1. Advanced Cardiac Life Support
ECG Interpretation
Advanced Cardiac Life Support
William A. Shapiro, M.D.
advancing health worldwide TM
Department of Anesthesia and Perioperative Care

2. Course Objectives & Description:
Recognize & initiate early management of peri-arrest conditions that may result in cardiac arrest
Manage cardiac arrest until return of spontaneous circulation, or transfer of care
Understanding of arrhythmia interpretation
Recognize the hemodynamic consequences of arrhythmias
How do you become good at running codes, saving lives, leading people?
Watching tv doctor shows?
Reading books?
Who are your role models when you watch codes?
And who are the people you do want to be like?
Reflect on each and every code, make the next one better, ask questions, and always be willing to ask for help.

3. Normal Sinus Rhythm
Normal sinus rhythm results from the initiation of an electrical signal (the cardiac impulse) by cells of the sinus node at a rate appropriate to the age and state of activity of the individual, and then the propagation of that signal in an orderly manner through the atria, A-V junction, ventricular specialized conducting system and the ventricular myocardium
There’s no number here

4. Cardiac Conduction System
Bachmann’s bundle
Sinus node
Internodal pathways
Left bundle branch
AV node
Bundle of His
Posterior division
Anterior division
Purkinje fibers
Right bundle branch

5. Arrhythmia
An arrhythmia reflects either abnormally rapid or slow impulse initiation by the sinus node, or interruption of the sinus rhythm by impulses originating from some other site in the heart, either for short or long periods of time
Define abnormal in terms of what deviates from the expected.

6. Mechanisms of Arrhythmias
Reentry
Automaticity
Altered normal automaticity
Abnormal automaticity
Triggered Rhythms due to DAD (delayed after depolarizations
At the bedside, watching a patient die is not the time to ponder the latest theories in the mechanisms of arrhythmia. This is the time to do the best you can do to restore cardiac rhythm and save a life.

7. Causes of Arrhythmias Physiologic and Pathologic Processes
Vagal stimulation, Fever, Hypothermia
Electrolyte abnormalities, CNS problems
Hypovolemia, Pain, anaphylaxis, etc.
Preexisting Cardiac & Pulmonary Disease
Acute coronary syndrome, HTN, AODM
COPD, hypoxia, hypercarbia
These are the things to think about. What’s going on with this patient, at this time, right now.

8. The Electrocardiogram

9. The ElectrocardiogramP T U Q S PR
Interval
QRS
Interval

10. The Electrocardiogram
PR Interval
QRS Interval
QT Interval

11. Cardiac Conduction System
Relationship of ECG to anatomy

12. Cardiac Conduction System
Relationship of ECG to anatomy

13. ACLS IN THE ACLS PROVIDER IS:
Today, we have time to reflect on some of the ecg rhythms for the scenarios you are learning. We’re all in this together. Our little helpers. If they don’t know an answer, come to me. If I don’t know, I go to the EP people. They always know. IN

14. Normal Sinus Rhythm Rate 60-100 beats per minute Rhythm: Regular
P waves: Upright in Leads: 1, 2, AVF

15. Determining the Rate
ECG paper has 3/6 second marks. Also, the machine reads the rate. The real problem is with unstable, or irregular rhythms. For those, count the number of beats in a minute.

16. Determining the Rate

17. Determining the Rhythm

18. Sinus Tachycardia Rate: Greater than 100 beats per minute
Rhythm: Regular
P waves: Upright in Leads: 1, 2, AVF

19. Sinus Tachycardia Rate: Greater than 100 beats per minute
Rhythm: Regular
P waves: Upright in Leads: 1, 2, AVF

20. Sinus Bradycardia Rate: Less than 60 beats per minute Rhythm: Regular
P waves: Upright in Leads: 1, 2, AVF

21. Sinus Bradycardia Rate: Less than 60 beats per minute Rhythm: Regular
P waves: Upright in Leads: 1, 2, AVF

22. Premature Atrial Complexes
P wave Rhythm: Irregular
P waves: Premature, often in the T-wave
QRS complex: Normal or widened
P-wave

23. Premature Atrial Complexes
P wave Rhythm: Irregular
P waves: Premature, often in the T-wave
QRS complex: Normal or widened

24. Premature Atrial Complexes
P wave Rhythm: Irregular
P waves: Premature, often in the T-wave
QRS complex: (Normal or widened) or blocked
Non conducted
P-wave

25. Atrial Tachycardia Rate: Atrial- 140-240 bpm, p-waves hard to see
Rhythm:
P-wave- regular
QRS- 1-1 conduction with atrial rates < 200 bpm
With atrial rates > 200 bpm, A-V conduction block common (less than 1-1 conduction)
PR interval- depends on the origin of the p-wave
QRS- usually normal

