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ECG Arrhythmia Dr. K. P. Misra Sr. Consultant Cardiologist
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Analyzing Arrhythmias :
Two Cardinal Rules For Analyzing Arrhythmias : Study the ventricular (QRS)) complex Look for the P waves (“cherchez le P”)
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If the ventricular complex is normal :
you know that the arrhythmia is supraventricular : i.e., either atrial or A – V nodal If the ventricular complex is abnormal and widened : you know that the arrhythmia is either ventricular or supraventricular with ventricular aberration (abnormal conduction through ventricles)
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Overview Electrical activity of the heart The electrocardiogram
Monitoring sytems Recognition of dysrhythmia in ACLS
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Location for chest electrodes Lead 1
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Location for chest electrodes Lead 2
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Location for chest electrodes Lead 3
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Normal Sinus Rhythm Rate : 60 to 100 / min Rhythm : regular
P waves : upright in I, II, aVF Therapy : none
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Normal Sinus Rhythm Lead 2
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Sinus Tachycardia Rate : greater than 100/min Rhythm : regular
P waves : upright in I, II, aVF Treat underlying cause
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Sinus Tachycardia Lead 2
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Sinus Bradycardia Rate : Less than 60 / min Rhythm : Regular
P waves : Upright in I, II, aVF Therapy : Usually only when hypotension or ventricular ectopic beats present Atropine drug of choice pacemaker may be necessary
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Sinus Bradycardia Lead V1
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(normal P wave preceding every QRS)
SINUS RHYTHMS (normal P wave preceding every QRS) SINUS ARRHYTHMIA – NOTE IRREGULARITY SINUS TACHYCARDIA - RATE 130 SINUS BRADYCARDIA - RATE 42
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Premature Atrial Complexes
Rhythm : irregular P waves : premature coupling interval noncompensatory pause PR : normal prolonged blocked QRS : normal widened (aberrant)
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Premature Atrial Complexes
Therapy : none if infrequent treat underlying cause specific drug therapy - Quindine Procainamide Propranolol Digoxin
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Premature Atrial Complexes
MCL1
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Atrial Premature Beat Run of premature P waves
(each followed by normal ventricular complex) = ATRIAL TACHYCARDIA
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Atrial Tachycardia with 2 to 1 A – V Block
Two P waves for every QRS - only every alternate impulse is conducted to ventricles.
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Atrial Tachycardia Rate : atrial rate Rhythm : atrial - regular
ventricular – usually regular with 1 to 1 conduction when atrial rate is less than 200 / min when atrial rate is more than 200 / min., AV block and variable AV conduction may occur P waves : often difficult to identify PR : normal or prolonged QRS : normal or widened (aberrant)
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Atrial Tachycardia Therapy : Paroxysmal atrial tachycardia
Parasympathetic maneuvers - Vagal stimulation – carotoid sinus message valsalva, vomiting Alpha receptor stimulation - Phenylephrine Cholinergic agent - edrophonium Synchronized DC Countershock Beta receptor blockage - Propranolol Other antidysrhythmic agents - Procainamide Lidocaine Digitalization Sedation Atrial Tachycardia
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Atrial Tachycardia Therapy : Nonparoxysmal atrial tachycardia
- treat underlying cause potential danger of digitalis intoxication
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Atrial Tachycardia Lead 2
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Atrial Flutter Rate : Atrial rate 300 / min (220 – 350)
Rhythm : Atrial - regular ventricular – regular with constant AV conduction ratio Irregular with variable AV conduction P waves : F waves resemble “sawtooth” or “picket fence” PR : Usually regular but may vary QRS : usually normal aberrancy may occur
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Atrial Flutter Therapy : Synchronized DC countershock digitalization
propranolol quinidine, procainamide overdrive pacing
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Atrial Flutter “Sawtooth” atrial flutter (“FF”) waves in regular relationship to QRS. 4 “F” waves to each QRS = 4 to 1A-V conduction.
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Atrial Flutter Lead 2
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Atrial Fibrillation Therapy : Digitalization synchronized DC
countershock quinidine, procainamide propranolol
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Atrial Fibrillation with
rapid ventricular response Lead 2
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Mitral stenosis and regurgitation in atrial fibrillation
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Premature junctional complexes
Rhythm : irregular P waves : retrograde inverted in II, III, aVF before, during, or after QRS compensatory or noncompensatory pause PR : with P before QRS usually less than sec. prolonged blocked QRS : normal widened (aberrant) Therapy : same as PACs
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Premature junctional complexes
Lead 2
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Junctional escape complexes and rhythm
Rate : junctional escape rhythm – 40 to 60/min Rhythm : junctional escape complexes – irregular junctional escape rhythm – regular P waves : retrograde inverted in II, III, aVF before, during, or after QRS compensatory or atrioventricular dissociation PR : variable QRS : normal widened (aberrant) Therapy : hemodynamically stable - none atropine isoproterenol pacemaker
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Junctional escape complexes
Lead 2
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Two examples of A-V nodal rhythm
Abnormal P wave () either shortly before or after QRS
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3 more examples of Ventricular Tachycardia
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VIP death
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Interesting Arrhythmias Some Examples
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The end
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