 Electrocardiography : is recording and study of Electrical Current

generated by the heart.

ECG Rhythm Interpretation
Cardiac Conduction System
 SA Node
•Primary pacemaker of the
heart
•Spontaneously initiates
electrical impulses at an
intrinsic rhythmic rate of
normal for the patients age
.eg 60-100 beats/min for
adult
Interatrial and Internodal
Pathways

Spread electrical
impulses from the SA
node across the atria to
the AV node resulting in
atrial depolarization
 AV Node
•Secondary Pacemaker of the
heart
•Intrinsic rate of 40-60
beats/min

•The impulse travels

from the AV node to
the AV junction just
below it. Here it
slows down allowing
the atria to contract.
Bundle of His & Bundle
Branches
•Once the atria have
contracted the impulse
travels through the
bundle of His, then
follows the right and left
bundle branches.
Purkinje Fibers
•Finally the impulse
continues into the smallest
branches, the Purkinje
fibers to the ventricular
myocardium resulting in
ventricular depolarization.

•Intrinsic pacemaker
ability with a rate of 15-40
beats/min
ECG Lead Placement

 The axis of lead II runs from the negative Rt.

Clavicle to the Positive Lowest Rib,
Midclavicular, & ground below Left Clavicle.
ECG Electrode Placement

• V1: Right 4th intercostal space (ICS)

• V2: Left 4th ICS

• V3: Halfway between V2 and V4

• V4: Left 5th Intercostal Space, Mid-clavicular Line

• V5: Horizontal to V4, Anterior Axillary Line

• V6: Horizontal to V5, Mid-axillar Line

 Recording of the ECG:
Leads used:
• Limb leads are I, II, II.
• Each of the leads are Bipolar; i.e., it requires two sensors on the skin to make a lead.
• If one connects a line between two sensors, one has a vector.
• There will be a positive end at one electrode and negative at the other.
 Types of ECG Recordings

 Bipolar leads record voltage between electrodes

placed on wrists & legs

 Right leg is ground

 Lead I records between right arm & left arm

 Lead II: right arm & left leg

 Lead III: left arm & left leg

13-61
 ECG Graph Paper

0.04 sec
0.2 sec

Time
Paper speed 25mm/sec
ECG Waveform

J point
P Wave

• Represents Atrial Depolarization

• 2.5mm height and 0.12 sec duration

• P picked - > 3mm shows Right Atria

Enlargement

• P wide and Bifid : > 0.12 sec and Bifid

Shows Left Atrial Enlargement
 PR Interval
 Represents the time of impulse travel from the SA node through the AV node and AV
junction to the bundle branches

• Measured from the

beginning of the P wave to
the beginning of the QRS
complex
•Normal duration is 0.12 to
P 0.2 seconds
 QRS
Complex
• Represents ventricular depolarization

•Normal duration
is 0.04 to 0.12
seconds

Q
S
 ST Segment
• Represents the beginning
of ventricular
repolarization. The
ventricles have contracted
and are beginning to refill.
• Extends from the end of
the QRS complex to the
beginning of the T wave.

•A normal ST segment is flat along the isoelectric line.

ST depression of greater than 1 mm below the baseline
or greater than 2mm above the baseline may be
indicative of an MI.
 T Wave
• Represents ventricular repolarization and occurs during the last part of ventricular
systole.
•Normally upright in lead II.

T
 QT Interval
•Normal duration is
0.36-0.44 seconds

• QT interval = time of onset of ventricular

depolarization to the completion of repolarization
• Measured from the beginning of the Q wave to
the end of the T wave on the isoelectric line
 U wave
•The U wave is a
small rounded
positive gradual or
abrupt slope after
the T wave and
occurs before the P
wave.
•U waves are not usually present on an ECG unless the
heart rate is slow.
•The U wave represents Purkinge fiber repolarization
•Prominent U waves may drug related or indicate
hypokalemia
 Steps to Rhythm
Interpretation
• Determine sinus or not
• Determine the rate
• Determine the regularity of the rhythm
• Evaluate the P waves
• Evaluate the PR interval
• Evaluate the QRS complex
• P wave/QRS relationships
• Is the rhythm sinus ?
• Evaluate the T wave
• Interpret the Rhythm and Evaluate It’s Clinical
Significance
 SInus rhythm
• Rhythms originating in the sinus node and have two
characteristics
P waves precede each QRS complex and QRS is
narrow
P wave is upright (positive in leads I, II, and aVF) and
inverted at AVR.
Rate – Large Box Method

Rate-Small box method:1500/ Number of small squares

Between the successive R waves
 Determine Regularity

R to R
P to P

Paper and Pencil Method

Caliper Method
 Determine Regularity

Is the rhythm regular or irregular?

 Irregular

Is there a pattern to the irregularity?

