ECG Webinar Series · 2020. 5. 19. · •O/E: CTA, HS-I-II-0, bilateral pitting oedema to mid calf •RR 20, SpO 2 95%, HR 122 (irreg irreg), BP 168/102 | 01895 730020 | [email protected]

ECG Webinar SeriesEpisode 2: Lead II Rhythms

18th May 2020 at 19:00

Presented by:

Mr Innes Eaton

Paramedic Practitioner

STC Training SolutionsAsk us about our BLS and ILS refresher training for

healthcare professionals!

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ECG Webinar Series | Episode 2 | Lead II Rhythms

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Session Plan

• Refresher of the individual waves

• Normal sinus rhythm

• Basic arrhythmias

• Atrial flutter & atrial fibrillation

• AV blocks

• Cardiac arrest rhythms

• Q&A Session



ECG Waves Refresher



The 6 Rules of NSR



1. Is it regular?

2. Is the rate 60-100bpm?

3. P:QRS = 1:1

4. PR interval 120-200ms & constant5. QRS duration ≤120ms

6. QTc duration ≤450ms (approx.)

Diagnosing Arrhythmias

• General• Fast or slow?

• Regular, regularly irregular or irregularly irregular?

• P-waves• Are they there?

• Are they monomorphic?

• Is the P:QRS ratio 1:1?

• Is the PR interval constant at 120-200ms?

• QRS complexes• Is there P-QRS association?

• Is the duration <120ms?

• Are they grouped together?

• Are there any dropped beats?



Fast or Slow?



Case Study 1

• 25 y/o Caucasian male, NF&W

• No PMH/PSH/DHx/Cardiac FHx

• Non-smoker, social drinker, no recreational drugs

• Sx suggestive of LRTI

• RR 16, SpO2 98%, HR 70 (reg irreg), T37.5, BP 116/78



Interactive Quiz



Sinus Arrhythmia

Differential Diagnoses (DDx)

• In younger, healthy patients• Respiratory sinus arrythmia (RSA)

• Inspiration: Reduced intrathoracic pressure reduces vagal tone and thus increases heart rate

• The opposite occurs during expiration

• This is a ‘normal’ finding and may actually improve V/Q matching in the alveoli

• In older, co-morbid patients• Non-respiratory sinus arrythmia (Alternans)

• Age related baroreceptor changes

• Heart disease

• Cardiac glycosides (Digoxin) and vagal agents (Morphine)



Regularly Irregular



Respiratory Sinus

Arrhythmia

Second Degree Heart Block – Type 1

(Mobitz I – Wenckebach)

Ventricular

Bigeminy

Irregularly Irregular



Atrial Fibrillation

Wandering Atrial

Pacemaker

Multifocal Atrial

Tachycardia

Atrial Fibrillation (AF) vs Atrial Flutter (AFT)



Co-ordinated atrial activity? Irregular or regular QRS complexes?

Case Study 2

• 82 y/o Caucasian female, doesn’t come in very often

• PMH: Essential HTN, DHx: Amlodipine 10mg Od

• 3/12 progressive exertional dyspnoea, ankle swelling and ‘flutters’ in her chest (especially at night)

• No sx of infection

• O/E: CTA, HS-I-II-0, bilateral pitting oedema to mid calf

• RR 20, SpO2 95%, HR 122 (irreg irreg), BP 168/102



Interactive Quiz



Case Study 2



Atrial Fibrillation



Interactive Quiz



Management of Atrial Fibrillation• CHA2DS2-VASc score to assess stroke risk

• 0 = Low Risk | 1 = Mid Risk | 2+ = High Risk

• HAS-BLED score to assess bleeding risk• Warfarin in preferred over NOACs in high falls risk• Apixaban is favoured with symptomatic heart failure• Rivaroxaban is favoured if there has already been a stroke/TIA

• Consider TTE/TOE in patients indicated for rhythm control

• Rate control• β blocker (Bisoprolol) or rate-limiting CCB (Verapamil/Diltiazem)• +/- Digoxin

• Rhythm Control• Cardioversion• Pharmacological• Ablation



Refer to

NICE CG180

Atrial Flutter



• Typically 2:1 or 3:1

• 1:1 is unsustainable

• ≥5:1 is known as high AV block

• Variable conduction is common

Refractory Periods



ARP vs RRP

• Voltage gated Na+ channels are

not ‘primed’ for use until passing

through -50mV during phase 3

• Before the end of this ‘Absolute

Refractory Period’ (ARP), no

further depolarisation can occur

• During the ‘Relative Refractory

Period’ (RRP), depolarisation can

occur if the stimulus is big enough

• The highest co-ordinated HR is

therefore around 240bpm

AV Blocks



• In health, the AV node delays the signal

travelling between the internodal pathways and

the Bundle of His by 120-200ms

• This forms the PR interval and is important to

allow ventricular pre-filling before contraction

• The AV node should conduct every impulse

that it receives

• A conduction delay of more than 200ms, or

the failure to conduct any of the impulses, is

known as an AV block

1st Degree AV Block



• The AV node delays the electrical impulse by

more than 200ms

• This presents as a prolonged PR interval

• If the PR interval is more than 300ms, it is

often called ‘Marked’ 1st Degree AV Block

3rd Degree AV Block



• Also called Complete Heart Block (CHB)

• The AV node does not conduct any electrical

impulses to the Bundle of His

• This presents as a disassociation between

P:QRS and a slow, wide QRS complex

2nd Degree AV Block – Type 1



• Also called Mobitz I or Wenckebach Phenomenon

• The AV conduction delay gradually increases to the point

of ‘dropping a beat’ (the impulse in not transmitted)

• This presents as a regularly irregular rhythm with a

gradually increasing PR interval

P’s on the run?

It’s Mobitz type 1!

2nd Degree AV Block – Type 2



• Also called Mobitz II or Hay Block

• AV conduction appears to be normal in most beats

(constant PR), but randomly fails to conduct an impulse

• This presents as a predominantly ‘normal’ ECG with

random ‘missing’ QRS complexes

P’s marching through?

It’s Mobitz type 2!

2nd Degree AV Block – 2:1 Conduction



• The AV node only conducts every other impulse

• It is not possible to definitively say whether the block is of

Mobitz I or Mobitz II pathology

• As Mobitz II usually occurs in the context of pre-existing

bundle blocks, it will usually produce a wider QRS complex

High Grade AV Block



• Generally considered to be a type of 2nd Degree AV Block

• This is where the AV node conducts fewer than 1 in 4

electrical impulses – a conduction of 4:1 or worse

• It is generally treated as 3rd Degree AV Block – urgent

cardiology input +/- pacemaker

Case Study 3

• 70 y/o Indian male comes in feeling faint

• He passes out in the waiting room

• You answer the crash call and go to assist

• O/E: Pain response, RR 20, HR 35 (reg), absent radial



Interactive Quiz



Interactive Quiz



Cardiac Arrest Rhythms



Asystole

PEA

VF

pVTNon-Shockable (Aystole/PEA)

• Adrenaline 1mg 3-5 mins

Shockable (VF/pVT)

• Shock every 2 mins

• Adrenaline 1mg 3-5 mins

• Amiodarone 300mg 3rd Shock

• Amiodarone 150mg 5th Shock

Thank You!



[email protected]

Documents

ECG Webinar Series · 2020. 5. 19. · •O/E: CTA, HS-I-II-0, bilateral pitting oedema to mid calf •RR 20, SpO 2 95%, HR 122 (irreg irreg), BP 168/102 | 01895 730020 | [email protected]