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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
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The Electrocardiogram
R
T a U
P
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Q
PR
Interval
S
QRS
Interval
The Electrocardiogram
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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
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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
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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
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P-wave
Premature Atrial Complexes
• P wave Rhythm: Irregular
• P waves: Premature, often in the T-wave
• QRS complex: Normal or widened
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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
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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
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P-Wave
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P-Wave
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Atrial Tachycardia
Atrial Tachycardia with variable block
P-Waves are regular at 160 bpm
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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
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F-waves
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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
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Atrial Fibrillation
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Atrial Fibrillation
Premature Junctional Complexes
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•
•
•
Rhythm: Irregular
P waves: Retrograde
PR interval: < .12 sec or nonexistent
QRS complex: Normal or widened
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Premature Ventricular Complexes
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•
•
•
Rhythm: Irregular
P waves: Usually not seen
QRS complex: Wide > .12 sec
Compensatory pause
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Premature Ventricular Complexes
Compensatory pause
This distance
is double the
sinus
distance
This is the
sinus and
the QRS
distance
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Premature Ventricular Complexes
• Unifocal PVCs
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• Multifocal PVCs
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Premature Ventricular Complexes
Compensatory pause
This distance
is double the
sinus
distance
This is the
sinus and
the QRS
distance
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Interpolated PVC
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Premature Ventricular Complexes
Ventricular Bigeminy
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Pairs of PVCs
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Premature Ventricular Complexes
PVC on T-wave precipitating
Ventricular Tachycardia
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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
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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
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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
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Junctional Escape Complexes
Junctional Rhythm
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Ventricular Escape Complexes
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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
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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
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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
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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- ?
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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