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ArrhythmiasArrhythmias
Dr. Ahmad HersiDr. Ahmad Hersi
Med 441Med 441
6/1/20096/1/2009
Conduction SystemConduction SystemConduction SystemConduction System
Septal Branch
Depolarization SequenceDepolarization Sequence
CatechismCatechismCatechismCatechism
Identification
Quality
Rate
Rhythm
Axis
Waves and intervals
Specifics
Identification
Quality
Rate
Rhythm
Axis
Waves and intervals
Specifics
Frontal (limb lead) axisFrontal (limb lead) axisFrontal (limb lead) axisFrontal (limb lead) axis
II
aVFaVF
IIII
Limb-lead MisplacementLimb-lead MisplacementLimb-lead MisplacementLimb-lead Misplacement
II
aVFaVF
IIII
Precordial LeadsPrecordial LeadsPrecordial LeadsPrecordial Leads
V4: 5th ICS mid-clavicular line
V6: lateral to V4 mid-axillary line
VV11: : Right 4th ICS parasternal
V2: Left 4th ICS parasternal
RateRateRateRate
300 100 60 40
150 75 50
Start if possible on a beat whose QRS (usually R wave) is on the border of a large squareStart if possible on a beat whose QRS (usually R wave) is on the border of a large square
Count Large squares
(0.2 seconds each)
Count Large squares
(0.2 seconds each)
This tracing example shows a rate of 100 bpm
Rate determination for irregular Rate determination for irregular rhythmrhythm
30
8 times 10 = 80 bpm
For irregular rhythm (such as atrial fibrillation), the method shown on the last slide
may be inaccurate. Use this alternate method.
Start as before by finding a QRS that lands on the border of a large square (*).
Then count 30 large squares (= 0.2 X 30 = 6 seconds). Add up all beats (QRSs)
that land within the interval (not counting that first beat (*) and multiple by 10.
This equals the number of beats per minute.
*
RhythmRhythmRhythmRhythm
““Cherchez la P”Cherchez la P” To be convinced of sinus rhythm, you To be convinced of sinus rhythm, you
should see a P wave in front of every should see a P wave in front of every QRS, and the PR interval should not QRS, and the PR interval should not alter, and be of a plausible length.alter, and be of a plausible length.
Lead II is usually the best lead for Lead II is usually the best lead for
seeing P waves, and is often used for seeing P waves, and is often used for rhythm strips.rhythm strips.
““Cherchez la P”Cherchez la P” To be convinced of sinus rhythm, you To be convinced of sinus rhythm, you
should see a P wave in front of every should see a P wave in front of every QRS, and the PR interval should not QRS, and the PR interval should not alter, and be of a plausible length.alter, and be of a plausible length.
Lead II is usually the best lead for Lead II is usually the best lead for
seeing P waves, and is often used for seeing P waves, and is often used for rhythm strips.rhythm strips.
QRS AxisQRS Axis
Left
Right Normal
I (-)aVF (-)II (-)
I (-)aVF (+)II (+)
I (+)aVF (-)II (-)
I (+)aVF (+)II (+)
Quick Method for QRS AxisQuick Method for QRS Axis
I
aVF
II
The P WaveThe P Wave
•Normally from sinus node
•Upright in I, II, aVF, V4-V6
•Monophasic (except V1)
•Normal ranges: o < 0.12 sec wideo < 2.5 mm tall
The PR IntervalThe PR IntervalThe PR IntervalThe PR Interval
Measure from Measure from beginning of P wave to beginning of P wave to onset of QRS. Usually onset of QRS. Usually measure in Lead II measure in Lead II
Measure the longest Measure the longest PR interval in the limb PR interval in the limb leadsleads
Normal range 0.12-Normal range 0.12-0.20 seconds0.20 seconds
< 0.12 = Accelerated conduction< 0.12 = Accelerated conduction > 0.2 = Heart block> 0.2 = Heart block
Measure from Measure from beginning of P wave to beginning of P wave to onset of QRS. Usually onset of QRS. Usually measure in Lead II measure in Lead II
Measure the longest Measure the longest PR interval in the limb PR interval in the limb leadsleads
Normal range 0.12-Normal range 0.12-0.20 seconds0.20 seconds
< 0.12 = Accelerated conduction< 0.12 = Accelerated conduction > 0.2 = Heart block> 0.2 = Heart block
Right Atrial EnlargementRight Atrial EnlargementRight Atrial EnlargementRight Atrial Enlargement
Left Atrial EnlargementLeft Atrial EnlargementLeft Atrial EnlargementLeft Atrial Enlargement
The QRS ComplexThe QRS ComplexThe QRS ComplexThe QRS Complex
The Q WaveThe Q WaveThe Q WaveThe Q Wave
The J - PointThe J - PointThe J - PointThe J - Point
QRS WaveformsQRS WaveformsQRS WaveformsQRS Waveforms
The ST SegmentThe ST SegmentThe ST SegmentThe ST Segment
The T WaveThe T WaveThe T WaveThe T Wave
T waves may be T waves may be normally inverted in normally inverted in aVR (almost always), aVR (almost always), III (frequently), and V1 III (frequently), and V1 (sometimes).(sometimes).
T waves are “tall” if T waves are “tall” if their height is: their height is: – > 50% QRS height > 50% QRS height – > 5mm in limb lead> 5mm in limb lead– > 10 mm in precordial > 10 mm in precordial
leadlead
T waves may be T waves may be normally inverted in normally inverted in aVR (almost always), aVR (almost always), III (frequently), and V1 III (frequently), and V1 (sometimes).(sometimes).
