Arrythmia recognition

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Arrhythmia Recognition An Emergency View
DR. SATHISH BABU P
Emergency Critical care Physician
Vinayaka Mission University
SALEM
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Cardiac conduction
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ELECTROCARDIOGRAM

• 5 steps approach to arrhythmias
• Step1 Is there a QRS
• Step2 Is there a P Wave
• Step3 What is the relationship between the
• P waves and the QRS complexes?
  Step4 Calculate rate
• Step5Miscellaneous

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Is there a QRS (No pulse)
YES
NO
CHAOTIC
FLAT LINE
WIDE
NARROW
PEA
Asystole
VF
VT
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No QRS Chaotic
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No QRS Flat line
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Wide QRS
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Wide QRS
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Wide QRS Polymorphic
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2) Is there a P Wave
YES
NO
RR Interval
MORPHOLOGY
RATE
VARY
CONSTANT
Inverted
220 to 350
AF
JUNCTIONAL
JUNCTIONAL
Atrial Flutter
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No P Varying RR interval
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3)What is the relationship between the P waves
and the QRS complexes?
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HEART BLOCK
Constant?
No Type1 IIo
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1st Degree block(AV Nodal Delay)
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P-R Interval

• IST Degree heart block
• nP nQRS ?
• P-R interval is gt0.2 Sec

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HEART BLOCK
Constant?
No Type1 IIo
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nP is not equal to nQRS?PR interval is
constant
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HEART BLOCK
Constant?
No Type1 IIo
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IIIrd Degree heart block

• nP is not equal to nQRS?
• PR intervals are not constant
• RR intervals are constant

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HEART BLOCK
Constant?
No Type1 IIo
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IInd Degree Type-I heart block
nP is not equal to nQRS ? Both PR and RR
intervals are not constant

• PROGRESSIVE PROLONGATION OF P-R INTERVAL
• DROPPED QRS COMPLEX

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4)Calculating Heart Rates
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Count the number of R waves in a 6-second strip
and multiply by 10.(especially for irregular
rhythm)

• Not very accurate
• Used only with very quick estimate

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Calculating Heart Rates(cont..)
B
Count the number of large squares between two
consecutive R waves and 300 / Big squares

• Very quick
• Not very accurate with fast rates
• Used only with regular rhythms

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Calculating Heart Rates (cont..)
C
Count the number of small squares between two
consecutive R waves and or 1500 / small
squares. .

• Most accurate
• Used only with regular rhythms
• Time consuming

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Calculating Heart Rates (cont..)
D
Count the number of BIG squares between two
consecutive R waves in descending order as
300,150,100,75,60,50...

• Not very accurate
• Used only with regular rhythms
• Time saving

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Supraventricular Tachycardia

• Narrow complex
• Regular Rate 140 to 220 / minute

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VT SVT with aberrancy

• Capture beat
• Fusion beat
• Concordance
• Time required to reach either the peak of R wave
  / the nadir of the S wave gt 0.07 second

• NO capture or fusion beats
• Concordance leads will not have the same polarity
  
• Time required to reach either the peak of R wave
  / the nadir of the S wave lt 0.07 second

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ECG Criteria

• Concordance
• All the ventricular complexes in V1 V6 is
  negative or positive diagnosis VT
• Concordant negativity RVT
• Concordant positivity LVT

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VT SVT with aberrancy

• Tall R VT
• A complete or almost complete absence of any
  positive deflection in V6 (QS or rS) Diagnostic
  of VT

• Tall R1 - RBBB
• A triphasic QRS morphology in lead V6- Diagnostic
  of SVT with aberrancy

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• Tall R1 - RBBB

Tall R VT
complete absence of any positive deflection in
V6
A triphasic QRS
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ventricular aberration
ventricular tachycardia
Monophasic R
rsR1 pattern
rS
qRs pattern
QS
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MISCELLANEOUS
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ELECTROCARDIOGRAM

• 5 steps approach to arrhythmias
• Step2 Fix the regularity
• Regular I I I I I I
• Premature I I I I I I I
  Escape I I I I I
  IIrregular I I I I I I
  I I

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PREMATURE COMPLEX

• ANY COMPLEX COMING BEFORE THE NEXT EXPECTED
  PERIOD
• WIDE NARROW
• (VENTRICULAR) (ATRIAL/JUNCTIONAL)

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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ESCAPE COMPLEX

• ANY COMPLEX COMING AFTER A PAUSE
• WIDE NARROW
• (VENTRICULAR) (ATRIAL/JUNCTIONAL)

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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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THANK YOU