ecg 3
TRANSCRIPT
VVIVVI
Premature BeatsPremature BeatsPremature Atrial Contraction (PAC) Premature Atrial Contraction (PAC)
•Origin: Atrium (outside the Sinus Node)
•Mechanism: Abnormal Automaticity
•Characteristics: An abnormal P-wave occurring
earlier than expected, followed
by compensatory pause
•Origin: Atrium (outside the Sinus Node)
•Mechanism: Abnormal Automaticity
•Characteristics: An abnormal P-wave occurring
earlier than expected, followed
by compensatory pause
Premature Junctional ContractionPremature Junctional Contraction
•Origin: AV Node Junction
•Mechanism: Abnormal Automaticity
•Characteristics:A normally conducted complex with
an absent p-wave, followed by a
compensatory pause
•Origin: AV Node Junction
•Mechanism: Abnormal Automaticity
•Characteristics:A normally conducted complex with
an absent p-wave, followed by a
compensatory pause
Premature BeatsPremature BeatsPremature BeatsPremature Beats
Premature Ventricular Contractions (PVCs)
Premature Ventricular Contractions (PVCs)
•Origin: Ventricles
•Mechanism: Abnormal Automaticity
•Characteristics: A broad complex occurring earlier
than expected, followed by a compensatory pause
•Origin: Ventricles
•Mechanism: Abnormal Automaticity
•Characteristics: A broad complex occurring earlier
than expected, followed by a compensatory pause
Premature BeatsPremature BeatsPremature BeatsPremature Beats
•Origin: Varies within the Ventricle
•Mechanism: Abnormal Automaticity
•Characteristics:Each premature beat changes axis;
implies a different focus origin for each beat
•Origin: Varies within the Ventricle
•Mechanism: Abnormal Automaticity
•Characteristics:Each premature beat changes axis;
implies a different focus origin for each beat
Multifocal PVCMultifocal PVC
ABERRANT VENTRICULAR ABERRANT VENTRICULAR CONDUCTIONCONDUCTION
A term that describes temporary alteration of QRS A term that describes temporary alteration of QRS morphology under conditions where a normal QRS morphology under conditions where a normal QRS might be expected. The common types are:might be expected. The common types are:
1. Through normal conduction pathways:1. Through normal conduction pathways: Cycle-length dependent (Ashman phenomenon)Cycle-length dependent (Ashman phenomenon) Rate-dependent tachycardia or bradycardiaRate-dependent tachycardia or bradycardia
2. Through accessory pathways (e.g., Kent 2. Through accessory pathways (e.g., Kent bundle)bundle)
Ashman PhenomenonAshman Phenomenon
““Las Vegas” type betting Las Vegas” type betting odds of making the right odds of making the right
diagnosisdiagnosis
1) fat little initial r-wave,1) fat little initial r-wave, 2) notch or slur in the 2) notch or slur in the
downstroke of the S downstroke of the S wave, wave,
3) a 0.06 sec or more 3) a 0.06 sec or more delay from the delay from the beginning of the QRS to beginning of the QRS to the nadir of the S-wave.the nadir of the S-wave.
•1&2-90% Aberrant Conduction•3- 50-50%- not helpful•4 -100:1- Ventricular Ectopy•5 - m/p Vntricular with two exceptions :
• Some people with normal ECG’s do not have an initial little r-wave in the QRS of lead V1. If RBBB occurs in such a person the QRS morphology in V1 will be a qR instead of an rsR’.• In a person with a previous anterior or anteroseptal infarction the V1 QRS often has a QS morphology, and RBBB in such a person will also have a qR pattern.
"Cherchez le P sur le T"
a “critical rate” -a “tired” a “critical rate” -a “tired” but not “dead” bundle but not “dead” bundle
branchbranch
Don’t be fooled by first Don’t be fooled by first impressions. impressions. Not all FLBs Not all FLBs
are ventricular in originare ventricular in origin!!
Based on originBased on origin
• Sinus Tachycardia• Atrial Tachycardia•AVRT•AVNRT• Atrial Flutter• Atrial Fibrillation
• Sinus Tachycardia• Atrial Tachycardia•AVRT•AVNRT• Atrial Flutter• Atrial Fibrillation
Tachyarrhythmia Tachyarrhythmia ClassificationsClassifications
• Ventricular Fibrillation (VF)• Ventricular Fibrillation (VF)
• Ventricular Tachycardia (VT)• Ventricular Tachycardia (VT)
Sinus TachycardiaSinus Tachycardia
•Origin: Sinus Node•Rate: 100-180 BPM•Mechanism: Abnormal (Hyper)
Automaticity
Ectopic Atrial Tachycardia Ectopic Atrial Tachycardia and Rhythmand Rhythm
Ectopic, discrete looking, unifocal P' waves with atrial rate Ectopic, discrete looking, unifocal P' waves with atrial rate <250/min (not to be confused with slow atrial flutter).<250/min (not to be confused with slow atrial flutter).
