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ECG Tutorial: Rhythm Recognition

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ECG Tutorial: Rhythm Recognition Review the systematic approach Rhythm the hardest part! Again be systematic Mind your p s & q s & follow the rules! – PowerPoint PPT presentation

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Title: ECG Tutorial: Rhythm Recognition


1
ECG 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

2
ECG 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

3
Rhythm 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!)

4
Rhythm
Is there a p wave? Sinus
Is it followed by a QRS?
5
How does the heart work
6
Is the rhythm regular or irregular?
7
Tachycardias 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?

8
Normal Sinus Rhythm Rate 75
9
  • Sinus Arrythmia
  • Typically a normal finding esp. in younger, fit
    individuals
  • Due to changes in autonomic tone during
    inspiration

10
Tachycardias 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

11
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12
Sinus 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)

13
Atrial Flutter characteristics?
14
Atrial Flutter characteristics?
15
  • Suspect A-flutter
  • Narrow complex tachycardia
  • F (flutter waves) rate of 300 (sawtooth)
  • Ventricular rate 150 bpm

16
Atrial Flutter what is happening in the heart!
17
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18
Other 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

19
AVNRT
20
Ectopic 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

21
Ectopic atrial tachycardia
22
Ectopic atrial tachycardiaCan occur with block
(ie-digoxin toxicity)
23
Tachycardias 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

24

25
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26
Atrial 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)

27
Remember this?
A-flutter with variable AV-block
28
MAT 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

29
MAT
30
Narrow 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

31
Doctorcome quick!
32
Wide 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

33
Doctor, hurry up read that EKG
34
Wide Complex Tachycardia
  • Rate gt 100 bpm
  • QRS duration gt 0.12 seconds
  • Again
  • Regular vs- Irregular

35
Wide Complex Tachycardia
  • Regular
  • Ventricular Tachycardia
  • A REGULAR SVT w/Aberrant conduction
  • Sinus tachycardia
  • A-flutter
  • AVNRT
  • Atrial Tachycardia

36
Wide 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

37
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38
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39
V-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

40
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41
Wide, Fast Irregularly, Irregular WPW
(usually)
Special Treatment
42
This patients resting EKG after you cardiovert
him
43
Bradyarrythmias
  • 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

44
Bradyarrythmias
  • 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

48
Summary
  • 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
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