Jane Huff

STAFF
Publ1 sher

J. Christopher Burghardt
AcqulslUoll5 Editor

BIll Lamsback
Prod uct DIrector
Moreau

Da~1d

Senior Product MIUIa$tCf

DIane Labus

Editors
Karen Comerford, Heather Ditch,
Erika KGrs

Editorial AssiSlants
Karen I. Kirk, Jeri O 'Shea, Unda

K. Rullf

TI>e cunacaJ treaUIlelltJ described and

TKO!IImended lllll'd. publication are based
on rHeuch I nd consult. don with lluf"Ilng.
medical, rnd legal authorlUes. To the best
of OUr knowledge, these procedures renect
curten~y aooepted pracUce. Neo.'enheleJII.
theycan'( be con'!looed absolute and unI \'enal reoommmdilions. For Individual
appllcaUons. all rerommendauons must
be considered In I1ghI ofille patient's dlnl
aol condlUon and. befor.! Idmlnlstrltion
of new or Infrequendy used drugs. In Ugh!
of the lillern pacb.ge lnsen lnfonnallon.
11le authon and publlst- dlsda1rn any
responslblUty for anyadverse effNIS .... ult.
tng from the suggested procedUles. from
any undetocted error.;. or from the r ~a der.
mlsundl'tIUllldlng of the text.
02012 by Upplncott WlUlams &< WlIkIIl .. All
fights reserved. Thls book 15 proteaed by
ropyrighL No pan of It may be reproduced.
ItOd In I reU1evall)'Slem. or transmUted,
In

Director
Doug Smock
Creatln~

Art Di rector
Elaine Kasmer

Illustrato r
Joseph Clark

any form or by any meanl-f!iearontc.

mochanlcal, photoropy. fl'C1)l'dlng. or ath.

erwlse-",1thout prior wrhten permission
of the pubbsher. eD:I'pt for br1ef quotatlons
embodied III crUIe" articles and re_1ews
and te9iLnH I nd e.'llluatlon mate'll", pro
vlded by publisher 10 Ins!ructon whose
IIChooII have adopted III Iccompvtylllg
r.nbook. For Infonnatlon. write Upplncotl
WlUlams &t WllkJlI5, 323 Non1stown Road,
Suite 200. Ambler, PA 190022756.

Vendor Manllger

Belh Martz

Prtnted In China.

Seillor MlUlu!acturlng Coo rdinat or

Belh J. Welsh

LIwa-y of

ECGWOOIHII0810

Cooo~

c .. alOP.I .t.a Pa~Ik .tt on

~.

Production Services
51'! Global

Huff. Jane. RN.

ECG wodout
l'.Ierdses III arThythmla
InterpretlitlOn I lane Huff.-tith ed.
p. ; CIl.

Includes IlldCl.
ISBN 97'8-1...0151H5S3 -6
I. Anh)lhntla_DlIIgIlOS1s-Problems,
n.erdllH,etc. 2. ElectrocardiographyI IlI~rpretatkm-ProbJems. ererdsH, etc.

,""'.

[DNLM: I ..... rrh)'lhmlas. cardlacdlagoosJs--.Probiems and E1erdses.

2. Electrocardiography-Problems and
E1erds .... WG 18.2]
RC685.A65H842012
616.1 '2807547076---<Ic23
2011014268

"

Preface

f.CG

I~o'froul:

Exerdsa;/I Arrhythmia Interpretation, Sb:lh Edition, was written 10 MMst

physicians. nurse!, medical and nursinl! 5I:udenls. paramedics, tmell/ency medial teetmi-

cians. telemetry tethnictans. and other allifd health

~nonnel

in ;w;quirinQ the knowledile

and skills essential for ldentilyina twit arrhythmias. It may also bt used as a rderenct for
electrocardiogram (ECC) review lor those already knowled2eable in ECG interpretation.
The text is writt~n in a simple manner and lUwtrated \!lith tiguru. tables, boxes, and ECC
tracinas. Each chapler is designed to build on the know\edae base I'rom the previous cIla!ten 50
that the beJlinnillJl stu:knl can quickly understand and I/I'35P lhe ba5k cmcepll of electrocardiOllJi\Pt\y. An etrort has been made ('(It only to proYide good quoN/y ECG trocirtgs, but abo to provide
a 5I.Ifticient number and \Wiety of EGC practice strips 50 the Iwner retls confident In arrhythmia
inlerpretllion. There are I.lI.I?r fn) proclice strips - more than any book on /he mQrlrel.

Chapter I provides a disculoSion ofbaJic anatomy alld p/ly$IoJO\IYol the heart. The electrical basis of t lectrocardiolOi is disCl.l!sed In Chapter 2. The components of the ECC traclnl!
twawforrns, intervals. sellmenl5, and complexes) are described in Chapter 3. Thischaplfr also

Iv

includes pndice tr.w:inlZS on w3wform identification. Cardiac monitol"$, lead JystflTl.'i, lead
placement ECC artifacts.:uld troubleshootinllllXlnllor probltmJ art discu!Sed in Chapter 4.
Astep-by-step lIuide to rhythm Jtritt :ulalysiJ is provided in Chapter 5. in addition to practice
tracin(lS on rhythm strip analYJis. The Indi\'itlual rhythm chapters (Chapter$ 6 throullh 9)
iocludt 3 description of each arrllythmia. arrhythmia uampltJ. causes. and ~ment
protocols. Current .ld'Janced cardiac life support (ACLS) Iluidelines are incorporated into each
arrhythmia chapter as awllcable to Ihe rh>thm discunion. Eadl arrhythmia chapttr abo
locludes approximately 100 !trips for self-evaluation. CIlapter 10 presents a \ltlleral discussion
of cardiac pacemakel"$ (twes. indications. function, pacemaker terminololZY, rmifimctions.
and PJCemaktr analYJ]J), alo~with practice tracinlU. Chapkr II is a postle!! comistinll ofa
mix 0( rhythm strips that can bt used as a stlf-evaluation tool or for ttstinll purpOstl.
The text has ~n thou!!htfully revisedartd I!QWIded to include nt.'WfiJlures. updated boxes
and tables, additional llIossary terms, and evtn more pr.w:tice rhythm 5trips. SkiJlbulfder
rhythm stripj. which are new to this edition. appear inunediate)y IOliowil1ll the practice
rhythm strips in Chapters 7. 8. and 9. Each Skillbuilder section provides a mix of strips that
test not onlY)IOUr urnknblldinQ. of Information It<lmW in that arrhythmia chapter but also
the concepts:uld skills learned in the chapter{s) immnHatdy precedinll il. For uample. the
Skill builder strips in Chapter 7 (Atrial arrhythmias) includr atrial rhythm strips as wt'll as
strips on sinw arrhythmias (Covtrtd in Chapter 6): Chapter 8 (Junctional arrhythmias and
AV blocksi includesjWlCtionalarrhythmias and AV blocks. as well as atrial and sinus arrhythmias: and Chaplt'r 9 (Ventricular arrll).-thmias and bundle-brandl block), a mix of all of thf:o
arrhythmias c!7.'tred In Chapters 6 throuall 9. Such practice wilh mixed !trips will enhallCe
your ability to differentiate ~!Y.'ttn rhythm I/TOIlPS as you prol/Tl'SS throUllh the book - a
definite adYanl:alle ...."hen you \Itt to the Posttest. A handy pull-out section consistin!! of 48
individual ~hcards further challell>!es )'OUr ability to identity different types of arrhythmias..
The ECC tracinlti included in this book are actual Jlrips from patients. Above each rhythm
strip are J...5OOd indic3tors for rapid-rate calculation. For precise rate calculation. an ECC conIX'TSian table fOr heart rate is printed 011 the inside back COYer. For COII\'ef\ience. a rerrJOv.Ible pJas...
ticversion is also attached to the inside backcOl'eT. The heart rates for Tq/IIIar rhythms listed in the
anlWer keys were determined by the proci.le rate calculation method and ....;11 not a/y,'IYS coincide
....ith the rapid-rale calculation method. Rate calculation methods are disawed in Chapter 5.
The author and publisher Ilaw made every attempt to check the content. especially di'UII
dosages and man.1Ilement protocoll. for accuracy. Medicine is continually c~l1II. and
the reader has the responsibility to keep informed of local care protocols and chanlles in
emerjlency ~ procedures.

This hook is dedicated to

NO/Jell Grace, a "busy" little girl.

Anatomy and physiology

of the heart
Description and location of the heart

Function of the heart

The heart is 11 hollow, four-chambtred muscular organ that

Theheart is thel.udest working organ in the body. The heart

functions primarily as a pump 10 circulate blood and supply
the body with O()'gen and nutrients. Each day the /lwrage
hellrt beats oller 100.000 times. During an awragt lifetime.
the human heart will beat more than 3 billion times.
The heart is capable of adjusting its pump pedormance
to meet the needs of the body. As needs increase. as with
exercise. the heart responds by accelerating the heart rate
to propel more blood to the body. As needs decrease. as
with sleep. the heart responds by decreasing the heart rate.
resulting in less blood flow to the body.
The heart consists 01:
four chambtrs
- two atria that receive incoming blood
- tv.o wntricles that pump blood out of the heart
four lIalves that control the fla,y of blood through the heart
an electrical conduction system that conducts electrical
impulses to the heart. resul ting in muscle controction.

lies in the middle of the thoracic cavity between the lungs,

behind the sternu m, in front oflne spinal column, and just
move the diaphragm (Figure 1-1). The top oIthe hellrt (the

base) is at approximately the level of the second intercostal

space. The bottom of the heart (the Qpex) is formed by the

tip or the left wntricie lind is positiooed just above the di,lphragm to the left of the sternum at the fifth intercostal
.5p.'Ke. midclaviculllr line. There. the apex tan be pllipated
during ventricular contraction. This physical examination
landmark is referred to as the poim of 11JtlXimal impu&
(PMI) and is.n indiclltor of the heart's position within the
thorax.
The heart is tilted forward and to the left so that the
right side of the heart lies toward the front. About tv.-othirds of the heart lies to the left 01 the body's midline lind
one-third extends to the right. The awrage adult heart is
apprO):imately 5- (12 em) long. 3W (8 to 9 em) wide. and
2W (6 cm thick) - II little larger than a normal-sized list.
The heart weighs betv.een 7 and 15m (200 and 425 grams).
Heart siu and weight are influenced by age. weight. body
build. frequency of exe rcise. and heart disease.

_~~?t:= Heart
Siernum

Heart surfaces
There are four lTIIIin heart surfaces to consider .... hen discussing the heart: anterior, pos/eriar. inferior. and lateral
(Figure 1-2). The hea rt sudaces are uplained below:
ante rior - the (ront
posterior - the back
inferi or - the bottom
lateral - the side.

Structure ofthe heart wall

The heart wall is arranged in three La~'ers (Fi gure 1-3):
theplln'curdium - the ootennost l<tyer

the myocardium - the middle muscular layer

the mdocartiium -

the inner layer.

Enclosing Md protecting the heart is tile pericardium,

l'.i1ich consists of an outer fibrous sac (the fibrous pericardium ) and an inner two-layered, t\uiiJ..-se<reting rmmbrane

Agu .... 1 1. LocaUoo of Ihe neart In lheltaa)(,

(the ~roUJ lJ'!ricanlium). Tile outu fibrous pericardium

comes in direct contact with the ooliering of the lung (the
pleura) and is attached to the cen ler oflhe diaphragm infe.

riorl)'. to tile sternum anteriorly, and to the esophagus.

trachea, and main bronchi posteriorly. This position

An nto OlYand p hysio logy of the h ellrl

Anletio. ----t-{

J\..-_--\-P05terJOf

friction lIS the heart beats. In certain conditions. la~

accumulations of fluid. blood. or exudales can enler the
perica rdialspace and may interfere with ventricular filling
1100 the heart's .bility to contract.
The myocardium is the thick, middle, muscular layer
that makes up the bulk of the heart wall. This layer is composed primarily of cardiac muscle cells and is responsible
for the heart's ability to contract. The thickness of the
Ol)IOtardium varies from one heart chamber 10 ~lOolher.
Chamber thickness is related to the amount of resistance the muscle must overcome to pump blood out of the
chilmber.
The endocardium is a thin layer ci tissue that lines the
innu surface of the heart muscle and the heart chambers.
Extensions and folds of this tissue form the valves of the

h<>rt.
Interior

F1l1u rI1 2. Hm arfaces.

anchors the heart to the chest and prevents it from shifting about in the thorax. The !t1'OU5 pericardium is II continuous membrane that forms two layers: the parietal La~-er
lines the inner surface of the fibroU5 ~c and the vi5(:era]
layer (81M) called epicardium) lines the outer SlJriace nfthe
heart muscle. Between the two layers of the !trous peri
cardium is the pericardia] space. or cavity. which is usually
filled with 10 to 30 mL of thin. cltaT fluid (the pericardial
fluid ) secrded by the serous layers. The primary function
of the pericardial fluid is to prOYide lubrication, preventing

Circulatory system
The circulatory system is required to provide a continuous
of blood to the body. The circulatoT')' system is a closed
system comisting of heart chambers and blood vessels.
The circulato!,), system consists of two separate circuits.
the systemic circuit and the pulmonary cin:uil. The systemic circuit is a large circuit and includes the left side of
the heart and blood vessels, which tarT')' OlI.ygenated blood
tn the body and deoxygenated hlond back to the right heart.
The pulmonary circuit is a small circuit and includes the
right side of the heart and blood vessels. which carT')' deOll.ygenated blood to the lungs and oxygenated blood back to
the ~ft heart. 1he two circuits are designed so that blood
flow is pumped from one circuit to the olher.

now

EndocaJdium --~<"c..'

-f1------ P~~c~

++-_____

Parietallaye.
'" S810US pllricardum

,./'d- - - - Fibrous pllricardium

FiIlU ... 1- l .

H!WIwaI.

Heart valves

Heart chambers
The interior of the heart consists of four hollow chambers
(Figure 1-4). The two upper chambers. the right atrium
"nd the left atrium. "re divided by" w,,11 ""lied the interatrial septum. The two lower chambers, the right ventricle and the left ventricle. are divided by a thicker wall
called the interventricular septum. The two septa divide
the heart into two pumping systems - a right heart and
a left heart.
The right heart pumps venous (deoxygenated )
blood through the pulmonary arteries to the lungs
(Figure 1-5). Oxygen and carbon dioxide exchange takes
place in the alveoli and arterial (oxygenated ) blood
returns via the pulmonary veins to the left heart. The
left heart then pumps arterial blood to the systemic
circulation, where oxygen and carbon dioxide exchange
takes place in the organs, tissues, and cells; then venous
blood returns to the right heart. Blood How within the
body is designed so that arteries carry oxygen-rich blood
away from the heart and veim carry oxygen-poor blood
back to the heart. This role is reversed in pulmonary
circulation: pulmonary arteries carry oxygen_poor blood
into the lungs, and pulmonary veins bring oxygen-rich
blood back to the left heart.
The thickness of the walls in each chamber is related
to the workload periormed by that chambu Both atria
are low-pre~ure chambers serving as blood-collecting
reservoirs for the ventricles. They add a small amount of
force to the moving blood. Therefore, their walls are relatively thin. The right ventricular wall is thicker than the
walls of the atria, but much thinner than that of the left
ventricle. The right ventricular chamber pumps blood a
fairly short distance to the lungs against a relatively low
resistam;e to flow, The left ventricle has the thickest wall,
because it must eject blood through the aorta against a

Inlerventricular ""PI"'"

Rgur. 1- 4, O\ambers oltho heart.

much greater resistance to flow (the arterial pressure in

the systemic circulation).

Heart valves
There are four valves in the heart: the tricuspid vallie,
separating the right atrium from the right ventricle: the
pulmonic /!{lIve, separating the right ventricle from the
pulmonary arteries: the mitral /!{lIve. separating the left
atrium from the left ventricle; and the aortic /!{lIve. separating the left ventricle from the aorta (Figure 1-5). The
primary function of the valves is to allow blood flow in
one direction through the hear!"s chambers and prevent
a backtlow of blood (regurgitation). Changes in chamber pressure govern the opening and closing of the heart
valves.
The tricuspid and mitral valves separate the atria from
the ventricles and are referred to as the atrioventricular
(AV) valves. These valves serve as in-flow valves for the ventricles. The tricuspid valve consists of three separate cusps
or leaflets and is larger in diamder and thinner than the
mitral valve. The tricuspid valve directs blood flow from
the right atrium to the right ventricle. The mitral valve (or
bicuspid valve) has only two cusps. The mitral valve directs
blood How from the left atrium to the left ventricle. Both
valves are encircled by tough. fibrous rings (valve rings ).
The leaflets of the AV valves are attached to thin strands
of fibrous cords called chordae tendineae (heart strings)
(Figure 1-6). The chordae tendineae are then attached to
papillary muscles, which arise from the walls and floor of
the ventricles. During ventricular filling (diastole) when
the AV valves are open. the valve leaHets, the chordae
tendineae, and the papillary muscles form a funnel. promoting blood flow into the ventricles. As pressure increases
during ventricular contraction (systole) , the valve cusps
close. Backflow of blood into the atria is prevented by contraction of the papillary muscles and the tension in the
chordae tendineae. Dysfunction of the chordae tendineae
or a papillary muscle can cause incomplete closure of anAV
valvt'. This may result in a regurgitation of blood from the
ventricle into the atrium, leading to cardiac compromise.
The first heart sound (8,) is the product of tricuspid and
mitral valve do.ure. S, i. bed heard at the apex of the heart
located on the left side of the chest. fifth intercostal space.
middavicular line.
The aortic and pulmonic valves have three cuplike cusps
shaped like a half-moon and are referred to as the semilunar (SL) vall!e5 . These valves serve as out-flow valves
for the ventricles, The cusps of the SL valves are smaller
and thicker than the AV valves and do not have the support of the chordae tendineae or papilla!)' muscles. Like
the AV valves. the rims of the semilunar valves are supported by valve rings. The pulmona!)' valve directs blood
flow from the right ventricle to the pulmonary artery.
The aortic valve directs blood flow from the left ventricle to the aorta. As pressure decreases during ventricular

Anatomy and physiology of th e h eart

Alveolus 01 lung ~

Pulmonary anerl'"
(to lungs)

--_-1

~~\

\\

~-'-'-_~ Aona (to body)

Superior vena cava

(Irom upper body)

Pulmonary veins
(from lungs)

Ir---;---- Aortic valve

Pulmonic valve

--i--::c-.\'}'_

M~ral

Tricuspid valve

"";,---'f-i---- Septum

Inlerior vena cava

(lrom lower body)

Figure 1-5. Chambers, YaIves, blood now.

RA, light atrium: RV, right wntllcle;
LA, left atrkJm: LV, len Y00Ir1c1e.

relaxation (diastole), the valve cU5~ close. BackHow of

blood into the ventricles is prevented because ofthe cus~'
fibrous strength, their dose approximation. and their
5hilpe. The second heart 50und (s.,) is produced by closure
of the aortic and pulmonic SL valws. It is best heard over
the second intercostal space on the left or right side of the
sternum.

Blood flow through the

heart and lungs
Blood How through the heart ilfId lungs is traditionally
described by tracing the How as blood returns from the systemic veins to the right side of the heart, to the lungs, back
to the left side of the heart. and out 10 the arterial vessels

Superior vena cava - - - - - - - - ,

"~.""m' ----------~~

~-t---

Inll";o< vona c ..va _ _ _ _ _ _ _ _---.J

Descendingaorla. - - - - - - - - - - - . . J

Figure 1-6. Papillary muscles and chordae tendheae.

valv!!

.,,,. ,...

Coronary circulation

of the systemic circuit (Figure I-S). The right atrium

receives venous blood from the Ixxly via two of the bodys
largest veins (the superior vena cava and the inferior vena
cava) and from the coronary sinus. The superior vena cava
returns venous blood from the upper body. The inferior
vena cava returns venous blood from the lower Ixxly. The
coronary sinus returns venous blood from the heart itself.
As the right atrium fills with blood. the pressure in the
chamber increases. When pressure in the right atrium
exceeds that of the right ventricle. the tricuspid valve
opens, allowing blood to flow into the right ventricle. As
the right ventricle fills with blood, the pressure in that
chamber increases, forcing the tricuspid valve shut and the
pulmonic valve open. ejecting blood into the pulmonary
arteries and on to the lungs. In the lungs, the blood picks
up oxygen and excretes carbon dioxide.
The left atrium receives arterial blood from the pulmonary circulation via the pulmonary veins. As the left atrium
fills with blood, the pressure in the chamber increases.
When pressure in the left atrium aceeds that of the left
wntricle, the mitral valw opens, allowing blood to flow into
the left ventricle. As the left ventricle fills with blood. the
pressure in that chamber increases, forcing the mitral valve
shut and the aortic valve open. ejecting blood into the aorta
and systemic circuit, where the blood releases oxygen to the
organs, tissues, and cells and picks up carbon dioxide.
Although hlood flow om he Imeed fmm th ... right. sid ... of
the heart to the left side of the heart, it is important to realize
that the heart worhas tv.o pumps (the right heart and the left
heart) working simultaneously. As the right atrium receives
venous blood from the systemic circulation. the left atrium
receives arterial blood from the pulmonary circulation. As
the atria fill with blood, pressure in the atria aceeds that of
the ventricles, forcing the AV valves open and allowing blood
to flow into the wntricles. Toward the end of ventricular fiJIing, the tv.o atria contract, pumping the remaining blood
into the ventricles. Contraction of the atria during the final
phase of diastole to complete ventricular filling is called the
atrial kick. The ventricles are 70% filled before theatria contract. The atrial kick adds another 30% to ventricular capacity. In nomtal heart rhythms, the atria contract before the
wntricles. In abnormal heart rh}1hms, the loss of the atrial
kick results in incomplete filling of the ventricles, causing a
reduction in cardiac output (the amount of blood pumped
out of the heart). Once the ventricles are filled with blood,
pressure in the ventricles increases. forcing the AV valves
shut and the SL valves open. The ventricles contract simultaneously, ejecting blood through the pulmonary artery into
the lungs and through the aortic valve into the aorta.

Coronary circulation
The blood supply to the heart is supplied by the right coronary artery. the left coronary artery, and their branches
(Figure \-7). There is some individual variation in the
""llnll of ~uruJldry "rl~ry br,,"d,iuK.. bul ill 1!~""r.. J, lI,,,

right coronary artery supplies the right side of the heart and
the left coronary artery supplies the left side of the heart.
The right coronary artery arises from the right side
of the aorta and consists of one long artery that travels
downward and then posteriorly. The major branches of the
right coronary artery are:
conus artery
sinoatrial (SA) node artery (in 55% of population)
anterior right ventricular arteries
acute marginal artery
AV node artery (in 90% of population)
posterior descending artery with septal branches
(in 90% of population)
posterior left wntricular arteries (in 90% of population).
Dominance is a term commonly used to describe coronary vasculature and refers to the distribution of the terminal
portion of the arteries. The artery that gives rise to both the
posterior descending artery with its septal branches and the
posterior left ventricular arteries is considered to be a "dominant' system. In approximately 90% of the population, tI-.e
right coronary artery (RCA) is dominant. The term can be
confusing because in most people the left coronary artery is of
wider caliber and penuses the largest percentage of the myocardium. Thus, the dominant artery usually does not perfuse
the largest proportion of the myocardium. The left coronary
artery arises from the left side of the aortaand consists of the
left m~in cnmn","y ",1,,-1)'. ~ _.hmt .t... m. ",hich dividp_. into
the left anterior descendingilrtery and the circumflexilrtery.
The left anterior descending (LAD) travels downward over
the anterior surface of the left ventricle, circles the apex, and
ends behind it. The major branches of the lAD are:
diagonal arteries
right ventricular arteries
septal perforator arteries.
The circumfla art~ry travels along the latual aspect of
the left ventricle and ends posteriorly. The major branches
of the circumflex are:
SA node artel)' (in 45% of population)
anterolateral marginal artery
posterolateral marginal artel)'
distal left circumflex artery.
In 10% of the population, the circumflex artery gives
rise to the posterior descending artery with its septal
branches, terminating as the posterior left ventricular
arteries. A left coronary artery with a circumflex that gives
rise to both the posterior descending artery and the posterior left ventricular arteries is considered a "dominant"'
left system. When the left coronary artery is dominant, the
entire interventricular .septum is supplied by this artery.
lithl ... 1_1 'lJmmari?p-. the cnron~I)' ~rI ... ry di,trihlJlion 10
the myocardium and the conduction system.
The right and left coronary artery branches are interconnected by an exlel15ive network of small arteries that provide
the potential for cross flow from one artery to the other.
These small arteries are commonly called roUa/eral vessels
ur wUa/t:TU/ c;;n;u/aliu .. Cundl~rdl cin;uldliul' ""i.l. ill birlh

Ana toOlYand physiology of the heart

Ri!tIt cor.....-v artery

,,-'I;- - - - - l I l ! fTIIIioI coronary art8fy

AcuC ..

marginal.""'" ---f---~

Arteria. rlglt vet1n:uiar

A V node sri.",

--t-- 7

- - - --\---j

--"''''':'''-::..J''-

Septal branch _ _ _ _ _ _ _ _ _

Figure 1 7. coronary ctaJlatkln.

lib.. ! ! .

Coronary arteries
COronary.n.ry Inclltl bllllCll" PortIon of lI'II'ocardlUm I~plld

Portion 01 condut::tlon . ysttm IUPpl'"

Righi Corona"f artlllY

RighI atrium
RigIt wnlridt
~Ieriof

SinoIriaI (SAl node (55")'

AbiIJoientricul. (AV) rIXIe and bundle ollis (90%)'

wall 0I1eIt ventricle (90%)'

Poaeriof ooe-titd of ~ sepllm (9O%f

Left oorona ry 3I1!ry
left anterior descendilg (\..AD)

'" of popula~

Anterior wal alief! w:nlril:le

AnIIIroIateral waI 01 left Y8llticle
Anterior two-llirds 01 intervmtriaJiar septum

R91t and Ief! boodle brandies

Leftatrium
AnIIIroIateral waI 0I1eit _triCIe
PosIBroIateral war alleft venR:le
Posterior wall 0I1ef! Y9n1ric1e
~Ierior wall 01 left ventricle (1 0%)'
Posterior one-lin! of ilIIIrYer!IriWa sepbn (IO'!W

SA node (45%)'
AV node and tude of His (10%)'

Cardiac innervation

but the vessels do not become functionally significant until

the myocardium experiences an ischemic insult. If a blockage occurs in a major coronary artery, the collateral vessels
enlarge and provide additional blood flow to those areas of
reduced blood supply. HOYtewr, blood flow through the collateral vessels isnt sufficient to meet the total needs of the
myocardium in most cases. In other vascular beds of the body.
arterial blood flow reaches a peak during ventricular contraction (systole). However, myocardial blood flow is greatest during ventricular diastole (when the ventricular muscle mass
is relaxed) than it is during systole (when the hearts blood
vessels are compressed). The blood that has passed through
the capillaries of the rq,rocardium is drained by branches of
the cardiac veins whose path rufl5 p.:lrallello those of the
coronary arteries. Some of these veins empty directly into the
ri~t atrium arxJ ri~t ventricle. but the majority feed into
the coronary sinus, ",tJich empties into the right atrium.

Cardiac innervation
The heart is under the control of the autonomic nervous system located in the medulla oblongata, a part of
the brain stem. The autonomic nervous system regulates functions of the body that are involuntary, or not
under conscious control. such as blood pressure and
heart rate. It includes the sympathetic nervous system
and the parasympathetic nertJOus system, each producing opposite effects when stimulated . Stimulation of
the sympathetic nervous system results in the release
of norepinephrine, a neurotransmitter, which accelerates the heart rate. speeds conduction through the AV
node, and increases the force of ventricular contraction . This system prepares the body to function under
stress ("fight-or-flight" response ). Stimulation of the
parasympathetic nervous system results in the release
of acetylcholine, a neurotransmitter, which slows the
heart rate, decreases conduction through the AV node,
and causes a small decrease in the force of ventricular
contraction. This system regulates the calmer functions
of the body (" rest-and-digest " response). Normally a balance is maintained between the accelerator effects of
the sympathetic system and the inhibitory effects of the
parasympathetic system.

Electrophysiology

Cardiac cells
The heart is compostd of thousands of cardiac cells. The
cardiac ceUs are long and narroY.\ and di\ide at their ends
into branches. These branches conned with branches of

adjacent cells, forming a branching and anastolTlO5ing

network of cells. At the junctions where the branches join
togethe r is a spedal~ed cellular membrane of low electri
cal resistance, which permits rapid conductionol electrical
impulses from one cell to another throughout the cell net-

work. Stimulation of one cardiK cell initiates stimula.tion

of adjacent cells and ultimately leads to cardiac muscle
contraction.

Thne are two basic kinds of cardja(: cells in the heart:

the m!lOcuniidl cefts (or "working" cells) lIfId the PUCilmaker cells. The myocardial cells are contained in the

muscular layer of the walls of the atria and ventricles. The

myocardial "'Working" cells art permeated by contractile
filaments which, when electrically stimulated. produce
myocardial mu~cJe controction. The primary function of
the myocardial cells is cardiac muscle contraction, followed by relaxation. The pacemaker cells are found in the
electrical conduction system of the heart and are primarily responsible for the spontaneous generation of electrical
impulSl$.
Cardiac cells have four primary cell characteristics:
Qutomaticit!l - the ability of the pacemaker cells to
generate their own electrical impulses spontane(lusly; this
characteristic is specific to the pacemaker cells.
uritability- the ability of the cardiac cells 10 respond
to an eleclrkal impulse: this characteristic is shared by all
cardiac cells.
conductitity - the ability of cardiac cells 10 conduct
an electrical impulse: this characteristic is shared by all
cardiac cells.
contractih"ty - the ability of cardiac cells to cause cardi<w:: mu.scle contraction: this charocteristic is specific to
myocardial cells.

Depolarization and repolnrizatlon

Cardiac cells aJ"e surrounded and filled with an electrolyte
lution. An electrolyte is a substance whOH molerules
dissociate into charged particles (ions) when placed in

waler, producing posi tively and negatively charged ions_

An ion with a positive charge is called aealioll . An ion with
II negative charge is called an anion. Potassium (K') is the
primary ion imide the cell and sodium rNa') is the primary
ion outside the cell.
A memb rane separates the inside of the cardiac cell
(intracellular) from the outside (extracellular). llwre is a
constant movement of ions across the cardiac ctll membrane. Differences in concentrations of these iom determine the celis electric dwge. The distribution of iom
on either side of the membrane is determined by several
faclors:
f.lembrane channels (pores) - The cell memb rllJle hu
openings through which ions pass back and forth between
the extracellular and intracellular spaces. Some channels
are always open; others am be opened or closed; still others
can be selectr.-e. allowing one kind ol ion to pass through
and excluding al l others.. Membrane channels open and
close in responst to a stimulus.
Concentration gradient - Particles in solution move.
or diffuse. from areas of higher concentration to areas of
lowtr concentration. In the case of uncharged particles.
lllOI.-ement proceeds until the particles are uniformly distri buted within the solution.
Electrical gradient - Charged particles also diffuse. but
the diffusion of charged particles is influenced not only by
the concentration gradient. but abo by an electrical gradi.
ent. Like charges repel: opjXlSite charges attr",t. TIlerefore.
positively charged particles tend to flow toward negatively
chlarged particles and negativdy charged particles toward
positively charged pa rt icles.
Sodium-potassium pump - The sodium-potassium
pump is a mechanism that actively transports ions an05$
the cell membrane against its electrochemical gradient.
This pump helps to reestab lish the resting concentrations
of sodium and potassium after card~ depolarization.
Electrical impulses are the result olthe flow of ions (primarily sodium and potassium) back and forth across the
cardiac cell membrane (Figure 2-1). Normally there is an
ionic diffe rence between the two sides. In the resting CaTdiac cell, there a.re more negative ions inside the cell than
outside the cell. When t~ ions are 50 aligned. the resting cell is called polarized. During this time. no electrical

Electrical conduction system of th e h eart

Electrical conduction system

ofthe heart

Resting cell
(polarized Slate)

traction are not the same. Depolarization is an electrical

event that results in muscl~ contraction, a mechanical
event.
After depolarization, the cardiac cell begins to recowr,
The sodium-potassium pump is activated to actiwly transport sodium out of the cell and mow potassium back into
the cell, The inside of the cell becomes more negative than
roositi"" (cell i, re[lOl;,ri"ed) and return_, tn it, r,,-,tjng ,tate.
Depolarization of one cardiac cell acts as a stimulus on
adjacent cells and causes them to depolarize. Propagation
of the electrical impulses from cell to cell produces an
electric current that can be ddect~d by skin electrodes and
recorded as waves or deflections onto graph paper. called

The heart is supplied with an electrical conduction system

that generates and conducts electrical impulses along
specialired pathways to the atria and ventricles, causing
them to contract (Figure 2-2). The system consists of the
sinoatrial node (SA node), the interatrial tract (Bachmann's bundle), the internodal tracts, the atriowntricular
node (...tV node), th~ bundle ofHis, the ri!/lt bundle branch.
the left bundle branch, and the Purlrinje fibers.
The SA node is located in the wall of the upper right
atrium near the inlet of the superior vena cava Specialized electrical cells, called pacemaker cells, in the SA node
discharge impulses at a rate of 60 to 100 times per minute.
Pacemaker cells are located at other sites along the conduction system, but the SA node is normally in control and
is called the pacemaker of the heart because it P05.!esses
the highest level of automaticity (its inherent firing rate
is greater than that of the other pacemaker sites). If the
SA node filils to generate electrical impulses at its normal
rate or stops functioning entirely, or if the conduction
of these impulses is blocked, pacemaker cells in secondary pacemaker sites can a5.!ume control as pacemaker of
the heart, but at a much slower rate. Such a pacemaker is
called an escape pacemaker because it usually only appears
("",care'') when the f,,-der firing pacemaker (m,,~lIy the
SA node) fails to function, Pilcemaker cells in the AV junction gene rate electrical impulses at 40 to 60 times per
minute. Pacemaker cells in the ventricles generate electrical impulses at a much slower rate (30 to 40 times per
minute or less). In general, the farther av,ay the impulse
originates from the SA node, the slower the rate. A beat or
series of beats arising from an escape pacemaker is called
ilne5capeheatore5cape mythm and is identified according
to its site of origin (for example, junctional, ventricular).
As the electrical impulse leaves the SA node, it is conducted through the left atria by way of Bachmann's bundle
and through the right atria via the internodal tracts, causing electrical stimulation (depolarization) and contraction
of the atria. The impulse is then conducted to the AV node
located in the lower right atrium near the interatrial S<!ptum. The AV node relays the electrical impulses from the
atria to the ventricles. It provides the only normal conduction pathway betv,een the atria and the ventricles. The AV
node has three main functions:
Toslow conduction of the electrical impulse through the
AV node to allow time for the atria to contract and empty
its contents into the ventricles (atrial kick) before the ventrid", contract. Thi, delay in th e AV nnde i, represented nn
the ECG Iracing as the flat line of the PR interval.
To serve as a backup pacemaker, if the SA node fails. at a
rate of 40 to 60 beats per minute
To block some of the impulses from being conducted to
the ventricles when the atrial rate is rapid, thus protecting

lh~ECG.

Ul~ """lrjcl~s

Depolarii!atioll
belllnnir>g
(st",.II... a.led S\ale)

Depolarization
oom~ete

Repclarlzalion
beginning
(reccvery

s ta!~1

....! __Lt......!......!_! _~
- - . - I

~,.L..t

I -

Ftepolanzation
complete

K'

i,..:.-=-.:-....:.....:......:..-.:-.:...-:..-.- :./ I
+

+ +

+ + +

Rgure 2-1 . Depola'ization lIld repola"lzaUOO 01 a cardiac cen.

activity is occurring and a straight 1in~ (isoelectric line) is

recorded on the ECG (Figure 2-5).
Once a cell is stimulated, the membrane permeability

changes. Potassium begins to leave the cell, increasing

cell permeability to sodium. Sodium rushes into the cell,

causing the inside of the cell to become more positive

than negatiw (cell is depolarized). Muscle contraction
follows d~polariMtion. Depolaril.alion and muscle con-

from

!.Idll!l~ruu>ly

f.... l rd.ll!S.

10

Electrophysiology

AnleriOllascicle 011011 burde branch

"":'i--i- -t,,-Interventriculaf ...ptum

AVnodo

Bundle 01 His

Righi bundle branch

Figure 2- 2. ElectrIcal conduction system ollhe hearI.

Mter the delay in the AV node. the impulse moves

through the bundle of His. The bundle of His divides into
two important conductil1ll pathways called the right bundle
branch and the left bundle branch. The right bundle branch
conducts the electrical impulse to the right ventricle. The
left bundle branch divides into two divisions: the anterior
fascicle, which carries the electrical impulse to the anterior
wall of the left ventricle. and the posterior fascicle. which
<:arrie.! the electrical impulse to the posterior willi of the
left ventricle. Both bundle branches terminate in a new,'ork
of conduction fibers <:ailed Purkinje fibers. These fibers
make upan elaborate web that <:arTY the electrical impulses
directly to the ventricular muscle cells. The ventricles are
capable of serving as a backup pacemaker at a rate of 30 to
40 beats per minute (sometimes less). Transmission of the
electrical impulses through the conduction system is slowed in the AV node and fastest in the Hi. Purkinje system
(bundle of His. bundle brunches. and Purkinje fibers).
The heart's electrical activity is represented on the
monitor or ECG tracing by three basic wawforms: the
P wave, the QRS complex. and the T u'(we (Figure 2-3).
A U waw is sometimes present. Between the waveforms
are the follo\,>;nll sellments and intervals: the PR intervill,
the PR segment. the ST segment. and the QT interval.
Although the letters themselves have no special significance. each component represents a particular event in the
depolariution- repolaril.ation cycle. The P waw depicts
atrial depolarization, or the spread of the impulse from
the SA node throughout the atria. A waveform representing atrial repolilrimtion IS usually not seen on the ECG

because atrial repolaril.ation occurs during ventricular

depolarization and is hidden in the QRS complex. The PR
interval represents the time from the onset of atrial depolarization to the onset ofwntricular depolariution. The PR
segment. a part of the PR interval. is the short isoelectric
line betv,'een the end of the P wave to the beginning of the
QRS complex. It is used as a baseline to evaluate elevation
or depression of the ST segment. The QRS complex depicts
wntricular depolari1.<ltion, or the spread of the impulse
throughout the wntricles. The ST segment represents
early ventricular repolariution. The T wave represents

,
,:.
,"

.:,

,PR IntelWl

: :0

ST segment

,
,

:
:

:-:"~-"''-",cc-c-~:
PR ""gment
aT Int .......

Rgure 2-3. Relatlonshp 01 the electrical conduction system to

the ECG.

Refrac to ry a nd s uperno nual periods of the cardi ac cycle

Figure 2- 4.

The cardiac cycle.

wntricular repolari1.ation. The U wave, which isn't always

present. represents late ventricular repolarization. The QT
interval represents total ventricular activity (the time from
the oru;et of ventricular depolarization to the end of ven_
tricular repolari1.ation).

The cardiac cycle

A cardiac cycle consists of one heartbeat or one PQRST
sequence. It represents a sequence of atrial contraction
and relaxation followed by ventricular contraction and
relaxation. The basic cycle repeats itself again and again
(Figure 2-4). Regularity of the cardiac rhythm can be
assessed by measuring from one heartbeat to the next
(from one R wave to the next R wave, also called the R-R
interval). Belvt'een cardiac cycles. the monitor or ECG
recorder returns to the isoelectric line (baseline). the flat
line in the ECG during which electrical activity is absent
(Figure 2-5). Any waveform abow the isoelectric line is
considered a positive (upright) deflection and any waveform below this line a negative (downward) deflection.
A deflection having both a positive and negative component is called a biphasic deflection. This basic concept

,
,

o ,

lsoele<:tric line

~
PositIVe defle<:tion
FIgure 2-5.

line.

11

NlIlIative deflection

Biphaslc dene<:tion

Relauonsnlp Detween wavelorms lIlO tne ISOeIeCUlC

Negative
deftection

Positive
deIkK:tion

2-6. RelaUOOshlp between current now and waYlllorm

dellecUons.
Figure

can be applied to the P wave. the QRS complex. and the

T wave deflections.

Waveforms and current flow

A monitor lead. or ECG lead, provides a view of the heart's
electrical activity belvt'een two points or poles (a positiw
pole and a negative pole). The direction in which the electric current flows determines how the wawforms appear
on the ECG tracing (Figure 2-6). An electric current flowing toward the positiw pole will produce apositive deflection: an electric current trawling toward the negative pole
produces a negative deflection. Current flowing away from
the poles will produce a hiphasic deflection (both positiw
and negative). Biphasic deflections may be equally positive
and negatiw. more negative than positive. or more positive
than negative (depending on the angle of current flow to
the positive or negative pole).
The size of the wave deflection depends on the magni tude of the electrical current flowing toward the individual
pole. The magnitude of the electrical current is determined
by how much voltage is generated by depolarization of a particular portion of the heart. The QRS complex is normally
larger than the P wave because depolari1.ation of the larger
muscle mass of the wntricles generates more vol tage than
does depolaril.lltion of the smaller muscle mass of the atria.

Refractory and supernormal

periods of the carruac cycle
There is a period of time in the cardiac cycle during which
the cardiac cells may be refractory. or unable to r... pond.
to a stimulus. Refractoriness is divided into three phases
(Figure 2-7):

12

Electrophysiology

OAS complex

Pwavi

TWaV8

abwUII

;:;:toty
Ab.soJute refractory period -

..po

~" V......

fIlati;
Altract

porl'"

FIgure :Z 7. Refractory and S!.p9mOnl1al periods.

During this period the

cells absolutely cannot respond to a stimulus. This period
extends from the onset of the QRS com pia to the peak of
th~ T wav~. During this tim~ th~ cardiac c~lIs hav~ d ~polar
ized and ar~ in th~ process of ~polarizing. Because the cardiac cells have not repolari~ed to their threshold potential
(Ihe le~1 at which a cell must be repolarized before it can
be depolarized again) they cannot be stimulated to depolarize. In other words. th~ myocardial cells cannot contract,
and the cells of the elect ri cal conduction system cannot
conduct an electrical impulse during the absolute refractory period .
Relative refractory period - During this period the
cardiac cells have repolarized sufticiently to respond to
a strong stimulus. This period begiru at the peak of the
T wave and ends with the end of the T wave. The relative
refractory period is also called Ihe vulnerable period of
repo/arization. A strong stimulus occurring during the
vulnerable period may usurp the primary pacemaker of
the heart (usually the SA node) and take over pacemaker
control. An example mighl be a prellUllure ventricular contraction (We ) that falls during the vulnerable per iod and
takes over control of the heart in the form of ventricular
tachycard ia.

Supernormal period - During this period the cardiac

Figure 2-8. EIec1rOCMdlographk: paper.

Figure 2- 9 . ORS width: 0.08 second; ORS height: 16 mm.

cells will respond to a Wfilker than normal stimulus. This

period occu rs during a short portion near the end of the
T wave. just before th~ cells have completely repolarized.

ECG graph paper

The PQRST sequence is recorded on special graph paper
made up of horizontal and vertical lines (Figure 2-8). The
horizonlllilines meilSure the duration of the waveforms in
seconds of time. Each small square measured hori~ontally
repr~nts 0.04 second in time. The width oflh~ QRS complex in Figure 2-9 extends across for 2 small squares and
represents 0.08 second (0.04 second x 2 squilres). The ver_
ticallinu measure the voltage or amplitude of the waveform in millimeters (mm). Each small square meilSured
vertically represents I mm in height. The height of Ihe
QRS complex in Figure 2-9 extends upward from baseline
16 small $quares and represents 16 mm volti\ge (I mm x
16squaru).

Waveforms, intervals,
segments, and
complexes
Much of the information that the ECG tracing provides is
obtained from the examination of the three prindpall<.<lVe.

forms (the P wave, the QRS compler. and the T wave) lind
their associated segments and intervals. Assessment of this

data provides the facts necessary for an ao;urate

rhythm interpretation.

~rdial;

Pwave
The first deflection of the cardiac cycle, the P waw,
is ClIusd by depolarization of the right lnd left otrill
(Figure 3-1). The fint part of the P wave represents depolari7.alion of the right atrium: the second part represents

depolarization of the left atrium. The waveform begins as

the deflection leaves baseline and ends when the defledioo
returns to baseline. A normal sinus P wave originates in
the sinus node and travels through normal atria, resulting
in normal depolarization. Normal Pw/!ves /lrt smooth and

round, positive in lead II (a positive lead). 0.5 10 2.5 mm

in height. 0.10 second or leu in width. with one P wallf
to each QRS complex. More than one P wave before a
QRS complex indicates a conduction disturbance. such 115
that which occurs in second and third-degree heart block
(discussed in Chapter 8).
There are two types of abnormal Pwaves:
Abnormal sinUJ P wove - An abnormal sinus P wallf
originates in the sinus node and tTilVels through enlarged
atri.!r.. resulting in ahnorcml depobriwtion of the atria.
Abnormal atria depolarization results in abnormal-lookinlt
P waves.
Impulses traveling throogh lin enlarged right atrium
(right atrial hypertrophy) result in P waves that are tall

,
Fillure 3-1 . Tte P waWl.

and peaked. 'Ole abnormal P wave in right atrial enlargement is sometimes referred to asp pulmonale because the
atrial enlargement that it signifies is common with severe
pulmonary disease (for example, pulmonary stenosis and
insufficiency. chronic ob$troctive pulmonary disease.
acute pulmonary embolism. and pulmonary edema).
Impulses traveling through an enlarged left atrium (left
atrial h}Pt'rtrophy) result in P waves that are: wide and
notched. The tenn p mitrale is used to describe the abnormal
P WiI\1eS seen in left atrialmJargement because they"''ere first
seen in patients with mitral valve stenosis and iO$ufficielK)'.
Left atrial enlargement can also be seen in left heart failure.
Edopic P u-'Ilce - The term ectopic means away from its
nonTIIIllOCiltion. Therefore, an ectopic P wave arises from a
site other than the SA. node. AbnoTffiilI sites include the atria
and theAV junction. P waves from the atria lTIlI,y be positive
or negative: some are small. pointed. Rat. w;.wy. or sawtooth
in appearance. Pwaves from theAV junction are atways negatillf (inverted) and may precede or follow the QRS complex
or be hidden within the QRS complex and not visible.
Examples of P waves are shown in Figu re 3-2.

PR In terval
The PH interval (sometimes abbreviated PRJ) represents
the time from the onset of atrial depolariz.ation to the onsd
of \'entricular depolarization. The PH interval (Figure 3-3)
indudes a P I<o'a~ and the short isoel~ctric line (PR segment) that follows it. The PR interval is meatu red from the
beginning of the P wave as it leaves baseline to the beginning of the QRS complex. The duration of the normal PR
intel'llal is 0.12 to 0.20 seconds.
Abnormal PH intervals may be short or prolonged:
Short PR in/enoal - A short PR interval is less than
0.12 seconds lind may be seen if the electrical impulse
originates in an ectopic site in the AV junction. A shortened PH inte~l may also occur if the electrical impulse
progresses from the atria to the ventricles through one
of several abnormal conduction pathways (called accessory pilthwa)l5) that b}'pilS5 a part or all of the AV node.
Wolff-Parkinson-White syndrome (WPW) is an example of
such an acceswry pathway.
Pro/OI1ged PR in/errol - A prolonged PR interval is
greater than 0.20 seconds and indicates that the impulse

13

14

Wa\'eforms, intervals, segments, and co mplexes

Normal PW3ve

No v>sible P waves

Figur.3- 2.

P W3YO

Two P waveS to each OAS

SDWlaoth P wav...

Flat P w.we

exam pIDs.

Inverted P wave

Wavy P w.wes

QRS complex

15

Allure 3-3. TIle PR nlllYal.

Figure 3-5. lhe ORS compleX.

was delayed longer than normal in the AV node. Prolonged

PR intervals are seen in first-degr AV block.
Examples of PR interv.ili are shown in Figure 3-4.

QRScomplex
Th e QR5 complex (Figure 3-5) represents depolariution
of the right and left vent ricles. The. QRS complex is larger
than the P wave because depolariz.alion of the ventricles
involves a larger muscle mass than depolariWion of the
atria.
The QR5 complex is composed of three waw deflections: the QU'l:lw. the R u.,,:we. and the S IL'Qt'Ol. The R waYe
is a posi tive waveform: the Q waw is II negative wavefonn
that precedes the R waw; the 5 wave is a negative waveform that follows the R wave. The normal QR5 compln
is predominantly positiw in lead II (a positive Iud) with a
duration of 0.10 second or less.
The QRS complex is measured from the beginning
01 the QRS complex (as the first wave of the compln.
leaVi!s baseline) to the end of the QR5 complex (when
the last wave of the complex bellins to level out into the
ST segment). The point whe re the QR5 complex meets
the 51 segment is called the} point (junction point).

Normal PR Werval 01 0.20

second (0.04 second ~ 5

Short PR inle<val

squa .... ).

01 O.eII slCord
(0.04 secord x
2aqu"'''')

Finding the beginning of the QRS complex usually isn 't

difficult. Fi nding the end of the QRS complex. however.
is at ti mes a challenge because of elevation or depres
sion of the ST segment. Remember, the QRS complex
ends as soon as the straight line of the 5T segment
begins, even though the straight line may be above or
below baseline.
Although the term QRS complex is used, not every QR5
complex contains a Q waYe, R wave. and 5 wave. Many
variations exist in the configuration of the QRS complex
(Figure 3-6). Whatever the variation. the complex is still
called the QRS complex. For example, you might .see
a QRS complex with a Q and an R .....ave. but no S wave
(Fi gure 3-6, example B). an Rand 5 wave without a Q wave
(Figure 3-6, eXlWTlple C), or an R wave without a Q or an
S wave (Figure 3-6, example 0). If the entire complex is
negative (Figure Hi, example F). it is termed a QS complex (not a ntgative R wave becauu R waves are always
positiYe). Ifs also pouible to have more than one R
wave (Figu re 3-6, example and more than one 5 waw;
(Figure3-6, example J). Thesecond R wave iscalledRprime
ilIld is written R'. The second S wave is called S prime and
is writlen 5'. To be labeled separately, II wave must cross

c
Long PR inhtrva l 010.38
second (OJ)( secord"

9i!z squares)

Flilure 3-4. PR Irterval ~Ies.

16

Waveforms, inte rval s, segments, and co mplexes

"

Nolchad A

,Jl A
E

' Ya,

01- 1r,
H

f
s

1\-,V"",,",,
S

s'

Figu re 3-6, DRS Vil"latlons.

0.12........d
13 ....-e 0.0* MCCI'Od)

0.10oecond
(210 _

Figure 3- 7. DRS examples.

.. . 0,(1.1

oeoondl

0,011 oeoond
(2 "",II" 0.(1.1

the baseli ne. A wave that cha nges direction but doesn't
crOM the baseline is Cillied a notch. (Figure 3-6. example E.
shows a notched R and Figure 3-6. example K. sho.,.,'S a
notched S.)
C~pital letters are used to designllte waves of large
amplitude (5 mm or more) and lowercase letters are used
to designate waves of small amplitude (less than 5 mm ).
This allows you to visualize a complex mentioned in a
textbook when illustrations aren't available. For example.
if a complex is described in II text as having an rS waveform. the reader Ciln easily picture a complex with a small
r wave and a big S wave.
An abnormal QRS complex is wide with a duration of
0.12 second or more. An abnormally wide QRS complex
may result from:
a block in the conduction of impulses through the right
or left bundle branch (bundle_branch block)
an electrical impulse that has arrived early (as with premature beats) at the bundle branches before repolarization is complde. allowing the electrical impulse to initiate
depolarization of the ventricles earlier than usual. resulting in abnormal (aber rant) ventricular conduction lind
causing a wide QRS complex
an electrical impulse thaI has been conduded from
the atria to the ventricles through an abnormal accessory
conduction pathway that bypasses the AV node. allowing the electrical impulse to initiate depolari7.ation of

0.0* oeoond

-oneil

(1 oquoN 0.(1.1

oeoondl

o.oeHCond

0.0II0e00nd

(1Y,....-e' xO.(I.I MCCI'Od)

(2 oquoros x O,(I.I

oeoondl

ST segm e nt

0.'0_
(211. _

.. Ko.OoI _oneil

0.1~__

13 _ " O.(l4........d)

0.08_
( 2 _ , .0,04 oeoondI

oq_.

O,CIe_
(2
0.04 .....-.I)

17

0.11_
(4' _
. 0.04 0K<>nd)

0.'1-'<1
(4 ......... o.Oot """""l

Figure 3-7. (cmtfnUsd)

the wnlricles earlier than usual. resulting in abnormal

(aberrant) vtntricular conduction and causing a wide QRS
complex
an electrical impulse that has originated in an ectopic
site in the vtntricles.
Examples of QR5 complexes are shown in Figure 3-7.

STsegment
The ST segment represents earl y vtntricular repolarization. The 51 segme nt is the flat line between the QRS complexand the Twave (Figure 3-8). Normally the S1 segment
is positioned at baseline (the isoelectric line). The ST seg..

Jpolnt

Figure 3-8. The ST segmect.

Imnt may be displaced abow baseline (elet'Oteti ST seg-

men/) or below baseline (depressed ST segment ). The PR

segment is normally used as II baseline reference to evaluate the degree of displacement of the ST segment from
the ~lectric Hne. An 51 segment illlbnormal .... hen it is
elevated or depressed 1 mm or more. measured at II point
0.04 second past the J point (the point where the QR5 complex and the 5T segment meet).
Elevated 5T segments may be horizontal (straight
across), con"," (rounded upward), or concave (rounded
inward). Common causes include 51 elevation myocardial
infarction (STEMI ). coronary artery spasm (prirwnetars
angi~), acute IX'ricarditis, ventricular aneurysm, early
repolarization p.atlern (a form of myocardial repolarization sn in normal healthy individuals that produces
51-segment elevation closely mimicking that of acute
myocardial infarc tion (M11or pericarditis), hyperkalemia.
and h~'pDthermia.
Depressed ST segments may be horiwntal. downsJoping. upsloping, or sagging. Common causes include
myocardial ischemia. non-ST elevation MI (nonSTEM!). reciprocaJ ECG changes associated with STEM!.
hypokalemia. and digitalis effect. Digitalis causes a sagging
ST-segment depression. ~;th a characteristic "scoopedout~ appearancr. Examples of ST segments are shown in
Figurr 3-9.

18

Waverorms, inte rval s, segm e m s, a nd complexes

A Noomal ST U51men1

NomIaI ST MgI1*1!

C Ccnvax eleYIIIion

Concave eI .....aOOn

~d&p", ..",

FiIlUnI 3-9. STsogmenl samples.

Twave

19

Twave
Th~ T wav~ represents v~ntricular r~polari1.ation. Th~ no r
mal T wave begins as th~ deflection gradually slopes upward
from the ST segment. and end. when the waveform returns
to baseline (Figure 310). Nonnal T waves ar~ rounded and
slightly asymmetrical (with th~ first part ofth~ T wave grad ually sloping to the peak and returning more abruptly to
baseline). positive in lead II (a positive lead). with an ampli
tud~ less than 5 mm. The T wave always follow. the QRS
complex ( r~polarization always foll<Mls depolarization) .

Rgure3-10 . Th8TW3Y11.

Normal TWINe

C Tsll. peaked T wave

figure 3-11 . TwaYII examples.

Flat T wavs

B;phasicTwave

20

Wa\'eforms, intervals, segm ents, a nd complexes

Abnormal T waves may be abnormally tall or low, flattened,

biphasic, or inverted. Common causes include myocardial
ischemia, acute MI, pericarditis, hyperkalemia. ventricular
enlargement, bundle-branch block. and subarachnoid hemorrhage. Significant rebrill di""""e. ,uch as subilrnchnoid
hemorrhage, may be associated with dply inverted T waves
(called cerebral T waves).
Examples of T waves are shown in Fi gure 3-11.

QT interval

Rgure 3-12.

The QT interval represents the time betv.-een the onset of

ventricular depolariution and the end of ventricular repolarization. The QT interval is measured from the beginning
of the QRS complex to the end of the T wave (Figure 3-12).

Duration of the QT interval can be determined by multipl\,"

ing the number of small squares in the QT interval by 0.04
second (Figure3-13). The length of the QT interval normaJJy

A 1. Numbe, 01 .mall squares belwoon R wav... '" 31. Hall 01

31", 15.
2. Numbe,oI small squ ares in aT Inlerval" 11
3. Compare the dilfe,80C9: aT inlerval " lass Ihan hal! the
RR Interval (11 small squa,es a,e I.... lhan 15small
squar... ); aT inlerval is ,..,,,,,,,110,Il-0l0 heart mta.
(Dumtion of aT i1Ierval: 11 qUa'lIII x 0.04 ~"0.44
""""'.)

B 1. Numbe, 01 small squarllll beIw""" R WIW8S" 38. Hall DI

38" 19.
2. Numbe, 01 small squar .... in aT inl"",al" 13
3. Compare the dilfemnc:a : aT interval 10 Ie than hall the
R-R int"",aI (13 sma! square. araless than 19 .mal
squares): aT inWNaI" """"allor ltd" heart rale.
(OoJUl.tlon 01 aT intorval: 13 small IiqUB'1III x 0.04
....,end" 0.52 secend.)

OTlnt9lVal.

C 1. Numbe, Dlsmall squares betwlHln R waVil." 18. HaN 01

18,,9.
2. Numb ... Dlsmall squar.. in aT InieNaI" 13.
3. Compare the diIf...once: aT inlerval is more than hall Ihe
R-R inlerval (13 small squares 8'" mo", than 9 small
squ ares); aT Inlurval is prolonged lor this heart rate.
(Dumtion olOT intorval: 13 squares ~ 0.04 second"
0.52 ....,end.)

figure 3-13.

aT Interval examples.

Uwnve
varies according to age. sex. and particularly heart rnte. The
QT interval is more prolonged with slow heMt rates.
Generally speaking. the normal QT interval should be
less than half the R -R interval (the distance between two
consecutive R wavu) when the rhythm is regular. The
determination of the QT interval should be made in a lead
where the T wave is mod prominent and shouldn't include
the U W<lVe. Accurate measurement of the QT interval can
be done only when the rhythm is regular for at least two
cardiac cycles before the measurement.
To determine if the QT interval is normal or prolonged:
Count the number of small boxes in the R-R interval
and divide by two.
Count the number of small boxes in the QT interval.
Compare the difference. If the QT interval measures less
than half the R-R interval. it's probably normal. If the QT
interval measures the same as half the R-R interval. it's
considered borderline. If the QT interval measures longer
than half the R-R interval. it'~ prolonged.
A prolonged QT interval indicates a delay in ven t ricular
repolarization. The prolongation of the QT interval lengthens the relative refractory period (the vulnerable period
of repolarization). allowing more time for an ectopic
focus to take control lind putting the ventricles at risk for
life-threateninll arrhythmias such as torsade$ de paiutes

Figure 314. The Uwave.

ventricular tachycardia (discussed in Chapter 9). Common causes include electrolyte imbalances (hypokalemia.
hypomallnesemia. hypocalcemia). hypothermia. bradyarrhythmias. liquid protein dids. myocardial ischemia.
antiarrhythmics. psychotropic agents (phenothiazines.
tricyclic antidepreants). and hereditary lonll-QT syndrome. It can al50 occur without a known cause (idiopathic).
Examples of QT intervals are shown in Pigure 3-13.

Uwave
The U wave is a small deHection sometimes seen following the T wave (Figure 3-14). Neither its presence nor its

ECG w ilh U wave

RvuRI 3-15. Uwave examples.

21

22

Waveromls, intervals, segme nts , and complexes

absence isconsidtred abool1T\aL llle U wave represents late

repolarization of the wntricles, probably a small ~ment
of the wntrides.
The waveform begins as the deflection leaves baseline
and ends when the deflection returns to base line. Normal U
wawsa re small. rounded. and symmetrical, positive in lead
II (a pruitiw lead), and 2 mm or less in amplitude (always
smaller than the preceding T wave). The U wave can best be
seen when the heart rate is slow.
Abool1T\al U waves are tall (greater than 2 mm in
height ). Common causes include hypokalemia, cardiomyopathy. and left wntricular enlargement. among other
causes. A large U wave may occasionally be mistaken for
a P ....<lve, but usually a comparison of the morphology of
both waveforms will hetp differentiate the U wave from the
P waw.
Exam ples of U waves are shown in Figure 315.

Waveform practice; Labeling wlives

23

Waveform practice: Labeling waves

For each of the following rhythm strips (strips 3-1 through 3-14). label the P. Q, R. S. T, and U waves. Some of the strips
may not have all of these wa...efornu. Check )'Our answers with the answer key in the back of the book.

Strip 3-1 ,

Strip 32,

strip 3-3.

Strip 3-4.

strip 3-5.

Strip 3-&.

24

Waveforms, intervals, segments, and complexes

Strip 3-7,

Strip 3-8.

Strip 3-9,

Strip 3-10,

Strip 3-11.

Strip 3-12,

Strip 3-13.

Strip 3-14,

Cardiac monitors

fil

-I'
Purpose of ECG monitoring
The electrocardiogram (EeC) iSI! reoordingofthe electrical
activity of the heart. The ECC records two basic electrical

processes:

Drpo/ariZl.ltKJn - the spread 01 the electrical stimulus

through tm heart muscle, producing the P wave from the
atria and the QRS oomplex from the ventricles.

Rrpo/arizotion - the recovery 01 the stimulated muscle to the resting state. producing the ST segment. the T

walle, lind the Uwave.

AL+---\!f>!

,
';jf,f-tLL

The depolariultion-repllarization process produces

electrical currents thai are transmitted to the surface of
the body. This rJectrkaJ activity is detected by electrodes
attached to the skin. Mer the electric current is detected.

FIg"re 4-1. HaOWIre morvtrIng - FtYe Ie8an'lre system.

irs amplified, displayed on II monitor screen (oscilloscope),

ThIs lluslratlon shc!Ws you wtlere 10 place the electrodes and

lind Ncorded on ECC graph paper as waves and complexes.

The .....aveforms can then be analyz;ed in iI ~ttmalic manner and the

~cardiac

rhythm" identified.

Bedside monitoring allows continuOU$ observation

of the heart's electrical activity and is used to identify
arrhythmias (d isturbances in rate. rhythm. or conduction).
evaluate pactmaku function, and evaluate the response
to medications (for e:JIdlllple, antiarrhythmies). Continuous cardiac monitoring is useful in monitoring patients in
critical care units, cardiac stepdown units, surgery su ites.
outpatient surgery departments, emergency departments,
and postaoesthnia reco\'el)' units.

Types ofECG monitoring

There are t~'O types of ECG monitoring: hordwirtl 4Ild
telemetry. With hardwire monitoring (bedside monitoring), electrode pads (conductive gel diKS) a re placed
on the patient's chut and attached to a lead-cable system and then connected to a monitor at the bedside.
With telemetry monitoring (portable monitoring). electrode pads are attached to tht patient's ches t and connected to leads that are attached to a portable monitor
transmitter_
Haruwire motliton"ng - Hardwire monitoring uses
either a filJf!-leadwire system or a three-leadwire system_
With the fiw,-Ieadwire S)'!i tem (Figure 4- IJ. five elee.
trode pads and five leadwires are used. One electrode
is placed below the right clavicle (2nd interspace. right

attadlleadw~9S using a fNe-leaCWIre system. The IeaCWlres are

coIor-c:od9d as tOiIOWS:
white - right ann (RAJ
black - left ann (LA)
green - right leg (Rl)
red -left leg (U)
broINn - cllest (C).
leads placed in the arm Md leg positions as shoNn al:m )00
to view leads ~ I," aVR, aVL. and aVF. To view chest leads V,-V,.
the dMIst lead must be placed in the speeD: chest lead posHkln
desired. In this example, the brown chest lead Is In V, posifun.

middavicular line), one below the left clavicle (2nd interspa~, Idt midclavkular line), one on the right lower rib
cage (8th intenp.xe, right midclavicuJar lint), one on the
left lov.-er rib cage (8th interspace, Jdt midclavicular line),
and one in achest lead position fY, to V.). The SDc chest lead
positions (Figure 4-2) include:
V, - 4th intercostal space. right sternal border
V, _ 4th intercostal sPi\te, left stunal border
V.-midv.-aybetweenVzandV,
V, - 5th intercostal space, left midclavicular line
V. _ 5th intercostal space, left anterior Miliary line
V. - 5th intercostal space, left midaxillary line
lhe right arm (RA) lead is attached to the eledrode pad
below the right clavicle: the left arm (LA) lead to the electrode pad below the left clavicle; the right leg (RL) lead
to the electrode pad on the right lowe r rib cage; the left

25

26

Cardiac monitors

flgLlre 4-2, Chest load posKIons,

leg (LL) lead to the electrode pad on the left lower rib cage:
and the chest lead to the electrode pad of the specific chest
position desired (V, through V,l.
With the five-leadwire system for hardwire monitoring, you can continuously monitor two l~ads using a
lead selector on the monitor. Leads placed in the arm
and leg positions allow you to view leads I, II, III, AVR,
AVL, and AVF (Figure 4-1). To view chest lead V, to V"
the chest lead must be placed in the specific chest lead
position desired. Generally, a limb lead (usually I, II. or
III) and a chest lead (usually V, or V,) are cho~n to be
monitored.
With the three-leadwire system (Figure 4-3), three electrode pads and three leadwires are used. One electrode pad
is placed below the right clavicle (2nd interspace, right
midclavicular line), one below the left clavicle (2nd interspace, left midclavicular line), and one on the left lower rib
cage (8th interspace. left midclavicular line). The RA lead
is attach~d to th~ electrode pad below the right clavicle,

Moddk>d CI>oc1 Lc.:>d v, (MCL,)

RIILl re 4-3. HardW __e monKorhg - ThrOO-lerulWire system.

lhls IIklslraUon shoWs you where to place the electrodes II1d attach
leadwlres using a three-leadWlre system. The lead wires are colorcoded as Iollows:
white - right arm (RAj
black -left arm (LA)
red -left leg (LL).
Leads placed in this position will allow you to monitor leads I,
II, or III using the lead selector on the mon~or.

the LA lead is attached to the electrode pad below the left

clavicle, and the LL lead is attached to the electrode pad on
the left loy,-er rib cage. You can monitor either limb leads
I. II. or III by turning the lead ~Iector on the monitor.
Although you can't monitor chest leads (V, to V,) with a
three-leadwire system, you can monitor modified chest
leads that provide similar infonnation. To monitor any of
these leads. reposition the LL lead to the appropriate position for the chest lead you want to monitor, and turn the
lead ~Iector on the monitor to lead III. Examples of modified chest lead V, (HCL,) and modified chest lead V, (HCL, )
are shown in Figur~ 4-4.

ModIk>d CI>oc1 Lco.d V. (MCL,,)

Figure iI-il. HardWlra monnor1ng - Tllree-leadwlre system: Leads MCL, and MCt... Modified chest leads can be monitored with tho threeleadW __o system by reposRlon1ng tho len leg (U) lead to the chest position desired and tumlng the lead selector on tho monttor to lead III.

Troub lesh ooting monitor problems

27

monitored at a time. and a lead selector on the monitor

isn't aVililable.

Applying electrode pads

RguflI 4-5. Telemetry monnorllg - Rve-leadwtre system.

lhls illustration shoWs you wtlefe to place the electrodes a1d
attach leadwlros USDJ a 11Ye-leadWlru system. The leadWlres are
COior-COCIed as TOIIOWS:

white - right arm (RAJ

black -left arm (LA)
green - right leg (RL)
red -Ieflleg (LL)
brown - chest (C).
With the fiye-Ieadwire system for telemetry monitoring you
can monitor anyone of the 121eads using a lead selector on the
mon~or. Leads placed in the convenlionallimb positions allow
you to view leads I, II, III, aVR, aVL., and a\'F. To view cheslleads
V,-V" the chest lead must be placed in the specific chest lead
desired.

Telemetry monitoring -

Wireless monitoring, or

teteme!!),. gives your patient more freedom than hardwire

monitoring. Instead of being connected to a bedside

monitor. the patient is connected to a portable monitor
transmitter. which can be placed in a pajama pocket or
in a telemetry pou,h. Telemetry monitoring systems are
available in a five-Ieadwire system and a three-leadwire
system.
The five-Ieadwire system for telemetry (Figure 4-5) is
connected in the same manner as the fiw-Ieadwire system for hardwire monitoring with the four limb positions
(RA. LA. RL. and LL ) in the conventional locations and the
'hest leads pla,ed in the dnired V! to V, location. With
this system you can monitor anyone of the 12 leads using
a lead selector on the monitor. Leads placed in the limb
positioru; as shown in Figure 4-5 allow you to view leads
I. II. Ill. AV . AVe' or AV.. To view chest leads V, through
V, . the chest lead must be placed in the specific chest lead
position desired.
The three-leadwire system for telemetry (Figure 4-6)
uses three electrodes and three leadwires. The lead wires
are connected to positive. negative. and ground connections on the telemetry transmitter and attached to electrode pads placed in specific chest lead positions (leads
I. II. III. MCL,. and MCL, ). Only one lead position can be

Proper attachment of the electrode pads to the skin is the

most important step in obtaining a good quality ECG tra,ing. Unless there is good contact bet"'een the skin and the
electrode pad, distortions of the ECG tracing (artifacts)
may appear. An artifact is any abnormal wave, spike. or
movement on the ECG tracing that isn't generated by the
electrical activity of the heart. The procedure for attaching
the electrodes is as follows:
Choose monitor lead position. It's helpful to assess the
12-lead ECG to ascertain which lead provides the but QRS
complex voltalle and P wave identification.
Prepare the skin. Clip the hair from the skin using a
clipper; hair interferes with good contact between the
electrode pad and the skin. Using a dry washcloth. wipe
site free of loose hair. If the patient is perspiring and the
electrodes won't stay adhered to skin, apply a thin coot of
tincture of benzoin and allow to dry.
Attach the electrode pads. Remove pads from packaging and check them for moist conductive gel; dried gel
can cause loss of the ECG signal. Place an electrode pad
on each prepared site. pressing firmly around periphery of
the pad and avoiding bony areas. such as the clavicles or
prominent rib milrkings.
Connect the leadwires. Attru:h ilppropriilte leadwires to
the electrode pads according to established electrode-lead
positioru;.

Troubleshooting monitor
problems
Many problems may be encountered during cardiac
monitoring. The most common problems are related to
patient movement. interference from equipment in or
neilr the patient's room. weak ECG signals. poor choice
of monitor lead or electrode placement. and poor contact
between the skin and electrode-Ieild attachments. Monitor problems 'an ,ause artifa't,s on the ECG tracing,
making identification of the cardiac rhythm difficult or
triggering false monitor alarms (false high-rate alarms
ilnd false low-rate alarms) . Some problems are potentially serious ilnd require intervention, whereas others
are temporary. non-life -threiltening occurrences that will
correct themselves. The nurse and monitor technician
need to be proficient in recognizing monitoring problems. identifying probable causes. and seeking solutions
to correct the problem. The most common monitoring
problems are:
FalsehifIJ-ratealarms ~ High-voltageartifact potentials
are commonly interpreted by the monitor as QRS complexes

28

Cardiac monitors

lead II

Lead III

Negative lead - 2nd Interspace

right midclavicula, line

N"9IIti.... lead - 2nd Intonp"""

right midclavicular Ii""

N&gative lead - 2nd inlelSplOCe

lelt midclavicula, line

Podive load - 2nd Interspace

left midcIDVic .... a' Ii""

Positive klad -11th Interspa::e

left midclavicular II""

lelt midclavicula, line

Ground load - 8th InllH'ap"""

Ground lead - 8th interspace

right midclavicula, line

right midclavlc:ular Ii""

Positil'll Iliad - 8111 Inl9f&paoo

Ground lead - 8111 Interspace
'ight midclavicular ina

G
ModifIed Chest Lead V, (MCL,)

tdodfted Chest leed V. (MC!..,;)

N&g8tive lead - 2nd Interspace

19ft midclavicula, line

Negative lead - 2nd interspace

lelt midclavicula, lina

Positi .... lead - 4th interspace

right 5t&mal borde,

Positive lead - 5th intlH"space

lelt midaxila ry Ina

Ground I9I1d - 8th ntar5piICII

right midclavicul9, I""

Grourlllaad - 81t! InllH"spac6

right midclavicula, line

Figure 4-6. Telemetry monRMng: Three-leadwlm system.

TM II1ree-leadwlrs system uses 1111'98 electrode pads and three leadWlres. Tho leadwlres lI'e connocted to JXlSRlYe. negative, or ground
connections on thetelemetry transmitter and attached to spectnc lead posKIons (lead I, lead II. lead III, lead MCL" or lead MCLJ. Only one
lead posRIon ClI'1 be monitored at a Dme.A lead selector 1sn1 available.

and acti"ate the high rate alarm. Most high voltage arti
facts are related to muscle movements from the piltient
turning in bed or moving the extremities (Figure 4-7).
Seizure activity can also produce high-voltage artifact
potentials (Figure 4-8) .
False low-rate alamu - Any disturbance in the transmission of the electrical signal from the skin electrode to
the monitoring system can activate a false low-rate alarm
(Figures 4-9, 4-10, 4-11. and 4-12 ). This problem is usually caused by ineffective contact bd""een the skin and the
electrode-Ieadwire system, resulting from dried conductive

gel, a loo"e electrode, or a disconnected lead wire. Low

voltage QRS complexes can also activate the low-rate
alarm; if the ventricular waveforms aren't tall enough.
the monitor detects no electrical activity and will sound
the low-rate alarm.
Muscle tremors - Muscle tremors (Fil/ures 4-13 and
4-14) can occur in tense, nervous patients or those shivering from cold or having a chill. The ECG baseline has an
uneven, coarsely jagged appearance, obscuring the waveforms on the ECG tracing. The problem may be continuous
or intermittent.

Trouble shooting monitor problems

Figure 4-7. Patient movement cause: str1ps above shoW pallent turning In bed Of extremity movement. SOIUtIm: Problem Is usually
Intermittent and no corractlon Is necesay. Movement tRact C~ be reduced by avoiding placement 01 electrode pads In areas where
extremity movemenlls greatesl (bony areas such as the davldes).

FIgure 4- 8. Setzln actlVlly C<rL activate the high-rate alarm on the monitor.

29

30

Ca rdiac lllonilOrs

Figuf1l 4 9, cont~uous straight Ina, QIJs,: DI18C1 conciJc1tt'a gaI, dl!ro"tl8Ctad lead wire, or dlsconn8cted el8ctrooa pad, sotJItm: Qlack
ellM:trode-lead syslem; re-prep alii fe-altach electrodes .nI1oacIs as necessary. fJie: A straight line may also h:llcali! the msenc:a 01
electrical acttvfty ~ thell8llt; the patJant must be avaIual9d Immediately !of the presenca 01 a pulse.

