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What the ECG tells you • Rhythm: Atrial and ventricular rhythms are regular. • Rate: The atrial rate is characterized by three or more successive ectopic atrial beats at a rate of 150 to 250 beats/minute. The rate rarely exceeds 250 beats/minute. The ventricular rate depends on the AV conduction ratio. • P wave: Usually upright, the P wave may be aberrant or hidden in the previous T wave. If visible, it precedes each QRS complex. • PR interval: May be unmeasurable if the P wave can’t be distinguished from the preceding T wave.
QT interval: Prolonged (indicating delayed ventricular repolarization) while the patient is in sinus rhythm. What causes it • AV block • Drug toxicity (particularly sotalol, quinidine [Novoquinidin], procainamide, and related antiarrhythmics such as disopyramide [Norpace]) • Electrolyte imbalance (hypokalemia, hypocalcemia, and hypomagnesemia) • Hereditary QT prolongation syndrome • Myocardial ischemia • Psychotropic drugs (phenothiazines and tricyclic antidepressants) • SA node disease that results in profound bradycardia What to look for • Palpitations, dizziness, chest pain, and shortness of breath (if the patient is conscious) • Rapidly occurring signs or symptoms of low cardiac output, such as hypotension and altered level of consciousness (LOC) • If rapid and prolonged torsades, loss of consciousness, pulse, and respirations Dizziness is one symptom of torsades de pointes.
Be careful. With type II seconddegree AV block, you won’t see a warning on the ECG before a dropped beat. What the ECG tells you • Rhythm: The atrial rhythm is regular. The ventricular rhythm can be regular or irregular. Pauses correspond to the dropped beat. If the block is intermittent, the rhythm is often irregular; if the block stays constant (for example, 2:1 or 3:1), the rhythm is regular. • Rate: The atrial rate is usually within normal limits. The ventricular rate, slower than the atrial rate, may be within normal limits.