Chapter 4 Dysrhythmia Recognition

Prof. Angel Torres NAEMT-P, FP, ASHI Instructor Advanced Training Center (787) 645-8329

Location of MI
Location of MI Affected Coronary Artery

Lateral
Inferior Septum

Left circumflex artery

Right coronary artery Left anterior descending artery

Anterior
Posterior

Left anterior descending artery

Right coronary artery or left circumflex artery

Right ventricle

Right coronary artery

Basic Electrophysiology

Types of Cardiac Cells

Myocardial cells
Working or mechanical cells Contain contractile filaments Pacemaker cells Specialized cells of the electrical conduction system Responsible for the spontaneous generation and conduction of electrical impulses

Cardiac Action Potential

Cell membranes contain membrane channels (pores)
Specific ions or other small, water-soluble molecules can cross the cell membrane from outside to inside through these channels

Polarization
Also called resting membrane potential
Resting state during which no electrical activity occurs Inside of cell is more negative than outside

Polarization

Depolarization = Stimulation
On the ECG:
P wave represents atrial depolarization QRS complex represents ventricular depolarization

Depolarization = Stimulation

Depolarization
Depolarization is not the same as contraction
Depolarization = Electrical event Expected to result in contraction Contraction = Mechanical event Pulseless electrical activity (PEA)

Repolarization = Recovery
Return to resting state
On the ECG: ST segment represents early ventricular repolarization T wave presents ventricular repolarization

Repolarization = Recovery

Refractory Periods

Refractory Periods
Refractoriness
The extent to which a cell is able to respond to a stimulus

Refractory Periods
Absolute refractory period
Onset of QRS complex to approximately peak of T wave Cardiac cells cannot be stimulated to conduct an electrical impulse, no matter how strong the stimulus

Refractory Periods
Relative refractory period
Corresponds with the downslope of the T wave Cardiac cells can be stimulated to depolarize if the stimulus is strong enough

Supernormal period
Corresponds with the end of the T wave A weaker than normal stimulus can cause depolarization of cardiac cells

Properties of Cardiac Cells

Automaticity
Excitability Conductivity Contractility

The Conduction System

Sinoatrial (SA) node
AV junction Bundle of His Right and left bundle branches

Purkinje fibers

The Electrocardiogram (ECG)

Records electrical voltages (potentials) generated by depolarization of heart muscle
Can provide information about: The orientation of the heart in the chest Conduction disturbances The electrical effects of medications and electrolytes The mass of cardiac muscle

The presence of ischemic damage

ECG
The ECG does not provide information about the mechanical (contractile) condition of the myocardium
Evaluated by assessment of pulse and blood pressure

Electrodes
Applied at specific locations on the patient's chest wall and extremities
Used to view the hearts electrical activity from different angles and planes

One end of a monitoring cable is attached to the electrode and the other end to an ECG machine

Leads
A lead is a record of electrical activity between two electrodes.

Types of Leads
There are three types of leads
Standard limb leads Augmented leads Precordial (chest) leads

Standard Limb Leads

Lead
Lead I

Positive Electrode
Left arm

Negative Electrode
Right arm

Heart Surface Viewed

Lateral

Lead II

Left leg

Right arm

Inferior

Lead III

Left leg

Left arm

Inferior

Augmented Limb Leads

Lead
Lead aVR Lead aVL Lead aVF

Positive Electrode
Right arm Left arm Left leg

Heart Surface Viewed

None Lateral Inferior

Augmented Limb Leads

Precordial Leads
Lead Lead V1
Lead V2 Lead V3 Lead V4 Lead V5 Lead V6

Positive Electrode Position Right side of sternum, 4th intercostal space Left side of sternum, 4th intercostal space Midway between V2 and V4
Left midclavicular line, 5th intercostal space Left anterior axillary line at same level as V4 Left midaxillary line at same level as V4

Heart Surface Viewed Septum

Septum Anterior Anterior Lateral Lateral

Left and Right Precordial Leads

ECG Paper
ECG paper is graph paper made up of small and larger, heavy-lined squares
Horizontal axis = Time Vertical axis = Voltage/amplitude

Waveforms
A waveform or deflection is movement away from the baseline in either a positive (upward) or negative (downward) direction.
A waveform that is partly positive and partly negative is biphasic. A waveform or deflection that rests on the baseline is isoelectric.

