1. ARRHYTHMIA DR MANSOUR ALQURASHI
Associate professor of Clinical Pediatrics
College of Medicine, Imam University, Riyadh.

2. Objectives At the end of this session students should be able to:
Distinguish the normal from abnormal rhythms.
Understand the pathophysiologic basis of arrhythmia.
Differentiate ventricular from supraventricular arrhythmias.
Recognize different types of supraventricular arrhythmias.
Recognize the different types of heart block.
Be familiar with strategies of arrhythmia management.

3. Conduction system hierarchy

4. Basic ECG elements ST interval TP segment T wave QT interval
ST segment
QRS
PR interval
PR segment
P wave
Duration Intervals
Joining Segments
Basic elements

5. 2 dimensions P Q R S T
Time
Axis

6. Classification of arrhythmia
Variable
Classes
Rate
Tachycardia
Bradycardia
Morphology
Narrow complex
Wide complex
Origin
Supra-ventricular
Junctional
Ventricular
Mechanism
Reentrant
Automatic
Triggered
P-QRS relationship
1st degree AV block
2nd degree AV block
3rd degree AV block

7. Mechanisms of arrhythmia
Enhanced automaticity
Reentry
Triggered activity

8. Reentry macro & micro reentry functional or structural

9. Rhythm analysis (P-QRS)
(P waves & QRS)
Present
Sinus / non sinus
Absent
Real / technical
Rate
Slow
Appropriate/inappropriate
Fast
Narrow/wide complex
Regularity
Regular
Irregular
Group beating or haphazard
P wave morphology
& QRS morphology
Axis
up/down P waves, extreme axis
Duration & Axis
Normal or wide (RBBB, LBBB), sup. axis
P-QRS relationship
Normal
1:1, normal PR interval
Abnormal
Ratio, duration (fixed, variable, unrelated)
Others
PR & QT intervals
Long or short

10. Normal sinus rhythm

11. Normal Sinus Rhythm

12. Sinus Tachycardia (Appropriate vs inappropriate)

13. Sinus Tachycardia

14. Sinus Bradycardia (Appropriate vs inappropriate)

15. Sinus Bradycardia

16. Sinus Arrhythmia (normal or abnormal?)

17. Sinus Arrhythmia

18. What is the abnormality ?

19. Atrial Flutter

20. Atrial Flutter

21. Atrial Fibrillation

22. Atrial Fibrillation

24. Paroxysmal supra- ventricular tachycardia
(AV nodal reentrant tachycardia)

25. Paroxysmal supra- ventricular tachycardia (AV nodal reentrant tachycardia)

26. Paroxismal SVT (AVNRT)

27. Clinical Signs of Tachyarrhythmia

29. 1st degree AV block

30. 1st degree AV block

31. Type I second degree AV block

32. 2 nd Degree Block Type 1

33. Type II second degree AV block

34. Second degree AV block (type- II)

35. Complete Heart Block (third degree AV block)

36. Complete heart block

39. What do you notice?

40. Non-sustained VT

42. Ventriculat tachycardia Why?P P P P

43. Monomorphic VT What is the mechanism?

44. Polymorphic VT What is the mechanism?

45. Ventricular fibrillation

46. Ventricular fibrillation

48. Asystole

51. Case Study 5

52. Long QT syndrome (Jervell-Nielson-Lange)
QT (corrected)
QTc= QT (msec)
√R-R (sec)
= 640/ 1.05
= 610 msec
> 450 m sec is long

54. WPW

56. Arrhythmia management
Aim:
Hemodynamic stability
Prevent complications
Symptomatic relief
Strategies:
Restoration of normal rhythm
Slowing of tachyarrhythmia
Augmenting the slow rhythm
Options:
Pharmacological agents
Electrical cardioversion
Transcatheter ablation
Device implantation
Emergency versus elective management
Electrophysiology lab

57. Emergency cardioversion

59. وَفِي أَنفُسِكُمْ أَفَلَا تُبْصِرُونَ