topics

See also type of

defined, 21, 472–473

downward, 18

intervals, 21

key points, 28

labeling (practice strips), 31–32

losing, 54

patterns, 20

practice strip examples, 31–38

segments, 21

self-test, 28–30

upright, 18

Wenckebach (Second-Degree Block, Type I). See SecondDegree Block, Type I (Wenckebach)

wide QRS, 56, 489

This page intentionally left blank

Flash Cards

Basic Arrhythmias is a self-instructional textbook. Each chapter is carefully constructed

to walk you through educational concepts, show you the skills you need, and enable

you to practice applying what you have learned.

Unfortunately, some things can’t be learned by reading or by practice. Some factual material, like the multiplication tables, just has to be memorized. There’s no way

around it.

These flash cards address all the factual material in this book that must be memorized for you to interpret basic arrhythmias. The front of each card asks the questions,

and the back provides the answers. Use them in drills, alone, or with fellow students,

until you have complete comfort with the information they contain.

This page intentionally left blank

EKG

COMPLEX

THE

AUTONOMIC

NERVOUS SYSTEM

PRI & QRS

COMPLEXES

Explain how PRI and QRS are measured:

The PRI is measured from

which point to which point?

What is the normal duration

for PRI?

The QRS is measured from

which point to which point?

What is the normal duration

for QRS?

MEASURING PRI MEASURING QRS

Name the parts of the conduction system:

2A:

2B:

5A:

5B:

Explain how the two branches of the autonomic

nervous system work in balance with each other to

control the heart:

1. Which chambers does this

branch affect?

2. When this branch is stimulated,

what happens to heart rate,

conduction, and irritability?

1. Which chambers does this

branch affect?

2. When this branch is stimulated,

what happens to heart rate,

conduction, and irritability?

SYMPATHETIC BRANCH PARASYMPATHETIC BRANCH

Locate the components of a normal cardiac cycle:

1. Waves: P, Q, R, S, T

2. PR Interval

3. PR Segment

4. QRS Complex

CARDIAC

CONDUCTION

SYSTEM

Complex

EKG

Basic Arrhythmias, 8th Edition, by Gail Walraven

PRI & QRS Complexes

Basic Arrhythmias, 8th Edition, by Gail Walraven

Cardiac Conduction System

Basic Arrhythmias, 8th Edition, by Gail Walraven

The Autonomic Nervous System

Basic Arrhythmias, 8th Edition, by Gail Walraven

—irritability

—conduction

—heart rate

Increases:

ventricles

and the

Affects the atria

—irritability

—conduction

—heart rate

Decreases:

atria

Affects only the

SYMPATHETIC

BRANCH

PARASYMPATHETIC

BRANCH

Inter

Intraatrial pathway

Sinoatrial (SA) node

nodal pathways

Purkinje fibers

Right bundle branch

Left bundle branch

Bundle of His

Atrioventricular (AV) junction

The parts of the conduction system:

MEASURING PRI MEASURING QRS

0.12

The normal PRI is

complex.

to the beginning of the QRS

the beginning of the P wave

The PRI is measured from

–0.20 second. <0.12 second.

The QRS is normally

to the end of the S wave.

the beginning of the Q wave

The QRS is measured from

2B:

2A:

5B:

5A:

Segment

QRS

PRI

} }

NORMAL SINUS

RHYTHM

HEART RATE

CALCULATION

INHERENT

RATES

EKG WAVE

PATTERNS

How do you calculate heart rate…

1. …when the rhythm is irregular, or you want a very quick (but rough)

estimate?

2. …when the rhythm is regular and you need a quick (but accurate)

estimate?

3. …when the rhythm is regular and accuracy is more important than

speed?

Name each EKG wave area and

explain its electrical activity:

The inherent rates of the three pacemaker sites are:

What are each of these areas called?

What cardiac electrical activity is associated with

each area?

SA Node

AV Node

Ventricles

bpm

What are the rules for this rhythm? (Regularity, Rate, P wave, PRI, QRS)

SINUS node is the pacemaker, firing at a regular rate of 60–100 times

per minute. Each beat is conducted normally through to the ventricles.

Heart Rate Calculation

Basic Arrhythmias, 8th Edition, by Gail Walraven

Normal Sinus Rhythm

Basic Arrhythmias, 8th Edition, by Gail Walraven

EKG Wave Patterns

Basic Arrhythmias, 8th Edition, by Gail Walraven

Inherent Rates

Basic Arrhythmias, 8th Edition, by Gail Walraven

No electrical activity

Ventricular repolarization

Ventricular depolarization

Delay at AV node

Atrial depolarization

ELECTRICAL ACTIVITY

REGULARITY:

RATE:

P WAVE:

PRI:

QRS:

The rules for this rhythm:

The QRS complex measures less than 0.12 second.

the PRI measurement is constant across the strip.

