atrium and is three times thicker

CARDIAC than the right ventricle.

Ventricular contraction (systole)

RHYTHM
moves blood forward into the
aorta. There it is transported
throughout the body via a

INTERPRETATION
network of arteries, capillaries
and veins.
Eventually the blood will return to
the right atrium where the
oxygenation process starts all
CARDIAC over again.
STRUCTURES
Cardiac Valves
______________. Separates right atrium and
right ventricle.
Mitral:
__________________________________________
___________________.
________________. Between right ventricle
and pulmonary artery.
________________. Between left ventricle and
aorta.
Conduction System of the Heart and
Functions of Each Part
1.__________________. small
Cardiac Chambers and Blood Flow group of cells that function as the
Through the Heart normal pacemaker of the heart
because it has the fastest rate of
The heart is a four-chambered pump made up
automaticity (60-100 times per
of two receiving chambers called atria and
minute).
two pumping chambers called ventricles.
2. __________________. small
group of cells near tricuspid
Right Atrium valve. The AV node have major
Receives oxygen-depleted blood returning functions:
from the body through the superior and
inferior vena cava.  Slows conduction of the
Right Ventricle impulse from atria to
Receives blood from the right ventricles to allow time for
atrium. Ventricular contraction ventricular filling.
(systole) pumps blood forward to  Has automaticity (40-60
the lungs via the right and left times per minute) so can
pulmonary arteries. The blood is function as a backup
oxygenated in the lungs. pacemaker if the sinus
Left Atrium node fails.
Receives oxygen-rich blood from the right 3. Bundle of His: short bundle
and left pulmonary veins. of fibers at the bottom of the AV
Left Ventricle node leading to the bundle
Receives blood from the right branches.
4. Bundle Branches: bundles of to all cells and the entire
fibers located along the septum chamber contracts as one unit.
that carry the impulse into the
right and left ventricles 2. Conducting Cells make up
5. _______________. hair-like the specialized conduction
fibers that spread out from the system in the heart and are
bundle branches along the responsible for initiating and
endocardial surface of both spreading the electrical impulse
ventricles and rapidly carry the in an orderly fashion through the
impulse to ventricular muscle heart. These cells do not
cells. contract; they initiate the
electrical stimulus and transmit
it to the contracting cells.

3. _________________is the
ability of the heart to initiate
an impulse spontaneously
without an external stimulus.
Origin and Spread of the Electrical
4. _______________is the
Impulse in the Heart ability of cardiac cells to reach a
threshold and respond to a
stimulus.

5. ________________is the ability of the

heart to transmit an impulse from cell to
cell.

6. Contractility is the ability of

muscle cells to shorten
(contract) in response to an
electrical stimulus.
7. ________________is the
electrical excitation of the cell
Terms Related to Electrical Physiology of membrane resulting from the
the Heart flow of ions across the
membrane. This wave of
1. Contracting Cells make up excitation spreads from cell to
walls of atria and ventricles and cell through the conduction
are responsible for contraction system and into the muscle
of the chambers. Cells are cells, providing the stimulus for
organized into fibers, which contraction.
connect with each other to form
muscle bundles. Muscle 8. ________________ is the
bundles wrap around each other return of the cell membrane to
and form the chamber. its resting state, again due to
Contracting cells must receive flow of ions across the
an electrical stimulus before membrane. Cells must
they contract. When one cell is repolarize before they can again
stimulated, the impulse spreads depolarize.
ECG Graph Paper and Measurements
● ECG graph paper has a pre-printed
graph
● The smallest unit on the paper is a ‘small
square’ which is 1 mm high and 1 mm
wide.
 ___________________measures time P Wave
of the graph paper.  Is the first component of a normal ECG
● ___________________measures the  Denotes electrical activity in the atria
amplitude or voltage in millimeters (mm).  Represents atrial depolarization which
initiates atrial contraction
 Normally precedes the QRS
TIME  Is small and rounded
 Each small square = Significance
 If a P wave precedes each QRS
 Five small squares = complex and shows an association
to the QRS complex, the impulses
are being conducted from the atria
 Each large square = to the ventricles.
 If a P wave precedes each QRS
 Five large squares = complex and shows an association
to the QRS complex, the impulses
are being conducted from the atria
 Thirty large squares = to the ventricles.
PR Interval Duration
 Three hundred large squares =  PR interval varies with age and

