ECG Rhythm Interpretation

ECG Rhythm Interpretation
‡ Course Objectives
± To recognize the normal rhythm of the heart Normal Sinus Rhythm. ± To recognize the 13 most common rhythm disturbances. ± To recognize an acute myocardial infarction on a 12-lead ECG.

ECG Rhythm Interpretation
‡ Learning Modules
± ECG Basics ± How to Analyze a Rhythm ± Normal Sinus Rhythm ± Heart Arrhythmias ± Diagnosing a Myocardial Infarction

The ECG Paper (cont)
3 sec 3 sec

‡ Every 3 seconds (15 large boxes) is marked by a vertical line. ‡ This helps when calculating the heart rate. NOTE: the following strips are not marked but all are 6 seconds long.

The ECG Paper ‡ Horizontally ± One small box .5 mV .20 s ‡ Vertically ± One large box .0.0.0.04 s ± One large box .

Normal Impulse Conduction Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers .

100 beats/minute. . ‡ AV Node .Dominant pacemaker with an intrinsic rate of 60 .Back-up pacemaker with an intrinsic rate of 20 .45 bpm.60 beats/minute. ‡ Ventricular cells .Pacemakers of the Heart ‡ SA Node .Back-up pacemaker with an intrinsic rate of 40 .

Impulse Conduction & the ECG Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers .

The PQRST ‡ P wave .Atrial depolarization ‡ QRS .Ventricular depolarization ‡ T wave .Ventricular repolarization .

The PR Interval Atrial depolarization + delay in AV junction (AV node/Bundle of His) (delay allows time for the atria to contract before the ventricles contract) .

Learning Modules ‡ ‡ ‡ ‡ ‡ ‡ ECG Basics How to Analyze a Rhythm Normal Sinus Rhythm Heart Arrhythmias Diagnosing a Myocardial Infarction Advanced 12-Lead Interpretation .

Assess the P waves. Determine QRS duration. Determine PR interval.Rhythm Analysis ‡ ‡ ‡ ‡ ‡ Step 1: Step 2: Step 3: Step 4: Step 5: Calculate rate. . Determine regularity.

Interpretation? 9 x 10 = 90 bpm . ± Reminder: all rhythm strips in the Modules are 6 seconds in length. then multiply by 10.Step 1: Calculate Rate 3 sec 3 sec ‡ Option 1 ± Count the # of R waves in a 6 second rhythm strip.

etc.Step 1: Calculate Rate R wave ‡ Option 2 ± Find a R wave that lands on a bold line. ± Count the # of large boxes to the next R wave.150. (cont) . 3 boxes . 4 boxes .100. 2 boxes . If the second R wave is 1 large box away the rate is 300.75.

150 .50 Interpretation? Approx.Step 1: Calculate Rate 3 1 1 0 5 0 7 6 5 0 0 0 5 0 0 ‡ Option 2 (cont) ± Memorize the sequence: 300 .60 . 1 box less than 100 = 95 bpm .75 .100 .

‡ Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular? Interpretation? egular .Step 2: Determine regularity R R ‡ Look at the R-R distances (using a caliper or markings on a pen or paper).

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 .

Step 4: Determine PR interval ‡ Normal: 0.12 seconds . (3 .0.12 .20 seconds.5 boxes) Interpretation? 0.

08 seconds . (1 .12 seconds.04 .3 boxes) Interpretation? 0.Step 5: QRS duration ‡ Normal: 0.0.

08 s Normal Sinus Rhythm .Rhythm Summary ‡ Rate ‡ Regularity ‡ P waves ‡ PR interval ‡ QRS duration Interpretation? 90-95 bpm regular normal 0.12 s 0.

medicalppt.Learning Modules ‡ ‡ ‡ ‡ ‡ ECG Basics How to Analyze a Rhythm Normal Sinus Rhythm Heart Arrhythmias Diagnosing a Myocardial Infarction For more presentations www.com .blogspot.

com .medicalppt.blogspot.Sinus Rhythms ‡ Sinus Bradycardia ‡ Sinus Tachycardia For more presentations www.

medicalppt.10 s Interpretation? Sinus Bradycardia For more presentations www.blogspot.12 s 0.Rhythm #1 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 30 bpm regular normal 0.com .

medicalppt.Rate < 60 bpm For more presentations www.Sinus Bradycardia ‡ Deviation from NSR .com .blogspot.

