ECG Interpretation

1. ECG Interpretation Advanced Cardiac Life Support William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro advancing health worldwide TM Department of Anesthesia and Perioperative Care

2. Course Objectives & Description: • Recognize & initiate early management of peri-arrest conditions that may result in cardiac arrest • Manage cardiac arrest until return of spontaneous circulation, or transfer of care • Understanding of arrhythmia interpretation • Recognize the hemodynamic consequencesof arrhythmias

3. Normal Sinus Rhythm Normal sinus rhythm results from the initiation of an electrical signal (the cardiac impulse) by cells of the sinus node at a rate appropriate to the age and state of activity of the individual, and then the propagation of that signal in an orderly manner through the atria, A-V junction, ventricular specialized conducting system and the ventricular myocardium

4. Cardiac Conduction System Bachmann’s bundle Sinus node Internodal pathways Left bundle branch AV node Posterior division Bundle of His Anterior division Purkinje fibers Right bundle branch

5. Arrhythmia An arrhythmia reflects either abnormally rapid or slow impulse initiation by the sinus node, or interruption of the sinus rhythm by impulses originating from some other site in the heart, either for short or long periods of time

6. Mechanisms of Arrhythmias • Reentry • Automaticity • Altered normal automaticity • Abnormal automaticity • Triggered Rhythms due to DAD (delayed after depolarizations

7. Causes of Arrhythmias • Physiologic and Pathologic Processes • Vagal stimulation, Fever, Hypothermia • Electrolyte abnormalities, CNS problems • Hypovolemia, Pain, anaphylaxis, etc. • Preexisting Cardiac & Pulmonary Disease • Acute coronary syndrome, HTN, AODM • COPD, hypoxia, hypercarbia

8. The Electrocardiogram

9. The Electrocardiogram R T P U Q S PR Interval QRS Interval

10. The Electrocardiogram PR Interval QRS Interval QT Interval

11. Cardiac Conduction System Relationship of ECG to anatomy

12. Cardiac Conduction System Relationship of ECG to anatomy

13. ACLS THE ACLS PROVIDER IS: IN

14. Normal Sinus Rhythm • Rate 60-100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF

15. Determining the Rate

16. Determining the Rate

17. Determining the Rhythm

18. Sinus Tachycardia • Rate: Greater than 100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF

19. Sinus Tachycardia • Rate: Greater than 100 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF

20. Sinus Bradycardia • Rate: Less than 60 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF

21. Sinus Bradycardia • Rate: Less than 60 beats per minute • Rhythm: Regular • P waves: Upright in Leads: 1, 2, AVF

22. Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: Normal or widened P-wave

23. Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: Normal or widened

24. Premature Atrial Complexes • P wave Rhythm: Irregular • P waves: Premature, often in the T-wave • QRS complex: (Normal or widened) or blocked Non conducted P-wave

25. Atrial Tachycardia • Rate: Atrial- 140-240 bpm, p-waves hard to see • Rhythm: • P-wave- regular • QRS- 1-1 conduction with atrial rates < 200 bpm • With atrial rates > 200 bpm, A-V conduction block common (less than 1-1 conduction) • PR interval- depends on the origin of the p-wave • QRS- usually normal

26. P-Wave P-Wave Atrial Tachycardia

27. Atrial Tachycardia Atrial Tachycardia with variable block P-Waves are regular at 160 bpm

28. Atrial Flutter • Rate: Atrial- 300 bpm (260-320) • Rhythm: • P-waves- regular • QRS- 2-1 conduction - 150 bpm, variable AV conduction with constant AV conduction ratio • P-waves: F-waves (Flutter), sawtooth pattern • QRS- usually normal, obviously sometimes wide

29. Atrial Flutter F-waves

30. Atrial Flutter Atrial Flutter with variable conduction (block)

31. Atrial Fibrillation • Rate: Atrial- rapid, Ventricular- Depends • Rhythm: • P-waves- irregular • QRS- beat to beat variability, Irregularly irregular • P-waves: From F-waves (Flutter) to absent • QRS duration- normal or wide

32. Atrial Fibrillation

33. Atrial Fibrillation

34. Atrial Fibrillation

35. Premature Junctional Complexes • Rhythm: Irregular • P waves: Retrograde • PR interval: < .12 sec or nonexistent • QRS complex: Normal or widened

36. Premature Ventricular Complexes • Rhythm: Irregular • P waves: Usually not seen • QRS complex: Wide > .12 sec • Compensatory pause

37. This is the sinus and the QRSdistance This distanceis double the sinus distance Premature Ventricular Complexes Compensatory pause

38. Premature Ventricular Complexes • Unifocal PVCs • Multifocal PVCs

39. This is the sinus and the QRSdistance This distanceis double the sinus distance Premature Ventricular Complexes Compensatory pause Interpolated PVC

40. Premature Ventricular Complexes Ventricular Bigeminy Pairs of PVCs

41. Premature Ventricular Complexes PVC on T-wave precipitating Ventricular Tachycardia

42. Ventricular Tachycardia • Rate: Approx 100-230 bpm • Rhythm: Usually regular • P waves: Usually not seen • Independent A and V activity • A-V dissociation • QRS complex: Wide > .12 sec • Capture beats, fusion beats

43. Ventricular Tachycardia

44. Ventricular Tachycardia Polymorphic Ventricular Tachycardia

45. Ventricular Fibrillation • Rate: Rapid- no effective cardiac rhythm • Rhythm: Irregular • P, QRS, T- waves: Absent • No blood pressure!

46. Ventricular Fibrillation Course VF Fine VF

47. Ventricular Fibrillation

48. Ventricular Asystole • P, QRS, T- waves: Complete absent of cardiac electrical activity • Complete absent of effective cardiac pumping function

49. Acute Coronary Syndromes

50. Acute Coronary Syndromes