Section 5 : Sinus Rhythms
Sinus rhythms are those that arise from the pacemaker in the sinus node (also called the SA node). The sinus pacemaker is our heart's normal pacemaker. We have three basic rhythms that originate in the sinus node. If the heart's rate is below 60 beats/min, we call it sinus bradycardia. If the rate is above 100 beats/min, the rhythm is called sinus tachycardia. If everything is just right, the rhythm is called normal sinus rhythm (NSR). (These rates apply to human adults. Pediatrics is a whole 'nother world.) Of course, if all rhythms started in the sinus node, we probably wouldn't have a section devoted specifically to sinus rhythms. While the normal heart rhythm is of sinus origin, there are many arrhythmias that do not start in the sinus. Why is the sinus the best place to start? One reason is that an impulse that originates in the sinus node follows a certain path that allows the atria to contract before the ventricles. If the two sets of chambers contracted at the same time, the atria would push against closed valves. Because there are no valves that separate the atria from their veins (vena cava and pulmonary vein), blood would flow backwards. This often causes the jugular veins in the neck to pulse. Between the atria and the ventricles is the A.V. node. On the diagram of the firecracker (figure x-x), this node is represented by the yellow tunnel. Conduction of the electrical impulse slows down in the A.V. node, allowing the atria to completely depolarize before the ventricles so that atria may contract first. On the ECG, the isoelectric part between the P wave and the QRS complex demonstrates this pause. If the conduction through the A.V. node were slowed too much, the ECG would show this as a PR interval that is longer than 0.20 seconds.
Figure 5-1 :The match represents the sinus pacemaker. The yellow tunnel represents the AV node.
How can you tell if an ECG rhythm originates in the sinus node? One thing to do is to look at the P wave. A rounded, upright P wave is often indicative of the sinus pacemaker. (Occasionally, the amplitude of an ECG is so great that the P wave will end up looking pointed even though it is sinus. Be very careful with this.) In non-sinus (i.e. ectopic) pacemakers, the P waves are often either notched, very pointed, inverted, or absent. To know what a normal rhythm looks like, it is best to be familiar with abnormal rhythms. Don't be caught off guard by a weird looking QRS complex. Just because it doesn't look like the "textbook example" of the QRS does not mean that it is abnormal. A normal QRS is less than 0.12 seconds, but it is not limited to a single shape. Although the QRS complexes can differ from ECG to ECG, it should not be considered normal if they were to differ in the same ECG.
Normal sinus rhythm A normal sinus rhythm (NSR) is the common, everyday rhythm. It must be, of course, sinus in origin. It must be regular and have a rate between 60 - 100 per minute. It must have a normal PRI and QRS duration.
Figure 5-2 : A normal sinus rhythm
Often times, an arrhythmia is described by saying the "underlying rhythm" and adding to that anything abnormal (e.g. sinus rhythm with first degree heart block). If any abnormalities exist, do not include the word normal when designating the underlying rhythm.
Sinus bradycardia This is just like a normal sinus rhythm except that the rate is slower than 60 per minute.
Figure 5-3 : Sinus bradycardia
Remember that the limits of 60 and 100 are arbitrary. A person who has a rate of 59 beats/min would not feel much different than he would at a rate of 60 beats/min. Some people (especially athletes) have a normal resting heart rate below 60. When President (George W.) Bush passed out after choking on a pretzel, it was revealed that his normal heart rate was around 45 beats/min. Many pundits became alarmed and criticized the president for not revealing his "disease" prior to the incident. The talking cardiologist heads were quick to point out that "disease IS as disease DOES"- that a disease is based on the patient and not always on standard one-size-fits-all guidelines. Some people
treatment should be aimed at the underlying cause. speeding up when the patient inhales and slowing down when the patient exhales. In more serious cases. How irregular is irregular? The criterion used by many is that the longest R-R interval should differ from the shortest by at least 0. This would be a good time to reiterate : treat the patient. We would call this relative bradycardia.