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

‡ ‡ ‡ ‡ ‡

Rate? Regularity? P waves? PR interval? QRS duration?

130 bpm regular normal 0.16 s 0.08 s

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 conducted normally. ‡ Remember: sinus tachycardia is a response to physical or psychological stress, not a primary arrhythmia.

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com .blogspot.Premature Beats ‡ Premature Atrial Contractions (PACs) ‡ Premature Ventricular Contractions (PVCs) For more presentations www.medicalppt.

2/7 different contour 0.com .14 s (except 2/7) 0.blogspot.Rhythm #3 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 70 bpm occasionally irreg.08 s Interpretation? NSR with Premature Atrial Contractions For more presentations www.medicalppt.

the PR interval.Premature Atrial Contractions ‡ Deviation from NSR ± These ectopic beats originate in the atria (but not in the SA node). and the timing are different than a normally generated pulse from the SA node. therefore the contour of the P wave.medicalppt.blogspot. For more presentations www.com .

Premature Atrial Contractions ‡ Etiology: Excitation of an atrial cell forms an impulse that is then conducted normally through the AV node and ventricles.com .medicalppt.blogspot. For more presentations www.

medicalppt. Bundle of His) and then is conducted normally through the ventricles.04 .12 s). AV node.blogspot. atrial cells.0. For more presentations www.com . the QRS will be narrow (0.Teaching Moment ‡ When an impulse originates anywhere in the atria (SA node.

blogspot.Rhythm #4 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 60 bpm occasionally irreg.14 s 0. none for 7th QRS 0.08 s (7th wide) Interpretation? Sinus Rhythm with 1 PVC For more presentations www.com .medicalppt.

blogspot. ± When there are more than 1 premature beats and look alike. they are called uniform .PVCs ‡ Deviation from NSR ± Ectopic beats originate in the ventricles resulting in wide and bizarre QRS complexes. they are called multiform .medicalppt.com . When they look different. For more presentations www.

For more presentations www.com .blogspot.medicalppt.PVCs ‡ Etiology: One or more ventricular cells are depolarizing and the impulses are abnormally conducting through the ventricles.

medicalppt. conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.blogspot.Teaching Moment ‡ When an impulse originates in a ventricle. For more presentations www.com .

Ventricular Conduction Normal Signal moves rapidly through the ventricles For more presentations www.blogspot.medicalppt.com Abnormal Signal moves slowly through the ventricles .

blogspot.com .Learning Modules ‡ ‡ ‡ ‡ ‡ ‡ ECG Basics How to Analyze a Rhythm Normal Sinus Rhythm Heart Arrhythmias Diagnosing a Myocardial Infarction Advanced 12-Lead Interpretation For more presentations www.medicalppt.

medicalppt.Arrhythmias ‡ ‡ ‡ ‡ ‡ Sinus Rhythms Premature Beats Supraventricular Arrhythmias Ventricular Arrhythmias AV Junctional Blocks For more presentations www.com .blogspot.

com .blogspot.Supraventricular Arrhythmias ‡ Atrial Fibrillation ‡ Atrial Flutter ‡ Paroxysmal Supraventricular Tachycardia For more presentations www.medicalppt.

com .06 s Interpretation? Atrial Fibrillation For more presentations www.Rhythm #5 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 100 bpm irregularly irregular none none 0.medicalppt.blogspot.

so no normal P waves (impulses are not originating from the sinus node).Atrial Fibrillation ‡ Deviation from NSR ± No organized atrial depolarization.medicalppt. affects 2-4%. up to 5-10% if > 80 years old For more presentations www.com .blogspot. ± Atrial activity is chaotic (resulting in an irregularly irregular rate). ± Common.

