EKG INTERPRETATION

Electrical Conduction System of Heart

1. Impulse starts in the SA NODE (Sinoatrial node)

Study Tip: On exams, we will most likely be asked what the “pacemaker” of the
electrical system and the answer is the SA node. The SA node beats at 60-100 bpm.
Furthermore, the SA node represents the P-wave (atrial contraction) on the EKG
tracing.

2. Travels down through the inter-nodal pathways to the AV NODE (Atrio-

Ventricularnode)

Study Tip: For exams, know that the AV node is known as the “gatekeeper “. The
AVnode is known for causing a delay so the atrium can fully empty into the ventricles.
If there wasn’t a delay the atriums would not fully empty into the ventricles which
would cause problems. The AV node beats at 40-60 bpm.

3. Then the impulse travels through the BUNDLES OF HIS which branches out into
theRIGHT & LEFT BRANCH BUNDLES.

4. Lastly, the impulse travels to the PURKINJE FIBERS and then starts all over.

Study Tip: The Purkinje fibers beat at 20-40 bpm.

When we look at a telemetry strip or EKG, we see electrical impulses generated by
our heart that are being transferred to electrodes (the sticky patches on patient’s skin),
which in turn displays that impulse on a screen for us to analyze.

Before we can start analyzing heart rhythms, (atrial fibrillation, atrial flutter, ventricular
tachycardia etc.) we must know the basics about the PQRST wave.

Basic PQRST EKG strip looks like:

Now let’s break each part of this strip down and talk about what each area represents.
We always read the PQRST wave starting from left to right. Please take note of the
study tips because these are common questions of exams.

Basic PQRST:

❖ P-wave: The first little “hump” or “bump” you see is known as the P-wave. The SA
node is responsible for this.

Study tip: The P-wave represents ATRIAL DEPOLARIZATION (Depolarization is a

big, fancy word for CONTRACTION).

❖ QRS Complex: The next area you see is a big spike. This spike is called the QRS
complex. The bundle of His, bundle branches, and Purkinje fibers are responsible
for this.

Study tip: The QRS complex represent VENTRICLE DEPOLARIZATION

(contractions of the ventricles)
❖ T-wave: After this spike, we will see a “bump” shortly after the complex. This “bump”
is called the T-wave and is caused by the ventricles relaxing. The ventricles are so
large that when they contract (depolarize) they form a large electrical impulse that
presents the QRS complex. Therefore, (because they are so large) when they relax
(repolarize) they form a small electrical impulse that presents as the T-wave.

Study tip: What area of PQRST EKG reading represents ventricle repolarization?
T-wave.

❖ U-wave: This is not very common. The u-wave sometimes is seen after the T-wave.
This is thought to be caused by the relaxation of the Purkinje fibers.

PR Interval & ST Segment:

❖ PR- interval: As noted on the diagram above, the PR-interval starts at atrial
contraction (remember atrial contraction is represented by the P-wave) and ends at
the beginning of ventricle depolarization. So, in other words, it starts at the P-wave
and ends at the beginning of the QRS complex.

❖ ST segment: This segment starts at the J-point. The J-point is where you start to
see an upward stroke after the S wave. The segment ends at the beginning of the
T-wave. The ST segment represents when the ventricles are relaxing, also called
repolarizing.
How to Calculate the Heart Rate on an EKG Strip with the Six Second
Rule
There are many ways through which we can count a heart rate on an EKG. The six
second rule is great for counting heart rhythms that aren’t regular like, atrial fibrillation,
atrial flutter,sinus arrhythmia, sinus rhythm with PVCs etc.

Here is a diagram to illustrate

Important things to note about the squares:

• Each large block contains 25 squares.

• Each small square represents 0.04 seconds of time.
• 5 small squares equal 0.20 seconds of time.
• When we are trying to calculate the heart rate with the six second rule, we must
count out enough LARGE squares to equal 6 seconds. Therefore, 30 large
squares would equal 6 seconds.
 How to Count Atrial and Ventricular Rate using the 6 Second Rule

➢ Atrial Rate

1. Identify the p-waves.

2. Beginning at the first p-wave start counting 30 large squares.
3. Then count how many p-waves are between the 30 large squares.
4. Take that number and multiple it by 10 and this is your heart rate.

➢ Ventricular Rate

1. Identify the r-waves.

2. Beginning at the first r-wave start counting 30 large squares.
3. Then count how many r-waves are between the 30 large squares.
4. Take that number and multiple it by 10 and this is your heart rate.

