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Includes IlldCl.
ISBN 97'8-1...0151H5S3 -6
I. Anh)lhntla_DlIIgIlOS1s-Problems,
n.erdllH,etc. 2. ElectrocardiographyI IlI~rpretatkm-ProbJems. ererdsH, etc.
,""'.
"
Preface
f.CG
I~o'froul:
physicians. nurse!, medical and nursinl! 5I:udenls. paramedics, tmell/ency medial teetmi-
~nonnel
and skills essential for ldentilyina twit arrhythmias. It may also bt used as a rderenct for
electrocardiogram (ECC) review lor those already knowled2eable in ECG interpretation.
The text is writt~n in a simple manner and lUwtrated \!lith tiguru. tables, boxes, and ECC
tracinas. Each chapler is designed to build on the know\edae base I'rom the previous cIla!ten 50
that the beJlinnillJl stu:knl can quickly understand and I/I'35P lhe ba5k cmcepll of electrocardiOllJi\Pt\y. An etrort has been made ('(It only to proYide good quoN/y ECG trocirtgs, but abo to provide
a 5I.Ifticient number and \Wiety of EGC practice strips 50 the Iwner retls confident In arrhythmia
inlerpretllion. There are I.lI.I?r fn) proclice strips - more than any book on /he mQrlrel.
Chapter I provides a disculoSion ofbaJic anatomy alld p/ly$IoJO\IYol the heart. The electrical basis of t lectrocardiolOi is disCl.l!sed In Chapter 2. The components of the ECC traclnl!
twawforrns, intervals. sellmenl5, and complexes) are described in Chapter 3. Thischaplfr also
Iv
includes pndice tr.w:inlZS on w3wform identification. Cardiac monitol"$, lead JystflTl.'i, lead
placement ECC artifacts.:uld troubleshootinllllXlnllor probltmJ art discu!Sed in Chapter 4.
Astep-by-step lIuide to rhythm Jtritt :ulalysiJ is provided in Chapter 5. in addition to practice
tracin(lS on rhythm strip analYJis. The Indi\'itlual rhythm chapters (Chapter$ 6 throullh 9)
iocludt 3 description of each arrllythmia. arrhythmia uampltJ. causes. and ~ment
protocols. Current .ld'Janced cardiac life support (ACLS) Iluidelines are incorporated into each
arrhythmia chapter as awllcable to Ihe rh>thm discunion. Eadl arrhythmia chapttr abo
locludes approximately 100 !trips for self-evaluation. CIlapter 10 presents a \ltlleral discussion
of cardiac pacemakel"$ (twes. indications. function, pacemaker terminololZY, rmifimctions.
and PJCemaktr analYJ]J), alo~with practice tracinlU. Chapkr II is a postle!! comistinll ofa
mix 0( rhythm strips that can bt used as a stlf-evaluation tool or for ttstinll purpOstl.
The text has ~n thou!!htfully revisedartd I!QWIded to include nt.'WfiJlures. updated boxes
and tables, additional llIossary terms, and evtn more pr.w:tice rhythm 5trips. SkiJlbulfder
rhythm stripj. which are new to this edition. appear inunediate)y IOliowil1ll the practice
rhythm strips in Chapters 7. 8. and 9. Each Skillbuilder section provides a mix of strips that
test not onlY)IOUr urnknblldinQ. of Information It<lmW in that arrhythmia chapter but also
the concepts:uld skills learned in the chapter{s) immnHatdy precedinll il. For uample. the
Skill builder strips in Chapter 7 (Atrial arrhythmias) includr atrial rhythm strips as wt'll as
strips on sinw arrhythmias (Covtrtd in Chapter 6): Chapter 8 (Junctional arrhythmias and
AV blocksi includesjWlCtionalarrhythmias and AV blocks. as well as atrial and sinus arrhythmias: and Chaplt'r 9 (Ventricular arrll).-thmias and bundle-brandl block), a mix of all of thf:o
arrhythmias c!7.'tred In Chapters 6 throuall 9. Such practice wilh mixed !trips will enhallCe
your ability to differentiate ~!Y.'ttn rhythm I/TOIlPS as you prol/Tl'SS throUllh the book - a
definite adYanl:alle ...."hen you \Itt to the Posttest. A handy pull-out section consistin!! of 48
individual ~hcards further challell>!es )'OUr ability to identity different types of arrhythmias..
The ECC tracinlti included in this book are actual Jlrips from patients. Above each rhythm
strip are J...5OOd indic3tors for rapid-rate calculation. For precise rate calculation. an ECC conIX'TSian table fOr heart rate is printed 011 the inside back COYer. For COII\'ef\ience. a rerrJOv.Ible pJas...
ticversion is also attached to the inside backcOl'eT. The heart rates for Tq/IIIar rhythms listed in the
anlWer keys were determined by the proci.le rate calculation method and ....;11 not a/y,'IYS coincide
....ith the rapid-rale calculation method. Rate calculation methods are disawed in Chapter 5.
The author and publisher Ilaw made every attempt to check the content. especially di'UII
dosages and man.1Ilement protocoll. for accuracy. Medicine is continually c~l1II. and
the reader has the responsibility to keep informed of local care protocols and chanlles in
emerjlency ~ procedures.
tip or the left wntricie lind is positiooed just above the di,lphragm to the left of the sternum at the fifth intercostal
.5p.'Ke. midclaviculllr line. There. the apex tan be pllipated
during ventricular contraction. This physical examination
landmark is referred to as the poim of 11JtlXimal impu&
(PMI) and is.n indiclltor of the heart's position within the
thorax.
The heart is tilted forward and to the left so that the
right side of the heart lies toward the front. About tv.-othirds of the heart lies to the left 01 the body's midline lind
one-third extends to the right. The awrage adult heart is
apprO):imately 5- (12 em) long. 3W (8 to 9 em) wide. and
2W (6 cm thick) - II little larger than a normal-sized list.
The heart weighs betv.een 7 and 15m (200 and 425 grams).
Heart siu and weight are influenced by age. weight. body
build. frequency of exe rcise. and heart disease.
_~~?t:= Heart
Siernum
Heart surfaces
There are four lTIIIin heart surfaces to consider .... hen discussing the heart: anterior, pos/eriar. inferior. and lateral
(Figure 1-2). The hea rt sudaces are uplained below:
ante rior - the (ront
posterior - the back
inferi or - the bottom
lateral - the side.
Anletio. ----t-{
J\..-_--\-P05terJOf
h<>rt.
Interior
Circulatory system
The circulatory system is required to provide a continuous
of blood to the body. The circulatoT')' system is a closed
system comisting of heart chambers and blood vessels.
The circulato!,), system consists of two separate circuits.
the systemic circuit and the pulmonary cin:uil. The systemic circuit is a large circuit and includes the left side of
the heart and blood vessels, which tarT')' OlI.ygenated blood
tn the body and deoxygenated hlond back to the right heart.
The pulmonary circuit is a small circuit and includes the
right side of the heart and blood vessels. which carT')' deOll.ygenated blood to the lungs and oxygenated blood back to
the ~ft heart. 1he two circuits are designed so that blood
flow is pumped from one circuit to the olher.
now
EndocaJdium --~<"c..'
-f1------ P~~c~
++-_____
Parietallaye.
'" S810US pllricardum
FiIlU ... 1- l .
H!WIwaI.
Heart valves
Heart chambers
The interior of the heart consists of four hollow chambers
(Figure 1-4). The two upper chambers. the right atrium
"nd the left atrium. "re divided by" w,,11 ""lied the interatrial septum. The two lower chambers, the right ventricle and the left ventricle. are divided by a thicker wall
called the interventricular septum. The two septa divide
the heart into two pumping systems - a right heart and
a left heart.
The right heart pumps venous (deoxygenated )
blood through the pulmonary arteries to the lungs
(Figure 1-5). Oxygen and carbon dioxide exchange takes
place in the alveoli and arterial (oxygenated ) blood
returns via the pulmonary veins to the left heart. The
left heart then pumps arterial blood to the systemic
circulation, where oxygen and carbon dioxide exchange
takes place in the organs, tissues, and cells; then venous
blood returns to the right heart. Blood How within the
body is designed so that arteries carry oxygen-rich blood
away from the heart and veim carry oxygen-poor blood
back to the heart. This role is reversed in pulmonary
circulation: pulmonary arteries carry oxygen_poor blood
into the lungs, and pulmonary veins bring oxygen-rich
blood back to the left heart.
The thickness of the walls in each chamber is related
to the workload periormed by that chambu Both atria
are low-pre~ure chambers serving as blood-collecting
reservoirs for the ventricles. They add a small amount of
force to the moving blood. Therefore, their walls are relatively thin. The right ventricular wall is thicker than the
walls of the atria, but much thinner than that of the left
ventricle. The right ventricular chamber pumps blood a
fairly short distance to the lungs against a relatively low
resistam;e to flow, The left ventricle has the thickest wall,
because it must eject blood through the aorta against a
Inlerventricular ""PI"'"
Heart valves
There are four valves in the heart: the tricuspid vallie,
separating the right atrium from the right ventricle: the
pulmonic /!{lIve, separating the right ventricle from the
pulmonary arteries: the mitral /!{lIve. separating the left
atrium from the left ventricle; and the aortic /!{lIve. separating the left ventricle from the aorta (Figure 1-5). The
primary function of the valves is to allow blood flow in
one direction through the hear!"s chambers and prevent
a backtlow of blood (regurgitation). Changes in chamber pressure govern the opening and closing of the heart
valves.
The tricuspid and mitral valves separate the atria from
the ventricles and are referred to as the atrioventricular
(AV) valves. These valves serve as in-flow valves for the ventricles. The tricuspid valve consists of three separate cusps
or leaflets and is larger in diamder and thinner than the
mitral valve. The tricuspid valve directs blood flow from
the right atrium to the right ventricle. The mitral valve (or
bicuspid valve) has only two cusps. The mitral valve directs
blood How from the left atrium to the left ventricle. Both
valves are encircled by tough. fibrous rings (valve rings ).
The leaflets of the AV valves are attached to thin strands
of fibrous cords called chordae tendineae (heart strings)
(Figure 1-6). The chordae tendineae are then attached to
papillary muscles, which arise from the walls and floor of
the ventricles. During ventricular filling (diastole) when
the AV valves are open. the valve leaHets, the chordae
tendineae, and the papillary muscles form a funnel. promoting blood flow into the ventricles. As pressure increases
during ventricular contraction (systole) , the valve cusps
close. Backflow of blood into the atria is prevented by contraction of the papillary muscles and the tension in the
chordae tendineae. Dysfunction of the chordae tendineae
or a papillary muscle can cause incomplete closure of anAV
valvt'. This may result in a regurgitation of blood from the
ventricle into the atrium, leading to cardiac compromise.
The first heart sound (8,) is the product of tricuspid and
mitral valve do.ure. S, i. bed heard at the apex of the heart
located on the left side of the chest. fifth intercostal space.
middavicular line.
The aortic and pulmonic valves have three cuplike cusps
shaped like a half-moon and are referred to as the semilunar (SL) vall!e5 . These valves serve as out-flow valves
for the ventricles, The cusps of the SL valves are smaller
and thicker than the AV valves and do not have the support of the chordae tendineae or papilla!)' muscles. Like
the AV valves. the rims of the semilunar valves are supported by valve rings. The pulmona!)' valve directs blood
flow from the right ventricle to the pulmonary artery.
The aortic valve directs blood flow from the left ventricle to the aorta. As pressure decreases during ventricular
Alveolus 01 lung ~
Pulmonary anerl'"
(to lungs)
--_-1
~~\
\\
Pulmonary veins
(from lungs)
--i--::c-.\'}'_
M~ral
Tricuspid valve
"";,---'f-i---- Septum
"~.""m' ----------~~
~-t---
Descendingaorla. - - - - - - - - - - - . . J
valv!!
.,,,. ,...
Coronary circulation
Coronary circulation
The blood supply to the heart is supplied by the right coronary artery. the left coronary artery, and their branches
(Figure \-7). There is some individual variation in the
""llnll of ~uruJldry "rl~ry br,,"d,iuK.. bul ill 1!~""r.. J, lI,,,
right coronary artery supplies the right side of the heart and
the left coronary artery supplies the left side of the heart.
The right coronary artery arises from the right side
of the aorta and consists of one long artery that travels
downward and then posteriorly. The major branches of the
right coronary artery are:
conus artery
sinoatrial (SA) node artery (in 55% of population)
anterior right ventricular arteries
acute marginal artery
AV node artery (in 90% of population)
posterior descending artery with septal branches
(in 90% of population)
posterior left wntricular arteries (in 90% of population).
Dominance is a term commonly used to describe coronary vasculature and refers to the distribution of the terminal
portion of the arteries. The artery that gives rise to both the
posterior descending artery with its septal branches and the
posterior left ventricular arteries is considered to be a "dominant' system. In approximately 90% of the population, tI-.e
right coronary artery (RCA) is dominant. The term can be
confusing because in most people the left coronary artery is of
wider caliber and penuses the largest percentage of the myocardium. Thus, the dominant artery usually does not perfuse
the largest proportion of the myocardium. The left coronary
artery arises from the left side of the aortaand consists of the
left m~in cnmn","y ",1,,-1)'. ~ _.hmt .t... m. ",hich dividp_. into
the left anterior descendingilrtery and the circumflexilrtery.
The left anterior descending (LAD) travels downward over
the anterior surface of the left ventricle, circles the apex, and
ends behind it. The major branches of the lAD are:
diagonal arteries
right ventricular arteries
septal perforator arteries.
The circumfla art~ry travels along the latual aspect of
the left ventricle and ends posteriorly. The major branches
of the circumflex are:
SA node artel)' (in 45% of population)
anterolateral marginal artery
posterolateral marginal artel)'
distal left circumflex artery.
In 10% of the population, the circumflex artery gives
rise to the posterior descending artery with its septal
branches, terminating as the posterior left ventricular
arteries. A left coronary artery with a circumflex that gives
rise to both the posterior descending artery and the posterior left ventricular arteries is considered a "dominant"'
left system. When the left coronary artery is dominant, the
entire interventricular .septum is supplied by this artery.
lithl ... 1_1 'lJmmari?p-. the cnron~I)' ~rI ... ry di,trihlJlion 10
the myocardium and the conduction system.
The right and left coronary artery branches are interconnected by an exlel15ive network of small arteries that provide
the potential for cross flow from one artery to the other.
These small arteries are commonly called roUa/eral vessels
ur wUa/t:TU/ c;;n;u/aliu .. Cundl~rdl cin;uldliul' ""i.l. ill birlh
AcuC ..
marginal.""'" ---f---~
--t-- 7
- - - --\---j
--"''''':'''-::..J''-
Septal branch _ _ _ _ _ _ _ _ _
lib.. ! ! .
Coronary arteries
COronary.n.ry Inclltl bllllCll" PortIon of lI'II'ocardlUm I~plld
RighI atrium
RigIt wnlridt
~Ieriof
'" of popula~
Leftatrium
AnIIIroIateral waI 0I1eit _triCIe
PosIBroIateral war alleft venR:le
Posterior wall 0I1ef! Y9n1ric1e
~Ierior wall 01 left ventricle (1 0%)'
Posterior one-lin! of ilIIIrYer!IriWa sepbn (IO'!W
SA node (45%)'
AV node and tude of His (10%)'
Cardiac innervation
Cardiac innervation
The heart is under the control of the autonomic nervous system located in the medulla oblongata, a part of
the brain stem. The autonomic nervous system regulates functions of the body that are involuntary, or not
under conscious control. such as blood pressure and
heart rate. It includes the sympathetic nervous system
and the parasympathetic nertJOus system, each producing opposite effects when stimulated . Stimulation of
the sympathetic nervous system results in the release
of norepinephrine, a neurotransmitter, which accelerates the heart rate. speeds conduction through the AV
node, and increases the force of ventricular contraction . This system prepares the body to function under
stress ("fight-or-flight" response ). Stimulation of the
parasympathetic nervous system results in the release
of acetylcholine, a neurotransmitter, which slows the
heart rate, decreases conduction through the AV node,
and causes a small decrease in the force of ventricular
contraction. This system regulates the calmer functions
of the body (" rest-and-digest " response). Normally a balance is maintained between the accelerator effects of
the sympathetic system and the inhibitory effects of the
parasympathetic system.
Electrophysiology
Cardiac cells
The heart is compostd of thousands of cardiac cells. The
cardiac ceUs are long and narroY.\ and di\ide at their ends
into branches. These branches conned with branches of
Resting cell
(polarized Slate)
lh~ECG.
Ul~ """lrjcl~s
Depolarii!atioll
belllnnir>g
(st",.II... a.led S\ale)
Depolarization
oom~ete
Repclarlzalion
beginning
(reccvery
s ta!~1
....! __Lt......!......!_! _~
- - . - I
~,.L..t
I -
Ftepolanzation
complete
K'
i,..:.-=-.:-....:.....:......:..-.:-.:...-:..-.- :./ I
+
+ +
+ + +
from
!.Idll!l~ruu>ly
f.... l rd.ll!S.
10
Electrophysiology
AVnodo
Bundle 01 His
,
,:.
,"
.:,
,PR IntelWl
: :0
ST segment
,
,
:
:
:-:"~-"''-",cc-c-~:
PR ""gment
aT Int .......
Figure 2- 4.
,
,
o ,
lsoele<:tric line
~
PositIVe defle<:tion
FIgure 2-5.
line.
11
NlIlIative deflection
Biphaslc dene<:tion
Negative
deftection
Positive
deIkK:tion
12
Electrophysiology
OAS complex
Pwavi
TWaV8
abwUII
;:;:toty
Ab.soJute refractory period -
..po
~" V......
fIlati;
Altract
porl'"
Waveforms, intervals,
segments, and
complexes
Much of the information that the ECG tracing provides is
obtained from the examination of the three prindpall<.<lVe.
forms (the P wave, the QRS compler. and the T wave) lind
their associated segments and intervals. Assessment of this
~rdial;
Pwave
The first deflection of the cardiac cycle, the P waw,
is ClIusd by depolarization of the right lnd left otrill
(Figure 3-1). The fint part of the P wave represents depolari7.alion of the right atrium: the second part represents
,
Fillure 3-1 . Tte P waWl.
and peaked. 'Ole abnormal P wave in right atrial enlargement is sometimes referred to asp pulmonale because the
atrial enlargement that it signifies is common with severe
pulmonary disease (for example, pulmonary stenosis and
insufficiency. chronic ob$troctive pulmonary disease.
acute pulmonary embolism. and pulmonary edema).
Impulses traveling through an enlarged left atrium (left
atrial h}Pt'rtrophy) result in P waves that are: wide and
notched. The tenn p mitrale is used to describe the abnormal
P WiI\1eS seen in left atrialmJargement because they"''ere first
seen in patients with mitral valve stenosis and iO$ufficielK)'.
Left atrial enlargement can also be seen in left heart failure.
Edopic P u-'Ilce - The term ectopic means away from its
nonTIIIllOCiltion. Therefore, an ectopic P wave arises from a
site other than the SA. node. AbnoTffiilI sites include the atria
and theAV junction. P waves from the atria lTIlI,y be positive
or negative: some are small. pointed. Rat. w;.wy. or sawtooth
in appearance. Pwaves from theAV junction are atways negatillf (inverted) and may precede or follow the QRS complex
or be hidden within the QRS complex and not visible.
Examples of P waves are shown in Figu re 3-2.
PR In terval
The PH interval (sometimes abbreviated PRJ) represents
the time from the onset of atrial depolariz.ation to the onsd
of \'entricular depolarization. The PH interval (Figure 3-3)
indudes a P I<o'a~ and the short isoel~ctric line (PR segment) that follows it. The PR interval is meatu red from the
beginning of the P wave as it leaves baseline to the beginning of the QRS complex. The duration of the normal PR
intel'llal is 0.12 to 0.20 seconds.
Abnormal PH intervals may be short or prolonged:
Short PR in/enoal - A short PR interval is less than
0.12 seconds lind may be seen if the electrical impulse
originates in an ectopic site in the AV junction. A shortened PH inte~l may also occur if the electrical impulse
progresses from the atria to the ventricles through one
of several abnormal conduction pathways (called accessory pilthwa)l5) that b}'pilS5 a part or all of the AV node.
Wolff-Parkinson-White syndrome (WPW) is an example of
such an acceswry pathway.
Pro/OI1ged PR in/errol - A prolonged PR interval is
greater than 0.20 seconds and indicates that the impulse
13
14
Normal PW3ve
No v>sible P waves
Figur.3- 2.
P W3YO
SDWlaoth P wav...
Flat P w.we
exam pIDs.
Inverted P wave
Wavy P w.wes
QRS complex
15
QRScomplex
Th e QR5 complex (Figure 3-5) represents depolariution
of the right and left vent ricles. The. QRS complex is larger
than the P wave because depolariz.alion of the ventricles
involves a larger muscle mass than depolariWion of the
atria.
The QR5 complex is composed of three waw deflections: the QU'l:lw. the R u.,,:we. and the S IL'Qt'Ol. The R waYe
is a posi tive waveform: the Q waw is II negative wavefonn
that precedes the R waw; the 5 wave is a negative waveform that follows the R wave. The normal QR5 compln
is predominantly positiw in lead II (a positive Iud) with a
duration of 0.10 second or less.
The QRS complex is measured from the beginning
01 the QRS complex (as the first wave of the compln.
leaVi!s baseline) to the end of the QR5 complex (when
the last wave of the complex bellins to level out into the
ST segment). The point whe re the QR5 complex meets
the 51 segment is called the} point (junction point).
Short PR inle<val
squa .... ).
01 O.eII slCord
(0.04 secord x
2aqu"'''')
c
Long PR inhtrva l 010.38
second (OJ)( secord"
9i!z squares)
16
"
Nolchad A
,Jl A
E
' Ya,
01- 1r,
H
f
s
1\-,V"",,",,
S
s'
0.12........d
13 ....-e 0.0* MCCI'Od)
0.10oecond
(210 _
.. . 0,(1.1
oeoondl
0,011 oeoond
(2 "",II" 0.(1.1
the baseli ne. A wave that cha nges direction but doesn't
crOM the baseline is Cillied a notch. (Figure 3-6. example E.
shows a notched R and Figure 3-6. example K. sho.,.,'S a
notched S.)
C~pital letters are used to designllte waves of large
amplitude (5 mm or more) and lowercase letters are used
to designate waves of small amplitude (less than 5 mm ).
This allows you to visualize a complex mentioned in a
textbook when illustrations aren't available. For example.
if a complex is described in II text as having an rS waveform. the reader Ciln easily picture a complex with a small
r wave and a big S wave.
An abnormal QRS complex is wide with a duration of
0.12 second or more. An abnormally wide QRS complex
may result from:
a block in the conduction of impulses through the right
or left bundle branch (bundle_branch block)
an electrical impulse that has arrived early (as with premature beats) at the bundle branches before repolarization is complde. allowing the electrical impulse to initiate
depolarization of the ventricles earlier than usual. resulting in abnormal (aber rant) ventricular conduction lind
causing a wide QRS complex
an electrical impulse thaI has been conduded from
the atria to the ventricles through an abnormal accessory
conduction pathway that bypasses the AV node. allowing the electrical impulse to initiate depolari7.ation of
0.0* oeoond
-oneil
(1 oquoN 0.(1.1
oeoondl
o.oeHCond
0.0II0e00nd
(2 oquoros x O,(I.I
oeoondl
ST segm e nt
0.'0_
(211. _
.. Ko.OoI _oneil
0.1~__
13 _ " O.(l4........d)
0.08_
( 2 _ , .0,04 oeoondI
oq_.
O,CIe_
(2
0.04 .....-.I)
17
0.11_
(4' _
. 0.04 0K<>nd)
0.'1-'<1
(4 ......... o.Oot """""l
STsegment
The ST segment represents earl y vtntricular repolarization. The 51 segme nt is the flat line between the QRS complexand the Twave (Figure 3-8). Normally the S1 segment
is positioned at baseline (the isoelectric line). The ST seg..
Jpolnt
18
A Noomal ST U51men1
NomIaI ST MgI1*1!
C Ccnvax eleYIIIion
Concave eI .....aOOn
~d&p", ..",
Twave
19
Twave
Th~ T wav~ represents v~ntricular r~polari1.ation. Th~ no r
mal T wave begins as th~ deflection gradually slopes upward
from the ST segment. and end. when the waveform returns
to baseline (Figure 310). Nonnal T waves ar~ rounded and
slightly asymmetrical (with th~ first part ofth~ T wave grad ually sloping to the peak and returning more abruptly to
baseline). positive in lead II (a positive lead). with an ampli
tud~ less than 5 mm. The T wave always follow. the QRS
complex ( r~polarization always foll<Mls depolarization) .
Rgure3-10 . Th8TW3Y11.
Normal TWINe
Flat T wavs
B;phasicTwave
20
QT interval
Rgure 3-12.
OTlnt9lVal.
figure 3-13.
aT Interval examples.
Uwnve
varies according to age. sex. and particularly heart rnte. The
QT interval is more prolonged with slow heMt rates.
Generally speaking. the normal QT interval should be
less than half the R -R interval (the distance between two
consecutive R wavu) when the rhythm is regular. The
determination of the QT interval should be made in a lead
where the T wave is mod prominent and shouldn't include
the U W<lVe. Accurate measurement of the QT interval can
be done only when the rhythm is regular for at least two
cardiac cycles before the measurement.
To determine if the QT interval is normal or prolonged:
Count the number of small boxes in the R-R interval
and divide by two.
Count the number of small boxes in the QT interval.
Compare the difference. If the QT interval measures less
than half the R-R interval. it's probably normal. If the QT
interval measures the same as half the R-R interval. it's
considered borderline. If the QT interval measures longer
than half the R-R interval. it'~ prolonged.
A prolonged QT interval indicates a delay in ven t ricular
repolarization. The prolongation of the QT interval lengthens the relative refractory period (the vulnerable period
of repolarization). allowing more time for an ectopic
focus to take control lind putting the ventricles at risk for
life-threateninll arrhythmias such as torsade$ de paiutes
ventricular tachycardia (discussed in Chapter 9). Common causes include electrolyte imbalances (hypokalemia.
hypomallnesemia. hypocalcemia). hypothermia. bradyarrhythmias. liquid protein dids. myocardial ischemia.
antiarrhythmics. psychotropic agents (phenothiazines.
tricyclic antidepreants). and hereditary lonll-QT syndrome. It can al50 occur without a known cause (idiopathic).
Examples of QT intervals are shown in Pigure 3-13.
Uwave
The U wave is a small deHection sometimes seen following the T wave (Figure 3-14). Neither its presence nor its
21
22
23
Strip 3-1 ,
Strip 32,
strip 3-3.
Strip 3-4.
strip 3-5.
Strip 3-&.
24
Strip 3-7,
Strip 3-8.
Strip 3-9,
Strip 3-10,
Strip 3-11.
Strip 3-12,
Strip 3-13.
Strip 3-14,
Cardiac monitors
fil
-I'
Purpose of ECG monitoring
The electrocardiogram (EeC) iSI! reoordingofthe electrical
activity of the heart. The ECC records two basic electrical
processes:
Rrpo/arizotion - the recovery 01 the stimulated muscle to the resting state. producing the ST segment. the T
AL+---\!f>!
,
';jf,f-tLL
~cardiac
rhythm" identified.
middavicular line), one below the left clavicle (2nd interspa~, Idt midclavkular line), one on the right lower rib
cage (8th intenp.xe, right midclavicuJar lint), one on the
left lov.-er rib cage (8th interspace, Jdt midclavicular line),
and one in achest lead position fY, to V.). The SDc chest lead
positions (Figure 4-2) include:
V, - 4th intercostal space. right sternal border
V, _ 4th intercostal sPi\te, left stunal border
V.-midv.-aybetweenVzandV,
V, - 5th intercostal space, left midclavicular line
V. _ 5th intercostal space, left anterior Miliary line
V. - 5th intercostal space, left midaxillary line
lhe right arm (RA) lead is attached to the eledrode pad
below the right clavicle: the left arm (LA) lead to the electrode pad below the left clavicle; the right leg (RL) lead
to the electrode pad on the right lowe r rib cage; the left
25
26
Cardiac monitors
leg (LL) lead to the electrode pad on the left lower rib cage:
and the chest lead to the electrode pad of the specific chest
position desired (V, through V,l.
With the five-leadwire system for hardwire monitoring, you can continuously monitor two l~ads using a
lead selector on the monitor. Leads placed in the arm
and leg positions allow you to view leads I, II, III, AVR,
AVL, and AVF (Figure 4-1). To view chest lead V, to V"
the chest lead must be placed in the specific chest lead
position desired. Generally, a limb lead (usually I, II. or
III) and a chest lead (usually V, or V,) are cho~n to be
monitored.
With the three-leadwire system (Figure 4-3), three electrode pads and three leadwires are used. One electrode pad
is placed below the right clavicle (2nd interspace, right
midclavicular line), one below the left clavicle (2nd interspace, left midclavicular line), and one on the left lower rib
cage (8th interspace. left midclavicular line). The RA lead
is attach~d to th~ electrode pad below the right clavicle,
Figure iI-il. HardWlra monnor1ng - Tllree-leadwlre system: Leads MCL, and MCt... Modified chest leads can be monitored with tho threeleadW __o system by reposRlon1ng tho len leg (U) lead to the chest position desired and tumlng the lead selector on tho monttor to lead III.
27
Telemetry monitoring -
Wireless monitoring, or
Troubleshooting monitor
problems
Many problems may be encountered during cardiac
monitoring. The most common problems are related to
patient movement. interference from equipment in or
neilr the patient's room. weak ECG signals. poor choice
of monitor lead or electrode placement. and poor contact
between the skin and electrode-Ieild attachments. Monitor problems 'an ,ause artifa't,s on the ECG tracing,
making identification of the cardiac rhythm difficult or
triggering false monitor alarms (false high-rate alarms
ilnd false low-rate alarms) . Some problems are potentially serious ilnd require intervention, whereas others
are temporary. non-life -threiltening occurrences that will
correct themselves. The nurse and monitor technician
need to be proficient in recognizing monitoring problems. identifying probable causes. and seeking solutions
to correct the problem. The most common monitoring
problems are:
FalsehifIJ-ratealarms ~ High-voltageartifact potentials
are commonly interpreted by the monitor as QRS complexes
28
Cardiac monitors
lead II
Lead III
G
ModifIed Chest Lead V, (MCL,)
and acti"ate the high rate alarm. Most high voltage arti
facts are related to muscle movements from the piltient
turning in bed or moving the extremities (Figure 4-7).
Seizure activity can also produce high-voltage artifact
potentials (Figure 4-8) .
False low-rate alamu - Any disturbance in the transmission of the electrical signal from the skin electrode to
the monitoring system can activate a false low-rate alarm
(Figures 4-9, 4-10, 4-11. and 4-12 ). This problem is usually caused by ineffective contact bd""een the skin and the
electrode-Ieadwire system, resulting from dried conductive
Figure 4-7. Patient movement cause: str1ps above shoW pallent turning In bed Of extremity movement. SOIUtIm: Problem Is usually
Intermittent and no corractlon Is necesay. Movement tRact C~ be reduced by avoiding placement 01 electrode pads In areas where
extremity movemenlls greatesl (bony areas such as the davldes).
FIgure 4- 8. Setzln actlVlly C<rL activate the high-rate alarm on the monitor.
29
30
Ca rdiac lllonilOrs
Figuf1l 4 9, cont~uous straight Ina, QIJs,: DI18C1 conciJc1tt'a gaI, dl!ro"tl8Ctad lead wire, or dlsconn8cted el8ctrooa pad, sotJItm: Qlack
ellM:trode-lead syslem; re-prep alii fe-altach electrodes .nI1oacIs as necessary. fJie: A straight line may also h:llcali! the msenc:a 01
electrical acttvfty ~ thell8llt; the patJant must be avaIual9d Immediately !of the presenca 01 a pulse.
Figure 4 1O. ~termttblnt straIgIIt line. GaUS8: r.ef1actNe contact betWiIen SkIn and electrooa pac:!. SDIIIt/on: Make sure hair Is Clpped
.nI electrode pad Is pI;Qd on clean, dry skin; " dlaph:lresls Is a problem, prep skin SII1'ace wtth Unctln 01 benZoin solIIIon.
Figure 4 11 . conUrwus low waveform 'I1tagi. GaUS8:LowYOIIage QftS compleJDIIS. so.tstIon:lUm ~ amplItUde (gain) knob on monlor
31
Fillure 4-12. Intermment loW waveform YO!t<Qe. ClIusfllntarmtttent 1oW-~e OIlS COOlplexes ara seen In both strtps aOOe.
SO/uI1on: Uthe pr~ Is frequent and acttvates the loW-rate alann, c:tmge lead posttlons.
Figure 4-13. contlnuollS musde tremor. cause: Muscle tremorn are usually related to tense or nenoos patients or Ihosa sIllYer1ng from
cold or a chili. SOlt/ltln: lI"eat cause.
32
Cardiu c monilOrs
Figure 4-14. .,lBrmltlenl musde 1r1lfl1CX. caUSI1: Muscle trernon thaI ClCClI' nlefmlllenlly. Sdu/fa!: correction Is usually unllBalSSal)'.
Nol6: In this str~, the palleR lias two p waves precedtrY;j each ORS complex \S8COOO-degrae atTklVenIrt:utaf block, MOOIIZ 11).11 the muscle
trem!n went continUOUS (as In Agulfl 4-13). yQJ wOUlCl be unable 10 identity this S8f1OUS IITt1ythmla.
Figure 4-15. Telemetry-rlllated Interference. cause: ECG sI!1lals 1I"e poorly received ~er the telemetry system causing sharp spIIes
nI someUmes kiss 01 signal recepllon. ThIs problem Is usually lfllated to wmk batteries or the transmltlef being usalin the outer fI1nges 01
Ihe ~11on lI"ea lor the base stallon receiver. SdutJon: Ctlange batteries; keep pall8nlln recepUon area 01 base station receivers
Telemetry-related interference -
Te lemetry-related
artifacts occur ",-hen the ECG signals are poorly received
owr a telemetry monitoring 5)'Stem (Figure 4-15). Weak
ECC signals are caused by weak batteries or by the transmitter being used in the outer fringes of the reception area
33
FIgure 4-17. wandertng baseline. CBUS8: Exaggerated resp~atory movements usually swn In paUents In respiratory distress (paUents
with chronic obstructlvo pulmonary disease). So/uIIon: AYOId placing electrode pads In lI'BaS where mOYOOler1ts 01 the accessory muscles 1I'lI
most exaggerated (Which can be anyw1lere on the <rltertf chest wal~. Ploc:e the pads on the uwer bock IX Iql 01 the shoolders " neceswy.
Analyzing a rhythm
strip
There are filii! basic steps to be fonowed in analyzing
II
Regular rhythms
Two methods can be used to talculale heart rate in regular
rhythms;
Rapid rate calculution - Count the numberofR WiIVU
in a &-second strip and multiply by 10 (6 secondS)( 10 = 60
seconds. or the heart rale per minute). This method provides an approximate heart rate in beats per minute, is
fast and simple. and tan be used with both regular and
irregular rhythms .
Prf!CiSIl rate rulculution - Count the number of small
.squares between two coMeCutive R wave.s (Figure 5-6) nnd
refer to the conversion table printed on the inside back
coverof the book. A remowble com'usion table is also provided.Although this method is accurate. it can be used only
for regular rhythms. If a conversion table isn't available.
divide the number of small squares be!>..'een the two consecutive R waves into 1500 (the number of small squares
in a I-minute rhythm ~trip). The heart rates ror regular
rhythms in the answer keys were determined by the precise
rate calculation method.
Irregular rhythms
Figure 5- 1.
34
Index ca-a.
35
~terYais vary
by 0.32 second.
Other hints
When rhythm strips have a premature beat (Figure 5-11).
the premature beat isn't included in the calculation of the
rate . In this example the fin;t rhythm is regular and the
heart rate is 68 beats per minute (22 small squares between
R waws = 68).
When rhythm strips have more than one rhythm on a
6-second strip (Figure 5-9), rates must be calculated for
each rh}1hm . This will aid in the identification of each
36
Figure So6. Regular rhy1tV1I; 25 small squares between Rwaves '" 60 heart rate.
Agure 5-10. calculallng rate wtIen a mytlvn COYen less IIIan 3 seconds.
37
38
Box 5-1.
such as normal sinus rhythm with one premature ventricular contraction (PVC) (Figure 5-8).
Z. C~k:U1iI1I! Hill!.
3. examine P waves.
