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Instructive ECGs in Emergency Medicine Clinical Content

Associate Editors:
— Pendell Meyers & Ken Grauer (2018)
— Jesse McLaren & Emre Aslanger (2022)
— Willy Frick (2024)

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Laddergrams in Dr. Smith’s ECG Blog

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MY Comment, by KEN GRAUER, MD (7/27/2025):

Learning to draw Laddergrams is challenging. I fully acknowledge that it took me significant time until I felt comfortable with this skill. That said — learning to read laddergrams is EASY — and important for enhancing your understanding of more complex arrhythmias.

  • I cover the basics of what a laddergram is in the 5-minute ECG Video below. With this as introduction — you should be able to understand the mechanism portrayed in most laddergrams you will see.
  • NOTE: You do not need to know how to draw laddergrams in order to attain excellence in arrhythmia interpretation — BUT — Becoming comfortable in reading laddergrams will be invaluable for taking you to your next level!

NOTE: If your browser does not show my Basics of Laddergrams Video that I have embedded below, then please — CLICK HERE —

ECG VIDEO on “The Basics” of Laddergrams: This video (5:07 minutes) reviews the basics of what a Laddergram is. The laddergram that I briefly illustrate (beginning at ~4 minutes in the video) is excerpted from my ECG Blog #187 (which provides additional detail on this case — including in the Addendum to Blog #187, several other possibilities for the mechanism of the arrhythmia).

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How to Draw a Laddergram (Step-by-Step Demonstration)

  • See ECG Blog #69 — For a Step-by-Step demonstration on drawing a Laddergram. 
  • ECG Blog #286 — presents another Step-by-Step demonstration for drawing the laddergram of a challenging case of Mobitz I 2nd-degree AV block.
  • For additional practice — I include LINKS below to more than 30 examples of laddergrams that I’ve drawn for cases in Dr. Smith’s ECG Blog.
  • For readers wanting more examples — My ECG Blog #188 features LINKS to over 133 clinical examples of laddergrams that I’ve drawn over the years on my Blog to illustrate cases (Many of these examples illustrate Step-by-Step demonstration).
  • User-Friendly LINK  = https://tinyurl.com/KG-Laddergrams — for this ECG Blog #188.
  • CLICK HERE — To DOWNLOAD my FREE Power Point Laddergram STENCIL (Here is the user-friendly LINK to my FREE PowerPoint Laddergram Stencil — tinyurl.com/KG-Laddergram-Stencil ).

Essential Laddergram Elements:

As a Summary of essential laddergram elements — I’ve added the following 2 figures (taken from my ACLS-2013-ePub book). Legends explaining the basic laddergram elements in Panel A and Panel B appear below each Figure.

— Where to find the Laddergrams LINK in the Top Menu —

Go to Research & Resources — then Resources — then Laddergrams …

For Practice in Reading Laddergrams: 

Please CHECK OUT the following posts in Dr. Smith’s ECG Blog — for which I’ve added laddergram illustrations. (Please scroll down to the BOTTOM of the page in each of these Blog posts for My Comment with laddergram illustration. Many of these posts will show step-by-step description on how I construct the laddergram).

  • No Clinical Information — from May 28, 2019 post.
  • Acute Inferior MI — from January 19, 2020 post.
  • Interpolated PVCs — from April 9, 2020 post.
  • AV Wenckebach (very long PR) — Sinus Arrhythmia — Use of Atropine (with Step-by-Step illustration for drawing this laddergram) — from May 16, 2020 post.
  • Drug Overdose and a Fascinating Arrhythmia — from June 13, 2020 post.
  • Palpitations and a Complicated Rhythm (Phase 4 = Bradycardia-induced Aberrancy — Step-by-Step Laddergrams) — from August 17, 2020 post.
  • Is there Wenckebach? (Dual AV Nodal Pathways with Mobitz I — jump in PR interval!) — from September 9, 2020 post.
  • High-grade AV Block with bundle branch escape — from September 24, 2020 post.
  • Group Beating that is not Wenckebach — from September 26, 2020 post.
  • Drawing Junctional Escape — from October 9, 2020 post.
  • A Fall and a Rhythm to Recognize (Digoxin) — from November 24, 2020 post.
  • A complex tracing with probable Mobitz I + an accelerated fascicular rhythm + variable degrees of fusion with the underlying rhythm — from June 17, 2021 post.
  • Dual-Level Wenckebach following Cardiac Arrest — from October 25, 2021 post.
  • Mobitz I with long PR (Vent. Standstill) — from March 14, 2022 post.
  • Acute Inf. MI with SA Block — from May 25, 2022 post.
  • A Pacer tracing with blocked beats — from August 3, 2022 post.
  • Assessing a long Wenckebach cycle (MY Post! ) — from January 26, 2023 post (also covers clinical significance of a very long 1st-degree ≥0.30 second).
  • Is this Rhythm Puzzling to You? (MY Post! — on AV Wenckebach with a very long PR interval) — from March 30, 2023 post.
  • AV Wenckebach misdiagnosed as AFib (not “Trifascicular” Block! ) — from April 6, 2023 post.
  • Dual-Level AV Wenckebach — from May 26, 2023 post.
  • Isorhythmic AV Dissociation (My CASE) — from June 26, 2023 post.
  • Junctional Escape + AV Wenckebach — from July 30, 2023 post.
  • SA Block vs blocked PACs (Group Beating! ) — from August 30, 2023 post.
  • AIVR usurps Mobitz I — from October 3, 2023 post.
  • Mobitz I vs Mobitz II — from January 23, 2024 post.
  • Precordial Swirl with Ladder of intermittent Fascicular Escape! — from the March 22, 2024 post by W.Frick.
  • AFlutter with dual-level Wenckebach conduction — from the June 3, 2024 post
  • AIVR (with “takeover” of AIVR from sinus rhythm) — from the August 9, 2024 post by Dr. Frick.
  • SA Block (Where did the P waves go? — complex laddergram) — from the August 14, 2024 post by Dr. Frick.
  • NSVT— Echo Beats (Retrograde) — from the November 3, 2024 —
  • Pacing (ATach — PVARP — Pacer-Mediated Tachycardia) Troubleshooting — from the December 20, 2024 post.
  • OMI with AIVR (Fusion beats) — from the January 5, 2025 post.
  • AFlutter with dual-level Wenckebach (variable conduction ratios) — from the January 26, 2025 post.
  • Sinus Bradycardia with Junctional Escape — from the May 10, 2025 post.
  • AFlutter with dual-level Wenckebach conduction — from the May 24, 2025 post.

(35 laddergram cases up to September 13, 2025)
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NOTE (4/16/2025): I’ll continue to add links to this page of additional laddergrams I use to illustrate cases.

  • SEND ME cases of your interesting arrhythmias that you’d like to see published on my ECG Blog. I’m always happy to acknowledge your contribution on the blog post! THANKS for your interest! (Ken Grauer, MD — ekgpress@mac.com )

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