EKG RATES

Okay, so far we have talked about the 3 basic ACLS rhythms, TOO FAST, TOO SLOW,
and TOO NONE (asystole). But, "how do I know how fast or slow it is?" Let's get
asystole or too none out of the way. Asystole is pretty obvious, there are no complexes on
the EKG tracing, however you should always look at the rhythm in another lead to verify
asystole! This is to make sure it is asystole and not "fine" v-fib (ventricular fibrillation),
as opposed to "coarse" v-fib. Remember, we defibrillate v-fib, we never defibrillate
asystole, we pace it! So always verify asystole in two different leads!

TOO SLOW

A heart rhythm that is too slow, is not "pumping" enough blood fast enough to perfuse the
tissues of vital organs. The "normal" heart rate is between 60 and 100 beats per minute. If
the heart rate is below 60, it's termed a "bradycardia". Does that mean if my patient's
heart rate is 50 beats per minutes, the patient is in trouble? No not always, remember
early on I said we were treating patients, and not just EKG rhythms? Well that's true, a
patient in good physical shape may have a resting heart rate of 50, that is "normal" for
him. So you always have to look at the patient too. But of course we live in a world of
numbers, so if the heart rate is below 60, it's still a bradycardia or too slow. As you start
EKG monitoring patients more and more, you'll recognize quickly when a rhythm is too
slow, but until then you will need a fast way to calculate the rate. Before we do that, let's
discuss too fast for a moment.

TOO FAST

A heart rhythm that is too fast, is "pumping" the heart muscle too fast to perfuse the
tissues of vital organs. The heart needs time to "fill" the ventricles with blood, if the rate
is too fast, there is not enough time for the heart to "fill". The "normal" heart rate is
between 60 and 100 beats per minute. If the heart rate is above 100, it's termed a
"tachycardia". Does that mean if my patient's heart rate is 110 beats per minutes, the
patient is in trouble? No not always, remember early on I said we were treating patients,
and not just EKG rhythms? There is hundreds of reasons why a patients heart rate may be
fast. To name a few, fear, increased body temperature, exercise, and so on. So you always
have to look at the patient too. But of course we live in a world of numbers, so if the heart
rate is above 100, it's still a tachycardia or too fast. As you start EKG monitoring patients
more and more, you'll recognize quickly when a rhythm is too fast, but until then you will
need a fast way to calculate the rate. So now look at Figure 1, below.
The first item to look at is the "Time Markings". You will see 3 of them (I only circled
one). Notice the period of time between each one of them is 3 seconds. And two, 3
second intervals represent 6 seconds. There are 10 six second periods in a minute. 10
times 6 equals 60 seconds! This is important! Make sure you "see this" and understand
this. Once you able able to identify a six second time period, rate determination is a snap!
Now look at the item QRS Complex. There are 8 of them on this six second strip.
Therefore, if we multiply 8 times 10 (because there are 10 six second intervals in a
minute), it equals 80! Let's do another! Look at Figure 2 below.

There are 5 QRS complexes in the 6 second strip. Take 5 times 10 (there are 10 six
second strips in a minute), and that equals 50. Therefore the heart rate is 50! Do you have
now? Let's find out...go to Figure 3 below, select the correct answer by clicking in it.

1. Rate of 90
 2. Rate of 100
3. Rate of 120
4. Rate of 150

There are other ways to determine EKG rates, such as the 300, 150, 100... method, but I
prefer you learn rate determination this way. This method helps you learn that as the strip
is traveling, it is actually recording time, in a precise manner. Each one of those little
boxes, and bigger boxes precisely represents time. See Figure 4 below.

