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ELECTROCARDIOGRAPHY
FOR HEALTHCARE PROFESSIONALS

Fourth Edition

Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS

Total Care Programming, Inc.
Palm Coast, Florida

Thomas O’Brien, AS, CCT, CRAT, RMA

Remington College
Allied Health Programs Chair
ELECTROCARDIOGRAPHY FOR HEALTHCARE PROFESSIONALS, FOURTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2016 by
McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous
editions © 2012, 2008, and 2004. No part of this publication may be reproduced or distributed in
any form or by any means, or stored in a database or retrieval system, without the prior written
consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic
storage or transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers
outside the United States.

This book is printed on acid-free paper.

1 2 3 4 5 6 7 8 9 0 RMN/RMN 1 0 9 8 7 6 5

ISBN 978-0-07-802067-4
MHID 0-07-802067-0

Senior Vice President, Products & Markets: Kurt L. Strand

Vice President, General Manager, Products & Markets: Marty Lange
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All credits appearing on page or at the end of the book are considered to be an extension of the
copyright page.

Library of Congress Cataloging-in-Publication Data

Booth, Kathryn A., 1957- author.

Electrocardiography for healthcare professionals / Kathryn A. Booth, Thomas
E. O’Brien. — Fourth edition.
p. ; cm.
Includes index.
ISBN 978-0-07-802067-4 (alk. paper) — ISBN 0-07-802067-0 (alk. paper)
I. O’Brien, Thomas E. (Thomas Edward), 1959- author. II. Title.
[DNLM: 1. Electrocardiography—methods—Problems and Exercises.
2. Arrhythmias, Cardiac—diagnosis—Problems and Exercises. WG 18.2]
RC683.5.E5
616.1’207547—dc23
2014019157

The Internet addresses listed in the text were accurate at the time of publication. The inclusion
of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and
McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.

www.mhhe.com
Dedication
To the individuals using this book, you have chosen a worthwhile and
rewarding career. Thank you; your skills and services are truly needed.
To my youngest grandaughter, Harper Kathryn, so happy you are in my life.
Kathryn Booth
I want to thank my beautiful wife, Michele, and our wonderful children,
Thomas, Robert, and Kathryn. Without their love and support, I would have
nothing. They inspire me every day to make a difference in people’s lives. I
also want to express my sincere thanks to the faculty, staff, and students of
Remington College for their encouragement and guidance. Today’s students
are the difference makers of tomorrow!
Thomas O’Brien
About the Author
Kathryn A. Booth, RN-BSN, RMA (AMT), RPT, CPhT, MS, is a registered
nurse (RN) with CPR and ACLS training as well as a master’s degree in educa-
tion and certifications in phlebotomy, pharmacy tech, and medical assisting.
She is an author, educator, and consultant for Total Care Programming, Inc.
She has over 30 years of teaching, nursing, and healthcare work experience
that spans five states. As an educator, Kathy has been awarded the teacher of
the year in three states where she taught various health sciences. She serves
on the American Medical Technologists registered Phlebotomy Technician
Examinations, Qualifications, and Standards Committee. She stays current in
the field by practicing her skills in various settings as well as by maintaining
and obtaining certifications. In addition, Kathy volunteers at a free healthcare
clinic and teaches online. She is a member of advisory boards at two educa-
tional institutions. Her larger goal is to develop up-to-date, dynamic health-
care educational materials to assist other educators as well as to promote the
healthcare professions. In addition, Kathy enjoys presenting innovative new
learning solutions for the changing healthcare and educational landscape to
her fellow professionals nationwide.

Thomas E. O’Brien, AS, CCT, CRAT, RMA, is the Allied Health Program chair-
person at Remington College, Fort Worth, Texas. Tom also works as an author
of CME activities and editor with Practical Clinical Skills (www.practical
clinicalskills.com). He is also on the Board of Trustees and Exam Chair for the
Certified Cardiographic Technician and Certified Rhythm Analysis Technician
Registry Examinations working with Cardiovascular Credentialing Interna-
tional (CCI). His background includes over 24 years in the U.S. Air Force and
U.S. Army Medical Corps. Tom’s medical career as an Air Force Independent
Duty Medical Technician (IDMT) has taken him all over the United States and
the world. He has several years’ experience working in the Emergency Ser-
vices and Critical Care arena (Cardiothoracic Surgery and Cardiac Cath Lab).
He was awarded Master Instructor status by the U.S. Air Force in 1994 upon
completion of his teaching practicum. He now has over 15 years of teaching
experience; subjects include Emergency Medicine, Cardiovascular Nursing,
Fundamentals of Nursing, Dysrhythmias, and 12-Lead ECG Interpretation. His
current position provides challenges to meet the ever-changing needs of the
medical community and to provide first-rate education to a diverse adult edu-
cation population.

iv
Brief Contents
Preface xi

CHAPTER 1 Electrocardiography 1
CHAPTER 2 The Cardiovascular System 28
CHAPTER 3 The Electrocardiograph 54
CHAPTER 4 Performing an ECG 82
CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121
CHAPTER 6 Atrial Dysrhythmias 147
CHAPTER 7 Junctional Dysrhythmias 166
CHAPTER 8 Heart Block Dysrhythmias 186
CHAPTER 9 Ventricular Dysrhythmias 204
C H A P T E R 10 Pacemaker Rhythms and Bundle Branch Block 234
C H A P T E R 11 Exercise Electrocardiography 253
C H A P T E R 12 Ambulatory Monitoring 282
C H A P T E R 13 Clinical Presentation and Management of the
Cardiac Patient 307
CHAPTER 14 Basic 12-Lead ECG Interpretation 334
APPENDIX A Cardiovascular Medications A-1
APPENDIX B Standard and Isolation Precautions B-1

v
 APPENDIX C Medical Abbreviations, Acronyms, and Symbols C-1
APPENDIX D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1

vi Brief Contents
Contents
Preface xi

CHAPTER 1 Electrocardiography 1

1.1 The ECG and Its History 2

1.2 Uses of an ECG 3
1.3 Preparing for an ECG 11
1.4 Safety and Infection Control 15
1.5 Vital Signs 18

CHAPTER 2 The Cardiovascular System 28

2.1 Circulation and the ECG 29

2.2 Anatomy of the Heart 29
2.3 Principles of Circulation 34
2.4 The Cardiac Cycle 36
2.5 Conduction System of the Heart 38
2.6 Electrical Stimulation and the ECG Waveform 41

CHAPTER 3 The Electrocardiograph 54

3.1 Producing the ECG Waveform 54

3.2 ECG Machines 59
3.3 ECG Controls 64
3.4 Electrodes 67
3.5 ECG Graph Paper 69
3.6 Calculating Heart Rate 71

vii
 CHAPTER 4 Performing an ECG 82

4.1 Preparation for the ECG Procedure 83

4.2 Communicating with the Patient 84
4.3 Identifying Anatomical Landmarks 86
4.4 Applying the Electrodes and Leads 88
4.5 Safety and Infection Control 91
4.6 Operating the ECG Machine 94
4.7 Checking the ECG Tracing 95
4.8 Reporting ECG Results 100
4.9 Equipment Maintenance 101
4.10 Pediatric ECG 102
4.11 Cardiac Monitoring 103
4.12 Special Patient Considerations 104
4.13 Handling Emergencies 107

CHAPTER 5 Rhythm Strip Interpretation and Sinus Rhythms 121

5.1 Rhythm Interpretation 121

5.2 Identifying the Components of the Rhythm 122
5.3 Rhythms Originating from the Sinus Node 129
5.4 Sinus Bradycardia 132
5.5 Sinus Tachycardia 134
5.6 Sinus Dysrhythmia 135
5.7 Sinus Arrest 137

CHAPTER 6 Atrial Dysrhythmias 147

6.1 Introduction to Atrial Dysrhythmias 147

6.2 Premature Atrial Complexes 148
6.3 Wandering Atrial Pacemaker 150
6.4 Multifocal Atrial Tachycardia 152
6.5 Atrial Flutter 153
6.6 Atrial Fibrillation 155

CHAPTER 7 Junctional Dysrhythmias 166

7.1 Introduction to Junctional Dysrhythmias 166

7.2 Premature Junctional Complex (PJC) 168
7.3 Junctional Escape Rhythm 169

viii Contents
 7.4 Accelerated Junctional Rhythm 171
7.5 Junctional Tachycardia 173
7.6 Supraventricular Tachycardia (SVT) 175

