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ECG Interpretation William A. Shapiro, M.D. William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro http://anesthesia.ucsf.edu/shapiro Advanced Cardiac Life Support Advanced Cardiac Life Support Department of Anesthesia and Perioperative Care advancing health worldwide TM

ECG Interpretation

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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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Page 1: ECG Interpretation

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

Page 2: ECG Interpretation

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

Page 3: ECG Interpretation

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

Page 4: ECG Interpretation

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

Page 5: ECG Interpretation

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

Page 6: ECG Interpretation

Mechanisms of ArrhythmiasMechanisms of Arrhythmias

•Reentry

•Automaticity–Altered normal automaticity–Abnormal automaticity

•Triggered Rhythms due to DAD (delayed after depolarizations

Page 7: ECG Interpretation

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

Page 8: ECG Interpretation

The ElectrocardiogramThe Electrocardiogram

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Page 9: ECG Interpretation

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PR Interval

QRS Interval

The ElectrocardiogramThe Electrocardiogram

Q

R

S

TP U

Page 10: ECG Interpretation

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PR Interval

QRS Interval

QT Interval

The ElectrocardiogramThe Electrocardiogram

Page 11: ECG Interpretation

Relationship of ECG to anatomy

Cardiac Conduction System Cardiac Conduction System

Page 12: ECG Interpretation

Relationship of ECG to anatomy

Cardiac Conduction System Cardiac Conduction System

Page 13: ECG Interpretation

THE ACLS THE ACLS

PROVIDER PROVIDER

IS:IS: IN

ACLS

Page 14: ECG Interpretation

Normal Sinus Rhythm Normal Sinus Rhythm

•Rate 60-100 beats per minute

•Rhythm: Regular

•P waves: Upright in Leads: 1, 2, AVF

Page 15: ECG Interpretation

Determining the RateDetermining the Rate

Page 16: ECG Interpretation

Determining the RateDetermining the Rate

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Page 17: ECG Interpretation

Determining the RhythmDetermining the Rhythm

Page 18: ECG Interpretation

Sinus Tachycardia Sinus Tachycardia

•Rate: Greater than 100 beats per minute

•Rhythm: Regular

•P waves: Upright in Leads: 1, 2, AVF

Page 19: ECG Interpretation

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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Page 20: ECG Interpretation

Sinus Bradycardia Sinus Bradycardia

•Rate: Less than 60 beats per minute

•Rhythm: Regular

•P waves: Upright in Leads: 1, 2, AVF

Page 21: ECG Interpretation

Sinus Bradycardia Sinus Bradycardia

•Rate: Less than 60 beats per minute

•Rhythm: Regular

•P waves: Upright in Leads: 1, 2, AVF

Page 22: ECG Interpretation

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

Page 23: ECG Interpretation

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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Page 24: ECG Interpretation

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

Page 25: ECG Interpretation

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

Page 26: ECG Interpretation

Atrial TachycardiaAtrial Tachycardia

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P-Wave

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P-Wave

Page 27: ECG Interpretation

Atrial TachycardiaAtrial Tachycardia

Atrial Tachycardia with variable block

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P-Waves are regular at 160 bpm

Page 28: ECG Interpretation

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

Page 29: ECG Interpretation

Atrial FlutterAtrial Flutter

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F-waves

Page 30: ECG Interpretation

Atrial FlutterAtrial Flutter

Atrial Flutter with variable conduction (block)

Page 31: ECG Interpretation

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

Page 32: ECG Interpretation

Atrial FibrillationAtrial Fibrillation

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Page 33: ECG Interpretation

Atrial FibrillationAtrial Fibrillation

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Page 34: ECG Interpretation

Atrial FibrillationAtrial Fibrillation

Page 35: ECG Interpretation

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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Page 36: ECG Interpretation

