EKG Reading

Basics

Leah Taylor
Western Kentucky University
Doctor of Physical Therapy
Program
Common Causes of Arrhythmias
Cardiac Conditions
MI: >90% experience some type of arrhythmia
CHF
Cardiac Surgery
Ventricular Aneurysm
Cardiomyopathies
Pericarditis
Myocardial Contusion
Pulmonary Conditions
Any acute conditions causing PO or pH (*Tachycardia)
COPD (*Atrial Tachycardia)
Pulmonary Emboli
Pulmonary Edema
Pneumonia
Common Causes of Arrhythmias (contd)
Sudden Hemodynamic or Metabolic Changes
Hypovolemia, Hemorrhage, Hypotension (*Tachycardia/Bradycardia)
Acidosis (*Tachycardia)
Alkalosis (Associated with K+ levels)
Electrolyte Imbalances
K+ (*Bradycardia)
K+ (*Tachycardia)
Ca (*Decreased contractility)
Drugs
Digoxin Toxicity (*Bradyarrhythmias, Ventricular Bigeminy, Ventricular Tachycardia, Ventricular Fibrillation)
Myocardial Depressants (*Bradyarrhythmias, Ventricular Tachycardia)
Myocardial Stimulants (*Tachyarrhythmias, Premature Ventricular Contractions)
Common Causes of Arrhythmias (contd)
Neurologic Conditions
Intracranial Pressure (*Sinus Bradycardia, Premature Atrial Contractions, Junction Rhythm, Ventricular
Tachycardia)
Parasympathetic Response - vagal stimulation (*Sinus Bradycardia, Bradyarrhythmias, Asystole)
Sympathetic Response (*Tachyarrhythmias, Premature Ventricular Contractions)
Normal EKG Pattern
P Wave: Atrial Depolarization
PR Interval: Propagation of the cardiac AP from the
atria through the AV node into the ventricles
QRS Complex: Ventricular Depolarization
QT Interval: Variable with heart rate
T Wave: Ventricular Repolarization
U Wave: Variable, Insignificant to PT
R-R Interval: Duration between peaks of QRS-QRS
Q Wave: 1st negative deflection off baseline
R Wave: 1st positive deflection off baseline
S Wave: 2nd negative deflection off baseline
R Wave: 2nd positive deflection off baseline
S Wave: 3rd negative deflection off baseline
https://upload.wikimedia.org/wikipedia/commons/thumb/3/34/EKG_Complex_en.svg/2000px-EKG_Complex_en.svg.png
Normal Sinus Rhythm
Sinus Bradycardia

Narrow QRS, longer R-R Interval

<60 bpm
Normal in children and well-conditioned athletes.
PT Implications: Monitor for dizziness and fatigue; caution with exercise.
Exercise may increase heart rate to return to normal sinus rhythm.
Sinus Tachycardia

Narrow QRS, shorter R-R Interval, less distance between P wave and Q wave, P wave may
merge with T wave

100-150 bpm
Normal response during exercise; stress.
PT Implications: Monitor for fatigue, pale coloration, anxiousness.
Use Karvonen HR calculation for determining exercise intensity.
Sinus Arrhythmia

Narrow QRS, upright P waves

Fluctuates with inspiration (HR increases) and expiration (HR decreases).

Often benign: Common in children, less common in older adults.
PT Implications:
Watch for hypoventilation; hyperventilation.
Abnormal Atrial Rhythms
Normal Sinus Rhythm with Premature Atrial Contractions

Narrow QRS; flattened, notched, peaked, or biphasic P waves

PT Implications:
In otherwise healthy patients: Often benign.
In patients with comorbidities: Monitor for potential progression to atrial fibrillation or atrial
flutter.
May indicate an underlying cardiac disease.
Atrial Flutter - Sawtooth Waves

Absent P wave, AV junction passes every second (2:1) or fourth (4:1) impulse

Atrial rate of 240-340 bpm (type I), 340-440 bpm (type II).
Ventricular rate may be increased, decreased, or normal.
PT Implications:
Patients have an increased risk of thrombus formation in the atria.
Often degenerates to atrial fibrillation.
Atrial Fibrillation - Irregularly Irregular

Absent P wave and PR interval; QRS may be widened

Atrial rate >350 bpm; ventricular rate may be normal, increased, or decreased.
PT Implications:
Patients have an increased risk of thrombus formation in the atria.
If new: report immediately for anticoagulation therapy and clot prevention.
If chronic: monitor for fatigue and loss of atrial kick to ventricles.
Watch for: heart palpitations, SOA, chest pain.
Abnormal Ventricular
Rhythms
Normal Sinus Rhythm with Premature Ventricular Complex

Abnormal QRS, typically widened, T wave typically dips negative

May be benign
A PVC every second complex is called ventricular bigeminy.
Every 3rd - ventricular trigeminy.
PT Implications:
Can indicate decreased oxygen saturation.
Ventricular Tachycardia

Absence of RS complex
>100 bpm with at least 3 abnormal heartbeats in a row.
PT Implications:
Often results in hemodynamic compromise (due to minimal ventricular filling time and the
absence of atrial kick).
Decreased cardiac output and blood flow to peripheral musculature.
Decreased consciousness, hypotension.
Often progresses to ventricular fibrillation, asystole.
Ventricular Fibrillation

Coarse Vfib is noted when the amplitude of the rhythm is equal to or more than
3 mm.
Fine Vfib is less than 3 mm in height and signifies less electrical energy within
the myocardium - less opportunity for a successful defibrillation.
PT Implications:
No cardiac output while in Vfib.
Abnormal Innate Pacemaker
Rhythms
Supraventricular Tachycardia

Narrow QRS; regular, rapid pattern; sharp peak of T wave.