4. Measure PR In1erval.
5. Measure aRS complex.
39
40
PR il\eMII:
PR in\eMII:
Pwave: _ _ _ _ __
DRS oomplex:'_ _ _ _ __
PR illeMll:
Pwave: _ _ _ _ __
DRS t:OII1p1ex:_ _ _ _ __
ORS t:OII1plex:_ _ _ _ __
Pwave: ______________
ORScomplex: _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplex: _ _ _ __
ORScomptex:_ _ _ _ __
Pwave: _ _ _ _ __
41
42
PR illefval:
PR 1n1eMl1:
R"" ________
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
PR inlefval:
Pwave: _ _ _ _ __
ORS cornpleJ::_ _ _ _ __
ORS compleJl:_ _ _ _ _ __
Pwa'o'e: _ _ _ _ __
PR lilt.....:
Pwa..,,: _ _ _ _ _~
OAS complex: _ _ _ _ _~
PR inlerwt:
43
CRS complex: _ _ _ _ _~
Pwa..,,: _ _ _ _ _~
Sinus arrhythmias
Overview
general. rderriog to all rhythms other than the norITIlIl rhythm of the heart (normal sinus rhythm). Sinus
arrhythmias (Figu re &-1) result from disturbances in
80a i-1.
Normal sinus rhythm: Identifying ECG features
Rhythm:
..
"'
"".
mias. However, sinus bradycardia at rest. sinus tachycardia with aen:ist, and sinus arrhythmia associated with
the phases of respiration are considered normal responses
of the heart
PW''IIiII:
60 to 100 tJeallolmlllJle
Normal In stze. sIlape, and tinction:
PH IntiIn'aI:
QRS
Normal sinus rhythm (Figure 6-2 and Box 6-1) reflects the
heart's normal electrital activity. TIle SA 00!k normally
initiates impulses at a rate or 60 to 100 beats per minute.
Sinus bradycardia
Sinus tachyca rdia
Sinus arrhythmia
Sinus arrest
Sinus block
44
posltlYe In
1eaCI1: one P WlIYfI!r9CEide5 each ORS complex
~C
Agure &-2.
Rb)'Ulm :
Regular
Rate:
P waVlI:
PRlnlllrYaI:
DRS complU:
8-4 beats/minute
NOrmal ar.IIX"8C8CIe each ORS
0.14toO. 16 ll9al1ld
0.06100.08 secood.
8016-2,
Sinus tachycardia
Sinus tachycardia (Figure 63 and So)[ 62) is a rhythm
thai originates in the sinus node and di~harges impuL'IeS
regularly at a rate bew,et:n 100 and 160 beats per minute.
The P waves .re normal in s~e. shape, and direction: po$i
live in le<KI 1i (. posilive lead), with one P wave preceding
each QRS complex. The duration of the PR interval and the
QRS complex is within normal limits. The distinguishing
feature of this rhythm is the sinus origin and the rate
bew,--een 100 and 160 beats per minute.
Figure 6-3.
Rb)'Ulm:
PWI'I'9S:
PR InIlIrYaI:
45
Sinus tacllycartlla.
"""",,
"'"to
115 beatsJrnhuto
A~hm;
Rate:
P wa... :
46
Sinus nrrhylhmins
Sinus bradycardia
Sinus bradycardia (Figure 6-4 and Box 6-3) is a rhythm
that originates in the SA node and discharges impulses
regularly at a rate between 40 and 60 beats per minute.
The P waves are nonnal in size, shape, and dirtction: positive in lead II (a positive lead), with one P wave preceding
each QRS complex. The duration of the PR interval and the
QRS complex is within nonnallimits. The distinguishing
feature of this rhythm is the sinus origin and a heart rate
between 40 and 60 beats per minute.
ao. ...3,
Sinus bradycardia: Identifying ECG leaba'es
R....
40 to 60 bealsImlnuls
Normal In sue, sI\ap&, and ttr9ctkln: posltlYe In
lead I: one P WW1I ~ecalBS each ORS complex
Pft IlItan'aI: Normal (0.121D 0.20 S8IXJId)
ORS compleX: Normal (0.10 sec::ooo or less)
Rhylhm:
Rot.
p.,.",..:
" ...
Nola:
hyperlr~.
Sinus arrhythmia
Allure 6-5.
RII)'II1m:
P waws:
PIt ln18rYaI:
SInus arrflrthmla
negular
SO beal&mloote
47
Sinus arrhythmia
Sinus arrhythmia (Figure 6-5 and Box 6-4) is a rhythm that
originates in the sinus node and discharges impulses irregularly. The heart rate may be normal (60 to 100 beats per
minute) or slow (commonly associated with a brMlycardic
48
Sinus arrhythmias
Box , .....
sinus arrest and sinus exit block. Sinus arrest and sinus
exit block. two separate arrhythmias with different pathophysiologies (Figur~ 6-6. 6-7. and 68 and Box 6-5), are
discuned together because distinguishing between them is
at times difficult. and because Iheir treatment and clinical
significance are the same.
Rhythm:
Irregular
Figure &-6.
Box 6-5.
Rate:
P Way":
P1Itnt,rval:
Ratl:
""~
Normal (0.12 to 0.20 second) with DaSI& rl'ly1hm:
absent during pause
Figure 6-7.
Rhythm:
Rala:
P waYIIS:
PfIlnterval:
DRS complex:
Rgure 6-8.
Rhythm:
Rate:
49
Normal sinus rhythm wllh sinus arras!; rale suppression Is presenlloltowlng pause.
BasIc rhythm rale 84 beatslmnute; rate slows to 56 boatslmlrule loIlowlng pause (temporll)' rate suppression may occur
lollowlng a pause In the bask: rhythm)
P waygs:
Sllus In baste rhythm; absent during pause
PfIlnl9rYat: 0.16 to 0.18 second In basic rhythm; absent during pause
DRS complex: 0.08100.10 second In basic rhythm; absent du~ng pause.
50
Sinus arrhythmias
P WlI'I":
PR Inltml:
QRS complel:
COmInlIt:
60 bBa~lfIJIe
51
Table 6-1.
Ral. (bIatsl
PR Interval
Normal (0.12 to
0.20 second)
minute)
Normal sinus
rhythm
R~'"
6010 100
Sinus
bradycardia
R~""
40"60
"""""
""...
100 to 160
"""""
Sinus
tachycardia
Sinus
alThytlvnia
trreg .....
6010 tOO(nonnaI)
or< 60 (slow)
Sinus block
and sinus
Basic ~ usually
regular, !here is a sOOden
pause in !he basic rhythm
(caJsing irreguarity) with
one or more missing
beats; temporary rete
suppr9ssion common
That of oodertying
rhythm, usually
.~,
,~
"""""
"""""
Normal (0.12 to
0.20 second)
Normal (0.12 10
o.20second)
Norm31 (0.12 to
0.20 second)
Normal (0.12
10 0.20 second)
with basic
rhythm; absent
IUing pause
DRS complex
....,
....,
....,
....,
Normal (0.10second
Normal (0.10second
loIowing pau&e
Ddfersntiatirtg
fealUrBII
Sirusbio:k:
Sirusarrest
Basic ~ resumes on
time after pause
..
Nuts: Hthe basic rhythm is iITll9Uar (sinus alThythmia~ sinus arrest cant be differentiated lrom sinus block. and !he rhythm is
interpretoo as sinus arrhythmia with sirllS pause.
52
Sinus arrhythmias
!>Ieasure PR interval.
Measure QRS complex.
Interpret the rhythm by comparing this data with the
ECG characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unless otherwise noted . Check your
ansVt'ers with the answer keys in the appendix.
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P wave: _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm interp-etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwaw: _ _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
53
Pwa..-e: _ _ _ _ __
PRInIefVal:
ORScomplex:,_ _ _ _ __
IIJythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRinteMlI:
Pwa...e: _ _ _ _ __
ORScompla:' _ _ _ __
""""'''0''01'''''' __------------------
PRInIefvai:
Pwa..-e: _ _ _ _ __
ORScomplex:,_ _ _ _ __
IIlyttwn interpretation:- - - - - - - - - - - - - - - -
54
Strip6-7.RhyIIvn: _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ __
Strip 6-B.lllythm: _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ __
Pwave: _ _ _ __
PR inleMll:
ORS complex:_ _ _ _ __
IIlythm Interp-etmon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR 1n1eMll:
IIlythmlnt~~ :
Pwave: _ _ _ _ __
ORS complex:'_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
55
ORS compleK: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PA interval:
ORS complex: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
56
Sinus arrhythmias
Pwave: _ _ _ _ __
PR interval:
ORS complex:- - - Rhythm Interpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
OIlS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
57
Pwa",,: _ _ _ _ __
ORS complex:_ _ _ _ _ __
RhyIhmlnt8fPfMalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa"": _ _ _ _ __
PR inieMi:
QRScornp/ex:,_ _ _ _ __
RIrythm Inrerpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip6-18 .Rhythm: _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ __
Pwa",,: _ _ _ _ __
PRinterval:
ORScomplelC _ _ _ _ _ __
RhyItn1 inteqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
58
Sinus arrhythmias
_ _ _ _ _ _ __
PwaY8: _ _ _ _ __
PR rnervai:
ORS complex:- - - Rhythm Interpntalbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ __
Pwa....: _ _ _ _ __
PR ilterval:
ORS cornpleJ.:_ _ _ _ __
Rhythm Interpret8tIon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PWaYB: _ _ _ _ _ __
RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
59
Pwave: _ _ _ _ __
PH interval:
ORScompltx;'_ _ _ _ __
Rhythm IntMpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ __
PH interval:
CR5 cornplex:,_ _ _ _ _ __
RhytI'm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
PH interval:
ORScomplelC _ _ _ _ _ __
RhyItvn inteqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
60
ShillS Ilrrhylhmill'
Strlp6-25. lIIyttIm: _ _ _ _ _ _ _ _ _ . ., _ _ _ _ _ _ __
PR interval:
~I~e~~~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Pwave: _ _ _ _ _ __
ORS complex:,_ _ _ _ __
_____________ PweWl: _ _ _ _ __
ORS compleJ::_ _ _ _ __
Rllythm Interprttalkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR ilterva:
ORS complex:c_ _ _ _ ___
Rbyttm interpretalioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
'>t. ________
ORScomplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
61
Pw,, _ _ _ __
ORS complex: _ _ _ _ __
Rhythm Int8fPl'etation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaYe: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ __
Rhythm intefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
62
Sinus nrrhylhmins
PR nterval:
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm interprela!ion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaV8: _ _ _ _ __
RIIythm interpretatDn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR iltervaI:
R~m
_ _ _ _ _ _ __
Pwave: ____________
ORS complex:
l ~ : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ __
63
Pwave: _ _ _ __
PfI inlerwi:
ORScomplex:,_ _ _ _ __
Rhythmlnleqmation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pfllmervai:
Pwave: _ _ _ _ __
ORScomplex:'_ _ _ _ __
Rhy1hm inIMprelation:_ _ _ _ __ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplex:_ _ _ _ _ __
Rhydvn inlMpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
64
Sinlls arrhythmias
ORS complex:_ _ _ _ _ __
Rhythm inierpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS
compl~ : _ _ _ _ __
Rhythm interpretatm:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaV8: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
65
Pwave: _ _ _ _ __
P1I interval:
ORScomplex:_ _ _ _ __
Rhyltvn Intetprttation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P1I inli!IMI:
Pwave:
_ _ _ _ __
ORS CXH11p1ex: _ _ _ _ __
!IJyhn interpn!la!ion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplex:_ _ _ _ _ __
Rhydvn inlMpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR intervai:
66
Sinus arrhythmias
'>t" ________
Pwa'l'l!: _ _ _ _ __
PR fmerval:
ORS complex:_ _ _ _ __
Rhytl'm InterpretatiJn:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
DRS complo:_
PR ilternt
P W3V'8 : _ _ _ __
_ _ __
RhytI'm iliterpelalDI:
PR ilIervat:
Rhytl'm i ~~a~ :'
Pwa'l'l!: _ _ _ _ __
ORS complex:_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
67
Pwave: _ _ _ __
PH interval:
ORScompIex: _ _ _ _ __
Rhythm IntefPfllation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ __
Pfl lnterwl:
ORS complex:_ _ _ _ __
RhyI!vn InIMprltation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PRinterval:
_ _ _ _ _ _ __
Pwa'o'e: _ _ _ _ __
ORScomplelC _ _ _ _ _ __
Rhyttvn inleqlf8!ation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
68
Sinus arrhythmias
QRS
PwaYfl: _ _ _ _ __
compleJ:: _ _ _ _ __
Rllyltlm Interpntatiln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
_ _ _ _ _ __
PweYfl: _ _ _ _ __
compleJ.:_ _ _ _ __
Rllyltlm interpfetatiln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
PwaYfl: _ _ _ _ _ __
PR iltelVlt.
ORS rompleJ::c_ _ _ _ __
Rbythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip &-S2.lflythrn: _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ __
69
Pwave: _ _ _ _ __
PfI interval:
ORScomplex:'_ _ _ _ __
Rhythm Inteqntatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PH interval:
ORScomplex: _ _ _ _ _ __
RhyIhmlnleqntation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
PfI interval:
0ftS complelC _ _ _ _ _ __
RhyItvn inleqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
70
ShillS Ilrrhylhmill'
PR nerval:
_ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
QRS complex:'_ _ _ _ __
RIryth'n Inlerpretatioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
RIIythm Inierpmallon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR neME
_ _ _ _ _ _ __
PwaVB: _ _ _ _ _ __
QRS cornple.l:_ _ _ _ __
RIIyIhm interpfetatioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
71
Strip 6-58. ~m : _ _ _ _ _ _ _ _ _
PR interval:
ORS complu: _ _ _ _ __
Rhyttvn Int8f)H'etatlOn: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
"'t. ________
PW3Y8: _ _ _ __
FVIyttITl intlHJll'etetion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaYe: _ _ _ _ __
FVIyttITl intefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
72
Sinus nrrhylhmins
Strip6-61 . Rhythm: _ _ _ _ _ _ _ _ _ _
Pft InteM!:
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplex:,_ _ _ _ __
IIlythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pft kJ1eMt.
_ _ _ _ "'" _ __
_ _ __
Pwave: _ _ __ __ _
ORS compleX:_ _ _ _ __
Rhythm Interprel3tion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR marva!:
ORS complex:_ _ _ _ __
RIIyI!un interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip6-U, Rh)'thm: _ _ _ _ _ _ _ _ _
_ _ _ _ _ __
73
Pwsve: _ _ _ _ __
PfI interval:
ORScomplex:,_ _ _ _ _ __
Rhyltwn lnteqntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Pfl lntllMll:
ORScomplex: _ _ _ _ __
fIly1hm InleqJrelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Rhythm inteqlfetalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
74
Sinusarrhythmitl.'l
_ _ _ _ _ __
Pwavt: _ _ _ _ __
PR i1tarwi:
ORS OJIT1p1ex:_ _ _ _ __
Rhythm In\erpfttaOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR i1tervai:
ORS complex:,_ _ _ _ __
RIIythm interpr8laOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
RIryttJn interpfetaooo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
75
Pwave: _ _ _ _ __
PR interval:
QRS caTlplex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR intEnrai:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
76
_ _ _ _ _ __
Pwave: _ _ _ _ __
PR ilteMil:
ORS complex:_ _ _ _ __
RlryIflm Inlerpfetamn: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _______
PH Interval:
DRS complex:,_ _ _ _ __
Rhythm Inlerpfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _______
PR marva!:
DRS oomplex:
RIIyI!un interpfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
77
Pwave: _ _ _ __
I'll int&rVal:
ORS canplu _ _ _ _ _ __
Rhytllm Irtetptelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip6-71.Rh~m :
_ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __
PfI interval:
Pwave: _ _ _ __
ORS canplex:_ _ _ _ __
Rhytllm Inteqnlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
I'll interval:
ORScomplex:_ _ _ _ _ __
RlyItrn inteqM'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
78
Sinus arrhythmias
Pwsve: _ _ _ _ __
PR ilterv.W:
ORS rornplex:_ _ _ _ __
Rllythm InterpmatOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwaw: _ _ _ _ _ __
PR ilIarvit.
ORS oomplex:
RIIyI!un interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
79
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
80
Sinus nrrhylhmioJ
PR rrterY8l:
R"" ________
Pwave: _ _ _ _ __
ORS complelC'_ _ _ _ __
Rbyttm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR ilterval:
____ _
_ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
Rhyttm Interpntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Strip 6 87. Rhythm: _ _ _ _ _ _ _ _ _ _ '"'" _ _ _ _ _ _ __
PR ilterval:
ORS complex:,_ _ _ _ __
RIrythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
81
Pwaw: _ _ _ _ __
ORScomplex:_ _ _ _ __
Itiythm Interpre(a\loo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pft interwl:
""""',.""
..
Pwave: _ _ _ __
ORScomplex:_ _ _ _ __
,,,,,- - - - - - - - - - - - - - - - - - - -
PR ilterva~
~mm~muoo :'
ORS romp/ex:,-
PwaYlt _ _ _ _ _ __
---
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
82
Sinus arrhythmias
Pwaw: _ _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwaw: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
Pwave: _ _ _ _ __
Pfl lnt&J'll3l:
ORS complU _ _ _ _ __
Rhyttvn inl8fPl1lta1ion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PA Int&lV8l:
PWllve: _ _ _ _ __
OftScomplex:,_ _ _ _ __
Rhyttvn inlefPrelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScompleic,_ _ _ _ _ __
Rhythm inlefJlfelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pfl interval:
83
84
SInus nrrhythmills
-------
Pwa....: _ _ _ _ __
CAS CGmp6lx:,_ _ _ __
1ItIytIIn.'''''ubdlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ __
Pwa....: _ _ _ _ __
11ft ~ervtt.
ORS complex:_ __ _ __
Rltythm IntMpntalion", _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ __ __ __
ORS CGmplex:, _
_ __
Pwa.... : _ __ __
Atrial arrhythmias
Mechan1sms of arrhythmias
Under certain drcumstances cardiac cells in any part Qfthe
other than the sinu~ node). The result can be ectopic beaU;
or rhythms. These rhythms llrt identified according to
the location of the ectopic pacemake r (for example. at rial.
features
Rllrthm:
Rllt:
R9jlular or Ir!"9glfar
85
86
Atrial arrhythmi as
~Aaialfll.lttel
Atll~llibrl li a tlOn
PoIntod
Squiggle
T.p wave
w""
Agutl 73.
Rhrtllm:
lITegular
60 beatslmln!1le
87
P "....:
PRIn'aval:
Allure 7- 4.
Rhythm:
Rate:
lITegular
P"awI:
PRlntBfYaI:
t40bealSltnnul8
s1r1I
aa
Figure 7-5. Normal si nus rhythm with pre matu re atr1al contraction (PAC).
Rhythm:
Basic rhylhm r69Jla'; 1'r69J1a' with PAC
Ratl:
Basic rhylhm rate 72 beats/mllllle; rale slows to 60 beal~mlnute following PAC (Tempol'MY rate suppression Is common
lailowlng a pause In the basic rhythm; alter several cardiac cycles the rale usually returns to the basic rhylhm rate.)
Pwaves:
Sinus P waves with basic rhythm; P wave assoclaled with PAC Is premalure and closely resembles thai 01 the sinus P waves
In the unclertylng rhylhm.lndlca.Ung tho ectopic atrial patenlOOJr site Is close 10 the SA node
PR Internt 0.12 second (basic rhythm and PAC)
otiS oomplex: 0.08 second (basic rhythm and PAC).
Figure 7-G.
Rhythm:
Rate:
P WaYss:
PR Interval:
QRS complex:
Box 7-2.
PR Int,rval:
,-,
ectopic site in the atrium. which interrupts the regularity of the basic rhythm (usually a sinus rhythm). The premature beat occurs in addition to the basic underlying
rhythm. PACs may originate from a singl~ ectopic pacemaker site or from multiple sitel; in the atria. The early
beat is characterized by a premature, abnormal P wave
and a premature QRS complex that's identical or similar
to the QRS complex of the normally conduded beats. and
is follol't~d by a pause.
P-wav~ morphology differs from sinus beats and varies
depending on th~ origin of th~ impulse in th~ atria If th~
ectopic focus i. in the vicinity of the SA node. the P wave
1m}' closely resemble the sinus P wave (Figure 7-5 ). Its sole
distinguishing feature may be its pr~rnaturity. As a rule.
Allure 1-1.
89
RhyttIm:
Allure 1-8.
Rhytnm:
Hormal sinus rhythm wIIll one premature atrial con1ractlon (PAC) wnh aberrant ventricular condllellolt
BasIc rhythm regular; lri1gularwntl MC
Rate:
BasIc rtr,'ltlll rata 68 beatslmnute
P waves:
stlUS In basic rhythm; premature, abnormal Pwave with PM;
PR InlefVaI: 0.18 to 0.18 second (baSIC rhythm): 0.24 98CCIIld (PAC)
OKS complex: 0.08 second (basic rhyIflm); 0.12 second (PAC).
90
Figure 1-9.
Rhythm:
Aat.:
PWlI'I'tS:
PR Interval:
QRS compIIx:
Commen!:
Figure 1-"
Nonconducted PAC
91
Nonconducted PAC
A nonconducted PAC (Figures 7-14 through 7-16 and
Box 7-3) results when an ectopic atrial focus occurs so
early that it finds the AV node refractory and the impulse
isnt conducted to the ventricles. This results in a premature. abnormal P wave not accompanied by a QRS complex,
but followed by a pause (Figure 7 1-1.).
Like the conducted PAC, the P wave associated with the
nonconducted PAC will be premature and abnormal insiz.e,
shape, or direction. The P wave is commonly found hidden
92
FiRure 7-13. Normal sinus rhythm with sinu s arrest and atrial escape beal
Basic rhythm regul.'l'; lrregul1l' dur~ pausa
Basic rhythm rate 63 bealslmlflJle; ralll slows to 58 bealslmlnulll aner paJSe due to temporay rate SLp'esslon (common
loIlow~ pauses nthe basic rhylhm)
PWavH:
Sinus P waves: P waves are notched In basic rhythm which could be duo to len atrial enlargement; peaked P WlJole with
escape beat
PH Intlrval: 0.1810 0.20 second (basic rhylhm and escape beal)
QRS compln: 0.08 second (basic rhylhm); 0.06 second (escape beal).
Rhythm:
Ratl:
FiRlire 7-14. Normal sinus rhythm with nonc:onducllld premature atrial contraction (PAC).
Rhythm:
Rate:
Box 7-3.
!lCClJ'
lu
b~ hj<.l<.l~"
ill
Ih~ I'",~~<.li"l!
WdV~).
All
No nconducted PAC
Figure 7- 15.
Rhythm:
Rata:
Pwaves:
93
Figure 7- 16. Dlfferentlallon of sinus alTllst or block from the nonconducted premature atrial contraction (PAC).
A Sinus arrest or blcx;k
1. Sudcloo pauoo In tho ba&1c rhythm
2. No Pwave present
3. T-WiJo/e contour occurring during pause remains unchalged
B Nonconducted PAC
1. Sudden paise In the basic rhythm
2. Abnormal. prema\u'8 Pwave present and oRen IolJId hidden In T wave
3. T-WiJo/9 contour OCCIITlng during pause will be different from the conloln of the basic rhythm.
94
Atrilll ll rrhythmi as
8017-4.
Atrial tachycardia: identifying ECG features
Rhythm:
Ratl:
P wa_:
lleglllar
140 kJ 250 beatsA'nlnute
Abnormal (commorly iDlted); usually Iidden in
PR InlIrYaI:
Rill:
188 DIlatsll'nRlte
P wIIYn :
HIdden
Figure 7-18. Normal sinus rhythm wlUl premature atrial contraction (PAC) and btwSt 01 paroxysmal atrial tachycardia {pAT}.
Rhythm:
Basic rhy1!1m regu~ IrregtU w1th PH: and lust 0/ PAT
Rata :
Basic rhy1!1m rate 94 beatsA'nlnute; PAT rate 167 beals/minute
P waYIII :
~us P waves w1th basic rhythm: premature, pOOIBd P waves wI1h PAC and PAT (P waves ;J"e supef1mposed on preceding
TwaYes.)
PR tntllrYlI: 0.16 second
ORS compl8ll: 0.08 second
COmment:
Arun oIlhroe or
At rial flutter
95
Atrial flutter
AtTi,,1 flnlter (Fi~ur~_~ 7_19 thm,,~h 7_22 ~od Box 7_S)
originates in an ectopic pacemaker site in the atria typi cally depolarizing at a rate between 250 and 400 beats per
minute (the ave rage rate is around 300 beats per minute) .
The atrial muscles respond to this rapid stimulation by
producing waveforms that resemble the teeth of a saw.
The sawtooth waveforms are called flutter waves (F waves) .
The typical atrial flutter wave consists of an initial negative
component followed by a positive component producing
V-shaped waveforms with a sawtooth appearance . The flut ter waves affe\:t the whole baseline to such a degree that
there is no isoelectric line betv,'een the F waves, and the
T wave is partially or completely obscu red by the flutter
waves. Atrial tlutter is primarily recognized by this sawtooth baseline. The PR interval is not measurable. The QRS
complexes are normal.
BOI 7- 5.
P waves:
96
Atrial arrhythmias
PIllnllrval:
No1 measuable
QRS
Atrial flutter
97
B
Figure 7- 21 . COmpar1son of alr1a1 nuttarwlth 2:1 AV conducUon and paroxysmal alr1a1 tachycardia (pAT).
Example A.The rhythm shoWs PAT. This str~ shoWs the T-P W3VO (the T .on:! Pwaves appell' as one denectlon). An IsoolecIrIc line Is present after 1118 T-P wave.
Example B. The rhythm shows atrial fkJIIer with 2:1 AV conduction. This strip shows two nutter (sawtoo1l1) waves belOfa each
ORS complex. There Is no Isoolectrk: line.
HR - 149
Figure 7-22.
50 JOULES
ClI'dloverslon 01 atrial nutter wl1I12:1 alrloYenlrtculll' conduction 10 normal sinus rhythm using 50 joules electrical energy.
rate is slower than the atrial rat~. with th~ rale depending
on the number of impul.u conduded through the AV node
10 the wntricles.
Becaus~atrial flutlerusually occurs at a rale of300beats
per minute and the AV node usually blocks at least half of
98
Atrilll llrrh)'thmias
Atrial fibrillation
Atrial fibrillation (Figures 7-23 through 7-26 and Box
7-6) is a rapid and highly il'Tegular heart rhythm caused
by chaotic electrical impulses that arise from an ectopic
site in the atria. depolarizing at a rate greater than
Rllyttlm:
mgutar
Rate:
com""n1:
Atrial fibrillation
99
negular
Yentr1cu1lV rate 130 beatslTnlr'llte
FI>r1Ilatory waves present
No! measurable
Rgure 7 25. A111a1l'b1la1lonwltfll WiMS so small they appear tel be almost a nat line between ORS complexes.
Rgure 7 26. Cll'dkMnlm of alr1al flbrlllalion kJ sinus ItlyUlm; ):n:IIonaI escape beat (discussed ~ ~tar 8) Iollows 1118 initial slrus Ileat.
100
BOI7-6,
Atrial ftbrtllatlon: Identifying ECG features
Rllylllnt
~ossly
rliQula/)
AtrIal rate: 400 b9alsltr*lule or me; not measu'able on sur1acl! ECG
Venlr1C1.J1a" rale: Va1es with numbel' of mpulses
coooucted hough AV node to the WIlb1c1es (WI be
leSS InaIl the alrlal rate)
P_
:
mlgula' W3'II! def\eclions called nbrlllal:ory waws
~ waves) aftecUng de baseline
PR ~t.ml: Not meaualie
(IRS OOmpillC Hmnal (0.1 0 serond or leSS)
Raw:
TablI7-1.
U_ """""
...Nom.-...
lkJ'ab(1l.10
S&COIId or 1a5s)
In preceding T \YaWl
"n
"""m
W...seringlltrill
RegIA.OI' iTegular
Normal (60-100)01'
""""""
"""","
Premahxe aflat
"..,.,....
CClIWIC1ion \PAC)
-~""
premalul'll atrill
~-
'0'
PR
~lIml
---
Premalln P _e that is
atrJormai il sim. shape. 01'
di"ection; commonly kM1d il
preceding Twaw. distorting
....,PAC
(O.10S&COlldor
"",
Pmnalne: oonnll
-..,
""""""'" PM;
T-wave conbJr
ParmysmaI atill
t\lI::hyellrdi. (PAl)
"".w
140-250
Nom(O.10S&COlldor
"'"
.AnaI'utter
Atrial: 250-400
Sawtooth deleclioro .ffdlg
V1tieu11t: 'Ia'iII with entire IlIRMe
number of impulses
Not measu'able
Nom.
(O.10.teeOnd or
"'"
~fvoL9:1AV
Anal fibrillation
=_. . .
Gross/y~r
(unless wmicular
rate is rapid. in which
m~_
number of impulses
~fInIlqlAV
Nol meastl'able
""""
(O. IOsecoodor
"'"
102
Atrial arrhythmias
Pwave: _ _ __ _ _
ORS cornplell:_ _ _ _ _ __
Rhythm inlerp'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm inlerp'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Inrerwl:
103
Pwave: _ _ _ _ __
aIlS complelC' _ _ _ _ _ __
Rhythm interpmtallon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Interval:
Pwave: _ _ _ _ __
OAS complex:, _ _ _ _ __
Rhythm Interpretatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
~ythrnint~~~on :
Pwave: _ _ _ _ __
OAS complex:, _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
104
PR inleMl:
ORS complex;,_ _ _ _ __
FIlythm interpnlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR inllMVaI:
DRS complex:_ _ _ __
FIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Inte!val:
R".' ________
PW8'o'11: _ _ _ _ __
DRS cornpleJ::_ _ _ _ __
IIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ _~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
105
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ _~
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip7-11 . ~ythm :
_ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PH Int&rVai:
Pwave: _ _ _ _ __
QRS comple)(: _ _ _ _ _ _~
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
106
Atrial arrhythmillS
R"" _______
Pwave: _ _ _ _ __
ORS wmpieJ::,_ _ _ _ __
Rtlythm InterpRtation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ __
Pwave: _ _ _ _ __
PR ilterval:
QRS oompleJ::_ _ _ _ __
Rhyttlm Interptetaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
R"'" ________
Pwave: _ _ _ _ __
PR ilterval:
ORS compleJ::c_ _ _ _ __
RbyItm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strlp7-15Rfltthn: _ _ _ _ _ _ _ _ """ _ _ _ _ _ __
PR interwl:
107
Pwave: _ _ _ _ __
CIRS romplelC _ _ _ _ _ __
~I~~~ _ _ _- - - - - - - - - - - - - - - - - - - -
Pwave: _ _ _ _ __
I'fI inteN3l:
ORScompleic_ _ _ _ __
Rhythm IntlfP(etatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PlIiI1erval:
~~mOCn
Pwave: _ _ _ _ __
ORScompleic_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
108
Atrial arrhythmias
R"" _______
PwaYe: _ _ _ _ __
PR merval:
ORS cornpleJ.:_ _ _ _ __
Rllylhm Interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
R"'" ________
Pwave: _ _ _ _ _ __
PR i1terval:
ORS cornplex:_ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
109
ORScomp\el:,_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
110
Atrial arrhythmias
R'"' _ _ ______
PwaWl: _ _ _ _ __
Strip 7-24. AIIythm: _ _ _ _ _ _ _ __
PR marval:
ORS IXImplBx:_ _ _ _ __
Rllyttlm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaWl: _ _ _ _ __
ORS compleX:_ _ _ _ __
RhytIlm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
PwaWl: _ _ _ _ __
PR interval:
ORS complex:,_ _ _ _ _ __
Rbyttvn interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __
III
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11 2
Atrial arrhythmias
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS comple~ :- - - Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
113
QRS compleK: _ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
114
Atrial arrhythmias
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm interpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Pwave: _ _ _ _ _ __
11 5
QRS complex: _ _ _ _ _ __
Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
116
Atrial arrhythmias
PR marva!:
QRS cornplex:_ _ _ _ _ __
Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
QRS cornplell: _ _ _ _ _ __
Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
QRS cornplex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11 7
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PH Interval:
QRS compleK: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
118
Atrial arrhythmias
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
119
Pwave: _ _ _ _ __
QAS CompIBl: _ _ _ _ _ __
Rhythm interprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QAS complex:_ _ _ _ _ __
Rhythm InterprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QAS complex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
120
Atrial arrhythmias
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex:
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS cornplex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
121
PR interval:
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
122
Atrial arrhythmias
ORS complex: _ _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
123
Pwave: _ _ _ _ __
PR Interval:
QRS complex: _ _ _ _ _ _~
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ _~
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ _~
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
12 4
Atrial arrhythmias
QRS
Pwave: _ _ _ _ __
cornplex:_ _ _ _ _ __
Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS cornplex:_ _ _ _ __
Rhythm Interpretatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm Inlerpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
125
OKS complex: _ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
126
Atrial arrhythmias
Pwave: _ _ _ _ _ __
PA i1terva1:
QRS complex:_ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
127
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS compleK: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
128
Atrial arrhythmias
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
QRS complex:_ _ _ _ __
Rhythm inrerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
Pwave: _ _ _ _ _ __
complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
129
Pwave: _ _ _ _ __
PR interval:
QAS complsl: _ _ _ _ _ __
Rhythm intsrpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QAS complex:_ _ _ _ __
Rhythm interprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QAS complex:_ _ _ _ _ __
Rhythm Interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
13 0
Atrial arrhythmias
OIlS complex:_ _ _ _ _ __
Rhythm inlBrpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm Inierpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS cornplex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~
131
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
132
Atrial arrhythmias
13 3
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
13 4
Atrial arrhythmias
II Skillbuilder practice
This section contains mixed sinus and atrial rhythm strips, allowing the student to practice differentiating between
two rhythm groups before progressing 10 a new group. As before, analyze the rhythm strips using the five-step process.
i nterepret the rhythm by comparing the data collected with the ECC characteristics for each rhythm . All strips are lead II.
a positive lead. unless otherwise noted . Check your answers with the answer key in the appendix .
ORS C1IITIplex:_ _ _ _ __
Rhythm inlBrpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm Interprelamn:_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P wave: _ _ _ _ __
ORS complex: _ _ _ _ _ __
Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
135
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
136
Atrial arrhythmias
Pwave: _ _ _ _ _ __
PRinterval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Interval:
137
Pwave: _ _ _ _ _ __
QAS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QAS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Junctional arrhythmias
and AV blocks
Overview
The atrioventricular (AVl node is located in the lower
portion of the right atrium. The bundle of His conoects
the AV node to Ihe two bundle branches. Together, the AV
node and the bundle of His are called Ihe AV junction. The
AV node doesn't contain pocemaker cells. The main funelion of the AV node is to slow conduction 01 the electric.aJ
impulse through the AV node to allow the atria to contract
First-degree AV block
Second-degree AV block, MobilZ I
Second-degree AV block, Mobitz II
Third-degree AV block
Premature Junctional Contrilctlon
Junctional rhythm
AcceleraK'CI junctional rhythm
~J;:
' ~9
Junctional tachycardia
138
139
lGad II
Lead II
LGadIl
P wav" belIOT"
ORS complex
P wave anar
ORSoompa..
P wave IIlc1dGn In
OAS C<ImJIIe.
my."".
8018-1.
Fillure 8-4.
Rh,-lhm:
hidd~n
140
Figure 8-5. Normal sinus roythm with 0l1li Pl9lllabJrtI Junctional contmctlon (pJC).
RhyIIIm:
Basic rtr,1IVn regul; ~ with P.IC
Rift:
Basic rtr,1IVn rate 72 beatslmlrute
P W8U;
~us P waves wllI1 basic rflythm; merted P waYII alter PJC (4111 ORS CO!!IPIIlQ
PH ~ltml; 0.14 to 0.16 second (basic: rflythm); 0.06 to D.OS SIIIXIfId (PJC)
ORS comp...: 0.06 to 0.08 second (basic rIl:;1hm); 0.08 second (PJC)
comlll8n1;
AUwavelsJUSenl
Figure 8-S.
......
,'...
141
RlJure B-7. Normal sinus rhythm WIth two pramaturli atrtal contractions (PACs) (4th and 8th complaJ.as) and OIlQ Junctional
escape beat (5th complex)
Rhythm:
Regular (basic rhythm); Irregular with PACS and Junctional escape beat
Rate:
75 beatstmlnute (basic rhythm)
P waves:
Sl1us (basic rhythm); pointed P waves with PACS; Inverted P waves with Junctional escape beat
PR Interval: 0.14 second (basic rhythm); 0.12 second (PACs); 0.08 second gunctlonal escape beal)
DRS ~omplel: 0.08 to 0.10 second (basic rhythm. PACS.lIld):llctlonal escape beat).
Agure 8-8.
Rhythm:
Rata:
P waves:
PR Inmal:
QRS ' III npl&~ :
imbalances; h}llOxia: congestive heart failure: coronary artery disease: and enhanced automaticity of the AV
junction caused by digitalis toxicity (the most common
cause). PJes may also occur without apparent cause.
Frequent PJCs are best treated by correcting the underlying CaU5e: decreasing or eliminating the cOf15umption
of caffeine. alcohol. or tobacco; correcting electrolyte
imbalances: administering oxygen; treating congestive
heart failure; and assessing digitalis levels. Frequent PJes
(more than 61minute) may precede the development of a
more serious junctional arrhythmia such as junctional
tachycardia.
142
fi~ure
8-B.
