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Copyright © 2007bybyF.F.
A.A. D
Davis.
Copyright © 2007 by F. A. D
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
PREFACE
PREFACE
So, you want to learn how to interpret ECGs. It may surprise you to learn that you already know some of the core con-
cepts. Do you know what a superhighway is? Do you know how a tollbooth works? Have you watched a teacher quickly
silence a rowdy classroom? Have you ever seen a boxing match or watched a football game? If you answered “yes” to
any of these questions, then you’re already on your way to interpreting ECGs.
I believe the best way to learn something new is to relate it to something common, some everyday thing that you
already understand. Some people call this “learning by analogy”; I call it using what you know to learn something new.
You see, the difference between prior knowledge and new knowledge can be as simple as a difference in descriptive
language. The concepts of ECG interpretation aren’t radically different from things you already know; we just describe
them using a new set of words and a new set of rules. Instead of screaming children,
children, we talk about ventricular fibrilla-
tion; instead of a tollbooth, we see the atrioventricular node; where you watch a boxing match, we observe AV node
block; where you see superhighways, we see bundle branches. This book uses ordinary, familiar ideas to help you under-
stand the heart and soul of ECG interpretation.
interpretation.
Learning ECG terminology is comparable to learning a foreign language. Imagine traveling to France, Italy, or Japan.
The first time you visit, you won’t be too familiar with the language. You may try to learn some French, Italian, or Japan-
ese before your trip, but when you try to use your limited knowledge, you’ll make all kinds of mistakes. You
You run into the
same difficulties when you first try to speak ECG language. But after you’ve used this book for a while, you’ll learn vocab-
ulary, grammar, and exceptions to the rules. If you go on to study ECG in more depth, you’ll soon be speaking like a
native.
This book teaches you the basics: words and sentence construction. When you study the language of a country you
plan to visit, you learn important questions like “Where am I?” or “Where is the bathroom?” You’ll
You’ll be able to understand
a lot of what you hear—maybe not word for word, but you’ll get the general idea. In ECG language, you’ll learn to iden-
tify rhythms. Once you can do that, you’re ready to visit ECG country (float to the telemetry or step-down unit or work
as a monitor tech). When you visit this new country, you may not understand everything you hear, but you’ll understand
enough to ask intelligent questions and answer simple ones. You’ll still be a tourist, but you won’t sound so much like
one. The words you know will become familiar and comfortable; meanwhile, new words and sentence structures will
begin to sound comprehensible, if not completely clear yet. For many of you, this is as far as you need or want to go in
learning ECG language. For those who want to go farther, more complex material abounds.
If you study ECG interpretation in greater depth, you will learn more complex sentence structure, more vocabulary,
and some exceptions to the rules you learned in the first book (think of “ I before e except after c ””).
). You’ll speak ECG as
if you’d been doing it all of your life, although natives will be able to tell that you’re really a well-educated tourist. (Yes,
(Yes, I
know there are no true natives of ECG, but let’s pretend.) You
You will be able to ask more complex questions, like “How do
I get to the grocery store at 3rd and Elm?” and the more complex answers will make sense. In ECG language, you will
learn treatments, new rules, exceptions to rules, and secrets of rhythm interpretation. In practical terms, you can emi-
grate to ECG land (become a staff nurse on the telemetry or step-down unit) and hold your own while you become even
more comfortable with the language. Conversation will get more interesting: you’ll exchange ideas with tourists, émigrés,
and, yes, natives.
If you explore ECG interpretation as far as you can go, the subtle nuances of the language—the slang, idioms, and
euphemisms—will become your own. You will finally become a native speaker. Tourists and émigrés will depend on you
to help them learn the language, and you’ll answer all their questions or at least know where to direct them for the
answers. They’ll turn to you as the resource person,
person, the wise provider of answers, and the mentor for the next genera-
tion of tourists.
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Copyright © 2007 by F. A. D
Preface
This book is structured for your benefit. I’ve devoted it to the basics so you can focus on mastering what you need to
know before you can move on to the next level. Many ECG books—”everything to everybody” books—cram too much
information between their covers; in fact, this type is prevalent in bookstores. As a result, the inexperienced reader often
has to decide what’s important to learn and what isn’t.
