Basic Arrhythmias

© 2011 American Heart Association. Do not edit. 1

 Objectives
• Explain Heart Anatomy and Basic
Electrophysiology
• Explain Normal ECG
Measurements
• Recognize and Understand Basic
Arrhythmias

2
 Basic Arrhythmias
Content
• Basic Anatomy
• Electrophysiology
• Baseline ECG Parameters
• Normal Sinus Rhythm

3
 Basic Arrhythmias
Content
• Sinus Bradycardia and Tachycardia
• Supraventricular Arrhythmias
• Ventricular Arrhythmias
• Asystole and Pulseless Electrical
Activity (PEA)
• Atrioventricular Block
• Atrial and Ventricular Pacing

4
 Basic Arrhythmias

Cardiac Anatomy
Understanding Electrophysiology

5
 Anatomy of the Heart

AO
AO = Aorta

LA
PA
LA = Left Atrium
RA
RA = Right Atrium
LV LV = Left Ventricle

PA = Pulmonary Artery RV

RV = Right Ventricle

6
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Pathways RV Right Bundle
Branch

Purkinje System
Atrioventricular (AV)
Node

7
 Pacemakers of the Heart

Sinus Node His Bundle

60-100 bpm

Purkinje
System
30-40 bpm
AV Node or less
(junctional
cells)
40-60 bpm

Failure of a pacemaker allows a subsidiary

pacemaker to fire. 8
 Anatomy of the ECG
QT Interval

• P wave
• PR interval
• QRS complex
•
ST

ST segment p AVN Segment

• T wave PR

• QT interval

9
 Mean Electrical Vector
Negative
Positive and Negative
Electrode
Positive
Electrode

Current Away From

Electrode

Current Toward
Electrode

10
 Lines and Calibration
10
mV

?
1 millivolt (mV) = 1 mm

What is the approximate

PR interval in this rhythm
1 second
strip?
0.04 second

0.20 second

11
 ECG Measurements

• PR interval
0.12  0.20 s
• QRS complex
<0.12 s

• QT interval
Corrected for
Heart Rate

12
 Heart Rate Estimation
300 150 100 75 60 50 40 30

So about 75

1. Pick a complex that falls on a heavy line

2. Then estimate the rate by counting heavy boxes
3. Using 300, 150, 100, 75, 60, 50, 40, 30
13
Standard Monitoring Leads
Lead 1

14
Standard Monitoring Leads
Lead 2

15
Standard Monitoring Leads
Lead 3

16
 12-Lead ECG
The Big Picture

  


 
 

= 17
18
 Basic Arrhythmias
Rhythm Strip Interpretation

Normal Sinus Rhythm

Sinus Bradycardia
Sinus Tachycardia

19
Initial Approach—Analysis
4 Questions
• Rate?
– Normal
– Bradycardia, Tachycardia
• Rhythm?
– Regular or Irregular
• Are there P waves?
– Is each P wave related to a QRS
with 1:1 impulse conduction?
• QRS normal or wide?

20
Arrhythmias—Etiology
• Disturbance in Automaticity
– Pacemaker speeds up
– New pacemaker takes over
• Disturbance in Conduction
− Slowing or block in conduction
of electrical impulse
• Combination of Both
− Reentry arrhythmias

21
 Normal Sinus Rhythm

• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 conduction
• Therapy None
22
 Sinus Bradycardia

• Rate <60/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 conduction
• Therapy Treat underlying cause
23
 Sinus Tachycardia

• Rate >100/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 conduction
• Therapy Treat underlying cause
24
 Self-Assessment
What are the rate and rhythm?

25
 Self-Assessment
What is this rhythm?

If there is no pulse, what is this rhythm?

26
 Basic Arrhythmias
Supraventricular Arrhythmias

Premature Atrial Contraction (PAC)

Premature Atrial Beat (PAB)
Atrial Premature Beat (APB)
Premature Atrial Complex

Atrial Fibrillation
Atrial Flutter
Reentry Tachycardia

27
Premature Atrial Contraction (PAC)


QRS
Normal
• Rate Sinus rate
• Rhythm Irregular—interrupted by PAC
Incomplete compensatory pause
• P waves Different morphology
• P → QRS Usually conducted with normal QRS
• Therapy Treat underlying cause

