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 Standard Chest Lead Electrode Placement
The chest leads are identified as V 1, V2 , V3 , V4 , V5 , and V6 • Each electrode
placed in a "V" position is positive.

Midclavicular
\ line
Anterior
axillary Iine
Midaxillary
line
 Elements of Chest Leads
Lead Positive Electrode Placement View of Heart
v, 4th lntercostal space to right of sternum Septum
V2 4th lntercostal space to left of sternum Septum
V3 Directly between V2 and V4 Anterior
v4 5th lntercostal space at left midclavicular line Anterior
Vs Level with V4at left anterior axillary line Lateral
Vs Level with Vs at left midaxillary line Lateral
 Constant speed of 25 mm/sec

0.04 sec
I• .. I

1mmID10.1 mv Large
Small box
5mm
box
0.5 mv
I• •I
0.20 sec
 Method 1: Count Large Boxes
Regular rhythms can be quickly determined by counting the number of
large graph boxes between two R waves. That number is divided into 300
to calculate bpm. The rates for the first one to six large boxes can be easily
memorized. Remember: 60 sec/min divided by 0.20 sec/large box = 300
large boxes/min.

-.---.--+-+--.-....---.--.--.-. 30 0 150 10 0 7 5 60
' I !' ! !

Counting large boxes for heart rate. The rate is 60 bpm.

 Method 2: Count Small Boxes
The most accurate way to measure a regular rhythm is to count the number
of small boxes between two R waves. That number is divided into 1500 to
calculate bpm. Remember: 60 sec/min divided by 0.04 sec/small box =1500
small boxes/min.
Examples: If there are three small boxes between two R waves: 1500/3 =
500 bpm.
If there are five small boxes between two R waves: 1500/5 =
300 bpm.
 Method 3: Six-Second ECG Rhythm Strip
The best method for measuring irregular heart rates with varying R-R intervals is to count the number
of R waves in a 6-sec strip (including extra beats such as PVCs, PACs, and PJCs) and multiply by 10. This
gives the average number of beats per minute.

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~ Clinical Tip: If a rhythm is extremely irregular, it is best to count the number of R-R intervals per
60 sec (1 min).
 Sinoatrial (SA) Node Arrhythmias
• Upright P waves all look similar. Note: All ECG strips in Tab 2 were recorded in Lead II.
• PR intervals and ORS complexes are of normal duration.

Normal Sinus Rhythm (NSR)

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Rate: Normal (60-100 bpm)

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)

~ Clinical lip: A normal ECG does not exclude heart disease.

~ Clinical lip: This rhythm is generated by the sinus node and its rate is within normal limits (60-SO bpm) .
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 Sinus Bradycardia
• The SA node discharges more slowly than in NSR.

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Rate: Slow (<60 bpm)

Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Normal (0.12-0.20 sec)
QRS: Normal (0.06-0.10 sec)

• Clinical lip: Sinus bradycardia is normal in athletes and during sleep. In acute Ml, it may be protec-
tive and beneficial or the slow rate may compromise cardiac output . Certain medications, such as beta
blockers, may also cause sinus bradycardia.
 Atrial Tachycardia
• A rapid atrial rate overrides the SA node and becomes the dominant pacemaker.
• Some ST segment and T wave abnormalities may be present.

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Rate: 150-250 bpm

Rhythm: Regular
P Waves: Normal (upright and uniform) but differ in shape from sinus P waves
PR Interval: May be short (<0.12 sec) in rapid rates
QRS: Normal (0.06-0.1 0 sec) but can be aberrant at times
 Supraventricular Tachycardia (SVT)
• This arrhythmia has such a fast rate that the P waves may not be seen.

Rate: 150-250 bpm

Rhythm: Regular
P Waves: Frequently buried in preceding T waves and difficult to see
PR Interval: Usually not possible to measure
QRS: Normal (0.06--0.10 sec) but may be wide if abnormally conducted through ventricles

• Clinical lip: SVT may be related to caffeine intake, nicotine, stress, or anxiety in healthy adults.
• Clinical lip: Some patients may experience angina, hypotension, light-headedness, palpitations,
and intense anxiety.
 Paroxysmal Supraventricular Tachycardia (PSVT)
• PSVT is a rapid rhythm that starts and stops suddenly.
• For accurate interpretation, the beginning or end of the PSVT must be seen.
• PSVT is sometimes called paroxysmal atrial tachycardia (PAT).

