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ECGs MADE EASY

NORMAL ECG

ELECTROCARDIOGRAM

The electrocardiogram (ECG) is a graphic recording of the electrical potentials produced by the cardiac tissue.

– Electrical impulse formation occurs within the conduction system of the heart.

– Excitation of the muscle fibers throughout the myocardium results in cardiac contraction.

The ECG is recorded by applying electrodes to various locations on the body surface and connecting them to a recording apparatus.

Clinical Value of the ECG

ELECTROCARDIOGRAM

– Atrial and ventricular hypertrophy

– Myocardial ischemia and infarction

– Pericarditis

– Systemic diseases that affect the heart

– Determination of the effect of cardiac drugs

– Disturbances in electrolyte balance

– Evaluation of function of cardiac pacemakers

ELECTROCARDIOGRAM

Considerable diagnostic value

– Conduction delay of atrial and ventricular electrical impulses

– Determination of the origin and behavior of dysrhythmias

ELECTROCARDIOGRAM

Value of ECG in the following clinical conditions

– Prediction of sudden cardiac death

– Prediction of ischemic pre-conditioning

– Prediction of adverse states in AMI, post-MI and silent ischemia cases

– Progression/regression of LV mass

RECORDING AND MONITORING AN ECG

Lead Configurations

– Bipolar Leads

• Two electrodes placed at 2 different sites

• Register the difference in potential between these 2 leads

– Unipolar leads

• Measure the absolute electrical potential at one site

• Requires a reference site

• Reference site formed by the limb leads

12 LEAD ECG

Limb Leads

RA

Red

Right arm

LA

Yellow

Left arm

LL

Green

Left leg

RL

Black

Right leg

Chest Leads

V

V

V

V

1

2

3

4

Red

4 th ICS RPSB

Yellow

4 th ICS LPSB

Green

Midway between V 2 and V 4

Brown

5 th ICS LMCL

ELECTROPHYSIOLOGY OF THE HEART

Four Electrophysiologic Events Involved in the Genesis of the ECG

– Impulse formation

– Transmission of the impulse

– Depolarization

– Repolarization

TRANSMEMBRANE ACTION POTENTIAL

TRANSMEMBRANE ACTION POTENTIAL

REFRACTORINESS

REFRACTORINESS

LAYERS OF THE HEART WALL

Epicardium

– Coronary arteries are found in this layer

Myocardium

– Responsible for contraction of the heart

Endocardium

– Lines the inside of the myocardium

– Covers the heart valves

Responsible for contraction of the heart Endocardium – Lines the inside of the myocardium – Covers

CONDUCTION SYSTEM OF THE HEART

CONDUCTION SYSTEM OF THE HEART SA Node Atrial Muscle AV Node Bundle of His Bundle Branches

SA Node

Atrial Muscle AV Node

Bundle of His Bundle Branches Purkinje Fibers Ventricular Muscle

MYOCARDIAL CELL TYPES

Kinds of

Where

Primary

Primary

Cardiac Cells

Found

Function

Property

Myocardial cells

Specialized cells of the electrical conduction system

Myocardium

Electrical

conduction

system

Contraction and Relaxation

Generation and conduction of electrical impulses

Contractility

Automaticity

Conductivity

Chronotropic Effect

TERMINOLOGY

– Refers to a change in heart rate

– A positive chronotropic effect refers to an increase in heart rate

– A negative chronotropic effect refers to a decrease in heart rate

Dromotropic Effect

– Refers to a change in the speed of conduction through the AV junction

– A positive dromotropic effect results in an increase in AV conduction velocity

– A negative dromotropic effect results in a decrease in AV conduction velocity

Inotropic Effect

– Refers to a change in myocardial contractility

– A postive inotropic effect results in an increase in myocardial contractility

– A negative inotropic effect results in a decrease in myocardial

TERMINOLOGY

TERMINOLOGY Waveform – Movement away from the baseline in either a positive or negative direction Segment

Waveform

– Movement away from the baseline in either a positive or negative direction

from the baseline in either a positive or negative direction Segment – A line between wave

Segment

baseline in either a positive or negative direction Segment – A line between wave forms Interval
baseline in either a positive or negative direction Segment – A line between wave forms Interval

