EKG - Dysrhythmia Workshop

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EKG - Dysrhythmia Workshop

• Wayne E. Ellis, Ph.D., CRNA

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Overview

• AnatomyFundamental ConceptsMyocardial
  InjuryModified Chest LeadsDysrhythmias Sinus
  Atrial AV node Junctional VentricularPractic
  e Strips

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Preop Predictors Periop Cardiac
Morbidity high risk patients
Recent MI Current CHF
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Lets consider the following uninterpreted
EKG
Lap-chole on 55 yo black male Hx HTN ( Rx
BP pill ) Per family member
Poor historian Lab normal 160 / 96 , 92 ,
12
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Your diagnosis ? a. I think its OK b.
Wait for cardiology to confirm ? How
should it / might it affect your anesthetic
plan? a. Delay case ? b. Cancel case ? c.
Proceed based upon surgeons request ? d.
Consult with other anesthesia team member
(MDA) proceed accordingly ? Where do you
stand medico-legally ?
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Cardiac Anatomy
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Left Coronary Artery
Sinus Artery
Right Coronary Artery
Circumflex
Left Anterior Descending
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Circumflex
Right Coronary Artery
Posterior Descending Coronary Artery
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Circumflex
Right Coronary Artery
Posterior Descending
Right Dominant Coronary Circulation
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Conduction System
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Bundle of His
S-A Node
Left Bundle Branch
Posterior Fascicle
Anterior Fascicle
A-V Node
Purkinje Fibers
Right Bundle Branch
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Coronary Circulation Distribution to the
Conduction System
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Bundle of His
S-A Node
A-V Node
RCA / Cx
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Posterior Fascicle
Anterior Fascicle
LAD
Purkinje Fibers
Right Bundle Branch
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Arrhythmias Type of MI

• Inferior - narrow complex dysrhythmias
• Sinus dysrhythmias
• Junctional dysrhythmias
• 3rd degree A-V block with a junctional
  escape rhythm
• Anterior - wide complex dysrhythmias
• Mobitz II
• 3rd degree A-V block with a ventricular
  escape rhythm

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Fundamentals of Electrocardiographic Monitoring
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ventricular depolarization
QRS
P atrial depolarization
ventricular repolarization
T
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a
v
c
CVP Tracing
P
QRS
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calibration pulse
1 mV 10 mm
sweep speed 25 mm / sec
vertical axis 1 mm 0.1 mV
each mm 0.04 sec
each square 1 mm
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Waveform, Interval, and Segment Identification
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Waveform, Interval, and Segment Identification
Isoelectric Line
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Waveform, Interval, and Segment Identification
Isoelectric Line
Positive Waveform Negative Waveform
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Waveform, Interval, and Segment Identification
Isoelectric Line
P
Positive Waveform Negative Waveform
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Waveform, Interval, and Segment Identification
Isoelectric Line
P
Positive Waveform Negative Waveform
Q
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Waveform, Interval, and Segment Identification
R
Isoelectric Line
P
Positive Waveform Negative Waveform
Q
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Waveform, Interval, and Segment Identification
R
Isoelectric Line
P
Positive Waveform Negative Waveform
Q
S
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Waveform, Interval, and Segment Identification
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Waveform, Interval, and Segment Identification
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Waveform, Interval, and Segment Identification
R
Isoelectric Line
T
P
Positive Waveform Negative Waveform
ST
Q
S
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Waveform, Interval, and Segment Identification
R
Isoelectric Line
T
P
Positive Waveform Negative Waveform
ST
PR interval
Q
S
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Waveform, Interval, and Segment Identification
R
Isoelectric Line
T
P
Positive Waveform Negative Waveform
ST
PR interval
Q
S
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
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QT Interval- Should be lt 1/2 preceding R
to R interval -
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
65 - 90 bpm
QT interval
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QT Interval- Should be lt 1/2 preceding R
to R interval -
65 - 90 bpm
QT interval
Normal QTc 0.46 sec
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D
A
C
B
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Atypical Q R S complex Possible explanation
for this morphology ?
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Atypical Q R S complex Possible explanation
for this morphology ? - MI -
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B
A
D
C
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B
A
D
C
RR1 complex Possible explanation for this
morphology ?
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B
A
D
C
RR1 complex Possible explanation for this
morphology ? - BBB -
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Standard 12 lead EKG
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Standard 12 Lead EKG

• Cheap
• Easy to do
• Noninvasive
• Mod - Poor sensitivity

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Sensitivity

• 50 - 70 patients with a history of stable
  angina will have a normal EKG if it is
  taken while they are not experiencing pain.

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• Limb Leads
• frontal plane
• 1 , 2 , 3 , aVR , aVL , aVF
• Chest Leads
• transverse plane
• V1 , V2 , V3 , V4 , V5 , V6

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• Regionalized Myocardial Injury
• - inferior -

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Bipolar Frontal Plane Leads
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LL
RA
LA

• Lead 1 is selected
• What lead is being monitored ?

