Dysrhythmia Review

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Review of Electrocardiography & Dysrhythmias : 

Review of Electrocardiography & Dysrhythmias Rory S Prue, EMT-P

Objectives : 

Objectives To gain a basic knowledge of cardiac electrophysiology To understand the representations of the cardiac cycle on the ECG To master techniques used for learning the characteristics of the different dysrhythmias To learn measurement and count techniques essential for dysrhythmia interpretation

Definitions : 

Definitions Tachycardia Bradycardia Intrinsic Firing Rate Isoelectric Line Rate of > 100 Rate if < 100 The normal firing rate for the rhythm of a certain pacemaker The baseline of a rhythm where no electrical activity is present

Definitions : 

Definitions Accelerated Rhythm Ectopic Beat Pacemaker A rhythm that fires above it’s normal intrinsic firing rate, but < 100 A beat originating outside the normal pacemaker’s control The location responsible for setting the rhythm and rate of a rhythm

Definitions : 

Definitions Depolarization Repolarization Refractory period The complete electrical firing of the cells of the heart The time during which the cells recharge after depolarization The time during the repolarization when cells rearm

Definitions : 

Definitions R – R Interval P – P Interval The distance between the peaks of the depolarization during each cardiac cycle The distance between the peaks of the depolarization phases of the atria during each cardiac cycle

Definitions : 

Definitions PR Interval The distance between the beginning of innervation of the sinus node to the beginning of ventricular depolarization

Cardiac Conduction : 

Cardiac Conduction

Cardiac Conduction : 

Cardiac Conduction

Cardiac Conduction : 

Cardiac Conduction Essentially 2 pumps Atria Ventricles Must operate in unison and in order Three Pacemakers Sinoatrial Node Atrio-Ventricular Junction Purkinje System

Cardiac Conduction : 

Cardiac Conduction P Q R S T

Cardiac Conduction : 

Cardiac Conduction PR .12 - .20 s Q R S <.12 s ST Seg.

Cardiac Conduction : 

Cardiac Conduction

EKG Paper : 

EKG Paper Measures time – horizontal in seconds Measures amplitude – vertical in milliamps Uses the Metric system Is very good for accuracy

EKG Paper : 

EKG Paper 1 mm .04 sec. .2 sec.

Rate Measurement : 

Rate Measurement .2 s X 30 = 6 sec.

Rate Measurement : 

Rate Measurement 300 divided by number of big blocks between R – R interval (must be a regular rhythm) i.e. 300/4 = 75

Rate Measurement : 

Rate Measurement Memorization and counting backward between R – R interval (must be regular) 300 150 100 75 60 50 43 37 33 30

Dysrhythmia Characteristics : 

Dysrhythmia Characteristics

Normal Sinus Rhythm : 

Normal Sinus Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 60-100 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Bradycardia : 

Sinus Bradycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular < 60 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Tachycardia : 

Sinus Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular > 100 and < 160 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Dysrhythmia : 

Sinus Dysrhythmia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular 60-100 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Arrest : 

Sinus Arrest Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular Normal - slow Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Wandering Pacemaker : 

Wandering Pacemaker Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Slightly Irregular Normal - slow Abnorm. morphology/absent Varies – can be < or >.12-.20 s .04-.12 s (40-120 ms)

Premature Atrial Contractions : 

Premature Atrial Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PACs); Non-compensatory Depends on underlying rhythm Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

(Paroxysmal) Atrial Tachycardia : 

(Paroxysmal) Atrial Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular > 150-250 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Atrial Flutter : 

Atrial Flutter Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Regular; Ventr.: Varies Atrial: 250-300; Ventr.: Varies Big F-Waves – Saw tooth pattern Normally constant – may vary .04-.12 s (40-120 ms)

Atrial Fibrillation : 

Atrial Fibrillation Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregularly irregular ventricular Atrial: 350-750; Ventr.: Varies Little F-Waves – no pattern No discernable P waves .04-.12 s (40-120 ms)

Premature Junctional Contractions : 

Premature Junctional Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PJCs); Comp/Non-comp. Depends on underlying rhythm Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

Junctional Rhythm : 

Junctional Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 40-60 BPM Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

Accelerated Junctional Rhythm : 

Accelerated Junctional Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 60–100 BPM Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

Junctional Tachycardia : 

Junctional Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 100–180 BPM Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

