I.Sinus Rhythms and Sinus Arrhythmias

1
I.Sinus Rhythms and Sinus Arrhythmias

• 1.ECG of Sinus RhythmsSinus rhythm must
  originate in the sino-atrial node.1).Regularly
  recurring sequences of P waves, QRS complexes,and
  T waves.P-P or R-R interval establishes a
  specific interval which should not vary more
  than 0.12 second.

2
I.Sinus Rhythms and Sinus Arrhythmias

• 2).The P wave is upward in lead I,II, avF,V4-5
  and downward in lead avR.3).The PR intervalgt0.12
  second.4).Heart rate between 60 and 100 rates
  per minute.

3
(No Transcript)
4
I.Sinus Rhythms and Sinus Arrhythmias

• 2. Sinus Tachycardia1). 1).2).and 3)2).Heart
  rate exceeding 100 per minute .

5

• Factors associated with Sinus Tachycardia
  Physiologic Exercise Strong emotion
  Pain Anxiety states

6
I.Sinus Rhythms and Sinus Arrhythmias

• PathologicFeverHyperthyroidismHemorrhageShock
  AnemiaInfectionCongestive heart
  failureMyocarditisHypoxia

7
I.Sinus Rhythms and Sinus Arrhythmias

• Other factorsDrugs Epinephrine Atropine
  Food,etcTea coffeeAlcoholTobacco

8

I.Sinus Rhythms and Sinus Arrhythmias

• 3.Sinus Bradycardia1).1),2) and 3).2).Heart
  rate is less than 60 per minute.

9
(No Transcript)
10

• Sinus Rhythms and Sinus
• Arrhythmias

• Common causes
• Physiologic bradycardiaLaborers and trained
  athletesEmotional states leading to
  syncopeCarotid sinus pressure, eyeball
  pressure,intracranial pressureSleep

11

• PathologicSystemic diseaseObstructive
  jaundiceObstructive diseases of the
  intestine,kidney or bladderDuring convalescence
  after some diseases marked by fever(e.g.influenza)
  myxedemamyocardial infarction(inferior wall or
  atrial infarction)high intracranial pressure

12
I.Sinus Rhythms and Sinus Arrhythmias

• DrugDigitalisMorphineQuinidinePropranolol

13
I.Sinus Rhythms and Sinus Arrhythmias

• 4.sinus arrhythmia
• (1) 1) .2) .3)and 4)
• (2) P-P or R-R interval varies in duration
  by at least 0.12 second

14
I.Sinus Rhythms and Sinus Arrhythmias

• Common Causes Active rheumatic fever
  Infectious diseases Atelectasis Chronic
  adhesive pleuritis Intracranial tension
  Digitalization Autonomic nerve (It is normal
  in children and young adults.)

15
I.Sinus Rhythms and Sinus Arrhythmias

• Note It varies with the phases of
  respiration,the Sinus rate increasing with
  inspiration and decreasing with expiration.

16
I.Sinus Rhythms and Sinus Arrhythmias

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

17
II.Premature beat

• The terms premature beat,premature
  contraction,premature systole,or
  extrasystole indicate that the atria ,AV
  junction, or ventricle are stimulated
  prematurely.

18
II.Premature beat

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

19
II.Premature beat

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

20

II.Premature beat

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

21
II.Premature beat

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

22
(No Transcript)
23
(No Transcript)
24
II.Premature beat

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

25
II.Premature beat

• 3).The P-R interval of the atrial premature beat
  is usually longer than the normal PR intervals in
  the ECG.4).An atrial premature beat is often
  followed by a noncompensatory pause.5).The
  ventricular complex is usually normal but may be
  aberrant in from if the premature atrial beat
  coincides with the refractory phase of the
  previous ventricular beat .The aberrant QRS is
  called aberrant conduction.

26
(No Transcript)
27
(No Transcript)
28

II.Premature beat

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

29
(No Transcript)
30
?.Ectopic tachycadia

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

31
?.Ectopic tachycadia

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

32
(No Transcript)
33

?.Ectopic tachycadia

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

34
(No Transcript)
35
?.Flutter and Fibrillation

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

36

?.Flutter and Fibrillation

• 1. Atrial FlutterECG
• 1).There are no P waves in ECG 2).Presence
  of saw-tooth flutter wave.3).F waves always
  uniform in size ,shape and frequency.4).Regular
  atrial rhythm with a rate of 250-3505).Ventricula
  r response of 11,21,31,41,or
  higher.6).Absence of isoelectric line.

