Arrhythmia Recognition

Mrs. SUMI JOSE

Cardiac
conduction

A&E Vinayaka

ELECTROCARDIOGRAM
5 steps approach to arrhythmias
Step1: Is there a QRS
Step2: Is there a P Wave
Step3: What is the relationship between the
P waves and the QRS complexes?
Step4: Calculate rate
Step5:Miscellaneous

1) Is there a QRS
(No pulse)
YES

NARROW

NO

WIDE

CHAOTIC

FLAT LINE

PEA
Asystole
VT

VF

No QRS & Chaotic

No QRS & Flat line

Wide QRS

Wide QRS

Wide QRS & Polymorphic

2) Is there a P Wave
YES

NO
RR Interval

RATE

MORPHOLOGY
VARY

220 to 350
Atrial Flutter

CONSTANT

Inverted
AF
JUNCTIONAL

JUNCTIONAL

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No P & Varying RR

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3)What is the
relationship between the
P waves and the QRS
complexes?

HEART BLOCK
Yes

nP = nQRS ?

PR interval
< 0.2

Normal

No

PR interval
Constant ?

> 0.2

Io AVB

No

Yes

RR interval

IIo AVB
type 2

Constant?

Yes
IIIoAVB

No
Type1 IIo

1st Degree block

(AV Nodal Delay)

First-degree AV block, or PR prolongation, is a disease

of the electrical conduction system of the heart in which the
PR interval is lengthened beyond 0.20 seconds.

P-R

Interval

IST Degree heart

block
nP = nQRS ?
P-R interval is >0.2 Sec

HEART BLOCK
Yes

nP = nQRS ?

PR interval
< 0.2

Normal

No

PR interval
Constant ?

> 0.2

Io AVB

No

Yes

RR interval

IIo AVB
type 2

Constant?

Yes
IIIoAVB

No
Type1 IIo

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nP is not equal to nQRS?

PR interval is constant

HEART BLOCK
Yes

nP = nQRS ?

PR interval
< 0.2

Normal

No

PR interval
Constant ?

> 0.2

Io AVB

No

Yes

RR interval

IIo AVB
type 2

Constant?

Yes
IIIoAVB

No
Type1 IIo

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IIIrd Degree heart

block

nP is not equal to
nQRS?

PR intervals are not constant

RR intervals are constant

HEART BLOCK
Yes

nP = nQRS ?

PR interval
< 0.2

Normal

No

PR interval
Constant ?

> 0.2

Io AVB

No

Yes

RR interval

IIo AVB
type 2

Constant?

Yes
IIIoAVB

No
Type1 IIo

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IInd Degree Type-I heart

block nP is not equal to nQRS ?
Both PR and RR intervals
are not constant

PROGRESSIVE PROLONGATION OF
P-R INTERVAL

DROPPED QRS COMPLEX

4)Calculating
Heart Rates
A Count the number of R waves in a
6-second strip and multiply by 10.
(especially for irregular rhythm)

Not very accurate

Used only with very quick
estimate

Calculating Heart
Rates(cont..)
B

Count the number of large squares

between two consecutive R waves and 300
/ Big squares

Very quick

Not very accurate with fast

rates
Used only with regular
rhythms

Calculating Heart
Rates (cont..)
Count the number of small squares
C between two consecutive R waves and or
1500 / small squares.

Most accurate
Used only with regular rhythms
Time consuming

Calculating Heart
Rates (cont..)
Count the number of BIG squares
D between two consecutive R waves in
descending order as
300,150,100,75,60,50...

Not very accurate

Used only with regular rhythms
Time saving

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Supraventricular
Tachycardia
Narrow complex
Regular Rate 140 to 220 / minute

VT
SVT with aberrancy
Capture beat
Fusion beat
Concordance
Time required to

reach either the

peak of R wave /
the nadir of the S
wave > 0.07
second

NO capture or fusion

beats
Concordance leads
will not have the
same polarity

Time required to

reach either the

peak of R wave /
the nadir of the S
wave < 0.07
second

ECG Criteria
Concordance
All the ventricular complexes in V1 V6

is negative or positive diagnosis VT

Concordant negativity RVT
Concordant positivity LVT

VT
SVT with aberrancy
Tall R VT
A complete or

almost complete
absence of any
positive
deflection in V6
(QS or rS)
Diagnostic of VT

Tall R1 - RBBB
A triphasic QRS

morphology in
lead V6Diagnostic of
SVT with
aberrancy

Tall R1 - RBBB
Tall R VT

complete absence of
any positive deflection
in V6

A triphasic QRS

ventricular
tachycardia

ventricular
aberration

Monophasic R

rsR1 pattern

rS
QS

qRs pattern

MISCELLANEOUS

PREMATURE COMPLEX
ANY COMPLEX COMING BEFORE THE
NEXT EXPECTED PERIOD

WIDE
(VENTRICULAR)
(ATRIAL/JUNCTIONAL)

NARROW

ELECTROCARDIOGRAM

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ELECTROCARDIOGRAM

ELECTROCARDIOGRAM

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ELECTROCARDIOGRAM

ESCAPE COMPLEX
ANY COMPLEX COMING AFTER A PAUSE

WIDE

NARROW

(VENTRICULAR)
(ATRIAL/JUNCTIONAL)

ELECTROCARDIOGRAM

ELECTROCARDIOGRAM

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