BASIC ARRYTHMIA

ANALYSIS

dr. M. Zakky Kurniawan SpJP. FIHA

 Basic Rhythm Analysis
Rate too fast or too slow?
Rhythm regular or irregular?
Is there a normal looking QRS? Is it
wide or narrow?
Are P waves present?
What is the relationship of the P
waves to the QRS complex?

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 Rhythm Analysis
Lethal vs non-lethal?

Shockable vs. non-shockable? Too fast vs too slow?

Symptomatic vs. asymptomatic?

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 Lethal Rhythms
Shockable (Defibrillation)
Ventricular fibrillation
Pulseless ventricular tachycardia

Non-shockable
Asystole
Pulseless electrical activity

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 Non-Lethal Rhythms
Too fast (tachycardias)
Sinus
Supraventricular (including a-fib/flutter)
Ventricular

Too slow (bradycardias)

Sinus
Heart block (1, 2, 3 AV block)

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 What is a Symptomatic
Dysrhythmia?
Any abnormal rhythm that produces signs or
symptoms of hypoperfusion..

Chest Pain/ischemic EKG changes

Shortness of Breath
Decreased level of consciousness
Syncope/pre-syncope
Hypotension
Shock - decreased Uop, cool extremities,
etc.
Pulmonary Congestion/CHF

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Name that rhythm

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 63 yo man with a witnessed
Collapse while mowing the
lawn

What is the rhythm?

What is the management?

Chikumaya, Wikimedia Commons 8

 Ventricular Fibrillation

Rapid and irregular

No normal P waves or QRS complexes

Jer5150, Wikimedia Commons 9

 VF / Pulseless VT
Secondary Survey - ABC

Primary Survey - ABC 10

Source unknown
 ACLS Algorithm
Primary Survey
Shock 360 J (monophasic) 200 J
(biphasic)
CPR
Secondary Survey
Vasopressor - Epi or Vasopressin IV
Shock 360J/200J
Antiarrhythmic Amiodarone,
Lidocaine or Magnesium Sulfate IV
Shock 360J/200J

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 79yo man s/p NSTEMI

What is the rhythm?

What is the management?

Glenlarson, Wikimedia Commons 12

 Ventricular Tachycardia

Rapid and regular

No P waves
Wide QRS complexes

Ksheka, Wikimedia Commons 13

 Ventricular Tachycardia
Monomorphic VT

Ksheka, Wikimedia Commons

Polymorphic VT

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Displaced, Wikimedia Commons
 Ventricular Tachycardia
Assume any wide complex tachycardia is VT
until proven otherwise

SVT with aberrant conduction may also

have wide QRS complexes

Attempt to establish the diagnosis

Ischemia risk and VT go together

15
 Treatment of VT
If pulseless - follow VF algorithm
If stable try anti-arrhythmics
Amiodarone
Lidocaine
Procainamide?
If patient has a pulse, but is
unstable or not responding to
meds Defib/DC-SHOCK

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 Treatment of VT
Anti-arrhythmics are also pro-arrhythmic
One antiarrhythmic may help, more than
one may harm
Anti-arrhythmics can impair an already
impaired heart
Electrical cardioversion should be the
second intervention of choice

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 60yo diabetic man with
chest pain

What is the rhythm?

What is the management?

Knutux, Wikimedia Commons 18

 Normal Sinus Rhythm

Regular rate and rhythm

Normal P waves and QRS
Evaluate for cause of chest pain and monitor
for change in rhythm

Knutux, Wikimedia Commons 19

 40 yo woman found down,
pulseless and apneic

What is the rhythm?

What is the management?

Masur, Wikimedia Commons 20

 Pulseless Electrical Activity
Any organized (or semi-organized)
electrical activity in a patient
without a detectable pulse
Non-perfusing

Treat the patient NOT the monitor

Find and treat the
cause!!!!!

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 PEA and Asystole
Secondary Survey - ABCD

Primary Survey - ABC

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Source unknown
 PEA
Primary Survey

Secondary Survey

Search for and Treat Causes

Epinephrine 1 mg IVP
repeat every 3-5 minutes

Atropine 1 mg IVP
if PEA is slow
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 Find and Treat the Cause

Non-shockable rhythm

The most effective treatment is to find and

fix the underlying problem

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Rama, Wikimedia Commons
 So what causes PEA?
#1 cause of PEA in adults is hypovolemia
#1 cause in children is hypoxia/respiratory
arrest

Other causes?

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 The Hs and Ts
Hypovolemia Toxins
Hypoxia Tamponade
Hydrogen ion (acidosis) Tension pneumothorax
Hyper-/hypokalemia Thrombosis (coronary or
Hypothermia pulmonary)
Hypoglycemia (rare) Trauma

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 Treat the Hs and Ts
Hypovolemia Toxins
Volume IVF, PRBCs Check levels
Hypoxia Charcoal
Oxygenate/Ventilate Antidotes
Hydrogen ion (acidosis) Tamponade
Sodium bicarbonate pericardiocentesis
Hyperventilation Tension pneumothorax
Hyper-/hypokalemia Needle decompression
Sodium bicarbonate Tube thoracostomy
Insulin/glucose Thrombosis (coronary or
Calcium pulmonary)
Hypothermia Thrombolytics
Warm -- invasive OR/cath lab
Hypoglycemia Trauma
Dextrose

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 19yo man with
palpitations

What is the rhythm?

What is the management?