Think about your grammar school career, starting with kindergarten. In every beginning course, whether language,
mathematics, or science, you most likely used one book. When you completed that first course and that first book, the
next course moved you on to a new, slightly more advanced book, and the next course, to one still more advanced.
Or think of undergraduate nursing education. When I was in nursing school, learning how to take a blood pressure in
the first semester, I had a book that showed me the steps in case I forgot them. Lots of practice helped me learn my
new skill on both a mental and a physical level. The next semester—in a different course, using a different book—I learned
about conditions that can cause high or low blood pressure. I put this knowledge into clinical practice during the next
several weeks, connecting actual patients with what I knew about blood pressure and other health issues. The following
semester—using a third book and building on the previous two semesters—I learned about how the medications used to
treat high or low blood pressure
pressure worked. At that point, with this minimal amount of knowledge, I was able to work in the
hospital environment, where I continued to learn from other books, my clinical experiences, and my coworkers. I’ve
brought the same concept to ECG interpretation: it’s a new language, which you must acquire in easy steps and use
every day to set it in your mind.
This book will teach you the basics of interpreting ECG rhythms and will prepare you for taking the next step toward
fluency. Stick around,
around, and together we’ll build your language skills slowly but
but logically. If you
you go far enough in your stud-
ies, you can step off a plane in ECG land with the exact degree of fluency you want.
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Copyright © 2007 by F. A. D
ACKNOWLEDGMENTS
ACKNOWLEDGMENTS
Writing a book, especially a complex, technical book such as this one, is a daunting task. It took years to hone my orig-
inal manuscript into the simple tex t you see today. There are a number of people who deserve credit for this book. The
first is my Publisher (Saint)
(Saint) Lisa (Biello) Deitch. She
She took a chance on me and my unique way of explaining
explaining this complex
material. Her ebullient personality was a major factor in my persevering through this long, arduous task. Her patience
qualifies her as a saint, at least to me!
Many of my coworkers at the variety of Pinellas County medical in stitutions in which I have worked in my 15-year
15-year career
provided me with some of the great strips that appear in this book. They also helped me refine my explanations and
analogies by asking for my assistance in interpreting ECG strips and then sitting through my several explanations. We
discovered together what worked best, and I thank them for asking and listening. Some who consistently provided me
with “good” strips and listened to more than their fair share of explanations are Sherri Wenzel, Aurelia Miller, and Matt
Handwerk.
There are a few people who went above and beyond, providing encouragement when I thought I would never finish
the book. To Dr.
Dr. Pyhel, a patient cardiologist; to David Dee ring, Krissy Sfarra, and Tina Lemiere, three nursing students
who are currently working as ECG and Patient Care techs and who bring me many ECGs to see if I can use them; to
Debbie Vass, my ever-optimistic boss; and to Cathy Massaro, a social worker with special skills, I offer my appreciation
for their constant support and their be lief in my ability to accomplish this almost overwhe lming task.
Creativity is not something that comes easily to me; it flourishes best when I am surrounded by creativity. To
To that end,
I must thank people whom I’ve never met but who provided a creative environment for my writing and fostered the devel-
opment of the analogies found in this book; they were whispering in my ears every time I sat down to write. Elton John,
Billy Joel, Helen Reddy, Tori Amos, Queen, James Taylor, David Bowie, and Dr. Hook are just a few of the artists whose
musical creativity allowed me to achieve a state of mind in which I became more creative, more at ease, and more self-
confident than I could have been without them. They each have a signed, dedicated copy of this book should they be
interested.
Of course, any list of acknowledgements would be incomplete without mentioning my mother, Mary Cushman. Besides
allowing me to survive my childhood, a test of tolerance if there ever was one, she instilled a desire to do more than just
know, more than just understand, but to learn deeply and fully; so fully that the knowledge seeps out my pores. She is
a smart lady, but she would rarely give me an answ er to a question. She would question me and help me figure out the
answer, or we would sometimes look up the answer together and discuss the topic. “What do you think?” was her
mantra. She was a firm believer in the adage, “Give a man a fish and he eats for a day, teach a man to fish and he eats
for a lifetime.” My belly is full, I will never want for fish, and this book will, I hope, help others to learn to fish for them-
selves, too.