Are there any ectopic beats?
 Evaluate the P Waves

Are the P waves present? Are they regular?

Is there one P wave preceding each QRS?
What is the morphology? Are they upright or inverted?
Are they all the same in shape and size.
Are the irregular P waves associated with ectopic beats?
 Evaluate the PR Interval
• Measure the PR interval. Is it within the normal range of
0.12-0.2 seconds?
• Is the PR interval constant or does it vary in duration?
 Evaluate the QRS Complex

Are the QRS complexes all alike in duration and shape?

Do the QRS complexes measure within the normal
duration of 0.04-0.12 seconds.
Are the abnormal QRS complexes associated with
ectopic beats?
Is the QRS Complex Normal?
 P Wave/QRS Relationships

Is there a P wave before every QRS complex?

Normal Sinus Rhythm
Is the Rhythm Sinus ?
 Evaluate the T Wave
Are the T waves of normal configuration, and are they
upright?
Are the T waves elevated or depressed from the isoelectric
line?
 T Wave and ST Changes

ST elevation &
depression

T-waves

peaked flattened inverted

Appearance
of pathologic
Q-waves
 Interpret the Rhythm and
Evaluate it’s Clinical
 What is the rhythm?
Significance
 Is the rhythm affecting the patient’s cardiac output? Is the patient
stable or unstable?
 Do you need to treat this rhythm? How are you going to treat it?
Is the Rhythm Sinus ?
Interpret this ECG
Copyrights apply
• It is Sinus Bradycardia
• What do you like to do ?

• What are the possible causes ?

• How do you mange ?

What is the interpretation of this
ECG
• It is Sinus Tachycardia
• What are the possible causes ?
• What do you do for it ?
Sinus Arrest
Supraventricular Tachycardia
 Rhythms Originating From
the Atria
• Supera ventricular tachycardia
(SVT)
• Atrial Fibrillation
• Atrial Flutter
Atrial Flutter
Atrial Fibrillation
 Rhythms Originating From the
Ventricles
• Ventricular Tachycardia
• Ventricular Fibrillation
• Torsades de Pointes
• Ventricular Standstill (Asystole)
VTach
Torsades de Pointes
Ventricular Fibrillation
Asystole
 Rhythms With Conduction
Delays
• First Degree AV Block
• Second Degree AV Block Type I
• Second Degree AV Block Type II
• Third Degree Heart Block
First Degree AV Block
Second Degree AV Block Type I
Second Degree AV Block
Type II
Third Degree AV Block
Sinus Tachycardia
Ventricular Fibrillation
Normal Sinus Rhythm with PVC
Atrial Fibrillation
Ventricular Tachycardia
Sinus Bradycardia
Second Degree Heart Block
Type I Wenkebach
Atrial Flutter
Third Degree Heart Block
What rhythm is this?

Asystole

Is this a shockable rhythm?

No
Brunet, Dahman - 2007; Simard -
2011
Summary of Cardiac Arrest Rhythms
• The 4 cardiac arrests rhythms are:
• V-fib
• V-tach
• PEA
• Asystole

• Initial treatment
• Call for help and AED (or defibrillator)
• CPR (chest compressions and BVM ventilation)
• Follow cardiac arrest algorithms

Brunet, Dahman - 2007; Simard -

2011
Cardiac Arrest
Algorithm

Brunet, Dahman - 2007; Simard -

2011
 Cardiac Arrest Rhythms
Pulseless electrical activity Ventricular
(PEA) / Asystole
fibrillation
Ventricular
tachycardia

• CAB’s Specific Tx: •CAB’S

• CPR H’s & T’s •CPR immediately
• Rx – Epi •DEFIB Immediately
•Rx – Epi,
Amioderone

Brunet, Dahman - 2007; Simard -

2011
 Epinephrine

• Epinephrine dose 0.1 mL / kg Concentration

differs according to route of administration.

Brunet, Dahman - 2007; Simard -

2011
 Possible Reversible Causes
H’s T’s

Hypoxia Toxins (overdose)

Hypovolemia Trauma (esp. non-accidental)

H+ (acidosis) Tension pneumothorax

Hypo/hyperkalemia Tamponade (cardiac)
Hypo/hyperglycemia Thrombus (MI)
Hypo/hyperthermia Thrombus (PE)
Brunet, Dahman - 2007; Simard -
2011
Bradycardias and
Tachycardias

Brunet, Dahman - 2007; Simard - 2011

 What rhythm is this?

Bradycardia

<60 beats/min + poor perfusion = start CPR

60 and less - compress
Brunet, Dahman - 2007; Simard -
2011
What rhythm is this?

Sinus Tachycardia
Narrow and Regular

Infants <220/min
Children <180/min Brunet, Dahman - 2007; Simard -
2011
 What rhythm is this?