Figure 4 1O. ~termttblnt straIgIIt line. GaUS8: r.ef1actNe contact betWiIen SkIn and electrooa pac:!. SDIIIt/on: Make sure hair Is Clpped
.nI electrode pad Is pI;Qd on clean, dry skin; " dlaph:lresls Is a problem, prep skin SII1'ace wtth Unctln 01 benZoin solIIIon.

Figure 4 11 . conUrwus low waveform 'I1tagi. GaUS8:LowYOIIage QftS compleJDIIS. so.tstIon:lUm ~ amplItUde (gain) knob on monlor

or change lead positions.

Troubleshooting monilor proble ms

31

Fillure 4-12. Intermment loW waveform YO!t<Qe. ClIusfllntarmtttent 1oW-~e OIlS COOlplexes ara seen In both strtps aOOe.
SO/uI1on: Uthe pr~ Is frequent and acttvates the loW-rate alann, c:tmge lead posttlons.

Figure 4-13. contlnuollS musde tremor. cause: Muscle tremorn are usually related to tense or nenoos patients or Ihosa sIllYer1ng from
cold or a chili. SOlt/ltln: lI"eat cause.

32

Cardiu c monilOrs

Figure 4-14. .,lBrmltlenl musde 1r1lfl1CX. caUSI1: Muscle trernon thaI ClCClI' nlefmlllenlly. Sdu/fa!: correction Is usually unllBalSSal)'.
Nol6: In this str~, the palleR lias two p waves precedtrY;j each ORS complex \S8COOO-degrae atTklVenIrt:utaf block, MOOIIZ 11).11 the muscle
trem!n went continUOUS (as In Agulfl 4-13). yQJ wOUlCl be unable 10 identity this S8f1OUS IITt1ythmla.

Figure 4-15. Telemetry-rlllated Interference. cause: ECG sI!1lals 1I"e poorly received ~er the telemetry system causing sharp spIIes
nI someUmes kiss 01 signal recepllon. ThIs problem Is usually lfllated to wmk batteries or the transmltlef being usalin the outer fI1nges 01
Ihe ~11on lI"ea lor the base stallon receiver. SdutJon: Ctlange batteries; keep pall8nlln recepUon area 01 base station receivers

Telemetry-related interference -

Te lemetry-related
artifacts occur ",-hen the ECG signals are poorly received
owr a telemetry monitoring 5)'Stem (Figure 4-15). Weak
ECC signals are caused by weak batteries or by the transmitter being used in the outer fringes of the reception area

of the base station receiYer, resulting in sharp spikes or

straight lines on the ECC tracing .
Ekdrical interference lAC intmerence) - Electrical
interference (Figure 4-16) can occur ",-hen mUltiple pieces
of electrical equipment are in use in the patient's room;

Trouble shooting monit o r problems

33

Figure 4-16. Electrical

Interference (N:, Interference).
CBUS8: Patient using electrical
eq.Jlpment (electric razor. ha~
dryer); muttlple electrtcal equipment In use In room; Improperly
grounded equipment; loose
electrical connecUons or exposed w~lng. So/UtJon: KpaUent
Is using electrical equ~men~
problem Is transient and will
wrloclIloolf.If pallunilli nul us-

Ing electrical equipment. lIlplug

all equ~ment not In contl1uous use. remat'e from service
lIld report any equipment wtth
breaks or wires sIlowhg. lIld
ask the electrical engineer to
check the wlrhg.

FIgure 4-17. wandertng baseline. CBUS8: Exaggerated resp~atory movements usually swn In paUents In respiratory distress (paUents
with chronic obstructlvo pulmonary disease). So/uIIon: AYOId placing electrode pads In lI'BaS where mOYOOler1ts 01 the accessory muscles 1I'lI
most exaggerated (Which can be anyw1lere on the <rltertf chest wal~. Ploc:e the pads on the uwer bock IX Iql 01 the shoolders " neceswy.

when the patient is using an electrical appliance (such as

an electric razor or hair dryer); when improperly grounded
equipment is in use; or when loose or exposed wiring is
present. This type of interference results in an artifact with
a wide baseline consisting of a wntinuous series of tine,
even. rapid spikes. I'tnich can obscure the waveforms on
the ECG tracing.
Wandering baseline ~A wandering baseline (Figure 4-17)
is a monitor pattern that wanders up and down on the monitor screen or ECG tracing and is caused by exalllleratiw
respiratory mowments commonly seen in patients with
severe pulmonary disease (for example, chronic obstructiw
pulmonary disease). This type of artifact makes it difficult
to identify the cardiac rhythm as well as changes in the ST
segment and T waw.

Analyzing a rhythm
strip
There are filii! basic steps to be fonowed in analyzing

II

rhythm strip. ~h step should Ix followed in sequence.

Eventually this will become II habit and \\;11 enable you to
identify II strip quickly and accurately.

Step 1: Determine the regularity

(rhythm) ofthe R waves
Starting at the left side of the rhythm drip. place an inda
card above the first two R waves (Figure 5-1). Using a sharp
pencil. mark on the index card .bove the tv.'O R waves.

Measure from R wave 10 R wave acro" the rhythm strip.

marking on the index card any variation in R wave regular-

ity. If the rhythm varies by 0.12 ~nd (3 small squares)

or more between the mortesl and longest R wave variation
marked on the index card. the rhythm is irregular. If the

rhythm doesn't vat'}' or lIaries by Ius than 0. 12 second. the

rhythm is considered regular.
Calipers may abo be used, instead of an index card. to

determine regularity olthe rhythm strip. R waw regularity

is assessed in the same manner as with the index card, by
placing the two caliper points on top of two consetutive R
waves and proceeding left to right across the rhythm strip.
noting any variation in the R-R regularity
The author prefers the index tard method, because eath
Rwave variation (however slight) can be IJUIrked and measured to determine if a 0_12-second or greater VilTiante e:J[ists
between the shorter and longer R-wave variatiom, With

calipers. a variation in the R-wave regularity may be noted,

but without marking and measuring between the shortest and longest R-wave variation, there is no way to determine how irregular the rhythm is, Examples of rhythm
measurement are shown in Figures 5-2. 5-3. and 5-4.

Step 2: Calculate th e heart rate

This measurement will al ....<l)'S refer to the ventricular rate
unless the atrial and ventritular rates differ, in which case
both will be given. The ventricular rate is usually determined by looking at a S-second rhythm strip. The top of the
electrocardiogram paper is marked at 3-second intervah;
two intervals equal 6 seooods (Figure 5-5). Several methods
tan be used to calculate heart rate. These methods differ
according to the regularity or irregularity of the rhythm,

Regular rhythms
Two methods can be used to talculale heart rate in regular
rhythms;
Rapid rate calculution - Count the numberofR WiIVU
in a &-second strip and multiply by 10 (6 secondS)( 10 = 60
seconds. or the heart rale per minute). This method provides an approximate heart rate in beats per minute, is
fast and simple. and tan be used with both regular and
irregular rhythms .
Prf!CiSIl rate rulculution - Count the number of small
.squares between two coMeCutive R wave.s (Figure 5-6) nnd
refer to the conversion table printed on the inside back
coverof the book. A remowble com'usion table is also provided.Although this method is accurate. it can be used only
for regular rhythms. If a conversion table isn't available.
divide the number of small squares be!>..'een the two consecutive R waves into 1500 (the number of small squares
in a I-minute rhythm ~trip). The heart rates ror regular
rhythms in the answer keys were determined by the precise
rate calculation method.

Irregular rhythms

Figure 5- 1.

34

Index ca-a.

Only rapid rate calculation is used to calculate hurt rate

in irregular rhythms, Count the number of R WilVes in a
6-second strip and multiple by 10 (Figure 5-7). or count
the number of R waves in a 3-second strip and multiply
by 20 (3 seconds )( 20 = 60 seconds, or the heart rate per
minute),

Step 2: Calcul a te the heart ra te

35

Figure 5- 2. Regularrhythm; R-R Intervals do not vary.

Figure 5- 3. Irregula' rhythm; R-R

~terYais vary

by 0.32 second.

Figure 5-4. Regular rhythm; R-R Intervals vary by 0.04 socoOO.

Other hints
When rhythm strips have a premature beat (Figure 5-11).
the premature beat isn't included in the calculation of the
rate . In this example the fin;t rhythm is regular and the
heart rate is 68 beats per minute (22 small squares between
R waws = 68).
When rhythm strips have more than one rhythm on a
6-second strip (Figure 5-9), rates must be calculated for
each rh}1hm . This will aid in the identification of each

rhythm. In the example. the first rh}1hm is irregular

r.. l~ i. 1401>0: ..1. p'" lUiJlul~ (7 R "'.. "". ill
3 seconds x 20 = 140). The second rhythm is regular and
the heart rate is 250 beats per minute (6 small squares
between R waws = 250).
When a rhythm coven; It'SI; than 3 seconds on a rhythm
strip (Figure 5-10). rate calculation is difficult. but not
impossible. In the example. the first rhythm takes up
half of a 3-second interval. There are only two R waves.
"lUllh~ h~"rl

36

Analyzing a rhythm s trip

Figure 5 5. ECG graph paper.

Figure So6. Regular rhy1tV1I; 25 small squares between Rwaves '" 60 heart rate.

Figure 5-7. n-egular fhytIIm; 11 Rwaves)( 10 '" 110 heartralB.

Therefo re , you can't determine if the rhythm is regular or
irregular. In this situation. multiply the two R waves by
40 (I Yi second x 40 '" 60 seconds. or the heart rate per
minute) to obtain an approximate heart rale of 80 beats
per minute. The second rhythm is regular. with a heart
rate of 167 beats per minute (9 small squares between R
waves '" 167).

As you hav'e seen. rh~1hm strips may have one rhythm

or sevoeral rhythms. Therefore, each rhythm stTip may
havoe one ans ....-er or several al1SY>ers. Figures 5-8, 5-9, and
510 have two different rhythms and thus MOO different
answers. Each rhythm on the strip must be analyzed separately. When interpreting a rhythm strip. describe the basic
underlying rh~thm first. then add additional information.

Step 2: Cnlcul nte the henrt rIl te

Allure 5-8. Rhythm With prematura beat.

Allure 5-9. Rhythm stlp wlltl two dlnerenl mythms.

Agure 5-10. calculallng rate wtIen a mytlvn COYen less IIIan 3 seconds.

37

38

Analyzing a rhythm strip

Figure 5-11 . NonnaiPwaves.

fillure 5-12 . Allllurrnal PWlfYlI!:S.

Figure 5- 13. PR Ilterval 0.16 second.

Box 5-1.

Rhythm strip analysis

1. De1ermlne regula~ty (rhythm).

Flgure 5-14. aRS complex 0.12 seo:.od.

such as normal sinus rhythm with one premature ventricular contraction (PVC) (Figure 5-8).

Z. C~k:U1iI1I! Hill!.
3. examine P waves.

Stl!P 3: Idl!nlify amll!xaminl! P wavl!s

4. Measure PR In1erval.
5. Measure aRS complex.

Analyze the P waves; one P wave should precede each

QRS complex. All P waves should be identical (o r near
identical) in size. shape, and position. In Figure 5-11

Step 5: Mellsure the QRS complex

Agure 5-15. ORS complex (l.l(l secooo.

there is one P wave to each QRS complex, and all

P waves are the $ame in si~. shape. and position. ]n
Figure 5-12 there is one P wave to each QRS complex.
but the P waves vary in size. shape. and position across
the rhythm strip.

Step 4: Measure the PR interval

Measure from the beginning of the P wave as it leaves
baseline to the beginning of the QRS complex. Count the
number of small squares contained in this interval and
multiply by 0.04 second. In Figure 5-13 the PR interval is
0.16 second (4 small squa res It 0.04 second", 0.16 sewnd).

Step 5: Measure the QRS complex

Measurefrom the beginningoftheQRS complex as it leaves
baseline until the end of the QRS complex. when the ST
segment begins. Count the number oIsmall squares in this
measurement and multiply by 0.04 second. In Figure 5-14
the QRS compt~ takes up 3 small squares and represenb
0.12 second (3 small squares x 0.04 second '" 0. 12 second).
In Figure 5-15 the QRS compl~ takes up 2Y.i small
squares and represents 0.10 second (2Y.i small squares x
0.04 second '" 0.10 second).
If rhythm strips are analyud using a syslematic stepbystep approach (Box 5-1). accurate interpretation will be
achieved mosl of the time.

39

40

An alyzing a rhythm strip

Rhythm strip practice: Analyzing rhythm strips

Analyze thf following rhythm strips using the five-step proceS$ diKulSed in th is chapter. Check )'OUr answen wi th the
answe r key in the append br:.

Strip 5-1 . 1Wlythm: _ _ _ _ _ _ _ _ _ ",.." _ _ _ _ _ _ __

PR il\eMII:

Strip 5-2. lIlythm: _ _ _ _ _ _ _ _ _ _ ,.,,, _ _ _ _ _ _ __

PR in\eMII:

Pwave: _ _ _ _ __

DRS oomplex:'_ _ _ _ __

Strip 5-3. lIlythm: _ _ _ _ _ _ _ _ _ ""," _ _ _ _ _ _ __

PR illeMll:

Pwave: _ _ _ _ __

DRS t:OII1p1ex:_ _ _ _ __

ORS t:OII1plex:_ _ _ _ __

Pwave: ______________

Rhythm strip practice: Analyzing rhythm s trips

'.,'5.""'",, ________ ...,_______ Pwave: _ _ _ __

PR.,IMvaI:

ORScomplex: _ _ _ _ __

Strip 5-5. Rhyttwn: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR.,IeMII:

Strip 5-6. RhytIwn: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR.,IeMII:

Pwave: _ _ _ _ __

ORScomplex: _ _ _ __

ORScomptex:_ _ _ _ __

Pwave: _ _ _ _ __

41

42

Analyzing n rhythm strip

SttlpS-7. lIlyIhm: _ _ _ _ _ _ _ _ _ R"" _ _ _ _ _ __

PR illefval:

Strip 5-8. lIlyIhm: _ _ _ _ _ _ _ _ _

PR 1n1eMl1:

R"" ________

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Strip 5-9. FIlythm: _ _ _ _ _ _ _ _ _ ,.,,, _ _ _ _ _ _ __

PR inlefval:

Pwave: _ _ _ _ __

ORS cornpleJ::_ _ _ _ __

ORS compleJl:_ _ _ _ _ __

Pwa'o'e: _ _ _ _ __

Rhythm strip practice; Anal yzing rhythm strips

strip 5-10. 1V1ytIvn: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR lilt.....:

Pwa..,,: _ _ _ _ _~

OAS complex: _ _ _ _ _~

strip5- 11 . RhytI"rn: _ _ _ _ _ _ _ _ _ Ratt: _ _ _ _ _ _ __

PR inlerwt:

43

CRS complex: _ _ _ _ _~

Pwa..,,: _ _ _ _ _~

Sinus arrhythmias

Overview

Since th is rate is faster than other pacemaker sites in the

conduction system, the SA node retains control as the primary pa.cemaker of the heart. Sinus rhythm originates in
the SA node and the impulse follows the normal Induction pa.thway through the atria, the AV node, the bundle
branches, and the ventricles, resulting in normal atrial and
ventricular depolarization.

The term arrhythmia (abo called dysmythmia ) is very

general. rderriog to all rhythms other than the norITIlIl rhythm of the heart (normal sinus rhythm). Sinus
arrhythmias (Figu re &-1) result from disturbances in

impulse discha rge or impulse conduction from the sinus

node. The sinus node retains its role as pacemaker of the
heart. but discharges impulses 100 fast (sinus tachycar-

dia) or too slow (sinus bradycardia); discharges impulses

irregularly (sinus arrhythmia); fails to discharge an

80a i-1.
Normal sinus rhythm: Identifying ECG features

impulse (sinus arrest ); or the impulse discharged is

blocked as it exits the sinoatrial (SA) node (SA exit block).

Rhythm:

..

"'

Sinus bradycardia. sinus tachycardia. sinus arrhythmia.

sinus arrest, and sinus block are all considHed arrhyth -

"".

mias. However, sinus bradycardia at rest. sinus tachycardia with aen:ist, and sinus arrhythmia associated with
the phases of respiration are considered normal responses
of the heart

PW''IIiII:

60 to 100 tJeallolmlllJle
Normal In stze. sIlape, and tinction:

PH IntiIn'aI:

Normal (0.12" 0.20 second)

QRS

Normal sinus rhythm (Figure 6-2 and Box 6-1) reflects the
heart's normal electrital activity. TIle SA 00!k normally
initiates impulses at a rate or 60 to 100 beats per minute.

Sinus bradycardia
Sinus tachyca rdia
Sinus arrhythmia
Sinus arrest
Sinus block

Figure 6 1, 5nJs armytllmlas.

44

comple.: Normal (0.10 sean:! or less)

Normal sinus rhythm is regular with a heart rate

between 60 and 100 beats per minute. The P waves are normal in size. shape. and direction: positive in JeadJl (a positive
leadl, ...ith one P wave pre<:eding each QRS complex. The
duration of the PR interval and the QRS complex is within

Normal sinus rhythm

No rmal sinus rhyt hm

posltlYe In
1eaCI1: one P WlIYfI!r9CEide5 each ORS complex

~C

Sinus loc hrca rdio

Agure &-2.

NOrmal sInUs Iflythm.

Rb)'Ulm :

Regular

Rate:
P waVlI:
PRlnlllrYaI:
DRS complU:

8-4 beats/minute
NOrmal ar.IIX"8C8CIe each ORS
0.14toO. 16 ll9al1ld
0.06100.08 secood.

nonnallimits. Normal sinus rhythm is the normal rhythm

8016-2,

of the heart. No treatment is indicated.

Sinus tachycardia: Identifying ECG features

Sinus tachycardia
Sinus tachycardia (Figure 63 and So)[ 62) is a rhythm
thai originates in the sinus node and di~harges impuL'IeS
regularly at a rate bew,et:n 100 and 160 beats per minute.
The P waves .re normal in s~e. shape, and direction: po$i
live in le<KI 1i (. posilive lead), with one P wave preceding
each QRS complex. The duration of the PR interval and the
QRS complex is within normal limits. The distinguishing
feature of this rhythm is the sinus origin and the rate
bew,--een 100 and 160 beats per minute.

Figure 6-3.

Rb)'Ulm:

PWI'I'9S:

PR InIlIrYaI:

45

Sinus tacllycartlla.

"""",,
"'"to

115 beatsJrnhuto

0.16 to 0.18 sean:I

DRS complex: 0.08 0.10 secood.

A~hm;

100 to 160 beaWm~uto

Normal In sIZe, shape, and direction; posftM: In
lead II; one P wa'o'9 precedas each DRS complex
PR lntenll: Ncrn\aI (0.12 to 0.20 sa:ond)
QAS compl": Normal (0.1 0 secood or less)

Rate:
P wa... :

Sinus tachycardia is the no rmal response of the heart

to the body, demand for an incTl'a5e in blood How (for
example, exercise). The sinus node increases its rate in
response 10 an increased need. ~n neds decrease, the

46

Sinus nrrhylhmins

heart rate slows down. Sinus tachycardia begins and ends

gradually in contrast to other tachycardias ...... hich begin
and end suddr:nly.
Sinus tachycardia can be caused by anything that
increases sympathetic lone or anything thai decreases
pal'Mympathelic lone. Factors commonly associated with
sinus tachycardia are:
anxiety. ucitement. stress. exertion. exercise
fewr. nnemia. shock
hypoxia. hypovolemia. hypotension. heart failure.
hyperthyroidism
pain, pulmonary embolism (sinus tachycardia is the
most common arrhythmia seen with pulmonaryemboJism)
myocardi;lJ ischemia. myocardial infarction (M!) (sinus
tachyeardia persisting after an &cute infarct implies extensive heart damage and is generall y a bad prognostic sign)
drogs that increase sympathetic tone (epinephrine,
nortpinephrine, dopamine. dobutamine, tricyclic antideprtS5ants, isoproterenol. and nitroprusside)
drogs that dec re;ue parasympathetic tone (atropine)
use of substances such as caffeine, cOGline, and nicotine.
Sinus tachycardia is usually a benign arrhythmia and
treatment is directed at correcting the underlying cause
(relief of pain, fluid replacement, rtmoval of offending
medications or substances, and reducing fever or anxiety).
Ho.....ever, persistent sinus tachycardia should never be
ignored in any patient, especially the cardiac p.1lient. A
rapid heart rate increases the workload of the heart and
ib oxygen requ irements and IT\iJ)' cause a decr\\il$ed stroke
volume leading to a decrease in cardiac output. In addi tion,
heart rates higher than norm;lJ decrease the amount of
time the heart spends in diastole, leading to a decrease in
coronary artery pe rfusion (coronary arteries are perfused

du ring diastole), Sinus tachy<:ardia that persisb may be

one of the first signs of early heart failure .

Sinus bradycardia
Sinus bradycardia (Figure 6-4 and Box 6-3) is a rhythm
that originates in the SA node and discharges impulses
regularly at a rate between 40 and 60 beats per minute.
The P waves are nonnal in size, shape, and dirtction: positive in lead II (a positive lead), with one P wave preceding
each QRS complex. The duration of the PR interval and the
QRS complex is within nonnallimits. The distinguishing
feature of this rhythm is the sinus origin and a heart rate
between 40 and 60 beats per minute.

ao. ...3,
Sinus bradycardia: Identifying ECG leaba'es
R....
40 to 60 bealsImlnuls
Normal In sue, sI\ap&, and ttr9ctkln: posltlYe In
lead I: one P WW1I ~ecalBS each ORS complex
Pft IlItan'aI: Normal (0.121D 0.20 S8IXJId)
ORS compleX: Normal (0.10 sec::ooo or less)
Rhylhm:

Rot.

p.,.",..:

Sinus brady<:ardia is tht: normal response of the heart

to rtlaxation or ~leeping ...ntn the parasympathetic tffect
on cardiac automaticity dominates over the sympathetic
effect. It's ,ommon among trained athletes who may have_
resting or sleeping pulse rate as 10was35 beats per minute.
Mild bradycardia may actually be beneficial in some
patients (for uample, awte loll) bec:ause of tht: decrease in
wo rkload on the heart,

Figure 6-4. Sinus bradycardia,

Regula'
R...
P WaY":
Sinus
PH Interval: 0.20 second
ORS comple x: 0.06 to 0.00 second
RllyItIm:

" ...

Nola:

A notched P WaYe Is usually Indlcallvo 01len alr1al

hyperlr~.

Sinus arrhythmia

Sinus bradycardia can be caused by anything that

incrtases potrMympathetic tont or anythinQ that decrtastS
sympotthetic t~. It commonly OCCUI1l with the following:
during sleep and in athldes
in acute inftrior waH!>!1 involving the right coronuy
artery. which usually supplies blood to the SA node
as a reperfusion rhythm after coronary angioplasty or
afte r treatment with thrombolytics
v&gal stimulation from vomiting, bearing down
(VaJsalva's maneuwr), or carotid sinus pressure
!IS a vasovagal reaction. A vasovagal reaction is an
utrtme body rtsponse that causes a marked decrease in
neart rate (due to vagal stimulation) and a marked decrease
in blood presw re (due to vasodilation), This reaction may
ocaJr with potin, nausea. vomi ting, fright. or :ltJdden stres.sful situations. The combination of extreme bradycardia and
hypotension may re:ItJlt in fainting (vaKIYagal syncope).
The situation is usually reversed ..... hen the individual
is placed into a reaJmbent position, thertby increasing
venous return to the heart. If fainting occu rs ..... ith the individual in a recumbent position. it can usually be revel1loed
with leg elevation.
carotid sinus hypersensitivity syndrome. sleep apnea
decreased metabolic rate (hypothyroidism. hypothermia); hyperkalemia
sudden movement from recumbent to an upright position (common in the elderly)
inc reased intracranial pressure (II. sudden appea rance
of sinus bradycardia in 11 pottient with cerebra l edema or
subdural hematoma is an important clinical obselVation)
drugs such .s digoxin, ca lcium channel blockel1l, lind
beta blockers
degenerative disease of the sinus node (sic k sinus
synd rome), Pel1listent sinus brAdycardia is the most

Allure 6-5.

RII)'II1m:

P waws:
PIt ln18rYaI:

SInus arrflrthmla
negular
SO beal&mloote

Normal In ron1Iguratloo; precede eadI 0fIS

0.12 to 0.1 4 second
ORS complex: 0.06 to 0.08 second

47

common and often the earl iest manifestation of sick sinus

synd rome, Sick sinus synd rome is a dysfunctioning sinus
node ...... hich is manifested on the ECG by marked bradyarrhythmias al ternating with episodes of tachyarrhythmias
and is commonly accompotnied by symptoms :ltJch!lS dizziness. fainting episodes, chest pain. shortnen ofbnath. and
heart failure. This syndrome has also been called tachybrady sfI71drome. Permanent pacemaker implantation is
recomm~nded once patients become symptomatic.
Sinus bradycardia doesn't require treatment unless the
patient becomes symptomatic. Some cliniCllI silins lind
symptoms requiring treatment include cold. clammy skin:
hypotension: shortness of breath, chest pain, changes in
menta l status. decrease in urine output, and heart failure.
If sinus bradycardia persists, the treatment of choice is
atropine, a drug that increases the heart rate bydecrea!iing
p.1rllSympathetic tone. 'l'ht usual dost is 0,5 rug IV push
every 5 minutes unti l the bradyca rdia is resolved or a maximum dose of3 mg is given. Atropine must beadministered
correctly; atropine administered too slowly or in d05e5 less
than 0.5 mg can further decrease the heart rate instead of
ifl(:re.uing it. If the rhythm still doesn't resolve lifte r the
atropine is administertd. 11 tran scutaneous (external) or
transvenous potcemaker may be needed. All medications
that cause a decrease in heart rate shou ld be reviewed lind
disoontinued if indicated. For chronic bradycardia. permanent pacing may be indicated.

Sinus arrhythmia
Sinus arrhythmia (Figure 6-5 and Box 6-4) is a rhythm that
originates in the sinus node and discharges impulses irregularly. The heart rate may be normal (60 to 100 beats per
minute) or slow (commonly associated with a brMlycardic

48

Sinus arrhythmias

Box , .....

sinus arrest and sinus exit block. Sinus arrest and sinus

Sinus arrhythmia: Identifying ECG features

exit block. two separate arrhythmias with different pathophysiologies (Figur~ 6-6. 6-7. and 68 and Box 6-5), are
discuned together because distinguishing between them is
at times difficult. and because Iheir treatment and clinical
significance are the same.

Rhythm:

Irregular

Normal (60 to 100 beats/mtlute) or SlOW ~ess \han

60 bealslmlnute)
Pwaves:
Normal., slm, shape.1Ild d ~ ectlon; posRIvo In
lead II; OI1e Pwave precedes each OAS complex
I'A InteMI: Normal (0,12 to 0,20 second)
QAS complex: Normal (0.10 secooo or less)
Ratl:

rate). The P wav~ are normal in sne. shape. and direction:

positive in lead II (a positive lead). with one P wave pre
ceding each QRS complex. The duration of the PR interval
and the QRS complex is with in normal limits. The distin
guishing feature of this rhythm is the sinus origin ood the
rhythm irregularity.
Sinus arrhythmia is commonly lWOCiated with the
phas~ of respiration, During inspiration. the sinus node
fires faster; during expiration. it slows down. This rhythm
is an extremely conunon finding among infants. children.
and young adults. but may occur in any agegroup. Sinus
arrhythmia is a normal phenomenon that usually doesn't
require treatmenl unlen it iSilccompanied bya bradycardia
rate that causes symptoms.

Sinus pause (sinus arrest and sinus

exit block)
Sinus pause is II broad term used to describe rhythms in
which there is a sudden failure of the SA node to initiate or
conduct an impulse, Two rhythms fall under this category:

Figure &-6.

Box 6-5.

Sinus arrest and sinus ellit block: Identifying

ECG leabJres
Rhythm:

Rate:
P Way":

P1Itnt,rval:

Ratl:

dOWn lor seY9r81 beats aner paJS8 ~ernporay rate

suppression) 001 returns 10 bask: rate
lhal oIl.11derlyllg rhythm. usually stlus
Sinus P waY9S with bask: rhythm; absenl dlSlng

""~
Normal (0.12 to 0.20 second) with DaSI& rl'ly1hm:
absent during pause

QRS complex: Normal (0.10 second or less)wllh basic rhythm;

absent during pause
DlffMM tlarlffj fH fU" $
SinUI~;
Basic rhythm (R-R regJlarlty) I"lIsumes 011 Urns alter

SInus Irmt: "'"~

Bask: rhythm (R-R regJlarlty) doesn't resume on
Ume alter pause
Both sinus arr~t and ~inus e)lit block originate in the
sinus node and are characterized by a sudden pause in the
sinus rhyl hm in which one or more beats (cardiac cycles)

Normal sinus rhythm with sinus block.

Bask: rhythm regular; Irregular during pause

Bask: rhythm 84 boatslmlrute
PW3'les:
Normal In basic rhythm;:men! rurlng pause
PR Interval: 0.16100.18 second In basic rhythm; :ment rurlng pause
QRS complex: 0.08100.10 second In basic rhythm; :ment rurlng pause
comment: ST-segment depression Is present.
Rhythm:

Bask: rhythm usually I"lIgular; there Is a sudden

pause In the bask: rhythm (causing Irregularity) with
one or mol"ll missing beals; neart rate may slOW

Sinus pause (sinus arrest and sinus exit block)

Figure 6-7.
Rhythm:
Rala:
P waYIIS:
PfIlnterval:
DRS complex:

Normal sinus rhythm with sinus arras!.

Basic rhythm regular.I'T~1<r durl'Y;! pause
BasIc rhythm 94 beats/minute
Normal In basic rhythm; absent during pause
0.16 to 0.18 second In basic rhythm: absent during pause
0.06100.08 second In basic rhythm; absent du~ng pause.

Rgure 6-8.
Rhythm:
Rate:

BasIc rhythm regutar; Irregutar <lJ~ng pause

49

Normal sinus rhythm wllh sinus arras!; rale suppression Is presenlloltowlng pause.

BasIc rhythm rale 84 beatslmnute; rate slows to 56 boatslmlrule loIlowlng pause (temporll)' rate suppression may occur
lollowlng a pause In the bask: rhythm)
P waygs:
Sllus In baste rhythm; absent during pause
PfIlnl9rYat: 0.16 to 0.18 second In basic rhythm; absent during pause
DRS complex: 0.08100.10 second In basic rhythm; absent du~ng pause.

an: missing. The P waves in the underlying rhythm will ~

nonnal in size. shape. and direction; positive in lead II (a
positive lead). with one Pwave pre\:eding each QRS complex.
The duration of the PR interval and the QRS complex in the
underlying rhythm is within normallimils. The distinguishing feature of both rhythms is the abrupt pause in the underlying sinus rhythm in which one or more beats are missing.
followed by a resumption of the basic rhythm after the pause.
Sinus arrest is caused by a failure of the SA node to initiate an impulse and is therefore a disorder of automaticity. This failure in the automaticity of the SA node upsets

the timing of the sinus node discharge, and the underlying

rhythm won't resume on time after the pause.
With sinus exit block. an electrical impulse is initiated
by the SA node. but is blocked as itexils the sinus node.
preventing conduction of the impulse to the atria. Thus.
SA exit block is a disorder of conductivity. Because the regularity of the sinus node discharge isn't interrupted (just
blocked), the underlying rhythm will resume on time after
the pause. Once the rhythm resumes after the pause (in
both sinus arrest and sinus exit block) it's common for the
rate to be slower for several cycles (rate suppression). Rate

50

Sinus arrhythmias

figure 6-1, SInus armythmla WIth sinus pause.

Rhrthm:
Rate:

Basic rhythm Irr9!rUIar

P WlI'I":
PR Inltml:
QRS complel:
COmInlIt:

Normal k'I bask; rnylMm; msenlllJrlng pause

0.1.10 0.16 second In bask: rhythm; rtlsenlllJrtng pause
0.06100.08 second In bask; rhythm; rment IlJrtng pause
Because of the Irregula'lIy of the basic rnythm , slnu:s afTest can't be dIfTlIrantlaled !rom slrus block, and the rnythm Is Interpreted using the broad term stills pause.1ndIc:lOIV that BItIw rhythm a1JId be present

60 bBa~lfIJIe

suppression is temporary and will cause a brief irregularity

in the underlying rhythm. but after sewral cycles the basic
rate and rhythm will return. An example of rate suppres
sion is shown in Figure 6-8.
Differentiating bet'o\'een the two rhythms involves com
paring the length of the pause with the underlying pop
or R-R interval to determine if the underlying rh}-1hm
resumes on time after the pause. This can be determined
only if the underlying rhythm is regular. If the underlying
rhythm is irregular. as in sinus arrhythmia (Figure 6-9).
it's impossible to distinguish sinus "rrest from sinus ait
block. In this case, the rhythm would best be interpreted
using the broad term sinus pause. indicating thilt either
rhythm could be present. Froma clinical viewpoint. distinguishing belY.-een sinus arrest and sinus exit block usually
isn't essential.
Sinus a rrest or sinus exit block can be caused by numerous factors. including:
increase in vagal (parasympathetic) tone on the SA node
myocardial ischemia or infarction
use of certain drugs such as digoxin. beta blocken, or
calcium channel blockers.

Th e patient may become symptomatic if the pauses

associated with sinus arrest or sinus exit block are frequent or prolonged. Another danger is that the SA node
may lose pacemake r cont rol. 'Nhen the sinus node sl<p.ys
down below its minimum firing rate of60 beats per minute
becau~ of bradycardia or II pause in the underlying
rhythm. an opportunity is provided for pacemaker cells
in other areas of the conduction system to usurp cont rol
from the sinus node and become the dominant pacemaker
of the heart. T~ term ectopic is commonly applied to
rhythms that originate from any si te other than the SA
node. Ectopic sites in the atria. AV node. or ventricl~ may
assume pacemaker control for one beat. ~ral beaU. or
continuously.
If symptomatic. the rhythm is treated the same lIS in
symptomatic sin us bradycardia. In addition. all medications that depress sinus node discharge or conduction
should be stopped.
A summary of the identifying ECG features of sinus
arrhythmias can be fOllnd in Table 6-1.

Sinus pause (sillus arrest and sillus exit bloc k)

51

Table 6-1.

Sinus arrhythmias: Summary 01 Identifying ECG features

Rhythm

Ral. (bIatsl

p W3W1 (lead II)

PR Interval

Positive in lead II; nonnal

in sim, shape, and
direction; 0IIII P wave
precedes each CfIS

Normal (0.12 to
0.20 second)

minute)

Normal sinus
rhythm

R~'"

6010 100

Sinus
bradycardia

R~""

40"60

"""""

""...

100 to 160

"""""

Sinus
tachycardia

Sinus
alThytlvnia

trreg .....

6010 tOO(nonnaI)
or< 60 (slow)

Sinus block
and sinus

Basic ~ usually
regular, !here is a sOOden
pause in !he basic rhythm
(caJsing irreguarity) with
one or more missing
beats; temporary rete
suppr9ssion common

That of oodertying
rhythm, usually

.~,

,~

Positive in lead II; nonnal

in sim, shape, and
dirvction; 0IIII P wave
precedes each CfIS

Positive in lead II; nonnal

in sim, shape, and
direction; 0IIII P wave
precedes each CfIS

"""""

Pooitive in tead II; norm.1

in sim, shape, and
direction; 0IIII P wave
precedes each CfIS

"""""

Sirul P waves willi basic

rhythm; absent dJring
,.~

Normal (0.12 to
0.20 second)

Normal (0.12 10
o.20second)

Norm31 (0.12 to
0.20 second)

Normal (0.12
10 0.20 second)
with basic
rhythm; absent
IUing pause

DRS complex

....,
....,
....,
....,

Normal (0.10second

Normal (0.10 second

Normal (0.10second

Nonn3I (0. to .cond

Normal (0.10 second

or less) with basic
rhythm; absent
d!Jing pause

loIowing pau&e
Ddfersntiatirtg
fealUrBII

Sirusbio:k:

Sirusarrest

Basic ~ resumes on
time after pause

..

Basic ~ does not

resume on time after
~

Nuts: Hthe basic rhythm is iITll9Uar (sinus alThythmia~ sinus arrest cant be differentiated lrom sinus block. and !he rhythm is
interpretoo as sinus arrhythmia with sirllS pause.

52

Sinus arrhythmias

Rhythm strip practice: Sinus arrhythmias

Analyze the following rhythm strips by following the five
basic steps:
Determine rhythm regularity.
Cakulatehearl rate (this usually refers to the ventricuIilr rate. but if atrial rate differs you nd to calculate both).
Identify and examine P waves.

!>Ieasure PR interval.
Measure QRS complex.
Interpret the rhythm by comparing this data with the
ECG characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unless otherwise noted . Check your
ansVt'ers with the answer keys in the appendix.

Strip &-1. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-2. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

P wave: _ _ _ _ _ __

ORS cornplex:_ _ _ _ _ __

Rhythm interp-etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-3. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR intel'lal:

Pwaw: _ _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm slrip practi ce: Sinus arrhythmins

Strip 6-4. RIryItvT1: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

53

Pwa..-e: _ _ _ _ __

PRInIefVal:
ORScomplex:,_ _ _ _ __
IIJythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6- 5. Rhythm: _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

PRinteMlI:

Pwa...e: _ _ _ _ __

ORScompla:' _ _ _ __

""""'''0''01'''''' __------------------

Sbip 6-6. Rhyttvn: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PRInIefvai:

Pwa..-e: _ _ _ _ __

ORScomplex:,_ _ _ _ __

IIlyttwn interpretation:- - - - - - - - - - - - - - - -

54

Sinus nrrhylhm ioJ

Strip6-7.RhyIIvn: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Strip 6-B.lllythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ __
PR inleMll:
ORS complex:_ _ _ _ __
IIlythm Interp-etmon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR 1n1eMll:
IIlythmlnt~~ :

Pwave: _ _ _ _ __

ORS complex:'_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-9. RhytIwn: _ _ _ _ _ _ _ _ _ '"'" _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PR inlefval:
ORS romplex:,_ _ _ _ __
IIlythm Interpretmon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Sinus arrhythmias

55

Strip6-10. Rhythm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR Interval:

ORS compleK: _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-11 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PA interval:

ORS complex: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip6-12. Rhythm: _ _ _ _ _ _ _ _ _ _ Rala: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

56

Sinus arrhythmias

Strip 6-13. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:- - - Rhythm Interpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-14. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PR interval:

OIlS complex:_ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-15. Rhythm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __ Pwav8: _ _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm s nip praclice: Sinus arrh)1.hmias

Strip 6-Hi. Rhythm: _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __

PH inielVillll:

57

Pwa",,: _ _ _ _ __

ORS complex:_ _ _ _ _ __

RhyIhmlnt8fPfMalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 611 , fIlythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwa"": _ _ _ _ __

PR inieMi:
QRScornp/ex:,_ _ _ _ __
RIrythm Inrerpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip6-18 .Rhythm: _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwa",,: _ _ _ _ __

PRinterval:
ORScomplelC _ _ _ _ _ __
RhyItn1 inteqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

58

Sinus arrhythmias

Strip 6-19. fIJyttrn: _ _ __ _ _ _ __ _

_ _ _ _ _ _ __

PwaY8: _ _ _ _ __

PR rnervai:
ORS complex:- - - Rhythm Interpntalbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 5-20. Rhyttrn: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwa....: _ _ _ _ __

PR ilterval:
ORS cornpleJ.:_ _ _ _ __
Rhythm Interpret8tIon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-21 . Rhythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __
PR ilterval:
QRS cornple.l:_ _ _ _ __

PWaYB: _ _ _ _ _ __

RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm snip pra(1i: Sinus Ilrrhydllllills

Strip 6-22. FIlythm: _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

59

Pwave: _ _ _ _ __

PH interval:
ORScompltx;'_ _ _ _ __
Rhythm IntMpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

51ri.O-23. ,.".,m' _ _ _ _ _ _ _ _ ,,,,, _ _ _ _ _ __

Pwave: _ _ _ __

PH interval:
CR5 cornplex:,_ _ _ _ _ __
RhytI'm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-24. Rhylhm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

PH interval:
ORScomplelC _ _ _ _ _ __
RhyItvn inteqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

60

ShillS Ilrrhylhmill'

Strlp6-25. lIIyttIm: _ _ _ _ _ _ _ _ _ . ., _ _ _ _ _ _ __

PR interval:
~I~e~~~

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Strip 5-25. Rhythm: _______________ _

PR ilterval:

Pwave: _ _ _ _ _ __

ORS complex:,_ _ _ _ __

_____________ PweWl: _ _ _ _ __

ORS compleJ::_ _ _ _ __

Rllythm Interprttalkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 5-27. 1tJyttvn: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR ilterva:
ORS complex:c_ _ _ _ ___
Rbyttm interpretalioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

1U\)'thm strip practice: Sinu s arrhythmias

Strip 6-21. lIIyI!lm: _ _ _ _ _ _ _ _ _

PR inll!Ml/:
~I~~em~ :

'>t. ________
ORScomplex: _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Strip 6-29. RIij1hm: _______________ Rate: _____________

PR interval:

61

Pw,, _ _ _ __

ORS complex: _ _ _ _ __

Rhythm Int8fPl'etation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6-30. RIij1hm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

PwaYe: _ _ _ _ __

PR interval:
ORS complex: _ _ _ _ __
Rhythm intefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

62

Sinus nrrhylhmins

Strip 6-31 . RhyItrn: _ _ _ _ _ _ _ _ "'" _ _ _ _ _ __

PR nterval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Rhythm interprela!ion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-32. Rhythm: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR rnerval:
ORS complu:,_ _ _ _ __

PwaV8: _ _ _ _ __

RIIythm interpretatDn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-13. RIrythm: _ _ _ _ _ _ _ _ _ _

PR iltervaI:
R~m

_ _ _ _ _ _ __

Pwave: ____________

ORS complex:
l ~ : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm sirip prncl ice: Sin us arrhyt hmias

Strip 6-]4. Rhythm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

63

Pwave: _ _ _ __

PfI inlerwi:
ORScomplex:,_ _ _ _ __
Rhythmlnleqmation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip 6-35. Rhythm: _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

Pfllmervai:

Pwave: _ _ _ _ __

ORScomplex:'_ _ _ _ __

Rhy1hm inIMprelation:_ _ _ _ __ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-36. Rhythm: _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

PRinlerval:

Pwave: _ _ _ _ __

ORScomplex:_ _ _ _ _ __

Rhydvn inlMpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

64

Sinlls arrhythmias

Strip &-37. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inierpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-38. Pllythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS

compl~ : _ _ _ _ __

Rhythm interpretatm:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-39. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
Rhythminterpr~ation :'

PwaV8: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Sinus arrhythmias

Sbip 6-40. Rhythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

65

Pwave: _ _ _ _ __

P1I interval:
ORScomplex:_ _ _ _ __
Rhyltvn Intetprttation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6--41. RhytIlm: _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __

P1I inli!IMI:

Pwave:

_ _ _ _ __

ORS CXH11p1ex: _ _ _ _ __

!IJyhn interpn!la!ion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-42. Rhythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

ORScomplex:_ _ _ _ _ __
Rhydvn inlMpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR intervai:

66

Sinus arrhythmias

Strip 6-43. Rhy1Im _ _ _ _ _ _ _ _ _

'>t" ________

Pwa'l'l!: _ _ _ _ __

PR fmerval:
ORS complex:_ _ _ _ __
Rhytl'm InterpretatiJn:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-44. FITy1Ivn: _ _ _ _ _ _ _ _ _ .",' _ _ _ _ _ _ __

DRS complo:_

PR ilternt

P W3V'8 : _ _ _ __

_ _ __

RhytI'm iliterpelalDI:

Strip 6-45. Rhy1h'n: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR ilIervat:
Rhytl'm i ~~a~ :'

Pwa'l'l!: _ _ _ _ __

ORS complex:_ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm snip praclice: Sinus arrh)1.hmias

Strip 6-46. fltythm: _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

67

Pwave: _ _ _ __

PH interval:
ORScompIex: _ _ _ _ __
Rhythm IntefPfllation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-47, Rh)thm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ __

Pfl lnterwl:
ORS complex:_ _ _ _ __
RhyI!vn InIMprltation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-48, Rhylhm: _ _ _ _ _ _ _ _ _ _

PRinterval:

_ _ _ _ _ _ __

Pwa'o'e: _ _ _ _ __

ORScomplelC _ _ _ _ _ __
Rhyttvn inleqlf8!ation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

68

Sinus arrhythmias

strip . -. . ,.,.",, _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

PR iltervat

QRS

PwaYfl: _ _ _ _ __

compleJ:: _ _ _ _ __

Rllyltlm Interpntatiln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Ship 6-50. Rhythm: _ _ _ _ _ _ _ _ _

PR iltelVlt.

QRS

_ _ _ _ _ __

PweYfl: _ _ _ _ __

compleJ.:_ _ _ _ __

Rllyltlm interpfetatiln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-51 . Rhythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

PwaYfl: _ _ _ _ _ __

PR iltelVlt.
ORS rompleJ::c_ _ _ _ __
Rbythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm snip practiC(': Sinus Ilrrhydllllills

Strip &-S2.lflythrn: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

69

Pwave: _ _ _ _ __

PfI interval:
ORScomplex:'_ _ _ _ __
Rhythm Inteqntatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-5l. RI'Iythrn: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PH interval:
ORScomplex: _ _ _ _ _ __
RhyIhmlnleqntation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-54. RI'Iythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

PfI interval:
0ftS complelC _ _ _ _ _ __
RhyItvn inleqlf8lation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

70

ShillS Ilrrhylhmill'

Strip &-55. Rrythm: _ _ _ _ _ _ _ _ _ -

PR nerval:

_ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

QRS complex:'_ _ _ _ __

RIryth'n Inlerpretatioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-5&. Rhythm: _ _ _ _ _ _ _ _ _

PR i1terr.t.

_ _ _ _ _ __

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ _ __

RIIythm Inierpmallon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-57. RIythm: _ _ _ _ _ _ _ _ _ _

PR neME

_ _ _ _ _ _ __

PwaVB: _ _ _ _ _ __

QRS cornple.l:_ _ _ _ __

RIIyIhm interpfetatioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

1U\)'thm strip practice: Sinu s arrhythmias

71

"'t. ________ Pwaw: _ _ _ __

Strip 6-58. ~m : _ _ _ _ _ _ _ _ _
PR interval:
ORS complu: _ _ _ _ __

Rhyttvn Int8f)H'etatlOn: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

"'t. ________

Strip 6-59. ltIyUlm: _ _ _ _ _ _ _ _ _ _

PH Interval:
ORS complex: _ _ _ _ __

PW3Y8: _ _ _ __

FVIyttITl intlHJll'etetion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6-&0. ~m : _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

PR interval:
ORS complex: _ _ _ _ __

PwaYe: _ _ _ _ __

FVIyttITl intefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

72

Sinus nrrhylhmins

Strip6-61 . Rhythm: _ _ _ _ _ _ _ _ _ _

Pft InteM!:

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

ORScomplex:,_ _ _ _ __

IIlythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-62. Rhyttrn: _ _ _ __

Pft kJ1eMt.

_ _ _ _ "'" _ __

_ _ __

Pwave: _ _ __ __ _

ORS compleX:_ _ _ _ __

Rhythm Interprel3tion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-63. RIrythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR marva!:
ORS complex:_ _ _ _ __
RIIyI!un interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm sirip prncl ice: Sin us arrhyt hmias

Strip6-U, Rh)'thm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

73

Pwsve: _ _ _ _ __

PfI interval:
ORScomplex:,_ _ _ _ _ __
Rhyltwn lnteqntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6-i5, Rhythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

Pfl lntllMll:

ORScomplex: _ _ _ _ __
fIly1hm InleqJrelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 6-66, Rhythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR interval:
ORScomplex:_ _ _ _ __

Pwave: _ _ _ _ __

Rhythm inteqlfetalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

74

Sinusarrhythmitl.'l

Strip 6-67. Rhythm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwavt: _ _ _ _ __

PR i1tarwi:
ORS OJIT1p1ex:_ _ _ _ __
Rhythm In\erpfttaOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-68. Rhythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR i1tervai:
ORS complex:,_ _ _ _ __
RIIythm interpr8laOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-69. Rhyth'n: _ _ _ _ _ _ _ _ _ _ '"'" _ _ _ _ _ _ __

PR i1terval:
ORS complex:,_ _ _ _ __

Pwave: _ _ _ _ __

RIryttJn interpfetaooo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Sinus arrhythmias

Strip6-10. Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

75

Pwave: _ _ _ _ __

PR interval:
QRS caTlplex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip 6-11. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR intEnrai:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip6-12. Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

76

Sinus nrrh ylhmins

Strip 6-7 3. Rhyttvn: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwave: _ _ _ _ __

PR ilteMil:
ORS complex:_ _ _ _ __
RlryIflm Inlerpfetamn: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-74. Rhyth'n: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _______

PH Interval:
DRS complex:,_ _ _ _ __
Rhythm Inlerpfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-75. RIrythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _______

PR marva!:
DRS oomplex:
RIIyI!un interpfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm s nip praclice: Sinus arrh)1.hmias

Strip 6-1ii.lflythm: _ _ _ _ _ _ _ _ ''''. _ _ _ _ _ __

77

Pwave: _ _ _ __

I'll int&rVal:
ORS canplu _ _ _ _ _ __
Rhytllm Irtetptelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip6-71.Rh~m :

_ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

PfI interval:

Pwave: _ _ _ __

ORS canplex:_ _ _ _ __

Rhytllm Inteqnlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-78. Rh~m : _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __

Pwave: _ _ _ _ __

I'll interval:
ORScomplex:_ _ _ _ _ __
RlyItrn inteqM'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

78

Sinus arrhythmias

Strip 5-19. RI!ythm: _ _ _ _ _ _ _ _ ''''' _ _ _ _ _ __

PW8ve: _ _ _ _ __
PR ilIervit.
QRS romplex:,_ _ _ _ __
Rllyttlm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 5-80. RIIythm: _ _ _ _ _ _ _ _ _ "'''' _ _ _ _ _ _ __

Pwsve: _ _ _ _ __

PR ilterv.W:
ORS rornplex:_ _ _ _ __
Rllythm InterpmatOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 5-81 . RIrythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwaw: _ _ _ _ _ __

PR ilIarvit.
ORS oomplex:
RIIyI!un interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Sinus arrhythmias

79

Strip 6-82. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

PR interval:
QRS complex.: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-83. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-84. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
QAS complex: _ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

80

Sinus nrrhylhmioJ

Strip 6 85. Rhythm: _ _ _ _ _ _ _ _ _

PR rrterY8l:

R"" ________

Pwave: _ _ _ _ __

ORS complelC'_ _ _ _ __

Rbyttm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 68G. Rhy1kn: _ _ __

PR ilterval:

____ _

_ _ _ _ _ __

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Rhyttm Interpntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ __
Strip 6 87. Rhythm: _ _ _ _ _ _ _ _ _ _ '"'" _ _ _ _ _ _ __
PR ilterval:
ORS complex:,_ _ _ _ __
RIrythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm snip practice: Sinus arrh)'1hmias

51rip 6-8a. ltiythm: _ _ _ _ _ _ _ _ _ _

PfI interval:

_ _ _ _ _ _ __

81

Pwaw: _ _ _ _ __

ORScomplex:_ _ _ _ __

Itiythm Interpre(a\loo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-a9. ltiythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

Pft interwl:

""""',.""

..

Pwave: _ _ _ __

ORScomplex:_ _ _ _ __

,,,,,- - - - - - - - - - - - - - - - - - - -

Strip 6-90. RIIythm: _ _ _ _ _ _ _ _ _ ,."" _ _ _ _ _ _ __

PR ilterva~
~mm~muoo :'

ORS romp/ex:,-

PwaYlt _ _ _ _ _ __

---

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

82

Sinus arrhythmias

Strip 6-91 . Rhythm: _ _ _ _ _ _ _ _ _ ..., _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalXln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip &-92. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PA ilterval:

Pwaw: _ _ _ _ _ __

ORS complex:_ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip &-93. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
ORS complelC:_ _ _ _ _ __

Pwaw: _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm slrip practi ce: Sinus arrhythmins

Strip 6- 94. Rhythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

Pwave: _ _ _ _ __

Pfl lnt&J'll3l:
ORS complU _ _ _ _ __
Rhyttvn inl8fPl1lta1ion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-95. Rhythm: _ _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __

PA Int&lV8l:

PWllve: _ _ _ _ __

OftScomplex:,_ _ _ _ __

Rhyttvn inlefPrelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 6-96 . Rhythm: _ _ _ _ _ _ _ _ _ _ " ' . _ _ _ _ _ _ __

Pwave: _ _ _ _ __

ORScompleic,_ _ _ _ _ __
Rhythm inlefJlfelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pfl interval:

83

84

SInus nrrhythmills

""' . ,,._-------- 11ft inIeMII:

-------

Pwa....: _ _ _ _ __

CAS CGmp6lx:,_ _ _ __

1ItIytIIn.'''''ubdlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 598. Rhyttrn: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __
Pwa....: _ _ _ _ __
11ft ~ervtt.
ORS complex:_ __ _ __
Rltythm IntMpntalion", _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip '-99. 111y11m: _ _ __ __ _ _ _

11ft inteMt
RhytI'm I"lapiillllltitwt

_ __ __ __

ORS CGmplex:, _

_ __

Pwa.... : _ __ __

Atrial arrhythmias

Mechan1sms of arrhythmias
Under certain drcumstances cardiac cells in any part Qfthe

heart may lake on the role of pacemaker of the heart. Such

II

pacemaker i5 called an ectopic pacelJl1lker (a pacemaker

other than the sinu~ node). The result can be ectopic beaU;
or rhythms. These rhythms llrt identified according to
the location of the ectopic pacemake r (for example. at rial.

junctional. or ventritular). Ttw three basic mechanisms

that are responsible for ectopic beau and rhythms art
oltered automaticity, tn"ggered aclivif!l. and reentry:
Altel't'd ~utomilt icity- NOT1T\alIIy the automaticity of the
sinus node exceeds that of all other parts oftht conduction
system, allm.ing il to control the heart rate and rhythm.

Pacemaker cells in other areas of the heart also have the

property of automaticity, including cells in the atria, atrioventricular (AV) junction, and the ventricles. The rates of

these other pacemaker sites ore slower. Therefore, they're

suppressed by the sinus node under normal circumstances.
Because the inherent firing rate of the pacemaker cells of
the sinus node ill faster than the other pacemaker situ. it
is the dominant and primary pacemaker of the heart. An
ectopic pacemaker site can take O\'er the role of pacemaker
either because it usurps control from the sinus node by
accelerating its own automaticity (enhanced automaticity)
or because the sinus node relinquishes its role by decreas-jng its automaticity. Conditions that may predispose
cardiac cells to altered automaticity include myocardial
ischemia or injury, hypoxia, an increase in sympathetic
tone, dillitalis toxicity. hypokalemia, and hypocalcemia.
1'riggered activ ity - Triggered activity results from
abnormal electrical impulses that occur during repolariz.a...
tion when cells are normally quiet. The ectopic pacemaker
cells may depolarize more than once aftu stimulation by
a single electrical impulse. Triggered activity may result in
atrial, junctional, or ventricular btats occurring singly. in
pairs, in runs (3 or more beats), or as a sustained ectopic
rhythm. CaUSt$ of triggered activity may include myocar_
dial ischemia or injury, hypoxia, an increase in sympathetic
tone, and digitalis toxicity.
Reentry _ Normally an impube spreads through
the heart only once. With reentry. an impulse can tra\'el
through an area of myocardium. depolarize it. and then
reenter that s.a.me area to depolarize it again. Reentry involves a circular movement of the impulse, which

continues as long as it encounters receptive cells, Reentry

(like triggered activity) may result in atrial. junctional. or
ventricular beats occurringsin!!ly. in pairs, in runs, or as
a sustained ectopic rhythlIL Common causes of reentry
indude myocardial ischemia or injury, hyperkalemia. and
the presence of an accessory conduction pathway between
the atria and the ventricles.
Atrial arrhythmias (Figure 7-1) originate from edopic
sites in the atria. Ectopic P waves from the atrium differ
in morphology (snape) from the normal sinus P waves
(Figure 7-2). For example, in slower atrial rhythms (premature atrial contractions, wandering atrial p;teemaker)
the P wave may appear as a small, pointed. and upright
....avtform; a small squiggle that is barely visible; or it may
be inverted if the impulse originates (rom a site in the
lov.'er atrium near the AV junction. In faster atrial rhythms.
the ectopic P wave is either superimposed on the preceding
T wave. appears in a sa ....tooth p4ttem (atrial flutter). or ill
seen as a ....avy baseline (atrial fibrillation).
Some atrial arrhythmias may be associated with rapid
ventricular rates. Increases in heart rate decrease the
length of time spent in diastole. If diastole is shortened.
thtre is leu time for coronary artery perfusion and le u
time for adequate ventricular tilling. Thul, an aceuively
rapid heart rale may lead to myocardial ischemia and may
compromise cardiac output.

Wandering atrial pacemaker

A ....anderinS atrial pacemaker (WAPj (Figure 7-3 and
Box 7-1) occurs ....tlen the pacemaker site shifts back and
Box 7-1.
Wandering atrial pacemaker: Identifying ECG

features
Rllrthm:
Rllt:

R9jlular or Ir!"9glfar

U5uaItf normal (60 to 100 bea1slmlrul9) 1M may be

stow tIIan 60 beatslmlnUls)

VIIy In size, shape, and dlrictIon across rITytIlm
strip; one P wa'I9 ~ 9ach ORS cunplex
P1ilntemt: USU/IIt)' normal IlnUon, but may be 8llrKm\aI
d9p9ndhg on dmglng pacemaker Iocalloo
ORS compleX: Normal (0.10 sec:ord or less)
P wa'lllS:

85

86

Atrial arrhythmi as

Wandering aUial PolccmJkcr

~, Premature atrial contr.lclion

~

Noncondllcted premature atllal cont raction

~ Paroxysm,ll att', al !JchyCJrd l<1

~Aaialfll.lttel
Atll~llibrl li a tlOn

Figure 1-1. Alrlalll'rhythmias.

PoIntod

Squiggle

T.p wave

w""

Figur.1-2. Atr1a1 Pwaves.

forth ~ho.een the sinus node and edopic atrial sites. The
P wave morphology will vary across the rhythm strip as
the pacemaker "wanders" ~tween the multiple sites.
The ectopic P wave may appear as a small. pointed. and
upright waveform; a small squiggle that is barely visible; or
it may be inverted if the impulse originates from a site in
the lower atrium near the AV junction. Generally, at least

three different P-wave morphologies should be identified

~fore making the diagnosis ofWAP.
The heart rate is usually normal. but may be slow.
The rhythm may be regular or irregular (each impulse
travels through the atria via a slightly different route).
The PR interval is usually normal, but may be abnormal
because of the different sites of impulse formation. The

Prema lllre atrial contraction

Agutl 73.

Wanderklg atr1 al pacemaker.

Rhrtllm:

lITegular
60 beatslmln!1le

87

Vary In sIZe, shape, across fhylhm str1p

0.1010 0.14 second
ORS COOlpla: 0.114 to 0.08 second.

P "....:
PRIn'aval:

QRS complex is normal in duration. Th~ distinguishing

f~ature of th is rhythm is the changing P_wave morphology
atnlS5 the rhythm strip.
WAf> may be a normal phenomenon seen as a result of
increased vagal effect on the 5inoo.trial (SA) node, slowing the si nus rate and allol'.ing other pactmaker sites
an opportunity to comlXte for control of the heart rate.
h tan al50 occur due to f nhanctd automatici ty of atrial
pacemaker cells that usu rp pacemaker control from the
SA node. WAP is comfTM)nly seen in patients with chronic
obstruc tive pulmonary disease,
WAf> usually isn't clinically s ign ificant, and treatment is
not indicated. If the heart rate is slow, medications should

Allure 7- 4.

Multllocal ami tacllyeanlla (MAT).

Rhythm:
Rate:

lITegular

P"awI:
PRlntBfYaI:

t40bealSltnnul8

Vary In slz8, shape, and dInIctIon across rtlythm

0.10toO.14seoJOd
QRS complex: 0.04 to 0.08 seoJOd.

s1r1I

be reviel'.'ed and discontinued if po!ISibk If the heart rate

is slow and the patient is symptomatic, treatment of the
rhythm is the samt as (or symptomatic sinus bradycardia.
When WAP is associated with a heart rate greater than
100 beats per minute, the rhythm is called multifOCflI
atriol tuc:l!ycurdia (MAT) (Figure 7-4). MAT is a relatively
infrequent arrhythmia and is most commonly observed in
patients with RVert chronic obstructive pul monary dista.w.

P rematu re a t ria l co n tract ion

A premature atrial contraction (PAC) (Figu res 7-5 through
7-12 and Box 7-2) is an early beat originating from an

aa

Atri al arrhyth mias

Figure 7-5. Normal si nus rhythm with pre matu re atr1al contraction (PAC).
Rhythm:
Basic rhylhm r69Jla'; 1'r69J1a' with PAC
Ratl:
Basic rhylhm rate 72 beats/mllllle; rale slows to 60 beal~mlnute following PAC (Tempol'MY rate suppression Is common
lailowlng a pause In the basic rhythm; alter several cardiac cycles the rale usually returns to the basic rhylhm rate.)
Pwaves:
Sinus P waves with basic rhythm; P wave assoclaled with PAC Is premalure and closely resembles thai 01 the sinus P waves
In the unclertylng rhylhm.lndlca.Ung tho ectopic atrial patenlOOJr site Is close 10 the SA node
PR Internt 0.12 second (basic rhythm and PAC)
otiS oomplex: 0.08 second (basic rhythm and PAC).

Figure 7-G.
Rhythm:
Rate:
P WaYss:
PR Interval:
QRS complex:

Normal sinus rhythm with premature atrial contraction (PAC).

Basic rhythm regulM; l'regulM with PAC
Basic rhythm rale 88 beats/mllllle
Sinus P waves with basic rhylhm; premature. Inverted Pwave with PAC
0.14 to 0.16 second (basic rhylhm); 0.14 second (PAC)
0.Q410 0.06 second (basic rhylhm); 0.06 second (PAC).

Box 7-2.

Premature atrial contraction (PAC): Identifying

ECG features
Rhythm:
Rate:
P WaYlS:

PR Int,rval:

~ng rhylhm usualtj regOO'; I'regularwllh PACs

That oIl1lC1er1yhg rhythm
P wave associated with PAC Is premature and
abnormal In size. shape. in:! direction (commonly appeln small. upright. and pointed; may be
Inverted); abnormal P wave commonly loond hidden
In preceding T wave. dlstOfUng tho T-wave COIllou'
Usualtj normal; not measurable" hidden In

,-,

QRS complel: Promalll'e; ramal dlJ'aUon (0.10 seam or less)

ectopic site in the atrium. which interrupts the regularity of the basic rhythm (usually a sinus rhythm). The premature beat occurs in addition to the basic underlying
rhythm. PACs may originate from a singl~ ectopic pacemaker site or from multiple sitel; in the atria. The early
beat is characterized by a premature, abnormal P wave
and a premature QRS complex that's identical or similar
to the QRS complex of the normally conduded beats. and
is follol't~d by a pause.
P-wav~ morphology differs from sinus beats and varies
depending on th~ origin of th~ impulse in th~ atria If th~
ectopic focus i. in the vicinity of the SA node. the P wave
1m}' closely resemble the sinus P wave (Figure 7-5 ). Its sole
distinguishing feature may be its pr~rnaturity. As a rule.

Pre m a llire a trial contractio n

Allure 1-1.

89

Hormal sinus rhythm wIIll prematul'l atrial contraction (pAC).

BasIc rtr,'ltllllll9ular, mtgular wlltl PAC

BasIc rhytlVn rata 84 beatslmnute
stlUS Pwaves wlltl basic rhythm; ~maturo, rtmormal PW;Ne w!Ih PAC (The P waYS Glthe PAC IS hmIIfl n IIle pr8C8dlng
'WIV":
T wave,!IstDrtIng the T-wave ccnru. [T wave IS taller and ITIOIlI pJlntBd.])
PR InlllVaI: 0.12 to 0.14 second (baSIC rhythm): no! measLniblEl with PM;
ORS complex: 0.06 to 0.08 second (baSt: rhythm); 0.06 S8COIld (PAC).

RhyttIm:

Allure 1-8.
Rhytnm:

Hormal sinus rhythm wIIll one premature atrial con1ractlon (PAC) wnh aberrant ventricular condllellolt
BasIc rhythm regular; lri1gularwntl MC
Rate:
BasIc rtr,'ltlll rata 68 beatslmnute
P waves:
stlUS In basic rhythm; premature, abnormal Pwave with PM;
PR InlefVaI: 0.18 to 0.18 second (baSIC rhythm): 0.24 98CCIIld (PAC)
OKS complex: 0.08 second (basic rhyIflm); 0.12 second (PAC).

l"1owevu, the P wave is different from the sinus P waves. In

lead II (a positive lead). it's generally upright and pointed
(Figure 7-9). o r it may Ix inverted (Pigure 7-6) if the pacemaker site is near the AV junction. If the premature beat
occurs very early, the abnormal P wave can be found hidden in the preceding T wave, causing a distortion of the
T-wave contour (Figure 7-7).
The PR intervals of the PACs are usually normal. similar to tho:14: of the unde rlying rhythm . Occasionally the
PR interval may be prolonged if the PAC is very early and
finds the AV junction still partially refractory and unable
to conduct at a normal rate. The PR interval will be

unmea:lurable if the abnormal P wave is obscured in the

preceding T wave.
lhe QRS of the PAC usually resembles that of the underlying rhythm becau:14: the impulse is conducted normally
through the bundle branches into the ventricles. The
ventricles depolarize simultaneously, resulting in a normal duration QRS complex. If the PAC occurs very early.
it is possible the bundle branches may not be repolarized
sufficiently to conduct the premature electrical impulse
normally. If the bundle branches are not sufficiently repolarized. the electrical impul:14: is conducted down one bundle branch (usually the left because it repolarizes quicke r)

90

i\lrlnl nrr hylhmlns

Figure 1-9.
Rhythm:
Aat.:
PWlI'I'tS:
PR Interval:
QRS compIIx:
Commen!:

NOmJal sinus rhythm with premature atrial contraction (PAC).

Basic rtr,'thm regul...; Hegul... \\11th PAC
Basic rtr,'thm rate 60 beatslmloote
Sinus Pwaves \\11th basic rhythm; premature. abnOrmal Pwave \\11th PAC
0.12 to 0.16 second (basic rhythm); 0.16 second (PAC)
0.08 second (basic rhythm and PAC)
To determine the type 01 pause arter prematLra beats, measure Irom the ORS complex betore the premature beat to the
ORS complex arter the premature beat. It the meauement eqJ8ls two R-R InteJVals. the paJS9ls compensatory. II the measurement equalS leSS lhIrilWO R-R IntervalS. the pause IS noncompensatory. ST-sllgmont dep'esSIOn IS present.

Figura 1-10. 8lgemlnal pr9ITlaiure atrial contractions.

Figure 1-"

Quadrigeminal premalure atrial contractions.

Nonconducted PAC

91

Rilure 7-12. Paired premallro a1r1a1 ContracUOIIS.

and not conduded down the other. The left ventricle is

depolarized first, followed by depolarization of the right
ventricle (sequential depol1lriz.alion). Sequential ventricular depolarization is slower, resulting in a wide QRS com-

plex of 0.12 5econd or greater. APAC associated with a wide

QRS complex is called a PAC with aberrancy, indicating
that conduction through the ventricles is abnormal (aberrant). Figure 7-8 shows a PAC with aberrant ventricular
conduction (the QRS is wide) and a long PR interval, indio
cating conduction through the AV node was also delayed.
Aberrantly conducted PACs must be differentiated from a

premature vt!ntricular contraction (PVC), especially if the

abnormal P wave associated with the PAC is obscured in
the preceding T wave. PVCs are discussed in Chapter 9.
The pause associated with the PAC is usually a noncompensatory pause (the measurement from the R wave before
the premature beat to the R wave after the premature beat
is less than two R-R intervals of the underlying regular
rhythm) (Figure 7-9). This pause is C<lJled an incomplete
pause because it doesnt equal two R-R intervals. Less commonly, the PAC may occur with a wmpensatory pause (a
pause that is equal to two R-R intervals), but this is usually
seen with the PVC. The compensatory pause is called a complete pause because it equals two R-R intervals. To differentiate between a complete pause and an incomplete pause,
the underlying rhythm must be regular. Rarely, the PAC
may occur with a pause that is longer than compensatory.
PACs may appear as a single beat (Figure 7-9). every
other beat (bigeminal PACs, Figure 7-10). every third beat,
(trigeminal PACs ), every fourth beat (quadrigeminal PACs,
Fi j!ure 7-11). in pairs (also called couplets. Fij!ure 7-12).
or in runs of three or more. Frequent PACs may initiate
more serious atrial arrhythmias, such as paroxysmal atrial
tachycardia (PAT ), atrial Hutter, or atrial fibrillation. Three
or more beats ofPACs in a row at a rate of 140 to 250 beats!
minute constitute a run of PAT.
Premature atrial beats are common. They can occur
in individuals with a normal heart or in those with heart
disease. PACs may be seen with emotional stress (due to
an increase in sym[Xlthdic tone), or ingestion of certain

substances such as alcohol, caffeine, or tobacco. Other

causes include hypoxia, electrolyte imbalances. myocardial
ischemia or injury, atrial enlargement, congestive heart
failure. and the administration of certain drugs, such as
epinephrine or nonepinephrine, that increase sympathetic
tone. PACs may also occur without apparent cause.
Infrequent PACs require no treatment. Frequent PACs
are treated by correcting the underlying cause: reducing
stress: reducing or eliminating the consumption of alcohol, caffeine, or tobacco; administering oxygen: correcting
electrolyte imbalances: treating congestive heart failure, or
discontinuing certain drugs. If needed, frequent PACs may
be treated with beta blockers. calcium channel blockers. or
antianxiety medications. Runs of PACs may require amiodarone to prevent more serious atrial arrh}1hmias from
developing.
Occasionally, an ectopic atrial beat will occur late
instead of early. This beat is called an atrial escape beat
(Figure 7-13). Atrial escape be<lts usually occur during a
pause in the underlying rhythm when the sinus node fails
to initiate an impulse (sinus arrest) or when conduction
of the sinus impulse is blocked for any reason (sinus exit
block. non conducted PAC, or Mobitz I second-degree AV
block). The pause in the rhythm allows an ectopic pacemaker site in the atria to assume control of the heartbeat.
The morphologic characteristics of the late beat will be the
same as the PAC. Escape beats act as an electrical backup to
maintain the heart rate and require no treatment.

Nonconducted PAC
A nonconducted PAC (Figures 7-14 through 7-16 and
Box 7-3) results when an ectopic atrial focus occurs so
early that it finds the AV node refractory and the impulse
isnt conducted to the ventricles. This results in a premature. abnormal P wave not accompanied by a QRS complex,
but followed by a pause (Figure 7 1-1.).
Like the conducted PAC, the P wave associated with the
nonconducted PAC will be premature and abnormal insiz.e,
shape, or direction. The P wave is commonly found hidden

92

Atri al arrhyth mias

FiRure 7-13. Normal sinus rhythm with sinu s arrest and atrial escape beal
Basic rhythm regul.'l'; lrregul1l' dur~ pausa
Basic rhythm rate 63 bealslmlflJle; ralll slows to 58 bealslmlnulll aner paJSe due to temporay rate SLp'esslon (common
loIlow~ pauses nthe basic rhylhm)
PWavH:
Sinus P waves: P waves are notched In basic rhythm which could be duo to len atrial enlargement; peaked P WlJole with
escape beat
PH Intlrval: 0.1810 0.20 second (basic rhylhm and escape beal)
QRS compln: 0.08 second (basic rhylhm); 0.06 second (escape beal).

Rhythm:
Ratl:

FiRlire 7-14. Normal sinus rhythm with nonc:onducllld premature atrial contraction (PAC).
Rhythm:
Rate:

Basic rhythm regul1l'; Irregul.'l' with noncon<iJcllld PAC

Basic ralll60 beatstmlnute; rate slows Iollowlng nonconclJcllld PAC (Rate suppression can
basic rhythm; aner several cycles, the rate will relum to the basic rhythm rate.)
PWa'lH:
Sinus P waves with basic rhythm; premature. abnormal P wave with noncon<iJcted PAC
PR Interval: 0.20 second
ORS oompIex: 0.06 to 0.08 second
COmment:
AU wlJoIels present

Box 7-3.

Nonconducted PACs: Identifying ECG features

Rhythm:

Underlying rhythm usually regular; Irregular wtth

nonconducted PACs
Rate:
That oIlJ'ldefly~ rhylhm
P waves:
P wave assoclallld wtth the nonconducted PAC
Is premature. and abnormal In size. shape. or
d ~ectlon; onen 10lJId hidden In preceding T wave .
distorting the T wave contour
PR Interval: Absentwtth nonconducted PAC
QRS compllll: Absentwtth rxn:onducted PIC,

!lCClJ'

Iollowlng a paJSe In the

in the preceding T wave. distorting the T-wave contour

(Figure 7-15). and the pause that follows is usually noncompensatory. The nonconducted PAC is th~ most common cause of unexpected piluses ina regular sinus rhythm.
The nonconduded PAC can be confused ....;th sinus
arrest or block (especially if the P wave of the PAC occurs
~drly ~JluuKl'

lu

b~ hj<.l<.l~"

ill

Ih~ I'",~~<.li"l!

WdV~).

All

three produce a sudden pause in the rhythm without QRS

complexes. To differentiate between these rhythms, one
must examine and compare T-wave contours (Figure 7-16).
The early, abnormal P wave of the nonconducted PAC will
distort the preceding T wave. In sinus arrest or sinus block.

No nconducted PAC

Figure 7- 15.
Rhythm:
Rata:
Pwaves:

93

Sinus rhythm with nonconducl9d premature atr1a1 contraction (PAC).

Basic rhythm regular. Irregular wlll1 nonconducted PACs
BasIc rhythm rata 88 beatstml1ute
Sl1us P WlMn wlII1 basic rhythm; P wave of nonconducted PAC Is premalu's. mnormal. and hkklen In the prec9CIlng T wave
(T wave Is taller and mOfS pol1led thM Ihos8 01 undertjlng rhythm.)
PfllnlllrYaI: 0.16 to 0.18 second (basic rhythm); not presenl with IIIIIICOOi:lJcted PAC
DRS compl8J.: 0.06 to 0.08 second (basic rhythm); nol present with nonconducted PAC.

