EKG Web Brain - Rate & Rhythm

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12-LEAD ECG's - A "Web Brain" for Easy Interpretation

Rate & Rhythm

Rhythm Analysis: Assessing the 5 Parameters
The most important clinical point (and the real KEY to rhythm interpretation) is to utilize a systematic approach. The system we favor is based on assessing for the following 5 parameters:

P waves QRS width Regular rhythm P waves Related to the QRS? Heart Rate
Memory Aid: "Watch your P's and Q's and the 3 R's".

Heart Rate: Calculating the Rate

The easiest way to estimate heart rate is to use the... Rule of 300 - Provided that the rhythm is regular, heart rate can be estimated by dividing 300 by the number of large boxes in the R-R interval. With the ECG machine set at the standard recording speed of 25 mm/second, the time required to record each little box on ECG grid paper is 0.04 second. Vertically, each little box is 1 mm in amplitude. The time required to record each large box on ECG grid paper is 0.20 second (because there are 5 little boxes in each large box,

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and 5 X 0.04 = 0.20). It can therefore be seen that the time required to record 5 large boxes will be one full second (0.20 X 5 = 1.0 second). Thus, if a QRS complex occurs with each large box (as in the figure),then the R-R interval will be 0.20 second, and the rate of the rhythm is 300 beats/minute (i.e., 5 beats occur each second X 60 seconds/minute = 300/minute). R-R interval is 2 large boxes, rate = 150 beats/minute (300 2) R-R interval is 3 large boxes, rate = 100 beats/minute (300 3) R-R interval is 4 large boxes, rate = 75 beats/minute (300 4) and so on . . .

Sinus Mechanism Rhythms/Arrhythmias

By definition, the P wave will always be upright in standard lead II when the mechanism of the rhythm is sinus. KEY Clinical Point- If the P wave in lead II is not upright, then sinus rhythm is not present (unless there is dextrocardia or lead reversal). By the Rule of 300 the rate of the sinus rhythm shown in this figure is 85 beats/minute, since the R-R interval is between 3 and 4 large boxes, or between 100 and 75 beats/minute. There are four basic types of sinus mechanism rhythms:
1. Normal sinus rhythm (NSR) - regular rhythm; rate between 60-

99 beats/minute. 2. Sinus bradycardia - regular rhythm; rate below 60 beats/minute. 3. Sinus tachycardia - regular rhythm; rate at 100 beats/minute or faster in an adult patient. 4. Sinus arrhythmia - irregular rhythm despite the presence of a sinus mechanism. Sinus arrhythmia is a common normal variant that is frequently seen in otherwise healthy children and young

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adults.

Other Supraventricular (Narrow QRS) Arrhythmias

A supraventricular rhythm is defined to be one in which the electrical impulse originates at or above the AV node (i.e., at or above the double dotted line in this figure. In addition to the sinus mechanism rhythms just described, the other principal entities in this category include:

Atrial fibrillation Atrial flutter (distinguish from MAT) PSVT (paroxysmal supraventricular tachycardia) & Vagal Manuevers Junctional (AV nodal) rhythms

Atrial Fibrillation (A Fib)

Atrial fibrillation is characterized by the presence of an irregularly irregular rhythm in the absence of P waves. Undulations in the baseline (known as "fib waves") may sometimes be seen (see figure). A Fib is therefore described as having one of the following:

A rapid ventricular response, if the rate averages over 120 beats/minute. A controlled (moderate) ventricular response, if the rate averages between 70-110 beats/minute. A slow ventricular response, if the rate averages less than 60 beats/minute.

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MAT (Multifocal Atrial Tachycardia)

A Fib should be distinguished from MAT, in which the rhythm is also irregularly irregular, but in which definite P waves are present. Clinically, MAT is most often seen in patients with either pulmonary disease or multi-system problems (sepsis, shock, electrolyte abnormalities, etc.). Treat the underlying cause!

Atrial Flutter (A Flutter)

Atrial flutter is characterized by a special pattern of regular atrial activity that in adults almost always occurs at a rate of 300/minute. Atrial flutter typically manifests a sawtooth appearance that is usually best seen in the inferior leads. At times, flutter waves may be very subtle (arrows in figure). The most common ventricular response to atrial flutter (by far!) is with 2:1 AV conduction. This means that the ventricular rate with untreated atrial flutter is usually close to 150/min (i.e., 300 2). Less commonly with flutter there is 4:1 AV conduction (vent. rate 75/minute)or a variable (irregular) ventricular response. Odd conduction ratios (i.e., 1:1, 3:1, 5:1) are rare. Note how much easier it is to identify flutter with 4:1 conduction (figure left) compared with 2:1 (figure above).

PSVT (Paroxysmal Supra-Ventricular Tachycardia)

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PSVT is a regular supraventricular tachycardia that most often occurs at a rate of between 150 to 240 beats/minute. Atrial activity is usually not evident, although subtle notching or a negative deflection (representing retrograde atrial activity) may sometimes be seen at the tail end of the QRS complex. Formerly this rhythm was known as PAT or PJT (paroxysmal atrial or junctional tachycardia). Mechanistically, PSVT is a reentry tachycardia that almost always involves the AV node (ergo the most recent name for this rhythm which is AVNRT = AV Nodal Reentry Tachycardia). The impulse continues to circulate within the AV node until the reentry pathway is interrupted by drugs, vagal maneuvers or stops spontaneously. KEY Point - Accurate determination of heart rate is essential for assessment of the SVTs. When the rhythm is regular and the rate is fast (as in the above figure), calculating the rate is most easily accomplished using the "Every-other-Beat" Method (i.e., the R-R interval of every other beat in the figure is 3 large boxes, so that half the rate is approx.100/minute. This means that the actual rate must be twice this (approx. 200/min).

