PHILIPPINE HEART ASSOCIATION

Council on CardioPulmonary Resuscitation

Approach to the Recognition of

The ACLS Rhythms

A Full Member of the

The Asian Representative of

 A C L S : Empirical Approach

Airway Breathing Compressions

Arrhythmia Recognition
• Important in any ACLS / CPR
sequence

• All algorithms start with

identifying the rhythm

• Cannot identify arrhythmia 

cannot manage correctly
 Outline
• Background on anatomy and physiology of cardiac
conduction

• Basic ECG interpretation

• Recognition of Normal Rhythm

• Recognition of Abnormal Rhythms

• Exercises
 ECG

• ELECTROCARDIOGRAM
– Valuable record of the heart’s electrical activity
– Easy to understand

• Tip: just recognize the waveforms

• Easy as ABC or 123
• or P-QRST
 ECG : Clinical Applications
• Rhythm abnormalities

• Chamber enlargement

• Ischemia / Infarction
Background: CARDIAC SYSTOLE & DIASTOLE
The Beating Heart- Electrophysiology
Electrical Stimulation And Contraction

BEFORE THE HEART CONTRACTS

IT MUST BE ELECTRICALLY STIMULATED

DEPOLARIZATION
Anatomy and Physiology of Cardiac Conduction

SINUS NODE
Sinus Node • The Heart’s ‘Natural
(SA Node) Pacemaker’
- 60-100 BPM at rest
LA
RA
LV
RV
Anatomy and Physiology of Cardiac Conduction

AV NODE
Sinus Node • Receives impulse from
(SA Node) SA Node
• Delivers impulse to the His-
Atrioventricular
Node (AV Node) Purkinje System
• 40-60 BPM if SA Node fails to
deliver an impulse
 Anatomy and Physiology of Cardiac Conduction

BUNDLE OF HIS
Sinus Node • Begins conduction to
(SA Node) the Ventricles

Atrioventricular
• AV Junctional Tissue:
Node (AV Node) 40-60 BPM

Bundle of His
 Anatomy and Physiology of Cardiac Conduction

THE PURKINJE NETWORK

Sinus Node
(SA Node) • Bundle Branches
• Purkinje Fibers
Atrioventricular
Node (AV Node)
• Moves the impulse through
the ventricles for contraction
Bundle of His • Provides ‘Escape Rhythm’:
20-40 BPM
Bundle Branches

Purkinje Fibers
Impulse Formation In SA Node
Atrial Depolarization
Delay At AV Node
Conduction Through Bundle Branches
Conduction Through Purkinje Fibers
Ventricular Depolarization
Plateau Phase of Repolarization
Final Rapid (Phase 3) Repolarization
 Normal ECG Activation
Major Waveforms of the ECG
 NORMAL SINUS RHYTHM

• Pacemaker impulses are initiated in the SA

node, traveling through atrial pathways, at
frequencies between 60-100 bpm.
• There is the presence of a P wave, followed by a
QRS complex at a regular rate.
 Normal Sinus Rhythm
Look at the p waves:
•rate is 60-100/min
•cycle length do not vary by 10%
•PR interval is 0.12 - 0.20 sec.

Lead II
 Normal Sinus Rhythm
Look at the p waves:
•same contour in same lead?
•upright in I, II, aVF & left precordial
leads
•followed by QRST?
Lead II
Normal ECG Activation
Normal Cardiac Depolarization

 ARRHYTHMIA
 Steps in ECG Interpretation for ACLS
• Regularity?
• Rate?
• Rhythm? Sinus?
• P-QRST
• Intervals: PR, QRS, QT
• Rhythm abnormalities?
• Clinical correlation
 Regularity
• Beat to beat interval(R to R intervals or P to P
intervals) the same
Regular or Irregular?
Regular or Irregular?
Regular or Irregular?
Regular or Irregular?
Regular or Irregular?
During ACLS/BLS:
•Patient is hooked to Cardiac
Monitor / Defbrillator
•Patient’s heart rate is
automatically detected
•Normal HR = 60 to 100 bpm
 Determination of Rate
Regular Rhythm

1 2 3 4

1500 / 23 = 65/min
 FAST METHOD
Start

300 300
150
100
75

150 60
50

100
75 ~63 BPM
60
50
REMEMBER….

