Basic EKG 2

ECG ECG AbnormalitiesAbnormalities

The ECG Paper (cont)The ECG Paper (cont)

Every 3 seconds (15 large boxes) is Every 3 seconds (15 large boxes) is marked by a vertical line.marked by a vertical line.

This helps when calculating the heart rate.This helps when calculating the heart rate.

NOTE:NOTE: the following strips are not marked the following strips are not marked but all are 6 seconds long.but all are 6 seconds long.

3 sec 3 sec

Determining the Rate

Frekuensi Denyut JantungFrekuensi Denyut Jantung

FDJ normal : 60 – 100 x/menitFDJ normal : 60 – 100 x/menit

Takikardi : > 100 x / menitTakikardi : > 100 x / menit

Bradikardi : < 60 x / menitBradikardi : < 60 x / menit

Takikardi abnormal : 140 – 250 x / menitTakikardi abnormal : 140 – 250 x / menit

Flutter : 250 – 350 x / menitFlutter : 250 – 350 x / menit

Fibrilasi : > 350 x / menitFibrilasi : > 350 x / menit

DISRITMIADISRITMIA

Aritmia terdiri dari aritmia yang Aritmia terdiri dari aritmia yang disebabkan oleh terganggunya disebabkan oleh terganggunya pembentukan impuls atau aritmia pembentukan impuls atau aritmia yang terjadi karena gangguan yang terjadi karena gangguan penghantaran impulspenghantaran impuls..

ECG DiagnosisECG Diagnosis

The trajectory of the The trajectory of the electric vector electric vector resulting from the resulting from the propagating propagating activation wavefront activation wavefront can be traced by the can be traced by the ECG and used to ECG and used to diagnose cardiac diagnose cardiac problemsproblems

Gangguan pembentukan Gangguan pembentukan impulsimpuls

11 Nodus SANodus SA ; ;

SINUS TACICARDIASINUS TACICARDIA

Factors associated with Sinus Tachycardia:Factors associated with Sinus Tachycardia: PhysiologicPhysiologic Exercise Exercise Strong emotion Strong emotion Pain Pain Anxiety statesAnxiety states

PathologicPathologicFeverFeverHyperthyroidismHyperthyroidismHemorrhageHemorrhageShockShockAnemiaAnemiaInfectionInfectionCongestive heart failureCongestive heart failureMyocarditisMyocarditisHypoxia Hypoxia

Other factorsOther factorsDrugsDrugs Epinephrine Epinephrine Atropine Atropine Food,etc Food,etcTea coffeeTea coffeeAlcoholAlcoholTobaccoTobacco

SINUS BRADICARDIASINUS BRADICARDIA Rate 40-59 bpm

P wave sinus

QRS normal (.06-.12)

ConductionP-R normal or slightly prolonged at slower rates

Rhythm regular or slightly irregular

Common causesCommon causes Physiologic bradycardiaPhysiologic bradycardiaLaborers and trained athletesLaborers and trained athletesEmotional states leading to syncopeEmotional states leading to syncopeCarotid sinus pressure, eyeball Carotid sinus pressure, eyeball pressure,intracranial pressurepressure,intracranial pressureSleepSleep

I. Sinus Bradicardia

PathologicPathologicSystemic diseaseSystemic diseaseObstructive jaundiceObstructive jaundiceObstructive diseases of the intestine,kidney or bladderObstructive diseases of the intestine,kidney or bladderDuring convalescence after some diseases marked by During convalescence after some diseases marked by fever(e.g.influenza)fever(e.g.influenza)myxedemamyxedemamyocardial infarction(inferior wall or atrial infarction)myocardial infarction(inferior wall or atrial infarction)high intracranial pressurehigh intracranial pressure

DrugDrugDigitalisDigitalisMorphineMorphineQuinidineQuinidinePropranololPropranolol

Rate 45-100/bpm

P wave sinus

QRS normal

Conduction normal

Rhythm regularly irregular

The rate usually increases with inspiration and decreases with expiration. This rhythm is most commonly seen with breathing due to fluctuations in parasympathetic vagal tone. During inspiration stretch receptors in the lungs stimulate the cardioinhibitory centers in the medulla via fibers in the vagus nerve.The non respiratory form is present in diseased hearts and sometimes confused with sinus arrest (also known as "sinus pause"). Treatment is not usually required unless symptomatic bradycardia is present.

Sinus arrhythmia

Sinus arrestSinus arrest There is no sinus P wave in ECG There is no sinus P wave in ECG suddenly.The long interval is not times of P-P suddenly.The long interval is not times of P-P interval.interval.

Premature beatPremature beat

The terms The terms ““premature beatpremature beat””,,””premature premature contractioncontraction””,,””premature systolepremature systole””,or ,or ““extrasystoleextrasystole”” indicate that the atria ,AV indicate that the atria ,AV junction, or ventricle are stimulated prematurely.junction, or ventricle are stimulated prematurely.