Figure 7- 16. Dlfferentlallon of sinus alTllst or block from the nonconducted premature atrial contraction (PAC).
A Sinus arrest or blcx;k
1. Sudcloo pauoo In tho ba&1c rhythm
2. No Pwave present
3. T-WiJo/e contour occurring during pause remains unchalged
B Nonconducted PAC
1. Sudden paise In the basic rhythm
2. Abnormal. prema\u'8 Pwave present and oRen IolJId hidden In T wave
3. T-WiJo/9 contour OCCIITlng during pause will be different from the conloln of the basic rhythm.

94

Atrilll ll rrhythmi as

no P wave is produced and thf T-wave contour relTlllins

unchanged.
Noncoooucted PACs have the samf significance a.s conducted PACs and may be treated in thf SlIme manner.

Paroxysmal atrial tachycardia

Paroxysmal atrial tachycardia (PAT) (Figures 717 and
7- 18 and Box 7_4) originates in an ectopk pacernalcer
site in the atria producing a rapid, regular atrial rhythm
between 140 and 250 beab per minute. Atrial tachycardia

8017-4.
Atrial tachycardia: identifying ECG features
Rhythm:
Ratl:
P wa_:

lleglllar
140 kJ 250 beatsA'nlnute
Abnormal (commorly iDlted); usually Iidden in

preceding Twave, making T_ and P1m'!! appear

as 00II Wi'" ddection (T-P_); one P WlMI 10 tIEl!
CR) complex Iriess AV bkx:Ir. is present

lIsuaIIy not maasuraDie

QRS COIllplQl: NOfll'IaJ (0.10 saconCl or leSS)

PR InlIrYaI:

Figurt: 7-17. Paroxysmal atilal tachycardia.

Rhyttm:
~ular

Rill:

188 DIlatsll'nRlte

P wIIYn :

HIdden

PR intffYlI: Not mBaSll"llllle

QRS compI.x: 0.00 to 0.08 secona.

Figure 7-18. Normal sinus rhythm wlUl premature atrial contraction (PAC) and btwSt 01 paroxysmal atrial tachycardia {pAT}.
Rhythm:
Basic rhy1!1m regu~ IrregtU w1th PH: and lust 0/ PAT
Rata :
Basic rhy1!1m rate 94 beatsA'nlnute; PAT rate 167 beals/minute
P waYIII :
~us P waves w1th basic rhythm: premature, pOOIBd P waves wI1h PAC and PAT (P waves ;J"e supef1mposed on preceding

TwaYes.)
PR tntllrYlI: 0.16 second
ORS compl8ll: 0.08 second
COmment:
Arun oIlhroe or

more con:sec:utlwl PIC!.Is conskIered PAT.

At rial flutter

is often precipitated by a PAC and commonly starts and

stops abruptly, occurring in bursts or paroxysms (thus the
name paroxysmal atrial tachycardia), By definition, three
or more con~cutive PAGs (at a rate of 140 to 250 beatsl
minute) is considered to be atrial tachycardia (Figure
7-18), This rhythm may be due to enhanced automaticily uf dlridl pi1\;erndkn ldb, r!:luUill!! ill rdvi~ firin!! of 411
e\:topic atrial focus, or to an atrial reentry circuit in which
an impulse travels rapidly and repeatedly around a circular
pathway in the atria,
The P waves associated ",ith atrial tachycardia are
abnormal (commonly pointed), but may be difficult to
identify because they're usually hidden in the preceding
T wave (the T wave and P wave appear as one ddled:ion
called the T-P wave), One P wave precedes each QRS complex, unless AV block is present. The PR interval is usually
not measurable, The duration of the QRS complex is normaL Atrial tachycardia is characterized by regular, narrow
QRS complexes, occurring at a rate of 140 to 250 beats per
minute, and ~parated by the T- P wave,
Atrial tachycardia may occur in people with healthy
hearts as well as those with diseased hearts , Atrial tachycardia has been associated with ingestion of substances such
as caffeine, alcohol, or tobacco: anxiety; hyperth}Toidism:
use of drugs such as albuterol or theophylline: mitral valve
disease; chronic obstructive pulmonary disease: and digit"li~ loxicity.
During an epi50de of atrial tachycardia, many individuals can feel the palpitations (rapid heart rate), and this is
a source of anxiety. When the ventricular rate is rapid . the
ventricles are unable to fill completely during diastole.
resulting in a significant reduction in cardiac output. In
addition, a rapid heart rate increasel; myocardial oxygen
requirements and cardiac workload. Treatment of atrial
ta,hycardia is dire, ted toward ,ontrolling the wntri,ular
rate and converting the rhythm .
Priorities of treatment depend on the patient's tolerance of the rhythm . Cardioversion (synchronized electrical shock) is the initial treatment of choice in patients
whose condition is unstable (patient is symptomatic
with low blood pressure; cool, clammy skin; complains
of chest pain or dyspnea ; and exhibits signs of heart failure) . If the patient's condition is stable, sedation alone
may terminate the rhythm or slow the rate. If sedation
is unsuccessful, vagal maneuvers may terminate some
episodes of PAT. Vagal maneuvers work by slowing the
heart rate through increasing parasympathetic tone.
Vagal maneuvers include coughing, bearing down (the
Va/salva maneuver), squatting, breath-holding, carotid
~in". [lre... "r .... dimlll" tion of th ... gag reflex, ,,"d imm ... r_
sion of the face in ice water. If vagal maneuvers fail.
administer a 6-mg bolus of adenosine N rapidly over I
to 2 seconds. followed by a rapid 10-mL flush of saline. If
the initial dose is ineffective after 2 minutes, administer a
12-mg bolus of adenosine N rapidly over 1 to 2 seconds,
followed by a rapid I O-mL flu~h of Mline. If Ihe se~ond

95

dose is ineffective after 2 minutes. repeat a 12-mg dose of

adenosine in the same manner.
If the patient doesn't respond to vagal maneuvers or to
the administration of three doses of adenosine. attempt rate
control using a calcium channel blocker (such as d iltiazem)
or a beta blocker. These drugs act primarily on nodal tissue.
either lu ~Iuw lhe Vl:lIlri~uI4r Tt:lpUIl:.t: by blulkill!! lOllduction through the AV node or to terminate the reentry
mechanism that depends on conduction through the AV
node . In the setting of significantly impaired left ventricu lar (LV) function (clinical evidence of congestive heart failure or moderately to severely reduced LV ejection fraction),
caution should be exerci~d in administering drugs with
negative inotropic effects. These include beta blockers and
calcium channel blockers, with the exception of diltiazem
(a calcium channel blocker that exhibits less depression of
contractility when compared with similar drugs) .
When AV nodal agents are unsuccessful, cardioversion
should be used to terminate the rhythm. Once the rhythm
is terminated . antiarrhythmics may be effective in controlling the rhythm . Radiofn:quency catheter ablation of
the e\:topic focus or reentry circuit is successful in many
ca~s.

Atrial flutter
AtTi,,1 flnlter (Fi~ur~_~ 7_19 thm,,~h 7_22 ~od Box 7_S)
originates in an ectopic pacemaker site in the atria typi cally depolarizing at a rate between 250 and 400 beats per
minute (the ave rage rate is around 300 beats per minute) .
The atrial muscles respond to this rapid stimulation by
producing waveforms that resemble the teeth of a saw.
The sawtooth waveforms are called flutter waves (F waves) .
The typical atrial flutter wave consists of an initial negative
component followed by a positive component producing
V-shaped waveforms with a sawtooth appearance . The flut ter waves affe\:t the whole baseline to such a degree that
there is no isoelectric line betv,'een the F waves, and the
T wave is partially or completely obscu red by the flutter
waves. Atrial tlutter is primarily recognized by this sawtooth baseline. The PR interval is not measurable. The QRS
complexes are normal.
BOI 7- 5.

Atrial nutter: Identifying ECG features

Rhythm :
Ram :

Regular or nogulll" (depends on AV conduction

ratios)
Atrial rate: 250 to 400 beatslmlruto
Ventrtculll" rate: VlI"les wtth number 01 Impulses
conducted ltTough AV node (WIll be less tIW1 the
atrial rate)

P waves:

sawtooth deflecUons called tkJtter waves (F waves)

aI1ecUng enure baseline
Pfllnlorval: Not measurable
OflS complu.: Normal (0.10 second or less)

96

Atrial arrhythmias

figure 1-19. Atrial nutter with 4:1 AV ronducUon.

Rhythm:
Regula"
Rail:
Atr1aJ: 428 beats/mlnuto
Yenlr1cula": 107 bealslmmte
Not8: 11 tho ventricular rate Is regular. mulUply tho rumber 01 nutler waves before each DRS x tho ventrlcula" rate 10 delermine alr1a1 rals.
P waves:
Four nutter waves belore each DRS (marked as F waves alloYs)
PIllnllml: No1 measuable
QRS

complex: 0.06 to 0.08 second.

Figure 7- 20. Atrial nultorwllh variable AY conducllon.

Rhythm:
Irregular
Rale:
Atr1aJ: 250 bealslmlnuts
Yenlr1cula": 60 beals/minute
Not8: II tho ventricular rate Is Irregular. COU11lhs number 01 nutter waves In a 6-secooo slr1p lIld mulUply x 10 to obtain
atrial rate.
I' WavYIi:

Fluller W'dVW berUlllllild1 DRS (ViI' ylng I~llu~)

PIllnllrval:

No1 measuable

QRS

complelt 0.08 second.

\','hile the atria can tolerate the extremely high heart

rate reasonably well, the 10,,",'l:r chambers (wntricles) cannot. Fortunately. the AV node is present to slow down
and diminish the number of impulses that pass through
to the wntricles. The AV node conducts the impulses in
various ratios. For example. the AV node might allow every
second impulse to travel through the AV junction to the
wntricles. resulting in a 2:1 AV conduction ratio (a 2:1
conduction ratio indicates that for every two flutter waves,

only one is followed by a QRS complex). Even ratios (2:1.

4:1 ) are more common than odd ratios (3:1, 5:1). If the
conduction ratio remains constant (2:1 ). the ventricular
rhythm will be regular. and the rhythm is described as
atrial flutter with 2:1 conduction. If the conduction ratio
varies (from 4:1 to 2:1 to 6:1 ). the ventricular rhythm will
be irregular. and the rhythm is described as atrial Hutter
with variable AV conduction. Conduction ratios are shown
in Figures 7-19 and 7-20. In atrial flutter, the ventricular

Atrial flutter

97

B
Figure 7- 21 . COmpar1son of alr1a1 nuttarwlth 2:1 AV conducUon and paroxysmal alr1a1 tachycardia (pAT).
Example A.The rhythm shoWs PAT. This str~ shoWs the T-P W3VO (the T .on:! Pwaves appell' as one denectlon). An IsoolecIrIc line Is present after 1118 T-P wave.
Example B. The rhythm shows atrial fkJIIer with 2:1 AV conduction. This strip shows two nutter (sawtoo1l1) waves belOfa each
ORS complex. There Is no Isoolectrk: line.

HR - 149

Figure 7-22.

50 JOULES

ClI'dloverslon 01 atrial nutter wl1I12:1 alrloYenlrtculll' conduction 10 normal sinus rhythm using 50 joules electrical energy.

rate is slower than the atrial rat~. with th~ rale depending
on the number of impul.u conduded through the AV node
10 the wntricles.
Becaus~atrial flutlerusually occurs at a rale of300beats
per minute and the AV node usually blocks at least half of

the5\: impulses. a ventricular rale of 150 beats per minute

is common (a 2:1 AV condudion ratiol. Atrial flutter with

2:1 AV condudion may be difficult 10 differentiate from

atrial tachycardia. especially if the heart rate in both
rhythms is 150 b~ats per minute. Th~se tv.o arrhythmias

98

Atrilll llrrh)'thmias

tan be differentiated by closely examining the baseline.

In atrial tachycardia. an isoeledric line can usually be
$een. whereas in atrial flutter the isoelectric line is absent.
A comparison of atrilll flutter with 2:1 AV conduction and
PAT is shown in Figure 1- 2l.
Atrial flutte r is rarely seen in people with a normal
htart. This arrhythmia most often occun in patients with
mitral or tricuspid vall.-e disea$e. Atrial flutter is common
af\:er ca rdiac surgery. It may also occur in isdlemic heart
disease. pulmol'l1lry embolism. and in alcohol intoxication.
Like PAT. the wntricular rate in atrial flutter may be
rapid. increasing my()(ardial ollYllen requirements and tardi.x: workload and decreasing cardiac output. In addition.
the atria do not contract strongly enough to empty all the
blood from the atrial (hambers into the ventricles. This
rtsults in a loss of the atrial kick, ....t.ich further decreases
cardiac output. Over time some blood in the at ria may
stagnate and mural thrombi (clots in the atrial chambt-rs)
may form. Pieces of the clot may break off. leading to a risk
of systemic or pulmonary emboli.
Prioritiu of trtatment include controlling the wntricubr rate. assessing anticoagulation needs. and restoring
sinus rhythm. As with PAT, controlling the ventricular rate
should be attempted first using a calcium channel bl()(ker.
such as diltiazem, or a bt-ta bl()(ker. using caution in thost
patients with impaired left ventricular function. Before
attempting conversion of the rhythm, it's essential to know
the approximate onsel of the arrh}thmia. If atrial flutte r
has been present for less than 48 hours, it's safe to convert the i'h)'thmwith cardioversion or lIIlliodarone, If atrial
flulter has betn present for mort lhan 48 hours (o r the
onset is unknown), pulmonary or systemic embolization

with conversion to sinus rhythm is a risk unless the

patient has been adequately anticoagulated. In this siluation. attempl$ 10 convert the rhythm with cardioversion
or an antiarrhythmic should be delayed until the patient is
adequately anticoagulated.
One method of anticoagulation involves placing the
patient on an oral anticoagulant at home for several weeks.
then itdmitting the patient tothe hospital for a tnnsesophageal echocardiogram (TEE). If the TEE is negative for atrial
clots, the patient can safely have the rhythm electrically cardioverted, The palient is then discharged home on an oral
anticoagu lant for several more weeks. Some physicians prefer a quicke r approach, using IV heparin or subcutaneous
enoxaparin (Ulvenox) or datteparin (Fragmin) in a hospital
setting, If the TEE is negative for mural thrombi. c:ardioversion may be attempted .....ithin 24 hours. The patient is discharged home on an oral anticoagulant for several weeks,
Unstable atrial flutter should be treated immediately
with cardioversion, regardless of the duration of the
arrhythmia, Figure 7-22 is an example of atrial flutter conwrting to sinus rhythm after cardioversion
Antiarrhythmics art useful in maintaining sinus rhythm
after conversion. RadiofTequency catheter ablation of the
flutter reentry drcuit is becoming the treatment of choice
for chronic or recurrent atrial flutter.

Atrial fibrillation
Atrial fibrillation (Figures 7-23 through 7-26 and Box
7-6) is a rapid and highly il'Tegular heart rhythm caused
by chaotic electrical impulses that arise from an ectopic
site in the atria. depolarizing at a rate greater than

Figure 7- 23. Atrlat nbfltlatlon (controtl9d rata).

Rllyttlm:

mgutar

Rate:

\lenlr1cu1a' rate 70 beals'mhJte

P WI....S:
AbI1tta!JJry waws present
PR Interval: N<rt meastnble
ORS complu: 0,04 to 0,00 second

com""n1:

ST-sogment ~ssIoo and T-waY!! hYerslon all present.

Atrial fibrillation

99

Rgurl 7 24. Alml fIbI1lalion (UncontlOli8d rale).

Rhythm:
Rate:
P waves:
PR IntamI:

negular
Yentr1cu1lV rate 130 beatslTnlr'llte
FI>r1Ilatory waves present
No! measurable

QRS compl8l: 0.06 to 0.08 seconc:l

COInn.nt
ST-segment depression Is present.

Rgure 7 25. A111a1l'b1la1lonwltfll WiMS so small they appear tel be almost a nat line between ORS complexes.

Rgure 7 26. Cll'dkMnlm of alr1al flbrlllalion kJ sinus ItlyUlm; ):n:IIonaI escape beat (discussed ~ ~tar 8) Iollows 1118 initial slrus Ileat.

100

Atrial arrhyt hmias

BOI7-6,
Atrial ftbrtllatlon: Identifying ECG features

Rllylllnt

~ossly

n9tJll<r (Ulless the ventrlcul<r rata Is wry

rapid. n wt1k:tI case the rhythm becomes more

rliQula/)
AtrIal rate: 400 b9alsltr*lule or me; not measu'able on sur1acl! ECG
Venlr1C1.J1a" rale: Va1es with numbel' of mpulses
coooucted hough AV node to the WIlb1c1es (WI be
leSS InaIl the alrlal rate)
P_
:
mlgula' W3'II! def\eclions called nbrlllal:ory waws
~ waves) aftecUng de baseline
PR ~t.ml: Not meaualie
(IRS OOmpillC Hmnal (0.1 0 serond or leSS)
Raw:

400 beats per minute. The mechanism of this rhythm is

most likely multiple reentry circuits in the atria. These
impulses are so rapid that they cause the atria to quiver
instead of contract nguiarly, producing irngular. WiNy
deflections. 1llese wave deflections are called fibn'lfalory
U11V1!'S (f WiNes). If the "''aVes art large, they'rt describtd
as coarse fibrilfotory waves and if small they're called fine
fibrilfalorgU11ves. Sometimes the fwaves are so small they
IIppear to be IIlmost II I1l1t line bet.....een the QRS complexes
(Figure 725). As in atrial flutter. the .....avy deflections seen
in atria l fibrillation aifed the whole baseline. Flutter waves
lire sometimes seen mixed with the fibriJ1atory waves. This
mi:.:ed rhythm is oommonly called atrial fib..flutter. mean
ing the bask rhythm is atrial fibrillation with some flutter
w.wes present. In atrial lib, an actual atrial rate is not measurable. The PR interval is also not measurable. The QRS
duration is nonnal. Because the atrial impulses occur very
irngularly. the ventricular response will be irregular also.
As in atrial flutter. the AV node block5 most of the
impulses from entering the ventricles. thus protecting
the ventricles from exctssive rates. The ventricular rate
is slo..... er than the atrial rate and depends on the number
of impulses conducted through the AV node to the ventricles. When the ventricular rate is less than 100 beilb per
minute. the rhythm is called controlled atrial fibrillation.
'Nhen the ventricular rate is greater than 100 beats per
minute. the rhythm is called uncontrolled atrial fibrillation or atriallibrillation with a rap id ventricular response.
Atrial fibrillation is primarily recognized by the wavy baseline and the grossly irregular ventricular rhythm (Figure
723). lf the ventricular rate is very rapid. the ventricular
rhythm becomes somewhat more regular (Figure 724 ).
Atrial fibrillation is the most common rhythm seen nat
to sinus rhythm. Atrial fibrillation can occur in healthy

individuals or in those with heart disease. In healthy

individuals, the rhythm is usually temporary and may be
associated with emotional stress or excessive alcohol con
sumpti on ("holiday heart 5)'ndrome~). In many patients
this type of atrial fibrillation spontaneously reverts to sinus
rhythm or is easily converted with drug therapy alone.
Other conditions commonly auociated with atrial fibrilla
tion include coronary artery disease. hypertension. valvu
lar heart disease, conge$tive heart failure. and pu lmonary
disease. It is also common after cardiac surgery.
The clinical consequences of atrial fibrillation are simi
lar to those of atrial flutter. The ventricular rate may be
rapid, increasing myocardial oxygen demands and cardiac
workload and decreasing cardiac output. Because the atria
quiver rather than contract effectively. the atrial kick i5
lost, which can further reduce cardiac output. Decreased
cardiac output is especially marked in patients with under
lying cardiac illlP"irment and in the elderly. who appear to
be mort dependent on atria l contraction for filling of the
ventricles. The non contracting atria cause blood to pool in
the atrial chambers. increasing the potential for thrombus
fOrmlltion. Dislodgment oi at rial clots may lead to pulmonary or systemic embolization.
Treatment of atrial fibrillation includes oontrolling
the heart rate, providing anticoagulation as a prophylaxis
for thromboembolism. and retu rning the atria to a sinus
rhythm. The treatment protocols for atrial fibrillation are
the s.ame as those for atrial ftutter. Rate control should be
achieved first. using a calcium channel blocker, such as
diltiaum. or a beta blocker. Use caution in those patients
with impaired left ventricular function . If the rhythm i5
less than 48 hooTS old. cardioversion or an antiarrhyth
mic. such as amio<larone, can be used in an attempt to
restore the rhythm to a sinus rhythm. If atrial fibrilla
tion has been present for more than 48 hours, the patient
must be adequately an ticoagu lated (refer to anticoagulation protocols for atrial flutter) before attempts are
made to restore sinus rhythm using cardioversion or an
antiarrhythmic. Unstable atrial fibrillation should be cardioverted immediately. regardless of the duration of the
arrhythmia. Patients with chronic atrial fibrillation (pre.
sent for months or years) may not convert to sinus rhythm
with any therapy. Tnatment of these patients should be
directed at controlling the ventricula r rate and providing
anticoagulation. An option to medication therapy is radio
ofrequency catheter ablation. which has been associated
with a high success rate.
Ca rdioversion of atrial fibrillation to a sinus rhythm is
shown in Figure 726. A summary of the identifying ECG
features of atrial arrhythmias can be found in Table 71.

Atria l fibrill ation

TablI7-1.

U_ """""

...Nom.-...

P wave wociated will PAC

is premature and abnormal
il allII.1Ihape. 01' direction

UuIy normal. boA

may be abnormal; IIDI
IllIIIIInbIe if hidden

lkJ'ab(1l.10
S&COIId or 1a5s)

(commonly ~I, ~lltld

panted; IIIII'f be ilwrt!!d);
commonlybn:f hidden il
preceding Twaw. dislorting
T-wave conlDUr

In preceding T \YaWl

Atlial arrhythmias: Summary of Identifying ECG features

"n

"""m

Rata (bnlslmlnutt) P WI_ (IncI11)

W...seringlltrill

RegIA.OI' iTegular

Normal (60-100)01'

""""""

"""","

Premahxe aflat
"..,.,....

Buit rflrthm usuallt

Thai of basic Itrjtlm

regular; irregular with

premalln atrial

CClIWIC1ion \PAC)

-~""
premalul'll atrill

~-

Basic rf?t1hm usualtt

That of basic Itrjtlm

regular; irregular with

""""""'" PM;

'0'

PR

~lIml

---

'hIy in ~. npe. and ctnclion: 0I'III PWlMI precedes

<1n1ion. wt may be
ed1 QRS CIlIIIJMl
Ing on dlanging
pilcemaker location

Premalln P _e that is
atrJormai il sim. shape. 01'
di"ection; commonly kM1d il
preceding Twaw. distorting

AbiseIt with norcort-

....,PAC

(O.10S&COlldor

"",

Pmnalne: oonnll

-..,
""""""'" PM;

T-wave conbJr

ParmysmaI atill

t\lI::hyellrdi. (PAl)

"".w

140-250

AOOormal P wa't'e (commoNy

panted~ usually hidden il
tntt<Ilng Twaw SO thaI
T and P _
appear as one
'NaW defleeton (T -P _I;
one P WlWlIO fIlCh ORS
complex uressAV block is

UuIy IIDI rneasurabIII

Nom(O.10S&COlldor

"'"

.AnaI'utter

ReglAar 01' iTegular

(depencIt on abi<MtltriclAar [AW) conduclion reIiat)

Atrial: 250-400
Sawtooth deleclioro .ffdlg
V1tieu11t: 'Ia'iII with entire IlIRMe
number of impulses

Not measu'able

Nom.

(O.10.teeOnd or

"'"

~fvoL9:1AV

node (wi. be las !han

niall1.le)

Anal fibrillation

=_. . .
Gross/y~r

(unless wmicular
rate is rapid. in which
m~_

Atrial: 400 01' more

(can" be cotnted)
Ventricular: 'I3ias with

number of impulses
~fInIlqlAV

node (wiI be less than

a1rial11.\e; controlled if
ram < loo.lrICOO.oIled if > 100)

Wavy de~ections affecting

entire baseline

Nol meastl'able

""""
(O. IOsecoodor

"'"

102

Atrial arrhythmias

Rhythm strip practice: Atria] arrhythmias

Analyze the following rhythm st r ips by following the five
basic steps:
Determine rhythm regularity.
Calculate heart rate. (This usually refers tothe ventricular
rate but. it the atrial rate dirrers, you need to calculate both.)
Identify and examine P waves.

Measure the PR interval

Measure the QRS co mplex.
Interpret the rhythm by comparing this data with the
ECG characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unless otherwise noted . Check your
ansVt'ers with the answer key in the appendix.

Strip 7-1 . Rhythm: _ _ _ __ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ __ _ _

ORS cornplell:_ _ _ _ _ __

Rhythm inlerp'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-2. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerp'etation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strlp 1- 3. Rhythm: _ _ _ _ _ _ _ _ _ Aate: _ _ _ _ _ _ __

PR Inrerwl:

103

Pwave: _ _ _ _ __

aIlS complelC' _ _ _ _ _ __

Rhythm interpmtallon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-4. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

Pwave: _ _ _ _ __

OAS complex:, _ _ _ _ __

Rhythm Interpretatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-5. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
~ythrnint~~~on :

Pwave: _ _ _ _ __

OAS complex:, _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

104

Atri lll lllThythmills

Strip H .Rhythrn: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR inleMl:

ORS complex;,_ _ _ _ __

FIlythm interpnlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-7. Rhythrn: _ _ _ _ _ _ _ _ _ ..,,, _ _ _ _ _ _ _ _ PW8'o'11: _ _ _ _ __

PR inllMVaI:

DRS complex:_ _ _ __

FIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-8. FI!ytIwn: _ _ _ _ _ _ _ _ _

PR Inte!val:

R".' ________

PW8'o'11: _ _ _ _ __

DRS cornpleJ::_ _ _ _ __

IIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strip 7- 9. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
~~im~i~

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ _~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-10. ~ythm : _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR imetval:

105

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ _~

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-11 . ~ythm :

_ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Int&rVai:

Pwave: _ _ _ _ __

QRS comple)(: _ _ _ _ _ _~

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

106

Atrial arrhythmillS

Strip 7-t2. Rt!ythm: _ _ _ _ _ _ _ _

PR ilterval:

R"" _______

Pwave: _ _ _ _ __

ORS wmpieJ::,_ _ _ _ __

Rtlythm InterpRtation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-13. Rhythm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwave: _ _ _ _ __

PR ilterval:
QRS oompleJ::_ _ _ _ __
Rhyttlm Interptetaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-14. Rhythm: _ _ _ _ _ _ _ _ _

R"'" ________

Pwave: _ _ _ _ __

PR ilterval:
ORS compleJ::c_ _ _ _ __
RbyItm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strlp7-15Rfltthn: _ _ _ _ _ _ _ _ """ _ _ _ _ _ __

PR interwl:

107

Pwave: _ _ _ _ __

CIRS romplelC _ _ _ _ _ __

~I~~~ _ _ _- - - - - - - - - - - - - - - - - - - -

strlp7-16. Ahythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

Pwave: _ _ _ _ __

I'fI inteN3l:
ORScompleic_ _ _ _ __
Rhythm IntlfP(etatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7- 17. Ahythm: _ _ _ _ _ _ _ _ _ ... _ _ _ _ _ _ __

PlIiI1erval:
~~mOCn

Pwave: _ _ _ _ __

ORScompleic_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

108

Atrial arrhythmias

Strip 1-18. ff1yttrn: _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS cornplex: _ _ _ _ __
Rhythm Interpntalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-19. RIIytt'rn: _ _ _ _ _ _ _ _

R"" _______

PwaYe: _ _ _ _ __

PR merval:
ORS cornpleJ.:_ _ _ _ __
Rllylhm Interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-2D. Rhythm: _ _ _ _ _ _ _ _ _

R"'" ________

Pwave: _ _ _ _ _ __

PR i1terval:
ORS cornplex:_ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Alrilll arrhytlunill$

109

Strip1-21 . Flhrthm: _ _ _ _ _ _ _ _ _ ""' _ _ _ _ _ _ _~ PwaWl: _ _ _ _ _~

PR interval:
ORS complex:,_ _ _ _ __
Rhy1hm I nt8fpnlta t jon :,~_ _ __ __ _ _ __ _ _ _ __ _ _ _ _ __ _ __

Strip 1-22. RI'Iythm: _ _ _ _ _ _ _ _ _ "'" _ _ _ _ _ _ _~ Pwa ....: _ _ _ _ _~

PR intervai:
ORScomplex:,_ _ _ _ __
Rhy1hm lnteqntation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-23. RI'Irthm: _ _ _ _ _ _ _ _ _ _ " ,. _ _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR intervai:
Rhy1hm i nt~on:

ORScomp\el:,_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

110

Atrial arrhythmias

R'"' _ _ ______

PwaWl: _ _ _ _ __
Strip 7-24. AIIythm: _ _ _ _ _ _ _ __
PR marval:
ORS IXImplBx:_ _ _ _ __
Rllyttlm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-25. RIyttrn: _ _ _ _ _ _ _ _ ,.,,, _ _ _ _ _ __

PR rrterwl:

PwaWl: _ _ _ _ __

ORS compleX:_ _ _ _ __

RhytIlm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-26. Rhythm: _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ __

PwaWl: _ _ _ _ __

PR interval:
ORS complex:,_ _ _ _ _ __
Rbyttvn interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __

Rhythm strip pmctice: Atrial arrhythmias

III

Strip 7-27. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex: _ _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 7-28. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-29. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

11 2

Atrial arrhythmias

Strip 7-30. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-31 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-32. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS comple~ :- - - Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

113

Strip 7-33. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval :
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-34. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS compleK: _ _ _ _ _ __

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-35. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

114

Atrial arrhythmias

Strip 7-36. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-37. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS cornplex:_ _ _ _ _ __

Rhythm interpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-38. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
Rhythm interprlitaltJn:

ORS complex:_ _ _ _ _ __

Pwave: _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

11 5

Strip 7-39. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS complex: _ _ _ _ _ __

Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-40. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip1-41 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Interval:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

116

Atrial arrhythmias

Strip HZ. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PR marva!:
QRS cornplex:_ _ _ _ _ __
Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-43. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
QRS cornplell: _ _ _ _ _ __
Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-44. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
QRS cornplex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

11 7

Strip 7-45. Rhylhm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-46. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-47. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PH Interval:
QRS compleK: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

118

Atrial arrhythmias

Strip 7-48. Rhythm: _ _ _ _ _ _ _ _ _ ..., _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-49. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-50. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR Interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

SUip 7-51 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

119

Pwave: _ _ _ _ __

QAS CompIBl: _ _ _ _ _ __

Rhythm interprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-52. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QAS complex:_ _ _ _ _ __

Rhythm InterprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-53. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QAS complex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

120

Atrial arrhythmias

Strip 7-54. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip 7-55. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PA iltervai:

QRS complex:

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-56. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:

ORS cornplex:_ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

121

strip 7-57, Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR Interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-58, Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-59, Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

122

Atrial arrhythmias

Strip 7-GO. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex: _ _ _ _ _ __

Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-61 . Rhythrn: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interYaI:

ORS complex:_ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-62. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS cornplex:_ _ _ _ _ __

Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strip 1-i3. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _~

123

Pwave: _ _ _ _ __

PR Interval:
QRS complex: _ _ _ _ _ _~
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-&4. Rhythm: _ _ _ _ _ _ _ _ _~ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ _~

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-65. Rhythm: _ _ _ _ _ _ _ _ _~ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ _~

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

12 4

Atrial arrhythmias

Sirip 7-66, Rhythm: _ _ _ _ _ _ _~ Rate: _ _ _ _ _ __

PR marva!:

QRS

Pwave: _ _ _ _ __

cornplex:_ _ _ _ _ __

Rhythm interpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-67, Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS cornplex:_ _ _ _ __

Rhythm Interpretatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-68, Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS cornplex:_ _ _ _ _ __

Rhythm Inlerpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

125

Strip 7-69. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

I'H Interval:

OKS complex: _ _ _ _ _ __

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-70. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-71. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

126

Atrial arrhythmias

Strip 7-72. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interY3l:
ORS complex:- - - Rhythm inlerpretaoon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-73. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PA i1terva1:
QRS complex:_ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-74. Rhythm: _ _ _ _ _ _ _ _ _ _ Ilale: _ _ _ _ _ _ _ __

PR rnerY3l:

Pwave: _ _ _ _ _ __

ORS cornplex:_ _ _ _ _ __

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

127

Strip7-75. Rhylhm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-76. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-77. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Interval:

Pwave: _ _ _ _ __

ORS compleK: _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

128

Atrial arrhythmias

Strip 7-7B. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-7 9. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PA interval:

Pwave: _ _ _ _ _ __

QRS complex:_ _ _ _ __

Rhythm inrerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-80. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

QRS

Pwave: _ _ _ _ _ __

complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

SUip 7-81 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

129

Pwave: _ _ _ _ __

PR interval:
QAS complsl: _ _ _ _ _ __
Rhythm intsrpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-82. Rhythm: _ _ _ _ _ _ _ _ _ _ Rats: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QAS complex:_ _ _ _ __
Rhythm interprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-83. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QAS complex:_ _ _ _ _ __
Rhythm Interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

13 0

Atrial arrhythmias

Strip 7-84. Rhythm: ~~~~~~~~_ Rate: ~~~~~~~~ Pwave: _ _ _ _ _ __

PR interval:

OIlS complex:_ _ _ _ _ __

Rhythm inlBrpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-85. Rhythm: ~~~~~~~~_ Rate: ~~~~~~~~ Pwave: _ _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm Inierpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-86. Rhythm: _~~~~~~~~~ Rate: ~~~~~~~~ Pwave: _ _ _ _ _ __

PR interval:

ORS cornplex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~

Rhythm strip practice: Atrial arrhythmias

Strip 7-87. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

131

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-88. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-89. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

132

Atrial arrhythmias

Strip 7-90. Rhythm: _ _ _ _ _ _ _ _ _ ..., _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-91. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
OIlS complex:_ _ _ _ _ __
Rhythm inlerpretamn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-92. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
OIlS cornplex:_ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strip 7-93. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

13 3

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-94. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-95. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __
Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

13 4

Atrial arrhythmias

II Skillbuilder practice
This section contains mixed sinus and atrial rhythm strips, allowing the student to practice differentiating between
two rhythm groups before progressing 10 a new group. As before, analyze the rhythm strips using the five-step process.
i nterepret the rhythm by comparing the data collected with the ECC characteristics for each rhythm . All strips are lead II.
a positive lead. unless otherwise noted . Check your answers with the answer key in the appendix .

Strip 7-96. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PR interval:

ORS C1IITIplex:_ _ _ _ __

Rhythm inlBrpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-97. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm Interprelamn:_ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-98. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

P wave: _ _ _ _ __

ORS complex: _ _ _ _ _ __

Rhythm Inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strip 7-99. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

135

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp7-tOO. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

S1rip7-101 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

136

Atrial arrhythmias

Strip 7-102. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PRinterval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 7-103. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-1D4. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Atrial arrhythmias

Strip 7- 105. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ __

PR Interval:

137

Pwave: _ _ _ _ _ __

QAS complex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip7-106. Pl1ythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QAS complex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip7-107. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR Interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Junctional arrhythmias
and AV blocks

Overview
The atrioventricular (AVl node is located in the lower
portion of the right atrium. The bundle of His conoects
the AV node to Ihe two bundle branches. Together, the AV
node and the bundle of His are called Ihe AV junction. The

AV node doesn't contain pocemaker cells. The main funelion of the AV node is to slow conduction 01 the electric.aJ
impulse through the AV node to allow the atria to contract

and complete tilling of the ventricles prio r to vt:ntricular

contraction. Pacemaker cells nearest the bundle of His in
the AV junction are responsible for secondary pacing func.

tion. Ar rhythmias originating in the AV junction are called

junctional rhythms (Figure 8- 1).

The inhertnt firing nle of the junctional pacemaker

celts is 40 to 60 beats pt r minute. A rhythm OCCUlTing
al this rate is called ajunetwool rhythm. Other rhythms
originating in the AV junctional area include prellUlture
junctionaJ contraclion./lCcelu atedjunc tional rhythm. and
junctional tachycardia.
When the AV junction is functioning as the pacemaker
of the heart. the electrical impulse produces a wave of

depolarization that spreads backward (retrograde) into the

atria as well as forward (antegradel into the ventricles. The
location of the Pwave relative to the QRS complex depends
on the speed of antegrade and retrograde conduction:
If the electrical impulse from the AV junction depolar
ius the atria first and then depolarizes the ventricles, the
P waw will be in front of the QRS complex.
If the electrical impulse from the AV junction depolar
izu the ventriclu first and then depolllrizes the atria, the
P Wil\'t ....ill bt alter the QRS complex.
If the electrical impulse from the AV junction depolarius both the atria and the ventriclu simultaneously, the P
wave will be hidden in the QRS compla.
Retrograde stimulation of the at ria is ju.st opposite
the direction of atrial depolarizat ion when normal sinus
rh}-1:hm is present and produces negative P waves (i nstead
of upright) in lead II (a positive lead). The PR interval is
short (0. 10 second or less). The ventricles are depolarized
normally. resulting in a normal duration QRS complex.
Identifying featu res of junctional rhythms are summarized
in Figure 8-2.

First-degree AV block
Second-degree AV block, MobilZ I
Second-degree AV block, Mobitz II
Third-degree AV block
Premature Junctional Contrilctlon
Junctional rhythm
AcceleraK'CI junctional rhythm

~J;:
' ~9

Junctional tachycardia

Figure 1 1. JIft:UOMI arrhylhmlas and AV bk:M;ks.

138

Premature junctional co ntrac tio n

139

lGad II

Lead II

LGadIl

P wav" belIOT"
ORS complex

P wave anar
ORSoompa..

P wave IIlc1dGn In
OAS C<ImJIIe.

Allure 8-2. kl9nlllylng leallXes 01 ~Ional

my."".

P waves ~'I8fte(Iln lead .

P waves WI ocrur In one 01 three panems:
- mm00la1l!iy be10re the QRS complex
- mmedla1l!iy after the ORS complex
- hldcJen WIthIn the 0ftS IXIITIpIeX.
PR Interval wtI be short (0.1 0 oocond or 11166).
ORS complex will be normal (0.10 sealfId or less).

8018-1.

Premature )mctlonal contraction (PJC):

Identifying ECG features
Allure 83, Pr&meture jUnctXlnaI CUlb'actlons ~I appear es a
sIngIB bealln

ollhe aboY81tree pattarns.

Premature junctional contraction

A premature junctional contraction (PJC) (Figures 8-3
through 8.8 and Box 81) is an early beat that originates
in an ectopic pac~maker site in the AV jUllCtion. Lik~ the
premature atrial contraction (PAC), the premature junc_
tional beat is characterized by a premature. abno rma l P
wave and a premature QRS complex lhars identical or similar to the QRS ,omplu of the normalJy conducted beats.
and is followtd by II pause tlmt is usually ooncompelUlltory. Some differences exist, however. beIY.'ten the two
premature beats. Because atrial depolarization occurs in

Fillure 8-4.
Rh,-lhm:

Lrldarlyhg rIlyIhm usually r~lar; Irragutar ~th

,.Ie
Rate:
Thal oIlhe \Ild9rIylng rtlyttvn
P w.wet:
Pwaves associated WIth the PJC WIll be premature.
IrMifted kllead I. n wi occur Immediately belore
It1a ORS CCfl1IIBX. Immedlalel~ aner thB ORS, or be
hidden wlltln the ORS
PH Intarra t
SI10rt (0.10 secmd or less)
QRS compln: Premature; fQ11lal duratlm (0.10 $&Com or less)
Rh,-lhm:

a retrograde fashion with the PJC, the P wave IUSOdated

with the premature beat ....ill be negative in lead II (a posi-

tive lead) . The inverted P waves ....ill occur immediately

before or after the QRS, or will be

Hormal sinus rhythm with one premature Junctional contraction (pJC).

Baslc rhy\tI1I regular, lmigular with PJC
Rate:
Baslc rtlyttvn rate 94 beaWmlnute
P waves:
Si-.us P waves with bask: rhythm; lnYerted P wave with PJC
PH InllfYaI: 0.1 4 to (l. 16 !IIICOIld (basic rhythm); 0.08 second (l'JC)
QRS complel: 0.08 secon:I
COIn""nt
ST-segment !lepresslor1ls present.

hidd~n

within the QRS

140

Ju nclionalllrrhYl hrnias lUld AV blocb

Figure 8-5. Normal sinus roythm with 0l1li Pl9lllabJrtI Junctional contmctlon (pJC).
RhyIIIm:
Basic rtr,1IVn regul; ~ with P.IC
Rift:
Basic rtr,1IVn rate 72 beatslmlrute
P W8U;
~us P waves wllI1 basic rflythm; merted P waYII alter PJC (4111 ORS CO!!IPIIlQ
PH ~ltml; 0.14 to 0.16 second (basic: rflythm); 0.06 to D.OS SIIIXIfId (PJC)
ORS comp...: 0.06 to 0.08 second (basic rIl:;1hm); 0.08 second (PJC)
comlll8n1;
AUwavelsJUSenl

Figure 8-S.

Normal sinus ltIythm with 0l1li premabJrtI Junctional contraction (PJC).

Basic rtr,1IVn regula";"'~ with P.IC
Basic rtr,1IVn rate 63 beatsfmlllJle; ralll slows to 56 beatstmDlle lolloWlng P.IC due to rate suppression (commm llIilowlng
a pause In 'he basic rIIyIhm)
P W8U;
Sinus Pwaves wllI1 basic rflyJhm; PWlVe assodalllcl with P.IC IS hldOOn In the CRS complllx
PH Inltml; 0.16 to 0.18 second (basic rflythm)
ORS comple x: 0.06 to 0.08 second (basic rIl:;1hm); 0.10 second (PJC)
comment;
AUwavelsJHSi!nl

......
,'...

complex. The PR interval will be mrt (O.10 5eCond or less).

Figure 8-4 shows a PJC with the P wave before the QRS
complex; Figure 8-5 shows a PJC with the P wave after Ih~
QRS complex;and in Figure8-6 the Pwave is hidden within
the QRS. PJCs are less common than PACs or premature
ventricular contractions (PVCs) (discussed in Chapter 9).
Inverted P waves in lead II may also occur with PACs
arising from the lower atria. but the associated PR inter
val is usually normal. If difficulty is encounte red in

differentiating PJCs from PACs. keep the following in

mind: PACs an much more common than PJCs. As a
result. narrow complex premature beats are more likely to
be PACs. A comparison of ectopic atrial beats and ectopic
junctional beats is shown in Figun 8-7. PJCs occur in addition to the underlying rhythm. They occur in the same pat.
terru as PACs; as asingle beat; in bigeminal, trigeminal, or
quadrigeminal patterns; or in pairs (Figure 8-8). A series of
thru or more consecutive junctional beats is considered

Premature junctional contraction

141

RlJure B-7. Normal sinus rhythm WIth two pramaturli atrtal contractions (PACs) (4th and 8th complaJ.as) and OIlQ Junctional
escape beat (5th complex)
Rhythm:
Regular (basic rhythm); Irregular with PACS and Junctional escape beat
Rate:
75 beatstmlnute (basic rhythm)
P waves:
Sl1us (basic rhythm); pointed P waves with PACS; Inverted P waves with Junctional escape beat
PR Interval: 0.14 second (basic rhythm); 0.12 second (PACs); 0.08 second gunctlonal escape beal)
DRS ~omplel: 0.08 to 0.10 second (basic rhythm. PACS.lIld):llctlonal escape beat).

a rhythm (junctional rhythm. accelerated junctional

rhythm. or junctional tachycardia). Differentiation of the
rhythm depends on the heart rate.
Like PACs, the premature junctional impulse may
(rarely) be conducted to the ventricles abnormally
(ilbemmtly). Thi.:! results in a wide QRS complex. A P]C
associated with a wide QRS complex is called a PJC
with aberrancy. indicating that conduction through the
ventricles is aberrant. Because of the wide QRS complex.
PJCs with aberrancy must be differentiated from PVCs.
Conditiof15 associated with PJCs include ingestion of
substances such as caffeine, alcohol, or tobacco: electrolyte

Agure 8-8.
Rhythm:
Rata:
P waves:
PR Inmal:
QRS ' III npl&~ :

imbalances; h}llOxia: congestive heart failure: coronary artery disease: and enhanced automaticity of the AV
junction caused by digitalis toxicity (the most common
cause). PJes may also occur without apparent cause.
Frequent PJCs are best treated by correcting the underlying CaU5e: decreasing or eliminating the cOf15umption
of caffeine. alcohol. or tobacco; correcting electrolyte
imbalances: administering oxygen; treating congestive
heart failure; and assessing digitalis levels. Frequent PJes
(more than 61minute) may precede the development of a
more serious junctional arrhythmia such as junctional
tachycardia.

Normal sinus rhythm with paired premature Junctional contractions (pJCs).

BasIc rhythm regular; Irregular loIlowhg paired PJCS
BasIc rhythm rate 100 beatslmlnute
Sl1us P waves wlll1 basic rhythm: Inverted P waves with PJCs
0.12 to 0.14 second (basic rhythm); 0.08 second \WIth PJCS)
0.06 to 0.08 S8&OIld (basic rIlythm and PJCs).

142

fi~ure

lun ctiollll l llrrh ythmills lind AV blocks

8-B.
Rhythm:
Aal.:

Normal sinus rhythm with a pause followed by a Junctional escape beat.

Bast rtTfIhm regul.Y; lrregul.Y \\11th escape Ileat
Bast rITfInm 60 tleats/mloole; rate sloWs to 45 Deats/minute alter es:ape Ileat (Aate suppression can occur folloWing any

pause In the baSiC rtTfIhm. Aller sewral cycles tile rale \\llIlIlIUn to the basIC rate.)
Sinus P waws \\11th basic rhythm; hklllen P wwe with escape boat
PRlntlrva l: 0.16second
OAS complu: 0.06 second
COmment:
ST-segment depresslon!llG a UWiNe am present.
P Wav.l:

O'C<!I5ionally. an ectopic jun,tional beat will occur late

instead of early. The late beat uSWllly occurs after a p.luse
in the underlying rhythm in which the dominant pacemaker (USWlJly the sinoatrial (SAl node) fails to initiate
an impulse. If t he ventricles are not activated by the SA.
node within a certain amount of time. a fows in the AV
junction may "escape" and pa,e Ihe heart. These are called
junctional escape beats (Figure 8-9).

Junctional rhythm
Junctional rhythm (Figures 8-1 0 through 8- 1311nd Box 8-2)
is an arrhythmia originating in the AV junction with a rate
between 40 and 60 beats per minute. Junctional rhythm is
the normal rh}1hm of the AV junction. Junctional rhythm
can occur under either of the following conditions:
The heart rate of the dominant pacemaker (usually
the SA. node) bewmes less than the heart rate of the AV
junction.

lead II

FigunI 8-10. JlJIC!IonaI rhythm will appear as a continuous

rtTfIhm al a rate 0140 to 60 beatsJrnlnulu In either 01 the aboYe
three patterns.

Boll 8-2.

Junctional rhythm: Identifying ECG features

Rhythm:
Ratl:

"""""

40 to 60 beats/mlnute
Inverted In lead II all(] OCCLl'S Immediately before
the ORS complex. Immediately alter the ORS
complex. or Is nkklen within tho QRS complex
Pfl lnllllrvat: Short (O.tO secood or less)
DRS complex: Normal (O.tO second or less)

PWlvn:

Electrical impulses from the SA. node or atria fail to

reach the ventricles because of sinus arrest. sinus exit
block. or third-degree AV block.
If the ventricles Me not a,tivated by the SA node or atria.
a focus in theAV junction can "escape" and pace the heart.
For this reason. junctional rhythm is commonly referred
to asjunctional escape rhythm.
Junctional rhythm is regular with oil heart rate between
40 and 60 beats per minute. The P waves are inverted in
lead II (a positive lead). and will occur immediately before
or after the QRS or will be hidden within the QRS complex.
The PR interval is short (0.10 second or less). The QRS
duration is norma1.1unctionaJ rhythm has the same characteristics as ao:eleratedjunctional rhythm and junctional
tachy<:ardia. This rhythm is differentiated from the other
junctional rhythms by the hea rt rate.
Junctional rhythm may be seen in acute myocardial
infarction (MI) (particularly inferior-wall MI) , increased
parasympathetic tone. disease of the SA node. and hypoxia.
It can also occur in patients taking digitalis, <:akium channel blockers. or beta blockers.

Accelcrtllcd JunctIo nal rhyth m

143

Agure 1-11 . Junctional rtlythm

Atlythm:

Regular

Rata:

50

PW8WS:

Hidden n ORS complex

PR Inl8rYal:

Not meastr.mle

beatsrm~ute

OAS compleX: 0.06 to 0.08 secm:I

&omrntnt
ST-segmentdepresslon Is present

The slow rate and loss of nol'ffiill atrial contraction

(atrial kick) secondary to retrograde atrial depolarization
may cause a decrease in cardiac output. Treatment for
symptomatic junctional rhythm inc ludes following the
protocols for significant bradycardia (atropine, pacing,
dopamine, or epinephrine infusions to increase blood pressure). Treatment should also be direded at identifying and
correcting the underlying cause of the rhythm if possible.
All medications should be revie\\led and discontinued if
indicated.

Agure 1-12. Junctional rtlythm .

Atlythm:
Rata:

Regular

33 bealslmJlute
P waY8S:
nwrted alter QRS complex
PR 111WmII: 0.08 to 0.10 second
OAS complex: 0.08 to 0.10 second.

Accelerated junctional rhythm

Al:celerated junctional rhythm (Figures 8--14 through
8-16 and Box 8-3) is an arrhythmia originating in the AV
junction with a rale between 60 and 100 beats per minute.
The term "acceleraled" denotes a rhythm that occurs at a
rate that exceeds the junctional escape rale of 40 to 60. bu t
isn't fast enough to be junctional tachycardia.
Accelerated junctional rhythm is regular wilh a heart
rate between 60 and 100 bfau per minute. The Pwaves are

144

Junctional arrhythmias a ndAV blocks

Figure 8-13, JuncUonal rhythm,

Rhythm:
Rali:

Regula'
35 beatslmll1Jle

P W3'l9S:

Inverted beroro tho ORS

0.06 to 0.08 second
QRS COmplel: 0.06 to 0.08 second.

PH Intlrval:

BOI8-3.

Accelerated Junctional rhythm: Identifying ECG

features
lead II

Rhythm:

FIIlU re 8-14. Acceleraled )jncUOnai rtlythm will appear as a

oootInuous rhylhm at a rale 0160 to 100 beatslmloote In any olllle
allow II1ree patterns.

Figure 8-1 5. Accelerated Junctional rhythm.

Rhythm:
Rale:

PW3'lH:

Regula'
65 beatslmlrute
Inverted before each ORS complex

P1Ilntlrval : 0.08100.10second
QRS oomplllx; 0.08 :illmlll
COmment:
ST-segment eleYatlon ~ Twavo Inversion am present

""".,

60 to 100 beats/minute
Inverted In lead II and occtn Immediately before
the ORS complex, immediately aner the ORS
complex, or Is hidden within the ORS complex
PH Interval: Sh:lrt (0.10 socond or less)
QRS complex; Normal (0.10 second or less)

Rate:
P wans:

Pa roxysm al junc tion al tach ycardia

145

Rgure 8-1&. Ac~grat9d Juncllonal rhythm .

Rhythm :
Regular
Ratl:
68 bilatslmlnuW
P waws:
Hidden In ORS complex
Pfllnl9rYaI: Not measurable
DRS complex: 0.06 to 0.08 second.

inverted in lead II (a positive lead). and will occur immediately before or after the QRS or will be hidden within
the QRS complex. The PR interval is short (0 .1 0 second
or less). The QRS duration is normal. Accelerated junctional rhythm has the same characteristics as junctional
rhythm and junctional tachycardia. This rhythm is differentiated from the othu junctional rhythms by the heart
rate. Accelerated junctional rhythm is not a common
arrhythmia.
Accelerated junctional rhythm may result from enhanced
automaticity of theAV junction caused by digitalis toxicity
(the most common came). Other causes include damage
to the AV junction from MI (usually inferior-wall MI). heart
failure . lInd electrolyte imbalances.
Usually the heart rate associated with accelerated junctional rhythm isn't a problem became it corresponds to
thai of the sinus node (60 to 100 beats per minute) . Problems are more likely to occur from the loss of the atrial
kick secondary to retrograde depolarization of the atria,
resulting in a reduction in cardiac output. Treatment is
directed at reversing the COtl..'iequences of reduced cardiac
output. if present. as well as identifying and correcting the
underlying cause of the rhythm. All medications should be
reviewed and discontinued if indicated.

Paroxysmal junctional tachycarcUa

Paroxysmal junctional tachycardia (PlT] (Figures 8-17 and
8-18 and Box 8-4) is an arrhythmia originating in the AV
junction with 11 heart rate exceeding 100 beats per minute.
Junctional tachycardia commonly starts and stops abruptly
(like paroxysmal atrial tachycardia] and is often precipi
tated by a premature junctional complex. Three or more
PJCs in a row at a rate exceeding 100 per minute constitute
a run of junctional tachycardia .

L" adll

Figure 9-17. Paroxysmal ).JncUonal tachycardia will appear as a

continuous rhythm at a rate exceeding 100 boatslmlnule In any 01
!he above IIlroe patterns.

Junctional tachycardia is regular with a heart rate

exceeding 100 beats per minute . The P waves are inverted
in lead II (a positive lead), and will occur immediately
before or after the QRS or will be hidden within the QRS
complex. The PR interval will be short (0.10 second or less).
The QRS duration is normal. Junctional tachycardia has
the same characteristics as junctional rhythm and accelerlIted junctional rhythm . This rhythm is differentiated from
the other junctional rhythms by the heMt rate. Junctional
tachycardia is not a common arrhythmia.

8018-4,

Paroxysmal Juncllonal tachycardia: Identifying

ECG features
Rhythm :
Rata :

",""

Greater than 100 boatslmlnule

P'MIYlS:
Inverted In lead II and OCClI'S Immediately belore
tho ORS complex. Immediately alter tho ORS complex. or IS hidden WIthin tile UKS complex
Pfllnlervat:
Short (0.1 0 second or less)
OIlS complex: Normal (0.10 second or less)

146

Junctional arrhythmias a ndAV blocks

Figure 8-18. Paroxysmal Junctional tachycardia.

Ahythnr.
Rale:

Regu~

115 beals'mlnute
Pwaves:
Inverted belore each CRS complex
Pfllntlrval: 0.08 second
QRS complll: 0.06 to 0.08 seCOl'Kl.

Junctionallachycardia may result from enhanced autoITUllicity of the AV junction caused by digitalis toxicity (the
most common cause). Olher causes include damage to the
AV junction from MI (usually inferior-wall MI ) and heart
failure.
Junctional tachycardia may lead to a decrease in cardiac
output related 10 the faster heart rate as well as the lo~
of the atrial kick s&ondary to retrograde depolarization
of the atria. Treatment is directed at re~rsing the consequences of reduced cardiac output. as well as identifying
and correcting the underlying cause of the rhythm. Symptomatic junctionol

tachy~~rdi~

m"}' respond to diltill.Zem.

beta blockers (use caution in patients with pulmonary

disease or heart f<lilure). or amiodarone.

AV heart blocks
The term heart block is used to describe arrhythmias in
which there is delayed conduction or failed conduction of
impulses through the AV node into the ~ntricles. Normally the AV node <lets as a bridge between the atria and
the ventricles. The PR interval is primilrily a measure of
conduction between the initial stimulation of the atria and
the initial stimulation of the ~ntricles. This measurement

that the PR interval is the key to identifying the type of

block present. The width of the QRS complex and the
ventricular rate are keys to differentiating the location
of the block (the lower the location of the block in the
conduction system. the wider the QRS complex and the
slower the ventricular rate ).
In first-degree AV block (the mildest form), the electrical impulses are delayed in the AV node longer than normill. but all impulses are conducted to the ventricles. In
second-degree AV block (type I and II). some impulses are
conducted to the ~ntricles and some are blocked. The
mo.t extrcme form ofhc;>.rt block i. third-degree AV bloc~.
in which no impulses are conducted from the atria to the
~ntricln. The clinkal signifiQme of an AV block depends
on the degree of block. the ~ntricular rate. and patient
response.
The ability to accurately diagnose AV blocks depends on
a systematic approach. The following steps are suggested:
Look for the P wave. Is there one P wave before each
QRS or more than one?
Measure the regulilTity of the atrial rhythm (the pop
interval) and the ventricular rhythm (the R-R interval).
Measure the PR interval. Is the PR interval consistent
or does it vary? Remember, the PR interval is the key to

i. norITllllly 0.12 to 0.20 ""cond.

identifying tho. type ofAV bled- present.

The site of pathology of theAV blocks may be at the level

of the AV node. the bundle of His. or Ihe bundle branches.
'Mten located at the level of the AV node or bundle of His,
the QRS complexes will be nonnal duration. The QRS complex will be wide if the site of pathology is located in the
bundle branches.
AV blocks are classified into first-degree. seconddegree (type I and 11). and third -degree. This classification system is based on the degree (type) of block and
the location of the block. It is important to remember

Look at the QRS complex. Is it narrow or wide?

First-degree AV block
In first-degree AV block (Figure 8-19 and Box 8-5), the
sinus impulse is normally conducted to the AV node.
where it's delayed longer than usual before being conducted to the ~ntricles. This delay in the AV node results
in a prolonged PR interval (> 0.20 second). This rhythm
is reflected on the ECG by a regular rhythm (both atrial

Second-degree AVblock, type 1 (Mo bitz 1 or Wenckebach)

147

Rgure 8-19. Sinus bradycardia With Ilrst-dagrgg AV block.

Rhythm :

Regular
48 bRats/mtnute
P waY8s:
Sllus P waves presen~ one P wave to each ORS complex
Pfllnl8rYaI: 0.28 to 0.32 second (remains constant)
QRS complex: 0.08 to 0.10 second
Noll:
A U wave Is present.
Rata:

and ventricular l, one P wave preceding each QRS complex,

a consistent but prolonged PR interval, and a narrow QRS
complex. Thi5 conduction disorder is located at the level
of the AV node (thus the narrow QRS complex) and isn't a
serious form of heart block.
The underlying sinus rh}thm is usually identified along
with theAV block when interpreting the rhythm (for exampie, normal sinus rhythm with first-degree AV block).
First-degree AV block may occur from ischemia or
injury to the AV node or junction secondary to acute !>II
(usually inferior-wall MI l. increased parasympathetic
(vagal ) tone, drug effects (beta blockers, calcium channel
blockers, digitalis, ilIlliodarone l, hyperkalemia, degeneration of the conduction pilthways associated with aging, and
unknown causes.
First-degree AV block produces no symptoms and
requires no treatment. Because first-degree heart block
can progress to a higher degree of AV block under cutain
conditions, the rhythm should continue to be monitored
until the blo;;k resolves or stabilil.es. Drugs causing AV
block should be revie",'e(] and discontinued if indicated.

BoI8-5.

First-degree AV block: Identifying ECG

features

Second-degree AV block, type I

(Mobitz I or Wenckebach)
Second-degree AV block, type I is commonly known
as !>Iobilz I or Wenckebach (for the early 20th century
physidan who discovered it) . This rhythm (Figures 8-20
through 8-23 and Box 8-6) is characterized by a failure of
some of the sinus impulses to be conducted to the ventricles. In !>Iobitz I, the sinu5 impulse is normally conducted
to the AV node, but each successive impulse has increasing difficulty passing through the AV node, until finally
an impulse does not pass through (isn't conducted ). This
rhythm is reflected on the ECG by P waves that occur at
regular intervals across the rhythm strip and PR intervals
that progressively lengthen from beat to beat until a P wave
appears that is not followed by a QRS complex, but instead
bya piluse. Themissing QRScomplex (dropped beat) causes

BOI 8-6.
Second~egree

Rhythm:
Rata :

Regular alrlal rhythm ; Irregular ventricular rhythm

Atrial: That of tho lJlCIorlyllg sinus rhythm
Ventrfcula': Vartes depending on number of Impulses conducted through AV node (will be less than
IhII alrlal rate)

P waY1lS :
PRlntervll:

Sllus

Rhythm:

Regular
ThaI 01 tho underlying slllls rhythm: both atrial
and vootrtculM rates will be tho same
P waves:
Sinus; one P w;Jo/e to each ORS complex
Pfl lnlerYaI:
Prolonged (> 0.20 second): remains consistent
QRS complex: Normal (0.10 second or less)
Rate:

AV block (Mobltz I): Identifying

ECG features

Varies; progressively lengthens until a P wave Isn1

conducted (P wave OCCII"S wlthoullho ORS complex); a pauselollows the !topped ORS complex

OIlS complex: Normal (0.10 second or less)

148

Juncliomli arrhyt hmias M d AV blocks

Fillure 8- 20. S8c0nd-degl'98 AV block, Mobttz I.

IIhrthm:
Rat.:

RegUI<r attIaIlhythm; ~eoular VM ..1cu1ar rhythm

AIrIaI: 72 beatslmlilJte
VIInlrlcula': 50 beatslmlnuls

P WlI'Its:

Sinus Pwaves present

PH Intlml:

ProgresstMy Ialglhensflllm 0.20 kI O.:ro sactnI

ORS compltx: 0.06 to 0.00 second

Noll:
ST -segment depression Is present

tht ventricular rhythm to be irregular. After each dropptd

beat the cycle repeats itself. The ovrrall a~arance of Ihe
rhythm demoru;trates group beating (groups 01 beats .separated by P,"Ull_) and is a dL~tinguishing characteristic of
J'.10bitz. I. Escape beats (atrial. junctional. or ventricular)
may occasionally oo::cur du ring the pause in the ventricular
rhythm. and may obscure the diagnosis because they interrupt Ihe group beating pattern (Figure 8-22 ). The location
of the conduction disturban<:e is at the level of the AV node
lind therefore the QRS complex will be narrow.

Fillure 8- 21 . S8c0nd-degl'98 AV block, Mobttz I.

IIhJlllm:

Regul<r ab1aIlflythm; In'eoular venn:ular rhythm

1Iat.:

AIr1aI: 75 beatslmlllJlB
Yenlrlcula': 60 beatslmlnuls

P Way":

Sinus Pwaves present

PH Intlml: Progr8SSlYely lengthens /rom 0.24 kl 0.38 SIICIIOO

ORS compltx: 0.08 second
comment:
Good OXiVllp!e 01 group beaUng.

Mobiu. I can be confused with the nonconducted PAC

(Figun 8-23). Both rhythms have episodes where P waves
are not followed by a QRS romplex. but instead by /I pau.'Se.
To differentiate Mm.een the two rhythrru, one must txlImine the configuration of the P waves and measure the pop
regularity. The nonconducted PAC will have an abnormal P
wave and will occur prematurely. In Mobiu. I. the P wave is
normal and occurs on schedule. nol prematurely.
Mobiu. , is common following acute inferior-wall MI
due to AV node ischemia. Other causes include increased

Second-degreeAV block, type 1 (Mobitz 1 or Wenckebach)

Flaure 8-22. Moblt2l WIth Junctional escape beal (during pause).

Rhythm:
Regular (basic rtr,'ttIm): Irregular <DIng pause
Rata:
Atrial (50 beatslmlnuie); vootrlrula' (48 boal slmlrule)
P W88S:
Sl'lus (basic rtr,'ttIm); hkldoo P WfWe wntl jl.l1CUOOal escape beat
Pft Interval: ProgesslY9ly tengthens from 0.20 10 0.24 second
QAS compiel: 0.04 to 0.06 second (bask: rhythm MIl )lfICtknllescape beaQ.

Pause I
rhythm
pop rEgularity I.IlCh~Bd (P wave occurs on lime)
P wave conIlguratlon same as $1M beats
PR Interval 01 basic rtlythm YllteS

rtr,'ttIm remains constant

Figure 8-23. DllTerentlalton 01 the nonconductad pl"BmabJ'e atrial cootractton from Mobitz I.

149

ISO

Junctio na l a rrhythmias a nd AV bl ocks

parasympathetic (vagal) tone. effects of medications

(digitalis. beta blockers...... Icium channd blockers). and
h~perkaJemia.. Mobitz I may also occur as a normal variant in athldes be ..... use of physiologic increase in vaga.!
tone. Mobitz I. under cutain conditions. 1m)" progress
to a higher degree of AV block. but generally this is oot
the case. This type of AV block is usually temporary and
rtsolves spontaneously.
Mobitz I is usually asymptomatic because the ventricular rate remains nearly normal and cardiac output
is usually not affected. If the vmtricular rale is slow and
the patient develops symptoms. protocob for symptomatic
bradycardia (atropine . external or trans venous pacing,
dopamine or epinephrine infusions 10 increase blood prtSsure) should be followed_ Conduction usually improves in
response to the administration of atropine. Drugs causing
AV block should be discontinued if indicaled.

Second-degree AVblock, type II

(Mobltz II)
"lobitz II (Figum 8-24 and 8-25 and Box 8-7), like Mobitz
I. ischaracterir.ed by a failure of some of the sinus impulses
to be conducted to the ventricles. There are differences,
no...~ver. in the location and severity of the conduction
disturbance. as well as in the ECC features. In Mobitz II,
there's mort than one P wave before each QRS complex
(usually two or three. but sometimes more) with only one
of the impulses being conducted to the ventricles. The
rh~1hm would be described as Mobitz II with 2:1. 3:1, or
4:1 AV conduction. Tht P waves are identical lind occur
regularly. In "1obitz 11 y,ith highH conduction ratios (3:1
or more), the P waves may be hidden in the ST segment

Fillure 8-24. SlIcorHHlegree AY block, Mobttz It

RhyII1m:
Regula' ab1aI an;! ven.-t:ulaf rhythm
Rate::

AlrIaI: 82 bealslmlllJlB
~n1r1cu1a': 41 beatslmnrte
p WIlY":
Two sinus P waves to each DRS complex
PH Intlrval: 0.16 SIIIXIIld (remains constant)
ORS complex: 0.1 4 second.

Box"1.
Second-degree AV block (Mobttz II): Identifying
ECG 1eabues
Rht1hm:

AtrIal: Regular
YIIlIrlcuIa': l8uaIy ~ IU: may bllrri9JlIIr "
AY~u~m~vru)

Rale:

Alrlat Tllal 0I1h8 uooertylng sms rhythm

Yenlrlcula-: Y\V1eS depending on numDer at
ImpOOes COfIIucItId Itrol1I1 AY node
lIIan the a1r1a1 mte)

cw- blless

P WI\IM:

stHJs; two or three P waws ($OJMIlmes more)

PR IntlrYaI:
DRS compleX:

bllcire BaCh ORS complex

May bll'I:lrITIai or prolor9Kt. remains consistent
Normal" bioc:t( IOCaItId at I8WII 0I1Xl1'ItIIII 01 HIS;
wide Wbloc:t( lacattld In tJurxlle branches

or T wave (Figure 8-25). The PR interval of the conducted

beat 1m)" be normal or prolonged. but remains c:oru;i~tent.
The vent ricular rhythm is usually regular unltss the AV
conduction ratio varies (alternating among 2:1. 3:1, and
4:1). The Ioc.a.tion of the conduction disturbance is below
the AV node in the bundlt of His or bundle brllnches. As II
result, the QRS complex may be narrow (if located in the
bundle of His) or wide (if located in the bundle branches).
The most common location is the bundle branches.
Mobitz II is usually associated with an anterior-walt MI
and. unli ke Mobitz J. is 001 the result 01 increastd vagal
tone or drug toxicity. Other causes include acute m)'OC<lrditis and degeneration of the electrical conduction system
seen in the elderly.
The patient's response to Mobilz II is usually rtlated to
the Yentricular rate. If the Yenlricu lar rale is within normal

Se<:ond-d egree AV bloc k, type II (Mobitz II)

lSI

Fillure 8-25. S9cond-dogra8 AV block, MobltZ II.

Rhythm:
Regul.Y atrial and venlrlcular rIlylhm
Rate:
AtrIal: 123 beatslmlllJle
Vlmtr1cul.Y: 41 beatslmlnule
P WlY8I:
Three SM Pwaves to BaCh QRS complex
PR Intern~ 0.24 to 0.26 second (remains constant)
IlfIS oornplllx: 0.12 second.

limits (rare). the patient may be asymptomatic. More commonly. the ventricular rate is extremely slow, cardiac output is decreased. and symptoms are present (hypotension.
shortness of breath. heart failure. chest pain. or syncope).
The syncopal episodes (called Slokes-Adams attacks or
Stokes-Adams syncope) are caused by a sudden slowing or
stopping of the heartbeat.
Mobilz II is less common but more serious than Mobitz I.
Mobitz II has the potential to progress suddenly to thirddegree AV block or ventricular standstill (asystole) with

little or no warning. Treatment is required immediately

for symptomatic Mobitz II and for asymptomatic Mobitz
II with wide QRS complexes in the setting of acute anterior-wall MI. An external pacemaker should be applied
"'nile preparations are made for insertion of a temporary
trall5venous pacemaker. Atropine is usually not effectivt in
reversing Mobitz. II second-degree AV block and mayactu ally worsen the conduction disturbance. A dopamine infusion may be used to increase blood pressure. Unresolvtd
Mobitz II will require II permanent pacemaker.

Rgufll 8-26. Mobltz 1. This strtp shows a typical Weockebach pattern durtng the nrst part of the strtp changing to a 2:1
oonduclJon rallo alllM! and ofllM! strtp. Evon though 2:1 conducllon Is saan (common wllh MobltZ II), 1119 prasallCQ 01 a Wanckabach
pattern conllrms tIM! diagnosis 01 Mobltz I.
Rhythm :
Atrial (regular); ventricular (Irregular)
Rate:
Atrial (100 beatstmlnute); ventriculii' (60 bealstmlnute)
P wallS:
Sl1us
Pfllnl9rYaI: ProgesslYely lengthens from 0.24 to 0.36 second
DRS complOJ : 0.06 to 0.08 socond.

152

Junctional arrhythmia s a nd AV blocks

A comment about 2:1 conduction: A 2:1 conduction

ratio is common with Mobitz II (jv,'o P waves to one QRS
complex). A 2:1 conduction ratio may also occasionally
occur with !>Iobitz I. In Mobitz I with 2:1 conduction. every
other impulse is not conducted and the ECG shows two
p waves to one QRS complex. The only difference on the
ECG would be a narrow QRS (sn in Mobitz I) and a wide
QRS (sn more commonly, but not exclusively, with Mobitz II). TWically. if Mobitz I with 2:1 conduction is present,
an occasional Wenckebach pattern will usually assert itself
when a longer rhythm strip is viewed, thus confirming the
diagnosis of Mobitz I. Figure 8-26 sho",'S such an example.
The AV block strips with consistent 2:1 AV conduction
and a narrow QRS complex have bn interpreted in the
answ~r keys as Mobil1. II with a notation that clinical correlation may be necess<lry to determine a definite diagnosis.

Third-degree AV block (complete

heart block)
Third-degree AV block (Figures 8-27 ilnd 8-28 ilnd Box 8-8)
represents complete absence of conduction between th~
atria and the ventricles. This rhythm is also called complete heart block. With third-degree heart block. the atria
and ventriclel; beat independently of each other and there's
no relationship bejv,'een atrial activity and ventricular
activity (AV dissociation). The atria are usually paced by
the sinus node at its inherent rate of 60 to 100 beats per
minute and the ventriclel; are either paced by a pacemaker
in the AV junction at a rate of 40 to 60 beats per minute
or in the ventricles at a rate of 30 to 40 beats per minute.
The P waves have no relationship with the QRS complexes,
and will be seen marching across the rhythm strip, hiding
inside QRS complexel; or in the ST segment or T wave. The

Bo18-8,

Third-degree AV block (complete heart block):

Identifying ECG features
Rhythm :

Atrial: Regular
Ventricular: Regular
Rate:
Atrial: That oIlhe lIIderlyPJ sinus rhythm
Ventricular: 40 to 60 beatstmlnute 1/ paced by AV
IlllCtlon; 30 to 40 beatstmlnute (or less)" paced by
ventricles; will be less than the atrial rate
P waves:
Sl'lus P waves wl1I1 no constant relaUOOshlp to 1I1e
CAS complex; P waves can be lound hidden In CRS
complexes, ST segments, and T waves
PR Inl8rYaI: Varies greaUy
QRS complex: Normal II block located at level 01 AV node arbul'ldle
01 His; wide K block located at lev&! 01 bundle

""'m

"hidden" P waves can be found by measuring the regularity of the atrial rhythm (the pop interval). The PR intervals ilre completely variable. Both the iltrial rhythm and
the ventricular rhythm are usually regular. The width of
the QRS complex and the ventricular rate reflect the location of the blockage. If the block is at the level of the AV
node or bundle of His. the QRS complex will be narrow and
the ventricular rate will be betwn 40 and 60 beats per
minute. If the blockage is in the bundle branches. the QRS
complel "'ill be wide and the ventricular rate much slower
(40 beats per minute or less). Generally, complete heart
block with ",ide QRS complexes tends to be less stable than
complete heart block with narrow QRS complexes.
Complete heart block associated with inferior-wall MI
is usually a result of a block at the level of the AV node
or bundle of His. The rhythm is usually stable ilnd the

fillure 8- 27. Third-degree AY block,

Rhythm:
Regula" (all1al); regular (vootrlcula") 011 by 2 squares
Ratl:
Atr1aJ (75 beats/mlnute); venlrlcular (33 to 34 beats/mmte)
P waves:
Sinus Pwaves (haw no relationship to CRS complexes; found hidden In DRS complexes, ST segments, lIldT waves)
Pfllntlrval: varws grvatly (Is not conslstmt)
QRS compl8l: 0.12 second.

Tips 011 heart blocks

153

Allure 8-21. Thlrdclegl1l8 AV block.

Regular atrial and Y9I11r'k:U13" rhythm
RIta;
Alrlal: 72 beaWmlnuIB
ventricular: '"' beatsmtlnJle

Rhythm :

P wawI:

snus P WaYeS present (bear no coos1art relatloosh~ to ORS complexes; found hidden ., QRS cornplroBs aJKI T waves)

PIt ln1afYaI: VarIes greatly

QRScompleX: O.12sean:1.

ventr icles a re paced by a junctional pacemaker with narrow QRS compl exes and a ventricular rate of 40 to 60
!>fau per minute. Third -deg ree AV block associated with
an inferior-wall MI often resolves on iu own. Complete
heart block associated with an anterio r-wall MI is usu ally a result of a blod .... ithin the bundle branches. The
rhythm is usually unstable and the ventricles are paced
by a ventricular pacemaker with wide QRS compteJIes
and a ventricular rate of 40 !>fats per minute or less_
Third-degree AV block a5S0ciated with an anterior MI
often does not resolve on its own and may require permanent pacing. Complete heart block can al50!>f seen in
older patients who h,we chronic degene rat ive changes in
their conduction system not related to acute Mi. It h;u
also been reported with Lyme disease. Complete heart
block may occur with digitalis toxicity.
The patient's response: to complete heart block is usually related to the ventricular rale. I(the ventricular rale is
within normal limits. the patient may be relatively a5)'1llPlomatic with minor symptoms such as weakness, fatigue,
dizziness. or I!l(ercise intolerance. More commonly, theventricuJar rate is extremely slow, cardiac output is decreased,
and symptoms are present (hypotension. dyspnea. heart
failure, chest pain, or SIokes-Adams s~cope).
Regardless of its cause, complete hear! block is a serious
and potentially life-threatening arrhythmia. Third-degree
AVblock. like Mobitz II. can quickly progress to ven tricular
standstill (asystole) with little or 00 warning. Treatment is
required immediately for symptomatic third-degree heart
block and for iU)'Illptomatic third-degree heart block with
wide QRS complexes in the ~tting of acute anterior-wall
MI. An external pacemaker should be applied while preparations are made for in~rtion of a temporary lTansvenous

pacemaker. Third-degree AV block with narrow QRS

complexes may occasionally respond to atropine. Hypot~nsion should !>f treated ....ith vasopressOT$. Unresolved
complete heart block will require a pennanent pacemaker.