P Wave
The first wave in the cardiac cycle
Represents atrial depolarization and spread of the electrical impulse throughout the right and left atria

Terminology
Segment - A line between waveforms
Interval - A waveform and a segment Complex - Several waveforms

PR Segment & PR Interval

PR segment
Part of the PR interval The horizontal line between the end of the P wave and the beginning of the QRS complex PR interval = P wave plus PR segment Normally measures 0.12 to 0.20 sec

QRS Complex
Represents the spread of the electrical impulse through the ventricles (ventricular depolarization)
In adults, normally measures between 0.06 and 0.10 second

ST Segment
The portion of the ECG tracing between the QRS complex and T wave
Represents the early part of repolarization of the right and left ventricles The point where the QRS complex and ST segment meet = J point or junction

ST Segment
The PR segment used as a baseline from which to evaluate the degree of displacement of the ST segment from the isoelectric line (elevation or depression)

ST Segment
ST segment is considered:
Elevated if the segment is deviated above the baseline of the PR segment Depressed if the segment deviates below it

T Wave
Represents ventricular repolarization
May be difficult to clearly determine the onset and end of the T wave

QT Interval
Represents total ventricular activity - the time from ventricular depolarization (activation) to repolarization (recovery) The duration of the QT interval varies according to age, gender, and heart rate

QT Interval - Measurement
Measure the R to R interval
Divide the number by two Now measure the QT interval If the measured QT interval is less than half the R-R interval, it is probably normal

Rate Measurement

6-Second Method
Count the number of complete QRS complexes within a period of 6 seconds
Multiply that number by 10

Large Boxes
Ventricular rate
Count the number of large boxes between two consecutive R waves (R-R interval) and divide into 300

Small Boxes
Ventricular rate
Count number of small boxes between two consecutive R waves and divide into 1500 Time consuming but accurate

Sequence Method
Select an R wave that falls on a dark vertical line
Number the next 6 consecutive dark vertical lines as follows: 300, 150, 100, 75, 60, and 50 Note where the next R wave falls in relation to the 6 dark vertical lines already marked

Rhythm/Regularity
When analyzing a rhythm strip, determine:
Atrial (P-P intervals) rhythm Ventricular (R-R intervals) rhythm If rhythm is regular, R-R intervals (or P-P intervals if assessing atrial rhythm) are same Plus or minus 10% acceptable

Analyzing a Rhythm Strip

Assess the rate
Assess rhythm/regularity Identify and examine P waves Assess intervals (evaluate conduction) PR interval, QRS duration, QT interval Evaluate overall appearance of the rhythm ST segment elevation/depression T wave inversion Interpret rhythm and evaluate clinical significance

Sinus Rhythm
Rate Rhythm P waves PR interval QRS 60-100 beats/min Regular Uniform in appearance, positive (upright) in lead II, one precedes each QRS complex 0.12-0.20 second and constant from beat to beat 0.10 second or less

Sinus Rhythm

Sinus Bradycardia
Rate Rhythm P waves PR interval QRS Less than 60 beats/min Regular Uniform in appearance, positive (upright) in lead II, one precedes each QRS complex 0.12-0.20 second and constant from beat to beat 0.10 second or less

Sinus Bradycardia

Sinus Tachycardia
Rate Rhythm P waves 101 - 180 beats/min Regular Uniform in appearance, positive (upright) in lead II, one precedes each QRS complex; at very fast rates it may be difficult to distinguish a P wave from a T wave 0.12-0.20 second and constant from beat to beat 0.10 second or less