These premature beats are called These premature beats are called ““atrial atrial premature beatspremature beats””when they arise in some when they arise in some portion of the atria .AV junctional premature portion of the atria .AV junctional premature beats arise in the AV junction. Ventricular beats arise in the AV junction. Ventricular premature beats arise in one of the branches premature beats arise in one of the branches of the bundle of His ,the Purkinje network ,or of the bundle of His ,the Purkinje network ,or the ventricular muscle.the ventricular muscle.

AtriumAtriumEkstrasistolEkstrasistol

Atrial premature beatsAtrial premature beats1)1).A premature P wave is present .It may be .A premature P wave is present .It may be surperimposed on the preceding T wave surperimposed on the preceding T wave because it is premature.The premature P wave because it is premature.The premature P wave is usually followed by a QRS complex and a T is usually followed by a QRS complex and a T wave.Occasionally, it is not followed by a QRS wave.Occasionally, it is not followed by a QRS complex and a T wave .(blocked atrial premature complex and a T wave .(blocked atrial premature beat).beat).2).2).The QRS and T waves that follow the The QRS and T waves that follow the premature P waves usually resemble the other premature P waves usually resemble the other QRS and T waves in the leadQRS and T waves in the lead

II.II.Premature beatPremature beat

22. Ventricular premature beats. Ventricular premature beats 1)1)The QRS complex is premature ,is 0.12second The QRS complex is premature ,is 0.12second or more wide ,and is aberrant,notched ,or or more wide ,and is aberrant,notched ,or slurred .It is associated with a T wave that slurred .It is associated with a T wave that usually point in a direction opposite to the main usually point in a direction opposite to the main deflection of the QRS complex.deflection of the QRS complex.2)2).The premature QRS complex is not preceded .The premature QRS complex is not preceded by a P wave.by a P wave.

3)3).A ventricular premature beat is often followed .A ventricular premature beat is often followed by a fully compensatory pause(the sum of the R-by a fully compensatory pause(the sum of the R-R intervals including the pre-premature beat and R intervals including the pre-premature beat and the post-premature beat interval equals the sum the post-premature beat interval equals the sum of two normal R-R intervals)of two normal R-R intervals)4)4).Multiply, ventricular premature beats that arise .Multiply, ventricular premature beats that arise from a single focus show a similar shape and from a single focus show a similar shape and usually a similar coupling intervals (distance from usually a similar coupling intervals (distance from the preceding normal QRS complex to the the preceding normal QRS complex to the premature ventricular beat) in any one lead.premature ventricular beat) in any one lead.

II.Ventricular Premature beat

II. VentricularII. VentricularPremature beatPremature beat

5)5).occasionally, a ventricular premature beat will .occasionally, a ventricular premature beat will occur simultaneously with the apex of the occur simultaneously with the apex of the preceding T wave,This is R on T phenomenon.preceding T wave,This is R on T phenomenon. When this occurs ,it may be a precursor of a When this occurs ,it may be a precursor of a ventricular tachycardia.ventricular tachycardia.

Note: Note: multifocal ventricular prematyre beat multifocal ventricular prematyre beat (VPB) and multiformed VPB(VPB) and multiformed VPB

PREMATURE VENTRICULAR CONTRACTIONPREMATURE VENTRICULAR CONTRACTIONA single impulse originates at right ventricle A single impulse originates at right ventricle

Time interval between normal R peaks Time interval between normal R peaks is a multiple of R-R intervalsis a multiple of R-R intervals

Causes of PVCsCauses of PVCs

Heart failureHeart failure

Electrolyte imbalancesElectrolyte imbalances

CaffeineCaffeine

HypoxiaHypoxia

Mitral valve prolapseMitral valve prolapse

Thyroid diseaseThyroid disease

Acute MIAcute MI

33. AV Junctional premature beats . AV Junctional premature beats 1)1).A premature AV junction P wave is followed by a QRS .A premature AV junction P wave is followed by a QRS and T wave.and T wave.2)2).The AV junction P waves in aVR become upward .The .The AV junction P waves in aVR become upward .The P waves in II,III, and aVF is downward.The PR interval is P waves in II,III, and aVF is downward.The PR interval is usually less than 0.12second ,if the P waves is before usually less than 0.12second ,if the P waves is before the QRS complexes. The P waves may appear after the the QRS complexes. The P waves may appear after the QRS complexes or may be hidden within the QRS QRS complexes or may be hidden within the QRS complex.complex.3)3).An AV junctional premature beat is followed by a fully .An AV junctional premature beat is followed by a fully compensatory.compensatory.

