1. ECG Tutorial: Rhythm Recognition Review – the systematic approach Rhythm – the hardest part! –Again – be systematic –Mind your p ’ s & q ’ s & follow the rules! The Approach – Tachy –vs- Brady Examples Quiz

2. ECG Tutorial: Rhythm Recognition My systematic approach: –Rate –Rhythm –Axis –Intervals (PR, QRS, QTc) –Blocks / Hypertrophy / Enlargement –Segments (PR, ST) –Waves (Q-waves, T-waves) –Ectopy –Compare to old ECG

3. Rhythm Recognition Golden rule: mind your ‘ p ’ s (& ‘ q ’ s ’ ) Step I – Is it fast or slow? –Tachycardia = >100 –Bradycardia = < 60 Step II – Is it sinus rhythm or not? –2 questions (rules): ‘ p ’ with every QRS complex? Upright ‘ p ’ in I, II & aVF? –Yes to BOTH = sinus origin (nice job!)

4. Rhythm : Is there a p wave? = Sinus Is it followed by a QRS?

5. PR QRS AHHV How does the heart work

6. Is the rhythm regular or irregular?

7. Tachycardias: The ‘ Down & Dirty ’ Common Need to recognize the ‘ bad boys ’ ! –ACLS, etc… 2 questions –Is the QRS narrow (<=0.12 second or 2.5 small boxes) or wide? “ Wide complex Tachycardia ” -vs- “ Narrow Complex Tachycardia ” –Is the rhythm regular or irregular?

8. Normal Sinus Rhythm; Rate = 75

9. Sinus Arrythmia -Typically a normal finding – esp. in younger, fit individuals -Due to changes in autonomic tone during inspiration

10. Tachycardias: DDx (Rule of 3 ’ s!) Narrow Complex & Regular: –Sinus Tachycardia –Atrial Flutter –Other supraventricular Tachycardia (SVT) AVNRT (A-V nodal reentrant tachycardias) Atrial reciprocating tachycardia (from pre- excitation, ex: WPW) Ectopic atrial tachycardia Other uncommon causes

12. Sinus Tachycardia…but why? Physiologic (#1) –Response to exercise –Stress, anger, etc.. ( ‘ fight or flight ’ ) Other causes: –Fever –Hyperthyroidism –Effective volume depletion, hypotension –Sepsis, Shock –Anemia –PE –CHF –Drugs (stimulants) –Drug withdrawal (ETOH) –Pheochromocytoma

13. Atrial Flutter – characteristics?

15. Suspect A-flutter: Narrow complex tachycardia ‘ F ’ (flutter waves) = rate of 300 ( “ sawtooth ” ) Ventricular rate = 150 bpm

16. Atrial Flutter – what is happening in the heart!

18. Other Narrow Complex Tachycardiaa - AVNRT NSR Premature Atrial Complex (PAC) -Regular, Narrow-complex tachycardia w/rate: 120-220 -‘ p ’ buried or after QRS (usually) & inverted (retrograde) in leads I, II & aVF -Most common non-fib/flutter SVT

19. AVNRT

20. Ectopic Atrial Tachycardia Regular narrow complex tachycardia Originates outside of the AV node Constant ‘ p ’ wave morphology Constant P-R intervals Use the “ rule of sinus rhythm ” & mind your ‘ p ’ s ’

21. Ectopic atrial tachycardia

22. Ectopic atrial tachycardia: Can occur with block (ie-digoxin toxicity)

23. Tachycardias: DDx Narrow Complex & IR-regular: –Atrial Fibrillation ( “ irregularly irregular ” ) –Atrial Flutter with variable A-V block –MAT (Multifocal Atrial Tachycardia) –Other Supraventricular tachycardias with variable AV block

26. Atrial Fibrillation The most common arrythmia in older patients ECG: –Absent ‘ p ’ -waves –“ fibrillatory waves ” – vary in appearance –Irregularly irregular R-R intervals –Typically narrow complex QRS (unless aberrant conduction) Bundle Branch Blocks / other blocks Re-entry (WPW) –Rate > 100 = “ rapid ventricular response ” (RVR)

