Basic Dysrhythmias

Adam Glaser, BS, EMT-P

-Electrical Conduction of the Heart -A System of Defining 3-Lead EKGs

Pieces Parts

Electrical Conduction and the ECG

The Isoelectric Line

EKG Waveforms

Cardiac Cycle = P, QRS, and T Waves

Deflections from/to iso-line

Segments
Sections between waveforms (ST)

Intervals
From wave to complex (PR-I)

The Electrocardiograph
Electrical Activity Not Muscle Records +/ impulses Paper 25mm/s Counting Rates 300-150-100-75-7060-50 6 s x 10 10 s x 6 The little number on the monitor

Lead Considerations
$25,000 mVoltmeter
Lead Views:
1 Superior 2 Inferior, Anterior 3 Inferior, Left

The Components
SA Node Internodal Pathways AV Junction AV Node Bundle of His L & R Bundle Branch Purkinje Network Purkinje Fibers

Ode to a Node
Have a heart, and have no fear, The SA node is over here. Beating at a constant rate, 60 100 is really great. The AV node can make a show, If SA node has gone too slow. 40 60 is not too bad If its all youve got, you will be glad. Should the whole thing drop its speed, His and bundle branches will take the lead. And that, my friend is the whole and part, Of the conduction system of your heart.
Flip and See ECG, Cohn/Gilroy-Doohan

Sino Atrial Node

The Natural Pacemaker
Connects directly to atrial fibers
0.20 Seconds per 5 Boxes
.04 Sec .04 Sec .04 Sec .04 Sec .04 Sec

Fires 60-100 times per minute Wavelike Atrial Depolarization The P-Wave

P-Wave
QWave

P-R Interval

AV Junction
Receives impulses from SA Node via the Atrial Cells
An electrical funnel Impulses hit at various times Causes delay
PR-I

Susceptible to blockage

Path from A to V
Delivers impulse to the AV Node

Atrio-Ventricular Node
Lies between the Atria and Ventricles Collects impulses from above Stimulates Ventricles If unstimulated
Intrinsic rate 40-60

Bundle of His / Left and Right Bundle Branches

Distributes Impulses from the Node The Ventricular Messengers

Purkinje Network/Fibers
Direct connection with ventricular tissue Intrinsic rate 20-40 if unstimulated
P-Wave
T-Wave

P-R Interval
QRS Complex

The Six Step Approach

What is the Rate? Is the Rhythm Regular? Are there P-Waves? Is the P-R Interval Normal? Is the QRS Complex Normal? Is There a P-Wave for Every QRS?

Step 1 = Rate
Is the rate between 60-100 (Sinus) Between 40-60 (Junctional/Bradycardic) Above 100 (Tachycardic) Between 20-40 (Ventricular)

Step 2 = Regularity
At-a-glance: Does it look regular? Are the P-Waves evenly spaced? Are the QRS Complexes evenly spaced?

Step 3 = P-Waves
Are P-Waves present? Are they upright and rounded? Are they irregular in any way: Notched / Peaked / Depressed? Are they all the same?

Step 4 = P-R Interval

Is the P-R Interval between 0.12-0.20? Is it too long / too short? (Block) Is it the same on every conduction? Is it absent?

Step 5 = QRS Complex

Is it there? Is it between 0.04 - 0.12? Does it have any abnormalities? (Notched / Rabbit Eared / Wide / Bizarre)

Step 6 = P-QRS Married?

Is there a P-wave for every QRS? Are there more P-Waves than QRS? Are the P-Waves after or within the QRS?

Describe What Youve Found!!!