Vagal Manuevers
Vagal maneuvers are commonly used to facilitate ECG diagnosis and/or to treat certain cardiac arrhythmias. Vagal maneuvers work by producing a transient increase in parasympathetic tone, thus slowing conduction through the AV node. Carotid Sinus Massage (CSM) Always perform under constant ECG monitoring. Use the right carotid first. Never press on both carotids at the same time. Remember that the carotid sinus is located high in the neck (at the angle of the jaw). Warn patient that the maneuver will be uncomfortable (as very firm pressure is needed for success). Rub for no more than 3-5 seconds at a time. If there is no response, you may repeat CSM on the left side (possibly after giving medication). Don't do CSM if patient has a carotid bruit (as you may dislodge a plaque!). Valsalva

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Have patient forcibly exhale (bear down) against a closed glottis (as if trying to go to the bathroom) for up to 15 seconds at a time. If properly performed, may be even more effective than CSM! Patient should be supine when attempting Valsalva. Usual Response to Vagal Maneuvers

Sinus Tachycardia - gradual slowing with CSM, resumption of tachycardia on release of pressure. PSVT - responds with either abrupt termination of PSVT (and conversion to sinus rhythm) or there is no response at all. Atrial Fib or Flutter - CSM typically slows the ventricular rate (which may facilitate rhythm diagnosis). Ventricular Tachycardia - does not respond to CSM.

Junctional (AV Nodal) Rhythms

Junctional (or AV Nodal) rhythms are regular supraventricular rhythms in which atrial activity reflects an AV nodal site of origin. As a result, the P wave in lead II will either be negative (preceding or following the QRS) or absent completely. There are three basic types of junctional rhythms (with the type determined by the rate of the rhythm): 1. AV nodal escape rhythm - The junctional rate in an adult is between 40-60 beats/minute. The rhythm arises because the SA node is either delayed or fails in its pacemaking function. 2. Accelerated junctional rhythm - The junctional rate speeds up to between 61-99 beats/minute and takes over the pacemaking function. 3. Junctional tachycardia - The rate exceeds 100/minute. KEY Clinical Point- In adults, the rate of an AV nodal escape rhythm is normally between 40-60 beats/minute. If the rate is faster than this and the patient is taking

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digoxin, strongly suspect digitalis toxicity.

Premature Beats
Premature beats are QRS complexes that interrupt the underlying rhythm by occurring earlier than expected. They are of 3 basic types: 1. PACs (Premature Atrial Contractions) The underlying rhythm is interrupted by an early beat arising from somewhere in the atria other than the SA node (different shape P Wave, see figure right). Most often the impulse will be conducted with a narrow QRS complex that is identical in appearance to that of normal sinus-conducted beats. 2. PJCs (Premature Junctional Contractions) The underlying rhythm is interrupted by an early beat arising from the AV node or junction. Most often the impulse is conducted with a narrow QRS complex that is similar (or identical) in appearance to that of normal sinus-conducted beats. The P wave in lead II is negative or absent . 3. PVCs (Premature Ventricular Contractions) The underlying rhythm is interrupted by an early beat arising from the ventricles. PVCs are wide and have an appearance that is very different from that of the normal sinusconducted beats.

Blocked PACs and Aberrant Conduction

Although most premature supraventricular beats (PACs or PJCs) are conducted to the ventricles normally (i.e., with a narrow

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QRS complex), this is not always the case. Instead, PACs or PJCs may sometimes occur so early in the cycle as to be "blocked" (i.e., non-conducted), because the conduction system is still in an absolute refractory state. Other times, premature beats may occur during the relative refractory period,in which case aberrant conduction (with a widened QRS) occurs. Practically speaking, aberrant conduction is most likely to take the form of some type of bundle branch block/hemiblock pattern (most commonly RBBB). Attention to QRS morphology may help to distinguish between aberrancy and ventricular beats. QRS Morphology Assess the etiology of wide beats when the QRS complex is upright in V1. (figure below)

Assess the etiology of wide beats when the QRS complex is negative in V1. (figure below)

KEY Clinical Point- Blocked PACs are often subtle and difficult to detect. They will

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be found if looked for, they'll often be hiding (notching) a part of the preceding T wave (see subtle T wave notching in the figure right).

Sustained Ventricular (Wide QRS) Arrhythmias

With the exception of the chaotic variability of ventricular fibrillation, sustained ventricular rhythms are most often regular (or at least fairly regular) rhythms that originate from the ventricles. As a result of their ventricular origin, the QRS complex is wide and very different in appearance from that of normal sinus-conducted beats (see figure right). Ventricular rhythms may arise either as escape rhythms (if supraventricular pacemakers fail), or usurping rhythms (when the ventricular focus accelerates and takes over the pacemaking function from the preexisting supraventricular pacemaker). Atrial activity with the ventricular rhythms may be absent, unrelated to the QRS complex, or retrograde. Slow Idioventricular escape rhythm The ventricular rate is "slow" (i.e., between 20-40 beats/ minute, which is the usual rate range of an intrinsic ventricular escape focus). AIVR (Accelerated Idio Ventricular Rhythm) The rate is more than 40/min, but does NOT exceed 110-120 beats/minute (see figure above). Ventricular tachycardia (VT) The rate exceeds 120-130/minute. VT is always a usurping rhythm. (see "2 Key Lists for Interpreting Tachycardias)

12-LEAD ECG's - A "Web Brain" for Easy Interpretation

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