ECG READING PLACEMENT OF 12 LOAD ECG

• ECG – also called electrocardiogram

- is a simple test that can be used to check
your heart's rhythm and electrical activity.
Sensors attached to the skin are used to
detect the electrical signals produced by
your heart each time it beats.
- Electrical signals are made due to action
potential. The movement of sodium,
potassium and calcium generates electrical
impulses since they are electrically charged
- It is a quick and painless procedure. EKG’s
captures a tracing of cardiac electrical
impulse as it moves from the atrium to the
ventricles. These electrical impulses cause
the heart to contract and pump blood.
EKG’s are interpreted by medical professionals to
understand the following:
o Heart rate
o Heartbeat regularity
o Strength and timing of the electrical signals
o Any possible abnormal conditions
ECG/EKG GRAPH SAMPLE:
• Sinoatrial node (pacemaker)
- Where the firing of electrical impulse
started. It is in the right atrium.
- As it fires, the muscles in the right atrium
are also delivered (impulse).
- 60 – 100 bpm
• Bachmann’s bundle
- Also called interatrial bundle.
- Used to deliver the electrical impulse
towards the left atrium
• Atrioventricular node • Isoelectric line – the straight line in the ECG. It is
- In between the atria and ventricles. also where there are no positive or negative
- 40 – 60 bpm charges of electricity to create deflections.
- This helps fire electrical impulses from the • Each small boxes are 0.04 seconds. So, one big
SA node towards the ventricle but the use box is equivalent for 0.2 seconds.
of the bundle branches. • Positive deflection – a line above the isoelectric
- That also separates in the Purkinje fibers. line.
Which is the last pathway • Negative deflection – a line below the
SIMPLE PATHWAY: isoelectric line.
SA nodes -> AV nodes -> bundle branches (left and • Depolarization – contraction.
right) -> Purkinje fibers (20 – 40 bpm) • Repolarization – means relaxation.

• Sinus rhythm (SR)

PLACEMENT OF ECG - A normal sinus rhythm refers to both a
normal heart rate and rhythm.
- Normal heart rates are from 60-100 beats
per minute
- With normal SR, the heart beat’s electrical
impulse originates in the Sinoatrial node
(SA).
- The P waves are upright and appear before
each QRS and have the same shape
 travels down the bundle branches, thought
the Purkinje fibers to the ventricles.

- P wave is due to depolarization or atrial

depolarization. It is seen in the positive
depolarization and that is due to Atrial
contractions.
- PR segment is a resting phase.
- Atrial relaxation is not really seen in the ECG
strip since the ventricle is so large it covered
that phase of the heart beat before starting
the ventricular depolarization.
- Q wave is the 1st negative deflection
- 2nd positive deflection is the R wave
- 2nd negative deflection is the S wave
- QRS complex is the ventricular
depolarization.
- ST segment is the resting period before the
3rd positive deflection or the T wave. - P and T wave must be upright.
- T wave is the relaxation of the ventricles (?) - To get the PRI, start the first box where the
- Then back the cycle. P wave started to go up then end before the
- PQRST wave is one cardiac cycle starting point of Q wave (?)
- PR interval (PRI) is important since it would - To check if regular or irregular rhythm is to
indicate if a patient has a heart block count all the boxed between each R wave.
- PRI is 0.12 – 0.20 seconds Starting from the first cycle until the next
- QRS complex is less than 0.12 seconds cycle and so on if the boxes are consistently
- Term used for abnormalities is aberration. distanced. (SABTA)
- ST segment important for patients with - If naay gamay na simang kay I count pd apil
myocardial infarction. ang small boxes. Still if naay ning simang na
atleast 1-2 small boxes (difference), it is still
Reading considered as regular rhythm.
- The shape of the EKG tracing will exhibit - If irregular rhythm, there are inconsistent
certain key attributes to be considered distance or number of boxes between each
normal. R wave. Still, both P and T waves are upright
and the distance of QRS wave are also
Classification consistent. Only the distance of each R
- The intervals between the P waves are wave is inconsistent.
regular although some variations can occur - Next step is to divide 300 (standard) and
with respiration. Sinus rhythms are the number of big boxes ang ning sulod
classified as: starting from the cardiac cycle till the next
o Normal sinus rhythm cardiac cycle. Ex. 300 divided by 4 (the 2nd
o Sinus arrhythmia and 3rd cycle of the sample EKG)
o Sinus bradycardia - For the small boxes, 1500 (standard) divided
o Sinus tachycardia by the number of small boxes in the
o Sinus exit block distance.
o Sinus arrest

