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ECG Rhythm Interpretation

ECG Basics

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Objectives

To recognize the normal rhythm of the

heart - Normal Sinus Rhythm.

To recognize the 13 most common

rhythm disturbances.

To recognize an acute myocardialinfarction on a 12-lead ECG.

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Learning Modules

ECG Basics

How to Analyze a Rhythm Normal Sinus Rhythm

Heart Arrhythmias

Diagnosing a Myocardial Infarction

Advanced 12-Lead Interpretation

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Normal Impulse ConductionSinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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Impulse Conduction & the ECGSinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

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The PQRST

P wave - Atrial

depolarization

T wave-Ventricular

repolarization

QRS-Ventricular

depolarization

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The PR Interval

Atrial depolarization

+

delay in AV junction

(AV node/Bundle of His)

(delay allows time forthe atria to contract

before the ventricles

contract)

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Pacemakers of the Heart

SA Node- Dominant pacemaker with an

intrinsic rate of 60 - 100 beats/minute.

AV Node- Back-up pacemaker with an

intrinsic rate of 40 - 60 beats/minute.

Ventricular cells- Back-up pacemakerwith an intrinsic rate of 20 - 45 bpm.

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The ECG Paper

Horizontally

One small box - 0.04 s

One large box - 0.20 s

Vertically

One large box - 0.5 mV

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The ECG Paper (cont)

Every 3 seconds (15 large boxes) ismarked by a vertical line.

This helps when calculating the heart

rate.NOTE:the following strips are not marked

but all are 6 seconds long.

3 sec 3 sec

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How to Analyze a Rhythm

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Objectives

To recognize the normal rhythm of the

heart - Normal Sinus Rhythm.

To recognize the 13 most common

rhythm disturbances.

To recognize an acute myocardialinfarction on a 12-lead ECG.

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Rhythm Analysis

Step 1: Calculate rate.

Step 2: Determine regularity.

Step 3: Assess the P waves. Step 4: Determine PR interval.

Step 5: Determine QRS duration.

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Step 1: Calculate Rate

Option 1

Count the # of R waves in a 6 second

rhythm strip, then multiply by 10.

Reminder: all rhythm strips in the Modules

are 6 seconds in length.

Interpretation? 9 x 10 = 90 bpm

3 sec 3 sec

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Option 2

Find a R wave that lands on a bold line.

Count the # of large boxes to the next Rwave. If the second R wave is 1 large box

away the rate is 300, 2 boxes - 150, 3

boxes - 100, 4 boxes - 75, etc. (cont)

R wave

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Option 2 (cont)

Memorize the sequence:

300 - 150 - 100 - 75 - 60 - 50

Interpretation?

30

0

15

0

10

0

7

5

6

0

5

0

Approx. 1 box less than

100 = 95 bpm

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Step 2: Determine regularity

Look at the R-R distances (using a caliper ormarkings on a pen or paper).

Regular (are they equidistant apart)?

Occasionally irregular? Regularly irregular?Irregularly irregular?

Interpretation? Regular

R R

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Step 3: Assess the P waves

Are there P waves?

Do the P waves all look alike?

Do the P waves occur at a regular rate? Is there one P wave before each QRS?

Interpretation? Normal P waves with 1 P

wave for every QRS

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Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation? 0.12 seconds

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Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation? 0.08 seconds

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Rhythm Summary

Rate 90-95 bpm

Regularity regular

P waves normal

PR interval 0.12 s QRS duration 0.08 s

Interpretation? Normal Sinus Rhythm

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Normal Sinus Rhythm

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Normal Sinus Rhythm (NSR)

Etiology:the electrical impulse is formed

in the SA node and conducted normally.

This is the normal rhythm of the heart;

other rhythms that do not conduct viathe typical pathway are called

arrhythmias.