Quick Heart Rate Quiz

Answer: Heart rate: 80 (normal sinus rhythm)

Answer: Heart Rate: 110s (sinus tachycardia)

 How to Measure the PR Interval on an EKG Strip | PR Interval EKG Quiz
The PR interval represents atrioventricular (AV) node conduction time. The AV node is part
of the electrical conduction system of the heart and is known as the gatekeeper of the
electrical system. The PR interval tends to be longer in older adults and shortens when the
heart rate increases. For example, a patient with tachycardia will have a shorter PR interval
compared to a patient with sinus bradycardia.

 Steps on How to Measure the PR Interval

A normal PR interval measures 0.12-0.20 seconds which is 3 to 5 small boxes on the EKG
strip. When you measure a PR interval, you start measuring at the BEGINNING of the p-
wave until the BEGINNING of the QRS complex.

Here are some simple steps on how to measure the PR interval:

1. Find the P-wave on the EKG strip

2. Determine where the PR interval is, and to do this you start measuring at the
beginning of the p-wave until the beginning of the QRS complex.
3. Count the SMALL boxes between there measurements.
4. Remember each box represents 0.04 seconds. So, if you measure 2 boxes the
measurement of the PR interval would be 0.08 seconds.
 PR Interval Quiz

What is the measurement of the PR interval in figure 1? (See answer key below)

What is the measurement of the PR interval in figure 2? (See answer key below)
What is the measurement of the PR interval in figure 3? (See answer key below)

Answer Key:

Figure 1: 0.08 seconds…note this is an abnormal PR interval

(Rational: There is 1 small box and 2 (0.5 boxes) which when you add 0.02
+0.02+0.04=0.08 seconds)

Figure 2: 0.16 seconds

(Rational: There are 4 small boxes, which when you add the boxes
0.04+0.04+0.04+0.04=0.16 seconds)

Figure 3: 0.28 seconds…note this is an abnormal PR interval

(Rational: There are 7 small boxes, which when you add the boxes
0.04+0.04+0.04+0.04+0.04+0.04+0.04=0.28 seconds)

5 Easy Steps to Always Follow When Analyzing Rhythms

1. Are p-waves present? If so, how many p-waves are present in 6
seconds? (When we count the p-waves you are calculating the atrial rate)
Normal atrial rates are 60-100 beats per minute.
2. Are the p-waves regular? This is where we will measure the distance between
each p-wave with calipers or a sheet of paper.

3. Are the r-waves regular? Again, we will use calipers or a sheet of paper to
measure the distance between each r-wave to see if they are regular.
4. How many r-waves are present in 6 seconds? This is how we calculate the
ventricular rate. We do this the same way we measured the atrial rate. A normal
ventricular rate of 60-100 bpm.
5. If there are p-waves, what is the measurement of the PR-interval? What is the
width of the QRS complex?
Note: We cannot measure a PR interval with a-fib or a-flutter because there are no p-
waves present.
Cardiac Dysrhythmias
❖ Sinus Rhythm
➢ Normal Sinus Rhythm
• Rhythm originates from the SA node.
• Atrial and ventricular rhythms are regular.
• Atrial and ventricular rates are 60 to 100 beats/minute
• PR interval and QRS width are within normal limits.

P waves = 0.18 sec

ORS = 0.06 sec
Atrial and ventricular rate = 70 b/min
There is one P wave before each ORS complex

In Normal Sinus Rhythm (NSR), we will always have the following:

1. P-waves will be present with atrial rate of 60-100 bpm (meaning there will be 6-10
p-waves present in 6 seconds)
2. P-waves will be regular
3. R-waves will be regular
4. There will be 6-10 QRS complexes in 6 seconds to equal a ventricular rate of 60-
100 bpm.
5. PR interval will be measurable and be a length of 0.12-0.20 seconds. And QRS
complex will measure less than 0.12 seconds.
❖ Sinus Dysrhythmias
➢ Sinus Bradycardia
• Atrial and ventricular rhythms are regular.
• Atrial and ventricular rates are less than 60 beats/minute.
• PR interval and QRS width are within normal limits.
• Treatment may be necessary if the client is symptomatic (signs of decreased
cardiac output).
• Note that a low heart rate may be normal for some individuals, such as in
athletes.

➢ Sinus Tachycardia
• Atrial and ventricular rates are 100 to 180.
• Atrial and ventricular rhythms are regular.
• PR interval and ORS width are within normal limits

 Intervention
✓ Identify the cause of tachycardia
✓ Decrease the heart rate to normal by treating the underlying cause.
❖ Atrial Dysrhythmias
➢ Atrial Fibrillation and Atrial Flutter

• Multiple rapid impulses from many foci depolarize in the atria in a totally
disorganized manner at a rate of 350 to 600 times/minute.
• The atria quiver, which can lead to the formation of thrombi.
• Usually, no definitive P wave can be observed, only fibrillatory waves before each
QRS.