28
Premature Atrial Contraction (PAC)
Pause (Incomplete)
Sinus Node Reset

Sinus Node   

Atrium  PAC

 AV Node

QRS
Normal Ventricle

Premature Beat
Present

29
 Atrial Fibrillation


• Rate Atrial rate cannot be measured

• Rhythm Ventricular rate—variable
Irregular (irregularly irregular)
• P waves Absent (fibrillation waves)
• F → QRS Conduction irregular
• Therapy Slow ventricular rate
Treat underlying cause 30
 Atrial Flutter

QRS
Normal

• Rate Atrial rate 250-400/min (often 300)

• Rhythm Ventricular rate—variable
Regular (2:1 AV block common)
• P waves Absent (flutter waves)
• F → QRS Conduction regular (unless variable block)
• Therapy Slow ventricular rate: terminate arrhythmia
Treat underlying cause 31
 Supraventricular Tachycardia (SVT)

AV Reentry Tachycardia AV Nodal Reentry Tachycardia Atrial Tachycardia

Connection between Uses dual pathway Ectopic atrial focus

atria and ventricle within AV node

32
 Reentry (Paroxysmal) SVT
AV Nodal Reentry Tachycardia
Dual AV Nodal
Pathway

 Blocked in fast pathway

PAC 

Allowing reentry

Should the QRS complex normally be narrow or wide?

33
Supraventricular Tachycardia (SVT)
AV Reentry Tachycardia

What is different
between these
2 examples?
(Look carefully at
the arrow directions)

Connection between Connection between

atria and ventricle atria and ventricle

Is the QRS complex

normal or wide for each?
Why?
34
 Reentry (Paroxysmal) SVT

Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, and aVF
• P → QRS Conduction regular
• Therapy Vagal maneuvers, adenosine,
synchronized cardioversion
35
 Self-Assessment
What are the rate and rhythm?

36
 Clinical Correlation

This patient is unresponsive and

BP is 70/50 mm Hg.

What is the rhythm?

What is your next action?

37
 Basic Arrhythmias
Ventricular Arrhythmias

Premature Ventricular Contraction (PVC)

Ventricular Premature Contraction (VPC)
Premature Ventricular Beat (PVB)
Premature Ventricular Complex

Ventricular Tachycardia
Ventricular Fibrillation

Asystole
Pulseless Electrical Activity (PEA)

38
 Premature Ventricular
Contraction (PVC)

Compensatory pause
Sinus node continues to discharge

2  HR 

P wave obscured

39
 Premature Ventricular
Contraction (PVC)
Pause (complete)
Sinus Node Fires

Sinus Node    

Atrium
AV node

X X refractory
from PVC
AV Node

Ventricle
 PVC

Premature Beat
Present
Monitor or Pulse
40
 Comparison of PVC and PAC
Pause (complete) Pause (Incomplete)
Sinus Node Reset
Sinus Node Fires

Sinus Node       
Atrium  PAC
AV node

AV Node X X refractory
from PVC

Ventricle  PVC

Premature Premature
Beat Present Beat Present
Monitor or
Pulse

41
 Mechanism PVCs

Unidirectional
Purkinje Fiber
Block

Reentry Muscle Fiber

42
PVC Morphology—Match the Name

• Unifocal
PVCs
• Multifocal 
PVCs
• Bigeminy 
• Ventricular
Tachycardia
• Torsades 

43
 Ventricular Tachycardia
Monomorphic*


*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Antiarrhythmic agent, cardioversion,
high-energy (defibrillation dose) shock
44
 Ventricular Tachycardia


Sinus Node Fires

Sinus Node   
P wave present but blocked.
Atrium Occasionally seen “buried” in the
QRS or T wave
X XX
X X X X X AV node
AV Node refractory
F from PVC below
VT     
Ventricle 

FUSION BEAT
An occasional sinus impulse “catches” the AV node repolarized. The resulting
beat is part supraventricular and part ventricular in morphology.

45
 Polymorphic VT*

*Torsades de pointes—QT prolonged

• Rate Atrial rate normal (obscured)

• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Unsynchronized high-energy shock,
magnesium (beneficial with baseline QTC
prolongation)
46
 Ventricular Fibrillation
Coarse VF

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate shock(s)

47
 Ventricular Fibrillation
Fine VF

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate shock(s)

48
 Asystole

Agonal Complexes ASYSTOLE

Pulseless Electrical
Activity

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS Not applicable
• Therapy CPR, vasopressor, atropine

49
 Pulseless Electrical Activity (PEA)

ARTERIAL PRESSURE

• Rate Variable—depends on baseline rhythm

• Rhythm PEA is not a single rhythm but any
organized rhythm without a pulse
• Therapy Identify and treat underlying cause
CPR, vasopressor

50
 Self-Assessment
What are the rate and rhythm?

C
B

A B

51
 Clinical Correlation
You see this rhythm on the monitor while
standing next to the patient.
How many rhythms do you see?
What is your first action?