26. Atrial Tachycardia
P-Wave
P-Wave

27. Atrial Tachycardia Atrial Tachycardia with variable block
P-Waves are regular at 160 bpm

28. Atrial Flutter Rate: Atrial- 300 bpm (260-320) Rhythm:
P-waves- regular
QRS- 2-1 conduction bpm, variable AV conduction with constant AV conduction ratio
P-waves: F-waves (Flutter), sawtooth pattern
QRS- usually normal, obviously sometimes wide

29. Atrial Flutter
F-waves

30. Atrial Flutter with variable conduction (block)

31. Atrial Fibrillation Rate: Atrial- rapid, Ventricular- Depends Rhythm:
P-waves- irregular
QRS- beat to beat variability, Irregularly irregular
P-waves: From F-waves (Flutter) to absent
QRS duration- normal or wide

32. Atrial Fibrillation

33. Atrial Fibrillation

34. Atrial Fibrillation

35. Premature Junctional Complexes
Rhythm: Irregular
P waves: Retrograde
PR interval: < .12 sec or nonexistent
QRS complex: Normal or widened

36. Premature Ventricular Complexes
Rhythm: Irregular
P waves: Usually not seen
QRS complex: Wide > .12 sec
Compensatory pause

37. Premature Ventricular Complexes
Compensatory pause
This distance is double the sinus distance
This is the sinus and the QRS distance
Resetting versus non resetting of the sinus node.

38. Premature Ventricular Complexes
Unifocal PVCs
Multifocal PVCs

39. Premature Ventricular Complexes
Compensatory pause
This distance is double the sinus distance
This is the sinus and the QRS distance
Interpolated PVC

40. Premature Ventricular Complexes
Ventricular Bigeminy
Pairs of PVCs

41. Premature Ventricular Complexes
PVC on T-wave precipitating Ventricular Tachycardia

42. Ventricular Tachycardia
Rate: Approx bpm
Rhythm: Usually regular
P waves: Usually not seen
Independent A and V activity
A-V dissociation
QRS complex: Wide > .12 sec
Capture beats, fusion beats

43. Ventricular Tachycardia

44. Ventricular Tachycardia
Polymorphic Ventricular Tachycardia

45. Ventricular Fibrillation
Rate: Rapid- no effective cardiac rhythm
Rhythm: Irregular
P, QRS, T- waves: Absent
No blood pressure!

46. Ventricular Fibrillation
Course VF
Fine VF

47. Ventricular Fibrillation

48. Ventricular Asystole
P, QRS, T- waves: Complete absent of cardiac electrical activity
Complete absent of effective cardiac pumping function

49. Acute Coronary Syndromes

50. Acute Coronary Syndromes

51. Acute Coronary Syndromes

52. Review

53. Review
Atrial Fibrillation

54. Review
Atrial Fibrillation
Sinus Rhythm

55. Acute Coronary Syndrome
Review
Atrial Fibrillation
Sinus Rhythm
Acute Coronary Syndrome

56. Review

57. Review
Asystole

58. Fine Ventricular Fibrillation
Review
Asystole
Fine Ventricular Fibrillation

59. Review Asystole Fine Ventricular Fibrillation
Coarse Ventricular Fibrillation

60. Review

61. Ventricular Tachycardia- ?
Review
Ventricular Tachycardia- ?

62. Review
Ventricular Tachycardia- ?
Premature Ventricular Complex (PVC)

63. Review Ventricular Tachycardia- ? Premature Ventricular Complex (PVC)

64. Review

65. Ventricular Tachycardia
Review
Ventricular Tachycardia

66. Review
Ventricular Tachycardia
Ventricular Tachycardia

67. Review Ventricular Tachycardia Ventricular Tachycardia
(Paroxsymal) Atrial Tachycardia (SVT)

68. Review

69. Paroxsymal Atrial Tachycardia (SVT)
Review
Paroxsymal Atrial Tachycardia (SVT)

70. Paroxsymal Atrial Tachycardia (SVT)
Review
Paroxsymal Atrial Tachycardia (SVT)
Atrial Flutter

71. Treatment of All Cardiac Arrhythmias
All arrhythmias that are hemodynamically significant require immediate cardioversion, defibrillation, or cardiac pacing

72. Break Time

73. AV Block Why is it important? Where is the block?
What’s a pacemaker anyway?

74. Rates of Intrinsic Cardiac Pacemakers
Primary pacemaker
Sinus node ( bpm)
Escape pacemakers
AV junction (40-60 bpm)
Ventricular (< 40 bpm)

75. Escape Patterns

76. Junctional Escape Complexes
Rate: Junctional escape rate bpm
Rhythm: Junctional
P-waves: Retrograde, inverted in 2,3, avf
Before, during, or after QRS
QRS: Normal or wide

77. Junctional Escape Complexes

78. Junctional Escape Complexes
Junctional Rhythm

79. Ventricular Escape Complexes

80. Classification of AV Block
Partial
First-degree AV block
Second-degree AV block, Types I (Wenckebach) and Type II
Complete AV block
Third-degree AV Block
“You should know the major AV blocks because important treatment decisions are based on the type of block present.” Page 79