T waves are “tall” if T waves are “tall” if their height is: their height is: – > 50% QRS height > 50% QRS height – > 5mm in limb lead> 5mm in limb lead– > 10 mm in precordial > 10 mm in precordial
leadlead
The QT IntervalThe QT IntervalThe QT IntervalThe QT Interval
RR
The U WaveThe U WaveThe U WaveThe U Wave
Causes:Causes:– NormalNormal– BradycardiaBradycardia– CADCAD– HypertensionHypertension– HypokalemiaHypokalemia– HypercalcemiaHypercalcemia
Causes:Causes:– NormalNormal– BradycardiaBradycardia– CADCAD– HypertensionHypertension– HypokalemiaHypokalemia– HypercalcemiaHypercalcemia
Left Ventricular HypertrophyLeft Ventricular HypertrophyLeft Ventricular HypertrophyLeft Ventricular Hypertrophy
*
* *
*
Right Ventricular Right Ventricular HypertrophyHypertrophyRight Ventricular Right Ventricular HypertrophyHypertrophy
LBBBLBBBLBBBLBBB
RBBBRBBBRBBBRBBB
Case 1Case 1
65 yr woman, presents to ER with 65 yr woman, presents to ER with Dizziness for 2hrs.Dizziness for 2hrs.
In the past, a doctor told her that In the past, a doctor told her that her heart rate is slow.her heart rate is slow.
Healthy otherwise, and is not on Healthy otherwise, and is not on med’s.med’s.
O/E : Bp=170/100 O/E : Bp=170/100
Another dizzy ladyAnother dizzy lady
Had syncope Had syncope
What is the appropriate What is the appropriate therapy?therapy?
Management Management
ABCABC V/SV/S If serious symptoms or signs:If serious symptoms or signs: - Atropine 1 mg- Atropine 1 mg - TCP- TCP - Dopamine - Dopamine - Epinephrine- Epinephrine - Isoproterenol - Isoproterenol
ManagementManagement
If clinically stable:If clinically stable:
- Prepare for TVP as a bridge device- Prepare for TVP as a bridge device
Case 2Case 2
25yr old woman 25yr old woman 1 hr h/o palpitation1 hr h/o palpitation No other cardiac symptomsNo other cardiac symptoms Intermittent palpitation in the last Intermittent palpitation in the last
3 months , this episode is long3 months , this episode is long BP= 120/70BP= 120/70
What is your What is your management?management?
Management Management
Serious signs and symptoms
Narrow Complex tachycardia
Immediate Cardioversion
Stable clinically
Vagal maneuvers
Adenosine or Verapamil
Consider BB, Diltiazem , or Digoxin
Case 3 Case 3
60 yrs C/O sudden onset dyspnea for 60 yrs C/O sudden onset dyspnea for last 1/2hr last 1/2hr
Past MI 1 yr ago, received Past MI 1 yr ago, received thrombolytics.thrombolytics.
His ECHO at the time revealed impaired His ECHO at the time revealed impaired LV systolic functionLV systolic function
Med’s: ASA, Bisoprolol, Lisinopril, and Med’s: ASA, Bisoprolol, Lisinopril, and LasixLasix
On exam , BP=80/50On exam , BP=80/50
Bouts of palpitations Bouts of palpitations
Short PR interval, less than 3 small squares (120 ms)
Slurred upstroke to the QRS indicating pre-excitation (delta wave)
Broad QRS
Secondary ST and T wave changes
• An accessory pathway, bundle of Kent, exists between atria and ventricles and causes early depolarisation of the ventricle.
WPW
Case 4Case 4
75 yrs woman75 yrs woman Presents to ER with fever and Presents to ER with fever and
productive coughproductive cough PMH= HTNPMH= HTN BP=150/90BP=150/90
How would you How would you manage ?manage ?
Management Management
If patient is hypoxemic If patient is hypoxemic O2 O2 Control BP ( may chose a BB or CCB Control BP ( may chose a BB or CCB
for rate control and BP control)for rate control and BP control) Rate control the ventricular Rate control the ventricular
response if tachycardia .response if tachycardia . Consider Long term anticoagulation Consider Long term anticoagulation
if no contraindications if no contraindications
Normal ECGNormal ECG
A 63 year old woman with 10 hours of chest pain and A 63 year old woman with 10 hours of chest pain and sweating.sweating.
An 83 year old man with aortic stenosis.An 83 year old man with aortic stenosis.
A 75 year old woman with loud first heart A 75 year old woman with loud first heart sound and mid-diastolic murmur.sound and mid-diastolic murmur.
A 59 year old woman with chronic bronchitis.A 59 year old woman with chronic bronchitis.
An 84 year old woman with hypertensionAn 84 year old woman with hypertension
A 73 year old woman with dizziness.A 73 year old woman with dizziness.
A 70 year old man with exercise A 70 year old man with exercise
intoleranceintolerance..
A 90 year old lady with syncope.A 90 year old lady with syncope.
A 76 year old man with SOBA 76 year old man with SOB
A woman with Romano-Ward SyndromeA woman with Romano-Ward Syndrome
A 45 year old women with palpitation A 45 year old women with palpitation and a history of CRFand a history of CRF
A 47 year old man with a long history of A 47 year old man with a long history of palpitations and blackouts.palpitations and blackouts.
A 58 year old man on hemodialysis A 58 year old man on hemodialysis presents with weaknesspresents with weakness
A 28 year old A 28 year old woman with woman with prolonged vomitingprolonged vomiting
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