– A line between wave forms

Interval

– A waveform and a segment

Complex

– Consists of several waveforms

ECG PAPER

ECG PAPER

Upward deflection

Upward deflection Downward deflection Diphasic deflection ELECTROGRAM - + - + - +

Downward deflection

Upward deflection Downward deflection Diphasic deflection ELECTROGRAM - + - + - +
Upward deflection Downward deflection Diphasic deflection ELECTROGRAM - + - + - +

Diphasic deflection

ELECTROGRAM

- +
-
+
Upward deflection Downward deflection Diphasic deflection ELECTROGRAM - + - + - +
- + - +
-
+
-
+
AVL I AVR AVF
AVL
I
AVR
AVF

THE NORMAL ELECTROCARDIOGRAM

P wave

– Generated by activation of the atria

PR segment

– Represents the duration of atrioventricular (AV) conduction

QRS complex

– Produced by activation of both ventricles

ST-T wave

– Reflects ventricular recovery

The P wave

– Atrial activation

– Height < 0.2 mV (2 mm)

– Duration < 0.12 sec

The P wave – Atrial activation – Height < 0.2 mV (2 mm) – Duration <

STANDARD 12 LEAD ECG

The P wave – Atrial activation – Height < 0.2 mV (2 mm) – Duration <

P-R Interval

STANDARD 12 LEAD ECG

– Intraatrial, internodal, His purkinje conduction

– Duration 0.12 to 0.20 or 0.22 sec

Interval STANDARD 12 LEAD ECG – Intraatrial, internodal, His purkinje conduction – Duration 0.12 to 0.20
Interval STANDARD 12 LEAD ECG – Intraatrial, internodal, His purkinje conduction – Duration 0.12 to 0.20

The QRS Complex

– Ventricular activation

– Duration of 100 msec

The QRS Complex – Ventricular activation – Duration of 100 msec STANDARD 12 LEAD ECG

STANDARD 12 LEAD ECG

The QRS Complex – Ventricular activation – Duration of 100 msec STANDARD 12 LEAD ECG

The ST-segment

STANDARD 12 LEAD ECG

– Phase 2 of transmembrane potential

– Isoelectric in normal subjects

The ST-segment STANDARD 12 LEAD ECG – Phase 2 of transmembrane potential – Isoelectric in normal
The ST-segment STANDARD 12 LEAD ECG – Phase 2 of transmembrane potential – Isoelectric in normal

STANDARD 12 LEAD ECG

The T wave

– Upright after the age of 16

Juvenile T wave

STANDARD 12 LEAD ECG The T wave – Upright after the age of 16 – Juvenile
STANDARD 12 LEAD ECG The T wave – Upright after the age of 16 – Juvenile

The U wave

STANDARD 12 LEAD ECG

– Surface reflection of negative after potential

– Repolarization of Purkinje fibers

– Ventricular relaxation

ECG – Surface reflection of negative after potential – Repolarization of Purkinje fibers – Ventricular relaxation
ECG – Surface reflection of negative after potential – Repolarization of Purkinje fibers – Ventricular relaxation

The QT Interval

STANDARD 12 LEAD ECG

– From beginning of QRS to end of T wave

– Reflects the duration of depolarization and repolarization

QRS to end of T wave – Reflects the duration of depolarization and repolarization – Bezett:
–

Bezett: Q-Tc Interval = Q-T/ R-R

QRS to end of T wave – Reflects the duration of depolarization and repolarization – Bezett:

ANALYZING A RHYTHM STRIP

Rate

Rhythm

Axis

P wave

PR Interval QRS Complex

T wave

Q-T Interval

ANALYZING A RHYTHM STRIP Rate Rhythm Axis P wave PR Interval QRS Complex T wave Q-T

ANALYZING A RHYTHM STRIP

What is the rate?

– To determine the ventricular rate,measure the distance between 2 consecutive R-waves (R-R interval)

– To determine the atrial rate, measure the distance between 2 consecutive P-waves (P-P interval)

Ventricular Rate

What Is The Rate?

– Small squares (R-R Interval) / 1500

– Big squares (R-R Interval) / 300

Ventricular Rate What Is The Rate? – Small squares (R-R Interval) / 1500 – Big squares

What Is The Rate?

Sinus rhythm

What Is The Rate? Sinus rhythm Atrial Fibrillation – QRS complexes in 6-sec strip X 10

Atrial Fibrillation

– QRS complexes in 6-sec strip X 10
– QRS complexes in 6-sec strip X 10

ANALYZING A RHYTHM STRIP

Is the rhythm regular or irregular?