37
(No Transcript)
38
?.Flutter and Fibrillation

• 2. Atrial FibrillationECG
• 1).Absence of P waves2).P waves replaced by
  f waves.3).f waves irregular in size ,shape
  ,and spacing. Rate between 350
  and 6004). Irregularly irregular ventricular
  rhythm, best seen in ?,?,Avf,V1 or V2.

39
(No Transcript)
40
(No Transcript)
41
?.Atrio ventricular block(AVB)

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

42
AVB

• 1. First degree heart block(??AVB)I?AVB is
  prolongation of the atrio-ventricular conduction
  time and is also referred to as first degree A-V
  block.ECGprolonged P-R intervallonger than
  0.20sec in adults and gt0.22s in old adults.The
  difference of P-R interval between two times is
  more than 0.04 second.NoteP-R interval varies
  with heart rate and age.

43
(No Transcript)
44
AVB

• 2.II?AVB (second degree heart block)1).Mobitz
  Type I(Wenckeback phenomenon)(1)The P-R interval
  becomes longer and longer (2)The R-R interval
  gets shorter and shorter, until there is a
  blocked or nonconducted ventricular beat with a
  long pause, then an escape rhythm or beat
  resumes.

45
(No Transcript)
46
AVB

• 2).II?II type(mobity type II AV block) Mobity
  II is characterized by failure of conduction of
  one or more sinus beats to the ventricle .There
  is a fixed numerical relationship between atrial
  and ventricular impulses,which may be 21 or 31
  or 41 .Mobitz II blocks become progressive worse
  until a complete heart block is established.Thus
  ,mobitz Type II require a pacemaker,whereas
  mobitz I does not require a pacemaker,since it
  does not progress to complete heart block.

47
(No Transcript)
48
AVB

• 3.III?AVB(Complete heart block) (Third
  degree A-V Block)ECG1).The atrial and the
  ventricular rhythms are absolutely
• independent of one another .2).There is
  no P-R to QRS relationship.3).The atrial rate is
  more rapid than the ventricular rate.4).regular
  P-P interval .5).rugular R-R interval

49
AVB

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

50
(No Transcript)
51
?.Bundle branch block

• The ventricular conduction system is composed of
  two major divisions.?the right bundle
  branch?the left bundle branch

52

?.Bundle branch block

• 1. Right Bundle Branch Block(RBBB)ECG
• 1).QRS 0.12 sec or wider2).Rsr(M)pattern in
  V1 and V2 and deep ,wide S wave in ?,V5-6.3).The
  ST segment is slight depressure with negative T
  wavesWhen incomplete RBBB is present ,the
  pattern is similar, but the QRS width is less
  than 0.12sec.

53
(No Transcript)
54

?.Bundle branch block

• 2. Left Bundle Branch Broch,(LBBB)
• ECG 1). QRS 0.12sec or more .2)absent q
  waves in I,V5 and V63).wide ,notched,or slurred
  R waves in V5-6 with depressed ST
  segments,downward T waves.4).wide QS or rS
  patters with elevated ST segments and upward T
  waves in V1-2.When incomplete LBBB in present
  ,the pattern is similar ,but the QRS width is
  less than 0.12 second.

55
(No Transcript)
56

?.Bundle branch block

• 3. Left anterior fascicular block (LAH)
• ECG criteria1).Left axis deviation (-30?to
  -45?or greater)2).Small q wave in lead
  I3).Deep s wave in lead II4).Decper S wave in
  lead III5).S wave in aVF and V6

57
(No Transcript)
58
  
?.Bundle branch block

• 4.left posterior fascicular block(LPH) (left
  posterior hemiblock)ECG criteria1).Right axis
  deviation of 120? or greater2).Large S wave in
  lead I3).Tall R waves in lead II and III.

59
(No Transcript)
60
7.Wolff-Parkinson-White Syndrome (W.P.W)

• ECG criteria1.Short P-R interval (less than
  0.10 sec to 0.12 sec2.prolonged QRS complex ,
  0.12 sec or greater3.Delta wave in the lower
  third of the ascending limb of the R wave4.Type
  A is characterized by dominantly upright QRS
  complexes in the right precordial leads,
  resulting in tall delta-R waves in leads V1-2.

61
Wolff-Parkinson-White Syndrome(W.P.W)

• 5.Type B is characterized by dominantly negative
  QRS complexes in the right precordial leads ,with
  tall delta-R wave in leads V5-6Conditions
  associated with wpw syndrome ? Atrial
  fibrillation? Atrial flutter? Atrial
  tachycardiasReciprocal tachycardias

62
(No Transcript)
63
(No Transcript)
64
(No Transcript)