II.Premature beat

ⅢⅢ.Ectopic tachycadia .Ectopic tachycadia

It is more common to paroxysmal tachycardia.It is more common to paroxysmal tachycardia. The paroxysmal tachycardia can be divided The paroxysmal tachycardia can be divided into two main groups.into two main groups.①① Paroxysmal Supraventricular tachycardia Paroxysmal Supraventricular tachycardia②② Paroxysmal ventricular tachycardia Paroxysmal ventricular tachycardia

ⅢⅢ.Ectopic tachycadia .Ectopic tachycadia

1.1.paroxymal supraventricular tachycardiaparoxymal supraventricular tachycardiaECG ECG 1)1).Heart rate is regular rhythm with a rate .Heart rate is regular rhythm with a rate o f 160-250/minute.o f 160-250/minute.2)2).The QRS complex in form is usually .The QRS complex in form is usually normal.normal.3)3).The P wave in not easy to see..The P wave in not easy to see.4)4).With abrupt onset and abrupt terminal..With abrupt onset and abrupt terminal.

Supraventricular tachycardia

Rateatrial 160-250/min: may conduct to ventricles 1:1, or 2:1, 3:1, 4:1 into the presence of a block.

P wave morphology usually varies from sinus

QRSnormal (unless associated with aberrant ventricular conduction).

Conduction

P-R interval depends on the status of AV conduction tissue and atrial rate: may be normal, abnormal, or not measurable.

PAT also known as Paroxysmal Supraventricular Tachycardia

This rhythm is often transient and usually requires no treatment. •However, it can usually be terminated with vagal maneuvers. •Digoxin, antiarrhythmics, adenosine and cardioversion may be used.

Frequent symptomatic episodes may require surgical intervention. When an accessory conduction pathway can be demonstrated, interventional surgery to ablate the accessory conduction pathway can be curative

2.2. paroxysmal ventricular tachycardia paroxysmal ventricular tachycardia1)1).The QRS complex are 0.12 second or more wide .The QRS complex are 0.12 second or more wide ,are aberrant ,and are followed by aberrant ST ,are aberrant ,and are followed by aberrant ST segments and T waves.segments and T waves.2)2) Ventricular rate is between 140 and 200/minute Ventricular rate is between 140 and 200/minute and regular rhythm or slightly irregular.and regular rhythm or slightly irregular.3)3).The P waves have no relation to the QRS .The P waves have no relation to the QRS complexes.complexes.4)4).Fusion beats or ventricular capture are present..Fusion beats or ventricular capture are present.5).5).Sometimes, P-P interval >R-R interval.but the P-Sometimes, P-P interval >R-R interval.but the P-R is no relation.R is no relation.

Ⅲ.Ectopic tachycadia

Ventricular tachycardia (VT)Ventricular tachycardia (VT)

Rapid rate, 100 to 250 beats per minuteRapid rate, 100 to 250 beats per minute

Wide, bizarre, QRS complex followed by large T Wide, bizarre, QRS complex followed by large T wavewave

Patient may be unconscious, pulseless, apneic--Patient may be unconscious, pulseless, apneic--initiate CPRinitiate CPR

If patient awake, treat as medical emergencyIf patient awake, treat as medical emergency

Cardiac Rhythm: VentricularCardiac Rhythm: VentricularVENTRICULAR FIBRILLATIONVENTRICULAR FIBRILLATIONChaotic ventricular depolarization – ineffective at pumping blood – death within minutesChaotic ventricular depolarization – ineffective at pumping blood – death within minutes

Rapid, wide, irregular ventricular complexesRapid, wide, irregular ventricular complexes

PACER RHYTHMPACER RHYTHMImpulses originate at transvenous pacemakerImpulses originate at transvenous pacemaker

Wide ventricular complexes preceded by pacemaker spikeWide ventricular complexes preceded by pacemaker spikeRate is the pacer rhythmRate is the pacer rhythm

VDD PPM

ⅣⅣ..Flutter and FibrillationFlutter and Fibrillation

The flutter and fibrillation arise from excitable The flutter and fibrillation arise from excitable ectoptic focus in the atria and ventricle and with ectoptic focus in the atria and ventricle and with a rapid rate and appropriate conduction block. a rapid rate and appropriate conduction block. Thus ,They are easily caused by a reentry.Thus ,They are easily caused by a reentry.

1. 1. Atrial FlutterAtrial FlutterECG:ECG:

1)1).There are no P waves in ECG .There are no P waves in ECG 2)2).Presence of saw-tooth flutter wave..Presence of saw-tooth flutter wave.3)3).F waves always uniform in size ,shape and .F waves always uniform in size ,shape and frequency.frequency.4)4).Regular atrial rhythm with a rate of 250-350.Regular atrial rhythm with a rate of 250-3505)5).Ventricular response of 1:1,2:1,3:1,4:1,or .Ventricular response of 1:1,2:1,3:1,4:1,or higher.higher.6)6).Absence of isoelectric line..Absence of isoelectric line.