First Degree AV Block : 

First Degree AV Block Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular; can be irregular Usually 60-100 BPM; Rhythm dep. Upright/Normal > .20 s (200 ms); Constant .04-.12 s (40-120 ms)

Second Degree AV Block (Type I) : 

Second Degree AV Block (Type I) Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Reg.; Ventr.: Regularly irreg. Atrial: Normal; Vent.: Norm./Slow Normal: extra P waves Not constant; Lengthens - drops beat Usually .04-.12 s (40-120 ms)

Second Degree AV Block (Type II) : 

Second Degree AV Block (Type II) Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Reg.; Ventr.: Regular or irreg. Atrial: Normal; Ventricular: Slow Normal; extra P waves Constant on conducted beats Usually .04-.12 s (40-120 ms)

Third-Degree AV Block : 

Third-Degree AV Block Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial & Ventricular: Regular Atrial: Normal; Vent.: 40-60; < 40 Normal: extra P waves No Atrial/Ventricular Relationship <.12 s (120 ms) Junct.;> .12 Ventr.

Pacemaker Rhythm : 

Pacemaker Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Paced: Reg.; Demand: Irregular Varies with pacemaker rate May be present No relationship > .12 s (120 ms);Ventricular

Premature Ventricular Contractions : 

Premature Ventricular Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PVCs); Compensatory Depends on underlying rhythm None on premature beat None on PVCs > .12s (120 ms) on PVC

Ventricular Tachycardia : 

Ventricular Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Usually Regular 100-250 BPM If present, not associated None > .12s (120 ms)

Ventricular Fibrillation : 

Ventricular Fibrillation Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Chaotic; no set rhythm ;fine/coarse None Absent Absent No discernable; medium F-waves

Asystole : 

Asystole Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: No electrical activity No electrical rhythm Absent Absent Absent

Idioventricular Rhythm : 

Idioventricular Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Usually Regular 15-40 BPM None None > .12 s (120 ms);exaggerated

Abberant Conduction : 

Abberant Conduction Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Normally regular; Supraventricular Usually normal; May be 40-60 BPM Upright/Normal .12-.20 s (120-200 ms) >.12 s (120 ms); May be notched

Normal Sinus Rhythm : 

Normal Sinus Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 60-100 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Bradycardia : 

Sinus Bradycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular < 60 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Tachycardia : 

Sinus Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular > 100 and < 160 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Dysrhythmia : 

Sinus Dysrhythmia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular 60-100 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Sinus Arrest : 

Sinus Arrest Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular Normal - slow Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Wandering Pacemaker : 

Wandering Pacemaker Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Slightly Irregular Normal - slow Abnorm. morphology/absent Varies – can be < or >.12-.20 s .04-.12 s (40-120 ms)

Premature Atrial Contractions : 

Premature Atrial Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PACs);Non-compensatory Depends on underlying rhythm Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

(Paroxysmal) Atrial Tachycardia : 

(Paroxysmal) Atrial Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular > 150-250 BPM Upright/Normal .12-.20 s (120-200 ms) .04-.12 s (40-120 ms)

Supraventricular Tachycardia : 

Supraventricular Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular > 150-250 BPM Indiscernible None seen .04-.12 s (40-120 ms)

Atrial Flutter : 

Atrial Flutter Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Regular; Ventr.: Varies Atrial: 250-300; Ventr.: Varies Big F-Waves – Saw tooth pattern Normally constant – may vary .04-.12 s (40-120 ms)

Atrial Fibrillation : 

Atrial Fibrillation Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregularly irregular ventricular Atrial: 350-750; Ventr.: Varies Little F-Waves – no pattern No discernable P waves .04-.12 s (40-120 ms)

Atrial Fibrillation (RVR) : 

Atrial Fibrillation (RVR) Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregularly irregular ventricular Atrial: 350-750; Ventr.: Varies Little F-Waves – no pattern No discernable P waves .04-.12 s (40-120 ms)

Premature Junctional Contractions : 

Premature Junctional Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PJCs); Comp/Non-comp. Depends on underlying rhythm Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

Junctional Rhythm : 

Junctional Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 40-60 BPM Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

Accelerated Junctional Rhythm : 

Accelerated Junctional Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 60–100 BPM Inverted – prior to or after; absent < .12 s if present .04-.12 s (40-120 ms)