Finally, but most importantly, I must thank my family: my wife Lynn and my three children, Ryan, Kim, and Hope. The
hour after hour I sat at my desk banging out manuscript on the keyboard, scanning the more than 1000
1000 strips that went
into developing this book, and reviewing editorial changes and artwork not only boggled the mind but diverted my time
and attention from them. (Also, they put up with the deluge of ECG strips that inundated the house—well over 4000 in
all.) They gave me the time to accomplish this dream of writing an ECG book.
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Copyright © 2007 by F. A. D
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Copyright © 2007 by F. A. D
Contents
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Copyright © 2007 by F. A. D
Contents
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Copyright © 2007 by F. A. D
Contents
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Copyright © 2007 by F. A. D
Contents
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Copyright © 2007 by F. A. D
Contents
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .459
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512
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Copyright © 2007 by F. A. D
S E CTION
1
Learning the Basics
Copyright © 2007 by F. A. D
The ECG Canvas
Estimating Heart Rate earlier in this chapter headed “Marking Time.” Remember
that each large box represents 0.20 seconds. Therefore
We can estimate heart rate in three basic ways. They all
five large boxes represent 1 second. If there are 60 sec-
give approximate results because they’re usually based on
onds in 1 minute and five large boxes in each second,
a six-second rhythm strip, not a full minute. Therefore
then there are 300 large boxes (60 ϫ 5) in 1 minute.
small differences are insignificant, and we’ve even come
to expect them. Now, to estimate the heart rate, all we have to do is
determine the number of large boxes between any two
QUICK ESTIMATE: THE SIX-SECOND consecutive QRS complexes. In Figure 3–7, first verify that
METHOD the rhythm is regular. Then measure the distance between
The first method of calculating heart rate is the easiest two consecutive QRS complexes. Using your calipers,
and can be used on any rhythm strip, whether the rhythm place one tip on the first QRS and the second tip on the
is regular or irregular. It’s called the six-second method, same point in the next QRS. Now, carefully, lift your
and the process is simple and painless. Just count the calipers and move them so the first tip is directly on any
number of QRS complexes in a six-second length of strip heavy line. Now count the number of large boxes between
and multiply by 10 (for you non–math majors out there, the tips of the calipers. The second tip will rarely fall
just put a zero after the number). This is where the extra directly on a heavy line, so you must frequently round to
time markings on the strip come in handy. If you look at the nearest box. In Figure 3–7, the measurements are
Figure 3–4, you’ll notice markings on the strip at one- done for you. You can count about three large boxes
second intervals. All you have to do is count the number between the second and third QRS complexes.
of QRS complexes in six of those one-second intervals. Remember, this strip represents a regular rhythm. If you
Figure 3–4 shows five QRS complexes in a six-second were drumming this rhythm, you’d strike your drum at
interval, and therefore the estimated heart rate is 50 bpm. about every third large box. How many groups of four
The six-second method is generally used to assess large boxes are there in 1 minute? Well, this is easily com-
heart rate quickly in an emergency, or to assess the accu- puted. All you need to do is divide the number of large
racy of the ECG machine in calculating heart rate. It’s the boxes in your measurement into 300 (the number of large
least precise technique and can be off by 10 bpm or boxes in 1 minute) and get about 100 bpm.
more. This amount is usually not important in practice and If you look at Figure 3–8, you’ll find the heart rates for
has minimum impact on treatment. However, actual inter- various numbers of large boxes. Commit the numbers in
pretation of the strip demands a more precise measure- Figure 3–8 to memory, in order: 300, 150, 100, 75, 60, 50.
ment. Also, this method can result in different values Then, when you want a quick estimate of heart rate on a
depending on which six-second interval you choose. regular strip, just count off the large boxes using this list
If the rhythm is irregular, the estimate can be less accu- of numbers, and voilà, you’ll have the heart rate by the
rate, but still close enough to help us out. With an irregu- large-box method.
lar rhythm, any given six-second period will represent the Now try this method on the three strips in Figure
overall rhythm well enough to give us the general heart 3–9A–C, and compare your answers with those provided.
rate. The rhythm in Figure 3–5 is irregular, but the strip
has the same three-second markings as in Figure 3–4.
