LS Reading the ECG Strip

LEARNING SUPPLEMENT
Reading the ECG Rhythm Strip (Rhythm Strip Review)

Rhythm Strip Components
Each heart beat consists of several electrical events within a single cardiac cycle. Most of these events are
represented on the rhythm strip (Figure 1):
■ P wave: The P wave represents depolarization of the atria. This event leads to contraction of the atria, though the
actual contraction is not seen on the ECG.
■ PR interval: The PR interval measures the time from the beginning of atrial depolarization to the beginning of
ventricular depolarization. It is measured from the beginning of the P wave to the beginning of the QRS complex.
It reflects the delay in conduction as the electrical impulse traverses the AV node, which allows the atria to finish
contracting before the start of ventricular contraction.
■ QRS complex: The QRS complex represents depolarization of the ventricles. This event leads to contraction of the
ventricles.
■ ST segment: The ST segment represents the time between the end of ventricular depolarization and the beginning
of ventricular repolarization. It is measured from the end of the QRS complex to the beginning of the T wave.
■ T wave: The T wave is a recording of the rest and repolarization of the ventricles. (Note: atrial repolarization occurs
during ventricular depolarization and is not represented [due to it occurring at the same time as the QRS complex
and thus cannot be seen] on the ECG.)
■ QT interval: The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This
encompasses the time from ventricular depolarization to the end of repolarization.
QRS
Complex
Ventricular
depolarization
R
Time between end of

depolarization and start of
repolarization of ventricles
Atrial contraction
Ventricular
ST repolarization
Segment
T
P
PR Interval
Q
S
Time between start of
Conduction through QT Interval depolarization and end of
AV node repolarization of ventricles
Figure 1 | ECG Components and Their Correlation with Electrical Conduction
© 2021 The American National Red Cross. ALL RIGHTS RESERVED | 1

LEARNING SUPPLEMENT
(continued)
Interpreting the Rhythm Strip
Taking a methodical approach to evaluating a rhythm strip ensures that you gather relevant details that can help you to
identify the rhythm accurately:
1. Rate: To estimate the atrial rate, count the number of P waves over a 6-second period and multiply by 10. To
estimate the ventricular rate, do the same with the QRS complexes. Alternatively, if the rhythm is regular, divide
300 by the number of large squares between two P waves (to get the atrial rate) and between two R waves
(to get the ventricular rate). If the heart rate is very fast, divide 1500 by the number of small squares between
two P waves (to get the atrial rate) and between two R waves (to get the ventricular rate). Are the atrial and
ventricular rates the same or different? Are they within normal limits?
2. Rhythm: Look at the rhythm to see if it is regular. Is the amount of time between each P wave the same?
What about the amount of time between each QRS complex (i.e., the R-R interval)?
3. P waves: Are P waves present? Do they all have the same morphology? Is there a 1:1 ratio between the
number of P waves and QRS complexes, or are there more P waves than QRS complexes?
4. PR interval: Measure the PR interval (Figure 2). Is it within the normal range for the patient’s age?
(Table 1) Is it consistent throughout the strip? If it varies, does the variation occur in a certain pattern?
PR Interval
Figure 2 | Measuring the PR Interval

LEARNING SUPPLEMENT
(continued)
Table 1. Normal Age-Based ECG Parameters for Children
Age PR Interval, Mean (range), sec QRS Duration, Mean (98th Percentile), sec
0–7 d 0.10 (0.08–0.12) 0.05 (0.07)
1–3 wk 0.10 (0.08–0.12) 0.05 (0.07)
1–6 mo 0.11 (0.08–0.13) 0.05 (0.07)
6–12 mo 0.12 (0.10–0.14) 0.05 (0.07)
1–3 y 0.12 (0.10–0.14) 0.06 (0.07)
4–5 y 0.13 (0.11–0.15) 0.07 (0.08)
6–8 y 0.14 (0.12–0.16) 0.07 (0.08)
9–11 y 0.14 (0.12–0.17) 0.07 (0.09)
12–16 y 0.15 (0.12–0.17) 0.07 (0.10)
>16 y 0.15 (0.12–0.20) 0.08 (0.10)
5. QRS complex: Does the QRS complex appear narrow or wide? Measure the duration of the QRS
complex (Figure 3). Count the number of small squares and multiply by 0.04 to get the total duration in
seconds. Is the duration within the normal range for age (see Table 1)? Do all the QRS complexes have
the same morphology?
QRS complex duration
Figure 3 | Measuring the QRS Complex Duration

LEARNING SUPPLEMENT
(continued)
6. QT interval: Measure the QT interval (Figure 4) and calculate the corrected QT interval (QTc) using a
consistent lead. Because the QT interval varies normally with the heart rate, the QTc is used to assess absolute
QT prolongation. The QTc adjusts for heart rate differences by dividing the QT interval (in seconds) by the
square root of the R-R interval (i.e., one cardiac cycle).
Normal values for QTc for children are as follows:

■ 0.44 seconds = 97th percentile for infants 3 to 4 days old
■ ≤0.45 seconds for all boys >1 week of age and for all prepubescent girls
■ ≤0.46 seconds for postpubescent girls
If the heart rate is greater than 120 beats per minute or less than 50 beats per minute, the formula for
calculating QTc has limited usefulness.
QT Interval
QTc = QT R-R
Figure 4 | Measuring the QT Interval and Calculating the QTc
7. Clinical significance: Determine the rhythm and its clinical significance. Is the patient showing signs or
symptoms of arrhythmia? Is the rhythm potentially life threatening? Is perfusion adequate or not?

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LEARNING SUPPLEMENT

Reading the ECG Rhythm Strip (Rhythm Strip Review)

Time between end of

Figure 1 | ECG Components and Their Correlation with Electrical Conduction

© 2021 The American National Red Cross. ALL RIGHTS RESERVED | 1

Figure 2 | Measuring the PR Interval

© 2021 The American National Red Cross. ALL RIGHTS RESERVED | 2

QRS complex duration

Figure 3 | Measuring the QRS Complex Duration

© 2021 The American National Red Cross. ALL RIGHTS RESERVED | 3

Normal values for QTc for children are as follows:

Figure 4 | Measuring the QT Interval and Calculating the QTc

© 2021 The American National Red Cross. ALL RIGHTS RESERVED | 4

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