Premature Ventricular ComplexesPremature Ventricular Complexes

•Rhythm: Irregular

•P waves: Usually not seen

•QRS complex: Wide > .12 sec

•Compensatory pause

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Page 37: ECG Interpretation

Premature Ventricular ComplexesPremature Ventricular Complexes

Compensatory pause

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This distanceis double the

sinus distance

This is the sinus and the QRSdistance

Page 38: ECG Interpretation

Premature Ventricular ComplexesPremature Ventricular Complexes

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•Unifocal PVCs

•Multifocal PVCs

Page 39: ECG Interpretation

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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Page 40: ECG Interpretation

Premature Ventricular ComplexesPremature Ventricular Complexes

Ventricular Bigeminy

Pairs of PVCs

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Page 41: ECG Interpretation

Premature Ventricular ComplexesPremature Ventricular Complexes

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PVC on T-wave precipitating Ventricular Tachycardia

Page 42: ECG Interpretation

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

Page 43: ECG Interpretation

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Ventricular TachycardiaVentricular Tachycardia

Page 44: ECG Interpretation

Ventricular TachycardiaVentricular Tachycardia

Polymorphic Ventricular Tachycardia

Page 45: ECG Interpretation

Ventricular FibrillationVentricular Fibrillation

•Rate: Rapid- no effective cardiac rhythm

•Rhythm: Irregular

•P, QRS, T- waves: Absent

•No blood pressure!

Page 46: ECG Interpretation

Ventricular FibrillationVentricular Fibrillation

Course VF

Fine VF

Page 47: ECG Interpretation

Ventricular FibrillationVentricular Fibrillation

Page 48: ECG Interpretation

Ventricular AsystoleVentricular Asystole

•P, QRS, T- waves: Complete absent of cardiac electrical activity

•Complete absent of effective cardiac pumping function

Page 49: ECG Interpretation

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Acute Coronary SyndromesAcute Coronary Syndromes

Page 50: ECG Interpretation

Acute Coronary SyndromesAcute Coronary Syndromes

Page 51: ECG Interpretation

Acute Coronary SyndromesAcute Coronary Syndromes

Page 52: ECG Interpretation

ReviewReview

Page 53: ECG Interpretation

ReviewReview

Atrial Fibrillation

Page 54: ECG Interpretation

ReviewReview

Atrial Fibrillation

Sinus Rhythm

Page 55: ECG Interpretation

ReviewReview

Atrial Fibrillation

Sinus Rhythm

Acute Coronary Syndrome

Page 56: ECG Interpretation

ReviewReview

Page 57: ECG Interpretation

ReviewReview

Asystole

Page 58: ECG Interpretation

ReviewReview

Asystole

Fine Ventricular Fibrillation

Page 59: ECG Interpretation

ReviewReview

Asystole

Fine Ventricular Fibrillation

Coarse Ventricular Fibrillation

Page 60: ECG Interpretation

ReviewReview

Page 61: ECG Interpretation

ReviewReview

Ventricular Tachycardia- ?

Page 62: ECG Interpretation

ReviewReview

Premature Ventricular Complex (PVC)

Ventricular Tachycardia- ?

Page 63: ECG Interpretation

ReviewReview

Premature Ventricular Complex (PVC)

Ventricular Tachycardia

Ventricular Tachycardia- ?

Page 64: ECG Interpretation

ReviewReview

Page 65: ECG Interpretation

ReviewReview

Ventricular Tachycardia

Page 66: ECG Interpretation

ReviewReview

Ventricular Tachycardia

Ventricular Tachycardia

Page 67: ECG Interpretation

ReviewReview

Ventricular Tachycardia

Ventricular Tachycardia

(Paroxsymal) Atrial Tachycardia (SVT)

Page 68: ECG Interpretation

ReviewReview

Page 69: ECG Interpretation

ReviewReview

Paroxsymal Atrial Tachycardia (SVT)

Page 70: ECG Interpretation

ReviewReview

Paroxsymal Atrial Tachycardia (SVT)

Atrial Flutter

Page 71: ECG Interpretation

Treatment of All Cardiac Arrhythmias

Treatment of All Cardiac Arrhythmias

All arrhythmias that are

hemodynamically significant

require immediate

cardioversion, defibrillation,

or cardiac pacing

Page 72: ECG Interpretation

Break Time

Page 73: ECG Interpretation

AV BlockAV Block

•Why is it important?