SMALL-BOX PRECISION
Here we find nine QRS complexes in a six-second period,
and therefore the estimated heart rate is 90 bpm. If you try to measure the dimensions of a room with a
foot-long stick of wood, you will get a pretty good esti-
Calculate the heart rate on the three strips in Fig-
mate to the nearest foot. However, if you want more a
ure 3–6A–C and compare your answers with the answers
more precise measurement, you can get a new measur-
listed.
ing device or simply mark the wood with a finer meas-
urement, such as inches. Then you can use the original
A LARGE-BOX ESTIMATE
measurement, but with more precision. In the case of an
The next method is called the large-box method and only ECG strip you can use the same caliper measurement,
works with regular rhythms. To understand the large-box but instead of counting the large boxes, simply count the
method you must refer back to the measurement section small boxes.
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Copyright © 2007 by F. A. D
Location, Location, Location
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Copyright © 2007 by F. A. D
S E CTION
2
Getting More Technical
Copyright © 2007 by F. A. D
The Shape of Things to Come
SURFING THE ALPHABET After the baseline, the easiest feature to recognize is the
QRS complex. The QRS complex is a set of straight lines,
A wave is a rounded curve or a straight line that leaves the usually the tallest part of the tracing. This portion is usually
baseline and returns to it. The ECG waveform is a group the most prominent and, as we’ll find out later, the most
of waves that record the electrical signal as it depolarizes important feature of the ECG strip. The QRS is the only
the heart muscle cells. It’s important to identify the pieces part of the tracing to have a three-letter designation. That’s
of the ECG tracings correctly because the measurements because it can actually have three distinct pieces. Its shape
of each individual wave can affect the rhythm strip doesn’t necessarily change the rhythm interpretation but
interpretation. may affect other ECG phenomena.
To describe the waveform in detail, we break it down The first piece of the QRS complex is the Q-wave. The
into parts that are easily recognizable and that corre- Q-wave is defined as the first downward, or negative,
spond to various parts of the heart. Each part of the deflection of the QRS before any upward deflection. So, if
waveform is designated by one or more of the letters P, the first QRS deflection is upward, there is no Q-wave.
Q, R, S, T, and U. The different parts of the waveform fre- Even without a Q-wave, the entire complex is still called a
quently occur in alphabetical order, although some QRS complex.
parts may be absent and some may appear more than
The R-wave is defined as any upward, or positive,
once in the same waveform. It’s important to under-
deflection of the QRS complex above the baseline. If the
stand what part of the heart, and therefore what part of
first deflection is positive, that’s the R-wave. If the first
the depolarization-repolarization cycle, the letters are
deflection is negative and the second positive, you have
associated with. This chapter will give you a basis on
both a Q-wave and an R-wave (Fig. 5–2A–B). Sometimes
which to begin interpreting different heart rhythms.
you’ll find only a single positive deflection; that’s an R-
Once you understand each rhythm, you’ll be able to
wave by itself (Fig. 5–2C).
learn its possible complications and their conse-
quences to the patient.
A B C
Figure 5–1 is the prototype of the normal ECG wave-
form. It contains all the letters, and everything is perfect
and easy to identify. Don’t get used to it, though. You’ll
almost never encounter a perfect ECG strip in a real
patient; there aren’t even many perfect strips in this book. qR Qr R
However, learning to read ECG strips is like learning a lan-
guage. First you must learn the letters and words and how D E F
qRS Qrs QS
Fig. 5–2A–L The QRS complex can come in many shapes. The shape
Fig. 5–1 The ECG tracing prototype. indicates only what path the electrical signal took through the ventricles.
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Copyright © 2007 by F. A. D
S E CTION
3
Moving to the Rhythm
Copyright © 2007 by F. A. D
CONSULTANTS
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