1. RHYTHM ANALYSIS
DAN MUSE, MD

2. EKG
EKG’S are loaded with acronyms.
EKG….LBBB….QTc……IRBBB……ETC

3. EKG
The one you should remember is……..KISS

4. EKG
KEEP IT SIMPLE STUPID!

5. EKG
EKG’s record electrical patterns that allow for medical interpretations
Acute Myocardial Infarction
Conduction Abnormalities
Rhythm Disturbances
Metabolic Abnormalities
Drug Toxicity
Pericarditis
Etc……

6. EKG GRID
The paper is graph paper that measures speed horizontally and amplitude vertically.
The horizontal box equals seconds. The darker box representing 5 small boxes equals 0.2 seconds

7. EKG GRID The vertical box measures amplitude.
The amplitude is a measure of voltage given in millivolts or MV
10 small boxes or 2 large boxes is equal to 1 mv

8. EKG GRID
EKG GRID

9. P WAVE P wave represents the depolarization of the atrium
Sinus node is in the right atrium resulting in the right atrium depolarizing first and then the left atrium
Normal duration is 0.12 sec…3 small boxes.

10. P WAVE
P WAVE

11. PR INTERVAL
PR interval is measured from the beginning of the p wave and to the beginning of the r (or q) wave.
It measures the time of atrial depolarization (p wave) conduction through the av node and conduction through the his-purkinje.
Normal duration is .14 to .20 seconds.

12. PR INTERVAL
PR INTERVAL

13. QRS COMPLEX
Q wave: a negative deflection indicating septal depolarization
Small Q waves may be seen in limb leads and v4-6
R wave: a positive deflection reflecting the depolarization of the left ventricle
S wave: the negative deflection reflects the depolarization of the high lateral wall

14. ST SEGMENT
Begins after the heart has depolarized and ends when the repolarization begins.
Ekg is “silent” during this time and should be isoelectric or at the baseline.

15. T WAVE Represents ventricular repolarization.
Slower than depolarization and the wave has a slow broad upstroke, returning quickly to baseline.
Depolarization travel endo to epicardium (inside-outside) with repolarization traveling epi to endocardium (outside-inside)

16. EKG COMPLEXES
COMPLEXES

17. QT INTERVAL Is a measure of the heart’s repolarization.
Measured from the QRS through the T wave
Changes with rate. A faster heart rate has a shorter QT interval and a slower heart rate has a longer one.

18. QT INTERVAL QT Interval is corrected to account for the heart rate.
QTc   =   QT interval  ÷  square root of the RR interval (in sec )
Normal QTc is less then or equal to sec.

19. QT INTERVAL
QT INTERVAL

20. U WAVE Occurs after the T wave Mechanism is not exactly understood
Has a low amplitude, usually less than .2 mv (2 small boxes)
Seen in metabolic abnormalities such as hypokalemia

21. U WAVE
U WAVE

22. EKG WAVES
THE WHOLE ENCHILADA

23. HEART RATE
Heart rate is measured by determining the distance between the QRS complexes.
Exact rate is not necessary…range will suffice.

24. HEART RATE
The rate is most easily determined by dividing 60 seconds by the number of large blocks separating the QRS complexes.
60 SECONDS / 0.2 (ONE LG BLOCK) = 300
60 SECONDS / 0.4 (2 LG BLOCKS) = 150
60 SECONDS / 0.6 (3 LG BLOCKS) = 100

25. HEART RATE NORMAL HEART RATE: 60-100 BRADYCARDIA: Less then 60
TACHYCARDIA: Greater then 100

26. RHYTHM ANALYSIS Locate the P wave Is every P wave the same?
Is the P wave associated with a QRS complex?
Is the p wave hidden in the QRS. Seen in Junctional or AV nodal reentrant tachycardia.
Is the P wave hidden in the ST segment…AV reentrant or ventricular tachycardia.

27. RHYTHM ANALYSIS What is the p wave rate (P-P Interval)?
Less than 60….Bradycardia
….Sinus Tachycardia
….Atrial Tachycardia, AV Nodal Reentrant Tachycardia, AV Reentrant Tachycardia.
…..Atrial Flutter

28. RHYTHM ANALYSIS OF RAPID RATE
What is the morphology of the qrs?
Less than 0.12 sec: (Narrow Complex) Supraventricular
Greater than 0.12 sec: (Wide Complex) Supraventricular With Aberrant Conduction Or Ventricular

29. RHYTHM ANALYSIS Match the findings to the patient.
Different age groups, different diseases and different lifestyles may produce different findings on the EKG.

34. SINUS BRADYCARDIA
Normal complexes
Rate less than 60

35. SINUS BRADYCARDIA

36. SINUS TACHYCARDIA
Rate a sinus rhythm
Normal complexes

37. SINUS TACHYCARDIA

38. IRREGULARLY IRREGULAR
ATRIAL FIBRILLATION
Typically rapid but chronically can be a slower controlled rate.
Don’t see P waves because so many are firing off at the same time.
IRREGULARLY IRREGULAR

39. ATRIAL FIBRILLATION

40. ATRIAL FLUTTER
Rate is variable and based on the recurrent conduction of the P waves
P waves can have a saw tooth pattern
Rate of 150…..Think A-Flutter
P waves have a propensity to hide in the T wave on a 2:1 conduction (for every QRS complex there are 2 P waves; 2:1 conduction)

41. ATRIAL FLUTTER

42. PVC’S PREMATURE VENTRICULAR CONTRACTIONS
Wide complex QRS intermixed with narrow complex QRS.
Always associated with a compensatory pause which when added with the previous normal QRS equals two QRS complexes.
May come in bunches.

46. 1ST DEGREE AV BLOCK
Prolonged PR interval
No medical consequence

47. 1ST DEGREE AV BLOCK

48. 3RD DEGREE AV BLOCK Complete blockage at the AV node
Results in p waves and the QRS complexes beating separately

49. 3RD DEGREE AV BLOCK
3RD DEGREE BLOCK

50. VENTRICULAR TACHYCARDIA
A wide complex ventricular tachycardia.
Rhythm is regular.

51. VENTRICULAR TACHYCARDIA

52. TORSADES A ventricular arrhythmia that rotates on its axis.
TORSADES = twists in French.
Treated with magnesium.

53. TORSADES
TORSADES

54. VENTRICULAR FIBRILLATION
Irregular ventricular complexes.
The smaller the complexes the less likely you can reverse the process.
NEXT COMPLEX…..ASYSTOLE!

55. VENTRICULAR FIBRILLATION