Lake EMS Basic EKG Review:Ventricular Rhythms

The Lake EMSQuality Development Team

This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only

Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500

352/383-4554 (w); 352/735-4475 (f); mhilliard@lakeems.org

The challenge With respect to the many revered instructors and

authors who teach electrocardiology rhythm assessment, there are many differences in opinion regarding things such as heart rates for rhythms So we defined our own parameters with the blessings of the

Lake County Medical Director, Pushpal R. Banerjee, D.O.

Our solution Consequently, our Basic EKG Online review meets the

criteria as set forth by our Quality Development Department: John Simpson, Chief Operations Officer Michael R. (Mike) Hilliard, Training Officer Jamie A. Lowery, District Chief, Field Training Coordinator Scott Temple, Clinical Training Officer Julie Treadwell, Clinical Quality Officer

And our Medical Director: Pushpal R. (Paul) Banerjee, D.O.

Basic stuff When electricity stimulates muscle we witness

depolarization This is an electrical phenomenon We hope mechanically that the muscle contracts

When a muscle relaxes we see repolarization on the monitor If the muscle mass is large enough

“Hey, that looks like…” Many of us were taught

how to visually recognize EKGs

We were taught a simple process of 5-steps that help define the rhythm characteristics; however, over time we returned to the visual recognition

Basic wave breakdown Please understand this is an interpretation

review, not a diagnostic patient assessment Always treat the patient and not the monitor

P-wave: Atrial depolarization QRS-complex: Ventricular depolarization T-wave: Ventricular repolarization

1st Axiom of EMS And if you forget to treat the patient and are

considering treating the monitor, remember the first axiom of EMS:

1st Axiom of EMS And if you forget to treat the patient and are

considering treating the monitor, remember the first axiom of EMS: If you’re not sure what to do,

1st Axiom of EMS And if you forget to treat the patient and are

considering treating the monitor, remember the first axiom of EMS: If you’re not sure what to do, ask your EMT what the

other paramedics would do in a similar situation.

5-Part EKG AssessmentYour key to success

1. Rate: QRS in 6-second strip, multiply x 10

2. Rhythm: QRS distances consistent throughout strip

3. P-waves (in the entire strip being assessed): Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?

4. P to R Interval (PRI): 0.12 to 0.20 seconds

5. QRS-Complexes: Narrow: <0.12-seconds (3 small boxes) Wide: >0.12-seconds

12

Ventricular Rhythms

Idioventricular A slow rhythm that originates in the ventricles Idioventricular is slow and wide!

Automaticity and Inherent Myocardial Cell Firings Remember the initiated heart rate from the

Ventricles is a back-up system; it is here to keep us alive: SA Node: 60-150 bpm (beats-per-minute) AV Junction: 40-60 bpm Ventricles: 30-40 bpm

These are normal values, other rates can and do occur at times

Idioventricular1. Rate:2. Rhythm:

3. P-waves:4. PRI:5. QRS:

< 60 bpm Usually regular, but can be

irregular None None Wide

Idioventricular

5-Part EKG Assessment1. Rate:

What is the rate?

5-Part EKG Assessment1. Rate:

30-bpm

5-Part EKG Assessment2. Rhythm:

Is the rhythm regular or irregular?

5-Part EKG Assessment2. Rhythm:

Regular

5-Part EKG Assessment3. P-waves:

Are P-waves present? Do they look like a small

rounded hill? Is there a P for every

QRS?

Is there a QRS for every P? Does each P looks like all the

others? Is each P the same distance

from the QRS?

5-Part EKG Assessment3. P-waves:

P-waves? No

5-Part EKG Assessment4. P to R Interval (PRI):

Is the PRI between 3-5 small boxes?

5-Part EKG Assessment4. P to R Interval (PRI):

No P-wave; no PRI

5-Part EKG Assessment5. QRS-Complexes:

Is QRS narrow or wide?

5-Part EKG Assessment5. QRS-Complexes:

Wide, 0.16-seconds

This is Idioventricular 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

30 Regular None None Wide

Ventricular Tachycardia Ventricular Tachycardia (VT) is defined as three

or more beats of ventricular origin in succession at a rate greater than 150 beats per minute

Morphology QRS complexes are wide The T-wave is commonly in the opposite

direction as the QRS

Morphology QRS complexes are wide The T-wave is commonly in the opposite

direction as the QRS Termed contralateral

Ventricular Tachycardia Ventricular tachycardia may be either:

Monomorphic (all QRS-complexes with the same shape), or

Polymorphic (varying QRS shapes) Regardless: VT is fast and wide!