CHAPTER 8 Heart Block Dysrhythmias 186

8.1 Introduction to Heart Block Dysrhythmias 186

8.2 First Degree Atrioventricular (AV) Block 187
8.3 Second Degree Atrioventricular (AV) Block, Type I (Mobitz or
Wenckebach) 188
8.4 Second Degree Atrioventricular (AV) Block, Type II (Mobitz II) 191
8.5 Third Degree Atrioventricular (AV) Block (Complete) 193

CHAPTER 9 Ventricular Dysrhythmias 204

9.1 Introduction to Ventricular Dysrhythmias 205

9.2 Premature Ventricular Complexes (PVCs) 205
9.3 Agonal Rhythm 210
9.4 Idioventricular Rhythm 211
9.5 Accelerated Idioventricular Rhythm 213
9.6 Ventricular Tachycardia 215
9.7 Ventricular Fibrillation 217
9.8 Asystole 220

CHAPTER 10 Pacemaker Rhythms and Bundle Branch Block 234

10.1 Introduction to Pacemaker Rhythms 234

10.2 Evaluating Pacemaker Function 236
10.3 Pacemaker Complications Relative to the ECG Tracing 241
10.4 Introduction to Bundle Branch Block Dysrhythmias 243

CHAPTER 11 Exercise Electrocardiography 253

11.1 What Is Exercise Electrocardiography? 253

11.2 Why Is Exercise Electrocardiography Used? 255
11.3 Variations of Exercise Electrocardiography 257
11.4 Preparing the Patient for Exercise Electrocardiography 260
11.5 Providing Safety 264
11.6 Performing Exercise Electrocardiography 265
11.7 Common Protocols 267
11.8 After Exercise Electrocardiography 270

Contents ix
 CHAPTER 12 Ambulatory Monitoring 282

12.1 What Is Ambulatory Monitoring? 282

12.2 How Is Ambulatory Monitoring Used? 284
12.3 Functions and Variations 285
12.4 Educating the Patient 290
12.5 Preparing the Patient 292
12.6 Applying an Ambulatory Monitor 293
12.7 Removing an Ambulatory Monitor and Reporting Results 296

CHAPTER 13 Clinical Presentation and Management

of the Cardiac Patient 307

13.1 Coronary Arteries 308

13.2 Cardiac Symptoms 310
13.3 Atypical Patient Presentation 312
13.4 Acute Coronary Syndrome 314
13.5 Heart Failure 316
13.6 Cardiac Patient Assessment and Immediate Treatment 318
13.7 Treatment Modalities for the Cardiac Patient 324

CHAPTER 14 Basic 12-Lead ECG Interpretation 334

14.1 The Views of a Standard 12-Lead ECG and Major Vessels 334
14.2 Ischemia, Injury, and Infarction 339
14.3 Electrical Axis 343
14.4 Bundle Branch Block 345
14.5 Left Ventricular Hypertrophy 347

Appendix A Cardiovascular Medications A-1

Appendix B Standard and Isolation Precautions B-1
Appendix C Medical Abbreviations, Acronyms, and Symbols C-1
Appendix D Anatomical Terms D-1
Glossary G-1
Photo Credits PC-1
Index I-1

x Contents
Preface
Healthcare is an ever-changing and growing field that needs well-trained indi-
viduals who can adapt to change. Flexibility is key to obtaining, maintain-
ing, and improving a career in electrocardiography. Obtaining ECG training
and certification, whether it be in addition to your current career or as your
career, will make you employable or a more-valued employee. This fourth edi-
tion of Electrocardiography for Healthcare Professionals will prepare
users for a national ECG certification examination, but most importantly
provides comprehensive training and practice for individuals in the field of
electrocardiography.
The fact that you are currently reading this book means that you are
willing to acquire new skills or improve the skills you already possess. This
willingness translates into your enhanced value, job security, marketability,
and mobility. Once you complete this program, taking a certification exami-
nation is a great next step for advancing your career.
This fourth edition of Electrocardiography for Healthcare Profes-
sionals can be used in a classroom as well as for distance learning. Check-
point Questions and Connect exercises correlated to the Learning Outcomes
make the learning process interactive and promote increased comprehension.
The variety of materials included with the program provides for multiple
learning styles and ensured success.

Text Organization
The text is divided into 14 chapters:
● Chapter 1 Electrocardiography includes introductory information about
the field as well as legal, ethical, communication, safety, and patient edu-
cation information. In addition, basic vital signs and troubleshooting are
addressed.
● Chapter 2 The Cardiovascular System provides a complete introduction
and review of the heart and its electrical system. The information focuses
on what you need to know to understand and perform an ECG. Specific top-
ics include anatomy of the heart, principles of circulation, cardiac cycle,
conduction system and electrical stimulation, and the ECG waveform.
● Chapter 3 The Electrocardiograph creates a basic understanding of the
ECG, including producing the ECG waveform, the ECG machine, elec-
trodes, and ECG graph paper.
● Chapter 4 Performing an ECG describes the procedure for performing
an ECG in a simple step-by-step fashion. Each part of the procedure is
explained in detail, taking into consideration the latest guidelines. The
chapter is divided into the following topics: preparation, communica-
tion, anatomical landmarks, applying the electrodes and leads, safety

xi
 and infection control, operating the ECG machine, checking the trac-
ing, reporting results, and equipment maintenance. Extra sections are
included regarding pediatric ECG, cardiac monitoring, special patient
circumstances, and emergencies. Procedure checklists are included to
practice performing both an ECG and continuous monitoring.
● Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms introduces
the five-step criteria for classification approach to rhythm interpretation
that will be utilized throughout Chapters 5 to 10. With updated, realistic
rhythm strip figures, explanations, and Checkpoint Questions, the user
learns to interpret the sinus rhythms, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 6 Atrial Dysrhythmias provides an introduction to and inter-
pretation of the atrial dysrhythmias, including criteria for classification,
how the patient may be affected, basic patient care, and treatment.
● Chapter 7 Junctional Dysrhythmias provides an introduction to and inter-
pretation of the junctional dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 8 Heart Block Dysrhythmias provides an introduction to and
interpretation of the heart block dysrhythmias, including criteria for
classification, how the patient may be affected, basic patient care, and
treatment.
● Chapter 9 Ventricular Dysrhythmias provides an introduction to and inter-
pretation of the ventricular dysrhythmias, including criteria for classifica-
tion, how the patient may be affected, basic patient care, and treatment.
● Chapter 10 Pacemaker Rhythms and Bundle Branch Block provides an
introduction to pacemaker rhythms, evaluation of pacemaker function,
and complications related to the ECG tracing. An introduction to bundle
branch block dysrhythmias, including criteria for classification, how the
patient may be affected, basic patient care, and treatment, is also included.
● Chapter 11 Exercise Electrocardiography provides the information nec-
essary to assist with the exercise electrocardiography procedure. The
competency checklist provides the step-by-step procedure for practice
and developing proficiency at the skill.
● Chapter 12 Ambulatory Monitoring includes the latest information
about various types of ambulatory monitors and includes what you need
to know to apply and remove a monitor. A procedure checklist is also
provided for this skill.
● Chapter 13 Clinical Presentation and Management of the Cardiac
Patient expands on the anatomy of the coronary arteries and relates them
to typical and atypical cardiac symptoms. STEMI, non-STEMI, and heart
failure are introduced. The chapter includes a section about sudden car-
diac death as compared to myocardial infarction and finishes with assess-
ment, immediate care, and continued treatment of the cardiac patient.
● Chapter 14 Basic 12-Lead ECG Interpretation provides an introduction
to 12-lead ECG interpretation. It includes anatomic views of the coronary
arteries and correlates the arteries with the leads and views obtained
on a 12-lead ECG. It also identifies the morphologic changes in the trac-
ing that occur as a result of ischemia, injury, and infarction. Axis devia-
tion, bundle branch block, and left ventricular hypertrophy round out the
chapter concepts. The last section helps users put all of these concepts
together for 12-lead interpretation.

xii Preface
These chapters can be utilized in various careers and training programs. Fol-
lowing are some suggested examples:
● Telemetry technicians (Chapters 1–12, depending on requirements)
● EKG/ECG technicians (the entire book, depending on requirements)
● Medical assistants (the entire book, depending on where they work)
● Cardiovascular technicians working in any number of specialty clinics,
such as cardiology or internal medicine (the entire book)
● Remote monitoring facilities personnel (transtelephonic medicine) (Chap-
ters 1–10, 12–14)
● Emergency medical technicians (Chapters 2, 5–10, 14, possibly more depend-
ing on where they work)
● Paramedics (Chapters 2–14)
● Nursing, especially for cross-training or specialty training (Chapters 2–14)
● Patient care tech or nursing assistant (Chapters 2–4, 12, perhaps more de-
pending on job requirements)
● Polysomnography technologist (Chapters 2–10)
● Echocardiography technologist (Chapters 2, 5–11)
● Cardiac cath lab technologist (Chapters 2–10, 14)

New to the Fourth Edition

● Over 25 new photos and revised figures for an improved, up-to-date, and
realistic look that also provides additional student practice.
● Complete revision of Chapter 1 including new and expanded sections on
safety and infection control and basic vital signs.
● Modified Bloom’s specific learning outcomes providing one learning out-
come per level 1 heading and corresponding questions to ensure student
understanding and success.
● Added and updated content about the following essential topics: cardiac
anatomy, lead descriptions, law and ethics, cardiac output, vagal tone,
stroke volume, premature complexes, Wolff-Parkinson-White syndrome,
Torsades de Pointes, pacemakers, exercise electrocardiography (includ-
ing a new table for common stress test chemicals), and ambulatory
monitoring.
● Modified and simplified descriptions of arrhythmias; changed the term
configuration to morphology when appropriate for accuracy.

