ECG Lead ll

Interpretation Answers
#1. 2nd Degree Block Type 1

• Every other complex on this strip looks different.

Step Finding • Looking at the first complex it has a normal
P-QRS-T configuration.
Rate 70 • The second complex has a prolonged P-R interval.
Rhythm Irregular • The second complex is followed by a ‘dropped beat’
(although the P waves preceding these dropped
P-R Interval 0.160s beats are difficult to see).
• A handy saying that may help you recall this rhythm
QRS Duration 0.080s is ‘longer, longer, drop one is type one’, referring to
P-QRS Ratio 1 to 1 the incrementally prolonged P-R interval followed
by a dropped beat.
#2. Junctional with Premature Ventricular Contractions
- Trigeminy

Step Finding
Rate 90 • The underlying rhythm is junctional, based on
its regular R-R interval, narrow QRS
Rhythm Irregular configuration (< .120 s) and no ‘P’ waves.
• There are also extra, wide complex beats;
P-R Interval n/a called PVCs.
• When every third beat is a PVC it is sometimes
QRS Duration 0.080s/0.120s referred to as ‘trigeminy’.
P-QRS Ratio n/a
#3. Torsades des Pointes

Step Finding
Rate n/a • This rhythm has a distinct
increasing then decreasing
Rhythm Irregular amplitude in a repeating pattern
typical of Torsades des Pointes.
P-R Interval n/a • If the patient is pulseless it should
be treated like any other pulseless
QRS Duration n/a V-tach or V-fib.
P-QRS Ratio n/a
#4. Accelerated Junctional

• The first complex on this strip has an upright ‘P’

wave, the rest are all inverted.
Step Finding • An inverted complex of any type means the
depolarisation is occurring ‘backwards’ or in the case
Rate 80 of a normal lead II, from the bottom upwards.
• An inverted ‘P’ wave thus means the depolarisation
Rhythm Regular after is coming from the bottom of the atria (at the
first QRS junction).
• A junctional rhythm is usually between 40-60 beats
P-R Interval 0.160s per minute.
• If it is faster than 60 but less than 100 it is
QRS Duration 0.080s
considered ‘accelerated junctional’. If it is greater
P-QRS Ratio 1 to 1 than 100 it
• is considered ‘junctional tachycardia’.
 #5. Sinus with
Premature Atrial Contractions

Step Finding • Every other complex on this strip

look different. Looking at the first
Rate 60 complex it has a normal P-QRS-T
configuration.
Rhythm Regularly • The second complex is premature
Irregular and also has a ‘P’ wave that falls
right behind the preceding ‘T’ wave.
P-R Interval 0.160s • A premature complex with a ‘P’ wave
is a premature atrial complex (PAC).
QRS Duration 0.120s • When determining the rate of a
P-QRS Ratio 1 to 1 rhythm all ‘extra’ beats are counted.
 #6. Atrial Flutter
with variable conduction

• The underlying atrial activity is atrial

flutter based on its fast rhythm and
Step Finding characteristic appearance. Because some
Rate 100 flutter waves are not followed by QRS
complexes there is also a second degree,
Rhythm Irregular type two, block.
• Because the number of ‘F’ waves with no
P-R Interval 0.160s associated QRS complex varies, the block
can be called ‘variable’.
QRS Duration 0.060s • There are only 25 large boxes visible on
P-QRS Ratio variable the strip and the rhythm is not regular so
it is impossible to determine an accurate
rate.
• I have estimated it to be close to 100.
 #7. Idioventricular

Step Finding
• “Wide and slow and the Ps don’t
Rate ~55 show, is idio..” is a saying that
might help you to remember this
Rhythm Irregular rhythm.
• There are not six seconds
P-R Interval n/a
available to determine the rate,
QRS Duration 0.200s but it looks relatively regular so
we can use the 300-150-100...
P-QRS Ratio n/a method.
 #8. Junctional into a
Supraventricular Tachycardia

Step Finding • This strip starts as a narrow

complex, regular rhythm with no
Rate 160 ‘P’ waves and then in short order
gets faster than 200 beats per
Rhythm Irregular minute and very regular (SVT).
turning regular • The sudden onset of this rhythm
makes it a true ‘paroxysmal supra
P-R Interval n/a ventricular tachycardia’ (PSVT),
QRS Duration 0.080s with the ‘paroxysmal’ referring to
the suddenness.
P-QRS Ratio n/a
#9. Supraventricular Tachycardia
conversion to a Sinus Bradycardia

