Far Eastern University NICANOR REYES MEDICAL FOUNDATION

Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

OUTLINE LIMB ELECTRODES

1. Review of the conduction system - RA Red Right arm
2. EKG leads - LA Yellow Left arm
3. EKG waveforms and intervals - LL Green Left leg
4. Interpretation/Approach - RL Black Right leg
5. Ischemia/Infarction
6. Common arrhythmias CHEST ELECTRODES
- V1 Red 4th ICS RPSB
ELECTROCARDIOGRAM - V2 Yellow 4th ICS LPSB
- The electrocardiogram (EKG) is a representation of the electrical events - V3 Green Midway between V2 and V4
of the cardiac cycle. - V4 Brown 5th ICS LMCL
- Each event has a distinctive waveform, the study of which can lead to - V5 Black LAAL Lateral & horizontal to V4
greater insight into a patient’s cardiac pathophysiology. - V6 Violet LMAL Lateral & horizontal to V4

- The electrocardiogram (ECG) is a graphic recording of the electrical

potentials produced by the cardiac tissue.
- Does not record directly the electrical activity of the source itself
- Electrical impulse formation occurs within the conduction system of the
heart.
- Excitation of the muscle fibers throughout the myocardium results in
cardiac contraction.
- The ECG is recorded by applying electrodes to various locations on the
body surface and connecting them to a recording apparatus.

WHAT TYPES OF PATHOLOGY CAN WE IDENTIFY AND STUDY FROM EKGS?

- Arrhythmias
- Myocardial ischemia and infarction
- Pericarditis
- Chamber hypertrophy
- Electrolyte disturbances (i.e. hyperkalemia, hypokalemia)
- Drug toxicity (i.e. digoxin and drugs which prolong the QT interval) - The abbreviation ‘a’ refers to augmented.
- A definition of augmented is to increase in size which simply means that
THE NORMAL CONDUCTION SYSTEM the ECG machine amplifies the signal to make it more readable (the
machine augments the reading by 50%)
- The ‘V’ refers to voltage
- R, L and F refer to right arm, left arm and left foot.

PRECORDIAL LEADS

ECG LEADS
- Leads are electrodes which measure the difference in electrical
potential between either:
o Two different points on the body (bipolar leads)
o One point on the body and a virtual reference point with
zero electrical potential, located in the center of the heart
(unipolar leads)

- The standard EKG has 12 leads:

o 3 Standard Limb Leads
o 3 Augmented Limb Leads
o 6 Precordial Leads

- The axis of a particular lead represents the viewpoint from which it

looks at the heart.

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

- QRS complex
o Produced by activation of both ventricles
- ST-T wave
o Reflects ventricular recovery

P wave - atrial depolarization

PR segment - AV nodal delay
PR interval - atrial depolarizatio + AV nodal delay
Q wave - interventricular septum depolarization
R wave - apical depolarization
S wave - basal depolarization
QRS Complex - entire ventricular depolarization
QT interval - whole ventricular action potential
T wave - Ventricular repolarization (phase 3)
ST segment - Ventricular repolarization (phase 2)
ST interval - whole ventricular repolarization
U wave - slow repolarization of papillary muscles
J point - end of depolarization start of repolarization

ECG PAPER

LIMB LEADS PRECORDIAL LEADS

I, II, III
BIPOLAR ---
Standard Limb Leads
aVR, aVL, aVF
UNIPOLAR V1 to V6
Augmented Limb Leads

WAVEFORMS AND INTERVALS

- The P-QRS-T sequence is recorded on special graph paper

- The vertical lines measure amplitude or voltage
o Each small box represents 0.1 mV
o Each large block (made up of 5 small boxes) represents 0.5 mV
o To determine the amplitude of a wave, segment or interval, count
the number of small boxes from the baseline to the highest or
lowest point
- The horizontal lines measure time
o Each small box equals 0.04 seconds
o Each large block (made up of 5 small boxes) equals 0.2 seconds
(multiply 0.04 x 5 = 0.2)
o The width of complexes and intervals are determined by the
number of small boxes they extend over, then multiply by the time
0.04
- P wave
o When measuring or analyzing a heart rate or rhythm, a minimum of
o Generated by activation of the atria
6 seconds (30 large blocks) should be used
- PR segment
o Represents the duration of atrioventricular (AV) conduction

