ECG Interpretation
Dysrhythmias for ACLS
Objectives
To be able to recognize ECG strip Dysrhythmia in emergency
situations.
Understand and differentiate various types of Bradyardias.
Understand and differentiate various types of Tachycardias.
High lights on the management according to ACLS
Algorithm.
ECG Basics
How to Analyze a
Rhythm
Normal Sinus Rhythm
Dysrhythmias
Normal Impulse
Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Pacemakers of the
Heart
SA Node - Dominant pacemaker with an
intrinsic rate of 60 - 100 beats/minute.
AV Node - Back-up pacemaker with an
intrinsic rate of 40 - 60 beats/minute.
Ventricular cells - Back-up pacemaker
with an intrinsic rate of 20 - 45
beats/minute.
The “PQRST”
P wave - Atrial
depolarization
• QRS - Ventricular
depolarization
• T wave - Ventricular
repolarization
The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of
His)
(delay allows time for
the atria to contract
before the ventricles
contract)
The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
Rhythm Analysis
Step 1: Assess the P waves.
Step 2: Determine PR interval.
Step 3: Calculate rate.
Step 4: Determine regularity.
Step 5: Determine QRS duration.
Step 1: Assess the P waves
Are there P waves?
Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?
Step 2: Determine PR interval
Normal: 0.12 - 0.20 seconds.
(3 - 5 boxes)
Interpretation?
Step 3: Calculate Rate
3 3
sec sec
Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Interpretation?
R
wave
Option 2
Find a R wave that lands on a bold line.
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
Step 4: Determine regularity
R R
Look at the R-R distances (using a caliper
or markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly
irregular? Irregularly irregular?
Interpretation?
Step 5: QRS duration
Normal: 0.04 - 0.12 seconds.
(1 - 3 boxes)
Interpretation?
P waves normal
PR interval 0.12 s
Rate 90-95 bpm
Regularity regular
QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm
Dysrhythmia
Recognition and management
Bradyarrhythmias:
1) Sinus bradycardia
2) AV block
3) Junctional escape rhythm
4) AF or flutter with slow ventricular
response
5) Ventricular escape rhythm
Rules of Interpretation
Sinus Bradycardia
Rate Less than 60
Rhythm Regular
Pacemaker
SA node
Site
Upright &
P Waves
normal
PRI Normal
QRS Normal
Rules of Interpretation
First-Degree AV
Rate
BlockDepends on
underlying
rhythm
Rhythm Usually regular
Pacemaker
SA node or atrial
Site
P Waves Normal
PRI > 0.20 Seconds
Usually < 0.12
QRS
seconds
Rules of Interpretation
Type I Second-Degree AV
Block
Atrial, normal;
Rate ventricular, normal
to slow
Atrial, regular;
Rhythm ventricular,
irregular
Pacemaker
SA node or arial
Site
Normal, some P
P Waves waves not followed
by QRS
Increases until
PRI QRS is dropped,
then repeats
Usually < 0.12
QRS seconds
Rules of Interpretation
Type II Second-Degree AV
Block
Atrial, normal;
Rate
ventricular, slow
May be regular
Rhythm
or irregular
Pacemaker
SA node or atrial
Site
Normal, some P
P Waves waves not followed
by QRS
Constant for conducted
PRI beats, may be > 0.20
seconds
Normal or > 0.12
QRS seconds
Rules of Interpretation
Third-Degree AV Block
Atrial, normal;
Rate ventricular, 40–
60
Both atrial and
Rhythm ventricular are
regular
SA node and AV
Pacemaker
junction or
Site
ventricle
Normal,with no
P Waves correlation to