AMPLITUDE(VOLTAGE)MEASUREMENTS
 Each small square is _________
 Each large square is________
 One mV (millivolt) equals 10 mm (10 small
squares or 2 large squares
heart rate. As the person ages,
The Isoelectric Line their heart rate decreases and the
Isoelectric refers to the state of no electrical PR interval lengthens. The limit
activity, no positive or negative electrical that you look for is:
potentials. Therefore, we would expect the  < 3 years 0.08 seconds
isoelectric line to be straight and flat. When
 3 – 16 years 0.10 seconds
monitoring a patient, any electrical change
 16 years 0.12 – 0.20 seconds
picked up by the ECG will show as
variations or waves off the isoelectric line. Significance
In the normal rhythm, as shown above and ● Normal PR interval represents a normal
below, the isoelectric line can be seen prior delay of the impulse through the AV
to the P wave, after the P wave and prior to junction.
the QRS complex, after the QRS complex ● ___________________ represents a
and prior to the T wave, and after the T conduction problem through the AV
wave prior to the next P wave. junction signifying an AV block.
QRS WAVE  Follows the S wave and
Represents ventricular depolarization. ST segment
 Consists of 3 waves  Typically rounded and
1. Q wave - ________________ smooth but slightly
2. R wave - ________________ asymmetrical – the
3. S wave - _________________ upslope is longer than the
Significance downslope
 Not taller than 5 mm
Normal duration -Adults0.08 seconds QT interval
 QT interval represents
The ventricular depolarization wave ventricular
(QRS) is larger than the P wave because  depolarization and
the ventricles are larger than the atria, so repolarization
require a stronger electrical impulse to  The QT interval extends
depolarize the ventricular mass. from the beginning of the
ST Segment QRS complex to the end
 The ST segment represents the end of the T wave
of ventricular depolarization and  Normal QT
the beginning of ventricular interval______________
repolarization ● Significance
 It extends from the end of the S ● QT interval represents
wave to the beginning of the T the time taken for the
wave. The end of the S wave is ventricular
identified as the point where it depolarization and
begins to flatten out into the repolarization cycle.
isoelectric line this point being ● If prolonged, can lead to
known as the J point potentially severe
 Normal ST segment is arrythmias
isoelectric – it is abnormal to e.g. ventricular
have a change greater than 1 mm tachycardia.
above or below the isoelectric
line U Wave
● U wave represent late
 ST Depression repolarization of endocardial
structures (the papillary muscles
and the Purkinje system)
● Significance
● The U wave may or may not
appear on the
 ST Elevation ECG.

11 Steps of ECG
Reading

Step 1. Others
Identify anything you consider unusual
or obvious about the rhythm, e.g., extra
T wave P waves, inverted T waves.
 Represents ventricular
repolarization
 buried within the QRS complex
Step 2. Evaluate the P Wave - Rhythm (R-R interval): regular
Are P waves present? -QRS complex: narrow(</=0.12 sec)
 Do the P waves have a normal
configuration?
 Do all the P waves have a similar
size and shape?
 Is the P wave consistently
followed by a QRS complex?
 Is there a QRS after every P
wave? D. Idioventricular Rhythm
Step 3. Determine the Rhythm -Pacemaker: His Purkinje system (HPS)
with a ventricular rate between 20 to 40
A. Regular Sinus Rhythm bpm)
*For atrial rhythm assessment, -P wave: absent
measure the intervals between - Rhythm (R-R interval): regular
consecutive P waves. -QRS complex: wide (>0.12 sec)
*Rhythm is normally
determined by the sinus node,
which fires at 60-100 beats per
minute.
*Each p wave is followed by a
QRS complex and each QRS
complex is preceded by a p wave
A. Regular Sinus Rhythm
Step 4. Determine the Rate
To determine the heart rate:
 Obtain a six-second rhythm strip
(a piece of ECG paper showing
30 large squares because 1 large
B. Sinus Arryhthmia square of 0.20 secs x 30 = 6 secs).
- Sinoatrial node discharges irregularly  Count the number of P waves and
(sinus node rate varies with the multiply by 10 for atrial rate (i.e.
respiratory cycle) a 6 second strip x 10 = 1 minute).
-Rate: normal (still within 60-100 bpm)  Count the number of QRS
-Rhythm: variation in the P-P interval or complexes and multiply by 10 for
R-R interval >/= 120 msecs (or the the ventricular rate.
shortest and longest of these
intervals differs by more than 10%)
-P waves, PR Interval andQRS:Normal
B. Sinus Arryhthmia