Features of the Text

● Key Terms and Glossary: Key terms are identified at the beginning of
each chapter. These terms are in bold, color type within the chapter and
are defined both in the chapter and in the glossary at the end of the book.
● Checkpoint Questions: At the end of each main heading in the chapter
are short-answer Checkpoint Questions. Answer these questions to make
sure you have learned the basic concepts presented.
● Troubleshooting: The Troubleshooting feature identifies problems and
situations that may arise when you are caring for patients or perform-
ing a procedure. At the end of this feature, you are asked a question to
answer in your own words.

Preface xiii
 ● Safety & Infection Control: You are responsible for providing safe
care and preventing the spread of infection. This feature presents tips
and techniques to help you practice these important skills relative to
electrocardiography.
● Patient Education & Communication: Patient interaction and educa-
tion and intrateam communication are integral parts of healthcare. As
part of your daily duties, you must communicate effectively, both orally
and in writing, and you must provide patient education. Use this feature
to learn ways to perform these tasks.
● Law & Ethics: When working in healthcare, you must be conscious of
the regulations of HIPAA (Health Insurance Portability and Accountabil-
ity Act) and understand your legal responsibilities and the implications
of your actions. You must perform duties within established ethical prac-
tices. This feature helps you gain insight into how HIPAA, law, and ethics
relate to the performance of your duties.
● Real ECG Tracings: Actual ECG tracings, or rhythm strips, have been
provided for easy viewing and to make the task of learning the various
dysrhythmias easier and more realistic. Use of these ECG rhythm strips
for activities and exercises throughout the program improves compre-
hension and accommodates visual learners.
● Chapter Summary: Once you have completed each chapter, take time
to read and review the summary table. It has been correlated to key con-
cepts and learning outcomes within each chapter and includes handy
page number references.
● Chapter Review: Complete the chapter review questions, which are pre-
sented in a variety of formats. These questions help you understand the
content presented in each chapter. Chapters 4, 11, and 12 also include Pro-
cedure Checklists for you to use to practice and apply your knowledge.

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xiv Preface
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Preface xv
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xvi Preface
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Preface xvii
Guided Tour
Features to Help You Study and Learn

The
Electrocardiograph
Learning Outcomes and Key Terms, and an Learning Outcomes 3.1 Explain the three types of leads and how each is recorded.
3.2 Identify the functions of common ECG machines.
Introduction begin each chapter to introduce 3.3
3.4
Explain how each ECG machine control is used.
Recognize common electrodes.

you to the chapter and help prepare you for the 3.5
3.6
Describe the ECG graph paper.
Calculate heart rates using an ECG tracing.

information that will be presented. Key Terms artifact

augmented lead
millimeter (mm)
millivolt (mV)
bipolar lead multichannel recorder
bradycardia output display
Einthoven triangle precordial lead
electrodes serial ECG comparison
gain signal processing
hertz (Hz) speed control
input tachycardia
lead unipolar lead
limb lead

3.1 Producing the ECG Waveform

In this chapter, we discuss the electrocardiograph and the equipment needed

Copyright © 2016 by McGraw-Hill Education

to perform an ECG and record the ECG waveform. You will discover how the
12-lead system works and how to read the measurements on the ECG graph
paper. Learning the equipment and lead system thoroughly and correctly will
prepare you to record your first ECG.
The electrical impulse that is produced by the heart’s conduction system
is measured with the ECG machine. The ECG machine interprets the impulse
and produces the ECG waveform. The waveform indicates how the heart is
functioning electrically.
A single heart rhythm tracing views the heart from one angle. Because
the heart is three-dimensional, it is necessary to view the electrical impulse
from different sides to obtain a complete assessment of its electrical activity.
A 12-lead ECG provides a complete picture, not of the heart’s structure, but of
its electrical activity. It records the heart’s electrical activity from 12 different

54

boo20670_ch03_054-081.indd 54 02/09/14 3:43 pm

Sinus Arrest
Troubleshooting exercises identify problems A patient is in sinus arrest that lasts longer than 6 seconds. This indicates
that no electrical current is traveling through the cardiac conduction system

and situations that may arise on the job. You asystole When no rhythm
or electrical current is
traveling through the cardiac
and is known as asystole. What should you do?

conduction system.
may be asked to answer a question about the
situation.
Check Point 1. Using the criteria for classification, select the rhythm that most
Question closely resembles sinus arrest.
(LO 5.7)
A.

Checkpoint Questions are provided at the end of B.

each section in the chapter to help you understand

Copyright © 2016 by McGraw-Hill Education

the information you just read.

Which distinguishing feature(s) led you to make the selection?

Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 139

boo20670_ch05_121-146.indd 139 02/09/14 4:26 pm

xviii
“I have been examining textbooks for approximately 4.1 Preparation for the ECG Procedure
eight years now and this ECG text provides students Now that you understand how the ECG is used, the anatomy of the heart, and
the electrocardiograph, the next step is to record an ECG. The ECG experi-
ence should be pleasant for the patient and not produce anxiety. The ECG

with the most complete and accurate information procedure must be done correctly, and the tracing must be accurate.
Prior to performing the ECG, you will need to prepare the room. Cer-
tain conditions in the room where the ECG is to be performed should be con-

without overwhelming them.” sidered. For example, electrical currents in the room can interfere with the
tracing. If possible, choose a room away from other electrical equipment and
x-ray machines. Turn off any nonessential electrical equipment that is in the

Donna Folmar, Belmont Technical College room during the tracing. The ECG machine should be placed away from other
sources of electrical currents, such as wires or cords.
An ECG must be ordered by a physician or other authorized personnel,
and an order form must be completed prior to the procedure. This form may
be called a requisition or consult and should be placed in the patient’s record.
It should include why the ECG was ordered and the following identifying
Patient Education & Communication boxes information:
● Patient name, identification number or medical record number, and birth

give you helpful information for communicating ●

date
Location, date, and time of recording
● Patient age, sex, race, and cardiac and other medications the patient is
effectively—both orally and written—with patients. ●
currently taking
Weight and height
● Any special condition or position of the patient during the recording
If this information is not included on the requisition or consult, you should
ask the patient or find the information in the patient’s record.
Most facilities now have computerized systems. The ECG order is fre-
quently entered through this system. Entering the patient’s identifying infor-
mation into the computer will produce the order form and generate patient
charges. Without a computer system, the information should be handwritten
on the order form, consult, or requisition, whichever your facility uses.

Cardiac Medications
Certain cardiac medications can change the ECG tracing. Prior to the ECG

Copyright © 2016 by McGraw-Hill Education

procedure, determine if your patient is on any cardiac medications and, if
so, inform the physician and write the names of the medications on the ECG
report. See the appendix Cardiovascular Medications for examples of com-
mon cardiac medications.

The patient’s identifying information should also be entered through the

LCD panel on the ECG machine prior to the recording. If the ECG machine
does not allow you to enter the information or there isn’t time due to an emer-
gency situation, you should write it on the completed ECG. Most importantly,
all information should be written or entered accurately no matter what type
of ECG machine or order system you are using.

Figure 9-7 Ventricular fibrillation.

Interpret-TIP features throughout boo20670_ch04_082-120.indd 83 02/09/14 4:20 pm

Chapters 5–10 provide simple and easy

guidelines to help you recognize each of Interpret-TIP Ventricular Fibrillation

the ECG rhythms presented. Ventricular fibrillation is the absence of organized electrical activity. The
tracing is disorganized or chaotic in appearance.