– To determine if the ventricular rhythm is regular or irregular, measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-r intervals.

– For atrial rhythm, measure the distance between 2 consecutive P-P intervals.

– Generally, a variation of up to 0.12 seconds (3 small boxes) is acceptable. The slower the heart rate, the more acceptable the variation.

ANALYZING A RHYTHM STRIP

What Is The Axis?

Normal

– 0 – (+90)

Left axis

– 0 – (-90)

Right axis

– (+90) – (+180)

Extreme axis

– (-90) – (-180)

AVL I AVR AVF
AVL
I
AVR
AVF
} 10
}
10

Lead I

} 10
}
10

AVF

What Is The Axis?

AVL I AVR AVF
AVL
I
AVR
AVF

ANALYZING A RHYTHM STRIP

Is there 1 P wave before each QRS?

– Are P waves present and uniform in appearance?

– Is there a P wave before each QRS or are there P waves that are not followed by QRS complexes?

– Is the atrial activity occurring so rapidly that there are more atrial beats than QRS complexes?

ANALYZING A RHYTHM STRIP

Is the PR interval within normal limits?

– If the PR interval is less than 0.12 or more than 0.20 second, conduction followed an abnormal pathway or the impulse was delayed in the area of the AV node.

– Is the PR interval of conducted beats constant or does it vary?

ANALYZING A RHYTHM STRIP

Is the QRS narrow or wide?

– What is the duration of the QRS complex?

• If it is 0.10 second or less (narrow), it is presumed to be supraventricular in origin.

• If it is greater than 0.12 second (wide), it is probably ventricular in origin.

– Do the QRS’s occur uniformly throughout the strip?

ANALYZING A RHYTHM STRIP

Interpret the rhythm

– Specifying the site where the dysrhythmia originated (sinus), the mechanism (bradycardia), and the vetnricular rate.

– For example, “sinus bradycardia with a ventricular response (rate) of 38/min.”

Localization I, AVL

– High lateral

II, III, AVF

– Inferior

ANALYZING RHYTHM STRIP

AVL I AVR AVF
AVL
I
AVR
AVF

ANALYZING THE RHYTHM STRIP

Localization

V1,V2

– Septal

V3,V4

– Anterior

V5,V6

– Apicolateral

V1-V3 or V4

– Anteroseptal

V3 or V4-V6

– Anterolateral

V1-V6 – Extensive anterior

I,AVL,V5,V6 - Lateral

V1-V3 or V4 – Anteroseptal V3 or V4-V6 – Anterolateral V1-V6 – Extensive anterior I,AVL,V5,V6 -

ANALYZING A RHYTHM STRIP

How is the rhythm clinically significant?

Rate

Rhythm

NORMAL SINUS RHYTHM

60-100 beats per minute Atrial regular

P waves

Ventricular regular Uniform in appearance, upright, normal shape, one preceding each QRS complex 0.12-0.20 second

PR interval QRS

0.10

second or less. If greater than

0.10

second in duration, the QRS is

termed “wide” since the existence of

a bundle branch block or other intraventricular conduction defect cannot be accurately detected in a single-lead.

Sinus Rhythms

Normal Sinus Rhythm

Rate

60-100 beats per minute

Rhythm

Atrial regular

 

Ventricular regular

P waves

Uniform in appearance, upright, normal shape, one preceding

 

each QRS complex

PR interval

0.12-0.20 second

QRS

0.10 second or less. If greater than 0.10 second in duration,

 

the QRS is termed “wide” since the existence of a bundle

 

branch block or other intraventricular conduction defect

 

cannot be accurately detected in a single-lead.