Rhythm:
Aal.:
pause In the baSiC rtTfIhm. Aller sewral cycles tile rale \\llIlIlIUn to the basIC rate.)
Sinus P waws \\11th basic rhythm; hklllen P wwe with escape boat
PRlntlrva l: 0.16second
OAS complu: 0.06 second
COmment:
ST-segment depresslon!llG a UWiNe am present.
P Wav.l:
Junctional rhythm
Junctional rhythm (Figures 8-1 0 through 8- 1311nd Box 8-2)
is an arrhythmia originating in the AV junction with a rate
between 40 and 60 beats per minute. Junctional rhythm is
the normal rh}1hm of the AV junction. Junctional rhythm
can occur under either of the following conditions:
The heart rate of the dominant pacemaker (usually
the SA. node) bewmes less than the heart rate of the AV
junction.
lead II
Boll 8-2.
"""""
40 to 60 beats/mlnute
Inverted In lead II all(] OCCLl'S Immediately before
the ORS complex. Immediately alter the ORS
complex. or Is nkklen within tho QRS complex
Pfl lnllllrvat: Short (O.tO secood or less)
DRS complex: Normal (O.tO second or less)
PWlvn:
143
Atlythm:
Regular
Rata:
50
PW8WS:
PR Inl8rYal:
Not meastr.mle
beatsrm~ute
Atlythm:
Rata:
Regular
33 bealslmJlute
P waY8S:
nwrted alter QRS complex
PR 111WmII: 0.08 to 0.10 second
OAS complex: 0.08 to 0.10 second.
144
Regula'
35 beatslmll1Jle
P W3'l9S:
PH Intlrval:
BOI8-3.
Rhythm:
PW3'lH:
Regula'
65 beatslmlrute
Inverted before each ORS complex
P1Ilntlrval : 0.08100.10second
QRS oomplllx; 0.08 :illmlll
COmment:
ST-segment eleYatlon ~ Twavo Inversion am present
""".,
60 to 100 beats/minute
Inverted In lead II and occtn Immediately before
the ORS complex, immediately aner the ORS
complex, or Is hidden within the ORS complex
PH Interval: Sh:lrt (0.10 socond or less)
QRS complex; Normal (0.10 second or less)
Rate:
P wans:
145
inverted in lead II (a positive lead). and will occur immediately before or after the QRS or will be hidden within
the QRS complex. The PR interval is short (0 .1 0 second
or less). The QRS duration is normal. Accelerated junctional rhythm has the same characteristics as junctional
rhythm and junctional tachycardia. This rhythm is differentiated from the othu junctional rhythms by the heart
rate. Accelerated junctional rhythm is not a common
arrhythmia.
Accelerated junctional rhythm may result from enhanced
automaticity of theAV junction caused by digitalis toxicity
(the most common came). Other causes include damage
to the AV junction from MI (usually inferior-wall MI). heart
failure . lInd electrolyte imbalances.
Usually the heart rate associated with accelerated junctional rhythm isn't a problem became it corresponds to
thai of the sinus node (60 to 100 beats per minute) . Problems are more likely to occur from the loss of the atrial
kick secondary to retrograde depolarization of the atria,
resulting in a reduction in cardiac output. Treatment is
directed at reversing the COtl..'iequences of reduced cardiac
output. if present. as well as identifying and correcting the
underlying cause of the rhythm. All medications should be
reviewed and discontinued if indicated.
L" adll
8018-4,
",""
146
Regu~
115 beals'mlnute
Pwaves:
Inverted belore each CRS complex
Pfllntlrval: 0.08 second
QRS complll: 0.06 to 0.08 seCOl'Kl.
Junctionallachycardia may result from enhanced autoITUllicity of the AV junction caused by digitalis toxicity (the
most common cause). Olher causes include damage to the
AV junction from MI (usually inferior-wall MI ) and heart
failure.
Junctional tachycardia may lead to a decrease in cardiac
output related 10 the faster heart rate as well as the lo~
of the atrial kick s&ondary to retrograde depolarization
of the atria. Treatment is directed at re~rsing the consequences of reduced cardiac output. as well as identifying
and correcting the underlying cause of the rhythm. Symptomatic junctionol
tachy~~rdi~
AV heart blocks
The term heart block is used to describe arrhythmias in
which there is delayed conduction or failed conduction of
impulses through the AV node into the ~ntricles. Normally the AV node <lets as a bridge between the atria and
the ventricles. The PR interval is primilrily a measure of
conduction between the initial stimulation of the atria and
the initial stimulation of the ~ntricles. This measurement
First-degree AV block
In first-degree AV block (Figure 8-19 and Box 8-5), the
sinus impulse is normally conducted to the AV node.
where it's delayed longer than usual before being conducted to the ~ntricles. This delay in the AV node results
in a prolonged PR interval (> 0.20 second). This rhythm
is reflected on the ECG by a regular rhythm (both atrial
147
Regular
48 bRats/mtnute
P waY8s:
Sllus P waves presen~ one P wave to each ORS complex
Pfllnl8rYaI: 0.28 to 0.32 second (remains constant)
QRS complex: 0.08 to 0.10 second
Noll:
A U wave Is present.
Rata:
BoI8-5.
BOI 8-6.
Second~egree
Rhythm:
Rata :
P waY1lS :
PRlntervll:
Sllus
Rhythm:
Regular
ThaI 01 tho underlying slllls rhythm: both atrial
and vootrtculM rates will be tho same
P waves:
Sinus; one P w;Jo/e to each ORS complex
Pfl lnlerYaI:
Prolonged (> 0.20 second): remains consistent
QRS complex: Normal (0.10 second or less)
Rate:
ECG features
148
IIhrthm:
Rat.:
P WlI'Its:
PH Intlml:
IIhJlllm:
1Iat.:
AIr1aI: 75 beatslmlllJlB
Yenlrlcula': 60 beatslmlnuls
P Way":
Pause I
rhythm
pop rEgularity I.IlCh~Bd (P wave occurs on lime)
P wave conIlguratlon same as $1M beats
PR Interval 01 basic rtlythm YllteS
149
ISO
AlrIaI: 82 bealslmlllJlB
~n1r1cu1a': 41 beatslmnrte
p WIlY":
Two sinus P waves to each DRS complex
PH Intlrval: 0.16 SIIIXIIld (remains constant)
ORS complex: 0.1 4 second.
Box"1.
Second-degree AV block (Mobttz II): Identifying
ECG 1eabues
Rht1hm:
AtrIal: Regular
YIIlIrlcuIa': l8uaIy ~ IU: may bllrri9JlIIr "
AY~u~m~vru)
Rale:
cw- blless
P WI\IM:
PR IntlrYaI:
DRS compleX:
lSI
limits (rare). the patient may be asymptomatic. More commonly. the ventricular rate is extremely slow, cardiac output is decreased. and symptoms are present (hypotension.
shortness of breath. heart failure. chest pain. or syncope).
The syncopal episodes (called Slokes-Adams attacks or
Stokes-Adams syncope) are caused by a sudden slowing or
stopping of the heartbeat.
Mobilz II is less common but more serious than Mobitz I.
Mobitz II has the potential to progress suddenly to thirddegree AV block or ventricular standstill (asystole) with
Rgufll 8-26. Mobltz 1. This strtp shows a typical Weockebach pattern durtng the nrst part of the strtp changing to a 2:1
oonduclJon rallo alllM! and ofllM! strtp. Evon though 2:1 conducllon Is saan (common wllh MobltZ II), 1119 prasallCQ 01 a Wanckabach
pattern conllrms tIM! diagnosis 01 Mobltz I.
Rhythm :
Atrial (regular); ventricular (Irregular)
Rate:
Atrial (100 beatstmlnute); ventriculii' (60 bealstmlnute)
P wallS:
Sl1us
Pfllnl9rYaI: ProgesslYely lengthens from 0.24 to 0.36 second
DRS complOJ : 0.06 to 0.08 socond.
152
Bo18-8,
Atrial: Regular
Ventricular: Regular
Rate:
Atrial: That oIlhe lIIderlyPJ sinus rhythm
Ventricular: 40 to 60 beatstmlnute 1/ paced by AV
IlllCtlon; 30 to 40 beatstmlnute (or less)" paced by
ventricles; will be less than the atrial rate
P waves:
Sl'lus P waves wl1I1 no constant relaUOOshlp to 1I1e
CAS complex; P waves can be lound hidden In CRS
complexes, ST segments, and T waves
PR Inl8rYaI: Varies greaUy
QRS complex: Normal II block located at level 01 AV node arbul'ldle
01 His; wide K block located at lev&! 01 bundle
""'m
"hidden" P waves can be found by measuring the regularity of the atrial rhythm (the pop interval). The PR intervals ilre completely variable. Both the iltrial rhythm and
the ventricular rhythm are usually regular. The width of
the QRS complex and the ventricular rate reflect the location of the blockage. If the block is at the level of the AV
node or bundle of His. the QRS complex will be narrow and
the ventricular rate will be betwn 40 and 60 beats per
minute. If the blockage is in the bundle branches. the QRS
complel "'ill be wide and the ventricular rate much slower
(40 beats per minute or less). Generally, complete heart
block with ",ide QRS complexes tends to be less stable than
complete heart block with narrow QRS complexes.
Complete heart block associated with inferior-wall MI
is usually a result of a block at the level of the AV node
or bundle of His. The rhythm is usually stable ilnd the
153
Rhythm :
P wawI:
snus P WaYeS present (bear no coos1art relatloosh~ to ORS complexes; found hidden ., QRS cornplroBs aJKI T waves)
ventr icles a re paced by a junctional pacemaker with narrow QRS compl exes and a ventricular rate of 40 to 60
!>fau per minute. Third -deg ree AV block associated with
an inferior-wall MI often resolves on iu own. Complete
heart block associated with an anterio r-wall MI is usu ally a result of a blod .... ithin the bundle branches. The
rhythm is usually unstable and the ventricles are paced
by a ventricular pacemaker with wide QRS compteJIes
and a ventricular rate of 40 !>fats per minute or less_
Third-degree AV block a5S0ciated with an anterior MI
often does not resolve on its own and may require permanent pacing. Complete heart block can al50!>f seen in
older patients who h,we chronic degene rat ive changes in
their conduction system not related to acute Mi. It h;u
also been reported with Lyme disease. Complete heart
block may occur with digitalis toxicity.
The patient's response: to complete heart block is usually related to the ventricular rale. I(the ventricular rale is
within normal limits. the patient may be relatively a5)'1llPlomatic with minor symptoms such as weakness, fatigue,
dizziness. or I!l(ercise intolerance. More commonly, theventricuJar rate is extremely slow, cardiac output is decreased,
and symptoms are present (hypotension. dyspnea. heart
failure, chest pain, or SIokes-Adams s~cope).
Regardless of its cause, complete hear! block is a serious
and potentially life-threatening arrhythmia. Third-degree
AVblock. like Mobitz II. can quickly progress to ven tricular
standstill (asystole) with little or 00 warning. Treatment is
required immediately for symptomatic third-degree heart
block and for iU)'Illptomatic third-degree heart block with
wide QRS complexes in the ~tting of acute anterior-wall
MI. An external pacemaker should be applied while preparations are made for in~rtion of a temporary lTansvenous
""0
154
Table B-1.
AV block comparisons
Pft constant
(Rrst-tgrH)
PH constant
PR _ _
PR varies
155
Talll, S-l.
..
""""
jun:tional
cmtraction
eJCI
JlIICtionai
""""
kcelerated
jun:tional
Rh,II'"
Rata (bIIatstrnlnutl)
PIIlntlnai
QRS compIeJ
Basic rhythm
usually regular;
ilTl9lla- with
PJC
0.10second er less
Premalure CfIS
complex;
."""
.,.60
....,.
6010100
""""
JlIICtionai
tachyc3"dia
".-
First-degree
atriownlricuar
Second-degree
."""
."""
,100
~,
....,
Ikration
(0.10 second
'=1
'=1
'=1
Prolonged (more
than 0.20 second);
remaillll consislllnt
Varies; progressively
lengthens lI"Itil a P
wave isn'l corducIed
(P wave occurs
wilhout the DRS
complex); a pausa
follows the d'opped
DRS complex
-,
Sinus orIgn
Second-degree
Atrial: reguar
VelllricUar. usually regular. but
may be ilTl9llar
~ conduction
ratios vary
Normal or prolonged;
mmains consistmt
Atrial: reguar
Venlricuar.
Varies~1Iy
AV_
MoI!itz II
Third-rIewM
AVbIocl<
(0.10 seo:nd or
"')
""""
(O.IOseconder
'=1
N~'
(O.IOseconder
"'I
N~'
(O.IOseconder
"')
A~
AUlal: regual
Venlricuar:
ilTl9lla-
AV_
",--
N~'
(0.10 second er
"'I
.....
Nmnal n tkd<.
Iuda ollis;
wide n tm:k in
............
Normal if block
allewl of AV
_A
block in buncle
1 56
Measure PR in/errol.
Measu re QRS complex.
Interpret the rhythm by compnrinll this data wit h the
ECC characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unln!; otherwise noted. Check your
ansVt'ers with the ansl'>'e r keys in the appendix.
Pwave: _ _ _ _ __
PR inteNal:
QRS complex:'_ _ _ _ _ __
interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ythm
Pwave: _ _ _ _ _ __
PR inteNal:
DRS complex:, _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
157
QRS caTIplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QAS complex:_ _ _ _ __
imerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
158
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR inleNaI:
Pwave: _ _ _ _ _ __
ORS oornplex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
Pwave: _ _ _ _ _ __
complex:_ _ _ _ _ __
Rhythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
159
Pwave: _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
OR5 complex: _ _ _ _ __
Rhythm interprellllion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
160
161
P wave: __________
________________________________________________
Pwave: _ _ _ _ __
Rhyttvn Intikpt8tatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pflinterval:
Rh~i~~~tio~
Pwave: __________
ORScomplelC,_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
16 2
PR ilterval:
R..." _ _ _ _ _ _ __
ORS complex;,_ _ _ __
PwaVII: _ _ _ _ _ __
Rhythm Interpr.tafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR marval:
PwaVII: _ _ _ _ _ __
ORS cornpleJ::_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
163
Pwave: _ _ _ _ __
PA interval:
ORS complex: _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PA interval:
PWdve: _ _ _ _ _ __
OAS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
164
FI"" _______
Pwa...e: _ _ _ _ __
PR i1teMi:
DRS oornplex:_ _ _ _ __
RllyIflm lilIeiPi8taOO'l:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa...e: _ _ _ _ _ __
PR i1tervai:
QRS romple.l:_ _ _ _ __
RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
165
Pwa'0'8: _ _ _ _ __
OftScomplex:,_ _ _ _ __
Rhythm IntllfJlfItatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa'0'8: _ _ _ _ __
Pft lnterval:
ORScomple:X:'_ _ _ _ __
Rhyttvn int8lp(8lation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa'0'8: _ _ _ _ __
OftScomplelC _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
166
Pfllnterval:
QRScomplo:_ _ _ _ __
FIIy1hm 1IIIIIfPf1Ution: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR merYal:
R~in~Om :'
ORS complex:- - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
167
PWS9: _ _ _ __
Pflinterval:
ORScomplu:_ _ _ _ _ __
Rhythm inI8qlfltation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
16 8
Pwave: _ _ _ __
PR iltBfWII:
ORS complex:' _ _ _ _ _ __
Rhythm InterpretaliGn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:, _ _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
QRS complex:' _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
169
Strip 8-40.lIlythm: _ _ _ _ _ _ _ _ _
_ _ _ _ _ __
Pwave: _ _ _ _ __
PfI interval:
ORScomplex:_ _ _ _ __
RhydvnlntMpretatiol1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Pflinterval:
ORScomplex:_ _ _ _ _ __
RIythm intMpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
170
Pwa~
_______
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwsve: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ __
RIryIhm Interpretaton:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
17 1
Pwave: _ _ _ __
PR interval:
QAS complex:.~_ _ _ __
Rhyttrn Int8fJ)retation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR int&Mi:
Pwave: _ _ _ __
QAScomplex:~_ _ _ __
RhyttrnintMFetaOOn _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P _: _ - - - - -
QAS complex:~_ _ _ __
FV!yttJn i!1ef)1retation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
172
QRS complex:_ _ _ _ _ __
Rhythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PA interval:
QRS cornplex:_ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval :
QRS complex:
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
173
Pwave: _ _ _ _ __
PR interval:
ORS cOOlplex:_ _ _ _ _ __
Rhythm interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interpreiation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
174
PR interwi:
Pwave: _ _ _ _ _ __
QAS comptex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
QRS
cornplex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
QRS
Pwave: _ _ _ _ _ __
complex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~
Pft Int&lVal:
~ i m~M~o~
Pwave: _ _ _ _ __
OOScomplex:,_ _ _ _ __
_ _ _ __ _ _ _ _ __ _ _ _ __ _ _ _ _ _ _ _ __
Pft interval:
17 5
_ _ __
_ __
_ _ _ __
Pwave: _ _ _ _ __
OOScomplex: _ _ _ _ __
Rhyttrn InteqJfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
OOScomplex:_ _ _ _ _ __
~ i nt~o ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pft interval:
176
PwaYe: _ _ _ _ __
PA Ilterval:
ORS complex:_ _ _ _ __
Rhyttvn interpretati:ln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa"": _ _ _ _ _ __
Rhythm Interpret1l.tJJn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa"": _______
PA ilterval:
ORS complex:,- - - RllytlIm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
177
PwaYe: _ _ _ _ __
ORScanplelt _ _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaYe: _ _ _ __
PI! intervai:
ORScomplex:_ _ _ _ __
Rhythm Inteq>retatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplelC _ _ _ _ _ __
RIythm inteqlfetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
178
_ _ _ _ _ _ __
Pwali8: _ _ _ _ __
PR iltsrva!:
ORS wmplex:,_ _ _ _ __
Rllythm Inlerpfetatk:m:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
R"" _______
PWSIi8: _ _ _ _ __
PR merva!:
ORS wmplex:_ _ _ _ __
Rllylhm Interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwali8: _ _ _ _ _ __
QRS cornple.l:_ _ _ _ __
RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11ft Interval:
~I~~boo~
M~~~M~
Pwave: __________
OftScomplex:,_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
PH imervaJ:
179
Pwa'o'e: __________
ORScomplex: __________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa'o'e: __________
ORScomplelC _ _ _ _ _ __
~im~ort _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11ft interval:
180
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
Rbythm Irrlerpntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Strip 8-73. Rhythm: _ _ _ _ _ _ _ _ """ _ _ _ _ _ __
fIR merva!:
ORS cornplex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
181
Pwave: _ _ _ __
PR interval:
ORScomplu: _ _ _ _ __
Rhythm lnttrpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
~imMFmaOOn
Pwave: _ _ _ _ __
ORS complex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaYe: _ _ _ _ __
PR interm:
ORS complex: _ _ _ _ __
Rhythm imef)lretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
182
fIR Interval:
Pwave: _ _ _ _ __
ORS complex:,_ _ _ _ __
RIryttJn Inlftipietatklll:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
Rlrythm Interpretalbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR i1terval:
_ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS complex:
Rbythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Rh ythm strip prac tice: Jun cti onal urThrthmins and AVblocks
PR interval:
~I~~e~oo~
183
Pwave: _ _ _ _ __
ORScanplelC_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR Interval:
ORScomplex: _ _ _ _ __
Rhy1h'n InIMprBlalio~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip 8-83.
~:
_ _ _ _ _ _ _ _ _ I.." _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR illerval:
ORS complex: _ _ _ _ __
Rhythmi,leijHetalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
184
_ _ _ _ _ __
Pwave: _ _ _ _ __
PR klterval:
ORS Ctlmplel:_ _ _ _ __
Rhythm InWrpfeIatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
R.'" ________
Pwave: _ _ _ _ _ __
ORS Ctlmplex:_ _ _ _ __
Rhythm int&rpfetatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
R.,,, ________
Pwave: _ _ _ _ __
ORS cornplex:_ _ _ _ __
RIryttvn interpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
185
Pweve: _ _ _ __
PRinterval:
ORScompielC_ _ _ _ _ __
Rhythm InteJpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PfI intimal:
ORScompleX: _ _ _ _ __
Rhyttrn Inleqwetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORScomplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
186
Pwave: _ _ _ _ __
PR ilhIrvai:
ORS oomplu:_ _ _ _ __
RlIyttlm Interpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR i1terval:
ORS oompleJ::_ _ _ _ __
Rllythm Interpfltation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR iltervai:
ORS complex:,_ _ _ _ __
Rbyttlm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
187
ORS complex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Pwa'o'e: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
188
Pwaw: _ _ _ _ _ __
PR interval:
ORS oornplex:,_ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
IUl)'lhm siril' prllctice: Juncti o nlll IIrTh )'1 hmius Ilnd AV blocks
Stripl-n.lllyttlm: _ _ __ __ _ _ _ _
PfI irftMII:
~~.On
_ __ __
_ __
189
Pwaw: _ __ __
QRS c:ompIa:,_ _ _ __
___ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ __
PfI intelVll:
~m~e~
________________________________________
PfI irtemf:
~m~mon
Pwave: _ _ _ _ __
OOScomplu: _ _ _ _ __
____________
Pwaw: _________
QRS compIIx:,_ _ __ __
___ _ _ _ _ _ __ __ _ _ _ _ __ _ _ _
190
IE Skillbuilder practice
This section contains mixed sinus, atrial, andjunctiollal and AV block rhythm strips, allowing the student to practice differentiating betv.~en two rIlythm groups before progressing to a new group. As ~fore, analyze the rIlythm strips using the
five-step process. Interpret the rhythm by comparing the data collected with the ECG characteristics for each rhyt hm. All
strips are lead II. a positive lead. unleu otherwise noted. Check ~r answers with the lInswer key in the appendix.
_______
PR InteMt:
~im~M
""< ________
__________________________________________
PR imenal:
R~m~~~ :
p~~ ------
ORS complelC _ _ _ _ __
Pwa~ :
_______
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Sbip8-104. lI1ythm: _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ __
PR klIerval::
ORS complex:,_ _ _ _ __
191
Pwave: _ _ _ _ __
la'lythm I!terpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ __
ORS complex:, _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa..,,: _ _ _ _ __
PR interval:
OftScomplelC _ _ _ _ _ __
Rhythm intefp-etatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
192
Pwave: _________
_______________________________________
Pwave: _________
Strip 8-108. FVlythm:_______________ "". ____________
PR iltBrYai:
ORScompiex:,_ _ _ _ __
Itlythm klterpretatkln''---_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR i1terval:
ORS romplex:,- - - IIIythm metpretatiJn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
StripB-110.lt1yttIm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __
PR Interval:
~~~ti~
~~~~allin
PwaVII: _ _ _ _ __
OftScomplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
193
PwaVII: _ _ _ _ __
OftSccmplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
StripB-112.fVlythm: _ _ _ _ _ _ _ _ _ ..,, _ _ _ _ _ _ __
PwaVII: _ _ _ _ __
PR interval:
OftScomplelC_ _ _ _ _ __
Rhythm intefp'etatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
194
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm inlerprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
OIlS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
OIlS cornplex:_ _ _ _ _ __
Rhythm inlerprBlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
195
Pwave: _ _ _ _ __
QRS complelt _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
196
Pft Interval:
~m~5moo :'
ORS complu::_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Pft interwl:
P wave: _ _ _ _ __
P wave: ___________
ORS cornplex:___________
~~ "-------------------
Ventricular arrhythmias
and bundle-branch
block
Overview
The three preding thapters have focused on $/Jprove/lIrieu/ar arrhythmias. Supraventricular arrhythmias
nofer to those: rhythms that originate a~ the bundle
branches and include the sinus, atTial. and junctional
rhythms. The electrical impulse: produced by supraventricular rhythms follows the normal conduction p.athway.
resulting in simultaneous depolarization of the right
Bundle-branch block
the intravr ntricular conduction system consists of the
right bundle branch Bnd the left main bundle branch, which
diVides into two fascicles: an anterior fascicle and a posterior
fucicle. Block may ()(:cur in any part of this conduction
system. Normally, the electrical impulses travel through
kIoo.t<""*<I.d ...
'O'X ....~II
197
198
the right bundle branch and the left bundle branch and its
fascicles at the same time, caming simultaneous depolarization of the right and left ventricles, resulting in normal
depolarization and a QRS duration of 0.10 second or less.
'Nhen one of the bundle branches is blocked. the electrical
impulse trilVels down the intact bundle. depolarizing that
wntricJe first, then the impulse progresses through the
interventricular septum to depolarize the othu ventricle.
Depolarization of one ventricle before the other is called
sequential depolarization. Depolarization of the ventricles is dela~d. resulting in a wide QRS complex of 0.12
second or greater. The presence of a bundle-branch block
(Figures 9-2 through 9-4 and Box 9-1 ) can be recognized
Box 9-1 .
Regular
lhal oIlhe underlying r11ythm (Usually sinus)
P WIY8S:
Sinus
PI! InllllrYaI: Normal (0.12 to 0.20 socond)
QRS complex: Wkle (0.12 second or grealer)
FIgure 9- Z.
Rhythm:
Ratl:
Figure 9-3.
Rhythm:
Rail:
Regula'"
75 beatslmlllJle
Sinus P waves are notched, which coold Indicate len atrial enla'"gemenl.
PIIlntlrval: 0.14toO.16second
QRS complu: 0.12 second
COmment:
A notched QRS cumplex Is a common pattern wm1 rtght blJldle-brMCll block.
P waY,S:
199
Rgure U .
Rhythm:
Rata:
Fillure 9-5.
Rhythm:
Ratl:
P W3Y8S :
PR Interva t.
IlRS complex:
COmment
200
Figure 1-&. SIIlIIS P waves occulTIng belora and aflllt' premature YIIntJ1cular contractions (PVCs).
The snus P waves of lIle tn:Ie~ytng mythm CIrl be seen Just belOl'8 the PVC ., example A Md aIt9r Iha PVC In 'tie ST saornenlln IIKllmple B. These P waves are assocIattld with the
tnIer1yI~
20 I
Agure 9-9.
QoJad~gemNi
202
Th~ paus~ associatd with th~ PVC is usually compensatory (th~ m~asur~ment from the ~at before the PVC to
the ~at after the PVC is equal to two R-R intervals of th~
underlying rhythm, Figure 9-5). The underlying rhythm
must be regular to determine a compensatory pause.
PVCs may occur in various patterns. They may appear
as a single beat (Figure 9-5), every other ~at (bigeminal
pattern. Figure 9-7), every third beat (trigeminal pattern,
Figure 9-8), every fourth beat (quadrigeminal pattern,
Figure 9-9), in pairs (also called COllplets, Figure 9-10), or
Box 9-2.
203
204
Ventricular tachycardia
8019-3.
Ventricular tachycardia (VT): Identifying
ECG features
Rhythm:
Rate:
Pwaves:
PR Interval:
QRS complel:
~eaI9f')
None klentilled
Not m98SU'abl9
Figure 9-11.
Rhythm:
Ratl:
P waves:
PR IntIM I:
QRS complu:
COmment:
ventrICular nunaf.
Regula'
375 beats/minute
Nol seen
Not meastJ'able
0.12 to 0.14 second
Yenlr1cula' nutter Is a lorm 01 ventricular tachycardia. The ventricular rate Is so last the ORS complexes have a sawtooth
appearance.
Ve ntricular tachycardia
205
Not measurable
ORS complex: 0.08 to 0.10 second (basic rhythm); 0.12 second (VI).
comment:
FIgure 9-20.
This type 01 ventriculii' lachycardla Is called torsad9 d6 poIntes (tn'lslhg oltho points). The DRS chalges !rom negative to
posttl8 polarity .nI appears to twist around the Isoeleclrlc 100.11 Is assoclaled wllh a prolonged OT Interval.nlls relraclory
to anDarrhylhmlcs.1V magnesium or overdrtve pacing has been successlUl ~ Ihetreatment ollhls rhythm.
206
Ventricular fibrillation
and positive to negative) as it twists around the isoelectric line. TdP is an intermediary arrhythmia between VT
and VF.
TdP typically occurs when the QT interval of the underlying rhythm is abnormally prolonged, usually 0.5 second
or greater. A prolonged QT interval or long QT syndrome
(LQTS) is an abnormality of the hearfs electrical system.
Although the mechanical function of the heart is entirely
normal. the electrical problem is thought to be caused by
changes in the cardiac ion channels that affect repolaril.ation, causing a lengthened relative refractory period (vulnerable period) that puts the Vl:ntrides at risk for TdP and
may result in sudden death.
Some causes of TdP VT include bradyarrhythmias
(marked sinus bradycardia. third-degree AV block with a
slow ventricular response): excessive administration of
antiarrhythmics (quinidine, procainamide. disopyramide.
amiodarone, soblol): phenothiazines (prochlorperazine,
chloropromazine, thioridazine); psychotropic medications (haloperidol, amitriptyline): electrolyte imbalances
(especially hypokalemia, hypomagnesemia, hypocalcemia); liquid protein diets; central nervous system disorders
(subarachnoid hemorrhage or intracranial trauma); and
congenital LQTS.
The ventricular rate in TdP VT is extremely rapid and
the patient usually becomes unstable very quickly. Recognition of TdP is critical not only because of the rapid
deterioration of the patient but also because the treatment
plan differs greatly from the treatment of monomorphic
VT. Amiodarone, a drug used in treating monomorphic VT,
can prolong the QT interval and make matters worse in
this situation.
207
Ventricular fibrillation
In ventricular fibrillation (VF) (Figures 9-21 and 9-22
ilIld Box 9-4) a disorganized, chaotic, electrical focus in
the ventrides takes over control of the heart. Organized
ventricular depolarization and contraction do not occur
(there is no QRS complex), but instead the wntricular
muscle quivers and is often described as resembling a "bag
of worms. The ECG in VF shows characteristic fibrillatory
waves that vary in shape and amplitude in an irregular and
chaotic pattern.
VF with large amplitude waves is called coarse J1F
(Figure 9-21). If the VF waves are small, the rhythm is
called line ]IF (Figure 9-22). Coarse VF waves are generally more irregular than fine VF waves. Fine VF may
resemble ventricular asystole and should be confirmed
by eJt1lmining the rhythm in different leads. The distinction between fine VF and coarse VF is significant because
coarse VF usually indicates a more recent onset and is
more likely to be reversed by early defibrillation. Fine
VF usually indicates that the rhythm has been present
longer and may require drug therapy and cardiopulmonary resuscitation (CPR) before defibrillation can be
effective. Fine VF will progress to asystole unless the
rhythm is treated.
8019-4.
208
Treatment protocols: VF
Check the pulse 8nd rapid ly IIMUS the patient. If there is
a pulse and the patient is conscious. VF im't the proble m.
ECG artifacts produced by loose or dry electrodes. patient
mOllement, or muscle tremors may resemble VF.
If there is 00 pulse and the patient is unconscious, defibrillate al 200 joules biphasic energy dose. If the 8rrest is
unwitnessed. perform CPR for 5 cycles (2 minutes) before
the ini tial shock.
P WlYas:
Absent; wave deftectlons are chaollc and vary ., size, shape, a-1CIl\elght
Plllntirval: Not meastnble
ORS complex: Absent.
l dioventricular rhythm
Figure 9-2J,
Rhythm :
Rata:
P W3Y8S:
PfI Interval:
Not measurable
DRS complex: 0,22 to 0,24 second,
209
ldioventricular rhythm
Idioventricular rhythm (IVR ) (Figure 9-23 and Box 9-5) is Il
very slow rhythm originating from a focus in the ventricles
"t " rate of 30 to 40 beats per minutes (sometime. less),
Because the impulse originates in the ventricles, there is
no P wave and the QRS complex is wide, The rhythm is
usually regular, IVR is the normal rhythm of the ventricles,
NR can occur under either ofthe following conditions:
The heart rate of the dominant pacemaker (usually the
sinus node) and the backup pacemaker (usually the AV
junction) becomes less than the heart rate of the ventricles,
The electrical impulses from the sinus node, the atria,
or the AV junction fail to reach the ventricles because of
sinus arrest, sinus exit block, or third-degree AV block.
If the ventricles are not adivated by the sinus node, the
atria, or theAV junction, a focus in the ventricles can "escape"
and pace the ventricles, For this reason, NR is also called
ventricular escape rhythm, NR may occur in short runs of
3 or more consecutive ventricular beats at a rate of 30 to 40
beats per minute and is usually related to increased vagal
effect on the higher pacing centers controlling the heart
rhythm, Treatment is usually unnecessary, Continuous NR
usually occurs in advanced heart disease and is commonly
Box 9-5,
Regular
30 to 40 beats/mlnute (someUmes less)
Absent
PfllntllYai:
Nol measurable
(0,12 second or greater)
210
Nol moasurable
beats per minute, but isn't fast enough to be Vr. AIVR has
the same ECG charucteristics as NR (no P waws. wide QRS
complex. regular rhythm ), but is differentiated by the heart
rate. AIVR can occur as a continuous rh}thm (Figure 9-25 )
or in short runs of 3 or more consecutive ventricular beats
at a rate of 50 to 100 beats per minute (Figure 9-26).
AIVR is common after acute inferior-wall MI and is frequentlya reperfusion rhythm following thrombolytic therapy. angioplasty. or spontaneous reperfusion. AIVR may
also be seen with digitalis toxicity.
AIVR is usually well tolerated and is rarely associated
with symptoms. If the patient is symptomatic. it is usually related to a decrease in cardiac output from a loss of
the atrial kick and not because of the heart rate. which is
within a normal range.
Treatment of AIVR with antiarrhythmics is not recommended. Abolishing the wntricular focus may lead to
a less desirable rate and rhythm. This rhythm is usually
tramient, requires no specific therapy. and spontam:ously
21t
Figure 1-2&. Nanna! sinus rtlyttlm WItt1 episode 01 accelerated kIIo8f1trlctJlar rtlythm (lJYR).
BasIc: rhy'lhm regular; AIVR basIcaIy IlI\IUlar (011 by 2 SQIJI'nSl
Rhythm:
RIte::
p
PAl"."...:
0.12t10.16sean:1
wa_
ORS complu: 0.0611 0.08 sec:md (basi: fIlyt!lm); 0.12 S8C(III(I WVI\I.
1019-6.
Rate:
Pwa_
PR IntarYaI:
QRS complft:
SO to 100 bIJalW'mDlte
Absenl
Hot mallSllllble
Wloe (0.12 saxnI 01' l1oa1er)
isch~mia or infarction). hypoxia. hyperkalemia. hypokalemia. hypothermia. drug overdose. and advanced heart
block. Cardiac trauma may also be a contributing factor.
Once ventricular standstill occurs. there is no cardiac
output. peripheral pul!-eS and blood pressure are ~nt,
"nd the ""Iienl hr.<:ornl"-' "nc(m~im.. ;mmedillj"ly.
Cyanosis and seizure IICtivity may IIbo be prtsent. Death
is imminent unless the arrh)(hmia is treated immediately.
Without cardiac monitoring. ~1!ntricuklr standstill cannot
be distinguished from VF at the bedside.
PR 1ntIn"1I:
ORS complex:
""-
""'"
212
figure 9-21. Normal sinus rflythm with one premature atr1al contraction changing to ventricular standstill.
Rhythm:
Basic rhythm regulM
Rail:
Basic rhythm 100 beaWmlnute
P wIVes:
Sinus P waves am present
PR lnten"al: 0.16 to 0.18 second (basic rhythm)
QRS complllJ:: 0.06 second (basic rhythm).
9) MI
Rail:
Pwans:
Table 9-1 .
...
..
,, ~
Rhythm
Rate (beals/minute)
PR Interval
DRS complH
Bundle-brarch
Reguar
That oIl1111er1yjng
rIrfIIm (usualy silllS)
Sinus origin
"
-..
ventricuar
"""'''"'
(I'Iq
Vmlricular
(0.12 second or
grcotcr)
Basic rhythm
usually rl9llar,
imlguar with
That oIlJ1der1ying
rIrftIm (usualy silllS)
PIC
Not measurable
Not measurable
PrematlR ORS
complex; abnormal
shape; wide
(0.12 second or
greater)
..
..."
"
Reguar (can be
sl911iy irregular)
140 to 250
Absm~
Not measurable
Idiovenlricuar
rf1yIhm (IVR)
Reguar
30 to 40 (sometimes
..."
"'-""' "
kcelerated IVR
Reguar
tachyC3"dia
(VT)
Vmlricular
fibrilation (VF)
-,
(0.12 second or
greater)
I~I
50 to 100
..
"..
..."
(0.12 second or
greater)
..."
Not measurable
(0.12 second or
greater)
Vmlricular
slaldstil
(YenIriruar
_I
AIriaI: ffPWlIYeS
present, wil hal'll
allial rhythm
Ventriwlar: None
Allial: if P waYeS
present. wil hal'll
allial rate
Ventricular: None
213
Not measurable
2 14
MeasurePRinterval.
Measure QRS complex.
Interpret the rhythm by comparing this data with the
ECG characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unless otherwise noted . Check your
ansVt-el'5 with the answer keys in the appendix.
