Finally, identify any EKG rhythm in 10 seconds of less. This podcast covers a SIMPLE 5 step method for rapid EKG interpretation and outlines the steps to help you quickly spot arrhythmias with confidence. There are many more factors involved in fully understanding EKGs but this simple 5 step method will help you know exactly where to start. If you work through the 5 steps in order you will be able to look at any strip any quickly notice abnormalities. You can view a PDF chart with essential heart rhythms and their criteria here.
- Rate
- P Wave
- QRS Complex
- P:QRS
- PR – Interval
To get a FREE EKG Chart click HERE.
Rate
With any strip you should start with the rate which can be determined (on a 6 second strip) by counting the P waves or the R waves and multiplying by 10. You can also count the number of large boxes between R waves and divide 300 by that number. For example, if you count 5 large boxes between each R wave than your rate would be approximately 60 bpm. Identifying the rate is a good way to determine where the impulse is initiating and can quickly rule out sinus rhythm.
P Wave
The P wave is representative of atrial depolarization and the wave should have an upward direction, it should be visible, and smooth. If you do not see P waves or they are misshapen you are not dealing with sinus rhythm.
QRS Complex
The QRS complex represents ventricular depolarization and should be present. The complex should have a length of 0.06 – 0..12 seconds (1.5 – 3 small squares). Anything out of this range is abnormal.
P:QRS
Every P wave should be followed directly by a QRS. The ratio between P and QRS should be 1:1. This represents the appropriate route of impulse travel. Deviation or alteration from the impulse traveling from SA node through Purkenji fibers in the right direction may be identified with the P:QRS.
PR Interval
The PR interval represents the onset of atrial depolarization and the onset of ventricular depolarization and is a factor in determining how long the impulse is held in the AV node. PR interval analysis is helpful in identifying AV heart blocks. The PR interval should be between 0.12 – 0.20 seconds (3 – 5 small squares).
This is intended as a brief introdution into the basics of EKG interpretation and will help you identify arrythmias in 10 seconds of less. For a FREE PDF EKG Chart Click HERE.
PODCAST TRANSCRIPT:
This is Jon. Welcome back again to another podcast episode with the Nrsng.com Podcast. Today, we’re going to be talking about the five-step interpretation of EKGs and how you can quickly identify and analyze these rhythms to identify the rhythm that you are seeing on a monitor or on the EKG strip.
Now, we will be giving away a free EKG chart, PDF chart that will help you have a quick reference sheet to all the different rhythms that you need to know and the different criteria for each of these five steps.
If you want that chart, go to Nrsng.com/ekg-chart, Nrsng.com/ekg-chart, and you can get that chart for free.
All right. So let’s go ahead and start. First, to be able to quickly identify rhythms, you need to understand very briefly how electrical impulses travel through the heart. Every electrical impulse should start from the SA node, that’s the sinoatrial node which is located in the top of the right atrium. And that should initiate an impulse that will then travel down to the AV node, the atrioventricular node which sits in between the atrium and the ventricles. That’s going to hold the impulse for a minute before it then travels down the bundle of His and into the Purkinje fibers which will then depolarize the ventricles.
So starting at the SA node, go to AV node, travel down to bundle of His and the Purkinje fibers to depolarize the ventricles. OK? So that’s the normal mode of transportation.
Within the heart, we have three different pacemakers that will set the rate for the heart. The first one is the SA node as we talked about, the sinoatrial node. It sits in the right atrium. That’s going to initiate an impulse every – about 60 to 100 times per minute. That’s why our normal heart rate is going to be 60 to 100.
Next, if the SA node isn’t able to fire, the AV node can actually initiate impulses 40 to 60 times per minute. If that ultimately fails, then you have the Purkinje fibers that can also initiate their own impulse at 20 to 40 beats per minute. So that’s why it’s really important that we understand that normal heart rate as 60 to 100 and analyze anything that is below that. We want to know if the person is bradycardic for reasons other than just being athletic or in extreme resting state. If they are not initiating impulse in the SA node, we need to know where that impulse maybe coming from and further analyze that.
- So there are a couple of complexes and waves that we are going to identify on a rhythm strip. First, we have our P wave. We have our Q wave, R wave, S wave, and T wave. There are few more waves but these are the ones that we’re going to identify, so P, Q, R, S, and T.
