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1Formulas and methods
ECG rhythm strip interpretation
Paper (25 mm/s, 10 mm/mV)
1 small box = 0.04 s, 1 large box = 0.20 s, 10 mm = 1 mV
Heart rate, regular rhythm
300 ÷ large boxes = 1500 ÷ small boxes = 60 ÷ RR (s)
Heart rate, irregular rhythm
QRS complexes in 6 s × 10
Normal PR interval
0.12–0.20 s
Normal QRS duration
< 0.12 s
QTc (Bazett)
QT/√RR
QTc (Fridericia)
QT/∛RR
QTc (Framingham)
QT + 154·(1 − RR)
Sinus rates
bradycardia < 60, normal 60–100, tachycardia > 100 /min
Escape rates
junctional 40–60, ventricular 20–40 /min
Fast rhythms
SVT 150–250 /min (narrow), VT > 100 /min (wide)
Method
Rate: for a regular rhythm divide 300 by the large boxes or 1500 by the small boxes between two R waves; for an irregular rhythm count the QRS complexes in 6 seconds and multiply by 10.
Rhythm: compare the R–R intervals. Equal is regular; a repeating pattern is regularly irregular; no pattern at all is irregularly irregular.
P waves: is there an upright P wave in lead II before every QRS, all alike? Look for fibrillatory or sawtooth waves, inverted P waves and P waves without a QRS.
PR interval: from the start of P to the start of the QRS, normally 0.12–0.20 s and constant. Watch whether it lengthens, stays fixed before a dropped beat, or varies at random.
QRS duration: below 0.12 s is narrow; 0.12 s or more is wide. Then name the rhythm, and for the QT use QTc = QT/√RR (Bazett) with times in seconds.
2Practice problems
1.ECG rhythm strip interpretationMedium
Interpret this lead II rhythm strip. Which rhythm is it? Click your answer.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1junctional rhythm
2sinus bradycardia
3normal sinus rhythm
4first-degree AV block
2.ECG rhythm strip interpretationHard
Interpret this lead II strip with the five steps in order: rate, rhythm, P waves, PR interval, QRS duration. At which step do you find the first abnormal finding? Click it.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
1rate
2rhythm
3P waves
4PR interval
5QRS duration
3.Human physiologyMedium
Which ABO blood group has both anti-A and anti-B antibodies in the plasma?
AGroup AB
BGroup A
CGroup B
DGroup O
4.Human physiologyHard
Why does fetal haemoglobin have a higher affinity for oxygen than adult haemoglobin?
AIt binds 2,3-BPG less strongly
BIt contains more iron per haem
CIt has five subunits instead of four
DFetal blood has a higher pH
3Solutions
1.ECG rhythm strip interpretation
Answer: junctional rhythm
Rhythm criteria (lead II): sinus rhythm has an upright P wave before every QRS, a constant PR of 0.12–0.20 s and a narrow QRS: normal sinus rhythm at 60–100/min, sinus bradycardia below 60, sinus tachycardia above 100. Atrial fibrillation: no P waves, a fibrillatory baseline and an irregularly irregular R–R. Atrial flutter: sawtooth flutter waves at about 250–350/min with a fixed conduction ratio such as 2:1 or 4:1. First-degree AV block: sinus rhythm with a constant PR above 0.20 s. Junctional rhythm: narrow QRS at 40–60/min with absent or inverted P waves (PR below 0.12 s, or P after the QRS). A PVC is an early, wide (0.12 s or more), bizarre QRS without a P wave, with the T wave in the opposite direction and usually a full compensatory pause; in bigeminy every second beat is a PVC.
Five steps
1. Rate: R–R = 29 small boxes, 1500 ÷ 29 ≈ 52 per minute.
2. Rhythm: regular, every R–R is 1.16 s.
3. P waves: inverted, just after each QRS.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
Interpretation
junctional rhythm
Answer
junctional rhythm
2.ECG rhythm strip interpretation
Answer: rhythm
Five steps for every strip: 1. rate (300 or 1500 method, or the 6-second method if irregular); 2. rhythm: are the R–R intervals equal; 3. P waves: present, upright in lead II, one before every QRS and all alike; 4. PR interval: 0.12–0.20 s and constant; 5. QRS duration: below 0.12 s. Only after the five steps name the rhythm. Normal sinus rhythm passes all five: 60–100/min, regular, upright P before every QRS, PR 0.12–0.20 s, QRS below 0.12 s.
Five steps
1. Rate: 7 QRS complexes in 6 s, × 10 = 70 per minute.
2. Rhythm: irregularly irregular, R–R from 0.66 to 0.98 s with no pattern.
3. P waves: none; the baseline shows small irregular fibrillatory waves.
4. PR interval: not measurable.
5. QRS: 0.08 s, narrow (below 0.12 s).
First abnormal step
rhythm → atrial fibrillation
Answer
rhythm
3.Human physiology
Answer: D · Group O
Why this is the answer
Group O people have no A or B antigens and make both anti-A and anti-B. Group AB has both antigens and neither antibody.
Answer
D · Group O
4.Human physiology
Answer: A · It binds 2,3-BPG less strongly
Why this is the answer
The gamma chains of HbF bind 2,3-BPG poorly, so the curve is shifted left. This lets fetal blood take oxygen from maternal blood in the placenta.