• This rhythm is similar to 8 only the other

way around.
Step Finding • It starts off as an SVT at about 240 per
Rate ~240 minute and then two ventricular beats is
followed by a sinus bradycardia.
Rhythm Regular then irregular • It is very possible that this patient had
been given adenosine moments prior to
P-R Interval 0.160s (once brady) this strip being printed.
QRS Duration 0.080s • Adenosine stops conduction through the
AV node for a short period of time thus
P-QRS Ratio 1 to 1 (once brady) terminating the out-of-control self
depolarisation that occur in these rhythms.
#10. 1st Degree Block

Step Finding • This rhythm looks normal other than that the
prolonged P-R interval.
Rate 60 • If the P-R interval is longer than 0.200 s it is
considered a 1 st degree A-V block.
Rhythm Regular • The prolonged interval means that the
conduction between the atria and the
P-R Interval 0.240s ventricles is slowed down more than usual.
• Vagal activation, beta blockers and
QRS Duration 0.080s
anti-alzheimers meds such as Aricept are
P-QRS Ratio 1 to 1 common culprits.
#11. Sinus Arrhythmia

Step Finding
Rate 60
Rhythm Irregular
P-R Interval 0.160s
QRS Duration 0.080s
P-QRS Ratio 1 to 1
#12. Sinus Tachycardia

Step Finding
• This rhythm looks ‘bad’ at a first
Rate 155 glance, but systematic analysis of
its components reveals that it is
Rhythm Regular normal other than being fast.
• Try to determine the cause of sinus
P-R Interval 0.120s tachycardia as it is often a
compensatory response to
QRS Duration 0.080s something; fever, pain, blood loss,
infection etc.
P-QRS Ratio 1 to 1
 #13. Atrial Flutter 3:1

• Atrial flutter is characterised by oddly shaped ‘P’ waves

that are renamed ‘F’ waves.
• A great hint is that these flutter waves are usually
Step Finding occuring at a rate of 300 per minute.
Rate 100 • To determine the ‘conduction ratio’, (the number of ‘F’
waves for each QRS) simply determine the QRS rate,
Rhythm Regular in this case 100.
• F : QRS
P-R Interval F waves present • 300 : 100 = 3:1 conduction ratio
QRS Duration 0.080s • This eliminates the common confusion of miscounting
the ‘F’ waves as there is usually one buried in the QRS
P-QRS Ratio F-QRS, 3:1 complex.
• The above strip is also shorter than six seconds so the
300-150-100... method is the only way of determining
the rate.
 #14. Sinus Rhythm
with multifocal Premature
Ventricular Contractions

• This rhythm is an underlying sinus rhythm with

Step Finding some extra beats.
• The beats are wide (ventricular) and premature,
Rate ~75 hence PVC.
• They also have different shapes, meaning that
Rhythm Irregular they originate in different areas of the ventricle
P-R Interval 0.200s (multifocal).
• There is also an episode where every other beat is
QRS Duration 0.080/0.120s a PVC (bigeminy).
• So could be called ‘underlying sinus with a run of
P-QRS Ratio 1 to 1 (except ectopics) multifocal, ventricular, bigeminy’.
• As a point of interest, the ‘T’ wave is usually
deflected in the opposite direction of the QRS in a
PVC, this holds true on the above strip.
 Ventricular Standstill

Step Finding
Rate 75 (atrial only)
• This rhythm is sometimes seen in a
Rhythm Regular person who is VSA.
• Basically there are P waves only.
P-R Interval n/a • The ventricles are not depolarizing
at all.
QRS Duration n/a
P-QRS Ratio n/a
 #16. Atrial Fibrillation

Step Finding
• This is another ‘narrow complex, irregularly
Rate 80
irregular rhythm with no ‘P’ waves’.
Rhythm Irregular • Even though these rhythms come in a wide
variety of ‘looks’ they are all atrial fibrillation.
P-R Interval n/a • 15% of people older than 65 years of age have
atrial fibrillation.
QRS Duration 0.060s • Many don’t even know that they have it.
P-QRS Ratio n/a
#17. Sinus Tachycardia or Junctional

• This one is tricky and might have more than

Step Finding one ‘right’ answer.
Rate 140 • Because of the rate and the configuration of
the complexes it is impossible to know for
Rhythm Regular (mostly) sure if there are ‘P’ waves present or not.
• The rate does not seem fast enough to be an
P-R Interval n/a SVT nor is it 100% regular (allthough very
QRS Duration 0.120s close).
• If there are no ‘P’ waves then it would be a
P-QRS Ratio n/a junctional tachycardia (a junctional
• rhythm >100 / min).
• If there are ‘P’ waves buried in the ‘T’ waves
then it is a sinus tachycardia.
#18. 3rd Degree Block

