ECG ArrhythmiaECG Arrhythmia

Dr. K. P. MisraSr. Consultant CardiologistDr. K. P. MisraSr. Consultant Cardiologist

Two Cardinal Rules For

Analyzing Arrhythmias :

1. Study the ventricular (QRS)) complex

2. Look for the P waves (“cherchez le P”)

Two Cardinal Rules For

Analyzing Arrhythmias :

1. Study the ventricular (QRS)) complex

2. Look for the P waves (“cherchez le P”)

If the ventricular complex is normal :you know that the arrhythmia is supraventricular :

i.e., either atrial or A – V nodal

If the ventricular complex is abnormal and widened :you know that the arrhythmia is

eitherventricular

orsupraventricular with ventricular aberration

(abnormal conduction through ventricles)

If the ventricular complex is normal :you know that the arrhythmia is supraventricular :

i.e., either atrial or A – V nodal

If the ventricular complex is abnormal and widened :you know that the arrhythmia is

eitherventricular

orsupraventricular with ventricular aberration

(abnormal conduction through ventricles)

OverviewOverview

• Electrical activity of the heart

• The electrocardiogram

• Monitoring sytems

• Recognition of dysrhythmia in ACLS

Location forchest electrodes

Lead 1

Location forchest electrodes

Lead 2

Location forchest electrodes

Lead 3

Normal Sinus Rhythm

• Rate : 60 to 100 / min

• Rhythm : regular

• P waves : upright in I, II, aVF

• Therapy : none

Normal Sinus Rhythm

• Rate : 60 to 100 / min

• Rhythm : regular

• P waves : upright in I, II, aVF

• Therapy : none

Normal Sinus Rhythm

Lead 2

Normal Sinus Rhythm

Lead 2

Sinus Tachycardia

• Rate : greater than 100/min

• Rhythm : regular

• P waves : upright in I, II, aVF

• Treat underlying cause

Sinus Tachycardia

• Rate : greater than 100/min

• Rhythm : regular

• P waves : upright in I, II, aVF

• Treat underlying cause

Sinus Tachycardia

Lead 2

Sinus Tachycardia

Lead 2

Sinus BradycardiaSinus Bradycardia

• Rate : Less than 60 / min• Rhythm : Regular• P waves : Upright in I, II, aVF

• Therapy : Usually only when

hypotension orventricular ectopicbeats presentAtropine drug of choicepacemaker may be necessary

• Rate : Less than 60 / min• Rhythm : Regular• P waves : Upright in I, II, aVF

• Therapy : Usually only when

hypotension orventricular ectopicbeats presentAtropine drug of choicepacemaker may be necessary

Sinus Bradycardia

Lead V1

Sinus Bradycardia

Lead V1

SINUS RHYTHMS(normal P wave preceding every QRS)

SINUS RHYTHMS(normal P wave preceding every QRS)

SINUS ARRHYTHMIA – NOTE IRREGULARITYSINUS ARRHYTHMIA – NOTE IRREGULARITY

SINUS TACHYCARDIA - RATE 130SINUS TACHYCARDIA - RATE 130

SINUS BRADYCARDIA - RATE 42SINUS BRADYCARDIA - RATE 42

Premature Atrial Complexes Premature Atrial Complexes

• Rhythm : irregular• P waves : premature

coupling intervalnoncompensatory pause

• PR : normalprolongedblocked

• QRS : normalwidened (aberrant)

• Rhythm : irregular• P waves : premature

coupling intervalnoncompensatory pause

• PR : normalprolongedblocked

• QRS : normalwidened (aberrant)

Premature Atrial ComplexesPremature Atrial Complexes

• Therapy : none if infrequenttreat underlying causespecific drug therapy- Quindine

Procainamide Propranolol Digoxin

• Therapy : none if infrequenttreat underlying causespecific drug therapy- Quindine

Procainamide Propranolol Digoxin

Premature Atrial Complexes

MCL1

Premature Atrial Complexes

MCL1

Atrial Premature BeatAtrial Premature Beat

Run of premature P waves(each followed by normal ventricular complex)

= ATRIAL TACHYCARDIA

Run of premature P waves(each followed by normal ventricular complex)

= ATRIAL TACHYCARDIA

Atrial Tachycardia with 2 to 1 A – V BlockAtrial Tachycardia with 2 to 1 A – V Block

Two P waves for every QRS - only every alternate impulse is conducted to ventricles.

Two P waves for every QRS - only every alternate impulse is conducted to ventricles.