Sinus Rhythms

Sinus Bradycardia

Rate

Less than 60 beats per minute

Rhythm

Atrial regular

 

Ventricular regular

P waves

Uniform in appearance, upright, normal shape, one preceding

 

each QRS complex

PR interval

0.12-0.20 second

QRS

Usually 0.10 second or less

Sinus Rhythms

Sinus Tachycardia

Rate

Usually 100-160 beats per minute

Rhythm

Atrial regular

 

Ventricular regular

P waves

Uniform in appearance, upright, normal shape, one preceding

 

each QRS complex

PR interval

0.12-0.20 second

QRS

Usually 0.10 second or less

Sinus Rhythms

Normal Heart Rates in Children

 

Age

Awake Heart Rate

Sleeping Heart Rate

 

(per minute)

(per minute)

Neonate

100-180

80-160

Infant (6 mos)

100-160

75-160

Toddler

80-110

60-90

Preschooler

70-110

60-90

School-aged

65-110

60-90

Adolescent

60-90

50-90

Sinus Rhythms

Sinus Dysrhythmia (Arrhythmia)

Rate

Usually 100-160 beats per minute but may be faster or slower

 

Irregular (R-R intervals shorten during inspiration and

Rhythm

lengthen during expiration)

 

Uniform in appearance, upright, normal shape, one preceding

P waves

each QRS complex

 

0.12-0.20 second

PR interval

Usually 0.10 second or less

QRS

Sinus Rhythms

Sinoatrial (SA) Block

Rate

Usually normal but varies because of pause

Rhythm

Irregular – the pause is the same as (or an exact multiple of)

 

the distance between two other P-P intervals

 

Uniform in appearance, upright, normal shape, one preceding

P waves

each QRS complex

 

0.12-0.20 second

PR interval

Usually 0.10 second or less

QRS

Sinus Rhythms

Sinus Arrest

Rate

Usually normal but varies because of the pause

Rhythm

Irregular – the pause is of undetermined length (more than

 

one PQRST complex is omitted) and is not the same

 

distance as other P-P intervals.

P waves

Uniform in appearance, upright, normal shape, one preceding

 

each QRS complex

PR interval

0.12-0.20 second

QRS

Usually 0.10 second or less

Atrial Rhythms

Premature Atrial Complexes

1. Early (premature) P waves

2. Upright P waves that differ in shape from normal sinus P waves in Lead II

P waves may be biphasic (partly positive, partly negative), flattened, notched

or pointed

3. The early P wave may or may not be followed by a QRS complex

Atrial Rhythms

Compensatory vs. Non-compensatory Pause

To determine whether or not the pause following a premature complex is

compensatory or non-compensatory, measure the distance between three

normal beats. Compare that distance between three beats, one of which

includes the premature complex.

Non-compensatory (incomplete) – if the normal beat following the premature

complex occurs before it was expected (i.e., when the distance is not the

same)

Compensatory (complete) – if the normal beat following the premature complex

occurs when expected (i.e., when the distance is the same).

Atrial Rhythms

Premature Atrial Complexes (PACs)

Rate

Usually normal but depends on underlying rhythm

Rhythm

Essentially regular with premature beats

P waves

Premature

 

Differ from sinus P waves – may be flattened, notched, pointed,

 

biphasic, or lost in the preceding T wave

PR interval

Varies from 0.12-0.20 second when the pacemaker site is near

 

the SA node; 0.12 second when the pacemaker site is nearer

 

the AV junction

QRS

Usually less than 0.10 second but may be prolonged. The QRS of

 

the PAC is similar to those of the underlying rhythm unless the

 

PAC is abnormally conducted.

Atrial Rhythms

Vagal Maneuvers

Vagal maneuvers – are methods used to stimulate baroreceptors in the internal

carotid arteries and the aortic arch. Stimulation of these receptors results in reflex

stimulation of the vagus nerve and release of acetylcholine. Acetylcholine slows

conduction in the AV node, resulting in slowing of the heart rate

• Coughing

AV node, resulting in slowing of the heart rate • Coughing • Bearing down • Squatting

• Bearing down

• Squatting

• Breath-holding

• Carotid sinus pressure (massage)

• Immersion of the face in ice water

• Stimulation of the gag reflex

Carotid pressure should be avoided in older patients. Simultaneous, bilateral carotid

pressure should never be performed.

pressure should be avoided in older patients. Simultaneous, bilateral carotid pressure should never be performed.

Atrial Rhythms

The Unstable Patient

Signs and Symptoms

• Shock

• Chest pain

• Hypotension

• Shortness of breath

• Pulmonary congestion

• Congestive heart failure

• Acute myocardial infarction

• Decreased level of consciousness

Atrial Rhythms

Supraventricular Tachycardia

Rate

150-250 beats per minute

Rhythm

Regular

P waves

Atrial P waves may be seen which differ from sinus P waves (may

 

be flattened, notched, pointed, or biphasic). P waves are

 

usually identifiable at the lower end of the rate range but are

 

seldom identifiable at rates above 200. May be lost in the

 

preceding T wave.