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Rate: 150- 250 bpm

Rhythm: Irregular
P Waves: Frequently buried in preceding T waves and difficult to see
PR Interval: Usually not possible to measure
ORS: Normal (0.06-0.10 sec) but may be wide if abnormally conducted through ventricles

• Clinical Tip: The patient may feel palpitations, dizziness, lightheadedness, or anxiety.
 Atrial Flutter (A-flutter)
• AV node conducts impulses to the ventricles at a ratio of 2:1, 3:1 , 4:1, or greater (rarely 1:1 ).
• The degree of AV block may be consistent or variable.

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Rate: Atrial: 250-350 bpm; ventricular: variable

Rhythm: Atrial: regular; ventricular: variable
P Waves: Flutter waves have a saw-toothed appearance; some may be buried in the ORS and not visible
PR Interval: Variable
QRS: Usually normal (0.06-0.10 sec), but may appear widened if flutter waves are buried in ORS

• Clinical Tip: A-flutter may be the first indication of cardiac disease.

• Clinical Tip: Signs and symptoms depend on ventricular response rate.
 Atrial Fibrillation (A-fib)
• Rapid, erratic electrical discharge comes from multiple atrial ectopic foci.
• No organized atrial depolarization is detectable.

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Rate: Atrial: >350 bpm; ventricular: variable

Rhythm: Irregular
P Waves: No true P waves; chaotic atrial activity
PR Interval: None
QRS: Normal (0.06-0.10 sec)

Clinical lip: A-fib is usually a chronic arrhythmia associated with underlying heart disease.
Clinical lip: Signs and symptoms depend on ventricular response rate.
 Wolff-Parkinson-White (WPW) Syndrome
• In WPW, an accessory conduction pathway is present between the atria and the ventricles.
Electrical impulses are rapidly conducted to the ventricles.
• These rapid impulses slur the initial portion of the ORS; the slurred effect is called a delta wave.

Rate: Depends on rate of underlying rhythm

Rhythm: Regular unless associated with A-fib
P Waves: Normal (upright and uniform) unless A-fib is present
PR Interval: Short (<0.12 sec) if P wave is present
QRS: Wide (>0.10 sec); delta wave present

• Clinical lip: WPW is associated with narrow-complex tachycardias, including A-flutter and A-fib.
 Ventricular Tachycardia (VT): Monomorphic
• In monomorphic VT, ORS complexes have the same shape and amplitude.

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Rate: 100-250 bpm

Rhythm: Regular
P Waves: None or not associated with the ORS
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

• Clinical Tip: It is important to confirm the presence or absence of pulses because monomorphic VT
may be perfusing or nonperfusing.
• Clinical Tip: Monomorphic VT will probably deteriorate into VF or unst able VT if sustained and not
treated.
 Ventricular Tachycardia (VT): Polymorphic
• In polymorphic VT, QRS complexes vary in shape and amplitude.
• The QT interval is normal or long.

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Rhythm: Regular or irregular
P Waves: None or not associated with the QRS
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

• Clinical Tip: It is important to determine whether pulses are present because polymorphic VT may
be perfusing or nonperfusing.
• Clinical Tip: Consider electrolyte abnormalities as a possible cause.
 Torsade de Pointes
• The ORS reverses polarity and the strip shows a spindle effect.
• This rhythm is an unusual variant of polymorphic VT with long QT intervals.
• In French the term means "twisting of points."

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Rate: 200-250 bpm

Rhythm: Irregular
P Waves: None
PR Interval: None
QRS: Wide (>0.10 sec), bizarre appearance

Clinical Tip: Torsade de pointes may deteriorate to VF or asystole.

Clinical Tip: Frequent causes are drugs that prolong the QT interval, and electrolyte abnormalities
such as hy oma nesemia.
 Ventricular Fibrillation (VF)
• Chaotic electrical activity occurs with no ventricular depolarization or contraction.
• The amplitude and frequency of the fibrillatory activity can define the type of fibrillation as coarse,
medium, or fine. Small baseline undulations are considered fine; large ones are coarse.

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Rate: Indeterminate
Rhythm: Chaotic
P Waves: None
PR Interval: None
QRS:None

• Clinical Tip: There is no pulse or cardiac output. Rapid intervention is critical. The longer the delay,
the less the chance of conversion.
 Pulseless Electrical Activity (PEA)
• The monitor shows an identifiable electrical rhythm, but no pulse is detected.
• The rhythm may be sinus, atrial, junctional, or ventricular.
• PEA is also called electromechanical dissociation (EMO) .

