ECG Cardiac Arrythmia

1. ECG
&
INTRO TO
ARRHYTHMIAS
M. Balaji
Manager – Education & Training | APV & CRHF

2. SURFACE ECG
The ECG is measured by placing skin electrodes on the body surface at
different locations and connecting these electrodes in different
configurations to a voltage amplifier and recorder

3. EINTHOVEN (1912)

4. The Heart from All Directions

5. Einthoven’s Leads

6. A QUESTION OF LOCATION……

7. Chest Leads V1 – V6

8. The Chest Leads: V1 - V6

9. NORMAL 12 LEAD ECG

10. 12 Lead ECG

11. VECTOR MAPPING

12. Vector Mapping

13. The ECG

14. NORMAL VALUES
P waves ~ 100ms
PR interval ~ 120 – 200ms
QRS duration ≤ 120ms usually between 80 to 100ms
QT interval is about 300 ms for rates of 100 bpm
QT interval is about 400 ms for rates of 60 bpm
Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only
14

15. CARDIAC ARRHYTHMIAS

16. INTRODUCTION TO ARRHYTHMIAS
Automaticity, Excitability & Conductivity are vital properties of cardiac cells
and tissue
These properties govern
the rate at which the heart beats
the sequence in which the different parts of the heart beat
And thereby give the heart its natural rhythm
Arrhythmia – Any variation from the natural, normal rate and rhythm of the
heart
Arrhythmias arise due to problems in automaticty or excitability or
conductivity or any combination of these

17. CLASSIFICATION OF ARRHYTHMIAS
Based on Heart Rate
Bradyarrhythmia or Bradycardia – Any heart rhythm where the rate
is less than 60 bpm
Tachyarrhythmia or Tachycardia – Any heart rhythm where the rate
is greater than 100 bpm

18. CLASSIFICATION OF ARRHYTHMIAS
Based on the anatomical location of the heart that is the source of
the arrhythmia
 Sinus Node Arrhythmias
 Atrial Arrhythmias
 AV Junctional Arrhythmias
 Ventricular Arrhythmias

19. SINUS ARRHYTHMIAS
(SICK SINUS SYNDROME)
Arrhythmias that arise from the Sino-Atrial node
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrest
Sinus Block
Brady Tachy Syndrome

20. NORMAL SINUS RHYTHM
 Atrial rate: 60-100 bpm, Ventricular Rate = Atrial Rate
Normal P waves
 PR interval: 120-200 ms (.12-.20 seconds)
 QRS interval: 60-100 ms (.06-.10 seconds)
 QT interval: 360-440 ms (.36-.44 seconds)
Rate = ?

21. SINUS BRADYCARDIA
Identifying features
Rhythm : Regular
Rate : 40 –60 bpm
P waves : Normal in shape and size, one P-wave precedes each QRS
complex
PR : Normal (120-200ms)
QRS : Normal (less than 120 ms)

22. SINUS BRADYCARDIA

23. SINUS TACHYCARDIA
Identifying features
Rhythm : Regular
Rate : 100 –160 bpm
P waves : Normal in shape and size, one P-wave precedes each QRS
complex
PR : Normal (120-200ms)
QRS : Normal (less than 120 ms)

24. SINUS TACHYCARDIA

25. SINUS/ARREST BLOCK
Identifying features
Rhythm : Regular underlying rhythm, irregular during pause
Rate : Underlying rhythm normal or slow
P waves : Normal in shape and size, one P-wave precedes each QRS
complex; No P wave during pause
PR : Normal (120-200ms), PR absent during pause
QRS : Normal (less than 120 ms), QRS absent during pause

26. SINUS BLOCK

27. SINUS ARREST

28. ATRIAL FLUTTER

29. ATRIAL FLUTTER

30. ATRIAL FIBRILLATION

31. ATRIAL FIBRILLATION

32. ATRIVENTRICULAR BLOCKS
AV Blocks – Disturbances in conduction of the impulse from the Atria to
the Ventricles due to problems within the AV Junction
Classifciation – based on location within the AV Junction and the severity
of the block
 First Degree AV Block
Second Degree AV Block – Type I, Type II
Third Degree AV Block
Typically occur due to degeneration of the AV nodal and HIS bundle cells