300 – 150 – 100

75 – 60 - 50
 Determination of Rate
Regular Rhythm

150 75
300 100

1500 / 23 = 65/min
 Determination of Rate
Irregular Rhythm

3 second strip

Rate /min = Number of complexes x 20

Or if 6 second strip:
Rate/min = number or complexes x 10
6 second strip
Is it regular or irregular?
Rate? Is it fast or slow or normal?
Rhythm?
Is there a P wave?
Is it followed by a QRS? All the time?
Are the intervals normal?PR interval normal?
Is the QRS wide or narrow?
• Sinus bradycardia • Sinus tachycardia  Asystole Benign ectopic
• Sinus pause • Supraventricular  Ventricular rhythms:
• Escape rhythms: tachycardia fibrillation  PACs
– Junctional rhythm • Atrial fibrillation  Pulseless VT  PVCs
– Idioventricular  Pulseless
• Atrial flutter
rhythm
• Multifocal atrial electrical activity
• Heart blocks Miscellaneous
tachycardia
 Artificial
• Ventricular Pacemaker rhythm
tachycardia  Preexcitation /
WPW pattern
BENIGN RHYTHMS
 Sinus Bradycardia

Regularly occurring PQRST

Rate < 60 / min

Rate = 48/min
Rate = 48/min
Sinus Bradycardia
 Sinus Tachycardia

Regularly occurring PQRST

Rate > 100 / min

Rate = 111/min Rate = 111/min Rate = 111/min

Sinus Tachycardia
 Premature Atrial Contraction

Prematurely occurring PQRST complex

P wave different in configuration
from the sinus beat.
PR interval often long.
QRS narrow.
 Premature Ventricular Contraction
Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
• Sinus bradycardia • Sinus tachycardia  Asystole Benign ectopic
• Sinus pause • Supraventricular  Pulseless VT rhythms:
• Escape rhythms: tachycardia  Ventricular  PACs
– Junctional rhythm • Atrial fibrillation fibrillation  PVCs
– Idioventricular  Pulseless
• Atrial flutter
rhythm
• Multifocal atrial electrical
• Heart blocks activity Miscellaneous
tachycardia
• Sick sinus syndrome  Artificial
• Ventricular Pacemaker rhythm
tachycardia  Preexcitation /
WPW pattern
 Sinus Bradycardia

Regularly occurring PQRST

Rate < 60 / min

Rate = 48/min
Rate = 48/min
SINUS PAUSE (SINUS ARREST)
 Sinus Arrest ( Sinus Pause)
Case: If the SA Node does not fire
Do you have a P wave? None
Do you have a QRST? None
What is the interval between the previous beat
and the next beat following the pause?
Less than twice the normal interval
40 mm 50 mm
AV Blocks
Normal Cardiac Depolarization
and the ECG

T
P

Q
S
Atrioventricular Blocks

T
P

Q
S
FIRST DEGREE
AV BLOCK

PR interval > 0.20 sec

0.28 sec 0.28 sec 0.28 sec

 First Degree
Atrioventricular Blocks
R
T
P

Q
S
Do you have a normal P wave? Yes
Do you have a normal PR segment? No
Do you have a normal PR interval? Prolonged (> 0.20 sec)
Do you have a normal QRS-T? Yes
 Second Degree
Atrioventricular Block
• Type I - Mobitz type I or Wenckebach

• Type II - Mobitz type II

• 2nd degree AV block Mobitz I

2nd degree AV block Mobitz II

 Second Degree
Atrioventricular Blocks

Do you have a normal P wave? Yes

Do you have a normal PR segment? No
Do you have a normal PR interval? No
Will there be intermittent P waves not followed
by QRS complex? Yes (dropped beats)
 SECOND DEGREE AV BLOCK
MOBITZ I

Progressive lengthening
of PR interval w/ intermittent
dropped beats .

0.20 sec 0.28 sec 0.20 sec

SECOND DEGREE BLOCK AT THE
AV BLOCK
Bundle of His
MOBITZ II
Bilateral bundle
branches

Fixed PR interval Trifascicle

w/ intermittent
dropped beats .