Ⅳ.Flutter and Fibrillation

Rate

atrial 250-350/min; ventricular conduction depends on the capability of the AV junction (usually rate of 150-175 bpm).

P wavenot present; usually a "saw tooth" pattern is present.

QRS normal

Conduction 2:1 atrial to ventricular most common.

Rhythmusually regular, but can be irregular if the AV block varies.

Atrial flutter almost always occurs in diseased hearts. It frequently precipitates CHF. The treatment depends on the level of hemodynamic compromise.

•Cardioversion, vagal maneuvers and verapamil are used when prompt rate reduction is needed. •Otherwise, digoxin and other antiarrhythmic drugs can be used.

Atrial flutter

ⅣⅣ..Flutter and FibrillationFlutter and Fibrillation

2. 2. Atrial FibrillationAtrial FibrillationECG:ECG:

1)1).Absence of P waves.Absence of P waves2)2).P waves replaced by f waves..P waves replaced by f waves.3)3).f waves : irregular in size ,shape ,and .f waves : irregular in size ,shape ,and spacing.spacing. Rate between 350 and 600 Rate between 350 and 6004)4). Irregularly irregular ventricular rhythm, best . Irregularly irregular ventricular rhythm, best seen in seen in ⅡⅡ,,ⅢⅢ,Avf,V,Avf,V1 1 or Vor V2.2.

Rateatrial rate usually between 400-650/bpm.

P wavenot present; wavy baseline is seen instead.

QRS normal

Conductionvariable AV conduction; if untreated the ventricular response is usually rapid.

Rhythmirregularly irregular. (This is the hallmark of this dysrhythmia).

Atrial fibrillation may occur paroxysmally, but it often becomes chronic. It is usually associated with COPD, CHF or other heart disease.

Treatment includes:•Digoxin, diltiazem, or other anti-dysrhythmic medications to control the AV conduction rate and assist with conversion back to normal sinus rhythm. •Cardioversion may also be necessary to terminate this rhythm.

Atrial fibrillation

Causes of AFCauses of AF

• Atrial enlargement due to COPDAtrial enlargement due to COPD

• Other lung diseases Other lung diseases

• Thyroid disease Thyroid disease

• Acute MI Acute MI

• Ischemic heart disease Ischemic heart disease

• Stress Stress

• FatigueFatigue

• AlcoholAlcohol

• CaffeineCaffeine

• CigarettesCigarettes

About AFAbout AF

Two hallmarks of AF:Two hallmarks of AF:– irregularly irregular rhythmirregularly irregular rhythm– f wavesf waves

If patient unstable or symptomatic: administer If patient unstable or symptomatic: administer oxygen and obtain I.V. accessoxygen and obtain I.V. access

All patients with AF lasting longer than 48 hours All patients with AF lasting longer than 48 hours are at increased risk for thrombusare at increased risk for thrombus

Cardiac Rhythm: SupraventricularCardiac Rhythm: Supraventricular

ATRIAL FLUTTERATRIAL FLUTTERImpulses travel in circular course in atria – No interval between T and PImpulses travel in circular course in atria – No interval between T and P

Rapid flutter waves, ventricular response irregularRapid flutter waves, ventricular response irregular

ATRIAL FIBRILLATIONATRIAL FIBRILLATIONImpuses have chaotic, random pathways in atriaImpuses have chaotic, random pathways in atria

Baseline irregular, ventricular response irregularBaseline irregular, ventricular response irregular

Electrical Conducting system Electrical Conducting system

ⅤⅤ.Atrio .Atrio ––ventricular block(AVB)ventricular block(AVB)

AV block, or heart block, exists when conduction AV block, or heart block, exists when conduction of the stimulus from the atria to the ventricle of the stimulus from the atria to the ventricle through the AV node is slowed or blocked.The through the AV node is slowed or blocked.The AV block may be transient ,intermittent ,or AV block may be transient ,intermittent ,or permanent .It may be incomplete or complete. A permanent .It may be incomplete or complete. A patient may show various types of AV block in patient may show various types of AV block in one ECG.one ECG.

AVBAVB

1.1. First degree heart block( First degree heart block(ⅠⅠ ゜゚ AVB)AVB)II ゜゚ AVB is prolongation of the atrio-ventricular AVB is prolongation of the atrio-ventricular conduction time and is also referred to as first conduction time and is also referred to as first degree A-V block.degree A-V block.ECG:prolonged P-R interval:longer than ECG:prolonged P-R interval:longer than 0.20sec in adults and >0.22s in old adults.0.20sec in adults and >0.22s in old adults.The difference of P-R interval between two times The difference of P-R interval between two times is more than 0.04 second.is more than 0.04 second.Note:Note:P-R interval varies with heart rate and age.P-R interval varies with heart rate and age.

