ECG Interpretation

Arrhythmias of Formation Chapters 4-5

Types of Arryhthmias:
Sinus Problems: Formed in the

sinus node, but irregular Ectopic Problems: Formed outside of the sinus node Conduction Problems: Formed in the sinus node, but conduction in error Pre-Excitation Problems: Short circuits in normal conduction

Causes of Arrhytmias:
Hypoxia: Lung disease Ischemia: CAD, angina (local hypoxia) Sympathetic Stimulation: Nervous,

exercise, CHF, hyperthyroidism Drugs: Caffeine, cocaine, stimulantsmany antiarryhtmic drugs Electrolyte Disturbances: K+, Ca++, Mg++ Bradycardia: Escape rhythms Stretch: CHF, hypertrophy, valve disease

Rhythm ID: Algorithm

P-Wave: rate and rhythm QRS: rate and rhythm - shape P-R Interval: Is AV conduction

normal? P:QRS regular? T Wave and QT Interval Any unusual complexes? IS IT DANGEROUS?

Clinical Manifestations:
Asymptomatic generally benign
Palpitations Awareness may

cause anxiety Compromised CO Syncope Myocardial Ischemia tachy CHF Chronic insufficiency Sudden Death Cardiac arrest

Define Normal
Regular Atrial and Ventricular

Rhythms: 1P : 1 QRS Rates: 60-100 P Morphology: small, round, regular and positive in Lead II QRS Morph: Similar size and shape Positive T waves in Lead II

P-Wave:
SA Node

1.SA Node fires 2. Right and Left

LA/RA Depol

Atria Depolarize AV 3. AV Node Node pauses Questions: P waves present? Regular rhythm?
1/QRS?

Sinus Rhythms
Normal Sinus Rhythm:

1P/QRS: 60-100 bpm

Sinus brady: 1P/QRS: <60 bpm Sinus tachy: 1P/QRS: >100 bpm Sinus Arrhythmia: 1P/QRS

Normal Irregularities caused by inspiration/expiration more noticeable in children / elderly

ABSENT PQRS Complex: Sinus Arrest:

Causes: Heart disease, acute infection, VAGAL stimulation (Bushs Pretzel Problem?) Sick Sinus Syndrome: Usually in elderly more irregular DANGER?
Rare

and asymptomatic Frequent and symptomatic

Atrial Arrhythmias:
PAC: Premature Atrial

Contraction Atrial Tachycardias: SVT with or without blocks, PAT Atrial Flutter: Atrial Fibrillation

Premature Atrial Contractions:

Ectopic
Triggered by: Alcohol, nicotine,

anxiety, fatigue, fever, and infections Usually benign Clinical Manifestations: Palpitations or skipped beats

PAC - ID:

Irregular P-R rhythms

Premature, irregular P waves

(sometimes lost in the T wave)

Atrial Tachycardias:
Also: Supra Ventricular

Tachycardia (PSVT) Rates: 100-250 bpm Regular Rhythms Hidden P waves (could be inverted indicating a Junctional focus PSVT) PAT = Common in warm-up/cool down and doesnt respond to Carotid Massage (dont try this!)

Afib Aflut

Atrial Fibrillation: Atrial Fib and/or PSVT?

Atrial Flutter: 2:1 Ventricular capture Ventricles can only respond to every other Atrial conduction

Fibrillation vs. Flutter?

Multi-focal One focus -

organized origins -chaotic Rate: 200-400 Rate: >400 bpm bpm IRREGULAR-R Atrial Cardiac Atrial Cardiac Output is compromised Output is lost :
Atria contribute ~20% of the total Cardiac output: A-Fib is non-lethal

Summarize: Sinus and Atrial Rhythms

Sinus: Normal, Tachy, Brady

Absent P: Sinus Arrest, A-fib,

Junctional (PSVT), PAT Weird P: A-Flut, PAC

Formation Arrhythmias
Junctional and Ventricular Chapters 6-7

Junctional:
Form in the AV (Junction) Node May be an Escape rescue if SA

node fails to fire or conduct

Escape

Rate ~40-60 bpm

May be an Ectopic Irritable Focus Ectopic Rate ~ 60-100 bpm

Responds to vagal stimulus

P Waves inverted, missing or

after the QRS

Ventricles: QRS Rhythms

Regular rhythms?
R-R

intervals equivalent

Regular irregular rhythms?

R-R

intervals equivalent with occasional irregularities intervals irregular

Irregular rhythms?
R-R

Regular Irregular
Premature Beats: PVC
Widened

QRS, not associated with preceding P wave Usually does not disrupt Pwave regularity T wave is inverted after PVC Often Followed by compensatory ventricular pause

Notice a Pattern in the PVCs?

PVC Patterns:
PVC: 1 Isolated beat

Couplet: 2 consecutive PVCs

Bigeminy: PVC every other

beat Non-Sustained VT: >3 beats for less than 1 minute Sustained VT: > 1 minute of ventricular tachycardia

Irregular Ventricular Rhythms: CHAOTIC

Ventricular Fibrillation:
Multi-focal

origins Irregular wave morphologies Cardiac Output = 0 Coarse vs. Fine V-Fib

Clinical Manifestations PVCs Often benign

BUT Compromised CO Possibly precipitate a lethal arrhythmia: Vtach, VFib

More on PVCs
Cardiac Output: Pulse deficit =

reduced CO (~20%) One PVC usually asymptomatic Symptoms: LOC or dizziness demand treatment Risk of Lethal Arrhythmias: V-Tach more dangerous in CAD

Rules of Malignancy:
Frequency: > 6 / minute
Runs: 3+ consecutive

Multiform
R on T

PVCs during MI

What is the threat of sustained Ventricular Tachycardia?

1. What happens to diastole? 2. What happens to Cardiac Output? 3. What happens to myocardial perfusion? 4. What happens to myocardial VO ?

Winslow Homer: The Stile