How the Patient Is Affected and What You Should Know

What appears to be ventricular fibrillation on the monitor may not be ventric-

Safety & Infection Control boxes ular tachycardia at all. Remember to always check your patient first. Fibril-
latory waveforms may be caused by a variety of different things, like poorly
attached or dried out electrodes, broken lead wires, and excessive patient
movement. If your patient is talking to you, the patient is not in ventricular
present tips and techniques for you to apply apnea The absence of
breathing.
fibrillation.
In true ventricular defibrillation, patients will be unresponsive when the

on the job. advanced cardiac life sup-

port (ACLS) A set of clinical
interventions for the urgent
ventricles are quivering without contracting. This will always be an emer-
gency situation. Check your patient first, then initiate CPR and activate EMS
or in a healthcare institution follow the protocol for the emergency. Every
treatment of cardiac arrest patient experiencing ventricular fibrillation will be unconscious, apneic
and other life-threatening (apnea means not breathing), and pulseless. CPR and emergency measures
medical emergencies, as should begin immediately. It is recommended that appropriate personnel
well as the knowledge begin the advanced cardiac life support (ACLS) to regain normal cardiac
and skills to deploy those function. Rhythm strips are maintained and used as documentation in the
interventions. patient’s medical record.

Copyright © 2016 by McGraw-Hill Education

Crash Cart
Emergency equipment found on the crash cart must be ready when a code
situation occurs. It is important that the cart be well stocked and the emer-
crash cart A cart or tray gency equipment functioning properly. Each facility has a policy that
containing emergency medi- requires regular checking and documentation of all emergency equipment
cation and equipment that and crash carts.
can be easily transported to
the location of an emergency
for life support.
Interpret
p TIP Supraventricular
Supravent
tricular Dysrhythmias

Supraventricular
Supraventrricular tachycardia describes a group of dysrhythmias
d that
218
present with a normal-to-narrow QRS compl
complex rate of greater than
lex and a ra
150 beats per
per minute.

boo20670_ch09_204-233.indd 218 29/08/14 10:01 am

How the Patient Is Affected and What You Should Know
There are various supraventricular dysrhythmias, all of which may cause the
patient to exhibit the same signs and symptoms. The patient may be in either
a stable or an unstable condition. The stable patient (one without signs and

Law & Ethics boxes help you gain insight into symptoms of decreased cardiac output) may complain only of palpitations and
state, “I’m just not feeling right” or “My heart is fluttering.” When the patient’s
condition is unstable, he or she may experience any symptom of low cardiac
necessary information related to the performance of output because the heart is not pumping effectively to other body systems.
Many patients may present initially with a stable condition and then a few min-
utes later experience unstable symptoms.
your duties.
Copyright © 2016 by McGraw-Hill Education

Observe the patient for signs and symptoms of low cardiac output.
Signs, symptoms, and rhythm changes need to be communicated quickly to a
licensed practitioner for appropriate medical treatment. Because tachycardia
significantly increases myocardial oxygen demand, treatment should begin
as early as possible. It is difficult to predict how long a patient’s heart can
beat at a rapid rate before it begins to affect the other body systems.

Scope of Practice
Your role regarding evaluation of the rhythm strip and assessment of the
patient will depend on your training and place of employment. Working out-
side your scope of practice is illegal, and you could be held liable for per-
forming tasks that are not part of your role as a healthcare professional.

Chapter 7 Junctional Dysrhythmias 177

boo20670_ch07_166-185.indd 177 28/08/14 9:28 pm

xix
 Criteria for Classification
● Rhythm: P-P interval cannot be determined; the R-R interval is regular.

ECG Rhythm Strips make the task of learning the ● Rate: Atrial rate cannot be determined due to the absence of atrial depo-
larization. The ventricular rate is 40 to 100 beats per minute.
● P wave morphology: The P wave is usually absent; therefore, no analy-
various dysrhythmias easier and more realistic. Over ●
sis of the P wave can be done.
PR interval: The PR interval cannot be measured because the P wave

200 strips are included within the textbook. ●

cannot be identified.
QRS duration and morphology: The QRS duration and morphology
measure 0.12 second or greater and have the classic ventricular wide and
bizarre appearance.

Interpret-TIP Accelerated Idioventricular Rhythm

“Practice ECG rhythm strips are key tools for prac- The accelerated idioventricular rhythm has an absence of P waves, a
ventricular rate of 40 to 100 beats per minute, and wide and bizarre QRS

Copyright © 2016 by McGraw-Hill Education

ticing rhythm recognition. An excellent comprehen- complexes.

sive textbook for the Electrocardiography student.” Figure 9-4 Accelerated idioventricular rhythm.

Stephen Nardozzi, Westchester Community College

Chapter 9 Ventricular Dysrhythmias 213

Key Points correlated to the learning

outcomes in each Chapter Summary help you Second
ond degree type II
boo20670_ch09_204-233.indd 213

Missing QRS
RS
S Complex
Co
C omplex Missing QRS
Mi
Missing QRS
Third degree (Complete)
29/08/14 10:01 am

Missing QRS
Mi
Missing QRS Missing QRS
Mi
Missing QRS Mi
M ssing QRS
Missing QRS Mi
Missing QRS
Missing QRS

review what was just learned.

PRI remains PRI remains PRI remains PRI remains P wave is partialy P wave is partialy P wave is partialy
the same the same the same the same buried within the T wave buried within the QRS buried within the T wave

Chapter Summary
Learning Outcomes Summary Pages

8.1 Describe the various heart block In heart block rhythms, the electrical current has difficulty 186
dysrhythmias. traveling along the normal conduction pathway, causing
a delay in or absence of ventricular depolarization. The
degree of blockage depends on the area affected and the
cause of the delay or blockage. The P-P interval is regular
with all heart blocks. There are three levels of heart blocks.

8.2 Identify first degree atrioventricular (AV) First degree AV block is a delay in electrical conduction 187–188
block using the criteria for classification, and from the SA node to the AV node, usually around the AV
explain how the rhythm may affect the patient, node, which slows the electrical impulses as they travel to
including basic patient care and treatment. the ventricular conduction system.

8.3 Identify second degree atrioventricular Second degree heart block type I has some blocked or 188–190
(AV) block, Mobitz I, using the criteria for nonconducted electrical impulses from the SA node to
classification, and explain how the rhythm the ventricles at the atrioventricular junction. The impulses

Copyright © 2016 by McGraw-Hill Education

may affect the patient, including basic patient coming from the atria are regular, but the conduction
care and treatment. through the AV node gets delayed.

8.4 Identify second degree atrioventricular Second degree atrioventricular block, Mobitz II, is 191–193
(AV) block, Mobitz II, using the criteria for often referred to as the “classical” heart block. The
classification, and explain how the rhythm atrioventricular node selects which electrical impulses
may affect the patient, including basic patient it will block. No pattern or reason for the dropping of
care and treatment. the QRS complex exists. Frequently this dysrhythmia
progresses to third degree atrioventricular block.

8.5 Identify third degree atrioventricular (AV) Third degree atrioventricular block is also known as third 193–196
block using the criteria for classification, and degree heart block or complete heart block (CHB). All
explain how the rhythm may affect the patient, electrical impulses originating above the ventricles are
including basic patient care and treatment. blocked and prevented from reaching the ventricles. There is
no correlation between atrial and ventricular depolarization.
In third degree atrioventricular block, the P-P and R-R
intervals are regular (constant) but firing at different rates.

196 Chapter 8 Heart Block Dysrhythmias

Chapter Review
boo20670_ch08_186-203.indd 196 28/08/14 10:12 pm

Multiple Choice
Circle the correct answer.
1. Which heart block rhythm is the one with the distinguishing feature of a PR interval that measures
greater than 0.20 second and measures the same duration each time? (LO 8.2)
a. First degree heart block
b. Second degree type I
c. Second degree type II
d. Third degree heart block
2. Which of the following heart block dysrhythmias is identified by a repetitious prolonging PR interval

Chapter Reviews consist of various methods of pattern after each blocked QRS complex? (LO 8.3)
a. First degree heart block
b. Second degree type I

quizzing you. True/false, multiple choice, matching, c. Second degree type II

d. Third degree heart block

and critical thinking questions, among others, appeal 3. Which of the following heart block dysrhythmias is identified by missing QRS complexes and a
consistent PR interval measurement? (LO 8.4)
a. First degree heart block

to all types of learners. b. Second degree type I

c. Second degree type II
d. Third degree heart block
4. Which of the following heart block dysrhythmias is identified by regular P-P and R-R intervals that
are firing at two distinctly different rates? (LO 8.5)
At the end of each chapter, you will be directed to visit a. First degree heart block
b. Second degree type I
c. Second degree type II
the Internet to experience more interactive activities
Copyright © 2016 by McGraw-Hill Education

d. Third degree heart block

5. P-P intervals are with all heart block dysrhythmias. (LO 8.2–8.5)
about the information you just learned. a. irregular
b. absent
c. regular
d. progressively prolonged
6. QRS complexes that measure 0.12 second or greater with a rate between 20 and 40 beats
per minute indicate that the impulses causing ventricular depolarization are coming from
the . (LO 8.5)
a. SA node
b. interatrial pathways
c. AV node
d. Purkinje fibers (ventricles)

Chapter 8 Heart Block Dysrhythmias 197

boo20670_ch08_186-203.indd 197 28/08/14 10:12 pm

xx
Procedure Checklists help you learn and apply the PROCEDURES CHECKLIST 12-1
Applying and Removing an Ambulatory (Holter) Monitor
knowledge presented. Practice Practice Performed Mastered
Procedure Steps (Rationale) Yes No Yes No Yes No Date Initials

Preprocedure

1. Gather supplies and equipment.

• Prep razor

• Alcohol

• Electrodes

• Gauze pads

• Skin rasp

• Tape

• Holter unit with strap and case

• Fresh batteries

• Digital disk (SD card)

• Pen and patient diary

2. Review patient instructions per facility policy

(to ensure accuracy and prevent problems
during the testing procedure).

