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# ARRYTHMIA (Part I) 2014 -2015

Dr. Payawal

ARRYTHMIA

o Abnormal cardiac rhythm
o Proper term is dysrrhytmia but they are interchangeable terms
 because there are several kinds of cardiac arrythmia
o it is important to distinguish benign from malignant [has capacity o IRREGULAR
to kill Px} -R-R intervals not same
 the #1 killer in Philippines is cardiovasculat disease (9 die
every hour)
 50 % of deaths from cv disease are sudden cardiac
death [death within one hour of symptom onset]
 Majority of sudden cardiac death is caused by o IRREGULAR
arrythmia [arrythmic death]
-in Px with acute coronary syndrome

STEPS IN ARRHYTHMIA RECOGNITION

 Cardiac Rhythm Identification
 Regularity o IRREGULAR
o Regular
o irregular 2. HEART RATE
 Cardiac rate based on ECG 2 methods to get the heart rate:
o Tachycardia  MATH
o bradycardia Heart rate = 1500
 Pattern of the rhythm # of small squares (0.04s)
o Normal Sinus Rhythm or not?  Count the number of small squares(0.04) between 2
o Is rhythm coming from sinus node? R waves (ventricular) or 2 P waves (atrial)
 Are there QRS complexes? -use this number to divide with 1,500
o Normal or abnormal? -1,500 because 1 small square is 0.04; 1,500 x 0.04 =
 Are there P waves? 60; there are 60 seconds in 1 minute
o Normal or abnormal?  Non-MATH
 What is the relationship between P and QRS complexes?  Sequence method: 300, 150, 100, 75, 60, 50
 P-QRS-T -just memorize this sequence
o does it follow the normal pattern?  Math method and Sequence Method is applicable for
 Clinical correlation? regular only
 Intervals: PR, QRS, QT  If irregular, count # of R-waves in a 3 (or 6)-second strip, X
20 (or 10)
1. REGULARITY
 Beat to beat interval (R to R or P to P intervals) the same BASIC ECG INTERPRETATION
 Use a calliper to have an exact measurement
 Regular: same interval R-R or P-P
 Gold standard to measure regularity: measure R-R or P-P
intervals
o regular: same measurement
 It is possible to have a rapid beat with regular rhythm

Determination of Rate
 IF RHYTHM IS REGULAR
 ECG paper:
 Count the # of small squares between 2 R waves
 Long lead II = 23
 REGULAR  1500/23 = 65 bpm
 Sequence method:
 If R wave falls on a thick line on big square, the rate would
be 300. Next 150, then 100.. 75..60..50.
 This one is between 60 and 75 but nearer to 60 so it is
around 65.
st
 1 arrow: 300
 REGULAR  1: 150

Magno Opere Somnia Dura Page 1 of 10

ARRYTHMIA (Part I) 2014 -2015 Dr.is 0. Payawal  2:100  3:75  4: 60 nd  2 arrow: approx.12 seconds or more [3 small squares or more]  P-R interval normal (0. followed by a QRS complex at a regular rate  3 second strip (15 big squares is 3 seconds)  Rate/min = # of complexes multiplied by 20 ECG LeadII  Count the number of R waves in 15 big squares This is a Normal sinus Rhythm:  Presence of P wave  6 second strip (30 big squares is 6 seconds)  P wave is followed by QRS  Rate/min = # of complexes (Rwaves) multiplied by 10  Rate is between 60-100  Count the number of R waves in 30 big squares Divide by 22 = 68  Remember: 5 big squares is 1 second  In the example given:  Counted 7 R waves  7 x 10 = 70 beats per minute 3. NORMAL SINUS RHYTHM  Criteria:  There should be a P wave (normal: upright) followed  same contour in same lead? by a QRS complex at a regular rhythm and normal rate  Upright in I. Magno Opere Somnia Dura Page 2 of 10 . 65  IF RHYTHM IS IRREGULAR  Also estimate  Count the number of big squares in a 6-second strip *there are 5 big squares in 1 second *30 big squares in 6 seconds  Regular  P waves normal  HR: around 60-70  PR interval IS normal .12 sec. Travelling through atrial pathways at a frequency between 60-100 bpm  cycle length do not vary by 10% o if cycle varies by >10%: sinus arrythmia  Regular Rhythm  Rate (75 using sequence method)  P wave upright  Followed by QRS (which is narrow or normal) *Wide QRS= 0. II. aVF & left precordial leads o Normal HR: 60-100bpm  followed by QRST? o Tachycardia: > 100 o Bradycardia: < 60 Review… o Pacemaker impulses are initiated in the SA node. or more  There is the presence of a P wave.60)  Therefore Normal sinus rhythm  ACLS Rhythms [Advanced Cardiac Life Support]  Arrhythmias are now being taught in the ACLS class because st arrhythmia is a common cause of death in the 1 48 hours after a heart attack.

