Basic Arrhythmias

© 2011 American Heart Association. Do not edit. 1

 ECG Measurements

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

• QT interval
Corrected for
Heart Rate

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 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
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Standard Monitoring Leads
Lead 1

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Standard Monitoring Leads
Lead 2

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Standard Monitoring Leads
Lead 3

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 Basic Arrhythmias
Rhythm Strip Interpretation

Normal Sinus Rhythm

Sinus Bradycardia
Sinus Tachycardia

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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?

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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

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 Normal Sinus Rhythm

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

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

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

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 Self-Assessment
What is this rhythm?

If there is no pulse, what is this rhythm?

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 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

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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

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

Sinus Node   

Atrium  PAC

 AV Node

QRS
Normal Ventricle

Premature Beat
Present

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 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 18
 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 19
 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

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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?
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 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
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 Self-Assessment
What are the rate and rhythm?

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 Clinical Correlation

This patient is unresponsive and

BP is 70/50 mm Hg.

What is the rhythm?

What is your next action?

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 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)
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 Premature Ventricular
Contraction (PVC)

Compensatory pause
Sinus node continues to discharge

2  HR 

P wave obscured

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 Mechanism PVCs

Unidirectional
Purkinje Fiber
Block

Reentry Muscle Fiber

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

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 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
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 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) 30
 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)

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 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)

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 Asystole

Agonal Complexes ASYSTOLE

Pulseless Electrical
Activity

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

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 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, atropine

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 Self-Assessment
What are the rate and rhythm?

C
B

A B

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 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?

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Basic Arrhythmias
Atrioventricular Blocks

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

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 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

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Atrioventricular Block
Normal AV Conduction

• Underlying sinus Sinus Node

rhythm P

• One P wave
AV Node
AV Nodal
Tissue
• PR interval 0.12 to 0.12-0.20 seconds

0.20 second QRS <0.12

• One P wave for each

QRS
His-Purkinje System
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 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
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First-Degree AV Block

Sinus Node

• Underlying sinus rhythm AV Node

AV Nodal
Tissue
• One P wave >0.20 seconds

QRS <0.12
• PR interval >0.20
second
• One P wave for each His-Purkinje System
QRS 41
 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 42
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
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 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

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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
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AV Block—Which Type?


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

A diabetic woman in the ED with chest tightness

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 Clinical Correlation
What treatment is indicated?

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

External pacer not immediately available

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

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Pacemakers –

• Transcutaneous
• Transvenous
− Ventricular
− Atrial
− Dual Chamber

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 Pacemakers

–
• Transcutaneous


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 Pacemakers

• Transvenous
— Ventricular

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Pacemaker Malfunction
Sinus Node

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 Pacemakers

Transvenous
— Atrial
— Dual Chamber

A V

“PR”

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 Cardioversion

• Synchronized –
• Transcutaneous


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 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

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 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) 57
 Basic
Arrhythmias

QUESTIONS?

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