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Arrhythmia Recognition
Premature Ventricular Conduction Pacemaker Lead Placement ST Segment Depression
Pacing Pacing
Lead Lead
V1 V1

J Point
Atrial Ventricular AV Sequential
Pacing Pacing Pacing Downsloping ST Upsloping ST Horizontal ST
The pacing lead is The pacing lead The pacing leads
inserted into the is inserted into are inserted into The J point occurs at the end of the QRS complex.
atrium to cause the ventricle to both the atrium and The ST segment begins at the J point
atrial depolarization. cause ventricular ventricle stimulating and extends to a user-defined interval.
Right Ventricular PVC Left Ventricular PVC depolarization. at set intervals.

Ventricular Rhythms Pacemaker Rhythms


Premature Ventricular Complex – PVC Ventricular Fusion Beat Electronic Pacemaker Spikes Failure to Capture
Heart Rate Rhythm P Wave PR Interval QRS
(in seconds) (in seconds)
N/A Irregular with N/A N/A ≥ 0.12
PVCs

Unifocal PVCs: Identical shapes

Heart Rate Rhythm P Wave PR Interval QRS


(in seconds) (in seconds)
N/A N/A Present Same as sinus ≥ 0.12 Electrical stimuli delivered by the electronic pacemaker to the
rhythm or shorter endocardium are seen as a spike on the surface ECG.
The pacemaker generates a pacemaker spike
but does not cause an intrinsic beat (P wave or QRS).
Ventricular Escape Beat Ventricular Pacemaker (single chamber)
Failure to Sense

Multifocal
Multifocal PVCs:More
PVCs: More than
thanone shape
one shape

Heart Rate Rhythm P Wave PR Interval QRS


(in seconds) (in seconds)
< 40 bpm Irregular Absent Absent ≥ 0.12 Single spike producing a wide QRS complex
(ventricular capture).

Idioventricular Rhythm Atrial Pacemaker (single chamber)

The pacemaker does not recognize the intrinsic beats


and generates an unnecessary pacemaker spike.

Failure to Fire
Paired PVCs (Couplet)
Single spike producing paced P wave
(atrial capture) followed by an intrinsic QRS complex.

Heart Rate Rhythm P Wave PR Interval QRS


(in seconds) (in seconds) AV Sequential Pacemaker (dual chamber)
20 – 40 bpm Regular Absent or not related N/A ≥ 0.12

Accelerated Idioventricular Rhythm (AIVR)

The pacemaker does not generate


R on T Phenomenon: PVC occurs at the peak a pacemaker spike when it is needed.
of the of T wave of the preceding beat
of the preceding beat First spike followed by a paced P wave (atrial capture)
followed by a second spike producing a wide QRS complex
(ventricular capture).

Paced Fusion Beat ECG Artifact


Any waveform on the ECG
that is not related to the patient’s cardiac events
Heart Rate Rhythm P Wave PR Interval QRS
(in seconds) (in seconds) Calibration Pulses
40 – 100 bpm Regular Absent, not related N/A ≥ 0.12
Ventricular Bigeminy: Every other beat is a PVC or retrograde conduc-
tion

Ventricular Tachycardia
(3 or more consecutive ventricular complexes) The electronic pacemaker and the patient’s own cardiac
rhythm occurs simultaneously producing a combination
of a paced beat and an intrinsic beat.
Deliberate artifact caused to show the interpreter the
relationship of the complexes with a known electrical
stimulus (standardization procedure).