Ventricular Tachycardia1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

> 150 bpm Usually regular None None Wide

Ventricular Tachycardia

5-Part EKG Assessment1. Rate:

What is the rate?

5-Part EKG Assessment1. Rate:

210-bpm

5-Part EKG Assessment2. Rhythm:

Is the rhythm regular or irregular?

5-Part EKG Assessment2. Rhythm:

Regular

5-Part EKG Assessment3. P-waves:

Are P-waves present? Do they look like a small

rounded hill? Is there a P for every

QRS?

Is there a QRS for every P? Does each P looks like all the

others? Is each P the same distance

from the QRS?

5-Part EKG Assessment3. P-waves:

P-waves? No

5-Part EKG Assessment4. P to R Interval (PRI):

Is the PRI between 3-5 small boxes?

5-Part EKG Assessment4. P to R Interval (PRI):

No P-wave; no PRI

5-Part EKG Assessment5. QRS-Complexes:

Is QRS narrow or wide?

5-Part EKG Assessment5. QRS-Complexes:

Wide, 0.16-seconds

This is Ventricular Tachycardia1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

210 Regular None None Wide

Ventricular Tachycardia And what should you immediately do after

seeing VT?

Ventricular Tachycardia 12-Lead?

Ventricular Tachycardia 12-Lead? No

Assess patient If stable, consider medication as per Practice

Parameters

Assess patient If stable, consider medication as per Practice

Parameters If unstable

Tincture of Florida Power

Torsades de Pointes Torsades de Pointes is a form of polymorphic VT

(varying QRS shapes) in which the QRS appears to be constantly changing

VT is fast and wide!

Torsades de Pointes1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

> 150 bpm Usually regular None None Wide and varying QRS shapes

Torsades de Pointes

5-Part EKG Assessment1. Rate:

What is the rate?

5-Part EKG Assessment1. Rate:

200-bpm

5-Part EKG Assessment2. Rhythm:

Is the rhythm regular or irregular?

5-Part EKG Assessment2. Rhythm:

Regular; no matter how you look at it

5-Part EKG Assessment3. P-waves:

Are P-waves present? Do they look like a small

rounded hill? Is there a P for every

QRS?

Is there a QRS for every P? Does each P looks like all the

others? Is each P the same distance

from the QRS?

5-Part EKG Assessment3. P-waves:

P-waves? No

5-Part EKG Assessment4. P to R Interval (PRI):

Is the PRI between 3-5 small boxes?

5-Part EKG Assessment4. P to R Interval (PRI):

No P-wave; no PRI

5-Part EKG Assessment5. QRS-Complexes:

Is QRS narrow or wide?

5-Part EKG Assessment5. QRS-Complexes:

Wide, 0.20-seconds

5-Part EKG Assessment5. QRS-Complexes:

Wide, 0.20-seconds And varying shapes

This is Torsades de Pointes1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

200 Regular None None Wide and varying shapes

Cardiac Arrest Patients in cardiac arrest are classified as

being in 3-categories:1. Ventricular fibrillation2. Pulseless Electrical Activity3. Asystole

Ventricular Fibrillation It is a rhythm in which multiple areas within the

ventricles vary in depolarization and repolarization

There is no cardiac output This is the most common initial rhythm in cardiac

arrest

Ventricular Fibrillation The terms coarse and fine have been used to

describe the amplitude of the waveforms in VF Coarse VF usually indicates the recent onset of

VF, which can be readily corrected by prompt defibrillation

Ventricular Fibrillation1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

None None None None None

Ventricular Fibrillation

Ventricular Fibrillation And what should you immediately do after

seeing VF?

Shock it until you recognize it!

Crew accidently found patient in rhythm and brought them back after a few shocks and subsequent treatments

Great Job!

5-Part EKG Assessment1. Rate:

What is the rate?

5-Part EKG Assessment1. Rate:

None

5-Part EKG Assessment2. Rhythm:

Is the rhythm regular or irregular?

5-Part EKG Assessment2. Rhythm:

None

5-Part EKG Assessment3. P-waves:

5-Part EKG Assessment3. P-waves:

P-waves? None

5-Part EKG Assessment4. P to R Interval (PRI):

Is the PRI between 3-5 small boxes?

5-Part EKG Assessment4. P to R Interval (PRI):

None

5-Part EKG Assessment5. QRS-Complexes:

Is QRS narrow or wide?

