ARRYTHMIA (Part I) 2014 -2015

Dr. Payawal

ARRYTHMIA

o Abnormal cardiac rhythm

o Proper term is dysrrhytmia but they are interchangeable terms
because there are several kinds of cardiac arrythmia
o it is important to distinguish benign from malignant [has capacity o IRREGULAR
to kill Px} -R-R intervals not same
the #1 killer in Philippines is cardiovasculat disease (9 die
every hour)
50 % of deaths from cv disease are sudden cardiac
death [death within one hour of symptom onset]
Majority of sudden cardiac death is caused by o IRREGULAR
arrythmia [arrythmic death]
-in Px with acute coronary syndrome

STEPS IN ARRHYTHMIA RECOGNITION

Cardiac Rhythm Identification

Regularity o IRREGULAR
o Regular
o irregular 2. HEART RATE
Cardiac rate based on ECG 2 methods to get the heart rate:
o Tachycardia MATH
o bradycardia Heart rate = 1500
Pattern of the rhythm # of small squares (0.04s)
o Normal Sinus Rhythm or not? Count the number of small squares(0.04) between 2
o Is rhythm coming from sinus node? R waves (ventricular) or 2 P waves (atrial)
Are there QRS complexes? -use this number to divide with 1,500
o Normal or abnormal? -1,500 because 1 small square is 0.04; 1,500 x 0.04 =
Are there P waves? 60; there are 60 seconds in 1 minute
o Normal or abnormal? Non-MATH
What is the relationship between P and QRS complexes? Sequence method: 300, 150, 100, 75, 60, 50
P-QRS-T -just memorize this sequence
o does it follow the normal pattern? Math method and Sequence Method is applicable for
Clinical correlation? regular only
Intervals: PR, QRS, QT If irregular, count # of R-waves in a 3 (or 6)-second strip, X
20 (or 10)
1. REGULARITY
Beat to beat interval (R to R or P to P intervals) the same BASIC ECG INTERPRETATION
Use a calliper to have an exact measurement
Regular: same interval R-R or P-P
Gold standard to measure regularity: measure R-R or P-P
intervals
o regular: same measurement
It is possible to have a rapid beat with regular rhythm

Determination of Rate
IF RHYTHM IS REGULAR
ECG paper:
Count the # of small squares between 2 R waves
Long lead II = 23
REGULAR 1500/23 = 65 bpm
Sequence method:
If R wave falls on a thick line on big square, the rate would
be 300. Next 150, then 100.. 75..60..50.
This one is between 60 and 75 but nearer to 60 so it is
around 65.
st
1 arrow: 300
REGULAR 1: 150

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal
2:100
3:75
4: 60
nd
2 arrow: approx. 65

IF RHYTHM IS IRREGULAR
Also estimate
Count the number of big squares in a 6-second strip
*there are 5 big squares in 1 second
*30 big squares in 6 seconds

Regular
P waves normal
HR: around 60-70
PR interval IS normal ;is 0.12 sec. or more
There is the presence of a P wave, followed by a QRS
complex at a regular rate
3 second strip (15 big squares is 3 seconds)
Rate/min = # of complexes multiplied by 20 ECG LeadII
Count the number of R waves in 15 big squares This is a Normal sinus Rhythm:
Presence of P wave
6 second strip (30 big squares is 6 seconds) P wave is followed by QRS
Rate/min = # of complexes (Rwaves) multiplied by 10 Rate is between 60-100
Count the number of R waves in 30 big squares Divide by 22 = 68
Remember: 5 big squares is 1 second
In the example given:
Counted 7 R waves
7 x 10 = 70 beats per minute

3. NORMAL SINUS RHYTHM

Criteria:
There should be a P wave (normal: upright) followed same contour in same lead?
by a QRS complex at a regular rhythm and normal rate Upright in I, II, aVF & left precordial leads
o Normal HR: 60-100bpm followed by QRST?
o Tachycardia: > 100
o Bradycardia: < 60 Review
o Pacemaker impulses are initiated in the SA node.
Travelling through atrial pathways at a frequency
between 60-100 bpm
cycle length do not vary by 10%
o if cycle varies by >10%: sinus arrythmia

Regular Rhythm
Rate (75 using sequence method)
P wave upright
Followed by QRS (which is narrow or normal)
*Wide QRS= 0.12 seconds or more [3 small squares or
more]
P-R interval normal (0.60)
Therefore Normal sinus rhythm

ACLS Rhythms [Advanced Cardiac Life Support]

Arrhythmias are now being taught in the ACLS class because

st
arrhythmia is a common cause of death in the 1 48 hours
after a heart attack.

