Normal

Question 1

RR interval

Answer 1

3-6 big squares

Question 2

P wave

Answer 2

3 small boxes

Sure! Here’s a mnemonic to remember that a P wave duration is 3 small boxes (0.12 seconds) on an ECG:

“P is Petite, Perfect at Three.”

• P is: Refers to the P wave.
• Petite: Indicates that it is small.
• Perfect: Highlights that the duration is just right.
• at Three: Reminds you that it is exactly 3 small boxes in duration.

Question 3

PR interval

Answer 3

3-5 small squares
Beginning of P wave to end of R segment

Sure! Here’s a mnemonic to remember that the PR interval duration is 3 to 5 small boxes (0.12 to 0.20 seconds) on an ECG:

“PRime Interval: 3 to 5.”

• PRime: Refers to the PR interval.
• Interval: Indicates the measurement period.
• 3 to 5: Reminds you that the duration is between 3 and 5 small boxes.

Question 4

PR segment

Answer 4

1.25-3 small squares
End of p wave to beginning of QRS

Question 5

QRS Complex

Answer 5

2-2.5 small squares
Beginning of q wave to END of S wave

Certainly! Here’s a mnemonic to remember that the QRS complex duration is 2 to 2.5 small boxes (0.08 to 0.10 seconds) on an ECG:

“Quick Rhythm Span: Two to Two and a Half.”

• Quick: Refers to the QRS complex.
• Rhythm Span: Indicates the duration of the QRS complex.
• Two to Two and a Half: Reminds you that it is between 2 and 2.5 small boxes in duration.

Question 6

ST segment

Answer 6

2-3 small squares
End of S wave to beginning of T wave

“STEMI ST is two to three” “elevation is 2 boxes”

Question 7

T wave

Answer 7

4 small squares

Question 8

QT interval

Answer 8

10.5 small squares
Beginning of Q wave to end of T wave

Question 9

What is the most common p wave abnormality?

Answer 9

The most common P wave abnormality is P pulmonale, which is typically associated with right atrial enlargement. This condition is often seen in patients with chronic pulmonary diseases such as chronic obstructive pulmonary disease (COPD).

• Tall P waves: P waves are taller than 2.5 mm in the inferior leads (II, III, and aVF).
• Peaked P waves: The P waves appear abnormally peaked or pointed.

These changes occur due to increased pressure and/or volume overload in the right atrium, leading to its enlargement.

Question 10

What is the most common QRS abnormality?

Answer 10

The most common QRS abnormality is Left Bundle Branch Block (LBBB). LBBB is a condition where there’s a delay or blockage in the electrical impulses that travel down the left bundle branch of the heart’s conduction system.

• Widened QRS Complex: The QRS duration is typically ≥ 120 milliseconds (≥ 3 small boxes on the ECG).
• Notched or Slurred QRS Complex: In leads I, V5, and V6, the QRS complexes often appear notched or slurred.
• Absence of Q Waves: The normal Q waves in the lateral leads (I, V5, and V6) are often absent.
• Secondary ST-T Changes: There may be discordant ST segment and T wave changes (opposite to the direction of the main QRS deflection).

LBBB is often associated with underlying heart conditions, such as coronary artery disease, hypertensive heart disease, or cardiomyopathy.

Question 11

What is the most common PR interval abnormality?

Answer 11

The most common PR interval abnormality is first-degree atrioventricular (AV) block.

• Prolonged PR Interval: The PR interval is longer than 200 milliseconds (0.20 seconds), which is more than 5 small boxes on the ECG.
• Consistent PR Interval: The PR interval remains consistently prolonged across all beats.

In first-degree AV block, every atrial impulse is still conducted to the ventricles, but there is a delay in the conduction through the AV node or the His-Purkinje system. This condition is often benign and asymptomatic but can be associated with underlying conditions such as ischemic heart disease, increased vagal tone, or the use of certain medications like beta-blockers or calcium channel blockers.

Question 12

What is the most common T wave abnormality?