Pweve: _ _ _ _ _ __
ORS oornplex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS cornplex:_ _ _ _ __
Rhythm interp-atalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
21 5
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ _ __
Rhyttvn interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhyttvn interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2 16
PR interval:
Pwave: _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR InlerYal:
DRS complex:' _ __ _ _ __
lIlythm inlerpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ _ __
DRS cornplex:, _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
217
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2 18
ORS oomplex:_ _ _ _ _ __
Rhythm inl&rpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PFI interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
219
CRS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
CRS complel: _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
220
Pwave: _ _ _ _ __
PR interval:
QRS complex:- - - Rhythm interpretamn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS rompleI:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR Interval:
QRS romplex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
221
Pwave: _ _ _ _ __
QRS complelC _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
222
Slrip9-25_RhyIhm: _ _ _ _ _ _ _ _ _ _ PR 1n1&Mll:
, _ _ _ _ _ _ _ _ PwaY8: _ _ _ _ __
ORS c:omplex:_ _ _ _ __
"""m'_'____________________
R"" _______
Pwave: _ _ _ _ __
R"""'_ -'____________________
PR Interval:
ORS cornplex:_ _ _ _ __
R"" ________
Strip 9-27_Rhythm: _ _ _ _ _ _ _ _ _
PR Interval:
ORS c:omplex:,_ _ _ _ __
Pwave: _ _ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
223
Pwave: _ _ _ _ __
PR intenai:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
224
PR interval:
ORS COOlplex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
OIlS complex:_ _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ _ __
ORS wrnplelC:_ _ _ _ _ __
Rhythm interpretali:Jn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
22 5
Pwave: _ _ _ _ __
PR intElV3i:
QRS complelC _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
226
PR Interval:
Pwava: _ _ _ _ __
aAS cornplex: _ _ _ _ __
Rhythm imerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
22 7
Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
228
QRS complex:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
229
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Interval:
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
230
Pwave: _ _ _ _ _ __
PH ilterval:
QRS complex:
Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
23 1
Pwave: _ _ _ _ __
PR intemil:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
232
Pwave: _ _ _ _ _ __
QRS oomplex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
233
"I'-t-+++-t+lb-HHI-t-++++-'l'-H--f4t-+-+-lI+
' j!-H-tl I
~ rnu"I.'~' ~
1 ~ututut~~U;~~1
strip 9-58_ 1IlyIhm: _ _ _ _ _ _ _ _ ..'" _ _ _ _ _ __
Pwaw: _ _ _ _ __
11ft interval:_ _ _ _ _ _ _ _ OftScomplex:_ _ _ __
RhyIhm Int8fJ)fetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwaw: _ _ _ __
ORS complex:_ _ _ _ __
Rhyttvnlnteqmatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ __
PwaYe: _ _ _ _ __
ORS complex: _ _ _ _ __
Rly1hm inleqlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
234
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS oornplex:_ _ _ _ __
Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PwaYII: _ _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerprellRion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
23 5
PR inteMlI:
QRS ComplelC _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
QAS ClIl1plex:_ _ _ _ __
Rhythm inlerpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
236
;;
OIlS complex:_ _ _ _ _ __
Rhythm inierpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwaw: _______
OIlS cornplex:_ _ _ _ __
Rhythm inlerpretalm:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa~ :
_______
OIlS complex:_ _ _ _ _ __
RhythminbMpretation :' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
237
ORS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
ORS complex: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
238
PR interval:
ORS complex:
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
'm" ________
Pwave: _ _ _ _ __
DRS complex:_ _ _ _ __
Rhythm interpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
239
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interwi:
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
24 0
PR interval:
DRS complex:_ _ _ _ _ __
Rhythm inrerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR iltervaI:
Pwave: _ _ _ _ _ __
DRS cornplex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS cornplex:_ _ _ _ _ __
Rhythm inrerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
241
PR interYai:
QRS complex: _ _ _ _ _ _~
Rhythm inlerpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~
PR intaMI:
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ __
Rhythm inlerpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interYai:
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ _~
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
242
PR interval:
QRS complex:- -Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR ilterval:
Pwave: _ _ _ _ _ __
oomplex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
PR inieNal:
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm inlerpretaliDfl: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
243
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
PR inteNaI:
Rh~i~e~remtioo :
QRS complex:_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
2 44
QRS complex:_ _ _ _ __
Rhythm Inl&rpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
DRS complex:_ _ _ _ __
Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
245
Pwave: _ _ _ __
ORS Cmlplex:_ _ _ _ _ __
Rhytlvn interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Interval:
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QAS curnpleJr.:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
246
ORS cornplex:_ _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Am" _ _ _ _ _ _ __ Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS cornplex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2 47
PR irterwi:
fI1ythmme~e~
ORS complex:, _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
248
II Skillbuilder practice
This section contains mixed sinus. atrial. andjunctioTUlI ondAV block. and ventricular rhythm strips. allowing the student
to practice differentiating betv,~n two rhythm groups before progressing to the Posttest As before. analyze the rhythm
strips usingthe five-step process. Interpret the rhythm by comparing the data collected with the ECG crurncteristiCl; for each
rhythm . All strips are lead II. a positive lead. unless otherwise noted. Check your answers with the answer key in theap~ndix.
Pwave: _ _ _ _ __
ORS C1IITIplex:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PFl interval:
Pwave: _ _ _ _ _ __
DRS complel:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PFl interval:
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interpretamn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
249
PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR inteMI:
QRS complex: _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
QRS complex: _ _ _ _ _ __
Rhythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
250
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interprelllticn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interprelllticn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpr8tafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
IUlytiUll slrlp pructlcc: Vcntrlculur urrh ythmlus und bundle- brunch block
25 1
Pwa~ : _______
Strip 11-110. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR Interval:
ORS compln:_ _ _ _ __
Rhythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
Strip&-112. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR inieMII:
ORS complex:, _ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
252
Pwa~ :
_________
PA Interval:
ORS oomplex:' _ _ _ _ __
Rhythm Interprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _________
PA interval:
ORS cornplex:, _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2 53
Pwave: _ _ _ _ __
PR Interval:
OAS complex:' _______
PJlythm ilterpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex: _ _ _ _ __
Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
254
P wave: _ _ _ _ __
ORS complex:' _ _ _ _ __
PJlythm inlerpreialion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P wave: _ _ _ _ __
Rhythm interpratation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
Strip9-121 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR interval:
ORS complex:, _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
255
PR interval :
Pwave: _ _ _ _ _ __
PR interval:
QAS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pacemakers
Overview
An
~rti1icial
Sinoatrial d)'dunction
I. Sinus bradycardia
2. Sinus alTl.'st
markd bradycardia alternating with periods of tachycardia, especially atrial flutter or fibrillation: abo called
tachy-brady syndrome).
6. Chronotropic incompetence {sinllS node is not Cllpa
ble of incrusing its rate in response to <tCtivity
AVblock
I. Seconddegree AV block, Mobitz II
2. Third-dq:jree AV block
H y~r!;e'nsitive carotid sinus _ Stimulation of the
carotid sinus that causes episodes of asystole resulting in
recurrent synco~: stimulators may include turning the
head from side 10 side. or wearing a tight necktie or collar.
Pacemakers may be inserted on II temporary or perma
nent basis depending on the clinical situation. Temporary
piKing is appropriate in emergent situations (transient
symptomatic bradycardias or AV block lISSOCiated ",ith
myocardial ischemia or drug toxicity). Temporary pacing
may also be used to provide prophylactic therapy for high.
risk patients during cardiac C4ltheterization, during and
after cardiac surgery. and to override liKhyarrhythmias
(~rdrive piKing). Permanent pacemaker implantation is
considered for unresoilltd rhythms or conditions in which
clinical symptoms are present and for which long-term
piKing is indicated.
A pacemaker system (Figures 10-5 and 10-6) consists of
a pulse generator and a pacinillead:
256
Pulse generator - The pulse generator houSl.'S a battery, a lead conntctor, and electronic circuitry for pacemaJrer sell ings.
Picing lead _ The pacing lead has one or twQ metal
poles (electrodts) at the tip of the catheter that come in
contact with the endocardium (Figure 101). A lead with
only one electrode at its tip is called II unipolar pacing
system. A lead with two electrodts at its tip is called a
bipolar pacing system. The pacing lead serves as a Iransmis.5ion line between the pulse generator and the endoC4l rd ium. Electrical impulses are transmitted from the
pulse generator (through the pacing lead) to the endocardium, while information about intrinsic electrical activity is relayed from the electrooe tip (through the pacing
lead) back to Ihe generator. If the generator responds by
sending a pacing impulse to the heart, it is called trig
gering. If a pacing impulse is not sent 10 the hurt, this
is called inhibition. Many permanent pacing leads are
constructed with fixation devicn (screws, tines, or barbs)
thai help guarantee long-term contact with the endocardium. Temporary pacing leads are not constructed with
fixation devices 50 they can be easily removed ...men pilcing is no longer required.
Pacemakers can function in a fixed rate mode or a
demand mode:
Fixed rate mode (asynchronous) - Fixed rate pacemakers initiate impulses at a set rate, regardless of the
patient's intrinsic heart rate. This moxie of pacing is
knOYoll as asynchronous pacing because it's not synch ronned to $eose the patient's own heart rhythm. This
may result in competition be""'een the patient's natural
(inlrinsic) rhythm and that produced by the pacemaker.
Ventricular tachycardia or ~ntricular fibrillation may be
induced if the pacing stimulus falls during the vulnerable period of the cardiac cycle. Fixed rale pacemakers are
rarely used today.
Oemand mode (sync hronous) - A demand pacemaker paces only when the heart fails to depolariz.e on
its own (fires only "on demand"). Demand pacemakers
are designed with a $ensing mechanism that inhibits
discharge when the patient's heart rate is adequale and
a pacing mechanism that triggers the pacemaker to fire
when no intrinsic activity occurs within a preset period.
This mode of pacing is called synchronous pacing because
Overview
257
..
Unipolar lead
Bipolar lead
258
Pacelllukers
Temporary pacemakers
Temporary pacing can be accomplished with transcutane
ous (tlCIernal), transvenoos, or epicardial methods:
Transcutaneouspacing(TCP)- TCPreters to the delivery of II pacing stimulus to the heart through pads placed
on tht patient's outer chest (Figure 10-3). Requirements
for Tep include pacing pads, a pacing cable. and a delibrillator monitor with pacing capabilities. TCP is recommended as the initial IWICing method of choice in emergent
oc
''''''''
I ~ ~.i--
.,'"
_--l
...- ~
, I, '
I
( ,~
-,.
\~, \
Temporary pacemakers
259
artifact.
vein
(tr~n""'-no". ~l"l"ro~ch ) _
Re'l,,;remenl., for
tr~n-",e_
nous pacing indude <In external pulse gener<ltor. a pacing lead wire, and a bridging cable to connect the two
(Figure 10-5).
Some indications for transvenous pacing include
symptomatic bradyarrhythmias (sinus bradycardia.
Mobitz II second-degree AV block. and third-degr~e AV
block). prophylactic therapy during cardiac catheterization for high-risk patients. <lnd overdrive pacing of
tachyarrhythmias. Transvenous pacing is usually not
effective when meaningful contractile activity is abs~nt
(wntricular standstill and PEA). For significant unresolved rhythm or conduction disorders. permanent
pacing is requird.
Temporary pulse generators are externally controlled by
manipulating dials on the face of the unit. Removable biltteries are contained within the generator housing. Prior to
insertion of a pacing lead. prepare the equipment. Insert a
new 9-volt batt~ry into the battery compartment; set pacing rate at 100 beats per minute. the rnA to 5. and the sensitivity knob to trnXimum clockwise position for demand
(synchronous) pacing. Insert the end of the bridging cable
into matching terminals on the pulse generator, and turn
1"111""
gl'.ner~tor
ne~~t;ve
~ttach~d
to the
260
Pacem akers
Bridgi"ll cable
I.!..
A
"'o,tPU~~
."
':"Q'~' ~"CD
,..
..oRa
te .. B
0'
"
"
. ~,""''-L D
BatieI)'
Pulse generator
Figure 1 0-5, Tempol3)' tI31svenoos pacemaker system.
A. Output or rnA dial
1. controls the amount 01 electrical energy delivered to endocardium.
2. Incroase rnA by turnhg dial cklckWlse to higher rumber; decreasa rnA by turning dial COlJItereiockWlsa to lower number.
B, Rata dial
1. Ootormh9S th9 hoa"t rata In boolslmlnuta a1 which tho stimulus Is to b9 dGllv9rod.
C, sensltlvtty or mY dial
1. controls the ability oflhe generator to sooselhe electrical actlvtty.
2. In maximum cIocI(\YIse position (5 o'dock), provides demllld (synchronous) pacing.
3. In maximum counterclockWise posttlon (7 o'clock), provides fixed rate (asynchronous) pachg.
4. Increase sooslUYity (mY) by turning mY dial cIockwtse to lower rumber, decrease senslUVIty by turning dial COUlIerdod<wtse to higher
number.
D, Onfotl control
1.
AcIIyat~actlYates
Permanent pacemakers
Pulse generator
r:::::~:t""'~dC~~f
E!ecrrical Battery
ClfCUI
261
Permanent pacemaker
identification codes
A universal coding system is used to describe the function of single- and dual-chamber pacemakers (Table 10-1).
The code is comprised of fiw positions. Various leiters are
used for each position to describe a pacemaker function or
characteristic. Only one letter is used per position:
First position ~ Identifies the chamber paced,
Second position ~ Identifies the chamber where intrinsic electrical activity is sensed.
Third position ~ Indicates how the pacemaker will
respond when it senses intrinsic electrical activity.
Fourth position ~ Identifies prOJ!rammablefunctions, the
capability for transmitting and receiving data (corrununication), and the availability ofrate responsiwness.
Fifth position ~ Identifies antitachycardia functions:
1. Antitachycardia pacing (ow rdrive pacing) ~ this function paces the heart faster than the intrinsic rate to convert
the tachycardia
2. Shock (synchronized cardioversion and defibrillation)
3. Dual ~ performs both a pacing function and a shock
function.
262
Pucemukers
Tlble 1(J.1.
SIeond Ieller
Third I1I18r
fourth tetter
f1nhtaller
Ch/mber paced
Ch/mber SIlnSlld
RBBpOfISIl 10 IIIifIS~
ProgrammM1le hncIions
Artill/ClrpurJia ~rn1ions
0 . ....
0 . ....
0_ None
0 . ...
0 _ None
A:Alrium
A:Alrium
P "Antitachycarda !llcing
V_ Ventricle
V_ Ventricle
M .. Multiprogfllmmeble
S .. Shock
C", Communication
A = Rate rflSpor16iYe
Pacemaker terms
Pacemaker firing
A pacemaker produces a programmed current (stimulus) at
Capture
The term capture refers to the successful stimulation of
the myoc .. rdium by a pacemaker stimulus. resulting in
depolarization. Capture is evidenced on the ECG by a p.1cemaker spike followed by either a.n atrial complex (P wave).
Figure 1 0-7. Unlpotar and bipolar pac~ spikes. (AI Largo pactng spikes 11"9 soon wtth a unlpotar pacing system. (8) Small p;rlng
spikes 11"0 seen with a blpol1l" pactng system. (C)"The electrtcal clrcun Is so small n a bipolar systom that som9 leads may not show a pac~
spike.
Pacemaker terms
263
Sensing
Sensing is the ability of the pacemaker to detect intrinsic
electrical impulses (the patient's awn electrical activity)
or electrical impulses produced by a pacemaker (paced
activity) . If the pacemaker detects electrical activity, it is
inhibited from delivering a stimulus. If the pacemaker does
not detect electrical activity, it is triggered to initiate an
electrical stimulus.
Intrinsic beat
An intrinsic beat (also called native beat) is produced
by the patient's natural electrical system (Figure 10-9,
example B). Intrinsic beats are normal.
Flllure 10-9, W ~lcular capture ooat, (B) na1lV9 beat, (e) fUsion beat
264
Pacemakers
Fusion beat
A fusion beat occurs when the pacemaker fires an electrical stimulus at th~ sam~ time the patimt's own electrical
impulse fires an electrical stimulus. This results in part
of the ventricle being depolarized by the pacemaker and
part by the patient's own intrinsic impulse. The fusion
beat is evidenced on the ECG by a pacemaker spike that
occurs at the programmed rate (occurs on time ). followed
by a QRS that is different in height or width from the
paced beats and the patient's intrinsic beats (Figures 10-9
and 10-10).
The fusion beat has characteristics of both pacemaker
and patient forces. although one usually dominates the
Pseudofusion beat
A pseudofusion beat occurs when the pacemaker fires an
electrical stimulus after the patient's spontaneous impulse
has already started depolarizing the ventricle. The pacing stimulus has no effect since the ventricle is already
being depolarized. The pseudofusion beat is evidenced on
the monitor by a pacemaker spike occurring at the programmed rate (occurs on time). along with a native QRS
complex. The intrinsic QRS is not altered in height or
width (Figure 10-11 ). P~udofusion beats are normal and
are usually seen only with ventricular pacing.
Pacemaker rhythm
Stimulation of the atria for one beat is called an atrial
paced beat. Continuous stimulation of the atria (all P waves
Figure 10-11 . Psoodolnluslon beat. The pacing spike Is located I1 Ih9 middle 01 Ih9 CRS In complex7.
Pacemaker mlllrunctiollS
265
Pacemaker malfunctions
Basic functions of all pacemakers include the ability to fire
(stimulus release). to sense electrical activity (intrinsic
and paced).llIId to capture (depolarize the chambers being
paced). M05t malfunctions can be traced to problems with
the generator (parameter settings, battery failure), the lead
(problems at the interface bety,'een the catheter tip and the
endocardium. fracture in the lead or its insulating surface).
or to a disconnection in the system.
This section includes a description of pacemaker malfunctions. common causes. and interventions. It is directed
primarily toward temporary transvenou5 ven tricular
Failure 10 fire
With fail ure to fire, the pacemaker does not discharge
a stimulus to the myocardium. Failure to tire wi ll be
evidenced on the ECC by an absence of a pacemaker
spike where expected (Figure 10-13). Failure to ti re is
abnormal.
CIUiM'S lnd interventions for failure to fire:
1. B~lIery depletion - Replace the battery.
2. Disc onnection in the system - Check the connections
between the generator, bridging cable. and lead: reconnect
or tighten connections.
3. Fracture of INd or lead in sulltion - Do an overpenetrated chest X-ray to detect fractures: have the physic~'n
replace the lead.
o!.. ElectromAgnetic interference (EMJ) - Exposure of a
pacing un it to such sources as electrocautery devices or
266
Pace makers
FaJlure to ca pture
With failure to capture. the pacemaker deliYers a pacing
stimulus. but electrical stimulation of the myocardium
(depolarization) does oot occur. This is evidenced on the
F.cc. by f"'Cemllker "(>ik... thilt ( I t t. . . at the programmed
rate. but are not followed by a P wave (for atrial pacing) or
a QRS (for vtntricular p-'cing). Figure 1014 shows loa of
capture with ventricular piKing. Lossof capture is abnorma.l.
CauSl'$ and in terventions for bilure 10 cilliure
I. rnA output is too low - Increase the mAon the generalor by turning the rnA dial clockwise to a higher number
(Figure 1(}'5). Over a period of days. inflammation or fibrin
formation at the calheter tip may raise the stimulation
thresho ld. requiring a highe r rnA output.
2. ltad is 01.11 of pos itiOIl or I}ing in infarcted tissue - The
eltctrode tip must be in contact with the endocardium for the
electrical stimulus to cause depolarization. Infarcted tissue
Sensl ng failure
So>:Ming fail"re occ""" ..-hen the f'IICtmilker either dOB
UluleNe/lsillg
Oversellsillg
The pacemaker is too sensitiw ("sees too much) and is
sensing the wrong signals (large P waves, large T waves,
muscle mowment), causing the pacemaker to fire later
267
,
Rgurll lD-t6.
OWroorr.:;lrl\l.
Example k. Pacemaker Is s911Slng a age T wave.
Example B: Pacemaker Is sensing a low wave/orm artIlact Note: Using the automaUc InterwllM"ks on hclex card, place
right mark on spike 01 late paclld beat. The len mark will malch whatEl't'er pacemaker Is sensing.
268
Pacemakers
269
Undersensing (abnormal)
Spike fXCUrs too lale
(spike Later than right mark)
Oversensing (abnonnal)
270
Pacemakers
~~~~: ------------------------------------------------
Slrlp11J-2. Analysis :, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~erpretation :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip11J-3. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~erpretation :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
..
271
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I~~~: _ _- - - - - - - - - - - - - - - - - - - - - - - -
272
Pacemakers
~~-------------------------------------------
~~----------------------------------------
~ --------------------------------------
2 73
274
Pacemakers
,"""""..,,,- - - - - - - - - - - - - - - - - - - -
-""",,,- - - - - - - - - - - - - - - - - - - -
275
--------------------------------
trtefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
276
Pacemakers
Strip 1O-19 . ~: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
lmerpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
277
278
Pacemakers
Imerpretatiorr. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~~~,----------------------------------------
~riptO-D . ~~
279
______________ ~___________________________________________
lrte!pretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip
_ _ _ _ ___
trtefJlretalion: _________________________________________________
strip
10 - 30 . ~~
______________ ~__________________________________________
IrtlNpretalion: _________________________________________________
280
Pacemakers
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip 1G-32.Analysls: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~etat ion :
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
281
Strlp10-34. AnalysIs: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Irtl!fPretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
strip10-36.Ana/ysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
trterpretaioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
282
11llccmllkcrs
~np1040 . ~~~
283
__________________________________________________________
Irferpretalion: _______________________________________________________
Posttest
PR i1terval:
PwaYe: _ _ _ _ __
ORS complex:, _ _ _ _ __
RIIyttrn Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS cornplex:,_ _ _ __
RIrythm interpretatkm:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
284
285
Pwave: _ _ _ __
OAS ComplelC' _ _ _ _ _ __
RhytIvn inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS C!J11p1ex: _ _ _ _ __
Rhythm interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
286
Pos Uest
Slrip11-7. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
P wave: _ _ _ _ __
ORS complel: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
287
Pwave: _ _ _ _ __
QAS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QAS complex:_ _ _ _ _ __
Pwave: _ _ _ _ ___
QRS complex:_ _ _ _ _ __
Rhythm interpratation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
288
Posttest
ORS complex:-
- - -
Rhythm interpretatkln:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
intc~.3I :
QRS compIcJC _ _ _ _ _ __
Rhythm interpretatim:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
289
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
PJlythrn interpretalion:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
290
Posttest
DRS complex:_ _ _ _ _ __
Rhythm illerpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
DRS cornplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
291
QRS complex:' _ _ _ _ _ _~
RhytlJ'n interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex:' _ _ _ _ _ _~
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:' _ _ _ _ _ _~
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
292
Posttt.'st
ORS complex:' _ _ _ _ __
Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS oornpIeJI :, _ _ _ _ __
Rhythm illerpre1ationc
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
293
QRS complBX: _ _ _ _ _ __
PlJythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex: _ _ _ _ _ __
PR interval:
nh~m~~~ :'
Pwave: _ _ _ _ _ __
QRS complex: _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
294
Posttest
PR interval:
ORS comple.l::_ _ _ _ __
Rhythm inlerpretati:m:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
OPOS complex: _ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ __
Ilhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
295
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
OAS complex: _ _ _ _ _ __
Rhythm Inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
296
Posttest
ORS complex:_ _ _ _ _ __
Rhythm ilterpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhvthm illerpretatbn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhythmilterpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
297
PR InteM!:
OftScomplex:_ _ _ _ __
fIIythm inteqntation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Interval:
_ _ _ _ _ _ _ _ Pwave: _ _ _ _ __
ORScomplex;_ _ _ _ __
fIlythm Interpretatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Sbip11-41 . fI1ythm : _ _ _ _ _ _ _ _ _ _
PR inteml::
_ _ _ _ _ _ __
P wave: _ _ _ _ _ __
ORS complex:,_ _ _ _ __
fIlyhn interpretation"~---------------------------
298
POSII CSt
Pwa~ :
_______
PR rrti9Nr.
ORS complex:'_ _ _ _ __
It1ythm rrtsrprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR inteMi:
ORScom~ex:'
Pwa~:
_ _ _ _ __
_______
RIIythm InterpretatJon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa~
_______
ORS cornpleJc_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
299
Strip11-4S. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inlerprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip11-46. AnaIysis :, _ _ _ _ _ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inlerpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
3 00
Posttest
ORS complex:_ _ _ _ _ __
OIlS cornplex:_ _ _ _ __
Rhythm inlerpretatkin:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
301
Pwave: _ _ _ _ __
PR Int8f'l8l:
OfIScomplex:_ _ _ _ __
fIIythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwa'o'll: _ _ _ _ __
Rbythmlrrtarprw!atJon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
PR inl8f'I8I:
ORScompIex:_ _ _ _ __
Rhythm InterprllIalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
302
POSllest
PR Interva:
,.t" _______
Pwsve: _ _ _ _ __
ORS c:omplex: _ _ _ _ __
~m~aOOn' c
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR melVa:
Pwa~
_ _ _ _ _ __
ORS complex:,_ _ _ _ __
IIlythm nterpretaOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
303
ORS complex:_ _ _ _ _ __
PJlythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __
Rhytlvn inlerpretalion :, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
304
Posttest
QRS complex: _ _ _ _ _ __
Rhythm interpretalion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm interprelatbn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS cornplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
30 5
ORS complex:_ _ _ _ _ __
ltJythm interpretalion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
ORS complex: _ _ _ _ _ __
Rhythm interpretation:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
306
POSII CSt
_ _ _ __ R..'" _ _ __
_ _ __
Pwa~:
_ _ __ __ _
DRS tomplex:'_ _ _ _ __
IIlyttlm i'!Ierpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Strip 1'-68.Anaysis: _ _ _ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~e~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 07
Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ __
Rhythm inlerpretalion :' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
Rhythm inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
308
Posttest
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
compleJC _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 09
QRS complex:_ _ _ _ _ __
Rhythm interpretawn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR IIterva~
Pwave: _ _ _ _ _ __
QRS complex: _ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
l'l1ythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
310
Posttest
PR interval:
ORS cornplex:_ _ _ _ __
Rhythm interpretation:,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 11
Pwave: _ _ _ _ __
ORScompleK:'_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR Intarl8l:
~mint~atioo :
Pwave: _ _ _ _ __
PR interval:
ORScomplu: _ _ _ _ __
FIIythm Interpretallon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Smpll - D . M~~
_ _ _ _ _ _ _ ~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
IlII8rpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 12
POSllest
ORS complex:_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
PR Interval:
PwaYe: _ _ _ _ __
PW81111: _ _ _ _ _ __
ORScomplex:_ _ _ _ __
RhyItlm IntlNpl"etatiort_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ _ __
QRS complex:, _ _ _ _ _ __
Rhythm intefpr8lation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 13
PR interval:
ORS complex: _ _ _ _ __
Rlytlvn interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
ORS compleJ::_ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS complex:_ _ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 14
Pos ttest
PH interval:
Pwave: _ _ _ _ _ __
QRS complex:_ _ _ _ __
Rhythm ilterpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
aIlS complex: _ _ _ _ _ __
Rhythm imerpretmon:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 15
Pwaw: _ _ _ _ _ __
ORS complell: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR lntervat:
~ i m~oo' c
_ _ _ _ _ __
Pwall8: _ _ _ _ __
PR intenal:
QRScomplex:_ _ _ _ __
ftIythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PR interval:
Pwave: _ _ _ _ __
QRScomplex:_ _ _ _ __
fIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 16
Posttest
ORS complex:
Rhythm Inlerpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex: _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
317
Pwave: _ _ _ _ __
PR intYill:
ORS complex: _ _ _ _ __
Rhythm inierpretation:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
318
Posttest
ORS complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS complex:_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS
complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3 19
Pwave: _ _ _ _ __
QRS compleK: _ _ _ _ _ __
Rhythm inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Index
321
Strip 3-1.
Strip 3-2.
Strip 3-3.
Strip 3-4.
Strip 3-5.
Strip 3-6.
322
Strip 3-7.
Strip 3-8.
Strip 3-9.
strip 3-10.
Strip 3-11.
323
324
Strip 3 12.
Strip 3-13.
Sbip 3-14.
Slrip 5-7
Rhythm: Regular
Rale: 68 beats/minute
P waves: Sinus
PR interval: 0.1610 0.18 second
QRS complex: 0.12 to 0.14 second
Comment: A U wave is present.
present.
Strip 5-2
Rhythm: Regular
Rate: 45 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Comment: A small U wave is seen
after the T wave.
Strip 5-3
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 020 second
QRS compln: 0.08 to 0.10 second
Comment A depressed ST segment
Slrip 5-8
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.1210 0.14 second
QRS complex: 0.06 to 0.08 second
Comment: An devated ST segment
and inverted T wave are present.
Strip 5-9
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Comment: A depressed ST segment
is present
Strip5- I O
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.14 to 0.16 second
Strip 5- 11
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 024 to 0.26 second
QRS complex: 0.04 to 0.06 second
Strip 6-1
Rhythm: Re gular
Rate: 54 beats/minute
Stri[l S_1i
P ......;we~: Si"".
Rhythm: Regular
Rate: 136 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS ~uJJlplu: 0.06 tu 0.08 ""~UJl\I
Strip 6-2
Rhythm: Regular
Rate: 68 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS compla: 0.06 to 0.08 second
Rh}1hm interpretation: Normal sinus
rhythm; ~i -segment depression and
T-wave inversion are present.
Strip 6-3
Rh}1hm: Regular
Rale: 79 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 6-4
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 10 0.08 second
Rhythm interpretation: Sinus
tachycardia: ~i -segment deprescsion
and T -wave inversion are present.
Strip 6-5
Rh}1hm: Regular
Rate: 58 beats/minute
P waves: Sinm
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: a U wave is present.
Strip 6-6
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 100 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
~Me"l during f"'use
PR interval: 0.16 to 0.20 second
QRS complex: 0.08 to 0.10 second
(basic rh}1hm)
Rhythm interpretation: Normal
,inus rhyllull willI sillu, block;
ST-sellment deprescsion and T-wave
inversion are present.
325
326
AnswerkeytoChupters5lhrough II
S b"ip 67
Rhythm: Regular
Rate: 54 ~atslminu te
P waves: Sinus (notched P waves
usually indicate left atrial
hwertrophy)
PR interval: 0.14 to 0.16 second
QRS compleI': 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradyca rdia; a U wave is present
S iri p fi.8
Rhythm: Irregular
Rate: 50 ~atslminu te
P waves: Sinus
PR inte rval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation; Sinus
arrhythmia with a bradycardic rat e;
a U wave is present.
S trip 6!!
Rhythm: Regular (basic rhythm):
irregula r during pau~
Rate: 58 ~atslminute (basic rhythm)
P waves: Sinus (bM ic rhythm):
absent during pause
PR interval: 0.}4 to 0.18 second
(basic rhythm ); ab~nt during
pause
QRS co m plu: 0.08 to 0.10 second
(basic rhythm ); ab~nt during
pause
Rhythm interpretation: Sinus
bradycardia with sinus arrtst:
a depressed ST segment and an
invert ed T I<.~ are preKnt.
S trip fi. 10
Rhythm: Regular
Rate: 125 beatslminu te
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complel': 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
S trip 6]]
Rhythm: Regular
Rate: 63 ~atslminute
P waves: Sinus
PR interval: 0.18 to 020 second
QRS compiel': 0.08 second
Rhythm interpretation: Normal sinus
rhythm: a U wave is present.
Strip 6 12
Rhythm: Regular
Rate: 47 ~atslminute
P waves: Sinus
PR interva l: 0.18 to 0.20 second
QRS complex; 0.08 second
Rhythm interpretat ion: Sinus
bradycardia: an elevated S1 segment
is present
51 rip 613
Rhythm: Irregular
Rate: 80 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS comp lex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Sirip 6- 14
Rhythm: Regular
Rate: 63 ~atS/minute
P waves: Sinus
PR interval: 0. 18 10 0.20 second
QRS complex: 0.08 to 0. 10 second
Rhythm interpretation: Normal sinus
rhythm: S1 segment depression and
T.w~ inversion are present.
Siri p 6- 15
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 84 beats/minute (basic
rhythm): slOW$ to 56 beats/minute
afte r a pause (temporary rate
suppression may occur after a pause
in the bask rhythm)
P waves: Sinus (basic rhythm ):
absent during pause
PR interval: 0.16 to 0.18 second
(basic rhythm); abse nt du ring pause
QRS comp lex: 0.08 to 0.10 second
(basic rhythm); absent during pause
Rh~1hm interpretation: Normal
sinus rhythm with sinus a rrest;
rate suppression is present after the
pausr.
Strip 6 16
Rhythm: Regular
Rate: 150 beats/minute
P waves: Sinus
PR interval: 0. 12 to 0.16 second
QRS comp lex: 0.0410 0.06 second
Rh~1hm interpretation: Sinus
tachycardia
St rip&-17
Rhythm: Regular
Rate: 52 ~ats/minute
P WaYes: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 ~cond
Rhythm interpretation: Sinus
bradycardia
St rip fi. 11I
Rhythm: Irregular
Rate: 60 ~atslminute
P WaYes: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0. 10 ~cond
Rhythm interpretation: Sinus
arrhythmia
St rlpfi.l !!
Rhythm: Regular
Rate; 79 ~ats/minute
P WaYes: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 second
Rhythm in terpretation: Normal sinus
rhythm
Slrip fi.20
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 88 ~atslminute (basic rhythm)
P WaYes: Sinus (basic rhythm ):
absent during pause
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.08 second (basic
rhythm)
Rhythm interpretation: Normal sinus
rhythm with sinus block; a U wave is
present.
Siripfi.2 I
Rhythm: Regula r
Rate: 150 ~atslminute
P WaYes: Sinus
PR interval: 0. 12 second
QRS complex: 0.06 second
Rhythm interpretation: Sinus
tachycard ia
Strip 622
Rhythm: Regular
Rate: 60 beats/minute
p waV\'s: Sinus
PR interval: 0.12 second
QRS complex: 0.08 second
Rhythm interpretation: Normal
sinus rhythm: T-wave inversion is
present.
Strip 6-23
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Sinus
PR interval: 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 6-2~
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 60 beats/minute (basic
rhythm); slows to 47 beats/minute
after a pause (temporary rate
suppression can occur after a pause
in the basic rhythm)
P waws: Sinus (basic rhythm);
absent during pause
PR interval: 0.16 to 0.18 second
(basic rhythm); absent during
pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Normal sinus
rhythm with sinus arrest
Strip 6-25
Rhythm: Regular
Rate: 125 beats/minute
P waws: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-26
Rhythm: Regular
Rate: 35 beats/minute
P waV\'s: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.10 second
Rhythm interpretation: Marked sinus
bradycardia
Strip 6-27
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
absent during piluse
PR interval: 0.14 to 0.16 second
(basic rhythm): absent during
pause
QRS complex: 0.08 to 0.10 second
(basic rhythm): absent during
pause
Rhythm interpretation: Normal sinus
rhythm with sinus block
Strip 6-28
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.10 second
Rhythm interpretation: Sinus
arrhythmia: a U waV\' is present.
Strip 6-29
Rhythm: Regular
Rate: 65 beats/minute
P waves: Sinus
PR interval: 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm; ST-segment depression and
T-waV\' inversion are present.
Strip 6-30
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 68 beats/minute (basic rhythm);
slows to 63 beats/minute after a
pause (temporary rate suppression
can O\:cur after a pause in the basic
rhythm: after sewral cycles the rate
returns to the basic rate)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 second (basic
rhythm): absent during pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Normal sinus
rh}1hm with sinus arrest; a U waV\' is
present.
327
Strip 6-31
Rhythm: Regular
Rate: 48 beats/minute
P waV\'S: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia
Strip 6-32
Rhythm: Irregular
Rate: 60 beats/minute
P waV\'S: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rh~1hm interpretation: Sinus
arrhythmia
Strip 6-33
Rhythm: Regular
Rate: 115 beats/minute
P waV\'S: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-301
Rhythm: Regular
Rate: 88 beats/minute
P waV\'S: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm; ~i -segment depression is
present.
Strip 6-35
Rhythm: Irregular
Rate: 60 beats/minute
P waV\'s: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 6-36
Rhythm: Regular
Rate: 41 beatslminute
P waV\'s: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: ~"T -segment depression
is present.
328
Strip 637
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.20 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with sinus arrest:
ST-segment depression is present.
Strip &-38
Rhythm: Regular
Rate: 107 beats/minute
r wa",,~: Sim,.
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-39
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia; sr-segment elevation is
present.
SLrip 640
Rhythm: Regular
Rdk 54 bt:dWmjlluk
P "'"aVes: Sinus (notched P waves
usually indicate left atrial hypertrophy)
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia
Strip &-4 1
Rhythm: Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 6-42
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 6-43
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
absent during pause
PR interval: 0.18 to 0.20 second
(basic rhythm): absent during
pause
QRS complex: 0.04 to 0.06 second
(basic rhythm): absent during
pause
Rhythm interpretation: Normal
.inu~ rhythm with ~jnu~ II.rre..t:
ST-segment depression is present.