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

P WAVE QT INTERVAL
- Represents atrial contraction - Normal QT for rates 60 -100 = 0.30 - 0.40 seconds
- Slow rounded wave
- Duration between 0.08 and 0.11secs (2 ½ small squares) o Abnormal:
- Height less than 2.0 mm (2 small squares) o Long - indicates that ventricular repolarization time has slowed,
- Upright in lead II (usual lead for a rhythm strip); which means that the relative refractory period (the vulnerable
- Inverted in Avr period) of the cardiac cycle is longer, predisposing patients to
potentially lethal ventricular dysrhythmias
- Normal P waves indicate: o Short - may result from digitalis toxicity or hypercalcemia
o the electrical impulse originated in the SA node
o that normal depolarization of the atria occurred T WAVE
- Abnormal P waves:
- Represents ventricular relaxation
o Inverted - indicates reverse (retrograde) conduction from the AV
- Rounded peak
junction backward toward the atria
- Should be in the same direction as the main QRS complex
o Peaked, notched or enlarged - the sinus impulse traveled through
- Abnormal if inverted, seen in LVH, Bundle branch blocks & ischemia
altered or damaged atria
- For adults more than 30 years old:
o Varying - the impulse may be coming from different sites
o normally inverted only in V1
o Absent - conduction by a route other that the SA node
- Less than 30 yrs. old:
o Not preceding a QRS - heart block
o normally inverted in V1-3

PR INTERVAL - Abnormal T waves indicate abnormal repolarization has occurred

- The time it takes the impulses to travel from the atria to the AV node
(atrio-ventricular conduction time)
- Measured from the onset of the P wave to the onset of the QRS U WAVE
complex - Prominent in V3 not >1 mm amplitude
- No more than 5 small squares in duration (0.20secs)
- Prolonged PR interval >0.20secs is 1st degree heartblock - Abnormal - prominent U waves may be due to hypercalcemia,
hypokalemia or digitalis toxicity
- Abnormal PR interval:
o Short - Electrical impulse was conducted through an abnormal INTERPRETATION AND APPROACH
pathway that bypasses the AV node, or
o The impulse originated in an ectopic site close to the AV junction
ARRANGEMENT OF LEADS ON THE EKG
o Long - indicates the electrical impulse is delayed traveling through
the AV node and bundle of His
I aVR V1 V4
QRS COMPLEX
II aVL V2 V5
- Represents ventricular contraction
- Measured from the onset of the Q to the end of the S wave
III aVF V3 V6
- Predominantly Upward in left sided leads and negative in negative in
right sided leads
- Between 0.08 and 0.12 secs in duration (3 small squares) ANATOMIC GROUPS (SEPTUM)

- Abnormal (wide) QRS indicates that abnormal depolarization has

occurred due to
o Bundle branch block
o Conduction through an abnormal pathway
o The impulse originated in an ectopic site in the ventricles

ST SEGMENT
- Isoelectric
- Normally deviate between -0.5 and +1mm from the baseline
- Measured between the end of the QRS and the beginning of the T wave
- Should be no more than 1mm above or below the baseline

- Abnormal
o Elevation is a sign of myocardial injury
o Depression is most often associated with myocardial ischemia

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

ANATOMIC GROUPS (ANTERIOR WALL) SINUS RHYTHMS

- Beats are ‘sinus’ if the P wave originated from the SA node and the
impulses have been conducted in the normal way
- Meaning they have a normal PQRST complex

- Normal sinus rhythm 60-100 beats/min

- Sinus Bradycardia <60 beats/min
- Sinus Tachycardia >100 beats/min

DETERMINING THE HEART RATE

RULE OF 300
- Take the number of “big boxes” between neighboring QRS complexes,
and divide this into 300. The result will be approximately equal to the
rate
- Although fast, this method only works for regular rhythms.
of 300
ANATOMIC GROUPS (LATERAL WALL)

Heart Rate = 300 / No. of Big Squares

300 / 6 = 50 bpm

ANATOMIC GROUPS (INFERIOR WALL)

Heart Rate = 300 / No. of Big Squares

300 / ~4 = ~75 bpm

ANATOMIC GROUPS (SUMMARY)

Heart Rate = 300 / No. of Big Squares
300 / 1.5 = 200 bpm

- It may be easiest to memorize the following table:

THE RULE OF 300

# OF BIG BOXES RATE
1 300
2 150
3 100
4 75
5 60
6 50

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

10 SECOND RULE
- As most EKGs record 10 seconds of rhythm per page
- count the number of beats present on the EKG and multiply by 6 to get
the number of beats per 60 seconds.
- This method works well for irregular rhythms.