PR interval QRS

Sinus Tachycardia

Sinus Arrhythmia
Rate Rhythm Usually 60-100 beats/min, but may be slower or faster Irregular, phasic with respiration; heart rate increases gradually during inspiration (R-R intervals shorten) and decreases with expiration (R-R intervals lengthen) Uniform in appearance, positive (upright) in lead II, one precedes each QRS complex 0.12-0.20 second and constant from beat to beat 0.10 second or less

P waves PR interval QRS

Sinus Arrhythmia

Sinoatrial (SA) Block

Rate Rhythm Usually normal but varies because of the pause Irregular due to the pause(s) caused by the SA block the pause is the same as (or an exact multiple of) the distance between two other P-P intervals Uniform in appearance, positive (upright) in lead II. When present, one precedes each QRS complex. 0.12-0.20 second and constant from beat to beat 0.10 second or less

P waves PR interval QRS

Sinoatrial (SA) Block

Sinus Arrest
Rate Rhythm Usually normal but varies because of the pause Irregular the pause is of undetermined length (more than one PQRST complex is omitted) and is not the same distance as other P-P intervals Uniform in appearance, positive (upright) in lead II. When present, one precedes each QRS complex. 0.12-0.20 second and constant from beat to beat 0.10 second or less

P waves
PR interval QRS

Sinus Arrest

Premature Atrial Complexes

Rate Usually within normal range, but depends on underlying rhythm

Rhythm
P waves

Regular with premature beats

Premature (occurring earlier than the next expected sinus P wave), positive (upright) in lead II, one precedes each QRS complex, often differ in shape from sinus P waves may be flattened, notched, pointed, biphasic, or lost in the preceding T wave May be normal or prolonged depending on the prematurity of the beat Usually less than 0.10 second but may be wide (aberrant) or absent, depending on the prematurity of the beat. The QRS of the PAC is similar in shape to those of the underlying rhythm unless the PAC is abnormally conducted.

PR interval QRS

Premature Atrial Complexes (PACs)

Wandering Atrial Pacemaker

Rate Usually 60-100 beats/min, but may be slow. If the rate is greater than 100 beats/min, the rhythm is termed multifocal (or chaotic) atrial tachycardia. May be irregular as the pacemaker site shifts from the SA node to ectopic atrial locations and the AV junction Size, shape, and direction may change from beat to beat. At least three different P wave configurations are required for a diagnosis of wandering atrial pacemaker or multifocal atrial tachycardia. Variable Usually less than 0.10 second unless an intraventricular conduction defect exists

Rhythm P Waves

PRI QRS

Wandering Atrial Pacemaker (Multiformed Atrial Rhythm)

Multifocal Atrial Tachycardia

Supraventricular Tachycardia
The term supraventricular tachycardia (SVT) may be used in two ways:
It describes all tachydysrhythmias that originate above the bifurcation of the bundle of His Thus, supraventricular tachycardias include: Sinus tachycardia Atrial tachycardia Atrial flutter

Atrial fibrillation
Junctional tachycardia

Supraventricular Tachycardia
SVT refers to a dysrhythmia with a rapid ventricular rate (tachycardia) and a narrow-QRS complex, but whose specific origin (atrial or junctional) is uncertain

Paroxysmal Supraventricular Tachycardia (PSVT)

Paroxysmal supraventricular tachycardia is a term used to describe SVT that starts and ends suddenly

Atrial Tachycardia
Atrial tachycardia is 3 or more sequential PACs occurring at a rate of more than 100 per minute
Atrial tachycardia that starts or ends suddenly is called paroxysmal atrial tachycardia (PAT)

Atrial Tachycardia
Rate Rhythm P Waves 150 to 250 beats/minute Regular One positive P wave precedes each QRS complex in lead II but the P waves differ in shape from sinus P waves. With rapid rates, it is difficult to distinguish P waves from T waves. May be shorter or longer than normal and may be difficult to measure because P waves may be hidden in T waves 0.10 second or less unless intraventricular conduction delay present