•Where is the block?

•What’s a pacemaker anyway?

Page 74: ECG Interpretation

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)

Page 75: ECG Interpretation

Escape PatternsEscape Patterns

Page 76: ECG Interpretation

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

Page 77: ECG Interpretation

Junctional Escape ComplexesJunctional Escape Complexes

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Page 78: ECG Interpretation

Junctional Escape ComplexesJunctional Escape Complexes

Junctional Rhythm

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Page 79: ECG Interpretation

Ventricular Escape ComplexesVentricular Escape Complexes

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Page 80: ECG Interpretation

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

Page 81: ECG Interpretation

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

Page 82: ECG Interpretation

First-Degree AV BlockFirst-Degree AV Block

Page 83: ECG Interpretation

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

Page 84: ECG Interpretation

Second-Degree AV Block, Type ISecond-Degree AV Block, Type I

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Page 85: ECG Interpretation

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

Page 86: ECG Interpretation

Second-Degree AV Block, Type IISecond-Degree AV Block, Type II

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Page 87: ECG Interpretation

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

Page 88: ECG Interpretation

Third-Degree AV Block Third-Degree AV Block

Page 89: ECG Interpretation

Third-Degree AV Block Third-Degree AV Block

Page 90: ECG Interpretation

All arrhythmias that are

hemodynamically significant

require immediate

cardioversion, defibrillation,

or cardiac pacing

Electrical TherapyElectrical Therapy

Page 91: ECG Interpretation

• 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

Page 92: ECG Interpretation

Cardioversion and DefibrillationCardioversion and Defibrillation

• Understand when cardioversion or

defibrillation is indicated

SYMPTOMS

SYMPTOMS

SYMPTOMS

Page 93: ECG Interpretation

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

Page 94: ECG Interpretation

Cardioversion and DefibrillationCardioversion and Defibrillation

Defibrillation

The electric shock depolarizes all

excitable myocardium, interrupts

reentrant circuits, discharges

foci, and establishes electrical

homogeneity

Page 95: ECG Interpretation

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

Page 96: ECG Interpretation

Cardioversion and DefibrillationCardioversion and Defibrillation

Page 97: ECG Interpretation

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

Page 98: ECG Interpretation

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

Page 99: ECG Interpretation

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

Page 100: ECG Interpretation

Cardioversion and DefibrillationCardioversion and Defibrillation

Cardioversion

The electric shock depolarizes all

excitable myocardium, interrupts

reentrant circuits, discharges

foci, and establishes electrical

homogeneity

Page 101: ECG Interpretation

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

Page 102: ECG Interpretation

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PR Interval

QRS Interval

QT Interval

The ElectrocardiogramThe Electrocardiogram

Page 103: ECG Interpretation

• 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

Page 104: ECG Interpretation

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

Page 105: ECG Interpretation

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

Page 106: ECG Interpretation

ReviewReview

Page 107: ECG Interpretation

ReviewReview

3rd Degree Heart Block

Page 108: ECG Interpretation

ReviewReview

3rd Degree Heart Block

2nd Degree Type II Block

Page 109: ECG Interpretation

ReviewReview

3rd Degree Heart Block

2nd Degree Type II Block

2nd Degree Type I Block

Page 110: ECG Interpretation

ReviewReview

Page 111: ECG Interpretation

ReviewReview

1st Degree Heart Block

Page 112: ECG Interpretation

ReviewReview

Junctional Escape Rhythm

1st Degree Heart Block

Page 113: ECG Interpretation

ReviewReview

Junctional Escape RhythmJunctional Escape Rhythm

Sinus Bradycardia

1st Degree Heart Block

Page 114: ECG Interpretation

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ReviewReview

Ventricular Tachycardia- ?

Page 115: ECG Interpretation
Page 116: ECG Interpretation

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