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• Remember what happens to the polarity of
• the electrodes any time lead 1 is selected

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LL
RA
LA

• Lead 1 is selected
• What lead is being monitored ?
• Answer Lead 2

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Axis of Each Bipolar Frontal Plane Lead
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LA
exploring electrode
zero potential
Central terminal
zero potential
Unipolar Frontal Plane Lead
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Axis of Each Unipolar Frontal Plane Lead
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-90
-
2
3
3
2
aVR
aVL
aVL
aVR
1

1
0
180


-
-


aVF
aVF
90

Combining triaxial figures of FRONTAL PLANE

Hexaxial Figure
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Unipolar Precordial Chest Leads True Chest
Leads
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4th intercostal space
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Axis of the Chest Leads
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V5

• Dipole Concept

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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4, 5
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4, 5
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1 , 2, 3, 4,
5 Posterior V 1 - 2
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1 , 2, 3, 4,
5 Posterior V 1 - 2
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4,
5 Posterior V 1 - 2 RV V4R , V1, 2,
3, 4, 5
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4,
5 Posterior V 1 - 2 RV V4R , V1, 2,
3, 4, 5
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4, 5, 1,
aVL Posterior V 1 - 2 RV V4R , V1,
2, 3, 4, 5
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Inferior 2, 3, aVF Lateral 1,
aVL, V 5 - 6 Anterior V 1, 2, 3, 4,
5 Posterior V 1 - 2 RV V4R , V1, 2,
3, 4, 5
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Inferior leads 2, 3, aVF
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Lateral Leads 1, aVL, V5 - V6
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Anterior Leads V1 - V5
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Posterior Leads V1 - V2
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RV Leads V4R, V1 - V5
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Myocardial Injury ST segment analysis
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Case Scenario

• 77 yo female
• (L) hallux IPJ fusion
• 70 kg, 155 cm
• ASA PS 2
• Arthritis , reflux
• HTN ( catapres , dyazide )
• 153 / 93 , 72 , 18
• labs nl
• 12 lead ( of course uninterpreted )

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Questions - Choices - Decisions

• What EKG lead(s) should you monitor?
• Does it matter ?
• What other variables ( if any ) should be
  checked before induction ?

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• ST Segment Changes
• ( myocardial injury )
• Setting Iso , J , ST pts
• Frequency Bandwidth
• Gain
• Lead Selection

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ST Segment Changes(myocardial injury)

• gt 1 mm ST seg depression
• (horizontal)
• gt 1 mm ST seg depression measured 60 - 80
  msec J point
• (upsloping / downsloping)
• gt 1 mm ST seg elevation
• (transmural injury)

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Upsloping ST Segment
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ST
Q
S
J point
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ST Segment Depression - Upsloping
Downsloping -
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Extending PR segment
1.5 mm
Q
ST
S
60 msec
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Extending PR segment
Q
ST
S
60 msec
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ST Segment Deviation - Horizontal Depression
Elevation -
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Hewlett Packard EKG Monitor Setting the

• Iso point
• J point
• ST point

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Iso pt
A single cardiac cycle depicting proper
placement of the Iso pt, J pt, ST pt.
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Iso pt
J pt
A single cardiac cycle depicting proper
placement of the Iso pt, J pt, ST pt.
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Iso pt
ST pt
J pt
A single cardiac cycle depicting proper
placement of the Iso pt, J pt, ST pt.
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Iso pt
ST pt
J pt
Placement of the ST pt 80 msec (2 mm) away
from the J pt.
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Iso pt
ST pt
J pt
Placement of the ST pt 60 msec (1.5 mm)
away from the J pt.
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- 2.5 mm
Iso pt
ST pt
J pt
A single cardiac cycle depicting proper
placement of the Iso pt, J pt, ST pt.
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R - 80 ms
R 60 ms
J 80 ms
- 2.5 mm
Iso pt
ST pt
J pt
A single cardiac cycle depicting proper
placement of the Iso pt, J pt, ST pt.
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R - 80 ms
R 60 ms
J 80 ms
- 2.5 mm
Iso pt
ST pt
J pt
Two cardiac cycles depicting placement of the Iso
pt, J pt, ST pt. In the 1st cardiac cycle each
parameter is properly placed. In the 2nd, the
Iso pt has been improperly positioned onto the P
wave.
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R - 80 ms
R 60 ms
J 80 ms
- 2.5 mm
Iso pt
Iso pt
ST pt
ST pt
J pt
J pt
Two cardiac cycles depicting placement of the Iso
pt, J pt, ST pt. In the 1st cardiac cycle each
parameter is properly placed. In the 2nd, the
Iso pt has been improperly positioned onto the P
wave.
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R - 160 ms
R 60 ms
J 80 ms
R - 80 ms
R 60 ms
J 80 ms
- 2.5 mm
Iso pt
Iso pt
ST pt
ST pt
J pt
J pt
Two cardiac cycles depicting placement of the Iso
pt, J pt, ST pt. In the 1st cardiac cycle each
parameter is properly placed. In the 2nd, the
Iso pt has been improperly positioned onto the P
wave.
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R - 160 ms
R 60 ms
J 80 ms
R - 80 ms
R 60 ms
J 80 ms
- 2.5 mm
Iso pt
Iso pt
ST pt
ST pt
J pt
J pt
Two cardiac cycles depicting placement of the Iso
pt, J pt, ST pt. In the 1st cardiac cycle each
parameter is properly placed. In the 2nd, the
Iso pt has been improperly positioned onto the P
wave.
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I I I
Depiction of the limitation of ST segment
analysis software when setting the J point
for three cardiac cycles / 3 different
leads. Note how the J point ends up being
improperly set in V 5 when it is properly
placed for leads 3 2 . Unfortunately
each cardiac cycle can not be set
individually.
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V5
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V5
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0.2 mm
V5
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3 mm
V5
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• Three lead display of ST segment analysis