. Sinus arrhythmia can be relatively common in young and is often asymptomatic. Sinus tachycardia in itself is not always a bad thing. a person in the early stages of shock may have a fast heart rate to compensate for the would-be-fall in blood pressure.
Sinus arrhythmia Sinus arrhythmia is similar to normal sinus rhythm except that it the rate is irregular.may become symptomatic when there heart rate falls even though it is still above 60. If you are a paramedic or EMT.
Figure 5-4 : Sinus tachycardia
Sinus tachycardia is common in everyone. It often matches the patient's breathing pattern.16 seconds. you will probably find plenty of patients in sinus tachycardia simply because they are nervous or excited. not the machine.
Sinus tachycardia This is just like a normal sinus rhythm except that the rate is faster than 100 per minute.
Figure 5-5 : Sinus arrhythmia
What is the difference between an electrical beat originating in the sinus and one originating in the atria? For one. upright.
Premature atrial complex When you feel your heart has "skipped a beat. The atrial pacemaker causes the wave of depolarization that resets the sinus node. etc. Sometimes they are pointy. Premature describes the fact that the beat occurred before the regular one would have. sometime flat. The ones from the sinus to the following atrial complexes are shorter than the others. Sinus P waves tend to be rounded. Look at the R-R intervals. Figure 6-1 shows a sinus rhythm that is twice interrupted by PACs. They can have a notch running down the middle of them. while atria P waves tend to be weird shaped. In figure 6-1. which means that one part is above the isoelectric line while one part is below it. Some are diphasic. The PACs shown consist of an atrial P wave along with a normal QRS complex and a normal T wave.
Figure 6-1 : A sinus rhythm with two premature atrial complexes
. Compare the P waves on both the sinus complexes and the PACs. A premature atrial complex (PAC) describes a wave or set of waves caused by an atrial pacemaker that interrupts the underlying rhythm.Section 6 : Atrial Rhythms
Atrial rhythms are rhythms that originate in the atria. The atrial rhythms that fall under the category of PSVT are mentioned elsewhere. the P wave tends to be a different shape." it very well may have been due to a PAC. you can imagine that the sinus pacemaker was firing along at a regular rhythm until it was unexpectedly (and rudely) interrupted by the atrial pacemaker.
Figure 6-2 : Atrial fibrillation
One of the major questions that doctors are asking themselves is : is it better to control or convert?
. you may see either a normal QRS or a wide QRS. you might find a single atrial P wave without the QRS complex and T waves. In these situations. Some of them are : The ventricles may be depolarized at too high a rate. it is entirely possible that the AV node is still refractory. stagnant blood tends to form thrombi (clots). We describe this as non-conducted. but are depolarized at irregular intervals. predisposing the patient to a stroke. The atria are unable to perform their normal function. It occurs when the electricity in the atria follows a seemingly random and repetitive path. The old saying "a rolling stone gathers no moss" might be applied to blood. (The word fibrillation means quivering. Instead of gathering moss. This rhythm can last for years and is not always symptomatic. The wide QRS in this case is due to what is called aberrancy. Clots may form in the left atrium.
Atrial fibrillation Atrial fibrillation (often called "a-fib") is relatively common among the elderly. When these impulses conduct. causing the atria to quiver. The ventricles are still functional. This is often due to one of the bundle branches still being refractory. PACs are also covered in Section 10 : Premature Complexes. they are unable to pump blood.) Because the atria are quivering. There are a few reasons why this rhythm is bad.When an atrial pacemaker fire prematurely.
Patients who undergo this "cardioversion" are often put on anticoagulants for weeks before the procedure. that someone who has been in atrial fibrillation for a while has a high chance of "throwing clots" in the left atrium. You might think this would be the obvious choice. When the rate of QRS complexes (and thus ventricular depolarizations) exceeds 100. In atrial flutter. the thrombi may become dislodged from the atrium.