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NSR Parameters

Rate 60 - 100 bpm

Regularity regular P waves normal

PR interval 0.12 - 0.20 s

QRS duration 0.04 - 0.12 sAny deviation from above is sinus

tachycardia, sinus bradycardia or an

arrhythmia

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Arrhythmia Formation

Arrhythmias can arise from problems in

the:

Sinus node

Atrial cells

AV junction

Ventricular cells

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SA Node Problems

The SA Node can:

fire too slow

fire too fast

Sinus Bradycardia

Sinus Tachycardia

Sinus Tachycardia may be an appropriate

response to stress.

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Atrial Cell Problems

Atrial cells can:

fire occasionally

from a focus

fire continuously

due to a looping

re-entrant circuit

Premature Atrial

Contractions (PACs)

Atrial Flutter

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Teaching Moment

A re-entrant

pathway occurs

when an impulseloops and results

in self-

perpetuatingimpulse

formation.

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Atrial Cell Problems

Atrial cells can also:

fire continuously

from multiple focior

fire continuously

due to multiplemicro re-entrant

wavelets

Atrial Fibrillation

Atrial Fibrillation

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Teaching Moment

Multiple micro re-

entrant wavelets

refers to wandering

small areas ofactivation which

generate fine chaotic

impulses. Collidingwavelets can, in turn,

generate new foci of

activation.

Atrial tissue

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AV Junctional Problems

The AV junction can:

fire continuously

due to a looping

re-entrant circuit

block impulses

coming from theSA Node

Paroxysmal

Supraventricular

Tachycardia

AV Junctional Blocks

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Ventricular Cell Problems

Ventricular cells can:

fire occasionally

from 1 or more foci

fire continuously

from multiple foci

fire continuously

due to a looping

re-entrant circuit

Premature Ventricular

Contractions (PVCs)

Ventricular Fibrillation

Ventricular Tachycardia

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Sinus Rhythms andPremature Beats

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Arrhythmias

Sinus Rhythms

Premature Beats Supraventricular Arrhythmias

Ventricular Arrhythmias


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Sinus Rhythms

Sinus Bradycardia

Sinus Tachycardia

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Rhythm #1

30 bpm Rate?

Regularity? regular

normal

0.10 s

P waves?

PR interval? 0.12 s QRS duration?

Interpretation? Sinus Bradycardia

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Sinus Bradycardia

Deviation from NSR

- Rate < 60 bpm

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Sinus Bradycardia

Etiology:SA node is depolarizing slower

than normal, impulse is conducted

normally (i.e. normal PR and QRS

interval).

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Rhythm #2

130 bpm Rate?

Regularity? regular

normal

0.08 s

P waves?


Interpretation? Sinus Tachycardia

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Sinus Tachycardia

Deviation from NSR

- Rate > 100 bpm

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Sinus Tachycardia

Etiology:SA node is depolarizing faster

than normal, impulse is conductednormally.

Remember: sinus tachycardia is a

response to physical or psychologicalstress, not a primary arrhythmia.

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Premature Beats

Premature Atrial Contractions

(PACs)

Premature Ventricular Contractions

(PVCs)

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Rhythm #3

70 bpm Rate?

Regularity? occasionally irreg.

2/7 different contour

0.08 s

P waves?

PR interval? 0.14 s (except 2/7) QRS duration?

Interpretation? NSR with Premature Atrial

Contractions

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Deviation from NSR

These ectopic beats originate in the

atria (but not in the SA node),

therefore the contour of the P wave,

the PR interval, and the timing are

different than a normally generated

pulse from the SA node.

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Etiology:Excitation of an atrial cell

forms an impulse that is then conductednormally through the AV node and

ventricles.

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Teaching Moment

When an impulse originates anywhere in

the atria (SA node, atrial cells, AV node,

Bundle of His) and then is conductednormally through the ventricles, the QRS

will be narrow (0.04 - 0.12 s).

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Rhythm #4

60 bpm Rate?

Regularity? occasionally irreg.

none for 7thQRS

0.08 s (7th wide)

P waves?


Interpretation? Sinus Rhythm with 1 PVC

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PVCs

Deviation from NSR

Ectopic beats originate in the ventriclesresulting in wide and bizarre QRScomplexes.