IN GENERAL (underlying rhythms)!!! What are the abnormalities? Does it originate in the Sinus Node? Does it follow through from the Atria to the ventricles? Are there abnormal delays? What are the exceptions to the underlying rhythm? (Describe those also)

E K G IN T E R P R E T A T IO N C H A R T RHYTHM NSR S in u s T a c h y c a r d ia S in u s B r a d y c a r d ia S in u s A r r h y t h m ia A t r ia l F ib r illa t io n A t r ia l F lu t t e r RATE 6 0 -1 0 0 A bo ve 100 B e lo w 6 0 6 0 -1 0 0 U s u a lly T achy M ay be N o rm al / T achy 1 4 0 -2 2 0 N o rm al N o rm al o r B rad y B rad y R E G U L A R IT Y R e g u la r R e g u la r R e g u la r I r r e g u la r I r r e g u la r A t r ia - r e g u la r / V e n t r ic le s r e g u la r o r ir r e g u la r R e g u la r R e g u la r I r r e g u la r P -W A V E (U /R ) N o r m a l/ U p r ig h t / R o u nded N o r m a l/ U p r ig h t / R o unded N o r m a l/ U p r ig h t / R o unded N o r m a l/ U p r ig h t / R o unded N o t D is c e r n ib le S aw to o th p attern, 2 : 1 , 3 : 1 , 4 : 1 r a t io s I n Q R S / T c o m p le x o r no t p resent N o r m a l/ U p r ig h t / R o unded N o r m a l/ U p r ig h t / R o u nded N o r m a l/ U p r ig h t / R o u n d e d 2 :1 , 3 :1 , 4 :1 N o r m a l/ U p r ig h t / R o unded P -R IN T E R V A L 0 .1 2 -0 .2 0 se c . 0 .1 2 -0 .2 0 se c 0 .1 2 -0 .2 0 se c 0 .1 2 -0 .2 0 se c N o t D is c e r n ib le 0 .1 2 -0 .2 0 o n th e c o n d u c t in g b e a t S ho rtened o r absent L o ng er than 0 .2 0 L e n g t h e n in g u n t il b e a t is d ro p p ed N o r m a l o r lo n g o n co nd u cted beats A t r ia in d e p e n d e n t o f V e n t r ic le s S h o r t / N o r m a l/ A bsent N o t D is c e r n ib le QRS 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 0 .0 4 0 .1 2 U s u a lly g reater than 0 .1 2 0 .0 4 0 .1 2 G reater than 0 .1 2 W id e / B i zarre N o ne W id e P -Q R S M ARRI Y es Y es Y es Y es Not D is c e r n ib O n the co nd u cti flu t t e r w No Y es No

(P )S V T 1 st D e g r e e B lo c k 2 nd D e g re e (T yp e 1 ) W enckebach 2 nd D e g re e (T yp e 2 ) M o b it z I I 3 rd D e g r e e C o m p le t e H e a r t B lo c k J u n c t io n a l ( a c c e l/ t a c h ) V e n t r ic u la r T a c h y c a r d ia

I r r e g u la r

4 0 -6 0

A t r ia - R e g u la r V e n t . - R e g u la r

O n the co nd u cti W ave No

4 0 -6 0 (6 0 + / 100+) 1 0 0 -2 2 0

R e g u la r

In v e rte d /R e tro g ra d e / A bsent N o t D is c e r n ib le ( u s u a lly )

Y e s - if P is v is ib le No

U s u a lly R e g u la r

V e n t r ic u la r R a p id / I r r e g u la r N o t d is c e r n ib le Not No F ib r illa t io n C h a o t ic D e t e r m in a b le A s y s t o le 0 N /A N o ne N one No A go nal 2 0 -4 0 I r r e g u la r N o ne N one No I d io v e n t r ic u la r - P V C - W id e , B iz a r r e Q R S C o m p le x , L o o k a t u n d e r ly in g r h y t h m . C a n a p p e a r in c o u p le t s , t r ip le t s , o r s h o r t r u n s o f V T b e m u lt i- fo c a l o r u n i- fo c a l. C a u s e d b y r a n d o m fir in g w it h in t h e v e n t r ic le s . N o a t r ia l fir in g . - P A C - C o n d u c t e d b e a t a p p e a r in g in a n o t h e r w is e n o r m a l r h y t h m . S t im u li o r ig in a t e s w it h in t h e a t r ia , b u t n o t in t h e S A . - I f B u n d le B r a n c h B lo c k o c c u r s , Q R S w ill u s u a lly b e w id e r t h a n 0 . 1 2 .