Tips on heart blocks

To distinguish one heart block from another, remember
the~ important tips:
,,1easure the poP interval. The poP interval is regular in
all the blocks. If you measure the pop interval. you ....ill be
able 10 track the P waves, This is very important in finding
hidden P waves ~en in third-degree AV block or Mabib: II
with higher condu,tion ratios (3: 1 or more).
"leasure the R-R interval. First-degree and third-degree
AV block have a regular ....entricular rhythm. Habib: I has
an irregular ventricular rhythm. The ventricular rhythm
in "lOOitz II may be regular or irregular. depending on
conduction ratios.
"leasure the PR interval. If the PR interval is consistent, choose be""een fi rst-degree and Mobilz II AV
block. First-degree AV block has one P wave to each QRS
while Mobitz II AV block has
or more P waves to
each QRS. If the PR interval is nol consistent, choose
between Mob itz I AV block and third-degree AV block. In
Mobib: I the PR interval is not consistent and the ventricular rhylhm is irregular. In third-degree AV block
the PR interval is not consistent and the ventricular
rhythm is regular.
Table 8-1 compares the ECG characteristics of each
type of AV block. A summary of the identifying ECG features of junctional rhythms and AV blocks can be found in
Table 8-2.

""0

154

Junctional arrhythmias andAVblocks

Table B-1.

AV block comparisons
Pft constant
(Rrst-tgrH)

PH constant
PR _ _

PR varies

One P wave to each aIlS

PR prt98SSively gilts longer

lIltil a ORS is dropped

Regular atrial rhythm;

reglJar ventricuar rhythm

RI9lIar atrial rhythm; irregular

venlriwlar rhytIm

(5ecMd-degr., MDbitz /I)

PR varies
PR normal Of prolonged; two or
three P waves (possi~ mom)
to each aIlS

P waves have 00 COfIStant relationship to aIlS (foood lidden i1

ORS complexes, S1 segments,
and 1waYeS)

Regular alrial rhythm; fl9Jlar

venmla- rhythm (liliess
conduction ratios vary)

Rl9llar atrial rhythm; regular

venlriwlar rhytIm

Tips on heart blocks

155

Talll, S-l.

Junctional arrhythmias and AV blocks: Summary of Identifying ECG features

,,~

..

""""

jun:tional

cmtraction

eJCI

JlIICtionai

""""
kcelerated
jun:tional

Rh,II'"

Rata (bIIatstrnlnutl)

P waYIIS (lia d II)

PIIlntlnai

QRS compIeJ

Basic rhythm
usually regular;
ilTl9lla- with
PJC

That of basic rhythm

Premalure P wave; inverted

in lead II and will OCCll"
immediately before the aIlS
complex er immediately
after the ~RS, or be hidden
within the ORS

0.10second er less

Premalure CfIS
complex;

."""

.,.60

....,.

6010100

""""
JlIICtionai
tachyc3"dia

".-

First-degree
atriownlricuar

Second-degree

."""
."""

,100

That of underlying sirIJs

rhythm; both atrial and
ventricular rates will be the

merted in lead II and

will OCC\I" immediately
before Ihe aIlS corrpIex II"
immediately after the DRS,
II" be hidden wilhi1 1he ORS
merted in lead II and
will OCCll" immediately
bafore the ORS COff1lIm:: II"
immediately after the DRS,
(I" be hiddlll wilhil lhe ORS
merted in lead II and
will OCCll" immediately
bafore the ORS COff1lIm:: II"
immediately after the DRS,
II" be hidden wilhi1 the ORS

~,

....,

Ikration
(0.10 second

Short (0.10 socond or

'=1

Short (0.1 0 socond or

'=1

Short (0.1 0 second or

'=1

Sinus origi1; one P wave to

each CflS compex

Prolonged (more
than 0.20 second);
remaillll consislllnt

Varies; progressively
lengthens lI"Itil a P
wave isn'l corducIed
(P wave occurs
wilhout the DRS
complex); a pausa
follows the d'opped
DRS complex

-,

Atrial: thai 01 unda1ylng

sinus rhylhm
Vlllbicular. depends on rlJmba" of impulses conducled
Ihrol9l AV oode; will be less
than atriallare

Sinus orIgn

Second-degree

Atrial: reguar
VelllricUar. usually regular. but
may be ilTl9llar
~ conduction
ratios vary

Atrial: thai of underlying

sinus rhythm
Vlllbicular. depends
on number of impulses
cordJcted thfOll\t1 AV node;
will be less than alriallal8

Sinus orIgi1; I'MJ or 111"00

P waves (sometimes mora)
bafore each ORS complex

Normal or prolonged;
mmains consistmt

Atrial: reguar
Venlricuar.

Atrial: thai of undB1ying

sinus rhylhm
Ventricular. 40 to 60 if pa:ed
by AVjunction; 30 to 40
(sorootimes less) if pa:ed by
ventricles; will be less than
atrial ral8

Sinus P waves with no

consmt relationship to
tOO ORS complex; P waves
Iound hidden in DRS
complelllS, ST segl1llllts,
IIId Twaves

Varies~1Iy

AV_
MoI!itz II

Third-rIewM

AVbIocl<

(0.10 seo:nd or

"')

""""

(O.IOseconder

'=1

N~'

(O.IOseconder

"'I

N~'

(O.IOseconder
"')

A~

AUlal: regual
Venlricuar:
ilTl9lla-

AV_

",--

N~'

(0.10 second er

"'I

.....

Nmnal n tkd<.

Iuda ollis;
wide n tm:k in

............
Normal if block
allewl of AV

_A

node II" bullle

of Hi:>; wide if

block in buncle

1 56

Junctional arrhythmia s a ndAVblocks

Rhythm strip pracl lce: Junction al arrhythmias and AV blocks

Analyze the following rhythm strips by following the five
basic steps:
Determine rhytnm regularity.
CalculatenetU1rate. (This usuallyreferstotheven t ricular
rate. but if atrial rate differs you need to calculate both.)
Identify and examine P wa.ve5.

Measure PR in/errol.
Measu re QRS complex.
Interpret the rhythm by compnrinll this data wit h the
ECC characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unln!; otherwise noted. Check your
ansVt'ers with the ansl'>'e r keys in the appendix.

Strlp8- 1. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ _ __

PR inteNal:
QRS complex:'_ _ _ _ _ __
interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~ythm

Strip 8-2. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR inteNal:
DRS complex:, _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Junctional arrhythmias andAVblocks

157

Strip 8-3. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
~ythmim~i~

QRS caTIplex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-4. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
~ythm

Pwave: _ _ _ _ __

QAS complex:_ _ _ _ __

imerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-5. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Interval:
~ythmim~~

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

158

Junctional arrhythmias andAVblocks

Strip 8-6. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-7. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR inleNaI:

Pwave: _ _ _ _ _ __

ORS oornplex:_ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-8. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

QRS

Pwave: _ _ _ _ _ __

complex:_ _ _ _ _ __

Rhythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Junctional arrhythmias andAVblocks

Strip 8-9. Rhy!hm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

159

Pwave: _ _ _ _ __

PR interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-10. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
OR5 complex: _ _ _ _ __
Rhythm interprellllion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-11 . PJ1ythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

160

Junctional nrrhythmlns nnd AV block ~

Strip 8- 12.. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR Interval:
DRS complex:, _ _ _ _ __
Rhythm Interpr9latbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-13. Rhythm: _ _ _ _ _ _ _ _ _ Aate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR Interval:
DRS complex:' _ _ _ _ __
Rhythm Interpr9latbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8- 101. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
ORS complex:' _ _ _ _ _ __
Rhythm interpr9lalioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhyd1l1l slrip praclice: Junc tional arrhythmias and AVblocks

Strip8-15. Rhythm: _ _ _ _ _ _ _ _ _ "",, _ _ _ _ _ _ __

Pfllnt&MI:
OOScomplex:'_ _ _ _ __
~~ I ~Mpremoo~

161

P wave: __________

________________________________________________

Strip8-1G. IWYyhn: _ _ _ _ _ _ _ _ "". _ _ _ _ _ __

PH inlsrva/:
ORS complelt _ _ _ _ _ __

Pwave: _ _ _ _ __

Rhyttvn Intikpt8tatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-17 . Rhythm: _________________ .... _______________

Pflinterval:
Rh~i~~~tio~

Pwave: __________

ORScomplelC,_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

16 2

Junctionaillrrh ythmills llnd AV biocb

Strip 8-11. Rhy1trn: _ _ _ _ _ _ _ _ _ """ _ _ _ _ _ _ __ P WiVII: _ _ _ _ __

fIR Interval:
ORS complex:,_ _ _ _ __
RIlyttm Inlerpfatatiln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-19. Rhyttvn: _ _ _ _ _ _ _ __

PR ilterval:

R..." _ _ _ _ _ _ __
ORS complex;,_ _ _ __

PwaVII: _ _ _ _ _ __

Rhythm Interpr.tafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-20. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR marval:

PwaVII: _ _ _ _ _ __

ORS cornpleJ::_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh}1hm strip practice: Junctional arrhythmias andAVblocks

163

Strip 8-21 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PA interval:
OAS compleK: _ _ _ _ _ __
Rhythm Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-22. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PA interval:
ORS complex: _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip I-l3. Rhythm : _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ __

PA interval:

PWdve: _ _ _ _ _ __

OAS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

164

Junclional arrhythmias and AV blocks

Strip 1-24. ffryttrn: _ _ _ _ _ _ _ _ _ Fl..'" _ _ _ _ _ _ __ Pwa...e: _ _ _ _ __

PR ilIIrvaI:
ORS wmplex:,_ _ _ _ __
Rllythm Inlerpfetatk:m:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-25. Rhythm: _ _ _ _ _ _ _ _

FI"" _______

Pwa...e: _ _ _ _ __

PR i1teMi:
DRS oornplex:_ _ _ _ __
RllyIflm lilIeiPi8taOO'l:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1-26. Rhythm: _ _ _ _ _ _ _ _ _ Fl.b' _ _ _ _ _ _ __

Pwa...e: _ _ _ _ _ __

PR i1tervai:
QRS romple.l:_ _ _ _ __
RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm snip practice: lunctional arrh ythmias and AVblocks

Strip 8-27. Rhyltlm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pft interval:

165

Pwa'0'8: _ _ _ _ __

OftScomplex:,_ _ _ _ __

Rhythm IntllfJlfItatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-28. RhyItlm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwa'0'8: _ _ _ _ __

Pft lnterval:
ORScomple:X:'_ _ _ _ __
Rhyttvn int8lp(8lation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-29. Rhyltlm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PRinterval:
~im~ort

Pwa'0'8: _ _ _ _ __

OftScomplelC _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

166

Junctional arrhytlunias alld AV blocks

strip 8-30. ltJythm: _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

Pfllnterval:

QRScomplo:_ _ _ _ __

FIIy1hm 1IIIIIfPf1Ution: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-31 . RIyIhm: _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ _ _ Pwaw: _ _ _ _ __

PR merva!:
ORS oomplex:_ _ _ _ __
RlIytflm Interpretatoo:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-32. 1IIyttvn: _ _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR merYal:
R~in~Om :'

ORS complex:- - - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: lunctional arrh ythmias and AVblocks

167

Strip 8-33. lt1ythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ PWS9: _ _ _ _ __

PfI inlerva:
ORScompltx;,_ _ _ _ __
Rhythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-34, Rhythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

PWS9: _ _ _ __

Pflinterval:
ORScomplu:_ _ _ _ _ __
Rhythm inI8qlfltation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sbip 8-35. Rhythm: _ _ _ _ _ _ _ _ _ .". _ _ _ _ _ _ __ Pwa9: _ _ _ _ __

PI! interval:
ORScomplelC_ _ _ _ _ __
Rhythrn i nl~ort _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

16 8

lunctionalllrrhythmias andAV blocks

Strip 8 -~ . Rhythrn: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ __

PR iltBfWII:
ORS complex:' _ _ _ _ _ __
Rhythm InterpretaliGn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp8-37. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:, _ _ _ _ _ __
Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-38. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __
PR interval:
QRS complex:' _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhyliuu snip practice: Jun c!iOIlIlI arrh)'1IlIllias and AVblocks

169

strip 8-19. ~m : _ _ _ _ _ _ _ _ _ " " _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PH Interval:
ORScomplelt _ _ _ _ __
Rhydvn IntMpretatiol1: _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-40.lIlythm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwave: _ _ _ _ __

PfI interval:
ORScomplex:_ _ _ _ __
RhydvnlntMpretatiol1: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-41 . Rhythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

Pflinterval:
ORScomplex:_ _ _ _ _ __
RIythm intMpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

170

Junclionnl nrrhythmias and AV blocks

Strip 8-42. RryttII1l: _ _ _ _ _ _ _ _ _ Rol" _ _ _ _ _ _ __

PR interval:
ORS toIllplex:,_ _ _ _ __
R~ml~ :

Pwa~

_______

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-43. ffIythm: _ _ _ _ _ _ _ _ Rol" _ _ _ _ _ __

Pwsve: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ __
RIryIhm Interpretaton:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-44. Rhythm: _ _ _ _ _ _ _ _ _ ""', _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS cornplex:c_ _ _ _ __
Rbyttm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IUt )thm sirip proclicc: luncllonalarrhrlhmlas and AV blocks

strip 8-45. Plt)1hm: _ _ _ _ _ _ _ _ _ "'''' _ _ _ _ _ _ __

17 1

Pwave: _ _ _ __

PR interval:
QAS complex:.~_ _ _ __
Rhyttrn Int8fJ)retation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 8-4" Plt)1hm: _ _ _ _ _ _ _ _ _ "',. _ _ _ _ _ _ __

PR int&Mi:

Pwave: _ _ _ __

QAScomplex:~_ _ _ __

RhyttrnintMFetaOOn _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-47, lI!ythm: _ _ _ _ _ _ _ _ _ "'.. _ _ _ _ _ _ __

PR interm:

P _: _ - - - - -

QAS complex:~_ _ _ __

FV!yttJn i!1ef)1retation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

172

Junctional arrhythmias andAVblocks

Strip 8-48. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ _ __

Rhythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-49. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PA interval:
QRS cornplex:_ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-50. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval :
QRS complex:
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip prac tice: Junctional arrhythmias andAVblocks

Strip 8-51. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

173

Pwave: _ _ _ _ __

PR interval:

ORS cOOlplex:_ _ _ _ _ __
Rhythm interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-52. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-53. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm interpreiation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

174

Junctional arrhythmias andAVblocks

Strip 8-54. Rhythm: _ _ _ _ _ _ _ _ _~ Rate: _ _ _ _ _ _ __

PR interwi:

Pwave: _ _ _ _ _ __

QAS comptex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-55. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _~ Pwave: _ _ _ _ _ __

PR interval:

QRS

cornplex:_ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-56. Rhythm: _ _ _ _ _ _ _ _ _~ Rate: _ _ _ _ _ _ __

PR interval:

QRS

Pwave: _ _ _ _ _ __

complex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~

IUl)'thm strip pructice: Junctionru nrrh r thmins nndAVblocks

Strip 8-57 . Rhythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pft Int&lVal:
~ i m~M~o~

Pwave: _ _ _ _ __

OOScomplex:,_ _ _ _ __
_ _ _ __ _ _ _ _ __ _ _ _ __ _ _ _ _ _ _ _ __

Strip 8-58 . Rhythm: _ _ __

Pft interval:

17 5

_ _ __

_ __

_ _ _ __

Pwave: _ _ _ _ __

OOScomplex: _ _ _ _ __

Rhyttrn InteqJfelalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ __
OOScomplex:_ _ _ _ _ __
~ i nt~o ~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-59 . Rhythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pft interval:

176

Junctional arrh ythmias nnd AV blocks

Strip I-50. RIIytIvn: _ _ _ _ _ _ _ _ _ Rail: _ _ _ _ _ _ __

PwaYe: _ _ _ _ __

PA Ilterval:
ORS complex:_ _ _ _ __
Rhyttvn interpretati:ln: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

R"" ____ ____

Strip 8-61 . RIyttrn: _ _ _ _ _ _ _ __

PA rrtemJ:
ORS complex: _ _ _ __

Pwa"": _ _ _ _ _ __

Rhythm Interpret1l.tJJn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-62. Rhyttrn: _ _ _ _ _ _ _ _ _ ," _ _ _ _ _ _ _ __

Pwa"": _______

PA ilterval:
ORS complex:,- - - RllytlIm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: lunctional arrh ythmias and AVblocks

Sbip I-U. Rhythrn: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PI! interval:
Rh~I~~~ti~

177

PwaYe: _ _ _ _ __

ORScanplelt _ _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-64, Rhythrn: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

PwaYe: _ _ _ __

PI! intervai:
ORScomplex:_ _ _ _ __
Rhythm Inteq>retatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-65, Rhythm: _ _ _ _ _ _ _ _ _ _ ..,. _ _ _ _ _ _ __

PI! interval:

Pwave: _ _ _ _ __

ORScomplelC _ _ _ _ _ __

RIythm inteqlfetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

178

Junclional arrhythmias and AV blocks

Strip 8-GG. Rhythm: _ _ _ _ _ _ _ __ _

_ _ _ _ _ _ __

Pwali8: _ _ _ _ __

PR iltsrva!:
ORS wmplex:,_ _ _ _ __
Rllythm Inlerpfetatk:m:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-&1. RIIyttwn: _ _ _ _ _ _ _ _

R"" _______

PWSIi8: _ _ _ _ __

PR merva!:
ORS wmplex:_ _ _ _ __
Rllylhm Interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip I-GIl. Rhythm: _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ __

PR merva!:

Pwali8: _ _ _ _ _ __

QRS cornple.l:_ _ _ _ __

RIIyIhm interpfetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhyliuu snip practice: Junc!iOIlIlI arrh)'1IlIllias and AVblocks

Strip 8-i9. lItythm: _ _ _ _ _ _ _ _ _ ..'" _ _ _ _ _ _ __

11ft Interval:
~I~~boo~

M~~~M~

Pwave: __________

OftScomplex:,_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Strip 8-70. FIlythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ _ __

PH imervaJ:

179

Pwa'o'e: __________

ORScomplex: __________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwa'o'e: __________
ORScomplelC _ _ _ _ _ __
~im~ort _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-71 . FIlythm: ___________________ ..'" ______________

11ft interval:

180

Junclionnl nrrh ythmias and AV blocks

Strip 8-72. RIythm: _ _ _ _ _ _ _ _ _ ",'" _ _ _ _ _ _ __

fIR IntM'l8l:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Rbythm Irrlerpntation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ __
Strip 8-73. Rhythm: _ _ _ _ _ _ _ _ """ _ _ _ _ _ __
fIR merva!:
ORS cornplex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-74. RIyttvn: _ _ _ _ _ _ _ _ _ ""', _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

fIR ilterva!:
ORS romplex:'_ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IUt )thm sirip proclicc: luncllonalarrhrlhmlas and AV blocks

strip 8-75. Rhythm: _ _ _ _ _ _ _ _ _ ,,,. _ _ _ _ _ _ __

181

Pwave: _ _ _ __

PR interval:
ORScomplu: _ _ _ _ __
Rhythm lnttrpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp8-7S. Rhythm: _ _ _ _ _ _ _ _ ''', _ _ _ _ _ __

PR interval:
~imMFmaOOn

Pwave: _ _ _ _ __

ORS complex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip8-n Rhythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PwaYe: _ _ _ _ __

PR interm:
ORS complex: _ _ _ _ __
Rhythm imef)lretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

182

JunclionnJ arrh yt hmias nnd AV blocks

Strip 8-78. RIythm: _ _ _ _ _ _ _ _ R" _ _ _ _ _ __

fIR Interval:

Pwave: _ _ _ _ __

ORS complex:,_ _ _ _ __

RIryttJn Inlftipietatklll:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-79. Rhyttrn: _ _ _ _ _ _ _ _ _ ," _ _ _ _ _ _ __

PR iltJr.IaJ:
ORS IX)IlIpltx:._ _ _ _ __

Pwave: _ _ _ _ _ __

Rlrythm Interpretalbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-80. RIrythm: _ _ _ _ _ _ _ _ _ _

PR i1terval:

_ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

ORS complex:

Rbythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm strip prac tice: Jun cti onal urThrthmins and AVblocks

Strip 8-81 .Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
~I~~e~oo~

183

Pwave: _ _ _ _ __

ORScanplelC_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-82. Rhythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR Interval:

ORScomplex: _ _ _ _ __
Rhy1h'n InIMprBlalio~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-83.

~:

_ _ _ _ _ _ _ _ _ I.." _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR illerval:
ORS complex: _ _ _ _ __
Rhythmi,leijHetalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

184

Junc tional arrhythmias3.nd AV blocks

Strip B-IU. RIyttvn: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwave: _ _ _ _ __

PR klterval:
ORS Ctlmplel:_ _ _ _ __
Rhythm InWrpfeIatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip B-BS. Rhyttvn: _ _ _ _ _ _ _ _ _

PR Interval:

R.'" ________

Pwave: _ _ _ _ _ __

ORS Ctlmplex:_ _ _ _ __

Rhythm int&rpfetatbn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip B-86. Rrythm: _ _ _ _ _ _ _ _ _

PR Interval:

R.,,, ________

Pwave: _ _ _ _ __

ORS cornplex:_ _ _ _ __

RIryttvn interpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Junctional arrh ythmias and AVblocks

Strip 8-87. Rhythm: _ _ _ _ _ _ _ _ RaI!: _ _ _ _ _ __

185

Pweve: _ _ _ __

PRinterval:
ORScompielC_ _ _ _ _ __
Rhythm InteJpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-88. Rhythm: _ _ _ _ _ _ _ _ _ ..,. _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PfI intimal:
ORScompleX: _ _ _ _ __
Rhyttrn Inleqwetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-89. Rhythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pflinlerval:
Rhythm i nl~on:

Pwave: _ _ _ _ __

ORScomplex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

186

Junctional arrhythmias andAV blocks

Strip .-90. Rhythm: _ _ _ _ _ _ _ _ ...., _ _ _ _ _ __

Pwave: _ _ _ _ __

PR ilhIrvai:
ORS oomplu:_ _ _ _ __
RlIyttlm Interpretafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip .-91. AIIyth:n: _ _ _ _ _ _ _ _ """ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR i1terval:
ORS oompleJ::_ _ _ _ __
Rllythm Interpfltation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip .-92. Rhyth'n: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR iltervai:
ORS complex:,_ _ _ _ __
Rbyttlm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: lunctional arrh ythmias and AVblocks

187

Strip a-93.lt!ytIlm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR inllll"M.
ORS complex: _ _ _ _ __
Rhyhnin1erpretation;' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip a-u . /tryttlm: _ _ _ _ _ _ _ _ "'. _ _ _ _ _ __

PR InIIll"t1t
~i~on :,

ORS complex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-95. Rhylhm: _ _ _ _ _ _ _ _ _ _ .". _ _ _ _ _ _ __

PR interval:
OftScomplelC _ _ _ _ _ __
~int~ort

Pwave: _ _ _ _ __

Pwa'o'e: _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

188

Junclional arrhythmias and AV blocks

StripB-9fi. Rhythm: _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PH interval:
ORS oomplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~m~~'~oo :

Strip 8-91. RIIythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwaw: _ _ _ _ __

PR interval:
ORS oompieJ::_ _ _ _ _ __
RIIyttun InterpretatOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-98. Rhyth'n: _ _ _ _ _ _ _ _ _ ""', _ _ _ _ _ _ __

Pwaw: _ _ _ _ _ __

PR interval:
ORS oornplex:,_ _ _ _ __
Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IUl)'lhm siril' prllctice: Juncti o nlll IIrTh )'1 hmius Ilnd AV blocks

Stripl-n.lllyttlm: _ _ __ __ _ _ _ _

PfI irftMII:
~~.On

_ __ __

_ __

189

Pwaw: _ __ __

QRS c:ompIa:,_ _ _ __

___ _ _ _ _ _ __ _ _ _ _ _ _ _ __ _ __

Strip 1-100. lIlyIhm: _______________ .... ____________

PfI intelVll:
~m~e~

________________________________________

SIrifI1-1 01 .1IIythm: _______________ _

PfI irtemf:
~m~mon

Pwave: _ _ _ _ __

OOScomplu: _ _ _ _ __

____________

Pwaw: _________

QRS compIIx:,_ _ __ __

___ _ _ _ _ _ __ __ _ _ _ _ __ _ _ _

190

Junctional ar rhythmias and AV blocks

IE Skillbuilder practice
This section contains mixed sinus, atrial, andjunctiollal and AV block rhythm strips, allowing the student to practice differentiating betv.~en two rIlythm groups before progressing to a new group. As ~fore, analyze the rIlythm strips using the
five-step process. Interpret the rhythm by comparing the data collected with the ECG characteristics for each rhyt hm. All
strips are lead II. a positive lead. unleu otherwise noted. Check ~r answers with the lInswer key in the appendix.

Strip 8-102. Rhythm: _ _

_______

PR InteMt:
~im~M

""< ________

__________________________________________

Strip8-103. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR imenal:
R~m~~~ :

p~~ ------

ORS complelC _ _ _ _ __

Pwa~ :

_______

ORS oomplex:_ _ _ _ ___

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rh ythm snip practice: lunctional arrh ythmias and AVblocks

Sbip8-104. lI1ythm: _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ __
PR klIerval::
ORS complex:,_ _ _ _ __

191

Pwave: _ _ _ _ __

la'lythm I!terpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-105. iIIythm: _ _ _ _ _ _ _ _ . . . _ _ _ _ _ __

PR interval:
1I1~1~~

Pwave: _ _ _ __

ORS complex:, _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-106. fIlythm : _ _ _ _ _ _ _ _ _ .",, _ _ _ _ _ _ __

Pwa..,,: _ _ _ _ __

PR interval:
OftScomplelC _ _ _ _ _ __
Rhythm intefp-etatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

192

JunClionnlllrrhylhm ins li nd AV blocks

Strip 8-107. fIIyttl'n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR ilterwl:
ORScomplex:'_ _ _ _ __
~m~tioo'~

Pwave: _________

_______________________________________

Pwave: _________
Strip 8-108. FVlythm:_______________ "". ____________
PR iltBrYai:
ORScompiex:,_ _ _ _ __
Itlythm klterpretatkln''---_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-1D9. Rhythm: _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR i1terval:
ORS romplex:,- - - IIIythm metpretatiJn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhydlln snip prUClice: Junc!ionul urrh)'!hlllius ulid AVblocks

StripB-110.lt1yttIm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR Interval:
~~~ti~

~~~~allin

PwaVII: _ _ _ _ __

OftScomplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-111 .ltJyttIm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR Imerval:

193

PwaVII: _ _ _ _ __

OftSccmplex: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

StripB-112.fVlythm: _ _ _ _ _ _ _ _ _ ..,, _ _ _ _ _ _ __

PwaVII: _ _ _ _ __

PR interval:
OftScomplelC_ _ _ _ _ __
Rhythm intefp'etatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

194

Junctional arrhythmias andAVblocks

Strip8-11J. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm inlerprBlation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-114. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

OIlS complex:_ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-115. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

OIlS cornplex:_ _ _ _ _ __

Rhythm inlerprBlalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Junctional arrhythmias andAVblocks

195

Slripl-11S. P1lythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR Interval:
QRS complelt _ _ _ _ _ __
Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip8-117. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR inlerWII:

Pwave: _ _ _ _ __

QRS complelt _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 8-118. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

196

Junctio nal arrhythmias andAV blocks

Strlp8-119. Rhythm: _ _ _ _ _ _ _ _ _ Ra1e: _ _ _ _ _ _ __

Pft Interval:
~m~5moo :'

ORS complu::_ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Strip 8-120. Rhythm: _________________ Rate: _______________

Pft interwl:

P wave: _ _ _ _ __

P wave: ___________

ORS cornplex:___________

~~ "-------------------

Ventricular arrhythmias
and bundle-branch
block
Overview
The three preding thapters have focused on $/Jprove/lIrieu/ar arrhythmias. Supraventricular arrhythmias
nofer to those: rhythms that originate a~ the bundle
branches and include the sinus, atTial. and junctional
rhythms. The electrical impulse: produced by supraventricular rhythms follows the normal conduction p.athway.
resulting in simultaneous depolarization of the right

and left vtntricles. The resulting QRS complex is narrow

(0.10 second or less in duration). Ventricular beats and

rhythms (Figure 9-1) originate below the bundle 01 His in

I

pacemaker site in either the right or left ventricle. When

impulses arise: in the ventricles. the impulse does not

enter the normal conduction pathway, but travels from

is predominantly positive, the ST segment is usually

depres!>ed and 1m T wave negat ive). A P wave is not produced in ventricular rhythms.
Ventricular arrhythmias include premature ventrkular
contractions (PVCs), ventricularbchycardia (VT), ventricular fibrillation (VF), idioventricular rhythm, accelerated idi_
oventricular rhythm, and ventricular standstill. All oflhese
rhythnu are a$5OCiated ~ith a ~ide QRS complex (except
\IF and ventricular standstill, ..-hich do not ha\'f QRS complexes). Because the ventricles are the least efficient of the
heart's pacemakers, most of these rhythms are (o r have the
potential to be) life-threatening and demand prompt recognition and treatment.
The electrical impulse in bundle-branch block origi-

cell to cell through the myocardium, depolarizing the

natts in the sinus node, not in ventricular ti.uue, but II dis-

ventricles asynchronously. Therefore, the ventricles are

not stimulated simultaneously and the stimulus spreads
through the ventricles in an aberrant manner, resulting
in a wide QRS complex of 0.12 second or greater.
Sincr ventricular depoiariMtion is abnormal, ventricular repolariution will also be abnormal, resulting in
changes in the ST segments and T waves. The ST segments
and T waves will slopt in the opposite direction from the
main QRS deHection (if the rctopic QRS complex is predominantly negative, the ST !>egment is usually elevatEd
and the T wave positive: if the ectopic QRS compleJl

cussion of bundle-branch block is included in this rhythm

Jlroup beCIlUSt of the location of the block within 1m lIentricles and the ..ide QRS complex.

Bundle-branch block
the intravr ntricular conduction system consists of the
right bundle branch Bnd the left main bundle branch, which
diVides into two fascicles: an anterior fascicle and a posterior
fucicle. Block may ()(:cur in any part of this conduction
system. Normally, the electrical impulses travel through

II'""''''''..... ,........... ---::::~"''-_....m' .....

.....". ...,ocuh. m\1hm

kIoo.t<""*<I.d ...

'O'X ....~II

Allure 9-1 . Ven!rlcular arrhytIvnIas and bundl&-branch block.

197

198

Ven tri cular arrhythmias an d bundl e-branch block

the right bundle branch and the left bundle branch and its
fascicles at the same time, caming simultaneous depolarization of the right and left ventricles, resulting in normal
depolarization and a QRS duration of 0.10 second or less.
'Nhen one of the bundle branches is blocked. the electrical
impulse trilVels down the intact bundle. depolarizing that
wntricJe first, then the impulse progresses through the
interventricular septum to depolarize the othu ventricle.
Depolarization of one ventricle before the other is called
sequential depolarization. Depolarization of the ventricles is dela~d. resulting in a wide QRS complex of 0.12
second or greater. The presence of a bundle-branch block
(Figures 9-2 through 9-4 and Box 9-1 ) can be recognized

Box 9-1 .

Bundle-branch block: Identifying ECG features

Rhythm :
Rate:

Regular
lhal oIlhe underlying r11ythm (Usually sinus)
P WIY8S:
Sinus
PI! InllllrYaI: Normal (0.12 to 0.20 socond)
QRS complex: Wkle (0.12 second or grealer)

by a monitoring lead. Differentiating between right and left

bundle-branch block requires a 12-lead electrocardiogram
(EeG).

FIgure 9- Z.
Rhythm:
Ratl:

Normal sinus rhythm with bundle-bran ch block.

Regular (off by 2 squares)
60 to 65 beats/minute
P waY":
Sinus
PIIlntlrval: 0.16toO.20second
QRS complu: 0.12to 0.14 second.

Figure 9-3.
Rhythm:
Rail:

Normal sin us rhythm with bundle-branch block.

Regula'"

75 beatslmlllJle
Sinus P waves are notched, which coold Indicate len atrial enla'"gemenl.
PIIlntlrval: 0.14toO.16second
QRS complu: 0.12 second
COmment:
A notched QRS cumplex Is a common pattern wm1 rtght blJldle-brMCll block.

P waY,S:

Premature ventricular contractions

199

Rgure U .

Atr1al nbrillation wnh bundle-branch block.

Irregular
70 beats/mlnuto
P W3Y11S:
FtlrIllatory waves present
Pfllntarval: Not measurable
IlRS compl8J.: 0.14 to 0.16 second.

Rhythm:
Rata:

Right bundle-brnm:h block (REBEl may be pr.-sent in

healthy individuals with no apparent underlying heart disease.
but more commonly occurs in the pr.-sence of coronary artery
disease (the most common cause). RBBB may be temporary or
chronic. Oc=ionally, RBBB may appear only when the heart
rate exceeds a certain critical level (rule-related BBB). Common causes include anteroseptal myocardial infarction (MD.
pulmonary embolism. congestive heart failure. peril:aTditis.
~-pertensi~ heart disease. cardiolJl)ql<l~, congenital RBBB,
and degenerative disease of the electrical conduction system.
Left bundle-branch block (LBBB ) is rarely seen in individuals with healthy hearts. It appears most commonly
in elderly individuals with diseased hearts . LBBB may be

Fillure 9-5.
Rhythm:
Ratl:
P W3Y8S :
PR Interva t.
IlRS complex:
COmment

temporary or ,hroni,. and may be rate-related. The most

common cause is hypertensive heart disease. Other causes
are the same as with RBBB.
Specific treatment is usually not indkated for a
bundle-bran,h block. Cardiac pacing may be indicated if
the bundle-branch block develops as a result of acute MI or
in the presence of AV block.

Premature ventricular contractions

A premature ventricular contraction (PVC) (Figures 9-5
through 9-14 and Box 9-2) is a premature, ectopic impulse
thai arises below the bundle of His in the ventricles. PVCs

Normal sinus rhythm with one premature vontrlcularcontractlon.

Basic rhylhm r9!Jlla"; ~r9iJl1a" WIth PVC
Basic rhylhm rate 79 beatslmlnulo
Sinus Pwaws WIth basic rhythm
0.16 to 0.20 second (basic rhythm)
0.08100.10 second (basic rhythm); 0.1 4 to 0.16 second (PVC)
Tho Intervallrom tho beal procedhg tho f\lCto tho beat loIlowhg tho f\IC Is equal to two cardiac cycles ~ reprwonts a lun
compgnsatory paIlSQ.

200

Ventri cular nrrhythlllins and bundle-branch block

Figure 1-&. SIIlIIS P waves occulTIng belora and aflllt' premature YIIntJ1cular contractions (PVCs).
The snus P waves of lIle tn:Ie~ytng mythm CIrl be seen Just belOl'8 the PVC ., example A Md aIt9r Iha PVC In 'tie ST saornenlln IIKllmple B. These P waves are assocIattld with the

tnIer1yI~

Iflythm (not the PIlI:) and usualy ~e hlalen wIlI*l the

WkIe ORS oIlha premall.re venlrlcular tooIracUoo.

EXamp19 A: Normal sinus rflythm with nrsl-de!Jee AV block !lid one PVC.
EXam~

B: Snus iWfhythmla wllh btnIle-bl'cn:h bIod( and one PVC.

Figure 1-7. agemlnal prematln venrcular contracllons.

Premature ve ntricular contractions

20 I

Agure 9-8. TrIgeminal j6IlIature yoolr1aJlM cootra:tms.

Agure 9-9.

QoJad~gemNi

pr9lTlature Yentrlcular contrattlcrls.

Figure 9-10. PaIred premature YOOIJ1cuIar con1ractlons.

occur as a result of reentry in the ventricles, enhanced

automaticity of a focus in the ventricles, or triggered activity occurring during ventri cular repolarization. PVCs have
the following characteristics:
The QRS is premature.
A P wave isn't a!oSOCiated with the PVC. Normally the
P wave of the underlying rhythm (usually sinus) is obscured
within the PVC, but sometimes it appears just before or
after the PVC in the ST segment orTwave (see Figure 9.6).

lhe QRS is wide (0. 12 second or greater) and the

morphology is different from the QRS complexes of the
underlying rhythm.
lhe ST segment and T wave slope in the opposite
direction from the main QRS deflection (if the ectopic
QRS complex is predominantly negative, the ST segment
is usually ele\"ilted and the T waves positive: if the ectopic
QRS complex is predominantly positive. the ST segment is
usually depressed and the T wave negative).

202

Ventricular arrhythmias and bundle-branch block

Th~ paus~ associatd with th~ PVC is usually compensatory (th~ m~asur~ment from the ~at before the PVC to
the ~at after the PVC is equal to two R-R intervals of th~
underlying rhythm, Figure 9-5). The underlying rhythm
must be regular to determine a compensatory pause.
PVCs may occur in various patterns. They may appear
as a single beat (Figure 9-5), every other ~at (bigeminal
pattern. Figure 9-7), every third beat (trigeminal pattern,
Figure 9-8), every fourth beat (quadrigeminal pattern,
Figure 9-9), in pairs (also called COllplets, Figure 9-10), or

in runs (Figure 9-11). A run of three or more consecutive

NCs constitutes a rhythm. The rate will determine which
rhythm is present (idioventricular rhythm, accelerated idioventricular rhythm, or VT).
PVCs that look the same in the same lead are Cillled uniFocal PVCs. These PVCS originate from a single ectopic
focus in the wntricles. PVCS that appear different from
one another in the same lead are Cillled multifocal PVCS
(Figure 9-12). These PVCS lJSlIa!Jy originate from different
ectopic sites, but sometimes Il"Iil}' fire from a single site and are

Allure 9-11 . Run 01 premature Ylmlrlcular contractrons (a blnt 01 ventricular tachycardia).

Fillure 9-12. MulU1oca1 premature ventricular contractions.

Box 9-2.

Premature ventricular contraction (PVC):

Identifying ECG features
Rhythm:
Rata:
P waves:

Figure 9-13. Interpolated premature ventricular contraction.

lnIErtyIng rl"rflhm usually regula"; negular with PVC

Thai oIl.1lC1ertytng rflylhm (usually stl1JS)
None assoctated with PVC; P waves associated
with the underlying sJoos rflythm cal occastonally
be seen )Jst belore the PVC or alter the PVC In
the ST segment or T wave; usually these P WaYes
Me hidden In the ORS complex
PR Interval: Not measurwle
QRS compleX: Premature ORS complex; wide (0.12 second or
grBaler)

Pre m a ture ve ntricular con tractions

203

Figur!! 9-14. R-on-T premature YIIntrlcular contraction.

conducted along different routes in the ventricles. resulting
in a QRS that differs in morphology in the same lead.
A PVC sandwiched between two normally conducted
sinus beats. without greatly disturbing the regularity
of the underlying rhythm. is called an interpolated PVC
(Figure 9-13). The compensatory pause. usually associated
with the PVC. is absent.
R _an_ T PVC (Figure 9_14) is a term used to describe a
PVC which falls on the down slope of the preceding T wave.
This period corresponds to the relative refractory period of
ventricular repolariz.ation when the myocllrdium is in its
most vulnerable state electrically. During this period. the
myocardial cells havt repolarized enough to respond to a
strong stimulus. Stimulation of the ventricle at this time
may precipitate repetitive ventricular contractions. resulting in VI or fibrillation.
PVCS are among the most commonly s~n arrhythmias.
PVCs may occur in individuals with a healthy heart, but are
more common in people with coronary heart disease. PVCs
ar~ commonly caused by an increase in SYmpilth~tic tone
from emotional stress: ingestion of substances such as alcohol. caffeine. or tobacco: mitral valve prolapse, myocardial
ischemia or infarction; cardiomyopathy; congestive heart
failure; hypoxia: electrolyte imbalances (especially hypokalemia); drug effects (digitalis. epinephrine, norepinephrine):
as a reperfusion arrhythmia after thrombolytic thera~ or

Figur!! 9-15. Yen1r1cu1ar escape beal.

angioplasty: or following insertion of invasive catheters into

the heart. such as pacing leads or a pulmonary artery catheter.
Treatment of PVCs depends on the cause. the patient's
symptoms, and the clinical setting. Because occasional
PVCs are a normal finding in healthy individuals, no treatment may be indicated. especiilHy if the per5<ln is asymptomatic. Initially. a search should be made for possible
reversible causes (such as oxygen for hypoxia; replacement
of electrolytes: diuretics for heart failure; elimination of
certain drugs; avoidance of alcohol. caffeine. or tobacco;
and administration of antianxiety if indicated). Significant
PVCs (more than 6 per minute. multifocal PVCs, paired
PVCs. R-on-T PVCS. or PVO; in runs of3 or more) should
be treated with an antiarrhythmic medication. eSpe\:iaJly in
the setting of acute MI or following cardiac surgery because
of the increased risk of VI and VF in this setting.
On some occasions a ventricular beat may occur late
instead of early. A late ectopic ventricular beat usually
occurs after a pause in the underlying rhythm in which the
dominant pacemilku (usll<lHy th~ sinus node) filils to initiilte
an impulse. If the ventricles are not activated by the sinus
node. atria. or AV junction within a certain period of time.
a focus in the ventricles may ~escape" and pace the heart .
These are called venfricufarescapebeats (Figure 9-15). The
ventricular escape beat is a protective mechanism. protecting the heart from slow rates. and no treatment is required .

204

Ven tri cular arrhyth mi as and bundl e- branch block

Ventricular tachycardia

8019-3.
Ventricular tachycardia (VT): Identifying

Ventricular tachycardia (VT) (Figures 9-\6 through 9-20

and Box 9-3) is an arrhythmia originating in an ectopic
focus in the ventricles discharging impulses at a rate of 140
to 250 beats per minute. VT is most likely due to reentry
in the ventricles. but can also be caused by enhanced automaticity of a focus in the wntricles or to tril!.l!ered activity occurring during wntrkular repolariMtion. VT occurs
as /I series of wide QRS complexes seen in short runs or
as a continuous rhythm. Because of the wntricu lar origin of the impulse. no P waves are produced. The rhythm
is usually regular. but may he slightly irregular. The

ECG features
Rhythm:

Rate:
Pwaves:
PR Interval:
QRS complel:

RegJI<r; can be slightly Irregular

140 to 250 bea\slm~u18

No P waves are associated w11h vr.

Not measurable
Wide (0.12 second or

~eaI9f')

Figure 9-16. Ventricular tac hycardia.

Rhythm:
Regula'
Ratl:
150 beats/minute
P wavn:
PA ~t'MI :

None klentilled
Not m98SU'abl9

QRS complU: 0.14 to 0.16 second.

Figure 9-11.
Rhythm:
Ratl:
P waves:
PR IntIM I:
QRS complu:
COmment:

ventrICular nunaf.
Regula'
375 beats/minute
Nol seen
Not meastJ'able
0.12 to 0.14 second
Yenlr1cula' nutter Is a lorm 01 ventricular tachycardia. The ventricular rate Is so last the ORS complexes have a sawtooth
appearance.

Ve ntricular tachycardia

205

FIgure 9-18. Atr1alllbr1llatlon with a burst 01 ventricular tachycardia (Vl) .

Rh\'lhm:
Basic rhythm Irregular; vr r69J1a'
Ratl:
160 beats/m~uto (basic rhythm); 250 bealslmlnuto (VT)
Pwa8s:
Rbflllation waves ~ basic rhythm; I"IOI'l9wllh VT
PR Inbn'aI:

Not measurable

ORS complex: 0.08 to 0.10 second (basic rhythm); 0.12 second (VI).

FIgure 9-19. Ventr1cular tachycardia (lorsade de polntes).

Rhythm:
Regular
Rata:
250 beats/m~ute
P waVlS:
None Identmlld
PR InllllrYaI:
Not measurable
QRS complex: 0.12 to 0.22 second (somo much wider 111M others)

comment:

FIgure 9-20.

This type 01 ventriculii' lachycardla Is called torsad9 d6 poIntes (tn'lslhg oltho points). The DRS chalges !rom negative to
posttl8 polarity .nI appears to twist around the Isoeleclrlc 100.11 Is assoclaled wllh a prolonged OT Interval.nlls relraclory
to anDarrhylhmlcs.1V magnesium or overdrtve pacing has been successlUl ~ Ihetreatment ollhls rhythm.

Electrical cardloverslon 01 ventricular tachycardia 10 slrus rhythm.

206

Ventricular arrhythmias and bundle-branch block

ST segment and T wave slope in the opposite direction

from the main QRS deflection. 'MIen the QRS complexes
are of the same morphology in the same lead. the rhythm
is termed monomorphic lIT. When the QRS complexes
differ in morphology in the same lead. the VT is called
polymorphic VT.
VT may occasionally occur at rates greater than 250 beatsl
minute. At such extreme rates the QRS complexes appear
sa\\1:ooth in appearance and the rhythm is commonly referred
to as ventricular Rutter (Figure 9-17). Ventriwlar flutter is
so rapid that there is virtually no cardiac output. Ventricular
flutter is often a precursor to wntricular fibrillation.
VT usually occurs in patients with underlying heart
disease. It may be preceded by significant PVC. (more than
6 per minute. paired PVCs. multifocal PVCs), but often
occurs without preexisting or precipitating PVC . The
most common cause of sustained VT is coronary artery
disease with prior MI. Other causes include myocardial
ischemia. acute MI, cardiomyopathy, conllestive heart fail ure, mitral valve prolapse. valvular heart disease, digitalis
toxicity, electrolyte imbalances (especially hypokalemia
and hypomallnesemia). myocardial contusion. mechanical
stimulation of the endocardium by a pacinll catheter or
pulmonary artery catheter, as an effect of reperfusion following thrombolytic therapy or angioplasty, and drulls that
increase sympathetic tone (epinephrine. norepinephrine,
dopamine). Certain medications or conditions may prolong the QT interval, causing the vt!ntricles to IN! particularly vulnerable to a!)'pe of polymorphic VT called torsade
de pointes (Figure 9-19).
When VT lasts for less than 30 seconds it is called nonsustained VT. VT occurring in short runs of three or more
consecutive PVCs at a rate of 140 to 250 beats per minute is
considered a "run" or "burst" of nonsustained VT (Figures
9-11 and 9-18). Nonsustained VT, unless frequent, usually
doesn't cause symptoms, but it can progress into sustained
VT. When VT lasts longer than 30 seconds, it is considered
sustained VT. Sustained VT is a life threateninll arrhythmia
for two major reasons:
1. The rapid ventricular rate and loss of atrial kick reduce
cardiac output. This reduction in cardiac output often
compounds the alreildy low I:<Irdiac output frequently seen
in the diseased hearts in y,-hich VT tends to occur.
2. The rhythm may dellenerate into VF or asystole.
Treatment is based on the patient's presentation. An
';unstable" patient refers to an individual who presents
with symptoms such as hypotension, chest pain, shortness
of breath. signs of decreased perfusion (cool. clammy skin;
peripheral cyanosis; decreased level of consciousness; or a
decrease in urine output). A "stable" patient refers to an
individual with normal blood pressure, no chest pain. and
no shortness of breath or signs of decreased perfusion. As
part of the initial a ..essment you should check for a pulse.
lf there is not a pulse (pulseless VT ), the rhythm must be
treated as VF. If there is a pulse, protocols for stahle VT and
unstable IT are followed.

Treatment protocols: Stable monomorphic

Vfwlthpulse
Amiodarone (150 rug in 100 mL D,W) is lIiwnas an intra
venous pi~back (IVPB) bolus over 10 minutes. An additional150 rug NPB bolus dose can be repeated in 10 minutes
for resistant VT. Once the rhythm converts to a stable rhythm,
an amiodarone maintenance infusion should be started to
prewnt reoccurrence of VT. The amiodarone maintenance
infusion (900 mil in 500 rnL D,W in a IIlass bottle) is started
at 1 mg per minute for 6 hours. then decreased to 0.5mg per
minute for 18 hours. The total dose of amiodarone (NPB bolus
doses plus maintenance infusion) should not exceed 2.211 in
24 hours. Oral amiodarone can be started once the maintenance infusion is completed. Elimination of the drug from
the body is extremely lonll (half-life lasts up to 40 days).
If the rhythm is un ..... pomive to amiodarone. sedate the
patient and perform synchronized cardioversion bellinning
at 100 joules biphasic energy dose. increasinll in a stepwise
fashion with subsequent attempts.
Some physicians prefer to skip drug therapy and go
directly to synchroniud cardioversion. Figure 920 shows
cardioversion ofVT to sinus rhythm.

Treatment protocols: Unstable

monomorphic vr with pulse
Sedate the patient (if conscious).
Convert the rhythm using synchronized cardioversion
beginning at 100 joules biphasic energy dose, inmas
ing in stepwise fashion with subsequent attempts. Once
cardioversion has converted the rhythm, a maintenance
infusion of amiodarone is usually started at I mg per
minute for 6 hours, then decreased to 0.5 mg per minute for 18 hours, followed by oral amiodarone once the
maintenance infusion is completed.
Treatment of chronic, re,urrent VT usuaJly includes
therapy y,;th an oral antiarrhythmic. Patients who are
refractory to a pharmacologic approach may require further
evaluation, which could include specialized electrophysi
ologic testing and endocardial mapping with longterm
options including the use of an implantable cardiowrter
defibrillator (ICD ) or reentry circuit ablation. The ICD is
a surllically implanted devi,e developed to deliver an ele,
tric shock directly to the heart durinll a lifethreateninll
tachycardia. Ablation (destruction) of the reentry circuit
involves delivering short pulses of radiofrequency current
through an intracardiac catheter. It produces a small burn
that effectively blocks the part of the circuit supportinl( the
reentranttype wave.

Torsade de pointes ventricular

tachycardia
Tornade de pointe. (TdP) (Figure 9 19) i. a form of poly
morphic VT. This name is deriwd from a French term
meaninll '"twisting of the points," which describes a QRS
complex that changes polarity (from negative to positive

Ventricular fibrillation

and positive to negative) as it twists around the isoelectric line. TdP is an intermediary arrhythmia between VT
and VF.
TdP typically occurs when the QT interval of the underlying rhythm is abnormally prolonged, usually 0.5 second
or greater. A prolonged QT interval or long QT syndrome
(LQTS) is an abnormality of the hearfs electrical system.
Although the mechanical function of the heart is entirely
normal. the electrical problem is thought to be caused by
changes in the cardiac ion channels that affect repolaril.ation, causing a lengthened relative refractory period (vulnerable period) that puts the Vl:ntrides at risk for TdP and
may result in sudden death.
Some causes of TdP VT include bradyarrhythmias
(marked sinus bradycardia. third-degree AV block with a
slow ventricular response): excessive administration of
antiarrhythmics (quinidine, procainamide. disopyramide.
amiodarone, soblol): phenothiazines (prochlorperazine,
chloropromazine, thioridazine); psychotropic medications (haloperidol, amitriptyline): electrolyte imbalances
(especially hypokalemia, hypomagnesemia, hypocalcemia); liquid protein diets; central nervous system disorders
(subarachnoid hemorrhage or intracranial trauma); and
congenital LQTS.
The ventricular rate in TdP VT is extremely rapid and
the patient usually becomes unstable very quickly. Recognition of TdP is critical not only because of the rapid
deterioration of the patient but also because the treatment
plan differs greatly from the treatment of monomorphic
VT. Amiodarone, a drug used in treating monomorphic VT,
can prolong the QT interval and make matters worse in
this situation.

Treatment protocols: TdP vr

The initial treatment should be immediate un.synchronized shock at 200 joules biphasic energy dose. Due to the
variability in the QRS complexes in TdP, it might be difficult or impossible to reliably synchronize to a QRS complex. Although TdP is responsive to electrical therapy. the
rhythm has a tendency to recur unless the precipitating
factors are eliminated.
Hagnesium is the pharmacologic treatment of choice
for TdP VT. Magnesium is usually very effective even in
patients with normal magnesium levels. Magnesium acts as
an antiarrhythmic and may terminate or prevent recurrent
episodes of TdP. Give a loading dose of 1 to 2 g N diluted
in 10 mL D,W slowly over 5 minutes. This is followed by a
0.5 to 1 g/h~ur IV drip. Aside effect of magnesium is hypotension, especially if administered rapidly. Magnesium also
reduces neuromuscular tone and dose monitoring of deep
tendon reflexes is suggested.
Potassium chloride (like magnesium) is a first-line
therapy for TdP. Pota.. ium is e..ential for maintenance
of intracellular tonicity: transmission of nerve impulses:
contraction of cardiac, skeletal, and smooth muscles; and
maintenance of normal renal function. Depletion usually

207

results from diuretic therapy, diabetic ketoacidosis, severe

diarrhea, or inadequate replacement during prolonged
parenteral nutrition therapy. Dosage of potassium depends
on the serum potassium level, hospital protocols. and
physician orders.
Removing or correcting precipitating factors:
1. Bradycardia-induced - Discontinue drugs that decreil..'ie
heart rate: overdrive pacing or isoproterenol infusion may
be used to increase heart rate.
2. Drug-induced - Discontinue drugs that prolong QT
interval.
3. Electrol}1e-induced - Correct electrolyte abnormalities:
magnesium and potassium are considered first-line therapy.
In treatment of congenital prolonged QT syndrome or
recurrent TdP VT, an implantable defibrillator ICD can be
used as prophylaxis.

Ventricular fibrillation
In ventricular fibrillation (VF) (Figures 9-21 and 9-22
ilIld Box 9-4) a disorganized, chaotic, electrical focus in
the ventrides takes over control of the heart. Organized
ventricular depolarization and contraction do not occur
(there is no QRS complex), but instead the wntricular
muscle quivers and is often described as resembling a "bag
of worms. The ECG in VF shows characteristic fibrillatory
waves that vary in shape and amplitude in an irregular and
chaotic pattern.
VF with large amplitude waves is called coarse J1F
(Figure 9-21). If the VF waves are small, the rhythm is
called line ]IF (Figure 9-22). Coarse VF waves are generally more irregular than fine VF waves. Fine VF may
resemble ventricular asystole and should be confirmed
by eJt1lmining the rhythm in different leads. The distinction between fine VF and coarse VF is significant because
coarse VF usually indicates a more recent onset and is
more likely to be reversed by early defibrillation. Fine
VF usually indicates that the rhythm has been present
longer and may require drug therapy and cardiopulmonary resuscitation (CPR) before defibrillation can be
effective. Fine VF will progress to asystole unless the
rhythm is treated.

8019-4.

Ventricular fibrillation (VF): Identifying ECG

features
None (P wtmJ .wi CRS complex are It>sent)
None (P wtmJ .wi CRS complex are It>sent)
Pwaves:
Absent: wavy,lrregulM deflections seen, varying
In slze,~, and height and representatIYe 01
qulverDJ oIlhe YOOtrlcles Instead 01 contraction:
!!eRectionS may be small (described as fIn6 W) or
I.Yge (desalbed as coarse W)
Pfllnterval: Not meastnble
QflS complox: Absent
Rhythm :
Rate :

208

Venlricul nr nrrhyth minsllnd bundle- bru nch block

FiIlUr. 9- 21 . V9Iltrlcuiarnbrlllation (coarse wa'flllforms),

IIIIJlhm:
Chaotic
IIIlt:
0 D&atslmhUl8 (nO ORS complexes .8 presen1)
P _85:
Nona; wa\l!l !lellectlons an! chaolk: a-1CI va-y In size, shape, a1d height
PR .,tlml: Hot maasuable
ORS COmpltl: Absent.

VF is the most common cause of cardiac death in

patients with <Kule MI. Other causes include myocardial
ischemia. hypoxia, cardiomyopathy, electrolyte imbalances
(especia lly hypokalemia and hypomagnesemia), digitalis toxicity. excessive doses of antiarrhythmics, cardiac
trauma, and mitral valve prolapse. VF may be preceded by
significant PVCs or VT. but it may also occur spontaneously
without precipitating rhythms. VF may also occur during
anesthesia, cardiac catheteriution procedures, pacemaker
implantat ion. placement of a pulmonary artery catheter, or
after accidental electrocution.
Once VF occurs there is no cardillC output, peripheral
pulsel and blood pressure are absent, and the patient

becomes unconscious immediately, Cyanosis and ui zure

adivity may also be present. Death is imminent unless the
rhythm is treated immediately.

Treatment protocols: VF
Check the pulse 8nd rapid ly IIMUS the patient. If there is
a pulse and the patient is conscious. VF im't the proble m.
ECG artifacts produced by loose or dry electrodes. patient
mOllement, or muscle tremors may resemble VF.
If there is 00 pulse and the patient is unconscious, defibrillate al 200 joules biphasic energy dose. If the 8rrest is
unwitnessed. perform CPR for 5 cycles (2 minutes) before
the ini tial shock.

Fillure 9- 22. V9Iltrlcuiarnbrlllation (1Ine wavllfonns).

IIhytIlnt
Chaollc
IlIte:

0 beatslmhUl8 (no ORS to/Ilplexes IrQ present)

P WlYas:
Absent; wave deftectlons are chaollc and vary ., size, shape, a-1CIl\elght
Plllntirval: Not meastnble
ORS complex: Absent.

l dioventricular rhythm

If unsuccessful, start CPR, establish an IV line, and

ventilate the patient. Intubate the patient when possible,
Administer epinephrine I rug IV push and repeat
every 3 to 5 minutes, Vasopressin 40 units N push may
be given >< I dose to rcpt.:.ce ht or 2nd dose epinephrine,
Continue CPR for 5 cycles to circulate drug: defibrillate
at360joulesxl,
Consider one of the following antiarrhythmics:
I. Amiodarone 300 rug IV push (dilution in 20 mL O.W is
recommended); if VF is refractory or recurs, consider one
additional dose of 150 mglVpush in3 t05 minutes (dilution
in 20 mL D,W is recommended), If drug therapy is successful, a maintenance infusion of arniodarone can be started at
1 mil per minute for 6 hours followed by 0,5 rug per minute
for 18 hours (total dose of N push and maintenance infu
sion should not exceed 2,2 g/24 hours), Oral amiodarone
can be started following completion of the N infusion,
2, Lidocaine 1 to 1.5 mg/kg N push followed by half the
initial dose (0 ,5 to 0,75 mg/kg N push) every 5 to 10
minutes to a maximum dose of 3 mgikg, If drug therapy
is successful, a rnaintellll.nce infusion of lidocaine can
be started at 1 to 4 mg/minute, The half-life of lidocaine
increases after 24 to 48 hours, Therefore, after 24 hours the
dosage should be reduced or blood levels monitored, Signs
of toxicity include slurred speech, altered consciousness,
muscle twitching, seizures, and bradycardia,
N()f", All ;mti"rrhylhmic< h;we some degree ofpmormyth_
mic effects (IMY induce or worsen wntricular arrhytlunias),
Use of more than one antiarrhythmic compounds the aclwrse
effects, partiwlarly for bradycardia, hypotension, and TdP,
Never use more than one agent unless absolutely necessary,
Continue drug therapy, CPR, and defibrillation attempts
(drug-C PR-shock pattern) until rh}1hm resolves or a decision is made to stop resuscitative efforts,

Figure 9-2J,
Rhythm :
Rata:
P W3Y8S:
PfI Interval:

Idlove ntrlcular rhythm,

Regular
41 beatstmlnute
Absent

Not measurable
DRS complex: 0,22 to 0,24 second,

209

ldioventricular rhythm
Idioventricular rhythm (IVR ) (Figure 9-23 and Box 9-5) is Il
very slow rhythm originating from a focus in the ventricles
"t " rate of 30 to 40 beats per minutes (sometime. less),
Because the impulse originates in the ventricles, there is
no P wave and the QRS complex is wide, The rhythm is
usually regular, IVR is the normal rhythm of the ventricles,
NR can occur under either ofthe following conditions:
The heart rate of the dominant pacemaker (usually the
sinus node) and the backup pacemaker (usually the AV
junction) becomes less than the heart rate of the ventricles,
The electrical impulses from the sinus node, the atria,
or the AV junction fail to reach the ventricles because of
sinus arrest, sinus exit block, or third-degree AV block.
If the ventricles are not adivated by the sinus node, the
atria, or theAV junction, a focus in the ventricles can "escape"
and pace the ventricles, For this reason, NR is also called
ventricular escape rhythm, NR may occur in short runs of
3 or more consecutive ventricular beats at a rate of 30 to 40
beats per minute and is usually related to increased vagal
effect on the higher pacing centers controlling the heart
rhythm, Treatment is usually unnecessary, Continuous NR
usually occurs in advanced heart disease and is commonly

Box 9-5,

Idloventrlcular rhythm: IdentIfYIng ECG features

Rhythm:
Rata :
P W3Y11S :

Regular
30 to 40 beats/mlnute (someUmes less)
Absent

PfllntllYai:

Nol measurable
(0,12 second or greater)

QRS CompllX: Wiele

210

Ventricular arrhythmias and bundle-branch block

Figure 9-24. Agonal rhythm. sometimes called "dying heart. .

the cardiac rh}1hm present just before the appearanceofthe

final rhythm. wntricular standstill (asystole ). Continuous
IVR is generally symptomatic due to the slow rute and the
loss of the atrial kick. The rhythm must be treated promptly
following the protocols for significant bradycardia (atropine.
pacing, and vasopressors to increase blood pressure).
If the rate of NR falls below 20 beats per minute and the
QRS complexes deteriorate into irregular, wide. indistinguishable waveforms. the rhythm is commonly referred to
as an agonal rhythm or "dying heart"(Figure 9-24 ). Treatment is usually ineffectiw at this point.

Accelerated idioventricular rhythm

Accelerated idioventricular rhythm (AlVR ) (Figures 9-25
and 9-26 and Box 9-6) originates in an ectopic pacemaker
site in the ventricles with a rate bern.een 50 and 100 beats
per minute. The term accelerated denotes a rhythm that
~ceeds the inherent idioventricular ncape rate of30 to 40

Figure 9-25. Aocelefallld Idloventr1cular rhythm.

Rhythm :
Regular
Rat.:
84 beatslmlnute
P waves:
None Identified
Pfllnlervai:

Nol moasurable

DRS ComplQI: 0.16 socooo.

beats per minute, but isn't fast enough to be Vr. AIVR has
the same ECG charucteristics as NR (no P waws. wide QRS
complex. regular rhythm ), but is differentiated by the heart
rate. AIVR can occur as a continuous rh}thm (Figure 9-25 )
or in short runs of 3 or more consecutive ventricular beats
at a rate of 50 to 100 beats per minute (Figure 9-26).
AIVR is common after acute inferior-wall MI and is frequentlya reperfusion rhythm following thrombolytic therapy. angioplasty. or spontaneous reperfusion. AIVR may
also be seen with digitalis toxicity.
AIVR is usually well tolerated and is rarely associated
with symptoms. If the patient is symptomatic. it is usually related to a decrease in cardiac output from a loss of
the atrial kick and not because of the heart rate. which is
within a normal range.
Treatment of AIVR with antiarrhythmics is not recommended. Abolishing the wntricular focus may lead to
a less desirable rate and rhythm. This rhythm is usually
tramient, requires no specific therapy. and spontam:ously

Velllricularstands tiU (asystole)

21t

Figure 1-2&. Nanna! sinus rtlyttlm WItt1 episode 01 accelerated kIIo8f1trlctJlar rtlythm (lJYR).
BasIc: rhy'lhm regular; AIVR basIcaIy IlI\IUlar (011 by 2 SQIJI'nSl

Rhythm:
RIte::
p

sms PW3YIIS wID1 basic r1lythm; nane with AMI

PAl"."...:

0.12t10.16sean:1

wa_

79 beaWmloota basic r1lyIvn; a-lUId 80 b8at~nunul8 AIYR mte

ORS complu: 0.0611 0.08 sec:md (basi: fIlyt!lm); 0.12 S8C(III(I WVI\I.

1019-6.

Accelerated Idloventrlcular rhythm: Identifying

ECG features
Rhythm:

Rate:
Pwa_
PR IntarYaI:
QRS complft:

SO to 100 bIJalW'mDlte
Absenl
Hot mallSllllble
Wloe (0.12 saxnI 01' l1oa1er)

resolves on its own. A "tinctu re of time" is most often the

best rrmedy.

Ventricular standstill (asystole)

Ventricular standstill (Figures 9-27 and 928 and Bo)(
9-7) is the abunce of all electrical activity in the ventricles. When the ventricles are inactive. there are no QRS
romplnes. lhe atria. however. may continue 10 gene rate
electrical activity. prGducing P waves. Thus, ventricular standstill has t"Y.'1) prt!>Cntations on the ECG trncing:
P Wa'Ves without QRS complnes (Figure 9-27) or a straight
line (Figure 9-28).
If P waves are pruenl. some form of advanced heart
block (Mobiu II second-degree AV block or third-degree
AV block) rn.IIy have preceded the arrh}1hmia. Ventricular
standshll WIth a straight line usually occurs follOWIng such
arrhythmi;u as VT. VF, NR. and pulseless electrical activity.
Asystole may abo occur following termination of a tachY<lrrhythmia by medications, defibrillation. or cardioversion.
Occasionally. ventricuklr standstill may occur without
an obvious precipitating cause. In Figure 927. asystole
occurred during the paU!>C following a PAC.
Conditions contributing to the dewlopmrnt of ventricular standstill include extensive lIl)'QCilTdiai damage (from

isch~mia or infarction). hypoxia. hyperkalemia. hypokalemia. hypothermia. drug overdose. and advanced heart
block. Cardiac trauma may also be a contributing factor.
Once ventricular standstill occurs. there is no cardiac
output. peripheral pul!-eS and blood pressure are ~nt,
"nd the ""Iienl hr.<:ornl"-' "nc(m~im.. ;mmedillj"ly.
Cyanosis and seizure IICtivity may IIbo be prtsent. Death
is imminent unless the arrh)(hmia is treated immediately.
Without cardiac monitoring. ~1!ntricuklr standstill cannot
be distinguished from VF at the bedside.

Treatment pro tocols: Ventricular standstill

(asystole)
Check pulse and rapidly a.s.sw the patient. If there is a
pulse and the patient is ,onscious. ventricu lar standstill;s
not the problem.
Check moni tor ltad system (a loose electrode pad or
lead wire will show a straight line).
Check rhythm in two leads (low amplitude QRS complnes
fro)' look like P Wave5; fine VF may look like a straight line).
StlIrt CPR. establish lin N line. and ventilate the patient.
Intubate the patient when poible.
Give epinephrine I mg IV push and repeat every
3 to 5 minutes. Vasopressin 40 units IV push may be given
Box 9-1.

Ventricular standstill: Identifying ECG features

Rhythm:
Ratl :
l'.nlS:

PR 1ntIn"1I:

ORS complex:

Atrial: II P waves present. will haVe atrial rhythm

ventricular: None
AtrIal: II P waves present, will haVe atrial ralB
ventrtcular: None
ECG tathg$ wli show either P waves without a
ORS cunpIex 01' a straglt IN

""-

""'"

212

Ventricular a rrhythmias and bundle- branch block

figure 9-21. Normal sinus rflythm with one premature atr1al contraction changing to ventricular standstill.
Rhythm:
Basic rhythm regulM
Rail:
Basic rhythm 100 beaWmlnute
P wIVes:
Sinus P waves am present
PR lnten"al: 0.16 to 0.18 second (basic rhythm)
QRS complllJ:: 0.06 second (basic rhythm).

>< 1 <.1o,", lo '''pldU< Jir.;l or

"""",,<.I <.los" "pj""phrj"". Co,,-

tinue CPR to circulate the drug.

Consider pos.o;ible causes of the rhythm:
1) Pulmonary embolism
2) Acidosis
3) Tension pneumothorax
4) Cardiac tamponade
5) HjollOVolemia (most common cause)
6) H}T!Oxia
7) H}T!Othermia or hyperthermia
8) H}T!Okalemia or hyperkalemia

9) MI

10) Drug overdose

Continue administe ring epinephrine and performing
CPR until the rhythm is resoNed or a decision is made to
discontinue resuscitatiw efforts.
Prognosis is extremely poor despite resuscitative efforts.
The only hope for resuscitation of a person in asystole is to
identify and treat a rewrsible cause. With asystole refractory to treatment. the patient is making the transition
from life to death. Medical personnel should try to make
that transition as sensitiw and dignified as possible.

Figure 9-28. One wide venb1cular complex changing to venb1cular standstill.

Rhythm:
o beatslmkluID
o beatslmlnul8
None kIenIlfIod
PR JnlerYal: Not mWSU'abl8
QIlS complllJ:: 0.28 socond or WIder.

Rail:

Pwans:

Pulseless electrical activity (PEA)

Pulseless electrical activity (PEA)

Pulseless electrical activity (P EA) is a clinical situation
(not a specific arrhythmia) in which an organized cardiac
rhythm (excluding pulseless VT) is observed on the monitor, but no pulse is palpated. Causes and treatment of PEA

are the same as asystole. PEA has a poor prognosis unless

the underlying cause can be quickly identified and managed appropriately.
A summary of the identifying ECC features ofventricular arrhythmias and bundle-branch block can be found in
Table 9-1.

Table 9-1 .

Ventricular arrhythmias and bundle-branch block: Summary of Identifying ECG features

...

..

,, ~

Rhythm

Rate (beals/minute)

P waYlS (IIad II)

PR Interval

DRS complH

Bundle-brarch

Reguar

That oIl1111er1yjng
rIrfIIm (usualy silllS)

Sinus origin

Nonnal (0.120.20 soc:ond)

"

-..

ventricuar

"""'''"'
(I'Iq
Vmlricular

(0.12 second or
grcotcr)

Basic rhythm

usually rl9llar,
imlguar with

That oIlJ1der1ying
rIrftIm (usualy silllS)

PIC

Nona associated with PVC; P

WlIV8S associated with underlying sillJl rhythm can sometimes be soon just belore PVC
or after PVC in ST segment or
TWlII'II, but these waves ara
usually hidden within I'IC

Not measurable

Nona associated lith vr

Not measurable

PrematlR ORS
complex; abnormal
shape; wide
(0.12 second or

greater)

..
..."
"

Reguar (can be
sl911iy irregular)

140 to 250

None (P wave and

DRS complex are

None (P '#me and DRS

complex are absent)

Absm~

Not measurable

Idiovenlricuar
rf1yIhm (IVR)

Reguar

30 to 40 (sometimes

..."

"'-""' "

kcelerated IVR

Reguar

tachyC3"dia
(VT)

Vmlricular
fibrilation (VF)

-,

(0.12 second or
greater)

wavy, i-reopar deftactions seen in various sims,

shapes, and he91t1, ropresentatil'll oIvenbicuiar ~iVllling
instead of contraction; dellactions may be small (described
as fine ].F) or large (described
as coarse IIF)

I~I

50 to 100

..
"..
..."

(0.12 second or
greater)

..."

Not measurable

(0.12 second or
greater)

Vmlricular
slaldstil
(YenIriruar

_I

AIriaI: ffPWlIYeS
present, wil hal'll
allial rhythm
Ventriwlar: None

Allial: if P waYeS
present. wil hal'll
allial rate
Ventricular: None

213

Tracing wi. show eithar

P waves wiIhaJl a (JIS
compl81 or a strai~t line

Not measurable

2 14

Ventricular arrhythmias and bundle-branch block

Rhythm strip practice: Ventricular arrhythmias and bundl e-branch block

Analyze the following rhythm strips by following the five
basic steps:
Determine rhythm regularity.
Calculatehearl rate. (This usually refers to thewntriculilr rate. but if atrial rate differs you nd to calculate both.)
Identify and examine Pwal!e5.

MeasurePRinterval.
Measure QRS complex.
Interpret the rhythm by comparing this data with the
ECG characteristics for each rhythm. All rhythm strips are
lead II, a positive lead, unless otherwise noted . Check your
ansVt-el'5 with the answer keys in the appendix.