Slrip 6-44
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
arrhythmia; ST-segment elevation is
present.
Strip 6-45
Rhythm: Regular
Rate: 27 beats/minute
P waves: Sinus
PR interval: 0.14 10 0.16 second
QRS ~uIJlPln: 0.08 lu 0.10 ..,~u",J
Rhythm interpretation: Sinus
bradycardia with extremely slow
rate; ST-segment depression is
present.
Strip 646
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic rate
Strip 6-47
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachy<:ardia
Strip 6-48
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
arrhythmia; a U wave is pr~nt.
Slrip 6-49
Rhythm: Regular
Rate: 52 beats/minute
P waves: Sinus
PR interval: 0.12 second
QIlS complex: 0.08 ~~cond
Rhythm interpretation: Sinus
bradycardia
Strip 6-50
Rhythm: Regular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm: an elevated ST segment is
present.
Strip 6-51
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR illkrvdl: 0.12 Lu 0.14 ",~ulll1
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-52
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 60 beats/minute (basic
rhythm); slaws to 31 beatsiminute
after a pause (temporary rate
suppression is common after a pause
in the basic rhythm)
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interprdation: Normal
sinus rhythm with sinus arrest;
ST-segment depression and T-wave
inversion are present.
SlTip 6-53
Rhythm: Irniular
Rate: 80 beaWminute
PWilves: Sinus
PR interval: 0.12 to 0. 14 seco nd
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Si nus
arrhythmia
Sirip 6-54
Rhythm: Regular (basic rhythm):
irngular during pause
Rate: 94 beaWminute (bouic
rhythm); rate slows to 54 beats/
minute after a pause (temporary rate
suppns.sion tan occur after a pa uw
in the basic rhythm)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 to 0. 18 second
(basic rhythm); absent during
pause
QRS com plex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with sinus bloc k
Strip 6-58
Rhythm: Regular
Rate: 72 beaWminute
P waws: Sinus
PR interval: 0.16 to 0.20 second
aRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm: ST-segment depression and
T-wave inversion are present.
Ship 6-59
Rhythm: Regular
Rate: 50 beats/minute
P ~"<M!S: Sinus
PR interval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
brad~rdia: 51-segment depression
and T-wave inversion are present.
Strip 6-55
Rhythm: Regular
Rate: 65 beaWminute
Pwaves: Sinus
PR interval: 0.16 to 0.18 seco nd
QRS complex: 0.06 second
Rhythm interpretation: Normal sinus
rhythm
Strip 6-60
Rhythm: Regular (bll5ic rhythm):
irregular during pause
Rate: 88 beats/minute (basic rhythm)
P "'"<M!S: Sinus (basic rhythm):
absent during pIIuse
PR interval: 0.14 to 0.20 second
(basic rhythm ): absent during pause
aRS complex: 0.08 to 0. 10 second
(basic rhythm ): absent during
pause
Rhythm interpretation: Normal
sinus rh}1hm with sinus block:
51-segment depression is present.
Strip 6-56
Rhythm: Regular
Rate: 125 beaWminule
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.08 seoond
Rhythm interpretation: Sinus
tachycardia: ST-segment depres.sion
is present.
Strip 6-61
Rhythm: Regular
Rate: 72 beats/minu te
P WaileS: Sinus
PR interval: 0.12 to 0.14 second
aRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm: an inverted T wave is
present.
Strip 6-57
Rhythm: Irregular
Rate: 40 beaWminute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 seoond
Rhythm interpretation: Sinus
arrhythmia ~;th a bradycardic rate; a
U wave is present.
Strip 6-62
Rhythm: Regular
Rate: 125 beats/minute
P "'"<M!S: Sinus
PR interval: 0.12 second
aRS complex: 0.04 second
Rhythm interpretation: Sinus
tach~rdia: 51-segment depres.sion
is present.
329
Sirip 6-63
Rhythm: Regular
Rat~: 44 beaWminute
P waves: Sinus
PR interval: 0.1 8 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interprdation: Sinus
bradycardia: a U wave is present.
Sirip 6-61
Rhythm: Regular
Rat~: 79 beaWminute
P waves: Sinus
PR interval: 0.14 to 0.16 second
aRS complex: 0.1 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm: T-wave inversion is present.
Strip 6-65
Rhythm: Regular
Rate: 107 beaWminute
P waves: Sinus
PR interval: 0.1 8 to 0.20 second
aRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia: an devated ST segment
is present.
Sirip 6-66
Rhythm: Regubr
Rate: 136 beaWminute
P walltS: Sinus
PR interval: 0. 16 to 0.20 second
QRS complex: 0.08 to 0.10 second
Rh~thm interpretation: Sinus
tachyo:ardia: an elevated ST segment
is present.
Sirip 6-67
Rhythm: Regubr
Rat~: 44 beaWminute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rh}thm interpretation: Sinus
bradycardia: a U wave is present.
Strip 6-68
Rh}thm: Regular
Rate: 88 beaWminute
P waves: Sinus
PR interval: 0.18 to 0.20 second
aRS complex: 0.06 to 0.08 second
Rh ~thm interpretation: Normal sinus
rhythm; a depressed ST segment is
present.
330
S trip 6-69
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
tachycardia; an elevated ST segment
is present.
S trip 6-70
Rhythm: Regular (basic rhythm):
irregular during pause
Rale: 56 beats/minute (basic rhythm);
slows to 50 beatslminute after a
pause (temporary rate suppression
can occur after a pause in the basic
rhythm: after several cycles the rate
returns to the basic rate)
P waves: Sinus (basic rhythm);
absent during pause
PH interval: 0.14 to 0.16 second
(basic rhythm); absent during pause
QRS complex: 0.08 to 0.10 second
(basic rhythm); absent during pause
Rhythm interpretation: Sinus
bradycardia with sinus arrest
Strip 6-71
Rhythm: Regular
Rate: 115 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia; ST-segment depression
is present.
Strip 6-74
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.08 to 0.10 second
Rh}thm interpretation: Normal
sinus rhythm: ST-segment
depression and a biphasic T wave
are present.
Strip 6-75
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.16 to 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
""<hm
Slrip 676
J{hythm: Hegular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Sinus
ta(hYGmlia
S trip 6-73
Rhythm: Regular
Rate: 54 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia; an elevated ST segment
is present.
rh~thm)
Strip 677
Rhythm: Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.18 to 020 second
QRS complex: 0.06 10 0.08 second
Rhythm interpretation: Normal sinus
rhythm; an elevated ST segment is
present.
Strip 6-72
Rhythm: Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Nortlkll sinus
rhythm: a depressed ST segment and
a biphasic T wave are present.
Strip 679
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 107 beats/minute (basic
rhythm): slows to 94 beats/
minute for one cycle after a pause
(temporary rate suppression can
occur after a pause in the basic
strip 6-81
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: T -wave inversion is
present.
Strip 678
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: an elevated ST segment
and a U wave are present.
Strip 6-82
Rhythm: Regular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-83
Rhythm: Irregular (basic rhythm)
Rate: 60 bfatslminute (basic rhythm)
P wavts: Sinus (basic rhythm);
absent during pause
PR interval: 0.14 to 0.16 sfcond
(buic rhythm): absent during
pause
QRS complex: 0.04 second (basic
rhythm); ab~nt during pau~
Rhythm interpretation: Sinus
arrhythmia with sinus pau~ (with
~n irregul~r basic rhythm it's
impossible 10 distinguish sinus arresl
from sinus block. so the rhythm is
intfrpretfd using the broad term
Sirip 6-87
Rhythm: Regular (baJic rhythm):
irregular during pau~
Rate: S4 beats/minute (basic rhythm);
slows to 75 beats/minute for one
cycle after the pau~ (temporlll)' rate
suppression is common after a paUSf
in the!>Mk rhylhm)
P waves: Sinus (basic rhythm);
ab~nt during pause
PR interval: 0. 16 to 0.18 second
(basic rhythm): ab~nt during pau~
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during pame
Rhythm interpretation: Norma l sinus
rhythm with sinus arrest
sillus pause).
Strip 6-8-1
Rhythm: Regular
Rate: 79 buts/minute
P wavts: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
Rhythm interpret~tion: Normal sinus
rhythm: an elevaled ST segment is
presenl.
Strip 6-85
Rhythm: Regular
Rate: 136 beatslminute
P wavts: Sinus
PR interval: 0.14 to 0.16 second
QRS complu: 0.06 to 0.08 second
Rhythm interprel~tion: Sinus
tachycardi~
Sirip 6-86
Rhythm: Regular
Rate: 54 be~tslminute
P waws: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 ~cond
Rhythm interpretation: Sinus
bradycardia
Sirip 6-88
Rhythm: Regular
Rate: 100 beats/minute
P waves: Sinus
PR inlerval: 0.1210 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Norma l sinus
rhythm: an elevated ST Sfgme nt is
present.
Sirip 6-89
Rhythm: Regular
Ralf: 54 beatslminulf
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm intfrpretation: Sinus
bradycardia: an flevated ST segment
and T-w~""I! invtrsion are present.
Sirip 6-90
Rhythm: Rfgular (baJic rhythm):
irregular during pause
Rate: 72 beats/minute (baJic rhythm);
slows to 68 beats/minute for two
cycles after a pau~ (temporary rate
suppression can occur after a pause in
the !>Mic rhythm)
P waves: Sinus (basic rhythm);
ab~nt during pause
PR interval: 0.12 to 0.14 second
(basic rhythm): ab~nt during pau~
QRS complex: 0.06 to 0.08 second
(basic rhythm); ab~nt during pau~
Rhythm interpretation: Normal sinus
rh}1hm with sinus arrest; T-wave
inwrsion is present.
331
Strip 6-91
Rhythm: Regular
Rate: 65 beats/minute
P wavts: Sinus
PR interval: 0.14 to 0.16 ~cond
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm: a U wave is present.
Sirip 6-92
Rhythm: Regular
Rate: 63 bfatslminute
P wavts: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm: ST -segment depression and
T-wave inversion are present.
Strip 6-93
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 79 beats/minute (basic
rhythm): slOI'>"5 to 72 beats/minute
after a pause (tempo rary rate
suppression c~n occur after a pause
in th~ bask rhythm)
P waves: Sinus (basic rhythm):
absent during piluse
PR interval: 020 second (basic
rhythm): absent during pause
QRS complex: 0.08 to 0.10 ~cond
(basic rhythm ): absent during pause
Rhythm interpretation: Normal
sinus rhythm with sinus arrest:
ST-segment depression and T-wave
inversion are present.
Sirip 6-91
Rhythm: Regular
Rate: 150 beats/minute
P waves: Sinm
PR interval: 0.12 second
QRS complex: 0.04 to 0.06 second
Rhythm in terpretation: Sinus
tachycardia
Sirip 6-95
Rh}1hm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complu: 0.06 to 0.08 second
Rh}1hm in terpretation: Sinus
tachycardia
332
Strip 6-96
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bmdycardic rate
Stri p 7-2
Rhythm: Regular
Rate: 188 beats/minute
P waves: Hidden in 1 waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Paroxysmal
atrial tachycardia
Strip 6-97
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic
rate and sinus pause. (With
an irregular basic rhythm it".
impossible to distinguish sinus arrest
from sinus block. so the rhythm is
interpreted using the broad term
sinus pause.)
Strip 7-3
Rhythm: Regular (basic rhythm);
irregular (PACs)
Rate: 94 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.12 second (basic
rhythm); 0.14 second (PACs)
QRS complex: 0.08 to 0.10 second
(basic rhythm and PACs)
Rhythm interpretation: Normal
sinus rhythm with 1',0,0 PACs (fou rth
and eighth complexes); ST-segment
depression is present.
Stri p 6-98
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia; ~"T-segment elevation is
present.
Strip 7-4
Rhythm: Regular (off by one square)
Rate: 65 to 68 beats/minute
P waves: Vary in size. shape, and
position
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 S&ond
Rhythm interpretation: Wandering
atrial pacemaker
Strip 6-99
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic rat~
Strip 7-5
Rhythm: Regular (basic rhythm );
irregular (PAC)
Rate: 125 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): premature and pointed (PAC)
PR interval: 0.12 second (basic
rhythm)
QRS complex: 0.04 to 0.06 S&ond
(basic rhythm)
Rhythm interpretation: Sinus tachycardia with one PAC (eighth complex)
S trip 7-1
Rhythm: Irregular
Rate: 60 beats/minute (ventricular);
atrial not measurable
P waves: Fibrillation waves present
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation; S1-segment depression
is present.
Strip 7-6
Rhythm: Regular
Rate: 167 beats/minute
P waves: Pointed, abnormal
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 S&ond
Rhythm interpretation: Paroxysmal atrial tachycardia: ST-segment
depression is present.
Strip 7-;
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal
(nonconducted PAC)
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with nonconducted PAC
(afte r the seventh QRS complex); ST
segment depression is present.
Strip 7-8
Rhythm: Irregular
Rate: 320 beats/minute (atrial );
120 beats/minute (ventricular )
P waves: Flutter wav". present
(varying ratios)
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction
Strip7 -9
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Vary in size, shape, and
direction
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip7- 10
Rhythm: Irregular
Rate: 60 beats/minute (ventricular):
atrial not measurable
P waves: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.04 to 0.06 S(cond
Rhythm interpretation: Atrial
fibrillation
Strip 7- 11
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PAC)
PR interval: 0.18 to 0.20 second
(basic rhythm)
QRS complex: 0.06 to 0.08 second
(basic rhythm)
Rhythm interpretation: Normal sinus
rhythm with one PAC (sixth complex)
Sirip 7-12
Rhythm: Regular
Rate: 237 beaWminute (at rial):
79 beat!lminute (ventricular)
Pwavu: ThrH Hutter waves to each
QRScompla
PR interval: Nol necessary to
measure
QRS complex: 0.04 $fOOfld
Rhythm interpretation: Atrial nutter
with 3:1 AV conduction
Slrip7-16
Rhythm: Regular
Rate: 300 bealY'minute (atrial):
100 beats/minute (ventricular)
P WiNeS: ThrH Hulter waves before
each QRS complex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial Hutter
with 3:1 AV conduction
Slrip7-17
Slrip 7-13
Rhythm: Regular (basic rhythm):
imgular (PAC)
Rate: 107 beatslminute (basic
rhythm)
Pwaves: Sinus (basic rhythm):
premature and pointed P wave
without a QRS compla after the fifth
QRS compla
PR interval: 0. 18 to 020 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tochycardia "'ith one nonconducted
PAC (after the fifth QRS complex)
Slrip 7-14
Rhythm: irregular
Rate: 110 beat!lminute (ventricular);
atrial not measurable
P waves: Fibrillatory wa\'fS preSl.'nt
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
til-illation; some flutter waves are
""''''.
Strip 7-15
Rhythm: Regular (both rhythms )
Rate: 167 beaWminute (tiT$t
rhythm); 100 beats/minute (second
rhythm)
P waves: Obscured in T waves
(fiT$1 rhythm); sinus (second
rhythm)
PR interval: Nol measurable (tirst
rhythm); 0. 1610 0.18 second (second
rhythm)
QRS complex: 0.08 second (both
rhythms)
Rhythm interpretation: Paroxysmal
atrial tachycardia converting to
nonnal sinus rhythm
Rhythm: Irregular
Rate: 40 bealY'minute
P WiNeS: FibrilJ",lory waves
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial
tibrilJ",tion
333
Strip 7-21
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 75 beats/minute (basic
rhythm); slows to 72 beatsl
minute for tv.'O <:ycles after a
pause (temporary rate suppression
is common after a pause in the
underlying rhythm)
P wa\oU; Sinus (bas ic rhythm );
premature and pointed ",ithout QRS
complex after the third QRS complex
PR interval: 0. 16 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with on t nonoonducted
PAC (after the third QRS complex);
a U wave is present
Stripi-18
Rhythm: IrreguJ",r
Rate: 320 bealY'minute (atrial);
90 bfat!lminute (ventricular)
P waves: Flulterwaves (varying ratios)
PR interval: Not discernible
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial Hutter
with variable AV conductioo
Strip 7-22
Rhythm: Regular
Rate: 260 beatsfminute (atrial);
65 beats/minute (ventricular)
P waves: Four Hutter waves to filch
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rh}thm interpretation: Alrial flutter
with 4:1 AV conduction
Strip1-19
Rhythm: Regular (basic rhythm):
irregular (PA<:I and nonconducted
PACs)
Rate: 84 beatslminute (basic rhythm)
P WiNeS: Sinus (basic rhythm);
premature and abnormal (pACs and
nonconducted PACs)
PR interval: 0.16 second (basic
rhythm)
QRS complex: 0.06 to 0.08 SI.',ond
(basic rhythm and PACs)
Rhythm interpretation: Normal
sinus rhythm with tv.o PACs (third
and ninth complexes) and tv.'O
nonconducted PACs (after the fourth
and fifth complexes)
Strip 1-23
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 79 beaWminute (bask rhythm)
P waves: Sinus (basi' rhythm );
premature and abnormal without
QRS complex after the fourth QRS
complex
PR interval: 0. 16 to 0.18 second
(basic rhythm )
QRS complex: 0.06 to 0.08 second
(basic rhythm )
Rhythm interprdation: Normal sinus
rhythm with one nonconduded
PAC (after the fourth QRS complex):
ST-segment depression and T-wave
inveT$ion are present.
Strip 7-20
Rhythm: Regular
Rate: 167 bealY'minute
P waves: Pointed and abnormal
PR interval: 0.1610 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 7-24
Rhythm; Irregular
Rale: 100 beaWminule
P waves: Fibril latory waves present
PR interval: Not measurable
QRS com pia.: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
334
S tril' 7-25
Rhythm: Regular
Rate: 84 beats/minute
P waves: Vary in size. shape. and
position
PR inter"al: 0.12 to 0.14 second
QRS compl ex: 0.00 to O.o.'! second
Rhythm interpretation: Wandering
atrial pacemaker: T-wave inversion is
present.
S trip 7-26
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 68 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm ):
premature and inverted (PAC )
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.12 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fou rth
complex); a U wave is present.
Strip 7-27
Rhythm: Regular
Rate: 232 beats/minute (atrial);
58 beats/minute (ventricular )
P waves: Four flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with 4:1 AV conduction
Strip 7-28
Rhythm: Regular (basic rhytlun);
irregular (PACs)
Rate: 42 beats/minute (basic rhythm:
measured betV>'een the fifth and sixth
complexes)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.16 second (PACs)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with four PACs
(second, fourth. seventh. and ninth
complexes)
Strip 7-29
Rhythm: Regular
Rate: 150 beats/minute
P waves: Obscured in preceding T wave
PR interval: Not measurable
QRS complex: 0.08 second
Rh}thm interpretation: Paroxysmal
atrial tachycardia
Strip 7-30
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
P waves: Two flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 second
Rh}thm interpretation: Atrial flutter
y,;th 2:1 AV conduction
Slrip 7-3 1
Rh}1hm: Regular (basic rhythm);
irregular (pACs and atrial fibrillation)
Rate: 68 beats/minute (basic
rhythm); 140 beats/minute (atrial
fibrillation)
P y,'aves: Sinus (ba.ic rhythm):
premature and abnormal (PAC5);
fibrillation waves (atrial fibrillation)
PR interval: 0.12 to 0.14 second
(basic rhythm)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with two PACs (second and
fifth complexes); last PAC initiale5
atrial fibrillation: ~'T -segment
depression is present.
Sirip 7-32
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 94 beats/minute (basic
rhythm): slows to 84 beats/minute
for one cycle after a pause (temporary
rate suppression can occur after a
pause in the basic rhythm)
P waves: Sinus (basic rhythm):
premature, abnormal P wave without
il QRS complex hidden in T waV\:
after the seventh QRS complex
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one non conducted PAC
(after the seventh QRS complex)
Strip 7-33
Rhythm: Regula r (basic rhythm);
irregular (PAC)
Rate: 47 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature and pointed (PAC)
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex): a U wave is present.
Strip 7-34
Rhythm: Irregular
Rate: 50 beats/minute (ventricular):
atrial not measurable
P waves: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
and T-wave inversion are present.
Strip 7-35
Rhythm: Regular
Rak 188 beats/minute
P waves: Obscured in T waves
PR interval: Unmeasurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia; ST-segment
depression is present.
Strip 7-36
Rhythm: Irregular
Rate: 50 beat5lminute
P waves: Vary in size, shape. or
direction across strip
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-37
Rhythm: Irregular
Rate: 260 beats/minute (atrial);
70 beats/minute (ventricular)
P waves: Flutter waves (varying
ratios)
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction
SlTiIl7-38
Rhythm: Regular
Rate: 150 beawminute
Pwaves: Obscured in T waves
(T-Pwaves)
PR interval: Not measurable
QRS complex 0.06 to 0.08 second
Rhythm interpretation: ParOX}'$mal
atrial tachycardia
Strip 7-39
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 136 beawminute (basic
rhythm)
P waves: Sinus (basic rhythm):
premature and pointed (PAC)
PR interval: 0.16 to 0. 18 second
(basic rhythm); 0.18 second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.06 second (PAC)
Rhythm interpretation: Sinus
tachycardia with one PAC (eleventh
complex)
Slr]p 7-"0
Rhythm: irregular
Rate: 130 beaWminule (ventricular);
atrial not measurable
P waws: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation (uncontrolled rate)
SlTip 7-t 1
Rhythm: Regular (basic rhythm);
irrtgular tnonconducted PAC)
Rate: 79 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
premature. abnormal P wave hidden
in the T wave after the seventh QRS
complex
PR interval: 020 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm ....ith one nonconducted
PAC (hidden in the T wave after the
seventh QRS romp lex); a U wave is
present.
Stri p 7..012
Rhythm: Regular (basic rhythm):
irrtgular with prematurt atrial
contraction (PAC)
Rate: 84 beats/minute (buic
rhythm)
P ....<Nes: Sinus (basic rhythm);
abnormal. pointed (PAC)
PR interval: 0.12 to 0.14 second
(basic rhythm); 028 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.06 second (PAC)
Rhythm interpretation: Normal sinus
rhythm with one PAC (conducted
with long PR interval)
Siri p 7-4.1
Rhythm: Regular
Rate: 68 beats/minute
P waves: Vary in size. shapt, and
position
PR interval: 0.12 second
QRS complex: 0,06 to 0.08 second
Rhythm interpretation: Wandering a!rial pacemaker: ST-segment
deprtMion is present.
Slri p 7-H
Rhythm: Regular
Rate: 272 beats/minute (atrial):
136 beats/minute (wntricular)
P ....<Nes: Two nuller waws to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial Hutter
with 2:1 AV conduction
Sirip 7-45
Rhythm: Regular
Rate: 188 beaWminute
P waves: Hidden in T ..... a\'es
PR interval: Not measurable
QRS complex: 0,04 to 0.06 second
Rhythm interpretation: Paroxysmal
atrial tachycardia; ST-segment
depression is present.
335
Strip 7-46
Rh ythm: Regular (basic rhythm):
irregular (premature beat)
Rate: 79 beats/minute (basic rhythm)
P waves: Sinu$ (Iw; ic rhythm );
prematurt and pointed (PAC)
PR interval: 0.14 to 0.16 second
(basic rhythm); 0,]2 second (PAC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one PAC (tifth romp lex)
Strip 7--17
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 84 beats/minute (basic rhythm)
P waves: Sinus; prematuTC and
poin ted (PAC)
PR interval: 0. 14 to 0.16 (basic
rhythm); 0.16 .second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm ); 0,08 second (PAC)
Rhythm interpretation: Nonnal
sinus rhythm with one PAC (seventh
complex); ST-segment depression is
present.
Strip 7-48
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Fibrillatory waves present
PR interval: Not mea.lUrable
QRS compla: 0,08 second
Rh ythm interpretation: Atrial
fibrillation (controlled rate )
Strip 7-49
Rhythm: Irregular
Rate: 280 beats/minute (atrial):
50 beats/minute (ventricular)
P waves: Flutterwaves present
(varying ratios)
PR interval: Not measurable
QRS com pIa: 0,06 to 0.08 second
Rhythm interpretation: Atria! flutter
with variable AV conduction
Strip 7-50
Rh~thm: Irregular
Rate: 300 beats/minute (atrial l:
100 beats/minute (ventricular)
P Willies: Flutter waves (varying mtios)
PR interval: Not measurable
QRS compla: 0.1 to O.06second
Rh ~thm interpretation: Atrial flutter
with vari able AV conduction
336
Strip i -51
Rhythm: Regular
Rate: 150 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Str ip i -52
Rhythm: Regular (basic rhythm);
irregular with PACs
Rate: 65 beats/minute (basic rhythm)
P waves: Sinm (basic rhythm):
nbnormnl. inv<:rted (pAC.)
PR interval: 0.20 second (basic
rhythm); 0.12 second (PACs)
QRS complex: 0.06 to 0.08 second
(basic rhythm and PACs)
Rhythm interpretation: Normal sinus
rhythm with paired PACs
Strip 7-53
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation:Atriai fibrillation: sr-segment depression is present.
S trip 7-54
Rhythm: R~KuJdr (iM.i" rhylluJl);
irregular (PAC)
Rate: 94 beaU/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and pointed (PAC)
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Nonnal sinus
rhythm with one PAC (eighth complex):
sr-segmentdepression is present.
Slrip 7-55
Rhythm : Irregular (first rhythm);
regular (second rhythm)
Rate: 120 beats/minute (first
rhythm): 75 beats/minute (second
rhythm)
P waves: Fibrillatory waves to sinus
PR interval: Not measurable (first
rhythm): 0.12 to 0.14 second (second
rhythm)
QRS complex: 0.04 to 0.08 second
(both rhythms )
Rhythm interpretation: Atrial
fibrillation to normal sinus rhythm
Strip i-56
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 84 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PAC )
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.12 second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fifth
complex); baseline artifact is present
(b....,linc artif"ct .houldn't be
confused with atrial fibrillation).
Strip 7-60
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation
Strip 7-61
Rhythm: Irregular
Rate: 210 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QIlS complex: 0.04 to 0.06 .Kcond
Rhythm interpretation: Atrial
fibrillation
Strip i-57
Rhythm: Regular
Rate: 225 beats/minute (atrial);
75 beats/minute (ventricular)
P waves: Three tlutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial tlutter
with 3:1 AV conduction
Sirip i-58
Rhythm: Regular (basic rhythm):
irregular (nonconducted PACs )
Rate: 88 heats/minute (basic
rhylhm); r"l~ .luw. lu 72 b~"W
minute after a pause (temporary rate
suppression is common after a pause
in the basic rhythm)
P waves: Sinus (basic rhythm);
premature, abnormal P wave without
a QRS complex hidden in the T wave
after the seventh QRS complex
PR interval: 0.12 to 0.14 second
(basic rhythm)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with one nonconducted PAC
(afte r the seventh QRS complex)
Strip 7-59
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Vary in size. shape, and
direction
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker; T-wave inversion is
present.
Strip j-62
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature, abnormal P wave (PAC)
PR interval: 0.16 to 0.18 second
(basic rhythm)
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex); a U wave is present.
Strill7-63
Rhythm : Irregular
Rate: 40 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial
fibrillation
Strip 7-64
Rhythm: Regular
Rate: 214 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 7-65
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 52 beats/minute (basic
rhythm)
P wa~5 : Sinus (basic rhythm):
premature. pointed P waw associated
with PAC hidden in the T wave after
the fourth QRS complex
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex); a U waw is present.
Strip 7-66
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 75 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
premature. abnormal P wave hidden
in the T wa~ after the fourth QRS
complex
PR interval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with on~ nonconducttd PAC
(after the fourth QRS complex): a U
wa~ is present.
Strip 7-67
Rhythm: Regular (off by tv.o
squares)
Rate: 79 b~aWminute
P wa~s: Vary in siu, shape. and
direction
PR interval: 0.12 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-68
Rhythm: Regular
Rate: 150 beats/minute
P wa~s: Hidden in preceding T
wa~s
Slrip7-69
Rhythm: Irregu lar
Rate: 250 beats/minute (atrial):
70 beats/minute (~ntricular)
P waves: Flutter waves before each
QRS complex (varying ratios)
PR interval: Not measurable
QRS compl ex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction
Strip 7-70
Rhythm: Irregular
Rate: 130 beats/minute (ventricular) ;
atrial not measurable
P waves: Fibrillatory waves: some
flutter waves
PR interval: Not measurable
QRS complex: 0.04 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
is present.
Strip 7-7 1
Rhythm: Regular (basic rhythm);
irregular (PACs)
Rate: 88 beats/minute (basic rh~1:hm)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with paired PACs (third and
fourth complens)
337
Strip 7-74
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 63 beatYminute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PAC)
PR interval: 0.12 to 0.14 second
(basic rh}1hm): 0.14 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fourth
complex): a small U wa~ is present.
Strip 7-75
Rh}1hm: Rellular
Rate: 150 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia: ST -segment
depression is present.
Sirip 7-76
Rhythm: Irregular
Rate: 80 beats/minute (ventricular);
atrial not measurable
P wa~s: Fibrillatory waves present
PR interval: Not measu rable
QRS complex: 0.04 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
and T-wave inversion are present.
Sirip 772
Rhythm: Regular
Rate: 54 beats/minute
P waves: Varying in size and shape
PR interval: 0.12 second
QRS complex: 0.08 to 0.10 5econd
Rhythm interpretation: Wandering
atrial pacemaker: ST -segment
depression is present.
Strip 7-77
Rhythm: Regular
Rate: 88 beats/minute
P waves: Vary in size. shape, and
position
PR interval: 0.12 to 0.14 second
QRS compJa: 0.06 to O.og second
Rhythm interpretation: Wandering
atrial pacemaker; T-wa~ in~rsion is
present.
Sirip 7-73
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
P waves: Two flutter wa~s to each
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction
Strip 7-78
Rhythm: Irregular
Rate: 50 beats/minute
P wa~s: Vary in size. shape, and
position
PR interval: 0.12 to 0.16 second
QRS complex: 0.08 second
Rh}1hm interpretation: Wandering
atrial pacemaker; ST-segment
depression is present.
338
Strip 7-79
Rhythm: Irregular
Rate: 280 beat5lminute (atrial):
100 beats/minute (ventricular)
P wavu: Flutter waws
PR intel>'al: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial flutter
with variable AV condudion
Strip 7-80
Rhythm: Regular (ba.sic rhythm);
irregular (nonconducted PACs)
Rate: 107 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal
(nonconducted PACs)
PR inten'al: 0.16 to 0.18 second
QRS wmplex: 0.00 to 0.08 second
Rhythm interpretation: Sinus.
tachycardia with two nonconducted
PACs (after the third and eighth QRS
oomplexes)
Sirip 7-81
Rhythm: Regular
Rate: 68 beats/minute
P waves: Vary in size, shape. and
direction
PR intel>'al: 0.12 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker: a U wave is present.
S lrtp 7-82
Rhythm: Regular
Rate: 260 beats/minute (atrial):
65 beats/minute (ventricular)
P waws: Flutter waws
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial flutter
with 4:1 AV condudion
S irip 7-8."1
Rhythm: Regular
Rate: 167 beat5lminute
P waves: Hidden in preceding T wave
PR intel>'al: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip7..s"
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Fibrillatory waves
PR interval: Not meuurable
QRS complex: 0.08 to O. 10 second
Rhythm interpretation: Atrial
fibrillation
Sirip 7..s5
Rhythm: Irregula r
Rate: 40 beats/minute
P waves: Vary in size. shape. and
direction
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Sirip 7-86
Rhythm: Regular (basic rhythm):
irregular (PACs)
Rate: 107 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PACs)
PR interval: 0.16 second (basic
rhythm)
QRS complex: 0.06 second
Rhythm interpretation: Sinus
tDchy<:ardia with three PAGs (fourth.
ninth. and eleventh complexes)
Strip 7-S7
Rhythm: Irre gular
Rate: 60 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip7..sS
Rhythm: Regular (first rhythm):
irregular (second rhythm )
Rate: 79 beats/minute (first rhythm);
140 beats/minute (second rhythm)
P waves: Sinus to fibrillatory waves
PR interval: 0.12 to 0.14 second (first
rhythm): not measurable (second
rhythm)
QRS oomplex: 0.04 to 0.08 second
(both rhythms)
Rhythm interpretation: Normal sinus
rhythm to atrial fibrillation
Strip 7-89
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 84 beats/minute (buic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed
(nonconducted PAC)
PR interval: 0.16 to 0.20 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation:
Normal sinus rhythm with one
non conducted PAC (after the
fifth QRS complex): ST-segment
depression is present.
Strip 7-90
Rhythm: Regular (buic rhythm);
irregular (PAC)
Rate: 54 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PAC)
PR intenoal: 0.16 to 0.18 second
QRS complex: 0.00 second
Rhythm in terpretation: Sinus
bradycardia with one PAC (fourth
complex)
Sirip 7-9 1
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rh}thm);
premature and abnormal (PAC)
PR interval: 0.14 to 0. 16 second
QRS complex: 0.00 second
Rhythm in terpretation: Normal
sinus rhythm with one PAC (fifth
complex); a U wave is present.
Strip 7-92
Rhythm: Regular
Rate: 235 beats/minute (atrial):
47 beats/minute (ventricular)
P waves: Five Hutter waves to each
QRS complex
PR intenoal: Not discernible
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 5:1 AV conduction; T-wave
inversion is present.
Str ip 7-93
Rhythm: Regular
Rate: 150 beats/minute
P waws: Obscured in T waws
(TP wmes)
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 7-91
Rhythm: Irregular
Rate: 50 beats/minute
Pwaws:Wavy
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation
Strip 7-95
Rhythm: Regular (basic rhythm):
irregular after a burst of PAT
Rate: 84 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): abnormal and premature with a run of PAT
PR interval: 0.16 to 0.18 second (basic
rhythm): not measurable in PAT
QRS complex: 0.04 to 0.06 second
(basic rhythm and PAT )
Rhythm interpretation: Normal sinus
rhythm with burst of PAT (three
PACs afler the fourth QRS complex)
Strip 7-96
Rhythm: Regular
Rate: 88 beats/minute
P waws: Sinus
PR intervill: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 7-97
Rhythm: Regular (basic rhythm)
but off by one square: irregulilr with
PACs
Rate: 84 to 88 beats/minute (basic
rhythm)
P WilVi:S: Sinus (basic rhythm):
abnormal, pointed (PACs)
PR interval: 0.14 to 0.16 (basic
rhythm and PACs)
QRS complex: 0.08 second (basic
rhythm and PAC s)
Rhythm interpretation: Normal sinus
rhythm with PAC~ every fourth be"t
(quadrigeminal pattern)
Strip 7-98
Rhythm: Regular
Rate: 150 beats/minute
P wmes: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 7-99
Rhythm: Regular
Rate: 250 beats/minute (atrial):
125 beats/minute (wntricular)
P wmes: Two flutter WavtS to each
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction
Strip7-IOO
Rhythm: Regular (biLIic rhythm);
irregular during pause
Rate: 48 beats/minute (basic
rhythm)
P wmes: Sinus (basic rhythm);
absent during pause
PR interval: 0.20 second (basic
rhythm); absent during pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Sinus
bradycardia with sinus arrest
Strip7-IO I
Rhythm: Irregular
Rate: 90 beat;;/minute
P wmes: Vary in size, shape, and
direction
PR interval: 0.12 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-102
Rhythm: Regular (off by one
square)
Rate: 45 to 47 bi:atslminute
P wmes: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Sinus
bradycardia
339
Strip 7- 103
Rhythm: Regular (first and second
rhythms)
Rate: 107 beats/minute (first
rhythm); 214 beats/minute (second
rhythm)
P waves: Sinus (first rhythm ):
abnormill, pointed (second
rhythm)
PR interval: 0.16 to 0.18 second (first
rhythm); not measurable (second
rhythm)
QRS complex: 0.08 to 0.10 second
(first and second rhythms)
Rhythm interpretation: Sinus
tachycardia with burst of PAT (8_beat
run initiated by PAC)
Strip 7- \ 04
Rhythm: Irregular
Rate: 100 beats/minute
P wavts: Fibrillatory wavts
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial
fibrillation
Strip 7- 105
Rh,1hm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 7- 106
Rhythm: Re~ular (first rhythm):
irregular (second rhythm)
Rate: 75 beats/minute (first
rhythm); 360 beats/minute atrial
(second rhythm); 140 beatslminute
wntricular (second rhythm )
P waws: Sinus (first rhythm ): Hutter
waws (second rhythm )
PR interval: 0.12 second (first
rhythm): not measurilble (second
rhythm)
QRS ,0mpJex: 0.06 to 0.08 second
(first and second rhythms)
Rhythm interpretation: Normal sinus
rhythm with PAC (fifth complex)
changing to iltrial Hutter with
variableAV conduction
340
S lrip7~ 1 07
Sirip 8-4
Strip 8-11
Rhythm: Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0. 12 to 0.14 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Normal s inus
rhythm
Strip 8-1
Rhythm: Regular (buic rhythm):
Irregular (PIC)
Rate: 58 beaU/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
premature and inverted (PIC)
PR interval: 0.14 to 0.16 second
(basic rhythm); 0.08 second (PIC)
QRS complex: 0.00 second (basic
rhythm and PIC)
Rhythm interpretation: Sinus
bradycardia with one PIC (fifth
complex): a U wave is present.
