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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
2first-degree AV block
3atrial fibrillation
4sinus bradycardia
2.ECG rhythm strip interpretationHard
This lead II strip shows an AV block, so the atria and the ventricles beat at different rates. Measure the P–P interval and find the atrial rate in beats per minute (1500 method, whole number).
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
3.Human physiologyMedium
What is the normal pH range of arterial blood?
A6.80 to 7.00
B7.50 to 7.65
C7.00 to 7.20
D7.35 to 7.45
4.Human physiologyHard
In Graves' disease, what thyroid function results are expected and why?
ALow T4 and low TSH, because the hypothalamus fails
BLow T4 and high TSH, because antibodies destroy the gland
CHigh T4 and low TSH, because antibodies stimulate the TSH receptor
DHigh T4 and high TSH, because the anterior pituitary gland is overactive
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 = 34 small boxes, 1500 ÷ 34 ≈ 44 per minute.
2. Rhythm: regular, every R–R is 1.36 s.
3. P waves: none visible.
4. PR interval: not measurable.
5. QRS: 0.10 s, narrow (below 0.12 s).
Interpretation
junctional rhythm
Answer
junctional rhythm
2.ECG rhythm strip interpretation
Answer: atrial rate = 65 bpm
AV blocks: march out the P waves and check which ones are followed by a QRS. First-degree: every P conducted, PR constant and above 0.20 s. Second-degree type I (Mobitz I, Wenckebach): the PR lengthens from beat to beat until one P wave is not conducted, then the cycle starts again (group beating). Second-degree type II (Mobitz II): the PR of the conducted beats stays constant, and P waves are suddenly not conducted; the QRS is often wide. Third-degree (complete) block: P waves and QRS complexes are each regular but independent, the PR varies at random and the atrial rate is faster than the escape rate (junctional 40–60/min with a narrow QRS, ventricular 20–40/min with a wide QRS). A 2:1 block cannot be called type I or type II from one strip.
Atrial rate
P–P = 23 small boxes = 0.92 s → 1500 ÷ 23 = 65.22 ≈ 65 per minute
Ventricular rate
5 QRS complexes in 6 s × 10 = 50 per minute
Answer
atrial rate = 65 bpm
Answer
atrial rate = 65 bpm
Second-degree type II: 4 P waves for every 3 QRS complexes, with a constant PR.
3.Human physiology
Answer: D · 7.35 to 7.45
Why this is the answer
Arterial pH is normally 7.35–7.45. Below 7.35 is acidaemia and above 7.45 alkalaemia.
Answer
D · 7.35 to 7.45
4.Human physiology
Answer: C · High T4 and low TSH, because antibodies stimulate the TSH receptor
Why this is the answer
TSH-receptor antibodies stimulate the thyroid independently of TSH. The resulting high T4 and T3 suppress pituitary TSH by negative feedback.
Answer
C · High T4 and low TSH, because antibodies stimulate the TSH receptor