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# EKG lab

There must be a full 12 leads recorded and
labelled plus a rhythm strip, usually from lead II.
The baseline must be stable and not wandering.
Leads must be well attached, even if it means
shaving a hairy chest.
There should be little interference from skeletal
muscle. The patient must be relaxed and
comfortable.
There should be a square wave calibration to
show that 1mV is equivalent to 1cm in height.
Speed should be 25mm/sec. Hence 1 large
square is 200msec and 1 small square is
40msec.
EKG interpretation: look at five areas, in
order, on each EKG.

Rate
Rhythm (Intervals)
Axis
Hypertrophy
Infarct
Right arm -> left arm aVR: right arm

Right arm -> left leg aVL: left arm

Left arm -> left leg aVF: left leg (foot)

Rhythm strip
Rhythm and Rate
Are there P waves?
Are they regular?
Does every one precede a QRS?
Is the PR interval constant?
What is the PR interval?
The PR interval should be between 120 and 240 msec (3 to 6
small squares)

Ventricular rate
Count the number of R waves over 15 large squares (3
seconds) and multiply by 20. To be slightly more accurate
count the number of R waves over 30 large squares (6 seconds)
and multiply by 10.
A positive wave form (QRS
mainly above the baseline) results
from the wave of depolarization
moving towards the positive end of
Normal

e.g.
A negative waveform (QRS mainly
EKG
below the baseline) is when a
wave of depolarization is moving
away from the positive electrode
(towards the negative end of the
EKG paper has 1 millimeter small
squares - so height and depth of
wave is measured in millimeters.
10 mm = 1.0 mVolt
Horizontal axis is time. Positive QRS in Lead I.
0.04 seconds for 1 mm Negative QRS in Lead aVR.
(1 small box).
0.2 seconds for 1 large box = 5 R wave = 7-8 mm high in Lead I = 7-8mV.
small boxes = 5 x .04 seconds. QRS wave = 0.06 seconds long in Lead I.

QRS
P T 7.0mV

0.5mV 0.06sec
0.2sec
Rate calculation
Memorize the number sequence:
300, 150, 100, 75, 60, 50, 40

-if the QRS lands on a heavy line count the next as 300
Mathematical method:
Use this method if there is a regular bradycardia, i.e. - rate < 50. If the
distance between the two R waves is too long to use the common method,
use the approach: 300/[# large boxes between two R waves].

## Count number of large boxes between first and second R waves=7.5.

300/7.5 large boxes = rate 40.

Six-second method:
Count off 30 large boxes = 6 seconds (remember 1 large box = 0.2
seconds, so 30 large boxes = 6 seconds). Then, count the number of R-R
intervals in six seconds and multiply by 10. This is the number of beats per
minute. This is most useful if you have an irregular rhythm (like atrial
fibrillation) when you want to know an average rate.

Count 30 large boxes, starting from the first R wave. There are 8 R-R
intervals within 30 boxes. Multiply 8 x 10 = Rate 80.
Estimating rate - quiz
Rhythm
A reasonable way to group arrhythmias is
in four general groups.
1. Irregular rhythms
2. Escape & premature beats
3. Ectopic beats
4. AV blocks
Rhythm

## If the beat is ventricular in origin, the QRS is wide and

bizarre because it doesn't come down the normal
pathway.

QRS is wide.
Group 1: Irregular
A) Sinus arrhythmia.
rate = 45-100 b/min
rhythms
if the rate varies a lot over the strip, this term is used.
P waves and P-R intervals are all identical because they originate
from the sinus node.
Sinus rate may vary normally a bit (increase with inspiration,
decrease with expiration)
inspiration stretch receptors in lung stimulate cardiac centers in the
medulla
QRS is normal

Sinus arrhythmia: P waves are not identical in spacing along the strip.
B) Wandering atrial pacemaker.
- pacemaker discharges from different atrial locations
- the clue here is the P waves are of varying shape and differing PR
intervals.
-PR interval is measured from the beginning of the the P wave to the
beginning of the QRS
- if the atrial pacemaker location varies it will take different lengths of
time to get to the ventricle - resulting in different PR intervals.
-also called multifocal atrial tachycardia.
C) Atrial fibrillation.
You will frequently see this arrhythmia.
there are no P waves, only irregular or wavy baseline.
the QRS complexes are irregularly spaced, therefore it is included under
irregular rhythms.

