1. Chapter 2 for 12 Lead Training -RHYTHM PRACTICE-
Ontario Base Hospital Group
Education Subcommittee
2008
TIME IS MUSCLE

2. RHYTHM PRACTICE AUTHOR REVIEWERS/CONTRIBUTORS Tim Dodd, AEMCA, ACP
Hamilton Base Hospital
REVIEWERS/CONTRIBUTORS
Al Santos A-EMCA, ACP
Donna L. Smith AEMCA, ACP
Hamilton Base Hospital
2008 Ontario Base Hospital Group

3. Let’s Have Some Fun!

4. Sinus Mechanisms
Try to point out the Hallmark signs of each rhythm to students and review!!! Stress that practice with the methods shown here will make ECG interpretation more accurate. Note the originating conduction pathway.

5. Sinus Node Normal Sinus Rhythm (NSR) Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
Sinus Arrest/Pause
Sinoatrial Exit Block

6. Normal Sinus Rhythm (NSR)
Rate: beats/min
Rhythm: regular
P waves: uniform, + (upright) in lead II, one precedes each QRS complex
PR interval: seconds and constant
QRS duration: < 0.12 sec

7. Normal Sinus Rhythm (NSR)

8. Sinus Bradycardia Rate: less than 60 beats/min Rhythm: regular
P waves: uniform in appearance, upright and one precedes each QRS complex
PR interval: sec and constant
QRS duration: < 0.12 sec

9. Sinus Bradycardia

10. Sinus Tachycardia Rate: greater than 100-150 beats/min Rhythm: regular
P waves: uniform, upright, one precedes each QRS
PR interval: sec and constant
QRS duration: < 0.12 sec

11. Sinus Tachycardia

12. ENOUGH OF SINUS

13. Sinus Arrhythmia Rate: 60-100 beats/min Rhythm: irregular
P waves: uniform in appearance, upright, one precedes each QRS
PR interval: sec and constant
QRS duration: < 0.12 sec

14. Sinus Arrhythmia

15. Sinus Arrest/Pause Rate: usually normal but varies due to the arrest
Rhythm: irregular; the arrest is of undetermined length
P waves: uniform in appearance, upright, one precedes each QRS
PR interval: sec and constant
QRS duration: < 0.12 sec

16. Sinus Arrest/Pause

17. Sinoatrial Exit Block Rate: varies due to the pause
Rhythm: irregular; each pause is the same as the distance between two other P-P intervals
P waves: uniform in appearance, upright, one precedes each QRS
PR interval: sec and constant
QRS duration: < 0.12 sec

18. Sinoatrial Exit Block

19. Atrial Dysrhythmias

20. Atrial Dysrhythmias Premature Atrial Complexes (PACs)
Wandering Atrial Pacemaker (WAP)
Supraventricular Tachycardia (SVT)
Wolff-Parkinson-White Syndrome (WPW)
Atrial Flutter
Atrial Fibrillation (A-Fib)

21. Premature Atrial Complexes (PACs)
Rate: depends on underlying rhythm
Rhythm: regular with premature beats
P waves: premature (earlier than expected) and may differ in shape from sinus P waves
PR interval: sec and constant
QRS duration: < 0.12 sec
Note: Ectopic complex

22. Premature Atrial Complexes (PACs)

23. Wandering Atrial Pacemaker (WAP)
Rate: usually beats/min; if greater than 100 beats/min, it’s termed multifocal atrial tachycardia
Rhythm: may be normal or irregular due to shift in ectopic atrial locations
P waves: size, shape and direction change (3 or more different P waves)
PR interval: may be normal or variable
QRS duration: < 0.12 sec

24. Wandering Atrial Pacemaker (WAP)

25. Supraventricular Tachycardia (SVT/PSVT)
Rate: beats/min
Rhythm: regular
P waves: not present
PR interval: not measurable
QRS duration: < 0.12 sec
Note: PSVT is an SVT
that starts/ends suddenly