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal
Id an arryhtmia is recognized early, you can resuscitate the
patient. Knowing how to recognize an arryhtmia will improve SLOW ARRYTHMIA
MI patient survival
So even non-doctors can learn cardiac arrythmia [nurses,
paramedics, med tech, therapists..]

TYPES OF RHYTHM

THE ACLS ARRHYTHMIA

SLOW RHYTHMS (HR: <60)
o Sinus Bradycardia
o Sinus Pause
o Escape Rhythms:
Junctional rhythm
Idioventricular rhythm
- when sinus node fails to fire (no depolarization), Px does
not go to cardiac arrest immediately because heart
has back-up pacemakers and it will be the one
initiating
AV node: junctional rhythm
ventricle: idioventricular rhythm
o Heart Blocks
FAST RHYTHMS (HR: >100)
o Sinus tachycardia
o Suprventricular tachycardia [SVP]
-above ventricle
o Atrial fibrillation
o Atrila flutter
o Multifocal atrial tachycardia
o Ventricular tachycardia
ARREST RHYTHMS
o Asystole
-(flat line) WILL be in the exam!
o Ventricular Fibrillation
o Pulseless VT (ventricular tachycardia)
o Pulseless Electrical Activity (PEA)
-Px has electrical activity but has no pulse
-easiest to recognize
-causes sudden cardiac death
BENIGN RHYTHMS
o PREMATURE ATRIAL COMPLEX (PAC)
o PREMATURE VENTRICULAR COMPLEX (PVC)
MISCELLANEOUS
o Artificial pacemaker rhythm
-pacemaker in patients esp. those with heart blocks
o Preexcitation/wpw pattern (wolff parkinson white syndrome)
-rare; congenital
-there is an accesory pathway excitation
*do not mind, di lalabas sa exam :D

1. SEPARATE RHYTHMS, either:

FAST (HR > 100)
SLOW (HR <60)

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

SINUS BRADYCARDIA SINUS PAUSE/ARREST

Sinus bradycardia follows all criteria for normal sinus rhythm Cause: if SA node does not fire
except for the rate There is a pause
Always ask for drug history (drugs that slow down HR) No P wave (as opposed to AV Block)
nd
o Beta blockers *2 degree AV block has P wave but no QRS
o Anti-arrythmic drugs No QRST
Always ask if hes athletic, especially in young patients
*athletes also have bigger hearts (LVH) but not sick

ECG paper: lead I

Rate = 48/min
65 y.o man with same ECG (as athletics)
Frequent
- Near-syncopal attack (nagdilim paningin) <1 sec
Irregular because there is a pause
- Sedentary lifestyle (not athlete)
Normal then pause then again normal beat
- No drugs that slows down HR
Sinus bradycardia due to sinus node dysfunction No P wave, no Q wave
-consider a pacemaker implantation What is the interval between the previous peak and the next
peak following the pause?
Interval is less than twice the normal interval between
beats
-this interval where the pause is, is shorter than the
2 normal beats
-the one with the pause is twice shorter than the 2
normal interval

AV BLOCKS

FIRST DEGREE AV BLOCK

Measure from start of P wave up to start of QRS

Sinus Bradycardia PR> 0.20 sec > only criteria
If P-R interval is prolonged (more than 5 small squares or 1 big
square): FIRST DEGREE AV BLOCK
Correlate clinically
Can be caused by drugs (digitalis)

Case: SA node does not fire. No P, no QRS

Interval less than 2x the normal
I2 cycles is always longer than the cycle with a pause

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

SECOND DEGREE AV BLOCK

P-R interval= 8 small squares x 0.04

= 0.32 (which is longer than 0.20 sec)

HAS TWO TYPES:

-need to distinguish because have different prognosis
-Different from each other
o PR interval not the same
o Has P wave with no QRS
o Cycle repeats itself: shorter PR interval.. longer PR.. then
non-conductive P wave.. repeat..