Normal Sinus Rhythm

Rate: 60 - 100 Regularity: Very P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages

Sinus Arrhythmia
Rate: 60 - 100 Regularity: Irregular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages

Sinus Tachycardia
Rate: Over 100 Regularity: Regular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages

Sinus Bradycardia
Rate: Less than 60 Regularity: Regular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages

Atrial Fibrillation
Rate: Usually tachy Regularity: Irregular (Irregularly irregular) P-Waves: Not Discernible P-R I: Undeterminable QRS: 0.04-0.12 sec Married: Undeterminable

Atrial Flutter
Rate: Usually tachy Regularity: Atria Regular

Ventricles May be Irregular

P-Waves: Sawtooth Pattern 2:1, 3:1, 4:1... P-R I: 0.12-0.20 sec on conducting beat QRS: 0.04-0.12 sec Married: P-waves outnumber QRS (Picket fence)

(Paroxysmal) Supra Ventricular Rate: 140-220 Tach

Regularity: Regular P-Waves: Usually falls within the QRS-T complex (not visible) P-R I: Shorter than 0.12, or absent QRS: 0.04-0.12 sec and Normal Married: Undeterminable

SVT
WPW
Usually based on Hx. Delta wave on Q Shortened PR-I No Verapamil Accessory Path use increase

1st Degree Heart Block

Rate: 60 - 100 Regularity: Very P-Waves: Present and Normal P-R I: Longer than 0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages

2nd Degree Heart Block (Type 1) Wenkebach

Rate: Can be Normal, or usually brady Regularity: Irregular P-Waves: Present and Normal P-R I: Lengthens until beat is dropped QRS: 0.04-0.12 sec and Normal Married: P-wave present on conducting beats, increased delay causes missed QRS

2nd Degree Heart Block (Type 2) Rate: Less than 60 Mobitz II

Regularity: Irregular P-Waves: Present, 2:1, 3:1, 4:1 P-R I: 0.12-0.20 sec on conducting beat QRS: 0.04-0.12 sec, may begin to widen Married: P-wave for every QRS and extras depending on conduction ratio

3rd Degree Heart Block (CHB) Complete Heart Block

Rate: Ventricular Rate 40-60 Regularity: Atria-Regular Vent-Regular P-Waves: Present and Normal P-R I: Atria independent of Ventricles QRS: Usually greater than 0.12 sec Married: P-waves completely unrelated to QRS Complexes.

Complete Heart Block

Junctional Rhythm Rate: 40-60

Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS, sometimes not visible

Junctional

Junctional Accelerated Rhythm

Rate: 60-100 Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS, sometimes not visible

Junctional Tachycardia
Rate: 100-140 Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS, sometimes not visible

Ventricular Tachycardia
Rate: 100-220 Well look at Torsades de Pointes in Lab Regularity: Regular P-Waves: None P-R I: None QRS: Greater than 0.12 sec Married: NO

Ventricular Tachycardia

Rate: No ventricular rate Regularity: Irregular P-Waves: No P-R I: No QRS: No, unorganized ventricular baseline Married: No

Ventricular Fibrillation

Ventricular Fibrillation

Asystole
Rate: 0 Regularity: N/A P-Waves: None P-R I: N/A QRS: None Married: No (verify a second lead)

Asystole

Agonal / Idioventricular
Rate: 20-40 Regularity: Irregular P-Waves: None P-R I: N/A QRS: Wider than 0.12 sec Married: NO (a dying heart)

Idioventricular
Less regular than this!