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Rhythm: Reflects underlying rhythm
P Waves: Reflects underlying rhythm
PR Interval: Reflects underlying rhythm
QRS: Reflects underlying rhythm

• Clinical lip: Potential causes of PEA are trauma, tension pneumothorax, thrombosis (pulmonary or
coronary), cardiac tamponade, toxins, hypo- or hyperkalemia, hypovolemia, hypoxia, hypoglycemia,
hypothermia, and hydrogen ion (acidosis).
 Asystole
• Electrical activity in the ventricles is completely absent.

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Rate: None
Rhythm: None
P Waves: None
PR Interval: None
QRS: None

• Clinical lip: Rule out other causes such as loose leads, no power, or insufficient signal gain.
• Clinical lip: Seek to identify the underlying cause as in PEA. Also, search to identify VF.
 Atrioventricular (AV) Blocks
• AV blocks are divided into three categories: first, second, and third degree.

Rrst-Degree AV Block

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Rate: Depends on rate of underlying rhythm
Rhythm: Regular
P Waves: Normal (upright and uniform)
PR Interval: Prolonged (>0.20 sec)
QRS: Normal (0.06- 0.10 sec)
• Clinical lip: Usually a first-degree AV block is benign, but if associated with an acute Ml it may lead
to further AV defects.
• Clinical lip: Often AV block is caused by medications that prolong AV conduction; these include
digoxin, calcium channel blockers, and beta blockers.
 Second-Degree AV Block-Type I
(Mobitz I or Wenckebach)
PR intervals become progressively longer until one P wave is totally blocked and produces no ORS
complex. After a pause, during which the AV node recovers, this cycle is repeated .

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Rate: Depends on rate of underlying rhythm

Rhythm: Atrial: regular; ventricular: irregular
P Waves: Normal (upright and uniform), more P waves than ORS complexes
PR Interval: Progressively longer until one P wave is blocked and a ORS is dropped
QRS: Normal (0.06-0.10 sec)

• Clinical lip: This rhythm may be caused by medication such as beta blockers, digoxin, and calcium
channel blockers. lschemia involving the right coronary artery is another cause.
 Second-Degree AV Block-Type II
(Mobitz II)
Conduction ratio (P waves to ORS complexes) is commonly 2:1, 3:1, or 4:1 , or variable.
ORS complexes are usually wide because this block usually involves both bundle branches.

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Rate: Atrial: usually 60-100 bpm; ventricular: slower than atrial rate
Rhythm: Atrial: regular; ventricular: regular or irregular
P Waves: Normal (upright and uniform); more P waves than ORS complexes
PR Interval: Normal or prolonged but constant
QRS: May be normal, but usually wide (>0.10 sec) if the bundle branches are involved

• Clinical Tip: Resulting bradycardia can compromise cardiac output and lead to complete AV block.
This rhythm often occurs with cardiac ischemia or an Ml.
 Third-Degree AV Block
• Conduction between atria and ventricles is totally absent because of complete electrical block at or
below the AV node. This is known as AV dissociation.
• "Complete heart block" is another name for this rhythm .

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Rate: Atrial: 60-100 bpm; ventricular: 40-60 bpm if escape focus is junctional, <40 bpm if escape focus
is ventricular
Rhythm: Usually regular, but atria and ventricles act independently
P Waves: Normal (upright and uniform); may be superimposed on ORS complexes or T waves
PR Interval: Varies greatly
QRS: Normal if ventricles are activated by junctional escape focus; wide if escape focus is ventricular

9 Clinical Tip: Third-degree AV block may be associated with ischemia involving the left coronary
arteries.
ST elevation is seen in leads II, III, aVF and reciprocal ST depression changes in
I, aVL,V5, V6.
Lateral Posterior Septa I Anterior

Inferior Lateral Septa I Lateral

Inferior Inferior Anterior Lateral

Inferior Wall Ml:

II aVL
 44 -

r, I- - t . H <

Acute inferior infarction; lateral ischaemia

Note
• Sinus rhythm, rate 70/min
• Normal axis
• Q waves in leads Ill and VF
• Normal QRS complexes
• Raised ST segments in leads II, Ill and VF
• Inverted T waves in lead VL (abnormal) and in lead V1 (normal)
Right Bundle Branch Block

i. Wide QRS complex

ii. RSR pattern or rabbit ear pattern in Vl
111. Broad and slurred S wave in leads I and V6
iv. Right axis deviation may be present
Slurred S wave in leads I and V6 are the major criteria that have to be looked.