. In the process of conversion to a sinus rhythm. These P waves are often called "flutter waves. These thrombi (clots) are thought to form in the atria when they are fibrillating. Convert refers to converting the rhythm into a sinus rhythm. although it can also vary. There are usually two readily apparent things in an ECG of atrial fibrillation. It may have an appearance ranging from coarse (large and jagged) to fine (relatively smooth). They are then likely to be sent through the left ventricle. The conduction ratio (P:QRS ratio) is often relatively constant at 2:1 or 4:1. This means that not all of the impulses will be conducted.350 times per minute. The AV node will normally only conduct impulses up to a rate around 220 per minute. the baseline usually appears chaotic. The problem is." The term is used for good reason : the P waves often looks like the teeth of a saw when viewed in Lead II. the aorta." In atrial flutter.Control refers to controlling the rate. The PRI cannot be measured. There is an extremely irregular QRS rate. however.
Atrial flutter The buzzword that everyone loves to use when describing atrial flutter is "saw tooth. 1. often minimizes the symptoms of this rhythm. This is the atrial contribution to the ECG. There are no easily discernible P waves. we call this rhythm uncontrolled atrial fibrillation. The R-to-R values often differ with each beat with no visible pattern to their timing. and into the arteries that supply the brain. Instead. Keeping the rate of ventricular contraction under 100/min. the atria are depolarizing about 250 . This could lead to a stroke. This is usually done with medication. the atria are depolarizing at an extremely rapid rate. 2.
atrial flutter QRS complexes tend to appear at regular intervals.With 2:1 conduction.
Figure 6-3 : Atrial flutter (2:1 conduction)
. Unlike atrial fibrillation. the ventricular rate is usually about 150.
. depending on who you ask. the "physiology people" call the general area the AV junction. The exact definition of the AV junction often varies. In the atrial part of the fuse. Emerging from the AV node is the bundle of His (also called the AV bundle). This would include the AV node and at least part of the bundle of His. the area around the AV node and the bundle of His. Figure 7-1 illustrates what happens when a pacemaker in the junction fires. As I've mentioned before. When it travels retrograde (which is a snooty. Because the "anatomy people" seem to disagree on where the AV node starts and stops. below the isoelectric line). the AV node is an electrically conducting path that connects the atria to the ventricles.Section 7 : Junctional Rhythms
Junction here refers to the AV junction. the activation travels in the reverse direction (from right to left on the diagram). We know that when it travels "forward" it produces an upright P-wave. causing the fire to travel both ways.e. polysyllabic way of saying "backward").
Figure 7-1 : A firecracker showing the firing of a junctional pacemaker
What is a junctional rhythm? A junctional rhythm is one that starts in the AV junction. the P wave is inverted (i. The match lights the fuse. upside down.
it is hard to predict which set of explosives will be ignited first. and thus the P wave is first. it will subtract from whatever the QRS is. ventricular depolarization) is the QRS complex. In figure 7-1. Perhaps they will be ignited at the same time.Thus. While simply looking at the figure. In addition to being upside-down. the atrial explosives are lit before those of the ventricles. When the sinus fires.e. which may vary.
Figure 7-2 : Sinus rhythm with a PJC
See Section 10 : Premature Complexes. the junctional P wave may not be before the QRS. The ignition of the explosives in the atria (i. the P wave may occur before. below negative.e. the atria are depolarized before the ventricles. Because the P wave in this case is negative. This depends on the exact location of the pacemaker. or after the QRS complex. an inverted P wave strongly indicates that the electrical impulse originated in the AV node or beyond. atrial depolarization) is the P wave while the ignition of the ventricular explosives (i.
. however. When two waves occur at the same time.
Premature Junctional Complex A premature junctional complex (PJC) is not a rhythm but rather denotes a complex caused by a junctional pacemaker that interrupts the underlying rhythm. In a junctional rhythm. Anything above the isoelectric line counts as positive. during. they add together.