• Documentation (diary), activities of daily living

(ADLs), when symptoms occur.

• Medications.

• Physical restrictions such as new activities

(should maintain normal routine), bathing,
showers, swimming while wearing the device.

• How to operate the event marker.

Copyright © 2016 by McGraw-Hill Education

• How to reapply an electrode if one comes
loose or falls off.

• Must return with the Holter and diary to

complete the test.

• Must wear loose-fitting garments on the

upper body to reduce artifact.

• Provide facility phone number, copy of

instructions, and “point of contact” if the
patient has questions, problems, or concerns.

• Provide picture of electrode locations,

extra electrodes, and adhesive tape per
clinic policy.

(Continued)

Chapter 12 Ambulatory Monitoring 303

boo20670_ch12_282-306.indd 303 30/08/14 8:48 pm

Critical Thinking Application Rhythm Identification

Review the dysrhythmias pictured here and, using the criteria for classification provided in the chapter as
clues, identify each rhythm and explain what criteria you used to make your decision. (LO 5.3 to 5.7)
Review and Practice Rhythm 23.

Identification throughout textbook

activities provide ample practice
opportunities.
Rhythm (regular or irregular): PR interval:
Rate: QRS:
P wave: Interpretation:

24.
Copyright © 2016 by McGraw-Hill Education

Rhythm (regular or irregular): PR interval:

Rate: QRS:
P wave: Interpretation:

Chapter 5 Rhythm Strip Interpretation and Sinus Rhythms 143

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xxi
Acknowledgments
Authors
Kathryn Booth: Thanks to all the reviewers who have spent time helping to
make sure this fourth edition is up-to-date. In addition, I would like to acknowl-
edge McGraw-Hill for supporting this book into its fourth edition and Jody
James for being my right hand through the process.
Additionally, I would like to acknowledge Patricia Dei Tos and the members
of the Inova Health system, who help to create and support the development
of this textbook, and the Inova Learning Network, which provided encourage-
ment and lab space for photo opportunities. Also, I would like to acknowledge
the members of the Inova Heart and Vascular Institute and Inova eICU for
their assistance in obtaining photographs and video selections.
Thomas O’Brien: I would like to acknowledge Mr. David Rubin, president
& CEO of Aerotel Medical Systems (1998) Ltd., 5 Hazoref St., Holon 58856,
Israel. I would like to express my sincere appreciation to a pair of former
students and Central Florida Institute graduates: Rebecca Walton, CCT, for
her contribution of Interpret-Tips and Jamie Merritt, CCT, for “bunny branch
block.” I would also like to give a special thank-you to the staff members of
the Non-Invasive Cardiology Departments at the Pepin Heart Hospital, Mor-
ton Plant Hospital, All Children’s Hospital, and Palms of Pasadena Hospital for
their inputs and generous donation of their time and expertise.
Additionally I would like to thank my co-workers and the leadership at CFI:
Rose Lynn Greene, Director; Susan Burnell, DOE; Steve Coleman, NCMA, Edu-
cation Supervisor; Amanda L. Jones, MBA, NR-CMA, NCPT, CPC, Medical Assis-
tant Program Director (CFI); and Nicholas R. Senger, RMA, Medical Assistant
Program Instructor (CFI). Additionally I would like to thank my former col-
leagues at Central Florida Institute: Mr. Jimmy Smith, DOE; Mr. John Michael
Maloney, RCIS; Mrs. Kathy Hellums, RCS; and Mr. Steve Coleman, NCMA.
Finally, a very special thank-you to my son Rob for his hours devoted to
scanning many of the cardiac rhythms in this text.

Consultants
Cynthia T. Vincent, MMS, PA-C
Alderson Broaddus College, Philippi, WV
Jennifer Childers, MS PAC
Alderson Broaddus College, Philippi, WV
Susan Hurley Findley, RN, MSN
Houston, TX
Lynn M. Egler, RMA, AHI, CPhT
St. Clair Shores, MI
Kimberly Speiring, MA
St. Clair Shores, MI
xxii
Reviewers
Stephanie Bernard, BA, NCMA David Martinez, Medical Assistant/
Sanford–Brown Institute EMT
Jacksonville, FL Vista College
Gayle Carr, CPFT, RRT, MS Richardson, TX
Illinois Central College John McBryde, Nationally
East Peoria, IL Registered Paramedic
Cyndi Caviness, CRT, CMA East Mississippi Community College
(AAMA), AHI Mayhew, MS
Montgomery Community College Cheryl McQuay, CPT, CMA, CPI, CEKG
Troy, NC Star Career Academy
Harvey Conner, NRP, AHA Brick, NJ
Oklahoma City Community College Sheri Melton, PhD, ACSM Certified
Oklahoma City, OK Exercise Specialist, ACSM
Mary Hewett, BSEMS, MEd, Certified Health Fitness Specialist
NREMTP West Chester University
University of New Mexico West Chester, PA
Albuquerque, NM Bharat Mody, MD
Charles Hill, Paramedic Star Career Academy
North Georgia Technical College Clifton, NJ
Clarksville, GA Nicole Palmieri, RN, AHI
Cynthia Hill, MBA, CPT, CEHRS, Advantage Career Institute
CMA Eatontown, NJ
NewBridge Cleveland Center for Arts Stephen Smith, MPA, RT, RRT
& Technology Stony Brook University
Cleveland, OH Stony Brook, NY
Scott Jones, BS, MBA, EMT-P Scott Tomek, Paramedic
Victor Valley College Century College
Apple Valley, CA White Bear Lake, MN
Konnie King Briggs, CCT, CCI; PBT, Suzanne Wambold, RN, PhD
ASCP; CPCI, ACA The University of Toledo
Houston Community College Toledo, OH
Houston, TX Andrew Wood, MS, NREMT-P
Joyce Lockwood, NREMTP Emergency Medical Training
Prince George’s Community College Professionals, LLC
Largo, MD Lexington, KY

Previous Edition Reviewers

Emil P. Asdurian, MD Nia Bullock, PhD
Bramson ORT College Miller-Motte Technical College
Forest Hills, NY Cary, NC
Vanessa J. Austin, RMA, CAHI Jesse A. Coale, PA-C
Clarian Health Sciences Center, Philadelphia University
Medical Assistant Philadelphia, PA
Indianapolis, IN
Stephen Coleman
Rhonda J. Beck, NREMT-P
Central Florida Institute
Central Georgia Technical College
Palm Harbor, FL
Macon, GA
Acknowledgments xxiii
 Harvey Conner, AS, REMT-P Elizabeth Laurenz
Oklahoma City Community College National College
Oklahoma City, OK Columbus, OH
Barbara S. Desch, LVN, CPC, AHI Sheri A. Melton, PhD
San Joaquin Valley College Inc. West Chester University
Visalia/Hanford Campus West Chester, PA
Visalia, CA
Stephen J. Nardozzi
Melissa L. Dulaney Westchester Community College
MedVance Institute of Baton Rouge Valhalla, NY
Baton Rouge, LA
David James Newton, NREMT-P
Mary Patricia English Dalton State College
Howard Community College Dalton, GA
Columbia, MD
R. Keith Owens
Michael Fisher, Program AB-Tech Community College
Director Asheville, NC
Greenville Technical College
Greenville, SC Douglas A. Paris, BS,
NREMT-P
Donna L. Folmar Greenville Technical College
Belmont Technical College Department of Emergency Medical
St. Clairsville, OH Technology
Anne Fox Greenville, SC
Maric College
David Rice, AA, BA, MA
Carson, CA
Career College of Northern Nevada
James R. Fry, MS, PA-C Reno, NV
Marietta College
Marietta, OH Dana M. Roessler, RN, BSN
Southeastern Technical College
Michael Gallucci, MS, PT
Glennville, GA
Assistant Professor of Practice,
Program in Physical Therapy Wayne A. Rummings, Sr.
School of Public Health, New York Lenoir Community College
Medical College Kingston, NC
New York, NY David Lee Sessoms, Jr., MEd, CMA
Jonathan I. Greenwald Miller-Motte Technical College
Arapahoe Community College Cary, NC
Littleton, CO Mark A. Simpson, NREMT-P, RN,
Grace Haines CCEMTP
National College Director of EMS
Dayton, OH Northwest-Shoals Community College
Linda Karp Muscle Shoals, AL
Atlantic Cape Community College Linda M. Thompson, MS, RRT
Mays Landing, NJ Madison Area Technical College
Deborah Kufs, MS, BSN, CEN, Madison, WI
EMT-P Dyan Whitlow Underhill, MHA, BS
Hudson Valley Community College Miller-Motte Technical College
Troy, NY Cary, NC
Susie Laughter, BSN, RN Eddy van Hunnik, PhD
Cambridge Institute of Allied Health Gibbs College Boston
Longwood, FL Boston, MA