81. First-Degree AV Block Rhythm: Regular
1:1 Conduction: Each P-wave is followed by a QRS complex
PR Interval: > .20 secs
QRS Complex: Generally normal
Hemodynamic implications: None

82. First-Degree AV Block

83. Second-Degree AV Block, Type I
Rate:
Atrial- regular
Ventricular- less than the atrial rate
Rhythm:
Ventricular- progressive shortening of the R-R interval before pause
PR: progressive increase until P blocked
Why is knowing this important

84. Second-Degree AV Block, Type I

85. Second-Degree AV Block, Type II
Rate:
Atrial- regular
Ventricular- less than the atrial rate
Rhythm:
Ventricular- usually irregular
PR: constant when present
Why is knowing this important

86. Second-Degree AV Block, Type II

87. Third-Degree AV Block Rate: Atrial- regular
Ventricular- less than the atrial rate
Rhythm:
Ventricular- regular
PR: varies with every beat
QRS: normal or wide
Hemodynamics: No atrial contribution

88. Third-Degree AV Block

89. Third-Degree AV Block

90. Electrical Therapy
All arrhythmias that are hemodynamically significant require immediate cardioversion, defibrillation, or cardiac pacing

91. Electrical Therapy
Understand when cardioversion or defibrillation is indicated
Know the difference between unsynchronized and synchronized shocks
Energy doses for specific rhythms
Challenges of delivering shocks safely and effectively- may include iv sedation

92. Cardioversion and Defibrillation
Understand when cardioversion or defibrillation is indicated
SYMPTOMS
SYMPTOMS
SYMPTOMS

93. Hemodynamically Significant
Tachycardia or Bradycardia
Hypotension (Systolic BP < 80 mmHg)
Altered mental status
Congestive heart failure
Angina
Does not respond promptly to medical management, if tried

94. Cardioversion and Defibrillation
The electric shock depolarizes all excitable myocardium, interrupts reentrant circuits, discharges foci, and establishes electrical homogeneity

95. Cardioversion and Defibrillation
AED: Learn the one in your setting
Biphasic: 200 watt-seconds (joules)
Monophasic: 360 watt-seconds (joules)
“The interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest.” Page 35

96. Cardioversion and Defibrillation

97. Cardioversion and Defibrillation
Procedure for Defibrillation
Power on
Apply pads
Analyze the rhythm
Select the energy level
Clear the area
Discharge the device

98. Cardioversion and Defibrillation
Know when cardioversion is indicated
Synchronized vs unsynchronized shock
What energy level for what arrhythmias
Establish iv and consider sedation

99. Cardioversion and Defibrillation
Anesthetic (amnestic) Agents
A physician skilled in airway management (ie., an anesthesiologist) should be in attendance, and all necessary equipment for emergency resuscitation should be immediately available

100. Cardioversion and Defibrillation
The electric shock depolarizes all excitable myocardium, interrupts reentrant circuits, discharges foci, and establishes electrical homogeneity

101. Cardioversion and Defibrillation
Synchronization
Synchronized cardioversion (defibrillation) uses a sensor to deliver the shock with the peak of the QRS complex. The goal is to avoid the shock on the T-wave, “R-on-T”, which is known to induce ventricular fibrillation in unstable hearts

102. The Electrocardiogram
PR Interval
QRS Interval
QT Interval

103. Cardioversion and Defibrillation
Synchronization
Energy Selection
Atrial flutter & SVT: J (monphasic)
Atrial fibrillation: J (monophasic)
Ventricular tachycardia: J

104. Cardioversion and Defibrillation
Procedure for Cardioversion
Power on
Apply pads
Turn on the SYNC control
Analyze the rhythm
Select the energy level
Clear the area
Discharge the device

105. Cardioversion and Defibrillation
Complications of Cardioversion
Ventricular fibrillation occurs
Turn off the SYNC control
Charge to 200 J (or more)
Clear the area
Discharge the device

106. Review

107. Review
3rd Degree Heart Block

108. Review
3rd Degree Heart Block
2nd Degree Type II Block

109. Review 3rd Degree Heart Block 2nd Degree Type II Block
2nd Degree Type I Block

110. Review

111. Review
1st Degree Heart Block

112. Junctional Escape Rhythm
Review
1st Degree Heart Block
Junctional Escape Rhythm

113. Review 1st Degree Heart Block Junctional Escape Rhythm
Sinus Bradycardia

114. Ventricular Tachycardia- ?
Review
Ventricular Tachycardia- ?

116. Advanced Cardiac Life Support
ECG Interpretation
Advanced Cardiac Life Support
That’s it- Now go forth and save lives- Make us all proud you’re from UCSF
William A. Shapiro, M.D.
advancing health worldwide TM
Department of Anesthesia and Perioperative Care