Strip 8-2
Rhythm: Regular
Rate: 60 beats/minute
P wart$; Sinus
PR interval: 0..24 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with lirst-degree AV block:
ST-segment elevation and T~wave
inversion are present.
Sir ip 8-3
Rhythm: Regular (atrial and
ventricular)
Rate: 96 beats/minute (atrial ):
32 beats/minute (ventrictJlar)
P waves: Three sinus Pwaves before
filch QRS compln
PR interval: 0.14 to 0.16 second
(remains consistent)
QRS complex: 0.12 second
Rhythm interpretation: r.10bitz II
with 3:1 AV conduction (third P wm.oe
hidden in T waves)
Sirip 8-5
Rhythm: Regular (first and second
rhythlTl5)
Rate: 84 beats/minute (first rhythm):
94 beaU/minute (second rh}1hm)
P waves: Sinus (first rhythm):
inverted (second rhythm)
PR interval: 0.12 second (fint
rhythm): 0.08 to 0.10 setond (second
rhythm )
QRS complex: 0.06 to 0.08 seoond
(lirst and second rhythlTl5 )
Rhythm interpretation: Normal sinus
rhythm changing to accelerated
junctional rhythm
Sirip 8-6
Rhythm; Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0.22 to 024 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with lirst..degree AV block
Sirip 8-7
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atcelerated
junctional rhythm; ST-segment elevation and T-wave inversion are present.
Strip 8-9
Rhythm: Regular
Rate; 47 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Junctional
rhythm: !>T-segment depression is
present.
Strip 810
Rhythm: Regular (atrial): irregular
(ventricular)
Rate: 75 beats/minute (atrial):
30 beat~minute (ventricular)
P waves: Two sinus P waVC;$ before
each QRS complex
PR interval: 020 to 0.22 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, "1obitz II (clinical
correlation is suggested to diagnose
Mobilz II when 2;1 conduction is
present with a narrow QRS complex).
Strip 8 11
Rhythm: Regular (atrial and
ventricu lar)
Rate: 63 beats/minute (atrial):
33 beats/minute (ventricularl
P waves: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block: ST-segment depression and
T-wave inversion are present.
Str ip S-12
Rhythm: Regular
Rate: 84 beats/minute
P waws: Hidden in the QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm: ST-segment
depression is present.
Strip S-13
Rhythm: Regular
Rate: 65 beats/minute
P waws: Sinus
PR interval: 0.44 to 0.48 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block:
an elevated ST-segment is present.
Slr ipS-H
Rhythm: Regular (basic rhythm):
irregular (PJC)
Rate: 136 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
hidden P waw (PJC)
PR interval: 0.12 to 0.14 se,ond
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia with one PJC (thirteenth
complex)
Strip S-15
Rhythm: Reguku
Rate: 94 beats/minute
P waws: Sinus
PR interval: 026 to 0.28 second
QRS complex: 0.06 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block:
ST -segment depression is present.
Strip 8-16
Hhythm: Hegular (basic rhythm):
irregular (premature beat)
Rate: 58 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
inverted (premature beat)
PR interv"l: 0.16 to 0.18 second
(basic rhythm); 0.08 second (PJC )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus bradycardia with one PJC (fourth complex);
~"T-segment depression is present.
Strip 8-17
Rhythm: Regular (atrial and
ventricular)
Rate: 108 beats/minute (atrial);
54 beats/minute (wntricular)
P waves: Two P waves to each QRS
complex
PR interval: 0.20 second and
constant
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, Mobitz II (clinical
correlation is suggested to diagnose
Mobitz II when 2:1 conduction is
present with a narrow QRS complex).
S1-segment elevation and T-waw
inwrsion are presmt.
Strip 8-18
Rhythm: Regular (atrial): irregular
(wntricular )
Rate: 65 beats/minute (atrial);
50 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthens from 0.20 to
0.48 second
QRS complex: 0.04 second
Rhythm interpreliltion:
Second-degree AV block. Hobitz I
Strip 8-19
Rhythm: Regular
Rate: 125 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Junctional
tachycardia
Strip 8-20
Rhythm: Regular (atrial and
ventricular)
Rate: 100 beats/minute (atrial);
::Ii! beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex; found hidden in
the QRS complex and T waves)
PR interval: VilI"ies greatly
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Third-degree
AV block: ST-segment depression is
present.
3 41
Strip S-21
Rh}1.hm: Regular (basic rhythm);
irregular (PJC)
Rate: 60 beawminute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and inverted (PJC)
PR interv.'Jl: 0.12 to 0.14 second
(basic rhythm); 0.08 second (PJC)
QRS compla: 0.08 second (basic
rhythm and PJC)
Rhythm interpretation: Normal
sinus rhythm with one PJC (fourth
complex)
Strip S-22
Rh}1.hm: Regular (basic rhythm) but
offby two squares
Rate: 54 to 58 beats/minute
P waves: Sinus (basic rhythm);
hidden within QRS complex
(junctional beats)
PR interval: 0.16 to 0.18 second
(basic rhythm)
QRS compla: 0.08 to 0.10 second
(basic rh}1hm and junctional beats)
Rhythm interpretation: Sinus
bradycardia with a paUie folk,,,,ro by
two junctional es\:il.])': beats; ~])':dfic
pause (sinus arrest or sinus block)
cannot be identified due to the
presence of the escape beats.
Strip S-23
Rhythm: Regular
Rate: 35 beatslminute
P waves: Sinus
PR interval: 0.60 to 0.62 second
(remains constant)
QRS compla: 0.06 second
Rhythm interpretation: Sinus
bradycardia with first-degree AV
block
Strip S-2~
Hhythm: Hegular (atrial): irregular
(ventricular )
Rate: 68 beawminute (atrial ):
60 beats/minute (ventricular)
P waws: Sinus
PR interval: 028 to 0.36 second
QRS com pI",,: 0.08 second
Rh}1hm interpretation:
Second-degree AV block. Mobitz I;
aU waw is present.
34 2
S tr ip 8-25
Rhythm: Regular
Rate: 75 beats/minute
P waves: Sinus
PR interval: 0.28 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
rhythm with first-degree AV block
Strip 8-26
Rhythm: Regular (basic rhythm);
irregular with premature beats
Rate: 100 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm ):
pointed P waw (PAC); inverted
P waw (PJCs)
PR interval: 0.20 second (basic
rhythm): 0.16 second (PAC);
0.06 second (PJCs)
QRS complex: 0.00 to 0.08 second
(basic rhythm and premature beats)
Rhythm interf\ ..... t~tion: Nor"",]
sinus rhythm with one PAC (seventh
complex) and paired PJC5 (eighth
and ninth complexes): ST-segment
depression is present.
Strip 8-27
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inwrted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm; elevated ST
segment is present.
Strip 8-28
Rhythm: Regular (basic rhythm);
irregular (non conducted PAC)
Rate: 56 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature, abnormal P wave without
a QRS complex
PR interval: 0.24 to 0.26 second
(remains ,onstant)
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia with first-degree AV
block and nonconducted PAC
(follows the fourth QRS complex);
ST-segment depression is present.
Strip 8-29
Rhythm: Regular (atrial); irregular
(vent ricular)
Rate: 72 beats/minute (atrial);
50 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthem from 0.24 to
0.36 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Mobitz I
Strip 8-30
Rhythm: Regular (atrial and
ventricular)
Rate: 79 beats/minute (atrial);
32 beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV!>lock
Strip 8-31
Rhythm: Atrial and ventricular rhythm reguklf (both off by
tv.o squares)
Rate: 80 beats/minute (atrial);
30 beats/minute (wntricular)
P waves: Three sinus P waves to each
QRS complex
PR interval: 0.20 to 022 second
(remains consistent)
QRS ,0mpJex: 0.14 to 0.16 S\!cond
Rhythm interpretation: Mobitz II
y,ith 3:1 AV conduction
Strip 8-32
Rhythm: Regular (atrial and
ventricular)
Rate: 75 beilts/minute (atrial);
34 beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex; found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AV block: &[ -segment elevation is
present.
Strip 8-33
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 100 beats/minute (basic
rhythm)
P waves: Inverted before the QRS
complex (basic rhythm); upright and
pointed (PAC)
PR interval: 0.08 second (basic
rhythm); 0.12 second (PAC)
QRS complex: 0.08 second (basic
rhythm and PAC)
Rhythm interpretation: Accelerated
junctional rhythm with one PAC
(sixth complex); ST-segment
depression is present.
Strip 8-34
Rhythm: Regular (atrial): irregular
(vent ricular)
Rate: 75 beats/minute (atrial);
50 beats/minute (ventricular)
PR interval: 0.28 to 0.40 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation:
Second-degree AV block, Mobilz I
Strip 8-35
Rhythm: Regular
Rate: 60 beals/minute
P waves: Sinus
PR interval: 0.24 to 0.26 second
QRS complex: 0.06 to 0.08 second
Rhythm interpreUltion: Normal
sinus rhythm with first-degree AV
block
Strip 8-36
Rhythm: Regular
Rate: 41 beats/minute
P waves: Inverted after the QRS
complex
PR interval: 0.04 10 0.06 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm
Str ip 837
Rhythm: Regular (basic rhythm):
irregular (P1Cs)
Rate: 58 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and inverted (P1Cs)
PR interval: 0.16 second (basic
rhythm); 0.08 to 0.10 second (P1Cs)
QRS complex: 0.08 second (basic
rhythm and P1Cs)
Rhythm interpretation: Sinus
bradycardia with two PJCs (fourth
and sixth complexes); a U wave is
pres<!nt.
Str ip 8-38
Rhythm: Regular
Rate: 60 beats/minute
P waves: Inverted
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Hhythm interpretation: Junctional
rhythm
Strip 8-39
Rhythm: Regular (atrial and
ventricular)
Rate: 65 beats/minute (atrial);
36 beats/minute (ventricular)
P waves: Sinus
PR interval: Varies (not consistent)
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-40
Rhythm: Regular (atrial and
ventricular)
Rate: 84 beatslminute (atrial):
30 beats/minute (ventricular)
P waves: Sinus
PR interval: Varies (not consistent)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-4 1
Rhythm: Regular
Rate: 84 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm
343
Strip 8-42
Rhythm: Regular (atrial and ventricular)
Rate: 125 beats/minute (at rial);
40 beats/minute (ventricular)
P waves: Three sinus P waves before
each QRS complex
PR interval: 0.22 to 0.24 second
(consistent)
QRS complex: 0.12 second
Rhythm interpretation: Mobitz II
second-degree AV block
Strip 8-46
Rh}1hm: Irregular
Rate: 40 beats/minute
P waves: Sinus
PR interval: 028 second (remains
constant)
QRS complex: 0.08 to 0.10 second
Rh}1hm interpretation: Sinus
arrhythmia with bradycardic rate
and first-degree AV block; a U wave is
present.
Strip 8-43
Rhythm: Irregular (first rhythm ):
regular (second rhythm)
Rate: 80 beats/minute (first rhythm):
42 beats/minute (second rhythm)
P waves: Fibrillatory waves (first
rh}1hm): hidden P waves (second
rhythm)
PR interval: Not measurable in either
rhythm
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation to junctional rhythm:
Si-segment depression is present.
Strip 8-47
Rhythm: Regular (atrilll ): irregular
(ventricular )
Rate: 79 beats/minute (atrial ):
50 beats/minute (vent ricular )
P waves: Sinus
PR interval: Lengthens from 0.24 to
0.40 second
QRS compla: 0.08 to 0.10 second
Hhythm interpretation:
Second-degree AV block. Mobilz I
Sirip 8-44
Rhythm: Regular (basic rhythm);
irregular (prematu re beats)
Rate: 60 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and abnormal (premature
beats)
PR interval: 0.12 to 0.16 second
(basic rhythm); 0.12 second (PAC);
0.08 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PAC (fourth
complex) and one PJC (fifth
complex); ST-sel/ment depression
and T-wave inversion are present.
Strip 8-45
Rhythm: Regular (atrial and
ventricular)
Rate: 72 beats/minute (atrial);
32 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex; hidden in the
QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block; ST-segment elevation is
present.
Strip 8-48
Rhythm: Regular (atrial and
ventricular)
Rate: 108 beatslminute (atrial );
54 beats/minute (ventricular )
P waves: Two sinus P waves before
each QRS complex
PR interval: 0.18 to 0.20 second
(remains constant)
QRS compla: 0.08 second
Rhjthm interpretation: Seconddegree AV block. Mobitz II (clinical
correlation is suggested to diagnose
Mobilz II when 2:1 conduction is
present with a narrow QRS complex);
ST-segment elevation and T-wave
inversion are present.
Strip 8-49
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.04 to 0.06 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm: ST -segment depression is
present.
344
S trip 850
Rhythm: Regular (buic rhythm):
irregular (esape ~al)
Rale: 84 bUlts/minute (bask
rhythm); slows to 7S buw
minute after ncallt' but
(tempo ra l'}' rille suppression can
ocrur after premature Of escape
beats; after ~rlll cycln rate will
rtlurn to buic rate)
P waves: Sinus; P wa~ hidden with
""'"
...,
PR interval: 0.14 to 0.16 second
Stri p 851
Rhythm: Regytar
Rate: 9-t btatsfminute
P 'o\",WtS: In~rted before 1M QRS
complex
PR interval: 0.08 second
QRS compla: 0.06 to 0.08 steond
Rhythm interpntalioo.: Acrtle rated
junctioTIIII rhythm
Sirip g-55
Rhythm: Regylar (!sic rh)thm)
Rate: 55 btatslminute (basic rh)"thm)
PIoIaWS: SiOOll (basic rh)1.hm); notched
Pwavt$ u$WI1y indicate Itft atrial h)'p!'rtrophy: no P __ e 5HIlwith fourth
complex: fifth COlT1lia has a P wave on
top oftht preceding T wa~
PR interval: 0.20 second (basic
mythm)
S trip 85 1
Rhythm: Regular (atrial) but off by
two squares: irregular (~ntricular)
Rate: 60 to 65 beal&iminute (atrial):
50 beats/minute (ventricuL!lr)
P wa~s: Sinus
PR interval: Lengthens from 028 to
0.40 second (not consistent)
QRS complex: 0.08 iltcond
Rhythm interprttation: Mobiul
second-degrH AV block
Strip 852
Rhythm: Regular
Ralt: 63 buts/minute
P WiveS: Hidden in the QRS
comple!
PR interval: Not measurable
QRS compla: 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm
Strip 8 53
Rhythm: Regular (atrial) but of( by
two squares: irregular (~ntricuL!lr)
Rate: 84 beats/minute (atrial):
40 beats/minute (ventricu L!lr)
P waves: Sinus (two or three P W/lWS
before each QRS complex)
PR interval: 0.12 second (consistent)
QRS complex: 0.12 second
Rhythm interpretation: Mobiu II
seconddegrH AV block with 2:1 and
3:1 AV conduction
Strip !loSt!
Rhythm: Regular (atrilll and
~ntricularl
""'u)
PR inte~l: 0.12 second (wic
rhythm): 0. 12 SKOI'Id (PAC): 0.08 to
0.10 second (pJCs)
QRS complex: 0.08 second
Rhythm interprttlltion: Normal
sinus I'h)thm with one PAC (third
complex) and paired Plel (Iixth and
seventh complexe$)
Strip 8-61
Rhythm: Regular
Rate:
beats/minute
P waves: Hidden in the QRS
complex
PR inlerval: Not measurable
QRS complex: 0.08 second
Rhythm interprelati on: Junctional
"7
mythm
Siri p 8-62
Rhythm: Regular (basic rhythm):
irrtgular (noncondutled PAC)
Rate: 79 beats/minute (basic rhythm~
5b.Ys 10 63 beaWminute after a ~
(temporary rate $uppressioo is comroon after a pause in the basic rhythm)
P waws: Sinus (basic rhythm):
premature. pointed P wa~ distorting
T wave after the $ixth QRS complex
PR interval: 024 second (remains
constant)
QRS complex: 0.08 second
Rhythm intupretation: Normal sinus
rhythm with tirst-degree AV blCK:k;
a nonconducted PAC is present after
the sixth QRS complex.
Siri p 8-63
Rhythm: Regular (atrial): irregular
(vtntrkular)
Rate: 75 beaWminute (atrial);
50 beatYminute (ventricular)
P waves; Sinus
PR interval: Lengthens (rom 0.24 to
0.32 second
QRS complex: 0.08 second
Rhythm interpretation:
Se<:ond_degree AV blCK:k. "lobia I
Slrip 8-&~
Rhythm: Regular (atrial and
ventri cular)
Rate: 72 beaWminute (atrial );
3 1 beatYminute (ventricular)
Pwaves; Sinus (bear no rd/ltionship
to the QRS complex: hidden in the
QRS compln: and T \\Ia\'eS)
PR interval: Varies greatly
QRS compleJC 0.12 second
Rhythm interpretation: Third-degree
AVblCK:k
Slrip 8-65
Rhythm: Regular (atrial and
ventricular)
Rate: 90 beaWminute (atrial );
45 beaWminute (ventricular)
P waws: Two sinus Wil\'eS to each
QRS complex
PR interval: 026 to 0.28 second
(remains constant)
QRS complex: 0.12 second
Rhythm interpretation: Seconddegree AV block. Mobilz. II;
Sf-segment elevation is present.
Slrip S-66
Rhythm: Regular
Rate: 79 bealY'minute
P waves; Inverted before tach QRS
complex
PR interval: 0.08 to 0.10 ~nd
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
jurn:tional rhythm
Strip S-67
Rhythm: Regular
Rate: 94 beats/minute
P ...."aVes: Sinus
PR interval: 024 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with tirst-degret AV block
Strip 8-68
Rhythm; Regular (bMic rhythm):
irregular (premature beats)
Rate: 72 beaWminute (basic
rhythm)
p wwes: Sinus (basic rhythm);
prell'Wlture and abnormal (premature
btats)
PR inteNal: 0.14 to 0.16 second
(basic rhythm); 0. 12 secood (PAC5):
0.10 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpr~tation: Normal sinus
rhythm with two PACs (third and
eighth complau) and one PJC (fifth
complex); a U .....~ is present.
Strip 8-6 9
Rhythm; Regular (basic rhythm);
irregular (premature beau)
Rate: 52 beaWminute (bas ic
rhythm)
P .....aves: Hidden (basic rhythm);
prell'Wlture and abnormal (premature
btau)
PR interval: Not measurable (basic
rhythm); 0.12 to 0.14 second (PACs)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm with two PACs (second
and fifth complexes); Sf-segment
depression is present.
345
Strip 8-70
Rhythm: Regular (atrial): irregular
(v~ntricular)
346
Strip 8-74
Rhythm: Regular (atrial): irregular
(vent ricular)
Rate: 54 beats/minute (atrial);
50 beats/minute (ventricular)
P waves: Sinus
PR interval: Lengthens from 0.34 to
0.44 second
QRS complex: 0.08 second
Rhythm interpretation:
Second-degree AV block. Mobitz I
S trip 8-75
Rhythm: Regular (basic rhytrun);
irregular (escape beat)
Rate: 58 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
hidden P wave (escape beat)
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with junctional escape
beat (fou rth complex) after a pause
in the basic rhythm
S tr ip 8-76
Rhythm: Regular
Rate: 47 beats/minute
P waves: Hidden in the QRS
complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm: ST -segment depression is
present.
Strip 8-77
Rhythm: Regular (atrial and
ventricular)
Rate: 94 beats/minute (atrial);
44 beals/minute (ventricular )
P waws: Sinus (bear no relationship
In the QR.'; complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Third-degree
AV block; ST-segment elevation is
present.
Stri p 8-78
Rhythm: Regular (basic rhythm):
irregular (premature beats)
Rate: 68 beats/minute (basic rh}thm )
P waves: Sinus (basic rhythm):
premature. abnormal P waves
(premature beab)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.14 second (PAC);
0.10 second (PJC )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PAC (third
complex) and one PJC (seventh
complex); a U wave is present.
Stri p 8-79
Rhythm: Regular (atrial and
ventricular)
Rate: 80 beats/minute (atrial);
40 beats/minute (ventricular)
P waves: 1"""0 P waves to each (,)~S
complex
PR interval: 0.12 to 0.14 second
(remain constant)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Seconddegree AV block. Mobil.l. II (clinical
correlation is suggested to diagnose
Mobitz II when 2:1 conduction
is present with a narrow QRS
complex).
Stri p 8-80
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature. pointed P wave without
a QRS complex afte r the sixth QRS
complex
PR interval: 0.2210 024 second
(rem~in~ con.~I'mt)
St rip 8-81
Rhythm: Regular
~ate: 8!! beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Accelerated
junctional rh~1:hm
Strip 8-82
Rhythm : regular (atrial); irregular
(ventricular)
Rate: 75 beats/minute (atrial):
50 beats/minute (ventricular)
P waves: Sinus P waves present
PR interval: Lengthens from 026 to
0.40 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Second
degree AV block. Mobitz I; STdepression is present.
St rip 8-&3
Rhythm: Regular
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
tachycardia
St rip 8-84
Rhythm: Two separale rhythms, both
regular
Rate: 79 beats/minute (first rhythm):
84 beats/minute (second rhythm)
P waves: Sinus (first rhythm):
inverted (second rh}thm)
PR interval: 0.14 to 0.16 second
(first rhythm); 0.08 S<!cond (second
rhythm)
QRS complex: 0.06 to 0.08 second
(both rhythms)
Rhythm interpretation: Normal sinus
rhythm changing to accelerated
junctional rhythm
Strip 8-85
Rhythm: Regular (atrial and
wntricular)
Rate: 79 beats/minute (atrial);
31 beats/minute (ventricular)
p waws: Sinus (bear no relationship
to the QRS complex: hidden in QRS
complexes and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-86
Rhythm: Regular
Rate: 60 beats/minute
P waws: Sinus P waves present
PR interval: 024 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block;
~"T -segment depression and T-wave
inversion are present.
Strip 8-87
Rhythm: Regular (atrial and
wntricular)
Rate: 88 beaWminute (atrial);
33 beats/minute (ventricula r)
P waws: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waws)
PR interval: Varies greatly
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AVblock
S irip 8-88
Rhythm: Regular (basic rhythm):
irregular (premature and escape
beats)
Rate: 60 beats/minute (basic rhythm)
P waws: Sinus (basic rhythm):
pointed (atrial beat): inverted
(junctional beats)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.14 second (atrial
beat); 0.08 to 0.10 second (junctional
beat)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PJC (third
complex), one atrial escape beat
(fourth complex), and one junctional
escape beat (fifth complex)
Sirip 8-89
Rhythm: Regular (atrial): irregular
(wntricular)
Rate: 65 beats/minute (atrial);
50 beats/minute (wntricuJar)
P waves: Sinus
PR interval: Lengthens from 0.32 to
0.40 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block. Mobitz I
Sirip 8-90
Rhythm: Regular
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Junctional
tachy~rdia
Sirip 8-9 1
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
prelrnture pointed P wave deforming
T wave after the sixth QRS complex;
pointed, abnormal P wave with the
sewnth QRS complex
PR interval: 0.22 to 0.24 second
(remains constant)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Nonnal sinus
rhythm with first-degree AV block;
nonconducted PAC (after the sixth
QRS complex): an atrial escape beat
(sewnth complex) occurs duril1ll the
pause after the nonconducted PAC
(note different P wave when compared
with that of underlying rhythm).
Sirip 8-92
Rhythm: Regular (atrial); irregular
(wntricular)
Rate: 75 beats/minute (at rial);
30 beats/minute (wntricular)
P waves: Sinus (two to three before
each QRS complex)
PR interval: 0.16 ~cond (remains
constant)
QRS complex: 0.12 second
Rhythm interpretation: Seconddegree AV block. Mobitz II with 2:1
and 3:1 AV conduction; ST -segment
depression is pr~nt.
347
Strip 8-93
Rhythm: Regular
Rate: 65 beats/minute
P waV\'S: Inwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Acceluated
junctional rhythm; ST-segment
elevation is present.
Strip 8-91
Rhythm: Regular (basic rhythm):
irregular (PJCs)
Rate: 72 beats/minute (basic
rhythm)
P waV\'S: Sinus (basic rhythm);
inverted (PJCs )
PR interval: 0.14 second (basic
rhythm); 0.08 ~cond (PJCs)
QRS compla: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with two PJCs (fourth and
sixth complexes)
Strip 8-95
Rhythm: Regular (atrial) but off by
two squares; regular (ventricular) off
by one square
Rate: 80 beats/minute (atrial );
40 beats/minute (ventricular)
P waV\'S: Two sinus P waves before
each QRS complex
PR interval: 0.12 ~cond (consistent)
QRS compla: 0.12 to 0.14 second
Rhythm interpretation: Mobitz II
second-degree AV block with 2:1 AV
conduction
Strip 8-96
Rhythm: Regular (atrial) : irregular
(ventricular )
Rate: 75 beats/minute (atrial):
70 beats/minute (ventricular)
P waV\'S: Sinus
PR interval: Lengthens from 0.32 to
0.40 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Second
degree AV block. Mobitz I
348
Strip 8 97
Rhythm: Regular
Rate: 40 beats/minute
P waves: Hidden in the QRS complex
PR interval: Not measurable
QRS complex: 0.10 second
Rhythm interpretation: Junctional
rhythm: !'>'Tsegment elevation is
present.
Strip 8-10 1
Rhythm: Regular
Rate: 44 beats/minute
P waves: Hidden in the QRS
compl""
PR interval: Not measurable
QRS complex: 0.08 to 0.l0 second
Rhythm interpretation: Junctional
St rip 8- 106
Rhythm: Irregular
Rate: 90 beats/minute
P waves: Vary in size, shape across
drip
PR interval: 0.12 to 0.20 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 8-98
Rhythm: Regular (atrial and
ventricular)
Rate: 80 beat51minute (atrial);
40 beats/minute (ventricular )
P waves: Two sinus P waves to each
QRS complex
PR interval: 0.22 to 0.24 second
(remains constant)
QRS complex: 0.10 second
Rhythm interprdation: Second
degree AV block, Mobitz II (clinical
correl"tion i< ~"ggp_ded to diagno.",
Mobilz II ",-hen 2:1 conduction is
present with a narrow QRS complex):
ST-segment eleviltion is present.
Strip 8-102
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
Strip 8- 107
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 72 beats/minute (basic rhythm
before pa.use): rate slows to 60 beats/
minute following pause due to rate
suppression.
P waves: Sinus (basic rhythm);
absent during pause
PR interval: 0.22 to 0.24 second
(basic rhythm); absent during piluse
QRS complex: 0.08 to 0.10 second
(],a~ic rhythm): ~],<ent durin!!
pause
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
and sinus arrest
Strip 8-99
Rhythm: Regular (basic rhythm);
irregular (PJC)
Rate: 84 beilts/minute (basic rhythm)
P waves: Sinus (basic rhythm);
inverted (PJC)
PR interval: 0.12 second (basic
rhythm); 0.08s.:cond (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretiltion: Normal sinus
rhythm with one PJC
Strip 8-100
Rhythm: Regular (basic rhythm);
irregular after PJC and run of PJT
Rate: 100 beats/minute (basic
rhythm): 136 beats/minute (PlT)
P waves: Sinus (basic rhythm );
inverted (pJCand PJT)
PR interval: 0.12 to 0.14 second (basic
rhythm): 0.08 second (PJC and PJT)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 to 0.10 second
(PJC and PJT )
Rhythm interpretation: Normal sinus
rhythm with one PJC (fifth complex)
and a three-beat run of PlT (eighth,
ninth, and tenth complexes)
"""'m
"""'m
Strip 8103
Rhythm: Irregular
Rate: 240 beats/minute (atrial);
90 ],eat.<Jminute (ven tricular)
P waves: Flutter waves
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Atrial Hutter
with variable AV conduction
Strip 8-1 04
Rhythm: Regular (basic rhythm );
irregular with PJC
Rate: 56 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
inverted P wave (PJC)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.06 second (PJC)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.10 second (PJC)
Rhythm interpretation: Sinus
bradycardia with one PJC (fifth
complex)
Strip 8-105
Rhythm: Regular
Rate: 68 beats/minute
P waves: Sinus
PR interval: 0.24 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal
sinus rhythm with first-degree AV
block
St rip 8- 108
Rhythm: Regular (atrial and
ventricular)
Rate: 82 beats/minute (atrial );
41 beats/minute (ventricular)
P waves: Two sinus P waves to each
QRS complex
PR interval: 0.16 to 0.18 second
(remains consistent)
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Mobitz II
second-degree AV block
St rip 8-109
Rhythm: Regular
Rate: 115 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
tachycardia
Strip 8-110
Rhythm: Regular (basic rhythm)
Rate: 40 beats/minute
P waws: Sinus (basic rhythm); one
premature pointed P wave
PR interval: 024 to 0.26 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus bradycardia with first-degree AV block and
one non conducted PAC
Strip S- I ll
Rhythm: Irregular
Rate: 80 beats/minute
P waws: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
arrhythmia
Slrip S- I IZ
Rhythm: Regular (atrial and
wntricular)
Rate: 72 beats/minute (atrial);
35 beats/minute (ventricular)
P waws: Sinus (no relationship to
QRS complex; found hidden in ~'T
segment, QRS complex)
PR interval: Varies (not consistent)
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-113
Rhythm: Irregular
Rate: 60 beats/minute
P waws: FibrilJatory waves
PR interv<ll: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip 8- 1 J.\
Rhythm: Regular (off by one
square)
Rate: 48 to 50 beats/minute
P waws: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 iecond
Rhythm interpretation: Sinus
bradycardia
349
Strip 8- 115
Rhythm: Regular
Rate: 167 beats/minute
P wmes: TP waw present (P waw
merged with T wave)
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 8- 120
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Rh}1hm interpretation: Accelerated
junctional rhythm
Strip8- 116
Rhythm: Regular
Rate: 58 beats/minute
P wmet: Hidden within QRS complex
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm
Strip 9- 1
Rhythm: Regular
Rate: 167 beats/minute
P waves: Abs<!nt
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia
Strip8- 117
Rhythm: Regular (atrial); irregular
(wntricular)
Rate: 94 beats/minute (atrial);
60 beats/minute (wntricular)
P wmes: Sinus
PR interval: Lengthens from 0.22 to
0.28 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Mobitz I
second-degree AV block
Strip 9-2
Rhythm: Regular
Rate: 65 beats/minute
P waves: Sinus: notched P
waves usually indicate left atrial
Strip 8- 11 8
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 9-3
Rhythm: Regular (basic rhythm);
irregular (PVCs)
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
no P waws as.sociated with PVCS;
sinus P waves can be seen after the
Strip 8-119
Rhythm: Regular (bru;ic rhythm);
irregular with premature beat
Rate: 88 beats/minute (basic rhythm)
P wmes: Sinus (basic rhythm); small,
pointed P wave with premature beat
PR interval: 0.12 to 0.14 sond
(basic rhythm); 0.12 second
(premature beat)
QRS complex: 0.08 second (basic
rhythm and premature beat)
Rhythm interpretation: Normal sinus
rhythm with one PAC
h~rtrophy
I'VC,
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second (basic
rhythm); 0.12 second (PVCs)
Rhythm interpretation: Normal sinus
rhythm with two unifocal PVCs (fifth
and eighth complex)
Strip 9-1
Rhythm: Irregular
Rate: 30 beaWminute
P waws: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
Idiowntricular rhythm
350
Strip 9-5
Rhythm: 0
Rate: Not measurable
P waves: Chaotic wave deflection of
varying height. size. and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-6
Rhythm: Regular (basic rhythm);
irregular (PVCS )
Rilte: 100 bo!atYminute (basic rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.08 second (basic
rhythm): 0.12 second (PVCs )
Rhythm interpretation: Normal
~inus rhythm with unifocal PVCs in
a bigeminal pattern (second, fourth.
sixth. and eighth complexes)
Strip 9-7
Rhythm: First rhythm can't be
determined (only one cardiac cycle);
second rhythm irregular
Rate: 54 beats/minute (first rhythm):
80 beats/minute (second rhythm)
P waves: Sinus P waves (basic rhythm)
PR interval: 0.16 second (basic rhythm)
QRS complex: 0.08 second (basic
rhythm): 0.12 second (ventricular
beats)
Rhythm interpretation: Sinus
bradycardia changing to accelerated
idioventricular rhythm: ST-segment
depression is present (basic rhythm).
Strip 9-8
Rhythm: Irreguklf (first and second
rhythms)
Rate: 60 beats/minute (first rhythm);
about 200 beats/minute (second
rhythm)
P waves: Fibrillation waves (fi rst
rhythm): none identified in the
second rhythm
PR interval: Not measurable
QRS complex: 0.00 to 0.08 second
(first rhythm): 0.12 to 0.14 second
(second rhythm)
Rhythm interpretation: Atrial fibrillation with burst ofventricular
tachycardia; ST-segrrtent depression
with basic rhythm
Strip 9-9
Rhythm: Regular
Rate: 250 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 to 0.20 second
Rhythm interpretation: Ventricular
tachycardia (torsade de pointes)
Sirip 9- 10
Rhythm: Regular (basic rhythm):
irregular (PVCS)
Rate: 79 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.16 second
QRS complex: 0.06 second (basic
rhythm); 0.14 to 0.16 second (WCs)
Rhythm interpretation: Normal sinus
rhythm with paired unifocal PVCS
(sixth and seventh complexes)
Slrip 9 11
Rhythm: Regular
Rate: 42 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation:
Idioventricular rhythm
Strip 9-12
Rhythm: Regular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.1 2 S(oond
QRS complex: 0.12 second
Rhythm interpretation: Sinus tachycardia with bundle-branch block; an
elevated ST segment is present.
Strip 9- 13
Rhythm: 0
Rate: 0 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: None identified
Rhythm interpretation: Ventricular
standstill (asystole)
Strip 9-1<\
Rhythm: Regular
Rate: 21<\ beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation: Ventricular
tachycardia
Slr ip9- 15
Rhythm: Regular (basic rhythm)
Rate: 50 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 second (basic
rhythm): 0.14 second (PVC)
Rhythm interpretation: Sinus
bradycardia with one PVC (thi rd
complex); 5T-segment depression is
present.
Slrip9- 16
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent: wave deflections are
irregular and vary in height, size.
and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Slrip9- 17
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Wave deflections are chaotic
and vary in height, siz.e, and shapi!
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation is followed by electrical
shock and a return to ventricular
fibrillation.
Sl rip9-18
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PI{ interval: U.16 to U.ll1second
QRS complex: 0.12 second
Rhythm interpretation: Sinus
tachycardia with bundle-branch block
Slrip9- 19
Rhythm: Irregular
Rate: 300 beats/minute (atrial ):
50 beats/minute (ventricular)
P waves: Flutter waws before each
QR5 complex
PR interval: Not measurable
QRS complex: 0.00 to 0.08 second
(basic rhythm); 0.12 second (PVC)
Rhythm interpretation: Atrial flutter
with variable AV conduction and one
PVC (fifth complex)
Strip 9-20
Rhythm: Regular (at rial)
Rate: 136 beats/minute (atrial):
obeats/minute (ventricular: no QRS
complel!.eJ)
P ..... aves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
S irip 9-2 1
Rhythm: Irregular
Rate: 40 beats/minute
P ..... aves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
ldioventricular rhythm
Strip 9-22
Rhythm: Chaotic
Rate: 0 beats/minute (no QRS
complexes)
P waves: None identified
PR interval: Not measurable
QRS complu: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-23
Rhythm: Regular
Rate: 88 beats/minute
Pwave5:Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Accelerated
idioventricular rhythm
S irip 9-24
Rhythm: Irregular (basic rhythm)
Rate: 60 beats/minute (basic rhythm)
P waws: Fibrillatory ..... aves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC5)
Rhythm interpretation: Atrial
fibrillation with paired PVCs
Sirip 9-25
Rhythm: Regular (basic rhythm)
Rate: 100 beats/minute (first rh~1hm):
188 beall/minute (second rhythm)
P .....aves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second (basic
rhythm): 0.12 to 0. 16 second
(wntricu lar beats)
Rhythm interpretation: Normal sinus
rh}1hm with burst of ventricular
tachycardi a and paired PVCs
Sirip 9-26
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 107 heats/minute (basic rhythm)
P wavet: Sinus (basic rhythm)
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 to 0.10 second
(basic rhythm): 0.16 second (PVC)
Rhythm interpretation: Sinus tachycardia with one PVC (R-on-T pattern):
an elevated ST segment is prese nt.