The boxes whether they are big or little going across represent TIME! The boxes whether
they are big or little going up and down represent AMPLITUDE! At this time don't
concern yourself with amplitude, only time. Seconds can be broken down into smaller
units, called milliseconds. There are 1,000 milliseconds in one second! There are 60
seconds in a minute! To find out how many milliseconds in a minute, we have to multiply
60 seconds times 1,000 milliseconds. That equals 60,000 milliseconds. Now please stay
with me. Look at Figure 4, I have "boxed" in black, one BIG BOX. You will see I have
magnified one big box. One Big Box equals 200 milliseconds. Five Big Boxes equal
1,000 milliseconds or one second! Do it by math...5 boxes times 200 milliseconds equals
1,000 milliseconds, or one second! Look at Figure 4, Using the time marks, start from the
left and count the number of big boxes (hint:use your mouse pointer, I also numbered the
first 15 boxes at the bottom of figure 4). You will find there are 15 big boxes between
each time mark. Take 15 boxes times 200 milliseconds (each box remember is 200
milliseconds) and that equals 3,000 milliseconds, or 3 seconds! If you count all the Big
Boxes from left to right, starting with the first time mark, including the center time mark,
to the last time mark on the right, you will have counted 30 Big Boxes. Multiply 30 Big
Boxes times 200 milliseconds (each box remember is 200 milliseconds) and that equals
6,000 milliseconds, or 6 seconds! Do you have it? If not read it again until you do. Let's
look inside the Big Box at the 5 small boxes. Look below at figure 5.
Figure 5 illustrates the Big Box with the small boxes inside. There are 5 boxes across,
with 5 boxes up and down. Remember, we are only concerned about counting the boxes
across from left to right.

Each small box is 40 milliseconds, also expressed as .04

Two small boxes is 80 milliseconds, also expressed as .08

Three small boxes is 120 milliseconds, also expressed as .12

Four small boxes is 160 milliseconds, also expressed as .16

Five small boxes is 200 milliseconds, also expressed as .20

Big concept! Very important! Why? "Because when you starting measuring intervals
between events, you will need to measure the timing!" An example: "Have you ever
heard of the "PR" interval?" That's the time delay between the electrical inpulse of the
Atrium and the Ventricle. The "P" wave is the Atrial response, and the "R" wave is the
Ventricular response. The normal time period is between 120 milliseconds and 200
milliseconds. This is expressed this way, The normal time period is between .12 and
.20 ! Why is this important! Just to entice you further, if the "PR" interval is greater than
.20, your patient has a 1st degree AV (atrial/ventricular) Block! Cool Huh? See you can
learn this stuff too! Let's try another. See figure 6 below.
Strip A on figure 6 is only a 3 second strip. How do we know that? There is only a
begining timing mark, and a second timing mark, also there are only 15 big boxes, 15 X
200 = 3000 milliseconds or 3 seconds. Strip B is a magnified view of the first two QRS
complexes of Strip A. They are circled. When measuring QRS complexes to QRS
complexes (these are actually "R" to "R" waves, more on this latter) choose the first
complex that is almost on the begining line of a Big Box (this makes it easier to count).
It's almost impossible to find QRS's to "fall" exactly on the lines, so choose the closest.
It's best to "round" off to the closest line. Notice the second QRS actually does not fall
right on the line. I used the closest line, look at the black marks that the arrow is
touching. There are 2 Big Boxes between QRS's, so...2 X 200 = 400, then 2 small boxes,
2 X 40 = 80, add the two totals together...400 + 80 = 480 milliseconds between each
line. Now remember there is 60,000 milliseconds in a minute.

So...60,000 divided by 480 = 125 So big deal, what is the number 125? Go back and
look look at the strip in figure 3. What did we estimate the heart rate at? We estimated it
120 beats per minute. Well, 125 is the exact rate! If, those first 2 QRS's remained the
same distance for the all the rest of the QRS's in a minute!

This concept is very important! You must have this rock solid before proceeding. Don't
skip to any of the levels throughout this instruction, if you are unsure of one concept.
Learning EKG's is like building a house, if the foundation is weak, the house won't stand!
Go back and read this page again if you are not sure. When your ready, go to the next
page.