xxiv Acknowledgments
Suzanne Wambold, PhD, RN First Edition
RDCS, FASE Civita Allard
The University of Toledo Mohawk Valley Community College
Toledo, OH Utica, NY
Danny Webb Vicki Barclay
Milan Institute West Kentucky Technical College
Visalia, CA Paducah, KY
Danielle Schortzmann Wilken Nina Beaman
Goodwin College Bryant and Stratton College
East Hartford, CT Richmond, VA
Stacey F. Wilson, MT/PBT Cheryl Bell
(ASCP), CMA Sanz School
Cabarrus College of Health Washington, DC
Sciences Lucy Della Rosa
Concord, NC Concorde Career Institute
Fran Wojculewicz, RN, BSN, MS Lauderdale Lakes, FL
Maricopa Community College Myrna Lanier
Glendale, AZ Tulsa Community College
Roger G. Wootten Tulsa, OK
Northeast Alabama Community Debra Shafer
College Blair College
Rainsville, AL Colorado Springs, CO

Acknowledgments xxv
 Electrocardiography

Learning Outcomes 1.1 Describe the history and the importance of the ECG.
1.2 Identify the uses of an ECG and opportunities for an electro-
cardiographer.
1.3 Troubleshoot legal, ethical, patient education, and communication
issues related to the ECG.
1.4 Perform safety and infection control measures required for the ECG.
1.5 Compare basic vital sign measurements related to the ECG.

Key Terms auscultated blood pressure ethics

automatic external healthcare providers
defibrillator (AED) hypertension
body mechanics hypotension
cardiac output isolation precautions
cardiopulmonary law
resuscitation (CPR) libel
cardiovascular disease (CVD) medical professional liability
cardiovascular technologist myocardial infarction (MI)
Code Blue personal protective equipment
coronary artery disease (CAD) (PPE)
defibrillator slander
diastolic blood pressure standard precautions
Copyright © 2016 by McGraw-Hill Education

dysrhythmia stat
ECG monitor technician systolic blood pressure
electrocardiogram (ECG) telemedicine
electrocardiograph vital signs
electrocardiograph (ECG)
technician

1
cardiovascular disease 1.1 The ECG and Its History
(CVD) Disease related to
The number one cause of death in the United States every year since 1918 is
the heart and blood vessels
cardiovascular disease (CVD), or a disease of the heart and blood vessels.
(veins and arteries).
Approximately 2,500 Americans die every day because of coronary artery
coronary artery disease disease (CAD), which is narrowing of the arteries of the heart, which causes
(CAD) Narrowing of the a reduction of blood flow. Unbelievably, one out of every three American
arteries around the heart, adults has some form of CAD. You may know someone who has hypertension
causing a reduction of blood (high blood pressure) or other heart conditions. Maybe someone you know
flow. has had a myocardial infarction (MI) or heart attack.
myocardial infarction An instrument known as an electrocardiograph allows the heart’s
(MI; heart attack) Damage electrical activity to be recorded and studied. It is used to produce an electri-
to the heart muscle caused cal (electro) tracing (graph) of the heart (cardio). This tracing is known as an
by lack of oxygen due to a electrocardiogram (ECG).
blockage of one or more of Scientists have known since 1887 that electrical currents are produced
the coronary arteries. during the beating of the human heart and can be recorded. An English physi-
cian, Dr. Augustus D. Waller (1856–1922), showed that electrical currents are
electrocardiograph An
produced during the beating of the human heart and can be recorded. Willem
instrument used to record
Einthoven (1860–1927) invented the first electrocardiograph, which resulted
the electrical activity of the
in a Nobel Prize in Physiology or Medicine in 1924. Advancements in this tech-
heart.
nology have brought about today’s modern ECG machines (see Figure 1-1).
electrocardiogram Computer technology continues to improve the availability and speed of com-
(ECG) A tracing of puter interpretation and quickly communicates this information to a health-
the heart’s electrical care professional. Digital communication allows healthcare professionals to
activity recorded by an monitor patients from remote locations miles away.
electrocardiograph.

Figure 1-1 Today’s 12-lead ECG machine

is attached to the patient’s chest, arms,
and legs using electrodes and lead wires.
It records a tracing of the electrical activity
of the heart.

Copyright © 2016 by McGraw-Hill Education

2 Chapter 1 Electrocardiography
 Another Random Document on
Scribd Without Any Related Topics
When the Fourth Book opens Æneas is still the honoured guest of
the queen, entertained by her at the banquet as each succeeding
night falls, and accompanying her during the day as she rides to
inspect the progress of her city. But Dido was no longer quite
untroubled in her happiness. She could not hide from herself her
growing love for the Trojan hero; and she was assailed by a sense of
wrong to her dead husband.
At first she fought against her passion and called up every resource
of pride and modesty to hide it from the prince. But the emotion of a
richly dowered nature was not easily to be kept in check; and Dido
had not learned to dissemble. The inner conflict grew daily stronger,
absorbing every thought: on the one hand drawing her irresistibly
toward Æneas, and on the other claiming fidelity to the memory of
Sichæus. At last, craving relief and counsel, she confided in her
sister Anna. But Anna was no idealist, and her advice to Dido was
the plainest commonsense. Was she to waste all her life for the sake
of faith to the dead? It was certain that Sichæus himself would not
desire it; and why then should Dido renounce the joys of love and
motherhood? Why pine alone all her days, her country menaced on
every side by wild African tribes, because she had no warrior at her
side to make them fear? So the argument ran, turning adroitly from
questions of sentiment to the call of patriotism and ambition.
Undoubtedly Dido was right in refusing marriage with the barbarian
chiefs who had asked for her hand; but she must remember that she
had thereby made enemies of them. Let her consider the danger to
her little state from these jealous kings; and on the other hand let
her think of the power and glory which Carthage might win, if only it
were allied to the race of Troy. Lastly, added the astute pleader, with
a word which she knew had power to move her sister, for her part
she believed that the coming of Æncas was ordained by heaven, and
by Juno herself, the great goddess of marriage.
No wonder that Dido’s resolution was weakened, when every instinct
of her being was thus championed, and the only opponent was an
idea, an abstraction, that even to herself began to look fantastic.
Again she begged her guest to remain in Carthage, and the memory
of Sichæus began rapidly to fade.
Now Dido leads
Æneas round the ramparts, to him shows
The wealth of Sidon, all the town laid out,
Begins to speak, then stops, she knows not why.[34]

Then at night, when the guests are gone from the banquet: when—
The wan moon pales her light, and waning stars
Persuade to sleep, she in her empty halls
Mourns all alone, and throws herself along
The couch where he had lain.[34]

Æneas himself was losing all thought of his mission in the society of
the lovely queen. Italy was forgotten in the peace and luxury of his
life; and he gave himself up to content, without one glance beyond
the present. He had toiled so long and hard; surely he might take his
ease for a while. Moreover, it would be mere churlishness to refuse
Dido’s gracious bounty; and he could not be so ungentle. So both
the lovers wrapped themselves in a golden dream, with reality shut
far away.
The unfinished flanking turrets cease to rise,
No more the young men exercise in arms,
Build harbours, or rear bastions for defence;
All work is at a standstill—giant walls
That frown defiance, cranes that climb the sky.[34]

All the happy toil of brain and muscle was suspended, and Carthage,
silent in the sun all day, gave itself up, like its queen, to idleness and
revelry. The weeks slipped quickly by, and one by one the restraints
which her clear spirit had imposed were loosened or forgotten. And
then the autumn came, and the fatal day of the hunt, when Dido
gave herself without reserve or shame to her lover.
 The nymphs
Along the mountain-tops were heard to wail.
That day bred death, disasters manifold;
For now she took no heed what men might say.[34]