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2
V
SaO2 97
RR 10
Sample Default Settings for HP Monitors
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2
V
SaO2 97
RR 10
Why resp rate ? consider priorities
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2
3
V
Rhythm - ST seg Changes - TW Changes 3
Regions of the Heart
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Reciprocal Changes( usually seen early (4-8)
hrs after MI )
- anterior - 1 , aVL , V 1 - V 5
- lateral - V 5 - V 6
2 , 3 , aVF - inferior -
V 1 , V 3 R
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Is ST - segment Depression Always the
Reciprocal Event ?
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• Frequency Bandwidth
• Gain / Amplitude

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Filter Mode( 0.5 - 20 Hz )VSDiagnostic
Mode( 0.05 - 130 Hz)
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Filter Mode

• Oscilloscope photograph of an acute infarct
  record. The DC record ( higher elevation of
  ST ) and the filtered one, displayed
  simultaneously. Berson AS, et al. Am. Heart
  Journal. 1966 71(6)779

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Filter Mode

• Oscilloscope photograph of an old infarct
  record showing distortion of the ST segment
  in the filtered record. The DC record
  has the downward sloping ST segment. Berson
  AS, et al. Am. Heart Journal. 1966
  71(6)779

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Filter Mode

• Resting ECG. Filtered record has produced a
  significant ST segment depression. DC
  record with less ST deviation. Berson AS,
  et al. Am. Heart Journal. 1966 71(6)779

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Filter Mode

• Resting ECG. Filtered and DC record show
  no significant difference. Berson AS, et al.
  Am. Heart Journal. 1966 71(6)779

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EKG recorded in the
? Filter mode ( 0.5 - 20 Hz ) ?
Monitoring mode ( 0.5 - 40 Hz ) ?
Diagnostic mode ( 0.05 - 130 Hz )
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So where should the bandwidthbe set on the
HP Monitorwhen ST seg analysis is engaged
?
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So where should the bandwidthbe set on the
HP Monitorwhen ST seg analysis is engaged
?

• In the Filter mode
• Because the bandwidth changes from ..
• 0.5 - 20 Hz to 0.05 - 20 Hz

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So where should the bandwidthbe set on the
HP Monitorwhen ST seg analysis is engaged
?

• In the Filter mode
• Because the bandwidth changes from ..
• 0.5 - 20 Hz to 0.05 - 20 Hz

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When ST seg analysis is engaged

• The HP EKG monitor changes the filter mode
  bandwidth so only the high end is
  filtered out
• 0.05 - 20 ( 21 - 130 Hz )

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Gain Setting( 1 mV 10 mm )

• False Negatives
• False Positives

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calibration pulse
1 mV 10 mm
sweep speed 25 mm / sec
vertical axis 1 mm 0.1 mV
each mm 0.04 sec
each square 1 mm
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Strip B 0.5 standardization / 1 mV 5
mm significant ? (1 mm) 0.5
mm ? Strip A Standardization / 1 mV
10 mm significant ?(1 mm) 1 mm ?
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Strip C 2 x standardization / 1
mV 20 mm significant ?(1 mm) 2 mm
? Strip A Standardization / 1 mV
10 mm significant ?(1 mm) 1 mm ?
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Selecting the Appropriate Lead System

• Lead II
• dysrhythmia interpretation
• P waves are important for Diagnosis
• V1 / MCL1
• aberrant beats vs PVCs
• V5 / MCL5
• detect ischemia / injury / MI

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True V5 or a Modified V5

• Blackburn 89 significant
• ST - seg depression after
• exercise found V5 of a 12 lead

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London MJ, Hollenberg MAnesthesiology
69232-241, 1988Intraoperative Myocardial
Ischemia Localization by Continuous 12 lead
ECG

• 109 pt with known / suspected CAD
• had noncardiac surgery via GA
• sensitivity greatest V5 ( 75 )
• median duration ischemia 10 min

143
London MJ, Hollenberg MAnesthesiology
69232-241, 1988Intraoperative Myocardial
Ischemia Localization by Continuous 12 lead
ECG

• 109 pt with known / suspected CAD
• had noncardiac surgery via GA
• sensitivity greatest V5 ( 75 )
• median duration ischemia 10 min

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What EKG Lead(s) Should You Monitor ?

1. Lead 1
2. Lead 2
3. Lead V5
4. Other?

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Mizutani M, Freedman SB, et alAm J Cardiology 66
(4)389-393, 1990ST Monitoring for
Myocardial Ischemia During and After
Coronary Angioplasty

• 97 pt with known CAD
• use single lead inadequate
• 2 appropriate leads 93 sensitivity
• 3 leads increased sensitivity 100
• ST elevation
• V3 ( LAD ) / III ( LCx RC )
• ST depression
• V3 ( L Cx ) / III ( LAD ) / V2 ( RC )

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Given this information ,Lets return to
case scenario 1With the original question
- which lead(s) do you monitor in ?
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Case Scenario 1 / Lead Selection ?

