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ECG Interpretation. Advanced Cardiac Life Support. William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro. advancing health worldwide TM. Department of Anesthesia and Perioperative Care. Course Objectives & Description:. - PowerPoint PPT Presentation
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ECG InterpretationECG Interpretation
William A. Shapiro, M.D.William A. Shapiro, M.D.
http://anesthesia.ucsf.edu/shapirohttp://anesthesia.ucsf.edu/shapiro
Advanced Cardiac Life SupportAdvanced Cardiac Life Support
Department of Anesthesia and Perioperative Care advancing health worldwide TM
Course Objectives & Description:Course Objectives & Description:
• Recognize & initiate early management of peri-arrest conditions that may result in cardiac arrest
• Manage cardiac arrest until return of spontaneous circulation, or transfer of care
• Understanding of arrhythmia interpretation
• Recognize the hemodynamic consequencesof arrhythmias
Normal Sinus RhythmNormal Sinus Rhythm
Normal sinus rhythm results from the initiation of an Normal sinus rhythm results from the initiation of an
electrical signal (the cardiac impulse) by cells of the electrical signal (the cardiac impulse) by cells of the
sinus node at a rate appropriate to the age and state of sinus node at a rate appropriate to the age and state of
activity of the individual, and then the propagation of activity of the individual, and then the propagation of
that signal in an orderly manner through the atria, A-that signal in an orderly manner through the atria, A-
V junction, ventricular specialized conducting V junction, ventricular specialized conducting
system and the ventricular myocardiumsystem and the ventricular myocardium
Cardiac Conduction System Cardiac Conduction System
Bachmann’s bundle
Left bundle branch
Posterior division
Anterior division
Purkinje fibersRight bundle branch
Bundle of His
AV node
Internodal pathways
Sinus node
ArrhythmiaArrhythmia
An arrhythmia reflects either abnormally rapid or An arrhythmia reflects either abnormally rapid or
slow impulse initiation by the sinus node, or slow impulse initiation by the sinus node, or
interruption of the sinus rhythm by impulses interruption of the sinus rhythm by impulses
originating from some other site in the heart, originating from some other site in the heart,
either for short or long periods of timeeither for short or long periods of time
Mechanisms of ArrhythmiasMechanisms of Arrhythmias
•Reentry
•Automaticity–Altered normal automaticity–Abnormal automaticity
•Triggered Rhythms due to DAD (delayed after depolarizations
Causes of ArrhythmiasCauses of Arrhythmias
• Physiologic and Pathologic Processes–Vagal stimulation, Fever, Hypothermia
–Electrolyte abnormalities, CNS problems
–Hypovolemia, Pain, anaphylaxis, etc.
• Preexisting Cardiac & Pulmonary Disease–Acute coronary syndrome, HTN, AODM
–COPD, hypoxia, hypercarbia
The ElectrocardiogramThe Electrocardiogram
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PR Interval
QRS Interval
The ElectrocardiogramThe Electrocardiogram
Q
R
S
TP U
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PR Interval
QRS Interval
QT Interval
The ElectrocardiogramThe Electrocardiogram
Relationship of ECG to anatomy
Cardiac Conduction System Cardiac Conduction System
Relationship of ECG to anatomy
Cardiac Conduction System Cardiac Conduction System
THE ACLS THE ACLS
PROVIDER PROVIDER
IS:IS: IN
ACLS
Normal Sinus Rhythm Normal Sinus Rhythm
•Rate 60-100 beats per minute
•Rhythm: Regular
•P waves: Upright in Leads: 1, 2, AVF
Determining the RateDetermining the Rate
Determining the RateDetermining the Rate
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Determining the RhythmDetermining the Rhythm
Sinus Tachycardia Sinus Tachycardia
•Rate: Greater than 100 beats per minute
•Rhythm: Regular
•P waves: Upright in Leads: 1, 2, AVF
Sinus Tachycardia Sinus Tachycardia
•Rate: Greater than 100 beats per minute
•Rhythm: Regular
•P waves: Upright in Leads: 1, 2, AVF
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Sinus Bradycardia Sinus Bradycardia
•Rate: Less than 60 beats per minute
•Rhythm: Regular
•P waves: Upright in Leads: 1, 2, AVF
Sinus Bradycardia Sinus Bradycardia
