ekg module
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ECG ModuleECG Module
The patient is an elderly man who presented to the emergency ward with dizziness
Rate – 42 bpm
Normal Sinus Rhythm
L axis deviationPR prolongation
Widened QRS
Peaked T waves
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Hyperkalemia (K 7.6) secondary to Hyperkalemia (K 7.6) secondary to acute renal failureacute renal failure
The earliest change (usu K>5.7) is a tall, peaked, most The earliest change (usu K>5.7) is a tall, peaked, most often often symmetrical (tented) T wave with a narrow basesymmetrical (tented) T wave with a narrow base Best seen in II,III, V2-4Best seen in II,III, V2-4 QRS complex may resemble RBBB, LBBB, LAFB, LPFBQRS complex may resemble RBBB, LBBB, LAFB, LPFB
Normal or decreased QTCNormal or decreased QTC QRS complex widens uniformly a level of 9 to 11 mEq/LQRS complex widens uniformly a level of 9 to 11 mEq/L Reduction in P-wave amplitude and PR prolongation Reduction in P-wave amplitude and PR prolongation
occurs K>7occurs K>7 At K>9 the P-wave becomes unrecognizableAt K>9 the P-wave becomes unrecognizable
SA and AV block as well as jxnal and escape rhythms can SA and AV block as well as jxnal and escape rhythms can also be seen.also be seen.
This 10-second rhythm shows at least three different rhythms! Can you find them?
Atrial Flutter Sinus BeatAtrial Fibrillation
Atrial FlutterAtrial Flutter Atrial rate is usu 250 to 350 bpm, but can be reduced to Atrial rate is usu 250 to 350 bpm, but can be reduced to
200 bpm with antiarrhythmic drugs200 bpm with antiarrhythmic drugs Ventricular Rate – usually half the atrial rateVentricular Rate – usually half the atrial rate
Significantly slower ventricular rate suggest AV nodal Significantly slower ventricular rate suggest AV nodal blockade or diseaseblockade or disease
ECG reveals regular sawtooth flutter waves best ECG reveals regular sawtooth flutter waves best visualized in II,III, AVf, or V1visualized in II,III, AVf, or V1 Inverted flutter waves in II and III are found in typical, type 1 Inverted flutter waves in II and III are found in typical, type 1
flutter due to counterclockwise re-entrant pathwayflutter due to counterclockwise re-entrant pathway Usually a regular rhythm except if there is variable blockUsually a regular rhythm except if there is variable block Flutter tends to be unstable and usually will revert to Flutter tends to be unstable and usually will revert to
sinus rhythm or degenerating into atrial fibrillationsinus rhythm or degenerating into atrial fibrillation
Atrial FibrillationAtrial Fibrillation Arrhythmia is characterized by wavelets propogating in Arrhythmia is characterized by wavelets propogating in
different directions different directions This caused disorganized atrial depolarization without effective This caused disorganized atrial depolarization without effective
atrial contractionatrial contraction On ECG, there are small irregular undulations of variable On ECG, there are small irregular undulations of variable
amplitudes called f wavesamplitudes called f waves Range from rates btw 350 and 600 bpm and commonly Range from rates btw 350 and 600 bpm and commonly
undetectable on surface ecgundetectable on surface ecg Represent multiple wavelets of depolarization generating larger Represent multiple wavelets of depolarization generating larger
vectorsvectors Ventricular response is grossly irregular and usu btw 100 Ventricular response is grossly irregular and usu btw 100
and 160 bpmand 160 bpm When ventricular rate is very rapid the rate may appear to be When ventricular rate is very rapid the rate may appear to be
more regularmore regular
Regular, Rate 93 bpm
Normal Sinus
Rhythm
R atrial enlargement
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Regular Ventricular Rate 90 bpm
Atrial Rate 180 bpm
Ventricular Rate 180 bpm
85-year-old patient with valvular heart disease and congestive heart failure. #18
Regular, Rate 88 bpm
P-wave downward in II,
Not Sinus Rhythm
Atrial rate – 220 with 2:1 AV block
Atrial TachycardiaAtrial Tachycardia AT is a regular, atrial rate >100 bpm originating outside the sinus AT is a regular, atrial rate >100 bpm originating outside the sinus
nodenode Arise from a single site in contrast to Arise from a single site in contrast to A. fib or flutter which involve multiple A. fib or flutter which involve multiple sites or circuitssites or circuits
Arise fromArise from Increased automaticity – Increased automaticity – acceleration of a nl automatic pacemakeracceleration of a nl automatic pacemaker Triggered activity – focal electrical events that are called Triggered activity – focal electrical events that are called
afterdepolarizationsafterdepolarizations Microreentry – in which slow conduction allows for allowing to regain it Microreentry – in which slow conduction allows for allowing to regain it
ability to become excitability forming a reentrant circuitability to become excitability forming a reentrant circuit Atrial rate usu bte 130 – 250 Atrial rate usu bte 130 – 250
P wave morphology can be similar or different to sinus P-wave P wave morphology can be similar or different to sinus P-wave depending on the origin of the pacemakerdepending on the origin of the pacemaker
Usu AV conduction is 1:1, but 2:1 block can occur if atrial rate>200 Usu AV conduction is 1:1, but 2:1 block can occur if atrial rate>200 and/or with significant AV nodal diseaseand/or with significant AV nodal disease
51-year-old female with palpitations. # 5
Regular Rate 142 bpm
No clear P waves before QRS – Not sinus rhythm
Retrograde P-waves, with short RP interval
Resting ECG in a 65 year-old male with complaint of palpitations.