● 14 QRS complexes are in the 6

second strip (30 large boxes)
● 14x10 = 140 beats / minute

C. Junctional (Atrioventricular) Rhythm Step 5. Calculate the Duration of the

-Pacemaker: AV junction with a PR Interval
ventricular rate of 40 to 60 bpm
-Pwave: may appear before, after or
  Count the number of small Step 11. Treatment
squares between the start of the P
wave and the start of the QRS ● Appropriate treatment will be based on the
complex. interpretation
 Normal PR Interval Between 0.12 of the rhythm.
and 0.20 seconds (3-5 small
squares) for adults. ● To summarize:
 Steps 1 – 6 are used to diagnose a
rhythm strip.
 Steps 7 - 9 are additional observations
that can be made when diagnosing a
Step 6. Calculate the Duration of the QRS rhythm strip. Their significance
becomes evident in the context of a 12
 Count the number of small squares from the Lead ECG.
start of the Q wave to the end of the S wave. ATRIAL DYSRHYTHMIAS
 Multiply the number of squares by 0.04 Sinus Node Arrhythmias
seconds. ● Rhythms Originating in the Sinus Node: The
 Normal QRS between 0.06 and 0.10 seconds sinus node is the normal pacemaker of the
heart because it has the fastest rate of
 (1.5 – 2.5 small squares) for adults.
automaticity of all potential pacemaker sites.
The sinus node usually fires regularly at a rate
Step 7. Evaluate the T Wave
between 60 and 100 beats/minute.
 Are T waves present?
1. RHYTHM: Normal Sinus Rhythm (NSR)
 Do they have a normal shape (upright and
A. Rhythm:
rounded)? B. Rate:
 Are there any bumps in the T wave (possibly C. P waves: precede every QRS and are consistent in
shape.
Step 8. Calculate the Duration of the QT Interval D. PR interval:
 Count the number of small squares from the E. QRS complex:
beginning of the Q wave to the end of the T
wave.
 Then multiply the number of squares by 0.04
seconds.
 Normal QT interval For an adult the normal
range is between 0.36 and 0.44 seconds (9 –
11 small squares). 2. RHYTHM: Sinus _________________
Rhythm: regular.
Step 9. Evaluate Any Other Components Rate: faster than 100 beats/minute.
P waves: present before every QRS, consistent in
 Check the ST segment for any abnormalities.
shape, may be hidden in preceding T wave if rate
 Is it isoelectric, depressed or elevated?
very rapid.
 Look for a U wave. PR interval: normal. May be difficult to measure
 Note any findings. when P waves buried in T waves.
QRS complex: usually normal
Step 10. Interpretation
● Based on your assessment of the strip, and by
knowing the rules associated with each
rhythm, what is your interpretation?
 6.RHYTHM:______________________________
3. RHYTHM: Sinus ___________________ Rhythms Originating in the Atria: Ectopic reentry
Rhythm:regular. circuits can occur in the atrial myocardium, resulting
Rate:<60beats minute. in atrial arrhythmias that take control away from the
P waves: precede every QRS, consistent in shape. sinus node.
PR interval: usually normal.
QRS complex: usually normal.

a. Origin: irritable focus in the atria fires before

the next sinus impulse is due.
b. Rhythm: irregular due to early
beats. Have a non compensatory
4. RHYTHM: Sinus Arrhythmia pause (interval between the beat
* Pwaves:consistent in shape, occur irregularly. preceding the PAC and the beat
*Rhythm:irregular, following PAC is deplorization of
* Rate: usually within normal range but can be the atria by the PAC also
bradycardic. prematurely depolarizes the sinus
d. PR interval: usually normal. node and causes it to “reset” itself.
e. QRS complex: normal. c. Rate: usually in normal range.
P waves: precede every QRS
PR interval: may be normal or long depending on
prematurity of PAC

7. RHYTHM: Atrial Tachycardia and

Paroxysmal Atrial Tachycardia (PAT):

5. RHYTHM: ––––––––––––––––––––––––––––– Origin: rapid firing of ectopic atrial focus or reentry

Sinus arrest occurs when sinus node automaticity is Rate: atrial: 150 – 250 bpm
depressed and impulses are not formed when Significance: Can be caused by MI, CHF, hypoxia,
expected. or electrolyte imbalances.
A. Rhythm: irregular due to absence of sinus
node discharge.
B. Rate:–within normal range but may be in
bradycardic.
C. Significance: sinus arrest occurs when sinus
node automaticity is depressed 8. RHYTHM: ____________________________

Atrial rate = 220-300/min

( P as flutter waves )
9. RHYTHM: ___________________________
11.Junctional Rhythm
Cells around the AV node have automaticity and
are capable of becoming pacemakers when the
sinus node fails.