•Rate: Less than 60 beats per minute
•Rhythm: Regular
•P waves: Upright in Leads: 1, 2, AVF
Premature Atrial Complexes Premature Atrial Complexes
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•P wave Rhythm: Irregular
•P waves: Premature, often in the T-wave
•QRS complex: Normal or widened
P-wave
Premature Atrial Complexes Premature Atrial Complexes
•P wave Rhythm: Irregular
•P waves: Premature, often in the T-wave
•QRS complex: Normal or widened
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Premature Atrial Complexes Premature Atrial Complexes
•P wave Rhythm: Irregular
•P waves: Premature, often in the T-wave
•QRS complex: (Normal or widened) or blocked
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Non conducted P-wave
Atrial TachycardiaAtrial Tachycardia
• Rate: Atrial- 140-240 bpm, p-waves hard to see
• Rhythm: – P-wave- regular
– QRS- 1-1 conduction with atrial rates < 200 bpm
– With atrial rates > 200 bpm, A-V conduction block common (less than 1-1 conduction)
• PR interval- depends on the origin of the p-wave
• QRS- usually normal
Atrial TachycardiaAtrial Tachycardia
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P-Wave
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P-Wave
Atrial TachycardiaAtrial Tachycardia
Atrial Tachycardia with variable block
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P-Waves are regular at 160 bpm
Atrial FlutterAtrial Flutter
• Rate: Atrial- 300 bpm (260-320)
• Rhythm: – P-waves- regular
– QRS- 2-1 conduction - 150 bpm, variable AV conduction with constant AV conduction ratio
• P-waves: F-waves (Flutter), sawtooth pattern
• QRS- usually normal, obviously sometimes wide
Atrial FlutterAtrial Flutter
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F-waves
Atrial FlutterAtrial Flutter
Atrial Flutter with variable conduction (block)
Atrial FibrillationAtrial Fibrillation
• Rate: Atrial- rapid, Ventricular- Depends
• Rhythm: – P-waves- irregular
– QRS- beat to beat variability, Irregularly irregular
• P-waves: From F-waves (Flutter) to absent
• QRS duration- normal or wide
Atrial FibrillationAtrial Fibrillation
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Atrial FibrillationAtrial Fibrillation
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Atrial FibrillationAtrial Fibrillation
Premature Junctional ComplexesPremature Junctional Complexes
•Rhythm: Irregular
•P waves: Retrograde
•PR interval: < .12 sec or nonexistent
•QRS complex: Normal or widened
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Premature Ventricular ComplexesPremature Ventricular Complexes
•Rhythm: Irregular
•P waves: Usually not seen
•QRS complex: Wide > .12 sec
•Compensatory pause
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Premature Ventricular ComplexesPremature Ventricular Complexes
Compensatory pause
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This distanceis double the
sinus distance
This is the sinus and the QRSdistance
Premature Ventricular ComplexesPremature Ventricular Complexes
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•Unifocal PVCs
•Multifocal PVCs
Premature Ventricular ComplexesPremature Ventricular Complexes
Compensatory pause
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This distanceis double the
sinus distance
This is the sinus and the QRSdistance
Interpolated PVC
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Premature Ventricular ComplexesPremature Ventricular Complexes
Ventricular Bigeminy
Pairs of PVCs
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Premature Ventricular ComplexesPremature Ventricular Complexes
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PVC on T-wave precipitating Ventricular Tachycardia
Ventricular TachycardiaVentricular Tachycardia
•Rate: Approx 100-230 bpm
•Rhythm: Usually regular
•P waves: Usually not seen
– Independent A and V activity
– A-V dissociation
•QRS complex: Wide > .12 sec
•Capture beats, fusion beats
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Ventricular TachycardiaVentricular Tachycardia
Ventricular TachycardiaVentricular Tachycardia
Polymorphic Ventricular Tachycardia
Ventricular FibrillationVentricular Fibrillation
•Rate: Rapid- no effective cardiac rhythm
•Rhythm: Irregular
•P, QRS, T- waves: Absent
•No blood pressure!