First- degree AV block

P-R interval is > 0.2 seconds (greater than one big box)

A-V BLOCK, FIRST DEGREEA-V BLOCK, FIRST DEGREEAtrio-ventricular conduction lengthenedAtrio-ventricular conduction lengthened

P-wave precedes each QRS-complex but PR-interval is > 0.2 sP-wave precedes each QRS-complex but PR-interval is > 0.2 s

Atrio-Ventricular (AV) Block Possible sites of AV block: AV node (most common)

His bundle (uncommon)

Bundle branch and fascicular divisions (in presence of already existing complete bundle branch block)

1st Degree AV Block: PR interval > 0.20 sec; all P waves conduct to the ventricles

Type I (Wenckebach) AV block (note the RR intervals in ms duration):

Type I AV block is almost always located in the AV node, which means that the QRS duration is usually narrow, unless there is preexisting bundle branch disease.

Activation Sequence DisordersActivation Sequence DisordersA-V BLOCK, FIRST DEGREEA-V BLOCK, FIRST DEGREEAtrio-ventricular conduction lengthenedAtrio-ventricular conduction lengthened

P-wave precedes each QRS-complex but PR-interval is > 0.2 sP-wave precedes each QRS-complex but PR-interval is > 0.2 s

A-V BLOCK, SECOND DEGREEA-V BLOCK, SECOND DEGREESudden dropped QRS-complexSudden dropped QRS-complex

Intermittently skipped ventricular beatIntermittently skipped ventricular beat

2nd Degree A-V Block

Cardiac conduction system disorder where some P waves fail to conduct to the ventricle to generate a QRS complex.

Mobitz IMobitz IAV blockAV block

(Wenckebach(Wenckebach))

Progressive prolongation of the P-Progressive prolongation of the P-R interval causing progressive R-R R interval causing progressive R-R interval shortening until a P wave interval shortening until a P wave fails to conduct to the ventricle.fails to conduct to the ventricle.

Mobitz IIMobitz IIAV blockAV block

Sudden unexpected blocked P Sudden unexpected blocked P waves without variation or waves without variation or prolongation of the PR interval.prolongation of the PR interval.

Second- degree type I AV Block

Second-degree type I AV block

AVBAVB

2).2).IIII ゜゚ II type(mobity type II AV block)II type(mobity type II AV block) Mobity II is characterized by failure of conduction of one Mobity II is characterized by failure of conduction of one or more sinus beats to the ventricle .There is a fixed or more sinus beats to the ventricle .There is a fixed numerical relationship between atrial and ventricular numerical relationship between atrial and ventricular impulses,which may be 2:1 or 3:1 or 4:1 .Mobitz II blocks impulses,which may be 2:1 or 3:1 or 4:1 .Mobitz II blocks become progressive worse until a complete heart block become progressive worse until a complete heart block is established.Thus ,mobitz Type II require a is established.Thus ,mobitz Type II require a pacemaker,whereas mobitz I does not require a pacemaker,whereas mobitz I does not require a pacemaker,since it does not progress to complete heart pacemaker,since it does not progress to complete heart block.block.

Second-degree type II AV block

2nd Degree A-V Block

Pathophysiology:– Mobitz I (Wenckebach) block is most often caused by

conduction delay in the AV node. A narrow QRS complex makes the site of delay even more likely to be the AV node. Wenckebach block with a wide QRS complex may be due to AV nodal or infranodal conduction delay.

– EP studies demonstrate that Mobitz II block is due to an infranodal His-Purkinje system conduction delay an is often associated with a wide QRS complex.

2nd-degree AV block

Mortality/Morbidity: – Most investigators believe that Mobitz I block localized to

the AV node is not significantly associated with morbidity or death in the absence of organic heart disease. Type I block localized to the His-Purkinje system has the same risks as type II block.

– Mobitz II block carries a high risk of progression to complete heart block, often with associated cardiovascular collapse

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2nd Degree Type I

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2nd Degree Type II

““Too Too Bad”Bad”

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Type II (Mobitz) AV block(note there are two consecutive constant PR intervals before the blocked P wave):

Type II AV block is almost always located in the bundle branches, which means that the QRS duration is wide indicating complete block of one bundle; the nonconducted P wave is blocked in the other bundle. In Type II block several consecutive P waves may be blocked

as illustrated below:

AVBAVB

33.III.III ゜゚ AVB(Complete heart block)AVB(Complete heart block) (Third degree A-V Block) (Third degree A-V Block)ECG:ECG:1).The atrial and the ventricular rhythms are absolutely 1).The atrial and the ventricular rhythms are absolutely

independent of one another .independent of one another .2).There is no P-R to QRS relationship.2).There is no P-R to QRS relationship.3).The atrial rate is more rapid than the ventricular rate.3).The atrial rate is more rapid than the ventricular rate.4).regular P-P interval .4).regular P-P interval .5).rugular R-R interval5).rugular R-R interval

AVBAVB

6).QRS is 0.12sec or greater.6).QRS is 0.12sec or greater. VR is 36 beats per minute or less.(20-40 VR is 36 beats per minute or less.(20-40 beats/mim)beats/mim)QRS is less than 0.12sec.QRS is less than 0.12sec.VR is 36 to 60 beats per min(40-60beats/min)VR is 36 to 60 beats per min(40-60beats/min)

AV Block

Third-degree AV block

High-grade atrioventricular block

Complete (3rd Degree) AV Block Usually see complete AV dissociation because the atria and ventricles are each controlled by separate pacemakers.