SINUS RHYTHM CATEGORIES:

• Normal sinus rhythm (60 – 100 bpm)
- Is the normal rhythm of the heart. The
electrical impulse originates within the SA
node and travels through the atria to the Av
node. After a brief delay, the impulse
 - For irregular rhythm, is to use the 6 second
method (it can also be used in regular
rhythm). Count the number of R wave
within the 6 second strip and multiply it by
10. To count our Heart rate. (Ex. 70 bpm)

SUMMARIZE:
• For regular rhythm:
- Big box method
- Small box method
- 6 second method
• For irregular rhythm:
- 6 second method

• Sinus bradycardia
- Is a sinus rhythm with a rate of 40-60 bpm
- Or less than 59 bpm
PREMATURE ATRIAL CONTRACTION:

- PAC is a problem in the atria where there is

irregular rhythm in the cardiac cycle
- 6 boxes with 3-4 small boxes (regular) - Early contraction of the atria which is seen in
the P wave (it must be noticed)
• Sinus tachycardia - The P wave is also inconsistent (ning lahi ang
- Is a normal sinus rhythm but with a heart form), early contraction then there is a
rate of over 100 bpm. It is a normal response compensatory pause or also called ectopy.
to exercise, excitement and some illnesses (Seen in the 2nd cardiac cycle and 7th cycle)
- Using the 6 second method, the number of
heart rate is 80 bpm (fall under sinus rhythm
but irregular) or Sinus rhythm with PACs
(since there are 2)

• Bigeminy
- One normal cardiac cycle plus an additional
PAC (premature atrial contraction).
- After every routine beat, you have a beat
that comes too early
- There is a pattern.
- Must occur in the 6 second strip.

• Sinus arrhythmia
- Looks normal for slight irregularities. A
frequency cause of sinus arrhythmia can be
rhythm variations caused by respirations

- Since the heart rate is 120 bpm, its base

rhythm is considered as sinus tachycardia
with PAC in bigeminy.
 • Trigeminy
- Every 3rd beat (?)
- is an abnormal heart rhythm that causes an
extra heartbeat. Specifically, the condition
causes an abnormal heart rhythm to occur
every third heartbeat.

- Sinus rhythm with PVC in Trigeminy

• Ventricular Tachycardia
- is a fast, abnormal heart rate. It starts in
your heart's lower chambers, called the
ventricles. VT is defined as 3 or more
heartbeats in a row, at a rate of more than
- Sinus bradycardia with PAC in trigeminy and 100 beats a minute. If VT lasts for more
PACs (“and PACs” kay naa may nahabilin na than a few seconds at a time, it can become
ectopy after the 3rd second) life-threatening.
- 58 bpm

PREMATURE VENTRICULAR CONTRACTION:

- is a too-early heartbeat that originates in
the ventricles and disrupts the heart's
normal rhythm. The pattern is a normal
beat, an extra beat (the PVC), a slight pause,
then a stronger-than-normal beat. It talks
the QRS complex being abnormal or wide
and bizarre.
- There is also a compensatory pause. - Sinus rhythm with 5 beats in Ventricular
tachycardia

• Ventricular couplets
- are defined as two PVCs in a row.
- There is often a compensatory pause after
the second premature beat. The two
premature beats may have an identical
morphology (unifocal couplet), or their
morphology may differ (multifocal couplet).
- Sinus rhythm with PVCs
ATRIAL FIBRILATION
• Bigeminy - is an irregular and often rapid heart
- After every routine beat, you have a beat rate that occurs when the two upper
that comes too early, or what's known as a chambers of your heart experience chaotic
premature ventricular contraction (PVC). electrical signals. The result is a fast and
irregular heart rhythm. The heart rate in
atrial fibrillation may range from 100 to 175
beats a minute.