Ventricular FibrillationVentricular Fibrillation
Course VF
Fine VF
Ventricular FibrillationVentricular Fibrillation
Ventricular AsystoleVentricular Asystole
•P, QRS, T- waves: Complete absent of cardiac electrical activity
•Complete absent of effective cardiac pumping function
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Acute Coronary SyndromesAcute Coronary Syndromes
Acute Coronary SyndromesAcute Coronary Syndromes
Acute Coronary SyndromesAcute Coronary Syndromes
ReviewReview
ReviewReview
Atrial Fibrillation
ReviewReview
Atrial Fibrillation
Sinus Rhythm
ReviewReview
Atrial Fibrillation
Sinus Rhythm
Acute Coronary Syndrome
ReviewReview
ReviewReview
Asystole
ReviewReview
Asystole
Fine Ventricular Fibrillation
ReviewReview
Asystole
Fine Ventricular Fibrillation
Coarse Ventricular Fibrillation
ReviewReview
ReviewReview
Ventricular Tachycardia- ?
ReviewReview
Premature Ventricular Complex (PVC)
Ventricular Tachycardia- ?
ReviewReview
Premature Ventricular Complex (PVC)
Ventricular Tachycardia
Ventricular Tachycardia- ?
ReviewReview
ReviewReview
Ventricular Tachycardia
ReviewReview
Ventricular Tachycardia
Ventricular Tachycardia
ReviewReview
Ventricular Tachycardia
Ventricular Tachycardia
(Paroxsymal) Atrial Tachycardia (SVT)
ReviewReview
ReviewReview
Paroxsymal Atrial Tachycardia (SVT)
ReviewReview
Paroxsymal Atrial Tachycardia (SVT)
Atrial Flutter
Treatment of All Cardiac Arrhythmias
Treatment of All Cardiac Arrhythmias
All arrhythmias that are
hemodynamically significant
require immediate
cardioversion, defibrillation,
or cardiac pacing
Break Time
AV BlockAV Block
•Why is it important?
•Where is the block?
•What’s a pacemaker anyway?
Rates of Intrinsic Cardiac Pacemakers
Rates of Intrinsic Cardiac Pacemakers
•Primary pacemaker
–Sinus node (60-100 bpm)
•Escape pacemakers
–AV junction (40-60 bpm)
–Ventricular (< 40 bpm)
Escape PatternsEscape Patterns
Junctional Escape ComplexesJunctional Escape Complexes
•Rate: Junctional escape rate 40-60 bpm
•Rhythm: Junctional
•P-waves: Retrograde, inverted in 2,3, avf
–Before, during, or after QRS
•QRS: Normal or wide
Junctional Escape ComplexesJunctional Escape Complexes
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Junctional Escape ComplexesJunctional Escape Complexes
Junctional Rhythm
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Ventricular Escape ComplexesVentricular Escape Complexes
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Classification of AV BlockClassification of AV Block
•Partial– First-degree AV block– Second-degree AV block,
Types I (Wenckebach) and Type II
•Complete AV block– Third-degree AV Block
“You should know the major AV blocks because important treatment decisions are based on the type of block present.” Page 79
First-Degree AV BlockFirst-Degree AV Block
•Rhythm: Regular
•1:1 Conduction: Each P-wave is followed by a QRS complex
•PR Interval: > .20 secs
•QRS Complex: Generally normal
•Hemodynamic implications: None
First-Degree AV BlockFirst-Degree AV Block
Second-Degree AV Block, Type ISecond-Degree AV Block, Type I
• Rate: – Atrial- regular– Ventricular- less than the atrial rate
• Rhythm: – Atrial- regular– Ventricular- progressive shortening of
the R-R interval before pause• PR: progressive increase until P blocked
• Why is knowing this important
Second-Degree AV Block, Type ISecond-Degree AV Block, Type I
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Second-Degree AV Block, Type IISecond-Degree AV Block, Type II
• Rate: – Atrial- regular– Ventricular- less than the atrial rate
• Rhythm: – Atrial- regular– Ventricular- usually irregular
• PR: constant when present• Why is knowing this important
Second-Degree AV Block, Type IISecond-Degree AV Block, Type II
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Third-Degree AV Block Third-Degree AV Block
• Rate: – Atrial- regular– Ventricular- less than the atrial rate
• Rhythm: – Atrial- regular– Ventricular- regular
• PR: varies with every beat• QRS: normal or wide• Hemodynamics: No atrial contribution
Third-Degree AV Block Third-Degree AV Block
Third-Degree AV Block Third-Degree AV Block
All arrhythmias that are
hemodynamically significant
require immediate
cardioversion, defibrillation,
or cardiac pacing
Electrical TherapyElectrical Therapy
