ECG Arrhythmia Dr. K. P. Misra Sr. Consultant Cardiologist Dr. K. P. Misra Sr. Consultant...

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