Regular Rate 150 bpm
No clear P waves before QRS – Not sinus rhythm
Retrograde P-waves, with short RP interval
Mechanism of ReentryMechanism of Reentry
An impulse initiated in the SA node passes through both the AV node and the accessory pathway
A premature atrial impulse occurs and reaches the accessory pathway when it is refractory, but conduction occurs through the AV node
The impulse takes sufficient time to circulate through the AV node to allow the accessory pathway to recover initiating reentry
Mechanisms of Supraventricular Tachycardia
AVNRT – the AV node is divided into two pathways and the activation of the atria and ventricle is synchronous so the retrograde P-wave is buried. Account for 60% of SVT. Usu are 150-200 bpm
Orthodromic AVRT – mechanism seen on previous slide. Usually, L atrium is the first site retrograde atrial activation. Accounts for 30% of SVT
Widened QRS
Antidromic AVRT – activation occurs in the opposite direction resulting in wide complex tachycardia that is indistinguishable from V tach
Regular Rate 166 bpm
No clear P waves before QRS – Not sinus rhythm
Wide QRS 160 ms
RBBB pattern
DDx of regular wide complex
tachycardia (WCT)
1) V. Tach
2) SVT w/ aberrant conduction or preexisting block
- Sinus tachycardia - A. flutter - AVRT/AVNRT - A. tachycardia
Retrograde P-waves associated
with the QRS complex
PVC
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A question of aberrancyA question of aberrancy Occurs when a supraventricular Occurs when a supraventricular
impulse encounters persistant impulse encounters persistant refractoriness in part of the refractoriness in part of the ventricular conduction system ventricular conduction system Refractory periodRefractory period RR intervalRR interval
Aberration can result from a Aberration can result from a shortened RR interval and shortened RR interval and refractory period (1) or a lengthened refractory period (1) or a lengthened RR interval and refractory period (2)RR interval and refractory period (2)
Always initially assume wide QRS is Always initially assume wide QRS is ventricular ventricular 80% of WCT are VT80% of WCT are VT
Triphasic rsR’ in V1 and qR in V6 Triphasic rsR’ in V1 and qR in V6 favor aberrancyfavor aberrancy
If the QRS morphology is similar If the QRS morphology is similar to sinus rhythm, then WCT to sinus rhythm, then WCT unlikely ventricular in originunlikely ventricular in origin
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Regular, Ventricular Rate 150 bpm
Wide QRS complex 180 ms
1) V. Tach
2) SVT w/ aberrant conduction or preexisting block
- Sinus tachycardia - A. flutter - AVRT/AVNRT - A. tachycardia
DDx of regular wide complex
tachycardia (WCT)
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Ventricular TachycardiaVentricular Tachycardia VT consists of at least three consecutive QRS complexes VT consists of at least three consecutive QRS complexes
originating from the ventricles and recurring at a rapid rate (>120 originating from the ventricles and recurring at a rapid rate (>120 bpm)bpm)
As a consequence of ischemic heart diseaseAs a consequence of ischemic heart disease May appear almost immediately after prox obstruction of a major May appear almost immediately after prox obstruction of a major
coronary artery – tends to be unstable VT that can degenerate into Vfibcoronary artery – tends to be unstable VT that can degenerate into Vfib Weeks to months after an MI – more stable VT can occurWeeks to months after an MI – more stable VT can occur
Other – nonischemic cardiomyopathy (idiopathic dilated, HOCM), Other – nonischemic cardiomyopathy (idiopathic dilated, HOCM), RV outflow tract, medicationsRV outflow tract, medications
Distinguishing btw VT and SVT with aberrant conductionDistinguishing btw VT and SVT with aberrant conduction AV dissociationAV dissociation Fusion and Capture beatsFusion and Capture beats No RS pattern in any of the precordial leads suggests VTNo RS pattern in any of the precordial leads suggests VT BiphasicBiphasic Rsr or monophasic R waves are suggestive of VT Rsr or monophasic R waves are suggestive of VT
Sustained VT is defined if it lasts for >30 seconds or more than 10 Sustained VT is defined if it lasts for >30 seconds or more than 10 beatsbeats
RBBB
Missed Beat – not sinus rhythm
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AV blockAV block Delay or interruption in the transmission of an impulse Delay or interruption in the transmission of an impulse
from the atria to the ventricles due to an anatomical or from the atria to the ventricles due to an anatomical or functional impairment in the conduction system. functional impairment in the conduction system.