. paramedics.when sinus node fails to fire (no depolarization). Knowing how to recognize an arryhtmia will improve SLOW ARRYTHMIA MI patient survival  So even non-doctors can learn cardiac arrythmia [nurses. congenital -there is an accesory pathway excitation *do not mind. SEPARATE RHYTHMS.] TYPES OF RHYTHM THE ACLS ARRHYTHMIA  SLOW RHYTHMS (HR: <60) o Sinus Bradycardia o Sinus Pause o Escape Rhythms:  Junctional rhythm  Idioventricular rhythm . therapists. Payawal  Id an arryhtmia is recognized early. you can resuscitate the patient. either:  FAST (HR > 100)  SLOW (HR <60) Magno Opere Somnia Dura Page 3 of 10 .ARRYTHMIA (Part I) 2014 -2015 Dr. di lalabas sa exam :D 1. Px does not go to cardiac arrest immediately because heart has back-up pacemakers and it will be the one initiating  AV node: junctional rhythm  ventricle: idioventricular rhythm o Heart Blocks  FAST RHYTHMS (HR: >100) o Sinus tachycardia o Suprventricular tachycardia [SVP] -above ventricle o Atrial fibrillation o Atrila flutter o Multifocal atrial tachycardia o Ventricular tachycardia  ARREST RHYTHMS o Asystole -(flat line) WILL be in the exam! o Ventricular Fibrillation o Pulseless VT (ventricular tachycardia) o Pulseless Electrical Activity (PEA) -Px has electrical activity but has no pulse -easiest to recognize -causes sudden cardiac death  BENIGN RHYTHMS o PREMATURE ATRIAL COMPLEX (PAC) o PREMATURE VENTRICULAR COMPLEX (PVC)  MISCELLANEOUS o Artificial pacemaker rhythm -pacemaker in patients esp. med tech. those with heart blocks o Preexcitation/wpw pattern (wolff parkinson white syndrome) -rare.

o man with same ECG (as athletic’s)  Frequent .Sedentary lifestyle (not athlete)  Normal then pause then again normal beat .ARRYTHMIA (Part I) 2014 -2015 Dr.Near-syncopal attack (nagdilim paningin) <1 sec  Irregular because there is a pause . No P. Payawal SINUS BRADYCARDIA SINUS PAUSE/ARREST  Sinus bradycardia follows all criteria for normal sinus rhythm  Cause: if SA node does not fire except for the rate  There is a pause  Always ask for drug history (drugs that slow down HR)  No P wave (as opposed to AV Block) nd o Beta blockers *2 degree AV block has P wave but no QRS  o Anti-arrythmic drugs  No QRST  Always ask if he’s athletic. especially in young patients *athletes also have bigger hearts (LVH) but not sick  ECG paper: lead I  Rate = 48/min  65 y. no QRS  Interval less than 2x the normal  I2 cycles is always longer than the cycle with a pause Magno Opere Somnia Dura Page 4 of 10 . is shorter than the 2 normal beats -the one with the pause is twice shorter than the 2 normal interval AV BLOCKS FIRST DEGREE AV BLOCK  Measure from start of P wave up to start of QRS  Sinus Bradycardia  PR> 0.No drugs that slows down HR  Sinus bradycardia due to sinus node dysfunction  No P wave.20 sec –> only criteria  If P-R interval is prolonged (more than 5 small squares or 1 big square): FIRST DEGREE AV BLOCK  Correlate clinically Can be caused by drugs (digitalis) Case: SA node does not fire. no Q wave -consider a pacemaker implantation  What is the interval between the previous peak and the next peak following the pause?  Interval is less than twice the normal interval between beats -this interval where the pause is.

ARRYTHMIA (Part I) 2014 -2015 Dr.32 (which is longer than 0... Second Degree Atrioventricular Block n Type I . Payawal SECOND DEGREE AV BLOCK  P-R interval= 8 small squares x 0. longer PR. then non-conductive P wave.Mobitz type I or Wenckebach  Transcient/temporary  No aggressive measures needed n Type II ...Mobitz type II  Usually goes into complete heart block/asystole/arrest  Prepare Px for pacemaker already  Type I Type II Temporary Goes into complete heart block From 1 cycle to next until the PR interval is constant and drop beat then drop beat Prepare for pacemaker implants  Normal sinus rhythm with first degree AV block Magno Opere Somnia Dura Page 5 of 10 .20 sec)  HAS TWO TYPES: -need to distinguish because have different prognosis -Different from each other o PR interval not the same o Has P wave with no QRS o Cycle repeats itself: shorter PR interval. repeat.04 = 0.