 

Usually not measurable because the P wave is difficult to

PR interval

distinguish from the preceding T wave. If P waves are seen,

 

the RR interval will usually measure 0.12-0.20 second.

 

Less than 0.10 second unless an intraventricular conduction

 

defect exists.

QRS

Atrial Rhythms

ELECTRICAL THERAPY – Synchronized Countershock

Description and Purpose

Synchronized countershock reduces the potential for delivery of energy during the

vulnerable period of the T wave (relative refractory period). A synchronizing

circuit allows the delivery of a countershock to be “programmed”. The

machine searches for the peak of the QRS complex (R wave deflection) and

delivers the shock a few milliseconds after the highest part of the R wave.

Indications:

• Supraventricular tachycardia

• Atrial fibrillation

• Atrial flutter

• Unstable ventricular tachycardia with pause

Atrial Rhythms

Wandering Atrial Pacemaker (Multiformed Atrial Rhythm)

Rate

60-100. If the rate is greater than 100 beats per minute, the

 

rhythm is termed multifocal (or chaotic) atrial tachycardia.

 

Atrial – irregular

Rhythm

Ventricular - irregular

 

Size, shape, and direction may change from beat to beat. At

P waves

least three different P waves are required for a diagnosis of

 

wandering atrial pacemaker

 

Variable

 

Usually less than 0.10 second unless an intraventricular

PR interval

conduction defect exists

QRS

Atrial Rhythms

Atrial Flutter

Rate

Atrial rate 250-350 beats per minute; ventricular rate variable

 

– determined by AV blockade. The ventricular rate will

 

usually not exceed 180 beats per minute due to the intrinsic

 

conduction rate of the AV junction.

 

Atrial regular

Rhythm

Ventricular may be regular or irregular

 

Not identifiable P waves; saw-toothed “flutter waves”

P waves

Not measurable

 

Usually less than 0.10 second but may be widened if flutter

PR interval

 

waves are buried in the QRS complex or if an

QRS

intraventricular conduction defect exists.

Atrial Rhythms

Atrial Fribrillation

Rate

Atrial rate usually greater than 350-400 beats per minute;

 

ventricular rate variable

Rhythm

Ventricular rhythms usually very irregular; a regular ventricular

 

rhythm may occur because of digitalis toxicity.

 

No identifiable P waves; fibrillatory waves present. Erratic

P waves

wavy baseline.

 

Not measurable

PR interval

Usually less than 0.10 second but may be widened if an

QRS

intraventricular conduction defect exists.

Atrial Rhythms

Wolff-Parkinson-White (WPW) Syndrome

Rate

If the underlying rhythm is sinus in origin, the rate is usually

 

60-100 beats per minute.

Rhythm

Regular unless associated with atrial fibrillation

P waves

Normal and upright unless WPW is associated with atrial

 

fibrillation

PR interval

If P waves are seen, less than 0.12 second

QRS

Usually greater than 0.12 second. Slurred upstroke of the

 

QRS complex (delta wave) is often seen in one or more

 

leads)

Junctional Rhythms

Premature Junctional Complexes

Rate

Usually normal, but depends on the underlying rhythm

 

Essentially regular with premature beats

Rhythm

May occur before, during, or after the QRS

P waves

If visible, the P wave is inverted in leads II, III, AVF

 

If the P wave occurs before the QRS, the PR interval will be

PR interval

usually less than or equal to 0.12 second. If no P wave

 

occurs before the QRS, there will be no PR interval.

 

Usually 0.10 second or less unless an intraventricular

 

conduction defect exists.

QRS

Junctional Rhythms

Junctional Escape Beat

Rate

Usually normal, but depends on the underlying rhythm

 

Essentially regular with L ATE beats

Rhythm

May occur before, during, or after the QRS

P waves

If visible, the P wave is inverted in leads II, III, AVF

 

If the P wave occurs before the QRS, the PR interval will be

PR interval

usually less than or equal to 0.12 second. If no P wave

 

occurs before the QRS, there will be no PR interval.

 

Usually 0.10 second or less unless an intraventricular

 

conduction defect exists.

