The Fabulous Fundamentals and Rules of Rhythm Interpretation...• Sequence the steps in analyzing...

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Continuing Education October 2018

Participant Handout

The Fabulous Fundamentals and

Rules of Rhythm Interpretation

Questions regarding this material are welcome and should be directed to

Susan Wood, RN, Paramedic EMS CE In-Field Coordinator

Upon completion of the class or credit questions and independent reading of handouts, each participant will independently do the following within their scope of practice with at least an 80% degree of accuracy and no critical errors:

• Describe the purpose and limitations of ECG monitoring.

• Describe the five steps of rhythm interpretation and use information to correctly identify ECG rhythms.

• Identify and locate the major electrical conduction system structures and state their intrinsic pacing rates.

• Describe information obtained from the vertical and horizontal axes of the ECG graph paper.

• Describe the markings on ECG paper and apply that knowledge to rhythm interpretation.

• State the time measurement of one small square and one large square on ECG paper. • Plan, assessment & treatment for a pt experiencing ACS, bradycardia, narrow & wide complex

tachycardia.

• Explain the etiology and methods to troubleshoot ECG artifact.

• Sequence the steps in analyzing an ECG rhythm strip. • Describe the normal parameters for the following aspects of an ECG rhythm strip: Rate,

Rhythm, P waves, PR interval, and QRS complex duration • Describe two common methods for calculating heart rate on an ECG rhythm strip and the

indications for using each method. • Given an ECG rhythm strip, identify the following:

P waves P-R intervals

QRS complexes J point and ST segments

P-P intervals T waves

R-R intervals isoelectric line

• Describe different configurations of P waves, QRS complexes and their significance.

• Given an ECG strip, describe the regularity, calculate the rate (atrial and ventricular) and determine the presence of P waves, the P-R interval and QRS duration.

• Correlate the mechanical responses in the heart to the electrical tracing on the cardiogram.

• Identify various rhythms on a 6 second strip.

Northwest Community Healthcare Continuing Education Rhythm RULES Connie J. Mattera, M.S., R.N., EMT-P

Rhythm Regularity Heart rate P wave configuration PRI

(Normal, short, long) Fixed/variable

P/QRS ratio QRS

Sinus rhythm Regular 60-100 Normal; upright 0.12-0.20; fixed 1:1 0.04-0.10 (< 0.12) Sinus bradycardia Regular < 60 (40-59) Normal, upright 0.12-0.20; fixed 1:1 < 0.12 Sinus tachycardia Regular 101-150 Normal, upright 0.12-0.20; fixed 1:1 < 0.12

Sinus arrhythmia Irregular; rate gradually increases w/ inspiration; decreases w/ expiration

Usually 60-100 Normal; upright 0.12-0.20; fixed 1:1 < 0.12

Sinus block/arrest Irregular w/ pauses; may be followed by an escape

beat

Normal to slow; depends on

frequency of sinus pauses

Normal in underlying rhythm; absent during

pause; escape beats may have no P if from junction or

ventricles

0.12-0.20; fixed if underlying rhythm is

sinus 1:1 < 0.12

PAC

Irregular on strip with early beat

Non-compensatory pause

Usually WNL for sinus; depends on

underlying rhythm & # PACs

PAC: early P wave; may differ in shape from sinus Ps. Shape depends on location of ectopic pacemaker (pointed, flat, biphasic, notched; inverted if close to AV node; may be hidden in preceding T wave) P precedes each QRS

PAC: Usually normal or sl. shortened; differs

from underlying rhythm. Not measurable if P

buried in QRS or non-conducted PAC

Usually 1:1 unless PAC is non-conducted to

ventricles (then early P w/o a QRS)

Usually < 0.12 unless PAC so early that

bundle branches are not repolarized

sufficiently to conduct impulse normally

(aberrant or abnormal conduction causes QRS to be wide)

Atrial Reentrant tachycardia

Preexcitation rhythms through accessory

pathway (Wolff-Parkinson-White or WPW Syndrome)

Regular if Afib not present

Irregular if Afib is present

PSVT and A-fib seen in WPW – can have

extremely rapid ventricular rate (250-

300) (NO calcium

blockers)

Present; normal shape Short (AV node bypassed) 1:1

Usually prolonged as ventricle gets beat early and depolarizes in cell-to-cell fashion instead

of through normal pathways

Distorted initial portion (slurred uptake called

delta wave)

AV nodal reentrant tachycardia (AVNRT

or PSVT)

Regular except at onset and termination 150-250 (170-250)

If present, may be pointed; originates in area around AV node; P waves may be hidden in QRS or distort end of QRS. 3 or more sequential PACs at rate > 100 = paroxysmal atrial tach

Usually not measurable If P waves seen: 1:1 < 0.12

NCH Continuing Education Rhythm RULES - page 4



P/QRS ratio QRS

Atrial flutter

Atrial: regular Ventricular: variable

depending on conduction ratio

Atrial: 250-450 (300) Ventricular: Variable depending on conduction ratio (not usually >180)

V-shaped waveforms resemble “sawtooth”

pattern called flutter waves. Not measurable Flutter wave/QRS

ratio varies

< 0.12 unless conduction disturbance

through ventricles

Atrial fibrillation

Irregularly irregular unless very fast – then

may appear almost regular

Atrial: 350 or more; not measurable Ventricular: varies < 100: Controlled > 100: Uncontrolled

None discernable Fib waves cause chaotic

baseline that may be fine or coarse

Not measurable Not measurable < 0.12

Wandering atrial pacemaker

(multifocal atrial rhythm)

Regular to irregularly irregular as pacemaker shifts from SA node to ectopic atrial location & AV node