She who had been so proud and chaste, whose wisdom and fidelity
had been the fame of all the countries round about, was now the
prey of every evil tongue. Rumour flew from city to city, soiling her
fair name; and soon it was known in all the jealous neighbouring
lands that the queen of Carthage had joined herself in unlawful
union with Æneas, Prince of Troy. The reputation that had been so
painfully won was quickly lost; and not one of her many qualities
were remembered. The courage and quick wit and resource, the
generous hospitality, the impartial judgment, the kindness and
tender sympathy—were all forgotten.
Dido knew of the malignance and scorn that were smouldering
about her; but she was too honest to hide her sin, and secure in
Æneas’ love, she paid no heed. Together they recommenced the
work which had lain idle so long; and as winter came, the towers
began to rise again.
But now the gods grew envious of the little barbarian state, and
Jupiter turned an angry glance upon Æneas. Was this the end for
which he had been saved from Troy—to make his home among a
savage people, heedless of the divine command? Has he so poor a
soul that he is content to spend his days in dalliance while the fair
land of Italy cries out for a hand to govern it? Let Mercury carry to
the prince this warning from the ruler of Olympus:
“With what hopes lingers he
‘Mongst hostile races, heedless of the great
Ausonian line, and the Lavinian plains?
Let him put out to sea! My last word this.“[34]

The message fell upon Æneas with a shock of fear and remorse. His
dream was shattered: his sleeping conscience suddenly sprang to
life, and in a flash he saw the long months spent in Carthage as
treachery to the gods, to his countrymen, and to the son who was to
inherit the great Roman state. In a rush of penitence, his first
thought was to flee instantly: to leave at once and for ever the land
that had seen his folly. But the moment after he remembered Dido,
and realized in horror all the suffering that he would bring to her. He
knew the intensity of her love; and recalling all her kindness to him
and his, he could not summon courage to face her and tell her that
he must go. Weakly he resolved to prepare in secret for departure;
and orders were sent down to the ships to fit out with all speed. But
the unworthy act was bound to bring disaster. Word was soon
brought to the queen that the Trojan fleet was being furtively
prepared for sea, and she leapt to the obvious conclusion. Æneas
intended to forsake her—and to go by stealth. All her frank nature
revolted at the deception. That he should wish to go at all, lightly
flinging away her love and honour, was a thing that her own fidelity
had never suspected; but to steal away thus was baseness that
drove her to fury. Her ungoverned Oriental rage was loosed upon
him.
“False as thou art, and didst thou hope, ay, hope
To keep thy infamous intent disguised,
And steal away in silence from my realm?“[34]
 THE DEATH OF DIDO

Gianbattista Tiepolo

By Permission of Ad Braun et Cie.

But the first gust of anger past, she dropped to a softer mood and
besought him by every tender plea that her tongue could frame, not
to leave her—by their great love: by her trust in him, and the pledge
that he had given her; by the constant service that she had paid
him, and all that she had forfeited for his sake.
 “Because of thee it is, the Libyan tribes,
And Nomad chieftains hate me; my own people
Are turned against me; all because of thee
My woman’s honour has been blotted out,
And former fair good name whereby alone
I held my head aloft. To whom dost thou
Abandon me, a woman marked for death?
My guest, my guest! Since only by that name
I am to know my husband!“[34]

It would seem that her anguish must melt a heart of stone, but
Æneas remained apparently immovable. Before him still shone the
vision of the god, and in his ears Jove’s message rang insistently.
Controlling every tender impulse, he answered in words that were
made harsh by restraint. To Dido their coldness was as cruel as
death and far more bitter. She did not know the gentle Æneas in the
grip of the force that was driving him, transforming him into a
monster of ingratitude.
“This man thrown up a beggar on my shores,
I took him in, insanely gave him up
A portion of my realm, from very death
Redeemed his comrades, saved his scattered ships.
... Go! Make for Italy!
Chased by the winds, across the wild waves seek
These vaunted kingdoms! But in sooth I hope,
If the benignant Gods can aught avail,
Vengeance will strike thee midway on the rocks,
Calling and calling upon Dido’s name.“[34]

She was borne away fainting, and Æneas, racked by pity that he
dare not show, made his way down to the harbour to hasten the
sailing of the fleet. Day by day his men toiled with a will, for they
were sick of inaction and eager to get away, although winter was
already upon them. And watching from her tower, Dido saw each
day’s work completed with deeper misery, and a growing sense of
despair. Very soon now all would be ready; the day was rapidly
approaching when Æneas would trust himself to that stormy winter
sea, with small chance, as she knew, of ever reaching Latium. At the
thought of that final parting and of her lover’s danger, Dido’s anger
melted, and every vestige of her pride was swept away. She could
not and would not let him go like this. At the risk of worse
humiliation still, she would make another effort to keep him in
Carthage, at least until the stormy season should be passed. In
feverish haste she called Anna and sent a poignant message.
“In pity of my love,
Let him concede this boon—the last I crave,—
And wait propitious winds to speed his flight.“[34]

But Æneas is inexorable, and when Anna returns to the queen with
his refusal, it adds the last intolerable touch to her pain and shame.
Nightlong she roams the palace, like one distraught; and finding her
way to the tomb of Sichæus, she prays to die. Strange omens
answer her; and to her maddened brain it seems that the voice of
her husband is calling her to come to him. The water of her libation
turns black as she pours it upon the altar, and the wine congeals to
blood. The high gods have answered her: they approve her purpose.
As soon as day comes, she begins with deliberate care to make all
ready for her death. Under her directions, a great pyre is built within
the courtyard, on which the queen announces that she intends to
offer a solemn sacrifice. Every relic of Æneas is gathered and laid
upon it; his armour, his cloak and his sword; while all about it Dido
herself hangs garlands and funeral chaplets. Her sister and her
women wonder, but have no hint of her intention. When night falls
and all the palace is sunk in sleep, Dido stands again before the altar
and consecrates herself for the sacrifice. But she cannot yet take the
fatal step. She longs for one more look from her watch-tower, down
upon the ships that are so soon to carry her lover away. So she
strains her eyes through the darkness, only to find, with the first
gleam of light, that the harbour is bare. The fleet has sailed: Æneas,
warned by a vision from Jove, has fled in the night. A bitter cry
escapes her:
“Oh rare
Fidelity and honour! And they say,
He takes his household gods about with him,
And on his shoulders bore his aged sire!“[34]

She calls upon the great powers of Earth and Sky and the dreadful
Underworld to avenge her wrongs; and looking forward to the years
that are to come, she invokes upon Æneas and his descendants the
curse that followed the Roman race through many generations:
“So then do you,
My Tyrians, harry with envenomed hate
His race and kin through ages yet to come:
Be this your tribute to my timeless death!...
Let coast conflict with coast, and sea with sea.
Embattled host with host, and endless war
Be waged, ‘twixt their and your posterity!“[34]

Then, rushing to the courtyard, she climbs the great pyre, and
grasps Æneas’ sword. For one moment, ere she falls upon it, the
frenzy lifts from her brain and shows her all the course of her
troubled life.
“Lo! I have lived my life, have run the course
Assigned to me by fate; now ‘neath the earth
I go, the queenly shade of what I was.
I have built a goodly city; I have seen
Its walls complete; I have avenged my spouse,
And struck my cruel brother blow for blow!...

“This heartless Trojan, let him from the waves

Drink in with startled eyes the funeral fires,
And bear with him the presage of my death!”[34]
So the founder of Carthage died; and the father of great Rome,
looking back with remorseful eyes from his fleeing ship, saw the
flames of her pyre reddening the dawn.