HEART RATE: ~68 bpm

1,500 METHOD
- FOR REGULAR RHYTHM
- Count the number of small squares between 2 R waves
- Divide the number of small squares by 1,500

1500 / 22 = 68 bpm

THE QRS COMPLEX

- The QRS axis represents the net overall direction of the heart’s
electrical activity.
- Abnormalities of axis can hint at:
o Ventricular enlargement
o Conduction blocks (i.e. hemiblocks)
33 X 10 = 330 bpm
THE AXIS
- Normal 0 – (+90)
OTHER METHODS - Left axis 0 – (-90)
- Right axis (+90) – (+180)
6 SECOND METHOD - Extreme axis (-90) – (-180)
- FOR IRREGULAR RHYTHM
- Count 30 large boxes (6 second strip) - By near-consensus, the normal QRS
- Count the number of R waves that falls within the 30 large boxes axis is defined as ranging from -30°
- Multiply the number of R waves by 10 to +90°.
- -30° to -90° is referred to as a left
axis deviation (LAD)
- +90° to +180° is referred to as a
right axis deviation (RAD)

8 X 10 = 80 bpm

SEQUENCE METHOD
- Rapid Method
- Choose any QRS complex that falls on a heavy black line. This will be
your reference QRS complex
- Identify the next QRS complex.
- Assign the following sequence of numbers to every black line after the
reference QRS complex
o 300, 150, 100, 75, 60, 50, 43, 37

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

DETERMINING THE AXIS

Positive in I, negative in aVF  Predominantly positive in II  Normal Axis

Predominantly Predominantly (non-pathologic LAD)
Equiphasic
Positive Negative
EQUIPHASIC APPROACH
QUADRANT APPROACH - Determine which lead contains the most equiphasic QRS complex. The
- Examine the QRS complex in leads I and aVF to determine if they are fact that the QRS complex in this lead is equally positive and negative
predominantly positive or predominantly negative. The combination indicates that the net electrical vector (i.e. overall QRS axis) is
should place the axis into one of the 4 quadrants below. perpendicular to the axis of this particular lead.
- Examine the QRS complex in whichever lead lies 90° away from the lead
identified in step 1. If the QRS complex in this second lead is
predominantly positive, than the axis of this lead is approximately the
same as the net QRS axis. If the QRS complex is predominantly
negative, then the net QRS axis lies 180° from the axis of this lead.

- In the event that LAD is present, examine lead II to determine if this

deviation is pathologic. If the QRS in II is predominantly positive, the
LAD is non-pathologic (in other words, the axis is normal). If it is
predominantly negative, it is pathologic.

Equiphasic in aVF  Predominantly positive in I  QRS axis ≈ 0°

Equiphasic in II  Predominantly negative in aVL  QRS axis ≈ +150°

Negative in I, positive in aVF  RAD

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

ISCHEMIA AND INFARCTION ST DEPRESSION

- Downsloping of ST segment consistent with ischemia
ST SEGMENT

- Isoelectric
- Normally deviate between -0.5 and
+1mm from the baseline

ST ELEVATION

ST WAVE CHANGES

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

- Sinus tachycardia
- Ectopic atrial tachycardia
- Torsade de pointes
- PAC,PVC, digitalis-
- induced SVT
- Paroxysmal SVT, atrial flutter/fibrillation, Vent. tachycardia/fibrillation

SINUS TACHYCARDIA
- Normal looking QRS
- rate >100 bpm
- regular rhythm
- P waves upright in I, II, AVF

ARRHYTHMIA
- Causes:
o Disturbances in automaticity
o Disturbances in conduction
o Combinations of altered automaticity and conduction
SINUS BRADYCARDIA
- Normal looking QRS
- rate <60 bpm
- regular rhythm
- P waves upright in I, II, AVF