- Take note is that patients with PVC have no

P wave in the ECG strip but there are also
patients who exhibits P waves in the ECG
despite having PVCs. - fibrillatory waves or (f waves) (gabalik2 sa
- Sinus rhythm with PVC in bigeminy. giagian), the electrical pulse would go to
different places other than the designated
• Trigeminy place or the next pathway. Balik2 in the
- is an abnormal heart rhythm that causes an atria.
extra heartbeat. Specifically, the condition - If a patient with Atrial fibrillation has a
causes an abnormal heart rhythm to occur heartrate of 100 bpm and above, it is called
every third heartbeat. rapid ventricular response (RVR).
- There is only have the QRS complex since
the ventricle are functioning properly, only
the atria is behaving abnormally.
- Atrial fibrillation with RVR
 • Atrial Flutter
- is a type of abnormal heart rhythm, or
arrhythmia. It occurs when a short circuit in
the heart causes the upper chambers (atria)
to pump very rapidly. Atrial flutter is
important not only because of its symptoms
but because it can cause a stroke that may
result in permanent disability or death.
- Rate: 100-150 bpm
- Rhythm: regular
- P waves: none or not associated with the
QRS
- PR interval: None
- QRS: Wide (0.10 sec), bizarre appearance

• Poly morphic
- QRS complexes in polymorphic VT vary in
shape and amplitude
- No P waves, the problem lies in the atria - The QT interval is normal or long
where there are no electrical impulse.
- Sotus appearance (?)
- 2 is to 1 atrial flutter, there are 2 big F
waves in 1 QRS complex
- There are no P waves

- Rate: 100 – 250 bpm

- Rhythm: regular or irregular
- P waves: none or not associated with the
QRS
- PR interval: None
- QRS: wide (0.10 sec) bizarre appearance

- 3 BIG F WAVES, it is called VARIABLE • Torsade de Pointes

CONDUCTION ATRIAL FLUTTER - The QRS complex reverses polarity and the
- Use 6 second method for measuring the strip shoes a spindle effect
heart rate - The rhythm is an unusual variant of
- Irregular R waves polymorphic VT with normal or long QT
- Rhythm varies intervals
- In French, the term means “twisting of the
• Supraventricular Tachycardia points”
- This arrhythmia has such a fast rate that the
P waves may not be seen
- Rate: 150-250 bpm
- Regular rhythm
- P waves: frequently buried in preceding T
waves and difficult to see
- PR interval: usually not possible to measure
- QRS: normal (0.06-0.10 seconds) but may
be wide if abnormally conducted through
ventricles - Rate: 200-250 bpm
- Rhythm: irregular
- P waves: none
- QRS: wide (0.10 sec) bizarre appearance

VENTRICULAR FIBRILLATION
- Chaotic electrical activity occurs with no
ventricular depolarization or contraction
- The amplitude and frequency of the
fibrillatory activity can be used to define the
type of fibrillation as course, medium or
- is a condition where your heart suddenly
fine
beats much faster than normal
- It is a part of the atria aberration since the
word supra means above the ventricle, (?)

VENTRICULAR TACHYCARDIA
• Monomorphic
- QRS complexes in monomorphic VT have
the same shape and amplitude
 - Rate: indeterminate
- Rhythm: chaotic
- P waves: none
- PR interval: None
- QRS: none
- Entails emergency response
- No cardiac output - The distance of PR interval are inconsistent
or Prolonging PRI (its interval)
• Pulseless electrical activity (PEA)
- Monitor shows an identifiable electrical • Mobitz type 2
rhythm but no pulse is detected - which refers to periodic atrioventricular
- Rhythm may be sinus, atrial, junctional, or block with constant PR intervals in the
ventricular in origin conducted beats.
- electromechanical dissociation (EMD)2wsx - Series of drop beats instead of QRS complex

• Asystole
- Electrical activity in the ventricles is
completely absent.

• 3rd degree heart block

- is an abnormal heart rhythm resulting from
- Rate: none a defect in the cardiac conduction system in
- Rhythm: none which there is no conduction through the
- P waves: none atrioventricular node (AVN), leading
- PR interval: None to complete dissociation of the atria and
- QRS: none ventricles

ATRIOVENTRICULAR BLOCKS
• First-degree AV block
- Rate: depends on rate of underlying rhythm
- Rhythm: regular
- P waves: normal (upright and uniform)
- PR interval: prolonged (0.20 sec)
- QRS: (0.06-0.10 sec)
- There are no correlation of P wave and the
QRS complex
- Not synchronous, both atria and ventricle
fire on their own.
- But the R and P waves are very regular

- Constant prolongation of PR interval on

each cardiac cycle

• Second-degree AV block
• Type 1 (Mobitz 1 or Wenckebach)
- P-R intervals become progressively longer
until one P wave is totally blocked and
produced no QRS. After a pause, during
which the AV node recovers, this cycle is
repeated