When there are more than 1 prematurebeats and look alike, they are calleduniform. When they look different, they arecalled multiform.

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PVCs

Etiology:One or more ventricular cellsare depolarizing and the impulses are

abnormally conducting through the

ventricles.

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Teaching Moment

When an impulse originates in a

ventricle, conduction through the

ventricles will be inefficient and the QRSwill be wide and bizarre.

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Ventricular Conduction

NormalSignal moves rapidly

through the ventricles

AbnormalSignal moves slowly

through the ventricles

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Supraventricular and


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Arrhythmias

Sinus Rhythms

Premature Beats

Supraventricular Arrhythmias



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Atrial Fibrillation

Atrial Flutter

Paroxysmal Supraventricular

Tachycardia

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Rhythm #5

100 bpm Rate?

Regularity? irregularly irregular

none

0.06 s

P waves?

PR interval? none QRS duration?

Interpretation? Atrial Fibrillation

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Atrial Fibrillation

Deviation from NSR

No organized atrial depolarization, so

no normal P waves (impulses are not

originating from the sinus node).

Atrial activity is chaotic (resulting in an

irregularly irregular rate).

Common, affects 2-4%, up to 5-10% if

> 80 years old

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Atrial Fibrillation

Etiology:Recent theories suggest that it

is due to multiple re-entrant wavelets

conducted between the R & L atria.Either way, impulses are formed in a

totally unpredictable fashion. The AV

node allows some of the impulses topass through at variable intervals (so

rhythm is irregularly irregular).

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Rhythm #6

70 bpm Rate?

Regularity? regular

flutter waves

0.06 s

P waves?

PR interval? none QRS duration?

Interpretation? Atrial Flutter

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Atrial Flutter

Deviation from NSR

No P waves. Instead flutter waves (notesawtooth pattern) are formed at a rateof 250 - 350 bpm.

Only some impulses conduct throughthe AV node (usually every otherimpulse).

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Atrial Flutter

Etiology:Reentrant pathway in the right

atrium with every 2nd, 3rd or 4thimpulse generating a QRS (others are

blocked in the AV node as the node

repolarizes).

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Rhythm #7

74148 bpm Rate?

Regularity? Regularregular

Normalnone

0.08 s

P waves?

PR interval? 0.16 snone QRS duration?

Interpretation? Paroxysmal Supraventricular

Tachycardia (PSVT)

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PSVT

Deviation from NSR

The heart rate suddenly speeds up,

often triggered by a PAC (not seen

here) and the P waves are lost.

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PSVT

Etiology:There are several types of

PSVT but all originate above theventricles (therefore the QRS is narrow).

Most common: abnormal conduction inthe AV node (reentrant circuit looping in

the AV node).

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Rhythm #8

160 bpm Rate?

Regularity? regular

none

wide (> 0.12 sec)

P waves?

PR interval?

none QRS duration?

Interpretation? Ventricular Tachycardia

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Deviation from NSR

Impulse is originating in the ventricles

(no P waves, wide QRS).

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Etiology:There is a re-entrant pathway

looping in a ventricle (most commoncause).

Ventricular tachycardia can sometimesgenerate enough cardiac output to

produce a pulse; at other times no pulse

can be felt.

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Rhythm #9

none Rate?

Regularity? irregularly irreg.

none

wide, if recognizable

P waves?

PR interval?

none QRS duration?

Interpretation? Ventricular Fibrillation

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Deviation from NSR

Completely abnormal.

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Etiology:The ventricular cells are

excitable and depolarizing randomly.

Rapid drop in cardiac output and death

occurs if not quickly reversed

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Arrhythmias

Sinus Rhythms

Premature Beats




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AV Nodal Blocks

1st Degree AV Block

2nd Degree AV Block, Type I

2nd Degree AV Block, Type II

3rd Degree AV Block

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Rhythm #10

60 bpm Rate?

Regularity? regular

normal

0.08 s

P waves?

PR interval?

0.36 s QRS duration?