QRS

Junctional Rhythms

Junctional Escape Rhythm

Rate

40 to 60 beats per minute

Rhythm

Atrial and ventricular rhythm very regular

P waves

May occur before, during, or after the QRS

 

If visible, the P wave is inverted in leads II, III, AVF

PR interval

If the P wave occurs before the QRS, the PR interval will be

 

usually less than or equal to 0.12 second. If no P wave

 

occurs before the QRS, there will be no PR interval.

 

Usually 0.10 second or less unless an intraventricular

QRS

conduction defect exists.

Junctional Rhythms

Accelerated Junctional Rhythm

Rate

60 to 100 beats per minute

Rhythm

Atrial and ventricular rhythm very regular

P waves

May occur before, during, or after the QRS

 

If visible, the P wave is inverted in leads II, III, AVF

PR interval

If the P wave occurs before the QRS, the PR interval will be

 

usually less than or equal to 0.12 second. If no P wave

 

occurs before the QRS, there will be no PR interval.

 

Usually 0.10 second or less unless an intraventricular

QRS

conduction defect exists.

Junctional Rhythms

The Unstable Patient

Signs and Symptoms

• Shock

• Chest pain

• Hypotension

• Shortness of breath

• Pulmonary congestion

• Congestive heart failure

• Acute myocardial infarction

• Decreased level of consciousness

Junctional Rhythms

Junctional Tachycardia

Rate

100 to 180 beats per minute

Rhythm

Atrial and ventricular rhythm very regular

P waves

May occur before, during, or after the QRS

 

If visible, the P wave is inverted in leads II, III, AVF

PR interval

If the P wave occurs before the QRS, the PR interval will be

 

usually less than or equal to 0.12 second. If no P wave

 

occurs before the QRS, there will be no PR interval.

 

Usually 0.10 second or less unless an intraventricular

QRS

conduction defect exists.

Ventricular Rhythms

Premature Ventricular Complexes

Rate

Usually normal but depends on the underlying rhythm

 

Essentially regular with premature beats. If the PVC is an

Rhythm

interpolated PVC, the rhythm will be regular.

 

There is no P wave associated with the PVC

 

None with the PVCs because the ectopic beat originates in

P waves

the ventricle

PR interval

Greater than 0.12 second.

 

Wide and bizarre.

QRS

T wave frequently in opposite direction of the QRS complex.

Ventricular Rhythms

Patterns of PVCs

1. Pairs (couplets) – two sequential PVCs

2. Runs or bursts – three or more sequential PVCs are called vntricular

tachycardia (VT)

3. Bigeminal PVCs (ventricular bigeminy) – every other beat is a PVC

4. Trigeminal PVCs (ventricular trigeminy) – every third beat is a PVC

5. Quadrigeminal PVCs (ventricular quadrigeminy) – every fourth beat is a PVC

Ventricular Rhythms

Common Causes of PVCs

• Normal variant

• Anxiety

• Exercise

• Hypoxia

• Digitalis toxicity

• Acid-base imbalance

• Myocardial ischemia

• Electrolyte imbalance (hypokalemia, hypocalcemia, hypercalcemia,

hypomagnesemia)

• Congestive heart failure

• Increased sympathetic tone

• Acute myocardial infarction

• Stimulants (alcohol, caffeine, tobacco)

• Drugs (sympathomimetics, cyclic antidepressants, phenothiazines)

Ventricular Rhythms

Warning Dysrhythmias

• Six or more PVCs per minute

• PVCs that occurred in pairs (couplets) or in runs or three or

more (ventricular tachycardia)

• PVCs that fell on the T wave of the preceding beat (R-on T

phenomenon)

• PVCs that differed in shape (multiformed PVCs)

Ventricular Rhythms

Ventricular Escape Beat

Rate

Atrial and ventricular rate dependent upon the underlying rhythm.

 

Irregular. The ventricular escape beat occurs LA TE , after the next

Rhythm

expected sinus beat.

 

There is no P wave associated with escape beat.

P waves

None with the escape beat because the complex originates from

PR interval

the ventricles.

 

Greater than 0.12 second.

QRS

T wave deflection is opposite that of the QRS complex.

Ventricular Rhythms

Idioventricular (Ventricular Escape) Rhythm

Rate

Atrial not discernible, ventricular 20-40 beats per minute

 

Atrial not discernible

Rhythm

Ventricular essentially regular

 

Absent

P waves

None

PR interval

Greater than 0.12 second.

