Transcript Arrythmia recognition

Arrhythmia Recognition
An Emergency View
DR. SATHISH BABU P
Emergency & Critical care Physician
Vinayaka Mission University
SALEM
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Cardiac conduction
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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
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1) Is there a “QRS”
(No pulse)
YES
NARROW
NO
WIDE
CHAOTIC
FLAT LINE
PEA
Asystole
VT
VF
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No “QRS” & Chaotic
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No QRS & Flat line
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Wide QRS
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Wide QRS
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Wide QRS & Polymorphic
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2) Is there a “P” Wave
YES
NO
RR Interval
RATE
MORPHOLOGY
VARY
220 to 350
Inverted
AF
Atrial Flutter
CONSTANT
JUNCTIONAL
JUNCTIONAL
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No “P” & Varying “RR” interval
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3)What is the relationship
between the P waves and
the QRS complexes?
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HEART BLOCK
Yes
n“P” = n“QRS” ?
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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st
1 Degree
block
(AV Nodal Delay)
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P-R Interval
IST Degree heart block
n“P” = n“QRS” ?
P-R interval is >0.2 Sec
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HEART BLOCK
Yes
n“P” = n“QRS” ?
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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n“P” is not equal to n“QRS”?
PR interval is constant
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HEART BLOCK
Yes
n“P” = n“QRS” ?
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
n“P” is not equal to n“QRS”?
PR intervals are not constant
RR intervals are constant
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HEART BLOCK
Yes
n“P” = n“QRS” ?
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
n“P” is not equal to n“QRS” ?
Both PR and RR intervals
are not constant
PROGRESSIVE PROLONGATION OF
‘P-R’ INTERVAL
DROPPED ‘QRS’ COMPLEX
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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
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B
Calculating Heart
Rates(cont..)
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
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C
Calculating Heart Rates
(cont..)
Count the number of small squares between
two consecutive R waves and or 1500 / small
squares.
.
•Most accurate
•Used only with regular rhythms
•Time consuming
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Calculating Heart Rates
(cont..)
Count the number of BIG squares between
D 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
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VT
SVT with aberrancy
• Capture beat
• Fusion beat
• Concordance
• 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
• Time required to
reach either the
peak of R wave / the
nadir of the S wave
< 0.07 second
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ECG Criteria
• Concordance
–All the ventricular complexes in
V1 –V6 is negative or positive
diagnosis – VT
–Concordant negativity – RVT
–Concordant positivity – LVT
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VT
SVT with aberrancy
• Tall R – VT
Tall R1 - RBBB
A triphasic QRS
• A complete or
morphology in
almost complete
lead V6absence of any
Diagnostic of SVT
positive deflection
with aberrancy
in V6 (QS or rS) –
Diagnostic of VT
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Tall R1 - RBBB
Tall R – VT
complete absence of
any positive deflection
in V6
A triphasic QRS
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ventricular
tachycardia
ventricular
aberration
Monophasic R
rsR1 pattern
rS
qRs pattern
QS
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MISCELLANEOUS
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ELECTROCARDIOGRAM
“5” steps approach to arrhythmias
Step2:
Fix the regularity
Regular
I
I
I
Premature
I
I
I
Escape
I
I
I
IIrregular
I
I I
I
I
I
I
I
I
I
I
I
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I
I
I
PREMATURE
COMPLEX
ANY COMPLEX COMING BEFORE THE
NEXT EXPECTED PERIOD
WIDE
(VENTRICULAR)
NARROW
(ATRIAL/JUNCTIONAL)
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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ESCAPE COMPLEX
ANY COMPLEX COMING AFTER A
PAUSE
WIDE
NARROW
(VENTRICULAR)
(ATRIAL/JUNCTIONAL)
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ELECTROCARDIOGRAM
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ELECTROCARDIOGRAM
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