If the rate is faster than 100.We have talked about the "backup" pacemakers in the heart.
Figure 7-3 : Junctional escape
Junctional tachycardia (I am using the term junctional tachycardia to refer specifically to the type caused by a junctional pacemaker. This is equivalent of a coup. "the fastest pacemaker calls the shots"? That means that the sinus pacemaker (usually around 75/min) will normally prevent the junctional pacemaker from firing. we call this junctional tachycardia. There happens to be one of these pacemakers in the AV junction. led by the a trouble maker in the AV junction. What might happen if the sinus rate were to fall to. Junctional escape will often have a rate between 40 and 60 beats/min. let's say. Remember the rule. the junctional pacemaker may start calling the shots. We call this type of "backup rhythm" an escape rhythm.) Let's suppose an ectopic pacemaker in the AV junction decides to overtake the sinus node. This junctional pacemaker's intrinsic rate is between 40 and 60 times/min.
Figure 7-4 : Junctional tachycardia
. 30 times/minute? Well. The type of junctional tachycardias caused by reentry are dealt with in the PSVT section.
Figure 7-5 : Accelerated junctional rhythm
.Accelerated junctional rhythm Occasionally. an ectopic pacemaker in the AV junction will have a rate that is too fast to be considered junctional escape but too slow to be considered junctional tachycardia. We call this an accelerated junctional rhythm.
1.S. it refers to people and things of North America and South America. In the more specific sense of the word. or PSVT. In other words. it is used to refer to people and things of the U. MORE GENERAL : Any tachycardia that originates in or depends on parts above the ventricles. Some in the rhythms in this group are AV nodal reentrant tachycardia. The different rhythms of this group are usually classified under the term SVT because they cannot be easily distinguished from one another. any tachycardia that is not from the ventricles. MORE SPECIFIC : This group of rhythms is often called "paroxysmal SVT". and sinus reentry tachycardia. This definition includes a number of rhythms.Section 8 : Supraventricular Tachycardias
The term supraventricular tachycardia (SVT) has at least two different meanings that are commonly in use.
. These rhythms tend to be between the rates of 150-250 and are paroxysmal. be familiar with this group.knowledge of each of the individual rhythms is not usually required for someone learning basic ECG interpretation. This is mostly used in the context of describing an unknown tachycardia. unifocal atrial tachycardia. sinus tachycardia is a type of supraventricular tachycardia.
Paroxysmal supraventricular tachycardia (PSVT) We will focus on the second definition of SVT (top of page) right now. 2. Under this definition. The term American is similar in that it has two meanings : in its most general sense. All tachycardia will fall under the categories of ventricular or supraventricular. Instead. A group containing certain tachycardia rhythms (of supraventricular origin) which all have a similar appearance.
it involves an accessory pathway. convert to a sinus rhythm. As the name suggests.
Figure 8-1 : A supraventricular tachycardia (SVT)
AV nodal reentrant tachycardia (AVNRT) This is the most common type of PSVT. Adenosine is a drug that temporarily blocks conduction in the AV node. An accessory pathway (in this case) is an abnormal connection between the atria and ventricles. also causing this rhythm to break. Circus movement tachycardia. this rhythm might "break. it denotes one that begins and ends suddenly. is often used to specifically refer to this rhythm. breathing against a closed glottis) will often slow conduction down at the AV node to the point that this rhythm breaks. This means that someone can go from a normal sinus rhythm to a PSVT with a rate of 180 in only second. Patients who are prone to this type of PSVT tend to have two pathways : the AV node and this accessory pathway. If it is your job to offer treatment.
.The word paroxysmal means sudden. this type also depends on reentry. carotid sinus massage. However. we can reason that if we were to temporarily disable the AV node.
