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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
This lead II strip shows atrial flutter. Measure the flutter-wave interval and find the atrial rate in beats per minute.
lead II, 25 mm/s, 10 mm/mV1 small box = 0.04 s, 1 large box = 0.20 sstrip length 6 s
atrial rate = bpm
2.ECG rhythm strip interpretationHard
Identify the rhythm on this lead II strip. 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
1atrial flutter, 4:1 conduction
2ventricular fibrillation
3atrial fibrillation
4asystole
3.Human physiologyMedium
What is the main function of pulmonary surfactant?
ATo reduce surface tension in the alveoli
BTo carry oxygen across the alveolar wall
CTo trap dust in the bronchi
DTo kill bacteria in the airways
4.Human physiologyHard
Which mechanism mainly creates the concentration gradient in the medulla of the kidney?
ASecretion of urea into the proximal tubule
BADH acting on the descending limb
CGlomerular filtration
DThe countercurrent multiplier of the loop of Henle
3Solutions
1.ECG rhythm strip interpretation
Answer: atrial rate = 300 bpm
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.
Flutter waves
F–F = 5 small boxes = 0.20 s → 1500 ÷ 5 = 300 per minute
QRS complexes
R–R = 20 small boxes = 0.80 s → 1500 ÷ 20 = 75 per minute
conduction ratio = 300 ÷ 75 = 4:1
Answer
atrial rate = 300 bpm
2.ECG rhythm strip interpretation
Answer: ventricular fibrillation
Ventricular rhythms: ventricular tachycardia is a run of three or more wide (0.12 s or more) complexes in a row at more than 100/min, usually 150–250/min, regular, without related P waves. Ventricular fibrillation is a chaotic, irregular waveform with no identifiable P waves, QRS complexes or T waves and no countable rate. Asystole is an almost flat line with no ventricular activity; a flat line is always confirmed by checking the patient, the leads and the gain and a second lead. In resuscitation guidelines VF and pulseless VT are the shockable rhythms and asystole is not.
Five steps
1. Rate: no countable ventricular rate.
2. Rhythm: chaotic, no repeating pattern.
3. P waves: none identifiable.
4. PR interval: not measurable.
5. QRS: no QRS complexes.
Interpretation
ventricular fibrillation
Answer
ventricular fibrillation
In resuscitation guidelines VF and pulseless VT are the shockable rhythms. This is identification practice only.
3.Human physiology
Answer: A · To reduce surface tension in the alveoli
Why this is the answer
Surfactant, made by type II alveolar cells, lowers surface tension so alveoli do not collapse and the lungs are easier to inflate.
Answer
A · To reduce surface tension in the alveoli
4.Human physiology
Answer: D · The countercurrent multiplier of the loop of Henle
Why this is the answer
The ascending limb actively transports NaCl into the interstitium without letting water follow, and the countercurrent flow multiplies this into a steep gradient that ADH then uses to concentrate urine.
Answer
D · The countercurrent multiplier of the loop of Henle