28
Displaced, Wikimedia Commons
 Supraventricular Tachycardia

Rapid (usually 150-250 bpm) and regular

P waves cannot be positively identified
QRS narrow

29
Displaced, Wikimedia Commons
 Treatment of Stable SVT
Consider vagal maneuvers
Carotid sinus massage
Valsalva
Eyeball massage
Ice water to face
Digital rectal exam
Adenosine
6 mg, 12 mg, 12 mg

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 Treatment of Unstable SVT
Electrical Cardioversion
Cardioversion is not defibrillation
Use defibrillator in sync mode
prevents delivering energy in the wrong
part of the cardiac cycle (R on T
phenomenon)

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 Electrical Cardioversion
Energy level somewhat controversial
100 J200J300J360J
Atrial flutter may convert with lower energy
50J
For polymorphic VT start with 200J
The EP guys tend to start with 360J

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 Electrical Cardioversion
Be prepared
Patient on monitor, IV, Oxygen
Suction ready and working
Airway supplies ready
Pre-medicate whenever possible
Conscious sedation
Electrical shocks are painful!

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 Tachycardia
Evaluate Patient

Stable? Unstable?

Lots of options Shock

based on rhythm

Treat the patient NOT the monitor!!!

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 Stable Tachycardias
Narrow complex? Wide complex?
Regular rhythm Uncertain rhythm
Sinus tachycardia assume VT
SVT Narrow complex
AV nodal reentry tachycardia with
aberrancy
Irregular rhythm
Ventricular tachycardia
Atrial fibrillation
Monomorphic or
Atrial flutter polymorphic

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 56 yo woman with shortness of breath and
chest pain

What is the rhythm?

What is the management?

J. Heuser, Wikimedia Commons 36

 Atrial fibrillation/flutter

J. Heuser, Wikimedia Commons

James Heilman, MD, Wikimedia Commons

May be rapid
Irregular (fib) or more regular (flutter)
No P waves, narrow QRS
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 Atrial fibrillation/flutter
Treatment based on patients clinical picture
Unstable = Immediate electrical cardioversion
Stable
Control the rate
Diltiazem
Esmolol (not if EF < 40%)
Digoxin
Provide anticoagulation

Treat the patient NOT the monitor!!!

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 78yo man found down, pulseless and
apneic, unknown duration

What is the rhythm?

What is the management?

D Dinneen, Wikimedia Commons 39

 Asystole

Is it really asystole?
Check lead and cable connections.
Is everything turned on?
Verify asystole in another lead.
Maybe it is really fine v-fib?

D Dinneen, Wikimedia Commons 40

 68 yo woman with h/o hypertension
presents with dizziness

What is the rhythm?

What is the treatment?

Mysid, Wikimedia Commons 41

 Sinus Bradycardia

Slow and regular

Normal P waves and QRS complexes

Mysid, Wikimedia Commons 42

 Bradycardias
Many possible causes
Enhanced parasympathetic tone
Increased ICP.
Hypothyroidism
Hypothermia
Hyperkalemia
Hypoglycemia
Drug therapy

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 Bradycardias
Treat only symptomatic bradycardias
Ask if the bradycardia causing the
symptoms
Recognize the red flag bradycardias
Second degree type II block
Third degree block

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 45
Source unknown
 Transcutaneous pacing
Class I for all symptomatic bradycardias
Always appropriate
Doesnt always work
Technique
Attach pacer pads
Set a rate to 80 bpm
Turn up the juice (amps) until you get
capture
Painful may need sedation / analgesia

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 Transvenous Pacing
Invasive
Time-consuming to establish
Skilled procedure
Better long-term than transcutaneous
May have better capture than transcutaneous
pacing

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 Bradycardia Treatment

Medications
Vagolytic
Atropine
Adrenergic
Epinephrine
Dopamine

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 What if the same patient had this rhythm?

What is the rhythm?

What is the treatment?

Jer5150, Wikimedia Commons 49

 Junctional Escape

Slow and relatively regular

No P waves
Narrow QRS
Arises from site near the junction of the atria and ventricles

Jer5150, Wikimedia Commons 50

 29 yo asymptomatic female

What is the rhythm?

What is the management?

Steven Fruitsmaak, Wikimedia Commons 51

 1 AV block

Regular rate and rhythm

Normal P wave with long PR interval
(>0.2msec/1 big box)
Normal QRS

Steven Fruitsmaak, Wikimedia Commons 52

 58yo asymptomatic woman

What is the rhythm?

What is the management?

Jer5150, Wikimedia Commons 53

 2 AV Block - Type I

aka Wenckebach
Regular rate and rhythm
Normal P waves and QRS complexes
Increasing PR interval until QRS dropped

Jer5150, Wikimedia Commons 54

 80 yo man with syncope

What is the rhythm?

What is the management?

Jer5150, Wikimedia Commons 55

 2 AV Block Mobitz Type II

Regular atrial rate with normal P wave

Consistent PR interval
Random QRS dropped

Jer5150, Wikimedia Commons 56

 Another 80 yo man with syncope

What is the rhythm?

What is the management?

MoodyGroove, Wikimedia Commons 57

 3 AV Block

Normal P waves
Normal QRS
No relationship between P and QRS
aka complete heart block

MoodyGroove, Wikimedia Commons 58

 Know When To Stop
With return of spontaneous circulation
No ROSC during or after 20 minutes of
resuscitative efforts
Possible exceptions include near-drowning,
severe hypothermia, known reversible cause,
some overdoses
DNR orders presented
Obvious signs of irreversible death

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THANK YOU