Narrow QRS rhythm suggests a junctional escape focus for the ventricles with block above the pacemaker focus, usually in the AV node.

Wide QRS rhythm suggests a ventricular escape focus (i.e., idioventricular rhythm). This is seen in ECG 'A' below; ECG 'B' shows the treatment for 3rd degree AV block; i.e., a ventricular pacemaker. The location of the block may be in the AV junction or bilaterally in the bundle branches

AV Dissociation (independent rhythms in atria and ventricles): Not synonymous with 3rd degree AV block, although AV block is one of the causes.

May be complete or incomplete. In complete AV dissociation the atria and ventricles are always independent of each other. In incomplete AV dissociation there is either intermittent atrial capture from the ventricular focus or ventricular capture from the atrial focus. There are three categories of AV dissociation (categories 1 & 2 are always incomplete AV dissociation):

1. Slowing of the primary pacemaker (i.e., SA node); subsidiary escape pacemaker takes over by default:

Bradycardia GuidelinesBradycardia Guidelines

• Treat only symptomatic bradycardias• Symptomatic bradycardia means that heart rate is slow

(<60bpm), patient has symptoms, and symptoms are due to the slow HR

• Symptoms: chest pain, SOB, decreased consciousness, weakness, fatigue, lightheadedness/dizziness, syncope

• Signs: hypotension, orthostatic hypotension, diaphoresis, pulmonary congestion on exam/CXR, CHF or pulmonary edema, bradycardia-related PVCs or VT

Bradycardia Guidelines

• Recognize bradycardias that are likely to deteriorate, even if asymptomatic:•2nd degree AV block type II•3rd degree AV block

Overall treatment approach•Atropine (1st line treatment in absence of

immediately reversible causes)•Transcutaneous pacing•Dopamine infusion•Epinephrine infusion

Transcutaneous PacingTranscutaneous Pacing

– Pacing delivers electrical stimulus causing electrical depolarization and subsequent cardiac contraction

– TCP delivers impulses through the skin using cutaneous electrodes– Most manual defibrillators now have a pacing mode

Set rate to 60/min to beginStart at low milliamp and increase until capture. Set it at 2 milliamps above what achieves consistent capture.

– Indications for emergent TCP:Hemodynamically symptomatic bradycardia unresponsive to atropine, particularly if high degree block (Mobitz II or 3rd degree block)Sx: SBP <80 mmHg, mental status changes, pulmonary edema

More on Pacing…More on Pacing…

– Following initiation of pacing, confirm electrical and mechanical capture. Reassess patient for improvement/stability.

– Analgesics and sedatives for pain control during pacing if time allows

– If TCP is ineffective (inconsistent capture), prepare for transvenous pacing and obtain expert consulation

ⅥⅥ.Bundle branch block.Bundle branch block

The ventricular conduction system is composed The ventricular conduction system is composed of two major divisions.of two major divisions.①①the right bundle branchthe right bundle branch②②the left bundle branchthe left bundle branch

1. Right Bundle Branch Block(RBBB)1. Right Bundle Branch Block(RBBB)ECG:ECG:

1).QRS 0.12 sec or wider1).QRS 0.12 sec or wider2).Rsr2).Rsr’’(M)pattern in V(M)pattern in V1 1 and Vand V22 and deep ,wide S wave in and deep ,wide S wave in

ⅠⅠ,V,V5-6.5-6.

3).The ST segment is slight depressure with negative T 3).The ST segment is slight depressure with negative T waveswavesWhen incomplete RBBB is present ,the pattern is similar, When incomplete RBBB is present ,the pattern is similar, but the QRS width is less than 0.12sec.but the QRS width is less than 0.12sec.