Strip 9-27
Rhythm: Irregular (difficult to
determine due to changing polarity
of QRS complex)
Rate: 250 beall/minute or greater
P .....aves: Absent
PR interval: Not measurable
QRS complex: 0.12 second or greater
Rhythm interpretation: Ventricular
tachycardia (touade de pointes)
Sirip 9-28
Rhythm: Regular
Rate: 250 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 to 0.16 second (QRS
complexes change in polarity from
negative to positive across the strip).
Rhythm interpretation: Ventricular
tachycardi a (torsades de pointes)
Strip 9-29
Rhythm: Regular
Rate: 84 beats/minute
P .....aves: None identified
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Accelerated
idioventricular rhythm
35 1
Strip 9-30
Rh}1hm: Chaotic
Rate: 0 beats/minute
P waws: Absent; wave deflections are
irregular and vary in height. Jize.
and shape.
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricu lar
fibrillation
S lrip 9-31
Rhythm: Regular (basic rhythm):
irregular (PVCs)
Rate: 115 beats/minute (basic
rhythm)
P ..... aws: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex:: 0.04 to 0.06 second
(basic rhythm); 0.12 second (PVC5)
Rhythm interpretation: Sinus
tachycardia with two unifocal PVCs
(fourth and twelfth complexes)
Sirip 9-32
Rhythm: Regular (basic rhythm):
imgular (PVes)
Rate: 125 beats/minute (ba5ic
rhythm)
P ..... aves: Sinus (bosic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
(basic rhythm); 0. 12 second (PVC5)
Rhythm interpretation: Sinus tachy_
cardia with multifocal paired PVCs
(eighth and ninth complexes)
Strip 9-33
Rhythm: Regular (basic rhythm)
Rate: 37 beats/minute (basic rhythm)
P ..... aves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (escape
beat)
Rhythm inte rpretation: Sinus bradycardia with one ventricular escape
beat (third complex)
352
Strip 9-,3.1
Rhythm: Regular (first and second
rhythms)
Rate: 72 beats/minute (first rhythm);
150 beats/minute (second rhythm)
P waws: Sinus (basic rhythm )
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second (basic
rhythm): 0.12 st'\:ond (wntricular
beats)
Rhythm interpretation: Normal sinus
rhythm with a burst of ventricular
tachycardia; an inverted T waw is
present in basic rhythm.
Strip 9-39
Rhythm: Regular (basic rhythm)
Rate: 115 beats/minute (basic
rhythm)
P waves: Inverted before each QRS
complex in basic rhythm
PR interval: 0.08 second (basic
rhythm)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Junctional
tachycardia y,ith one PVC (tenth
complex)
Strip 9-43
Rhythm: Regular (first rhythm):
irregular (second rhythm)
Rate: 100 beats/minute (first rhythm);
100 beats/minute (second rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.12 second
QRS complex: 0.12 to 0.14 second
(tirst rhythm): 0.12 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
with transient episode of accelerated
idioventricu lar rhythm
Strip 9-40
Rhythm: Chaotic
Rate: 0 beats/minute
P waws: Absent: wave defledions
val)' in height. size. and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-36
Slrip 9-41
Rhythm: Irregular
Rate: About 30 beats/minute
P waws: Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation:
Idiowntricular rhythm; ST-segment
elevation is present.
Strip 9-35
Strip 9-37
Rhythm: Not measurable
Rate: Not measurable (one complex
present)
P waws: None identified
PR interval: Not measurable
QRS complex: 028 second or wider
Rhythm interpretation: One
wntricular complex followed by
wntricular standstill
Strip 9-38
Rhythm: Regular
Rate: 84 beats/minute
P waws: None identified
I'R interval: Not mCII.umble
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Accelerated
idiowntricular rhythm
Strip 9-44
Rhythm: First rhythm cant be
detennined (only one cardiac cycle
present); second rhythm regular
Rate: 50 beats/minute (first rhythm);
41 beats/minute (second rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.12 second (tirst rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm): 0.12 to 0.14 second
(second rhythm)
Rhythm interpretation: Sinu.
bmdycardia changing to idiOVl!ntricular
rhythm: a U wave is present.
Slrip 9-45
Rhythm: Regular
Rate: 214 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second or
wider
Rhythm interpretation: Ventricular
tachycardia
Strip 9-42
Rhythm: Irregular (ti rst rhythm);
regular (second rhythm)
Rate: 100 beats/minute (first
rhythm); 167 beats/minute (second
rhythm)
P waves: Fibrillation waves (basic
rhythm)
PR interval: Not measurable
QRS complex: 0.08 second (basic
rhythm): 0.12 second (VI)
Rhythm intcrpret.. tion: Atrial
fibrillation with a burst of ventricular
tachycardia
Strip 9",(6
Rhythm: Regular (basic rhythm);
irregular (ventricular beats)
Rate: About 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.20 second
QRS complex: 0.06 second (basic
rhythm); 0.16 second (first
wntricular beat); 0.12 st'\:ond
(.ccond ventricul .. r bCllt)
Rhythm interpretation: Sinus
bradycardia with one PVC (fourth
complex) and one ventricular escape
beat (fifth complex): ST-segment
depression is present.
Strip 9-47
Rhythm: Regular (basic rhythm)
Rate: 68 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 ~econd
QRS complex: 0.08 to 0.10 second
(basic rhythm); 0.12 to 0.14 second
(PVC)
Rhythm interpretation: Normal sinus
rhythm with one PVC
Strip 9-48
Rhythm: Not measurable
Rate: Not measurable (one complex
present)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: One
ventricular complex followed by
ventricular standstill
Strip 11_411
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.12 second
Rhythm interpretation: Sinus
bradycardia with bundle-branch
block: ST-segment depression is
present.
Strip 9-50
Rhythm: Regular
Rate: 188 beats/minute
p waves: Not identified
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Ventricular
tachycardia
Strip II 5 1
Rhythm: Regular (atrial): irregular
(vent ricular )
Rate: 58 beats/minute (atrial); about
40 beats/minute (ventricular)
P waves: Sinus
PR interval: Lenllthens from 0.30 to
0.36 second
QRS complex: 0.08 second (basic
rhythm); 0.12 second (escape beat)
Rhythm interpretation: Seconddegree AV block, Mobitz I with
one ventricular escape beat (third
complex)
Sirip 9-52
Rhythm: Regular (first and second
rh}1hms)
Rate: 72 beats/minute (first rhythm);
72 beo.t>lminute (.... cond rhythm)
P waves: Sinus in first rhythm
PR interval: 0.12 to 0.14 second (first
rhythm)
QRS complex: 0.08 second (first
rh}1hm): 0.12 to 0.14 second (second
rh}1hm)
Rhythm interpretation: Normal
sinus rhythm with a transient
episode of accelerated idioventricular
rhythm
Strip 9-53
Rhythm: Slightly irregular (atrial)
Rate: About 40 beats/minute (atrial):
obeats/minute (ventricular; no QRS
complexes)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Sirip 9-51
Rhythm: Regular
Rate: 84 beats/minute
p waves: Sinus
PR interval: 0.16 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Normal sinus
rh}1hm with bundle-branch block; a
depressed ST segment is present.
Strip 9-55
Rhythm: Regular
Rate: 41 beats/minute
P waves: Absent
PR interval: Not measurable
QRS comptex: 0.16 second
Rhythm interpretation: Idioventricular rhythm
Strip 9-56
Rhythm: Regular
Rille: 75 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.16 to 0.18 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block;
T-wave inversion is present
353
Strip 9-57
Rh}1hm: Regular (basic rhythm);
irregular (PVCS)
Rate: 72 beats/minute (basic
rhythm)
p waves: Sinus (basic rhythm)
PR interv.'Jl: 0.12 second
QRS complex: 0.08 second (basic
rhythm); 0.12 to 0.14 second
(PVCs)
Rhythm interpretation: Normal
sinus rhythm with unifocal PVCs
(fourth and eighth complexes) in a
quadrigeminal pattern
Strip 9-58
Rhythm: Regular (atrial); ventricular
not measurable (only one
QRS complex present)
Rate: 29 beats/minute (atrial);
ventricular not measurable (only one
QRS complex present)
P waves: Sinus
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: One QRS
complex followed by ventricular
standstill
Sirip 9-59
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent: wave deflections
are irregular and chaotic and vary in
size, shape, and height
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-60
Rhythm: Nol measurable (only one
QRS comp]"",)
Rate: Not measurable (only one QRS
complex)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 second or
!treater
Rhythm interpretation: One QRS
complex foll(Med by ventricular
standstill
354
Strip 9-6 1
Rhythm: Regular (first and second
rhythms)
Rate: 100 beats/minute (first
rhythm); 100 beats/minute (second
rhythm)
P waws: Sinus (first rhythm); none
(second rhythm)
PR interval: 0.14 to 0.16 second (first
rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm): 0.12 second (second
rhythm)
Rhythm interpretation: Norllkll sinus
rhythm changing to accelerated
idioventricular rhythm
Strip 9-62
Rhythm: Regulu
Rate: 40 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
Idioventricular rhythm
Strip 9-63
Rhythm: Regular
Rate: 167 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second
Rhythm interpretation: Ventricular
tachycardia
Strip 9-64
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.22 to 0.24 second
QRS complex: 0.12 second
Rhythm interprdation: Norllkll sinus
rhythm with bundle-branch block
and first-degree AV block
Strip 9-65
Rhythm: Irregular
Rate: 80 beats/minute (basic
rhythm)
P waves: Fibrillation waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.12 second (PVCS)
Rhythm interprdation: Atrial
fibrillation with paired PVCs
Strip 9-66
Rhythm: Regular (basic rhythm)
Rate: 84 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.24 second
QRS complex: 0.08 S<!cond
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
changing to ventricular standstill
Strip 9-67
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: Absent
Rh}thm interpretation: Ventricular
fibrillation
Strip 9-7 1
Rhythm: Regular
Rate: 100 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Aa:elerated
idioventricular rhythm
Strip 9-72
Rhythm: 0 beats/minute (only one
QRS complex present)
Rate: 0 beats/minute (only one QRS
complex present)
P waves: None identified
PR interval: Not measurable
QRS complex: 024 to 0.26 second
Rhythm interprdation: One QRS
complex followed by ventricular
standstill
Sirip 9-68
Rhythm: Regular
Rate: 167 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Ventricular
ta(hYGmlia
Strip 9-69
Rhythm: Regular (first rhythm):
slightly irregular (second rhythm)
Rate: 115 beats/minute (first
rhythm): about 214 beats/minute
(second rhythm)
P waves: Sinus (fi rst rhythm): none
identified in the second rhythm
PR interval: 0. 12 to 0.14 second (first
rhythm)
QRS complex: 0.10 second (first
rhythm): 0.12 to 0.16 second (second
rhythm)
Rhythm interpretation: Sinus tachycardia with a burst of ventricular
tachycardia returning to sinus tachycardia; an inverted T wave is present.
Strip 9-70
Rhythm: Regular
Rate: 40 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm intcrpreUltion: Idioventricular rhythm
Strip 9-73
Rhythm: Regular
Rate: 188 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 020 second or
wider
Rhythm interpretation: Ventricular
tachycardia followed by electrical
shock and return to ventricular
tachycardia
Strip 9-74
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 100 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second (basic
rhythm); 0.1 2 second (PVC)
Rhythm interpretation: Normal
sinus rhythm with one PVC (fifth
complex)
Strip 9-75
Rhythm: Regular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Sinus
bradyc~rdi" with bundle-branch
block
Strip 9-76
Rhythm: 0 beats/minute
Rate: 0 beats/minute (no QRS
complexes)
p ",a"".: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Strip 9-77
Rhythm: Re!lular
Rate: 41 beats/minute
P waves: Ab5ent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation:
ldioventricular rh}1hm
Strip 9-78
Rhythm: 0 beats/minute (only one
QRS complex)
Rate: 0 beats/minute (only one QRS
complex)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.14 second
Rhythm interpretation: One ventricular complex (ollowed by ventricular
standstill
Strip 9-79
Rhythm: 0 beats/minute
Rate: 0 beats/minute
P waves: Absent: wave deHections are
chaotic and vary in height. size. and
shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation changing to ventricular
standstill
Strip 9-80
Rhythm: Regular (first and second
rhythms)
Rate: 94 beats/minute (first rhythm);
75 beats/minute (second rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.16 second
QRS complex: 0.12 second (first
rhythm): 0.12 second (second rh}1hm)
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
changing to accelerated idioventricular rhythm and back to normal sinus
rhythm with bundle-branch block;
T-wave inversion is present.
Strip 9-81
Rhythm: Regular (atrial); ventricular
rhythm can't be determined (only
one cardiac cycle)
Rate: 111 beal.5lminut.. (atrial);
40 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies greatly
QRS complex: 0.14 second
Rhythm interpretation: Third-de!lree
AV block changing to ventricular
standstill
Strip 9-82
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Stri p 9-8,3
Rhythm: Regular (first rhythm);
irregular and chaotic (second rhythm)
Rate: 214 beats/minute (first rhythm)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second
(first rhythm)
Rhythm interpretation: Ventricular
tachycardia changing to ventricular
fibrillation
Strip 9-84
Rhythm: Regular
Rate: 32 beaWminute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.20 second
Rhythm interpretation: ldioventrkular rhythm
Strip 9-85
Rhythm: Regular (basic rhythm):
irregular (PVCs)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR intelVal: 0.12 second
QRS complex: 0.06 to 0.08 SKond
(basic rhythm); 0.12 second (PVCs)
Rhythm interpretation: Sinus tachycardia with multifocal paired PVCs
(eighth and ninth complexes)
355
Strip 9-86
Rh}1hm: Regular (atrial)
Rate: 52 beats/minute (atrial);
o beats/minute (ventricular)
p waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Sirip 9-87
Rhythm: Regular (first rhythm):
irregular (second rhythm)
Rate: 68 beats/minute (first rhythm);
about 80 beats/minute (second
rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (fi rst
rhythm); 0.12 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm ch;mging to ~cCl'.ler~ted
idioventricular rhythm
Strip 9-BS
Rhythm: Regular
Rate: 167 beatslminute
P waves: Not identified
PR interval: Not measu rable
QRS complex: 0.16 to 0.20 second
Rhythm interpretation: Ventricular
tachycardia (torsades de pointes)
Strip 9-89
Rh}1hm: Regular (basic rhythm);
irregular (PVCs)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Sinus Utchycardia with paired PVCS (seventh and
eighth complexes)
Strip 9-90
Rhythm: Regular (atrial )
Rate: 72 beats/minute (atrial);
o beats/minute (ventricular )
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
356
Strip 9-9 1
Rhythm: Regular
Rate: 188 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.18 to 0.20 second or
wider
Rhythm interpretation: Ventricular
tachycardia
Strip 9-92
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Wave defle(tions (haotk:
vary in size. shape, and direction
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation: 60-cycle (electrical)
interference noted on baseline.
Strip 9-93
Rhythm: Regular
Rate: 28 beats/minute
P waves: None
PR interval: Not measurable
QRS complex: 020 second or wider
Rhythm interpretation:
Idiowntricular rhythm
Slrip 9-94
Rhythm : Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Strip 9-95
Rhythm: Regular (basic rhythm)
Rate: 68 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.12 second (PVC)
Rhythm interpretation: Normal
sinus rhythm with one interpolated PVC (seventh complex).
Interpolated PVCs are sandwiched
be""'een ""'0 sinus beats and have
no compensatory pause. STsegment depression and T-wave
inversion are pruenl.
Strip 9-96
Rhythm: Regular (basic rhythm);
irregular (PVCs)
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (basic
rhythm): 0. 12 to 0.14 second
(PVCs )
Rhythm interpretation: Normal sinus
rhythm with PVCS in a trigeminal
pattern
Strip 9-97
Rhythm: Irregular
Rate: 80 beats/minute
P waves: Wavy fibrillatory waves
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Atrial
fibrillation with bundle-branch
block
Strip 9-98
Rhythm: Regular (fi rst rhythm);
regular but off by ""'0 squares
(second rhythm)
Rate: 43 beats/minute (first rhythm);
45 beats/minute (second rhythm)
P waves: Sinus (first rhythm): no
associated P waves (second rhythm)
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS (omplex: 0.10 second (basil;
rhythm): 0.14 to 0.16 second (second
rhythm)
Rhythm interpretation: Sinus
bradycardia with three-beat run of
idioventricular rhythm
Strip 9-99
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 79 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.20 second
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
and sinus exit block
Strip 9-100
Rhythm: None
Rate: 0 beats/minute
P waves: None identified; wavy baseline
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation changing to wntricular
standstill
Strip 9- 101
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip9 102
Rhythm: Regular
Rate: 167 beats/minute
P waves: TP waves present
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 9- 103
Rhythm: Regular
Rate: 45 beats/minute
P waves: Hidden within QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm
Strip 9- 1 0~
Rhythm: Regular
Rate: 63 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Strip 9- 105
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 8<\ beats/minute (atrial);
70 beats/minute (ventricular)
P waves: Sinus
PR interval: Lengthens from
020 second to 0.32 second
QRS complex: 0.087 to 0.10 second
Rhythm interpretation:
Second-degree AV block, Mobilz I
Strip 9- 106
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 72 beatY'minute (bMi,
rhythm); rate dec:reaS1';5 to 65 bt-aW
minute folkP.ving pause dut to
temporary rate suppression_
P waYeS: Sinus (basic rhythm):
absent during pause
PR interval: 0.24 5ewnd: absent
during pause
QRS complu: 0_06 to 0.08 second:
absent during pause
Rhythm inlerpreLIIlion: Normal sinus
rh~1hm with first_degree AV bla<:k
and sinus arrest
S trip ~ 1 0 7
Rhythm: Regular (basi, rhythm):
irregular with premature beat
Rate: 52 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): sma ll,
pointed P wave with premature bt-at
PR interval: 0.14 to 0.16 second (basic
rhythm): 0.12 second (premature beat)
QRS complex: 0.08 to 0.10 second
(basic rhythm): 0.10 second
(premature bt-at)
Rhythm interpretation: Sinus bradycardia with one PAC
Sirip 9-108
Rhythm: Regular (basic rhythm)
Rate: 45 beatY'minute (basic rhythm)
P waves: Absent
PR interval: Not measurable
QRS comple:!: 0_16 to 0.18 second
Rhythm interpretation: Idiovmt ricuI..,. rhythm 10 vcntricuL!o, Jblndstill
Strip ~1 09
Rhythm: Regular
Rate: 84 bt-atY'minute
P waves: Sinus
PR interval: 0.30 to 0.32 .second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV bla<:k
Strip 9-110
Rh}thm: Regular (basic rhythm)
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.14 to 0.16 .second
QRS complex: 0.06 to 0.08 second (basic rhythm): 0.12 to 0.14 5etOnd (PVC)
Rhythm interpretation: Normal sinus
rhythm with one PVC
Sirip 9- 11 1
Rhythm: Regular
Rale: 240 beatY'minute (atrial):
60 beatY'minute (ventricular)
P waves: F1utler WiIVl'S
PR inte rval: Not measurable
QRS complex: 0_08 second
Rhythm interpretation: Atrial flutter
with 4: 1 AV conduction
Slrip 9- 11 2
Rhythm: Regular
Rate: 11 5 beatY'minute
P. . .aves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Sinus
t&chycardia
Stri p 9- 11 3
Rhythm; Not measurable (one
complex)
Rate: Not measurable (one complex)
P .....aves: Absent
PR interval: Not measurable
QRS complex: 0.20 to 0.24 second
Rhythm interpretation: One ventricular complex to ventritul~r standstill
Strip 9- IH
Rhythm: Regular (bas ic rhythm) but
off by two squares
Rate: 72 to 75 beatY'minute
P .....aves: Vary in s~e_ shape. direction
PR interval; 0.12 to 0_ 16 second
QRS complo: o.~ to O.l~ (basic
rhythm); 0.12 second or greater (premature beat)
Rhythm interpretation: Wandering
atrial pacemaku with PVC
S trl p 9- 11 5
Rhythm: F1llit rhythm probably regular
(only two QRS cOqllo:es): seOOlld
rhythm regular (off by two squares)
Rate: 75 beats/minute (basic rhythm):
72 to 79 beats/minute (second rhythm)
P waves: Sinus (tirst rhythm): absent
(Iecond rhythm)
PR interval: 0.18 to 0.20 second (tirst
rhythm); absent (second rhythm)
QRS complex: 0.00 10 O.08secOfld
(first rhythm); 0.12 seOOlld or greater
(second rhythm)
Rhythm interpretation: Normal sinus
rhythm with episode of accelerated idioventricular Ihythm going back to NSR
357
Strip 9-116
Rhythm: Regular (off by one square)
Rate: 54 to 56 beatY'minute
P waYeS: Si nus
PR interval: 0. 14 to 0_ 16 second
QRS complex: O.~ .sewnd
Rhythm interprellltion: Sinus
b~ycardia
S trip ~117
Rhythm: Irregular
Rate : 70 beatY'minute
P waYeS: Fibrillatory wal'l'S
PR interval: Not lTM'asurable
QRS complex: O.~ to 0.00 .second
Rhythm interpretation: Atrial
fibrillation
S trip ~11 8
Rhythm: Regular
Rate: ISO beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia
Strip9- ll9
Rhythm: Regular
Rate: 100 beatY'minute
P waYeS: Inverted bt-fore each QRS
complex
PR interval: 0.0810 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Ac:ederated
junctional rhythm
Strip ~ 1 20
Rhythm: Regular (atrial) but off by
one square: regular (ventricular)
Rate: 88 to 94 bnl5lminute (atrial):
44 beau/minute (ventricular)
P WilI'eS: Sinus
PR interval: Varies greatly (not
wnsistent)
QRS complex: 0.06 to 0.08 .second
Rh}1hm interpretation: Third-degree
AV bla<:k
S trip 9-12 1
Rhythm: Chaotic and irregular
Rate: 0 beats/minute
P waves: Fibrillatory waves which
are irregular: vary in siu, shape,
amplitude
PR interval: Not lTM'asurable
QRS complex: Absent
Rhythm interpretation: Ventr icular
fibrillation
358
Strip 9-122
Rhythm: Regular
Rate: 63 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Nortllill sinus
rhythm: U wave is present.
Strip 9-\23
Rhythm: Regular (basic rhythm)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm ):
inverted P waves before each
premature beat
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.08 second
(prematu re beats)
QRS complex: 0.08 second (basic
rhythm and PJC5)
Rhythm interpretation: Nortllill
sinus rhythm with tv,o premature
junctional contractions
Strip 9-124
Rhythm: Regular (atrial) but off by
two squares; regular (ventricular)
Rate: 65 to 72 beat.'lminute (atrial);
34 beats/minute (ventricular )
P waves: Sinus (tv,o P waves before
QRS complex)
PR interval: 0.12 to 0.14 second
(consistent)
QRS complex: 0.12 second
Rhythm interpretation:
Second-degree AV block: Mobitz II
Strip 10- \
Analysis: The first four beats are
ventricular paced beats followed
by one intrinsic beat and three
wntricular paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat
(normal pacemaker function)
Strip 10-2
Analysis: The first three beats are
wntricular paced beats followed
by two intrinsic beats, a paci"!!
spike that occurs too early, an
intrinsic beat, a fusion beat, and tv,o
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with thr~ intrinsic beats, one
fusion beat, and one episode of undersensing (abnonnal pacemaker function)
Strip 10-3
Analysis: The first complex is an
intrinsic beat foll(Med by tv,o
ventricular paced beats, an intrinsic
beat. and tv,o ventricular paced
beats.
Interpretation: Ventricular paced
rhythm with tv,o intrinsic beats
(normal pacemaker fundion)
Stri p 10-4
Analysis: The first two complexes are
ventricular paced followed by a pacing spike with failure to capture, a
ventricular paced beat. a pacing spike
with failure to capture, an intrinsic
beat. a ventricular paced beat, a pacing spike with failure to capture, and
an intrinsic beat.
Interpretation: Ventricular paced
rhythm with t-,.,o intrinsic beats and
three episodes 01 failure to capture
(abnormal pacemaker function)
Stri p 10-5
Analysis: No patient or paced beats
are seen: pacing spikes are present
that fail to capture the wntric1es.
Interpretation: Failure to capture
in the presence of ventricular
standstill
Stri p 10-6
Analysis: The first five complexes
are intrinsic beats follOolled by mo
ventricular paced beats, tv,o intrinsic
beats, and one ventricular paced
beat.
Interpretation: Ventricular paced
rhythm with seven intrinsic beats
(normal pacemaker function)
Stri p 10-7
Analysis: The first complex is an
intrinsic beat followed by a ventricular paced beat that occurs too early.
tv,o ventricular paced beats, a fusion
beat, an intrinsic beat, a pacing spike
that occurs too early, and three
intrinsic beats.
Interpretation: Ventricular paced
rhythm with five intrinsic beats,
one fusion beat. and two episodes
of undersensing (one with capture
and one without capture). This is
abnormal pacemaker function.
Strip 10-8
Analysis: The first five complexes are
ventricular paced followed by a pause
in pacing, a ventricular paced beat
that occurs later than expected, and
a ventricular paced beilt.
Interpretation: Ventricular paced
rhythm with one episode of oversensing (pacemaker sensed the small
waveform artifad seen during the
pause). This is abnormal pacemaker
function.
St rip 10-9
Analysis: The first two complexes
are ventricular paced beats followed by a pacing spike that fails
to capture, an intrinsic beat, three
ventricular paced beats, and an
intrinsic beat.
Interpretation: Ventricular pilced
rhythm with tv,o intrinsic beats and
one episode of failure to capture
(abnormal pacemaker function)
Strip 10-10
Analysis: All complexes are pacemaker induced.
Interpretation: Ventricular paced
rhythm
Strip 10-11
Analysis: The first three complexes
are ventricular paced beats foll(Med
by an intrinsic beat, a pacing spike
that occurs too early, an intrinsic
beat, a pacing spike with capture
that occurs too early. and three
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with tv,o intrinsic beats and
two ~pisod~s of undusensing (one
episode without capture and one
episode with capture).This represents
abnormal pacemaker fundion.
Strip 10-12
Analysis: The first six complexes are
intrinsic beats followed by two ventricular paced beats and two intrinsic
beats.
Interpretation: Ventricular paced
rhythm with eight intrinsic beats
(normal pacemaker function)
Strip 10-1-4
An"'i)l$is: The tirst two complexu
<lITe intrinsic buts followed by a
fusion beat (note pacing spike ",t
onset of QRS). ",not her fusion beat.
",nd three ventricular paced beats.
Interpretation: Ventricular paced
rhythm with two intrinsic beats and
two fusion beats (normal pacemaker
function)
Strip 10-15
Analysis: The first three complexes
",re ventricuillr paced beats: ..... hen the
p"'cemaker is turnd off the under[ying rhythm is ventricular standstill:
two ventricular p"'ced beats are
seen when the p"'cemaker is turned
ba~ on.
Interpr~tation: Ventricular pac~d
rhythm with an underlying
rhythm of ventricular standstill
when the pacemaker is turned oIf.
This strip shows an indication for
permanent pacemaker implant",tion
if the underlying rhythm donn't
resolve .
Strip 10- \ 6
Analysis: The first two beats are
ventricular p"'ced beats followed
by an intrinsic beat, a pacing spike
that fails to C<IIpture, 1\',"0 ventricular
paced beats. two intrinsic beats, and
'" ventricular paced beat.
Interpretation.: Ventricular paced
rhythm with three intrinsic beats
and one episode of failure to capture
(abnormal pacemaker function)
Sirip 10- 17
Ana[)I$is: The lirst t\\.o complexes are
ventricular paced beats followed by
a fusion belli, two intrinsic beats, a
pacing spike that occurs too early.
an intrinsic beat, a pacing spike that
occurs too uriy, an intrinsic beat, '"
pacing spike y,ith capture that occurs
too urly, and II ventricular paced
be",\.
Strip 10- 19
Anal)l$is: The lirst four complexes
are ventricular paced beats followed
by MI intrinsic beat and three
ventricular paced beats.
Interpretation: Ventr icular paced
rhythm with one intrinsic beat
(normal pacemaker function)
Stri p 10-20
Anal)l$is: The tirst complex is a
ventricular paced beat folloo'ed by
two pacing spikes with failure to
captu re, a ventricular paced beat. a
pacing spike with failure to capture.
a ventricular paced beat.ll pacing
spike with failure to ~pture, two
ventricular paced beats. MId a pacing
spike with failure to capture.
Interpretation: Ventricular paced
rhythm with five episodes of failure
to ~pture (abnormal pacemaker
function)
359
Strip 10-2 1
Analysis: All complexes are
pacemaker indu<:ed.
Interpretation: Ventricular paced
rh~thm (normal pacemaker function)
Strip 10-22
Anal)l$is: One ventricu tar paced beat
changing to ventricular tachycardia
(ton<Mle de pointu)
Interpretation: Ventricular paced beat
changing to torde de pointu VT
Strip 10-23
Analysis: The first four complexes are
ventricular paced beats followed by
an intrinsic beal a pacing spike that
occurs too early. '" fusion beat, and a
ventricular paced beat.
Interpretation: Ventricular pKed
rhythm with one intrinsic beat,
one fusion beat. and one episode of
undersensing (abnormal pacemaker
function)
Strip 10-24
Analysis: The first complex is it
ventricular paced beat followed by a
pacing spike with failure to capture,
an intrinsic beat. II pacing spike with
failure to capture. an intrinsic beat. a
ventriculu pllCed beat, II pacing spike
with failure to capture, an intrinsic
beat, a pacing spike wi th failure to
capture, and an intrinsic !>tat.
Interpretation: Ventricular paced
rhythm with four intrinsic beats, and
four episodes 01 (llilure to capture
(abnormal pacemaker (unction)
Strip 10-25
Anal)l$is: A[[ complexes are pKemaker induced.
Interpretation: Ventricular paced
rh}thm (normal pacemaker function)
Strip 10-26
AnaI)I$is: The first two beats are ventricular paced beats followed by an
intrinsic beat. two ventricular paced
beats. a fusion beat. an intrinsic beat,
and two ventricular paced beats.
Interpretation: Ventricular pKed
rhythm with two intrinsic beats, and
one fusion beat (normal pacemaker
function)
360
Str ip 10-27
Analysis: The first four complexes are
wntricular paced beats followed by
wntricular standstill (asystole).
Interpretation: Ventricular paced
rhythm with failure to fire resulting
in ventricular standstill (abnormal
pacemaker function)
Strip 10-2B
Analysis: The first four complexes
are ventricular paced beats followed
by two pacing spikes with failure to
capture. an intrinsic beat, \',0,0 pacing
spikes with failure to capture, and an
intrinsic beat.
Interpretation: Ventricular paced
rhythm with two intrinsic beats and
four episodes of failure to capture
(abnormal pacemaker function)
Strip 10-29
Analysis: The first two complexes
are ventricular paced beats followed
by three intrinsic beats and three
wntricular paced beats.
Interpretation: Ventricular paced
rhythm with three intrit15ic beats
(normal pacemaker function)
S lrip 10-30
Analysis: The first complex is a
pseudofusion beat (note spike in
QRS complex with no change in
amplitude or width) fol1Oo11ed by
intrinsic beats. three ventricular
paced beats, one fusion beat, and one
intrinsic beat.
Interpretation: Ventricular paced
rhythm with one pseudofusion
beat, one fusion beat, and three
intrit15ic beats (normal JXlcemaker
function)
mo
Strip 10-3 1
Analysis: The first three complexes
are ventricular paced beats followed by two intrinsic beats (paired
pVes) and four ventricular JXlced
beau.
Interpretation: Ventricular paced
rhythm with two intrinsic beats
(normal pacemaker function)
Strip 10-32
Analysis: The first four complexes
are ventricular paced beats followed
by one intrinsic beat (PVC), a pacing
spike occurring too early, and three
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of undersensing malfunction (abnormal pacemaker function)
Strip 10-33
Analysis: The first \',0,0 complexes are
ventricular paced beats followed by
two intrinsic beats, a fusion beat, and
two ventricular paced beats.
Interpretation: Ventricular paced
rhythm with \',0,0 intrinsic beats and
one fusion beat (normal pacemaker
function)
Strip 10-34
Analysis: The first four complexes are
ventricular paced beats foll(M>ed by a
pacing spike with failure to capture,
an intrinsic beat, a pacing spike that
occur< too early. and two ventricular
pilced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat, one
episode of failure to capture. and one
episode of undersensing (abnormal
pacemaker function)
Strip 10-35
Analysis: The first tv.o complexes are
ventriw\ar paced beats folkM-ed by an
intrinsic beat, a fusion beat, an intrinsic beat, one pacing spike with capture
that occurs too early, twoventricular
paced beats, and an intrinsic beat.
Interpretation: Ventricular paced
rl"(ythm I'tith three intrinsic beats. one
fusion beat, and one episodeot undersensing (abnormal pacemaker function)
Strip 10-36
Analysis: The first two complexes are
ventricular paced beats followed by
an intrinsic beat, a pacing spike that
occurs too early. three intrinsic beats,
and three wntricular paced beats.
Interpretation: Ventricular paced
rhythm with four intrinsic beats and
one episode of undersensing malfunction (abnormal pacemaker function)
Strip 10-37
Analysis: The first five complexes are
wntricular paced beats followed by
an intrinsic beat and \',0,0 ventricular
paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat
(normal pacemaker function)
Strip 10-38
Analysis: The first four complexes are
wntricular paced beats followed by a
pause in pacing, a wntricular paced
beat that occurs later than expected,
a wntricular paced beat, and an
intrinsic beat.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of owrsensing (the pacemaker sensed the large T wave at the
start of the piluse).This is abnormal
pacemaker function.
St rip 10-39
Analysis: The first complex is wntriwlar paced follov,ed by three intrinsic
beats and four ventricular paced beats.
Interpretation: Ventricular paced
rh~1:hm with three intrinsic beats
(normal pacemaker function)
strip 1040
Analysis: The first complex is wntricular paced followed by ventricular
standstill (asystole).
Interpretation: Ventricular paced
beat with failure to fire resulting
in ventricular standstill (abnormal
pacemaker function)
Strip 1 1-1
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 ~cond
Rhythm interpretation: Sinus
tachycardia
Strip 11-2
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.12 second
Rhythm interpretation: Sinus bradycardia with bundle-branch block;
sr-segment depression is present.
Strifl ll -3
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 84 ~aWminute (at rilll):
30 beaWmilWte (ventricular)
Pwaves: Sinus (two P waves or four
Pwaves before each QRS complex)
PR int~rvaJ; 024 to 028 S&ond
(consistent)
QRS complex: 0.08 second
Rhythm interpretation; Mobilz []
with 2:1 a0<l4:1 AV conduction
Strip 11 -8
Rhythm: R~gular (atrial dlld
ventricular)
Rate: 75 beaWm inute (atrial):
26 beats/minute (ventricular)
P ....~s: Sinus (bear no constdllt
relationship to the QRS complex)
PR interval: Varies
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Third-degree
AV block: ST-segment ~Ievation is
present.
Strip 11 -4
Rhythm: irregular
Rat~: 100 ~at~minute
P waves: Flbrillatory waves pr~sent;
some nutter waves mixed with fib
waves
PR int~rvaJ; Not measurable
QRS complu: 0.04 second
Rh}'lhm interpretation: Atrial
fibrillation
Sirip 11 -9
Rhythm: Regular
Rate: 188 beaWminute
P w~s : Not discernibl~
PR interval: Not discernible
QRS complex: 0.16 to 0.20 second
Rhythm int~rpretation: Ventricular
Sirip 11 -5
Rhythm: Regular
Rate: 48 ~at~minut~
P .... aves: Hidden in the QRS compla
PR int~rvaJ; Nol measurable
QRS complex: 0.08 second
Rhythm interpretation; Junctional
rhythm: ST-segment depression is
present.
Strip 11 -6
Rhythm: Regular
Rat~; 188 beat5iminute
P waves: Hidden in preceding
Twaves
PR int~rvaJ; Not measurable
QRS complex: 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 11 -7
Analysis: The first four complexes
ar~ ventricular paced beats followed
by two intrinsic beats. a ventricular paced beal and two intrinsic
beats.
Interpretation: Ventricular paced
rhythm I'.ith four intrinsic beats
(normal pacemaker function)
36 1
Sirip 11 - 13
Rhythm: Regular
Rate: 232 b~atslminute (atrial ):
58 btatslminutf (ventricular)
P waves: Four lIutter waves before
each QRS com pia
PR interval: Not measurable
QRS complex: 0.06 to 0.08 S&ond
Rh)thm interpretation: Atriaillutter
with 4;) AV conduction
Sirip 11-14
Rhythm: Regular
Rate: 79 beatslminute
P waves: SinlU
PR interval: 0.16 to 0.18 second
QRScompla: O. IOsecond
Rhythm interpretation: Normal sinlU
rhythm: ST segment elevation is
present.
tKh~ardia
Strip 11 -\0
Rhythm: Regular
Rate: 42 beaWminute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm int~rpretation: IdioventricuIlIr rhythm
Strip 11 -11
Rhythm: Regular (basic rhythm)
Rate; 56 b~aWminute (basic
rhythm)
P w~s: Sinus (appear notched.
which may indicate Idt atrial hypertrophy)
PR interval: 0.16 second
QRS complex; 0.06 second (basic
rhythm); 0.16 second (PVC)
Rhythm interpretation: Sinus bradycardia with one int~rpolated PVC;
ST-segment depression is present.
