1. ECG Arrhythmia
Dr. K. P. Misra
Sr. Consultant Cardiologist

3. Analyzing Arrhythmias :
Two Cardinal Rules For
Analyzing Arrhythmias :
Study the ventricular (QRS)) complex
Look for the P waves (“cherchez le P”)

4. If the ventricular complex is normal :
you know that the arrhythmia is supraventricular :
i.e., either atrial or A – V nodal
If the ventricular complex is abnormal and widened :
you know that the arrhythmia is
either
ventricular or
supraventricular with ventricular aberration
(abnormal conduction through ventricles)

5. Overview Electrical activity of the heart The electrocardiogram
Monitoring sytems
Recognition of dysrhythmia in ACLS

6. Location for
chest electrodes
Lead 1

7. Location for
chest electrodes
Lead 2

8. Location for
chest electrodes
Lead 3

9. Normal Sinus Rhythm Rate : 60 to 100 / min Rhythm : regular
P waves : upright in I, II, aVF
Therapy : none

10. Normal Sinus Rhythm
Lead 2

11. Sinus Tachycardia Rate : greater than 100/min Rhythm : regular
P waves : upright in I, II, aVF
Treat underlying cause

12. Sinus Tachycardia
Lead 2

13. Sinus Bradycardia Rate : Less than 60 / min Rhythm : Regular
P waves : Upright in I, II, aVF
Therapy : Usually only when
hypotension or
ventricular ectopic
beats present
Atropine drug of choice
pacemaker may be necessary

14. Sinus Bradycardia
Lead V1

15. (normal P wave preceding every QRS)
SINUS RHYTHMS
(normal P wave preceding every QRS)
SINUS ARRHYTHMIA – NOTE IRREGULARITY
SINUS TACHYCARDIA - RATE 130
SINUS BRADYCARDIA - RATE 42

16. Premature Atrial Complexes
Rhythm : irregular
P waves : premature
coupling interval
noncompensatory pause
PR : normal
prolonged
blocked
QRS : normal
widened (aberrant)

17. Premature Atrial Complexes
Therapy : none if infrequent
treat underlying cause
specific drug therapy
- Quindine
Procainamide
Propranolol
Digoxin

18. Premature Atrial Complexes
MCL1

19. Atrial Premature Beat Run of premature P waves
(each followed by normal ventricular complex)
= ATRIAL TACHYCARDIA

20. Atrial Tachycardia with 2 to 1 A – V Block
Two P waves for every QRS - only every alternate impulse is conducted to ventricles.

22. Atrial Tachycardia Rate : atrial rate Rhythm : atrial - regular
ventricular –
usually regular with
1 to 1 conduction when
atrial rate is less than
200 / min when atrial rate is
more than 200 / min., AV
block and variable AV
conduction may occur
P waves : often difficult to identify
PR : normal or prolonged
QRS : normal or widened (aberrant)

23. Atrial Tachycardia Therapy : Paroxysmal atrial tachycardia
Parasympathetic maneuvers
- Vagal stimulation –
carotoid sinus message
valsalva, vomiting
Alpha receptor stimulation
- Phenylephrine
Cholinergic agent
- edrophonium
Synchronized DC
Countershock
Beta receptor blockage
- Propranolol
Other antidysrhythmic agents
- Procainamide
Lidocaine
Digitalization
Sedation
Atrial Tachycardia

24. Atrial Tachycardia Therapy : Nonparoxysmal atrial tachycardia
- treat underlying cause
potential danger of
digitalis intoxication

25. Atrial Tachycardia
Lead 2

26. Atrial Flutter Rate : Atrial rate 300 / min (220 – 350)
Rhythm : Atrial - regular
ventricular –
regular with constant AV
conduction ratio
Irregular with variable
AV conduction
P waves : F waves resemble
“sawtooth” or “picket fence”
PR : Usually regular but may vary
QRS : usually normal
aberrancy may occur

27. Atrial Flutter Therapy : Synchronized DC countershock digitalization
propranolol
quinidine, procainamide
overdrive pacing

28. Atrial Flutter
“Sawtooth” atrial flutter (“FF”) waves in regular relationship to QRS.
4 “F” waves to each QRS = 4 to 1A-V conduction.

29. Atrial Flutter
Lead 2

30. Atrial Fibrillation Therapy : Digitalization synchronized DC
countershock
quinidine, procainamide
propranolol

31. Atrial Fibrillation with
rapid ventricular response
Lead 2

33. Mitral stenosis and regurgitation in atrial fibrillation

35. Premature junctional complexes
Rhythm : irregular
P waves : retrograde inverted in II, III, aVF
before, during, or after QRS
compensatory or
noncompensatory pause
PR : with P before QRS
usually less than sec.
prolonged
blocked
QRS : normal
widened (aberrant)
Therapy : same as PACs

36. Premature junctional complexes
Lead 2

37. Junctional escape complexes and rhythm
Rate : junctional escape
rhythm – 40 to 60/min
Rhythm : junctional escape complexes – irregular
junctional escape rhythm – regular
P waves : retrograde inverted in II, III, aVF
before, during, or after QRS
compensatory or
atrioventricular dissociation
PR : variable
QRS : normal
widened (aberrant)
Therapy : hemodynamically stable
- none
atropine
isoproterenol
pacemaker

38. Junctional escape complexes
Lead 2

39. Two examples of A-V nodal rhythm
Abnormal P wave () either shortly before or after QRS

41. 3 more examples of Ventricular Tachycardia

42. VIP death

46. Interesting
Arrhythmias
Some Examples

52. The end