52
Basic Arrhythmias
Atrioventricular Blocks

First-Degree AV Block
Second-Degree AV Block
Third-Degree AV block

53
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

Type II—Mobitz II

• Complete AV Block
Third-Degree AV Block

54
Atrioventricular Block
Normal AV Conduction

• Underlying sinus Sinus Node

rhythm P

• One P wave
AV Node
AV Nodal

• PR interval 0.12 to Tissue

0.12-0.20 seconds

0.20 second QRS <0.12

• One P wave for each

QRS
His-Purkinje System
55
 First-Degree AV Block

Sinus Node

• Underlying sinus rhythm P

• One P wave
AV Nodal
Tissue
• PR interval >0.20 >0.20 seconds
second
QRS <0.12
• One P wave for each
QRS
His-Purkinje System
56
First-Degree AV Block

Sinus Node

• Underlying sinus rhythm AV Node

AV Nodal

• One P wave
Tissue
>0.20 seconds

QRS <0.12
• PR interval >0.20
second
• One P wave for each His-Purkinje System
QRS 57
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

Sinus Node

P
• Underlying sinus rhythm
• P wave fails to AV Nodal
periodically Tissue

conduct >0.20 seconds

PR interval
• PR interval prolonged
X
• One P wave for each
QRS
QRS until block
His-Purkinje System 58
Second-Degree AV Block—
Mobitz II
PR intervals unchanged
  Sinus Node

P
Block
• Underlying sinus rhythm

• One P wave AV Node

• PR interval usually Often Normal

AV Nodal
Tissue
normal, no prolongation Often normal
QRS complex
• One P wave for each QRS
until sudden block and
dropped QRS
His-Purkinje System
59
 Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS

• Underlying sinus rhythm

(usual) Sinus Node

• Escape junctional rate 40-60 P

QRS from
• PR interval variable 
AV-His
escape
• P waves unrelated to QRS AV Node

• Narrow QRS = block above QRS <0.12

His junction

His Purkinje System

60
Third-Degree AV Block—
Ventricular Escape
P waves unrelated to QRS

Sinus Node

P
• Underlying sinus rhythm AV Node
(usual)
• Escape ventricular rate
30-40
QRS from
• PR interval variable QRS >0.12
 His-Purkinje
escape
• P waves unrelated to QRS
• Wide QRS = block below
His junction His-Purkinje System
61
AV Block—Which Type?


62
 Clinical Correlation
What treatment is indicated?
An athlete in the ED with a sprained ankle

A diabetic woman in the ED with chest tightness

63
 Clinical Correlation
What treatment is indicated?

A 78-year-old woman with altered consciousness, BP 80/60 mm Hg

External pacer not immediately available

64
 Basic Arrhythmias
Pacing
Transcutaneous—Transvenous
Ventricular,
Atrial, and Dual Chamber

65
Pacemakers –

• Transcutaneous
• Transvenous
− Ventricular
− Atrial
− Dual Chamber

66
 Pacemakers

–
• Transcutaneous


67
 Pacemakers

• Transvenous
— Ventricular

68
 Sinus Node

Pacemaker Malfunction

69
 Pacemakers

Transvenous
— Atrial
— Dual Chamber

A V

“PR”

70
 Cardioversion

• Synchronized –
• Transcutaneous


71
 Cardioversion
Energy Recommendations
Biphasic Waveform
–
• Atrial Fibrillation 120-200 J Initial
• Atrial Flutter & SVT 50-100 J Initial 

• Monomorphic VT 100 J Initial

• Increase the energy dose in a stepwise
fashion for any subsequent
cardioversion attempts
• Use manufacturer-recommended doses

72
 Cardioversion
Energy Recommendations
Monophasic Waveform
• Atrial Fibrillation 200 J
–
• Atrial Flutter & SVT 200 J
• Monomorphic, Unstable 

With Pulse 100 J

• Polymorphic or Pulseless VT—Treat as

VF with high-energy unsynchronized
defibrillation doses

(Do not use low energy—high likelihood of causing

VF in unsynchronized mode) 73
 Basic
Arrhythmias

QUESTIONS?

74