5-Part EKG Assessment5. QRS-Complexes:

None

This is Ventricular Fibrillation1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

None, wavy line None None None None

Pulseless Electrical Activity PEA is any rhythm (with a QRS) without a pulse Any rhythm can be categorized as PEA

However, if pulseless VT, treat as VF There is no pulse in PEA!

Pulseless Electrical Activity

PEA usually looks like this

Asystole (Cardiac Standstill) Asystole represents the total absence of

electrical activity Since depolarization does not occur, there is no

ventricular contraction

Asystole (Cardiac Standstill) 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

None None None None None

Asystole

5-Part EKG Assessment1. Rate:

What is the rate?

5-Part EKG Assessment1. Rate:

None

5-Part EKG Assessment2. Rhythm:

Is the rhythm regular or irregular?

5-Part EKG Assessment2. Rhythm:

None

5-Part EKG Assessment3. P-waves:

5-Part EKG Assessment3. P-waves:

P-waves? None

5-Part EKG Assessment4. P to R Interval (PRI):

Is the PRI between 3-5 small boxes?

5-Part EKG Assessment4. P to R Interval (PRI):

None

5-Part EKG Assessment5. QRS-Complexes:

Is QRS narrow or wide?

5-Part EKG Assessment5. QRS-Complexes:

None

This is Asystole 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:

None None None None None

Pacer Rhythms Pacers provide a low energy burst of electricity

that can be identified on the EKG by a pacer spike

Pacer Rhythms

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Look for the pacer spikes

Pacer Rhythms Or the friendly reminders to look for pacer

spikes

Ectopi A beat originating from a source of cardiac

stimulus other than the SA node

Ectopi A beat originating from a source of cardiac

stimulus other than the SA node, usually caused by some irritation of the myocardium

Premature VentricularContraction (PVC) A PVC is a depolarization that arises in either

ventricle before the next expected beat This results in a bizarre-appearing QRS

The sequence of repolarization is also altered, usually resulting in a ST segment and T wave in a direction opposite to the QRS complex

PVCs PVCs have 3 primary hallmarks:

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Wide

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide

3. Compensatory Pause: Yes

PVCs PVCs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide

3. Compensatory Pause: Yes Let me explain

PVCs Regularity:

PVCs Regularity: Irregular

≠

PVCs Regularity: Irregular QRS Complex:

PVCs Regularity: Irregular QRS Complex: Wide

PVCs Regularity: Irregular QRS Complex: Wide Compensatory Pause:

PVCs Regularity: Irregular QRS Complex: Wide Compensatory Pause: Yes

Compensatory/Non-Compensatory Pause Measure the distance between 3 normal/regular

QRSs Compare the distance between the normal QRS

before and after the beat in question If the distance is the same there is a compensatory

pause If the distance is not the same, there is no

compensatory pause

PVCs Measure distance between 3 normal QRS-

waves

PVCs Measure distance between 3 normal QRS-

waves

PVCs This distance is our standard measurement

PVCs This distance is our standard measurement It can only be measured with regular complexes

PVCs This distance is our standard

If a funny looking beat does not disturb this rhythm tempo then it is said to have a compensatory pause

PVCs Good, now identify the normal QRS-waves

before and after the funny looking beat

PVCs Now measure the distance and compare to the

original measurement

PVCs The distance is the same

PVCs So we have a compensatory pause

Compensatory pause

PVCs So we have a compensatory pause So this is a PVC because it is wide and has the

compensatory pause

Compensatory pause

Significance of compensatory pause When an electrical discharge occurs within the

ventricles, it depolarizes all of the other cells in both ventricles

Significance of compensatory pause When an electrical discharge occurs within the

ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems

Significance of compensatory pause When an electrical discharge occurs within the

ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them

Significance of compensatory pause When an electrical discharge occurs within the

ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them So the timing is unchanged

Significance of compensatory pause When an electrical discharge occurs within the

ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them So the timing is unchanged And that is why we have a compensatory pause as

the timing is undisturbed

PVCs How about if there are different shaped ectopic

beats?

PVCs Measure distance between 3 normal QRS-

waves Just like before as the process is still the same

PVCs Now measure the distance and compare to the

original measurement

PVCs First funny looking beat is the same distance

Compensatory pause

PVCs They are the same

Compensatory pause

PVCs Even for different looking PVCs

Compensatory pause

PVCs Even for different looking PVCs

Also known as multifocal

Compensatory pause Compensatory pause

PVCs What about back-to-back PVCs?

