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# 2 rate & rhythms

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### 2 rate & rhythms

2. 2. Rate & Rhythm• Interpret the rhythm – Identify the rate – Is it regular or irregular? – Identify P-waves – Identify PR-interval
3. 3. Rate & Rhythm Calculate the Rate300 150 100 75 60
4. 4. Rate & Rhythm• Is the rate too fast or too slow?• Intrinsic Rates: – SA Node - 60 to 100 – AV Junction - 40 to 60 – Purkinje Fibers - 20 to 40
5. 5. Rate & RhythmRegular or Irregular
6. 6. Rate & RhythmRegular or Irregular
7. 7. Rate & Rhythm P-Waves• Are P-waves present?• Is there a P-wave for every QRS?• Is there a QRS for every P-wave?• Do the P-waves appear after the QRS?
8. 8. Rate & Rhythm PR-Interval• Is the PR-interval consistent?• Is the PR-interval > 0.20 sec (200ms)?• Does the PR-interval lengthen?
9. 9. Rate & Rhythm• The next step is to interpret the rhythm that the patient is in.• The following is a brief ECG arrhythmia review.
10. 10. Sinus Rhythms
11. 11. Normal Sinus Rhythm• Rate: 60 - 100 bpm• Rhythm: Regularly Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
12. 12. Normal Sinus Rhythm
13. 13. Normal Sinus Rhythm
14. 14. Normal Sinus Rhythm
15. 15. Normal Sinus Rhythm
16. 16. Sinus Arrhythmia• Rate: 60 - 100 bpm• Rhythm: Varies with respiration• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
17. 17. Sinus Arrhythmia
18. 18. Sinus Bradycardia• Rate: < 60 bpm• Rhythm: Regularly-Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
21. 21. Sinus Tachycardia• Rate: > 100 bpm• Rhythm: Regularly-Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
22. 22. Sinus Tachycardia
23. 23. Sinus Tachycardia
24. 24. Sinus Pause/Arrest• Rate: Varies• Rhythm: Irregular• P wave: Present except for pause• P:QRS ratio: 1 to 1• PR-interval: Normal• QRS Width: < 120 ms (0.12 sec)
25. 25. Premature Atrial Contraction• Rate: Determine underlined rate• Rhythm: Irregular• P wave: Present, may be different w/ PAC• P:QRS ratio: 1 to 1• PR-interval: Normal, may vary w/ PAC• QRS Width: < 120 ms (0.12 sec)
26. 26. Ectopic Atrial Tachycardia• Rate: 100 - 180 bpm• Rhythm: Regular• P wave: Present, may be different w/ ectopy• P:QRS ratio: 1 to 1• PR-interval: Normal, different w/ ectopy• QRS Width: < 120 ms (0.12 sec)
27. 27. Wandering Atrial Pacemaker• Rate: < 100 bpm• Rhythm: Irregularly-Irregular• P wave: At least 3 different morphologies• P:QRS ratio: 1 to 1• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
28. 28. Multifocal Atrial Tachycardia• Rate: > 100 bpm• Rhythm: Irregularly-Irregular• P wave: At least 3 different morphologies• P:QRS ratio: 1 to 1• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
29. 29. Atrial Flutter
30. 30. Atrial Flutter• Rate: Atria (250-350), Ventricles (125-175)• Rhythm: Usually Regular• P wave: Saw toothed “F waves”• P:QRS ratio: Variable, 2:1 is common• PR-interval: Variable• QRS Width: < 120 ms (0.12 sec)
31. 31. Atrial Flutter 3:1
32. 32. Atrial Flutter 2:1
33. 33. Atrial Fibrillation
34. 34. Atrial Fibrillation
35. 35. Atrial Fibrillation• Rate: Variable, depending on ventricles• Rhythm: Irregularly-Irregular• P wave: None, chaotic atrial activity• P:QRS ratio: None• PR-interval: None• QRS Width: < 120 ms (0.12 sec)
36. 36. Atrial Fibrillation
37. 37. Atrial Fibrillation
38. 38. Atrial Fibrillation
39. 39. Atrial Fibrillation
40. 40. Premature Junctional Contraction• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
41. 41. Junctional Escape Beat• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
42. 42. Junctional Rhythm• Rate: 40 - 60 bpm• Rhythm: Regular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
43. 43. Accelerated Junctional Rhythm• Rate: 60 - 100 bpm• Rhythm: Regular• P wave: none, antegrade, or retrograde• P:QRS ratio: 1:1 or retrograde• PR-interval: None, short, or retrograde• QRS Width: < 120 ms (0.12 sec)
44. 44. Narrow Complex Tachycardia Sinus Tach P MAT P Ectopic A-Tach P Junctional P AVNRT/AVRT P A-Flutter F F F F P P-Wave F Flutter Wave
45. 45. Premature Ventricular Contraction• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: None with PVC• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
46. 46. Premature Ventricular Contraction • Polymorphic – More than one one shape of QRS complex • Multifocal – More than one focus or site of initial impulse.