Strip 9-1.l1hythm: _ _ _ _ _ _ _ _ _ _ _ nate: _ _ _ _ _ _ _ __

PR interval:

Pweve: _ _ _ _ _ __

ORS oornplex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp 9-2. lI1ythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-3. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS cornplex:_ _ _ _ __

Rhythm interp-atalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

strip 9-4, Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

21 5

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ _ __

Rhyttvn interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-5, Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhyttvn interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-6, Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS complex: _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

2 16

Ventricular urrhythmias und bundl e brunc h block

Strip &-7. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

DRS complex :' _ _ _ _ _ __

Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-8. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR InlerYal:

DRS complex:' _ __ _ _ __
lIlythm inlerpratalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-9. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

DRS cornplex:, _ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

Strip 9-10_ Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

217

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-11_ Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-12_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

2 18

Ventricular arrhythmias and bundle-branch block

Strip 9-13, Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PFI ilterval:

ORS oomplex:_ _ _ _ _ __

Rhythm inl&rpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-14. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PFI ilterval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-1S. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PFI interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ve ntricular arrhythmias and bundle-branch block

219

Strip 9-1Ii. Rhythm: _ _ _ _ _ _ _ _ _ Rata: _ _ _ _ _ _ __ Pwava: _ _ _ _ __

PR inlerwi:

CRS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-17. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
CRS complel: _ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-18. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interwl:
CRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

220

Ventricular arrhythmias and bundle- branch block

Strip 9-19. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:- - - Rhythm interpretamn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-20. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS rompleI:_ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp9-21. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR Interval:
QRS romplex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

221

Strip 9-22_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS ComplelC _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-23_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complelC _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-24. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

222

Venlriculur urrh)'lhmiu$ and bUlldle-bru ilch block

Slrip9-25_RhyIhm: _ _ _ _ _ _ _ _ _ _ PR 1n1&Mll:

, _ _ _ _ _ _ _ _ PwaY8: _ _ _ _ __

ORS c:omplex:_ _ _ _ __

"""m'_'____________________

StrIp 9-2&' RIIyttrn: _ _ _ _ _ _ _ _

R"" _______

Pwave: _ _ _ _ __

R"""'_ -'____________________
PR Interval:

ORS cornplex:_ _ _ _ __

R"" ________

Strip 9-27_Rhythm: _ _ _ _ _ _ _ _ _
PR Interval:
ORS c:omplex:,_ _ _ _ __

Pwave: _ _ _ _ _ __

Rbythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

Sirip 9-28_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

223

Pwave: _ _ _ _ __

PR intenai:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-29. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ __
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-30. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

224

Ventricular arrhythmias and bundle- branch block

Strip 9-31 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS COOlplex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-32. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

OIlS complex:_ _ _ _ _ __

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-33. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS wrnplelC:_ _ _ _ _ __

Rhythm interpretali:Jn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

22 5

Strlp 9-34_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR inteMlI:
QRS ComplelC _ _ _ _ _ __
Rhyttvn inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-35_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR intElV3i:
QRS complelC _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strtp 9-36_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

226

Ventricular arrhythmias and bundle-branch block

Strip 9-37_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-38. Rhylhm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

Pwava: _ _ _ _ __

aAS cornplex: _ _ _ _ __

Rhythm imerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-39. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

22 7

Strip 9-40_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Stri" 9-41 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex: _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-42. Rhytllm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
ORS complex: _ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

228

Ventricular arrhythmias and bundle-branch block

Strip 9-43. Rhythm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inrerpretatkJn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-44. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-45. Rhythm: _ _ _ _ _ _ _ _ __ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm Interpretatioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

229

Strip 9-46. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-47. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-48. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

230

Ventricular arrhythmias and bundle-branch block

Strip 9-49. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlefpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-50. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PH ilterval:
QRS complex:
Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-51 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

23 1

Strip 9-52_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR Interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-53_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR intemil:
QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-54. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

232

Ventricular arrhythmias and bundle- branch block

Strip 9-55. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwal'l!: _ _ _ _ __

PR interval:
QRS complex:- - - Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-56. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR ilterval:

Pwave: _ _ _ _ _ __

QRS oomplex:_ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-57. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

233

"I'-t-+++-t+lb-HHI-t-++++-'l'-H--f4t-+-+-lI+
' j!-H-tl I

~ rnu"I.'~' ~
1 ~ututut~~U;~~1
strip 9-58_ 1IlyIhm: _ _ _ _ _ _ _ _ ..'" _ _ _ _ _ __

Pwaw: _ _ _ _ __
11ft interval:_ _ _ _ _ _ _ _ OftScomplex:_ _ _ __
RhyIhm Int8fJ)fetation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-59. Rhythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

PfI interval:

Pwaw: _ _ _ __

ORS complex:_ _ _ _ __

Rhyttvnlnteqmatioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-iO. Rhy1h'n: _ _ _ _ _ _ _ _ _ _

P'R interval:

_ _ _ _ _ _ __

PwaYe: _ _ _ _ __

ORS complex: _ _ _ _ __

Rly1hm inleqlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

234

Ventricular arrhythmias and bundle- branch block

Strip 9-1i1. Rhytlvn: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ PwaYII: _ _ _ _ __

PR int8fVaI:

QRS complex: _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-62. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ PwaYII: _ _ _ _ __

PR interval:

ORS oornplex:_ _ _ _ __

Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-63. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PwaYII: _ _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm inlerprellRion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

23 5

Strlp 9-54_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR inteMlI:

QRS ComplelC _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-65_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QAS ClIl1plex:_ _ _ _ __

Rhythm inlerpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-66_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

236

Ventricular arrhythmias and bundle- branch block

;;

Strip 9-&7. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PFI interval:

OIlS complex:_ _ _ _ _ __

Rhythm inierpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-&8. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PFI interval:

Pwaw: _______

OIlS cornplex:_ _ _ _ __

Rhythm inlerpretalm:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-69. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PFI interval:

Pwa~ :

_______

OIlS complex:_ _ _ _ _ __

RhythminbMpretation :' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

237

Sirip 9-70_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-71. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR interval:

Strip 9-72_Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex: _ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

238

Ventricular arrhythmias and bundle-branch block

Strip 9-73. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:
Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-74. Rhythm: _ _ _ _ _ _ _ _ _ _

PR interval:

'm" ________

Pwave: _ _ _ _ __

DRS complex:_ _ _ _ __

Rhythm interpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-75. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ve ntricular arrhythmias and bundle-branch block

239

Strip 9-76. Rhylhm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

QRS complex: _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-77. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interwl:

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-78. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ __ _ _ _ __

Pwave: _ _ _ _ __

PR interwi:
QRS complex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

24 0

Ventricular arrhythmias and bundle- branch block

Strip 9-79. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
DRS complex:_ _ _ _ _ __
Rhythm inrerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-SO. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR iltervaI:

Pwave: _ _ _ _ _ __

DRS cornplex:_ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-81 . Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS cornplex:_ _ _ _ _ __
Rhythm inrerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

241

strip 9-82_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _~ Pwave: _ _ _ _ __

PR interYai:

QRS complex: _ _ _ _ _ _~

Rhythm inlerpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~

Strip 9-93_Rhythm: _ _ _ _ _ _ _ _ _~ Rale: _ _ _ _ _ _ __

PR intaMI:

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ __

Rhythm inlerpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 9-84_Rhythm: _ _ _ _ _ _ _ _ _~ Rate: _ _ _ _ _ _ __

PR interYai:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ _~

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

242

Ventricular arrhythmias and bundle- branch block

Strip 9-85. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwal'l!: _ _ _ _ __

PR interval:
QRS complex:- -Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-Bi. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR ilterval:

Pwave: _ _ _ _ _ __

oomplex:_ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
QRS

Strip 9-B7. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR inieNal:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm inlerpretaliDfl: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

Strip 9-88_Rhytlvn: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
Rh~i~e~remtioo :

243

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

Strip 9-89_Rh~: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR inteNaI:
Rh~i~e~remtioo :

QRS complex:_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

St rip 9-90_ Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

2 44

Ventricular arrhythmias and bundle-branch block

Strip 9-91 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ __

Rhythm Inl&rpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-92. Rhythm: _ _ _ _ _ _ _ _ _ _ 'm" _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:

DRS complex:_ _ _ _ __

Rhythm inlerpretatkln:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-93. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ve ntricular arrhythmias and bundle-branch block

Strip 9-S4. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

PR interval:

245

Pwave: _ _ _ __

ORS Cmlplex:_ _ _ _ _ __

Rhytlvn interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-95. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR Interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-96. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ __ _ _ _ __

PR inlelV'd1:

Pwave: _ _ _ _ __

QAS curnpleJr.:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

246

Ventricular arrhythmias and bundle-branch block

Strip 991_Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS cornplex:_ _ _ _ _ __

Rhythm Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-98. Rhythm: _ _ _ _ _ _ _ _ _

PR interval:

Am" _ _ _ _ _ _ __ Pwave: _ _ _ _ __
ORS complex:_ _ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-99. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS cornplex:_ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm slTip praclice; Ventricular arrhythmias and bundle-branch block

2 47

Strip9-100. fI1ythm: _ _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ _ __ p~: ------

PR irterwi:
fI1ythmme~e~

ORS complex:, _ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

248

Ventricular a rrhythmias and bundle- branch block

II Skillbuilder practice
This section contains mixed sinus. atrial. andjunctioTUlI ondAV block. and ventricular rhythm strips. allowing the student
to practice differentiating betv,~n two rhythm groups before progressing to the Posttest As before. analyze the rhythm
strips usingthe five-step process. Interpret the rhythm by comparing the data collected with the ECG crurncteristiCl; for each
rhythm . All strips are lead II. a positive lead. unless otherwise noted. Check your answers with the answer key in theap~ndix.

Strip 9-1 01 . Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS C1IITIplex:_ _ _ _ __

Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-102. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PFl interval:

Pwave: _ _ _ _ _ __

DRS complel:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-1 03. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PFl interval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm interpretamn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

249

Strip 9-104. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-105. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR inteMI:
QRS complex: _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-106. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex: _ _ _ _ _ __

Rhythm interprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

250

Ventricular arrhythmias and bundle-branch block

Strip9-107. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm interprelllticn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp9-10B. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm interprelllticn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9- 109. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpr8tafun:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IUlytiUll slrlp pructlcc: Vcntrlculur urrh ythmlus und bundle- brunch block

25 1

Pwa~ : _______
Strip 11-110. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR Interval:
ORS compln:_ _ _ _ __
Rhythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp &-111 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR InteMII:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ __
Strip&-112. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR inieMII:
ORS complex:, _ _ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

252

Ventricular urrhythmias und bundl e brunc h block

Slrip9- 113. Rhytlvn: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

Pwa~ :

_________

PA Interval:
ORS oomplex:' _ _ _ _ __
Rhythm Interprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-11'. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ P wave: _ _ _ _ ___

PR Interval:
ORS compleX:, _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip9-115. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _________

PA interval:
ORS cornplex:, _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip prnclice: Ventricu lar arrhythmia s and bUlldle-bran(;h blo(;k

StrIp 9-116. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

2 53

Pwave: _ _ _ _ __

PR Interval:
OAS complex:' _______
PJlythm ilterpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strlp9-117. Rhythm: _ _ _ _ _ _ _ _ _ Ratlt. _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex: _ _ _ _ __

Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip9-11B. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

254

Vc ntril:ulnr a rrhythmias und bundl e-brunch block

Strip 9- 119. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

P wave: _ _ _ _ __

ORS complex:' _ _ _ _ __

PJlythm inlerpreialion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-1 20. Rhythm: _ _ _ _ _ _ _ _ _ Rala: _ _ _ _ _ _ __

PR interval:

P wave: _ _ _ _ __

CRS complex:' ________

Rhythm interpratation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __
Strip9-121 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __
PR interval:
ORS complex:, _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Ventricular arrhythmias and bundle-branch block

255

Strip 9-122. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

QRS complex: _ _ _ _ _ __
Rhythm ilterpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

PR interval :

Slrip9-123. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
QAS complex:_ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __
PR interval:
QRS complex: _ _ _ _ _ __
Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 9-124. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pacemakers

Overview
An

~rti1icial

pactlTl4ker is an electronic device that gener-

ales and transmih an electrical stimulus to the atria. the

wntrides. or both. resulting in depolari!;illion. followed

by muscle contraction. The use of artificial pacemakers

may be necessitated wmn there is a significant ffiillfunc-

tion of the heart's electrical system, usually inyolving the

sinus node, the atria. or the atriOl.'enlricular (AV) conduction pathways. The result may be a slow, fast. or irregular
rhythm. whkh can affect the heart's pumping ability and

may lead toa decrease in cardiac output and in the quality

of life. Some indications for pacing include:

Sinoatrial d)'dunction
I. Sinus bradycardia
2. Sinus alTl.'st

3. Sinus exit block

4. Atrial flutte r or fibri llation
5. Sick sinus syndrorrre (rhythms in which there is

markd bradycardia alternating with periods of tachycardia, especially atrial flutter or fibrillation: abo called
tachy-brady syndrome).
6. Chronotropic incompetence {sinllS node is not Cllpa
ble of incrusing its rate in response to <tCtivity
AVblock
I. Seconddegree AV block, Mobitz II
2. Third-dq:jree AV block
H y~r!;e'nsitive carotid sinus _ Stimulation of the
carotid sinus that causes episodes of asystole resulting in
recurrent synco~: stimulators may include turning the
head from side 10 side. or wearing a tight necktie or collar.
Pacemakers may be inserted on II temporary or perma
nent basis depending on the clinical situation. Temporary
piKing is appropriate in emergent situations (transient
symptomatic bradycardias or AV block lISSOCiated ",ith
myocardial ischemia or drug toxicity). Temporary pacing
may also be used to provide prophylactic therapy for high.
risk patients during cardiac C4ltheterization, during and
after cardiac surgery. and to override liKhyarrhythmias
(~rdrive piKing). Permanent pacemaker implantation is
considered for unresoilltd rhythms or conditions in which
clinical symptoms are present and for which long-term
piKing is indicated.
A pacemaker system (Figures 10-5 and 10-6) consists of
a pulse generator and a pacinillead:

256

Pulse generator - The pulse generator houSl.'S a battery, a lead conntctor, and electronic circuitry for pacemaJrer sell ings.
Picing lead _ The pacing lead has one or twQ metal
poles (electrodts) at the tip of the catheter that come in
contact with the endocardium (Figure 101). A lead with
only one electrode at its tip is called II unipolar pacing
system. A lead with two electrodts at its tip is called a
bipolar pacing system. The pacing lead serves as a Iransmis.5ion line between the pulse generator and the endoC4l rd ium. Electrical impulses are transmitted from the
pulse generator (through the pacing lead) to the endocardium, while information about intrinsic electrical activity is relayed from the electrooe tip (through the pacing
lead) back to Ihe generator. If the generator responds by
sending a pacing impulse to the heart, it is called trig
gering. If a pacing impulse is not sent 10 the hurt, this
is called inhibition. Many permanent pacing leads are
constructed with fixation devicn (screws, tines, or barbs)
thai help guarantee long-term contact with the endocardium. Temporary pacing leads are not constructed with
fixation devices 50 they can be easily removed ...men pilcing is no longer required.
Pacemakers can function in a fixed rate mode or a
demand mode:
Fixed rate mode (asynchronous) - Fixed rate pacemakers initiate impulses at a set rate, regardless of the
patient's intrinsic heart rate. This moxie of pacing is
knOYoll as asynchronous pacing because it's not synch ronned to $eose the patient's own heart rhythm. This
may result in competition be""'een the patient's natural
(inlrinsic) rhythm and that produced by the pacemaker.
Ventricular tachycardia or ~ntricular fibrillation may be
induced if the pacing stimulus falls during the vulnerable period of the cardiac cycle. Fixed rale pacemakers are
rarely used today.
Oemand mode (sync hronous) - A demand pacemaker paces only when the heart fails to depolariz.e on
its own (fires only "on demand"). Demand pacemakers
are designed with a $ensing mechanism that inhibits
discharge when the patient's heart rate is adequale and
a pacing mechanism that triggers the pacemaker to fire
when no intrinsic activity occurs within a preset period.
This mode of pacing is called synchronous pacing because

Overview

257

..

EllIC1rodu( ..) _______::I---!:::;";~;;;;"::' ,-1

Unipolar lead

Bipolar lead

Figure 10-1 . Unipolar and bipolar pacing leads.

it is synchronized to sense the patient's cardiac rhythm.

Demand pacing is the most commonly u~d pacemaker
mode today.
A pacemaker system may be single- or dual-chamber:
Single-c hamber - A single-chamber pacemaker system
uses one lead inserted into either the right atrium or the
right ventricle. This pacemaker can sense and pace only
the chamber into which it is inserted.
If a single-chamber atrial pacemaker senses a P wave.
the pacemaker is inhibited from firing an electrical stimulus. If it does not sense a P wave. the pacemaker sends
an electrkal stimulus to the atrium. Stimulation of the
atrium produces apacemalcer spike (a vertical line on the
ECG), followed by a P wave (Figure 10-2, example A).

If a single-chamber vent ricular pacemaker senses

a QRS complex, the pacemaker is inhibited from firing an electrical stimulus. If it does not sense a QRS
complex. the pacemaker sends an electrical stimulus
to the ventricle. Stimuliltion of the ventricle produces
a pacemaker spike followed by a wide QRS complex.
resembling a ventricular ectopic beat (Figure 10-2,
example B). Single-chamber ventricular pacing is the
most commonly used temporary type of pacing and
is also frequently used for permanent pacing. Singlechamber atrial or ventricular pacing can be used with
epkardial pacing wires.
DUill-chim.ber - A dualo.Chamber pacemaker system
uses ""'0 leads, one going to the right atrium and the other

Figure 10-2. Single-chamber and dual-chamber pacing examples.

(AI TIle singlechamber atrial pacemaker looks Ill' a P wave <nI1~es Into the atrkJm " no Pwave Is sensed; the poclng spl<e Is lolklWed by a
Pwave.
(B) The slngle-dlambor ventricular pacemaker looks lor a ORS complex and !Ires ~o the ventr1d8" no ORS Is sensed; the pachg spike Is
lallowed by a wide ORS complex.
(C) The dualchamber pacemaker looks lor a Pwave; II no Pwave Is sensed. the pacemaker delivers a stimulus I1to the alrlum; the pacing
splkllis Iallowed by a Pwave. After a programmed eleclronlc PR ~ervaI (theAV Interval). II no ORS Is sensed, a seconcI stimulus Is delivered
Into the ventrIcIo: the pacing spike Is loIlowllCl by a wide ORS complex.

258

Pacelllukers

to the right IIfntricie. 1he dual-chamber pacemaker can

sense and pace in both chambers.
If a duakhamber pacemaker senses a P waw, the pace
maker is inhibited from firing an electrical stimulus. If the
pacemaker does not sense a P wave. the pacemaker sends
an electrical stimulus to the atrium. Stimulation of the
atrium produces a pacemaker spike. followed by a P "'ave.
The pacemaker is programmed to wait, simulating an electronic PR interval. In pacing terminology the artificial PR
interval is called the AV interval. If a dual-chamber pacemaker senses a QRS complex. it is inhibi ted from liring an
electrical stimulus. If the pacemaker does not sense a QRS
complex. the pacemaker will send an electrical stimulus to
the wntricle. Stimulation of the ventricle producs a pace
maker spike followed by a wide QRS complex. Figu re 10-2,
example C, snows stimulati on of the atria and the ventricle
by a dual chamber pacemake r.
Dual-chamber pacemakers lin oCten called AV sequential pacemakers becaust of their ability to stimulate the
atria and ventricles in sequence (first the atria, then the
ventriclu), mimicking normal htart physiology and thus
preserving the atrial kick.
Dual _chambe r pacemakers are frequently used with
permanent pacing and can also be used with epicardial
pacing. DuaI-chamber temporary pacing can be done, but
it is difficult to place temporary atrial wires and it is not as
reliable u ventricula r pacing.

Temporary pacemakers
Temporary pacing can be accomplished with transcutane
ous (tlCIernal), transvenoos, or epicardial methods:
Transcutaneouspacing(TCP)- TCPreters to the delivery of II pacing stimulus to the heart through pads placed
on tht patient's outer chest (Figure 10-3). Requirements
for Tep include pacing pads, a pacing cable. and a delibrillator monitor with pacing capabilities. TCP is recommended as the initial IWICing method of choice in emergent

cardiac situations. External pacemakers are noninvasive.

effectiw. lind quick and easy to apply. rcp provides only
ventricular pacing.
TCP is indiCllted a.s a treatment for symptomatic
bradyarrhythmias (sinus bradycardia. slow atrial Hutter
or fibrillation, Mobil1. [I second-degree AV block. or
third-degree AV block). TCP is not effective in rhythms
without meaningful contractile activity such as wntricular stands till and pulseless electrical activity (PEA) that
occur in the setting of cardiac arrest. This is because the
primary problem in these situations is the inability of the
myocardium to contract when appropriately stimulated.
External pacemakers should not be relied upon for an
extended period of time. They should be used only as a
temporary measure in emergency situations until trllnsvenous access is available or the c.ause of the bradyarrhythmia is resolved. Transvenoos pacing is still the treatment of
choice for patients requiring a temporary but longer period
of pacemaker support
The technique of rcp involves:
I. Attach plICing pads toches!. rcp involves attaching two
large pacing pads to the skin surface of the patient's chest.
Multifunction pads have the capability to monitor the heart
rhythm, externally pace. and defibrillate through one set of
pads. The pads have conductive gel on the inner surface to
help transmit the electrical current through the chest wall.
The large surface IIrea of the pad and the conductive gel
also help minimize the possibility of skin bums from the
procedure. If po$Sible. eJlCS5 hair should be clipped before
the pads are appli ed to maximize contact with the skin
surface.
Most manufacturers recommend the pads be placed in
an anterior-posterior pos.ition. The anterior pad (labeled
"front") is placed to the left of the sternum, halfway
betv.'Un the Kiphoid process and the left nipple. In the
female patient. the anterior pad shoul d be positioned under
the left breast. The posterior pad (labeled ~backW) is placed
on the left posterior chest directly behind the anterior pad.
Successful TCP requires a higher electric.al current
output (mA) than conventional transvenous pacing to
overcome the resistance
the chest wall. Placement of
the pacing pads affects the amount of current required
to depolarize the ventricle. The placement that offers the
most direct pathway to the heart usually requires the lowest rnA in order to pace the heart. Currents of 50 rnA or
more may be associated with discomfort and sedation may
be required.
2. Connect pacing pads to defibrillator or monitor. Conned the pacing pads to a pacing cable and a defibrillator
monitor system v.ith pacing capabilities.
J. Initiate pacing. Set the defibrillator or monitor to pace
setting. Set the pacing rate first (usually 70). then slowly
increase the rnA until consistent ventricular capture is
seen on the monitor (a pacing spike followed bya wide QRS
complex. Figure 104). If capture is lost during pacing, the
mA may have to be increased.

oc

''''''''

I ~ ~.i--

.,'"

_--l

...- ~

, I, '
I

( ,~

-,.

\~, \

Figne 1 0-3. External pacing pad placement (anteoo--posterD

Temporary pacemakers

259

Rgure 10..... Eleclr1cal cap1ure oflhe ventr1c1e with an external pacemaker.

lhls ligll'e shows a square pacing spike (Zoll monltor.oollbrillator with external pacemaker). other external pacemakers may have a dlnerenl
pac~

artifact.

Verify that electrical capture (seen on the monitor) is

with mechanical capture (verified by palpable pulses). Evalu<lte pulses on the patient's right side to
avoid confusion between the presence of an actual pulse
and skeletal muscle contractions caused by the external
pacemaker.
Transvenous pacing - Transwnous pacing rders to
the deliwry of a pacing stimulus to the heart through a
associat~d

vein

(tr~n""'-no". ~l"l"ro~ch ) _

Re'l,,;remenl., for

tr~n-",e_

nous pacing indude <In external pulse gener<ltor. a pacing lead wire, and a bridging cable to connect the two
(Figure 10-5).
Some indications for transvenous pacing include
symptomatic bradyarrhythmias (sinus bradycardia.
Mobitz II second-degree AV block. and third-degr~e AV
block). prophylactic therapy during cardiac catheterization for high-risk patients. <lnd overdrive pacing of
tachyarrhythmias. Transvenous pacing is usually not
effective when meaningful contractile activity is abs~nt
(wntricular standstill and PEA). For significant unresolved rhythm or conduction disorders. permanent
pacing is requird.
Temporary pulse generators are externally controlled by
manipulating dials on the face of the unit. Removable biltteries are contained within the generator housing. Prior to
insertion of a pacing lead. prepare the equipment. Insert a
new 9-volt batt~ry into the battery compartment; set pacing rate at 100 beats per minute. the rnA to 5. and the sensitivity knob to trnXimum clockwise position for demand
(synchronous) pacing. Insert the end of the bridging cable
into matching terminals on the pulse generator, and turn
1"111""

gl'.ner~tor

on to verify pro[ll'r f"nct;on;n!! of thl'.

battery and unit.

The prderred routes of access for transvenous pacing
are the right internal jugular win. the right subclavian. and
the right femoral win. The pacing lead is inserted into the
win of choice and guided into the heart using fluoroscopy.
Once- the- w;re- ;s v;,ullliz.cd in thc right ~tr;um. ~ bll.lloon

at the tip of the pacing catheter is inflated and the wire

is floated through th~ tricuspid valve into the apex of th~
rightventride for single-chamber ventricular pacing. Even
though single-chamber atrial pacing and dual-chamber
pacing can be done. single-chamber wntricular pacing
is the most reliable and prderred choice for transwnous
pacing. Onc~ proper placement is wrified. the balloon is
deflated. The distal tail of the pacing catheter is connected
to thl'.

ne~~t;ve

connec.t;on of the hr;dp;;np; CJlhle and thl'.

proximal t.:lil is connected to the positive connection of the

bridging cable.
Using the dials on the external pulse generator. adjust
the pacemaker sdtings:
1. Determine voltage threshold. This is the smallest
amount of voltage (rnA) required to pace the heart. 'Nhile
watching the cardiac monitor. gradually turn down the rnA
until capture is lost (usually 0.7 to 1.0 mAl <lnd thengradually turn up the rnA until capture is regained. The point at
y,-h.ich capture is regained is the threshold. Set the rnA at
twice threshold level.
2. Set Pilcing rate. This is determined by the physician
(usually 70 beats per minute).
3. Set sensitivity. Sensitivity is usually maintained at maximum clockwi~e position (5 oclock).
The number of temporary transwnous pacing leads
being placed is decreasing, largely due to the improwd
reperfusion management of acute MI and improved access
to permanent pacing systems .
Epicarclial pacing - Epicardial pacing refers to the
delivery of a pacing stimulus to the heart through wires
placed on the epicardial surface of the atrium, wntricle, or
hoth, during Qlrd;~c. _""I!ery_ 'lWo w;re., are

~ttach~d

to the

atrium for singl~-chamber atrial pacing (one wire serws as

ground) or to the wntricle for single-chamber ventricular pacing. or two wires are attached to both chambers for
dual-chamber pacing. The wires are loosely sutured to the
outer surface of the heart and pulled through th~ chest
wall where they Ilre Ilttll<:hed to a bridging coble II.Ild lIll

260

Pacem akers

Bridgi"ll cable

I.!..
A

"'o,tPU~~

."
':"Q'~' ~"CD

,..

..oRa
te .. B

0'

"

"

. ~,""''-L D

BatieI)'

Pulse generator
Figure 1 0-5, Tempol3)' tI31svenoos pacemaker system.
A. Output or rnA dial
1. controls the amount 01 electrical energy delivered to endocardium.
2. Incroase rnA by turnhg dial cklckWlse to higher rumber; decreasa rnA by turning dial COlJItereiockWlsa to lower number.
B, Rata dial
1. Ootormh9S th9 hoa"t rata In boolslmlnuta a1 which tho stimulus Is to b9 dGllv9rod.

C, sensltlvtty or mY dial
1. controls the ability oflhe generator to sooselhe electrical actlvtty.
2. In maximum cIocI(\YIse position (5 o'dock), provides demllld (synchronous) pacing.
3. In maximum counterclockWise posttlon (7 o'clock), provides fixed rate (asynchronous) pachg.
4. Increase sooslUYity (mY) by turning mY dial cIockwtse to lower rumber, decrease senslUVIty by turning dial COUlIerdod<wtse to higher

number.
D, Onfotl control

1.

AcIIyat~actlYates

the pulse generator.

external pulse generator. Atrial wires usually exit to the

Permanent pacemakers

right of the sternum and wntri,ular wires exit to the Idt.

A permanent pa,emaker system (Figure 10-6) refers to

'Mten no longer neded, the wires are gently pulled out

through the wound .
Epicardial pacing is used after cardiac surgery to treat
symptomatic bradyarrhythmias, as a prophylactic measure
for high-risk patients. and to treat tachyarrhythmias using
overdrive pacing techniques.

an implanted generator and a lead wire (or ".,ires) that is

introduced into the heart through a central vein (often the
subclavian). The implant procedure is relatively simple.
usually performed under local anesthesia and conscious
sedation, and lasts about 1 hour. The procedure is facilitated by fluoroscopy. which enables the physician to view

Pulse generator

r:::::~:t""'~dC~~f
E!ecrrical Battery
ClfCUI

Figure 10-6, Permanent pacE1rMlr system.

Permanent pacemaker identification codes

the passage of the lead wire. After satisfactory placement of

the pacing lead is confirmed, the lead is connected to the
pacemaker generator. The generator is placed in the subcutaneous tissue just below the left or right clavicle. Generally the patient's nondominant side is chosen to minimize
interference with the patient's daily activities.
The major reason for implanting a pacemaker is the
presence of a symptomatic bradycardia. Symptomatic
bradycardia is a term used to define a bradycardic rhythm
that is directly responsible for symptom.! such as syncope,
transient dizziness, confusion, fatigue, exercise intolerance, congestive heart failure, dyspnea, and hypotension.
Permanent pacemaker technology has undergone
major advances since pacemakers were first introduced in
the 1950s. Early pacemakers paced a single chamber (the
right ventricle) at a futed rate. Today', pacemaker< func_
tion as demand pacemakers, sensing the patient's natural
beats and pacing the heart "on demand" (pacing only when
needed). Most of the permanent pacemakers used today
are the dual-chamber demand type. Although these dualchambu models are more expensive, they maintain AV
synchrony (the atria pace first, then the ventricles), preserving the atrial kick and often providing patients with a
higher quality of life. Studies have shown that unnecessary
pacing of the right ventricle can lead to heart failure and an
increased incidence of atrial fibrillation. The new~r dualchamber devices can keep the amount of right wntricular
pacing to a minimum and thus prevent worsening of the
heart disease.
Permanent pacemakers are also available for specific
conditions or needs:
Rate-responsiw pacemilker ~ This pacemaker has
sensors that detect changes in the patient's physical activity and automatically adjust the pacing rate to meet the
body's metabolic needs, Rate-responsive pacing mimics the
heart's normal rhythm, enabling patients to participate in
more activit ie5.
BiventricuJar pacemaker ~ A biwntricular pacemaker,
also known as cardiac resynchroni1.ation therapy (C RT),
stimulates both the right and left ventricles. By pacing both
wntricles, the pacemaker can resynchronize a heart whose
opposing walls do not contrilct in sym;hrony (/I problem
that occurs in 25% to 50% of heart failure patients). CRT
devices have been shown to reduce mortality and improw
quality of life in patients with an ejection fraction of 35%
or less or in patients with heart failure symptoms.
ImplantiJble cardiowrter-defi.brillators (JCDs) - These
devices haw the ability to pace for bradycardia, and overdriw pace for tachycardia (anti tachycardia pacing) and
shock therapy (cardioversion and defibrillation). They are
used in the treatment of patients at risk for sudden cardiac
death.
Once the pacemaker i. implanted, the following infor
mation is helpful to share with the patient:
I. Periodic pacemaker checkups ~ The pacemaker is
periodically checked to ensure the device is operational

261

and performing appropriately. This can be done in the

physician's office or owr the phone (remote monitoring). Most pacemakers are programmable, enabling the
physician to adjust pacing therapy.
2. Pilcemilker Silfety ~ Built-in filters protect pacemakers
from electrical interference from most devices encountered in daily life, including microwave owns. Security
devices at airports should not cause any interference to
the normal operation of the pacemaker; however, they may
detect the metal in the pacemaker. In this situation, the
pacemaker wearer can present an ID card indicating they
have a pacemaker. Cell phones do not seem to damage or
affect how the pacemaker works. Any activity that involves
intense magnetic fields (such as arc welding) should be
avoided. Medical tests involving the use of magnetic resonance im"lling (MRI ) are usually n,]ed out for patients
with pacemakers.
3. Pacemaker replacement ~ The life of a pacemaker
is affected by the type of pacemaker and how it is programmed to pace the heart. Today's pacemakers usually
contain lithium-iodine batteries, which are d~igned to
last many years. Pacemakers have a built-in indicator
to signal when the battery is approaching depletion.
Most refled baltery depletion by a gradual decrease in
the pacing rate. The pacemaker is designed to operate
for several months to allow adequate time to schedule
a replacement procedure. Because the batteries are permanently sealed inside the pacemaker, the entire pacemaker is replaced when the battery runs down. Device
replacement is usually a simpler procedure than the
original insertion as it does not normally require leads
to be replaced.

Permanent pacemaker
identification codes
A universal coding system is used to describe the function of single- and dual-chamber pacemakers (Table 10-1).
The code is comprised of fiw positions. Various leiters are
used for each position to describe a pacemaker function or
characteristic. Only one letter is used per position:
First position ~ Identifies the chamber paced,
Second position ~ Identifies the chamber where intrinsic electrical activity is sensed.
Third position ~ Indicates how the pacemaker will
respond when it senses intrinsic electrical activity.
Fourth position ~ Identifies prOJ!rammablefunctions, the
capability for transmitting and receiving data (corrununication), and the availability ofrate responsiwness.
Fifth position ~ Identifies antitachycardia functions:
1. Antitachycardia pacing (ow rdrive pacing) ~ this function paces the heart faster than the intrinsic rate to convert
the tachycardia
2. Shock (synchronized cardioversion and defibrillation)
3. Dual ~ performs both a pacing function and a shock
function.

262

Pucemukers

Tlble 1(J.1.

FlveleHer pacemaker Identification code

Arstlethlr

SIeond Ieller

Third I1I18r

fourth tetter

f1nhtaller

Ch/mber paced

Ch/mber SIlnSlld

RBBpOfISIl 10 IIIifIS~

ProgrammM1le hncIions

Artill/ClrpurJia ~rn1ions

0 . ....

0 . ....

0_ None

0 . ...

0 _ None

A:Alrium

A:Alrium

I '" IrtJibits pacing

P '" Simple prOlJ"ammable

P "Antitachycarda !llcing

V_ Ventricle

V_ Ventricle

T.. Triggers pacing

M .. Multiprogfllmmeble

S .. Shock

o" Duat {A and 'vi

0", Duat {Aand\?

D" Duat (I aod T)

C", Communication

o '" Ouat (P and 5)

A = Rate rflSpor16iYe

Pacemaker terms
Pacemaker firing
A pacemaker produces a programmed current (stimulus) at

a set rate to the myocardium. This enellly tra~ls from the

pacemaker generator through the lead wires to the myocardial m1.lS(:le. This is knownaspacem~ker firing and produces
a pacemaker spike (a vertical line) on Ihe ECG tracing.
Basic pacemaker operation consists of a closed-loop circuit in which electrical current flov,s betv,~en tv,o metal
poles (one negati~. the othe r positi~). The stimulating
pube i, de1i~red through the ntgative electrode. PacerlUIker 'ystems may be either unipolar or bipolar. Unipolar
pacing has one pole (electrode) wilhin the heart. with the
other pole being the metal case of the pulse generator. Pacemaker systems utilizing unipolar padng involve a large electrical circuit. The circuit tra~ls between the electrode on
the distal tip of the pacing lead in contact with the rTlyOC<lr-

A. Unipolar pacing system (I""d II)

dium (the negative pole) to the pacemaker generator located

in soft tissue (the positi~ pole). Because of the greater distance between the two poles. the ECC tracing will show a
tallle. easily visible pacing spike (Figure 10-7, example
A). Pacemaker systems utilizing bipolar pacing involve a
small electrical circuit. The current travels between the electrode on the distal tip of the pacing lead (negative pole) to
the proximal electrode located a few millimeters above the
distal tip (the positi~ pole). Because of the smaller dit lilnce
betv,een the ty,,o poles. the ECG tracing will show a small
spike (Figure 10- 7, example B) or may not be visible in some
leads on an ECG (Figure 10-7. example C).

Capture
The term capture refers to the successful stimulation of
the myoc .. rdium by a pacemaker stimulus. resulting in
depolarization. Capture is evidenced on the ECG by a p.1cemaker spike followed by either a.n atrial complex (P wave).

B. Bipolar pacing Iyst"'" (lead III)

c. Bipolar P""ing system (lead II)

Figure 1 0-7. Unlpotar and bipolar pac~ spikes. (AI Largo pactng spikes 11"9 soon wtth a unlpotar pacing system. (8) Small p;rlng
spikes 11"0 seen with a blpol1l" pactng system. (C)"The electrtcal clrcun Is so small n a bipolar systom that som9 leads may not show a pac~
spike.

Pacemaker terms

263

FIgure 10-8. Examplesor atrral caplurll.

(A) Atrral capture wtth normal-lookIllQ P waves conducted wrth IoIlQ PR nleml.
(8) Atrial capture with abnormar-Iooklng P waves.
(C) Atrrar capture with smarl. pointed P waves not Immedlatetj rorlowllg the atrial spike.

a ventricular complex (Q RS). or both, depending on the

chambers being pilced. Capture beats are nOrJllill.
Atrial depolaril.ation from a pacing stimulus results
in ~ p;lcing ."ike follov"ed hy "lr;,,1 "ct;vity (P w"",,) . The
morphology of the P waves produced may resemble that of
sinus beats and be normal looking, or may be abnormal in
appearance and so small that they are difficult to see. The P
waws may not immediately follow the atrial pacing spike.
The P waves may also be associated with a long PR interval.
Examples are shown in Figure 10-8.
Normal ventricular depolarization is simultaneous
(both ventricles depolarize at the same time), resulting
in a narrow QRS complex of 0.10 second or less in duration. Ventricular depolarization from a pacing stimulus
is sequential (one ventricle depolarizes, then the other),
prolonging the duration of depolarization, resulting
in a wide QRS complex of 0.12 second or greater. The
wide QRS complex immediately follows the pacing spike
(Figure 10-9, example A). An exception to the wide
QRS rule is the biventricular pacemaker. This pacemaker simultaneously paces the right and left ventricle,

resultin g in normal depolarization and a narrow QRS

compl ex.

Sensing
Sensing is the ability of the pacemaker to detect intrinsic
electrical impulses (the patient's awn electrical activity)
or electrical impulses produced by a pacemaker (paced
activity) . If the pacemaker detects electrical activity, it is
inhibited from delivering a stimulus. If the pacemaker does
not detect electrical activity, it is triggered to initiate an
electrical stimulus.

Intrinsic beat
An intrinsic beat (also called native beat) is produced
by the patient's natural electrical system (Figure 10-9,
example B). Intrinsic beats are normal.

Automatic interval (pacing interval)

The automatic interval refers to the heart rate at which
the pacemaker is set. This interval is measured from one
pacing spike to the next consecutive pacing spike. For

Flllure 10-9, W ~lcular capture ooat, (B) na1lV9 beat, (e) fUsion beat

264

Pacemakers

Figure 10-10. (AI Automatic Interval and (8) IUslon beat

atrial pacing. measure from one atrial pacing spike to the
next consecutive atrial pacing spike. This is called the A-A
interval. analogous to the Pop interval of intrinsic wavefonus. For ventricular pacing. measure from one ventricular pacing spike to the next consecutive ventricular
pacing spike (Figure 10-10. example A). This is called the
V-V interval. analogous to the R-R interval of intrinsic
wavdorms.

Fusion beat
A fusion beat occurs when the pacemaker fires an electrical stimulus at th~ sam~ time the patimt's own electrical
impulse fires an electrical stimulus. This results in part
of the ventricle being depolarized by the pacemaker and
part by the patient's own intrinsic impulse. The fusion
beat is evidenced on the ECG by a pacemaker spike that
occurs at the programmed rate (occurs on time ). followed
by a QRS that is different in height or width from the
paced beats and the patient's intrinsic beats (Figures 10-9
and 10-10).
The fusion beat has characteristics of both pacemaker
and patient forces. although one usually dominates the

other. In Figure 10-9, example C, the fusion beat has

more characteristics of the patient's paced beats than his
intrinsic beats. In Figure 10-10. example B. the fusion beat
has more characteristics of the patient's intrinsic beats
than his paced beats. Fusion beats are normal and are
usually seen only with ventricular pacing.

Pseudofusion beat
A pseudofusion beat occurs when the pacemaker fires an
electrical stimulus after the patient's spontaneous impulse
has already started depolarizing the ventricle. The pacing stimulus has no effect since the ventricle is already
being depolarized. The pseudofusion beat is evidenced on
the monitor by a pacemaker spike occurring at the programmed rate (occurs on time). along with a native QRS
complex. The intrinsic QRS is not altered in height or
width (Figure 10-11 ). P~udofusion beats are normal and
are usually seen only with ventricular pacing.

Pacemaker rhythm
Stimulation of the atria for one beat is called an atrial
paced beat. Continuous stimulation of the atria (all P waves

Figure 10-11 . Psoodolnluslon beat. The pacing spike Is located I1 Ih9 middle 01 Ih9 CRS In complex7.

Pacemaker mlllrunctiollS

265

FIgure 10-12. VOnIr1CUl!i' pat:od rhythm.

are pacemaker induced) is clliled an atrial paced rhythm.

Stimulntion of the ventricle for one btat is called a ventricular paced beat. Continuous stimulation of the ventride (all QRS complexes are pacemaker induced) is called a
ventricular paced rhythm (Figure 10-12). Stimulati on of
the atrin and the ventricle for one btat is called an AV paced
beat. Continuous stimulation of the atria and ventricles
(all P waves and QRS complexes are pacemaker induced) is
called an AV paced rhythm.

Pacemaker malfunctions
Basic functions of all pacemakers include the ability to fire
(stimulus release). to sense electrical activity (intrinsic
and paced).llIId to capture (depolarize the chambers being
paced). M05t malfunctions can be traced to problems with
the generator (parameter settings, battery failure), the lead
(problems at the interface bety,'een the catheter tip and the
endocardium. fracture in the lead or its insulating surface).
or to a disconnection in the system.
This section includes a description of pacemaker malfunctions. common causes. and interventions. It is directed
primarily toward temporary transvenou5 ven tricular

Figure 10-13. Fatturoto flre.

demand pacemakers since nurses can interact more

directly with them than with permanent pacemakers. The
same concepts apply to permanent pacemakers. but co rrection of malfunctions requires the use of a pacemaker
programmer or an actual surgical procedure to reposition
the pacing lead or replace the generator.

Failure 10 fire
With fail ure to fire, the pacemaker does not discharge
a stimulus to the myocardium. Failure to tire wi ll be
evidenced on the ECC by an absence of a pacemaker
spike where expected (Figure 10-13). Failure to ti re is
abnormal.
CIUiM'S lnd interventions for failure to fire:
1. B~lIery depletion - Replace the battery.
2. Disc onnection in the system - Check the connections
between the generator, bridging cable. and lead: reconnect
or tighten connections.
3. Fracture of INd or lead in sulltion - Do an overpenetrated chest X-ray to detect fractures: have the physic~'n
replace the lead.
o!.. ElectromAgnetic interference (EMJ) - Exposure of a
pacing un it to such sources as electrocautery devices or

266

Pace makers

Figure 10-14. Loss 01 capwre.

1>lRI may result in inhibition of the pacing stimulus. Avoid

expo5ure.
5. Pacemake r is turned off ~ Make sure the pacemaker is
turned on: the generator should be secured awll)' from thf
patient.

FaJlure to ca pture
With failure to capture. the pacemaker deliYers a pacing
stimulus. but electrical stimulation of the myocardium
(depolarization) does oot occur. This is evidenced on the
F.cc. by f"'Cemllker "(>ik... thilt ( I t t. . . at the programmed
rate. but are not followed by a P wave (for atrial pacing) or
a QRS (for vtntricular p-'cing). Figure 1014 shows loa of
capture with ventricular piKing. Lossof capture is abnorma.l.
CauSl'$ and in terventions for bilure 10 cilliure
I. rnA output is too low - Increase the mAon the generalor by turning the rnA dial clockwise to a higher number
(Figure 1(}'5). Over a period of days. inflammation or fibrin
formation at the calheter tip may raise the stimulation
thresho ld. requiring a highe r rnA output.
2. ltad is 01.11 of pos itiOIl or I}ing in infarcted tissue - The
eltctrode tip must be in contact with the endocardium for the
electrical stimulus to cause depolarization. Infarcted tissue

Figure 10-15. l)jderseoslog.

does not respond to a stilTJ.llus. Do an overpenelratfd chest

X'1'iI)' to determine the catheter po5ition. If the catheter is
out of position. a temporary maneuver is to tu m the patient
on his left side (gravity may allow the catheter loconlact lhe
endocardium).A physician will have to reposition the lead.
J. Electrolyte imbalance ~ Electrolyte imbalances can
alter the abi lityof the heart to rtspond to a p-'cing stimu Ius.
Check serum electrolyte levels and replace if needed.

Sensl ng failure
So>:Ming fail"re occ""" ..-hen the f'IICtmilker either dOB

no t sense m)'OCllrdial electrical activity or the pacemaker

the wrong signals. Sensing failure falls into two
categories: undersensing and oversensillll.
OvtT5tnse5

UluleNe/lsillg

The most common cause of sensing failure is undersensing.

The ~maker does not sense (does not "seel myocardial
electrical activity (eithe r intrinsic or paced) and fires earlier
than it should. Undersensing is recognized on the ECG by a
[Cing spike that occurs earlier than expected. It can occur
with capturt (Figure 1(}. IS. examples B and C) or without
(Figu re 1015. example A).

Analyzing pacemaker strips (ventricular demand type)

Cluses and intelVentions {or undersensing

I. Se nsitivity sd too low - Increase sensitivity by turning

sensitivity dial clockwise to a 10l'>"l:r number.
2. Pie ing catheter out o{ pos ition or lying in infarcted
tissue - The electrode tip must be in contact with the
endocardium to sense appropriately. Infarcted tissue does
not haw the ability to sense. Do an overpc!netrated chest
X-ray to determine catheter position. If the catheter is
out of position, a temporary maneuver is to turn the patient
on his left side, which may allow migration of the catheter
into a beller position. A physician will have to reposition
the lead.
3. PACemaker set on lS}'I1c hronou s (fixed rate) mode With asynchronous pacing, the sensing circuit is off. Turn
the sensitivity dial to synchronous (demand) pacing mode.

Oversellsillg
The pacemaker is too sensitiw ("sees too much) and is
sensing the wrong signals (large P waves, large T waves,
muscle mowment), causing the pacemaker to fire later

267

than it should. Oversensing is recognized on the ECC by a

paced beat that occurs later than ex~cted. (Figure 10-\6).
CIUseS il nd interventions {or oversensing
I . Sensitivity set too high - Decrease sensitivity by turning the sensitivity dial counterclockwise to higher number.

Analyzing pacemaker strips

(ventricular demand type)
When analyzing pacemaker rhythm strips, you will again
need to use either cali~rs or an index card. The following
steps should be helpful.
Step one - Place an index card above two consecutively
pilced beats. Mark the autornatic intelVa!. 'Left mark and
"right mark' mentioned in the steps below refer to marks
on the index card. The automatic interval measurement
will assist you in determining if the pacemaker fired on
time, too early, too late, or not at all.
Step two - Starting on the left side of the strip. analyze
each pacing spike you see. The patient"s intrinsic beats

,
Rgurll lD-t6.

OWroorr.:;lrl\l.
Example k. Pacemaker Is s911Slng a age T wave.
Example B: Pacemaker Is sensing a low wave/orm artIlact Note: Using the automaUc InterwllM"ks on hclex card, place
right mark on spike 01 late paclld beat. The len mark will malch whatEl't'er pacemaker Is sensing.

268

Pacemakers

Figure 1 0-17. Pacemaker lIlaty'sls str1p II.

Th9 ootomatlt Interval can be meastlod lrom 14 to 15. Mark aJlOOlaUc Interval on i1dex card.lon marl<..nI right marl<. In steps be~
refer 10 marks on IndeX al"d.
12 can be a-.alyzOO by placing len mark on spl~e 01 paced beat)JsI belore II; 12 matches right mark; 12 oa:urs on Ume. but does not
caJSe ventricular depoIa1zatlon (no ORS). so KIndicates lanll"e 10 caplll"e.
13 Is a native beat and doesnt nood analyzing.
#4 can be ma/yzed by placing len mark on Rwave 01 nallve ORS Jusl before K; #4 matches right mn; #4 ocrus on lime and causes
ventr1cula' depola'ization (ORS present).lndIcaUng ventr1cula' captum beat.
15, #6, and 17 can be ana/yZed by plachg len mark on spikes 01 the paced beats Immediately prealdlng each beat to be analyZed; all
occur on time and caJSe ventricular depola~zaUOn.lndlcatlng ventricular caplll"e beats.
IntlBfJlretallon: ventricular paced rhythm wtth one Intrinsic beat and one episode 01 lall.l'o 10 capture (abnormal pacemakerlUnctIon).

Figure 10-18. Pacemaker analysts strip 12.

The automatic 1lIerva1 can be measured lrom #1 to 12. MarkaJIomatlc Interval on Index card. Len mark and right mn ~ steps below
reler to marks on Index card.
12 cal be malyzed by placing len mark on sptke 01 paced beat Immediately before II; 12 matches right mark; 12 occurs on tlmo and
causes vootr1culil' depolil'lzatlon, IndlcaUng ventr1cula' capture beat.
13 has a Uny spike at tho beginning of tho Rwave so Rneeds ~a/yZIng; place ten mark on sptke 01 paced beat Just beforo tt; #3 matches
right mark ald Is dmerent In het1rt or wtdth from tho native and paced boats. so this represents a IUsIon beat.
#4 and #5 Me native beats and do not need analyzing.
#6 cal be malyzed by placing ten mark on Rwave 01 native boat ~t befOl'8 It; t6 ocrus Ba'iler than right mark; t6 Indicates that the
pacemaker did not sense the precadlng beat and represents an undersenslng problem.
'7 IS a natIVe Deat ana ooos not neea ~a/yZIng.
18 cal be lIlatjzed by placing len mark on Rwave 01 native beat ~st befOl'8 R; 18 ocrus Ba'iler than right mark; #8 Indicates that tho
pacemaker did not sense the preceding beat and represents an undersenslng problem. Nmr. #6 represents an unclersenslng problem without
caphn. IItllle #8 represents an undersenslng problem wtth capture. #6 occurs during the rerractory period when caplin Is urmle to occur.
19 cal be lIlaIyzed by placing len mark on sptke 01 paced beat Just before n; #9 matches right mn; 19 OCCll'S on tlmo ald causes
ventricular depola4zatlon.lndlcallng a ventricular caplin beat.
110 can be ~a1yzed by placing len mark on spl~e 01 paced beat)JsI belOl'8 R; It 0 matches ~ght mark; '10 OCCll'S on lime ald causes
ventricular depola'lzatlon.lndlcaUng a ventricular capllrll beat.
Interpretation: YenIr1cuIar paced rhythm wtth onelUslon boat, three ~tr1nstc beats, and two episodes 01 undersenslng (abnormal pacemaker
IUnctlon).

Analyzing pacemaker s trips (venlricular dema nd type)

269

Fillure 10-19. Pacemaker anatjsls stJlIl3.

TIle automatic tltervaI Clfl be measured from 12 10 n, Mar\( automatic tlterval on IIl(!ex ard. Lett mCll( and rIQIC mark In steps b91110
ffIJ8r to nwkS on tldex caf11.
.1 Is a natIVe beat anddoesn't need IRIIyzlng.
.2 Clfl be arIatfled by placing len mark on Rwave 01 natIVe ORS jUst belora It; .2 malches right marl(; .2 occurs on time aoo causes

ventricular O!IpOIIW1zauon, lndlcatrlg WdrICular captu"e beat

13 Clfl be analyzed by placing len mn on spike of paced beli jUst bele It; 13 malches right rnark; 13 OCC\I"S 00 lime a1d causes
~Iar cIepoIaf1zaUon, lndlcat~ WdrICular captu"e beat
'4 Clfl be lIWped by placing len mark on spike 01 paced beat)Jst belOl"l1t; 14 malches right rnark; '4 OCCtn on lime a1d causes
Y8IIb1cular ~zaUoo, Indlcatrlg 'IIII1IIt:Ular captu"e beat.
.5 C<Il be IWWtzed by placing len mn on spike 01 paced beat jUst betOl"l1t; 15 matches right rnark; .5 shoWs a pacing spll<8 wIllch
octus at tile same tlma as the mtMl beat, but does rill alter Its heI!trt 01" wklth,lndlcatlng a pseudOlnlUslon beat
16 Is a natIVe beat and doesn't need analyzing.
'7 C<Il be ~ed by placing len matt on Rwave 01 natIVe ORS jUst beIonIlt;.7 malches right marI(:.7 occurs 00 time MCI causes
ventricular !IepOIII1zaUon, lOOlcatrlg ventricular captu-a beat.
.8 C<Il be ~ed by placing len mark on spike of paced 1lea:}.Ist befe II; 18 matches right rnark; .8 OCC\I"S 00 lime a1d causes
Y8IIb1cular cIepoIaItzaUon, Indlcat~ wntrk:Ular capllre beat.
Intorpflllatlort V8nlr1CU1a" pa:ed rhythm 11th one pseuoofuSkIn beat !lid two IntrrlSk: beals (normal pacemaker fI..n:1IOO).

do not need analyzing. but you need 10 bt able to identify

them from the paced beaU.
Step three - Ident ify the pacing spike to be analyzed
(only analyze one spike at a lime). Using the marked index
card, place the left mark on the spike of the paced but or

R wave oflhe n.a.live beat immediately preceding the pacing

spike being analyzed.
S tep four - Ob5erve the relationship of the right mark
with the spike being an.a.Iyzed to determine the answu:

Spike fXCUTJ on timil

Spiki/ fXCUrs too rorlg

(spike matches right mark)

(spike earlier than right mark)

Ventricular capture beat (normal)

Fusion beat (normal)
P~udofusion beal (normal)
Failure to capture (abnormal)

Spike doesn'l occur

Undersensing (abnormal)
Spike fXCUrs too lale
(spike Later than right mark)

Failure to tire (abnormal)

Figures 10-17 through 1019 hal'!! been analyzed for you.

Oversensing (abnonnal)

270

Pacemakers

Rhythm strip practice: Pacemakers

Follow the four basic steps for analyzing pacemaker rhythm strips. Analyze and interpret each pacing strip as shown in
Figures 1017 through 10 19. All pacemaker strips are lead 1I, II positive lead. unless otherwise noted. Chk your answers
with the answer keys in the appendix.

Strip 11J-1 . Analysis :, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~~~~: ------------------------------------------------

Slrlp11J-2. Analysis :, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~erpretation :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11J-3. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~erpretation :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm slrip prllclke: Pllcemakers

..

Strip 111-4. AnaIysis:_ _ _ _ _ __

271

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

, '.' '"",, ______________________

Strip 10-S, AIWysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I~~~: _ _- - - - - - - - - - - - - - - - - - - - - - - -

strip 10-6. AIWysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I~erpretation: _ _ _- - - - - - - - - - - - - - - - - - - -

272

Pacemakers

Strip 11).7. Are/ysil:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~~-------------------------------------------

Strip 10-8. MIIIysis"_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~~----------------------------------------

Strip 10-9. Are/ysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___

~ --------------------------------------

Rhythm strip prtu::lice: Pacemakers

2 73

strip to-to. AnaJysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IrlefPretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 10-t1 . Ana/ysIs: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Ir1eqlretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-12. AnaJysIs: _ _ _ _ _ _ _ ~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

lrleq>retation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

274

Pacemakers

,"""""..,,,- - - - - - - - - - - - - - - - - - - -

Strip 10-13. ANIysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-14. Malysis:_ _ _ _ _ _ _ _ _ _ _ _ ~_ _ _ _ _ _ _ _ _ _ _ _ _ _ __

-""",,,- - - - - - - - - - - - - - - - - - - -

Strip 10-15. Anaysis:_ _ _ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

,~ ------------------------------------------

IUlythm strip practice: Pacemakers

275

Strip 10-16. Analysls: _ _

Irteq>retalion:

--------------------------------

Strip 10-t7. Anatysis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IrtBfPretaIion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 10-18. Analysis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

trtefJlretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

276

Pacemakers

Strip 1O-19 . ~: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
lmerpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-20. Nl~is:

htefpretatiln:- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Rhythm strip practice: Pacemakers

277

S1rtp 10-22. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-23. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-24. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Inlerpretation :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

278

Pacemakers

Strip 11).25. AlWysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Imerpretatiorr. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11).26. Malysis: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~~~,----------------------------------------

Strip 11).27. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

l m~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Pacemakers

~riptO-D . ~~

279

______________ ~___________________________________________

lrte!pretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip

10- 29. AnaIys~

_ _ _ _ ___

trtefJlretalion: _________________________________________________

strip

10 - 30 . ~~

______________ ~__________________________________________

IrtlNpretalion: _________________________________________________

280

Pacemakers

Strip 10-31 . Analysis:

~etaOOn :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1G-32.Analysls: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~etat ion :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm strip practice: Pacemakers

281

Strlp10-34. AnalysIs: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Irtl!fPretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 10-35. Ana/ys1s:

IrtefPretaIioo: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip10-36.Ana/ysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

trterpretaioo:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

282

11llccmllkcrs

Strip 10-37. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Interprellltlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-39. Analysis:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 10-39. AnaIysis:,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Interprelation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Rhythm s trip practice: Pacemakers

~np1040 . ~~~

283

__________________________________________________________

Irferpretalion: _______________________________________________________

Posttest

For pacemaker sl rips

PosHest: All rhythm groups

For arrhythmia strips

Fo llow the four basit steps for analyzing pacemaker rhythm

Follow the fiw basic steps in analyzing ~ rhythm strip.

Interpret the rhythm by comparing this data with the ECG
dw<Kteristia for tilth rhythm.

strips. Analyze and interpret each pocing strip 115 shown in

Figures IO-17through 10-19.

All slri] are lead 11, 11 positive lfad, unlen otherwise

noted. Check your answers with the answer key in 1m
appendix.

Strip 11-1 . Rhythm: _ _ _ _ _ _ _ _ '''''' _ _ _ _ _ __

PR i1terval:

PwaYe: _ _ _ _ __

ORS complex:, _ _ _ _ __

RIIyttrn Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip1'-2. Rhyth'n: _ _ _ _ _ _ _ _ R"" _ _ _ _ _ __

PR nterval:

Pwave: _ _ _ _ __

ORS cornplex:,_ _ _ __

RIrythm interpretatkm:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

284

I)osues!: All rh ythm groulls

Strip 11 -3, Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

PR intM'8l:

285

Pwave: _ _ _ __

OAS ComplelC' _ _ _ _ _ __

RhytIvn inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -4 , Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PA Interval:

ORS C!J11p1ex: _ _ _ _ __

Rhythm interpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -5, Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

286

Pos Uest

Strip 11-6. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ _ __

PA inteMI:
DRS complex:_ _ _ _ __
Rhythm interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip11-7. Analysis:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip11 -8. Rhythm: _ _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

PR interwl:

P wave: _ _ _ _ __

ORS complel: _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

strip 11 -9. Rhythm: _ _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

287

Pwave: _ _ _ _ __

QAS complex: _ _ _ _ _ __

Rhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip1' -'0. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
Rh~int~~aoon :'

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 11 -11 . 1Itrj1hm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ __

PH Imerval:

Pwave: _ _ _ _ __

QAS complex:_ _ _ _ _ __

Pwave: _ _ _ _ ___

QRS complex:_ _ _ _ _ __

Rhythm interpratation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

288

Posttest

Slrtp11-12. Rhythm: _ _ _ _ _ _ _ _ R"" _ _ _ _ _ _ _ _ Pwa'le: _ _ _ _ __

PR interval:
QRS cornplex:_ _ _ _ _ __
Rhythm interpretatkin :'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip11-13. Rhylhm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:-

- - -

Rhythm interpretatkln:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-14. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR

intc~.3I :

QRS compIcJC _ _ _ _ _ __

Rhythm interpretatim:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

289

Strip 11 -15. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR ilterval:

QRS complex: _ _ _ _ _ __

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -1&. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11-17. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ _ __
PJlythrn interpretalion:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

290

Posttest

Strip 11-18. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

DRS complex:_ _ _ _ _ __

Rhythm illerpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrlpll- 19. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
ORS cornplex:_ _ _ _ _ __
Rhythm inlerpretation:,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-20. Rhythm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
Rhythminle~aRm :'

DRS cornplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

Postte st: All rhythm groups

291

Strip11 -21 . Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _~ Pwave: _ _ _ _ __

PR interwl:

QRS complex:' _ _ _ _ _ _~

RhytlJ'n interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11 -22. Rhythm: _ _ _ _ _ _ _ _ "'.. _ _ _ _ _ _ _~ Pwave: _ _ _ _ __

PR interval:

QRS complex:' _ _ _ _ _ _~

Rhythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-23. Rhythm: _ _ _ _ _ _ _ _ _ Rats: _ _ _ _ _ _ __

PRinterwl:

Pwave: _ _ _ _ __

QRS complex:' _ _ _ _ _ _~

Rhythm Interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

292

Posttt.'st

Strip 11-2.... Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PA interval:

ORS complex:' _ _ _ _ __

Rhythm ilterpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -25. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS oornpIeJI :, _ _ _ _ __

Rhythm illerpre1ationc
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -26. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
ORS complex:' _ _ _ _ _ __
Rhythm interpreiation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

293

Strip 11 -27. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwa..-e: _ _ _ _ __

PR interval:

QRS complBX: _ _ _ _ _ __

PlJythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11- 28. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ PwaV8: _ _ _ _ __

PR interval:

QRS complex: _ _ _ _ _ __

Rhythm interpretalion :,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip11-29. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:
nh~m~~~ :'

Pwave: _ _ _ _ _ __

QRS complex: _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

294

Posttest

Strip 11- 30. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS comple.l::_ _ _ _ __

Rhythm inlerpretati:m:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 11-31 . PJlytIvn: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

OPOS complex: _ _ _ _ __

Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -32. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ __
Ilhythm inlerpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

295

S1rip11 -JJ. Rhylhm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

PR interval:
OAS complex:_ _ _ _ _ __
Rhythm inlerpretalion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip 11-34. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~erpremtioo :

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

S1rip11 -35. Rhythm : _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

OAS complex: _ _ _ _ _ __

Rhythm Inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

296

Posttest

Strip 11-36. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm ilterpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-37. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhvthm illerpretatbn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-38. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR Interval:

ORS complex:_ _ _ _ _ __

Rhythmilterpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Postlest: All rhythm groups

297

Strip ll -J9.ItJytIvn: _ _ _ _ _ _ _ _ _ . ", _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR InteM!:

OftScomplex:_ _ _ _ __

fIIythm inteqntation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 11-40. fIrr1hm: _ _ _ _ _ _ _ _ _ ....

PR Interval:

_ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

ORScomplex;_ _ _ _ __

fIlythm Interpretatlon: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sbip11-41 . fI1ythm : _ _ _ _ _ _ _ _ _ _

PR inteml::

_ _ _ _ _ _ __

P wave: _ _ _ _ _ __

ORS complex:,_ _ _ _ __

fIlyhn interpretation"~---------------------------

298

POSII CSt

Strip 11-42. Rhythm: _ _ _ _ _ _ _ _ _ R" _ _ _ _ _ _ __

Pwa~ :

_______

PR rrti9Nr.
ORS complex:'_ _ _ _ __
It1ythm rrtsrprelation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11-43. lflyt!lm: _ _ _ _ _ _ _ _ _ "". _ _ _ _ _ _ __

PR inteMi:

ORScom~ex:'

Pwa~:

_ _ _ _ __

_______

RIIythm InterpretatJon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-44. Rhythm: _ _ _ _ _ _ _ _ _ ...., _ _ _ _ _ _ _ __

PR interval:
~m~too' "_

Pwa~

_______

ORS cornpleJc_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

299

Strip11-4S. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inlerprelalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11-46. AnaIysis :, _ _ _ _ _ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inlerpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11 -41. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

PJlythm interpretalion :' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 00

Posttest

Strip 11-48. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm interpretatkin :'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-49. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PH interval:

OIlS cornplex:_ _ _ _ __

Rhythm inlerpretatkin:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11- 50 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ P wave: _ _ _ _ __

PR interval:
Rhythminle~atkln :'

QRS

complex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

PostleSl: All rhythm groups

Slrip11 -51 .fWlythm: _ _ _ _ _ _ _ _ _ "'''' _ _ _ _ _ _ __

301

Pwave: _ _ _ _ __

PR Int8f'l8l:
OfIScomplex:_ _ _ _ __
fIIythm interpretalion: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -52. iIlyttlm: _ _ _ _ _ _ _ _ _~ Rale: _ _ _ _ _ _ __

PR Interval:
OfIScomple:x;_ _ _ _ __

Pwa'o'll: _ _ _ _ __

Rbythmlrrtarprw!atJon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Sirip 11-53. falythm : _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR inl8f'I8I:
ORScompIex:_ _ _ _ __
Rhythm InterprllIalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

302

POSllest

Strip 11-54. Rhythm: _ _ _ _ _ _ _ _

PR Interva:

,.t" _______

Pwsve: _ _ _ _ __

ORS c:omplex: _ _ _ _ __

~m~aOOn' c

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

,.t" ________ Pwave: _ _ _ _ __

Strip 11-55. Rhythm: _ _ _ _ _ _ _ _ _

PR mma:
ORS complex:'_ _ _ _ __
~mn~Woo:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-5&. Rhy!hm: _ _ _ _ _ _ _ _ _ ," _ _ _ _ _ _ __

PR melVa:

Pwa~

_ _ _ _ _ __

ORS complex:,_ _ _ _ __

IIlythm nterpretaOOn:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

303

Slrip11 -S7. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

PJlythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 11-58. Analysis:_ _ _ _ _ _ _ ~_ _ _ _ _~ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ __

Interpretalion:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-59. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex:_ _ _ _ _ __

Rhytlvn inlerpretalion :, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

304

Posttest

Strip11-GO. Rhythm: _ _ _ _ _ _ _ _ Rata: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR intenal:

QRS complex: _ _ _ _ _ __

Rhythm interpretalion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-61. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ _ __

Rhythm interprelatbn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-62. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
Rhythminte~atbn :'

QRS cornplex:_ _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

Posttest: All rhythm groups

30 5

Strip 11 -1i3. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

ltJythm interpretalion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -64. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS complex: _ _ _ _ _ __

Rhythm interpretation:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-65. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~e~mlim : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

306

POSII CSt

Strip 11-66. Rhythm: _ _ __

PR n\MVM:

_ _ _ __ R..'" _ _ __

_ _ __

Pwa~:

_ _ __ __ _

DRS tomplex:'_ _ _ _ __

IIlyttlm i'!Ierpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-67. RI'Iythm: _ _ __ _ _ _ __ ...., _ _ __ _ _ __ Pwa....: _ _ __ _ _

PR i1tervM:
DRS compIeJI: _ _ _ _ __
Illythm interptetation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 1'-68.Anaysis: _ _ _ _ _ _ _ _~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
~e~

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

3 07

Strip 11 -69. Rhythrn: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
ORS complex:_ _ _ _ _ __
Rhythm inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip1' -70. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ __
Rhythm inlerpretalion :' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-71 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR IrnerYal:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

Rhythm inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

308

Posttest

Strip 11-72. Rhylhm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:_ _ _ _ _ __

Rhythm inlerpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

StripI 1-73. Analysis:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Interpretatit1l: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Stripll-74. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR Interval:
Rhythminterprem~ :'

QRS

compleJC _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

3 09

Slrtp11-7S. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ P wave: _ _ _ _ __

PR interval:

QRS complex:_ _ _ _ _ __

Rhythm interpretawn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

StripI1 -76. Rhytlvn: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR IIterva~

Pwave: _ _ _ _ _ __

QRS complex: _ _ _ _ __

Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -77. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

l'l1ythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

310

Posttest

Strip 11-78. Rhythm: _ _ _ _ _ _ _ _ FI"" _ _ _ _ _ _ _ _ Pwa'le: _ _ _ _ __

PR interval:
QRS cornplex:_ _ _ _ _ __
Rhythm interpretatkin :'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-19. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
ORS cornplex:_ _ _ _ __
Rhythm interpretation:,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-80. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
QRS cornplex:_ _ _ _ _ __
Ilhythm inierpretlltion :'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posuesl: All rhythm groups

3 11

Pwave: _ _ _ _ __
ORScompleK:'_ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

strip 11 -81 . 1t1ythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR Intarl8l:
~mint~atioo :

Stripll -82. 1lythm: _ _ _ _ _ _ _ _ _ RaIe: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR interval:
ORScomplu: _ _ _ _ __
FIIythm Interpretallon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Smpll - D . M~~

_ _ _ _ _ _ _ ~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

IlII8rpretation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 12

POSllest

Strip 11-84. Rhythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ __

PR i1Ierva:
~m~a~' c

ORS complex:_ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____

Sbip 11 -85. Rhytflm: _ _ _ _ _ _ _ _ _ RH _ _ _ _ _ _ __

PR Interval:

PwaYe: _ _ _ _ __

PW81111: _ _ _ _ _ __

ORScomplex:_ _ _ _ __

RhyItlm IntlNpl"etatiort_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

S1rip 11 -86. 1t1ythm: _ _ _ _ _ _ _ _ _ . . . _ _ _ _ _ _ __

PR interva~

Pwave: _ _ _ _ _ __

QRS complex:, _ _ _ _ _ __

Rhythm intefpr8lation: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Postte st: All rhythm groups

3 13

Strlp 11 -87. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ __

PR interval:

ORS complex: _ _ _ _ __

Rlytlvn interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip " -S8. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

ORS compleJ::_ _ _ _ __

Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11 -S9. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Interval:

Pwave: _ _ _ _ __

QRS complex:_ _ _ _ _ __

Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 14

Pos ttest

Strip 11-90. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
QRS complex:_ _ _ _ __
Rhythm ilterpretati:m:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-91 . Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH interval:

Pwave: _ _ _ _ _ __

QRS complex:_ _ _ _ __

Rhythm ilterpretation:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-92. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

rn interval:

Pwave: _ _ _ _ __

aIlS complex: _ _ _ _ _ __

Rhythm imerpretmon:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posuest: All rhythm groups

3 15

Pwaw: _ _ _ _ _ __
ORS complell: _ _ _ _ __
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11- 93. FIlythm: _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR lntervat:
~ i m~oo' c

Strlp11 -94. lVlythm: _ _ _ _ _ _ _ _ _

_ _ _ _ _ __

Pwall8: _ _ _ _ __

PR intenal:
QRScomplex:_ _ _ _ __
ftIythm Interpretatlon:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-95. FIlythm: _ _ _ _ _ _ _ _ _ .... _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRScomplex:_ _ _ _ __

fIlythm interpretation:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 16

Posttest

Strip 11-9Ei. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:

ORS complex:

Rhythm Inlerpretamn:'_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slripll-97. Rhylhm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
Rhythminler~oon :'

QRS complex: _ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-98. J\nalysie: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

~e~~oo : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

317

Strip 11-99. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR interval:
ORS complex:_ _ _ _ _ __
FI1ythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-100. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __

PR intYill:
ORS complex: _ _ _ _ __
Rhythm inierpretation:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11-101 . Rhythrn: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PH Imerval:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

Rhythm interpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

318

Posttest

Strip 11-102. Rhythm: _ _ _ _ _ _ _ _ _ Rale: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PR interval:
Rhythm~Ie~~a~ :'

ORS complex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11- 103. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PH interval:
Rhythm~OOf~~a~ :'

QRS complex:_ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Slrip11-104. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ _ _ Pwave: _ _ _ _ __

PH Interval:
Rhythm~te~~a~ :'

QRS

complex:_ _ _ _ _ __

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Posttest: All rhythm groups

3 19

Slrip11-105. Rhythm: _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __ Pwave: _ _ _ _ __

PR Interval:
QRS complex: _ _ _ _ _ __
Rhythm inlerpretalion:, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip 11-106. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

PR interval:

Pwave: _ _ _ _ __

QRS compleK: _ _ _ _ _ __

Rhythm inlerpretation:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Strip11-101. Rhythm: _ _ _ _ _ _ _ _ _ Rate: _ _ _ _ _ _ __

Pwave: _ _ _ _ __
PR interval:
QRS complex:_ _ _ _ _ __
l'l1ythm interpretetion:' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Answer key to Chapter 3

Answer key to Chapters 5 through 11
Glossary

Index

321

Answer key to Chapter 3

Strip 3-1.

Strip 3-2.

Strip 3-3.

Strip 3-4.

Strip 3-5.

Strip 3-6.

322

Answer key to Chapter 3

Strip 3-7.

Strip 3-8.

Strip 3-9.

strip 3-10.

Strip 3-11.

323

324

Answer key IQ Chllpter 3

Strip 3 12.

Strip 3-13.

Sbip 3-14.

Answer key to Chapters 5 through 11

Strip 5.-1
Rhythm: Regular
Rate: 79 beats/minute
P waws: Sinus

PR interval: 0.14 to 0.16 second

QRS complex: 0.06 to 0.08 second
Comment: An inverted T wave is

Slrip 5-7
Rhythm: Regular
Rale: 68 beats/minute
P waves: Sinus
PR interval: 0.1610 0.18 second
QRS complex: 0.12 to 0.14 second
Comment: A U wave is present.

present.
Strip 5-2
Rhythm: Regular

Rate: 45 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Comment: A small U wave is seen
after the T wave.

Strip 5-3
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 020 second
QRS compln: 0.08 to 0.10 second
Comment A depressed ST segment

Slrip 5-8
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.1210 0.14 second
QRS complex: 0.06 to 0.08 second
Comment: An devated ST segment
and inverted T wave are present.
Strip 5-9
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Comment: A depressed ST segment
is present

and biphasic T wave are present.

Strip 5-4
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second

Strip5- I O
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.14 to 0.16 second

QRS complex: 0.04 second

Strip 5-5
Rhythm: Regular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second

Strip 5- 11
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 024 to 0.26 second
QRS complex: 0.04 to 0.06 second

QRS complex: 0.06 to 0.08 second

Comment An elevated ST segment is
present.

Strip 6-1
Rhythm: Re gular
Rate: 54 beats/minute

Stri[l S_1i

P ......;we~: Si"".

Rhythm: Regular
Rate: 136 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS ~uJJlplu: 0.06 tu 0.08 ""~UJl\I

PR interval: 0.18 to 0.20 second

QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia

Strip 6-2
Rhythm: Regular
Rate: 68 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS compla: 0.06 to 0.08 second
Rh}1hm interpretation: Normal sinus
rhythm; ~i -segment depression and
T-wave inversion are present.
Strip 6-3
Rh}1hm: Regular
Rale: 79 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 6-4
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 10 0.08 second
Rhythm interpretation: Sinus
tachycardia: ~i -segment deprescsion
and T -wave inversion are present.
Strip 6-5
Rh}1hm: Regular
Rate: 58 beats/minute
P waves: Sinm
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: a U wave is present.
Strip 6-6
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 100 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
~Me"l during f"'use
PR interval: 0.16 to 0.20 second
QRS complex: 0.08 to 0.10 second
(basic rh}1hm)
Rhythm interpretation: Normal
,inus rhyllull willI sillu, block;
ST-sellment deprescsion and T-wave
inversion are present.

325

326

AnswerkeytoChupters5lhrough II

S b"ip 67
Rhythm: Regular
Rate: 54 ~atslminu te
P waves: Sinus (notched P waves
usually indicate left atrial
hwertrophy)
PR interval: 0.14 to 0.16 second
QRS compleI': 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradyca rdia; a U wave is present
S iri p fi.8
Rhythm: Irregular
Rate: 50 ~atslminu te
P waves: Sinus
PR inte rval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation; Sinus
arrhythmia with a bradycardic rat e;
a U wave is present.

S trip 6!!
Rhythm: Regular (basic rhythm):
irregula r during pau~
Rate: 58 ~atslminute (basic rhythm)
P waves: Sinus (bM ic rhythm):
absent during pause
PR interval: 0.}4 to 0.18 second
(basic rhythm ); ab~nt during
pause
QRS co m plu: 0.08 to 0.10 second
(basic rhythm ); ab~nt during
pause
Rhythm interpretation: Sinus
bradycardia with sinus arrtst:
a depressed ST segment and an
invert ed T I<.~ are preKnt.

S trip fi. 10
Rhythm: Regular
Rate: 125 beatslminu te
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complel': 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
S trip 6]]
Rhythm: Regular
Rate: 63 ~atslminute
P waves: Sinus
PR interval: 0.18 to 020 second
QRS compiel': 0.08 second
Rhythm interpretation: Normal sinus
rhythm: a U wave is present.

