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Ecg 3

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Ecg 3

  1. 3. VVI
  2. 7. Premature Beats Premature Atrial Contraction (PAC) <ul><li>Origin: Atrium (outside the Sinus Node) </li></ul><ul><li>Mechanism: Abnormal Automaticity </li></ul><ul><li>Characteristics: An abnormal P-wave occurring </li></ul><ul><li>earlier than expected, followed </li></ul><ul><li>by compensatory pause </li></ul>
  3. 8. Premature Beats Premature Junctional Contraction <ul><li>Origin: AV Node Junction </li></ul><ul><li>Mechanism: Abnormal Automaticity </li></ul><ul><li>Characteristics: A normally conducted complex with </li></ul><ul><li>an absent p-wave, followed by a </li></ul><ul><li>compensatory pause </li></ul>
  4. 9. Premature Beats Premature Ventricular Contractions (PVCs) <ul><li>Origin: Ventricles </li></ul><ul><li>Mechanism: Abnormal Automaticity </li></ul><ul><li>Characteristics: A broad complex occurring earlier </li></ul><ul><li>than expected, followed by a </li></ul><ul><li>compensatory pause </li></ul>
  5. 18. Multifocal PVC <ul><li>Origin: Varies within the Ventricle </li></ul><ul><li>Mechanism: Abnormal Automaticity </li></ul><ul><li>Characteristics: Each premature beat changes axis; </li></ul><ul><li>implies a different focus origin for </li></ul><ul><li>each beat </li></ul>
  6. 21. ABERRANT VENTRICULAR CONDUCTION <ul><li>A term that describes temporary alteration of QRS morphology under conditions where a normal QRS might be expected. The common types are: </li></ul><ul><li>1. Through normal conduction pathways: </li></ul><ul><ul><li>Cycle-length dependent (Ashman phenomenon) </li></ul></ul><ul><ul><li>Rate-dependent tachycardia or bradycardia </li></ul></ul><ul><li>2. Through accessory pathways (e.g., Kent bundle) </li></ul>
  7. 22. Ashman Phenomenon
  8. 23. “ Las Vegas” type betting odds of making the right diagnosis <ul><li>1) fat little initial r-wave, </li></ul><ul><li>2) notch or slur in the downstroke of the S wave, </li></ul><ul><li>3) a 0.06 sec or more delay from the beginning of the QRS to the nadir of the S-wave. </li></ul><ul><li>1&2-90% Aberrant Conduction </li></ul><ul><li>3- 50-50%- not helpful </li></ul><ul><li>4 -100:1 - Ventricular Ectopy </li></ul><ul><li>5 - m/p Vntricular with two exceptions : </li></ul><ul><ul><li>Some people with normal ECG’s do not have an initial little r-wave in the QRS of lead V1. If RBBB occurs in such a person the QRS morphology in V1 will be a qR instead of an rsR’. </li></ul></ul><ul><ul><li>In a person with a previous anterior or anteroseptal infarction the V1 QRS often has a QS morphology, and RBBB in such a person will also have a qR pattern. </li></ul></ul>
  9. 24. &quot;Cherchez le P sur le T&quot;
  10. 26. a “critical rate” -a “tired” but not “dead” bundle branch
  11. 27. Don’t be fooled by first impressions. Not all FLBs are ventricular in origin!
  12. 28. Tachyarrhythmia Classifications Based on origin <ul><li>Sinus Tachycardia </li></ul><ul><li>Atrial Tachycardia </li></ul><ul><li>AVRT </li></ul><ul><li>AVNRT </li></ul><ul><li>Atrial Flutter </li></ul><ul><li>Atrial Fibrillation </li></ul><ul><li>Ventricular Fibrillation (VF) </li></ul><ul><li>Ventricular Tachycardia (VT) </li></ul>
  13. 29. Sinus Tachycardia <ul><li>Origin: Sinus Node </li></ul><ul><li>Rate: 100-180 BPM </li></ul><ul><li>Mechanism: Abnormal (Hyper) Automaticity </li></ul>
  14. 31. Ectopic Atrial Tachycardia and Rhythm <ul><li>Ectopic, discrete looking, unifocal P' waves with atrial rate <250/min (not to be confused with slow atrial flutter). </li></ul><ul><li>Ectopic P' waves usually precede QRS complexes with P'R interval < RP' interval (i.e., not to be confused with paroxysmal supraventricular tachycardia with retrograde P waves shortly after the QRS complexes). </li></ul><ul><li>The above ECG shows sinus rhythm, a PVC, and the onset of ectopic atrial tachycardia (note different P wave morphology) </li></ul><ul><li>Ventricular response may be 1:1 (as above ECG) or with varying degrees of AV block (especially in the setting of digitalis toxicity. </li></ul><ul><li>Ectopic atrial rhythm is similar to ectopic atrial tachycardia, but with HR < 100 bpm </li></ul>
  15. 33. Atrial Flutter <ul><li>Origin: Right & Left Atrium </li></ul><ul><li>Mechanism: Reentry </li></ul><ul><li>Characteristics: Rapid, regular p-waves </li></ul>* Animation
  16. 37. Atrial Fibrillation (AF) <ul><li>Origin: Right and/or left atrium </li></ul><ul><li>Mechanism: Multiple wavelets of reentry </li></ul><ul><li>Rate 400 BPM </li></ul><ul><li>Characteristics: Random, chaotic rhythm; </li></ul><ul><li>atria quiver; associated with </li></ul><ul><li>irregular ventricular rhythm </li></ul>* Animation
  17. 39. Atrial Fibrillation (AF)
  18. 40. Other AF Mechanisms Multifocal Firing <ul><li>Mechanism: Abnormal Automaticity (multi-sites) </li></ul><ul><li>Characteristics: Many depolarization waves; </li></ul><ul><li>activation occurs asynchronously; </li></ul><ul><li>not in rhythm with sinus node </li></ul>
  19. 42. Atrial Flutter vs. Atrial Fibrillation Atrial Flutter Summary of Disease Characteristics Underlying Mechanism Pattern Atrial Rate Ventricular Rate Rhythm Atrial Fibrillation <ul><li>Multiple wavelet reentry </li></ul><ul><li>Multiple/single focus </li></ul><ul><li>firing </li></ul><ul><li>Wavy baseline </li></ul><ul><li>400 BPM </li></ul><ul><li>Varies w/conduction </li></ul><ul><li>Grossly Irregular </li></ul><ul><li>Reentry via macro </li></ul><ul><li>reentrant circuit </li></ul><ul><li>Saw tooth baseline </li></ul><ul><li>250 to 400 BPM </li></ul><ul><li>Varies w/conduction </li></ul><ul><li>Usually regular </li></ul>
  20. 45. F/S AVNRT
  21. 47. WPW

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