The PR interval measures between 0.12 and 0.20 second;

in front of every QRS complex.

The P waves are upright and uniform. There is one P wave

between 60 and 100 bpm.

The atrial and ventricular rates are equal; heart rate is

The R–R intervals are constant; the rhythm is regular.

Ventricles

AV Node

SA Node

bpm

bpm 60 100

40 60

20 40

METHOD FEATURES

consecutive R waves and divide into 300.

Count the number of large squares between 2

and multiply by 10.

Count the number of R waves in a 6-second strip

–OR– memorize this scale:

Count the number of small squares between 2

consecutive R waves and divide into 1,500. •

• Most accurate

Time-consuming

• Used only with regular rhythms

• Only used with regular rhythms

• Not very accurate with fast rates

• Very quick

• Used only for very quick estimate

• Not very accurate

2 large squares = 150 bp

1 large square = 300 bpm

3 large squares = 100 bpm

4 large squares = 75 bpm

5 large squares = 60 bpm

6 large squares = 50 bpm

Isoelectric line

T wave

QRS complex

PR segment

P wave

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Sinus Arrhythmia

Basic Arrhythmias, 8th Edition, by Gail Walraven

Wandering Pacemaker

Basic Arrhythmias, 8th Edition, by Gail Walraven

Sinus Bradycardia

Basic Arrhythmias, 8th Edition, by Gail Walraven

Sinus Tachycardia

Basic Arrhythmias, 8th Edition, by Gail Walraven

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measures less than 0.12 second.

less than 0.12 second.

All PRI measurements should be less than 0.20 second; some may be

The PRI measurement will vary slightly as the pacemaker site changes.

be difficult to see, depending on the pacemaker site.

There is one P wave in front of every QRS complex, although some may

The morphology of the P wave changes as the pacemaker site changes.

normal range (60–100 bpm) but can be slower.

The atrial and ventricular rates are equal; heart rate is usually within a

rhythm can be slightly irregular.

The R–R intervals vary slightly as the pacemaker site changes; the

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measures less than 0.12 second.

the PRI measurement is constant across the strip.

The PR interval measures between 0.12 and 0.20 second;

There is a uniform, upright P wave in front of every QRS complex.

160 bpm).

is greater than 100 bpm (usually between 100 and

The atrial and ventricular rates are equal; the heart rate

The R–R intervals are constant; the rhythm is regular.

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

The R–R intervals vary; the rate changes with the patient’s

The QRS complex measures less than 0.12 second.

the PRI measurement is constant across the strip.

The PR interval measures between 0.12 and 0.20 second;

There is a uniform, upright P wave in front of every QRS complex.

can be slower.

usually in a normal range (60–100 bpm), but

The atrial and ventricular rates are equal; heart rate is

respirations.

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measures less than 0.12 second.

the PRI measurement is constant across the strip.

The PR interval measures between 0.12 and 0.20 second;

There is a uniform, upright P wave in front of every QRS complex.

less than 60 bpm.

The atrial and ventricular rates are equal; heart rate is

The R–R intervals are constant; the rhythm is regular.

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Basic Arrhythmias, 8th Edition, by Gail Walraven

The rules for this rhythm:

The R–R intervals are constant; the rhythm is regular.

Atrial Tachycardia

Atrial Flutter

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

REGULARITY:

RATE:

PRI:

QRS:

rhythm is grossly irregular, having no pattern to its irregularity

The atrial rhythm is unmeasurable; all atrial activity is chaotic. The ventricular

100 bpm or less, the rhythm is said to be “controlled”. If it is over 100 bpm

because the AV node blocks most of the impulses. If the ventricular rate is

that it exceeds 350 bpm. The ventricular rate is significantly slower

The atrial rate cannot be measured because it is so chaotic; research indicates

, it is

considered to have a “rapid ventricular response” and is called “uncontrolled.”

The QRS complex measurement should be less than 0.12 second.

Since no P waves are visible, no PRI can be measured.

“fibrillatory” waves, or grossly chaotic undulations of the baseline.

are fibrillating. Thus, no P wave is produced. All atrial activity is depicted as

In this arrhythmia the atria are not depolarizing in an effective way; instead, they

Atrial Fibrillation

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

than the P waves of the rest of the strip. The ectopic beat will have

The P wave of the premature beat will have a different morphology

The overall heart rate will depend on the rate of the underlying rhythm.

regularity of the underlying rhythm.