The AV node allows some of the impulses to pass through at variable intervals (so rhythm is irregularly irregular). impulses are formed in a totally unpredictable fashion.com . Either way. For more presentations www.Atrial Fibrillation ‡ Etiology: Recent theories suggest that it is due to multiple re-entrant wavelets conducted between the R & L atria.medicalppt.blogspot.

06 s Interpretation? Atrial Flutter For more presentations www.Rhythm #6 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 70 bpm regular flutter waves none 0.blogspot.medicalppt.com .

medicalppt. ± Only some impulses conduct through the AV node (usually every other impulse). For more presentations www. Instead flutter waves (note sawtooth pattern) are formed at a rate of 250 .com .blogspot.Atrial Flutter ‡ Deviation from NSR ± No P waves.350 bpm.

medicalppt.com . 3rd or 4th impulse generating a QRS (others are blocked in the AV node as the node repolarizes).Atrial Flutter ‡ Etiology: Reentrant pathway in the right atrium with every 2nd. For more presentations www.blogspot.

medicalppt.16 s 0.com .Rhythm #7 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 74 148 bpm Regular regular Normal none 0.08 s none Interpretation? Paroxysmal Supraventricular Tachycardia (PSVT) For more presentations www.blogspot.

medicalppt. For more presentations www.com .PSVT ‡ Deviation from NSR ± The heart rate suddenly speeds up. often triggered by a PAC (not seen here) and the P waves are lost.blogspot.

PSVT ‡ Etiology: There are several types of PSVT but all originate above the ventricles (therefore the QRS is narrow).com . For more presentations www.medicalppt.blogspot. ‡ Most common: abnormal conduction in the AV node (reentrant circuit looping in the AV node).

Bundle Branch Blocks For more presentations www.com .blogspot.medicalppt.

blogspot.Bundle Branch Blocks Turning our attention to bundle branch blocks Remember normal impulse conduction is SA node AV node Bundle of His Bundle Branches Purkinje fibers For more presentations www.medicalppt.com .

com .medicalppt.blogspot.Normal Impulse Conduction Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers For more presentations www.

For more presentations www. depolarization of the Bundle Branches and Purkinje fibers are seen as the QRS complex on the ECG.blogspot. a conduction block of the Bundle Branches would be reflected as a change in the QRS complex. Therefore.com Right BBB .Bundle Branch Blocks So.medicalppt.

and if it is a right vs. For more presentations www.com . 2.Bundle Branch Blocks With Bundle Branch Blocks you will see two changes on the ECG.medicalppt.blogspot. QRS morphology changes (varies depending on ECG lead. 1.12 sec). QRS complex widens (> 0. left bundle branch block).

blogspot. For more presentations www.com .medicalppt.Bundle Branch Blocks Why does the QRS complex widen? When the conduction pathway is blocked it will take longer for the electrical signal to pass throughout the ventricles.

virtually diagnostic shape in those leads overlying the right ventricle (V1 and V2).Right Bundle Branch Blocks What QRS morphology is characteristic? For RBBB the wide QRS complex assumes a unique.com .blogspot. V1 ³Rabbit Ears´ For more presentations www.medicalppt.

V1 and V2).Left Bundle Branch Blocks What QRS morphology is characteristic? For LBBB the wide QRS complex assumes a characteristic change in shape in those leads opposite the left ventricle (right ventricular leads .com Normal .medicalppt.blogspot. Broad. deep S waves For more presentations www.

Conduction abnormalities .

Conduction System His Bundle L Bundle R Bundle Katrina Kardos. MD PGY-3 Albany Medical Center .

emedu. MI) http://www.st 1 Degree AV block Beta blockers Frequent in elderly AV node (valve surgery.org/ .

st 1 Degree AV block Beta blockers Frequent in elderly AV node (valve surgery. MI) http://www.org/ .emedu.

MVR. TVR) .nd 2 Degree AV block type 1 Lesion to conduction tissues (AVR.

MVR.emedu.org/ .nd 2 Degree AV block type 2 Lesion to conduction tissues (AVR. TVR) http://www.