170-230 bpm
PT Implications:
Can be exercise induced - monitor HR.
Decreased cardiac output; decreased blood pressure.
Normal Sinus Rhythm with 1 Atrioventricular Block

Prolonged PR interval
Normal heart rate.
PT Implications:
Usually asymptomatic.
2 Atrioventricular Block Type I (Wenckebach)

Lengthening of PR interval followed by dropped QRS (P wave not partnered)

Caused by enhanced vagal tone, myocardial ischemia or the effects of drugs

such as calcium-channel blockers, digitalis and beta-blockers.
PT Implications:
Stop exercise.
Can progress to asystole.
2 Atrioventricular Block Type II (Mobitz)

One or more QRS complexes are dropped with PR intervals that do not change

Typically caused by an intermittent block (interrupted supraventricular

impulse) below the AV node.
PT Implications:
Low cardiac output is likely when multiple dropped QRS complexes occur.
Monitor for progression to third degree AVB.
May exercise patient if asymptomatic.
2 Atrioventricular Block with 2:1

Each alternative P wave is not paired with a QRS complex.

Decreased heart rate.

PR interval remains constant.
PT Implications:
Low cardiac output associated with a slow heart rate.
Potential to progress to third degree AV block.
3 Atrioventricular Block

P wave without an accompanied QRS complex; chaotic PR intervals; narrow QRS

Atrial and ventricular rhythms are independent.

PT Implications:
Monitor for low BP, fatigue, dizziness.
Monitor for progression to ventricular standstill or asystole.
Idioventricular Rhythm

Absent P wave, absent PR interval, wide QRS interval

20-40 bpm
AV and SA nodes are either not firing or firing slower than the ventricular
pacemaker rate
PT Implications:
Rate not sufficient for maintaining functional cardiac output.
Accelerated Idioventricular Rhythm

Absent PR interval, absent P wave, wide QRS interval

41-100 bpm
Common following MI, cardiomyopathy.
PT Implications:
Can rapidly progress to either asystole or ventricular tachycardia
Sinus Exit Block (Sinoatrial Block)

Results from blocked sinus impulses - impulses not getting through to depolarize the
atria. While the sinus is firing on schedule, the tissue around the SA node is not
carrying the impulse.
Each pause is equal to a multiple of previous P-P intervals.
PT Implications:
Severity is dependent on frequency and duration of arrest.
Heart skipped a beat.
May be asymptomatic.
Sinus Arrest (Sinus Pause)

Pause is NOT equal to the multiple of P-P intervals seen in Sinus Exit Block.
Often an escape pacemaker such as the AV junction will assume control of the
heart.
PT Implications:
Severity is dependent on frequency and duration of arrest.
Heart skipped a beat.
May be asymptomatic
Wandering Pacemaker

Narrow QRS complex, absent P wave

Supraventricular rhythm with varying locations of impulse formation resulting

in three or more different P waves.
Varying locations of impulse formation (atria, junction, sinus node).
PT Implications:
Usually asymptomatic unless combined with hypoperfusion.
Abnormal AV Junction
Rhythms
Normal Sinus Rhythm with Premature Junctional Complex

Inverted P wave, shortened PR interval, early QRS

P wave may be entirely absent.

PT Implications:
May be asymptomatic.
Patient may report palpitations.
Junctional Rhythm (Junctional Escape)

Inverted or absent P waves

40-60 bpm
Originates from the AV junction (AV node and Bundle of His).
PT Implications:
Can cause decreased cardiac output when combined with bradycardia.
Typically asymptomatic if >50 bpm.
Accelerated Junctional Rhythm

Inverted or absent P waves, shortened PR interval, QRS complexes are narrow

60-100 bpm
Results from enhanced automaticity, increased sympathetic nervous system
activity (catecholamines) or ischemia.
PT Implications:
Typically asymptomatic.
Junctional Tachycardia

Inverted or absent P waves, shortened PR interval, narrow QRS

>100 bpm
Results from enhanced automaticity, increased sympathetic activity
(catecholamines) and ischemia.
PT Implications:
Abundant urine output after rhythm ceases.
Can be normalized by massage of the carotid artery.
Normal Electronic Pacemaker
Rhythms
Paced Atrial Rhythm

Vertical spike prior to P wave

An electronic pacemaker lead repeatedly generates a small but sufficient

current to begin depolarization of the atria and the resulting P wave.
Paced Ventricular Rhythm

Vertical spike prior to QRS complex

An electronic pacemaker lead repeatedly generates a small but sufficient

current to begin depolarization of the ventricle and the resulting QRS complex.
Troubleshooting
Static electricity
interference
R/L reversal of electrodes
Loose electrodes
Patient restlessness
Tremors
Shivering
Dry electrode gel
Excessively oily skin
Tape residue on skin
http://lifeinthefastlane.com/wp-content/uploads/2010/05/5-electrode-ECG.jpg
References
Eldar M. A Missense Mutation in the CASQ2 Gene Is Associated with Autosomal-Recessive
Catecholamine-Induced Polymorphic Ventricular Tachycardia. Trends in Cardiovascular Medicine. 2003;
13(4):148-151.
Hillegass E. Essentials of Cardiopulmonary Physical Therapy. 3rd ed. S.l.: Elsevier Saunders; 2010.
Physical Therapy Reviewer. https://physicaltherapyreviewer.wordpress.com/electrocardiogram-ecg-
2/reading-an-ecg/. Published 2015.
Practicalskills.com. practicalskills.com.
http://www.practicalskills.com/ekg.aspx.
Rhythms and Criteria. https://www.andrews.
edu/~schriste/course_notes/rhythms_and_criteria/rhythms_and_criteria.html.
SkillSTAT.
http://www.skillstat.com/tools/ecg-simulator#/-home.