12 sec or more)  rate <40bpm  Ventricular rate usually slower -depend on where is the pacemaker of ventricle -back-up pacemakers of heart are not as efficient (slower compared to sinus node)  More P wave than QRS -Because in complete heart block. Payawal 2° Type II  non-conductive P-wave (drooped beat): has P wave but no QRS  MOBITZ TYPE I  Prolongation in PR interval  Non-conductive P wave (dropped beat)  MOBITZ TYPE II  No prolongation of PR interval. constant  Just have dropped beat THIRD DEGREE/COMPLETE AV BLOCK  More advanced block  Atrium is controlled by sinus node  Ventricle do not get depolarized from the sinus node anymore  Ventricle has its own pacemaker o AV node o Bundle of His o Bundle branches o Ventricle itself -So you will have different rates already  AV node pacemaker:  QRS will not be wide  rate= 40-60 bpm  pacemaker from ventricle itself:  QRS is wade (0.ARRYTHMIA (Part I) 2014 -2015 Dr. in QRS. depending on atrial beat P-P = atrial rate constant R-R = ventricular rate constant BUT atrial and ventricular rate is not the same Magno Opere Somnia Dura Page 6 of 10 . the atrial rate is usually faster than the ventricular arte  P wave do not cause QRS anymore  Measure P-P interval: it is constant  Sometimes P wave is buried in T wave.

does not respond to mediastinum  Symptom: hypotension. etc. but rate is coming from AV node.ARRYTHMIA (Part I) 2014 -2015 Dr. it is constant o Does not cause QRS o HR: <40 (pacemaker is in the ventricle) Magno Opere Somnia Dura Page 7 of 10 .)  If rate <40 and QRS is wide: will not respond to drugs. Syncope – magdidilim paningin  If QRS is narrow: may respond to drugs (Dopamine. pacemaker is needed. need pacemaker already  Ventricle-independent from poor SA node  AV node: QRS not wide  Ventriclr itself – Wide QRS. Normal atrial rate is faster/greater than ventricular rate  Clinically: if complete heart block. Payawal  In AV block. etc. complete heart block. o If you measre P-P interval. rate <40  Atrio-ventricular Dssociation  P-P and R-R intervals are constant  Arrows are pointing to P waves o Buried in QRS. it will respond to mediastinum  If from ventricle. T wave.

fatigue. fever  Lead I rate = 111/min Magno Opere Somnia Dura Page 8 of 10 . Payawal FAST ARRYTHMIAS SINUS TACHYCARDIA  Has same criteria as Sinus rhythm except that rate is >100bpm  Not necessarily mean there’s a problem in the heart *you have sinus tachycardia during exams   Always correlate clinically -know what patient is tachypneic about -Consider conditions that will increase heart rate like stress.ARRYTHMIA (Part I) 2014 -2015 Dr. emotional disturbance.

Long here is diff. from that of first degree AV block -distinguish PAC from PJC (premature junctional  CRITERIA complex?) o Markedly different (wider than usual beat) -ectopic focus comes from AV node o No P wave o P wave different in configuration but predominantly o T wave opposite polarity of QRS complex upright o There is a pause o Narrow QRS  P waves are different but upright  PR interval is > 0. there is a P wave  T wave is opposite from QRS complex o Does the P wave differ from the sinus beat? -If ORS is predominantly upright. T wave will be upright  Criteria for PAC: -opposite polarity o P-R interval is often long [>0. it looks different -If QRS predominantly negative. it’s premature beat the same as 2 normal beats *here.>0.10 sec  Many physicians are scared to see PVCs .12 sec (0.08 sec) -compensate for two normal beats o Look if there is a P wave before the QRS of that *if you measure interval from beat before and after PVC. T wave is negative *here. Payawal BENIGN ECTOPIC RHYTHMS PREMATURE VENTRICULAR COMPLEX (PVC) PREMATURE ATRIAL COMPLEX (PAC)  Ectopic focus comes from ventricles  Ectopic focus outside that of the sinus node comes from  QRS complex is wide because the ventricle is a wider chamber atrium -markedly different -If in Lead II = ectopic focus on right atrium that fired .ARRYTHMIA (Part I) 2014 -2015 Dr.12 sec] instead of 0. usually in V2? You scrutinize it:  With compensatory pause o Does it have a wide or narrow QRS? -either a pause after PVC *here it is narrow: 2 small squares (0.12 sec or more  When you see premature beat (beat occuring earlier than it  No P wave usually because it came from the ventricles should be).16 or 4 small squares)  QRS narrow  meets criteria for PAC Magno Opere Somnia Dura Page 9 of 10 .

ARRYTHMIA (Part I) 2014 -2015 Dr. Payawal Others: (hindi nabanggit ang classification sa lecture) Magno Opere Somnia Dura Page 10 of 10 .