QRS
No relationship to
PRI QRS
0.12 seconds or
QRS greater
Rules of Interpretation
Junctional Escape
Complexes and Rhythms
Rate 40–60
Irregular in
single
Rhythm occurrence,
regular in escape
Pacemaker rhythm
AV junction
Site
Inverted, may
P Waves
occur after QRS
Normal if P
PRI occurs before
QRS
QRS Usually normal
Rules of Interpretation
Ventricular Escape
Complexes
and Rhythms
Rate 15–40
Escape complex,
irregular;
Rhythm escape rhythm,
Regular
Pacemaker
Ventricle
Site
P Waves None
PRI None
>0.12 seconds,
QRS
bizarre
Tachyarrhythmias:
Narrow QRS complex
1) Sinus Tachycardia
2) PSVT
3) Atrial Flutter
4) AF
Wide QRS complex
1) VT
2) SVT or atrial fibrillation or flutter, with
aberrant ventricular conduction
Rules of Interpretation
Sinus Tachycardia
Rate Greater than 100
Rhythm Regular
Pacemaker
SA node
Site
Upright &
P Waves
normal
PRI Normal
QRS Normal
Rules of Interpretation
Paroxysmal
Supraventricular
Tachycardia
Rate 150–250
Rhythm Regular
Pacemaker Atrial (outside SA
Site Node)
Often buried in
P Waves
preceding T wave
PRI Usually normal
QRS Usually normal
Rules of Interpretation
Atrial Flutter
Atrial rate 250–350
Rate Ventricular rate
varies
Rhythm Usually regular
Pacemaker Atrial (outside SA
Site node)
F waves are
P Waves
present
PRI Usually normal
QRS Usually normal
Rules of Interpretation
Atrial Fibrillation
Atrial rate 350–500
Rate Ventricular rate
varies
Irregularly
Rhythm
irregular
Pacemaker Atrial (outside SA
Site Node)
P Waves None discernible
PRI None
QRS Normal
Rules of Interpretation
Ventricular
Rate
Tachycardia100–250
Rhythm Usually regular
Pacemaker
Ventricle
Site
If present, not
P Waves associated with
QRS
PRI None
>0.12 seconds,
QRS
bizarre
Dysrrhythmia
What is the rate?? Tachyarrhythmia
Bradyarrhythmia
Tachycardia with pulse
Is the patient stable??
stable Follow the ACLS Algorithm
unstable
Perform Immediate Synchronized
Cardioversion
Indications for synchronized
cardioversion
Any unstable condition related to tachycardia
Chest pain
AMI
Shortness of breath
Pulmonary congestion/CHF
Decreased level of consciousness
Low blood pressure
Shock
Synchronized Cardioversion
Energy selection
PSVT: 50 J, 100 J, 200 J, 300 J, 360 J
Atrial fibrillation: 100 J, 200 J, 300 J, 360 J
Atrial flutter: 100 J, 200 J, 300 J, 360 J
VT: 100 J, 200 J, 300 J, 360 J
Polymorphic VT (treat like VF): 200 J, 200 to
300 J, 360 J
Bradycardia
Is the patient stable??
stable Follow the ACLS
Algorithm
unstable
Prepare for Transcutaneous
Pacing
Cardiac arrest ( Pulseless
Arrest)
I. Ventricular Tachyarrhythmias :
a. Ventricular fibrillation
b. Sustained Ventricular Tachycardia
II. Ventricular standstill ( Asystole)
III. Pulseless Electrical Activity (PEA)
Rules of Interpretation
Ventricular
Rate Fibrillation
No organized
rhythm
No organized
Rhythm
rhythm
Pacemaker Numerous
Site ventricular foci
P Waves Usually absent
PRI None
QRS None
Torsade de Pointes
Polymorphic VT.
Caused by the use of certain
antidysrhythmic drugs.
Exacerbated by co-
administration of
antihistamines, azole
antifungal agents and
macrolide antibiotics,
erythromycin, azithromycin,
and clarithramycin.
Rules of Interpretation
Asystole
No Electrical
Rate
Activity
No Electrical
Rhythm
Activity
Pacemaker No Electrical
Site Activity
P Waves Absent
PRI Absent
QRS Absent
PEA
Shockable rhythm
Pulseless Arrest with:
VF
VT
Thank you