34. From Sir Theodore Martin’s translation of the Æneid (Wm.

Blackwood & Sons).
Index

Absyrtus, 229, 230

Achilles, 24, 30, 33, 34, 40, 41, 139, 140, 257, 266, 274
Admetus, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222,
223, 224, 225, 226
Adrastus, 190
Aeêtes, 229
Ægeus, 238
Æneas, 37, 273, 274, 275, 276, 277, 278, 279, 280, 281, 282, 283,
284, 285, 286, 287
Æschylus, 101, 102, 103, 104, 118, 132, 133, 136, 137, 139, 148,
150, 151, 163, 164, 165, 168, 187, 190, 209, 257
Aeolus, King, 62
Agamemnon, 35, 39, 58, 59, 103, 104, 105, 106, 107, 108, 109,
110, 111, 112, 113, 114, 117, 118, 120, 127, 129, 136, 140, 142,
143, 146, 152, 256, 257, 258, 259, 262, 266, 267, 268
Aigeus, 190
Ajax, 23
Alcestis, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 220,
221, 222, 223, 224, 225, 226, 227
Alcinous, 60, 62, 85, 90, 93, 94, 97, 230
Alcmena, 42
Andromache, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 140
Andromeda, 22
Anna, 281, 286
Antigone, 22, 150, 166, 171, 186, 187, 188, 189, 191, 192, 193,
194, 195, 196, 199, 200, 201, 202, 203, 204, 205, 206, 207
Antinous, 42, 46, 47
Aphrodite, 18, 19, 20, 23, 25, 26, 244, 245, 246, 250, 255
Apollo, 97, 105, 109, 112, 113, 118, 123, 126, 129, 131, 133, 135,
137, 140, 144, 146, 168, 169, 172, 173, 181, 189, 212, 213, 214,
226, 238, 258, 271
Ares, 21, 40
Arete, Queen, 85, 97, 230
Argus, 157, 158
Artemis, 92, 93, 213, 244, 246, 247, 255, 257, 258, 261, 262, 271,
272
Astyanax, 35, 36, 37
Atè, 115, 132
Athena, 18, 19, 24, 30, 31, 42, 44, 45, 46, 50, 55, 76, 85, 87, 88,
89, 92, 93, 95, 97, 137, 256, 272
Athene (see Athena)
Atlas, 76, 151
Augustus, 273

Bacchus, 280

Cadmus, 149, 163, 206

Calypso, 43, 60, 73, 74, 75, 76, 77, 78, 79, 81, 82, 83, 84, 87
Camilla, 12
Cassandra, 35, 109, 112, 135, 136, 137, 138, 139, 140, 141, 142,
143, 144, 145, 164
Castor, 23
Charon, 218
Charybdis, 72
Chiron, 228
Chrysothomis, 165
Cilix, 149
Circe, 60, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 230
Clytemnestra, 102, 103, 104, 105, 106, 107, 108, 109, 110, 112,
113, 114, 115, 116, 117, 118, 119, 120, 121, 123, 127, 129, 130,
131, 137, 143, 144, 164, 165, 256, 257, 258, 266
Creon, 12, 171, 172, 173, 174, 176, 177, 178, 185, 186, 187, 188,
190, 193, 194, 196, 197, 198, 199, 200, 201, 202, 203, 204, 206,
207, 231, 232, 234, 235, 241
Creusa, 276
Cronos, 151, 157
Cyclôpes, 269
Cypris, 244, 250, 251

Diana, 277
Dido, 10, 12, 273, 274, 275, 276, 277, 279, 280, 281, 282, 283, 284,
285, 286, 287
Diomedes, 30
Dionysus, 101
Eëtion, 30
Egisthus, 106, 107, 115, 117, 121, 124, 127, 130
Electra, 12, 116, 118, 119, 120, 121, 123, 124, 125, 126, 127, 128,
129, 130, 132, 133, 134, 164, 166
Elpenor, 71
Enone, 18, 21
Epaphus, 149, 161
Epicasta, 167
Erinys, 115
Eteocles, 171, 188, 190, 191, 193, 197
Euripides, 10, 35, 102, 132, 133, 136, 137, 150, 209, 210, 211, 212,
214, 231, 243, 247, 256
Europa, 149
Euryclea, 50, 53, 57
Eurydice, 208
Eurylochus, 67
Eurystheus, 216, 220

Force, 152

Glaucé, 231, 237, 239, 240, 241

Hæmon, 202, 203, 204, 207

Hector, 21, 24, 25, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 139, 273
Hecuba, 29, 32, 35, 36, 140, 141
Hekabe (see Hecuba)
Helen, 12, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30,
35, 37, 41, 42, 43, 103, 135, 138, 141, 259, 265
Helenus, 37
Hephæstus, 152, 153
Hera, 18, 19, 24, 33, 98, 148, 150, 156, 169
Heracles, 161, 220, 221, 223, 224, 225, 226, 270
Hermes, 65, 66, 77, 78, 79, 119
Hesiod, 152
Hippolytus, 243, 244, 245, 246, 249, 251, 252, 253, 254
Homer, 9, 11, 12, 16, 25, 29, 58, 65, 73, 85, 87, 99, 163, 167, 274
Hymen, 141

Icarius, 46, 59, 60

Idomeneus, 23, 139
Ilione, 280
Inachus, 150, 157, 158
Io, 148, 149, 150, 151, 157, 158, 160, 161, 162, 164, 167
Iphigenia, 103, 104, 105, 121, 211, 256, 257, 259, 260, 261, 262,
263, 264, 265, 267, 268, 269, 270, 271
Ismene, 166, 171, 192, 194, 195, 196, 201, 202
Iulus, 276

Jason, 228, 229, 230, 231, 232, 233, 234, 235, 236, 237, 238, 239,
240, 242
Jocasta, 150, 163, 166, 167, 168, 170, 171, 177, 178, 179, 180, 181,
182, 183, 184, 185
Jove, 108, 287
Juno, 276, 280
Jupiter, 280, 283

Laertes, 59
Laius, 168, 169, 170, 171, 173, 175, 178, 179, 181
Leto, 261
Loxias, 141, 180

Medea, 211, 228, 229, 230, 231, 232, 234, 235, 236, 238, 239, 240,
241, 242, 243, 247
Medon, 48, 49
Menelaus, 17, 19, 20, 21, 22, 23, 25, 26, 27, 35
Mercury, 283
Merope, 169, 180, 182
Minos, 53
Mycene, 42

Nausicaa, 60, 85, 86, 87, 88, 89, 90, 91, 93, 94, 95, 96, 97, 98
Neoptolemus, 140

Oceanus, 153, 154

Odysseus, 23, 27, 39, 40, 41, 43, 44, 46, 48, 50, 51, 52, 53, 54, 55,
56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 71, 72, 73, 74,
75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 87, 88, 89, 90, 92, 93,
94, 96, 97, 98, 140, 274
Œdipus, 12, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176,
177, 178, 179, 180, 181, 182, 183, 184, 185, 187, 188, 189, 190,
 191, 192, 195, 201
Orestes, 118, 119, 121, 122, 123, 124, 125, 126, 127, 128, 129,
130, 131, 133, 164, 165, 256, 257, 258, 259, 260, 261, 262, 263,
264, 265, 266, 267, 268, 269, 270, 272
Othryoneus, 138

Paris, 17, 18, 19, 20, 21, 23, 29, 30, 137, 138, 276
Patroclus, 33, 34
Pelias, 212, 228, 230, 231
Pelops, 262
Penelope, 39, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54,
55, 56, 57, 58, 59, 60, 61, 62, 75, 79, 82, 86, 87, 163, 164
Persephone, 69, 70
Phædra, 211, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 254
Phemius, 45
Pheres, 222, 223
Phoebus, 173
Pollux, 23
Polybus, 168, 169, 180, 181, 182, 183
Polynices, 171, 188, 190, 191, 192, 193, 194, 196, 197, 198, 207
Polyxena, 140
Poseidon, 27, 39, 40, 87, 88, 94, 189, 191, 254
Priam, 17, 18, 22, 24, 25, 29, 30, 32, 34, 35, 36, 109, 135, 137, 138,
280
Prometheus, 149, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160,
161, 162, 189
Pygmalion, 276, 277
Pylades, 118, 119, 130, 131, 258, 261, 263, 264, 267, 268

Rhodius, Apollonius, 228

Scylla, 72
Sichæus, 276, 277, 281, 282, 286
Sophocles, 102, 132, 133, 150, 163, 165, 166, 172, 186, 194, 206,
209, 210

Talthybius, 140, 142

Tantalus, 103, 123
Telemachus, 27, 43, 44, 45, 46, 47, 48, 50, 51, 55, 56
Themis, 162
Theseus, 189, 190, 191, 243, 248, 253, 254
Thetis, 33, 41
Thoas, 259, 261, 267, 270, 271, 272
Tiresias, 69, 70, 170, 171, 174, 175, 178, 206
Tyndareus, 19, 20, 41
Typhon, 151
Tyro, 42

Venus, 276, 277, 278

Virgil, 9, 12, 273, 274

Zeus, 18, 24, 27, 32, 33, 41, 47, 49, 50, 54, 65, 73, 76, 77, 78, 79,
93, 94, 97, 98, 112, 126, 127, 128, 148, 149, 151, 152, 153, 154,
155, 156, 157, 158, 160, 161, 167, 200, 226
 TRANSCRIBER’S NOTES
1. Changed ‘hales’ to ‘hails’ on p. 220.
2. Silently corrected typographical errors.
3. Retained anachronistic and non-standard
spellings as printed.
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