AV reentrant tachycardia (with accessory pathway) Like AVNRT. while sometimes applied to any tachycardia involving a loop. Because the mechanism depends on the AV node.g. this rhythm is due to a reentrant impulse at the site of the AV node." that is. when used with arrythmias. Vagal maneuvers (e. then check with your local protocols on how to proceed.
ectopic pacemaker). It can be caused by a intra-atrial reentrant circuit or by automaticity (i.Atrial tachycardia Atrial tachycardia is usually considered a type of PSVT. it can be subdivided even further based on its mechanism.e. The important thing to note is that these tachycardias are not dependent on the AV node for their survival.
it would have to cut over through the ventricular septum ("slow fuse") to depolarize the other ventricle. Note that the fuse representing the ventricular septum is a "slow fuse". Pick one of the matches and predict the path the impulse (fire) would follow. If you imagine that the impulse starts where the bottom match is lighting the fuse.Section 9 : Ventricular Rhythm
Figure 9-1 : A firecracker showing a number of potential ventricular pacemaker locations. In a normal sinus beat. These are all portions of the Purkinje system. It covers both ventricles simultaneously. It generally depolarizes the ventricles in less than 0. What else might cause a QRS to last longer than 0.) An impulse that originates in the sinus node would be normal up until it reaches the block. You can see why this
. This should explain why ventricular pacemakers cause a QRS complex longer than 0. you can see it now has to cover both ventricles. just after the A. (The bundle branches start at the fork. node.10 seconds? Imagine that one of the bundle branches were blocked.
Several matches have been drawn in figure 9-1 to represent some of the possible locations of the ventricular pacemaker. the impulse forks at the bundle of His.10 s.10 seconds. The "slow fuse" is where the impulse can travel through the ventricular septum and into the other ventricle. Perhaps can now imagine why impulses that originate in the ventricles produce wide QRS complexes.V. If the impulse could only travel down ONE of the branches.
On the other hand. not from the ventricles). Not everything that glitters is gold. On the other hand.e. Supraventricular QRS complexes : NARROW or WIDE Ventricular QRS complexes : WIDE only
Premature Ventricle Complex Premature ventricular complex (PVC) is a term that originally was called premature ventricular contraction. virtually all narrow complex QRS complex are supraventricular (i. Because the mechanical contraction of the ventricles cannot be inferred from the ECG.e. All QRS complexes of ventricular origin are wide (> 0. PVCs tend to be compensating (i." you might want to reread this paragraph. Does it logically follow that all wide QRS complexes are ventricular? No. They also may give a person the feeling of having "skipped a beat". Let's say we can put all rhythms in one of two categories : supraventricular or ventricular. If this didn't "click.would take longer. Unlike the other three rhythms in this section. VPBs. the distance from the normal P wave before the PVC to the P wave after the PVC is twice the underlying P-P interval. In fact. they don't travel back and reset the underlying pacemaker).
. the word complex has replaced contraction. and VPCs. it is the case that NOT ALL WIDE QRS COMPLEXES ARE FROM THE VENTRICLES. it does not. These are also referred to as : premature ventricular beats (PVB). In these cases. and not every QRS that is wide is caused by a ventricular pacemaker. PVCs frequently occur in normal healthy hearts and often go unnoticed. PVCs in an unhealthy heart may be a bad omen.12 s).
quivering Fredo is unable to successfully wield a gun.. well. functional ventricles are a prerequisite for staying alive.they cannot pump blood.Figure 9-2 : Sinus rhythm with a unifocal PVC
PVCs are also covered in Section 10 : Premature Complexes. As the heart dies. often abbreviated VF) describes the electrical activity associated with the quivering of the ventricles. When Don Corleone is shot. You can understand why v-fib is one of the evil rhythms. there really is no pattern. The pattern for ventricular fibrillation is. It is random electrical activity. Sometimes the amplitude of the waves is large (coarse VF). As the minutes pass. Coarse v-fib will turn into fine v-fib. and fine v-fib will transition into asystole. It has almost a "kindergarten artwork" quality to it. while other times the amplitude is so small (fine VF) that the rhythm is almost asystole. cells in the body become damaged due to the lack of oxygenated blood. I mentioned earlier that. untreated v-fib can progress to death within minutes. Thus. Among these are cells of the heart. while functional atria are a prerequisite for playing tennis or jogging. Quivering ventricles are about as effective as quivering Fredo. v-fib is likely to blame. When someone suddenly drops dead from a cardiac arrest.
