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Rhythm abnormalities
Chamber enlargement
Ischemia / Infarction
Anatomy and Physiology of Cardiac Conduction
SINUS NODE
Sinus Node • The Heart’s ‘Natural
(SA Node) Pacemaker’
- 60-100 BPM at rest
LA
RA
LV
RV
Anatomy and Physiology of Cardiac Conduction
AV NODE
Sinus Node • Receives impulse from
(SA Node) SA Node
• Delivers impulse to the
Atrioventricular
Node (AV Node) His- Purkinje System
• 40-60 BPM if SA Node
fails to deliver an impulse
Anatomy and Physiology of Cardiac Conduction
BUNDLE OF HIS
Sinus Node • Begins conduction to
(SA Node) the Ventricles
Atrioventricular
• AV Junctional Tissue:
Node (AV Node) 40-60 BPM
Bundle of His
Anatomy and Physiology of Cardiac Conduction
THE PURKINJE
NETWORK
Sinus Node
(SA Node) • Bundle Branches
• Purkinje Fibers
Atrioventricular
Node (AV Node)
• Moves the impulse
through the ventricles for
Bundle of His contraction
• Provides ‘Escape
Bundle Branches Rhythm’:
20-40 BPM
Purkinje Fibers
Impulse Formation In SA Node
Atrial Depolarization
Delay At AV Node
Conduction Through Bundle Branches
Conduction Through Purkinje Fibers
Ventricular Depolarization
Plateau Phase of Repolarization
Final Rapid (Phase 3) Repolarization
Normal ECG Activation
Major Waveforms of the ECG
Normal Sinus Rhythm
Look at the p waves:
•rate is 60-100/min
•cycle length do not vary by 10%
•PR interval is 0.12 - 0.20 sec.
Lead II
Normal Sinus Rhythm
ARRHYTHMIA
Steps in ECG Interpretation for ACLS
Regularity?
Rate?
Rhythm? Sinus?
P-QRST
Intervals: PR, QRS, QT
Rhythm abnormalities?
Clinical correlation
Regularity
1 2 3 4
1500 / 23 = 65/min
FAST METHOD
Start
300 300
150
100
75
150 60
50
100
75 ~63 BPM
60
50
REMEMBER….
75 – 60 - 50
Determination of Rate
Regular Rhythm
150 75
300 100
1500 / 23 = 65/min
Determination of Rate
Irregular Rhythm
3 second strip
Rate = 48/min
Rate = 48/min
Sinus Bradycardia
Sinus Tachycardia
Rate = 48/min
Rate = 48/min
SINUS PAUSE (SINUS ARREST)
Sinus Arrest ( Sinus Pause)
Case: If the SA Node does not fire
Do you have a P wave? None
Do you have a QRST? None
What is the interval between the previous beat
and the next beat following the pause?
Less than twice the normal interval
40 mm 50 mm
AV Blocks
Normal Cardiac Depolarization
and the ECG
T
P
Q
S
Atrioventricular Blocks
T
P
Q
S
FIRST DEGREE
AV BLOCK
Q
S
Do you have a normal P wave? Yes
Do you have a normal PR segment? No
Do you have a normal PR interval? Prolonged (> 0.20 sec)
Do you have a normal QRS-T? Yes
Second Degree
Atrioventricular Block
Type I - Mobitz type I or Wenckebach
Progressive lengthening
of PR interval w/ intermittent
dropped beats .
Features
progressive prolongation of PR interval
progressive shortening of the RR interval
pause encompassing the blocked P wave that is less
than the sum of two P-P cycles
SECOND DEGREE BLOCK AT THE
AV BLOCK
Bundle of His
MOBITZ II
Bilateral bundle
branches
w/ intermittent
dropped beats .
Features
constant P-P intervals and R-R intervals
constant PR intervals prior to the unexpected failure of a P
wave to conduct to the ventricle
a pause encompassing the blocked P wave that equals two
P-P cycles
occurs almost exclusively in association with a bundle branch
block, and the anatomical site of block is usually within or below
the His bundle
ARE YOU GUYS MORE CONFUSED?
WAIT TILL YOU SEE THE NEXT SLIDE!!!
R
T
P
Q
S
Ventricular rate = 43 BPM Ventricular rate = 43 BPM
Regular Irregular
With P wave;
P wave No P wave No P wave
No P-QRS abnormal
relation PR
P-QRS
Narrow QRS Wide QRS
Group beating
Slow AF
Sinus
brady Junctional Idio- 3rd degree 2nd degree AV
ventricular block
AV block
Bradyarrhythmias
LET ME
Sinus Paroxysmal Atrial Flutter WORRY
Tach. SVT (reentrant)
Atrial Rate/min >100 140-250 250-350
ABOUT
P morphology (N) peaked/
inverted
“saw-tooth” THIS!!!
Response to atrial abruptly reverts AV block,
carotid massage rate to (N) may increase
slows
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Sinus Tachycardia
Management:
Nonsustained
Sustained
Monomorphic
Polymorphic
Torsades pointes
Ventricular Fibrillation
Ventricular Fibrillation
Associated with coarse or
fine chaotic undulations of the
ECG baseline
No P wave
No true QRS complexes
Indeterminate rate
Regular Irregular VT
The accredited
affiliate society of
A Full Member of
RESUSCITATION
COUNCIL OF ASIA
TREAT THE
PATIENT…
NOT THE
MONITOR!!!
Thank you for your attention.