Then we have our PR interval which goes from the beginning of the P wave to the beginning of the QRS complex. And then we also have our QRS complex. QRS complex makes up the QRS waves and that’s going to identify ventricular and depolarization.
So really, for our needs in identifying our rhythms quickly, we are going to look at our rate, our P wave, our QRS complex, our PR interval, and the P to QRS ratio. OK. So P wave is going to identify atrial depolarization. QRS complex represents ventricular depolarization. PR interval represents the onset of atrial depolarization to the onset of ventricular depolarization.
- Now, to have sort of five things again that we’re going to identify to interpret our rhythm is going to be our rate, is going to be our P waves, our P wave to QRS complex ratio, our QRS complexes and our PR interval.
Now, a normal rate is going to be 60 to 100 beats minute. And there’s a couple of ways to identify what your rate is if you’re looking at 6-second EKG strip then you can just take the amount of beats in those 6 seconds, multiply it by 10. If you don’t have a 6-second strip or you want to maybe get a little bit more accurate, then you can identify your R waves or your P waves, count how many large boxes are between those and divide 300 by that number.
So for example, if you identify your R waves and you know that there are six large boxes between those two R waves then your rate is going to 5 beats per minute. OK?
The next thing after rate that we’re going to look at is our P waves. We want to notice that there are P waves present and that they are upright and that they are smooth, that they aren’t jagged or sharp. So we want P waves to be present. We want them to be upright and we want them to be smooth.
Next, we’re going to notice if we have QRS complexes. We want to notice if our QRS complexes are present. And we want to count the number of small boxes between our Q and RS. We want there to be 1.5 to 3 small boxes between our QRS – our Q and RS wave. So we want present QRS complexes and we want 1.5 to 3 small boxes between the Q and the S.
Next, we want to notice the P to QRS ratio and we want there to be a P wave before every QRS and we want there to be one P wave for each QRS. So there needs to be a P wave for every QRS and the P wave needs to come before the QRS complex.
The last thing we’re going to identify in our five-step method is going to be our PR interval. Now, the PR interval starts at the beginning of the P wave, the beginning of the QRS, and we want there to be 3 to 5 small boxes.
- So you have to count the number of small boxes between those two and you want there to be 3 to 5 small boxes. OK? So first rate, then P waves then QRS then P to QRS ratio and then PR interval. So that’s how we’re going to identify our rhythms. OK?
So one more time, we’ll go through it. We want to identify our rate. We want our rate to be between 60 to 100 beats per minute. We want to then look at our P waves. We want there to be present P waves. We want them to be upright and we want them to be smooth.
Next, we’re going to look at our P to QRS. We’re going to look at – make sure that our QRS complexes that they are 1.5 to 3 small boxes, between the Q and S. And then we’re going to notice our P to QRS ratio. We want that to be a one to one ratio, for every P there is a QRS and the P comes before the QRS.
And then we’re going to look at our PR interval. We want that PR interval between beat to beat, about 3 to 5 small boxes. So as you go through these checklists, as you look at the rhythm, you can quickly start identifying what the rhythm is and you can start eliminating specific rhythms based on each of these criteria. So I mean first of all, if you look at your rhythm and your rate is 150, you can already eliminate sinus rhythm because it’s greater than 100.
If you’re on there and you look at your PR interval is greater than the five boxes, you’re going to start looking at some of your heart blocks. But that impulse is being held in the AV node too long. If you start seeing that the P waves are either absent or going downward rather than upward and smooth, you might start looking at junctional rhythms.
So to really understand this, I really recommend that you go Nrsng.com/ekg-chart and you just download that free chart. That will really help you look through the criteria for each of the different rhythms that you’re looking at and give you some kind of practice in identifying rhythms and working through these five criteria.
But if you look – work through these five criteria to be able to identify any rhythm and quickly be able to rule out specific arrhythmias and determine if it’s sinus rhythm or if it maybe more of a lethal rhythm or if it might just be a little nuance that you may not have seen if you hadn’t worked through these five steps.
So that’s going to be my suggestion. This was just a quick podcast on what you’re looking at. We didn’t really go into the different arrhythmias here …