Interpretation? 1st Degree AV Block

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1st Degree AV Block

Deviation from NSR

PR Interval > 0.20 s

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1st Degree AV Block

Etiology:Prolonged conduction delay in

the AV node or Bundle of His.

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Rhythm #11

50 bpm Rate?

Regularity? regularly irregular

nl, but 4th no QRS

0.08 s

P waves?

PR interval?

lengthens QRS duration?

Interpretation? 2nd Degree AV Block, Type I

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Deviation from NSR

PR interval progressively lengthens,

then the impulse is completely blocked

(P wave not followed by QRS).

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Etiology:Each successive atrial impulse

encounters a longer and longer delay inthe AV node until one impulse (usually

the 3rd or 4th) fails to make it through

the AV node.

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2nd Degree AV Block, Type II

Etiology:Conduction is all or nothing

(no prolongation of PR interval);typically block occurs in the Bundle of

His.

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Rhythm #13

40 bpm Rate?

Regularity? regular

no relation to QRS

wide (> 0.12 s)

P waves?

PR interval?

none QRS duration?

Interpretation? 3rd Degree AV Block

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3rd Degree AV Block

Deviation from NSR

The P waves are completely blocked in

the AV junction; QRS complexes

originate independently from below the

junction.

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3rd Degree AV Block

Etiology:There is complete block of

conduction in the AV junction, so theatria and ventricles form impulses

independently of each other. Without

impulses from the atria, the ventriclesown intrinsic pacemaker kicks in at

around 30 - 45 beats/minute.

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Remember

When an impulse originates in a ventricle,

conduction through the ventricles will be

inefficient and the QRS will be wide and

bizarre.

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CARDIOGENIC SHOCKElectrocardiogram

Acute myocardial ischemia is diagnosed based on the

presence of ST-segment elevation, ST-segment

depression, or Q waves.

T-wave inversion, although a less sensitive finding, may

be seen in persons with myocardial ischemia..

A normal ECGdoes not rule out the possibility.

ECGs are often most helpful when they can be compared

with previous tracings.

ECG with right-sided chest leads may document RV

infarction and may be useful in prognosis in addition to

diagnosis.

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CARDIAC TAMPONADEWith a 12-lead electrocardiogram, the following findings are

suggestive but not diagnostic of pericardial tamponade.

Sinus tachycardia

Low-voltage QRS complexes

Electrical alternans (also observed during supraventricular and

ventricular tachycardia): Alternation of QRS complexes, usually ina 2:1 ratio, on electrocardiogram findings is called electrical

alternans. This is due to movement of the heart in the pericardial

space. Electrical alternans is also observed in patients with

myocardial ischemia, acute pulmonary embolism, and

tachyarrhythmias.

PR segment depression
http://emedicine.medscape.com/article/154706-overviewhttp://emedicine.medscape.com/article/154706-overviewhttp://emedicine.medscape.com/article/154706-overviewhttp://emedicine.medscape.com/article/154706-overview

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CARDIAC TAMPONADE

S

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PERIKARDITIS

Peradangan pada epikard

Gambaran EKG menyerupai

gambaran injuri pada epikard,

yaitu elevasi ST

Pada perikarditis yang hanyasedikit menimbulkan keradangan

pada epikard, EKG bisa normal.

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EKG Pada Perikarditis

Elevasi ST Biasanya luas, kecuali V1 dan aVR

Bentuk konkaf cekung ke atas

Kurang dari 5 mm

T menjadi terbalik, terutamasetelah segmen ST kembali ke

garis isoelektrik Tidak timbul Q

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Perikarditis akut

Elevasi ST kurang dari 5 mm, bentuk cekung keatas, tidak timbul Q

PERICARDITIS

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Findings: General

ST segment

Concave upward ("Smiley face")

Similar to early repolarization

Contrast with Myocardial Infarction

ST is convex upward in EKG in Acute MI

ST segment changes often diffuse

Contrast with focal changes on EKG in Acute MI

ST segment to T Waveratio (measure in lead V6)

Pericarditis: >0.25

Early Repolarization:

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