated as PEA.

HEART BLOCKS
FIRST DEGREE AVB
Delayed conduction through the AV node- Conduction is not blocked, but delayed.

Rate: Regular
Rhythm: usually regular
P Wave: All look alike
PR interval: > 0.20
QRS Duration: 0.10 second less.

SECOND DEGREE AVB: INTERMITTENT CONDUCTION

MOBITZ I : WENCKEBACH
A type of second degree heart block in which sinus impulses are delayed at the AV
node for increasingly long periods until conduction is blocked completely. The cycle
then repeats itself.

There is a progressively lengthening PR interval in two or more

consecutive beats until a P wave is blocked (no QRS following that P-
wave)

Rhythm: Irregular. Progressive prolongation occurs: longer, longer, drop”

Rate: Usually slow but can be normal.
P waves: Sinus P waves present. Some are not followed by QRS complexes
PR Interval: Progressively lengthens.
QRS: 0.10 second or less unless an intraventricular conduction delay exists

P-P Intervals are unchanged since the SA node is intact and the problem is at the AV
junction

MOBITZ II:
A type of second degree heart block in which the AV node selectively blocks every
second, third, fourth, etc., beat.

Less common but much more serious usually occurs in the intranodal region of the
bundle of HIS or distal conduction system.

Rhythm: Regular- Can be i rregular if conduction ratio varies.

Rate: Usually slow.
P waves: Two, three, or four P waves before each QRS
PR Interval: Before QRS is constant. Usually <.20 Normal
QRS: 0.10 second or less unless an intraventricular conduction delay exists
P-P Intervals are unchanged since the SA node is intact and the problem is at
the AV junction.
The Hallmark of second-degree AV block Type II, is consistent PR interval
for all conducted beats and an all or nothing conduction pattern

THIRD DEGREE AV BLOCK: COMPLETE HEART BLOCK: AV

DISSOCIATION
No impulses are conducted from the sinus node or the atria through to the
ventricles. No communication between the P waves and the QRS
Rate: 20-40
Rhythm: Usually Regular
P waves:
PR Interval: There is no PR interval (PR interval will appear to vary throughout
strip)
QRS Duration: Greater than 0.10 seconds, wide morphology
P to P constant
R to R constant

PACEMAKERS
A cardiac pacemaker is an external device that delivers an
electrical current to the heart to stimulate depolarization.

Oversensing occurs when the device interprets non-cardiac sources of energy as

being cardiac. This results in the device not turning on when it should.

Undersensing results in a device that doesn’t know when to turn off. This may
result in pacemaker competition, a potentially dangerous situation Capture refers
to when the device delivers an electrical impulse of sufficient strength to result in
depolarization. The waveform immediately follows the pacing spike.

Loss or Failure to Capture may occur for a number of reasons, but commonly
occurs when the generator is unable to deliver a sufficient amount of energy to
cause depolarization. This may be due to the age of the batteries. This will result in
a spike with no corresponding depolarization or a delayed depolarization of unusual
morphology.

ATRIAL VENTRICULAR (AV) PACING

When the pacemaker stimulates both the atria and the ventricles, a first spike is
followed by a A-wave, then a second spike, is followed by a V wave.
Dual chamber pacemakers have two leads. One lead goes into the atrium and one
goes into the ventricle.
Dual chamber pacemakers can pace both the atrium and the ventricle.

VENTRICULAR (V) PACING

When the ventricles are stimulated by the pacemaker, the spike is followed by a
QRS complex and a T-wave. Pacemaker technology calls paced ventricular
complexes “V” waves.

The V wave (paced complex) is wider than a natural QRS complex because of the
track of depolarization.

Paced depolarization of the ventricle begins at the tip of the ventricular wire (not
the Bundle of His).

ATRIAL (A) PACING

Stimulation of the atria produces a pacemaker spike on the ECG, followed by a P-
wave. This rhythm is easily identified by the presence of a pacing spike immediately
preceding the P wave
 PACEMAKER FAILURE TO CAPTURE
Failure to capture is the inability of the pacemaker stimulus to depolarize the
myocardium and is recognized on the ECG by visible pacemaker spikes not followed
by P wave or QRS complex.

THIS IS THE END OF THE STUDY

GUIDE.
 Always remember to take your time and use
the steps to ECG interpretation. Practice,
Practice, Practice!

References

Aehlert, B. (2013). ECG’s Made Easy (5th ed.). St. Louis, Missouri: Elsevier,
Mosby.

Huff, J. (2017). ECG Workout Exercises in Arrhythmia Interpretation (7th ed.).

Philadelphia, PA: Wolters Kluwer.