Strip 6 12
Rhythm: Regular
Rate: 47 ~atslminute
P waves: Sinus
PR interva l: 0.18 to 0.20 second
QRS complex; 0.08 second
Rhythm interpretat ion: Sinus
bradycardia: an elevated S1 segment
is present
51 rip 613
Rhythm: Irregular
Rate: 80 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS comp lex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia

Sirip 6- 14
Rhythm: Regular
Rate: 63 ~atS/minute
P waves: Sinus
PR interval: 0. 18 10 0.20 second
QRS complex: 0.08 to 0. 10 second
Rhythm interpretation: Normal sinus
rhythm: S1 segment depression and
T.w~ inversion are present.
Siri p 6- 15
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 84 beats/minute (basic
rhythm): slOW$ to 56 beats/minute
afte r a pause (temporary rate
suppression may occur after a pause
in the bask rhythm)
P waves: Sinus (basic rhythm ):
absent during pause
PR interval: 0.16 to 0.18 second
(basic rhythm); abse nt du ring pause
QRS comp lex: 0.08 to 0.10 second
(basic rhythm); absent during pause
Rh~1hm interpretation: Normal
sinus rhythm with sinus a rrest;
rate suppression is present after the
pausr.

Strip 6 16
Rhythm: Regular
Rate: 150 beats/minute
P waves: Sinus
PR interval: 0. 12 to 0.16 second
QRS comp lex: 0.0410 0.06 second
Rh~1hm interpretation: Sinus
tachycardia

St rip&-17
Rhythm: Regular
Rate: 52 ~ats/minute
P WaYes: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 ~cond
Rhythm interpretation: Sinus
bradycardia
St rip fi. 11I
Rhythm: Irregular
Rate: 60 ~atslminute
P WaYes: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0. 10 ~cond
Rhythm interpretation: Sinus
arrhythmia
St rlpfi.l !!
Rhythm: Regular
Rate; 79 ~ats/minute
P WaYes: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 second
Rhythm in terpretation: Normal sinus
rhythm
Slrip fi.20
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 88 ~atslminute (basic rhythm)
P WaYes: Sinus (basic rhythm ):
absent during pause
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.08 second (basic
rhythm)
Rhythm interpretation: Normal sinus
rhythm with sinus block; a U wave is
present.
Siripfi.2 I
Rhythm: Regula r
Rate: 150 ~atslminute
P WaYes: Sinus
PR interval: 0. 12 second
QRS complex: 0.06 second
Rhythm interpretation: Sinus
tachycard ia

Answer key to Ch ap ters 5 through II

Strip 622
Rhythm: Regular
Rate: 60 beats/minute
p waV\'s: Sinus
PR interval: 0.12 second
QRS complex: 0.08 second
Rhythm interpretation: Normal
sinus rhythm: T-wave inversion is
present.
Strip 6-23
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Sinus
PR interval: 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 6-2~
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 60 beats/minute (basic
rhythm); slows to 47 beats/minute
after a pause (temporary rate
suppression can occur after a pause
in the basic rhythm)
P waws: Sinus (basic rhythm);
absent during pause
PR interval: 0.16 to 0.18 second
(basic rhythm); absent during
pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Normal sinus
rhythm with sinus arrest
Strip 6-25
Rhythm: Regular
Rate: 125 beats/minute
P waws: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-26
Rhythm: Regular
Rate: 35 beats/minute
P waV\'s: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.10 second
Rhythm interpretation: Marked sinus
bradycardia

Strip 6-27
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
absent during piluse
PR interval: 0.14 to 0.16 second
(basic rhythm): absent during
pause
QRS complex: 0.08 to 0.10 second
(basic rhythm): absent during
pause
Rhythm interpretation: Normal sinus
rhythm with sinus block
Strip 6-28
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.10 second
Rhythm interpretation: Sinus
arrhythmia: a U waV\' is present.
Strip 6-29
Rhythm: Regular
Rate: 65 beats/minute
P waves: Sinus
PR interval: 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm; ST-segment depression and
T-waV\' inversion are present.
Strip 6-30
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 68 beats/minute (basic rhythm);
slows to 63 beats/minute after a
pause (temporary rate suppression
can O\:cur after a pause in the basic
rhythm: after sewral cycles the rate
returns to the basic rate)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 second (basic
rhythm): absent during pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Normal sinus
rh}1hm with sinus arrest; a U waV\' is
present.

327

Strip 6-31
Rhythm: Regular
Rate: 48 beats/minute
P waV\'S: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia
Strip 6-32
Rhythm: Irregular
Rate: 60 beats/minute
P waV\'S: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rh~1hm interpretation: Sinus
arrhythmia
Strip 6-33
Rhythm: Regular
Rate: 115 beats/minute
P waV\'S: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia

Strip 6-301
Rhythm: Regular
Rate: 88 beats/minute
P waV\'S: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm; ~i -segment depression is
present.
Strip 6-35
Rhythm: Irregular
Rate: 60 beats/minute
P waV\'s: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 6-36
Rhythm: Regular
Rate: 41 beatslminute
P waV\'s: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: ~"T -segment depression
is present.

328

Answer key to Chapters 5 through II

Strip 637
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.20 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with sinus arrest:
ST-segment depression is present.
Strip &-38
Rhythm: Regular
Rate: 107 beats/minute
r wa",,~: Sim,.
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-39
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia; sr-segment elevation is
present.
SLrip 640
Rhythm: Regular
Rdk 54 bt:dWmjlluk
P "'"aVes: Sinus (notched P waves
usually indicate left atrial hypertrophy)
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia
Strip &-4 1
Rhythm: Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 6-42
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia

Strip 6-43
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
absent during pause
PR interval: 0.18 to 0.20 second
(basic rhythm): absent during
pause
QRS complex: 0.04 to 0.06 second
(basic rhythm): absent during
pause
Rhythm interpretation: Normal
.inu~ rhythm with ~jnu~ II.rre..t:
ST-segment depression is present.
Slrip 6-44
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
arrhythmia; ST-segment elevation is
present.
Strip 6-45
Rhythm: Regular
Rate: 27 beats/minute
P waves: Sinus
PR interval: 0.14 10 0.16 second
QRS ~uIJlPln: 0.08 lu 0.10 ..,~u",J
Rhythm interpretation: Sinus
bradycardia with extremely slow
rate; ST-segment depression is
present.
Strip 646
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic rate
Strip 6-47
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachy<:ardia

Strip 6-48
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
arrhythmia; a U wave is pr~nt.
Slrip 6-49
Rhythm: Regular
Rate: 52 beats/minute
P waves: Sinus
PR interval: 0.12 second
QIlS complex: 0.08 ~~cond
Rhythm interpretation: Sinus
bradycardia
Strip 6-50
Rhythm: Regular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm: an elevated ST segment is
present.
Strip 6-51
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR illkrvdl: 0.12 Lu 0.14 ",~ulll1
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
tachycardia
Strip 6-52
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 60 beats/minute (basic
rhythm); slaws to 31 beatsiminute
after a pause (temporary rate
suppression is common after a pause
in the basic rhythm)
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interprdation: Normal
sinus rhythm with sinus arrest;
ST-segment depression and T-wave
inversion are present.

Answer key to Chapters 5 through II

SlTip 6-53
Rhythm: Irniular
Rate: 80 beaWminute
PWilves: Sinus
PR interval: 0.12 to 0. 14 seco nd
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Si nus
arrhythmia
Sirip 6-54
Rhythm: Regular (basic rhythm):
irngular during pause
Rate: 94 beaWminute (bouic
rhythm); rate slows to 54 beats/
minute after a pause (temporary rate
suppns.sion tan occur after a pa uw
in the basic rhythm)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 to 0. 18 second
(basic rhythm); absent during
pause
QRS com plex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with sinus bloc k

Strip 6-58
Rhythm: Regular
Rate: 72 beaWminute
P waws: Sinus
PR interval: 0.16 to 0.20 second
aRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm: ST-segment depression and
T-wave inversion are present.
Ship 6-59
Rhythm: Regular
Rate: 50 beats/minute
P ~"<M!S: Sinus
PR interval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
brad~rdia: 51-segment depression
and T-wave inversion are present.

Strip 6-55
Rhythm: Regular
Rate: 65 beaWminute
Pwaves: Sinus
PR interval: 0.16 to 0.18 seco nd
QRS complex: 0.06 second
Rhythm interpretation: Normal sinus
rhythm

Strip 6-60
Rhythm: Regular (bll5ic rhythm):
irregular during pause
Rate: 88 beats/minute (basic rhythm)
P "'"<M!S: Sinus (basic rhythm):
absent during pIIuse
PR interval: 0.14 to 0.20 second
(basic rhythm ): absent during pause
aRS complex: 0.08 to 0. 10 second
(basic rhythm ): absent during
pause
Rhythm interpretation: Normal
sinus rh}1hm with sinus block:
51-segment depression is present.

Strip 6-56
Rhythm: Regular
Rate: 125 beaWminule
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.08 seoond
Rhythm interpretation: Sinus
tachycardia: ST-segment depres.sion
is present.

Strip 6-61
Rhythm: Regular
Rate: 72 beats/minu te
P WaileS: Sinus
PR interval: 0.12 to 0.14 second
aRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm: an inverted T wave is
present.

Strip 6-57
Rhythm: Irregular
Rate: 40 beaWminute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 seoond
Rhythm interpretation: Sinus
arrhythmia ~;th a bradycardic rate; a
U wave is present.

Strip 6-62
Rhythm: Regular
Rate: 125 beats/minute
P "'"<M!S: Sinus
PR interval: 0.12 second
aRS complex: 0.04 second
Rhythm interpretation: Sinus
tach~rdia: 51-segment depres.sion
is present.

329

Sirip 6-63
Rhythm: Regular
Rat~: 44 beaWminute
P waves: Sinus
PR interval: 0.1 8 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interprdation: Sinus
bradycardia: a U wave is present.
Sirip 6-61
Rhythm: Regular
Rat~: 79 beaWminute
P waves: Sinus
PR interval: 0.14 to 0.16 second
aRS complex: 0.1 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm: T-wave inversion is present.
Strip 6-65
Rhythm: Regular
Rate: 107 beaWminute
P waves: Sinus
PR interval: 0.1 8 to 0.20 second
aRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia: an devated ST segment
is present.
Sirip 6-66
Rhythm: Regubr
Rate: 136 beaWminute
P walltS: Sinus
PR interval: 0. 16 to 0.20 second
QRS complex: 0.08 to 0.10 second
Rh~thm interpretation: Sinus
tachyo:ardia: an elevated ST segment
is present.
Sirip 6-67
Rhythm: Regubr
Rat~: 44 beaWminute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rh}thm interpretation: Sinus
bradycardia: a U wave is present.
Strip 6-68
Rh}thm: Regular
Rate: 88 beaWminute
P waves: Sinus
PR interval: 0.18 to 0.20 second
aRS complex: 0.06 to 0.08 second
Rh ~thm interpretation: Normal sinus
rhythm; a depressed ST segment is
present.

330

Answe r key to Chapters 5 through II

S trip 6-69
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
tachycardia; an elevated ST segment
is present.
S trip 6-70
Rhythm: Regular (basic rhythm):
irregular during pause
Rale: 56 beats/minute (basic rhythm);
slows to 50 beatslminute after a
pause (temporary rate suppression
can occur after a pause in the basic
rhythm: after several cycles the rate
returns to the basic rate)
P waves: Sinus (basic rhythm);
absent during pause
PH interval: 0.14 to 0.16 second
(basic rhythm); absent during pause
QRS complex: 0.08 to 0.10 second
(basic rhythm); absent during pause
Rhythm interpretation: Sinus
bradycardia with sinus arrest
Strip 6-71
Rhythm: Regular
Rate: 115 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia; ST-segment depression
is present.

Strip 6-74
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.08 to 0.10 second
Rh}thm interpretation: Normal
sinus rhythm: ST-segment
depression and a biphasic T wave
are present.

Strip 6-75
Rhythm: Regular
Rate: 94 beats/minute
P waves: Sinus
PR interval: 0.16 to 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus

""<hm
Slrip 676
J{hythm: Hegular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Sinus
ta(hYGmlia

S trip 6-73
Rhythm: Regular
Rate: 54 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia; an elevated ST segment
is present.

rh~thm)

P waves: Sinus in basic rhythm;

absent during pause
PR interval: 0.16 to 0.20 second
(basic rhythm); absent during
pause
QRS complex: 0.10 second (basic
rhythm): absent during pause
Rhythm interpretation: Sinus
tachycardia with sinus block:
baseline artifact is present.
S lrip 680
Hhythm: Hegular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.06 second
Rhythm interpretation: Normal
sinus rhythm; T-wave inwrsion is
present.

Strip 677
Rhythm: Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.18 to 020 second
QRS complex: 0.06 10 0.08 second
Rhythm interpretation: Normal sinus
rhythm; an elevated ST segment is
present.

Strip 6-72
Rhythm: Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Nortlkll sinus
rhythm: a depressed ST segment and
a biphasic T wave are present.

Strip 679
Rhythm: Regular (basic rhythm);
irregular during pause
Rate: 107 beats/minute (basic
rhythm): slows to 94 beats/
minute for one cycle after a pause
(temporary rate suppression can
occur after a pause in the basic

strip 6-81
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: T -wave inversion is
present.

Strip 678
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia: an elevated ST segment
and a U wave are present.

Strip 6-82
Rhythm: Regular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia

Answer key to Chupters 5 through 11

Strip 6-83
Rhythm: Irregular (basic rhythm)
Rate: 60 bfatslminute (basic rhythm)
P wavts: Sinus (basic rhythm);
absent during pause
PR interval: 0.14 to 0.16 sfcond
(buic rhythm): absent during
pause
QRS complex: 0.04 second (basic
rhythm); ab~nt during pau~
Rhythm interpretation: Sinus
arrhythmia with sinus pau~ (with
~n irregul~r basic rhythm it's
impossible 10 distinguish sinus arresl
from sinus block. so the rhythm is
intfrpretfd using the broad term

Sirip 6-87
Rhythm: Regular (baJic rhythm):
irregular during pau~
Rate: S4 beats/minute (basic rhythm);
slows to 75 beats/minute for one
cycle after the pau~ (temporlll)' rate
suppression is common after a paUSf
in the!>Mk rhylhm)
P waves: Sinus (basic rhythm);
ab~nt during pause
PR interval: 0. 16 to 0.18 second
(basic rhythm): ab~nt during pau~
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during pame
Rhythm interpretation: Norma l sinus
rhythm with sinus arrest

sillus pause).
Strip 6-8-1
Rhythm: Regular
Rate: 79 buts/minute
P wavts: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
Rhythm interpret~tion: Normal sinus
rhythm: an elevaled ST segment is
presenl.
Strip 6-85
Rhythm: Regular
Rate: 136 beatslminute
P wavts: Sinus
PR interval: 0.14 to 0.16 second
QRS complu: 0.06 to 0.08 second
Rhythm interprel~tion: Sinus
tachycardi~

Sirip 6-86
Rhythm: Regular
Rate: 54 be~tslminute
P waws: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 ~cond
Rhythm interpretation: Sinus
bradycardia

Sirip 6-88
Rhythm: Regular
Rate: 100 beats/minute
P waves: Sinus
PR inlerval: 0.1210 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Norma l sinus
rhythm: an elevated ST Sfgme nt is
present.
Sirip 6-89
Rhythm: Regular
Ralf: 54 beatslminulf
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm intfrpretation: Sinus
bradycardia: an flevated ST segment
and T-w~""I! invtrsion are present.
Sirip 6-90
Rhythm: Rfgular (baJic rhythm):
irregular during pause
Rate: 72 beats/minute (baJic rhythm);
slows to 68 beats/minute for two
cycles after a pau~ (temporary rate
suppression can occur after a pause in
the !>Mic rhythm)
P waves: Sinus (basic rhythm);
ab~nt during pause
PR interval: 0.12 to 0.14 second
(basic rhythm): ab~nt during pau~
QRS complex: 0.06 to 0.08 second
(basic rhythm); ab~nt during pau~
Rhythm interpretation: Normal sinus
rh}1hm with sinus arrest; T-wave
inwrsion is present.

331

Strip 6-91
Rhythm: Regular
Rate: 65 beats/minute
P wavts: Sinus
PR interval: 0.14 to 0.16 ~cond
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm: a U wave is present.
Sirip 6-92
Rhythm: Regular
Rate: 63 bfatslminute
P wavts: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm: ST -segment depression and
T-wave inversion are present.
Strip 6-93
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 79 beats/minute (basic
rhythm): slOI'>"5 to 72 beats/minute
after a pause (tempo rary rate
suppression c~n occur after a pause
in th~ bask rhythm)
P waves: Sinus (basic rhythm):
absent during piluse
PR interval: 020 second (basic
rhythm): absent during pause
QRS complex: 0.08 to 0.10 ~cond
(basic rhythm ): absent during pause
Rhythm interpretation: Normal
sinus rhythm with sinus arrest:
ST-segment depression and T-wave
inversion are present.
Sirip 6-91
Rhythm: Regular
Rate: 150 beats/minute
P waves: Sinm
PR interval: 0.12 second
QRS complex: 0.04 to 0.06 second
Rhythm in terpretation: Sinus
tachycardia
Sirip 6-95
Rh}1hm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complu: 0.06 to 0.08 second
Rh}1hm in terpretation: Sinus
tachycardia

332

Answer key to Chapters 5 through II

Strip 6-96
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bmdycardic rate

Stri p 7-2
Rhythm: Regular
Rate: 188 beats/minute
P waves: Hidden in 1 waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Paroxysmal
atrial tachycardia

Strip 6-97
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic
rate and sinus pause. (With
an irregular basic rhythm it".
impossible to distinguish sinus arrest
from sinus block. so the rhythm is
interpreted using the broad term
sinus pause.)

Strip 7-3
Rhythm: Regular (basic rhythm);
irregular (PACs)
Rate: 94 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.12 second (basic
rhythm); 0.14 second (PACs)
QRS complex: 0.08 to 0.10 second
(basic rhythm and PACs)
Rhythm interpretation: Normal
sinus rhythm with 1',0,0 PACs (fou rth
and eighth complexes); ST-segment
depression is present.

Stri p 6-98
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
tachycardia; ~"T-segment elevation is
present.

Strip 7-4
Rhythm: Regular (off by one square)
Rate: 65 to 68 beats/minute
P waves: Vary in size. shape, and
position
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 S&ond
Rhythm interpretation: Wandering
atrial pacemaker

Strip 6-99
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
arrhythmia with a bradycardic rat~

Strip 7-5
Rhythm: Regular (basic rhythm );
irregular (PAC)
Rate: 125 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): premature and pointed (PAC)
PR interval: 0.12 second (basic
rhythm)
QRS complex: 0.04 to 0.06 S&ond
(basic rhythm)
Rhythm interpretation: Sinus tachycardia with one PAC (eighth complex)

S trip 7-1
Rhythm: Irregular
Rate: 60 beats/minute (ventricular);
atrial not measurable
P waves: Fibrillation waves present
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation; S1-segment depression
is present.

Strip 7-6
Rhythm: Regular
Rate: 167 beats/minute
P waves: Pointed, abnormal
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 S&ond
Rhythm interpretation: Paroxysmal atrial tachycardia: ST-segment
depression is present.

Strip 7-;
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal
(nonconducted PAC)
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with nonconducted PAC
(afte r the seventh QRS complex); ST
segment depression is present.
Strip 7-8
Rhythm: Irregular
Rate: 320 beats/minute (atrial );
120 beats/minute (ventricular )
P waves: Flutter wav". present
(varying ratios)
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction
Strip7 -9
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Vary in size, shape, and
direction
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip7- 10
Rhythm: Irregular
Rate: 60 beats/minute (ventricular):
atrial not measurable
P waves: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.04 to 0.06 S(cond
Rhythm interpretation: Atrial
fibrillation
Strip 7- 11
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PAC)
PR interval: 0.18 to 0.20 second
(basic rhythm)
QRS complex: 0.06 to 0.08 second
(basic rhythm)
Rhythm interpretation: Normal sinus
rhythm with one PAC (sixth complex)

Answer key to Chllptel'8 5 duough II

Sirip 7-12
Rhythm: Regular
Rate: 237 beaWminute (at rial):
79 beat!lminute (ventricular)
Pwavu: ThrH Hutter waves to each
QRScompla
PR interval: Nol necessary to
measure
QRS complex: 0.04 $fOOfld
Rhythm interpretation: Atrial nutter
with 3:1 AV conduction

Slrip7-16
Rhythm: Regular
Rate: 300 bealY'minute (atrial):
100 beats/minute (ventricular)
P WiNeS: ThrH Hulter waves before
each QRS complex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial Hutter
with 3:1 AV conduction

Slrip7-17
Slrip 7-13
Rhythm: Regular (basic rhythm):
imgular (PAC)
Rate: 107 beatslminute (basic
rhythm)
Pwaves: Sinus (basic rhythm):
premature and pointed P wave
without a QRS compla after the fifth
QRS compla
PR interval: 0. 18 to 020 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tochycardia "'ith one nonconducted
PAC (after the fifth QRS complex)
Slrip 7-14
Rhythm: irregular
Rate: 110 beat!lminute (ventricular);
atrial not measurable
P waves: Fibrillatory wa\'fS preSl.'nt
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
til-illation; some flutter waves are

""''''.

Strip 7-15
Rhythm: Regular (both rhythms )
Rate: 167 beaWminute (tiT$t
rhythm); 100 beats/minute (second
rhythm)
P waves: Obscured in T waves
(fiT$1 rhythm); sinus (second
rhythm)
PR interval: Nol measurable (tirst
rhythm); 0. 1610 0.18 second (second
rhythm)
QRS complex: 0.08 second (both
rhythms)
Rhythm interpretation: Paroxysmal
atrial tachycardia converting to
nonnal sinus rhythm

Rhythm: Irregular
Rate: 40 bealY'minute
P WiNeS: FibrilJ",lory waves
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial
tibrilJ",tion

333

Strip 7-21
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 75 beats/minute (basic
rhythm); slows to 72 beatsl
minute for tv.'O <:ycles after a
pause (temporary rate suppression
is common after a pause in the
underlying rhythm)
P wa\oU; Sinus (bas ic rhythm );
premature and pointed ",ithout QRS
complex after the third QRS complex
PR interval: 0. 16 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with on t nonoonducted
PAC (after the third QRS complex);
a U wave is present

Stripi-18
Rhythm: IrreguJ",r
Rate: 320 bealY'minute (atrial);
90 bfat!lminute (ventricular)
P waves: Flulterwaves (varying ratios)
PR interval: Not discernible
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial Hutter
with variable AV conductioo

Strip 7-22
Rhythm: Regular
Rate: 260 beatsfminute (atrial);
65 beats/minute (ventricular)
P waves: Four Hutter waves to filch
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rh}thm interpretation: Alrial flutter
with 4:1 AV conduction

Strip1-19
Rhythm: Regular (basic rhythm):
irregular (PA<:I and nonconducted
PACs)
Rate: 84 beatslminute (basic rhythm)
P WiNeS: Sinus (basic rhythm);
premature and abnormal (pACs and
nonconducted PACs)
PR interval: 0.16 second (basic
rhythm)
QRS complex: 0.06 to 0.08 SI.',ond
(basic rhythm and PACs)
Rhythm interpretation: Normal
sinus rhythm with tv.o PACs (third
and ninth complexes) and tv.'O
nonconducted PACs (after the fourth
and fifth complexes)

Strip 1-23
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 79 beaWminute (bask rhythm)
P waves: Sinus (basi' rhythm );
premature and abnormal without
QRS complex after the fourth QRS
complex
PR interval: 0. 16 to 0.18 second
(basic rhythm )
QRS complex: 0.06 to 0.08 second
(basic rhythm )
Rhythm interprdation: Normal sinus
rhythm with one nonconduded
PAC (after the fourth QRS complex):
ST-segment depression and T-wave
inveT$ion are present.

Strip 7-20
Rhythm: Regular
Rate: 167 bealY'minute
P waves: Pointed and abnormal
PR interval: 0.1610 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia

Strip 7-24
Rhythm; Irregular
Rale: 100 beaWminule
P waves: Fibril latory waves present
PR interval: Not measurable
QRS com pia.: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation

334

Answe r key to Chapters 5 through II

S tril' 7-25
Rhythm: Regular
Rate: 84 beats/minute
P waves: Vary in size. shape. and
position
PR inter"al: 0.12 to 0.14 second
QRS compl ex: 0.00 to O.o.'! second
Rhythm interpretation: Wandering
atrial pacemaker: T-wave inversion is
present.
S trip 7-26
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 68 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm ):
premature and inverted (PAC )
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.12 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fou rth
complex); a U wave is present.
Strip 7-27
Rhythm: Regular
Rate: 232 beats/minute (atrial);
58 beats/minute (ventricular )
P waves: Four flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with 4:1 AV conduction
Strip 7-28
Rhythm: Regular (basic rhytlun);
irregular (PACs)
Rate: 42 beats/minute (basic rhythm:
measured betV>'een the fifth and sixth
complexes)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.16 second (PACs)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with four PACs
(second, fourth. seventh. and ninth
complexes)

Strip 7-29
Rhythm: Regular
Rate: 150 beats/minute
P waves: Obscured in preceding T wave
PR interval: Not measurable
QRS complex: 0.08 second
Rh}thm interpretation: Paroxysmal
atrial tachycardia
Strip 7-30
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
P waves: Two flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 second
Rh}thm interpretation: Atrial flutter
y,;th 2:1 AV conduction
Slrip 7-3 1
Rh}1hm: Regular (basic rhythm);
irregular (pACs and atrial fibrillation)
Rate: 68 beats/minute (basic
rhythm); 140 beats/minute (atrial
fibrillation)
P y,'aves: Sinus (ba.ic rhythm):
premature and abnormal (PAC5);
fibrillation waves (atrial fibrillation)
PR interval: 0.12 to 0.14 second
(basic rhythm)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with two PACs (second and
fifth complexes); last PAC initiale5
atrial fibrillation: ~'T -segment
depression is present.
Sirip 7-32
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 94 beats/minute (basic
rhythm): slows to 84 beats/minute
for one cycle after a pause (temporary
rate suppression can occur after a
pause in the basic rhythm)
P waves: Sinus (basic rhythm):
premature, abnormal P wave without
il QRS complex hidden in T waV\:
after the seventh QRS complex
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one non conducted PAC
(after the seventh QRS complex)

Strip 7-33
Rhythm: Regula r (basic rhythm);
irregular (PAC)
Rate: 47 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature and pointed (PAC)
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex): a U wave is present.
Strip 7-34
Rhythm: Irregular
Rate: 50 beats/minute (ventricular):
atrial not measurable
P waves: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
and T-wave inversion are present.
Strip 7-35
Rhythm: Regular
Rak 188 beats/minute
P waves: Obscured in T waves
PR interval: Unmeasurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia; ST-segment
depression is present.
Strip 7-36
Rhythm: Irregular
Rate: 50 beat5lminute
P waves: Vary in size, shape. or
direction across strip
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-37
Rhythm: Irregular
Rate: 260 beats/minute (atrial);
70 beats/minute (ventricular)
P waves: Flutter waves (varying
ratios)
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction

Answer key 10 Chaplers 51hrough II

SlTiIl7-38
Rhythm: Regular
Rate: 150 beawminute
Pwaves: Obscured in T waves
(T-Pwaves)
PR interval: Not measurable
QRS complex 0.06 to 0.08 second
Rhythm interpretation: ParOX}'$mal
atrial tachycardia
Strip 7-39
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 136 beawminute (basic
rhythm)
P waves: Sinus (basic rhythm):
premature and pointed (PAC)
PR interval: 0.16 to 0. 18 second
(basic rhythm); 0.18 second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.06 second (PAC)
Rhythm interpretation: Sinus
tachycardia with one PAC (eleventh
complex)
Slr]p 7-"0
Rhythm: irregular
Rate: 130 beaWminule (ventricular);
atrial not measurable
P waws: Fibrillatory waves present
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation (uncontrolled rate)

SlTip 7-t 1
Rhythm: Regular (basic rhythm);
irrtgular tnonconducted PAC)
Rate: 79 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
premature. abnormal P wave hidden
in the T wave after the seventh QRS
complex
PR interval: 020 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm ....ith one nonconducted
PAC (hidden in the T wave after the
seventh QRS romp lex); a U wave is
present.

Stri p 7..012
Rhythm: Regular (basic rhythm):
irrtgular with prematurt atrial
contraction (PAC)
Rate: 84 beats/minute (buic
rhythm)
P ....<Nes: Sinus (basic rhythm);
abnormal. pointed (PAC)
PR interval: 0.12 to 0.14 second
(basic rhythm); 028 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.06 second (PAC)
Rhythm interpretation: Normal sinus
rhythm with one PAC (conducted
with long PR interval)
Siri p 7-4.1

Rhythm: Regular
Rate: 68 beats/minute
P waves: Vary in size. shapt, and
position
PR interval: 0.12 second
QRS complex: 0,06 to 0.08 second
Rhythm interpretation: Wandering a!rial pacemaker: ST-segment
deprtMion is present.
Slri p 7-H

Rhythm: Regular
Rate: 272 beats/minute (atrial):
136 beats/minute (wntricular)
P ....<Nes: Two nuller waws to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial Hutter
with 2:1 AV conduction
Sirip 7-45

Rhythm: Regular
Rate: 188 beaWminute
P waves: Hidden in T ..... a\'es
PR interval: Not measurable
QRS complex: 0,04 to 0.06 second
Rhythm interpretation: Paroxysmal
atrial tachycardia; ST-segment
depression is present.

335

Strip 7-46
Rh ythm: Regular (basic rhythm):
irregular (premature beat)
Rate: 79 beats/minute (basic rhythm)
P waves: Sinu$ (Iw; ic rhythm );
prematurt and pointed (PAC)
PR interval: 0.14 to 0.16 second
(basic rhythm); 0,]2 second (PAC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one PAC (tifth romp lex)
Strip 7--17
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 84 beats/minute (basic rhythm)
P waves: Sinus; prematuTC and
poin ted (PAC)
PR interval: 0. 14 to 0.16 (basic
rhythm); 0.16 .second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm ); 0,08 second (PAC)
Rhythm interpretation: Nonnal
sinus rhythm with one PAC (seventh
complex); ST-segment depression is
present.
Strip 7-48
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Fibrillatory waves present
PR interval: Not mea.lUrable
QRS compla: 0,08 second
Rh ythm interpretation: Atrial
fibrillation (controlled rate )

Strip 7-49
Rhythm: Irregular
Rate: 280 beats/minute (atrial):
50 beats/minute (ventricular)
P waves: Flutterwaves present
(varying ratios)
PR interval: Not measurable
QRS com pIa: 0,06 to 0.08 second
Rhythm interpretation: Atria! flutter
with variable AV conduction
Strip 7-50
Rh~thm: Irregular
Rate: 300 beats/minute (atrial l:
100 beats/minute (ventricular)
P Willies: Flutter waves (varying mtios)
PR interval: Not measurable
QRS compla: 0.1 to O.06second
Rh ~thm interpretation: Atrial flutter
with vari able AV conduction

336

Answer key to Chapters 5 through II

Strip i -51
Rhythm: Regular
Rate: 150 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Str ip i -52
Rhythm: Regular (basic rhythm);
irregular with PACs
Rate: 65 beats/minute (basic rhythm)
P waves: Sinm (basic rhythm):
nbnormnl. inv<:rted (pAC.)
PR interval: 0.20 second (basic
rhythm); 0.12 second (PACs)
QRS complex: 0.06 to 0.08 second
(basic rhythm and PACs)
Rhythm interpretation: Normal sinus
rhythm with paired PACs
Strip 7-53
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation:Atriai fibrillation: sr-segment depression is present.
S trip 7-54
Rhythm: R~KuJdr (iM.i" rhylluJl);
irregular (PAC)
Rate: 94 beaU/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and pointed (PAC)
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rh}thm interpretation: Nonnal sinus
rhythm with one PAC (eighth complex):
sr-segmentdepression is present.
Slrip 7-55
Rhythm : Irregular (first rhythm);
regular (second rhythm)
Rate: 120 beats/minute (first
rhythm): 75 beats/minute (second
rhythm)
P waves: Fibrillatory waves to sinus
PR interval: Not measurable (first
rhythm): 0.12 to 0.14 second (second
rhythm)
QRS complex: 0.04 to 0.08 second
(both rhythms )
Rhythm interpretation: Atrial
fibrillation to normal sinus rhythm

Strip i-56
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 84 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PAC )
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.12 second (PAC )
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fifth
complex); baseline artifact is present
(b....,linc artif"ct .houldn't be
confused with atrial fibrillation).

Strip 7-60
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation
Strip 7-61
Rhythm: Irregular
Rate: 210 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QIlS complex: 0.04 to 0.06 .Kcond
Rhythm interpretation: Atrial
fibrillation

Strip i-57
Rhythm: Regular
Rate: 225 beats/minute (atrial);
75 beats/minute (ventricular)
P waves: Three tlutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial tlutter
with 3:1 AV conduction

Sirip i-58
Rhythm: Regular (basic rhythm):
irregular (nonconducted PACs )
Rate: 88 heats/minute (basic
rhylhm); r"l~ .luw. lu 72 b~"W
minute after a pause (temporary rate
suppression is common after a pause
in the basic rhythm)
P waves: Sinus (basic rhythm);
premature, abnormal P wave without
a QRS complex hidden in the T wave
after the seventh QRS complex
PR interval: 0.12 to 0.14 second
(basic rhythm)
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with one nonconducted PAC
(afte r the seventh QRS complex)

Strip 7-59
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Vary in size. shape, and
direction
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker; T-wave inversion is
present.

Strip j-62
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature, abnormal P wave (PAC)
PR interval: 0.16 to 0.18 second
(basic rhythm)
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex); a U wave is present.
Strill7-63
Rhythm : Irregular
Rate: 40 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial
fibrillation

Strip 7-64
Rhythm: Regular
Rate: 214 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia

Answer key to Ch ap ters 5 through II

Strip 7-65
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 52 beats/minute (basic
rhythm)
P wa~5 : Sinus (basic rhythm):
premature. pointed P waw associated
with PAC hidden in the T wave after
the fourth QRS complex
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia with one PAC (fifth
complex); a U waw is present.
Strip 7-66
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 75 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
premature. abnormal P wave hidden
in the T wa~ after the fourth QRS
complex
PR interval: 020 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with on~ nonconducttd PAC
(after the fourth QRS complex): a U
wa~ is present.
Strip 7-67
Rhythm: Regular (off by tv.o
squares)
Rate: 79 b~aWminute
P wa~s: Vary in siu, shape. and
direction
PR interval: 0.12 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-68
Rhythm: Regular
Rate: 150 beats/minute
P wa~s: Hidden in preceding T
wa~s

PR interval: Not measurable

QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Paroxysmal
atrial tachycardia: ST -segment
depression is present.

Slrip7-69
Rhythm: Irregu lar
Rate: 250 beats/minute (atrial):
70 beats/minute (~ntricular)
P waves: Flutter waves before each
QRS complex (varying ratios)
PR interval: Not measurable
QRS compl ex: 0.06 to 0.08 second
Rhythm interpretation: Atrial flutter
with variable AV conduction
Strip 7-70
Rhythm: Irregular
Rate: 130 beats/minute (ventricular) ;
atrial not measurable
P waves: Fibrillatory waves: some
flutter waves
PR interval: Not measurable
QRS complex: 0.04 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
is present.
Strip 7-7 1
Rhythm: Regular (basic rhythm);
irregular (PACs)
Rate: 88 beats/minute (basic rh~1:hm)
P waves: Sinus (basic rhythm);
premature and abnormal (PACs)
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with paired PACs (third and
fourth complens)

337

Strip 7-74
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 63 beatYminute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PAC)
PR interval: 0.12 to 0.14 second
(basic rh}1hm): 0.14 second (PAC)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.08 second (PAC)
Rhythm interpretation: Normal
sinus rhythm with one PAC (fourth
complex): a small U wa~ is present.
Strip 7-75
Rh}1hm: Rellular
Rate: 150 beats/minute
P waves: Hidden in T waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia: ST -segment
depression is present.
Sirip 7-76
Rhythm: Irregular
Rate: 80 beats/minute (ventricular);
atrial not measurable
P wa~s: Fibrillatory waves present
PR interval: Not measu rable
QRS complex: 0.04 second
Rhythm interpretation: Atrial
fibrillation; ST-segment depression
and T-wave inversion are present.

Sirip 772
Rhythm: Regular
Rate: 54 beats/minute
P waves: Varying in size and shape
PR interval: 0.12 second
QRS complex: 0.08 to 0.10 5econd
Rhythm interpretation: Wandering
atrial pacemaker: ST -segment
depression is present.

Strip 7-77
Rhythm: Regular
Rate: 88 beats/minute
P waves: Vary in size. shape, and
position
PR interval: 0.12 to 0.14 second
QRS compJa: 0.06 to O.og second
Rhythm interpretation: Wandering
atrial pacemaker; T-wa~ in~rsion is
present.

Sirip 7-73
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
P waves: Two flutter wa~s to each
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction

Strip 7-78
Rhythm: Irregular
Rate: 50 beats/minute
P wa~s: Vary in size. shape, and
position
PR interval: 0.12 to 0.16 second
QRS complex: 0.08 second
Rh}1hm interpretation: Wandering
atrial pacemaker; ST-segment
depression is present.

338

AnslI'er key to Chaplers 5 through II

Strip 7-79
Rhythm: Irregular
Rate: 280 beat5lminute (atrial):
100 beats/minute (ventricular)
P wavu: Flutter waws
PR intel>'al: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial flutter
with variable AV condudion
Strip 7-80
Rhythm: Regular (ba.sic rhythm);
irregular (nonconducted PACs)
Rate: 107 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal
(nonconducted PACs)
PR inten'al: 0.16 to 0.18 second
QRS wmplex: 0.00 to 0.08 second
Rhythm interpretation: Sinus.
tachycardia with two nonconducted
PACs (after the third and eighth QRS
oomplexes)
Sirip 7-81
Rhythm: Regular
Rate: 68 beats/minute
P waves: Vary in size, shape. and
direction
PR intel>'al: 0.12 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker: a U wave is present.
S lrtp 7-82
Rhythm: Regular
Rate: 260 beats/minute (atrial):
65 beats/minute (ventricular)
P waws: Flutter waws
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial flutter
with 4:1 AV condudion
S irip 7-8."1
Rhythm: Regular
Rate: 167 beat5lminute
P waves: Hidden in preceding T wave
PR intel>'al: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia

Strip7..s"
Rhythm: Irregular
Rate: 50 beats/minute
P waves: Fibrillatory waves
PR interval: Not meuurable
QRS complex: 0.08 to O. 10 second
Rhythm interpretation: Atrial
fibrillation
Sirip 7..s5
Rhythm: Irregula r
Rate: 40 beats/minute
P waves: Vary in size. shape. and
direction
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Sirip 7-86
Rhythm: Regular (basic rhythm):
irregular (PACs)
Rate: 107 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (PACs)
PR interval: 0.16 second (basic
rhythm)
QRS complex: 0.06 second
Rhythm interpretation: Sinus
tDchy<:ardia with three PAGs (fourth.
ninth. and eleventh complexes)
Strip 7-S7
Rhythm: Irre gular
Rate: 60 beats/minute
P waves: Fibrillatory waves
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip7..sS
Rhythm: Regular (first rhythm):
irregular (second rhythm )
Rate: 79 beats/minute (first rhythm);
140 beats/minute (second rhythm)
P waves: Sinus to fibrillatory waves
PR interval: 0.12 to 0.14 second (first
rhythm): not measurable (second
rhythm)
QRS oomplex: 0.04 to 0.08 second
(both rhythms)
Rhythm interpretation: Normal sinus
rhythm to atrial fibrillation

Strip 7-89
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 84 beats/minute (buic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed
(nonconducted PAC)
PR interval: 0.16 to 0.20 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation:
Normal sinus rhythm with one
non conducted PAC (after the
fifth QRS complex): ST-segment
depression is present.
Strip 7-90
Rhythm: Regular (buic rhythm);
irregular (PAC)
Rate: 54 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and abnormal (PAC)
PR intenoal: 0.16 to 0.18 second
QRS complex: 0.00 second
Rhythm in terpretation: Sinus
bradycardia with one PAC (fourth
complex)
Sirip 7-9 1
Rhythm: Regular (basic rhythm):
irregular (PAC)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rh}thm);
premature and abnormal (PAC)
PR interval: 0.14 to 0. 16 second
QRS complex: 0.00 second
Rhythm in terpretation: Normal
sinus rhythm with one PAC (fifth
complex); a U wave is present.
Strip 7-92
Rhythm: Regular
Rate: 235 beats/minute (atrial):
47 beats/minute (ventricular)
P waves: Five Hutter waves to each
QRS complex
PR intenoal: Not discernible
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 5:1 AV conduction; T-wave
inversion is present.

Answer key to Chapters 5 through II

Str ip 7-93
Rhythm: Regular
Rate: 150 beats/minute
P waws: Obscured in T waws
(TP wmes)
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 7-91
Rhythm: Irregular
Rate: 50 beats/minute
Pwaws:Wavy
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial
fibrillation
Strip 7-95
Rhythm: Regular (basic rhythm):
irregular after a burst of PAT
Rate: 84 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): abnormal and premature with a run of PAT
PR interval: 0.16 to 0.18 second (basic
rhythm): not measurable in PAT
QRS complex: 0.04 to 0.06 second
(basic rhythm and PAT )
Rhythm interpretation: Normal sinus
rhythm with burst of PAT (three
PACs afler the fourth QRS complex)
Strip 7-96
Rhythm: Regular
Rate: 88 beats/minute
P waws: Sinus
PR intervill: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm
Strip 7-97
Rhythm: Regular (basic rhythm)
but off by one square: irregulilr with
PACs
Rate: 84 to 88 beats/minute (basic
rhythm)
P WilVi:S: Sinus (basic rhythm):
abnormal, pointed (PACs)
PR interval: 0.14 to 0.16 (basic
rhythm and PACs)
QRS complex: 0.08 second (basic
rhythm and PAC s)
Rhythm interpretation: Normal sinus
rhythm with PAC~ every fourth be"t
(quadrigeminal pattern)

Strip 7-98
Rhythm: Regular
Rate: 150 beats/minute
P wmes: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia
Strip 7-99
Rhythm: Regular
Rate: 250 beats/minute (atrial):
125 beats/minute (wntricular)
P wmes: Two flutter WavtS to each
QRScomplex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction
Strip7-IOO
Rhythm: Regular (biLIic rhythm);
irregular during pause
Rate: 48 beats/minute (basic
rhythm)
P wmes: Sinus (basic rhythm);
absent during pause
PR interval: 0.20 second (basic
rhythm); absent during pause
QRS complex: 0.06 to 0.08 second
(basic rhythm); absent during
pause
Rhythm interpretation: Sinus
bradycardia with sinus arrest
Strip7-IO I
Rhythm: Irregular
Rate: 90 beat;;/minute
P wmes: Vary in size, shape, and
direction
PR interval: 0.12 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker
Strip 7-102
Rhythm: Regular (off by one
square)
Rate: 45 to 47 bi:atslminute
P wmes: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Sinus
bradycardia

339

Strip 7- 103
Rhythm: Regular (first and second
rhythms)
Rate: 107 beats/minute (first
rhythm); 214 beats/minute (second
rhythm)
P waves: Sinus (first rhythm ):
abnormill, pointed (second
rhythm)
PR interval: 0.16 to 0.18 second (first
rhythm); not measurable (second
rhythm)
QRS complex: 0.08 to 0.10 second
(first and second rhythms)
Rhythm interpretation: Sinus
tachycardia with burst of PAT (8_beat
run initiated by PAC)
Strip 7- \ 04
Rhythm: Irregular
Rate: 100 beats/minute
P wavts: Fibrillatory wavts
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Atrial
fibrillation
Strip 7- 105
Rh,1hm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 7- 106
Rhythm: Re~ular (first rhythm):
irregular (second rhythm)
Rate: 75 beats/minute (first
rhythm); 360 beats/minute atrial
(second rhythm); 140 beatslminute
wntricular (second rhythm )
P waws: Sinus (first rhythm ): Hutter
waws (second rhythm )
PR interval: 0.12 second (first
rhythm): not measurilble (second
rhythm)
QRS ,0mpJex: 0.06 to 0.08 second
(first and second rhythms)
Rhythm interpretation: Normal sinus
rhythm with PAC (fifth complex)
changing to iltrial Hutter with
variableAV conduction

340

Answer key I() Ch:aplcrs 5 Ihrough II

S lrip7~ 1 07

Sirip 8-4

Strip 8-11

Rhythm: Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0. 12 to 0.14 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Normal s inus
rhythm

Rhythm; Regular (basic rhythm):

irregular (junctional beat)
Rate: 58 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
hidden Pwave (junctional beal)
PR interval: 0.16 to 0. 18 second
(basic rhythm)
QRS compln: 0.08 to 0.10 second
(basic rhythm and junctional beat)
Rhythm interpretation; Sinus
bradycardia with junctional escape
beal (fourth complex) after pause in
basic rhythm: ST~segment depression
is present.

Rhythm: Regular (atrial): irregular

(ventricular)
Rate: 75 beat.slminute (atrial):
70 beats/minute (ventricular)
P waves: Sinus
PR interval: Lengthens from 028 to
0.32 second
QRS complex: O.Got to 0.08 se cond
Rhythm interpretation: Second-degree
AV block, Mobitz I; 51-segment depression and T-wave im'Crslon are present.

Strip 8-1
Rhythm: Regular (buic rhythm):
Irregular (PIC)
Rate: 58 beaU/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
premature and inverted (PIC)
PR interval: 0.14 to 0.16 second
(basic rhythm); 0.08 second (PIC)
QRS complex: 0.00 second (basic
rhythm and PIC)
Rhythm interpretation: Sinus
bradycardia with one PIC (fifth
complex): a U wave is present.

Strip 8-2
Rhythm: Regular
Rate: 60 beats/minute
P wart$; Sinus
PR interval: 0..24 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with lirst-degree AV block:
ST-segment elevation and T~wave
inversion are present.

Sir ip 8-3
Rhythm: Regular (atrial and
ventricular)
Rate: 96 beats/minute (atrial ):
32 beats/minute (ventrictJlar)
P waves: Three sinus Pwaves before
filch QRS compln
PR interval: 0.14 to 0.16 second
(remains consistent)
QRS complex: 0.12 second
Rhythm interpretation: r.10bitz II
with 3:1 AV conduction (third P wm.oe
hidden in T waves)

Sirip 8-5
Rhythm: Regular (first and second
rhythlTl5)
Rate: 84 beats/minute (first rhythm):
94 beaU/minute (second rh}1hm)
P waves: Sinus (first rhythm):
inverted (second rhythm)
PR interval: 0.12 second (fint
rhythm): 0.08 to 0.10 setond (second
rhythm )
QRS complex: 0.06 to 0.08 seoond
(lirst and second rhythlTl5 )
Rhythm interpretation: Normal sinus
rhythm changing to accelerated
junctional rhythm

Sirip 8-6
Rhythm; Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0.22 to 024 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with lirst..degree AV block

Sirip 8-7
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atcelerated
junctional rhythm; ST-segment elevation and T-wave inversion are present.

Strip 8-9
Rhythm: Regular
Rate; 47 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: Junctional
rhythm: !>T-segment depression is
present.

Strip 810
Rhythm: Regular (atrial): irregular
(ventricular)
Rate: 75 beats/minute (atrial):
30 beat~minute (ventricular)
P waves: Two sinus P waVC;$ before
each QRS complex
PR interval: 020 to 0.22 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, "1obitz II (clinical
correlation is suggested to diagnose
Mobilz II when 2;1 conduction is
present with a narrow QRS complex).

Strip 8 11
Rhythm: Regular (atrial and
ventricu lar)
Rate: 63 beats/minute (atrial):
33 beats/minute (ventricularl
P waves: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block: ST-segment depression and
T-wave inversion are present.

Answer key to Chapters 5 through II

Str ip S-12
Rhythm: Regular
Rate: 84 beats/minute
P waws: Hidden in the QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm: ST-segment
depression is present.
Strip S-13
Rhythm: Regular
Rate: 65 beats/minute
P waws: Sinus
PR interval: 0.44 to 0.48 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block:
an elevated ST-segment is present.
Slr ipS-H
Rhythm: Regular (basic rhythm):
irregular (PJC)
Rate: 136 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
hidden P waw (PJC)
PR interval: 0.12 to 0.14 se,ond
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia with one PJC (thirteenth
complex)
Strip S-15
Rhythm: Reguku
Rate: 94 beats/minute
P waws: Sinus
PR interval: 026 to 0.28 second
QRS complex: 0.06 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block:
ST -segment depression is present.
Strip 8-16
Hhythm: Hegular (basic rhythm):
irregular (premature beat)
Rate: 58 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm);
inverted (premature beat)
PR interv"l: 0.16 to 0.18 second
(basic rhythm); 0.08 second (PJC )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus bradycardia with one PJC (fourth complex);
~"T-segment depression is present.

Strip 8-17
Rhythm: Regular (atrial and
ventricular)
Rate: 108 beats/minute (atrial);
54 beats/minute (wntricular)
P waves: Two P waves to each QRS
complex
PR interval: 0.20 second and
constant
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, Mobitz II (clinical
correlation is suggested to diagnose
Mobitz II when 2:1 conduction is
present with a narrow QRS complex).
S1-segment elevation and T-waw
inwrsion are presmt.
Strip 8-18
Rhythm: Regular (atrial): irregular
(wntricular )
Rate: 65 beats/minute (atrial);
50 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthens from 0.20 to
0.48 second
QRS complex: 0.04 second
Rhythm interpreliltion:
Second-degree AV block. Hobitz I
Strip 8-19
Rhythm: Regular
Rate: 125 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Junctional
tachycardia
Strip 8-20
Rhythm: Regular (atrial and
ventricular)
Rate: 100 beats/minute (atrial);
::Ii! beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex; found hidden in
the QRS complex and T waves)
PR interval: VilI"ies greatly
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Third-degree
AV block: ST-segment depression is
present.

3 41

Strip S-21
Rh}1.hm: Regular (basic rhythm);
irregular (PJC)
Rate: 60 beawminute (basic rhythm)
P waves: Sinus (basic rhythm);
premature and inverted (PJC)
PR interv.'Jl: 0.12 to 0.14 second
(basic rhythm); 0.08 second (PJC)
QRS compla: 0.08 second (basic
rhythm and PJC)
Rhythm interpretation: Normal
sinus rhythm with one PJC (fourth
complex)
Strip S-22
Rh}1.hm: Regular (basic rhythm) but
offby two squares
Rate: 54 to 58 beats/minute
P waves: Sinus (basic rhythm);
hidden within QRS complex
(junctional beats)
PR interval: 0.16 to 0.18 second
(basic rhythm)
QRS compla: 0.08 to 0.10 second
(basic rh}1hm and junctional beats)
Rhythm interpretation: Sinus
bradycardia with a paUie folk,,,,ro by
two junctional es\:il.])': beats; ~])':dfic
pause (sinus arrest or sinus block)
cannot be identified due to the
presence of the escape beats.
Strip S-23
Rhythm: Regular
Rate: 35 beatslminute
P waves: Sinus
PR interval: 0.60 to 0.62 second
(remains constant)
QRS compla: 0.06 second
Rhythm interpretation: Sinus
bradycardia with first-degree AV
block
Strip S-2~
Hhythm: Hegular (atrial): irregular
(ventricular )
Rate: 68 beawminute (atrial ):
60 beats/minute (ventricular)
P waws: Sinus
PR interval: 028 to 0.36 second
QRS com pI",,: 0.08 second
Rh}1hm interpretation:
Second-degree AV block. Mobitz I;
aU waw is present.

34 2

Answer key to Chapters 5 through II

S tr ip 8-25
Rhythm: Regular
Rate: 75 beats/minute
P waves: Sinus
PR interval: 0.28 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
rhythm with first-degree AV block
Strip 8-26
Rhythm: Regular (basic rhythm);
irregular with premature beats
Rate: 100 beats/minute (basic
rhythm)
P waws: Sinus (basic rhythm ):
pointed P waw (PAC); inverted
P waw (PJCs)
PR interval: 0.20 second (basic
rhythm): 0.16 second (PAC);
0.06 second (PJCs)
QRS complex: 0.00 to 0.08 second
(basic rhythm and premature beats)
Rhythm interf\ ..... t~tion: Nor"",]
sinus rhythm with one PAC (seventh
complex) and paired PJC5 (eighth
and ninth complexes): ST-segment
depression is present.
Strip 8-27
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inwrted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm; elevated ST
segment is present.
Strip 8-28
Rhythm: Regular (basic rhythm);
irregular (non conducted PAC)
Rate: 56 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm );
premature, abnormal P wave without
a QRS complex
PR interval: 0.24 to 0.26 second
(remains ,onstant)
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia with first-degree AV
block and nonconducted PAC
(follows the fourth QRS complex);
ST-segment depression is present.

Strip 8-29
Rhythm: Regular (atrial); irregular
(vent ricular)
Rate: 72 beats/minute (atrial);
50 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthem from 0.24 to
0.36 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Mobitz I
Strip 8-30
Rhythm: Regular (atrial and
ventricular)
Rate: 79 beats/minute (atrial);
32 beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV!>lock
Strip 8-31
Rhythm: Atrial and ventricular rhythm reguklf (both off by
tv.o squares)
Rate: 80 beats/minute (atrial);
30 beats/minute (wntricular)
P waves: Three sinus P waves to each
QRS complex
PR interval: 0.20 to 022 second
(remains consistent)
QRS ,0mpJex: 0.14 to 0.16 S\!cond
Rhythm interpretation: Mobitz II
y,ith 3:1 AV conduction
Strip 8-32
Rhythm: Regular (atrial and
ventricular)
Rate: 75 beilts/minute (atrial);
34 beats/minute (wntricular)
P waves: Sinus (bear no relationship
to the QRS complex; found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AV block: &[ -segment elevation is
present.

Strip 8-33
Rhythm: Regular (basic rhythm);
irregular (PAC)
Rate: 100 beats/minute (basic
rhythm)
P waves: Inverted before the QRS
complex (basic rhythm); upright and
pointed (PAC)
PR interval: 0.08 second (basic
rhythm); 0.12 second (PAC)
QRS complex: 0.08 second (basic
rhythm and PAC)
Rhythm interpretation: Accelerated
junctional rhythm with one PAC
(sixth complex); ST-segment
depression is present.
Strip 8-34
Rhythm: Regular (atrial): irregular
(vent ricular)
Rate: 75 beats/minute (atrial);
50 beats/minute (ventricular)
PR interval: 0.28 to 0.40 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation:
Second-degree AV block, Mobilz I
Strip 8-35
Rhythm: Regular
Rate: 60 beals/minute
P waves: Sinus
PR interval: 0.24 to 0.26 second
QRS complex: 0.06 to 0.08 second
Rhythm interpreUltion: Normal
sinus rhythm with first-degree AV
block
Strip 8-36
Rhythm: Regular
Rate: 41 beats/minute
P waves: Inverted after the QRS
complex
PR interval: 0.04 10 0.06 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm

Answer key to Chapters 5 through II

Str ip 837
Rhythm: Regular (basic rhythm):
irregular (P1Cs)
Rate: 58 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and inverted (P1Cs)
PR interval: 0.16 second (basic
rhythm); 0.08 to 0.10 second (P1Cs)
QRS complex: 0.08 second (basic
rhythm and P1Cs)
Rhythm interpretation: Sinus
bradycardia with two PJCs (fourth
and sixth complexes); a U wave is
pres<!nt.
Str ip 8-38
Rhythm: Regular
Rate: 60 beats/minute
P waves: Inverted
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Hhythm interpretation: Junctional
rhythm
Strip 8-39
Rhythm: Regular (atrial and
ventricular)
Rate: 65 beats/minute (atrial);
36 beats/minute (ventricular)
P waves: Sinus
PR interval: Varies (not consistent)
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-40
Rhythm: Regular (atrial and
ventricular)
Rate: 84 beatslminute (atrial):
30 beats/minute (ventricular)
P waves: Sinus
PR interval: Varies (not consistent)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-4 1
Rhythm: Regular
Rate: 84 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm

343

Strip 8-42
Rhythm: Regular (atrial and ventricular)
Rate: 125 beats/minute (at rial);
40 beats/minute (ventricular)
P waves: Three sinus P waves before
each QRS complex
PR interval: 0.22 to 0.24 second
(consistent)
QRS complex: 0.12 second
Rhythm interpretation: Mobitz II
second-degree AV block

Strip 8-46
Rh}1hm: Irregular
Rate: 40 beats/minute
P waves: Sinus
PR interval: 028 second (remains
constant)
QRS complex: 0.08 to 0.10 second
Rh}1hm interpretation: Sinus
arrhythmia with bradycardic rate
and first-degree AV block; a U wave is
present.

Strip 8-43
Rhythm: Irregular (first rhythm ):
regular (second rhythm)
Rate: 80 beats/minute (first rhythm):
42 beats/minute (second rhythm)
P waves: Fibrillatory waves (first
rh}1hm): hidden P waves (second
rhythm)
PR interval: Not measurable in either
rhythm
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation to junctional rhythm:
Si-segment depression is present.

Strip 8-47
Rhythm: Regular (atrilll ): irregular
(ventricular )
Rate: 79 beats/minute (atrial ):
50 beats/minute (vent ricular )
P waves: Sinus
PR interval: Lengthens from 0.24 to
0.40 second
QRS compla: 0.08 to 0.10 second
Hhythm interpretation:
Second-degree AV block. Mobilz I

Sirip 8-44
Rhythm: Regular (basic rhythm);
irregular (prematu re beats)
Rate: 60 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature and abnormal (premature
beats)
PR interval: 0.12 to 0.16 second
(basic rhythm); 0.12 second (PAC);
0.08 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PAC (fourth
complex) and one PJC (fifth
complex); ST-sel/ment depression
and T-wave inversion are present.
Strip 8-45
Rhythm: Regular (atrial and
ventricular)
Rate: 72 beats/minute (atrial);
32 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex; hidden in the
QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block; ST-segment elevation is
present.

Strip 8-48
Rhythm: Regular (atrial and
ventricular)
Rate: 108 beatslminute (atrial );
54 beats/minute (ventricular )
P waves: Two sinus P waves before
each QRS complex
PR interval: 0.18 to 0.20 second
(remains constant)
QRS compla: 0.08 second
Rhjthm interpretation: Seconddegree AV block. Mobitz II (clinical
correlation is suggested to diagnose
Mobilz II when 2:1 conduction is
present with a narrow QRS complex);
ST-segment elevation and T-wave
inversion are present.
Strip 8-49
Rhythm: Irregular
Rate: 40 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.04 to 0.06 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm: ST -segment depression is
present.

344

Answer key 10 Choplera 5 Ihrough II

S trip 850
Rhythm: Regular (buic rhythm):
irregular (esape ~al)
Rale: 84 bUlts/minute (bask
rhythm); slows to 7S buw
minute after ncallt' but
(tempo ra l'}' rille suppression can
ocrur after premature Of escape
beats; after ~rlll cycln rate will
rtlurn to buic rate)
P waves: Sinus; P wa~ hidden with

""'"
...,
PR interval: 0.14 to 0.16 second

QRS compla: 0.06 to 0.08 second

Rhythm interpreilltion: Normal
sinus rhythm with junclioTIIII ucape
beat (fifth complex) after II pause
in the basic rhythm: a U 'o\"1IYe is
present.

Stri p 851
Rhythm: Regytar
Rate: 9-t btatsfminute
P 'o\",WtS: In~rted before 1M QRS
complex
PR interval: 0.08 second
QRS compla: 0.06 to 0.08 steond
Rhythm interpntalioo.: Acrtle rated
junctioTIIII rhythm
Sirip g-55
Rhythm: Regylar (!sic rh)thm)
Rate: 55 btatslminute (basic rh)"thm)
PIoIaWS: SiOOll (basic rh)1.hm); notched
Pwavt$ u$WI1y indicate Itft atrial h)'p!'rtrophy: no P __ e 5HIlwith fourth
complex: fifth COlT1lia has a P wave on
top oftht preceding T wa~
PR interval: 0.20 second (basic
mythm)

S trip 85 1
Rhythm: Regular (atrial) but off by
two squares: irregular (~ntricular)
Rate: 60 to 65 beal&iminute (atrial):
50 beats/minute (ventricuL!lr)
P wa~s: Sinus
PR interval: Lengthens from 028 to
0.40 second (not consistent)
QRS complex: 0.08 iltcond
Rhythm interprttation: Mobiul
second-degrH AV block
Strip 852
Rhythm: Regular
Ralt: 63 buts/minute
P WiveS: Hidden in the QRS
comple!
PR interval: Not measurable
QRS compla: 0.08 second
Rhythm interpretation: Accelerated
junctional rhythm
Strip 8 53
Rhythm: Regular (atrial) but of( by
two squares: irregular (~ntricuL!lr)
Rate: 84 beats/minute (atrial):
40 beats/minute (ventricu L!lr)
P waves: Sinus (two or three P W/lWS
before each QRS complex)
PR interval: 0.12 second (consistent)
QRS complex: 0.12 second
Rhythm interpretation: Mobiu II
seconddegrH AV block with 2:1 and
3:1 AV conduction

QRS complex: 0.06 to 0.08 second

Rhythm interpretation: Sinus
bradycardia with a paU5e followed
by a junclion.l tstape beat (fourth
complex) and a PAC (tifth complex);
IIbnorrMl P wa~ al5O(:iated 'o\ith
PAC is obJtTYtd in preceding T wa~.
Siri p 8-56
Rhythm: Regular (lirst and second
myth~)

Rate: 72 braWminute (first rhythm);

obout 140 lxaUlminute (second
mythm)

P waves: Sinus (first rhythm):

in~rted (second rhythm)
PR interval: 0.12 second (first rhythm):
0.08 to 0.10 5tCOOd (second rh)Ithm)
QRS complex: 0.08 second
Rhythm interpretation: Normal
sinllll rhythm cm.ng;ng to junctiOOllt
tachycardia: STsegment depression
is pl'"esent.
S tnp 857
Rhythm: Regular
Rate: 84 beats/minute
P waves: Sinus
PR interval: 0..30 to 0.32 second
(remains constant)
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm with lirst--degree AV block;
STsegment elevation is present.

Strip !loSt!
Rhythm: Regular (atrilll and
~ntricularl

Rate: 7S btatyminute (atrial);

30 beats/minute (ventricular)
P WIVes: Sinus (bear no relationship
to 1M QRS complex)
PR inteT\'al: Variu greatly
QRS complex: 0.12to 0.14 second
Rhythm interprtllltion: Thirddegree:
AVblock
Strip 1159
Rhythm: Regular (atrial and
ventricular)
Rate: 93 beats/minute (alrill):
31 buWminute (ventricular)
P WIVes: Three linus waws to
tach QRS comple)! (one hidden in
T wave)
PR interval: 0.32 to 0.36 second
QRS complex: 0.08 second
Rhythm interprelMion: Second
degree AV block. Mobil.1l1;
STsegment depre$5ion i. present.
Strip 8-60
Rhythm: Regular (buic rhythm):
irregular (premature beats)
Rate: 60 bnt"minute (basic
rhythm)
P W/IYes: Sinus (basic rhythm);
prermture and abnormal (prtfl"\llture

""'u)
PR inte~l: 0.12 second (wic
rhythm): 0. 12 SKOI'Id (PAC): 0.08 to
0.10 second (pJCs)
QRS complex: 0.08 second
Rhythm interprttlltion: Normal
sinus I'h)thm with one PAC (third
complex) and paired Plel (Iixth and
seventh complexe$)
Strip 8-61
Rhythm: Regular
Rate:
beats/minute
P waves: Hidden in the QRS
complex
PR inlerval: Not measurable
QRS complex: 0.08 second
Rhythm interprelati on: Junctional

"7

mythm

Answer key to Chapters 5 through II

Siri p 8-62
Rhythm: Regular (basic rhythm):
irrtgular (noncondutled PAC)
Rate: 79 beats/minute (basic rhythm~
5b.Ys 10 63 beaWminute after a ~
(temporary rate $uppressioo is comroon after a pause in the basic rhythm)
P waws: Sinus (basic rhythm):
premature. pointed P wa~ distorting
T wave after the $ixth QRS complex
PR interval: 024 second (remains
constant)
QRS complex: 0.08 second
Rhythm intupretation: Normal sinus
rhythm with tirst-degree AV blCK:k;
a nonconducted PAC is present after
the sixth QRS complex.
Siri p 8-63
Rhythm: Regular (atrial): irregular
(vtntrkular)
Rate: 75 beaWminute (atrial);
50 beatYminute (ventricular)
P waves; Sinus
PR interval: Lengthens (rom 0.24 to
0.32 second
QRS complex: 0.08 second
Rhythm interpretation:
Se<:ond_degree AV blCK:k. "lobia I

Slrip 8-&~
Rhythm: Regular (atrial and
ventri cular)
Rate: 72 beaWminute (atrial );
3 1 beatYminute (ventricular)
Pwaves; Sinus (bear no rd/ltionship
to the QRS complex: hidden in the
QRS compln: and T \\Ia\'eS)
PR interval: Varies greatly
QRS compleJC 0.12 second
Rhythm interpretation: Third-degree
AVblCK:k

Slrip 8-65
Rhythm: Regular (atrial and
ventricular)
Rate: 90 beaWminute (atrial );
45 beaWminute (ventricular)
P waws: Two sinus Wil\'eS to each
QRS complex
PR interval: 026 to 0.28 second
(remains constant)
QRS complex: 0.12 second
Rhythm interpretation: Seconddegree AV block. Mobilz. II;
Sf-segment elevation is present.

Slrip S-66
Rhythm: Regular
Rate: 79 bealY'minute
P waves; Inverted before tach QRS
complex
PR interval: 0.08 to 0.10 ~nd
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accelerated
jurn:tional rhythm
Strip S-67
Rhythm: Regular
Rate: 94 beats/minute
P ...."aVes: Sinus
PR interval: 024 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with tirst-degret AV block
Strip 8-68
Rhythm; Regular (bMic rhythm):
irregular (premature beats)
Rate: 72 beaWminute (basic
rhythm)
p wwes: Sinus (basic rhythm);
prell'Wlture and abnormal (premature
btats)
PR inteNal: 0.14 to 0.16 second
(basic rhythm); 0. 12 secood (PAC5):
0.10 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpr~tation: Normal sinus
rhythm with two PACs (third and
eighth complau) and one PJC (fifth
complex); a U .....~ is present.
Strip 8-6 9
Rhythm; Regular (basic rhythm);
irregular (premature beau)
Rate: 52 beaWminute (bas ic
rhythm)
P .....aves: Hidden (basic rhythm);
prell'Wlture and abnormal (premature
btau)
PR interval: Not measurable (basic
rhythm); 0.12 to 0.14 second (PACs)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm with two PACs (second
and fifth complexes); Sf-segment
depression is present.

345

Strip 8-70
Rhythm: Regular (atrial): irregular
(v~ntricular)

Rate: 79 beaWminute (atrial);

70 beaWminute (~ntricularl
Pwa~:SinU$

PR interval; Lengthens from 0.24 to

028 second
QRS compla: 0.08 second
Rhythm interpretation:
Sttond-degree AV block. ,.lOOil:1. I
Strip 8-7 1
Rhythm: Regular (atrial and
ventriculu)
Rale: 80 beaWminute (atrial);
40 beaWminute (~nt ricular)
P wa~: Two sinus P waves to e~ch
QRScompla
PR interval: 024 5e(;ond (remains
constant)
QRS complex: 0.Q..t to 0.06 5e(;ond
Rhythm interpretation:
Sttond-degree AV block. ,.1obitz II
(clinical correlation is suggested
to diagnose Mobitz II when 2:1
conduction is present with a narrow QRS complex): ST-segment
depression is present.
Strip 8-72
Rhythm: Regular (atrial and
ventricular)
Rale: 94 beaWminute (atrial);
40 beatslminut~ (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex: hidden in the
QRS complex and T waves)
PR interval: Varies greatly
QRS comple!{: 0. 10 secood
Rhythm interpretation; Third-degree
AV block
Strip 8-73
Rhythm: Regular
Rate: 84 beaWminute
P ..... aves: Hidden in QRS complexes
PR interval: Not measurable
QRS comple!{: 0.06 second
Rhythm interpretation: Accelerated
junctional rhythm; ST-segment
depression and T-wave inversion are
present.

346

Answe r key to Chapters 5 through II

Strip 8-74
Rhythm: Regular (atrial): irregular
(vent ricular)
Rate: 54 beats/minute (atrial);
50 beats/minute (ventricular)
P waves: Sinus
PR interval: Lengthens from 0.34 to
0.44 second
QRS complex: 0.08 second
Rhythm interpretation:
Second-degree AV block. Mobitz I
S trip 8-75
Rhythm: Regular (basic rhytrun);
irregular (escape beat)
Rate: 58 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
hidden P wave (escape beat)
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with junctional escape
beat (fou rth complex) after a pause
in the basic rhythm
S tr ip 8-76
Rhythm: Regular
Rate: 47 beats/minute
P waves: Hidden in the QRS
complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm: ST -segment depression is
present.
Strip 8-77
Rhythm: Regular (atrial and
ventricular)
Rate: 94 beats/minute (atrial);
44 beals/minute (ventricular )
P waws: Sinus (bear no relationship
In the QR.'; complex: found hidden in
the QRS complex and T waves)
PR interval: Varies greatly
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Third-degree
AV block; ST-segment elevation is
present.

Stri p 8-78
Rhythm: Regular (basic rhythm):
irregular (premature beats)
Rate: 68 beats/minute (basic rh}thm )
P waves: Sinus (basic rhythm):
premature. abnormal P waves
(premature beab)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.14 second (PAC);
0.10 second (PJC )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PAC (third
complex) and one PJC (seventh
complex); a U wave is present.
Stri p 8-79
Rhythm: Regular (atrial and
ventricular)
Rate: 80 beats/minute (atrial);
40 beats/minute (ventricular)
P waves: 1"""0 P waves to each (,)~S
complex
PR interval: 0.12 to 0.14 second
(remain constant)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Seconddegree AV block. Mobil.l. II (clinical
correlation is suggested to diagnose
Mobitz II when 2:1 conduction
is present with a narrow QRS
complex).
Stri p 8-80
Rhythm: Regular (basic rhythm);
irregular (nonconducted PAC)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
premature. pointed P wave without
a QRS complex afte r the sixth QRS
complex
PR interval: 0.2210 024 second
(rem~in~ con.~I'mt)

QRS complex: 0.04 to 0.06 second

Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
and one nonconducted PAC (afte r
the sixth QRS complex); ST-segment
depression and T-wave inversion are
present.

St rip 8-81
Rhythm: Regular
~ate: 8!! beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.00 to 0.08 second
Rhythm interpretation: Accelerated
junctional rh~1:hm
Strip 8-82
Rhythm : regular (atrial); irregular
(ventricular)
Rate: 75 beats/minute (atrial):
50 beats/minute (ventricular)
P waves: Sinus P waves present
PR interval: Lengthens from 026 to
0.40 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Second
degree AV block. Mobitz I; STdepression is present.
St rip 8-&3
Rhythm: Regular
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
tachycardia
St rip 8-84
Rhythm: Two separale rhythms, both
regular
Rate: 79 beats/minute (first rhythm):
84 beats/minute (second rhythm)
P waves: Sinus (first rhythm):
inverted (second rh}thm)
PR interval: 0.14 to 0.16 second
(first rhythm); 0.08 S<!cond (second
rhythm)
QRS complex: 0.06 to 0.08 second
(both rhythms)
Rhythm interpretation: Normal sinus
rhythm changing to accelerated
junctional rhythm

Answer key to Chapters 5 through II

Strip 8-85
Rhythm: Regular (atrial and
wntricular)
Rate: 79 beats/minute (atrial);
31 beats/minute (ventricular)
p waws: Sinus (bear no relationship
to the QRS complex: hidden in QRS
complexes and T waves)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AVblock

Strip 8-86
Rhythm: Regular
Rate: 60 beats/minute
P waws: Sinus P waves present
PR interval: 024 second
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block;
~"T -segment depression and T-wave
inversion are present.
Strip 8-87
Rhythm: Regular (atrial and
wntricular)
Rate: 88 beaWminute (atrial);
33 beats/minute (ventricula r)
P waws: Sinus (bear no relationship
to the QRS complex: found hidden in
the QRS complex and T waws)
PR interval: Varies greatly
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degree
AVblock
S irip 8-88
Rhythm: Regular (basic rhythm):
irregular (premature and escape
beats)
Rate: 60 beats/minute (basic rhythm)
P waws: Sinus (basic rhythm):
pointed (atrial beat): inverted
(junctional beats)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.14 second (atrial
beat); 0.08 to 0.10 second (junctional
beat)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal
sinus rhythm with one PJC (third
complex), one atrial escape beat
(fourth complex), and one junctional
escape beat (fifth complex)

Sirip 8-89
Rhythm: Regular (atrial): irregular
(wntricular)
Rate: 65 beats/minute (atrial);
50 beats/minute (wntricuJar)
P waves: Sinus
PR interval: Lengthens from 0.32 to
0.40 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block. Mobitz I
Sirip 8-90
Rhythm: Regular
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Junctional
tachy~rdia

Sirip 8-9 1
Rhythm: Regular (basic rhythm):
irregular (nonconducted PAC)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
prelrnture pointed P wave deforming
T wave after the sixth QRS complex;
pointed, abnormal P wave with the
sewnth QRS complex
PR interval: 0.22 to 0.24 second
(remains constant)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Nonnal sinus
rhythm with first-degree AV block;
nonconducted PAC (after the sixth
QRS complex): an atrial escape beat
(sewnth complex) occurs duril1ll the
pause after the nonconducted PAC
(note different P wave when compared
with that of underlying rhythm).
Sirip 8-92
Rhythm: Regular (atrial); irregular
(wntricular)
Rate: 75 beats/minute (at rial);
30 beats/minute (wntricular)
P waves: Sinus (two to three before
each QRS complex)
PR interval: 0.16 ~cond (remains
constant)
QRS complex: 0.12 second
Rhythm interpretation: Seconddegree AV block. Mobitz II with 2:1
and 3:1 AV conduction; ST -segment
depression is pr~nt.

