Title: ECG Tutorial: Rhythm Recognition
1ECG Tutorial Rhythm Recognition
- Review the systematic approach
- Rhythm the hardest part!
- Again be systematic
- Mind your ps qs follow the rules!
- The Approach Tachy vs- Brady
- Examples
- Quiz
2ECG Tutorial Rhythm Recognition
- My systematic approach
- Rate
- Rhythm
- Axis
- Intervals (PR, QRS, QTc)
- Blocks / Hypertrophy / Enlargement
- Segments (PR, ST)
- Waves (Q-waves, T-waves)
- Ectopy
- Compare to old ECG
3Rhythm Recognition
- Golden rule mind your ps ( qs)
- Step I Is it fast or slow?
- Tachycardia gt100
- Bradycardia lt 60
- Step II Is it sinus rhythm or not?
- 2 questions (rules)
- p with every QRS complex?
- Upright p in I, II aVF?
- Yes to BOTH sinus origin (nice job!)
4Rhythm
Is there a p wave? Sinus
Is it followed by a QRS?
5How does the heart work
6Is the rhythm regular or irregular?
7Tachycardias The Down Dirty
- Common
- Need to recognize the bad boys!
- ACLS, etc
- 2 questions
- Is the QRS narrow (lt0.12 second or 2.5 small
boxes) or wide? - Wide complex Tachycardia-vs-Narrow Complex
Tachycardia - Is the rhythm regular or irregular?
8Normal Sinus Rhythm Rate 75
9- Sinus Arrythmia
- Typically a normal finding esp. in younger, fit
individuals - Due to changes in autonomic tone during
inspiration
10Tachycardias DDx(Rule of 3s!)
- Narrow Complex Regular
- Sinus Tachycardia
- Atrial Flutter
- Other supraventricular Tachycardia (SVT)
- AVNRT (A-V nodal reentrant tachycardias)
- Atrial reciprocating tachycardia (from
pre-excitation, ex WPW) - Ectopic atrial tachycardia
- Other uncommon causes
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12Sinus Tachycardiabut why?
- Other causes
- Fever
- Hyperthyroidism
- Effective volume depletion, hypotension
- Sepsis, Shock
- Anemia
- PE
- CHF
- Drugs (stimulants)
- Drug withdrawal (ETOH)
- Pheochromocytoma
- Physiologic (1)
- Response to exercise
- Stress, anger, etc.. (fight or flight)
13Atrial Flutter characteristics?
14Atrial Flutter characteristics?
15- Suspect A-flutter
- Narrow complex tachycardia
- F (flutter waves) rate of 300 (sawtooth)
- Ventricular rate 150 bpm
16Atrial Flutter what is happening in the heart!
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18Other Narrow Complex Tachycardiaa - AVNRT
Premature Atrial Complex (PAC)
NSR
- Regular, Narrow-complex tachycardia w/rate
120-220 - p buried or after QRS (usually) inverted
(retrograde) in leads I, II aVF - Most common non-fib/flutter SVT
19AVNRT
20Ectopic Atrial Tachycardia
- Regular narrow complex tachycardia
- Originates outside of the AV node
- Constant p wave morphology
- Constant P-R intervals
- Use the rule of sinus rhythm mind your ps
21Ectopic atrial tachycardia
22Ectopic atrial tachycardiaCan occur with block
(ie-digoxin toxicity)
23Tachycardias DDx
- Narrow Complex IR-regular
- Atrial Fibrillation (irregularly irregular)
- Atrial Flutter with variable A-V block
- MAT (Multifocal Atrial Tachycardia)
- Other Supraventricular tachycardias with variable
AV block
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26Atrial Fibrillation
- The most common arrythmia in older patients
- ECG
- Absent p-waves
- fibrillatory waves vary in appearance
- Irregularly irregular R-R intervals
- Typically narrow complex QRS (unless aberrant
conduction) - Bundle Branch Blocks / other blocks
- Re-entry (WPW)
- Rate gt 100 rapid ventricular response (RVR)
27Remember this?