MVR.org/ .rd 3 Degree AV block Lesion to conduction tissues (AVR.emedu. TVR) http://www.

blogspot.com .Ventricular Arrhythmias ‡ Ventricular Tachycardia ‡ Ventricular Fibrillation For more presentations www.medicalppt.

com .medicalppt.blogspot.Rhythm #8 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? 160 bpm regular none none wide (> 0.12 sec) Interpretation? Ventricular Tachycardia For more presentations www.

For more presentations www.com .blogspot.medicalppt. wide QRS).Ventricular Tachycardia ‡ Deviation from NSR ± Impulse is originating in the ventricles (no P waves.

medicalppt.com .Ventricular Tachycardia ‡ Etiology: There is a re-entrant pathway looping in a ventricle (most common cause). ‡ Ventricular tachycardia can sometimes generate enough cardiac output to produce a pulse. at other times no pulse can be felt.blogspot. For more presentations www.

none none wide.medicalppt.Rhythm #9 ‡ ‡ ‡ ‡ ‡ Rate? Regularity? P waves? PR interval? QRS duration? none irregularly irreg.blogspot. if recognizable Interpretation? Ventricular Fibrillation For more presentations www.com .

blogspot.medicalppt. For more presentations www.com .Ventricular Fibrillation ‡ Deviation from NSR ± Completely abnormal.

Ventricular Fibrillation ‡ Etiology: The ventricular cells are excitable and depolarizing randomly.medicalppt.com . ‡ Rapid drop in cardiac output and death occurs if not quickly reversed For more presentations www.blogspot.

blogspot. ‡ To recognize the 13 most common heart arrhythmias. ‡ To recognize an acute myocardial infarction on a 12-lead ECG.Course Objectives ‡ To recognize the normal rhythm of the heart Normal Sinus Rhythm.medicalppt.com . For more presentations www.

blogspot. a sequence of injurious events occur beginning with ischemia (inadequate tissue perfusion). ‡ The ECG changes over time with each of these events For more presentations www. and eventual fibrosis (scarring) if the blood supply isn't restored in an appropriate period of time.ST Elevation and non-ST Elevation MIs ‡ When myocardial blood supply is abruptly reduced or cut off to a region of the heart. followed by necrosis (infarction).medicalppt.com .

medicalppt.blogspot.com flattened inverted .ECG Changes Ways the ECG can change include: ST elevation & depression T-waves peaked Appearance of pathologic Q-waves For more presentations www.

com . or ±Non-ST Elevation (Subendocardial or non-Q-wave) For more presentations www.ECG Changes & the Evolving MI Non-ST Elevation There are two distinct patterns of ECG change depending if the infarction is: ST Elevation ±ST Elevation (Transmural or Q-wave).blogspot.medicalppt.

Fibrosis (months later) with persistent Q. but normal ST segment and T. Ischemia from coronary artery occlusion results in ST depression (not shown) and peaked Twaves C.ST Elevation Infarction Here¶s a diagram depicting an evolving infarction: A.blogspot.waves For more presentations www. Ongoing infarction with appearance of pathologic Q-waves and T-wave inversion F.waves. Infarction from ongoing ischemia results in marked ST elevation D/E. Normal ECG prior to MI B.medicalppt.com .

com .ST Elevation Infarction The ECG changes seen with a ST elevation infarction are: Before injury Normal ECG Ischemia Infarction Fibrosis ST depression. but Q-waves persist For more presentations www. peaked T-waves.medicalppt. then Twave inversion ST elevation & appearance of Q-waves ST segments and T-waves return to normal.blogspot.

emedu.ST segment depression Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink.org/ . Twist) Air embolism http://www.

Twist) Air embolism http://www.emedu.ST segment depression Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink.org/ .

(2000) .. Ph.ST segment depression LVH LBBB RBBB ISCHEMIA David Arnall. P.T.D.

org/ . Twist.emedu.ST segment Elevation Acute MI Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink. Dissection ) Air embolism Preoperative Sequella http://www.

emedu.org/ .ST segment Elevation http://www.

emedu.org/ .ST segment Elevation http://www.

MD PGY-3 Albany Medical Center .ECG: MI Evolution OR CSU > 3 Wks Katrina Kardos.

Thank You! .

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