PR Interval

QRS

Atrial Tachycardia

AV Nodal Reentrant Tachycardia (AVNRT)

Two conduction pathways within AV node
Fast pathway Conducts impulses rapidly Long refractory period (slow recovery time) Slow pathway Conducts impulses slowly Short refractory period (fast recovery time)

AV Nodal Reentrant Tachycardia (AVNRT)

AV Reentrant Tachycardia (AVRT)

Preexcitation
Term used to describe rhythms that originate from above the ventricles but in which the impulse travels via a pathway other than the AV node and bundle of His

The supraventricular impulse excites the ventricles earlier than normal

Patients with preexcitation syndromes are prone to AVRT

Preexcitation Syndrome
Three major forms of preexcitation syndrome
Wolff-Parkinson White (WPW) syndrome Lown-Ganong-Levine (LGL) syndrome Unnamed syndrome involving Mahaim fibers

Wolff-Parkinson-White Syndrome (WPW)

Rate Rhythm P Waves PRI Usually 60-100 beats/min, if the underlying rhythm is sinus in origin Regular, unless associated with atrial fibrillation Normal and positive in lead II unless WPW is associated with atrial fibrillation If P waves are observed, less than 0.12 second

QRS

Usually greater than 0.12 second. Slurred upstroke of QRS complex (delta wave) may be seen in one or more leads.

Wolff-Parkinson-White Syndrome (WPW)

Note short PR interval, delta wave, wide QRS complex, and secondary ST and T wave changes

Atrial Flutter
Atrial flutter is an ectopic atrial rhythm in which an irritable site depolarizes regularly at an extremely rapid rate

Atrial Flutter - Types

Type I atrial flutter
Also called typical or classical atrial flutter Due to a reentrant circuit localized in right atrium Atrial rate ranges from 250 to 350 beats/min Type II atrial flutter Also called atypical or very rapid atrial flutter Precise mechanism has not been defined Atrial rate ranges from 350 to 450 beats/min

Atrial Flutter ECG Characteristics

Rate Atrial rate 250-450 beats/min, typically 300 beats/min; ventricular rate variable determined by AV blockade. The ventricular rate will usually not exceed 180 beats per minute due to the intrinsic conduction rate of the AV junction. Atrial regular, ventricular regular or irregular depending on AV conduction/blockade No identifiable P waves; saw-toothed flutter waves are present Not measurable Usually less than 0.10 second but may be widened if flutter waves are buried in QRS complex or an intraventricular conduction delay exists.

Rhythm P Waves PRI QRS

Atrial Flutter ECG Characteristics

Atrial Fibrillation
Occurs because of multiple reentry circuits in the atria
Atria are depolarized at a rate of 400 to 600 beats/min Cause the muscles of the atria to quiver (fibrillate) Results in: Ineffectual atrial contraction Subsequent decrease in cardiac output Loss of atrial kick

Atrial Fibrillation ECG Characteristics

Rate
Rhythm P Waves PRI QRS Duration

Atrial rate usually greater than 400-600 beats/min; ventricular rate variable
Ventricular rhythm usually irregularly irregular No identifiable P waves; fibrillatory waves present. Erratic, wavy baseline. Not measurable Usually less than 0.10 second but may be widened if an intraventricular conduction delay exists

Premature Junctional Complexes (PJCs)

A PJC arises from an ectopic focus within the AV junction that discharges before the next expected sinus beat
A P wave may or may not be present with a PJC If a P wave is present, it is inverted (retrograde) and may precede or follow the QRS QRS will usually measure 0.10 second or less

PJCs ECG Characteristics

Rate Rhythm P Waves PR Interval Usually within normal range, but depends on underlying rhythm Regular with premature beats May occur before, during, or after the QRS. If visible, the P wave is inverted in leads II, III, and aVF. If a P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless intraventricular conduction delay exists

QRS Duration

PJCs ECG Characteristics

Junctional Escape Beats

Rate Rhythm P waves Usually within normal range, but depends on underlying rhythm Regular with LATE beats May occur before, during, or after the QRS. If visible, the P wave is inverted in leads II, III, and aVF If a P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval.