Second Degree
Atrioventricular Block
n Type I - Mobitz type I or Wenckebach
Transcient/temporary
No aggressive measures needed
n Type II - Mobitz type II
Usually goes into complete heart
block/asystole/arrest
Prepare Px for pacemaker already

Type I Type II
Temporary Goes into complete heart
block
From 1 cycle to next until the PR interval is constant and
drop beat then drop beat
Prepare for pacemaker
implants

Normal sinus rhythm with first degree AV block

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

2 Type II

non-conductive P-wave (drooped beat): has P wave but no QRS

MOBITZ TYPE I
Prolongation in PR interval
Non-conductive P wave (dropped beat)

MOBITZ TYPE II
No prolongation of PR interval; constant
Just have dropped beat

THIRD DEGREE/COMPLETE AV BLOCK

More advanced block

Atrium is controlled by sinus node
Ventricle do not get depolarized from the sinus node
anymore
Ventricle has its own pacemaker
o AV node
o Bundle of His
o Bundle branches
o Ventricle itself
-So you will have different rates already

AV node pacemaker:
QRS will not be wide
rate= 40-60 bpm
pacemaker from ventricle itself:
QRS is wade (0.12 sec or more)
rate <40bpm
Ventricular rate usually slower
-depend on where is the pacemaker of ventricle
-back-up pacemakers of heart are not as efficient (slower
compared to sinus node)

More P wave than QRS

-Because in complete heart block, the atrial rate is usually
faster than the ventricular arte
P wave do not cause QRS anymore

Measure P-P interval: it is constant

Sometimes P wave is buried in T wave, in QRS, depending on
atrial beat

P-P = atrial rate constant

R-R = ventricular rate constant
BUT atrial and ventricular rate is not the same

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal
In AV block, complete heart block. Normal atrial rate is
faster/greater than ventricular rate
Clinically: if complete heart block, but rate is coming from AV
node, it will respond to mediastinum
If from ventricle, pacemaker is needed, does not respond to
mediastinum
Symptom: hypotension, Syncope magdidilim paningin

If QRS is narrow: may respond to drugs (Dopamine, etc.)

If rate <40 and QRS is wide: will not respond to drugs; need
pacemaker already

Ventricle-independent from poor SA node

AV node: QRS not wide
Ventriclr itself Wide QRS, rate <40
Atrio-ventricular Dssociation
P-P and R-R intervals are constant

Arrows are pointing to P waves

o Buried in QRS, T wave, etc.
o If you measre P-P interval, it is constant
o Does not cause QRS
o HR: <40 (pacemaker is in the ventricle)

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

FAST ARRYTHMIAS
SINUS TACHYCARDIA

Has same criteria as Sinus rhythm except that rate is >100bpm

Not necessarily mean theres a problem in the heart
*you have sinus tachycardia during exams
Always correlate clinically
-know what patient is tachypneic about
-Consider conditions that will increase heart rate like stress,
fatigue, emotional disturbance, fever

Lead I rate = 111/min

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

BENIGN ECTOPIC RHYTHMS PREMATURE VENTRICULAR COMPLEX (PVC)

PREMATURE ATRIAL COMPLEX (PAC)

Ectopic focus comes from ventricles

Ectopic focus outside that of the sinus node comes from QRS complex is wide because the ventricle is a wider chamber
atrium -markedly different
-If in Lead II = ectopic focus on right atrium that fired - >0.12 sec or more
When you see premature beat (beat occuring earlier than it No P wave usually because it came from the ventricles
should be), usually in V2? You scrutinize it: With compensatory pause
o Does it have a wide or narrow QRS? -either a pause after PVC
*here it is narrow: 2 small squares (0.08 sec) -compensate for two normal beats
o Look if there is a P wave before the QRS of that *if you measure interval from beat before and after PVC, its
premature beat the same as 2 normal beats
*here, there is a P wave T wave is opposite from QRS complex
o Does the P wave differ from the sinus beat? -If ORS is predominantly upright, T wave is negative
*here, it looks different -If QRS predominantly negative, T wave will be upright
Criteria for PAC: -opposite polarity
o P-R interval is often long [>0.12 sec] instead of 0.10 sec Many physicians are scared to see PVCs
- Long here is diff. from that of first degree AV block
-distinguish PAC from PJC (premature junctional CRITERIA
complex?) o Markedly different (wider than usual beat)
-ectopic focus comes from AV node o No P wave
o P wave different in configuration but predominantly o T wave opposite polarity of QRS complex
upright o There is a pause
o Narrow QRS

P waves are different but upright

PR interval is > 0.12 sec (0.16 or 4 small squares)
QRS narrow
meets criteria for PAC

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ARRYTHMIA (Part I) 2014 -2015
Dr. Payawal

Others: (hindi nabanggit ang classification sa lecture)

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