Ventricular fibrillation Ventricular fibrillation ("v-fib".
. it loses its ability to conduct electricity..
12 seconds. the ventricles may beat so frequently that there is not adequate time for the blood to refill. often abbreviated VT) refers to a rhythm that arises from the ventricles causing the heart to beat at a rate faster than 100 beats per minute. In fact. The ventricular rate is usually above 120 beats/min and may exceed 250 beats/min. A heart in VT is vulnerable to going into ventricular fibrillation. then you should call a tachycardia with wide QRS complexes a "wide complex tachycardia. the common sequence of arrhythmias in patients who die in this rhythm is: V-tach to V-fib to asystole."
. A patient in ventricular tachycardia MAY or MAY NOT have a pulse. but not all cases look like this. The QRS complex will be wider than 0. At some point. Unless you have been trained to distinguish a ventricular QRS complex from a wide QRS of non-ventricular origin. Figure 9-5 shows the stereotypical V-tach.Figure 9-3 : Ventricular fibrillation (coarse)
Figure 9-4 : Ventricular fibrillation (fine)
Ventricular tachycardia Ventricular tachycardia (V-tach.
A few things can cause this : 1. The intrinsic rate of a ventricular pacemaker is 20 . often called idioventricular escape. subsequently. There is a block that prevents impulses of the sinus (or junctional) pacemaker from reaching the ventricles.40 times/minute. It is the "flat-line". is when an ectopic "backup" pacemaker in the ventricles kicks in. it is only slightly more compatible with life than asystole.
Figure 9-6 : Idioventricular rhythm
Asystole Asystole is not a ventricular rhythm. In other words. Although it is considered a "backup" rhythm. it is the easiest rhythm to recognize. asystole does
. The sinus and junctional pacemakers have failed 2. this is a very bad rhythm.Figure 9-5 : Ventricular tachycardia
Ventricular escape Ventricular escape. Because it has no electrical activity.
very little will show on that lead's ECG. If an electrically active heart has all of its activity perpendicular to a given lead. In these cases. Always make sure the equipment is connected to the patient. Pronounced uh-SIS-toe-lee.not readily belong into any of the other groups of arrhythmias. check more than one lead to confirm that the rhythm is asystole. I have included in this section because it is often the end result of ventricular fibrillation. Also. another lead (pointing a different direction) should pick up on this hidden activity.
Figure 9-7 : Asystole
I have put together in this section an extended metaphor that addresses the topics common to premature atrial. Each duck is ordered to maintain a ruler's length distance between the duck ahead of it and itself. He is very picky when it comes to marching. junctional.Section 10 : Premature Complexes
I'm frequently asked if there is some way that I can explain the concept of the human heart's premature ectopic complexes using waterfowl.
The normal mallard rhythm Figure 10-1 shows a number of mallards marching along. In response to these requests. and ventricular complexes. and he requires that each duck maintain a specified distance between himself and the duck before him. Let's assume there exists some commander of the ducks (who is not shown in the diagram).
Figure 10-1 : Sinus ducks marching. Each mallard represents the ECG complex above it. This distance is the length of a single ruler (shown below ducks).
In figure x-x. we call this goose premature. This would mean that the goose has shifted the entire marching formation behind him a little bit more forward than they would have been. the goose is following a little too closely (much like bad drivers do). There is no compensatory pause. Remember. 2. In addition to this. you see that a goose (representing a ventricular complex) has joined the parade. Thus.
