Arrhythmia Recognition An Emergency View

1. Arrhythmia Recognition An Emergency View DR. SATHISH BABU P Emergency & Critical care Physician Vinayaka Mission University SALEM

2. Cardiac conduction

5. 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 Step5:Miscellaneous

6. Is there a “QRS”(No pulse) YES NO NARROW WIDE CHAOTIC FLAT LINE PEA Asystole VT VF

7. No “QRS” & Chaotic

8. No QRS & Flat line

9. Wide QRS

10. Wide QRS

11. Wide QRS & Polymorphic

12. 2) Is there a “P” Wave YES NO RR Interval RATE MORPHOLOGY VARY CONSTANT Inverted 220 to 350 AF JUNCTIONAL JUNCTIONAL Atrial Flutter

14. No “P” & Varying “RR” interval

16. 3)What is the relationship between the P waves and the QRS complexes?

17. n“P” = n“QRS” ? Yes No PR interval PR interval Constant ? < 0.2 > 0.2 Normal Io AVB No Yes IIoAVB type 2 RR interval Yes IIIoAVB HEART BLOCK Constant? No Type1 IIo

18. 1st Degree block(AV Nodal Delay)

19. P-R Interval IST Degree heart block n“P” = n“QRS” ? P-R interval is>0.2 Sec

20. n“P” = n“QRS” ? Yes No PR interval PR interval Constant ? < 0.2 > 0.2 Normal Io AVB No Yes IIoAVB type 2 RR interval Yes IIIoAVB HEART BLOCK Constant? No Type1 IIo

22. n“P” is not equal to n“QRS”?PR interval is constant

23. n“P” = n“QRS” ? Yes No PR interval PR interval Constant ? < 0.2 > 0.2 Normal Io AVB No Yes IIoAVB type 2 RR interval Yes IIIoAVB HEART BLOCK Constant? No Type1 IIo

25. IIIrd Degree heart block n“P” is not equal to n“QRS”? PR intervals are not constant RR intervals are constant

27. n“P” = n“QRS” ? Yes No PR interval PR interval Constant ? < 0.2 > 0.2 Normal Io AVB No Yes IIoAVB type 2 RR interval Yes IIIoAVB HEART BLOCK Constant? No Type1 IIo

29. IInd Degree Type-I heart block n“P” is not equal to n“QRS” ? Both PR and RR intervals are not constant PROGRESSIVE PROLONGATION OF ‘P-R’ INTERVAL DROPPED ‘QRS’ COMPLEX

31. 4)Calculating Heart Rates A 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

32. 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

33. 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

34. 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

43. Supraventricular Tachycardia • Narrow complex • Regular Rate 140 to 220 / minute

45. 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 > 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 < 0.07 second

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

49. 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

50. Tall R1 - RBBB Tall R – VT complete absence of any positive deflection in V6 A triphasic QRS