Answer 12

The most common T wave abnormality is T wave inversion.

• Inverted T Waves: The T waves are upside down (negative deflection) in comparison to the normal T wave morphology.
• Location: T wave inversions can occur in various leads, commonly seen in leads V1-V4, depending on the underlying condition.

• Ischemia: T wave inversion can indicate myocardial ischemia, especially when it appears in the context of other ischemic changes.
• Left Ventricular Hypertrophy (LVH): T wave inversion is often seen in the lateral leads in patients with LVH.
• Bundle Branch Blocks: T wave inversions are common in leads corresponding to the affected bundle (e.g., right bundle branch block).
• Pericarditis: Global T wave inversion can be seen in pericarditis during the late stages.
• Cerebrovascular Accidents: CNS events, particularly subarachnoid hemorrhage, can cause diffuse T wave inversions.

T wave inversions should always be evaluated in the clinical context to determine their significance.

Question 13

What is a good mnemonic for differentiating a MOBITZ type 1 from a MOBITZ type 2 on a rhythm strip?

Answer 13

A good mnemonic to differentiate Mobitz Type I (Wenckebach) from Mobitz Type II on a rhythm strip is “Lengthen, Lengthen, Drop for Type I; Fixed, Fixed, Drop for Type II.”

• Lengthen, Lengthen, Drop:
  
  • Lengthen: The PR interval progressively lengthens with each successive beat.
  • Drop: Eventually, a QRS complex is dropped (i.e., a P wave is not followed by a QRS complex).

• Fixed, Fixed, Drop:
  
  • Fixed: The PR interval is constant and does not change from beat to beat.
  • Drop: Suddenly, a QRS complex is dropped without the prior lengthening of the PR interval.

These mnemonics emphasize the progressive nature of PR interval changes in Mobitz Type I and the sudden nature of the dropped beats with a fixed PR interval in Mobitz Type II.

Question 14

What is most common RR interval abnormality?

Answer 14

The most common RR interval abnormality is sinus arrhythmia.

• Irregular RR Intervals: The RR intervals vary, typically in a cyclic pattern.
• Respiratory Sinus Arrhythmia: The most common form, where the heart rate increases during inspiration and decreases during expiration. This is more pronounced in young, healthy individuals and can be considered a normal physiological response.
• Non-respiratory Sinus Arrhythmia: This can occur independently of the respiratory cycle and may be seen in various conditions.

• Variation in RR Intervals: Observe the rhythm strip for cyclical changes in the RR intervals.
• P-wave before each QRS Complex: Ensuring that the rhythm is sinus in origin, there should be a P-wave before each QRS complex, confirming that the variability is due to sinus node activity.

1. Check for Regular P-wave: Ensure there is a P-wave before every QRS complex.
2. Measure RR Intervals: Look for variation in the duration of RR intervals.
3. Observe Cyclic Pattern: For respiratory sinus arrhythmia, observe if the variation correlates with the breathing cycle.

“Irregular Rhythm with Regular P-wave”

This mnemonic helps remember that the irregularity in the rhythm is due to variations in the RR interval while maintaining regular P-wave activity before each QRS complex.

Question 15

What are the main types of pacemaker problems that can be identified on rhythm strips?

Answer 15

The main types of pacemaker problems that can be identified on rhythm strips include:

1. Failure to Capture:
   
   • Definition: The pacemaker stimulus is delivered but does not result in myocardial depolarization.
   • Identification: Absence of a paced QRS complex following the pacemaker spike.
2. Failure to Sense:
   
   • Definition: The pacemaker fails to detect intrinsic cardiac activity and inappropriately delivers a pacing impulse.
   • Identification: Pacemaker spikes occur despite the presence of intrinsic P waves or QRS complexes.
3. Pacemaker-Mediated Tachycardia (PMT):
   
   • Definition: The pacemaker initiates a tachycardic rhythm due to interactions between the atrial and ventricular leads.
   • Identification: Rapid, regular rhythm with pacing spikes preceding each QRS complex. Typically, the rate is within the pacemaker’s programmed rate range.
4. Pacemaker Malfunction:
   