QRS

T wave deflection is in the opposite direction of the QRS.

Ventricular Rhythms

Accelerated Idioventricular Rhythm

Rate

Atrial not discernible, ventricular 40-100 beats per minute

 

Atrial not discernible

Rhythm

Ventricular essentially regular

 

Absent

P waves

None

PR interval

Greater than 0.12 second.

QRS

T wave deflection is in the opposite direction of the QRS.

Ventricular Rhythms

Ventricular Tachycardia (VT)

Rate

Atrial rate not discernible, ventricular rate 100-250 beats per

 

minute

Rhythm

Atrial rhythm not discernible

 

Ventricular rhythm is essentially regular

P waves

May be present or absent; if present they have no set

 

relationship to the QRS complexes – appearing between

 

the QRS’s at a rate different from that of the VT.

 

None

PR interval

Greater than 0.12 second.

QRS

Often difficult to differentiate between the QRS and the T

 

wave.

Ventricular Rhythms

VENTRICULAR TACHYCARDIA - CAUSES

• Hypoxia

• Exercise

• R-on T PVCs

• Catecholamines

• Digitalis toxicity

• Myocardial ischemia

• Acid-base imbalance

• Electrolyte imbalance

• Ventricular aneurysm

• Coronary artery disease

• Rheumatic heart disease

• Acute myocardial infarction

• CNS stimulants (cocaine, amphetamines)

Ventricular Rhythms

LONG QT INTERVAL - CAUSES

Drug induced

• Cyclic antidepressants

• Phenothiazines

• Type 1A antidysrhythmics (quinidine, procainamide, disopyramide)

• Organophosphate insecticides

Eating disorders (bulimia, anorexia)

Electrolyte abnormalities (hypomagnesemia, hypokalemia, hypocalcemia)

Ventricular Rhythms

ANTIDYSRHYTHMIC CLASSIFICATIONS

Group I

Primarily inhibit the fast sodium channel in cardiac tissue, resulting

 

in an increased refractory period

 

1A - increased conduction velocity and prolong the action potential

 

(Quinidine, Procainamide, Disopyramide)

 

1B - Either increase or have no effect on conduction velocity

 

(Lidocaine, Phenytoin, Tocainide, Mexiletine)

 

1C - Decrease conduction velocity (Flecainide, Encainide)

 

Beta-adrenergic blockers (Propranolol)

 

Prolong repolarization (Bretylium, Amiodarone)

 

Block slow calcium channels, resulting in decreased automaticity,

Group II

and depression of myocardial and smooth muscle contraction

Group III

(Verapamil, Nifedipine, Diltiazem)

Group IV

Ventricular Rhythms

Torsades de Pointes (TdP)

Rate

Atrial rate not discernible, ventricular rate 150-250 beats per

 

minute

Rhythm

Atrial not discernible

 

Ventricular may be regular or irregular

P waves

None

PR interval

None

QRS

Greater than 0.12 second.

 

Gradual alteration in the amplitude and direction of the QRS

Ventricular Rhythms

Ventricular Fibrillation

Rate

Cannot be determined since there are no discernible waves or

 

complexes to measure

Rhythm

Rapid and chaotic with no pattern or regularity

P waves

Not discernible

PR interval

Not discernible

QRS

Not discernible

Ventricular Rhythms

Defibrillation (Unsynchronized Countershock)

Description and Purpose:

The purpose of defibrillation is to produce momentary asystole. The shock

attempts to completely depolarize the myocardium and provide an opportunity

for the natural pacemaker centers of the heart to resume normal activity.

Defibrillation is a random delivery of energy – there is no relation of the

discharge of energy to the cardiac cycle.

Indications:

• Unstable ventricular tachycardia with a pulse

• Pulseless ventricular tachycardia

• Ventricular fibrillation

• Sustained Torsades de Pointes

Ventricular Rhythms

Asystole

Rate

Ventricular usually indiscernible but may see some atrial

 

activity.

Rhythm

Atrial may be discernible.

 

Ventricular indiscernible.