Figure 10-2 : A premature waterfowl (followed by a compensatory pause). This puts the duck that follows the goose in a dilemma. the distance after the goose would be longer than a ruler. He has two options : 1. Even though the
. He took ("stole") the place of one of the "regularly scheduled" ducks. The duck could march at a distance of one ruler's length behind the goose. Compensating for the too-short distance before the goose.Enter the goose Now let's look at the duck-duck-goose patterns. each of the ducks was originally given the order to march at a distance of one ruler's length behind the duck directly in front of him. This "distance" is called a compensatory pause. This is the equivalent of following the length of two rulers behind the previous mallard (the one before the goose). The duck can ignore the goose and follow one ruler's length behind where the missing duck would have been.
Thus. you should suspect a PVC. a goose may be able to squeeze between two ducks without messing with their pattern at all. Notice how the overall pattern is reset by the blue-headed (premature) ducks. if a premature complex is followed by a compensatory pause.goose takes the place of one of ducks.
Interpolated complexes Sometimes. in figure 10-4. The red rulers indicate a distance that is too short. This is exhibited by the compensatory pause following the goose. When this happens with an PVC. PACs (and PJCs) tend to reset the sinus while PVCs tend not to reset the sinus.
. there are no missing ducks.
In the heart. The mallards that follow the premature ducks are basing their position on these blue-headed troublemakers. Thus.
Figure 10-3 : Premature waterfowl (no compensatory pause). Although this is by no means a fixed rule. Lack of the compensatory pause is generally attributed to the impulse from the premature complex conducting retrograde towards the sinus node and resetting it. we call it an interpolated PVC. Those complexes that cause a compensatory pause are those whose impulse does not reach the normal (sinus) pacemaker. it does not alter the overall spacing of the group. An interpolated complex is a premature complex that is early enough so that no complex is skipped. the "option" is usually decided by where the premature complex originates.
they can occur in a variety of places. If all of the PVCs had the same general shape. As far as the ventricles are concerned. atria. and the junction (normally) all share the same path. and a PJC are all likely to have similarly shaped QRS complexes. These different places should produce different QRS complexes. we designate them multifocal. For example. Thus. we would refer to them as unifocal. We should assume. This is a premature goose who. The QRS shape often reflects where the impulse entered the ventricular conduction system. rather than take the place of one of the ducks. we see two different PVCs. Thus a sinus complex. because of their dissimilarity. has managed to squeeze between two ducks without altering their pattern. that these PVCs each originated from a different part of the ventricular conduction system. in figure 10-5.Figure 10-4 : An interpolated goose.
Unifocal versus multifocal Remember the following generalization : different shape means different origin.
. Pacemakers in the ventricular conduction system are not limited to one location. No ducks have gone missing. pacemakers in the sinus node. a PAC.
If their appearance seems random. none of the following terms are applicable.Figure 10-5 : Mallard rhythm with multifocal geese. Bigeminy : every other beat Trigeminy : every third beat Quadrigeminy : every fourth beat
Multiple premature beats
Patterns of premature beats These terms describe how often the premature complexes appear.
Paired complexe s (also called couplets) A salvo of complexe s (also called a run) The term salvo (as in barrage) is used to describe the occurrence of multiple premature complexes in a row.
. (Many consider "multiple" in this case to mean three or more. you should probably start looking at them less in terms of premature complexes and more in terms of tachycardia.) When many premature complexes occur in a row.
If AV conduction is slowed.20 seconds. For example. you would call the rhythm : sinus bradycardia with a first degree heart block. how will this appear on an ECG? If conduction is completely blocked. you generally name the rhythm according to this pattern : <underlying rhythm> with a first degree heart block. This is manifested as a PRI that is longer than 0. Use what you already know about P waves. In a nutshell. This PRI will generally remain constant. and the space between them. occasionally) blocked 3rd degree heart block : AV conduction is completely blocked Before you continue.22. stop and predict what each type of heart block will look like. We generally speak of three broad types (or degrees) of heart blocks. QRS complexes.) When you see a rhythm with a first degree heart block.e. will QRS complexes follow P waves?