Fig. 7.41 : ECG of right bundle branch block

Left Bundle Branch Block
Criteria
i. Wide QRS complex with duration of> 0.12 s (> 3 mm)
ii. Deep and broad S wave in Vl with no R wave.
ni. Broad slurred R wave or RR' pattern without a Q wave in leads I and V6.
1v. Always associated with left axis deviation.
 Digoxi n effect
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ST segment elevation in acute anterior ST segment elevation myocardial infarction

Note
• Sinus rhythm, rate 75/min
• Normal axis
• Normal QRS complexes
• ST segments elevated in leads V1-V5
• Normal T waves
• The ST segment elevation could be confused with high take-off ST segments, but the trace has to be
interpreted in the context of a patient with acute chest pain
I
ECG 1
Ventricular Fibrillation

The rules for this rhythm:

REGULARITY: There are no waves or complexes that can be analyzed to
determine regularity. The baseline is totally chaotic.
RATE: The rate cannot be determined since there are no discern-
ible waves or complexes to measure.
P WAVE: There are no discernible P waves.
PRI: There is no PRI.
QRS: There are no discernible ORS complexes.
ECG 2
Complete Heart Block
The rules for this rhythm:
REGULARITY: Both the atrial and the ventricular foci are tiring regularly; thus the P-P intervals
and the R-R intervals are regular.
RATE: The atrial rate will usually be in a normal range. The ventricular rate
will be slower. If a junctional focus is controlling the ventricles, the rate will
be 40-60 bpm. If the focus is ventricular, the rate will be 20-40 bpm.
P WAVE: The P waves are upright and uniform. There are more P waves than QRS complexes.
PRI: Since the block at the AV node is complete, none of the atrial impulses is conducted
through to the ventricles. There is no PAI. The P waves have no relationship to the
QRS complexes. You may occasionally see a P wave superimposed on the QRS
complex.
QRS: If the ventricles are being controlled by a junctional focus, the ORS complex will
measure less than 0.12 second. If the focus is ventricular, the ORS will measure
0.12 second or greater.
ECG 3
Wenckebach Type I Second-Degree Heart Block

The rules for this rhythm:

REGULARITY: The R-R interval is irregular in a pattern of grouped beating.

RATE: Since some beats are not conducted, the ventricular rate is usually
slightly slower than normal (<100 bpm). The atrial rate is
normal {60-100 bpm).
P WAVE: The P waves are upright and uniform. Some P waves are not followed
by QRS complexes.
PRI: The PR intervals get progressively longer, until one P wave is not
followed by a ORS complex. After the blocked beat, the cycle starts
.
again.
QRS: The ORS complex measurement will be less than 0.12 second.
ECG 4
First-Degree Heart Block

The rules for this rhythm:

REGULARITY: This will depend on the regularity of the underlying rhythm.
RATE: The rate will depend on the rate of the underlying rhythm.
P WAVE: The P waves will be upright and uniform. Each P wave will
be followed by a QRS complex.
PRI: The PRI will be constant across the entire strip, but it will
always be greater than 0.20 second.
QRS: The ORS complex measurement will be less than 0.12
second.
ECG 5
Atrial Tachycardia
{ Pj~
The rules for this rhythm: ~-

REGULARITY: The R-R intervals are constant; the rhythm is regular.

RATE: The atrial and ventricular rates are equal; the heart rate is usually 150-250
bpm.
P WAVE: There is one P wave in front of every QRS complex. The configuration of the
P wave will be different than that of sinus P waves; they may be flattened or
notched. Because of the rapid rate, the P waves can be hidden in the T
waves of the preceding beats.
PRI: The PRI is between 0.12 and 0.20 seconds and constant across the strip.
The PRI may be difficult to measure if the P wave is obscured by the T wave.
QRS: The QRS complex measures less than 0.12 second.
ECG 6
Atrial Fibrillation

The rules for this rhythm:

