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ECG Interpretation Advanced Cardiac Life Support William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro advancing health worldwide TM Department of Anesthesia and Perioperative Care Course Objectives & Description: • Recognize & initiate early management of periarrest conditions that may result in cardiac arrest • Manage cardiac arrest until return of spontaneous circulation, or transfer of care • Understanding of arrhythmia interpretation • Recognize the hemodynamic consequences of arrhythmias Normal Sinus Rhythm Normal sinus rhythm results from the initiation of an electrical signal (the cardiac impulse) by cells of the sinus node at a rate appropriate to the age and state of activity of the individual, and then the propagation of that signal in an orderly manner through the atria, AV junction, ventricular specialized conducting system and the ventricular myocardium Cardiac Conduction System Bachmann’s bundle Sinus node Internodal pathways AV node Bundle of His Left bundle branch Posterior division Anterior division Right bundle branch Purkinje fibers Arrhythmia An arrhythmia reflects either abnormally rapid or slow impulse initiation by the sinus node, or interruption of the sinus rhythm by impulses originating from some other site in the heart, either for short or long periods of time Mechanisms of Arrhythmias • Reentry • Automaticity –Altered normal automaticity –Abnormal automaticity • Triggered Rhythms due to DAD (delayed after depolarizations Causes of Arrhythmias • Physiologic and Pathologic Processes –Vagal stimulation, Fever, Hypothermia –Electrolyte abnormalities, CNS problems –Hypovolemia, Pain, anaphylaxis, etc. • Preexisting Cardiac & Pulmonary Disease –Acute coronary syndrome, HTN, AODM –COPD, hypoxia, hypercarbia The Electrocardiogram QuickTime™ and a decompressor are needed to see this picture. The Electrocardiogram R T a U P and QuickTime™ decompressor are needed to see this picture. Q PR Interval S QRS Interval The Electrocardiogram QuickTime™ and a decompressor are needed to see this picture. PR Interval QRS Interval QT Interval Cardiac Conduction System Relationship of ECG to anatomy Cardiac Conduction System Relationship of ECG to anatomy ACLS THE ACLS PROVIDER IS: IN Normal Sinus Rhythm • Rate 60-100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF Determining the Rate Determining the Rate QuickTime™ and a decompressor are needed to see this picture. Determining the Rhythm Sinus Tachycardia • Rate: Greater than 100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF Sinus Tachycardia • Rate: Greater than 100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Sinus Bradycardia • Rate: Less than 60 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF Sinus Bradycardia • Rate: Less than 60 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: Normal or widened QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. P-wave Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: Normal or widened QuickTime™ and a decompressor are needed to see this picture. Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: (Normal or widened) or blocked Non conducted P-wave QuickTime™ and a decompressor are needed to see this picture. Atrial Tachycardia • Rate: Atrial- 140-240 bpm, p-waves hard to see • Rhythm: – P-wave- regular – QRS- 1-1 conduction with atrial rates < 200 bpm – With atrial rates > 200 bpm, A-V conduction block common (less than 1-1 conduction) • PR interval- depends on the origin of the p-wave • QRS- usually normal Atrial Tachycardia QuickTime™ and a decompressor are needed to see this picture. P-Wave QuickTime™ and a decompressor are needed to see this picture. P-Wave QuickTime™ and a decompressor are needed to see this picture. Atrial Tachycardia Atrial Tachycardia with variable block P-Waves are regular at 160 bpm QuickTime™ and a decompressor are needed to see this picture. Atrial Flutter • Rate: Atrial- 300 bpm (260-320) • Rhythm: – P-waves- regular – QRS- 2-1 conduction - 150 bpm, variable AV conduction with constant AV conduction ratio • P-waves: F-waves (Flutter), sawtooth pattern • QRS- usually normal, obviously sometimes wide Atrial Flutter QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. F-waves QuickTime™ and a decompressor are needed to see this picture. Atrial Flutter Atrial Flutter with variable conduction (block) Atrial Fibrillation • Rate: Atrial- rapid, Ventricular- Depends • Rhythm: – P-waves- irregular – QRS- beat to beat variability, Irregularly irregular • P-waves: From F-waves (Flutter) to absent • QRS duration- normal or wide Atrial Fibrillation QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Atrial Fibrillation QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Atrial Fibrillation Premature Junctional Complexes • • • • Rhythm: Irregular P waves: Retrograde PR interval: < .12 sec or nonexistent QRS complex: Normal or widened QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes • • • • Rhythm: Irregular P waves: Usually not seen QRS complex: Wide > .12 sec Compensatory pause QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes Compensatory pause This distance is double the sinus distance This is the sinus and the QRS distance QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes • Unifocal PVCs QuickTime™ and a decompressor are needed to see this picture. • Multifocal PVCs QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes Compensatory pause This distance is double the sinus distance This is the sinus and the QRS distance QuickTime™ and a decompressor are needed to see this picture. Interpolated PVC QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes Ventricular Bigeminy QuickTime™ and a decompressor are needed to see this picture. Pairs of PVCs QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Premature Ventricular Complexes PVC on T-wave precipitating Ventricular Tachycardia QuickTime™ and a decompressor are needed to see this picture. Ventricular Tachycardia • Rate: Approx 100-230 bpm • Rhythm: Usually regular • P waves: Usually not seen – Independent A and V activity – A-V dissociation • QRS complex: Wide > .12 sec • Capture beats, fusion beats Ventricular Tachycardia QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Ventricular Tachycardia Polymorphic Ventricular Tachycardia Ventricular Fibrillation • • • • Rate: Rapid- no effective cardiac rhythm Rhythm: Irregular P, QRS, T- waves: Absent No blood pressure! Ventricular Fibrillation Course VF Fine VF Ventricular Fibrillation Ventricular Asystole • P, QRS, T- waves: Complete absent of cardiac electrical activity • Complete absent of effective cardiac pumping function Acute Coronary Syndromes QuickTime™ and a decompressor are needed to see this picture. Acute Coronary Syndromes Acute Coronary Syndromes Review Review Atrial Fibrillation Review Atrial Fibrillation Sinus Rhythm Review Atrial Fibrillation Sinus Rhythm Acute Coronary Syndrome Review Review Asystole Review Asystole Fine Ventricular Fibrillation Review Asystole Fine Ventricular Fibrillation Coarse Ventricular Fibrillation Review Review Ventricular Tachycardia- ? Review Ventricular Tachycardia- ? Premature Ventricular Complex (PVC) Review Ventricular Tachycardia- ? Premature Ventricular Complex (PVC) Ventricular Tachycardia Review Review Ventricular Tachycardia Review Ventricular Tachycardia Ventricular Tachycardia Review Ventricular Tachycardia Ventricular Tachycardia (Paroxsymal) Atrial Tachycardia (SVT) Review Review Paroxsymal Atrial Tachycardia (SVT) Review Paroxsymal Atrial Tachycardia (SVT) Atrial Flutter Treatment of All Cardiac Arrhythmias All arrhythmias that are hemodynamically significant require immediate cardioversion, defibrillation, or cardiac pacing Break Time AV Block • Why is it important? • Where is the block? • What’s a pacemaker anyway? Rates of Intrinsic Cardiac Pacemakers • Primary pacemaker –Sinus node (60-100 bpm) • Escape pacemakers –AV junction (40-60 bpm) –Ventricular (< 40 bpm) Escape Patterns Junctional Escape Complexes • Rate: Junctional escape rate 40-60 bpm • Rhythm: Junctional • P-waves: Retrograde, inverted in 2,3, avf –Before, during, or after QRS • QRS: Normal or wide Junctional Escape Complexes QuickTime™ and a decompressor are needed to see this picture. Junctional Escape Complexes Junctional Rhythm QuickTime™ and a decompressor are needed to see this picture. Ventricular Escape Complexes QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Classification of AV Block • Partial – First-degree AV block – Second-degree AV block, Types I (Wenckebach) and Type II • Complete AV block – Third-degree AV Block “You should know the major AV blocks because important treatment decisions are based on the type of block present.” Page 79 First-Degree AV Block • Rhythm: Regular • 1:1 Conduction: Each P-wave is followed by a QRS complex • PR Interval: > .20 secs • QRS Complex: Generally normal • Hemodynamic implications: None First-Degree AV Block Second-Degree AV Block, Type I • Rate: – Atrial- regular – Ventricular- less than the atrial rate • Rhythm: – Atrial- regular – Ventricular- progressive shortening of the R-R interval before pause • PR: progressive increase until P blocked • Why is knowing this important Second-Degree AV Block, Type I QuickTime™ and a decompressor are needed to see this picture. Second-Degree AV Block, Type II • Rate: – Atrial- regular – Ventricular- less than the atrial rate • Rhythm: – Atrial- regular – Ventricular- usually irregular • PR: constant when present • Why is knowing this important Second-Degree AV Block, Type II QuickTime™ and a decompressor are needed to see this picture. Third-Degree AV Block • Rate: – Atrial- regular – Ventricular- less than the atrial rate • Rhythm: – Atrial- regular – Ventricular- regular • PR: varies with every beat • QRS: normal or wide • Hemodynamics: No atrial contribution Third-Degree AV Block Third-Degree AV Block Electrical Therapy All arrhythmias that are hemodynamically significant require immediate cardioversion, defibrillation, or cardiac pacing Electrical Therapy • Understand when cardioversion or defibrillation is indicated • Know the difference between unsynchronized and synchronized shocks • Energy doses for specific rhythms • Challenges of delivering shocks safely and effectively- may include iv sedation Cardioversion and Defibrillation • Understand when cardioversion or defibrillation is indicated SYMPTOMS SYMPTOMS SYMPTOMS Hemodynamically Significant Tachycardia or Bradycardia • • • • • Hypotension (Systolic BP < 80 mmHg) Altered mental status Congestive heart failure Angina Does not respond promptly to medical management, if tried Cardioversion and Defibrillation Defibrillation The electric shock depolarizes all excitable myocardium, interrupts reentrant circuits, discharges foci, and establishes electrical homogeneity Cardioversion and Defibrillation Defibrillation • AED: Learn the one in your setting • Biphasic: 200 watt-seconds (joules) • Monophasic: 360 watt-seconds (joules) “The interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest.” Page 35 Cardioversion and Defibrillation Cardioversion and Defibrillation Procedure for Defibrillation • • • • • • Power on Apply pads Analyze the rhythm Select the energy level Clear the area Discharge the device Cardioversion and Defibrillation Cardioversion • Know when cardioversion is indicated • Synchronized vs unsynchronized shock • What energy level for what arrhythmias • Establish iv and consider sedation Cardioversion and Defibrillation Cardioversion Anesthetic (amnestic) Agents A physician skilled in airway management (ie., an anesthesiologist) should be in attendance, and all necessary equipment for emergency resuscitation should be immediately available Cardioversion and Defibrillation Cardioversion The electric shock depolarizes all excitable myocardium, interrupts reentrant circuits, discharges foci, and establishes electrical homogeneity Cardioversion and Defibrillation Synchronization Synchronized cardioversion (defibrillation) uses a sensor to deliver the shock with the peak of the QRS complex. The goal is to avoid the shock on the T-wave, “R-on-T”, which is known to induce ventricular fibrillation in unstable hearts The Electrocardiogram QuickTime™ and a decompressor are needed to see this picture. PR Interval QRS Interval QT Interval Cardioversion and Defibrillation Synchronization Energy Selection • Atrial flutter & SVT: 50-100 J (monphasic) • Atrial fibrillation: 100-200 J (monophasic) • Ventricular tachycardia: 100-200 J Cardioversion and Defibrillation Procedure for Cardioversion • • • • • • • Power on Apply pads Turn on the SYNC control Analyze the rhythm Select the energy level Clear the area Discharge the device Cardioversion and Defibrillation Complications of Cardioversion • Ventricular fibrillation occurs • Turn off the SYNC control • Charge to 200 J (or more) • Clear the area • Discharge the device Review Review 3rd Degree Heart Block Review 3rd Degree Heart Block 2nd Degree Type II Block Review 3rd Degree Heart Block 2nd Degree Type II Block 2nd Degree Type I Block Review Review 1st Degree Heart Block Review 1st Degree Heart Block Junctional Escape Rhythm Review 1st Degree Heart Block Junctional Escape Rhythm Sinus Bradycardia Review Ventricular Tachycardia- ? QuickTime™ and a decompressor are needed to see this picture. ECG Interpretation Advanced Cardiac Life Support That’s it- Now go forth and save livesMake us all proud you’re from UCSF William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro advancing health worldwide TM Department of Anesthesia and Perioperative Care