1st degree heart blocks : This occurs when conduction at the AV node is slowed beyond the normal amount.Section 11 : AV Heart Blocks
Atrioventricular heart blocks (referred to simply as heart blocks from here on) is the name given to conditions in which electrical conduction at the AV node is somehow affected. you may a second degree heart block.
. (If the PRI is changing from beat to beat. they are : 1st degree heart block : AV conduction is (excessively) slowed 2nd degree heart block : AV conduction is incompletely (i. if you were to see a case of sinus bradycardia but the PRI consistently measures 0.
(There would be an gradual-increasing PR intervals until it disappears/skips. This is like showing up for work Monday an hour late. Mobitz I is the same thing as 2nd degree heart block type I.)
Figure 11-2 : Second degree heart block type I (Wenckebach)
2nd degree heart block type II : This rhythm is also called Mobitz II. Therefore. I have always considered this the "duck duck goose" rhythm because it maintains a relatively constant PRI until it skips. and so on until Friday comes around and you don't even show up at all. This rhythm lacks the increasing PRI that is seen with the Wenckebach type.
. It would be as if you showed up 30 minutes late Monday through Thursday. think 2nd degree heart block. Whenever you see Mobitz. It is also called Wenckebach. This occurs when a QRS suddenly fails to show up after a P wave. It usually makes an appearance the next wave. The process is then repeated.Figure 11-1 : Sinus rhythm with a first degree heart block
2nd degree heart blocks : The most confusing thing about second degree heart blocks is that there are two subtypes and they are called a variety of names. The following Monday. you start the same cycle again. but failed to show up Friday. 2nd degree heart block type I : This rhythm is also called Mobitz I. on Tuesday two hours late. It consists of the PRI getting longer with each electric beat until eventually a P wave occurs but the QRS never shows (essentially skipping a beat). You could call this behavior "pulling a Wenckebach" but nobody would get it and people would just think you're weird.
Figure 11-4 : Third degree heart block
. The atria are being controlled by one pacemaker. sometimes vice-versa. but they don't seem to affect each other. there will be only one PRI. Sometimes it may look like a P wave follows a QRS. This often manifests itself on an ECG as P waves occuring at regular intervals with QRS complexes occuring at regular intervals. If no electricity travels through the AV node for a little while. This is the conductance ratio. but no apparent relationship between any P wave or QRS complex. This is when the atria and the ventricles are essentially divorced. In a second degree heart block with a 2:1 conductance.
3rd degree heart blocks : These are also called complete heart blocks. the ventricle's backup pacemaker starts calling the shots.Figure 11-3 : Second degree heart block type II
It is important to recognize the two subtypes of 2nd degree heartblocks. Note : For second degree heart blocks. The second subtype tends to be much worse than the first subtype (Wenckebach). It will be impossible to distinguish between the two subtypes of 2nd degree heart blocks using only the ECG. it is common to specify the ratio of P waves to QRS complexes. the ventricles by another.
The first two are clearly visible. you would see these two impulses cancel each other out. You should notice a slight difference where you expect the P wave to be. To be considered a true third degree heart block. the ventricles should be in an escape rhythm. the atria and ventricles would be doing their own thing despite no real problem with AV conduction.In figure x-x. the P wave is evident at the very end. In the middle QRS. Why? There are many situations in which the atria and ventricles can be completely independent when there is no "true block" between the atria and ventricles. it is at the very beginning. If a ventricular ectopic pacemaker were firing at such a rate that the sinus and ectopic impulses meet head-on somewhere in the junction. Compare the shape of the QRS complexes. The last two are hiding in QRS complexes. In the last QRS complex.
. you may have to play "Where's Waldo?" with the P waves.