26. Supraventricular Tachycardia (SVT)

27. Wolff-Parkinson-White Syndrome (WPW)
Rate: usually beats/min (can be associated with runs/episodes of A-Fib)
Rhythm: regular
P waves: uniform in appearance, upright, one precedes each QRS
PR interval: sec and constant
QRS duration: usually > 0.12 sec; slurred upstroke of the QRS complex (delta wave)

28. Wolff-Parkinson-White Syndrome (WPW)

29. Atrial Flutter
Rate: atrial rate beats/min; ventricular rate will not usually exceed 180 beats/min
Rhythm: atrial regular; ventricular regular or irregular
P waves: saw-toothed “flutter” waves
PR interval: not measurable
QRS duration: < 0.12 sec

30. Atrial Flutter

31. Atrial Fibrillation (A-fib)
Rate: variable
Rhythm: irregularly irregular
P waves: no identifiable P waves
PR interval: not measurable
QRS duration: < 0.12 sec

32. Atrial Fibrillation (A-fib)

33. Junctional Rhythms

34. Junctional Rhythms Premature Junctional Complex (PJC)
Accelerated Junctional Rhythm
Junctional Tachycardia

35. Premature Junctional Complexes (PJC)
Rate: usually normal but depends on the underlying rhythm
Rhythm: regular with premature beats
P waves: may occur before, during or after the QRS (inverted if visible)
PR interval: if P visible, < or = to 0.12 sec
QRS duration: < 0.12 sec
Note: Ectopic complex

36. Premature Junctional Complexes (PJC)

37. Junctional Rhythm Rate: 40-60 beats/min Rhythm: regular
P waves: not present or may occur before, during or after the QRS (inverted if present)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec
Note rate and P wave direction!

38. Junctional Rhythm

39. Junctional Rhythm

40. Accelerated Junctional Rhythm
Rate: beats/min
Rhythm: regular
P waves: not present or may occur before, during or after the QRS (inverted if present; may be notched or S waved)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec

41. Accelerated Junctional Rhythm

42. Junctional Tachycardia
Rate: beats/min
Rhythm: regular
P waves: not present or may occur before, during or after the QRS (inverted if present)
PR interval: not measurable, but if present usually < or = to 0.12 sec
QRS duration: < 0.12 sec

43. Junctional Tachycardia

44. Ventricular Rhythms

45. Ventricular Rhythms Premature Ventricular Complexes (PVC's)
Idioventricular Rhythm
Ventricular Tachycardia (VT)
Torsades de Pointes (TdeP)
Ventricular Fibrillation (VF)
Asystole

46. Premature Ventricular Complexes (PVC's)
Rate: depends on underlying rhythm
Rhythm: regular with premature beats
P waves: absent
PR interval: none
QRS duration: > 0.12 sec, wide and bizarre!
Note: Ectopic complex

47. Premature Ventricular Complexes (PVC's)
Note – Complexes not Contractions

48. PVC’s Uniformed/Multiformed Couplets/Salvos/Runs
Bigeminy/Trigeminy/Quadrageminy

49. Uniformed PVC’s

50. R on T Phenomena

51. Multiformed PVC’s

52. PVC Couplets

53. PVC Salvos and Runs

54. Bigeminy PVC’s

55. Trigeminy PVC’s

56. Quadrageminy PVC’s

57. Ventricular Escape Beats
Rate: depends on underlying rhythm
Rhythm: regular with late beats; occurs after the next expected sinus beat
P waves: absent
PR interval: none
QRS duration: > 0.12 sec. wide and bizarre
Note: Ectopic complex

58. Ventricular Escape Beats

59. Idioventricular Rhythm
Rate: beats/min
Rhythm: regular
P waves: absent
PR interval: none
QRS duration: > 0.12 sec
Note: “Wide and Slow, (Oh No!) it’s Idio”

60. Idioventricular Rhythm

61. Ventricular Tachycardia (VT)
Rate: beats/min
Rhythm: regular
P waves: absent
PR interval: none
QRS duration: > 0.12 sec. often difficult to differentiate between QRS and T wave
Note: Monomorphic - same shape
and amplitude

62. Ventricular Tachycardia (VT)

63. V Tach

64. Torsades de Pointes (TdeP)
Rate: beats/min
Rhythm: regular or irregular
P waves: none
PR interval: none
QRS duration: > 0.12 sec. gradual alteration in amplitude and direction of the QRS complexes

65. Torsades de Pointes (TdeP)

66. Ventricular Fibrillation (VF)
Rate: CNO as no discernible complexes
Rhythm: rapid and chaotic
P waves: none
PR interval: none
QRS duration: none
Note: Fine vs. coarse?