Ⅵ.Bundle branch block

Right bundle-branch block (RBBB)Right bundle-branch block (RBBB)

Impulse conduction to right ventricle is blockedImpulse conduction to right ventricle is blocked

Examine lead VExamine lead V11 to identify to identify

RBBBRBBB

ECG show delayed or positive R waveECG show delayed or positive R wave

Key identifier is QRS complex wider than 0.12 Key identifier is QRS complex wider than 0.12 second, with positive R wave in Vsecond, with positive R wave in V11

Bundle-branch BlockBundle-branch BlockRIGHT BUNDLE-BRANCH BLOCKRIGHT BUNDLE-BRANCH BLOCKQRS duration greater than 0.12 sQRS duration greater than 0.12 sWide S wave in leads I, VWide S wave in leads I, V55 and V and V66

Right bundle branch block

22. Left Bundle Branch Broch,(LBBB). Left Bundle Branch Broch,(LBBB)

ECG: 1).ECG: 1). QRS 0.12sec or more .QRS 0.12sec or more .2)absent q waves in I,V2)absent q waves in I,V5 5 and V and V66

3).wide ,notched,or slurred R waves in V3).wide ,notched,or slurred R waves in V5-6 5-6 with with depressed ST segments,downward T waves.depressed ST segments,downward T waves.4).wide QS or rS patters with elevated ST 4).wide QS or rS patters with elevated ST segments and upward T waves in Vsegments and upward T waves in V1-2.1-2.

When incomplete LBBB in present ,the pattern is When incomplete LBBB in present ,the pattern is similar ,but the QRS width is less than 0.12 similar ,but the QRS width is less than 0.12 second.second.


Left bundle branch block (LBBB)Left bundle branch block (LBBB)

Electrical impulses don’t reach left side of Electrical impulses don’t reach left side of the heartthe heart

QRS wider than 0.12 secondQRS wider than 0.12 second

Key to recognizing LBBB is a Key to recognizing LBBB is a wide downward S wave or wide downward S wave or rS wave in leads VrS wave in leads V11 and V and V22

Left bundle branch block

3. Left anterior fascicular block (LAH)3. Left anterior fascicular block (LAH)

ECG criteriaECG criteria1).Left axis deviation (-301).Left axis deviation (-30 ゜゚ to -45to -45 ゜゚ or greater)or greater)2).Small q wave in lead I2).Small q wave in lead I3).Deep s wave in lead II3).Deep s wave in lead II4).Decper S wave in lead III4).Decper S wave in lead III5).S wave in aVF and V5).S wave in aVF and V66


ECG ECG AbnormalitiesAbnormalities

Associated with ischaemiaAssociated with ischaemia

Coronary Artery CirculationCoronary Artery Circulation

Coronary Artery CirculationCoronary Artery Circulation

Right Coronary ArteryRight Coronary Artery

right atriumright atrium

right ventricleright ventricle

inferior wall of left inferior wall of left ventricleventricle

posterior wall of left posterior wall of left ventricleventricle

1/3 interventricular 1/3 interventricular septumseptum

Coronary Artery CirculationCoronary Artery Circulation Left Main Stem Artery divides in two:Left Main Stem Artery divides in two:

Left Anterior Descending Left Anterior Descending ArteryArtery

antero-lateral surface of antero-lateral surface of left ventricleleft ventricle2/3 interventricular 2/3 interventricular septumseptum

Circumflex ArteryCircumflex Arteryleft atriumleft atriumlateral surface of left lateral surface of left ventricleventricle

Surfaces of the Left VentricleSurfaces of the Left Ventricle

Inferior - underneathInferior - underneath

Anterior - frontAnterior - front

Lateral - left sideLateral - left side

Posterior - backPosterior - back

Inferior SurfaceInferior Surface

Leads Leads II, III and avFII, III and avF look UP from below to the look UP from below to the inferior surface of the left ventricleinferior surface of the left ventricle

Mostly perfused by the Mostly perfused by the Right Coronary ArteryRight Coronary Artery

Inferior LeadsInferior Leads

–IIII

–IIIIII

–aVFaVF

Anterior SurfaceAnterior Surface

The The frontfront of the heart viewing the left ventricle and of the heart viewing the left ventricle and the septumthe septum

Leads Leads V2V2, , V3V3 and and V4V4 look towards this surface look towards this surface

Mostly fed by the Mostly fed by the Left Anterior DescendingLeft Anterior Descending branch branch of the Left arteryof the Left artery

Anterior LeadsAnterior Leads

–V2V2

–V3V3

–V4V4

Lateral SurfaceLateral Surface

The left sided wall of the left ventricleThe left sided wall of the left ventricle

Leads Leads V5V5 and and V6, IV6, I and and avLavL look at this surface look at this surface

Mostly fed by the Mostly fed by the CircumflexCircumflex branch branch of the left of the left arteryartery

Lateral LeadsLateral Leads

V5, V6, I, aVLV5, V6, I, aVL

Posterior SurfacePosterior Surface

Posterior wall infarcts are rarePosterior wall infarcts are rare

Posterior diagnoses can be made by looking at the Posterior diagnoses can be made by looking at the anterior leads as a mirror image. Normally there are anterior leads as a mirror image. Normally there are inferior ischaemic changesinferior ischaemic changes

Blood supply predominantly from the Blood supply predominantly from the Right Right Coronary ArteryCoronary Artery