• 77 yo female
• (L) hallux IPJ fusion
• 70 kg, 155 cm
• ASP PS 2
• arthritis, reflux
• HTN (catapres, dyazide)
• 153/93 , 72 , 18
• labs nl
• 12 lead

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And you have a 5 cable system to monitor
with
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Five Cable System

• Leads
• 1 , 2 , 3
• aVR , aVL , aVF
• V 1 - 6

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Five Cable System

• Leads
• 1 , 2 , 3
• aVR , aVL , aVF
• V 1 - 6

LL
LA
C
RA
RL
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Unipolar Precordial Chest Leads True Chest
Leads
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So what are the lead(s) youve selected to
monitor?
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2
3
V5
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But what if all you have to work with is
a three - cable system ?
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Three Cable System

• Leads
• CS 5
• CM 5
• CC 5
• CB 5

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• Three wire systems

Einthovens Triangle !
I
-

-
-
III
II
The mechanics
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Bipolar Frontal Plane Leads
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Bipolar Frontal Plane Leads
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Apply what you learned about Einthovens
Triangle !

• Which lead wire / electrode becomes negative
  when limb lead 3 is selected ?
• Answer
• LA electrode
• Which lead wire / electrode becomes positive
  when limb lead 3 is selected ?
• Answer
• LL electrode

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• Three wire systems Monitoring leads CS5

• Monitoring for anterior ischemia
• Right arm electrode unchanged
• Left arm electrode moved to V5 position
• Left leg electrode unchanged
• Selector on Lead I CS5
• Selector on Lead II Lead II

-
I

CS5 a modification of a true V5
The mechanics
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CS5 a modification of a true V5
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Apply what you learned about Einthovens
Triangle !

• How would you set up a CS5
• if limb lead 3 was selected ?
• Which lead wire / electrode becomes negative
  when limb lead 3 is selected ?
• Answer
• LA electrode

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Apply what you learned about Einthovens
Triangle !

• Which lead wire / electrode becomes negative
  when limb lead 3 is selected ?
• Answer
• LA electrode
• Which lead wire / electrode becomes positive
  when limb lead 3 is selected ?

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Apply what you learned about Einthovens
Triangle !

• Which lead wire / electrode becomes negative
  when limb lead 3 is selected ?
• Answer
• LA electrode
• Which lead wire / electrode becomes positive
  when limb lead 3 is selected ?
• Answer
• LL electrode
• Now just put the electrodes where they
  belong to monitor in a CS5 !

168
How would you set up a CS5 if limb lead
3 was selected ?
169

• Three wire systems Monitoring leads CM5

• Monitoring for anterior ischemia
• Right arm electrode Manubrium
• Left arm electrode V5 position
• Left leg electrode unchanged

-
I

CM5 a modification of a true V5
The mechanics
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CM5 a modification of a true V5
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• Three wire systems Monitoring leads CC5

• Monitoring for ischemia
• Right arm electrode Right anterior axillary line
• Left arm electrode V5
• Left leg electrode unchanged

-

I
The mechanics
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CC5 a modification of a true V5
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• Three wire systems Monitoring leads CB5

• Monitoring for anterior ischemia
• Good P wave for diagnosis of arrhythmias
• Right arm electrode center of right scapula
• Posteriorly
• Left arm electrode V5
• Left leg electrode unchanged

-
I

The mechanics
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CB5 a modification of a true V5
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• Three wire systems Monitoring leads MCL1

• Good P wave and QRS complex, useful for diagnosis
  of arrhythmias
• Right arm electrode unchanged
• Left arm electrode Under clavicle
• Left leg electrode moved to V1 position

-
III

The mechanics
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Factors Predisposing Development Ischemia / MI

• CAD , HTN, prior MI
• Diabetes mellitus , smoking
• Age ( elderly ) , drug abuse
• Hyper / hypotension , tachycardia
• Surgery
• duration procedure
• skills surgeon
• skills anesthesia provider
• induction , emergence

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Other Causes ST - TW Changes

• Drugs
• Electrolyte abnormalities
• Conduction disturbances
• LVH , RV or LV strain

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Strain

• Sustained / delayed repolarization
• Correlates with increase LV mass , pressure
  overload , slowing intraventricular conduction
• Strain ? myocardial ischemia
• EKG changes seen
• ST segment depression , elevation
• TW inversion
• U waves inversion ( L ) precordial leads

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Other Causes ST - TW Changes

• Drugs
• Electrolyte abnormalities
• Conduction disturbances
• LVH , RV or LV strain
• Intracranial hemorrhage
• Positioning
• Pericarditis

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Stage I of pericarditis Diffuse ST
segment elevation with concave appearance in
inferior and left precordial leads. The TW
are also upright
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Treatment Options Myocardial Injury

• Nitroglycerine
• Beta blockers
• CEB
• Volume resuscitation
• Diuretics
• Deepen anesthetic
• ASA
• 160 - 325 mg

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ST Segment Analysis Algorithm

• False Positives
• improper electrode placement
• gain set gt standardization
• filtering bandwidth
• improper setting iso, J, ST pts
• nonspecific change
• BUNDLE BRANCH BLOCKS

• False Negatives
• improper lead selection
• gain set lt standardization
• filtering bandwidth
• improper setting iso, J, ST pts
• nonspecific change

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ST Segment Analysis Algorithm

• lead V3, III, II unless 12 lead shows otherwise
  - scan other leads intraop
• gain set 1 cm/mV
• diagnostic mode
• set document Iso , J , ST pts

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ST Segment Analysis Algorithm

• lead V3, III, II unless 12 lead shows otherwise
  - scan other leads intraop
• gain set 1 cm/mV
• diagnostic mode unless using HP monitor ?
  filter
• set DOCUMENT Iso , J , ST pts