347

Strip 8-93
Rhythm: Regular
Rate: 65 beats/minute
P waV\'S: Inwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 second
Rhythm interpretation: Acceluated
junctional rhythm; ST-segment
elevation is present.
Strip 8-91
Rhythm: Regular (basic rhythm):
irregular (PJCs)
Rate: 72 beats/minute (basic
rhythm)
P waV\'S: Sinus (basic rhythm);
inverted (PJCs )
PR interval: 0.14 second (basic
rhythm); 0.08 ~cond (PJCs)
QRS compla: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with two PJCs (fourth and
sixth complexes)
Strip 8-95
Rhythm: Regular (atrial) but off by
two squares; regular (ventricular) off
by one square
Rate: 80 beats/minute (atrial );
40 beats/minute (ventricular)
P waV\'S: Two sinus P waves before
each QRS complex
PR interval: 0.12 ~cond (consistent)
QRS compla: 0.12 to 0.14 second
Rhythm interpretation: Mobitz II
second-degree AV block with 2:1 AV
conduction
Strip 8-96
Rhythm: Regular (atrial) : irregular
(ventricular )
Rate: 75 beats/minute (atrial):
70 beats/minute (ventricular)
P waV\'S: Sinus
PR interval: Lengthens from 0.32 to
0.40 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Second
degree AV block. Mobitz I

348

Answer key to Chapters 5 through II

Strip 8 97
Rhythm: Regular
Rate: 40 beats/minute
P waves: Hidden in the QRS complex
PR interval: Not measurable
QRS complex: 0.10 second
Rhythm interpretation: Junctional
rhythm: !'>'Tsegment elevation is
present.

Strip 8-10 1
Rhythm: Regular
Rate: 44 beats/minute
P waves: Hidden in the QRS
compl""
PR interval: Not measurable
QRS complex: 0.08 to 0.l0 second
Rhythm interpretation: Junctional

St rip 8- 106
Rhythm: Irregular
Rate: 90 beats/minute
P waves: Vary in size, shape across
drip
PR interval: 0.12 to 0.20 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker

Strip 8-98
Rhythm: Regular (atrial and
ventricular)
Rate: 80 beat51minute (atrial);
40 beats/minute (ventricular )
P waves: Two sinus P waves to each
QRS complex
PR interval: 0.22 to 0.24 second
(remains constant)
QRS complex: 0.10 second
Rhythm interprdation: Second
degree AV block, Mobitz II (clinical
correl"tion i< ~"ggp_ded to diagno.",
Mobilz II ",-hen 2:1 conduction is
present with a narrow QRS complex):
ST-segment eleviltion is present.

Strip 8-102
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus

Strip 8- 107
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 72 beats/minute (basic rhythm
before pa.use): rate slows to 60 beats/
minute following pause due to rate
suppression.
P waves: Sinus (basic rhythm);
absent during pause
PR interval: 0.22 to 0.24 second
(basic rhythm); absent during piluse
QRS complex: 0.08 to 0.10 second
(],a~ic rhythm): ~],<ent durin!!
pause
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
and sinus arrest

Strip 8-99
Rhythm: Regular (basic rhythm);
irregular (PJC)
Rate: 84 beilts/minute (basic rhythm)
P waves: Sinus (basic rhythm);
inverted (PJC)
PR interval: 0.12 second (basic
rhythm); 0.08s.:cond (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretiltion: Normal sinus
rhythm with one PJC
Strip 8-100
Rhythm: Regular (basic rhythm);
irregular after PJC and run of PJT
Rate: 100 beats/minute (basic
rhythm): 136 beats/minute (PlT)
P waves: Sinus (basic rhythm );
inverted (pJCand PJT)
PR interval: 0.12 to 0.14 second (basic
rhythm): 0.08 second (PJC and PJT)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.08 to 0.10 second
(PJC and PJT )
Rhythm interpretation: Normal sinus
rhythm with one PJC (fifth complex)
and a three-beat run of PlT (eighth,
ninth, and tenth complexes)

"""'m

"""'m

Strip 8103
Rhythm: Irregular
Rate: 240 beats/minute (atrial);
90 ],eat.<Jminute (ven tricular)
P waves: Flutter waves
PR interval: Not measurable
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Atrial Hutter
with variable AV conduction
Strip 8-1 04
Rhythm: Regular (basic rhythm );
irregular with PJC
Rate: 56 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm):
inverted P wave (PJC)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.06 second (PJC)
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.10 second (PJC)
Rhythm interpretation: Sinus
bradycardia with one PJC (fifth
complex)
Strip 8-105
Rhythm: Regular
Rate: 68 beats/minute
P waves: Sinus
PR interval: 0.24 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal
sinus rhythm with first-degree AV
block

St rip 8- 108
Rhythm: Regular (atrial and
ventricular)
Rate: 82 beats/minute (atrial );
41 beats/minute (ventricular)
P waves: Two sinus P waves to each
QRS complex
PR interval: 0.16 to 0.18 second
(remains consistent)
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Mobitz II
second-degree AV block
St rip 8-109
Rhythm: Regular
Rate: 115 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
tachycardia

Answer key to Chapters 5 through II

Strip 8-110
Rhythm: Regular (basic rhythm)
Rate: 40 beats/minute
P waws: Sinus (basic rhythm); one
premature pointed P wave
PR interval: 024 to 0.26 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus bradycardia with first-degree AV block and
one non conducted PAC
Strip S- I ll
Rhythm: Irregular
Rate: 80 beats/minute
P waws: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
arrhythmia
Slrip S- I IZ
Rhythm: Regular (atrial and
wntricular)
Rate: 72 beats/minute (atrial);
35 beats/minute (ventricular)
P waws: Sinus (no relationship to
QRS complex; found hidden in ~'T
segment, QRS complex)
PR interval: Varies (not consistent)
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AVblock
Strip 8-113
Rhythm: Irregular
Rate: 60 beats/minute
P waws: FibrilJatory waves
PR interv<ll: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip 8- 1 J.\
Rhythm: Regular (off by one
square)
Rate: 48 to 50 beats/minute
P waws: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.06 to 0.08 iecond
Rhythm interpretation: Sinus
bradycardia

349

Strip 8- 115
Rhythm: Regular
Rate: 167 beats/minute
P wmes: TP waw present (P waw
merged with T wave)
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Paroxysmal
atrial tachycardia

Strip 8- 120
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Rh}1hm interpretation: Accelerated
junctional rhythm

Strip8- 116
Rhythm: Regular
Rate: 58 beats/minute
P wmet: Hidden within QRS complex
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm

Strip 9- 1
Rhythm: Regular
Rate: 167 beats/minute
P waves: Abs<!nt
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia

Strip8- 117
Rhythm: Regular (atrial); irregular
(wntricular)
Rate: 94 beats/minute (atrial);
60 beats/minute (wntricular)
P wmes: Sinus
PR interval: Lengthens from 0.22 to
0.28 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Mobitz I
second-degree AV block

Strip 9-2
Rhythm: Regular
Rate: 65 beats/minute
P waves: Sinus: notched P
waves usually indicate left atrial

Strip 8- 11 8
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
tachycardia

Strip 9-3
Rhythm: Regular (basic rhythm);
irregular (PVCs)
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
no P waws as.sociated with PVCS;
sinus P waves can be seen after the

Strip 8-119
Rhythm: Regular (bru;ic rhythm);
irregular with premature beat
Rate: 88 beats/minute (basic rhythm)
P wmes: Sinus (basic rhythm); small,
pointed P wave with premature beat
PR interval: 0.12 to 0.14 sond
(basic rhythm); 0.12 second
(premature beat)
QRS complex: 0.08 second (basic
rhythm and premature beat)
Rhythm interpretation: Normal sinus
rhythm with one PAC

h~rtrophy

PR interval: 0.14 to 0.16 second

QRS complex: 0.12 to 0.14 second
Rhjthm interpretation: Normal sinus
rh}1:hm with bundle-branch block:
an elevated ST segment is present.

I'VC,
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second (basic
rhythm); 0.12 second (PVCs)
Rhythm interpretation: Normal sinus
rhythm with two unifocal PVCs (fifth
and eighth complex)
Strip 9-1
Rhythm: Irregular
Rate: 30 beaWminute
P waws: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
Idiowntricular rhythm

350

Answer key to Chapters 5 through II

Strip 9-5
Rhythm: 0
Rate: Not measurable
P waves: Chaotic wave deflection of
varying height. size. and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-6
Rhythm: Regular (basic rhythm);
irregular (PVCS )
Rilte: 100 bo!atYminute (basic rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS complex: 0.08 second (basic
rhythm): 0.12 second (PVCs )
Rhythm interpretation: Normal
~inus rhythm with unifocal PVCs in
a bigeminal pattern (second, fourth.
sixth. and eighth complexes)
Strip 9-7
Rhythm: First rhythm can't be
determined (only one cardiac cycle);
second rhythm irregular
Rate: 54 beats/minute (first rhythm):
80 beats/minute (second rhythm)
P waves: Sinus P waves (basic rhythm)
PR interval: 0.16 second (basic rhythm)
QRS complex: 0.08 second (basic
rhythm): 0.12 second (ventricular
beats)
Rhythm interpretation: Sinus
bradycardia changing to accelerated
idioventricular rhythm: ST-segment
depression is present (basic rhythm).
Strip 9-8
Rhythm: Irreguklf (first and second
rhythms)
Rate: 60 beats/minute (first rhythm);
about 200 beats/minute (second
rhythm)
P waves: Fibrillation waves (fi rst
rhythm): none identified in the
second rhythm
PR interval: Not measurable
QRS complex: 0.00 to 0.08 second
(first rhythm): 0.12 to 0.14 second
(second rhythm)
Rhythm interpretation: Atrial fibrillation with burst ofventricular
tachycardia; ST-segrrtent depression
with basic rhythm

Strip 9-9
Rhythm: Regular
Rate: 250 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 to 0.20 second
Rhythm interpretation: Ventricular
tachycardia (torsade de pointes)
Sirip 9- 10
Rhythm: Regular (basic rhythm):
irregular (PVCS)
Rate: 79 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.16 second
QRS complex: 0.06 second (basic
rhythm); 0.14 to 0.16 second (WCs)
Rhythm interpretation: Normal sinus
rhythm with paired unifocal PVCS
(sixth and seventh complexes)
Slrip 9 11
Rhythm: Regular
Rate: 42 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation:
Idioventricular rhythm
Strip 9-12
Rhythm: Regular
Rate: 125 beats/minute
P waves: Sinus
PR interval: 0.1 2 S(oond
QRS complex: 0.12 second
Rhythm interpretation: Sinus tachycardia with bundle-branch block; an
elevated ST segment is present.
Strip 9- 13
Rhythm: 0
Rate: 0 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: None identified
Rhythm interpretation: Ventricular
standstill (asystole)
Strip 9-1<\
Rhythm: Regular
Rate: 21<\ beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation: Ventricular
tachycardia

Slr ip9- 15
Rhythm: Regular (basic rhythm)
Rate: 50 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 second (basic
rhythm): 0.14 second (PVC)
Rhythm interpretation: Sinus
bradycardia with one PVC (thi rd
complex); 5T-segment depression is
present.
Slrip9- 16
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent: wave deflections are
irregular and vary in height, size.
and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Slrip9- 17
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Wave deflections are chaotic
and vary in height, siz.e, and shapi!
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation is followed by electrical
shock and a return to ventricular
fibrillation.
Sl rip9-18
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PI{ interval: U.16 to U.ll1second
QRS complex: 0.12 second
Rhythm interpretation: Sinus
tachycardia with bundle-branch block
Slrip9- 19
Rhythm: Irregular
Rate: 300 beats/minute (atrial ):
50 beats/minute (ventricular)
P waves: Flutter waws before each
QR5 complex
PR interval: Not measurable
QRS complex: 0.00 to 0.08 second
(basic rhythm); 0.12 second (PVC)
Rhythm interpretation: Atrial flutter
with variable AV conduction and one
PVC (fifth complex)

Answer key 10 Chapl elll5 through II

Strip 9-20
Rhythm: Regular (at rial)
Rate: 136 beats/minute (atrial):
obeats/minute (ventricular: no QRS
complel!.eJ)
P ..... aves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
S irip 9-2 1
Rhythm: Irregular
Rate: 40 beats/minute
P ..... aves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
ldioventricular rhythm
Strip 9-22
Rhythm: Chaotic
Rate: 0 beats/minute (no QRS
complexes)
P waves: None identified
PR interval: Not measurable
QRS complu: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-23
Rhythm: Regular
Rate: 88 beats/minute
Pwave5:Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Accelerated
idioventricular rhythm
S irip 9-24
Rhythm: Irregular (basic rhythm)
Rate: 60 beats/minute (basic rhythm)
P waws: Fibrillatory ..... aves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC5)
Rhythm interpretation: Atrial
fibrillation with paired PVCs

Sirip 9-25
Rhythm: Regular (basic rhythm)
Rate: 100 beats/minute (first rh~1hm):
188 beall/minute (second rhythm)
P .....aves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second (basic
rhythm): 0.12 to 0. 16 second
(wntricu lar beats)
Rhythm interpretation: Normal sinus
rh}1hm with burst of ventricular
tachycardi a and paired PVCs
Sirip 9-26
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 107 heats/minute (basic rhythm)
P wavet: Sinus (basic rhythm)
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 to 0.10 second
(basic rhythm): 0.16 second (PVC)
Rhythm interpretation: Sinus tachycardia with one PVC (R-on-T pattern):
an elevated ST segment is prese nt.
Strip 9-27
Rhythm: Irregular (difficult to
determine due to changing polarity
of QRS complex)
Rate: 250 beall/minute or greater
P .....aves: Absent
PR interval: Not measurable
QRS complex: 0.12 second or greater
Rhythm interpretation: Ventricular
tachycardia (touade de pointes)
Sirip 9-28
Rhythm: Regular
Rate: 250 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 to 0.16 second (QRS
complexes change in polarity from
negative to positive across the strip).
Rhythm interpretation: Ventricular
tachycardi a (torsades de pointes)
Strip 9-29
Rhythm: Regular
Rate: 84 beats/minute
P .....aves: None identified
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Accelerated
idioventricular rhythm

35 1

Strip 9-30
Rh}1hm: Chaotic
Rate: 0 beats/minute
P waws: Absent; wave deflections are
irregular and vary in height. Jize.
and shape.
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricu lar
fibrillation
S lrip 9-31
Rhythm: Regular (basic rhythm):
irregular (PVCs)
Rate: 115 beats/minute (basic
rhythm)
P ..... aws: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex:: 0.04 to 0.06 second
(basic rhythm); 0.12 second (PVC5)
Rhythm interpretation: Sinus
tachycardia with two unifocal PVCs
(fourth and twelfth complexes)
Sirip 9-32
Rhythm: Regular (basic rhythm):
imgular (PVes)
Rate: 125 beats/minute (ba5ic
rhythm)
P ..... aves: Sinus (bosic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 to 0.10 second
(basic rhythm); 0. 12 second (PVC5)
Rhythm interpretation: Sinus tachy_
cardia with multifocal paired PVCs
(eighth and ninth complexes)
Strip 9-33
Rhythm: Regular (basic rhythm)
Rate: 37 beats/minute (basic rhythm)
P ..... aves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (escape
beat)
Rhythm inte rpretation: Sinus bradycardia with one ventricular escape
beat (third complex)

352

Answer key to Chapters 5 through II

Strip 9-,3.1
Rhythm: Regular (first and second
rhythms)
Rate: 72 beats/minute (first rhythm);
150 beats/minute (second rhythm)
P waws: Sinus (basic rhythm )
PR interval: 0.18 to 0.20 second
QRS complex: 0.08 second (basic
rhythm): 0.12 st'\:ond (wntricular
beats)
Rhythm interpretation: Normal sinus
rhythm with a burst of ventricular
tachycardia; an inverted T waw is
present in basic rhythm.

Strip 9-39
Rhythm: Regular (basic rhythm)
Rate: 115 beats/minute (basic
rhythm)
P waves: Inverted before each QRS
complex in basic rhythm
PR interval: 0.08 second (basic
rhythm)
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Junctional
tachycardia y,ith one PVC (tenth
complex)

Strip 9-43
Rhythm: Regular (first rhythm):
irregular (second rhythm)
Rate: 100 beats/minute (first rhythm);
100 beats/minute (second rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.12 second
QRS complex: 0.12 to 0.14 second
(tirst rhythm): 0.12 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
with transient episode of accelerated
idioventricu lar rhythm

Strip 9-40
Rhythm: Chaotic
Rate: 0 beats/minute
P waws: Absent: wave defledions
val)' in height. size. and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation

Rhythm: Regular (atrial)

Rate: 30 beats/minute (atrial): 0 beats!
minute (wntricular; no QRS
complexes)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill

Strip 9-36

Slrip 9-41

Rhythm: Irregular
Rate: About 30 beats/minute
P waws: Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation:
Idiowntricular rhythm; ST-segment
elevation is present.

Rhythm: Regular (basic rhythm ):

irregular (PVCs )
Rate: 65 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 st'\:ond
(basic rhythm); 0.12 st'\:ond (PVCs)
Rhythm interpretation: Normal
sinus rhythm with two unifocal
PVCs (third and sixth complexes);
ST-segment depression is present.

Strip 9-35

Strip 9-37
Rhythm: Not measurable
Rate: Not measurable (one complex
present)
P waws: None identified
PR interval: Not measurable
QRS complex: 028 second or wider
Rhythm interpretation: One
wntricular complex followed by
wntricular standstill

Strip 9-38
Rhythm: Regular
Rate: 84 beats/minute
P waws: None identified
I'R interval: Not mCII.umble
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Accelerated
idiowntricular rhythm

Strip 9-44
Rhythm: First rhythm cant be
detennined (only one cardiac cycle
present); second rhythm regular
Rate: 50 beats/minute (first rhythm);
41 beats/minute (second rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.12 second (tirst rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm): 0.12 to 0.14 second
(second rhythm)
Rhythm interpretation: Sinu.
bmdycardia changing to idiOVl!ntricular
rhythm: a U wave is present.

Slrip 9-45
Rhythm: Regular
Rate: 214 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second or
wider
Rhythm interpretation: Ventricular
tachycardia

Strip 9-42
Rhythm: Irregular (ti rst rhythm);
regular (second rhythm)
Rate: 100 beats/minute (first
rhythm); 167 beats/minute (second
rhythm)
P waves: Fibrillation waves (basic
rhythm)
PR interval: Not measurable
QRS complex: 0.08 second (basic
rhythm): 0.12 second (VI)
Rhythm intcrpret.. tion: Atrial
fibrillation with a burst of ventricular
tachycardia

Strip 9",(6
Rhythm: Regular (basic rhythm);
irregular (ventricular beats)
Rate: About 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.20 second
QRS complex: 0.06 second (basic
rhythm); 0.16 second (first
wntricular beat); 0.12 st'\:ond
(.ccond ventricul .. r bCllt)
Rhythm interpretation: Sinus
bradycardia with one PVC (fourth
complex) and one ventricular escape
beat (fifth complex): ST-segment
depression is present.

Answer key to Chapters 5 through II

Strip 9-47
Rhythm: Regular (basic rhythm)
Rate: 68 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 ~econd
QRS complex: 0.08 to 0.10 second
(basic rhythm); 0.12 to 0.14 second
(PVC)
Rhythm interpretation: Normal sinus
rhythm with one PVC
Strip 9-48
Rhythm: Not measurable
Rate: Not measurable (one complex
present)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: One
ventricular complex followed by
ventricular standstill
Strip 11_411
Rhythm: Regular
Rate: 56 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.12 second
Rhythm interpretation: Sinus
bradycardia with bundle-branch
block: ST-segment depression is
present.
Strip 9-50
Rhythm: Regular
Rate: 188 beats/minute
p waves: Not identified
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Ventricular
tachycardia
Strip II 5 1
Rhythm: Regular (atrial): irregular
(vent ricular )
Rate: 58 beats/minute (atrial); about
40 beats/minute (ventricular)
P waves: Sinus
PR interval: Lenllthens from 0.30 to
0.36 second
QRS complex: 0.08 second (basic
rhythm); 0.12 second (escape beat)
Rhythm interpretation: Seconddegree AV block, Mobitz I with
one ventricular escape beat (third
complex)

Sirip 9-52
Rhythm: Regular (first and second
rh}1hms)
Rate: 72 beats/minute (first rhythm);
72 beo.t>lminute (.... cond rhythm)
P waves: Sinus in first rhythm
PR interval: 0.12 to 0.14 second (first
rhythm)
QRS complex: 0.08 second (first
rh}1hm): 0.12 to 0.14 second (second
rh}1hm)
Rhythm interpretation: Normal
sinus rhythm with a transient
episode of accelerated idioventricular
rhythm
Strip 9-53
Rhythm: Slightly irregular (atrial)
Rate: About 40 beats/minute (atrial):
obeats/minute (ventricular; no QRS
complexes)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Sirip 9-51
Rhythm: Regular
Rate: 84 beats/minute
p waves: Sinus
PR interval: 0.16 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Normal sinus
rh}1hm with bundle-branch block; a
depressed ST segment is present.
Strip 9-55
Rhythm: Regular
Rate: 41 beats/minute
P waves: Absent
PR interval: Not measurable
QRS comptex: 0.16 second
Rhythm interpretation: Idioventricular rhythm
Strip 9-56
Rhythm: Regular
Rille: 75 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.16 to 0.18 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block;
T-wave inversion is present

353

Strip 9-57
Rh}1hm: Regular (basic rhythm);
irregular (PVCS)
Rate: 72 beats/minute (basic
rhythm)
p waves: Sinus (basic rhythm)
PR interv.'Jl: 0.12 second
QRS complex: 0.08 second (basic
rhythm); 0.12 to 0.14 second
(PVCs)
Rhythm interpretation: Normal
sinus rhythm with unifocal PVCs
(fourth and eighth complexes) in a
quadrigeminal pattern
Strip 9-58
Rhythm: Regular (atrial); ventricular
not measurable (only one
QRS complex present)
Rate: 29 beats/minute (atrial);
ventricular not measurable (only one
QRS complex present)
P waves: Sinus
PR interval: Not measurable
QRS complex: 0.08 second
Rhythm interpretation: One QRS
complex followed by ventricular
standstill
Sirip 9-59
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent: wave deflections
are irregular and chaotic and vary in
size, shape, and height
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Strip 9-60
Rhythm: Nol measurable (only one
QRS comp]"",)
Rate: Not measurable (only one QRS
complex)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.12 second or
!treater
Rhythm interpretation: One QRS
complex foll(Med by ventricular
standstill

354

Answe r key to Chapters 5 through II

Strip 9-6 1
Rhythm: Regular (first and second
rhythms)
Rate: 100 beats/minute (first
rhythm); 100 beats/minute (second
rhythm)
P waws: Sinus (first rhythm); none
(second rhythm)
PR interval: 0.14 to 0.16 second (first
rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm): 0.12 second (second
rhythm)
Rhythm interpretation: Norllkll sinus
rhythm changing to accelerated
idioventricular rhythm
Strip 9-62
Rhythm: Regulu
Rate: 40 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation:
Idioventricular rhythm
Strip 9-63
Rhythm: Regular
Rate: 167 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second
Rhythm interpretation: Ventricular
tachycardia
Strip 9-64
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.22 to 0.24 second
QRS complex: 0.12 second
Rhythm interprdation: Norllkll sinus
rhythm with bundle-branch block
and first-degree AV block
Strip 9-65
Rhythm: Irregular
Rate: 80 beats/minute (basic
rhythm)
P waves: Fibrillation waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.12 second (PVCS)
Rhythm interprdation: Atrial
fibrillation with paired PVCs

Strip 9-66
Rhythm: Regular (basic rhythm)
Rate: 84 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.24 second
QRS complex: 0.08 S<!cond
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
changing to ventricular standstill

Strip 9-67
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: Absent
Rh}thm interpretation: Ventricular
fibrillation

Strip 9-7 1
Rhythm: Regular
Rate: 100 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation: Aa:elerated
idioventricular rhythm
Strip 9-72
Rhythm: 0 beats/minute (only one
QRS complex present)
Rate: 0 beats/minute (only one QRS
complex present)
P waves: None identified
PR interval: Not measurable
QRS complex: 024 to 0.26 second
Rhythm interprdation: One QRS
complex followed by ventricular
standstill

Sirip 9-68
Rhythm: Regular
Rate: 167 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Ventricular
ta(hYGmlia

Strip 9-69
Rhythm: Regular (first rhythm):
slightly irregular (second rhythm)
Rate: 115 beats/minute (first
rhythm): about 214 beats/minute
(second rhythm)
P waves: Sinus (fi rst rhythm): none
identified in the second rhythm
PR interval: 0. 12 to 0.14 second (first
rhythm)
QRS complex: 0.10 second (first
rhythm): 0.12 to 0.16 second (second
rhythm)
Rhythm interpretation: Sinus tachycardia with a burst of ventricular
tachycardia returning to sinus tachycardia; an inverted T wave is present.

Strip 9-70
Rhythm: Regular
Rate: 40 beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm intcrpreUltion: Idioventricular rhythm

Strip 9-73
Rhythm: Regular
Rate: 188 beats/minute
P waves: Not identified
PR interval: Not measurable
QRS complex: 0.16 to 020 second or
wider
Rhythm interpretation: Ventricular
tachycardia followed by electrical
shock and return to ventricular
tachycardia
Strip 9-74
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 100 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second (basic
rhythm); 0.1 2 second (PVC)
Rhythm interpretation: Normal
sinus rhythm with one PVC (fifth
complex)
Strip 9-75
Rhythm: Regular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Sinus
bradyc~rdi" with bundle-branch
block

Answer key to Ch ap ters 5 through II

Strip 9-76
Rhythm: 0 beats/minute
Rate: 0 beats/minute (no QRS
complexes)
p ",a"".: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Strip 9-77
Rhythm: Re!lular
Rate: 41 beats/minute
P waves: Ab5ent
PR interval: Not measurable
QRS complex: 0.12 second
Rhythm interpretation:
ldioventricular rh}1hm
Strip 9-78
Rhythm: 0 beats/minute (only one
QRS complex)
Rate: 0 beats/minute (only one QRS
complex)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.14 second
Rhythm interpretation: One ventricular complex (ollowed by ventricular
standstill
Strip 9-79
Rhythm: 0 beats/minute
Rate: 0 beats/minute
P waves: Absent: wave deHections are
chaotic and vary in height. size. and
shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation changing to ventricular
standstill
Strip 9-80
Rhythm: Regular (first and second
rhythms)
Rate: 94 beats/minute (first rhythm);
75 beats/minute (second rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.16 second
QRS complex: 0.12 second (first
rhythm): 0.12 second (second rh}1hm)
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
changing to accelerated idioventricular rhythm and back to normal sinus
rhythm with bundle-branch block;
T-wave inversion is present.

Strip 9-81
Rhythm: Regular (atrial); ventricular
rhythm can't be determined (only
one cardiac cycle)
Rate: 111 beal.5lminut.. (atrial);
40 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies greatly
QRS complex: 0.14 second
Rhythm interpretation: Third-de!lree
AV block changing to ventricular
standstill
Strip 9-82
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Stri p 9-8,3
Rhythm: Regular (first rhythm);
irregular and chaotic (second rhythm)
Rate: 214 beats/minute (first rhythm)
P waves: None identified
PR interval: Not measurable
QRS complex: 0.16 to 0.18 second
(first rhythm)
Rhythm interpretation: Ventricular
tachycardia changing to ventricular
fibrillation
Strip 9-84
Rhythm: Regular
Rate: 32 beaWminute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.20 second
Rhythm interpretation: ldioventrkular rhythm
Strip 9-85
Rhythm: Regular (basic rhythm):
irregular (PVCs)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR intelVal: 0.12 second
QRS complex: 0.06 to 0.08 SKond
(basic rhythm); 0.12 second (PVCs)
Rhythm interpretation: Sinus tachycardia with multifocal paired PVCs
(eighth and ninth complexes)

355

Strip 9-86
Rh}1hm: Regular (atrial)
Rate: 52 beats/minute (atrial);
o beats/minute (ventricular)
p waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill
Sirip 9-87
Rhythm: Regular (first rhythm):
irregular (second rhythm)
Rate: 68 beats/minute (first rhythm);
about 80 beats/minute (second
rhythm)
P waves: Sinus (first rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (fi rst
rhythm); 0.12 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm ch;mging to ~cCl'.ler~ted
idioventricular rhythm
Strip 9-BS
Rhythm: Regular
Rate: 167 beatslminute
P waves: Not identified
PR interval: Not measu rable
QRS complex: 0.16 to 0.20 second
Rhythm interpretation: Ventricular
tachycardia (torsades de pointes)
Strip 9-89
Rh}1hm: Regular (basic rhythm);
irregular (PVCs)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Sinus Utchycardia with paired PVCS (seventh and
eighth complexes)
Strip 9-90
Rhythm: Regular (atrial )
Rate: 72 beats/minute (atrial);
o beats/minute (ventricular )
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill

356

Answer key to Chapters 5 through II

Strip 9-9 1
Rhythm: Regular
Rate: 188 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.18 to 0.20 second or
wider
Rhythm interpretation: Ventricular
tachycardia
Strip 9-92
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Wave defle(tions (haotk:
vary in size. shape, and direction
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation: 60-cycle (electrical)
interference noted on baseline.
Strip 9-93
Rhythm: Regular
Rate: 28 beats/minute
P waves: None
PR interval: Not measurable
QRS complex: 020 second or wider
Rhythm interpretation:
Idiowntricular rhythm
Slrip 9-94
Rhythm : Regular
Rate: 79 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Strip 9-95
Rhythm: Regular (basic rhythm)
Rate: 68 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm )
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
(basic rhythm); 0.12 second (PVC)
Rhythm interpretation: Normal
sinus rhythm with one interpolated PVC (seventh complex).
Interpolated PVCs are sandwiched
be""'een ""'0 sinus beats and have
no compensatory pause. STsegment depression and T-wave
inversion are pruenl.

Strip 9-96
Rhythm: Regular (basic rhythm);
irregular (PVCs)
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (basic
rhythm): 0. 12 to 0.14 second
(PVCs )
Rhythm interpretation: Normal sinus
rhythm with PVCS in a trigeminal
pattern
Strip 9-97
Rhythm: Irregular
Rate: 80 beats/minute
P waves: Wavy fibrillatory waves
PR interval: Not measurable
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Atrial
fibrillation with bundle-branch
block
Strip 9-98
Rhythm: Regular (fi rst rhythm);
regular but off by ""'0 squares
(second rhythm)
Rate: 43 beats/minute (first rhythm);
45 beats/minute (second rhythm)
P waves: Sinus (first rhythm): no
associated P waves (second rhythm)
PR interval: 0.14 to 0.16 second
(basic rhythm)
QRS (omplex: 0.10 second (basil;
rhythm): 0.14 to 0.16 second (second
rhythm)
Rhythm interpretation: Sinus
bradycardia with three-beat run of
idioventricular rhythm
Strip 9-99
Rhythm: Regular (basic rhythm):
irregular during pause
Rate: 79 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm):
absent during pause
PR interval: 0.20 second
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
and sinus exit block

Strip 9-100
Rhythm: None
Rate: 0 beats/minute
P waves: None identified; wavy baseline
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation changing to wntricular
standstill
Strip 9- 101
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip9 102
Rhythm: Regular
Rate: 167 beats/minute
P waves: TP waves present
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 9- 103
Rhythm: Regular
Rate: 45 beats/minute
P waves: Hidden within QRS complex
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Junctional
rhythm
Strip 9- 1 0~
Rhythm: Regular
Rate: 63 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Normal sinus
rhythm with bundle-branch block
Strip 9- 105
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 8<\ beats/minute (atrial);
70 beats/minute (ventricular)
P waves: Sinus
PR interval: Lengthens from
020 second to 0.32 second
QRS complex: 0.087 to 0.10 second
Rhythm interpretation:
Second-degree AV block, Mobilz I

An sw e r key to Ch a pters 5 through II

Strip 9- 106
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 72 beatY'minute (bMi,
rhythm); rate dec:reaS1';5 to 65 bt-aW
minute folkP.ving pause dut to
temporary rate suppression_
P waYeS: Sinus (basic rhythm):
absent during pause
PR interval: 0.24 5ewnd: absent
during pause
QRS complu: 0_06 to 0.08 second:
absent during pause
Rhythm inlerpreLIIlion: Normal sinus
rh~1hm with first_degree AV bla<:k
and sinus arrest
S trip ~ 1 0 7
Rhythm: Regular (basi, rhythm):
irregular with premature beat
Rate: 52 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm): sma ll,
pointed P wave with premature bt-at
PR interval: 0.14 to 0.16 second (basic
rhythm): 0.12 second (premature beat)
QRS complex: 0.08 to 0.10 second
(basic rhythm): 0.10 second
(premature bt-at)
Rhythm interpretation: Sinus bradycardia with one PAC
Sirip 9-108
Rhythm: Regular (basic rhythm)
Rate: 45 beatY'minute (basic rhythm)
P waves: Absent
PR interval: Not measurable
QRS comple:!: 0_16 to 0.18 second
Rhythm interpretation: Idiovmt ricuI..,. rhythm 10 vcntricuL!o, Jblndstill
Strip ~1 09
Rhythm: Regular
Rate: 84 bt-atY'minute
P waves: Sinus
PR interval: 0.30 to 0.32 .second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV bla<:k

Strip 9-110
Rh}thm: Regular (basic rhythm)
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.14 to 0.16 .second
QRS complex: 0.06 to 0.08 second (basic rhythm): 0.12 to 0.14 5etOnd (PVC)
Rhythm interpretation: Normal sinus
rhythm with one PVC

Sirip 9- 11 1
Rhythm: Regular
Rale: 240 beatY'minute (atrial):
60 beatY'minute (ventricular)
P waves: F1utler WiIVl'S
PR inte rval: Not measurable
QRS complex: 0_08 second
Rhythm interpretation: Atrial flutter
with 4: 1 AV conduction
Slrip 9- 11 2
Rhythm: Regular
Rate: 11 5 beatY'minute
P. . .aves: Sinus
PR interval: 0.12 to 0.16 second
QRS complex: 0.04 to 0.08 second
Rhythm interpretation: Sinus
t&chycardia
Stri p 9- 11 3
Rhythm; Not measurable (one
complex)
Rate: Not measurable (one complex)
P .....aves: Absent
PR interval: Not measurable
QRS complex: 0.20 to 0.24 second
Rhythm interpretation: One ventricular complex to ventritul~r standstill
Strip 9- IH
Rhythm: Regular (bas ic rhythm) but
off by two squares
Rate: 72 to 75 beatY'minute
P .....aves: Vary in s~e_ shape. direction
PR interval; 0.12 to 0_ 16 second
QRS complo: o.~ to O.l~ (basic
rhythm); 0.12 second or greater (premature beat)
Rhythm interpretation: Wandering
atrial pacemaku with PVC
S trl p 9- 11 5
Rhythm: F1llit rhythm probably regular
(only two QRS cOqllo:es): seOOlld
rhythm regular (off by two squares)
Rate: 75 beats/minute (basic rhythm):
72 to 79 beats/minute (second rhythm)
P waves: Sinus (tirst rhythm): absent
(Iecond rhythm)
PR interval: 0.18 to 0.20 second (tirst
rhythm); absent (second rhythm)
QRS complex: 0.00 10 O.08secOfld
(first rhythm); 0.12 seOOlld or greater
(second rhythm)
Rhythm interpretation: Normal sinus
rhythm with episode of accelerated idioventricular Ihythm going back to NSR

357

Strip 9-116
Rhythm: Regular (off by one square)
Rate: 54 to 56 beatY'minute
P waYeS: Si nus
PR interval: 0. 14 to 0_ 16 second
QRS complex: O.~ .sewnd
Rhythm interprellltion: Sinus
b~ycardia

S trip ~117
Rhythm: Irregular
Rate : 70 beatY'minute
P waYeS: Fibrillatory wal'l'S
PR interval: Not lTM'asurable
QRS complex: O.~ to 0.00 .second
Rhythm interpretation: Atrial
fibrillation
S trip ~11 8
Rhythm: Regular
Rate: ISO beats/minute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia
Strip9- ll9
Rhythm: Regular
Rate: 100 beatY'minute
P waYeS: Inverted bt-fore each QRS
complex
PR interval: 0.0810 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Ac:ederated
junctional rhythm
Strip ~ 1 20
Rhythm: Regular (atrial) but off by
one square: regular (ventricular)
Rate: 88 to 94 bnl5lminute (atrial):
44 beau/minute (ventricular)
P WilI'eS: Sinus
PR interval: Varies greatly (not
wnsistent)
QRS complex: 0.06 to 0.08 .second
Rh}1hm interpretation: Third-degree
AV bla<:k
S trip 9-12 1
Rhythm: Chaotic and irregular
Rate: 0 beats/minute
P waves: Fibrillatory waves which
are irregular: vary in siu, shape,
amplitude
PR interval: Not lTM'asurable
QRS complex: Absent
Rhythm interpretation: Ventr icular
fibrillation

358

Answe r key to Chapters 5 through II

Strip 9-122
Rhythm: Regular
Rate: 63 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Nortllill sinus
rhythm: U wave is present.
Strip 9-\23
Rhythm: Regular (basic rhythm)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm ):
inverted P waves before each
premature beat
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.08 second
(prematu re beats)
QRS complex: 0.08 second (basic
rhythm and PJC5)
Rhythm interpretation: Nortllill
sinus rhythm with tv,o premature
junctional contractions
Strip 9-124
Rhythm: Regular (atrial) but off by
two squares; regular (ventricular)
Rate: 65 to 72 beat.'lminute (atrial);
34 beats/minute (ventricular )
P waves: Sinus (tv,o P waves before
QRS complex)
PR interval: 0.12 to 0.14 second
(consistent)
QRS complex: 0.12 second
Rhythm interpretation:
Second-degree AV block: Mobitz II
Strip 10- \
Analysis: The first four beats are
ventricular paced beats followed
by one intrinsic beat and three
wntricular paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat
(normal pacemaker function)
Strip 10-2
Analysis: The first three beats are
wntricular paced beats followed
by two intrinsic beats, a paci"!!
spike that occurs too early, an
intrinsic beat, a fusion beat, and tv,o
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with thr~ intrinsic beats, one
fusion beat, and one episode of undersensing (abnonnal pacemaker function)

Strip 10-3
Analysis: The first complex is an
intrinsic beat foll(Med by tv,o
ventricular paced beats, an intrinsic
beat. and tv,o ventricular paced
beats.
Interpretation: Ventricular paced
rhythm with tv,o intrinsic beats
(normal pacemaker fundion)
Stri p 10-4
Analysis: The first two complexes are
ventricular paced followed by a pacing spike with failure to capture, a
ventricular paced beat. a pacing spike
with failure to capture, an intrinsic
beat. a ventricular paced beat, a pacing spike with failure to capture, and
an intrinsic beat.
Interpretation: Ventricular paced
rhythm with t-,.,o intrinsic beats and
three episodes 01 failure to capture
(abnormal pacemaker function)
Stri p 10-5
Analysis: No patient or paced beats
are seen: pacing spikes are present
that fail to capture the wntric1es.
Interpretation: Failure to capture
in the presence of ventricular
standstill
Stri p 10-6
Analysis: The first five complexes
are intrinsic beats follOolled by mo
ventricular paced beats, tv,o intrinsic
beats, and one ventricular paced
beat.
Interpretation: Ventricular paced
rhythm with seven intrinsic beats
(normal pacemaker function)
Stri p 10-7
Analysis: The first complex is an
intrinsic beat followed by a ventricular paced beat that occurs too early.
tv,o ventricular paced beats, a fusion
beat, an intrinsic beat, a pacing spike
that occurs too early, and three
intrinsic beats.
Interpretation: Ventricular paced
rhythm with five intrinsic beats,
one fusion beat. and two episodes
of undersensing (one with capture
and one without capture). This is
abnormal pacemaker function.

Strip 10-8
Analysis: The first five complexes are
ventricular paced followed by a pause
in pacing, a ventricular paced beat
that occurs later than expected, and
a ventricular paced beilt.
Interpretation: Ventricular paced
rhythm with one episode of oversensing (pacemaker sensed the small
waveform artifad seen during the
pause). This is abnormal pacemaker
function.
St rip 10-9
Analysis: The first two complexes
are ventricular paced beats followed by a pacing spike that fails
to capture, an intrinsic beat, three
ventricular paced beats, and an
intrinsic beat.
Interpretation: Ventricular pilced
rhythm with tv,o intrinsic beats and
one episode of failure to capture
(abnormal pacemaker function)
Strip 10-10
Analysis: All complexes are pacemaker induced.
Interpretation: Ventricular paced
rhythm
Strip 10-11
Analysis: The first three complexes
are ventricular paced beats foll(Med
by an intrinsic beat, a pacing spike
that occurs too early, an intrinsic
beat, a pacing spike with capture
that occurs too early. and three
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with tv,o intrinsic beats and
two ~pisod~s of undusensing (one
episode without capture and one
episode with capture).This represents
abnormal pacemaker fundion.
Strip 10-12
Analysis: The first six complexes are
intrinsic beats followed by two ventricular paced beats and two intrinsic
beats.
Interpretation: Ventricular paced
rhythm with eight intrinsic beats
(normal pacemaker function)

Answer key to Chapters 5 th ro ugh II

Sirip 10- 13
Analysis: All complexes are
pacemaker induced.
interpretation: Ventricular paced
rhythm (normal pacemaker
function)

Strip 10-1-4
An"'i)l$is: The tirst two complexu
<lITe intrinsic buts followed by a
fusion beat (note pacing spike ",t
onset of QRS). ",not her fusion beat.
",nd three ventricular paced beats.
Interpretation: Ventricular paced
rhythm with two intrinsic beats and
two fusion beats (normal pacemaker
function)

Strip 10-15
Analysis: The first three complexes
",re ventricuillr paced beats: ..... hen the
p"'cemaker is turnd off the under[ying rhythm is ventricular standstill:
two ventricular p"'ced beats are
seen when the p"'cemaker is turned
ba~ on.
Interpr~tation: Ventricular pac~d
rhythm with an underlying
rhythm of ventricular standstill
when the pacemaker is turned oIf.
This strip shows an indication for
permanent pacemaker implant",tion
if the underlying rhythm donn't
resolve .

Strip 10- \ 6
Analysis: The first two beats are
ventricular p"'ced beats followed
by an intrinsic beat, a pacing spike
that fails to C<IIpture, 1\',"0 ventricular
paced beats. two intrinsic beats, and
'" ventricular paced beat.
Interpretation.: Ventricular paced
rhythm with three intrinsic beats
and one episode of failure to capture
(abnormal pacemaker function)

Sirip 10- 17
Ana[)I$is: The lirst t\\.o complexes are
ventricular paced beats followed by
a fusion belli, two intrinsic beats, a
pacing spike that occurs too early.
an intrinsic beat, a pacing spike that
occurs too uriy, an intrinsic beat, '"
pacing spike y,ith capture that occurs
too urly, and II ventricular paced
be",\.

Interpretation: Ventricular paced

rhythm with four intrinsic buts, one
(usion belt. and three episodes o(
undersensing (tv.'O episodes y,ithout ~pture ",nd one episode with
capture).This represents abnormlll
pacemaker function.
Slrip 10- 18
Anal)l$is: The first two complexes
art ventricular paced beals followed
by II fusion be",t and four intrinsic
beals_
Interpretation: Ventricular paced
rhythm with one fusion beat
and lOur intrinsic beats (normal
pacemaku function)

Strip 10- 19
Anal)l$is: The lirst four complexes
are ventricular paced beats followed
by MI intrinsic beat and three
ventricular paced beats.
Interpretation: Ventr icular paced
rhythm with one intrinsic beat
(normal pacemaker function)

Stri p 10-20
Anal)l$is: The tirst complex is a
ventricular paced beat folloo'ed by
two pacing spikes with failure to
captu re, a ventricular paced beat. a
pacing spike with failure to capture.
a ventricular paced beat.ll pacing
spike with failure to ~pture, two
ventricular paced beats. MId a pacing
spike with failure to capture.
Interpretation: Ventricular paced
rhythm with five episodes of failure
to ~pture (abnormal pacemaker
function)

359

Strip 10-2 1
Analysis: All complexes are
pacemaker indu<:ed.
Interpretation: Ventricular paced
rh~thm (normal pacemaker function)
Strip 10-22
Anal)l$is: One ventricu tar paced beat
changing to ventricular tachycardia
(ton<Mle de pointu)
Interpretation: Ventricular paced beat
changing to torde de pointu VT
Strip 10-23
Analysis: The first four complexes are
ventricular paced beats followed by
an intrinsic beal a pacing spike that
occurs too early. '" fusion beat, and a
ventricular paced beat.
Interpretation: Ventricular pKed
rhythm with one intrinsic beat,
one fusion beat. and one episode of
undersensing (abnormal pacemaker
function)

Strip 10-24
Analysis: The first complex is it
ventricular paced beat followed by a
pacing spike with failure to capture,
an intrinsic beat. II pacing spike with
failure to capture. an intrinsic beat. a
ventriculu pllCed beat, II pacing spike
with failure to capture, an intrinsic
beat, a pacing spike wi th failure to
capture, and an intrinsic !>tat.
Interpretation: Ventricular paced
rhythm with four intrinsic beats, and
four episodes 01 (llilure to capture
(abnormal pacemaker (unction)
Strip 10-25
Anal)l$is: A[[ complexes are pKemaker induced.
Interpretation: Ventricular paced
rh}thm (normal pacemaker function)

Strip 10-26
AnaI)I$is: The first two beats are ventricular paced beats followed by an
intrinsic beat. two ventricular paced
beats. a fusion beat. an intrinsic beat,
and two ventricular paced beats.
Interpretation: Ventricular pKed
rhythm with two intrinsic beats, and
one fusion beat (normal pacemaker
function)

360

Answer key to Chapters 5 through II

Str ip 10-27
Analysis: The first four complexes are
wntricular paced beats followed by
wntricular standstill (asystole).
Interpretation: Ventricular paced
rhythm with failure to fire resulting
in ventricular standstill (abnormal
pacemaker function)
Strip 10-2B
Analysis: The first four complexes
are ventricular paced beats followed
by two pacing spikes with failure to
capture. an intrinsic beat, \',0,0 pacing
spikes with failure to capture, and an
intrinsic beat.
Interpretation: Ventricular paced
rhythm with two intrinsic beats and
four episodes of failure to capture
(abnormal pacemaker function)
Strip 10-29
Analysis: The first two complexes
are ventricular paced beats followed
by three intrinsic beats and three
wntricular paced beats.
Interpretation: Ventricular paced
rhythm with three intrit15ic beats
(normal pacemaker function)
S lrip 10-30
Analysis: The first complex is a
pseudofusion beat (note spike in
QRS complex with no change in
amplitude or width) fol1Oo11ed by
intrinsic beats. three ventricular
paced beats, one fusion beat, and one
intrinsic beat.
Interpretation: Ventricular paced
rhythm with one pseudofusion
beat, one fusion beat, and three
intrit15ic beats (normal JXlcemaker
function)

mo

Strip 10-3 1
Analysis: The first three complexes
are ventricular paced beats followed by two intrinsic beats (paired
pVes) and four ventricular JXlced
beau.
Interpretation: Ventricular paced
rhythm with two intrinsic beats
(normal pacemaker function)

Strip 10-32
Analysis: The first four complexes
are ventricular paced beats followed
by one intrinsic beat (PVC), a pacing
spike occurring too early, and three
ventricular paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of undersensing malfunction (abnormal pacemaker function)
Strip 10-33
Analysis: The first \',0,0 complexes are
ventricular paced beats followed by
two intrinsic beats, a fusion beat, and
two ventricular paced beats.
Interpretation: Ventricular paced
rhythm with \',0,0 intrinsic beats and
one fusion beat (normal pacemaker
function)
Strip 10-34
Analysis: The first four complexes are
ventricular paced beats foll(M>ed by a
pacing spike with failure to capture,
an intrinsic beat, a pacing spike that
occur< too early. and two ventricular
pilced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat, one
episode of failure to capture. and one
episode of undersensing (abnormal
pacemaker function)
Strip 10-35
Analysis: The first tv.o complexes are
ventriw\ar paced beats folkM-ed by an
intrinsic beat, a fusion beat, an intrinsic beat, one pacing spike with capture
that occurs too early, twoventricular
paced beats, and an intrinsic beat.
Interpretation: Ventricular paced
rl"(ythm I'tith three intrinsic beats. one
fusion beat, and one episodeot undersensing (abnormal pacemaker function)
Strip 10-36
Analysis: The first two complexes are
ventricular paced beats followed by
an intrinsic beat, a pacing spike that
occurs too early. three intrinsic beats,
and three wntricular paced beats.
Interpretation: Ventricular paced
rhythm with four intrinsic beats and
one episode of undersensing malfunction (abnormal pacemaker function)

Strip 10-37
Analysis: The first five complexes are
wntricular paced beats followed by
an intrinsic beat and \',0,0 ventricular
paced beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat
(normal pacemaker function)
Strip 10-38
Analysis: The first four complexes are
wntricular paced beats followed by a
pause in pacing, a wntricular paced
beat that occurs later than expected,
a wntricular paced beat, and an
intrinsic beat.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of owrsensing (the pacemaker sensed the large T wave at the
start of the piluse).This is abnormal
pacemaker function.
St rip 10-39
Analysis: The first complex is wntriwlar paced follov,ed by three intrinsic
beats and four ventricular paced beats.
Interpretation: Ventricular paced
rh~1:hm with three intrinsic beats
(normal pacemaker function)
strip 1040
Analysis: The first complex is wntricular paced followed by ventricular
standstill (asystole).
Interpretation: Ventricular paced
beat with failure to fire resulting
in ventricular standstill (abnormal
pacemaker function)
Strip 1 1-1
Rhythm: Regular
Rate: 107 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.06 to 0.08 ~cond
Rhythm interpretation: Sinus
tachycardia
Strip 11-2
Rhythm: Regular
Rate: 58 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.12 second
Rhythm interpretation: Sinus bradycardia with bundle-branch block;
sr-segment depression is present.

Answer key 10 ChllplCrs Slhrough II

Strifl ll -3
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 84 ~aWminute (at rilll):
30 beaWmilWte (ventricular)
Pwaves: Sinus (two P waves or four
Pwaves before each QRS complex)
PR int~rvaJ; 024 to 028 S&ond
(consistent)
QRS complex: 0.08 second
Rhythm interpretation; Mobilz []
with 2:1 a0<l4:1 AV conduction

Strip 11 -8
Rhythm: R~gular (atrial dlld
ventricular)
Rate: 75 beaWm inute (atrial):
26 beats/minute (ventricular)
P ....~s: Sinus (bear no constdllt
relationship to the QRS complex)
PR interval: Varies
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Third-degree
AV block: ST-segment ~Ievation is
present.

Strip 11 -4
Rhythm: irregular
Rat~: 100 ~at~minute
P waves: Flbrillatory waves pr~sent;
some nutter waves mixed with fib
waves
PR int~rvaJ; Not measurable
QRS complu: 0.04 second
Rh}'lhm interpretation: Atrial
fibrillation

Sirip 11 -9
Rhythm: Regular
Rate: 188 beaWminute
P w~s : Not discernibl~
PR interval: Not discernible
QRS complex: 0.16 to 0.20 second
Rhythm int~rpretation: Ventricular

Sirip 11 -5
Rhythm: Regular
Rate: 48 ~at~minut~
P .... aves: Hidden in the QRS compla
PR int~rvaJ; Nol measurable
QRS complex: 0.08 second
Rhythm interpretation; Junctional
rhythm: ST-segment depression is
present.
Strip 11 -6
Rhythm: Regular
Rat~; 188 beat5iminute
P waves: Hidden in preceding
Twaves
PR int~rvaJ; Not measurable
QRS complex: 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Strip 11 -7
Analysis: The first four complexes
ar~ ventricular paced beats followed
by two intrinsic beats. a ventricular paced beal and two intrinsic
beats.
Interpretation: Ventricular paced
rhythm I'.ith four intrinsic beats
(normal pacemaker function)

36 1

Sirip 11 - 13
Rhythm: Regular
Rate: 232 b~atslminute (atrial ):
58 btatslminutf (ventricular)
P waves: Four lIutter waves before
each QRS com pia
PR interval: Not measurable
QRS complex: 0.06 to 0.08 S&ond
Rh)thm interpretation: Atriaillutter
with 4;) AV conduction
Sirip 11-14
Rhythm: Regular
Rate: 79 beatslminute
P waves: SinlU
PR interval: 0.16 to 0.18 second
QRScompla: O. IOsecond
Rhythm interpretation: Normal sinlU
rhythm: ST segment elevation is
present.

tKh~ardia

Strip 11 -\0
Rhythm: Regular
Rate: 42 beaWminute
P waves: Absent
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm int~rpretation: IdioventricuIlIr rhythm
Strip 11 -11
Rhythm: Regular (basic rhythm)
Rate; 56 b~aWminute (basic
rhythm)
P w~s: Sinus (appear notched.
which may indicate Idt atrial hypertrophy)
PR interval: 0.16 second
QRS complex; 0.06 second (basic
rhythm); 0.16 second (PVC)
Rhythm interpretation: Sinus bradycardia with one int~rpolated PVC;
ST-segment depression is present.
Strip 11 -12
Rhythm: R~gular
Rate: 54 beaWminut~
P w~s: Inverted before each QRS
complex
PR interval: 0.10 ~cond
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Accflerated
junctional rhythm

Str ip 11 - 15
Rh~thm: Regular
Ratf: 88 beatslminute
P waves: Absent
PR inl~rvaJ : Not measurable
QRS compJ\'X: 0. 14 to 0.16 sond
Rhythm interpretation: Accelerated
idiowntricu lar rhythm
Strip II - Hi
Rhythm: Regular (basic rhythm);
irregulllrwith pause
Rate; 75 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm): one
premature, abnonnal P wave without
a QRS complex (afte r the fifth QRS
complex)
PR int~rval : 024 to 0.28 second
QRS compl\'X: 0.06 to 0.08 S&ond
Rhythm interpretation: Normal sinlU
rhythm with fil'5l-degre~ AV block
and one nonconducled PAC (follows
the fifth QRS complex)

Sirip 11 -17
Rh~thm: Regular
Rate: 115 beats/minute
P waves: Sinus
PR int~rval : 0.14 to 0.16 second
QRS compla: 0.06 second
Rhythm interpr~tation: Sinus
tachycardia

362

Answer key to Chapters 5 through II

Strip 11-18
Rhythm: Regular
Rate: 48 beats/minute
P waves: Sinus
PR interval: 0.12 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus bradycardia; ST-segment elevation is
present.

Strip II -ZJ
Rhythm: Irregular atrial rhythm
Rate: 40 beats/minute (atrial);
obeats/minute (ventricular)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill

Strip 11-19
Rhythm: Regular (basic rhythm):
irregular (prelllilture beats)
Rate: 72 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm);
inverted (premature beat.)
PR interval: 0.12 to 0.14 second
(basic rhythm); 0.08 second
(premature beats)
QRS complex: 0.08 second
Rhythm interpretation: Normal sinus
rhythm with two premature junctional contractions (fou rth and sixth
complexes)

Strip \1 -24
Rhythm: Irregular
Rate: 70 beats/minute
P waves: Sinus
PR interval: 0.44 to 0.48 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus arrhythmia with first-degree AV block;
ST-segment elevation is present.

Strip 11-20
Rhythm: Regular
Rate: 63 beats/minute
P waws: Vary in size. shape, and
position
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Wandering atrial pacemaker: ST -segment
depres.lion is present.
Strip \1 -21
Rhythm: Chaotic
Rate: 0 beats/minute (no QRS
complexes)
P waves: No P waves; waw deflections are chaotic and irregular and
vary in height, size, and shape
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
fibrillation
Slri1l 1 1-22
Rhythm: Regular
Rate: 107 beats/minute
P waws: Inwrted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.01 to 0.06 second
Rhythm interpretation: Junctional
tachycardia

S irip 11 -25
Rhythm: Regular (basic rhythm )
Rate: 48 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.36 second
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Sinus bradycardia with first-degree AV block and
sinus arrest
Strip 11 -26
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 72 beilts/minute (iltrial);
40 beats/minute (wntricular)
P waves: Sinus
PR interval: Lengthens from 0.20 to
0.28 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: SeconddegreeAV blo,k, Mobitz I;
ST-segment depression is present.
Slrip 11 -27
Rhythm: Regular
Rate: 72 beats/minute
P waves: Sinus
PR intuval: 0.20 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Normal sinus
rhythm: ST-segment depres.lion and
T-wave inversion are present.

Strip 1 1-28
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 72 beats/minute (basic
rhythm): slows to 63 beats/minute
during first cycle after pause: rate
Juppres.lion can occur for sewral
cycles after an interruption in the
basic rhythm.
P waves: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm with sinus arrest
Strip 1129
Rhythm: Regular (basic rhythm);
irregular (prelllilture beat)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (premature
beat)
PR interval: 0.14 to 0.16 second
(basic rhythm): 0.12 second
(prematu re beat)
QRS complex: 0.08 second
Rhythm interpreUltion: Normal
sinus rhythm with one PAC (fifth
complex)
St r ip 1 1-30
Rhythm: Regular (basic rhythm);
irregular (PVCS)
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.12 second (basic
rhythm and PVCS)
Rhythm interpretation: Normal
sinus rhythm with bundle-brancll
block and paired PVCs: a U waw is
present.
Strip 11 -31
Rhythm: Regular (atrial and ventricular)
Rate: 240 beats/minute (atrial);
60 beats/minute (ventricular)
P waves: Four flutter waves to each
QRS complex
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Atrial flutter
with 4:1 AV conduction

Answer key to Chapters 5 through II

Strip 11-3'2
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 54 beats/minute (basic
rhythm)
P wa~s: Sinus (basic rhythm): none
(fourth and fifth complexes)
PR interval: 0.18 to 0.20 second
(basic rh~1:hm )
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus brady
cardia with a pause follo",~d by \"1'>0
junctional escape beats: the specific
pause (sinus arrest or block) cant be
identified due to the presence of the
escape beats.
Strip 11 -33
Rhythm: Regular
Rate: 25 beats/minute
P waws: None kkntified
PH interval: Not measurable
QRS complex: 024 second or
greater
Rhythm interpretation:
Idiowntricular rhythm
Strip 11-31
Analysis: The first three complexes
are ventricular paced beats
follo",~d by a pacing spike that fails
to capture the ventricle, an intrinsic beat, and two ventricular paced
beats.
Interpretation: Ventricular paced
rhythm with one intrinsic beat and
one episode of failure to capture
(abnonnal pacemaker function)
Strip 11-35
Rhythm: Regular
Rate: 84 beal5lminute
P w"v<:s: Not identified
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rh}1:hm interpretation: Accelerated
idioventricular rhythm

S tri p 11 -36
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent; wave deflectiofl5
are chaotic and irregular and vary in
size, shape, and height
PR interval: Not measurable
QRS complex: Ab~nt
Rhythm interpretation: Ventricular
fibrillation. followed by electrical
shock and return to ~ntricular
fibrillation
S tri p 11 -37
Rhythm: Regular
Rate: 52 beats/minute
P waves: Sinus
PR interval: 0.18 to 0.20 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Sinus
bradycardia; a U wave is present.
Strip 11 -38
Rhythm: Regular
Rate: 94 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.08 second
Rhythm interpretation: Accelerated
junctional rh}1:hm; baseline artifact
is pre~nt.
S trip 11 -39
Rhythm: Regular (basic rhythm);
irregular with premature beat
Rate: 72 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
premature abnormal P wa~ with
premature beat
PR interval: 0.14 to 0.16 second
(basic rhythm); 0.12 second
(prematu re beat)
QRS complex: 0.04 to 0.08 ~cond
(basic rhythm); 0.08 second
(premature beat)
Rhythm interpretation: Nonnal sinus

rllyllnu wilh VLL~ pr~UJdlur~ dlriui

contraction (PAC )

363

Str ip 11-.40
Rh}1.hm: Regular (basic rhythm) off
by two squares
Rate: 79 beats/minute (basic
rhythm)
P wa~s: Sinus (basic rhythm);
premature abnormal P wave without
QRS following fifth QRS complex
PR interval: 020 second
QRS complex: 0.08 to 0.10 second
(basic rh}1.hm): 0.08 second
(premature beat)
Rhythm interpretation: Normal sinus
rhythm with nonconducted PAC
followed by a PJC
Strip 1 1 -~ 1
Rh}1hm: P waves occur regularly
Rate: 88 beats/minute (atrial); 0
(ventricular )
P waves: Sinus
PH interval: Not measurable
QRS complex: Absent
Rh}1hm interpretation: Ventricular
standstill
S tr ip 11-42
Rhythm: Regular (basic rhythm);
irregular (premature beats)
Rate: 63 beats/minute (basic
rhythm)
P waves: Sinus (basic rh}1:hm)
PR interval: 0.12 to 0.14 ~cond
QRS complex: 0.08 second (basic
rhythm); 0.12 to 0.l6 second (PVC)
Rhythm interpretation: Normal sinus
rhythm with paired multifocal PVC!
(fourth and fifth complexes)
Str ip 11-43
Rh}1hm: Regular (basic rhythm):
irregular (PACs)
Rate: 136 beats/minute (""sie
rhythm)
P waves: Sinus (basic rhythm);
premature and pointed (premature
beats)
PR interval: 0.16 to 0.20 second
QRS wmph:x: 0.06 Iv 0.08 ~~wwJ
Rhythm interpretation: Sinus
tachycardia with \"1'>0 PACs (fourth
and eighth complexes)

364

Answer key to Chapters 5 through II

S tr ip 1144
Rhythm: Regular (basic rhythm);
irregular with pause
Rate: 84 beats/minute (basic
rhythm): slol'>'S after pause but
returns to basic rate after four cycles.
P waws: Sinus
PR interval: 0.20 second
QRS complex: 0.08 second
Rhythm interpretation: Normal
.inus rhythm with sinus ftrre:st;
ST-segment depression and T-wave
inversion are present.
S lri p 1145
Analysis: No patient or paced beats
are sn: pacing spikes are noted that
fail to capture the ventricles.
Interpretation: Failure to capture in
the presence of ventricular standstill
S tr ip 11 -46
Analysis: The first two complexes
are intrinsic beats followed by a
fusion beat, two intrinsic beats, two
ventricular paced beats. and a fusion
beat.
Interpretation: Ventricular paced
rhythm with four intrinsic beats and
tv,o fusion beats (normal pacemaker
function)
S tr ip 11 -47
Rhythm: Regular
Rate: 42 beats/minute
P waves: Hidden in QRS complex
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
rhythm
S tr ip 11-48
Rhythm: Regular (atrial); irregular
(ventricular)
Rate: 79 beats/minute (atrial);
50 bcat.tminute (ventricular)
P waves: Sinus
PR interval: Lengthens from 020 to
0.32 se,ond
QRS complex: 0.08 to 0.10 second
Rhythm interpretation:
S\:u)II<.l-<.l~!,/'n AV bl<><:k. Mubitt. I

Stri p 11 -49
Rhythm: Regular (basic rhythm);
irregular (premature beat)
Rate: 107 beats/minute
P waves: Inverted before each QRS
complex (except the ninth QRS
complex, which has a premature.
pointed P wave )
PR interval: 0.08 to 0.10 second
(basic rhythm): 0.10 second
(pfem~tUrc beat )
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Junctional
tachYCimlia with one PAC (ninth
complex)
Stri p II -50
Rhythm: Regular (atrial and
ventricular)
Rate: 84 beats/minute (atrial);
28 beats/minute (ventricular)
P waves: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies greatly
QRS complex: 0.12 second
Rhythm interpretation: Third-degree
AV block; ~i -segment depression is
present.
Stri p 11 -5 1
Rhythm: Irregular
Rate: 70 beats/minute
P WdVt:li: Sillu.
PR interval: 0.18 to 020 second
QRS ,omplex: 0.08 to 0.10 SI!,ond
Rhythm interpretation: Sinus
arrhythmia
Stri p 11 -52
Rhythm: Regular (basic rhythm);
irregular (premature beats)
Rilte: 72 beats/minute (lxl:!i'
rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.16 second
QRS complex: 0.10 .Kcond
Rhythm interpretation: Normal
sinus rhythm with unifocal PVCs in
a trigeminal pattern. sr-segmmt
depression and T-wave inversion are
present.

S tr ip I I-53
Rhythm: Regular
Rate: 93 beats/minute (atrial);
3 1 beatY-minute (ventricular)
P waves: Three sinus P waves to each
QRS complex (one hidden in the
T wave)
PR interval: 0.36 second (remains
constant)
QRS complex: 0.08 second
Rhythm intcrprdotion: Seconddegree AV block. Mobitz II
St r ip 11 -54
Rhythm: Regular (basic rhythm );
irregular (PVCs)
Rate: 72 beats/minute (basic
rhythm )
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 second (basic rhythm): 0.14 to 0.16 second
(PVCs)
Rhythm interpretation: Normal sinus
rhythm with multifocal PVCs
S trip I I-55
Rhythm: Regular (atrial and
ventricular)
Rate: 62 beats/minute (atrial):
31 beatY-minute (ventricular)
P waves: Two sinus P waves before
~dcll QRS ~ulllpln
PR interval: 0.44 second (remains
comtantj
QRS complex: 0.14 to 0.16 second
Rhythm interpretation: Seconddegree AV block, Mobitz II
S trip 1 156
Rhythm: Regular
Rate: 65 beats/minute
P waves: Inverted before each QRS
complex
PR interval: 0.10 second
QflS complex: 0.04 ~econd
Rhythm interpretation: Accelerated
junctional rhythm: ~i -segment
elevation is present.

Answer key 10 Chapl elll5 through II

Sirip I I -57
Rhythm: Regular (basic rhythm):
irr~gul<lr with pause
R<lt~: 68 be~t!lminute (basic rhythm)
P w~ws: Sinus
PR interval: 022 to 0.24 second
QRS complex: 0.08 to 0.10 second
Rhythm interpret~tion: Normal
sinus rhythm with first-degree AV
block and sinus arrest: ST-segment
elevation is present.
Sirip I I -58
Analysis: The tirst complex is an
intrinsic beat followed by a pacing
spike with failure to capture. an
intrinsic beat, a pacing spike with
failure to capture, two intrinsic
beah. a pacing spike with failure to
capture, an intrinsic beat, a pacing
spi ke with failure to capture, and iUl
intrinsic beat.
Interpretation: Strip shows an
intrinsic rhythm (sinus arrhythmia
with first-degree AV block and
two PVCs) with complete failure
to capture (abnormal pac~maku
function); since there were no two
consecutive paced beats or two
consecutive pacing spikes, I used
the interval from Ihe R wave of the
natiw beat to the pacing spike as my
estimated automatic interval.
Strip I I -59
Rhythm: Regular
Rate; 1M beats/minute
P waws: Not identified
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation; Paroxysmal
atrial tachycardia
Strip 11-60
Rhythm: Irregular
Rate: 30 beats/minute
P waves: None present
PR interval: Not measurable
QRS complex: 0.16 second
Rhythm interpretation: Idioventricular rhythm: ST-segment depression
is present.

365

Strip 11 - 6 1
Rhythm: Regular (atrial): irregular
(wntricuJar)
Rate; 125 beats/minute (atrial);
80 beats/minute (wntricular )
P waves: Sinus
PR interval: Lengthens from 0.12 to
0.24 SKond
QRS complex; 0.06 to 0.08 second
Rhythm interpretation: Seconddegree AV block. Mobitz I: T-waw
inwrsion is present.

Strip 11-66
Rh}1hm: Regular
Rate: 78 beats/minute (atrial);
39 beats/minute (ventricular)
P waves: Two sinus P waves to each
QRS compla
PR interval: 0.24 second with a
COnstiUlt relationship to the QRS
complex
QRS compla: 0.12 to 0.14 second
Rh}1hm interpretation:
Sond-degree AV block, Mobitz II

Strip 11 -62

Strip 11-67

Rhythm: Regular (basic rhythm);

irregular (nonconducted PAD)
Rate: 100 beats/minute (basic
rhythm)
P waves; Sinus: two premature
abnormal P waves without QRS
complex (after the fourth and eighth
complexes)
PR interval; 0.12 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Nonna l sinus
rhythm with two nonconducted
PACs; T-wa~ inversion is present.

Rh}1hm: Regular (basic rhythm) but

offby one square
Rate: 52 beats/minute
P waW5: No visible P wave (hidden in
QRS compla)
PR interval : Not measurable
QRS compla: 0.06 to 0.08 second
Rhythm interpremtion: JunctionOlI
rhythm

Strip 11 - 63
Rhythm: Regular
Rate: 75 beats/minute
P waves: Sinus
PR interval: 0.16 to 0.18 sond
QRS complex: 0.12 to 0.14 SKond
Rhythm interpretation: Norma l sinus
rhythm with bundle-branch block;
Sl-segment elevation is present.
Strip ll -M
Rhythm: Regular
Rate: 50 beats/minute
P waves: Sinus
PR interval: 0.16 5ond
QRS complex: 0.06 to 0.08 SKond
Rhythm interpretation: Sinus
bradycardia; a U wave is present .
Strip 11-65
Analysis: All complexes are
pacemaker induced.
Interpretation: Ventricular paced
rhythm (normal pacemaker
function)

Strip 1 1-68
Analysis: The first four complexes
are v,ntricular paced followtd by a
fusion beat and an intriruic beat.
Interpretation: Ventricular paced
rhythm with one fusion beat and one
intrinsic beat (normal pacemaker
function)
Strip 11-69
Rhythm: Regular
Rate: liS beats/minute
P waW5: [nwrted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.06 to 0.08 second
Rhythm inlerpremtion: Junctional
mchycardia
Strip 11-70
Rhythm: Regular (basic rhythm);
irregular (PIC)
Rate: 58 beats/minute (basic
rhythm)
P waves: Sinus (basic rhythm);
inverted (PIC)
PR interval: 0.14 to 0.16 second
(bilsic rh}1hm): 0.10 second (PJC)
QRS corupla: 0.08 second
Rh}1hm in terpretation: Sinus
bradycardia with one PIC

366

AnslI'er key to C h aplers 5 through II

Str ip 11-7 1
Rhythm: Regular (basic rhythm);
irregul(lor (non conducted PAC)
Rate: 63 beats/minute (bMic rhythm)
P wavu: Sinus (basic rhythm): one
premature. abnormal P wave without
a QRS complex (after the fourth
complex)
PR interval: 0.2S to 0.32 tecond
QRS complex: 0.12 second
Rhythm interpretation: Normal sinus
rhythm with first-degree AV block
and bundle-branch block with one
nonconducted PAC after the fourth
QRS complex: 31 -segment elevation
and T _wave inversion are present.

Strip 11-72
Rhythm: Regular (basic rhythm);
irregular (PVC)
Rate: 50 beats/minute (bMic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.12 to 0.14 iecond
QRS complex: 0.08 second (basic
rhythm): 0.18 second (PVC)
Rhythm interpretation: Sinus bradycardia with one PVC (after the third
QRS complex): ST-segment elevation
is present.

S irip 11-7:.l
Analysis: The first two complexes
are ventricular paced followed by
a fusion beat. a pseudofusion beat
(note spike at beginning of R wave).
three intrinsic beats. a pacing spike
that occurs too early. an intrinsic
beat. a pacing spike that ocrtJ rs too
farly. an intrinsic bfat, and a pacing
spike that occurs too early.
Interpretation: Ventricular paced
rh}1hm with one fusion beat. one
pseudofusion beat. five intrinsic beats.
and three episodes of under sensing
(abnormal pacemaker function)

Strip 1 1-70\
Rhythm: Regular
Rate: 50 beats/minute
P waves: None identified
PR interval: Not measurable
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Junctional
rhythm; ST -segment depression and
T-wave inversion are present.

Strip 11 -75
Rhythm: Irregular atrial rhythm
Rate: 40 beats/minute (atrial);
(ventricular)
P waves: Sinus
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill

Stri p 11 -76
Rhythm: Irregular
Rate: 60 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus arrhythmia; ST -segment elevatio n is
preienl.
Sirlp 11 -77
Rhythm: Regular
Rate: 68 beilts/minute
P waves: P waves vary in size, shape.
and position
PR interval: 0.14 to 0.16 second
QRS com pin.; 0.06 to 0.08 second
Rhythm interpretation: Wandering
atrial pacemaker; T-wave inversion is
pre.sent.

Slrip ll -78
Rhythm: Regular
Rate: 214 beats/minute
P waves: H idden
PR interval: Not measurable
QRS complex: 0.06 to 0.08 .second
Rhythm interpretation: Paroxysmal
atrial tachyc<lrdia

Sirip 11 -79
Rhythm: Regular (first and second
rhythms)
Rate: 94 beats/minute (first rhythm):
136 beatslminute (iecond rhythm )
P waves: Sinus (first rhythm)
PR interval: 0.18 to 020 second (first
rhythm)
QRS complex: 0.06 to 0.08 second
(first rhythm ): 0.1 2 second (second
rhythm)
Rhythm interpretation: Normal sinus
rhythm changing to ventricular
tachycardia

Strip 11-80
Rhythm: Regular (basic rhythm)
Rate: 107 beats/minute (bMic
rhythm)
P waves; Sinus (basic rhythm)
PR interval: 0.14 to 0.16 second
QRS complex: 0.06 to 0.08 .setond
(basic rhythm); 0.12 second
(ventrltular beau)
Rhythm interpretation: Sinus
tachytardia with a four-beat burst of
ventricular tathycardia and paired.
unifocal PVCs

Strip 11-81
Rhythm: Irregular
Rate: 260 beats/minute (atrial):
70 beats/minute (ventricular)
P waves: Flutter waves
PR interval: Not measurable
QRS tompl('JI: 0.06 to 0.08 second
Rhythm in terpretation: Atrial Hutter
with variilble block

Sirip 11-82
Rhythm: Regulu
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.12 setond
QRS compl('JI: 0.04 to 0.06 .second
Rhythm in terpretation; Normal sinus
rhythm

SLrip 11-83
Analysis: The fint beat is a
pteudofmion beat (note spike inside
QRS with complex untharged)
followed by two intrinsic beats. three
ventricular pated beats. a fusion
beat. and an intrinsit beat.
Interpretation: Ventricular paced
rhythm with one pseudofusion
beat. one fusion beat. and three
intrinsic beats (normal pacemaker
function)
Si rip 11-84
Rhythm: Regular
Rate: 136 beats/minute
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.06 to 0.08 .second
Rhythm interpretation: Sinus
tathycardia

Answer key to Ch ap ters 5 through II

367

Strip 11 -85
Rhythm: Regular
Rate: 54 beats/minute
P waV\'s: Sinus
PR interval: 024 to 0.26 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Sinus
bradycardia with first-degreeAV
block

Strip 11 -90
Rhythm: Regular
Rate: 88 beats/minute
P waves: Sinus
PR interval: 0.16 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rh}1hm; ST-segment depression and
T-waV\' inversion are present.