• Understand when cardioversion or defibrillation is indicated
• Know the difference between unsynchronized and synchronized shocks
• Energy doses for specific rhythms
• Challenges of delivering shocks safely and effectively- may include iv sedation
Electrical TherapyElectrical Therapy
Cardioversion and DefibrillationCardioversion and Defibrillation
• Understand when cardioversion or
defibrillation is indicated
SYMPTOMS
SYMPTOMS
SYMPTOMS
Hemodynamically SignificantHemodynamically Significant
Tachycardia or Bradycardia
• Hypotension (Systolic BP < 80 mmHg)
• Altered mental status
• Congestive heart failure
• Angina
• Does not respond promptly to medical
management, if tried
Cardioversion and DefibrillationCardioversion and Defibrillation
Defibrillation
The electric shock depolarizes all
excitable myocardium, interrupts
reentrant circuits, discharges
foci, and establishes electrical
homogeneity
Cardioversion and DefibrillationCardioversion and Defibrillation
Defibrillation
• AED: Learn the one in your setting
• Biphasic: 200 watt-seconds (joules)
• Monophasic: 360 watt-seconds (joules)
“The interval from collapse to defibrillation is
one of the most important determinants of
survival from cardiac arrest.” Page 35
Cardioversion and DefibrillationCardioversion and Defibrillation
Cardioversion and DefibrillationCardioversion and Defibrillation
• Power on
• Apply pads
• Analyze the rhythm
• Select the energy level
• Clear the area
• Discharge the device
Procedure for Defibrillation
Cardioversion and DefibrillationCardioversion and Defibrillation
Cardioversion
• Know when cardioversion is indicated
• Synchronized vs unsynchronized shock
• What energy level for what arrhythmias
• Establish iv and consider sedation
Cardioversion and DefibrillationCardioversion and Defibrillation
Cardioversion
A physician skilled in airway management
(ie., an anesthesiologist) should be in
attendance, and all necessary equipment
for emergency resuscitation should be
immediately available
Anesthetic (amnestic) Agents
Cardioversion and DefibrillationCardioversion and Defibrillation
Cardioversion
The electric shock depolarizes all
excitable myocardium, interrupts
reentrant circuits, discharges
foci, and establishes electrical
homogeneity
Cardioversion and DefibrillationCardioversion and Defibrillation
Synchronization
Synchronized cardioversion (defibrillation) uses
a sensor to deliver the shock with the peak of the
QRS complex. The goal is to avoid the shock on
the T-wave, “R-on-T”, which is known to induce
ventricular fibrillation in unstable hearts
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PR Interval
QRS Interval
QT Interval
The ElectrocardiogramThe Electrocardiogram
• Atrial flutter & SVT: 50-100 J (monphasic)
• Atrial fibrillation: 100-200 J (monophasic)
• Ventricular tachycardia: 100-200 J
Cardioversion and DefibrillationCardioversion and Defibrillation
Synchronization
Energy Selection
Cardioversion and DefibrillationCardioversion and Defibrillation
• Power on
• Apply pads
• Turn on the SYNC control
• Analyze the rhythm
• Select the energy level
• Clear the area
• Discharge the device
Procedure for Cardioversion
Cardioversion and DefibrillationCardioversion and Defibrillation
• Ventricular fibrillation occurs
• Turn off the SYNC control
• Charge to 200 J (or more)
• Clear the area
• Discharge the device
Complications of Cardioversion
ReviewReview
ReviewReview
3rd Degree Heart Block
ReviewReview
3rd Degree Heart Block
2nd Degree Type II Block
ReviewReview
3rd Degree Heart Block
2nd Degree Type II Block
2nd Degree Type I Block
ReviewReview
ReviewReview
1st Degree Heart Block
ReviewReview
Junctional Escape Rhythm
1st Degree Heart Block
ReviewReview
Junctional Escape RhythmJunctional Escape Rhythm
Sinus Bradycardia
1st Degree Heart Block
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ReviewReview
Ventricular Tachycardia- ?
ECG InterpretationECG Interpretation
William A. Shapiro, M.D.William A. Shapiro, M.D.http://anesthesia.ucsf.edu/shapirohttp://anesthesia.ucsf.edu/shapiro
Advanced Cardiac Life SupportAdvanced Cardiac Life Support
Department of Anesthesia and Perioperative Care advancing health worldwide TM
That’s it- Now go forthThat’s it- Now go forthand save lives-and save lives-
Make us all proud you’re from UCSFMake us all proud you’re from UCSF