Since this is a single premature ectopic beat, it will interrupt the

The QRS complex measurement will be less than 0.12 second.

PRI measurements of the other complexes.

prolonged; the PRI of the ectopic will probably be different from the

The PRI should measure between 0.12 and 0.20 second, but can be

be hidden within the T wave of the preceding complex.

P wave, but it can be flattened, notched, or otherwise unusual. It may

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

the ventricular rate will be irregular

node conducts impulses through in a consistent pattern. If the pattern varies,

The atrial rhythm is regular. The ventricular rhythm will be regular if the AV

difficult if one or more Flutter waves is concealed within the QRS complex.

The QRS complex measures less than 0.12 second; measurement can be

a PRI in this arrhythmia. Therefore, the PRI is not measured in Atrial Flutter.

proximity of the wave to the QRS complex, it is often impossible to determine

Because of the unusual configuration of the P wave (Flutter wave) and the

seen together, these “Flutter” waves have a sawtooth appearance.

When the atria flutter they produce a series of well-defined P waves. When

depend on the ratio of impulses conducted through to the ventricles.

Atrial rate is between 250 and 350 bpm. Ventricular rate will

Premature Atrial Complex

Basic Arrhythmias, 8th Edition, by Gail Walraven

The QRS complex measures less than 0.12 second.

There is one P wave in front of every QRS complex. The configuration of th

bpm.

The atrial and ventricular rates are equal; the heart rate is usually 150–250

notched. Because of the rapid rate, the P waves can be hidden in the

P wave will be different than that of sinus P waves; they may be flattened or

The PRI is between 0.12 and 0.20 seconds and constant across the strip

waves of the preceding beats.

The PRI may be difficult to measure if the P wave is obscured by the T wave.

P WAVE:

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REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measurement will be less than 0.12 second.

it, there will be no PRI.

0.12 second. If the P wave falls within the QRS complex or following

If the P wave precedes the QRS complex, the PRI will be less than

inverted.

lost entirely within the QRS complex. If visible, the P wave will be

The P wave can come before or after the QRS complex, or it can be

Usual range is 100–180 bpm.

range, but does not usually exceed 180 bpm.

Atrial and ventricular rates are equal. The rate will be in the tachycardia

The R–R intervals are constant; the rhythm is regular.

Junctional Tachycardia

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measurement will be less than 0.12 second.

it, there will be no PRI.

0.12 second. If the P wave falls within the QRS complex or following

If the P wave precedes the QRS complex, the PRI will be less than

inverted.

lost entirely within the QRS complex. If visible, the P wave will be

The P wave can come before or after the QRS complex, or it can be

Junction is 40–60 bpm.

Atrial and ventricular rates are equal; the inherent rate of the AV

The R–R intervals are constant; the rhythm is regular.

Junctional Escape Rhythm

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex will be less than 0.12 second.

it, there will be no PRI.

0.12 second. If the P wave falls within the QRS complex or following

If the P wave precedes the QRS complex, the PRI will be less than

inverted.

lost entirely within the QRS complex. If visible, the P wave will be

The P wave can come before or after the QRS complex, or it can be

It will be in the 60–100 bpm range.

AV junction’s inherent rate but not yet into a true tachycardia range.

Atrial and ventricular rates are equal. The rate will be faster than the

The R–R intervals are constant; the rhythm is regular.

Accelerated Junctional Rhythm

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measurement will be less than 0.12 second.

it, there will be no PRI.

0.12 second. If the P wave falls within the QRS complex or following

If the P wave precedes the QRS complex, the PRI will be less than

inverted.

lost entirely within the QRS complex. If visible, the P wave will be

The P wave can come before or after the QRS complex, or it can be

The overall heart rate will depend on the rate of the underlying rhythm.

regularity of the underlying rhythm. The R–R interval will be irregular.

Since this is a single premature ectopic beat, it will interrupt the

Premature Junctional Complex

Basic Arrhythmias, 8th Edition, by Gail Walraven

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Basic Arrhythmias, 8th Edition, by Gail Walraven

The rules for this rhythm:

Complete Heart Block

Basic Arrhythmias, 8th Edition, by Gail Walraven

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: The QRS complex measurement will be less than 0.12 second.

again.

followed by a QRS complex. After the blocked beat, the cycle starts

The PR intervals get progressively longer, until one P wave is not

by QRS complexes.

The P waves are upright and uniform. Some P waves are not followed

normal (60–100 bpm).

slightly slower than normal (<100 bpm). The atrial rate is

Since some beats are not conducted, the ventricular rate is usually

The R–R interval is irregular in a pattern of grouped beating.