 No discernible waves
 Irregular RR interval
 Impulses from the AV node
9.A  P wave inverted or buried w/in QRS or
RHYTHM:_________________________ follows the QRS
 Rate can be slow or accelerated
 QRS narrow

9.B Atrial fibrillation

9.C
RHYTHM:_________________________

10. RHYTHM:_________________________

Interpretation: Junctional Rhythm tachycardia(HR

more than 100)

a. Rhythm: regular.
b. Rate: 150 – 300bpm
c. P waves: usually not visible or buried.
 13.E.
VENTRICULAR DYSRHYTHMIAS Interpretation:____________________________
Ventricular Rhythms: Ventricular rhythms
originate in ventricular myocardium or Purkinje
system and are considered to be more dangerous than
supraventricular rhythms because of their greater
potential to limit cardiac output.

12. Premature Ventricular Complexes (PVCs)

A. Origin: focus in ventricular 13.F
myocardium. Interpretation: Normal sinus rhythm with unifocal
B. Rhythm: irregular due to early beats bigemini PVCs
or due to pause allowing escape beat.
C. Rate: may occur at any heart rate and
with any basic rhythm.

12.A. Interpretation: Normal sinus rhythm with

unifocal PVCs

13.G Interpretation:__________________________

12.B. Interpretation: Normal sinus rhythm with

multifocal PVCs

13.H Interpretation:__________________________

13.C.
Interpretation:____________________________

Ventricular Tachycardia
● VT is a ventricular rhythm
● Rate: faster than 100 beats/minute.
* Monomorphic, meaning that all QRS complexes
13.D look alike,
Interpretation:____________________________ * Polymorphic, QRS complexes change shape and
do not look alike. A special type of polymorphic VT,
called Torsade de Points (“twisting of the points”)
14.Interpretation:____________________________ c. Rate: unable to measure due to rapid,
uncoordinated activity.
d. P waves: none.
e. PR interval: none.
f. QRS complex: none

Interpretation:Ventricular Fibrillation

15.Interpretation:____________________________

16.Interpretation:____________________________

Asystole:

Asystole is total loss of ventricular electrical activity

resulting in no ventricular contraction and no cardiac
output. Asystole is always fatal unless it can be
corrected immediately.
17.Interpretation:____________________________
__________________________________________

a. Rhythm: none.
b. Rate: none.
c. P waves:none
d. PR interval: none.

Significance: always fatal unless immediately

corrected
Ventricular Fibrillation:
------Flatline Protocol-----
● VF is chaotic electrical activity in the 1.Check lead attachment
ventricles that results in quivering of the 2. Increase Size Selection of leads
ventricles and total loss of cardiac output. VF 3. Check power on/off
is always fatal unless treated immediately.

a. Origin: rapid, disorganized electrical

activity within the ventricles.
b. Rhythm: chaotic, irregular.
HEART BLOCKS Rhythm: Second Degree AV Block – Type I (Wenckebach)
AV block is used when there is delayed or failed
conduction of impulses from the atria to the
ventricles.
Interpretation:__________________________

● P waves present
● QRS complexes present
● P wave morphology and axis usual for the
subject
● QRS complexes morphology and axis usual
for the subject
• Rhythm: usually regular ● Progressive prolongation of the P-R interval
• PR interval > 0.20 sec with each succeeding beat until one P wave
• P waves: normal, occurs without a QRS ( dropped beat)
precede every QRS.

Second Degree Atrio-Ventricular Blocks Second Degree AV block- Type II (Mobitz)

A. Rhythm: irregular due to blocked

beats.

B. P waves: normal and precede each

QRS. Some P waves are not followed
by QRS complexes.(drop beat)

C. PR interval: constant before

conducted beats. The PR interval
preceding the pause is the same as
that following the pause.
Third Degree AV Block

All atrial impulses are blocked in the AV node or

bundle branch system; resulting in dissociation
between the sinus or atrial rhythm and the junctional
or ventricular escape rhythm controlling the
ventricles.
 P waves: normal but dissociated from
QRS complexes.
 PR interval: no relationship between
P waves and QRS complexes, so no
consistent PR intervals

----------------------Nothing Follows--------------------

Pacemakers: Prepared by:

Jojo A. Sarmiento RN, SCFHS-RN,NHRA-RN, USRN

Temporary pacemakers:
● A temporary pacemaker is often inserted in
an emergency. The patient may show signs of
decreased cardiac output, such as
hypotension or syncope.
● types of temporary pacemakers are available,
including transvenous, and transcutaneous.

Permanent pacemaker
 is used to treat chronic heart
conditions such as AV block. It is
surgically implanted, usually under
local anesthesia.