0.18 sec 0.18 sec 0.18 sec

2 : 1 AV BLOCK
HIGH GRADE AV BLOCK
 Criteria for High-Grade
Atrio-Ventricular Block

• P waves present
• QRS complexes present
• Some P waves followed by QRS complexes and some are not
• Atrio-ventricular conduction ratio is
3:1 or higher
• P-R interval following a QRS is constant but may be normal or
prolonged
ARE YOU GUYS MORE CONFUSED?
WAIT TILL YOU SEE THE NEXT
SLIDE!!!
 3rd degree AV block

Ventricular rate = 43 BPM Ventricular rate = 43 BPM

Atrial rate = 80 BPM Atrial rate = 80 BPM

Atrial rate = 80 BPM
 R

T
P

Q
S
 Ventricular rate = 43 BPM Ventricular rate = 43 BPM

Atrial rate = 80 BPM Atrial rate = 80 BPM

Atrial rate = 80 BPM
 THIRD DEGREE
AV BLOCK
Complete atrioventricular block
Impulses originate at both SA node and at
the subsidiary pacemaker below the block
Do you have regularly occurring P waves and QRS complexes? Yes
Are the P waves related to the QRST complexes? No
Is the atrial rate < = > ventricular rate? greater

Ventricular rate = 43 BPM Ventricular rate = 43 BPM

Atrial rate = 80 BPM Atrial rate = 80 BPM

Atrial rate = 80 BPM
 Criteria for Third Degree (“Complete”) Atrio-
Ventricular Block
• No recognizable consistent or meaningful relationship between atrial and
ventricular activity
• ATRIO-VENTRICULAR DISSOCIATION
• QRS complexes often abnormal in shape, duration and axis (occasionally
normal)
• QRS morphology constant
• QRS rate constant ( 15-60 beats/min )
• Any form of atrial activity seen (most commonly sinus initiated)
Junctional Rhythm
Junctional Rhythm

Impulses from the AV node

P wave inverted or buried w/in
QRS or follows the QRS
Rate slow
QRS narrow
 Inverted P waves

P waves buried in the end of the QRS

Idioventricular Rhythm
 Idioventricular Rhythm
Impulse ventricular in origin
Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to QRS
Rate < 40 / min
Rate < 40 / min
Asystole (ventricular standstill)
 HR < 60

Slow
Regularity

Regular Irregular

With P wave;
P wave No P wave No P wave
No P-QRS abnormal PR
P-QRS relation
Narrow QRS Wide QRS
Group beating
Slow AF
Sinus
brady Junctional Idio-ventricular 3rd degree 2nd degree AV
AV block block
 Bradyarrhythmias

Sinus pause/sinus arrest

We’re halfway through folks!
• Sinus bradycardia • Sinus tachycardia  Asystole Benign ectopic
• Sinus pause • Supraventricular  Pulseless VT rhythms:
• Escape rhythms: tachycardia  Ventricular  PACs
– Junctional rhythm • Atrial fibrillation fibrillation  PVCs
– Idioventricular  Pulseless
• Atrial flutter
rhythm
• Multifocal atrial electrical
• Heart blocks activity Miscellaneous
tachycardia
• Sick sinus syndrome  Artificial
• Ventricular Pacemaker rhythm
tachycardia  Preexcitation /
WPW pattern
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
 Tachycardia

Narrow QRS Wide QRS

Regular rhythm Grossly Irregular No relationship P- Constant Relationship P-

Rhythm QRST QRST

> 3 P wave No distinct Ventricular SVT w/ aberrancy

shapes P waves
tachycardia
Multifocal Atrial Atrial
Tachycardia Fibrillation
Sinus Paroxysmal Atrial Flutter LET ME
Tach. SVT (reentrant)
WORRY
Atrial Rate/min >100 140-250 250-350
P morphology (N) peaked/ “saw-tooth” ABOUT
inverted
Response to atrial abruptly reverts AV block, THIS!!!
carotid massage rate to (N) may increase
slows
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
Sinus Tachycardia
Management:

A. No specific drug treatment.

B. Identification of cause
C. Treatment of underlying cause
D. Check hemodynamics
Multifocal Atrial Tachycardia
 Multifocal Atrial
Tachycardia
Impulses originate irregularly
and rapidly at different points
in the atrium
Varying P wave, PR, PP and RR intervals
Ventricular rate > 100/min