 Interventions
✓ Administer oxygen.
✓ Administer anticoagulants as prescribed because of the risk of emboli.
✓ Administer cardiac medications as prescribed to control the ventricular rhythm
and assist in the maintenance of cardiac output.
✓ Prepare the client for cardioversion as prescribed.
✓ Instruct the client in the use of medications as prescribed to control the dysrhythmia.

➢ Difference Between Atrial Fibrillation and Atrial Flutter

 In atrial fibrillation, we will always have the following:
• No p-waves will be present. The little humps we are seeing are called f-waves
(fibrillary waves). Therefore, we cannot count the atrial rate.
• P-waves are not present so we can’t measure if the p-waves are regular.
• R-waves will be irregular because of the random fibrillary waves quivering at various
times.
• Typically, there are 6-10 r-waves in a-fib in 6 seconds, BUT if the patient is having
what is called a-fib with RVR (rapid ventricular response) we can have many r-
waves varying from 11-200. On the heart monitor you would see a fluctuating heart
rate of 110-200 when the a-fib is not controlled.
• PR interval is not measurable because you don’t have p-waves and the QRS
complex is usually less than 0.12 seconds.
 In atrial flutter, we will always have the following:
• No p-waves will be present BUT a wave of f-wave called SAW-TOOTH WAVES. This
will NEVER be present in a-fib. This is a big difference in how you tell if the rhythm
is a-flutter or a-fib.
• P-waves are not present so you can’t measure if the p-waves are regular.
• R-waves tend to be regular BUT they can be irregular depending on the quivering
of the atrium. You can see in the example I provided that this r-waves are irregular.
• Typically, there are 6-10 r-waves in a-flutter in 6 seconds, BUT if the patient is having
what is called rapid a-flutter, you can have many r-waves varying from 11-
• 200. On the heart monitor you would see a fluctuating heart rate of 110-200 when
the a-flutter is not controlled.

• PR interval is not measurable because you don’t have p-waves and the QRS
complex is usually less than 0.12 seconds.

Conclusion
The major difference between a-fib and a-flutter are the saw-tooth waves in a-flutter and
that in a-fib the r-waves are always irregular. The r-waves in a-flutter can be regular or
irregular.
➢ Supra Ventricular Tachycardia (SVT)

➢ Paroxysmal Supraventricular Tachycardia (PSVT)

• HR can be 150-220/min regular rhythm
• P wave often not visible, buried in the QRS or T wave, abnormal shape if seen.
• Patient may experience evidence of reduced CO such as hypotension, palpitations,
dyspnea, and angina.

 Interventions
✓ Vagal maneuvers: Valsalva, coughing, carotid massage
✓ Adenosine (DOC) MR x2
✓ BB, CCB and amiodarone can be considered alternatives.
✓ If vagal maneuvers and drug therapy are unsuccessful, synchronized cardioversion
may be used.
❖ Ventricular Dysrhythmias
➢ Ventricular Tachycardia

• VT occurs because of a repetitive firing of an irritable ventricular ectopic focus at a rate

of 140 to 250 beats/minute or more.
• VT may present as a paroxysm of 3 self-limiting beats or more or may be a sustained
rhythm.
• Ventricular tachycardia is characterized by the absence of P waves, wide QRS
complexes (longer than 0.12 seconds), and typically a rate between 140 and 180
impulses/minute. The rhythm is regular.
• VT can lead to cardiac arrest.

 Stable client with Sustained VT

(With pulse and no signs or symptoms of decreased cardiac output)
✓ Administer oxygen as prescribed.
✓ Administer anti-dysrhythmics as prescribed.

 Unstable client with VT (with pulse and signs and symptoms of decreased
cardiac output)

✓ Administer oxygen and antidysrhythmic therapy as prescribed.

✓ Prepare for synchronized cardioversion if the client is unstable.
✓ The HCP may attempt cough cardiopulmonary resuscitation (CPR) by asking the client
to cough hard every 1 to 3 seconds.

 Pulseless client with VT: Defibrillation and CPR

➢ Ventricular Fibrillation
• Impulses from many irritable foci in the ventricles fire in a totally disorganized manner.
• Ventricular fibrillation has no measurable rate and no visible P waves or QRS
complexes and results from electrical chaos in the ventricles.
• VF is a chaotic (confusion) rapid rhythm in which the ventricles quiver and there is no
cardiac output.
• VF is fatal if not successfully terminated within 3 to 5 minutes.
• Client lacks a pulse, BP, respirations, and heart sounds, and is unconscious.