Ectopic P' waves usually precede QRS complexes with P'R interval Ectopic P' waves usually precede QRS complexes with P'R interval < RP' interval (i.e., not to be confused with paroxysmal < RP' interval (i.e., not to be confused with paroxysmal supraventricular tachycardia with retrograde P waves shortly after supraventricular tachycardia with retrograde P waves shortly after the QRS complexes).the QRS complexes).
The above ECG shows sinus rhythm, a PVC, and the onset of ectopic The above ECG shows sinus rhythm, a PVC, and the onset of ectopic atrial tachycardia (note different P wave morphology)atrial tachycardia (note different P wave morphology)
Ventricular response may be 1:1 (as above ECG) or with varying Ventricular response may be 1:1 (as above ECG) or with varying degrees of AV block (especially in the setting of digitalis toxicity.degrees of AV block (especially in the setting of digitalis toxicity.
Ectopic atrial rhythm is similar to ectopic atrial tachycardia, but Ectopic atrial rhythm is similar to ectopic atrial tachycardia, but with HR < 100 bpm with HR < 100 bpm
Atrial FlutterAtrial Flutter
•Origin: Right & Left Atrium
•Mechanism: Reentry
•Characteristics: Rapid, regular p-waves
•Origin: Right & Left Atrium
•Mechanism: Reentry
•Characteristics: Rapid, regular p-waves
*Animation
Atrial Fibrillation (AF)Atrial Fibrillation (AF)
•Origin: Right and/or left atrium
•Mechanism: Multiple wavelets of reentry
•Rate 400 BPM
•Characteristics: Random, chaotic rhythm;
atria quiver; associated withirregular ventricular rhythm
•Origin: Right and/or left atrium
•Mechanism: Multiple wavelets of reentry
•Rate 400 BPM
•Characteristics: Random, chaotic rhythm;
atria quiver; associated withirregular ventricular rhythm
*Animation
Atrial Fibrillation (AF)Atrial Fibrillation (AF)
Multifocal FiringMultifocal FiringMultifocal FiringMultifocal FiringOther AF MechanismsOther AF Mechanisms
•Mechanism: Abnormal Automaticity (multi-sites)
•Characteristics:Many depolarization waves;
activation occurs asynchronously;not in rhythm with sinus node
•Mechanism: Abnormal Automaticity (multi-sites)
•Characteristics:Many depolarization waves;
activation occurs asynchronously;not in rhythm with sinus node
Atrial Flutter vs. Atrial Flutter vs. Atrial FibrillationAtrial Fibrillation
Atrial Flutter Atrial Flutter
Summary of Disease CharacteristicsSummary of Disease Characteristics
Underlying Underlying MechanismMechanismUnderlying Underlying MechanismMechanism
PatternPatternPatternPattern
Atrial RateAtrial Rate
Ventricular Ventricular RateRate
RhythmRhythm
Atrial RateAtrial Rate
Ventricular Ventricular RateRate
RhythmRhythm
Atrial FibrillationAtrial Fibrillation
Multiple wavelet reentryMultiple wavelet reentry Multiple/single focusMultiple/single focus
firingfiring
Multiple wavelet reentryMultiple wavelet reentry Multiple/single focusMultiple/single focus
firingfiring
Wavy baselineWavy baseline Wavy baselineWavy baseline
• 400400 BPMBPM
• Varies w/conductionVaries w/conduction
• Grossly IrregularGrossly Irregular
• 400400 BPMBPM
• Varies w/conductionVaries w/conduction
• Grossly IrregularGrossly Irregular
Reentry via macroReentry via macro
reentrant circuitreentrant circuit
Reentry via macroReentry via macro
reentrant circuitreentrant circuit
Saw tooth baselineSaw tooth baseline Saw tooth baselineSaw tooth baseline
250250 to 400 BPMto 400 BPM
Varies w/conductionVaries w/conduction
Usually regularUsually regular
250250 to 400 BPMto 400 BPM
Varies w/conductionVaries w/conduction
Usually regularUsually regular
F/S AVNRTF/S AVNRT
WPWWPW