27. Remember this? A-flutter with variable AV-block

28. MAT – Multifocal Atrial Tachycardia Narrow complex, irregularly irregular You ’ re thinking A-fib, but… –You see clearly conducted ‘ p ’ -waves –‘ p ’ -waves are not all the same You see 3 different ‘ p ’ -wave morphologies “ Multifocal ” Varying P-P & R-R intervals –Associated with lung disease (COPD), theophylline, hypertension, etc…

29. MAT

30. Narrow Complex Tachycardias - Review Regular: –Sinus Tachycardia –Atrial Flutter –Other “ SVT ” AVNRT (A-V nodal reentrant tachycardias) Atrial reciprocating tachycardia (from pre- excitation, ex: WPW) Ectopic atrial tachycardia Others (uncommon) IR-regular: –Atrial Fibrillation ( “ irregularly irregular ” ) –Atrial Flutter with variable A-V block –MAT (Multifocal Atrial Tachycardia) –Others

31. Doctor…come quick!

32. Wide Complex Tachycardias (WCT) A Big Deal…may require emergent treatment! A limited Differential Diagnosis –Ventricular Tachycardia (VT) –NOT Ventricular Tachycardia: SVT w/aberrant conduction (Aberrancy) SVT w/pre-excitation (ie-WPW) –What is “ aberrancy ” ? Assume Ventricular Tachycardia until proven otherwise –Esp. in a patient over 40 years old

33. Doctor, hurry up & read that EKG…

34. Wide Complex Tachycardia Rate > 100 bpm QRS duration > 0.12 seconds Again –Regular –vs- Irregular

35. Wide Complex Tachycardia Regular –Ventricular Tachycardia –A REGULAR SVT w/Aberrant conduction Sinus tachycardia A-flutter AVNRT Atrial Tachycardia

36. Wide Complex Tachycardia IR-Regular –Ventricular Fibrillation –An IR-Regular SVT w/Aberrant conduction Atrial fibrillation Aflutter with variable AV block MAT –Special Case: WPW & A-fib

39. V-Tach –vs- SVT w/Aberrancy Assume V-T until proven otherwise –Treatment for SVT can kill a patient in VT –Treatment for VT usually won ’ t kill a patient in SVT –Criteria – Brugada, others (beyond our scope) AV dissociation, increased age, CV risk factors = VT Fusion / Dresler beats = VT

41. Wide, Fast & Irregularly, Irregular = WPW (usually) Special Treatment

42. This patients resting EKG after you cardiovert him…

43. Bradyarrythmias I. Pauses –#1 cause of a pause is a non-conducted PAC II. Early, weird-looking beats: PVC –vs- PAC –PVC Wide complex Compensatory pause –PAC Narrow, no compensatory pause

44. Bradyarrythmias I. Problem is sinus or at the AV node –Sinus: Sinus bradycardia Sinus Arrest –AV Node: 1 st Degree AV block 2 nd Degree –Mobitz I (Wenkebach) –Mobitz II 3 rd Degree AVB

45. 2 nd degree Mobitz I (Wenkebach) -lengthening PR interval…then…dropped beat -“ Group Beating ” = Wenkeback until proven otherwise -Block at AV node -Normal in young patients (high vagal tone) -Think Meds (B-blockers, CCBs)

46. 2 nd degree Mobitz II -Constant PR interval…then dropped beat -Block always BELOW AV node (more serious) -Never normal -Likely needs a pacemaker

47. 3 rd degree (complete) heart block -A-V dissociation is present -‘ p ’ waves “ march ” out -Atrial rate > ventricular rate** -“ Escape ” rhythm -Clinical settings -Likely needs a pacemaker

48. Summary Follow the rules – be systematic –Tachycardia Narrow or Wide Regular or Irregular –Bradycardia Mind your ‘ p ’ s ’ Know the basics Questions Now, let ’ s do some examples