Strip 11 -12
Rhythm: R~gular
Rate: 54 beaWminut~
P w~s: Inverted before each QRS
complex
PR interval: 0.10 ~cond
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accflerated
junctional rhythm
Str ip 11 - 15
Rh~thm: Regular
Ratf: 88 beatslminute
P waves: Absent
PR inl~rvaJ : Not measurable
QRS compJ\'X: 0. 14 to 0.16 sond
Rhythm interpretation: Accelerated
idiowntricu lar rhythm
Strip II - Hi
Rhythm: Regular (basic rhythm);
irregulllrwith pause
Rate; 75 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm): one
premature, abnonnal P wave without
a QRS complex (afte r the fifth QRS
complex)
PR int~rval : 024 to 0.28 second
QRS compl\'X: 0.06 to 0.08 S&ond
Rhythm interpretation: Normal sinlU
rhythm with fil'5l-degre~ AV block
and one nonconducled PAC (follows
the fifth QRS complex)
Sirip 11 -17
Rh~thm: Regular
Rate: 115 beats/minute
P waves: Sinus
PR int~rval : 0.14 to 0.16 second
QRS compla: 0.06 second
Rhythm interpr~tation: Sinus
tachycardia
362
Strip 11-18
Rhythm: Regular
Rate: 48 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus bradycardia; ST-segment elevation is
present.
Strip II -ZJ
Rhythm: Irregular atrial rhythm
Rate: 40 beats/minute (atrial);
obeats/minute (ventricular)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Strip 11-19
Rhythm: Regular (basic rhythm):
irregular (prelllilture beats)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
inverted (premature beat.)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.08 second
(premature beats)
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with two premature junctional contractions (fou rth and sixth
complexes)
Strip \1 -24
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Sinus
PR interval: 0.44 to 0.48 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus arrhythmia with first-degree AV block;
ST-segment elevation is present.
Strip 11-20
Rhythm: Regular
Rate: 63 beats/minute
P waws: Vary in size. shape, and
position
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering atrial pacemaker: ST -segment
depres.lion is present.
Strip \1 -21
Rhythm: Chaotic
Rate: 0 beats/minute (no QRS
complexes)
P waves: No P waves; waw deflections are chaotic and irregular and
vary in height, size, and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Slri1l 1 1-22
Rhythm: Regular
Rate: 107 beats/minute
P waws: Inwrted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.01 to 0.06 second
Rhythm interpretation: Junctional
tachycardia
S irip 11 -25
Rhythm: Regular (basic rhythm )
Rate: 48 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.36 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Sinus bradycardia with first-degree AV block and
sinus arrest
Strip 11 -26
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 72 beilts/minute (iltrial);
40 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthens from 0.20 to
0.28 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: SeconddegreeAV blo,k, Mobitz I;
ST-segment depression is present.
Slrip 11 -27
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR intuval: 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm: ST-segment depres.lion and
T-wave inversion are present.
Strip 1 1-28
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 72 beats/minute (basic
rhythm): slows to 63 beats/minute
during first cycle after pause: rate
Juppres.lion can occur for sewral
cycles after an interruption in the
basic rhythm.
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm with sinus arrest
Strip 1129
Rhythm: Regular (basic rhythm);
irregular (prelllilture beat)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (premature
beat)
PR interval: 0.14 to 0.16 second
(basic rhythm): 0.12 second
(prematu re beat)
QRS complex: 0.08 second
Rhythm interpreUltion: Normal
sinus rhythm with one PAC (fifth
complex)
St r ip 1 1-30
Rhythm: Regular (basic rhythm);
irregular (PVCS)
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.12 second (basic
rhythm and PVCS)
Rhythm interpretation: Normal
sinus rhythm with bundle-brancll
block and paired PVCs: a U waw is
present.
Strip 11 -31
Rhythm: Regular (atrial and ventricular)
Rate: 240 beats/minute (atrial);
60 beats/minute (ventricular)
P waves: Four flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial flutter
with 4:1 AV conduction
Strip 11-3'2
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 54 beats/minute (basic
rhythm)
P wa~s: Sinus (basic rhythm): none
(fourth and fifth complexes)
PR interval: 0.18 to 0.20 second
(basic rh~1:hm )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus brady
cardia with a pause follo",~d by \"1'>0
junctional escape beats: the specific
pause (sinus arrest or block) cant be
identified due to the presence of the
escape beats.
Strip 11 -33
Rhythm: Regular
Rate: 25 beats/minute
P waws: None kkntified
PH interval: Not measurable
QRS complex: 024 second or
greater
Rhythm interpretation:
Idiowntricular rhythm
Strip 11-31
Analysis: The first three complexes
are ventricular paced beats
follo",~d by a pacing spike that fails
to capture the ventricle, an intrinsic beat, and two ventricular paced
beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of failure to capture
(abnonnal pacemaker function)
Strip 11-35
Rhythm: Regular
Rate: 84 beal5lminute
P w"v<:s: Not identified
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rh}1:hm interpretation: Accelerated
idioventricular rhythm
S tri p 11 -36
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent; wave deflectiofl5
are chaotic and irregular and vary in
size, shape, and height
PR interval: Not measurable
QRS complex: Ab~nt
Rhythm interpretation: Ventricular
fibrillation. followed by electrical
shock and return to ~ntricular
fibrillation
S tri p 11 -37
Rhythm: Regular
Rate: 52 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia; a U wave is present.
Strip 11 -38
Rhythm: Regular
Rate: 94 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.08 second
Rhythm interpretation: Accelerated
junctional rh}1:hm; baseline artifact
is pre~nt.
S trip 11 -39
Rhythm: Regular (basic rhythm);
irregular with premature beat
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature abnormal P wa~ with
premature beat
PR interval: 0.14 to 0.16 second
(basic rhythm); 0.12 second
(prematu re beat)
QRS complex: 0.04 to 0.08 ~cond
(basic rhythm); 0.08 second
(premature beat)
Rhythm interpretation: Nonnal sinus
363
Str ip 11-.40
Rh}1.hm: Regular (basic rhythm) off
by two squares
Rate: 79 beats/minute (basic
rhythm)
P wa~s: Sinus (basic rhythm);
premature abnormal P wave without
QRS following fifth QRS complex
PR interval: 020 second
QRS complex: 0.08 to 0.10 second
(basic rh}1.hm): 0.08 second
(premature beat)
Rhythm interpretation: Normal sinus
rhythm with nonconducted PAC
followed by a PJC
Strip 1 1 -~ 1
Rh}1hm: P waves occur regularly
Rate: 88 beats/minute (atrial); 0
(ventricular )
P waves: Sinus
PH interval: Not measurable
QRS complex: Absent
Rh}1hm interpretation: Ventricular
standstill
S tr ip 11-42
Rhythm: Regular (basic rhythm);
irregular (premature beats)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rh}1:hm)
PR interval: 0.12 to 0.14 ~cond
QRS complex: 0.08 second (basic
rhythm); 0.12 to 0.l6 second (PVC)
Rhythm interpretation: Normal sinus
rhythm with paired multifocal PVC!
(fourth and fifth complexes)
Str ip 11-43
Rh}1hm: Regular (basic rhythm):
irregular (PACs)
Rate: 136 beats/minute (""sie
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (premature
beats)
PR interval: 0.16 to 0.20 second
QRS wmph:x: 0.06 Iv 0.08 ~~wwJ
Rhythm interpretation: Sinus
tachycardia with \"1'>0 PACs (fourth
and eighth complexes)
364
S tr ip 1144
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 84 beats/minute (basic
rhythm): slol'>'S after pause but
returns to basic rate after four cycles.
P waws: Sinus
PR interval: 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Normal
.inus rhythm with sinus ftrre:st;
ST-segment depression and T-wave
inversion are present.
S lri p 1145
Analysis: No patient or paced beats
are sn: pacing spikes are noted that
fail to capture the ventricles.
Interpretation: Failure to capture in
the presence of ventricular standstill
S tr ip 11 -46
Analysis: The first two complexes
are intrinsic beats followed by a
fusion beat, two intrinsic beats, two
ventricular paced beats. and a fusion
beat.
Interpretation: Ventricular paced
rhythm with four intrinsic beats and
tv,o fusion beats (normal pacemaker
function)
S tr ip 11 -47
Rhythm: Regular
Rate: 42 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm
S tr ip 11-48
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 79 beats/minute (atrial);
50 bcat.tminute (ventricular)
P waves: Sinus
PR interval: Lengthens from 020 to
0.32 se,ond
QRS complex: 0.08 to 0.10 second
Rhythm interpretation:
S\:u)II<.l-<.l~!,/'n AV bl<><:k. Mubitt. I
Stri p 11 -49
Rhythm: Regular (basic rhythm);
irregular (premature beat)
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex (except the ninth QRS
complex, which has a premature.
pointed P wave )
PR interval: 0.08 to 0.10 second
(basic rhythm): 0.10 second
(pfem~tUrc beat )
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
tachYCimlia with one PAC (ninth
complex)
Stri p II -50
Rhythm: Regular (atrial and
ventricular)
Rate: 84 beats/minute (atrial);
28 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block; ~i -segment depression is
present.
Stri p 11 -5 1
Rhythm: Irregular
Rate: 70 beats/minute
P WdVt:li: Sillu.
PR interval: 0.18 to 020 second
QRS ,omplex: 0.08 to 0.10 SI!,ond
Rhythm interpretation: Sinus
arrhythmia
Stri p 11 -52
Rhythm: Regular (basic rhythm);
irregular (premature beats)
Rilte: 72 beats/minute (lxl:!i'
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.16 second
QRS complex: 0.10 .Kcond
Rhythm interpretation: Normal
sinus rhythm with unifocal PVCs in
a trigeminal pattern. sr-segmmt
depression and T-wave inversion are
present.
S tr ip I I-53
Rhythm: Regular
Rate: 93 beats/minute (atrial);
3 1 beatY-minute (ventricular)
P waves: Three sinus P waves to each
QRS complex (one hidden in the
T wave)
PR interval: 0.36 second (remains
constant)
QRS complex: 0.08 second
Rhythm intcrprdotion: Seconddegree AV block. Mobitz II
St r ip 11 -54
Rhythm: Regular (basic rhythm );
irregular (PVCs)
Rate: 72 beats/minute (basic
rhythm )
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (basic rhythm): 0.14 to 0.16 second
(PVCs)
Rhythm interpretation: Normal sinus
rhythm with multifocal PVCs
S trip I I-55
Rhythm: Regular (atrial and
ventricular)
Rate: 62 beats/minute (atrial):
31 beatY-minute (ventricular)
P waves: Two sinus P waves before
~dcll QRS ~ulllpln
PR interval: 0.44 second (remains
comtantj
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Seconddegree AV block, Mobitz II
S trip 1 156
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.10 second
QflS complex: 0.04 ~econd
Rhythm interpretation: Accelerated
junctional rhythm: ~i -segment
elevation is present.
Sirip I I -57
Rhythm: Regular (basic rhythm):
irr~gul<lr with pause
R<lt~: 68 be~t!lminute (basic rhythm)
P w~ws: Sinus
PR interval: 022 to 0.24 second
QRS complex: 0.08 to 0.10 second
Rhythm interpret~tion: Normal
sinus rhythm with first-degree AV
block and sinus arrest: ST-segment
elevation is present.
Sirip I I -58
Analysis: The tirst complex is an
intrinsic beat followed by a pacing
spike with failure to capture. an
intrinsic beat, a pacing spike with
failure to capture, two intrinsic
beah. a pacing spike with failure to
capture, an intrinsic beat, a pacing
spi ke with failure to capture, and iUl
intrinsic beat.
Interpretation: Strip shows an
intrinsic rhythm (sinus arrhythmia
with first-degree AV block and
two PVCs) with complete failure
to capture (abnormal pac~maku
function); since there were no two
consecutive paced beats or two
consecutive pacing spikes, I used
the interval from Ihe R wave of the
natiw beat to the pacing spike as my
estimated automatic interval.
Strip I I -59
Rhythm: Regular
Rate; 1M beats/minute
P waws: Not identified
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation; Paroxysmal
atrial tachycardia
Strip 11-60
Rhythm: Irregular
Rate: 30 beats/minute
P waves: None present
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation: Idioventricular rhythm: ST-segment depression
is present.
365
Strip 11 - 6 1
Rhythm: Regular (atrial): irregular
(wntricuJar)
Rate; 125 beats/minute (atrial);
80 beats/minute (wntricular )
P waves: Sinus
PR interval: Lengthens from 0.12 to
0.24 SKond
QRS complex; 0.06 to 0.08 second
Rhythm interpretation: Seconddegree AV block. Mobitz I: T-waw
inwrsion is present.
Strip 11-66
Rh}1hm: Regular
Rate: 78 beats/minute (atrial);
39 beats/minute (ventricular)
P waves: Two sinus P waves to each
QRS compla
PR interval: 0.24 second with a
COnstiUlt relationship to the QRS
complex
QRS compla: 0.12 to 0.14 second
Rh}1hm interpretation:
Sond-degree AV block, Mobitz II
Strip 11 -62
Strip 11-67
Strip 11 - 63
Rhythm: Regular
Rate: 75 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 sond
QRS complex: 0.12 to 0.14 SKond
Rhythm interpretation: Norma l sinus
rhythm with bundle-branch block;
Sl-segment elevation is present.
Strip ll -M
Rhythm: Regular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.16 5ond
QRS complex: 0.06 to 0.08 SKond
Rhythm interpretation: Sinus
bradycardia; a U wave is present .
Strip 11-65
Analysis: All complexes are
pacemaker induced.
Interpretation: Ventricular paced
rhythm (normal pacemaker
function)
Strip 1 1-68
Analysis: The first four complexes
are v,ntricular paced followtd by a
fusion beat and an intriruic beat.
Interpretation: Ventricular paced
rhythm with one fusion beat and one
intrinsic beat (normal pacemaker
function)
Strip 11-69
Rhythm: Regular
Rate: liS beats/minute
P waW5: [nwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm inlerpremtion: Junctional
mchycardia
Strip 11-70
Rhythm: Regular (basic rhythm);
irregular (PIC)
Rate: 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
inverted (PIC)
PR interval: 0.14 to 0.16 second
(bilsic rh}1hm): 0.10 second (PJC)
QRS corupla: 0.08 second
Rh}1hm in terpretation: Sinus
bradycardia with one PIC
366
Str ip 11-7 1
Rhythm: Regular (basic rhythm);
irregul(lor (non conducted PAC)
Rate: 63 beats/minute (bMic rhythm)
P wavu: Sinus (basic rhythm): one
premature. abnormal P wave without
a QRS complex (after the fourth
complex)
PR interval: 0.2S to 0.32 tecond
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
and bundle-branch block with one
nonconducted PAC after the fourth
QRS complex: 31 -segment elevation
and T _wave inversion are present.
Strip 11-72
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 50 beats/minute (bMic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 iecond
QRS complex: 0.08 second (basic
rhythm): 0.18 second (PVC)
Rhythm interpretation: Sinus bradycardia with one PVC (after the third
QRS complex): ST-segment elevation
is present.
S irip 11-7:.l
Analysis: The first two complexes
are ventricular paced followed by
a fusion beat. a pseudofusion beat
(note spike at beginning of R wave).
three intrinsic beats. a pacing spike
that occurs too early. an intrinsic
beat. a pacing spike that ocrtJ rs too
farly. an intrinsic bfat, and a pacing
spike that occurs too early.
Interpretation: Ventricular paced
rh}1hm with one fusion beat. one
pseudofusion beat. five intrinsic beats.
and three episodes of under sensing
(abnormal pacemaker function)
Strip 1 1-70\
Rhythm: Regular
Rate: 50 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Junctional
rhythm; ST -segment depression and
T-wave inversion are present.
Strip 11 -75
Rhythm: Irregular atrial rhythm
Rate: 40 beats/minute (atrial);
(ventricular)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Stri p 11 -76
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus arrhythmia; ST -segment elevatio n is
preienl.
Sirlp 11 -77
Rhythm: Regular
Rate: 68 beilts/minute
P waves: P waves vary in size, shape.
and position
PR interval: 0.14 to 0.16 second
QRS com pin.; 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker; T-wave inversion is
pre.sent.
Slrip ll -78
Rhythm: Regular
Rate: 214 beats/minute
P waves: H idden
PR interval: Not measurable
QRS complex: 0.06 to 0.08 .second
Rhythm interpretation: Paroxysmal
atrial tachyc<lrdia
Sirip 11 -79
Rhythm: Regular (first and second
rhythms)
Rate: 94 beats/minute (first rhythm):
136 beatslminute (iecond rhythm )
P waves: Sinus (first rhythm)
PR interval: 0.18 to 020 second (first
rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm ): 0.1 2 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm changing to ventricular
tachycardia
Strip 11-80
Rhythm: Regular (basic rhythm)
Rate: 107 beats/minute (bMic
rhythm)
P waves; Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 .setond
(basic rhythm); 0.12 second
(ventrltular beau)
Rhythm interpretation: Sinus
tachytardia with a four-beat burst of
ventricular tathycardia and paired.
unifocal PVCs
Strip 11-81
Rhythm: Irregular
Rate: 260 beats/minute (atrial):
70 beats/minute (ventricular)
P waves: Flutter waves
PR interval: Not measurable
QRS tompl('JI: 0.06 to 0.08 second
Rhythm in terpretation: Atrial Hutter
with variilble block
Sirip 11-82
Rhythm: Regulu
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.12 setond
QRS compl('JI: 0.04 to 0.06 .second
Rhythm in terpretation; Normal sinus
rhythm
SLrip 11-83
Analysis: The fint beat is a
pteudofmion beat (note spike inside
QRS with complex untharged)
followed by two intrinsic beats. three
ventricular pated beats. a fusion
beat. and an intrinsit beat.
Interpretation: Ventricular paced
rhythm with one pseudofusion
beat. one fusion beat. and three
intrinsic beats (normal pacemaker
function)
Si rip 11-84
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 .second
Rhythm interpretation: Sinus
tathycardia
367
Strip 11 -85
Rhythm: Regular
Rate: 54 beats/minute
P waV\'s: Sinus
PR interval: 024 to 0.26 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
bradycardia with first-degreeAV
block
Strip 11 -90
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rh}1hm; ST-segment depression and
T-waV\' inversion are present.
Strip 11 -95
Rhythm: Regular
Rate: 100 heats/minute
P waves: InV\'rted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Acceluated
junctional rhythm
Strip 11 -86
Rhythm: Regular (atrial and
V\'ntricular)
Rate: 94 beats/minute (atrial);
37 beats/minute (ventricular)
P waV\'s: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degr
AVblock
Strip 11 -91
Rhythm: Regular (basic rhythm):
irregular (PVCI
Rate: 115 beats/minute (basic
rhythm)
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.04 to 0.06 second
(hasic rhythm); 0.12 second (premature beat)
Rhythm interpretation: Junctional
tachycardia with one PVC
Strip 11 -96
Rhythm: Regular (atrial): irregular
(ventricular)
Rate: 84 beats/minute (atrial):
70 beats/minute (ventricular )
P waves: Sinus
PR interval: ungthens from 0.20 to
0.36 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, Mobitz I;
ST-segment depression is present.
Strip 11 87
Rhythm: Regular
Rate: 150 heats/minute
P waV\'s: None identified
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia
Strip 11 -88
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 56 beats/minute (ba~ic rhythm)
P waV\'s: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with sinus arrest:
~'T -~egment depres~ion and T-wave
inversion are present.
Strip 11 -89
Rhythm: 0 beats/minute
Rate: 0 heats/minute
P waV\'s: Absent
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Strip 11 -92
Rhythm: Regular
Rate: 188 beats/minute
P waves: T -P wave (P waVi: obscured
in TwaV\' )
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Sirip 11 -93
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent; fihrillatory waves
present
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventrkular
fibrillation
Sirip 11 -94
Rhythm: Regular (basic rhythm):
irrel/ular with pause
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.24 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with first degree AV block
and sinus exit block
Strip 11 -97
Rhythm: Irregular
Rate: 100 beats/minute
P waves: Fibrillatory waV\'s
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rh}1hm): 0.12 second (PVC)
Rhythm interpretation: Atrial
fibrillation with one PVC
Strip 11 -98
Analysis: The first two complexes
are ventricular paced beats follol't'ed
hyan intrinsic heat, two V\'ntricular
paced beats. a pacing spike with failure to capture. an intrinsic heat. and
a ventricular paced beat.
Interpretation: Ventricular paced
rhythm with t\'t'o intrinsk beat~ and
one episode of failure to capture
(abnormal pacemaker function)
Strip 11 -99
Rh}1hm: Rel/ular (basic rhythm):
irregular (prematu re beat)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.12 second
QRS complex: O.o.t to 0.06 second
Rhythm interpretation: Sinus
tachycardia with one PAC (twelfth
complex)
368
Strip 11 100
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
r WQ""~: Two flutter wavo to eoch
QRS complex
PR interval: Not measurable
QRS complex: 0.04 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction
Strip 11 10 1
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 11 102
Rhythm: Regular
Rate: 48 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia; a U waw is present.
Strip 111 03
Rhythm: Regular
Rate: 214 beats/minute
P waws: None identified
PR interval: Not measurable
QRS complex: 0.16 second or greater
Rhythm interpretation: Ventricular
tachycardia
Strip 11 \0<1
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Fibrillatol)' waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip 11 105
Rhythm: Regular (basic rhythm)
Rate: 72 beats/minute (basic rhythm)
P waws: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Normal sinus
rhythm with one interpolated PVC;
STsegment depression is present.
Strip 11 106
Rhythm: Regular (basic rhythm):
irregular (PJC)
Rate: 65 beats/minute (basic rhythm)
r wavo : Sinu. (b....ic rhythm):
inwrted (PJC )
PR interval: 0.12 to 0.16 second
(basic rhythm); 0.10 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one PJC: a U wave is
present.
S lrip 11 107
Rhythm: Regular (basic rhythm );
irregular (PVCs)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm with three PVCS
Glossary
Aberrant - Abnormal
Abcrr",ntly concluded ~upr.vcn
50
369
370
Glossary
premature eetopic
charge.
Cbordae tendineal! ~ Thin strands of
fibrous connective tissue that extend
from the cusps of the atrimentricular
valves to the papillary muscles and
prevent the AV valves from bulging
biKk into th~ atria during ventricular
contraction.
Glossary
bt:~u",~
Electrocardiogrlph ~ A machine
used to record the electrocardiogram.
Defibrillation ~ An unsynchronized
electrical shock used to terminate
ventricular fibrillation and pulseless
\'entricular tachycardia: uses higher
joules of electricity. Also knO\\T1 as
unsynchronized shock.
Deflection ~ Refers to the wavefonns
in the ECG tracing (P wave, QRS complex. T wave, and U wave). A deflection
may be po5iti~ (upright), negative
(inverted), biphasic (having both positive and negative components), or equiphil.'iic (equally positive and nel!41iw),
Depolarintion ~ Electrical activation of a cardiac cell due to movement of ions across a cell membrane,
causing the inside of the cell to
become more positive. Depolari;o.ation
is an electrical event expected to
result in muscle contraction, a
mechanical event. Depolarization
of the atria produces the P wave.
Depolarization of the ventricles
produces the QRS complex.
Djaphor~sis ~
Profuse sweating.
Shortness of breath,
Conducti~ity
fUlldiu".l1y
371
372
Glossary
Interatrial s~ptum - The I\-all separating the right and left atria.
heart, trachea, esophagus, and great ve5sels (pulmonary arteries and veins, aorta,
and the superior and inferior vena cava).
Glossary
arrh~1:hmias.
Pulmonic valve. - One of two semilunar valves. Located between the right
wntricle and the pulmonary artery.
373
Q wilve
R wa\~.
ization.
Reperfusion Thythnu ~ Rh)'lhms
that may occur following reperfusion therapy. Examples of reperfusion
rhythms include sinus bradycardia.
accelerated idiowntricular rhythm,
premature wntricular contractions,
ventricular tachycardia, and wntricular fibrillation.
374
Glossary
160 Iw.llt<lminnte.
s~Tldrome
is often accompanied by
symptoms such as dizzinm, faint in!!,
chest pain, dyspnea, and congestive
heart failure. Permanent pacemaker
implantation is recommended once
the patient becomes s)'lllptomatic. Also
known as tachy-brady syndrome.
SA ~ abbr sinwtnal
Second-degn atrioventricular (AV)
block Mobilz I ~ An arrhythmia in
which there is prO{lre!sive delay in
the conduction of electrical impulses
through the AV node until an impulse
is blIKked and not ,onducted to the
ventricle!. Characterized by regularly
occurring P waves; progressive lengthening of the PR interval until a P wave
appears without a QRS. but is followed
by a pause; normal QRS duration: and
<II, irr~J!uldr v~"lri~uldr rhyllllll. Ab"
known as Wenckebach.
Second-degree atrioventricular
block Mobitz " - An arrhythmia in
which some electrical impulses are
conducted to the ventricle., but mo.t
are blocked. Characterized by regularly
occurring sinus P waves; consistent PR
Sinus nod ~ The dominant pacemaker of the heart located in the wall
of the right atrium close to the inlet of
the superior vena cava.
Sinus tachycardiA ~ An arrh~1hmia
originating in the sinus node
characterized by a regular rhythm;
normal P wa~'es, PR interval, and QRS
duration; and a rate betl'..~en 100 and
br...JYHr~i. ~AJl
drrhyllt-
ill
Glossary
inserted into a large vein and positioned in the right wntride. Electrical
impulses are conducted from an external power source (pacing generator)
through thc lcad wire to thc right
ventricle.
Tricuspid valve - One of two atrioventricular valves. Located between
the right atrium and the rightventride. Similar in structure to the mitral
valve, but has three cusps.
Trigemin~ - An arrh)ll:hmia in
which every third beat is a premature
ectopic beat. The premature beals
may be atrial, junctional, or ventricular in origin ( i.e., atrial trigeminy,
junctional trigeminy, ventricular
trigeminy).
375
Index
Accel~raled
A
Aberrantly conducted .upravenlr;cular
pr~rnalu ... ~u.
369
idiowntricular rhythm,
210--211. 21Oi, 211i. 2131. 369
144i. 1441, 145i. 369
Anion. 8
Antellrnde conduction. 369
B
Bachmann's bundle. 9. 10. 10i. 370
Beta blocke,.". 370
Bii!<miny.370
Bipilasic deflection. 11, 11i, 370
Biventricular p.:tumaker. 261
Bradycardia. 370
Bradyc:trdic rhythm, 261
; rde,." toan illl1.'!trat;on; t ",Ie .. to a table.
376
D
Udjb"llatlOn.371
Defle<tion.371
Depolarization. !'.-9. 9i. 371
Di""tole.371
DuakhamMr pacemakers. 258
[)yin, heart. 371
[)ysplII:a.371
Dysrhythmia. 44, 371
E
ECC i/raph paper. 12. 12i
ECC monitoring
applyini/electrode pads. 27
pUf]XISC. 25
troubleshootinil problem. 27--33.
29--33i
Ectopic junctional boat.. 140. 140i
Ectopic pacemaker. 85
Ectopic P wa ..... 13
Electrical conduction 'ystem. heart.
9-ll.10i
Electrical impul.... !'.-9. 9i
Electrical interiertnce. 32--33. 33i
Electrocardiogram (ECC). 371
ElectrocardiOllrallh.371
Electrode pads. &IIPlyini/. 27
Electrolyte. 8. 9. 371
Endocardium. 1- 2. 2i. 371
F.nh.n~.d ~"tom.t;~;ty.
::171
F
Pailure to calltur . 266. 266i
Paise hiJIh-rat~ alarms. 27- 2B. 29i
Pal.. low-rate alarms. 28. 30i. 31i
Pascicle.371
Pib-f1utter. 100
Pibrillatory Wi ...... 100
Pirst-dei/ree AV block. 371
Pirst-deQree h""rt blocks. 146--147.
147i.147t
Piutter wa ...... 95
FUsion beat. 263i. 2M. 2Mi
1'''''''....",.95
f wa ...... 100
H
Hardwirt rnonitorinQ
five-leadwire syst~m. 25-26. 25i
thrte-Iudwirt 'ystem. 26, 26i
Heart
blood fico,., throllllh. 4- 5. 4i
cardiac innervation. 7
chambo... 3. 3i
circulatory system. 2
description. 1
electrical conduction system.
10--12.10i
Index
Hurt (rontinun/J
funclion. I
location. I. Ii
.!ruclurl wall. 1- 2. 2i
lumen, I, 2i
\\11"u.3-oI,4i
Heart blocks. 146. 153. 1541, ISS!
finl-d~Qnc, 146-147, 147i.1471
Iccood-ckQttc. ~ I, 147-150. 1471,
14B~ 149i
lOI'Id-dfQrtc. I~ II, 150--152. 150~
lSOt, 151;
thini-dC1lra:, 152-153, 152;. 1521. 153i
H~art
209~
I mpbntab~ ard~rttr-ckfibrillalors
N
NC1Io>tivt deflection .. 11. Ili. 372
Nonrompens.otory ","use. 9O~ 91. 372
Nonronductl prematun atrial conlr.IC!ion. 91 - 94. 92i. 93i. 1011. 372
Normal.inu5 rhythm. 44-45,45i. Si t.
312
with .in... arrest. 49i
with .inlll bloc:k. 48i
Notch. 16. 16i
J poinl. 372
JunclioroJ ucapt oots. 142. 142i
JunclioroJ escapo rhythm. 142
Junctional rl-(ythm. 142- 143. 142;. 142t,
l43i. lUi, 372
Junctional bc~rdia. 312
L
Left anterior dosandinQ (lAD). 5--7
Left bundle-branch. 9--10.10;
Left bundle-branch block Il.BBB). 199
l.unQS. blood flow !hrou~. 4-5. 4;
M
/Iokdiastinum.372
MilliarnJl.... 372
I .. kn to an Illuslratlon; I rekn
to
a tiIIl<.
2 S~ .
2ntli
377
Pamrysmal junctionJ.llAchycaroia,
145--146. I ~i. 1451. 146i
Pericanlium. 1-2.2i
Permantnl pacemaken. 260---261. 260i
idt-nlificalion codu. 261, 2621
Point of mu;mlIl impulse (P/Ioll). I
Positive dd lection. 11. 11 i. 373
Posttest, 284-319i
Premature alrial contraction (PAC).
87- 91. 88~ 89i. 90i. 91i. lOl l.
139.373
Pre"",lure junctinnlr.1 c",,,,,,,,,tinn (PJC ),
139--142. 1391,1391. 1401. 141i.
142i.373
Premature .... nlncular contractions
(PVt.). 140.199-203. 199i. 200i.
201i. 2cr.!i, 203i. 213t. 373
PR inle ...... l. 13-15, 15;. 38i.
39,373
Pri~nvbl'. ilnQina. 373
Pl'Omhythmic tl'fotru. 209. 373
PR ""IIment. 373
PKudof... ion ixal, 264. 264i
Pulmonary circuil. 2
Pulmonary wi"", 3. 4i
Pulmonic ""I..... 3, 4~ 5
PulseJesa electrical activity (PEA), 213
Purkinje tiber5, 9--10.lOi
P waves. 13. 13i. 141.38--39, 38i, 373
Q
QRSromJlla. 15--17. lSi, 16i, 17i.39
39i.373
QS comJllex. 15. 16i
QT inle ...... l. 20--21, :roi. 373
Q wa.e. 373
R
Rate s..,prcssion. 373
ReeiJlrocal chanlle. 373
Rnlry,85
R~btivt refractory ptriod. 373
R. ptrfw.ion rhythms., 373
R~ pobriu.lion. 8-9. 9 374
R. lrottndt. 37~
Rhythm "1I"tuily. S2
3 78
Index
heart blocks.
147-1 50.1471.148.,149.
Second-del!~" type II hu.rt blo<:ks.
150-152. 15Oi. lSOt.15 1i
Semilunar val ...... 3-4. 4i
Sequenlial IkJ)Olarization. 198. 374
s;.:k sinus .yndrome. 47.374
Sinoatrial (SA), 374
Sinoatrial dysfuotlion. 256
Sinw arrest.48-50. 49i. 511. 374
5inw arrhythmia... 47-18.47i. Sit 374
ECG f\'.ll.tu~ 48t. 511
rhythm strip practice, 52-84i
with sinus po""". 48--50, SOi
Sinw bmlyocardi ... 46-47.46i, Sit 374
Sinw ait block, 48-50. 481, Sit. 374
Sinus n<><k. 374
Sinw paUst. 48--50. 50~ Sit
Sinw Ulchycardia. 45-16,45i. Sit. 374
Sodiurn--pobMium pump. 8-9. 9i
StoIcfS,AIbnu attacks. 151.374
StoIcfS-Adamuyncopto.15L 153
srsqlm~nt. ]7. 17i. 18i.374
51 H1Iment dev.tion myoQrdial
infarction (STEMI), 17
5~rior ....... cava. 374
5~roorlTllOJ Pfriod. 374
S.... TI"Itntncul.u arrhythmiu. 197
5 ....ve.374
$ympathdk '"'NOW syslffll. 7. 374
Syncope. 375
Systo:mic circu't. blood fIowand. 2
$yawle.7
Second-del!~t. type J
T
T~hybrady .yndrome. 47
Telemetry monitorinll. 27. 27i
fi .... -leadwire system. 27, 27i
Ihret-leadwir. syslem, 27. 28i
Ttmporary pattlNktrs
rpicard,al pacing. 2S--260
TCP lhniQun. 258-259. 258,. 2591
traru .... now pacinI!. 259. 260i
Third-degree heart blocks. 152- 153.
152i. 1521. 153i
Torsade d. poinl.. (TdP),2t 205,.
206--207, 375
I~tm.nl protocols. 207
TramctltmtoUO PKino: (TeP). 258-259,
258i. 2591, 375
Transt50phaj/eaJ cchOCllrdioilram (TEE),
98
V
Vallal man.u ........ 375
V.balva, ~r.47. 95.375
V~.I reaction. 375
V.ntric"".375
Ventricula'lIrrl'o-thmias
buls lAd rhythms. 197. 197i
rilfthm .Irip practice for.2 14-255i
Ventricular t.tape beals. 203. 203;
Ventricular fibrilLltion. 2<17-2119. 208~
213t.375
treatment protocol. 20S-209
Ventricular (luuer. 204i. 206
Ventricular .tm<ktill. 211- 212. 212i.
213t.375
Ventrkular tac~rdil. 204-206. 204i,
205,. 21lt, 375
IUlhIe monomorphic. wilh
pulst.2(16
Wl5U1ble monomorphic, wilh pul..,.
2"
Vul,",rablt
375
J'Kriodofrtpo~riulion.l2.
W
WanderinQ al rial paoemaktr, 85-87. 871,
101t.375
several beats following pause (temporary rate suppression), but reuns to basic rate after several cycles
Rate: Normal (60 to 1()() beats/minute) or slow (less tIlan 60 beats/minute)
P waves: Normal with basic rhythm; absent during pause
PR Interval: Normal with basic rhythm: absent dlJ'ing pause
10
11
12
10
P waves: Vary in size, shape, direction across rhythm strip; 0f1e Pwave precedes each
QRSoomplex
PR Interval: Usually normal duration, but may be abnormal depending on changing pacemaker locations
QRS complex: Normal (0.10 second or less)
11
P waves: Pwave associated with PAC is premature, abnormal (commonly appears small, upright, and pointed,
but may be inverted or a squiggle); abnormal P wave is often fOlJ1d hidden in preceding T wave, distorting
T-wave rontour
PR Interval: Usually normal but may be abnormal
QRS complex: Premature, normal duration ORS (0.1 0 second or less); followed by a pause
12
Answer: Sinus bradycardia with one PAC (abnormal Pwave associated with
PAC Is hidden In preceding T wave, distorting T-wave contour)
13
14
15
13
14
Answer: Normal sinus rhythm with one nonconducted PAC (abnormal P wave associated with PAC is
hidden in preceding T wave, distorting T-wave contour)
15
,.
17
,.
16
17
,.
Answer: Atrial flutter wtth 4:1 AV conduction
19
20
21
19
20
21
22
23
24
22
23
24
25
26
27
25
26
27
2B
29
30
28
29
Ventricular: Depends on number of impulses conducted through AV node; will be less than atrial rate
P waves: Sirlls
PR Interval: Varies; progressively lengthens until a P wave Isn't conducted (P wave appears without ORS
complex); a pause follows the dropped QRS complex
QRS complex: Normal (0.10 second or less)
30
31
32
33
31
32
Answer: Second-degree AV block., Mobitz II with 3:1 AV conduction (one P wave hidden on top ofT wave)
33
34
36
34
35
36
37
38
39
37
38
39
40
41
42
40
41
42
43
44
45
43
44
P waves: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)
45
P waves: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)
46
47
48
46
P wave: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)
47
4e