Approach to the Recognition of

The ACLS Rhythms

PHA Council on CPR
National BLS and ACLS Training
Easy ECG Recognition of Arrhythmias
An Associate Member of the

The Asian Representative of

 What is an ECG?

ELECTROCARDIOGRAM
Valuable record of the heart’s electrical activity
Easy to understand

Tip: just recognize the waveforms

Easy as ABC or 123
 ECG : Clinical Applications

Rhythm abnormalities

Chamber enlargement

Ischemia / Infarction
The Beating Heart- Electrophysiology
Electrical Stimulation And Contraction

BEFORE THE HEART CONTRACTS

IT MUST BE ELECTRICALLY STIMULATED

DEPOLARIZATION
Anatomy and Physiology of Cardiac Conduction

SINUS NODE
Sinus Node • The Heart’s ‘Natural
(SA Node) Pacemaker’
- 60-100 BPM at rest
LA
RA
LV
RV
 Anatomy and Physiology of Cardiac Conduction

AV NODE
Sinus Node • Receives impulse from
(SA Node) SA Node

Atrioventricular Node
• Delivers impulse to the
(AV Node) His- Purkinje System
• 40-60 BPM if SA Node
fails to deliver an impulse
 Anatomy and Physiology of Cardiac Conduction

BUNDLE OF HIS
Sinus Node • Begins conduction to
(SA Node)
the Ventricles
Atrioventricular Node • AV Junctional Tissue:
(AV Node) 40-60 BPM

Bundle of His
 Anatomy and Physiology of Cardiac Conduction

THE PURKINJE
NETWORK
Sinus Node
(SA Node) • Bundle Branches
• Purkinje Fibers
Atrioventricular Node
(AV Node) • Moves the impulse
through the ventricles for
Bundle of His contraction
• Provides ‘Escape
Bundle Branches Rhythm’:
20-40 BPM
Purkinje Fibers
Impulse Formation In SA Node
Atrial Depolarization
Delay At AV Node
Conduction Through Bundle
Branches
Conduction Through Purkinje Fibers
Ventricular Depolarization
Plateau Phase of Repolarization
Final Rapid (Phase 3) Repolarization
Normal ECG Activation
 NORMAL SINUS RHYTHM
Pacemaker impulses are initiated in the
SA node, traveling through atrial
pathways, at frequencies between 60-100
bpm.
There is the presence of a P wave,
followed by a QRS complex at a regular
rate.
 Normal Sinus Rhythm
Look at the p waves:
•rate is 60-100/min
•cycle length do not vary by 10%
•PR interval is 0.12 - 0.20 sec.

Lead II
 Normal Sinus Rhythm

Look at the p waves:

•same contour in same lead?
•upright in I, II, aVF & left precordial
leads
•followed by QRST?
Lead II
 Normal ECG Activation
Normal Cardiac Depolarization

 ARRHYTHMIA
Steps in ECG Interpretation for ACLS

Regularity?
Rate?
Rhythm? Sinus?
P-QRST
Intervals: PR, QRS, QT
Rhythm abnormalities?
Clinical correlation
 Regularity

Beat to beat interval(R to R intervals or P

to P intervals) the same
Is it regular or irregular?
Rate? Is it fast or slow or normal?
Rhythm? Is it sinus?
Is there a P wave?
Is it followed by a QRS? All the time?
Are the intervals normal?PR interval normal?
 Sinus bradycardia  Sinus tachycardia  Asystole Benign ectopic
 Sinus pause  Supraventricular  Pulseless VT rhythms:
 Escape rhythms: tachycardia  Ventricular  PACs
 Junctional rhythm  Atrial fibrillation fibrillation  PVCs
 Idioventricular  Atrial flutter  Pulseless
rhythm
 Multifocal atrial electrical
 Heart blocks activity Miscellaneous
tachycardia
 Artificial
 Ventricular Pacemaker
tachycardia rhythm
 Preexcitation /
WPW pattern
 Sinus Tachycardia

Regularly occurring PQRST

Rate > 100 / min

Rate = 111/min Rate = 111/min Rate = 111/min

Sinus Tachycardia
 Sinus Arrhythmia
Identical but irregularly
occurring PQRST
longest PP or RR > the
shortest by 0.16 sec or more
Rate = 71/min
Rate = 94/min Rate = 94/min
Rate = 79/min
Sinus Arrhythmia
Inspiration Expiration Inspiration
 Sinus bradycardia  Sinus tachycardia  Asystole Benign ectopic
 Sinus pause  Supraventricular  Pulseless rhythms:
 Escape rhythms: tachycardia VT  PACs
 Junctional rhythm  Atrial fibrillation  Ventricular  PVCs
 Idioventricular  Atrial flutter fibrillation
rhythm
 Multifocal atrial  Pulseless
 Heart blocks electrical Miscellaneous
tachycardia
 Sick sinus activity  Artificial
syndrome  Ventricular Pacemaker
tachycardia rhythm
 Preexcitation /
WPW pattern
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Sinus Tachycardia
Multifocal Atrial Tachycardia
 Multifocal Atrial
Tachycardia
Impulses originate irregularly
and rapidly at different points
in the atrium
Varying P wave, PR, PP and RR intervals
Ventricular rate > 100/min

3 different P wave morphologies

Irregularly occurring QRS complexes
Supraventricular Tachycardia
 Supraventricular Tachycardia
• Characterized by tachycardia with a narrow QRS
complex
• sudden onset and termination
• 150-250 beats/min (180 to 200 bpm in adults)
• regular rhythm
• QRS complex is normal in contour and duration
• No P waves
• P waves are generally buried in the QRS complex
• Often, P wave is seen just prior to or just after the end of the QRS and
causes a subtle alteration in the QRS complex that results in a pseudo-S or
pseudo-r
Paroxysmal Supraventricular Tachycardia
Atrial Flutter
 Atrial Flutter

Atrial rate = 250-350/min

( P as flutter waves )
Variable degree of AV block
( irregular RR interval )
Atrial Flutter
Atrial Fibrillation
 Atrial Fibrillation

No discernible P waves

Irregular RR interval
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
 Premature Ventricular Contraction
Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
 Premature Ventricular Contraction
in Couplets

Two Premature ventricular

contractions occurring consecutively
 Premature Ventricular Contraction
in Bigeminy

Alternating normal sinus beat and

a PVC
 Premature Ventricular Contraction
in Trigeminy

PVC’s regularly occurring every

third beat
 Premature Ventricular Contraction
in Quadrigeminy

PVC’s regularly occurring every

fourth beat
 Multifocal Premature Ventricular
Contraction
PVC’s coming from different foci in
the ventricle
PVC’s assuming different polarities
in a single lead
PVC’s of different morphology and
coupling interval
 Premature Ventricular Contraction
R on T Phenomenon

R or Q of the PVC occurring at the

T wave of the preceding sinus beat
Most dangerous PVC
Nonsustained Ventricular Tachycardia
 Ventricular Tachycardia

At least 3 consecutive PVC’s

Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
No P wave (ventricular impulse
origin)

Rate > 100 / min

Ventricular Tachycardia
 Ventricular Tachycardia

 Nonsustained

 Sustained

 Monomorphic

 Polymorphic

 Torsades pointes
Ventricular Fibrillation
 Ventricular Fibrillation
Associated with coarse or
fine chaotic undulations of the
ECG baseline
No P wave
No true QRS complexes
Indeterminate rate

Coarse Fibrillation Fine Fibrillation

Atrium

AV
Node Ventricle

Left
Bundle
Branch
Right
Bundle
Branch