 Interventions
✓ Initiate CPR until a defibrillator is available.
✓ The client is defibrillated immediately with 120 to 200 joules (biphasic defibrillator) or
360 joules (monophasic defibrillator); check the entire length of the client 3 times to
make sure no one is touching the client or the bed when clear, proceed with
defibrillation.
✓ CPR is continued for 2 minutes, and the cardiac rhythm is reassessed to determine
need for further counter shock.
✓ Administer oxygen as prescribed.
✓ Administer antidysrhythmic therapy as prescribed.

➢ Premature Ventricular Contractions (PVC)

• Premature conduction of a QRS complex
• Wide and distorted in shape compared to a QRS conducted through the normal
conduction pathway.
• Associated with stimulants (caffeine), meds (dig), heart disease, electrolyte
imbalances, hypoxia and emotional stress.
• Tx is based on underlying cause (o2 for hypoxia, reduction of caffeine intake,
electrolyte replacement).
 ➢ Torsades de pointes
• Polymorphic Vtach coupled with prolonged QT interval
• Lethal cardiac arrhythmia that leads to dec CO and can develop quickly into Vfib.
• Assess labs for low mag (normal 1.5-2.5meq/L)
• Tx: IV mag

Pace Rhythms
❖ Atrial
• Pacemaker spike before the P wave only.
• P wave may appear normal, or abnormal, QRS will appear normal.

❖ Ventricular
• Only have pacer spike prior to a wide QRS complex
• Generally, only one ventricle (RV)
❖ Atrioventricular (Dual chamber)
• Paces the RA and RV in sequence
• Will have 2 pacer strikes
• One before the P wave
• One before the QRS complex
• AV pacemakers improve cardiac synchrony between atria and ventricles

❖ Failure to capture
• Pacer spike with no QRS complex
• results in bradycardia, or asystole and dec CO
• usually because of pacer lead (wire) displacement or battery failure.
• Requires immediate attention by MD
 Heart Block
How to tell the Difference Between AV Heart Blocks 1 Degree, Wenckebach,
Mobitz II,Third Degree

• AV 1st Degree
• 2nd Degree Type 1, also called Wenckeback, Mobitz I
• 2nd Degree Type 2, also called Mobitz II
• 3rd Degree which is known as a Complete Heart Block

❖ 1st Degree AV Heart Block

• Regular P-waves and R-waves

• P-wave always accompanying the QRS complex
• QRS complex will measure normal
• PR INTERVAL WILL BE PROLONGED

The big thing we need to take away from this rhythm is that it looks normal (like
normalsinus rhythm) BUT it has a secret. Note the PR interval on the strip. It is much
longer than a normal PR interval. A normal PR interval is 0.12-0.20 and here the PR
interval is greater than 0.20. In addition, this is what will be present with a 1st Degree
AV Heart Block.

❖ 2ND Degree Type 1 | Wenckebach | Mobitz I

• P-waves & R-wave will be IRREGULAR

• PR intervals ABNORMAL

• Missing QRS complex

• CYCLIC
This rhythm is so easy to remember once you figure out its “hallmark”. Note the PR
interval on the EKG strip. See how the PR interval are progressively lengthening and
then suddenly, a QRS complex is missing and then the pattern starts all over? This is
the key in understanding a Wenckebach.

This rhythm is CYCLIC and will always present with progressively lengthen PR
intervals until a QRS complex disappears and then it will repeat itself.

❖ 2nd Degree Type 2 | Mobitz II

• P-waves will be regular, however R-waves will NOT
• PR interval will measure normal (most of the time)
• NO Pattern
• Missing QRS Complexes after p-waves randomly

Many people like to confuse this rhythm with a Wenckebach and third degree.
However,there are some major differences. One being the rhythm is not cyclic, it does
NOT have a pattern. Second, its QRS complexes will be IRREGULAR, and this is the
opposite for a 3rd degree heart block. Third, it can have NORMAL PR Intervals, where
a 3rd degree heart block does not contain any PR Intervals.

Notice the strip above: The p-waves are nice and regular while there are some missing
QRS complexes which makes the R-wave irregular. In addition, there is no pattern of
lengthening p-waves.
❖ 3rd Degree Heart Block (Complete Heart Block)

• P-waves will be Regular AND R-waves will be Regular.

• P-wave will not accompany QRS complexes and vice versus, hence no
relationship between the atriums and ventricles.
• You can’t measure a PR interval because the atriums and ventricles are
independent.

Out of all the heart blocks for a patient, this is the worst one. It requires major
interventions. In this rhythm, the atriums and ventricles are NOT beating together
andare working independently of each other.