33. Identifying features
Rhythm : Regular
Rate : Normal, atrial & ventricular rate are same
P waves : Normal Sinus
PR : Prolonged, greater than 200 ms
QRS : Normal (100ms or less)
FIRST DEGREE AV BLOCK

34. FIRST DEGREE AV BLOCK

35. Identifying features
Rhythm : Atrial - Regular
: Ventricular - Irregular
Rate : Atrial – Normal Sinus Rate
: Ventricular – Less than atrial rate during block
P waves : Normal Sinus
PR : PR varies and successively prolongs until a P wave occurs without
a QRS. A pause follows the dropped QRS
QRS : Normal (100ms or less)
SECOND DEGREE TYPE I BLOCK

36. SECOND DEGREE TYPE I BLOCK

37. Identifying features
Rhythm : Atrial - Regular
: Ventricular – Regular unless ratio of AV conduction varies
Rate : Atrial – Normal Sinus Rate
: Ventricular – Less than atrial rate during blocks
P waves : Normal Sinus
PR : PR may be normal or prolonged but does not vary
QRS : Normal (100ms or less) if block is in the HIS bundle
Broad or Wide if block is in the bundle branches
SECOND DEGREE TYPE II BLOCK

38. SECOND DEGREE TYPE II BLOCK

39. Identifying features
Rhythm : Atrial - Regular, Ventricular – Regular
Rate : Atrial – Normal Sinus Rate
: Ventricular – 30 to 40 (ventricular pacemaker)
- 40 to 60 (AV nodal pacemaker)
P waves : Normal Sinus
PR : PR varies greatly, no relationship between P waves and QRS
QRS : Normal (100ms or less) if block is in the HIS bundle
Broad or Wide if block is in the bundle branches
THIRD DEGREE AV BLOCK OR COMPLETE HEART
BLOCK

40. THIRD DEGREE AV BLOCK OR COMPLETE HEART
BLOCK

41. VENTRICULAR ARRHYTHMIAS
Ventricular arrhythmias originate anywhere in the ventricles below the
level where the HIS bundle branches out
Types
Bundle Branch blocks
Idioventricular Rhythm or Ventricular Escape Rhythm
Accelerated Idioventricular Rhythm
Premature Ventricular Contractions (PVC, VPC, VPB)
Ventricular Tachycardia (VT)
Ventricular Fibrillation (VF)
Ventricular Asystole or Standstill
All ventricular arrhythmias except VF and standstill are characterised by a
wide or broad QRS complex

42. BUNDLE BRANCH BLOCK
One Ventricle depolarizes before the other

43. BUNDLE BRANCH BLOCK

44. IDIOVENTRICULAR RHYTHM OR
VENTRICULAR ESCAPE RHYTHM

45. PREMATURE VENTRICULAR CONTRACTION

46. Multifocal PVC’s
PREMATURE VENTRICULAR CONTRACTION

47. VENTRICULAR TACHYCARDIA
Arise from ectopic pacemaker circuits or (less commonly) sites in
ventricular tissue, discharging impulses at a rate of 140-25 bpm
Reentry or enhanced automaticity
Sustained VT – VT that lasts for 30 seconds or more
Non-sustained VT - VT that lasts for less than 30 s

48. Monomorphic Sustained VT
VENTRICULAR TACHYCARDIA

49. Polymorphic VT
VENTRICULAR TACHYCARDIA

50. VENTRICULAR FIBRILLATION
Arises due to simultaneous action of several differnet ectopic circuits in
the ventricles randomly, chaotically and uncoordinatedly depolarising
different portions of ventricular tissue at different times
The ventricles do not beat in a coordinated fashion – they quiver
asynchronously and ineffectively
There is little or no Cardiac output, blood pressure drops to zero and the
patient becomes unconscious almost immediately
Death is almost certain unless the arrhythmia is treated immediately

51. VENTRICULAR FIBRILLATION

52. VENTRICULAR STANDSTILL OR ASYSTOLE

53. 53
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