SUPRAVENTRICULAR TACHYCARDIA: NARROW COMPLEX TACHYCARDIA

- Atrial Fibrillation
- Atrial Flutter
- Paroxysmal SVT (PSVT)
o Non paroxysmal atrial tachycardia
BRADYARRHYTHMIAS o Multifocal atrial tachycardia (MAT)
o Junctional tachycardia
ABNORMALITY MECHANISM EXAMPLES
Altered impulse formation Phase 4: depolarization - SUPRAVENTRICULAR ARRHYTHMIAS
Sinus Bradycardia
- Decreased automaticity (cholinergic stimulation) o Irregular Rhythm
Ischemic, anatomic, or  Atrial fibrillation
Altered impulse conduction 1st, 2nd, 3rd degree
drug-induced impaired  Atrial flutter with varying AV conduction
- Conduction blocks AV Blocks
conduction  Wandering atrial pacemaker
 Multifocal atrial tachycardia
TACHYARRHYTHMIAS o Regular Rhythm
- Altered Impulse Formation  Sinus Tachycardia
o Enhanced automaticity  Atrial tachycardia
 Sinus node  Junctional/atrioventricular rhythm
 Ectopic focus  Atrial flutter with fixed AV conduction
o Triggered activity  AV nodal reentrant tachycardia
 Early afterdepolarization  AV reentrant tachycardia
 Delayed afterdepolarization
- Altered Impulse Conduction ATRIAL FIBRILLATION
o Reentry - Results from multiple areas of re-entry with in the atria from multiple
- Increased phase 4 depolarization ectopic foci
o sympathetic stimulation - Atrial Rate = 400 - 700/min
- Acquired phase 4 depolarization - irregularly irregular; fibrillation waves
- Prolonged action potential - no organized atrial activity; no P waves
o tissue damage or drug-induced
- Intracellular calcium overload
o digitalis toxicity
- Unidirectional block + slowed retrograde conduction

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

- Atrial flutter produces an atrial rate between 250 and 400 BPM. The
ventricular rate may increase, but it is always slower than the atrial rate.
During atrial flutter, atrial impulses are conducted to the ventricles in
various ratios.
- Even conduction ratios (2:1, 4:1) are more common than odd ratios (3:1,
5:1). In a 2:1 ratio, there are two flutter waves for every QRS complex.
- A constant conduction ratio (e.g., 2:1) results in a regular ventricular
rhythm (most common). A variable ratio (e.g., 4:1 to 2:1 to 5:1) results in
an irregular ventricular rhythm.
- Regular atrial activity with a "clean" saw-tooth appearance in leads II, III,
aVF, and usually discrete 'P' waves in lead V1. The atrial rate is usually
about 300/min, but may be as slow as 150-200/min or as fast as 400-
450/min.

TREATMENT:
- if unstable
o cardiovert
- if stable
o digoxin
o verapamil
- Atrial Fibrillation (AF) is characterized by random, chaotic contractions of o diltiazem
the atrial myocardium. Patients have an atrial rate of 400 BPM or more, o B-blockers
often too fast to measure on an EKG.
- A surface EKG shows atrial fibrillation as irregular, wavy deflections PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
(fibrillatory waves) between narrow QRS complexes. The fibrillatory waves - circus movement or reciprocating tachycardias
vary in shape, amplitude, and direction. - utilize the mechanism of reentry
- The chaotic nature of atrial fibrillation results in a grossly irregular - Sudden onset
ventricular rhythm. The rhythm is considered controlled if the ventricular - Stops abruptly
rate is less than 100 BPM; uncontrolled if the ventricular rate conducts to - Usually a narrow QRS complex tachycardia
greater than 100 BPM. - Exceptions:
- Mechanism: o Pre-existing conduction
- In AF, the multiple wavelets of reentry do not allow the atria to o Aberrant ventricular conduction
organize. o Pre-excitation
- The ectopic focus or foci are said to be located around or within the
pulmonary veins.
- Drugs such as flecainide, sotalol and amiodarone can terminate and
prevent atrial fibrillation. Drug therapy can be used before or after DC
cardioversion to maintain sinus rhythm after cardioversion.

ATRIAL FLUTTER
- Atrial rate 220-350/min - Regular narrow-complex Tachycardia without discernible p waves
- ventricular rhythm may be regular - Sudden onset or cessation
- P waves: flutter waves resemble SAWTOOTH or PICKET FENCE
- RE-ENTRY

o Reentry refers to an electrical impulse continuously traveling

an electrical loop within the myocardium. The depolarization
wave-front reenters areas that have just been repolarized,
creating a circular, continuous series of depolarizations and
repolarizations.
o The following anatomic and physiologic properties create a
reentrant loop:

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

 Two parallel conduction pathways around a PREMATURE VENTRICULAR CONTRACTION IN BIGEMINY

central obstacle (A and B in above figure). - Alternating normal sinus beat and a PVC
Conducting tissue connects the pathways at both
ends.
 One of the pathways (A) conducts more slowly
than the other
 The other pathway, (B), exhibits unidirectional
block, usually in the form of a substantially longer
refractory period than the other pathway

PREMATURE VENTRICULAR CONTRACTION IN TRIGEMINY

- PVCs regularly occurring every third beat

SUBSTRATE + TRIGGER = REENTRY

- To put it briefly:
o The tissue that forms the block and pathways for a reentry circuit MULTIFOCAL PREMATURE VENTRICULAR CONTRACTION
is called the substrate - PVC’s coming from different foci in the ventricle
o A premature impulse (such as a Premature Ventricular - PVC’s assuming different polarities in a single lead
Contraction, or PVC) serves as a trigger - PVC’s of different morphology and coupling interval
o Substrate + Trigger results in reentry
- Note: A substrate may develop due to scar tissue from various forms of
heart disease.