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ST Segment Analysis Algorithm

• lead V3, III, II unless 12 lead shows otherwise
  - scan other leads intraop
• gain set 1 cm/mV
• diagnostic mode unless using HP monitor ? filter
• set document Iso , J , ST pts
• assess for presence of risk factors
  (eg, HTN,
  cardiomegaly, tachycardia)
• determine primary site injury / consider
  reciprocal change
• tx accordingly
  (eg, NTG,
  esmolol, dobutamine, robinul, deepen anesthetic)

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Dysrhythmia Recognition
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Cardiac Dysrhythmias( incidence )

• 16.3 - 84 for both cardiac noncardiac
  surgery
• serious arrhythmias lt 1
• Whats important here is how you define
  serious ( e.g., VT, VF vs outcome )

190
Forrest JB et al. Anesth 76 3
1992Multicenter Study of General Anesthetics
involving 17,201 patients

• When the etiology of severe adverse
  outcomes are assessed ..
• Cardiac arrhythmias account for 44 (
  372 of 847 ) poor outcomes !

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Most Common DysrhythmiasUnder Anesthesia

• PACs
• bradycardias
• nodal rhythms
• simple PVCs
• In children ? SVT
• ( not under anesthesia )

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Factors Precipitate Dysrhythmias

• Ischemia / hypoxemia
• acidosis / alkalosis
• electrolyte abnormalities
• increase catecholamines
• drug toxicities
• hypothermia
• anesthetics
• volatile , opioids

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Causes of Dysrhythmias

• altered automaticity
• (phase 4)
• changes threshold potential
• altered conductivity
• (phase 0)
• hyperpolarization

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mV
Hyperpolarization
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Mechanisms Action - Antidysrhythmics -

• Na channel blockade
• Ca2 channel blockade
• Prolongation refractory period
• blockade sympathetic effects
• hyperpolarization ? K

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Electrophysiologic Effects ADO
ADO A 1 hyperpolarization
K
K
K
K
K
K
197
Guidelines Rhythm Analysis

• overall rhythm regular ?
• reasons for irregular rhythm .

198
Reasons for Irregular Heart Rates( R to R
intervals are inconsistent )

• Discharge rate from primary pacemaker site
  is occurring at an irregular interval
• ( Sinus dysrhythmia )
• Premature extrasystoles are interrupting an
  otherwise regular pattern
• ( PACs , PJCs )
• Periods of cessation of electrical activity
• ( sinus pause , sinus exit block )

199
Guidelines Rhythm Analysis

• overall rhythm regular ?
• determine HR ( atrial vent )
• morphology p - waves
• pr - intervals / are they fixed ?
• relationship between p - waves QRS
• morphology QRS ( shape width )

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Determining Heart Rate
201
6 sec strip technique

• Count R waves that occur in 6 sec
• Multiply by 10
• Equals beats per minute ( BPM )

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Lead 2
Heart Rate ?
203
Lead 2
8 x 2 16 x 10 160 bpm
Heart Rate ?
204
5
15
20
25
10
Heart Rate ? Is this a 6 second strip ? How
do you determine this is 6 sec of data
? Remember , 25 mm / sec
205

• R to R Technique

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Lead 2
What is the Heart Rate ? 120 bpm
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What is the Heart Rate ?
210
170 bpm
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Lead 2
What is the Heart Rate ? Need to use 6
sec strip technique Reason underlying
irregular rhythm
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Diagnosis with Heart Rate

• NSR 60 - 100 bpm
• SB lt 60 bpm
• ST 100 - 150 bpm
• AT 150 - 250 bpm (Supraventricular SVT)
• AF 250 - 350 bpm
• Af gt 350 bpm

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Diagnosis with Heart Rate

• NSR 60 - 100 bpm
• SB lt 60 bpm
• ST 100 - 150 bpm
• AT 150 - 250 bpm
• AF 250 - 350 bpm
• Af gt 350 bpm

214
Diagnosis with Heart Rate

• NSR 60 - 100 bpm
• SB lt 60 bpm
• ST 100 - 150 bpm
• AT 150 - 250 bpm
• AF 250 - 350 bpm
• Af gt 350 bpm

215
Normal Sinus Rhythm

• sino-atrial rate 60 - 100 bpm
• (p - waves)
• ventricular rate ? variable
• (QRS complexes)
• morphology QRS ? variable
• pr - interval ? variable / none

216
SA Dysrhythmias
217
Lead 2

• Constant changing R to R interval
• No fixed pattern identified
• Phasic sinus rhythm vs sinus irregularity

218
Lead 2

• Constant changing R to R interval
• No fixed pattern identified
• Phasic sinus rhythm vs sinus irregularity

219
Reasons for Irregular Heart Rates( R to R
intervals are inconsistent )

• Discharge rate from primary pacemaker site
  is occurring at an irregular interval
• ( Sinus dysrhythmia )
• Premature extrasystoles are interrupting an
  otherwise regular pattern
• ( PACs , PJCs )
• Periods of cessation of electrical activity
• ( sinus pause , sinus exit block )

220
Lead 2

• Your interpretation ?

221
Lead 2

• Your interpretation ?
• Sinus Bradycardia with 1 1 vent conduction

222
Sinus Bradycardia

• sino-atrial rate lt 60 bpm
• (p - waves)
• ventricular rate ? variable
• (QRS complexes)
• morphology QRS ? variable
• pr - interval ? variable / none

223
Lead 2

• Your interpretation ?

