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Arrhythmia Recognition An Emergency View DR. SATHISH BABU P Emergency & Critical care Physician Vinayaka Mission University SALEM A&E Vinayaka Cardiac conduction A&E Vinayaka A&E Vinayaka A&E Vinayaka ELECTROCARDIOGRAM “5” steps approach to arrhythmias Step1: Is there a “QRS” Step2: Is there a “P” Wave Step3: What is the relationship between the P waves and the QRS complexes? Step4: Calculate rate Step5:Miscellaneous A&E Vinayaka 1) Is there a “QRS” (No pulse) YES NARROW NO WIDE CHAOTIC FLAT LINE PEA Asystole VT VF A&E Vinayaka No “QRS” & Chaotic A&E Vinayaka No QRS & Flat line A&E Vinayaka Wide QRS A&E Vinayaka Wide QRS A&E Vinayaka Wide QRS & Polymorphic A&E Vinayaka 2) Is there a “P” Wave YES NO RR Interval RATE MORPHOLOGY VARY 220 to 350 Inverted AF Atrial Flutter CONSTANT JUNCTIONAL JUNCTIONAL A&E Vinayaka A&E Vinayaka A&E Vinayaka No “P” & Varying “RR” interval A&E Vinayaka 3)What is the relationship between the P waves and the QRS complexes? A&E Vinayaka HEART BLOCK Yes n“P” = n“QRS” ? PR interval < 0.2 Normal No PR interval Constant ? > 0.2 Io AVB No Yes RR interval IIo AVB type 2 Constant? Yes IIIoAVB No Type1 IIo A&E Vinayaka st 1 Degree block (AV Nodal Delay) A&E Vinayaka P-R Interval IST Degree heart block n“P” = n“QRS” ? P-R interval is >0.2 Sec A&E Vinayaka HEART BLOCK Yes n“P” = n“QRS” ? PR interval < 0.2 Normal No PR interval Constant ? > 0.2 Io AVB No Yes RR interval IIo AVB type 2 Constant? Yes IIIoAVB No Type1 IIo A&E Vinayaka A&E Vinayaka n“P” is not equal to n“QRS”? PR interval is constant A&E Vinayaka HEART BLOCK Yes n“P” = n“QRS” ? PR interval < 0.2 Normal No PR interval Constant ? > 0.2 Io AVB No Yes RR interval IIo AVB type 2 Constant? Yes IIIoAVB No Type1 IIo A&E Vinayaka A&E Vinayaka IIIrd Degree heart block n“P” is not equal to n“QRS”? PR intervals are not constant RR intervals are constant A&E Vinayaka A&E Vinayaka HEART BLOCK Yes n“P” = n“QRS” ? PR interval < 0.2 Normal No PR interval Constant ? > 0.2 Io AVB No Yes RR interval IIo AVB type 2 Constant? Yes IIIoAVB No Type1 IIo A&E Vinayaka A&E Vinayaka IInd Degree Type-I heart block n“P” is not equal to n“QRS” ? Both PR and RR intervals are not constant PROGRESSIVE PROLONGATION OF ‘P-R’ INTERVAL DROPPED ‘QRS’ COMPLEX A&E Vinayaka A&E Vinayaka 4)Calculating Heart Rates A Count the number of R waves in a 6-second strip and multiply by 10.(especially for irregular rhythm) •Not very accurate •Used only with very quick estimate A&E Vinayaka B Calculating Heart Rates(cont..) Count the number of large squares between two consecutive R waves and 300 / Big squares •Very quick •Not very accurate with fast rates •Used only with regular rhythms A&E Vinayaka C Calculating Heart Rates (cont..) Count the number of small squares between two consecutive R waves and or 1500 / small squares. . •Most accurate •Used only with regular rhythms •Time consuming A&E Vinayaka Calculating Heart Rates (cont..) Count the number of BIG squares between D two consecutive R waves in descending order as 300,150,100,75,60,50... •Not very accurate •Used only with regular rhythms •Time saving A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka A&E Vinayaka Supraventricular Tachycardia • Narrow complex • Regular Rate 140 to 220 / minute A&E Vinayaka A&E Vinayaka VT SVT with aberrancy • Capture beat • Fusion beat • Concordance • NO capture or fusion beats • Concordance leads will not have the same polarity • Time required to reach either the peak of R wave / the nadir of the S wave > 0.07 second • Time required to reach either the peak of R wave / the nadir of the S wave < 0.07 second A&E Vinayaka A&E Vinayaka A&E Vinayaka ECG Criteria • Concordance –All the ventricular complexes in V1 –V6 is negative or positive diagnosis – VT –Concordant negativity – RVT –Concordant positivity – LVT A&E Vinayaka VT SVT with aberrancy • Tall R – VT Tall R1 - RBBB A triphasic QRS • A complete or morphology in almost complete lead V6absence of any Diagnostic of SVT positive deflection with aberrancy in V6 (QS or rS) – Diagnostic of VT A&E Vinayaka Tall R1 - RBBB Tall R – VT complete absence of any positive deflection in V6 A triphasic QRS A&E Vinayaka ventricular tachycardia ventricular aberration Monophasic R rsR1 pattern rS qRs pattern QS A&E Vinayaka MISCELLANEOUS A&E Vinayaka ELECTROCARDIOGRAM “5” steps approach to arrhythmias Step2: Fix the regularity Regular I I I Premature I I I Escape I I I IIrregular I I I I I I I I I I I I IA&E IVinayaka I I I PREMATURE COMPLEX ANY COMPLEX COMING BEFORE THE NEXT EXPECTED PERIOD WIDE (VENTRICULAR) NARROW (ATRIAL/JUNCTIONAL) A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka ESCAPE COMPLEX ANY COMPLEX COMING AFTER A PAUSE WIDE NARROW (VENTRICULAR) (ATRIAL/JUNCTIONAL) A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka ELECTROCARDIOGRAM A&E Vinayaka A&E Vinayaka A&E Vinayaka