Usually 60-100; may be slow If rate > 100: multifocal atrial tachycardia

Change as pacemaker site changes (“wanders”) Vary in size, shape, direction. Should see 3 different P’s on one strip

Varies based on location of impulse

formation & conduction; may be < 0.12

1:1 < 0.12

Junctional rhythm Regular 40-60 If precedes QRS: may be inverted, absent, or after QRS

If present: < 0.12 If P waves seen: 1:1 < 0.12

Accelerated junctional rhythm Regular 61-100

Junctional configuration If present: < 0.12 If P waves seen: 1:1 < 0.12

Junctional Tachycardia Regular > 100 – 180 (220)

Junctional configuration (often hidden) If present: < 0.12 If P waves seen: 1:1 < 0.12

Junctional escape beat Irregular due to late beat

Slow; allows junction to beat in late

Junctional configuration for late beat If present: < 0.12 If P waves seen: 1:1 < 0.12

PJC Irregular due to early

junctional beat Non-compensatory pause

60-100 if underlying rhythm sinus Junctional configuration for

early beat If present: < 0.12 If P waves seen: 1:1 < 0.12

1st degree AVB Generally reg if AVB is only abnormality

May occur at any underlying rate

Present, upright P-P regular

Consistently >0.20 Fixed

1:1 All atrial impulses conduct to ventricles

< 0.12

2nd degree type I (Wenckebach)

P-P regular R-R Irregular with distinct

pattern to irregularity (grouped beating)

Atrial usually normal Ventricular may be slow depending on # of dropped QRS complexes

Present; upright Variable

Progressively lengthens prior to dropped QRS

More Ps than QRS < 0.12

2nd degree type II

P-P regular R-R may be regular or irregular depending on

conduction ratio

Atrial usually normal Ventricular may be slow depending on # of dropped QRS complexes

Present; upright

Fixed for conducted beats

May be normal or > 0.20 sec

More Ps than QRS May be normal or

prolonged depending on site of block

3rd degree AVB (CHB)

P-P regular (may need to look for them) R-R regular

Atrial rate usually WNL for SA node Ventricular (R) rate 40-60 if paced by AV 20-40 if paced by ventricles

Present; upright – may be buried in a QRS

Variable; no correlation between Ps and QRSs More Ps than QRS

Narrow (<0.12) if Junctional escape

pacemaker Wide (≥ 0.12) if

ventricular escape pacemaker




P/QRS ratio QRS

Idioventricular rhythm R-R essentially regular 20-40 None None Only QRS complexes

≥ 0.12; T wave opposite polarity to

main QRS

Accelerated idioventricular rhythm R-R essentially regular 41-100 None None Only QRS

complexes

≥ 0.12; T wave opposite polarity to

main QRS

Ventricular tachycardia

monomorphic Regular R-R

101-250 If > 250, QRS

complexes appear sawtoothed –

ventricular flutter

Usually none May be present dissociated

from QRS Not measurable

More QRSs than P waves due to

ventricular beats

Uniform ventricular configuration: wide; T wave opposite polarity

to main QRS

VT polymorphic w/ prolonged QT Torsades de pointes (twisting of the points)

Regular to irregular Very rapid None None Only QRSs due to ventricular beats

QRS direction rotates up and down in same lead causing complexes to look very different

Ventricular escape beat

Irregular due to late ventricular beat Slow None associated w/

ventricular beat None measurable w/

ventricular beat

More QRSs than P waves due to late ventricular beat

Ventricular configuration: wide; T wave opposite polarity to main QRS

Premature Ventricular

contraction (PVC)

Irregular due to early ventricular beat

Full compensatory pause R on T phenomenon is deadly

Depends on underlying rhythm None associated w/ PVC None associated w/

PVC

More QRSs than P waves due to early

ventricular beat

Ventricular configuration: wide; T wave opposite polarity to main QRS Uniformed or multiformed

Ventricular fibrillation Irregularly irregular No distinguishable

waves – cannot count rate

None None None

None Irregular, chaotic

baseline Coarse or fine

Ventricular asystole No QRS complexes present None

Usually none; but may be present if original rhythm

was 2nd or 3rd degree AVB None None None

Paced rhythm

Regular or irregular depending on patient’s native rhythm

Usually set at 70; depends on native rhythm if demand pacer

None with demand and external paced beats Present with A-V sequential pacemaker; preceded by a “pacer spike”

None with demand and external paced beats Set between 0.12-0.20 in sequential pacemaker

Varies with type of pacemaker and patient’s native rhythm

Preceded by pacer spike; usually ≥ 0.12

Intraventricular conduction delay

(defect) BBB Depends on underlying rhythm; usually regular

Depends on underlying rhythm Present, upright May be normal or

delayed; Fixed 1:1 Wide; ≥ 0.12


There are only three supraventricular rhythms that are irregularly irregular:

• Sinus arrhythmia (one P-wave morphology and stable PR interval);

• Multifocal atrial rhythm with a rate <100 beats/min and multifocal atrial tachycardia with a rate >100 beats/min (three or more different P-wave morphologies and PR intervals without any P wave morphology being dominant); and

• Atrial fibrillation in which there are no organized P waves.

NCH EMS System Continuing Education: October 2018. Rhythm Rules and Interpretation Participant Edition Rhythms MAY BE USED MORE THAN ONCE. If a rhythm has ectopy, list underlying rhythm & ectopy.

Rate Regularity QRS width

P waves present? PR Interval

Identify the rhythm:

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NCH EMS System Continuing Education: October 2018. Rhythm Rules and Interpretation Participant Edition




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The Rhythm Is Gonna Get Ya!

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