   • Definition: Various technical malfunctions affecting pacemaker function, such as battery depletion, lead dislodgement, or circuitry issues.
   • Identification: Patterns of pacing spikes and QRS complexes may be irregular, inconsistent, or absent altogether.
5. Lead Dislodgement:
   
   • Definition: Displacement of the pacing lead from its optimal position within the heart.
   • Identification: Changes in pacing spike morphology or absence of paced QRS complexes may indicate lead dislodgement.
6. Undersensing:
   
   • Definition: Failure of the pacemaker to detect intrinsic cardiac activity, resulting in inadequate pacing.
   • Identification: Pacemaker spikes may be absent despite the absence of intrinsic QRS complexes or P waves.
7. Oversensing:
   
   • Definition: Inappropriate detection of non-cardiac signals as cardiac activity, leading to inhibition of pacing.
   • Identification: Pacemaker spikes may be absent or asynchronous with intrinsic cardiac activity due to inhibition by non-cardiac signals.

“COPS FFLU”
- C: Capture Problems (Failure to Capture)
- O: Oversensing
- P: Pacemaker-Mediated Tachycardia (PMT)
- S: Sensing Problems (Failure to Sense, Undersensing)
- F: Failure to Pace (Failure to Deliver Pacing Stimulus)
- F: Flutter (Pacemaker-Mediated)
- L: Lead Dislodgement
- U: Undersensing

This mnemonic can help remember the main types of pacemaker problems identified on rhythm strips.

Question 16

Differentiate failure to capture vs failure to sense.

Answer 16

Failure to Capture**:
- Definition: The pacemaker stimulus is delivered but does not result in myocardial depolarization.
- Identification: Absence of a paced QRS complex following the pacemaker spike.

Failure to Sense:
- Definition: The pacemaker fails to detect intrinsic cardiac activity and inappropriately delivers a pacing impulse.
- Identification: Pacemaker spikes occur despite the presence of intrinsic P waves or QRS complexes

Question 17

What is a junctional rhythm?

Answer 17

A junctional rhythm is a type of cardiac rhythm where the electrical impulse originates within the atrioventricular (AV) junction, specifically the atrioventricular node (AV node) or the junctional tissue near it, rather than from the sinoatrial (SA) node, which is the heart’s natural pacemaker.

• Origin: The electrical impulse originates from the AV junction, either from the AV node itself or the surrounding junctional tissue.
• Rate: The rate of a junctional rhythm can vary but is typically between 40 and 60 beats per minute.
• P Waves: P waves may be absent, inverted, or appear after the QRS complex (retrograde P waves) due to retrograde conduction from the AV node to the atria.
• PR Interval: If present, the PR interval may be short (< 0.12 seconds) or absent due to the impulse bypassing the atria.
• QRS Complex: The QRS complex is usually narrow (≤ 0.12 seconds) unless there is underlying bundle branch block or other conduction abnormality.

1. Accelerated Junctional Rhythm: A junctional rhythm with a rate slightly faster than the typical junctional rate (60-100 bpm).
2. Junctional Escape Rhythm: A junctional rhythm that occurs when the SA node fails to generate an impulse, and the AV junction takes over as the pacemaker.
3. Junctional Bradycardia: A slow junctional rhythm with a rate below 40 bpm.
4. Non-paroxysmal Junctional Tachycardia (NPJT): A sustained junctional rhythm with a rate exceeding 100 bpm.

• Junctional rhythms can occur in various clinical situations, including during acute myocardial infarction, digitalis toxicity, electrolyte imbalances, or as a result of certain medications.
• In some cases, junctional rhythms can be benign and asymptomatic, while in other cases, they may indicate underlying cardiac pathology or require intervention.

Overall, a junctional rhythm reflects the ability of the AV junction to serve as a backup pacemaker when the SA node function is compromised or suppressed.