224
Lead 2

• Your interpretation ?
• Sinus Tachycardia with 1 1 vent conduction

225
Sinus Tachycardia

• sino-atrial rate 100 - 150 bpm
• (p - waves)
• ventricular rate ? variable
• (QRS complexes)
• morphology QRS ? variable
• pr - interval ? variable / none

226
Atrial Dysrhythmias
227
Lead 2

• Your interpretation ?

228
Lead 2
229
Lead 2
Premature

• Sinus bradycardia with 11 vent conduction
  with a single conducted PAC

230
Lead 2

• So where is the P wave ?
• The P wave is hidden in the T wave

231
Lead 2

• Note the distortion of the T wave

232
Lead 2

• Your interpretation ?

233
Lead 2

• Grossly , appears to have ratio 2 1
• Therefore , 2 1 AV block , Mobitz Type II
• However , the P wave rate is what ?
• FAST !

234
Lead 2

• Atrial tachycardia with 2 1 AV block
• Remember , the reasons for failed conduction
  can include ...

235
Reasons for Failed Conduction

• Premature extrasystoles
• PACs , PJCs
• Disease of the lower part of the
  conduction system
• Mobitz II , CHB infranodal
• Physiologic - rate induced
• SVT
• Pharmacologic
• OD antidysrhythmic

236
Atrial Tachycardia

• atrial rate 150 - 250 bpm
• ( p - waves may become lost )
• ventricular rate ? variable
• ( QRS complexes )
• morphology QRS ? variable
• pr - interval ? variable / none

237
Lead 2

• Your interpretation ?
• Atrial flutter - classical flutter waves

238
Atrial Flutter

• atrial rate 250 - 350 bpm
• ( p - waves ? sawtooth )
• ventricular rate ? irregular / regular
• ( 14, 16 )
• morphology QRS ? variable
• pr - interval ? variable / none

239
Lead 2

• Your interpretation ?
• Atrial fibrillation

240
Atrial Fibrillation

• atrial rate gt 350 bpm
• ( p - waves ? fine or indistinguishable
  )
• ventricular rate ? irregular
• morphology QRS ? variable
• pr - interval ? none

241
Lead 2

• Your interpretation ?
• Atrial fibrillation

242
Irregular Rhythm Trouble Discerning P -
Waves Atrial Fibrillation
243
Question ...

• How would you recognize atrial fibrillation
  with complete AV block ?
• What would be the criteria to diagnose
  this ?

244
Accessory Pathways
245

• Normal activation sequence

246

• Premature ventricular septal activation
• Classical shortened PR interval delta wave

247

• Accessory tract fusing with Bundle His
• Shortened PR interval / no delta wave

248

• Accessory tract originating off base AV
  node
• Normal PR interval with a delta wave

249
Wolff - Parkinson - White

• Shortened PR interval
• / or
• Delta wave

250
Arrhythmias Associated with Wolff - Parkinson
- White

• premature beats
• supraventricular tachycardia
• atrial flutter
• atrial fibrillation

251
Practice Strips
252
Lead 2

• Your interpretation ?
• Sinus Tachycardia with 1 1 vent conduction

253
Lead V 1

• Your interpretation ?
• SB 1 1 vent conduction interrupted by a
  nonconducted PAC followed by a compensatory
  pause

254

• Nonconducted P wave
• Remember , another reason for failed
  conduction - premature extrasystole

255
V 1
2

• Whats the message with this slide ?
• Use other leads to facilitate diagnosis

256
V 1

• Your interpretation ?
• Atrial fibrillation with an isolated PVC

257
Therapy SA Atrial Dysrhythmias
258

• Your interpretation ?
• SVT

259
Narrow QRS Complex Tachycardia ( SVT
) - causes

• sino - atrial or atrial rate
  (100 - 250 bpm)
• P waves associated with QRS
  (may not be discernible)
• Reentry Mechanism
  (S-A nodal, A-V nodal,
  intra-atrial)
• Can be secondary reciprocating tachycardia
  (not due to enhanced automaticity)

260
Supraventricular TachycardiaCauses

• light anesthesia
• hypovolemia
• hypotension
• febrile
• CHF
• malignant hyperthermia

261
Supraventricular Tachycardia

• Caused by Cocaine or Amphetamines
• Use Labetolol
• Avoid Esmolol
• Caution with hydralizine
• If Hypotensive and heart rate control is not
  occurring, consider neosynephrine

262
Treating Supraventricular Tachycardia( sinus ,
atrial , junctional tachycardias )

• Serious S S ? cardiovert 25 - 100 J
• vagal maneuvers
• adenosine 6 mg , repeat 12 mg ( may repeat
  once in 1 - 2 min )
• PSVT will recur up to 50 - 60 time ?
  ? verapamil
• verapamil 1.25 - 5 mg ( may repeat 5 - 10 mg
  in 15 - 30 min )
• digoxin , esmolol , diltiazem , overdrive
  pacing
• If ECG complex appears wide unclear of
  diagnosis ( VT vs SVT
  with aberrant conduction ) give adenosine or
  begin to treat rhythm as if it were
  VT do NOT use verapamil if unsure of
  diagnosis

