Rate , Rhythm, P wave, QRS, T-wave and intervals

P wave : is atrial activation

PR interval : time from onset of atrial activation to onset of ventricular activation
QRS : duration is ventricular activation
ST-T : wave represents ventricular repolarization
QT : interval is duration of ventricular activation and recovery
U : wave represents “ after repolarization” in the ventricles
TACHYARRHYTHMIA (> 100BPM)
 SVT
regular  Sinus Tachycardia

Wide
 Atrial Fibrillation
irregular  Atrial Flutter
QRS
 MAT

Narrow regular  Ventricular Tachycardia

irregular  Ventricular Fibrillation

Sinus Tachycardia

Causes :
- Physioloical : pain or exertion
- Pharmacological : sympathomimetics, caffeine or bronchodilators
- Patholigical : fever, hypoxia, anemia, hypovolemia, pulmonary embolism or hyperthyroidism

Supraventricular Tachycardia

Causes :
Heart failure, thyroid disease, heart disease, chronic lung disease
Atrial Flutter

Causes :
-Ischemic heart disease, CHF, acute MI, pulmonary embolus, myocarditis, blunt chest trauma, and digoxin
toxicity

ECG:
-regular atrial rate between 250-350 beats/min
- “saw tooth” flutter directed superiorly and most visible in lead II,III and aVf

Atrial Fibrillation

Causes:
-longstanding hypertension, ischemic heart disease, rheumatic heart disease, alcohol use, COPD,
thyrotoxicosis

ECG:
- Fibrilatory wave of atrial activity, best seen in leads V1, V2,V3 and aVf
- An irregular ventricular response ( 170-180 beats/min)
Multifocal Atrial Tachycardia

Causes:
- Decompensated COPD, congestive cardiac failure, sepsis, methylxanthine toxicity or digoxin
toxicity

ECG:
-3 or more differently shaped P wave
-changing PP,PR and RR intervals
-atrial rhythm between 100-180 beats/min

Ventricular Tachycardia

Causes:
- IHD and acute MI
- Others: hypertrophic cardiomyopathy, mitral valve prolapse, drug toxicity( digoxin, antiarrthymia or
sympathomimetic ), hypoxia, hypokalaemia and hyperkalaemia

ECG:
-wide QRS complex
-rate >100 beats/min
- Regular rhythm
- Constant QRS axis
Ventricular Fibrillation

Causes:
-IHD, with or without acute MI, digoxin or quinidine toxicity, hypothermia, chest trauma, hypokalaemia,
hyperkalaemia or mechanical stimulation( catheter wire)

ECG:
- Fine to coarse zigzag pattern without discernible P wave or QRS complexes

Polymorphic VT ( Torsade De Pointes)

Causes:
- Ischemia
- Electrolyte imbalance
- Drug toxicity

ECG:
- Long QT interval (>0.44sec)
- Rapid and irregular
- Changes from upright to inverted position
BRADYARRHYTHMIA (<60 BPM)

• Rate: Less than 60 beats per minute.

• Rhythm: Regular.
• P waves: Upright, consistent, and normal in morphology and duration.
• P-R Interval: Between 0.12 and 0.20 seconds in duration.
• QRS Complex: Less than 0.12 seconds in width, and consistent in morphology

PR interval is lengthened beyond 0.2 seconds

Second Degree AV Blok Mobitz Type 1

• Almost always a disease of the AV node

• Progressive prolongation of the PR interval on ECG followed by a blocked P wave
• Almost always disease of distal conduction. Often symptomatic, may become 3rd Degree.
• Intermittently non-conducted P waves not preceded by PR prolongation

• The P waves with a regular P-to-P interval

• The QRS complexes with a regular R-to-R interval (escape rhythm)
• Usually severe bradycardia
HYPERKALEMIA

• Defined as measured serum (K+) of >5.5

mEq/L

Clinical Features :
• Cardiac dysrhythmias
• Neuromuscular dysfunctional weakness
• Paresthesias
• Areflexia
• Ascending paralysis
• GI effects (nausea, vomiting, diarrhea)
Investigations :
• ECG
• Electrolytes profile
• ABG
• Urine analysis
• Digoxin level

Treatment :

• Stabilize the cardiac membrane : CaCl2 or Calcium gluconate

• Shift K+ into the cell : glucose and insulin and/or bicarbonate and/or albuterol
• Enhance K+ excretion : Sodium polystyrene sulfonate (Kayexalate) , diuretics or dialysis in severe
cases

For levels over 7.0 mEq/L OR any ECG changes :

• Give IV Calcium chloride (10%) 5 to10 ml
OR
IV Calcium gluconate (10%) 10 to 20 ml
• In acidotic patient , give 50 to 100 mEq of sodium bicarbonate slow IV
• Give 50mL of D50W with 10 to 20 units regular insulin IV push
• Kayexalate 15 to 30g PO
• Albuterol 5 to 10 mg by neb
• Acute renal failure patient- consult nephrologist for dialysis