Strip 11 -95
Rhythm: Regular
Rate: 100 heats/minute
P waves: InV\'rted before each QRS
complex
PR interval: 0.08 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Acceluated
junctional rhythm

Strip 11 -86
Rhythm: Regular (atrial and
V\'ntricular)
Rate: 94 beats/minute (atrial);
37 beats/minute (ventricular)
P waV\'s: Sinus (bear no relationship
to the QRS complex)
PR interval: Varies
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Third-degr
AVblock

Strip 11 -91
Rhythm: Regular (basic rhythm):
irregular (PVCI
Rate: 115 beats/minute (basic
rhythm)
P waves: Inverted before each QRS
complex
PR interval: 0.08 to 0.10 second
QRS complex: 0.04 to 0.06 second
(hasic rhythm); 0.12 second (premature beat)
Rhythm interpretation: Junctional
tachycardia with one PVC

Strip 11 -96
Rhythm: Regular (atrial): irregular
(ventricular)
Rate: 84 beats/minute (atrial):
70 beats/minute (ventricular )
P waves: Sinus
PR interval: ungthens from 0.20 to
0.36 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Seconddegree AV block, Mobitz I;
ST-segment depression is present.

Strip 11 87
Rhythm: Regular
Rate: 150 heats/minute
P waV\'s: None identified
PR interval: Not measurable
QRS complex: 0.12 to 0.14 second
Rhythm interpretation: Ventricular
tachycardia
Strip 11 -88
Rhythm: Regular (basic rhythm):
irregular with pause
Rate: 56 beats/minute (ba~ic rhythm)
P waV\'s: Sinus (basic rhythm):
absent during pause
PR interval: 0.16 to 0.18 second
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Sinus
bradycardia with sinus arrest:
~'T -~egment depres~ion and T-wave
inversion are present.
Strip 11 -89
Rhythm: 0 beats/minute
Rate: 0 heats/minute
P waV\'s: Absent
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventricular
standstill

Strip 11 -92
Rhythm: Regular
Rate: 188 beats/minute
P waves: T -P wave (P waVi: obscured
in TwaV\' )
PR interval: Not measurable
QRS complex: 0.08 to 0.10 second
Rhythm interpretation: Paroxysmal
atrial tachycardia
Sirip 11 -93
Rhythm: Chaotic
Rate: 0 beats/minute
P waves: Absent; fihrillatory waves
present
PR interval: Not measurable
QRS complex: Absent
Rhythm interpretation: Ventrkular
fibrillation
Sirip 11 -94
Rhythm: Regular (basic rhythm):
irrel/ular with pause
Rate: 75 beats/minute (basic rhythm)
P waves: Sinus (basic rhythm)
PR interval: 0.24 second
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with first degree AV block
and sinus exit block

Strip 11 -97
Rhythm: Irregular
Rate: 100 beats/minute
P waves: Fibrillatory waV\'s
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
(basic rh}1hm): 0.12 second (PVC)
Rhythm interpretation: Atrial
fibrillation with one PVC
Strip 11 -98
Analysis: The first two complexes
are ventricular paced beats follol't'ed
hyan intrinsic heat, two V\'ntricular
paced beats. a pacing spike with failure to capture. an intrinsic heat. and
a ventricular paced beat.
Interpretation: Ventricular paced
rhythm with t\'t'o intrinsk beat~ and
one episode of failure to capture
(abnormal pacemaker function)
Strip 11 -99
Rh}1hm: Rel/ular (basic rhythm):
irregular (prematu re beat)
Rate: 125 beats/minute (basic
rhythm)
P waves: Sinus
PR interval: 0.12 second
QRS complex: O.o.t to 0.06 second
Rhythm interpretation: Sinus
tachycardia with one PAC (twelfth
complex)

368

Answer key to Chapters 5 through II

Strip 11 100
Rhythm: Regular
Rate: 272 beats/minute (atrial);
136 beats/minute (ventricular)
r WQ""~: Two flutter wavo to eoch
QRS complex
PR interval: Not measurable
QRS complex: 0.04 second
Rhythm interpretation: Atrial flutter
with 2:1 AV conduction
Strip 11 10 1
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
arrhythmia
Strip 11 102
Rhythm: Regular
Rate: 48 beats/minute
P waves: Sinus
PR interval: 0.14 to 0.16 second
QRS complex: 0.08 second
Rhythm interpretation: Sinus
bradycardia; a U waw is present.
Strip 111 03
Rhythm: Regular
Rate: 214 beats/minute
P waws: None identified
PR interval: Not measurable
QRS complex: 0.16 second or greater
Rhythm interpretation: Ventricular
tachycardia
Strip 11 \0<1
Rhythm: Irregular
Rate: 60 beats/minute
P waws: Fibrillatol)' waves
PR interval: Not measurable
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Atrial
fibrillation
Strip 11 105
Rhythm: Regular (basic rhythm)
Rate: 72 beats/minute (basic rhythm)
P waws: Sinus
PR interval: 0.16 to 0.18 second
QRS complex: 0.06 to 0.08 second
(basic rhythm): 0.12 second (PVC)
Rhythm interpretation: Normal sinus
rhythm with one interpolated PVC;
STsegment depression is present.

Strip 11 106
Rhythm: Regular (basic rhythm):
irregular (PJC)
Rate: 65 beats/minute (basic rhythm)
r wavo : Sinu. (b....ic rhythm):
inwrted (PJC )
PR interval: 0.12 to 0.16 second
(basic rhythm); 0.10 second (PJC)
QRS complex: 0.06 to 0.08 second
Rhythm interpretation: Normal sinus
rhythm with one PJC: a U wave is
present.
S lrip 11 107
Rhythm: Regular (basic rhythm );
irregular (PVCs)
Rate: 88 beats/minute (basic rhythm)
P waves: Sinus
PR interval: 0.12 to 0.14 second
QRS complex: 0.04 to 0.06 second
Rhythm interpretation: Normal sinus
rhythm with three PVCS

Glossary
Aberrant - Abnormal
Abcrr",ntly concluded ~upr.vcn

tricular premature beats - A pre-

mature electrical impulse ori{!inatinll

in the atria or AV junction may occur
early that the impulse arrives at
the bundle of His before the bundle
branches have been sufficiently repolarized. Becau.\e the right bundle
branch is 5Jo~r to repolariz.e, the

50

impulse traV\!ls down the left bundle

branch first, and then stimulates the
right bundle branch. Because of this
delay in ventricular depolarization the
QRS complex will be wide. Premature
atrial contractions (PACs) associated
with a wide QRS complex are called

PACs wilb aberrant ventricular conduction, indicating thai conduction

through the ventricles is abnormal.
Premature junctional contractions
(PJCs) lmOCiated with a wide QRS
complex are called PJCs with aberrant
ventricular conduction. Also known u
PACs or PJCs with aberrancy.
Absolutr refractory period ~ The
period of time during ~ntricular
depolarization and most of repolaril.iltion when cardiac cells cannot be
stimulated to conduct an electrical
impulse. This period be(!ins with the
onset of the QRS complex and ends at
the peak of the T waw.
Accderated idiowntricular rhytbm ~
An arrhrthmia originating in an ectopic
site in the wntricles characterized by a
re(!ular rhythm, an absence of P waves,
ond wide QRS complexe. at 0 rote of SO
to 100 beats/minute. The rate is faster
than the inherent tiring rate of the ventricles. but is slower than ventricular
tachycardia. Also known as AIVR.
Accelerated junction,l rhythm ~ An
orrhythmilt origi""ting in the otrioventricular (AV) junction characterized by a regular rhythm; irwerted P
waves immediately before the QRS,

immediately after the QRS, or hidden

within the QRS complex with a short
PR intetval of 0.10 =ond or 1=; a
normal duration QRS complex; and a
rate between 60 and 100 beats/minute.
The rate is faster than the inherent firing rate of the AV junction. but slower
than junctional tachycardia.
Accessory conduction pathways Several abnormal electrical conduction
pathwa~'s within the heart that allow
electrical impulses to bypass the atrioventricular node before entering the
ventricles.
Acetylcholine ~ The chemical neurotransmitter for the parasrmpathetic
nelVOUS s~'stem.
Acutr myocardial infarction Necrosis of the mrocardium caused by
prolonged and complete interruption
of blood ftow to an area of the m)lOC4rdi.>.l mwdcm=.
Agonal rhythm ~ A rh~1hm seen in
a dying heart, in which the QRS complexes deteriorate into irregular. wide,
indistinguishable waveforDl.! just prior
to ventricular standstill.
A1VR ~ aMr accelerated idioventricular rh~1hm
Amplitude - The height or depth
of a wave or complex on the ECG
measured in millimeters (mm). Also
known as voltage.
Angino ~ The term .... ed to ducribc
the pain that results from a reduction
in blood supply to the m)lOC4rdium.
The pain is typically described as chest
heaviness, pressure, squee1:ing, or constriction. Associated srmptoms include
nausea and diaphoresis.
Angjoplasty ~ The insertion of a
balloon-tipped catheter into an occluded or narrowed coronary artery to

reopen the artery br inflating the balloon, compressing the atherosclerotic

ploque. and dilating the lumen of the
artery. Often followed by insertion of
a coronary artery sten!. Also known as
percutanrous trllTlSluminal coronary
angiop/asty or P1t:4.
Anion ~ An ion with a negative
chaflle
Antegrade conduction ~
Conduction ofthe electrical impulse in
a forward direction
Aortic valve ~ One of two semilunar
valves; located between the left ventricle and the aorta.
Apex of th~ heart ~ The bottom of
the heart formed by the tip of the left
~entricle; located to the left of the
sternum at approximately the fifth
intercostal space. midclavicular line.
Arrhythmia ~ A general term referring to any cardiac rh~1hm other than a
sinus rh)'lhm. Often used interchangeably with dysrhythmia, a more appropriate term. but one used less often.
Artifacts ~ Distortion of the ECG
tracing by activity that is noncardiac in
origin. such as patient movement, electrical interference, or muscle tremors.
Also knov.n as interferimCe or noise.
As~stole ~ Absence of ventricular
electrical activity. Tracing will show
P waves only or a straight line. Also
colled ventricular standstill.

Atria ~ The two thin-walled upper

chambers of the heart. The right and
left atria are separated from the ~entri
cles by the mitral and tricuspid valws.
Atrial fibrillation ~ An arrhythmia originating in an ectopic site
(or numerous sites) in the atria
characterized by an atrial rate of 400

369

370

Glossary

beats/minute or more: atrial waveforms

appearing as an irrejlular, wavy baseline:
a normal QRS duration: a grossly irregular ventricular rh~1hm:.md a rate that
may be fiLIt or slow depending on the
number of impulses conducted through
the atrioventricular node.
Atrial flutter ~ An arrh~1:hmia originating in an ectopic site in the atria
characterized by an atrial rate between
250 and 400 beatyminute: atrial waveforms appearing in a sav,10oth pattern:
a nonnal QRS duration: a regular or
irregular ventricular rh~1:hm: and a
rate which may be fast or slow depending on the number of impulses conducted through the AV node.
Atrial kick ~ Blood pushed into the
ventricles 11.1 a result of atrial contraction to complete filling of the ventricles just before the ventricles contract

control). Includes the sympathetic

and parasympathetic nervous systems.
each producing opposite effects when
stimulated.
AV ~ abbr atrioventricular
Bachma.nn's bundle ~ A branch of
the internodal atrial conduction tracts.
Conducts the electrical impulses from
the sinoatrial node to the left atrium.
Ba.seUne ~ The straight line between
E:CG wavdonns when no electrical
activity is detected.

Base of the heirt ~ Top of the heart

located at approximately the level of
the second intucostal space.
Ikta blockers - A group of drugs
that block sympathetic activity. Used
to treat tachyarrh~1:hmias, MI, angina.
and hypertension.

Atrioventricular block (AV block) ~

A delay or failure of conduction of electrical impulses thr~ the AV node.

every other ""lIt i.

Atrioventricular junction IAV

junction) - Consists of the AV node
and the bundle of His.

beat. The premature beat may be

atrial, junctional. or ventricular in
origin (i.e., atrial bigeminy, junctional
bigeminy, ventricular bigeminy).

AtrioventricuJiT n<><k IAV node) ~

Located in the lov.~r portion of the
right atrium near the interatrial septum: only normal pathway for conduction of atrial impulses to the ventricles:
primary function is to slov. conduction
of electrical impulses through the AV
node to allow the atria to contract
(atrial kick) and complete filling the
\entride.s.

Bigeminy ~ An arrhythmia in which

~

premature eetopic

Biphasic deflection ~ A waveform

that is part positive and part negative.
Bradycardil -An arrhythmia with a
rate of less than 60 beats/minute.
Bundle-brancb block - A block of
conduction of the electrical impulses
through either the right or left bundle
branch, resulting in a right or left
bundle-branch block.

Atrioventricular valves (AV

valves) ~ The two valves located
between the atria and the ventricles.
The tricuspid separates the right atrium from the right ventricle, the mitral
separates the left atrium from the left
ventricle.

Bundle branches ~ A part of the

electrical conduction system consisting
of the right and left bundle branches that
conducts the electrical impulses from the
bundle r:i His to the Purkinje network.

Automlticity ~ Ability of a cell to

spontaneously generate an impulse.

Bundle of His ~ A part of the

electrical conduction system that connects the atrioventricular node to the
bundle branches.

Autonomic nelVOUS system ~

Regulates functions of the body that
are involuntary (not under conscious

Bunts ~ Thre~ or more conse,utive

premature ectopic beats (atrial,

junctional. or ventricular). Also knOv,,,

as sallJ() or run.
Calcium chinrnd blockers ~A
group of drugs that block entry of calcium ions into cells, especially those of
cardiac and vascular smooth muscle.
U~d to treat hypertension, angina.
and as an antiarrhythmic.
Cudiac cells ~ Cells of the heart consisting of the myocardial cells responsibl~ for contraction of the heart muscle
and the pacemaker cells of the electrical conduction system, which spontaneously generate electrical impulses.
CardiiC cycle ~ Consists of one
heartbeat or one PQRST sequence.
Represents atrial contraction and
relaxation follov.~d by l'entricular contraction and relaxation.
Cardiac ta.mpolude ~ Compression
of the heart due to the effusion of Huid
into the pericardial cavity (as occurs
in ["O'.ricarditi<) or the ac.mm"l.tion of

blood in the pericardium (11.1 occu~ in

heart rupture or penetrating trauma).
Cardiomyopathy ~ A disease of the
hurt muscle. Characterized by chamber dilation, wall thickening, decreased
contractility, and conduction disturbances. End result is usually severe
dysfunction of the heart muscle,
resulting in terminal heart failure.
CardiO\ersion ~ An electric shock
synchronized to fire during the QRS
complex: used to terminate rh~1:hms
such as atrial fibrillation or Hutter,
paroxysmal atrial tachycardia. and ventricular tachycardia to normal sinus
rhythm: uses lov,~r joules of electricity. Also known as synchronized shock.
C~tion ~ An

ion with a positive

charge.
Cbordae tendineal! ~ Thin strands of
fibrous connective tissue that extend
from the cusps of the atrimentricular
valves to the papillary muscles and
prevent the AV valves from bulging
biKk into th~ atria during ventricular
contraction.

Glossary

Chronic obstructiv~ pulmonlTY

disease - A chronic disease of the
lungs characterized by episodes of
bronchitis, pneumonia, a chronic producti~ cough. and dyspnea at rest or
with exertion. Also kno",>TI as COPD.
Circulatory system - A closed system
consisting of two separate circuits: the
systemic circuit and the pulmonary circuit. The systemic circuit consists of the
left heart and blood vessels, which carTY
blood from the left heart to the body
and bock to the right heart. The pulmonary circuit consists of the right heart
and blood vessels, which carry blood to
the lungs and back to the left heart.
Collateral circulation - Collateral
arteries found throughout the
myocardium, Th~ are present at
birlh, bul <lu flul

bt:~u",~

Couplet ~ Two consecutive premature beats. Also knOlm as pair.

Electrocardiogrlph ~ A machine
used to record the electrocardiogram.

Cyanosis ~ A purplish discoloration

of the skin caused by the presence of
unoX}'!Ienated blood.

Electrol}1e ~ A substance whose

molecules dissociate into charged
components when placed in water,
producing positively and negatively
charged ions.

Defibrillation ~ An unsynchronized
electrical shock used to terminate
ventricular fibrillation and pulseless
\'entricular tachycardia: uses higher
joules of electricity. Also knO\\T1 as
unsynchronized shock.
Deflection ~ Refers to the wavefonns
in the ECG tracing (P wave, QRS complex. T wave, and U wave). A deflection
may be po5iti~ (upright), negative
(inverted), biphasic (having both positive and negative components), or equiphil.'iic (equally positive and nel!41iw),

Compmsatory pau~ - A pause

following a premature beat.
A compensatory pause is identified
on the ECG by measuring from the R
wave before the premature beat to the
R waw following the premature beat; if
that measurement equals two cardiac
cycles (the sum of two R-R intervals),
the pause is considered compensatory. A compensatory pause cannot be
identified if the underlying rhrthm is
irregular. Also called complete pause.

Depolarintion ~ Electrical activation of a cardiac cell due to movement of ions across a cell membrane,
causing the inside of the cell to
become more positive. Depolari;o.ation
is an electrical event expected to
result in muscle contraction, a
mechanical event. Depolarization
of the atria produces the P wave.
Depolarization of the ventricles
produces the QRS complex.
Djaphor~sis ~

Profuse sweating.

Diastole ~ The period of atrial or

ventricular relaxation.
Dying heart ~ See a!}Qool rhythm.
D~spnea ~

Shortness of breath,

Conducti~ity

The ability of a cardi

ac cell to receive an electrical impulse
and conduct that impulse to an adjacent cardiac cell.
Congestive bent failure -An overload of fluid in the lungs andlor body
caused by inefficient pumping of the
ventricles. Also knO\\T1 as CHF.
ContnctiJity - The ability of cardiac
cells to cause cardiac muscle contraction in response to an electrical
stimulus.

Endocardium - The innermO.lt layer

of the heart, composed of thin, smooth
connecti~ tissue.
Enh,nced automaticit~ ~ An
abnormal condition of pacemaker cells
in which their firing rate is increased
beyond the inherent rate.
Escape beats or rhythms - A term
used when the sinus node slows dov,l1
or fails to initiate IIIl impulse and a
>e<;umLuy Jld~~"",k,,, ,il~ "">WII'" 1"'''''-

fUlldiu".l1y

significant until the myocardium experiences an ischemic insult: collaterals

contribute significantly to myocardial
perfusion. but blood flow is insufficient to meet the total needs of the
myocardium,

371

Dysrh)1bmia ~ Any rhythm other

than 4 sinus rhythm. Used interchangeably with arrhythmia.
Ectopic - A beat or rhythm
originating (rom a source other than
the sinoatrial node.
Ekctrocardiognm (ECG) ~
A graphic recording of the electrical
activity of the heart generated by the
depolari;o.ation and repolari:r.ation of
the atria and ventricles.

maker control of the heart. Escape beats

may arise from the atrium (atrial escape
beat), the atrioventricular junction
ijunctional escape beat), or the ventricles (ventricular escape beat). Examples
of ~scape rhythms are junctional escape
rh,thm and ventricular escape rhythm.
ExcitabiUty ~ The ability of a cardiac
cell to resporxJ to an electrical stimulus.
Fascicle - A bundle of muscle or
nerve fibers, The left main bundle
branch divides into an anterior fascicle
and a posterior fascicle, which form
the two major divisions of the left
bundle branch before it divides into
the Purkinje fibers.
First-degree Atrioventricular (AV)
block An arrhythmia in which
there is a delay in the conduction of
the electrical impulses through the AY
node. Characterized by sinus P waves
with one P wave to each QRS complex;
a consistent PR interval that is abnormally prolonged (greater than 0.20 second); and a normal QRS duration.
Hearl Tlte ~ The number of heartbeats or QRS complexes per minute.
His-Purkinje s)'Stem - The part of the
electrical conduction system consisting

372

Glossary

of the bundle of His, the bundle

branches, and the Purkinje fibers.
Hypertrophy - An increase in the
thickness of a heart chamber because
of a chronic increase in pressure
amVor volwne within the chamber.
H~-pertrophy may occur in both the
atria and the ventricles.
Idioventriculu rhythm - An
arrhythmia arising in an ectopic site in
the ventricles characterized by a regular rh~thm; an absena! of P waves; wide
QRS complexes; and a rate between
30 and 40 (sometimes lessl beats/
minute. This is the inherent rh~thm of
the ventricles. Also known as IVR.
Infarction - Death (necrosis) of
tissue caused by an interruption of
blood supply to the affected tissue.
lnkrior ven ~ cavil - One of two
large ~"eins that empty venous blood
into the right atrium.
Inherent firing rate - The normal
rate at which electrical impulses are
generated in a pacemaker. whether
it is the sinoatrial node or an ectopic
pacemaker. Also known as the intrinsic firing rote.

Interatrial s~ptum - The I\-all separating the right and left atria.

Ion - Electrically charl!ed particle.

Ischemiil - Reduced blood flow to
tissue caused by narrowing or occlusion of the artery supplying blood to it.

Interpolated PVC - A premature

~entricular contraction (IVe) that falls
between two QRS complexes without
a pause.
IntTilventriculiT ~ptum - The wall
separating the right and left ventricles.
Intrinsic beat - Beats produced by
the heart's own electrical conduction
system. Also known as IUltive beat.

Morphology - The shape of II

waveform.

boelectric line - See baseline.

IVR - abbr idioventricular rhythm
J point - The point where the QRS
complex and ST segment meet.
Junctional rh)thm - An arrhythmia
arising in the atrioventricular (AY)
junction characterized by a rel/ular
rh~thm; inverted P waves immediately
before the QRS, immediately after the
QRS, or hidden within the QRS complex, with a short PR interval of 0.10
second or less; a normal-duration QRS
complex; and a rate betl\"een 40 and 60
beats/minute. Junctional rhythm is the
inherent rhythm of the AY node.
Junctional tachycardia - An
arrhythmia arising in the atrioventricular jundion characteri~ed by
a regular rhythm; inverted P waves
immediately before the QRS. immediately after the QRS, or hidden
within the QRS complex, with a short
PR interval of 0.10 second or less; a
normal -duration QRS complex; and a
rate greater than 100 beats/minute,
rnA - abbr milliampere

Internodal atriill conduction

trilds - Part of the electrical conduction system. Consists of three
pathways of specialized conducting
tissue JOCllt~d in th~ walb ofthe right
atrium. Conducts impulses from the
sinoatrial node to the atrioventricular
node.

Monomorphic - Refers to QRS complexes of the same morphology in the

same lead.

Mediastinum - Located in !"he middle

of the thoracic cavity. Contains the

heart, trachea, esophagus, and great ve5sels (pulmonary arteries and veins, aorta,
and the superior and inferior vena cava).

Multifocll - Indicates an arrhythmia

originating in multiple pacemaker
sites.
Multifocll premillure ventricular
contractions - l'Yes originating in
multiple paa!maker 5ites in the ventricles having different QRS morphology
in the same lead.
Mural thrombi - Clots in the chambers of the atria caused by ineffective
atrial contraction (may occur in atrial
fibrillation or flutter)
Myocilrdium ~ The middle and
thickest la~"er of the heart composed
primarily of cardiac muscle cells and
responsible for the hearts ability to
contract.
Nf"gativ( deflection - A wa~efonn
that is below baseline.
Noncompensatory pilU ie - A pause
following a premature beat. A noncompensatol)' pause is identified on the
ECG by measuring from the R Wllve
before the premature heat to the R
wave following the premature beat; if
that measurement is less than two cardiac cycles (less than the sum of two
R-R intervals), the pause is considered
noncompensatory. A noncompensatory pause (annot be identified if the
underlying rhythm is irregular. Also
known as incomplete pame.

Ml - abbr myocardial infarction

Milliampere - Unit of measure
of electrical current needed to
cause depolarization of the myocardium. A tenn used most often with
pacemakers.
Mitral valve - One of ""0 atrioventricular valves. Located bet",-een the
left atrium and left ventricle. Similar
in structure to the tricuspid valve, but
has only two cusps.

Nonconducted prematul"( atrial

cOlltnction - A premature abnormal
P wa~"e not accompanied by a QRS
complex, but follOl\"ed by a piluse.
Nomlll sinus rhythm - The nonnal
of the heart originating in
the sinoatrial node characterized by a
regular rhythm; normal P waves,
PR interval. and QRS duration;
and a rate be""een 60 and 100 beats!
minute.
rh~1hm

Glossary

Overdrive pacing ~ Pacing the heart

at a rate faster than the tachycardia to
terminate the tachyarrhythmia.
PAC ~ abbr premature atrial
contraction
Pacemaker ~ A device that deliv
ers an electric current to the heart to
stimulate depolarization.
Papillary muscles ~ Projections of
myocardium arising from the walls
of the ventrides connected to fibr0U5
cords called chordae tendineae, which
are attached to the valve leaflets.
During ventricular contraction the
papillary muscles contract and pull on
the chordae tendineae. thus preventing inversion of the atrioventricular
valve leaflets into the atria,
Para.~ymrathetic n ~\"Vnll~ .<ydem ~
A part of the autonomic nervous
system. Stimulation of this system decreases the heart rate. slows
conduction through the atrioventricu lar node, decreases the force ofventricular contraction. and causes a drop
in blood pressure.

Paroxysmal ~ A term used to

describe the sudden onset or cessation
of an arrhythmia.

Premature iltrial contraction - An

early beat originating in the atria. characterized by a premature, abnormal P
wave (usually upright); a PR interval
that may be normal or abnormal; and a
normal-duration QRS complex followed
by a pause. Also knO\'ln asPAC.
Premilure junctional contraction An early beat originating in the atrio\~ntricular junction characterized by
a premature inverted P wave occurring inunediately before the QRS,
immediately after the QRS, or hidden
within the QRS complex with a short
PR interval of 0.10 second or les,s and
a normal-duration QRS complex followed by a pause. Also known as PJC.
Premature ventricular contr~c
lion - An early beat originating
in the ventricles characterized by a
rrem.tur~, wide QR.'; cnml'lu with
no associated P wave and an ST seg
ment and T wave that slope opposite
the main QRS deflection followed by
a pause. Also known as PVC.
PR interval - The period of time
from the beginning of atrial depolarization (P wave) to the beginning of
\~ntricular depolaril.ll.tion (QRS complex). The normal PR interval duration
is 0.12 to 0.20 second.

Paroxysmal IITial tachycardia ~ An

arrhythmia originating in the atria
characterized by abnormal P wave!
that are u.lUally hidden in the preceding T waws; a normal QRS duration;
and a regular rhythm betv.~en 140 and
250 beats/minute,

Prinzmetal's angina - A type of

angina occurring when the coronary
arteries experience spasms and
constrict.

PAT - abbr paroxysmal atrial

tachycardia

arrh~1:hmias.

Proarrhythmic - The effect of

certain drugs (especially antiarrhrth mics) to induce or wo ... en wntricular

PJC ~ abbr premature junctional

contraction

PR segment ~ The portion of the

ECC betv.~en the end of the P wave
and the beginning of the QRS complex.

PolymoTphic - Refers to QRS complexes of different morphology in the

same lead.

Pulmonic valve. - One of two semilunar valves. Located between the right
wntricle and the pulmonary artery.

Positive deflection - A waveform

that is above baseline.

Pulseles,s electrical activity A clinical situation in which an

organized cardiac rh~thm (excluding

373

pulse less ventricular tachycardia) is

observed on the ECC, but no pulse is
palpated. Treatment protocols are the
same as for wntricular standstill.
PUTkinje fibers - A network of fibers
that carry electrical impulses directly
to ventricular muscle cells.

P wave - The waveform represent

ing depolarization of the right and left
atria.
~ The negative deflection of
the QRS complex that precedes the

Q wilve
R wa\~.

QRS complex - The waveform that

represents depolarization of the ventricles; consists of the Q, R and S waves.
Normal duration is 0,10 second or less,
QT inte\"Val _ The portinn nf thp.
ECC between the onset of the QRS
complex and the end of the T waw,
representing ventricular depolarization
and repolarization.
Rate suppnssion - A decrease in the
heart rate for several cycles following a
pause in the basic rh~1:hm.
RecipTOCill change - A change
detected by the ECC in an area of the
heart opposite the site of a myocardial
infarction.
Relative refnctory period - The
period oftime during ventricular
repolarization during which the ven
tricles can be stimulated to depolarize
by an eiearical impulse stronger than
u,,,al. Thi, period beWn, at the peak
of the T waw and ends with the end
of the T waw. Also known as the tul
nerable period of lIentricular repo/ar-

ization.
Reperfusion Thythnu ~ Rh)'lhms
that may occur following reperfusion therapy. Examples of reperfusion
rhythms include sinus bradycardia.
accelerated idiowntricular rhythm,
premature wntricular contractions,
ventricular tachycardia, and wntricular fibrillation.

374

Glossary

Reperfusion ther,py ~ Treatment

to reopen an occluded coronary artery
using a thrombol~1:ic agent or corollary interventions. such as balloon
angioplasty, coronary artery stenting,
or atherectomy.
Repolarization ~ An electrical
process by which a depolarized cell
returns to its resting state (negative
charge) due to the mmement of ions
acr05.! a cell membrane. The repolarization process produces the ST segment, the T waw, and the U waw.
Retrograde ~ "'oving backward or in
the oppo.lite direction to that which is
considered normal.

intervals with two, three, or more P

waves before each QRS complex; a ventricular rhythm that may be regular or
irregular depending on the number of
impulses conducted to the ventricles;
and a QRS complex that may be narrow or wide depending on the site of
the conduction disturbance.
Sequential ventricular depoliriza tion ~ One ventricle depolarizes
before the other (instead of simultaneously), resulting in a wide QRS
complex.
Sick sinu& s~Tldrome ~A
degenerative disease of the sinus node
resulting in bradyarrh~1:hmias alternating with tachyarrhythmia_. _ Thi.

160 Iw.llt<lminnte.

s~Tldrome

is often accompanied by
symptoms such as dizzinm, faint in!!,
chest pain, dyspnea, and congestive
heart failure. Permanent pacemaker
implantation is recommended once
the patient becomes s)'lllptomatic. Also
known as tachy-brady syndrome.

R-R interval ~ The period of time

from one R wave to the next consecutive Rwa~~.

Sinus i1JTest ~ An arrhythmia ",used

by a failure of the sinoatrial node to
initiate an impulse (a disorder of automaticity). The ECG tracing will show
a sudden pause in the sinus rhythm
in which one or more beats are mming. The underl~ing rhythm does not
resume on time following the pause,

SA ~ abbr sinwtnal
Second-degn atrioventricular (AV)
block Mobilz I ~ An arrhythmia in
which there is prO{lre!sive delay in
the conduction of electrical impulses
through the AV node until an impulse
is blIKked and not ,onducted to the
ventricle!. Characterized by regularly
occurring P waves; progressive lengthening of the PR interval until a P wave
appears without a QRS. but is followed
by a pause; normal QRS duration: and
<II, irr~J!uldr v~"lri~uldr rhyllllll. Ab"
known as Wenckebach.
Second-degree atrioventricular
block Mobitz " - An arrhythmia in
which some electrical impulses are
conducted to the ventricle., but mo.t
are blocked. Characterized by regularly
occurring sinus P waves; consistent PR

Sinus nod ~ The dominant pacemaker of the heart located in the wall
of the right atrium close to the inlet of
the superior vena cava.
Sinus tachycardiA ~ An arrh~1hmia
originating in the sinus node
characterized by a regular rhythm;
normal P wa~'es, PR interval, and QRS
duration; and a rate betl'..~en 100 and

R-on -T premillure ventricular

contnction (PVC) ~A PVC that falls
on the down slope of the preceding
T wave. Stimulation of the ventricle
at this time may precipitate repetitive
ventricular contractions, resulting in
ventricular tachycardia or fibrillation.

R wive ~ The positive wave in the

QRS complex.

of the electrical impulse from the

sinoatrial node to the atria (a disorder of conduction). The ECG tracing
""ill show a sudden pause in the sinus
rh~1hm in which one or more beats
are missing. The underlying rh~1:hm
resumes on time following the pause.

SinU& ,rrhythmia ~ An alTh~1hmia

originating in the sinoatrial (SA) node
that occurs ""tten the SA node discharges
impulses irregularly. Sinus arrhythmia
is a normal phenomenon associated with
th\: phases 0( mpiration, This rh)thm
is characterized by an irregular rhythm
normal P waves, PR interval, and QRS
duration, and may be associated ""iih a
normal or bradycardic rate.
Sinus

br...JYHr~i. ~AJl

drrhyllt-

ST segment ~ The Hat line between

the QRS complex and the T wave that
represents early ventricular repolarization. The ST segment is nonnaUy at
baseline.
Stoku-Ad,ms iltKla ~ Fainting
episodes that oo;ur when the heart
rate suddenly slows or stops momentarily; common with second..degree
atrio~~ntricular (AY) block, Mobitz II.
and third-degree AV block.
Superior vena cava ~ One of two
lar~ veins that empty venous blood
into the right atrium.
Supemonnal period - The last
phase of repolarizatiOil during which
the cardiac cell ",n be stimulated to
depolarize by a weaker than nonnal
electrical stimulus, This period oo;urs
near the end of the T waw just before
the cells have completely repolariz.ed.
Supraventriculu ~A general tenn
used to describe arrhythmias that
"rilli''''l~

ill

.il~ ...b""" lh~ bWldl~

mia originating in the sinus node

characterized by a regular rhythm;
normal P waves, PR interval, and QRS
duration; and a rate between 40 and
60 beats/minute.

branches (i.e., sinus node , atria, and

atrioventricular junction).
S Wive - The negative deflection of tile
QRS complex that follows the R waw.

Sinus exit block ~ An arrhythmia

caused by a block in the conduction

Sympilhetic nervous system - A

part of the autonomic nervous system.

Glossary

Stimulation of this system increases

heart rate, speeds conduction through
the atrioventricular node, increases the
force of ventricular contraction, and
causcs an incrca:;c in blood prcssurc,
Syncope - Fainting, U.!ual1y resulting from cardiac or neurologic events,
TCP - aM, transcutaneous pacing
TdP -obb, torsade de pointes
Third-Ikgret atriovtntricular (AV)
block -An arrhythmia in which
there is no conduction of electrical
impulses through the AV nook There
is independent beating of the atria
and ventricles, The atria are paced by
the sinoatrial node at a rate of 60 to
100 beats/minute and the ventricles
are paced either by the AV junction
at a rate of 40 to 60 beats/minute
or by the ventricles at a rate of 30
to 40 beats/minute, This rh~1hm is
characterized by sinus P waves that
have nn cnn.,i,tp.nt relatinn.,hi" to the
QRS complexes (variable PR intervals); P waves found hidden in the
QRS complexes, ST segments, and T
waves; a regular atrial and ventricular
rh~1hm; a narrow QRS complex if the
wntricles are paced by the AV junction; and a wide QRS if paced from a
wntricular site, Also known as complete hea,t block.
Torude de pointes - A form of
wntricular tachycardia associated with
a prolonged QT interval. The name
is derived from a French term meaning "twisting of the points," I'lhich
describe. a QRS complex that changes
polarity (from negative to positive and
positive to negative) as it twists around
the isoelectric line. Also knol'tTI as TdP.
Transcutaneous pacing (TCP) External Qrdiac pacin~, Consists of two
large electrode pads commonly placed
in an anterior-posterior position on the
patient's chest to conduct electrical
impulses through the skin to the heart.
Transvenous pacing - Cardiac
pacing through a win. A lead wire is

inserted into a large vein and positioned in the right wntride. Electrical
impulses are conducted from an external power source (pacing generator)
through thc lcad wire to thc right
ventricle.
Tricuspid valve - One of two atrioventricular valves. Located between
the right atrium and the rightventride. Similar in structure to the mitral
valve, but has three cusps.
Trigemin~ - An arrh)ll:hmia in
which every third beat is a premature
ectopic beat. The premature beals
may be atrial, junctional, or ventricular in origin ( i.e., atrial trigeminy,
junctional trigeminy, ventricular
trigeminy).

T wave - A wa~'e that follows the

ST segment. Represents ventricular
repolarization.
Unifoul PVCS - Premature
ventricular c.nntr.ctinn., (PVc.,) origi_
nating in the same site in the ventricle
having the same QRS morphology in
the same lead.
U wave - A wave that sometimes
follows the T wave. Represents late
ventricular repolarization.
Vagal maneuvers - Methods used
to stimulate vagal (paras~mpathetic)
tone in an attempt to slow the heart
rate. Methods include coughing,
bearing down (Valsalva maneuwr),
squatting, breath-holding, carotid
sinus pressure, stimulation ofthe
gag reflex, and immersion of the face
in ice water.
Valsaln maneuver - Forceful act of
expiration with mouth and nose closed
producing a "bearing down" action.
One of sewral ViI~alllliLlleuvers,
Vasovagal ruction - An extreme
body response that causes marked bradycardia (due to vagal stimulation) and
marked hypotension (due to vasodilation). A vasovagal reaction may result
in fainting (vasovagal s~ncope,.

375

Ventricle, - The two thick-walled

lower chambers of the heart; they
receive blood from the atria and pump
it inlo the pulmonary and systemic
circulation. The ventricle. an: scporatcd
from the atria by the mitral and tricuspid valves.
VentricullT fibriJlillion - An
arrhythmia arising from a disorganized, chaotic electrical focus in Ihe
ventricles in which the ventricles
quiver inslead of contracting effectivtly. The ECG tracing sho ....'S an
irregular, wavy baseline without QRS
complexes.
"fntricullT standstill - An arrhythmia in which there is an absence of
all ventricular acti~'ily. The ECG tracing Will5how either P waves without
QRS complexes or a straight line. Also
knO ....T1 as ventricula, asystole.
Ventricular hchycardia - An
arrhythmia arising from an ectopic
.,ite in the wntride,- On the F.Cc, the
rh,1:hm appears a5 a 5eries of wide
QRS complexes with no associated P
waves; a regular or slightly irregular
rhythm; and a rate of 140 to 250 beats/
minute.
Vulnerable period - The period of
time during ventricular repolariz.ation in which the ventricles can be
stimulated to depolarize by a strong
electrical stimulus. This period
corresponds to the do",,, slope of the
T wave (relative refractory period).
Electrical stimuli occurring during
the vulnerable period may lead to
ventricular tachycardia or wntricular
fibrillation.
Wandering atrial pilcemaker - An
arrhythmia arising from multiple
pacemaku sites in the atria. The ECG
tracin~ will show a normal or slow
rate; a regular or irregular rhythm;
P waves thai vary in size, shape, and
direction across the rhythm strip; a
PR interval that is usually normal, but
may be abnormal because of the different sites of impulse formation; and a
normal QRS duration.

Index

Accel~raled

Bund'e-branch block, 197- 199. 197i.

198i. 199i. 213t. 370
rlvthm strip practice for, 214-255i
Bund'e branch ... 370
Bund:c of Hi.!, 9--10. 10i. 370

Accderat.d junctional rh)'lhm, 143--145,

A
Aberrantly conducted .upravenlr;cular
pr~rnalu ... ~u.

369

Absolute .. fractory period. 369

idiowntricular rhythm,
210--211. 21Oi, 211i. 2131. 369
144i. 1441, 145i. 369

Acceuory conduction pathway., 369

Acetylcholine,369
AC interferone . 32--33. 33;
Acute ltl)Iocardial infarction, 142, 369

AIIonaJ rhythm. 210. 21Oi. 369

Angina, 369
AngioI>J ... ty,369

Anion. 8
Antellrnde conduction. 369

Aortic ""I....,. 3, 4i. 369

Arrhythmia, 44. 369
Arti(""t.. ,::\fi9

As",toJ . 211- 212. 212i. 2131. 369

Atria. I. 3
Atrial arrhythmi .... 85--1001. lOll
mechanisms. 85,!!6i

rnorpholOlb'. 85, 86i

practice rhythm .trips for, 102- 137;

Atrial escape brot. 91. 92i

Atrial fibrillation. 98--100, 98i. 99i.
1011.369
Atrial Huttu. 95-98. 96i. 97i, Wit. 370
Atrial kick, 5
Alriowntricular block (AV block), 370
Alriownt.icula. junction, 370
Atrj"""nlricula. junctionil arrhytlunias

and atrio .... ntricWar bloch, 138.--156

rhythm 5trip practice. 156--196i
Atriowntricular node. 5. 6i. 6t. 7. 370
Atriowntricular .....1...... 3. 4i. 370
Automatic interval. 263-261. 2Mi
Automaticity. 370
altered. 85
Autonomic nervous system. 370

B
Bachmann's bundle. 9. 10. 10i. 370
Beta blocke,.". 370
Bii!<miny.370
Bipilasic deflection. 11, 11i, 370
Biventricular p.:tumaker. 261
Bradycardia. 370
Bradyc:trdic rhythm, 261
; rde,." toan illl1.'!trat;on; t ",Ie .. to a table.

376

Calcium channel blockers. 370

Cardiac cell .. 370
characleri..tics, 8
de;>olarization and rtpolarization.
!'.-9.9i
tyl\U. B
Cardiac cycle. H. lli. 370
Cardiac innervation. 7
Cardiac monito ... 25-33
Cardiac rhythm. 25
Cardiac tamponade. 370
Cardi'>rnyopathy.370
Cardi,,....,.,,ion. 95. 370
Cardi,,.,..,rter defbrillator (ICD). 206
Cation. 8
Chest lead pmitions. 25-27. 26i, 27i
Chordae tendineae. 3. 4i. 370
Chronic obstructi .... pulmonary di ..ase.
371
Circulatory 5)'stern. 2. 371
Codini/ system for pacemaku 261. 262t
Collat..al circulation. 5- 7. 371
Com~ematory pause. 91. 371
Com~lete heart block, 152--153.
152i.l53i
Cond""tivity. 8. 371
Con~e.tiw hurt failure. 371
Contractility. 8. 371
Coronaryarteri.,.. 5-7. 6t
Coronary circulation, 5-7. 6i. 6t
Couplet. 371
CurT..,t flcm and wawforms. 11. Hi
Cyanosis, 371

D
Udjb"llatlOn.371
Defle<tion.371
Depolarization. !'.-9. 9i. 371
Di""tole.371
DuakhamMr pacemakers. 258
[)yin, heart. 371
[)ysplII:a.371
Dysrhythmia. 44, 371

E
ECC i/raph paper. 12. 12i
ECC monitoring
applyini/electrode pads. 27
pUf]XISC. 25
troubleshootinil problem. 27--33.
29--33i
Ectopic junctional boat.. 140. 140i
Ectopic pacemaker. 85
Ectopic P wa ..... 13
Electrical conduction 'ystem. heart.
9-ll.10i
Electrical impul.... !'.-9. 9i
Electrical interiertnce. 32--33. 33i
Electrocardiogram (ECC). 371
ElectrocardiOllrallh.371
Electrode pads. &IIPlyini/. 27
Electrolyte. 8. 9. 371
Endocardium. 1- 2. 2i. 371
F.nh.n~.d ~"tom.t;~;ty.

::171

EDicardial !>"cinil. 259-260

Escape beat. or rhythrru. 371
Excitability. 371

F
Pailure to calltur . 266. 266i
Paise hiJIh-rat~ alarms. 27- 2B. 29i
Pal.. low-rate alarms. 28. 30i. 31i
Pascicle.371
Pib-f1utter. 100
Pibrillatory Wi ...... 100
Pirst-dei/ree AV block. 371
Pirst-deQree h""rt blocks. 146--147.
147i.147t
Piutter wa ...... 95
FUsion beat. 263i. 2M. 2Mi
1'''''''....",.95
f wa ...... 100

H
Hardwirt rnonitorinQ
five-leadwire syst~m. 25-26. 25i
thrte-Iudwirt 'ystem. 26, 26i
Heart
blood fico,., throllllh. 4- 5. 4i
cardiac innervation. 7
chambo... 3. 3i
circulatory system. 2
description. 1
electrical conduction system.
10--12.10i

Index

Hurt (rontinun/J
funclion. I
location. I. Ii
.!ruclurl wall. 1- 2. 2i
lumen, I, 2i
\\11"u.3-oI,4i
Heart blocks. 146. 153. 1541, ISS!
finl-d~Qnc, 146-147, 147i.1471
Iccood-ckQttc. ~ I, 147-150. 1471,
14B~ 149i
lOI'Id-dfQrtc. I~ II, 150--152. 150~
lSOt, 151;
thini-dC1lra:, 152-153, 152;. 1521. 153i

rate ....kulation. 34-38. 36;. 37i

Uis-Pu rkin;e syslfm. 10, 371
Holiday hurt syndrome, 100
Hyptnens;I;'" a rolid sinU$. 256
Unltrt rophy,372

Mitral ..... I..... 3.4i

Mobitz 1. 147- 150.1471. 148i, 149i
Mobiu n. 150--152. 1501. l SOt, ISH. 211
MultilocaJ atrial tachycardi.a (MAT). 87.
81;
Multibcal Jlrematurt v~ntTic:ul:or con
tractions. 372
Mural thrombi. 98, 372
Muscle tremors. 28. 32i
Myoardial cdls. 8
~rdial in .... rrtion (MI), 17
Mynordiat ;om.,mia, SO

M)-ocardium. 1- 2_ 2i. 4i. 6t.312

H~art

Idiowntricular rhythm. 209-210.

2131.312

209~

I mpbntab~ ard~rttr-ckfibrillalors

(lCOS), 206. 261

Infarction.372
Inffrior ~OII ca...... 372
Inhtrent firina rit~. 372
InttrJ.trial..,ptwn.372
Inlfntrial trK\' 9. lOi
InttrJlOdal tracls, 9-10. IO~ 372
Inttrpoiall PVC. 202i. 203, 372
inlfM'nlricubr ",plum. 3, 3i. 4i
Intravenous p,--back (IVPS). 206
I nlra ~nl rieulu ..,plum. 312
Intrins;c ixal, 263. 263i, 372
Ischemia.312
1"""leelric liIX. 372

N
NC1Io>tivt deflection .. 11. Ili. 372
Nonrompens.otory ","use. 9O~ 91. 372
Nonronductl prematun atrial conlr.IC!ion. 91 - 94. 92i. 93i. 1011. 372
Normal.inu5 rhythm. 44-45,45i. Si t.
312
with .in... arrest. 49i
with .inlll bloc:k. 48i
Notch. 16. 16i

J poinl. 372
JunclioroJ ucapt oots. 142. 142i
JunclioroJ escapo rhythm. 142
Junctional rl-(ythm. 142- 143. 142;. 142t,
l43i. lUi, 372
Junctional bc~rdia. 312

PactmaktrCl.ptun. 262-263, 263i

l'aamak.rctlls.8. 9.10.11
P<>CCINoker tirin& 262. 262i
Pact,.,....ke r maifunct;OIl5
fa.ilure 10 caJltu ... 266. 266i
.... ilu"' 10 tin. 265-266, 26Si
owrsenainQ.267,267i
..,nsinQ failure, 266-267. 266;. 267i
unlienfnsinll. 266-267, 266i
Pal%lTIIIker rhythm. 264-265, 265;
Pactmaken
dtfinilion. 256
functions. 256-258. 257;
indications. 256. 261li
Pact,.,....kn Knsina. 263
Paamaker spike. 257. 257;
Paamake r strips. onalyzina, 267- 269.
268-269i
JlBcticinQ. r~thm .triJl. 270--283i
p""._"",k,_, _<<I"",,

L
Left anterior dosandinQ (lAD). 5--7
Left bundle-branch. 9--10.10;
Left bundle-branch block Il.BBB). 199
l.unQS. blood flow !hrou~. 4-5. 4;

M
/Iokdiastinum.372
MilliarnJl.... 372
I .. kn to an Illuslratlon; I rekn

to

a tiIIl<.

2 S~ .

2ntli

Paamaktr wandt rinQ.85---87

Pacil\ll interval. 263---261. 264i
Pacil\llitads. 256. 257i
PalpilatiOll5.95
Papillary mlJ5Cles. 3----4. 4~ 373
Parasympatn.lic .ffect. 46
Parasympatn.lic ""''",us system. 7. 373
ParooysmalatTiaJ tachycordio (PAn.
94-95.94 IOlt. 373

377

Pamrysmal junctionJ.llAchycaroia,
145--146. I ~i. 1451. 146i
Pericanlium. 1-2.2i
Permantnl pacemaken. 260---261. 260i
idt-nlificalion codu. 261, 2621
Point of mu;mlIl impulse (P/Ioll). I
Positive dd lection. 11. 11 i. 373
Posttest, 284-319i
Premature alrial contraction (PAC).
87- 91. 88~ 89i. 90i. 91i. lOl l.
139.373
Pre"",lure junctinnlr.1 c",,,,,,,,,tinn (PJC ),
139--142. 1391,1391. 1401. 141i.
142i.373
Premature .... nlncular contractions
(PVt.). 140.199-203. 199i. 200i.
201i. 2cr.!i, 203i. 213t. 373
PR inle ...... l. 13-15, 15;. 38i.
39,373
Pri~nvbl'. ilnQina. 373
Pl'Omhythmic tl'fotru. 209. 373
PR ""IIment. 373
PKudof... ion ixal, 264. 264i
Pulmonary circuil. 2
Pulmonary wi"", 3. 4i
Pulmonic ""I..... 3, 4~ 5
PulseJesa electrical activity (PEA), 213
Purkinje tiber5, 9--10.lOi
P waves. 13. 13i. 141.38--39, 38i, 373

Q
QRSromJlla. 15--17. lSi, 16i, 17i.39
39i.373
QS comJllex. 15. 16i
QT inle ...... l. 20--21, :roi. 373
Q wa.e. 373

R
Rate s..,prcssion. 373
ReeiJlrocal chanlle. 373
Rnlry,85
R~btivt refractory ptriod. 373
R. ptrfw.ion rhythms., 373
R~ pobriu.lion. 8-9. 9 374
R. lrottndt. 37~
Rhythm "1I"tuily. S2

Rhythm 51rip. anaiyz:;nQ. 34-43

Jlract;a sl riJl for. 40--43i
Riitht bundle-branch, 9--10.1 01
Riitht bundle-branch bloc k
(RBBB).I99
Riithl coronal)' artery. 5. 6i. 6t
R--on-T phenomenon. 203. 203~ 374
R-R interval. 37~
R waves. 34. 34~ 3S~ 374

3 78

Index

heart blocks.
147-1 50.1471.148.,149.
Second-del!~" type II hu.rt blo<:ks.
150-152. 15Oi. lSOt.15 1i
Semilunar val ...... 3-4. 4i
Sequenlial IkJ)Olarization. 198. 374
s;.:k sinus .yndrome. 47.374
Sinoatrial (SA), 374
Sinoatrial dysfuotlion. 256
Sinw arrest.48-50. 49i. 511. 374
5inw arrhythmia... 47-18.47i. Sit 374
ECG f\'.ll.tu~ 48t. 511
rhythm strip practice, 52-84i
with sinus po""". 48--50, SOi
Sinw bmlyocardi ... 46-47.46i, Sit 374
Sinw ait block, 48-50. 481, Sit. 374
Sinus n<><k. 374
Sinw paUst. 48--50. 50~ Sit
Sinw Ulchycardia. 45-16,45i. Sit. 374
Sodiurn--pobMium pump. 8-9. 9i
StoIcfS,AIbnu attacks. 151.374
StoIcfS-Adamuyncopto.15L 153
srsqlm~nt. ]7. 17i. 18i.374
51 H1Iment dev.tion myoQrdial
infarction (STEMI), 17
5~rior ....... cava. 374
5~roorlTllOJ Pfriod. 374
S.... TI"Itntncul.u arrhythmiu. 197
5 ....ve.374
$ympathdk '"'NOW syslffll. 7. 374
Syncope. 375
Systo:mic circu't. blood fIowand. 2
$yawle.7

UndtrStnsinl!. 266-267. 2661

U _ve. 21-22. 21 . 375

Second-del!~t. type J

T
T~hybrady .yndrome. 47
Telemetry monitorinll. 27. 27i
fi .... -leadwire system. 27, 27i
Ihret-leadwir. syslem, 27. 28i
Ttmporary pattlNktrs
rpicard,al pacing. 2S--260
TCP lhniQun. 258-259. 258,. 2591
traru .... now pacinI!. 259. 260i
Third-degree heart blocks. 152- 153.
152i. 1521. 153i
Torsade d. poinl.. (TdP),2t 205,.
206--207, 375
I~tm.nl protocols. 207
TramctltmtoUO PKino: (TeP). 258-259,
258i. 2591, 375
Transt50phaj/eaJ cchOCllrdioilram (TEE),

98

T""'-"""nous pacinQ. 259. 2fj{Ii. 375

Tricw.pid valve, 375
Tril!cminy.375
Tr~redacl'vity, 85
T ....ve. 19--20, ]9i. 375

V
Vallal man.u ........ 375
V.balva, ~r.47. 95.375
V~.I reaction. 375
V.ntric"".375
Ventricula'lIrrl'o-thmias
buls lAd rhythms. 197. 197i
rilfthm .Irip practice for.2 14-255i
Ventricular t.tape beals. 203. 203;
Ventricular fibrilLltion. 2<17-2119. 208~
213t.375
treatment protocol. 20S-209
Ventricular (luuer. 204i. 206
Ventricular .tm<ktill. 211- 212. 212i.
213t.375
Ventrkular tac~rdil. 204-206. 204i,
205,. 21lt, 375
IUlhIe monomorphic. wilh
pulst.2(16
Wl5U1ble monomorphic, wilh pul..,.

2"

Vul,",rablt
375

J'Kriodofrtpo~riulion.l2.

W
WanderinQ al rial paoemaktr, 85-87. 871,
101t.375

Wandering bastlint. 33. 33.

Waveforms, cum:nt tI!M and, I I. Iii
practice slriPJ for labe liflll. 23-24;
Weotktbach. U7-ISO. 148i. 149i

Answer: Normal sinus rhythm

Nonnal sinus rhythm: Identifying ECG features

Rhythm: Regular
Rate: 60 to 100 Deats/minute
P waves: Normal In size, shape, direction; positive illead II, a positive lead ; one P wave precedes each DRS
complex
PR Interval: Normal (0.12 to 0.20 second)
QRS complex: Normal (0.10 second or less)

Answer; Sinus bradycardia

Sinus bradycardia: Identifying ECG features

Rhythm: Regular
Rate: 40 to 60 beats/minute
P waves: Normal In size, shape, direction; positive illead II, a positive lead ; one P wave precedes each DRS
complex
PR Interval: Normal (0.12 to 0.20 second)
QRS complex: Normal (0.10 second or less)

Answer: Sinus tachycardia

Sinus tachycardia: Identifying ECG features

Rhythm: Regular
Rate: 100 to 160 beats/minute
P waves: Normal in size, shape, direction; positive illead II, a positive lead ; one P wave precedes each DRS
complex
PR Interval: Normal (0.12 to 0.20 second)
QRS complex: Normal (0.10 second or less)

Answer: Sinus tachycardia

Sinus tachycardia: Identifying ECG features

Rhythm: Regular
Rate: 100 to 160 beats/minute
P waves: Normal in size, shape, direction; positive illead II, a positive lead ; one P Yr.Ive precedes each ORS
complex
PR Interval: Normal (0. 12 to 0.20 second)
QRS complex: Normal (0.1 0 second)

Answer: Sinus arrhythmia (with bradycardic rate)

Sinus arrhythmia: Identifying ECG features

Rhythm: Irregular
Rate: Nonnal (60 to 100 beats/minute) or slow (less tIlan 60 beats/minute; often seen with a bradycardic rate)
P waves: Normal in size, shape, direction; positive in lead II, a positive lead; one P wave precedes each ORS
complex
PR Interval: Normal (0.12 to 0.20 second)
QRS complex: Normal (0.10 second or less)

Answer: Sinus arrhythmia

Sinus arrhythmia: Identifying ECG features

Rhythm: Irregul<l"
Rate: Normal (60 to 100 beats/minute) or slow (less tIlan 60 beats/minute; often seen with a bradycardic rate)
P waves: Normal in size, shape, direction; positive il lead II. a positive lead; one P VvCIve precedes each ORS
complex
PR interval: Normal (0.12 to 0.20 second)
QRS complex: Normal (0.10 second or less)

Answer: Normal sinus rhythm with sinus block

Sinus block: Identifying ECG features

Rhythm: Basic rhythm usually regular; sudden pause in basic rtlythm (causing irregularity) with one or more
missing cardiac cycles; rhythm (RR regularity) resumes on time following pause; heart rate may slow for

several beats following pause (temporary rate suppression), but reuns to basic rate after several cycles
Rate: Normal (60 to 1()() beats/minute) or slow (less tIlan 60 beats/minute)
P waves: Normal with basic rhythm; absent during pause
PR Interval: Normal with basic rhythm: absent dlJ'ing pause

QRS complex: Normal with basic rtlythm ; absent during pause

Answer: Normal sinus rhythm with sinus arrest

Sinus arrest: Identifying ECG features

Rhythm: Basic rhythm usually regular; sudden pause in basic rhythm (causing Irregularity) with one or more
missing cardiac cycles; rhythm (RR regularity) does not resume on time following pause; heart rate may slow
for several beats following pause (temporary rate suppression), but returns to basic rate after several cycles
Rate: Normal (60 to 1()() beats/minute) or slow (less than 60 beats/minute)
P waves: Normal with basic rhythm; absent during pause
PR Interval: Normal with basic rhythm: absent dlJ'ing pause
QRS complex: Normal with bask: rhythm ; absent during pause

Answer: Wandering atrial pacemaker

Wandering atrial pacemaker: Identifying ECG features

Rhythm: Regular or IrrelJ.llar
Rate: Normal (60 to 1()() beats/minute) or slow (less than 60 beats/minute)
P waves: Vary in size, shape, direction across rhythm strip; orte P wave precedes each aRS complex
PR interval: Usually normal duration, but may be abnormal depending on changing pacemaker locations
QRS complex: Normal (0.10 second or less)

10

11

12

10

Answer: Wandering atrial pacemaker

Wandering atrial pacemaker: Identifying ECG features

Rhythm: Regular or irregular
Rate: Normal (60 to 1()() beats/minute) or slow (less than 60 beats/minute)

P waves: Vary in size, shape, direction across rhythm strip; 0f1e Pwave precedes each
QRSoomplex
PR Interval: Usually normal duration, but may be abnormal depending on changing pacemaker locations
QRS complex: Normal (0.10 second or less)

11

Answer: Normal sinus rhythm with two PACs

Premature atrial contraction: Identifying ECG features

Rhythm: Underlying rtryll1m usually regular; irregular with premature beat
Rate: That of underlying rhythm

P waves: Pwave associated with PAC is premature, abnormal (commonly appears small, upright, and pointed,
but may be inverted or a squiggle); abnormal P wave is often fOlJ1d hidden in preceding T wave, distorting
T-wave rontour
PR Interval: Usually normal but may be abnormal
QRS complex: Premature, normal duration ORS (0.1 0 second or less); followed by a pause

12

Answer: Sinus bradycardia with one PAC (abnormal Pwave associated with
PAC Is hidden In preceding T wave, distorting T-wave contour)

Premature atrial contraction: Identifying ECG features

Rhythm: Underlying rtlythm usually regular; irregular with premature beat
Rate: That of underlying rhythm
P waves: Pwave associated with PAC is premature, abnormal (commonly appears small, upright, and pointed,
but may be inverted or a squiOOIe); abnormal P wave is onen fOlJld hidden in preceding T wave, distorting
T-wave contour
PR Interval: Usually normal, but may be abnormal
ORS complex: Premature, normal duration ORS (0.10 second or less); followed by a pause

13

14

15

13

Answer: Sinus tachycardia with two nonconducted PAGs

Nonconducled PACs: Idenlifying ECG fealures

Rhythm: Under1ying rhythm usually regular; Irregular with nonconducted PACs

Rate: That of underlylf'lg rhythm

P waves: Premature and abnormal; oMen found hidden in preceding T wave, distorting T-wave contour;
a pause follows the nonconciJcted Pwave
PR Interval: Absent with nonconducted PAC
QRS complex: Absent with nonconructed PAC

14

Answer: Normal sinus rhythm with one nonconducted PAC (abnormal P wave associated with PAC is
hidden in preceding T wave, distorting T-wave contour)

Nonconducled PACs: Idenlifying ECG fealures

Rhythm: Underlying rhythm usually regular; Irregular with nooconducted PACs
Rate: That of underlying rhythm
P waves: Premature and abnormal; otten found hidden In preceding T wave, distorting T-wave contour;
a pause follows the noncon<i.Jcted Pwave

PR Interval: Absent with nonconducted PAC

QRS complex: Absent with nonconwcted PAC

15

Answer: Paroxysmal atrial tach~ardia

Paroxysma I alrial tachycardia: Identifying ECG fealures

Rhythm: Regular
Rate: 140 to 250 beals/minute
P waves: Abnormal (commonly pointed); usually hidden In preceding T wave so that T wave and P wave
appear as one wave defecUoo (T-P wave); one Pwave to each GRS unless AV block is present
PR Interval: Usually not measurable
QRS complex; Normal (0.10 second or less)

,.

17

,.

16

Answer: Paroxysmal atrfal lachycardia

Paroxysmal atrial tachycardia: Identifying ECG features

Rhythm: Regular
Rate: 140 to 250 beals/minute
P waves: Abnormal (commonly pointed); usually hidden in preceding T wave so that T wave and P wave
appear as one wave defecUon (T-P wave); one P wave to each QRS unless AV block is present
PR Interval: Usually not measurable
QRS complex: Normal (0.10 second or less)

17

Answer: Atrial flutter with variable AV conduction

Atrial flutter. Identifying ECG features

Rhythm: Regular or irre~ar (depends on AV conduction ratios)
Rate: Atrial: 250 to 400 beats/minute
Ventricular: Varies with number of impulses conducted through AV node; will be less than the
atrial rate
P waves: Sawtooth wave deflections affecting the entire baseline
PR Interval: Not measurable
QRS complex: Normal (0. 10 second or less)

,.
Answer: Atrial flutter wtth 4:1 AV conduction

Atrial flutter. Identifying ECG features

Rhythm: Regular or irregular (depends on AV conduction ratios)
Rate: Atrial: 250 10 400 beals/minute
Ventricular: Varies wiltl number of impulses conducted through AV node; will be less Ihan
the atrial rate
P waves: Sawtooth wave deflectioos affecting Itle entire baseline
PR Interval: Not measurable
QRS complex: Normal (0.10 second or less)

19

20

21

19

Answer: Atrial flutter with 2:1 AV conduction

Atrial flutter. Identifying ECG features

Rhythm: Regular or irregular (depends on AV conduction ratios)
Rate: Atrial: 250 to 400 beats/minute
Ventricular: Varies with number of impulses conducted through AV node; will be less than the
atrial rate
P waves: Sawtooth wave deflections affecting ttte entire baseline
PR Interval: Not measurable
QRS complex: Normal (0.10 second or less)

20

Answer: Atrial fibrillation (with uncontrolled ventricular rate)

Atrial fibrillation: Identifying ECG features

Rhythm: Grossly irregula'" (lI1less ventricular rate is rapid, in wtlich case the rhythm becomes more regular)
Rate: Atrial: 400 beats/minute Of more; not measur.:tlle due to wavy baseline
Ventricular: Varies with number 01 impulses conducted through AV node to ventricles; ventricular rate
is controlled if rate is less than 1()() beats/minute; ventrictJlar rate is uncontrolled if rate is greater
than 100 beats/minute
P waves: Wavy denections that affect the entire baseline
PR Interval: Not measurable
QRS complex: Normal (0.10 second or less)

21

Answer: Atrial fibrillation (with controlled ventricular rate)

Atrial fibrillation: Identifying ECG features

Rhythm: Grossly irregulC" (lflless ventricular rate is rapid, in which case the rhythm becomes more regliar)
Rate: Atrial: 400 beats/minute Of more; not measurable due to wavy baseline
Ventricular: Varies with number of impulses conducted through AV node to ventricles; ventricular rate
is controlled if rate is less than 100 beats/minute; ventricular rate is uncontrolled if rate is greater than
100 beats/minute
P waves: Wavy denections that affect the entire baseline
PR Interval: Not measurable
ORS complex: Normal (0.10 second Dr less)

22

23

24

22

Answer: Normal sinus rhythm with one PJC

Premature junctional contractions: Identifying ECG features

Rhythm: Underlying rhythm usually regula'; irregular with PJC

Rate: That of under1ying rhythm

P waves: Pwaves associated with the PJC will be premature, inverted In lead II (a positive lead), and will occur
immediately before the DRS, immediately aHer the DRS, or will be hidden within the DRS complex
PR Interval: Short (0.10 second or less)
QRS: Normal (0.10 second or less)

23

Answer: Normal bradyccrdia with one PJC

Premature junctional contractions: Identifying ECG features

Rhythm: Underlying rhythm usually regular; Irregular with PJC

Rate: That of underlying rhythm
P waves: Pwaves associated with the PJC will be premature, Inverted In lead II (a positive lead), and will occur
Immediately before the DRS, immediately aHer the DRS, or will be hidden within the QRS complex
PR Interval: Short (0.10 second or less)
QRS: Normal (0.10 second or less)

24

Answer: Junctional rhythm

Junctional rhythm: Identifying ECG features

Rhythm: Regular
Rate: 40 to 60 beats/minute
P waves: Inverted In lead II (a posIUve lead) and will occur Immediately before the ORS, Immeclately after the
ORS, or will be hidden within the ORS complex
PR Interval: Short (0.10 second or less)
QRS complex: Normal (0.10 second or less)

25

26

27

25

Answer: Accelerated Junctional rtlythm

Accelerated junctional rhythm: Identifying ECG features

Rhythm: Regular
Rate: 60 to 100 Deats/minute
P waves: Inverted in lead II (a positive lead) and will occur immediately before the DRS, immediately after the
DRS, or will be hidden within the DRS complex
PR Interval: Short (0. 10 second or less)
QRS complex: Normal (0.10 second or less)

26

Answer: Junctional tachycardia

Junctional tachycardia: Identifying ECG features

Rhythm: Regular
Rate: Greater than 100 beats/minute
P waves: Inverted in lead II (a positive lead) and will occur immediately before the DRS, immeclately after the
DRS, or will be hidden within the QRS complex
PR Interval: Short (0. 10 second or less)

QRS complex: Normal (0.10 seoond or less)

27

Answer: Normal sinus rhythm with first-degree AV block

First-degree AV block: Identifying ECG features

Rhythm: Usually regular
Rate: That of the underlying sinus rhythm
P waves: SirlJs; one P wave to each DRS complex
PR Interval: Prolonged (greater than 0.20 second); remains consistent
QRS complex: Normal (0.10 second or less)

2B

29

30

28

Answer: Normal sinus rhythm with first-degree AV block

First-degree AV block: Identifying ECG features

Rhythm: Usually regular
Rate: That of the underlying sinus rhythm

P waves: SirKJS; one P wave to each DRS complex

PR Interval: Prolonged (greater than 0.20 second); remains consistent
QRS complex: Normal (0.10 second or less)

29

Answer: Second-degree AV block, Mobitz I

MobilZ I: Identifying ECG features

Rhythm: Atrial: Regular
Ventricular: Irregular
Rate: Atrial: That of underlying r1lythm

Ventricular: Depends on number of impulses conducted through AV node; will be less than atrial rate

P waves: Sirlls
PR Interval: Varies; progressively lengthens until a P wave Isn't conducted (P wave appears without ORS
complex); a pause follows the dropped QRS complex
QRS complex: Normal (0.10 second or less)

30

Answer: Second-degree AV block, Mobitz I

MobilZ I: Identifying ECG features

Rhythm: Atrial: Regular
VentrJcular: Irregular

Rate: Atrial: That of underlying rhythm

Ventricular: Depends on number of Impulses conducted through AV node; will be less than atrial rate
P waves: Sil'lls
PR Interval: Varies; progressively lengthens until a P wave Isn't conducted (P wave appears without ORS
complex); a pause follows the dropped ORS complex
ORS complex: Normal (0.10 second or less)

31

32

33

31

Answer: Second-degree AV block, Mobitz II with 2:1 and 3:1 AV conduction

Mobilz II: Identifying ECG features

Rhythm: Atrial: Regular
Ventricular: Usually regul~ : may be irregular if AV conduction ratios vary
Rate: Atrial: That of underlying rhythm
Ventricular: Depends on number of Impulses conducted through AV node; will be less than atrial rate
P waves: Sirlls; two or three Pwaves (sometimes more) before each QRS complex
PR Interval: Normal or prolonged; remains consistent
QRS complex: Normal duration if block at bundle of His; wide il block in buncle branches

32

Answer: Second-degree AV block., Mobitz II with 3:1 AV conduction (one P wave hidden on top ofT wave)

Mobilz II: Identifying ECG features

Rhythm: Atrial: Regular
Ventricular: Usually regular; may be Irregular If AV conductloo ratios vary
Rate: Atrial: That of underlying rhythm
Ventricular: Depends on Il..Imber of imptjses conducted through AV node; will be less than atrial rate
P waves: SirlJs; ~ or three P waves (sometimes more) before each QRS complex
PR Interval: Normal or prolonged; remains ronsistent
QRS complex: Normal duration if block at level of bundle of His; wide if block in bumle branches

33

Answer: Third-degree AV block

Third-degree AV block: Identifying ECG features

Rhythm: Atrial: Regular
Ventricular: Regular
Rate: Atrial: That of underlying sinus rhythm
Ventricular: 40 to 60 beatslminute If paced by AV Junction; 30 to 40 beats/minute (sometimes less) If
paced by the ventricles; rate will be less th.!f1 the atrial rate
P waves: SirlJS P waves with no consistent relationship to the QAS complex; P waves found hidden in QRS
complexes, ST segments, and T waves
PR Interval: Varies (is not consistElfl~
QRS complex: Normal duration if block at level of AV node or bundle of His; wide if block In buncle branches

34

36

34

Answer: Third-degree AV block

Third-degree AV block: Identilying ECG features

Rhythm: Atrial: Regular
Ventricular: Regular
Rate: Atrial: That of underlying sinus rhythm
Ventricular: 40 to 60 beats/minute if paced by AV junction; 30 to 40 beats/minute (sometimes less) if
paced by the ventricles; rate will be less than the atrial rate
P waves: Sirus P waves with no consistent relationship to the QAS complex; P waves found hidden in QRS

complexes, ST segments, and T waves

PR Interval: Varies (is not consistent)
QRS complex: Normal duration if block at level of AV node or bundle of His; wide if block in bundle branches

35

Answer: Normal sinus rhythm with bundle-branch block

Bundle-branch block: Identilying ECG features

Rhythm: Usually regular
Rate: That of underlying rhythm (usually sinus)
P waves: Sirus
PR Interval: Normal (0. 12 to 0.20 second)
QRS complex: Wide (0.12 second or greater)

36

Answer: Normal sinus rhythm with bundlebranch block

Bundle-branch block: Identilying ECG features

Rhythm: UsuaJly regular
Rate: That of under1ying rhythm (usually sinus)
P waves: Sirus
PR Interval: Normal (0. 12 to 0.20 second)
QRS complex: Wide (0.12 second or greater)

37

38

39

37

Answer: Normal sinus rhythm with two multi focal PVCs

Premature ventricular contraction: Identifying ECG features

Rhythm: Underlying rhythm usually regula'; irregular with PVC
Rate: That of underlying rhythm
P waves: None associated with PVC
PR Interval: Not measurable
QRS complex: Premature, wide ORS (0.12 secortd or greater) with ST segment and T wave sloping opposite
the maln OAS deflection; followed by a pause

38

Answer: Normal sinus rhythm with two unifocal PVCs

Premature ventricular contraction: Identifying ECG features

Rhythm: Underlying rhythm usually regular; Irregular with PVC
Rate: That of underlying rhythm
P waves: None associated with PVC

PR Interval: Not measurable

QRS complex: Premature, wide ORS (0. 12 secortd or greater) with ST segment and T wave sloping opposite
the maln OAS deflection; followed by a pause

39

Answer: VentriclJar tachycal1la

Ventricular tachycardia: Identifying ECG features

Rhythm: Usually regular (may be slightly irregular)
Rate: 140 to 250 beats/minute
P waves: No associated P waves

PR Interval: Not measurable

QRS complex: Wide (0.12 second or greater) with ST segments and T waves sloping opposite the main OAS
deflection

40

41

42

40

Answer: VentrlctJar tachycarma (torsade de pointes)

Torsade de poinles: Idenlifying ECG fealures

Rhythm: Usually regular (may be slightly irregular)
Rate: 200 beats/minute or more
P waves: None
PR Interval: Not measurable
QRS complex: 0.12 second or greater (some much wider than others)

41

Answer: Normal sinus rhythm with 3-beat run of vr

Ventricular lachycardia: Identifying ECG fealures

Rhythm: Usually regular (may be slightly irregular)
Rate: 140 to 250 beals/minute
P waves: No associated P waves
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater) with ST segments and T waves slopirlg opposite the main ORS
deflection

42

Answer: VentrlclAar tlbrlllation (coarse deflections present)

Ventricular fibrillalion: Idenlifying ECG fealures

Rhythm: None (P wave and ORS are absent)
Rate: None (P wave and ORS are absent)
P waves: Wavy, irregular deflection representative of ventricular quivering; deflectiollS may be small (fine
ventriculer fibrillation) or COCl"se (coarse ventricular fibrillation)
PR Interval: Not measurable
QRS complex:Absent

43

44

45

43

Answer: VentriCliar fibrillation (fine deHections present)

Ventricular fibrillation: Identifying ECG features

Rhythm: None (P wave and ORS are absent)

Rate: None (Pwave and QRS are abseo~

P waves: Wavy, irregular clenections representative of ventrlaAar Quivering; deHections may be small (fine
veotrlcula- flblillaUon) or coocse (coarse ventricular fibrillation)
PR Interval: Not measurable
QRS complex: Absent

44

Answer: Idioventricular rtJythm

IdiD_entricular rhythm: Identifying ECG features

Rhythm: Regular
Rate: 30 to 40 beats/minute (sometimes less)

P waves: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)

45

Answer: Accelerated idiovenlricular rhythm

Accelerated idio_entricular rhythm: Identifying ECG features

Rhythm: Regular
Rate: 50 to 100 Deats/minute

P waves: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)

46

47

48

46

Answer; Normal sinus rhythm with 3-beat run AIVR

Accelerated idioventricular rhythm: Identifying ECG features

Rhythm: Regular
Rate: 50 to 100 Deats/minute

P wave: Absent
PR Interval: Not measurable
QRS complex: Wide (0.12 second or greater)

47

Answer: Ventrlruar standst~1 (asystole)

Ventricular standstill: Identifying ECG features

Rhythm: Atrial: If waves present, will have atrial rhytIlm

Ventricular: NOlle; flO QRS complexes are present

Rate: Atrial: If P 1N3.ves present. will have atrial rate
Ventricular: None; no QRS complexes are present
P waves: Tracing will show only P waves or a straight line
PR Interval: Not measurable
QRS complex: Absent

4e

Answer: VentrlciJar standst~1 (asystole)

Ventricular standstill: Identifying ECG features

Rhythm: Atrial: If P waves present, will have atriallflythm
Ventricular: Nooe; no QRS complexes are present
Rate: Atrial: If P 1N3.ves present, will have atrial rate
Ventricular: None; no ORS complexes are present
P waves: Tracing will show only P waves or a straight tine
PR Interval: Not measurable
QRS complex: Absent