263

• Your interpretation ?
• NSR with 1 1 vent conduction with
  evidence of WPW

264
(No Transcript)
265
WPW associated with

• VSD , MVP
• Transposition Great Vessels
• Ebsteins Anomaly

266
WPW( contraindicated )

• digitalis
• verapamil / diltiazem

267
Treatment WPW

• vagal manuvers
• adenosine
• procainamide ( doc )
• cardioversion
• quinidine
• disopyramide
• surgery

268

• Your interpretation ?
• No discernable P waves
• junctional or .
• Atrial fibrillation
• Reason for latter diagnosis ?
• Irregular ventricular response

269
Atrial FibrillationCauses

• Reentrant phenomenon
• COPD with cor pulmonale
• pulmonary embolism
• valvular disease
• CAD , acute MI
• hyperthyroidism
• electrolyte abnormalities
• toxic effects secondary meds
• eg , digoxin , quinidine

270
Atrial FibrillationCauses

• increased sympathetic activity
• febrile illness
• pneumonia , systemic viral infection
• possibly unknown

271
Tx Atrial Fibrillationhemodynamics stable /
unstable

• Vagal maneuvers
• esmolol 0.5 mg / kg , 50 mg , 100 mg , 200 mg
• metoprolol 5 - 10 mg slow IV push
• 5 min intervals max 15 mg
• verapamil 1.25 mg - 5 mg IV slowly
• max dose 20 mg
• diltiazem 0.25 mg / kg IV slowly
• 5 - 20 mg repeat 25 mg if necessary
• digoxin 0. 25 - 1 mg IV over at least 15 min
• less effective with paroxysmal atrial fib
• adenosine 6 mg IV push

272
Treat Atrial Fibrillation hemodynamically
stable / unstable

• Procainamide quinidine for conversion to
  NSR
• Cardioversion 50 - 100 J
• Rapid atrial pacing
• Verapamil , diltiazem , digoxin
• can worsen ventricular response if atrial
  fibrillation is occurring 2nd WPW

273
Lead 2

• Your interpretation ?
• Profound sinus bradycardia with 1 1 vent
  conduction

274
Lead 2

• Your interpretation ?
• Profound sinus bradycardia with 1 1 vent
  conduction

275
Lead 2
276
Sinus BradycardiaCauses

• increased vagal tone
• myocardial infarction
• intracranial lesion
• anticholinesterase drugs
• repeat dose succinylcholine

277
Sinus BradycardiaTreatment

• Glycopyrrolate (Anesthesia)
• repeat 0.2 mg doses prn
• Atropine 0.4 - 1 mg IV
• max dose 0.04 mg / kg
• can be given via ETT 1 - 2 mg mixed 10
  ml NaCl
• Ephedrine 5 - 10 mg IV
• Epinephrine 2 - 10 mcg / min
• Isoproterenol 2 - 10 mcg / min (temporary only)
• Transvenous / or transcutaneous pacing

278
So when do you tx sinus bradycardia ?

• If symptomatic
• chest pain , hypotensive , ischemic changes
• Declines to 30 bpm
• even if still asymptomatic
• Always still pursue underlying cause

279
Atropine

• Ineffective in denervated transplanted hearts
• Care with use with an acute MI
• VT / VF
• Care in use with Mobitz II

280
Atropine vs Glycopyrrolate
281
Lead 2

• Your interpretation ?
• Atrial flutter

282
Atrial FlutterCauses

• Reentrant phenomenon
• COPD with cor pulmonale
• pulmonary embolism
• valvular disease
• CAD , acute MI
• hyperthyroidism
• electrolyte abnormalities
• toxic effects secondary meds
• eg , digoxin , quinidine

283
Tx Atrial Flutterhemodynamics stable /
unstable

• Vagal maneuvers
• esmolol 0.5 mg / kg , 50 mg , 100 mg , 200 mg
• metoprolol 5 - 10 mg slow IV push
• 5 min intervals max 15 mg
• verapamil 1.25 mg - 5 mg IV slowly
• max dose 20 mg
• diltiazem 0.25 mg / kg IV slowly
• 5 - 20 mg repeat 25 mg if necessary
• digoxin 0. 25 - 1 mg IV over at least 15
  min
• less effective with paroxysmal atrial
  flutter
• adenosine 6 mg IV push

284
Tx Atrial Flutter hemodynamics stable /
unstable

• Procainamide quinidine for conversion to
  NSR
• Cardioversion 25 - 100 J
• often used prior to drug administration
• Rapid atrial pacing
• Verapamil , diltiazem , digoxin
• both can worsen ventricular response if
  atrial flutter is occurring as a result of
  W-P-W

285
Atrial Flutter

• Less stable than atrial fibrillation

286
Junctional Dysrhythmias
287
Three FormsJunctional Dysrhythmias

• Key to understanding
• Activation sequence
• Dipole concept ( lead 2 )

288
Activation Sequence

• Retrograde atrial depolarization

289
Activation Sequence
1 st

• Retrograde atrial depolarization

290
Activation Sequence
1 st

• Retrograde atrial depolarization , followed
  by .

291
Activation Sequence
2 nd

• Retrograde atrial depolarization , followed by
  ..
• Antegrade ventricular depolarization

292
Lead 2

• Simultaneous retrograde atrial , antegrade
  ventricular depolarization

293
Lead 2

• Antegrade ventricular depolarization followed
  by retrograde atrial depolarization

294
Lead 2

• Antegrade ventricular depolarization followed
  by retrograde atrial depolarization
• Inverted P wave on the ST segment

295
V 5

• Your interpretation ?
• Junctional rhythm - no apparent P waves

296
V 5

• What is the activation sequence ?
• Simultaneous retrograde atrial , antegrade
  vent depolarization

297
V 5

• Are you sure ?
• Are there any other questions that you
  should ask ?
• Yes you should ask another question , like
  , can I see other leads ?