Supraventricular Tachycardia (SVT)

Narrow and Regular

Infants ≥ 220/min
Children ≥ 180/min Brunet, Dahman - 2007; Simard -
2011
What rhythm is this?

Ventricular Tachycardia (VT or V-Tach)

Wide complex

± Pulse
Brunet, Dahman - 2007; Simard -
2011
 Systematic approach
• Assess
• Categorize
• Decide
• Act
• Reassess
 General Approach
How does the patient look?
Stable (Good Perfusion) vs Unstable (Poor Perfusion)
Stable Unstable
Normal Altered LOC
consciousness
CAB’s, IV, O2, Monitor
Full set of vital signs Syncope
Asymptomatic Pale
Normal colour Respiratory distress
No distress
Abnormal vitals
Normal vitals
Rescue Tx: Specific Tx:
• CPR? H’s & T’s
• Rx?
• Defib?
• Cardioversion? Brunet, Dahman - 2007; Simard -
2011
 Bradyarrhythmias
Too slow
(HR < 60/min)

Stable Unstable
(Good perfusion) (Poor perfusion)

Rescue Tx: Specific Tx:

• CAB’s H’s & T’s
Observe closely
• O2!!!
• CPR (60 or less compress)
• Epinephrine
• Atropine (vagal)
• Transcutaneous Pacing
Too Slow - Bradyarrhrythmias
Bradycardi
a
Bradycardi
a
 Review Bradycardica
• CPR for 5 cycles
• Give O2
• Epi –Repeat every 3-5 minutes
• CPR for 5 cycles
• Consider Pacing/ Atropine
• If pulseless got Arrest/PEA algorithm
Tachycardia
Tachycardia Narrow QRS
Tachycardia Narrow QRS
 Tachycardia
Wide QRS / VT
 Tachycardia Review
• Evaluate QRS Narrow or Wide
• Narrow
– ST - evaluate for cause
– SVT – Adenosine, Cardiovert
• Wide
– VT – Adenosine, Cardiovert
Arrest
 Arrest
•
 Arrest
Asystole/PEA
 VF/VT
• Give 1 shock 2 J/Kg
• Resume CPR immediately
• Give 5 cycles of CPR
VF/VT
VT/V
F
VT/VF 3rd
shock
 Review Asystole/PEA
• CPR
• Epi
• CPR for 5 cycles
• Check rhythm
• Shockable rhythm goto VT/VF
• Repeat if no rhythm
 Review VT/VF
• Shock 2 J/kg (1st shock)
• CPR 5 cycles
• Check rhythm
• Shockable, shock 4 J/kg (2nd shock)
• EPI
• CPR 5 cycles
 Review VT/VF
• Check rhythm
• Shockable, shock 4j/kg (3rd shock)
• CPR
• Consider Amiodarone/Lidocain
• Repeat CPR, Shock 4j/kg, Epi
 Tachyarrhythmias
Narrow
comple
Tooxfast

Sinus (ST): Supraventricular (SVT):

• Rate:Infants <220/min • Rate:Infants ≥ 220/min
Children <180/min Children ≥ 180/min

Find the cause Good Perfusion: Poor Perfusion:

• Fever • CAB’s • CAB’s
• Anxiety • O2 • O2
• Pain • Vagal maneuvers • Sync. Cardiovert
• Dehydration • Adenosine • ± sedation
Brunet, Dahman - 2007; Simard -
• Exercise • Sync. Cardiovert 2011
 Tachyarrhythmias
Wide
comple
Tooxfast

Ventricular Tachycardia Ventricular

with NO pulse (Cardiac Arrest) Tachycardia
WITH pulse
•CAB’s Good Perfusion: Poor Perfusion:
•CPR immediately • CAB’s • CAB’s
•DEFIB. Immediately • O2 • O2
•Rx – Epi and • Rx – Adenosine • Sync. Cardiov.
Amioerone • Amio/ Proc • ± sedation
Brunet, Dahman - 2007; Simard -
• Sync. Cardiov. 2011
 Tachycardias
• In Summary
• Stable (good perfusion) patients
• Medications
• If they don’t work
• Synchronized cardioversion

• Unstable (poor perfusion) patients

• Synchronized cardioversion immediately
• (skip medications – no time)

Brunet, Dahman - 2007; Simard -

2011
 Electrical Therapy
• Defibrillation
• Ventricular Fibrillation or
• Ventricular Tachycardia with NO PULSE ONLY

• Synchronized cardioversion
• Tachycardias WITH A PULSE ONLY
• Unstable (poor perfusion) – immediately
• Stable (good perfusion) – if meds don’t work

• BEWARE  ALL OTHER RHYTHMS ARE UNSHOCKABLE!

Brunet, Dahman - 2007; Simard -

2011
Questions?

Brunet, Dahman - 2007; Simard - 2011