Junctional Tachycardia : 

Junctional Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 100–180 BPM Inverted – prior to or after; absent < .12s if present .04-.12 s (40-120 ms)

First Degree AV Block : 

First Degree AV Block Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular; can be irregular Usually 60-100 BPM; Rhythm dep. Upright/Normal > .20 s (200 ms); Constant .04-.12 s (40-120 ms)

Second Degree AV Block (Type I) : 

Second Degree AV Block (Type I) Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Reg.; Ventr.: Regularly irreg. Atrial: Normal; Vent.: Norm./Slow Normal: extra P waves Not constant; Lengthens - drops beat Usually .04-.12 s (40-120 ms)

Second Degree AV Block (Type II) Classical : 

Second Degree AV Block (Type II) Classical Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Reg.; Ventr.: Regular or irreg. Atrial: Normal; Ventricular: Slow Normal; extra P waves Constant on conducted beats Usually .04-.12 s (40-120 ms)

Second Degree AV Block (Type II) Variable : 

Second Degree AV Block (Type II) Variable Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial: Reg.; Ventr.: Regular or irreg. Atrial: Normal; Ventricular: Slow Normal; extra P waves Constant on conducted beats Usually .04-.12 s (40-120 ms)

Third-Degree AV Block : 

Third-Degree AV Block Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Atrial & Ventricular: Regular Atrial: Normal; Vent.: 40-60; < 40 Normal: extra P waves No Atrial/Ventricular Relationship <.12 s (120 ms) Junct.;> .12 Ventr.

Pacemaker Rhythm : 

Pacemaker Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Paced: Reg.; Demand: Irregular Varies with pacemaker rate May be present No relationship > .12 s (120 ms);Ventricular

Premature Ventricular Contractions : 

Premature Ventricular Contractions Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (PVCs); Compensatory Depends on underlying rhythm None on premature beat None on PVCs > .12s (120 ms) on PVC

Ventricular Tachycardia : 

Ventricular Tachycardia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Usually Regular 100-250 BPM If present, not associated None > .12s (120 ms)

Ventricular Fibrillation : 

Ventricular Fibrillation Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Chaotic;no set rhythm;fine/coarse None Absent Absent No discernable; medium F-waves

Asystole : 

Asystole Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: No electrical activity No electrical rhythm Absent Absent Absent

Idioventricular Rhythm : 

Idioventricular Rhythm Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Usually Regular 15-40 BPM None None > .12 s (120 ms);exaggerated

Abberant Conduction : 

Abberant Conduction Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Normally regular; Supraventricular Usually normal; May be 40-60 BPM Upright/Normal .12-.20 s (120-200 ms) >.12 s (120 ms); May be notched

TIME FORSOME : 

TIME FORSOME PRACTICE

REMEMBER!!! : 

REMEMBER!!! Use a systematic approach Go through all the steps Take your time! Compare with your characteristics list Interpret the dysrhythmia

Atrial Flutter : 

Atrial Flutter Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular 70 Big F (Flutter) Waves .20 s Normal; .04-.12 s

Sinus Dysrhythmia : 

Sinus Dysrhythmia Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular 60 BPM Normal; upright .16 s Normal

Third Degree Heart Block : 

Third Degree Heart Block Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regular 37 BPM Normal; upright; extra Non-constant; No relationship Normal

Sinus Tachy with PVCs (UF) : 

Sinus Tachy with PVCs (UF) Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (due to ectopics) 110 BPM Present underlying; none ectopics .16 s Normal; .16 for ectopics

Sinus Arrest : 

Sinus Arrest Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Regularly Irregular; loses complexes 40 BPM Normal; upright .16 s Normal

Sinus Rhythm with PAC : 

Sinus Rhythm with PAC Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (due to ectopics) 60 Normal; upright; present for ectopic .18 s; .14 s for ectopic Normal for all complexes

Sinus Rhythm with V-Tach : 

Sinus Rhythm with V-Tach Rhythm: Rate: P Waves: P-R Interval: (Q)RS Complex: Irregular (due to ectopics) 80 BPM Normal; upright – none for ectopics .14 s; none on ectopics Normal; .14 s on ectopics

Summary : 

Summary You need to learn the definitive characteristics Use a complete, systematic approach to dissect the rhythm Take your time Mistakes are made when steps are skipped Practice! Practice! Practice!

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