Exceptions / Disruptions
Premature Ventricular Contractions Premature Atrial Contractions Bundle Branch Blocks Pacer Considerations (Atrial, Ventricular or Both)

Premature Ventricular Contractions

Wide, Bizarre QRS Complex Always identify the underlying rhythm first Can appear in couplets, triplets, short runs of V-Tach, bigeminy and trigeminy Can be uni-focal or multi-focal Caused by random firing within the ventricles Not accompanied by a P-wave

PVCs

PACs
P-QRS Complex appearing in an unexpected location Caused by a stimulus from within the Atria, but not from the SA Node

PJC

Bundle Branch Block

Any rhythm having a BBB will have a widened twin peaked R-Wave

Paced Rhythms
Patients may have various types of pacemakers Atrial Ventricular Both Vertical spike on monitor is an indicator

Paced Rhythms Various

Artifact
60 Cycle Interference

Loose Leads/Moving Ambulance

Rhythm Interpretation and Patient Assessment

A 68 year-old female complains of shortness of breath for the last day. She is feverish and has a productive cough. Her BP is 164/78, HR matches with the ECG below, and RR of 20. She speaks in 6 word-sentences. She has rhonchi in her right lung. Her past medical history includes an MI 4 years ago and mild hypertension.

A 61 year-old male collapses at a local business. CPR was started by his coworkers. The patient has a history of high cholesterol, hypertension and was recently diagnosed with angina. Your quick-look reveals the following rhythm.

A 65 year-old male calls for weakness. The patient states that he has been feeling this way over the last 2 days and becomes more short of breath with activity. He also becomes dizzy when he stands up. The patient has a history of COPD and is on home oxygen at 2 liters/minute. His BP is 128/84, RR 22 with some pursed-lip breathing. He states that he has a history of skipped heart beats. Lung sounds reveal wheezes in the mid-lobes and bases. He takes Alupent, prednisone, Altace and Cozaar.

A 78 year-old male is found unconscious in his bed. He was last seen the night before by his family. As you move him to the floor, you see that a bottle of nitroglycerin falls out of the bed and onto the floor. The patient is warm but his back reveals mottling. He is pulseless and apneic.

You respond to a 58 year-old male in cardiac arrest. The patients daughter tells you that he didnt feel well for the last few days. She also states that he is a chronic alcoholic. The patient is lying in his bed, pale-gray in color and apneic. He is also pulselessness. His abdomen is distended and he has large blood stains on his pillow.

A 58 year-old male complains of dizziness and nausea. The symptoms started 45 minutes ago when he was getting dressed for work. The symptoms did not change when he lied down on the couch. He denies chest pain or jaw pain. He had a similar episode 4 months ago but the symptoms resolved. His BP is 100/50, HR below, and RR of 16. His CBG is 80. Lung sounds are 6-second strip clear.

A 70 year-old male experienced a syncopal episode. He is found on his bed, pale and diaphoretic. He has had problems with dizziness when standing up for the last few days. He had dark tarry stools for the last week. His BP is 88/40, RR of 28 and HR below. He is pale.

A 52 year-old female complains of epigastric pain. Onset was 30 minutes ago. She also complains of nausea and mild shortness of breath. Her history includes CHF, Type II diabetes and high cholesterol. BP is 134/88, HR matches the ECG below, and RR is 12. Her medications include furosemide, K-Dur, digitalis, and metoprolol.

And Now For the Summary

The ECG should confirm what you know about the patient
V-fib for dead folks Tachycardia for dehydration PVCs for chronic heart conditions AV blocks chronic or acute conditions

Treat the rhythm in perspective

Underlying cause drug overdose, hypovolemia

Sources In order of preference

Many of the pictures and info from:
Flip and See ECG, 2nd Edition
Cohn/Gilroy-Doohan
A great resource

Paramedic Paramedic Textbook, Revised 2nd Edition

Mick J. Sanders, Mosby

ECGs Made Easy, 2nd Edition

Barbara Aehlert, RN, Mosby

Basic Dysrhythmias, Interpretation and Management, 3rd Edition

Robert J. Huszar, Mosby