47. 47. Premature Ventricular Contraction 1 2
48. 48. Ventricular Escape Beat• Rate: Determine underlying rhythm• Rhythm: Irregular• P wave: None with PVC• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
49. 49. Ventricular Rhythms
50. 50. Idioventricular Rhythm• Rate: 20 - 40 bpm• Rhythm: Regular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
51. 51. Idioventricular Rhythm
52. 52. Accelerated Ventricular Rhythm• Rate: 40 - 100 bpm• Rhythm: Regular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
53. 53. Ventricular Tachycardia• Rate: 100 - 200 bpm• Rhythm: Regular• P wave: None, complete AV disassociation• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
54. 54. Ventricular Tachycardia
55. 55. Torsade de Pointes• Rate: 200 - 250 bpm• Rhythm: Irregular• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: > 120 ms (0.12 sec) WIDE
56. 56. Ventricular Fibrillation• Rate: Indeterminate• Rhythm: Chaotic• P wave: None• P:QRS ratio: None• PR-interval: None• QRS Width: None
57. 57. 1st Degree Heart Block• Rate: Identify underlying rate• Rhythm: Regular• P wave: Present• P:QRS ratio: 1 to 1• PR-interval: > 200 ms (0.20 sec)• QRS Width: < 120 ms (0.12 sec)
58. 58. 1st Degree Heart Block
59. 59. 2nd Degree Heart Block - Type I• Rate: Identify underlying rate• Rhythm: Regularly-Irregular• P wave: Present• P:QRS ratio: Variable• PR-interval: Variable (going, going, gone…)• QRS Width: < 120 ms (0.12 sec)
60. 60. 2nd Degree Heart Block - Type II• Rate: Identify underlying rate• Rhythm: Regularly-Irregular• P wave: Present• P:QRS ratio: x:x - 1• PR-interval: Normal *Dropped QRS• QRS Width: < 120 ms (0.12 sec)
61. 61. 3rd Degree Heart Block• Rate: Atrial & Ventricular rates differ• Rhythm: Regular• P wave: Present• P:QRS ratio: Variable• PR-interval: No pattern• QRS Width: Normal or WIDE
62. 62. 3rd Degree Heart Block
63. 63. AV Blocks
64. 64. Interpretation Pearl• When interpreting an ECG rhythm, always consider the company it keeps. – Associated Signs & Symptoms – Past medical history – Medications…etc
65. 65. ECG Rhythms• You must understand the basic ECGarrhythmias prior to moving on.• Review the previous slides until you thinkyou’ve got it.• The next slide may assist you if you’re stillhaving a hard time.
66. 66. The Golden RuleECG Interpretation is largely based on THEORY.Give five cardiologists the same ECG to interpret,and you may receive five different interpretations.