Step Finding
• This strip has two different regular rhythms
Rate 30 on it.
• ‘P’ waves are regular at around 65
Rhythm Regular
beats per minute.
P-R Interval n/a • QRS complexes are regular at 30
beats per minute.
QRS Duration 0.160s • However, there is no relation between the
P-QRS Ratio No relation two rhythms, they are essentially divorced,
‘doing their own thing’.
• There is a complete disconnect between the
atria and the ventricles.
#19. Sinus Tachycardia

• The black markers at the top of this

Step Finding strip are 3 second markers.
• Because there aren’t two of those
Rate 140 markers visible on the strip, there
Rhythm Regular are two options to determine the
rate.
P-R Interval 0.160s • One is to count 30 large boxes
(6 seconds).
QRS Duration 0.080s Or
• Because the rhythm is regular,
P-QRS Ratio 1 to 1
you can use the 300-150-
100... method.
 #20. Atrial-Ventricular
Sequential Pacemaker

• This strip consists of a pacemaker spike

Step Finding followed by a ‘P’ wave (atrial pacemaker).
Rate 90 • Right after the ‘P’ wave there is another
pacemaker spike followed by a wide QRS
Rhythm Regular complex (ventricular pacemaker).
• This type of pacemaker is called an
P-R Interval 0.160s A-V sequential pacemaker and has two
QRS Duration 0.160s electrodes, one that triggers the atria and
one that triggers the ventricles shortly
P-QRS Ratio 1 to 1 after, hence the patient retains their atrial
kick.
#21. 2nd Degree Block Type 2

Step Finding • This strip look quite normal except that

every now and then there is a ‘P’ wave
Rate 70 that is not followed by a QRS complex;
sometimes refered to as a ‘dropped
Rhythm Irregular beat’.
• When a beat is dropped but all other ‘P’-
P-R Interval 0.160s QRS relations are normal it is refered to
as a second degree, type two, AV block.
QRS Duration 0.080s • It is concerning as it often deteriorates
P-QRS Ratio Sometimes no into a third degree AV block.
QRS for P
#22. Ventricular Tachycardia

Step Finding
Rate 200 • The wide complex and fast rate
Rhythm Regular makes this rhythm quite easy to
recognize.
P-R Interval n/a • Keep in mind v-tach might or
might not have a pulse.
QRS Duration 0.160s
P-QRS Ratio n/a
#23. Ventricular Tachycardia

• This is another example of ventricular

Step Finding tachycardia.
• The Laerdal Heartstart 3000 SAED that
Rate 160
many paramedics started using as their
Rhythm Mostly regular first defibrillator was programmed to only
shock v-tach faster than 180 beats per
P-R Interval n/a minute.
• The newer monitors (Zoll and LP12) will
QRS Duration 0.240s shock much slower v-tach in their semi-
automatic modes.
P-QRS Ratio n/a • It is important to check for a pulse,
especially in slower v-tachs.
#24. Supraventricular Tachycardia

Step Finding • The rate of this rhythm can be

determined either by counting the
Rate 180 number of beats in 6 seconds (the
vertical lines at the top of the paper
Rhythm Regular are 3 second markers)
OR
P-R Interval Difficult to discern
• By the 300-150-100... method.
QRS Duration 0.080s
• On a fast rhythm like this the second
P-QRS Ratio 1 to 1 (if present) method is much faster than counting
18 beats over the 6 seconds.
#25. Normal Sinus Rhythm

Step Finding
Rate 80
Rhythm Regular
P-R Interval 0.160s
QRS Duration 0.080s
P-QRS Ratio 1 to 1
#26. Ventricular Fibrillation

Step Finding
Rate n/a
Rhythm Irregular
P-R Interval n/a
QRS Duration n/a
P-QRS Ratio n/a
 Sinus Bradycardia

• This strip is totally normal except for

Step Finding the rate.
Rate 30 • Usually this slowing is caused by vagal
nerve stimulation.
Rhythm Regular • If the patient is suffering a potential
myocardial infarction consider the
P-R Interval 0.160s potential of a inferior wall MI as these
often lead to vagal nerve irritation and
QRS Duration 0.080s bradycardia.
• Nausea, vomiting, GI upset,
P-QRS Ratio 1 to1
neurocardiogenic syncope are other
causes of vagal stimulation.