Atrial Fibrillation
-No identifiable P waves
-Irregular R-R
-Random (can be fast, regular,
or slow) atrial spikes
-loss of atrial kick
-MOST COMMON
NORM CAUSE OF CVD
Alcohol, infection, caffeine
Wandering
Pacemaker
-normal overall rate
-P wave shape varies (at least 3
different P wave shapes)
-Irregular R-R
-Atrial rate is <100 bpm
Multifocal Atrial
Tachycardia (MAT)
-P wave shape varies
-Irregular R-R (ventricular
rhythm)
-Atrial rate is >100 bpm
- common in pulmonary issues
(COPD)
-digoxin toxicity
*fibrillations are all the atrial foci randomly firing; only some make it through to ventricles (QRS)
*irregularly shaped P waves may be hidden by rapid rate
(Rate is much faster in MAT than in wandering pacemaker)
Atrial Escape Beat/
Rhythm
60 – 80 bpm
Pause followed by:
Pointed or normal P wave
Normal QRS
Junctional Escape
Beat/ Rhythm
40 – 60 bpm
Pause followed by:
NO P wave or inverted
Normal QRS
Ventricular Escape
Beat/ Rhythm
< 40 bpm
Pause followed by:
NO P wave
Wide QRS > .12
Usually no P because no atrial
depolarization
Can be because of
parasympathetic activity
Premature Atrial
Beats/ Contractions
(PAC)
Irregular R-R
Unusually shaped P wave
followed by a QRST
Beat comes BEFORE
compensatory pause
P wave and reg. rhythm reset
after one cycle
*P’ may be hidden in previous T wave�look for T taller than others
Premature Junctional
Beats/ Contractions
Irregular R-R
NO P wave/inverted P wave
Slightly widened QRS (or
normal)
Beat comes BEFORE pause
Premature Ventricular
Beats/ Contractions
(PVC)
Irregular R-R
NO P wave
Wide and deep QRS
Beat comes BEFORE
compensatory pause
Cause: HYPOXIA
Atrial Flutter
“Saw Tooth”
Multiple P waves, not all
followed by QRS
P P P P P QRS P P P
Regular: R to R the same
Numbers indicate a ratio of #
of P waves to QRS
Baseline vanishes between
flutters
Supraventricular
Tachycardia (SVT)
Narrow QRS (b/c coming from
above ventricles)
No P waves (hidden by
preceeding T waves)
Can be atrial or junctional (PAT
or PJT) (narrow PR interval)
Regular R-R
**big diff b/w a fib
Rate: 150-250
Has a subtype: paroxysmal
atrial tachycardia (PAT)
meaning it is intermittent SVTs
*usually regular, but it can vary in # of P waves sometimes
Ventricular
Tachycardia (VT)
(BAD)
Tosades de Pointes
Ventricular Fibrillation
(WORST!)
Wolff-ParkinsonWhite Syndrome
(WPW)
First degree
Second degree, Type I
(Wenkebach)
Wide QRS
>=3 consecutive PVCs
No visible P wave
REGULAR
1 irritable foci
Long QT interval
250-350 bpm
Series of ventricular complexes
Due to hypomagnesium
“twisted ribbon” outline
Causes: low K, meds,
congenital QT
Can develop into Vfib
NO identifiable waves/pattern
“bag of worms”
Ventricles are twitching
CARDIAC ARREST
Rapid discharge of multiple
irritable ventricular foci
Immediate CPR and
defibrillation
Delta wave
Wide QRS BASE (>0.12s)
Short PR interval
Impulse is getting to ventricles
from SA node
Reentrant rhythm
PR interval >0.2 seconds
PR length is consistent
Think delay
Long PR interval – lengthens
in successive cycles
Irregular R-R
Dropped QRS
“Long, longer, longer, drop,
now you’ve got a Wenkebach”
Not dangerous
*push immediate MgSO4 and then find the cause
*Hypoxia sets in and causes sustained damage & scarring
*NOT obvious on EKG
Second degree, Type
II (Mobitz or Mobitz
type II)
PR intervals consistent
Dropped QRS
Occurs below AV
DANGEROUS; need a
pacemaker
Third degree
Multiple P waves and a lot less
QRS complexes
R-R equal
P-P equal
* Some P waves are hidden in
other waves
Will not be sinus because
things are out of order
Right Bundle Branch
Block (RBBB)
Left Bundle Branch
Block (LBBB)
- RT ventricular dep. is delayed
- CLASSICAL APPEARANCE:
- Wide QRS
- “Rabbit ears” in V1 and V2:
R-R’(prime)
- Slurred S wave in I and V6
- LT ventricular dep. is delayed
- CLASSICAL APPEARANCE:
- Wide QRS
- “Rabbit ears” in V5 & V6:
R-R’(prime)
- Wide, deep, downward
deflection in V1 & V2
MISCELLANEOUS
WPW (WolfeParkinson-White)
Wide QRS BASE
Delta wave
Short PR interval
Long and narrow unslurring
Impulse is getting to ventricles rom SA node
Asystole
Straight line
Artifact
Looks like Afib, but it is not because R-R equal
Occurs if person is moving or lead not pushed on well
EKG must be redone
REGULAR
Common causes:
Movement, electrical interference, breathing heavy
(heart moving)
Atrial pacing/
Pacer Spikes
Ventricular pacing/
Pacer Spikes
If pacer spike happens before the P wave
Straight up and down lines that doesn’t look like a
wave
Wide QRS
Pacer spike appears before QRS
Wandering
Baseline
Brugada
“Rollercoaster”
Caused by respiratory distress and movement
Baseline is not uniform
Young men
famHx SCD
V1/2 tenting/ski slope
Wellen’s waves
Deep, symmetrical t waves
Pending STEMI
Take to cath lab
Hyperkalemia
Elevated potassium
Peaked t waves � wide QRS
Hypokalemia
Low potassium
Hypercalcemia
High calcium
QT interval = short
Hypocalcemia
Low calcium
QT interval = long