ECG is easy depending on how open minded you are.  Do not place pressure on yourself to find the correct rhythm but rather eliminate rhythms until you have one option left.  The remaining rhythm is more than most likely the correct answer.  As a paramedic you all will make one major mistake that telemetry technicians will not.  You will look at a rhythm and venture a guess as to what you think it is.  A telemetry technician will collect all the data first and then interpret the data to find the correct answer.

5 step data collection:

  1. Rhythm - is the underlining rhythm regular or irregular (do not include premature beats)
  2. Rate - you need to record the atrial and ventricular rates.  Three common ways to calculate rate are listed below.
  3. P wave formation - uniform, upright, inverted, sawtooth, wavy, changes
  4. PRI - .12 to .20 is normal or does it change
  5. QRS - less than .12 is normal

Calculating Rate:

Method A - Count the number of waves in a 6 second strip and multiply by 10.  This is best used when the underlining rhythm is irregular.

Method B - Count the number of big boxes from two consecutive waves and divide in to 300.  (300, 150, 100, 75, 60, 50)  Regular rhythms only

Method C - Count the number of little boxes of two consecutive waves and divide into 1500.  Most accurate. Regular rhythms only

Basic Arrhythmias consist of only about 20 basic rhythms.  They are divided into 5 categories:

bulletSinus - originating in the SA node
bulletAtrial - originating in the atria's but outside of the SA node
bulletJunctional - originating from the AV node
bulletVentricular - originating from the ventricles
bulletHeart Blocks

When you collect the 5 lines of data only plug in the abnormal finding(s) into the chart below. Here are the normal findings

Rhythm - regular

Rate - atrial between 60 to 100 / ventricle rate 60 to 100.

P wave - uniform (same) and upright

PRI - equal to or between .12 to .20

QRS - less than .12

Example:  If you collect the data you do not even need to view the strip to know what it is.  Pick out the abnormal finding in the following example.

Rhythm        Regular

Rate            atrial rate 56    ventricular rate 56 (the atrial and ventricular rate should be 1 to 1 or the same)

P wave        uniform and upright

PRI              .16

QRS            .10

The only abnormal finding was the rate is less than 60.  So using the chart below plug in the less than 60 and the answer has to be sinus brady.  It is that simple.

This chart contains general rules.  There are exceptions that will be discussed at the study session.  If you do not attend the study session you may find this chart confusing until explained to you.  But at the end it is a great learning tool.

The following chart is long hand.  Click here for the condensed chart. Using the charts try to complete the following problems and we will review them at the study session.  Click here for problems

Rhythm What is abnormal?
   
Sinus Rhythms P waves upright and uniform to pick these rhythms
Normal Sinus Rhythm ventricular rate between 60 to 100, everything else normal
Sinus Brady ventricular rate less than 60, everything else normal
Sinus Tach ventricular rate greater than 100 until you cannot see the P waves, everything else normal
Sinus Arrhythmia Slightly irregular
   
Atrial Rhythms P waves are abnormal
Wandering Pace Maker Slightly irregular and P waves change
Atrial Flutter

Atrial rate between 250 and 350. P waves are sawtooth/picket fence

Atrial Fib Irregular R to R, Atrial rate greater than 350. P waves are wavy
Atrial Tach (SVT) Cannot see P waves and ventricular rate greater than 150.
   
Junctional Rhythms P waves inverted (located before, in or after the QRS)
Escaped Junctional Rhythm P waves inverted or absent and ventricular rate of 40 to 60
Accelerated Junctional P waves inverted or absent and ventricular rate of 60 to 100
Junctional Tach P waves inverted or absent and ventricular rate of 100 to 180
   
Ventricular Rhythms QRS measures at or greater than .12
Ventricular Tach Ventricular rate of 100 to 300
Ventricular Fib Ventricles are chaotic and fast
Idioventricular No P waves and Ventricular rate of 20 to 40
Asystole No activity and leads are on pt.
   
Heart Blocks Extra P waves
1st degree 1 P and 1 QRS but the PRI is constant and greater than .20
2nd degree type 1 The PRI consequently gets progressively longer until  dropping a QRS. Saying "PRI gets longer, longer, longer, drop one type 1.
2nd degree type 2 Extras P waves but PRI is constant
3rd degree PRI has no pattern
   

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