298
V 5
299
(No Transcript)
300

• Whats the answer now ?
• Antegrade ventricular depolarization followed
  by retrograde atrial depolarization

301
Junctional Rhythm

• atrial rate variable
  ( p - waves ? inverted , hidden )
• ventricular rate 40 - 60 bpm
• morphology QRS ? variable
• pr - interval ? variable / none

302
Lead 2

• Your interpretation ?
• NSR with 1 1 vent conduction an
  isolated conducted PJC

303
AV Node Dysrhythmias
304
Classification of AV Block

• According to Degree
• Partial
• First degree AV block
• Second degree AV block ( Types I II )
• Complete
• Third degree AV block

305
Classification of AV Block

• According to Site
• AV node
• Infranodal
• Bundle of His
• Bundle Branches

306
AV node
1 st Degree HB
Bundle of His
Bundle Branches
307
First Degree AV block

• Prolonged PR interval
• gt 0.20 sec
• and , fixed PR interval !

308
Lead 2

• Your interpretation ?
• NSR with 1 1 vent conduction first
  degree AV block

309
Lead 2
gt 5 mm

• Prolonged PR interval

310
Lead 2
gt 5 mm

• Prolonged PR interval
• Fixed PR interval

311
AV node
2 nd Degree HB - Mobitz I -
Bundle of His
Bundle Branches
312
Lead 2

• Your interpretation ?
• Second degree AV block , Mobitz Type I
• Underlying rhythm is NSR

313
Lead 2

• Progressive lengthening PR interval

314
Lead 2

• Progressive lengthening PR interval
• Leads to a dropped QRS complex

315
Lead 2

• Progressive lengthening PR interval
• Leads to a dropped QRS complex

316
Lead 2

• Fixed P to P interval

317
AV node
2 nd Degree HB - Mobitz II -
Bundle of His
Bundle Branches
318
Lead 2

• Your interpretation ?
• Second degree AV block , Mobitz Type II
• Underlying rhythm is NSR

319
Lead 2

• Fixed P to P interval
• Second degree AV block, Mobitz Type II

320
Lead 2

• Fixed P to P interval
• Second degree AV block, Mobitz Type II

321
Lead 2

• Fixed P to P interval
• Second degree AV block, Mobitz Type II

322
Lead 2

• Fixed P to P interval
• Second degree AV block, Mobitz Type II

323
Lead 2

• Fixed P to P interval
• Second degree AV block, Mobitz Type II

324
Lead 2

• Fixed P to P interval
• P wave rate 62 bpm

325
Lead 2

• 21 A-V conduction
• P waves that conduct

326
Lead 2

• 21 A-V conduction
• P waves that conduct
• The reason their known to conduct ?

327
Lead 2

• 21 A-V conduction
• P waves that conduct
• The reason their known to conduct ?
• Fixed PR intervals !

328
Lead 2

• 21 A-V conduction
• P waves that do not conduct

329
AV node
2 nd Degree HB - Mobitz II -
Bundle of His
Bundle Branches
330
Lead 2

• Your interpretation ?
• Second degree AV block , Mobitz Type II
  with an IVCD
• Underlying rhythm is NSR

331
Lead 2

• Your interpretation ?
• Second degree AV block , Mobitz Type II
  with an IVCD
• Underlying rhythm is NSR

332
Lead 2

• Your interpretation ?
• Second degree AV block , Mobitz Type II
  with an IVCD
• Underlying rhythm is NSR

333
Lead 2

• Your interpretation ?
• Third degree AV block , Junctional escape
  rhythm
• Underlying rhythm is NSR

334
Lead 2

• No fixed PR intervals !

335
Lead 2

• Separate P wave rate

336
Lead 2

• Separate P wave rate
• Separate R wave rate

337
Lead 2

• Width of the QRS ?
• Narrow or wide ?
• Therefore you have .
• Third degree AV block , Junctional escape
  rhythm

338
AV node
3 rd Degree HB - Junctional Escape -
Bundle of His
Bundle Branches
339
Lead 2

• Your interpretation ?
• Third degree AV block , Ventricular escape
  rhythm
• Underlying rhythm is NSR

340
Ventricular Dysrhythmias
341
Lead 2

• Your interpretation ?
• Unifocal PVCs
• Underlying rhythm is NSR

342
Lead 2

• Unifocal PVCs

343
Lead 2

• Unifocal PVCs
• Compensatory pause after each PVC
• compensates for the prematurity of
  the extrasystole

344
Lead 2

• Compensatory pause after each PVC
• Notice the continuation of the cardiac
  cycle sequence , hence , compensates for
  the prematurity of the extrasystole

345
Ventricular Tachycardia
346
Lead 2

• Your interpretation ?
• Unifocal ventricular tachycardia

347
Ventricular TachycardiaTorsades de
PointesVentricular Fibrillation
348

• TdP
• Usually nonsustained
• Rates vary 180 - 250 bpm
• Probably due to a reentry mechanism

349

• TdP
• Usually nonsustained
• Rates vary 180 -