REGULARITY: The atrial rhythm is unmeasurable; all atrial activity is chaotic. The ventricular
rhythm is grossly irregular, having no pattern to its irregularity.
RATE: The atrial rate cannot be measured because it is so chaotic; research indicates
that it exceeds 350 bpm. The ventricular rate is significantly slower
because the AV node blocks most of the impulses. If the ventricular rate is
100 bpm or less, the rhythm is said to be "controlled". If it is over 100 bpm, it is
considered to have a "rapid ventricular response" and is called "uncontrolled."
P WAVE: In this arrhythmia the atria are not depolarizing in an effective way; instead, they
are fibrillating. Thus, no P wave is produced. All atrial activity is depicted as
'~ibrillatory"
waves, or grossly chaotic undulations of the baseline.
PRI: Since no P waves are visible, no PRI can be measured.
QRS: The ORS complex measurement should be less than 0.12 second.
ECG 7
Ventricular Tachycardia

The rules for this rhythm:

REGULARITY: This rhythm is usually regular, although it can be slightly irregular.
RATE: Atrial rate cannot be determined. The ventricular rate range is
150-250 bpm. If the rate is below 150 bpm, it is considered a slow
VT. If the rate exceeds 250 bpm, it is called Ventricular Flutter.
P WAVE: None of the QRS complexes will be preceded by P waves. You may
see dissociated P waves intermittently across the strip.
PRI: Since the rhythm originates in the ventricles, there will be no PRI.
QRS: The ORS complexes will be wide and bizarre, measuring at least
0.12 second. It is often difficult to differentiate between the ORS and
the T wave.
ECG 8
Type II Second-Degree Heart Block
{~-
.P )
The rules for this rhythm:
REGULARITY: If the conduction ratio is consistent, the R-R interval will be constant,
and the rhythm will be regular. If the conduction ratio varies, the R-R
will be irregular.
RATE: The atrial rate is usually normal (60-100 bpm). Since many of the
atrial impulses are blocked, the ventricular rate will usually be in the
bradycardia range(< 60 bpm) , often one half, one third, or one
fourth of the atrial rate.
P WAVE: The P waves are upright and uniform. There are always more P waves
than ORS complexes.
PRI: The PRI on conducted beats will be constant across the strip, although
it might be longer than a normal PAI measurement.
QRS: The ORS complex measurement will be less than 0.12 second.
ECG 9
Sinus Tachycardia

The rules for this rhythm:

REGULARITY: The R-R intervals are constant; the rhythm is regular.

RATE: The atrial and ventricular rates are equal; the heart rate
is greater than 100 bpm (usually between 100 and
160 bpm).
P WAVE: There is a uniform P wave in front of every ORS complex.
PRI: The PR interval measures between 0.12 and 0.20 second;
the PRI measurement is constant across the strip.
QRS: The ORS complex measures less than 0.12 second.
ECG 10
Sinus Bradycardia
(~-
P)
The rules for this rhythm:

REGULARITY: The R-R intervals are constant; the rhythm is regular.

RATE: The atrial and ventricular rates are equal; heart rate is
less than 60 bpm.
P WAVE: There is a uniform P wave in front of every QRS complex.
PRI: The PR interval measures between 0.12 and 0.20 second;
the PRI measurement is constant across the strip.
QRS: The ORS complex measures less than 0.12 second.
ECG 11
Atrial Flutter

The rules for this rhythm:

REGULARITY: The atrial rhythm is regular. The ventricular rhythm will be regular if the AV
node conducts impulses through in a consistent pattern. If the pattern varies,
the ventricular rate will be irregular.
RATE: Atrial rate is between 250 and 350 bpm. Ventricular rate will
depend on the ratio of impulses conducted through to the ventricles.
P WAVE: When the atria flutter they produce a series of well-defined P waves. When
seen together, these "Flutter' waves have a sawtooth appearance.
PRI: Because of the unusual configuration of the P wave (Flutter wave) and the
proximity of the wave to the ORS complex, it is often impossible to determine
a PAI in this arrhythmia. Therefore, the PRI is not measured in Atrial Flutter.
QRS: The ORS complex measures less than 0.12 second; measurement can be
difficult if one or more Flutter waves is concealed within the ORS complex.
ECG 12
Sinus Arrhythmia

The rules for this rhythm:

REGULARITY: The R-R intervals vary; the rate changes with the patient's
respirations.
RATE: The atrial and ventricular rates are equal; heart rate is
usually in a normal range (60-100 bpm), but
can be slower.
P WAVE: There is a uniform P wave in front of every ORS complex.
PRI: The PR interval measures between 0.12 and 0.20 second;
the PRI measurement is constant across the strip.
QRS: The QRS complex measures less than 0.12 second.
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