VENTRICULAR TACHYCARDIA: WIDE COMPLEX TACHYCARDIA

PREMATURE VENTRICULAR CONTRACTION

- Prematurely occurring complex.
- Wide, bizarre looking QRS complex.
- Usually no preceding P wave.
- T wave opposite in deflection to the QRS complex. PREMATURE VENTRICULAR CONTRACTION: R ON T PHENOMENON
- Complete compensatory pause following every premature beat. - R or Q of the PVC occurring at the T wave of the preceding sinus beat
- Most dangerous PVC

PREMATURE VENTRICULAR CONTRACTION IN COUPLETS

- Two Premature ventricular contractions occurring consecutively

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

ACCELERATED IDIOVENTRICULAR RHYTHM

- Impulse ventricular in origin
- Absence of (N), upright P wave associated with QRS complexes
- QRS > 0.10 sec
- T wave opposite in direction to QRS
- Rate = 40-120 / min

VENTRICULAR TACHYCARDIA
- At least 3 consecutive PVC’s
- Rapid, bizarre, wide QRS complexes (> 0.10 sec)
- No P wave (ventricular impulse origin)

With 2 foci of ventricular activity

PRE EXCITATION: WOLFF PARKINSON WHITE

- Rhythm is sinus except during pre excited tachycardia
- Short PR interval
- QRS distorted by delta wave

IDIOVENTRICULAR RHYTHM
- Impulse ventricular in origin
- Absence of (N), upright P wave associated with QRS complexes
PRE EXCITED TACHYCARDIA
- QRS > 0.10 sec
- T wave opposite in direction to QRS
- Rate < 40 / min

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

TORSADES DE POINTES
- A form of polymorphic VT
- Electrical tracing appears to be twisted into a helix
- This form of ventricular tachycardia degenerates relatively often into
ventricular fibrillation

FINE VENTRICULAR FIBRILLATION

TREATMENT:
- Only DEFIBRILLATION provides definitive therapy!

VENTRICULAR ASYSTOLE
- total absence of ventricular electrical activity
- absence of ventricular electrical activity
- sometimes p waves or ventricular escape beats (agonal beats) may
occur
- FLAT LINE PPROTOCOL :
o check 2 leads on the monitor perpendicular to each other to
make sure patient is in asystole
- Check all connections of patient to monitor
- Adjust gain sensitivity

TREATMENT:
- amiodarone
- lidocaine

- if unstable: TREATMENT:
o electrical cardioversion or defibrillation - epinephrine
- for torsades de pointes: - atropine
o Magnesium Sulfate - search for reversible cause
o overdrive pacing - CPR

VENTRICULAR FIBRILLATION BRADYCARDIAS: ATRIOVENTRICULAR BLOCKS

- Associated with coarse or fine chaotic undulations of the ECG baseline
- No P wave JUNCTIONAL COMPLEXES
- No true QRS complexes - conducting tissue near AV node has taken over the pacemaker of the
- Indeterminate rate heart
- single most important rhythm for an ACLS provider to recognize - rate 40-60
- no organized ventricular depolarization - usually with retrograde P waves
- no EFFECTIVE cardiac output
- may be coarse or fine

COARSE VENTRICULAR FIBRILLATION

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 Far Eastern University NICANOR REYES MEDICAL FOUNDATION
Doctor of Medicine
2019
CARDIOLOGY: ELECTROCARDIOGRAM (ECG)
Melinda R. Abad – Vencio, MD, FPCP, FPCC
Medicine 3A
Drkhkh

FIRST DEGREE AV BLOCK THIRD DEGREE AV BLOCK

- delay in passage of impulse from atria to ventricles - Complete absence of conduction between atria and ventricles
- normal QRS; regular rhythm - atrial rate is always equal to or more than ventricular rate
- PR interval prolonged >0.20 sec. - QRS may be narrow or wide depending on level of block

SECOND DEGREE AV BLOCK:

MOBITZ TYPE 1 (WENCKEBACH)
- progressive prolongation of PR
- interval until an impulse is blocked

LEVEL OF AV NODE

SECOND DEGREE AV BLOCK:

MOBITZ TYPE II VENTRICULAR LEVEL
- No lengthening of PR interval before a dropped beat

TREAT THE PATIENT, NOT THE MONITOR

HIGH GRADE AV BLOCK

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