ia] ECG Interpretation & Arrhythmia Management A practical guide to understanding Electrocardiograms (ECGs) and managing common arrhythmias. {@] What is an ECG & How It Works Electrocardiography (ECG): A non-invasive graphic recording of the heart's electrical activity. ssa Camera Analogy Think of ECG as photographing the heart’s electricity from different angles: * Cameras (Electrodes): Small devices placed on the patient's body to capture signals. * Views (Leads): \* Views (Leads): © Chest Leads (V1-V6): > V1 — Sees electricity moving away (negative deflection |). >» V2-V6 — Record different chest angles. © Augmented Leads (AVR, AVL, AVF): >» AVR > Right arm, usually negative deflection. >» AVL > Left arm. > AVF > Left leg. © Bipolar Leads (I, II, Ill): > Lead Il = Positive deflection (t). ¢ Total Leads: 9 electrodes — 12 different lead views.ECG Paper & Measurement * Thermal Printer: No ink, uses heat to mark paper. * Grid System: ° Horizontal axis = Time > 1 small box = 0.04 sec > 1 large box (5 small) = 0.20 sec > 5 large boxes = 1 sec © Vertical axis = Voltage > 1 small box = 1 mm (0.1 mV) > 1 large box = 5 mm (0.5 mV) ¢ Standard Settings: o Paper speed: 25 mm/sec ° Voltage gain: 10 mm/mV * Normal ECG Criteria: a. No artifacts.1 mm = 0.1 mV, 0.045 5mm = 0.5 mV, 0.2s 10mm = 1.0 mV, 0.45¢ Normal ECG Criteria: a. No artifacts. b. AVR negative deflection. c. Lead II positive deflection. Cardiac Conduction System & Heart Cell Properties * SA Node: Main pacemaker, 60-100 bpm. ¢ AV Node: a. Backup pacemaker (40-60 bpm) b. Impulse filter c. Delay function d. Only atria-to-ventricle pathway ¢ Bundle of His ~ Bundle Branches > Purkinje FibersElectrical system of the heart Bachmann's bundle Sinoatrial (SA) Left bundle node \ branch Posterior Atrioventricular Conduction (AV) node Right bundle pathways branch* Cell Properties: © Automaticity @ ° Excitability 4 © Conductivity {@ ° Contractility & (23) ECG Wave Components ° P Wave — Atrial depolarization (s 0.12 sec, < 2.5mm) © PR Interval — 0.12-0.20 sec, constant © QRS Complex — Ventricular depolarization (s 0.10 sec) * ST Segment — Should be flat; deviations may indicate MI or ischemia ¢ T Wave —> Ventricular repolarization (smooth, upright) * QT Interval — Depolarization + repolarization‘ ‘ ‘ ‘ 4 TEE 1 | ° ° * * * *. ”- HH H |= * U Wave > Late repolarization (may be absent) (5) ECG Reading - Step-by-Step 1. Regularity (R-R interval check) 2. Heart Rate: © Regular — Rule of 300 / 1500 method ° Irregular — 6-second x10 method 3. P Waves: Present? Same shape? Before QRS? 4. PR Interval: Normal range & constant? 5. QRS Duration: Narrow or wide? 6. ST Segment: Elevated or depressed? 7. T Wave: Upright, smooth, within height limits? WL(@) Normal Sinus Rhythm (NSR) Parameters ¢ Rate: 60-100 bpm ¢ Rhythm: Regular ¢ P wave before each QRS ¢ PR: 0.12-0.20 sec ¢ QRS: 0.04-0.10 sec ¢ Normal ST & T waves Indications for ECG ¢ Routine checkupIndications for ECG * Routine checkup * Chest pain, palpitations ¢ Syncope, shock ¢ Pacemaker assessment e Pre-op screening ¢ Detect: ° Arrhythmias ° Inflammations ° Electrolyte imbalances o Hypertrophy ° Conduction defects ° Ischemia/infarction ° Drug toxicityArrhythmia Classification - 5 Rules 1. SA Node Origin — Normal P wave 2. Atrial Origin > Abnormal/absent P wave 3. AV Node Origin — Always regular rhythm 4. Supraventricular Origin > Narrow QRS 5. Ventricular Origin > Wide QRS Common Sinus Rhythms & Management ‘@ Sinus Bradycardia (< 60 bpm) * Causes: Sleep, athletes, hypothermia, drugs (B-blockers, digoxin) ° Tx: ° Asymptomatic — No Tx(| Common Sinus Rhythms & Management ‘@ Sinus Bradycardia (< 60 bpm) ° Causes: Sleep, athletes, hypothermia, drugs (B-blockers, digoxin) ° Tx: o Asymptomatic — No Tx ° Symptomatic > 1) ABC + Oxygen 2) IV access + ECG monitor 3) If complete block — Immediate pacemaker 4) If not > Atropine 1 mg IV (max 3 mg) = If fails: pacing / Adrenaline / Dopamineay InGEEGESSEgEBEEE Pre‘k, Sinus Tachycardia (> 100 bpm) * Causes: Fever, anemia, hypoxia, dehydration, hyperthyroidism, drugs (atropine, adrenaline) ¢ Tx: Treat cause; B-blockers or Ca-channel blockers if ischemia (i) Sinus Pause (< 3 sec) * Monitor, remove offending drugs if needed @ Sinus Arrest (2 3 sec) ¢ Treat as symptomatic bradycardia Sick Sinus Syndrome (SSS) ¢ Alternating bradycardia & tachycardia; irregular rhythm pre/post pause 22 Sinus Arrhythmia ¢ Normal ECG but irregular rhythm (often respiratory-related) * Monitor unless drug-induced¥ 7. Asystole * Definition: Complete absence of ventricular electrical activity (flat line on ECG). No cardiac output, no pulse. This is a cardiac arrest rhythm. ¢ Management: © 3€ No Defibrillation (no electrical activity to shock) ° Start CPR immediately © Adrenaline (Epinephrine) 1 mg IV/IO every 3-5 min o Identify & treat reversible causes (6 Hs & 6 Ts)4 8. Pulseless Electrical Activity (PEA) ¢ Definition: Any organized electrical activity on ECG without a palpable pulse. ¢ Management: © 3X No defibrillation (not a shockable rhythm) o CPR + Adrenaline 1 mg IV/IO every 3-5 min o Treat reversible causes (6 Hs & 6 Ts)PEA: Pulseless Electrical Activity non-shockable = Exclude / treat reversible causes. = Adrenaline 1 mg IV every 4 mins (2 cycles) (until a z, shockable rhythm is reached).& B. Atrial Cell Problems (Atrial Arrhythmias) Originate from abnormal foci in the atria > abnormal or absent P waves. 1. Premature Atrial Contractions (PACs) * Definition: Early beat from an ectopic atrial focus ° ECG Features: 9 Irregular rhythm when PAC present ° Different P wave morphology (bizarre/ inverted) ° PR interval variable ° QRS usually normal * Causes: Catecholamines, stress, stimulants, infection, electrolyte imbalance, digitalis toxicity, post-open-heart surgery ¢ Management: Observation + treat cause2. Atrial Fibrillation (AFib) * Definition: Multiple disorganized atrial impulses (300-600/min) — quivering atria * ECG Features: © Irregularly irregular rhythm © No P waves (fibrillatory waves instead) ° Variable ventricular rate: > Rapid AF (>100 bpm) > Controlled AF (60-100 bpm) > Slow AF (<60 bpm) ° Management: o Unstable: Immediate synchronized cardioversion (if <48h OR after TEE if >48h)© Stable: > Rate control: Beta-blockers, CCBs, Digoxin, Amiodarone (if HF or EF <40%) > Anticoagulation: Warfarin (INR 2-3) if chronic or high stroke risk >» Rhythm control: Cardioversion or antiarrhythmics > Radiofrequency ablation if refractory 3. Atrial Flutter * Definition: Re-entrant atrial circuit (200-400/min), often around tricuspid valvePo Lt Po occ eee Y3. Atrial Flutter ¢ Definition: Re-entrant atrial circuit (200-400/min), often around tricuspid valve ¢ ECG Features: ° “Saw-tooth” flutter waves o Usually regular rhythm o 2-4 P waves per QRS ¢ Causes: CAD, mitral valve disease, RHD, PE, COPD, hyperthyroidism ¢ Management: Similar to AFib (rate/rhythm control, anticoagulation, cardioversion effective)@ C. AV Junction Problems 1. Junctional Rhythm * Rate: 40-60 bpm * Regular rhythm * P waves: Absent/inverted or after QRS * Management: No treatment if asymptomatic, treat cause, stop digoxin if toxic 2. Accelerated Junctional Rhythm * Rate: 60-100 bpm * Regular, abnormal P waves 3. Junctional Tachycardia * Rate: >100 bpm * Regular, abnormal P wavesJunctional Rhythm HR Range is 40-60 b/min Accelerated Junctional Rhythm HR Range is >60-100 b/min Junctional Tachycardia HR Range is >100 b/min3. Junctional Tachycardia * Rate: >100 bpm ¢ Regular, abnormal P waves 4. Paroxysmal Supraventricular Tachycardia (PSVT/SVT) * Definition: Sudden onset/termination of rapid rhythm above ventricles (150-250 bpm) * Management (Stable): a. Vagal maneuvers @@ b. Adenosine (6 mg > 12 mg > 12 mg IV push + flush) c. Beta-blockers / CCBs d. Synchronized cardioversion if unstable cL§ D. AV Nodal Blocks (Heart Blocks) * 1st Degree: PR >0.20s, all P waves conducted — no treatment * 2nd Degree Type | (Mobitz I): Progressive PR t > dropped QRS — Atropine/ Dopamine/Epi, pacemaker if needed e 2nd Degree Type II: Constant PR but dropped beats — pacemaker needed ¢ 3rd Degree (Complete): AV dissociation > immediate pacemaker| 1 | | ~ H\ ~ T | }} E. Bundle Branch Blocks (BBB) ¢ RBBB: V1 = M-shape, V6 = W-shape ¢ LBBB: V1 = W-shape, V6 = M-shape e Wide QRS (>0.12s) ° Treat symptoms, pacemaker/CRT if indicatedWiLLiaM MoRRoW3 F. Ventricular Cell Problems (Ventricular Arrhythmias) 1. Premature Ventricular Contractions (PVCs) ¢ Wide, bizarre QRS, no P wave * Types: Unifocal, Multifocal, R-on-T, Bigeminy, Trigeminy, Couplet ¢ Management: No treatment if benign; Amiodarone/Lidocaine if symptomatic or dangerous> Uniform (Unifocal PVCs) eae ow Nursing Education Team2. Ventricular Tachycardia (VT) * Rate: 100-250 bpm, wide QRS ¢ With pulse: Amiodarone, synchronized cardioversion * Pulseless: Defibrillation + CPR (shockable) 3. Ventricular Fibrillation (VF) * Chaotic rhythm, no pulse * Management: Immediate defibrillation + CPR (shockable) “3v G. General Golden Rules e “No symptoms — don’t touch” * Always assess stability (BP, consciousness, chest pain, HF signs)ventricular Tachycardia Tae Polymorphic Ventricular Tach (cardia — Torsade de AVA ann (i_— ¢« VT occurs when more than three depolarization's occur from a ventricular focus. ¢ VT less than 30 seconds duration is termed nonsustained ventricular tachycardia. _ * QRS complex is generally wide and regular * rate higher than 100 beats/min (usually 150—200)Ventricular fibrillationf=] Defibrillation vs. Synchronized Cardioversion Therapy Defibrillation + Cardioversion [j Indication Sync? Energy Sedation VF / Pulseless VT x< High ox Unstable 7] Lower tachyarrhythmia with pulse¥ ©Hs & 6Ts — Reversible Causes 6 Hs: Hypovolemia, Hypoxia, Hypothermia, Hypo/Hyperkalemia, Acidosis, Hypoglycemia 6 Ts: Toxins, Tamponade, Tension Pneumothorax, Coronary Thrombosis, Pulmonary Thrombosis, Trauma s” Special ECG Types * Right-Sided ECG: Detect right ventricular issues * Posterior ECG: Detect posterior Ml ¢ Atrial ECG: Enhance atrial activity visibility (Lewis lead / epicardial wires)J® VIIL Key Notes & Principles from the Lecturer ¢ @ “No symptoms — don't touch.” Only intervene if the patient is symptomatic or unstable. ° ,y Prioritize Stability: © Stable (Asymptomatic): No urgent intervention © Unstable (Symptomatic): Immediate action based on rhythm ¢ Q Distinguishing Between Rhythms: Focus on P wave presence/shape, rhythm regularity, QRS width, and heart rate. ° ¥ Electrical vs. Mechanical Activity: © ECG shows electrical events (depolarization/repolarization) © Does not guarantee actual contraction or blood flow° Always check the pulse to confirm mechanical activity ¢ @ CPR in Arrest Rhythms: © Start CPR immediately for pulseless rhythms: > VF (Ventricular Fibrillation) > Pulseless VT (Ventricular Tachycardia) > Asystole > PEA (Pulseless Electrical Activity) ¢ J Adrenaline in Arrest Rhythms: © Dose: 1 mg IV/IO o Frequency: Every 3-5 minutes ° Used in all cardiac arrest rhythms (shockable & non-shockable)¢ §¢ ECG Artifacts: © Causes: Patient movement, shivering, loose electrodes, external electrical devices (e.g., phones, beds) o If severe & unavoidable (e.g., metal implants, tremors) — use artifact filter Y Final Takeaway: By applying these core principles with a systematic ECG interpretation approach, you can manage arrhythmias with confidence and precision.° k ECG Artifacts: © Causes: Patient movement, shivering, loose electrodes, external electrical devices (e.g., phones, beds) ° If severe & unavoidable (e.g., metal implants, tremors) — use artifact filter y Final Takeaway: By applying these core principles with a systematic ECG interpretation approach, you can manage arrhythmias with confidence and precision.