EtiologyEtiology Idiopathic progressive cardiac conduction disease (rare)Idiopathic progressive cardiac conduction disease (rare) Ischemic heart disease (approx 40%)Ischemic heart disease (approx 40%) DrugsDrugs Increased vagal toneIncreased vagal tone Valvular disease – calcification of aortic and mitral valveValvular disease – calcification of aortic and mitral valve Infection – Lyme disease, toxoplasmosis, endocarditis, syphilis Infection – Lyme disease, toxoplasmosis, endocarditis, syphilis
diphthiria, rheumatic feverdiphthiria, rheumatic fever Infitrative process – sarcoidosis, amyloidInfitrative process – sarcoidosis, amyloid Inflammatory – SLE, rheumatoidInflammatory – SLE, rheumatoid HyperkalemiaHyperkalemia
Wenckebach: Mobitz type 1Wenckebach: Mobitz type 1 Almost always involves the AV nodeAlmost always involves the AV node Marked by gradual lengthening of the PR interval and a Marked by gradual lengthening of the PR interval and a
gradual shortening of the RR interval and an eventual dropped gradual shortening of the RR interval and an eventual dropped beatbeat The first PR interval of the second cycle will invariably be The first PR interval of the second cycle will invariably be
shorter than the last PR interval of the preceding cycleshorter than the last PR interval of the preceding cycle Progressive PR interval occurs because each atrial impulse Progressive PR interval occurs because each atrial impulse
arrives progressively earlier in the refractory period of the AV arrives progressively earlier in the refractory period of the AV nodenode This it takes progressively longer to penetrate the node and This it takes progressively longer to penetrate the node and
reach the ventriclesreach the ventricles Maximal increase in the PR interval happens btw the first and Maximal increase in the PR interval happens btw the first and
second cycle, and the increase becomes successively smaller second cycle, and the increase becomes successively smaller in subsequent cyclesin subsequent cycles This leads to progressively shortening of the RR intervalThis leads to progressively shortening of the RR interval
LBBB
Non conducting beat
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Atrial rate 88 bpm
Ventricular rate 50 bpm
Complete Heart BlockComplete Heart Block Always produces AV disassociationAlways produces AV disassociation
Independent atrial and ventricular rateIndependent atrial and ventricular rate But AV disassociation can be caused byBut AV disassociation can be caused by
Decreased sinus automaticty, junctional or ventricular Decreased sinus automaticty, junctional or ventricular escape, ventricular tachycardia which make the AV node escape, ventricular tachycardia which make the AV node refractory so the sinus impulse cannot traverse the AV noderefractory so the sinus impulse cannot traverse the AV node
If the sinus rate < ventricular rate then one must If the sinus rate < ventricular rate then one must consider that a junctional or ventricular consider that a junctional or ventricular pacemaker has taken over pacemaker has taken over
If the sinus rate > ventricular rate, then If the sinus rate > ventricular rate, then complete heart block becomes apparent, as both complete heart block becomes apparent, as both the atrial and ventricular complexes maintain the atrial and ventricular complexes maintain independent rhythmsindependent rhythms
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