## Group 2: Escape & Premature

beats
escape beat is late
premature beat is early
Atrial escape
Different appearing and late
P wave.
Ventricular escape
No P, wide, bizarre QRS.-
An ectopic pacemaker fires ventricular escape
early before the next
scheduled beat.
Premature atrial
contraction
"PAC", early and differently
shaped P wave, narrow
QRS.
Premature ventricular contraction
-No P, wide bizarre QRS.
-PVCs that occur three (3) or more in a row
is called ventricular tachycardia

## PVC PVC PVC

[150-250] Paroxysmal tachycardia Group 3: Ectopic
[250-350] Flutter
[350+] Fibrillation
Paroxysmal supraventricular
tachycardia: note accelerated rate
and narrow QRS complexes.
Ventricular tachycardia: note fast rate and wide bizarre QRS.
Atrial flutter: sawtooth pattern prior to
QRS complexes.

## Ventricular fibrillation: erratic and wavy

baseline.
Group 4: AV blocks
(occur in three (3) degrees, like skin burns; third
degree is the worst).

1st degree
-PR interval > 0.2 seconds (1 large box), each P is
followed by a QRS.
-PR interval is measured from the beginning of the P
wave to the beginning of the QRS.

seconds.
dropped QRS

## 2nd degree block - type 1

-Also called "Wenkebach".
-PR interval gets progressively longer
each beat until finally a QRS is "dropped"
(missing).

## Figure 20: Note the increasing PR interval

before the QRS is dropped, then the cycle
is repeated.
2nd degree block - type 2
-Also called "Mobitz II".
-Look out! A more serious conduction
problem than Type 1.
-PR intervals are constant and a QRS is
"dropped" intermittently.

## Figure 21: Note the dropped QRS after the

second and sixth P wave in lead II (the
rhythm strip).

## Dropped QRS P wave

P wave Dropped QRS

Normal PR interval
3rd degree block
The atrial rate is independent of the ventricular rate (P wave and QRS march out
separately.
The clue here is no relationship at all of the P-R intervals.
The P-R interval is constantly changing, the QRS is usually wide and bizarre
because it is ventricular origin.

Figure 22: Note the P waves and QRS waves are independent of each
other.

P P P P
Intervals
An interval is a portion of the baseline and at
least one wave.
We measure an interval on the horizontal
axis in seconds.
The PR, QRS, and QT are the intervals which
should be routinely scanned on each ECG.
For measuring intervals, look at the widest

## PR interval (beginning of P wave to the

beginning of the next QRS).
Normally, < 0.2 seconds or one large box.
If it is >0.2 seconds, it is a first degree block.

## Figure 24: Note the prolonged PR interval

(.28 seconds), especially at the second beat.
QRS interval (beginning of Q to the end of the S wave) should be < .12 seconds (< 3 small boxes).
If QRS is > 0.12sec, check for bundle branch block.

## Figure 25: RBBB.

0.04sec x 20 = 0.8sec

## Bundle Branch Block

Right bundle branch block occurs as a congenital anomaly or is associated with volume overload in the
right ventricle.
Left bundle branch block is almost always pathological, reflecting disease of the left ventricle.
Right bundle branch block produces a prolonged QRS, usually about 160 msecs or 4 small squares
Left bundle branch block produces a longer QRS, usually around 200 msec with a more square pattern
than RBBB. The changes are best seen in the lateral V leads.
If QRS is > 0.12 and RR occurs in the left chest leads (V5-V6), this indicates a left bundle branch block.

## Figure 26: LBBB.

EKG lab: in class lab

## Estimate the rhythm of this strip

What condition is this??
FOR EACH OF THE FOLLOWING STRIPS diagnose the condition and justify