PRI

QRS

Usually 0.10 second or less unless an intraventricular conduction delay exists.

Junctional Escape Beat

Junctional Escape Rhythm

Rate
Rhythm P waves PR interval

40 to 60 beats/minute
Very regular May occur before, during, or after the QRS. If visible, the P wave is inverted in leads II, III, and aVF If a P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval.

QRS duration

Usually 0.10 second or less unless an intraventricular conduction delay exists.

Junctional Escape Rhythm

Accelerated Junctional Rhythm

Rate Rhythm
P waves PR interval

60 to 100 beats/minute Very regular

May occur before, during, or after the QRS. If visible, the P wave is inverted in leads II, III, and aVF If a P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PRI. Usually 0.10 second or less unless an intraventricular conduction delay exists.

QRS duration

Accelerated Junctional Rhythm

Junctional Tachycardia
Rate Rhythm P waves PR interval 101-180 beats/minute Very regular May occur before, during, or after the QRS. If visible, the P wave is inverted in leads II, III, and aVF If a P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 second. If no P wave occurs before the QRS, there will be no PR interval. Usually 0.10 second or less unless an intraventricular conduction delay exists.

QRS duration

Junctional Tachycardia

Premature Ventricular Complexes

Rate Rhythm Usually within normal range, but depends on underlying rhythm Essentially regular with premature beats. If the PVC is an interpolated PVC, the rhythm will be regular. Usually absent or, with retrograde conduction to the atria, may appear after the QRS (usually upright in the ST segment or T wave) None with PVC because the ectopic originates in ventricles Greater than 0.12 second, wide and bizarre, T wave frequently in opposite direction of the QRS complex

P waves

PR interval QRS duration

Uniform PVCs

Multiform PVCs

R-on-T PVCs

Paired PVCs

Ventricular Escape Beat

A ventricular ectopic beat that occurs after a pause in which the supraventricular pacemakers failed to initiate an impulse
QRS measures 0.12 second or greater Occur LATE in the cardiac cycle, appearing after the next expected sinus beat

Ventricular Escape Beat

Rate Rhythm Usually within normal range, but depends on underlying rhythm Essentially regular with late beats. The ventricular escape beat occurs after the next expected sinus beat. Usually absent or, with retrograde conduction to the atria, may appear after the QRS (usually upright in the ST segment or T wave) None with the ventricular escape beat because the ectopic beat originates in the ventricles

P waves

PR interval

QRS duration

Greater than 0.12 second, wide and bizarre, T wave frequently in opposite direction of the QRS complex

Ventricular Escape Beat

Ventricular Escape (Idioventricular) Rhythm

Rate Rhythm P waves 20 to 40 beats/minute Essentially regular Usually absent or, with retrograde conduction to the atria, may appear after the QRS (usually upright in the ST segment or T wave) None Greater than 0.12 second, T wave frequently in opposite direction of the QRS complex

PR interval QRS duration

Ventricular Escape (Idioventricular) Rhythm

Accelerated Idioventricular Rhythm (AIVR)

Rate Rhythm P waves 41 to 100 beats/minute Essentially regular Usually absent or, with retrograde conduction to the atria, may appear after the QRS (usually upright in the ST segment or T wave) None Greater than 0.12 second, T wave frequently in opposite direction of the QRS complex

PR interval QRS duration

Accelerated Idioventricular Rhythm (AIVR)

Ventricular Tachycardia (VT)

Rate Rhythm P waves 101-250 beats/minute Essentially regular May be present or absent. If present, they have no set relationship to the QRS complexes appearing between the QRSs at a rate different from that of the VT. None Greater than 0.12 second; often difficult to differentiate between the QRS and T wave