Full Compensatory Pause


AC Interference (60 cycle)
vs. Noncompensatory Pause

Ventricular Trigeminy: Every third beat is a PVC

Heart Rate Rhythm P Wave PR Interval QRS


(in seconds) (in seconds)
> 100 bpm Regular Absent, not related, N/A ≥ 0.12
or retrograde
conduction 1:1, 2:1,
or VA Wenckeback
Sixty even, regular spikes in a one-second interval
caused by electrical current near the patient.
Ventricular Fibrillation

Muscle Tremor (Somatic)

Ventricular Quadrigeminy:
Every fourth beat is a PVC

Heart Rate Rhythm P Wave PR Interval QRS


(in seconds) (in seconds)
300 – 600 bpm Extremely ir- Absent Absent Absent
regular

Ventricular Asystole
To measure a Full Compensatory Pause:
Electrical interference
1. Mark off three normal cycles. caused by the patient’s tensed muscles.
2. Place the first mark on the P wave of the normal cycle
preceding the premature complex.
Heart Rate Rhythm P Wave PR Interval QRS 3. The third mark should fall exactly on the P wave following
(in seconds) (in seconds) Wandering Baseline (Drift)
Absent Absent Absent or present Absent Absent the premature complex to be called a compensatory pause.

Arrhythmia Recognition (poster 2 of 2) Normal ECG Standards for Children by Age This poster includes Premature Ventricular Conduction, Pacemaker Lead
Placement, ST Segment Depression, Ventricular Rhythms, Pacemaker
This is part two of two posters to assist healthcare professionals in 0–1d 1–3d 3–7d 7 – 30 d 1 – 3 mo 3 – 6 mo 6 – 12 mo 1–3 y 3–5y 5–8y 8 – 12 y 12 – 16 y
Rhythms, Full Compensatory Pause and ECG Artifact. The ECG rhythm
recognizing basic arrhythmias. According to the Practice Standards Heart
Rate/Min
94 -155
(122)
91 - 158
(122)
90 - 166
(128)
106 - 182
(149)
120 - 179
(149)
105 - 185
(141)
108 - 169
(131)
89 - 152
(119)
73 - 137
(109)
65 - 133
(100)
62 - 130
(91)
60 - 120
(80) strips display lead II as the top waveform and lead V1 as the bottom
for Electrocardiographic Monitoring in Hospital Settings (Circulation. PR Interval 0.08 - 0.16 0.08 - 0.14 0.07 - 0.15 0.07 - 0.14 0.07 - 0.13 0.07 - 0.15 0.07 - 0.16 0.08 - 0.15 0.08 - 0.16 0.09 - 0.16 0.09 - 0.17 0.09 - 0.18 waveform. Classic examples are shown for each rhythm to provide basic
2004;110:2721-2746) in general, the mechanisms of arrhythmias are Lead II (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) visualization and avoid complexities. The intended use of this poster is
the same in both adults and children. However, the ECG appearance of (Seconds) to compliment a text and/or course — in addition to a reference guide for
the arrhythmias may differ due to developmental issues such as heart QRS Interval 0.02 - 0.07 0.02 - 0.07 0.02 - 0.07 0.02 - 0.08 0.02 - 0.08 0.02 - 0.08 0.03 - 0.08 0.03 - 0.08 0.03 - 0.07 0.03 - 0.08 0.04 - 0.09 0.04 - 0.09 arrhythmia recognition
size, baseline heart rate, sinus and AV node function, and automatic Lead V5 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07)
The most common ECG rate, interval, and duration measurements are from the following publications:
innervation. (Seconds)
• Clinical Electrocardiography (Post Graduate Institute for Medicine).
All values 2nd – 98th percentile; numbers in parentheses, means. Adapted from Pediatr Cardiol. 1979;1:123.
• Understanding Electrocardiography (Mary Boudreau Conover).
ECG terminology and diagnostic criteria often vary from text to text and • How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis).
from one teacher to another. There are often several terms describing • Principles of Clinical Electrocardiography (M. J. Goldman).
An undulating baseline
similar findings (for example: Premature Atrial Contraction, Atrial • Basic Dysrhythmias Interpretation and Management (Robert Huszar).
with waveform present.
Premature Complex, Atrial Extrasystole, Supraventricular Ectopic Beat, • An Introduction to Electrocardiography (Leo Shamroth).
etc.) It is important to correlate the ECG interpretation with the clinical • Interpretation of Arrhythmias (Emanual Stein).
observation of the patient.

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