Atrial TachycardiaAtrial Tachycardia• Rate : atrial rate• Rhythm : atrial - regular

ventricular –usually regular with1 to 1 conduction whenatrial rate is less than200 / min when atrial rate ismore than 200 / min., AVblock and variable AVconduction may occur

• P waves : often difficult to identify• PR : normal or prolonged • QRS : normal or widened (aberrant)

• Rate : atrial rate• Rhythm : atrial - regular

ventricular –usually regular with1 to 1 conduction whenatrial rate is less than200 / min when atrial rate ismore than 200 / min., AVblock and variable AVconduction may occur

• P waves : often difficult to identify• PR : normal or prolonged • QRS : normal or widened (aberrant)

Atrial TachycardiaAtrial Tachycardia

• Therapy : Paroxysmal atrial tachycardiaParasympathetic maneuvers- Vagal stimulation –carotoid sinus message

valsalva, vomitingAlpha receptor stimulation

- PhenylephrineCholinergic agent

- edrophoniumSynchronized DCCountershockBeta receptor blockage

- PropranololOther antidysrhythmic agents

- Procainamide Lidocaine

DigitalizationSedation

• Therapy : Paroxysmal atrial tachycardiaParasympathetic maneuvers- Vagal stimulation –carotoid sinus message

valsalva, vomitingAlpha receptor stimulation

- PhenylephrineCholinergic agent

- edrophoniumSynchronized DCCountershockBeta receptor blockage

- PropranololOther antidysrhythmic agents

- Procainamide Lidocaine

DigitalizationSedation

Atrial TachycardiaAtrial Tachycardia

• Therapy :Nonparoxysmal atrial tachycardia

- treat underlying cause

potential danger of

digitalis intoxication

• Therapy :Nonparoxysmal atrial tachycardia

- treat underlying cause

potential danger of

digitalis intoxication

Atrial Tachycardia

Lead 2

Atrial Tachycardia

Lead 2

• Rate : Atrial rate 300 / min (220 – 350)• Rhythm : Atrial - regular

ventricular –regular with constant AVconduction ratioIrregular with variable AV conduction

• P waves : F waves resemble“sawtooth” or “picket fence”

• PR : Usually regular but may vary• QRS : usually normal

aberrancy may occur

• Rate : Atrial rate 300 / min (220 – 350)• Rhythm : Atrial - regular

ventricular –regular with constant AVconduction ratioIrregular with variable AV conduction

• P waves : F waves resemble“sawtooth” or “picket fence”

• PR : Usually regular but may vary• QRS : usually normal

aberrancy may occur

Atrial Flutter

• Therapy : Synchronized DCcountershockdigitalizationpropranololquinidine, procainamideoverdrive pacing

• Therapy : Synchronized DCcountershockdigitalizationpropranololquinidine, procainamideoverdrive pacing

Atrial Flutter

Atrial FlutterAtrial Flutter

“Sawtooth” atrial flutter (“FF”) waves in regular relationship to QRS.

4 “F” waves to each QRS = 4 to 1A-V conduction.

“Sawtooth” atrial flutter (“FF”) waves in regular relationship to QRS.

4 “F” waves to each QRS = 4 to 1A-V conduction.

Atrial Flutter

Lead 2

Atrial Flutter

Lead 2

Atrial FibrillationAtrial Fibrillation

• Therapy : Digitalization

synchronized DC

countershock

quinidine, procainamide

propranolol

• Therapy : Digitalization

synchronized DC

countershock

quinidine, procainamide

propranolol

Atrial Fibrillation withrapid ventricular response

Lead 2

Atrial Fibrillation withrapid ventricular response

Lead 2

Mitral stenosis and regurgitation in atrial fibrillationMitral stenosis and regurgitation in atrial fibrillation

Premature junctional complexesPremature junctional complexes

• Rhythm : irregular• P waves : retrograde inverted in II, III, aVF

before, during, or after QRScompensatory ornoncompensatory pause

PR : with P before QRSusually less than 0.12 sec.prolongedblocked

• QRS : normalwidened (aberrant)

• Therapy : same as PACs

Premature junctional complexes

Lead 2

Premature junctional complexes

Lead 2

Junctional escape complexes and rhythmJunctional escape complexes and rhythm

• Rate : junctional escaperhythm – 40 to 60/min

• Rhythm : junctional escape complexes – irregularjunctional escape rhythm – regular

• P waves : retrograde inverted in II, III, aVFbefore, during, or after QRScompensatory oratrioventricular dissociation

• PR : variable• QRS : normal

widened (aberrant)• Therapy : hemodynamically stable

- noneatropineisoproterenolpacemaker

Junctional escape complexes

Lead 2

Junctional escape complexes

Lead 2

Two examples of A-V nodal rhythmTwo examples of A-V nodal rhythm

Abnormal P wave () either shortly before or after QRSAbnormal P wave () either shortly before or after QRS

3 more examples of Ventricular Tachycardia3 more examples of Ventricular Tachycardia

VIP death

InterestingArrhythmias

Some Examples

InterestingArrhythmias

Some Examples

The endThe end