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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
