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ECG interpretation for beginners Part 3 - Bradyarrhythmias. Paul Williams Cardiology Specialist Registrar. Normal ECG!. Native pacemaker sites. SA node SR (50-180) Escape rhythms AV node “junctional” - narrow 50-60bpm Ventricle “ventricular” - broad 30-40bpm Unstable.

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ecg interpretation for beginners part 3 bradyarrhythmias

ECG interpretation for beginnersPart 3 - Bradyarrhythmias

Paul Williams

Cardiology Specialist Registrar

native pacemaker sites
Native pacemaker sites
  • SA node
    • SR (50-180)
  • Escape rhythms
    • AV node
      • “junctional” - narrow
      • 50-60bpm
    • Ventricle
      • “ventricular” - broad
      • 30-40bpm
      • Unstable
only two things make your heart go too slow
Only two things make your heart go too slow!

1) Failure of normal pacemaker

2) Blocked conduction at the AV node

DANGEROUS!

slide6

Is it a problem with the SA node or the AV node (or both)?

    • Sinus bradycardia
    • SA nodal disease
    • Junctional rhythm (escape)
    • AV block
      • 1 HB (doesn’t affect rate)
      • 2 HB – Wenckebach (doesn’t need PPM). Mobitz type 2
      • 3 HB (or CHB)
    • Slow AF
key questions
Key questions

Concentrate on rhythm strip (II, V1)

  • Are there P waves at all?
  • Is there a P wave before each QRS?

Use a piece of paper if not sure

For management

Is this causing symptoms?

Is this dangerous?

Is there a risk of asystole?

sinus bradycardia
Sinus bradycardia
  • Normal
  • No treatment!
av block
AV block
  • All indicate problems with AV nodal conduction
  • 3 degrees - progressive
  • Usually intermittent to start with
  • Higher degree AV block is dangerous and needs a PPM (risk of asystole & VF)
  • Most rate-lowering drugs work by slowing AV conduction
av block 1 st degree
AV block – 1st degree
  • Lengthened PR interval (>0.2s)
  • Always P wave before each QRS
  • Doesn’t affect rate so not necessarily bradycardic….
  • In isolation doesn’t need treatment
av block 2 nd degree
AV block – 2nd degree

Two types:

  • Mobitz one
    • Wenckebach phenomenon
    • Usually benign if sleeping
  • Mobitz two
    • 2:1, 3:1, 4:1 etc
    • Not benign!!!
    • Risk of SCD - needs a PPM
wenckebach
Wenckebach
  • Karel Frederik Wenckebach
  • Dutch anatomist
  • 1864-1940
complete heart block
Complete heart block
  • Can only reliably be diagnosed if patient in SR (so can see P waves)
  • No relationship between P waves & QRS complexes. Usually both will be regular
  • Is there a risk of imminent asystole?
    • Very slow rate
    • Pauses
    • Broad QRS (ie. ventricular escape rhythm)
  • Needs a PPM if occurs off drugs
  • Needs a TPW if symptomatic or high-risk features
  • Exception = transient CHB during inferior MI
slow af flutter
Slow AF/flutter
  • Normally AF/flutter is fast!
  • AV conduction must be slowed
  • ? Drugs ? AV nodal disease
  • If ventricular rhythm is slow, regular and broad likely to be CHB with ventricular escape (easily missed)
management of bradyarrhythmias
Management of bradyarrhythmias
  • ABC!
  • Conscious? BP?

CPR

External pacing

Temporary pacing wire

Permanent pacemaker

external pacing
External pacing
  • Most “defibs” can also pace
  • Must have limb leads on
  • Two main options:
    • Rate
    • Power
  • It is painful (sedation) & unreliable
  • Only stopgap measure
temporary pacing wire
Temporary pacing wire
  • Need central access (jugular, femoral, subclavian)
  • Pass wire to heart using fluoroscopy
  • High complication rate in amateur hands
  • Not commonly performed now as external pacing available and little wait for PPMs
further management
Further management
  • Stop bradycardic agents
    • B-blockers
    • Ca-blockers,
    • Digoxin
    • Amiodarone
    • Sotalol
  • Consider a PPM
permanent pacemakers
Permanent pacemakers
  • Improve prognosis
    • 2nd degree and 3rd degree HB
  • Improve symptoms
    • SA nodal disease
  • Or both…..
pacemaker types
Pacemaker types
  • One lead? (VVI)
    • RV
  • Two leads? (DDD)
    • RV and RA
  • Three leads? (BiV-PPM or CRT)
    • RV, RA and LV (via coronary sinus)
  • Any of above + defib (ICD)
question 1
Question 1
  • What is the rate, rhythm and axis?
  • Management
question 2
Question 2
  • What is the rate, rhythm and axis?
  • Management?
question 3
Question 3
  • What is the rate, rhythm and axis?
  • Management?
question 4
Question 4
  • What is the rate, rhythm and axis?
  • Management?
question 5
Question 5
  • What is the rate & rhythm?
  • Management?