PVCs Also known as Salvos

PVCs Salvo PVCs

Compensatory pause

Compensatory pause Indicates that the ectopic beat did not interrupt

the atrial firing Subsequently, it occurred south of the AV Node

Premature AtrialContraction (PAC) A beat originating from a source of cardiac

stimulus within the atrium, other than the SA node, usually caused by some irritation of the myocardium Can easily be confused with Sinus Arrhythmia

PACs PACs have 3 primary hallmarks:

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Narrow

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the

normal pathways to enter the ventricles

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the

normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the

normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response

3. Compensatory Pause: No

PACs PACs have 3 primary hallmarks:

1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become

irregular

2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the

normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response

3. Compensatory Pause: No Termed non-compensatory pause

PACs Hint Easy way to identify if PAC is hidden:

The P-wave does not look like normal P-waves in this complex

PACs Regularity:

PACs Regularity:

PACs Regularity:

≠

PACs Regularity: Irregular

≠

PACs Regularity: Irregular QRS Complex:

PACs Regularity: Irregular QRS Complex: Narrow

PACs Regularity: Irregular QRS Complex: Narrow Compensatory Pause:

PACs Regularity: Irregular QRS Complex: Narrow Compensatory Pause: No

PACs P-wave does not look like normal P-waves in

either complexes

PACs Measure the distance between 3 normal QRS-

waves Assessment process does not change

PACs Now measure the distance from the normal beat

before and after the questionable beat

PACs They are not the same

NO compensatory pause

Non-compensatory pause Indicates that the ectopic beat did interrupt the

normal SA Node firing

Non-compensatory pause Indicates that the ectopic beat did interrupt the

normal SA Node firing Subsequently, it occurred inside the atria

Non-compensatory pause Indicates that the ectopic beat did interrupt the

normal SA Node firing Subsequently, it occurred inside the atria

Hence, it “reset or rebooted” the atrium and SA Node

Non-compensatory pause Indicates that the ectopic beat did interrupt the

normal SA Node firing Subsequently, it occurred inside the atria

Hence, it “reset or rebooted” the atrium and SA Node And thereby changed the timing

Sinus arrhythmia The difference between a rhythm with a PAC

and Sinus Arrhythmia is in Sinus Arrhythmia:

Sinus arrhythmia The difference between a rhythm with a PAC

and Sinus Arrhythmia is in Sinus Arrhythmia: All P-waves look the same to each other

Premature JunctionalContraction (PJC) A premature junctional complex is an electrical

impulse that originates in the AV junction and occurs before the next expected sinus impulse

A retrograde P wave may precede, coincide with, or follow the QRS

PJCs Conduction from the junction to the ventricles

usually occurs along normal pathways Thus the QRS complex is usually narrow The pause following a PJC may be

compensatory or non-compensatory

PJCs Regularity: Irregular QRS Complex: Narrow Compensatory Pause: Can have either

What? Can have either a compensatory or non-

compensatory pause; however…

PJC Hint No visible P-wave

Special Notes on Ectopi Unifocal

Multifocal

All PVCs have same morphology (shape)

When the QRS morphologies (shape) vary, the PVCs may be arising from different areas within the ventricles

Special Notes on Ectopi Quadrigeminy

Trigeminy

Bigeminy

Every fourth beat is a PVC (3 normal beats, 1 PVC)

Every third beat is a PVC (2 normal beats, 1 PVC)

Every other beat is a PVC (1 normal beat, 1 PVC)

Special Notes on Ectopi Salvos PVCs that occur

repetitively in pairs, also called coupling. Even though they are paired, they still retain the expected full compensatory pause seen from ectopi starting from the ventricles

Special Notes on Ectopi VT

R on T phenomenon

When three or more PVCs occur in a row, VT is present

PVCs that fall on the T wave (during the so-called vulnerable period of ventricular repolarization) may precipitate VT or VF

When three or more PVCsoccur in a row, VT is present

R on T phenomenon A PVC can land in the early relative refractory

period of a T-wave and immediately set VT into motion

R on T phenomenon This would be bad

R on T phenomenon

EKG Training

EKG Training So easy,

EKG Training So easy, Well, you get

the picture

As a Department, the Lake EMS Quality Development Team is here to serve youin your educational needs

This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only

Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500

352/383-4554 (w); 352/735-4475 (f); mhilliard@lakeems.org

Lake EMS Basic EKG Review:Ventricular Rhythms

The Lake EMSQuality Development Team