ecg arrhythmia dr. k. p. misra sr. consultant cardiologist dr. k. p. misra sr. consultant...
TRANSCRIPT
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