Inferior II, III, AVF

Antero-SeptalV1,V2, V3,V4

Lateral I, AVL, V5, V6

Posterior V1, V2, V3

RIGHT LEFT

Anatomic region of heart & associated Anatomic region of heart & associated coronary arterycoronary artery

Inferior MI----------------Inferior MI----------------RCARCA

Antero-septal MI---------Antero-septal MI---------LADLAD

Antero-lateral MI---------Antero-lateral MI---------CircumflexCircumflex

Posterior MI--------------Posterior MI--------------RCARCA

----------------------------------------------------------------------------------------------------------------------

Inferior leads-------------Inferior leads-------------II, III, aVFII, III, aVF

Antero-septal leads------Antero-septal leads------V1,V2,V3&V4V1,V2,V3&V4

Antero-lateral leads------Antero-lateral leads------I,aVL,V2-V6I,aVL,V2-V6

Myocardial Ischemia and InfarctionMyocardial Ischemia and Infarction

Oxygen depletion to heart Oxygen depletion to heart can cause an oxygen debt in can cause an oxygen debt in the muscle (ischemia)the muscle (ischemia)If oxygen supply stops, the If oxygen supply stops, the heart muscle dies heart muscle dies (infarction)(infarction)The infarct area is The infarct area is electrically silent and electrically silent and represents an inward facing represents an inward facing electric vector…can locate electric vector…can locate with ECGwith ECG

Ischaemic ChangesIschaemic Changes

S-T segment elevationS-T segment elevation

S-T segment depressionS-T segment depression

Hyper-acute T-wavesHyper-acute T-waves

T-wave inversionT-wave inversion

Pathological Q-wavesPathological Q-waves

Left bundle branch blockLeft bundle branch block

ST Segment ElevationST Segment Elevation

The ST segment lies above the isoelectric The ST segment lies above the isoelectric line:line:

Represents myocardial injuryRepresents myocardial injuryIt is the It is the hallmarkhallmark of Myocardial Infarction of Myocardial InfarctionThe injured myocardium is slow to repolarise The injured myocardium is slow to repolarise and remains more positively charged than the and remains more positively charged than the surrounding areassurrounding areasOther causes to be ruled out include Other causes to be ruled out include pericarditis and ventricular aneurysmpericarditis and ventricular aneurysm

ST-Segment ElevationST-Segment Elevation

RecognizingRecognizingmyocardial infarction (MI)myocardial infarction (MI)

Series of predictable ECG changes occur in MISeries of predictable ECG changes occur in MI

ST-segment-elevation MI (STEMI)--ST-segment-elevation MI (STEMI)--serious type of MI, associated serious type of MI, associated with more complications, with more complications, higher risk of death higher risk of death

NOTE: The Q wave is the first downward stroke of the QRS complex, and it is never preceded by anything in the complex. In the QRS complex, if there is any positive wave - even a tiny spike - before the downward wave, the downward wave is an S wave (and the upward wave preceding it is an R wave).

Sequence of changes in Sequence of changes in evolving AMIevolving AMI

1 minute after onset 1 hour or so after onset A few hours after onset

A day or so after onset Later changes A few months after AMI

Q

R

P

QT

STR

P

Q

ST

P

Q

T

ST

R

P

S

T

P

QT

ST

R

P

Q

T

Anterior infarctionAnterior infarctionAnterior infarction

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Left coronary artery

Inferior infarctionInferior infarctionInferior infarction


Right coronary artery

Lateral infarctionLateral infarctionLateral infarction


Left circumflexcoronary artery

Location of infarct combinationsLocation of infarct combinations

aVR V1 V4I

II

III

LATERAL

INFERIOR

ANTPOST ANT

SEPTAL

ANT

LAT

aVL

aVF

V2

V3

V5

V6

T wavesT waves

The T wave represents ventricular The T wave represents ventricular repolarisation repolarisation

Should be in the same direction as and Should be in the same direction as and smaller than the QRS complexsmaller than the QRS complex

Hyperacute T waves occur with S-T Hyperacute T waves occur with S-T segment elevation in acute MIsegment elevation in acute MI

T wave inversion occurs during ischaemia T wave inversion occurs during ischaemia and shortly after an MIand shortly after an MI

Hyperacute T wavesHyperacute T waves

T wave inversion in an evolving T wave inversion in an evolving MIMI

Wide QRS (LBBB)Wide QRS (LBBB)

Q WavesQ Waves

Non Pathological Q wavesNon Pathological Q waves

Q waves of less than 2mm are normalQ waves of less than 2mm are normal

Pathological Q wavesPathological Q waves

Q waves of more than 2mm Q waves of more than 2mm

indicate full thickness myocardial indicate full thickness myocardial

damage from an infarctdamage from an infarct

Late sign of MI (evolved)Late sign of MI (evolved)

Basic EKG 2

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