A-flutter with variable AV-block
28MAT Multifocal Atrial Tachycardia
- Narrow complex, irregularly irregular
- Youre thinking A-fib, but
- You see clearly conducted p-waves
- p-waves are not all the same
- You see 3 different p-wave morphologies
- Multifocal
- Varying P-P R-R intervals
- Associated with lung disease (COPD),
theophylline, hypertension, etc
29MAT
30Narrow Complex Tachycardias - Review
- Regular
- Sinus Tachycardia
- Atrial Flutter
- Other SVT
- AVNRT (A-V nodal reentrant tachycardias)
- Atrial reciprocating tachycardia (from
pre-excitation, ex WPW) - Ectopic atrial tachycardia
- Others (uncommon)
- IR-regular
- Atrial Fibrillation (irregularly irregular)
- Atrial Flutter with variable A-V block
- MAT (Multifocal Atrial Tachycardia)
- Others
31Doctorcome quick!
32Wide Complex Tachycardias (WCT)
- A Big Dealmay require emergent treatment!
- A limited Differential Diagnosis
- Ventricular Tachycardia (VT)
- NOT Ventricular Tachycardia
- SVT w/aberrant conduction (Aberrancy)
- SVT w/pre-excitation (ie-WPW)
- What is aberrancy?
- Assume Ventricular Tachycardia until proven
otherwise - Esp. in a patient over 40 years old
33Doctor, hurry up read that EKG
34Wide Complex Tachycardia
- Rate gt 100 bpm
- QRS duration gt 0.12 seconds
- Again
- Regular vs- Irregular
35Wide Complex Tachycardia
- Regular
- Ventricular Tachycardia
- A REGULAR SVT w/Aberrant conduction
- Sinus tachycardia
- A-flutter
- AVNRT
- Atrial Tachycardia
36Wide Complex Tachycardia
- IR-Regular
- Ventricular Fibrillation
- An IR-Regular SVT w/Aberrant conduction
- Atrial fibrillation
- Aflutter with variable AV block
- MAT
- Special Case WPW A-fib
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39V-Tach vs- SVT w/Aberrancy
- Assume V-T until proven otherwise
- Treatment for SVT can kill a patient in VT
- Treatment for VT usually wont kill a patient in
SVT - Criteria Brugada, others (beyond our scope)
- AV dissociation, increased age, CV risk factors
VT - Fusion / Dresler beats VT
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41Wide, Fast Irregularly, Irregular WPW
(usually)
Special Treatment
42This patients resting EKG after you cardiovert
him
43Bradyarrythmias
- I. Pauses
- 1 cause of a pause is a non-conducted PAC
- II. Early, weird-looking beats
- PVC vs- PAC
- PVC
- Wide complex
- Compensatory pause
- PAC
- Narrow, no compensatory pause
44Bradyarrythmias
- I. Problem is sinus or at the AV node
- Sinus
- Sinus bradycardia
- Sinus Arrest
- AV Node
- 1st Degree AV block
- 2nd Degree
- Mobitz I (Wenkebach)
- Mobitz II
- 3rd Degree AVB
45- 2nd degree Mobitz I (Wenkebach)
- lengthening PR intervalthendropped beat
- Group Beating Wenkeback until proven
otherwise - Block at AV node
- Normal in young patients (high vagal tone)
- Think Meds (B-blockers, CCBs)
46- 2nd degree Mobitz II
- Constant PR intervalthen dropped beat
- Block always BELOW AV node (more serious)
- Never normal
- Likely needs a pacemaker
47- 3rd degree (complete) heart block
- A-V dissociation is present
- p waves march out
- Atrial rate gt ventricular rate
- Escape rhythm
- Clinical settings
- Likely needs a pacemaker
48Summary
- Follow the rules be systematic
- Tachycardia
- Narrow or Wide
- Regular or Irregular
- Bradycardia
- Mind your ps
- Know the basics
- Questions
- Now, lets do some examples