P waves

Usually not discernible

PR interval

Not measurable

QRS

Absent

Ventricular Rhythms

Causes of Pulseless Electrical Activity (MATCHx4ED)

Myocardial infarction (massive acute)

Acidosis

Tension pneumothorax

Cardiac tamponade

Hypovolemia (most common cause)

Hypoxia

Hyperkalemia

Hypothermia

Embolus (massive pulmonary)

Drug overdoses (cyclic antidepressants, calcium channel blockers, beta-blockers,

digitalis)

Atrioventricular Blocks

Classification of AV Blocks Degree Partial First-degree AV block of block (incomplete) Second-degree AV block
Classification of AV Blocks
Degree
Partial
First-degree AV block
of block
(incomplete)
Second-degree AV block type I
blocks
Second-degree AV block type II
Second-degree AV block 2:1 conduction
Third-degree AV block
Complete block
First-degree AV block
Site of
AV node
Second-degree AV block type I
block
Third-degree AV block
Second-degree AV block type II – (uncommon)
Infranodal
Bundle
Third-degree AV block
of His
Second-degree AV block type II – (more
common)
Bundle
Third-degree AV block
branches

Atrioventricular Blocks

First Degree AV Block

Rate

Atrial and ventricular rates the same; dependent upon

 

underlying rhythm.

Rhythm

Atrial and ventricular regular

P waves

Normal in size and shape

 

Only one P wave before each QRS

PR interval

Prolonged (greater than 0.20 second) but constant

QRS

Usually 0.10 second or less unless an intraventricular

 

conduction exists

Atrioventricular Blocks

Second-Degree AV Block, Type I (Wenckebach)

Rate

Atrial rate is greater than the ventricular rate. Both are often

 

within normal limits.

Rhythm

Atrial regular (P’s plot through)

 

Ventricular irregular.

P waves

Normal in size and shape. Some P waves are not followed by

 

a QRS complex (more P’s than QRS’s).

 

Lengthens with each cycle (although lengthening may be very

PR interval

slight), until a P wave appears without a QRS complex. The

 

PRI after the nonconducted beat.

 

Usually 0.10 second or less but is periodically dropped.

QRS

Atrioventricular Blocks

Second-Degree AV Block, Type II (Mobitz)

Rate

 

Atrial rate is greater than the ventricular rate.

 

Ventricular rate is often slow.

Rhythm

Atrial regular (P’s plot through)

 

Ventricular irregular.

P waves

Normal in size and shape. Some P waves are not followed by

 

a QRS complex (more P’s than QRS’s).

 

Within normal limits or prolonged but always constant for the

PR interval

conducted beats. There may be some shortening of the PRI

 

that follows a nonconducted P wave.

 

Usually 0.10 second or greater, periodically absent after P

 

waves.

QRS

Atrioventricular Blocks

Second-Degree AV Block, 2:1 Conduction

Rate

Atrial rate is greater than the ventricular rate.

 

Atrial regular (P’s plot through)

Rhythm

Ventricular regular.

P waves

Normal in size and shape; every other P wave is followed by a

 

QRS complex (more P’s than QRS’s)

 

Constant

PR interval

Within normal limits if the block occurs above the bundle of

QRS

His (probably type I); wide if the block occurs at or below

 

the bundle of His (probably type II); absent after every other

 

P wave.

Atrioventricular Blocks

Complete (Third-Degree) AV Block

Rate

Atrial rate is greater than the ventricular rate. The ventricular

 

rate is determined by the origin of the escape rhythm.

 

Atrial regular (P’s plot through). Ventricular regular. There is

Rhythm

no relationship between the atrial and ventricular rhythm.

 

Normal in size and shape.

 

None – the atria and ventricles beat independently of each

P waves

other, thus there is no true PR interval.

PR interval

Narrow or broad depending on the location of the escape

 

pacemaker and the condition of the intraventricular

QRS

conduction system.

 

Narrow = junctional pacemaker; wide = ventricular

 

pacemaker.

Atrioventricular Blocks

Classification of AV Blocks

 
 

Second-Degree AV Block

Second-Degree AV Block

 

Type I

Type II

Ventricular Rhythm

   

PR Interval

Irregular

Irregular

QRS Width

 

Constant

 

Lengthening

 
 

Usually narrow

Usually wide

 

Second-Degree AV Block,

Complete (Third-Degree)

 

2:1 Conduction

AV Block

Ventricular Rhythm

   

PR Interval

Regular

Regular

 

Constant

None – no relationship between P

   

waves and QRS complexes

QRS Width

 

May be narrow or wide

 

May be narrow or wide