3 different P wave morphologies

Irregularly occurring QRS complexes
Supraventricular Tachycardia
 Supraventricular Tachycardia

• Characterized by tachycardia with a narrow QRS

complex
• sudden onset and termination
• 150-250 beats/min (180 to 200 bpm in adults)
• regular rhythm
• QRS complex is normal in contour and duration
• No P waves
• P waves are generally buried in the QRS complex
• Often, P wave is seen just prior to or just after the end of the QRS and
causes a subtle alteration in the QRS complex that results in a pseudo-S or
pseudo-r
Paroxysmal Supraventricular Tachycardia
Atrial Flutter
 Atrial Flutter

Atrial rate = 250-350/min

( P as flutter waves )
Variable degree of AV block
( irregular RR interval )
Atrial Flutter
Atrial Fibrillation
 Atrial Fibrillation

No discernible P waves

Irregular RR interval
AF with controlled ventricular response
AF with slow ventricular response
AF with rapid ventricular response
Narrow QRS Complex Tachycardia Wide QRS Complex Tachycardia
< 0.12 secs or < 120 msec >0.12 secs or >120 msec
 Premature Ventricular Contraction
Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
 Premature Ventricular Contraction
in Couplets

Two Premature ventricular

contractions occurring consecutively
 Premature Ventricular Contraction
in Bigeminy

Alternating normal sinus beat and

a PVC
 Premature Ventricular Contraction
in Trigeminy

PVC’s regularly occurring every

third beat
 Premature Ventricular Contraction
in Quadrigeminy

PVC’s regularly occurring every

fourth beat
 Multifocal Premature Ventricular
Contraction
PVC’s coming from different foci in
the ventricle
PVC’s assuming different polarities
in a single lead
PVC’s of different morphology and
coupling interval
 Premature Ventricular Contraction
R on T Phenomenon

R or Q of the PVC occurring at the

T wave of the preceding sinus beat
Most dangerous PVC
Deadly PVC
Nonsustained Ventricular Tachycardia
 Ventricular Tachycardia

At least 3 consecutive PVC’s

Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
No P wave (ventricular impulse
origin)

Rate > 100 / min

Ventricular Tachycardia
 Ventricular Tachycardia

• Nonsustained

• Sustained

• Monomorphic

• Polymorphic

• Torsades pointes
Ventricular Fibrillation
 Ventricular Fibrillation
Associated with coarse or
fine chaotic undulations of the
ECG baseline
No P wave
No true QRS complexes
Indeterminate rate

Coarse Fibrillation Fine Fibrillation

 HR > 100

Fast
Narrow QRS Wide QRS

Regular Irregular VT

P wave No P wave P wave No P wave Flutter

waves
P-QRS Different P morphologies

Sinus tach SVT MAT Rapid AF Atrial flutter

 Wolf Parkinson White Syndrome

Supraventricular rhythm with wide

QRS complex because of pre-excitation
Short or no PR segment followed by a
delta wave (slurred upstroke of QRS)
Atrium

AV
Node Ventricle

Left
Bundle
Branch
Right
Bundle
Branch
WPW Patients – may present with preexcited rapid AF 
irregular wide complex tachycardia
 Pacemaker Rhythm
No P wave (ventricular impulse origin)
Wide QRS complex (>0.10 sec)
Pacemaker spike precede the wide
QRS complexes
V.F.!!!  DON’T JUST STAND THERE,
SHOCK THE PATIENT!
ECG CONNECTED?
LEADS ATTACHED?
DO CPR
ASSESS HEMODYNAMICS
PULSELESS VT  TREAT AS V.F.
STABLE  STABLE VT ALGORITHM
UNSTABLE, WITH PULSE  VT ALGORITHM
Bradycardia Algorithm
 Important Points
KNOW THY ACLS

• Review your arrhythmias

– Too fast
– Too slow
• Correlate clinically
• Treat the patient… not the monitor
Good Luck in your ACLS exams!!!
1 and 2 and 3 and 4
and 5 and 6 and 7
and….

The accredited
affiliate society of

A Full Member of
RESUSCITATION
COUNCIL OF ASIA
TREAT THE
PATIENT…

NOT THE
MONITOR!!!
Thank you for your attention.