PR interval QRS duration

Monomorphic Ventricular Tachycardia

Polymorphic VT
Rate Rhythm P waves PRI QRS 150 to 300 beats/min, typically 200-250 beats/min May be regular or irregular None None Greater than 0.12 second; gradual alteration in amplitude and direction of the QRS complexes

Torsades de Pointes (TdP)

Ventricular Fibrillation (VF)

Rate Rhythm P waves Cannot be determined because there are no discernible waves or complexes to measure Rapid and chaotic with no pattern or regularity Not discernible

PR
QRS

Not discernible
Not discernible

Ventricular Fibrillation (VF)

Asystole
Rate Ventricular usually not discernible but atrial activity may be observed (P-wave asystole)

Rhythm P waves PRI QRS

Ventricular not discernible, atrial may be discernible Usually not discernible Not measurable Absent

P-wave Asystole

Pulseless Electrical Activity

PEA Causes (PATCH-4-MD)

Pulmonary embolism Acidosis Tension pneumothorax Cardiac tamponade

Hypovolemia (most common cause)

Hypoxia Heat / cold (hypo-/hyperthermia) Hypo-/hyperkalemia (and other electrolytes) Myocardial infarction Drug overdose / accidents (cyclic antidepressants, calcium channel blockers, beta-blockers, digoxin)

First-Degree AV Block
Rate
Rhythm P waves

Usually within normal range, but depends on underlying rhythm Regular

Normal in size and shape, one positive (upright) P wave before each QRS in leads II, III, and aVF

PR interval
QRS duration

Prolonged (greater than 0.20 second) but constant

Usually 0.10 sec or less unless an intraventricular conduction delay exists

Second-Degree AV Block, Type I

Rate
Rhythm P waves

Atrial rate is greater than the ventricular rate

Atrial regular (Ps plot through); ventricular irregular Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs). Lengthens with each cycle (although lengthening may be very slight), until a P wave appears without a QRS complex. The PRI after the nonconducted beat is shorter than the interval preceding the nonconducted beat. Usually 0.10 second or less but is periodically dropped

PR interval

QRS

Second-Degree AV Block, Type I

Second-Degree AV Block, Type II

Rate Rhythm P waves Atrial rate is greater than the ventricular rate. Ventricular rate is often slow. Atrial regular (Ps plot through). Ventricular irregular. Normal in size and shape. Some P waves are not followed by a QRS complex (more Ps than QRSs).

PRI

Within normal limits or slightly prolonged but constant for the conducted beats. There may be some shortening of the PR interval that follows a nonconducted P wave. Usually 0.10 second or greater, periodically absent after P waves

QRS

Second-Degree AV Block, Type II

Second-Degree AV Block, 2:1 Conduction (2:1 AV Block)

Rate Rhythm P waves Atrial rate is twice the ventricular rate Atrial regular (Ps plot through). Ventricular regular. Normal in size and shape; every other P wave is followed by a QRS complex (more Ps than QRSs) Constant Within normal limits, if the block occurs above the bundle of His (probably type I); wide if the block occurs below the bundle of His (probably type II); absent after every other P wave.

PRI QRS

Second-Degree AV Block, 2:1 Conduction (2:1 AV Block)

Complete AV Block
Rate Atrial rate is greater than the ventricular rate. The ventricular rate is determined by the origin of the escape rhythm. Atrial regular (Ps plot through). Ventricular regular. There is no relationship between the atrial and ventricular rhythms. Normal in size and shape. None the atria and ventricles beat independently of each other, thus there is no true PR interval. Narrow or wide depending on the location of the escape pacemaker and the condition of the intraventricular conduction system. Narrow = junctional pacemaker, wide = ventricular pacemaker.

Rhythm

P waves PR interval

QRS

Complete AV Block

Right Bundle Branch Block

Left Bundle Branch Block

Questions?