67. Ventricular Fibrillation (VF)

68. Ventricular Fibrillation (VF)

69. …”Next time, try to remove his shirt!”

70. Asystole (Cardiac Standstill)
The Mother of all Bradycardias – Rob Theriault
Rate: none
Rhythm: none
P waves: none
PR interval: not measurable
QRS duration: absent

71. Asystole (Cardiac Standstill)

72. Asystole The Mother of all Bradycardias

73. QUESTIONS?

74. AtrioVentricular (AV) Blocks

75. Atrioventricular (AV) Blocks
First-degree AV block
Second-degree AV block, type I (Wenckebach or Mobitz I)
Second-degree AV block, type II (Mobitz II)
Third-degree AV block (Complete AV Block)

76. First-degree AV block
Rate: depends on underlying rhythm (usually regular)
Rhythm: regular
P waves: normal in size and shape
PR interval: > 0.20 sec but constant
QRS duration: < 0.12 sec

77. First-degree AV block

78. 2nd Degree AV block Type I (Wenckebach/Mobitz Type I)
Rate: atrial rate > ventricular rate
Rhythm: atrial reg.; ventricular irreg.
P waves: normal in size and shape
PR interval: lengthens with each cycle until a P appears with no QRS complex
QRS duration: < 0.12 sec (Periodically dropped QRS complex!)

79. 2nd Degree AV block Type I (Wenckebach/Mobitz Type I)

80. 2nd Degree AV block Type II (Mobitz Type II)
Rate: atrial rate > the ventricular rate
Rhythm: atrial reg.; ventricular irreg.
P waves: normal in size and shape
PR interval: within normal limits or slightly prolonged but constant
QRS duration: < 0.12 sec (Periodically dropped QRS complex!)

81. 2nd Degree AV block Type II (Mobitz Type II)

82. 3rd Degree AV block (Complete AV Block)
Rate: atrial rate is > ventricular rate
Rhythm: atrial reg.; ventricular reg. (P waves plot through)
P waves: normal in size and shape
PR interval: no relationship (independent)
QRS duration: narrow or wide depending on location of pacemaker

83. 3rd Degree AV block (Complete AV Block)

84. 3rd Degree AV block

85. Pacemaker Rhythms

86. Cardiac Pacemakers Definition Uses
Delivers artificial stimulus to heart
Causes depolarization and contraction
Uses
Bradyarrhythmias
Asystole
Tachyarrhythmias (overdrive pacing)

87. Cardiac Pacemakers Fixed Demand Fires at constant rate
Can discharge on T-wave
Very rare
Demand
Senses patient’s rhythm
Fires only if no activity sensed after preset interval (escape interval)

88. Cardiac Pacemakers

89. Cardiac Pacemakers Demand Pacemaker Types Atrial Ventricular
Fires atria
Atria fire ventricles
Requires intact AV conduction
Ventricular
Fires ventricles

90. Cardiac Pacemakers Demand Pacemaker Types Atrial Synchronous
Senses atria
Fires ventricles
AV Sequential
Two electrodes
Fires atria/ventricles in sequence

91. Cardiac Pacemakers Special Considerations
Pacemaker does NOT affect treatment of cardiac arrest
Do NOT defibrillate directly over pacemaker generator
Pacemakers may keep AEDs from advising shock

92. Atrial Pacemaker (Single Chamber)
Capture?

93. Ventricular Pacemaker (Single Chamber)

94. Dual Paced Rhythm
pacemaker

95. Pulseless Electrical Activity (PEA)
The absence of a detectable pulse and blood pressure
Presence of electrical activity of the heart as evidenced by ECG rhythm, but not VF or VT
= 0/0 mmHg +

97. QUESTIONS?

98. Education Subcommittee
START
QUIT
Well Done!
Education Subcommittee