ECGs and Arrhythmias

Matthew Howell

ECGs and Arrhythmias

Matthew Howell

Objectives
12 lead ECG ECG interpretation Common arrhythmias

Sino-atrial node depolarisation

Atrial Depolarisation (P Wave)

Atrial Contraction (P Wave)

AVN depolarisation (PR Interval)

Ventricular depolarisation (QRS Complex)

Ventricular contraction (QRS Complex)

Ventricular Repolarisation (T Wave)

What does an ECG show?

Electrical activity in relation to the lead

Lead I

Lead I

Chest Leads

Limb Leads

An Abnormal ECG

Assessing the ECG

Patient Rate Rhythm Axis P wave P-R interval QRS complex S-T segment T wave

Patient What does an ECG tell you?

Cardiac electrical activity

What it does not tell you?

Patients clinical condition

Patient 1

Patient 2

Patient 1
Unconscious, HR 0bpm Pulseless Electrical Activity

Patient 2
Content patient in chair, HR 80bpm RBBB Normal Variant

Treat the patient, not the ECG

Rate
small square = 0.04s large square = 0.2s
30 large squares = 6s Rate = QRS in 30 squares x 10 (or QRS in 10sq x 30) Rate = 300 / number large squares between QRS - QRS

Rhythm
Regularly Regular Regularly Irregular Irregularly Irregular

Axis

Left Axis Deviation

QRS is positive (dominant R wave) in lead I QRS is positive (dominant S wave) in lead II LEAVING

Right Axis Deviation

QRS is negative (dominant S wave) in lead I QRS is positive (dominant R wave) in lead II REACHING

Differentials
LAD LVH Inferior MI Left anterior hemiblock Obesity RAD RVH Cor pulmonae Left posterior hemiblock Thin

P wave

P Mitrale mitral stenosis = large LA P Pulmonae Pulmonary stenosis = large RA Absent P waves Atrial Fibrillation

P wave
Atrial fibrillation = Continuous, rapid atrial activation, resulting in an irregular ventricular response.

Atrial flutter = Macro re-entry circuit within the right atrium, causing an organised but grossly increased atrial rate.

Management
Atrial Fibrillation New or chronic? Treat underlying cause Curative Direct current (DC) cardioversion Rhythm control Amiodarone, flecanide Rate control -blocker, digoxin, verapamil Anticoagulation Indicated by the CHADS2 score. Target INR 2.0-3.0 Atrial Flutter Acute: Carotid sinus massage Adenosine Catheter ablation

PR interval
Normal = 120 200ms (3-5 squares)

PR interval

PR interval
First degree heart block Slow conduction in the AVN, rarely symptomatic. ECG: Prolonged PR interval (>0.22s). Usually requires no intervention

Second Degree Heart Block

Mobitz I block (Wenckebach phenomenon) Progressive PR interval prolongation until a P wave fails to conduct (= no QRS). Block in the AV node. Monitoring only.

Mobitz II block / 2:1 block Regular P waves fail to conduct Block in His bundle (can be AV node) Pacemaker usually required. Greater risk of complete heart block & asystole (Stokes-Adams)

Third Degree (Complete) Heart Block

All atrial activity fails to conduct to the ventricles. Ventricles activate independently of the SA node creating an escape rhythm. Regular P to P interval + Regular R to R interval but no correlation Management - Pacemaker

QRS complex & BBB

Normal = 0.08 0.12s (2 3 small sqs) Remember: WiLLiaM MaRRoW V1 V6

Differentials
LBBB
Coronary artery disease (new onset) Hypertension Aortic valve disease Cardiomyopathy

RBBB
Normal variant (1% young, 5% elderly) Coronary artery disease RVH, e.g. pulmonary embolism, cor pulmonale Congenital heart disease, e.g. atrial septal defect

Narrow Complex Tachycardias

Atrioventricular Nodal Re-entry Tachycardia (AVNRT) Re-entry in the right atrium & AV node. Tachycardia, P-waves often hidden (engulfed by QRS complex)

Atrioventricular Reciprocating Tachycardia (AVRT) Re-entry between atria and the ventricles. Conduction takes place partly through the AV node & partly through the accessory pathway. When this is symptomatic it is known as Wolff-Parkinson-White Syndrome. Delta waves, Short PR interval

Narrow Complex Tachycardias

Atrioventricular Nodal Re-entry Tachycardia (AVNRT) Re-entry in the right atrium & AV node. Tachycardia, P-waves often hidden (engulfed by QRS complex)

Atrioventricular Reciprocating Tachycardia (AVRT) Re-entry between atria and the ventricles. Conduction takes place partly through the AV node & partly through the accessory pathway. When this is symptomatic it is known as Wolff-Parkinson-White Syndrome. Delta waves, Short PR interval

Management Vagal manouvres Adenosine Cardiac ablation Also consider AF & Atrial Flutter

Broad Complex Tachycardias

Broad Complex Tachycardias

Ventricular Tachycardia (VT)

Ventricular Fibrillation (VF)

Management Shock

ST segment
Elevation = STEMI MI definitions 2mm in 2 or more chest leads 1mm in 2 or more limb leads New LBBB

Locating the MI

T wave
Peaked T wave hyperkalaemia Flattened T wave hypokalaemia Inverted MI (not full thickness)