Wenckebach Type I Second-Degree Heart Block

Basic Arrhythmias, 8th Edition, by Gail Walraven

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

and the rhythm will be regular. If the conduction ratio varies, the R–

If the conduction ratio is consistent, the R–R interval will be constant,

bradycardia range (< 60 bpm), often one half, one third, or on

atrial impulses are blocked, the ventricular rate will usually be in the

The atrial rate is usually normal (60–100 bpm). Since many of the

will be irregular.

The QRS complex measurement will be less than 0.12 second.

it might be longer than a normal PRI measurement.

The PRI on conducted beats will be constant across the strip, although

than QRS complexes.

The P waves are upright and uniform. There are always more P waves

fourth of the atrial rate.

REGULARITY:

RATE:

P WAVE:

PRI:

QRS:

The atrial rate will usually be in a normal range. The ventricular rat

and the R–R intervals are regular.

Both the atrial and the ventricular foci are firing regularly; thus the P–P intervals

be 40–60

will be slower. If a junctional focus is controlling the ventricles, the rate will

bpm. If the focus is ventricular, the rate will be 20–40 bpm.

Since the block

The P waves are upright and uniform. There are more P waves than QRS complexes.

at the AV node is complete, none of the atrial impulses is conducted

measure less than 0.12 second. If the focus is ventricular, the QRS will measur

If the ventricles are being controlled by a junctional focus, the QRS complex will

complex.

QRS complexes. You may occasionally see a P wave superimposed on the QRS

through to the ventricles. There is no PRI. The P waves have no relationship to the

0.12 second or greater.

Type II Second-Degree Heart Block

Basic Arrhythmias, 8th Edition, by Gail Walraven

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

second.

The QRS complex measurement will be less than 0.12

always be greater than 0.20 second.

The PRI will be constant across the entire strip, but it will

be followed by a QRS complex.

The P waves will be upright and uniform. Each P wave will

The rate will depend on the rate of the underlying rhythm.

This will depend on the regularity of the underlying rhythm.

First-Degree Heart Block

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REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

This rhythm is usually regular, although it is less reliable as

0.12 second.

The QRS complex is wide and bizarre, measuring at least

There is no PRI.

There are no P waves in this arrhythmia.

below 20 bpm.

The ventricular rate is usually 20–40 bpm, but it can drop

the heart dies.

Idioventricular Rhythm

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

the T wave.

0.12 second. It is often difficult to differentiate between the QRS and

The QRS complexes will be wide and bizarre, measuring at least

Since the rhythm originates in the ventricles, there will be no PRI.

see dissociated P waves intermittently across the strip.

None of the QRS complexes will be preceded by P waves. You may

VT. If the rate exceeds 250 bpm, it is called Ventricular Flutter.

150–250 bpm. If the rate is below 150 bpm, it is considered a slow

Atrial rate cannot be determined. The ventricular rate range is

This rhythm is usually regular, although it can be slightly irregular.

Ventricular Tachycardia

The rules for this rhythm:

Ventricular Fibrillation

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS:

direction from the QRS complex.

underlying QRS complexes. The T wave is frequently in the opposite

second. The configuration will differ from the configuration of the

The QRS complex will be wide and bizarre, measuring at least 0.12

Since the ectopic comes from a lower focus, there will be no PRI.

P wave near the PVC, but it is dissociated.

The ectopic is not preceded by a P wave. You may see a coincidental

not produce a pulse.

usually included in the rate determination because they frequently do

The rate will be determined by the underlying rhythm. PVCs are not

is interpolated).

will interrupt the regularity of the underlying rhythm (unless the PVC

The underlying rhythm can be regular or irregular. The ectopic PVC

Premature Ventricular Complex

REGULARITY:

RATE:

P WAVE:

PRI:

QRS:

determine regularity. The baseline is totally chaotic

There are no waves or complexes that can be analyzed to

There is no PRI

There are no discernible P waves.

ible waves or complexes to measure.

The rate cannot be determined since there are no discern-

There are no discernible QRS complexes.

Basic Arrhythmias, 8th Edition, by Gail Walraven

ASYSTOLE

The heart has lost its electrical activity. There is no electrical pacemaker

to initiate electrical flow.

What are the rules for this rhythm? (Regularity, Rate, P wave, PRI, QRS)

Basic Arrhythmias, 8th Edition, by Gail Walraven

REGULARITY:

The rules for this rhythm:

RATE:

P WAVE:

PRI:

QRS: There is no electrical activity; only a straight line.

There is no electrical activity; only a straight line.

There is no electrical activity; only a straight line

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