Arrhythmia Recognition

Cardiac Conduction System ECG Components Electrical and Mechanical Events 1 sec (1000 msec) RIGHT RIGHT VENTRICLE ATRIUM .2 sec .04 sec EJECTION (200 msec) (40 m sec) Paper Speed: 25 mm/sec LEFT LEFT VENTRICLE ATRIUM EJECTION 1 mm PR QT LEFT Interval Interval ATRIUM 5 mm Sinoatrial R Node P T HIS Bundle 1 mV Q R S RIGHT T ATRIUM P J Point U Lef t Bundle Atrioventric ular Branch Node Q S Right Bu ndle QRS Branch LEFT Duration VENTRICLE Vertical Axis Horizontal Axis 1 Small Square = 1 mm (0.1 mV) 1 Small Square = .04 sec (40 msec) RI GHT Mid Atrial Isovolumic Ventricula r Isovo lumic VENTRICLE 1 Large Square = 5 mm (0.5 mV) 1 Large Square = .2 sec (200 msec) Diastole Contraction Ventricular Ejection Ventr icular 2 Large Squares = 1 mV 2 Large Squares = 1 sec (1000 msec) Contraction Relaxation

Sinus Rhythms Supraventricular Rhythms Conduction Defects Normal Sinus Rhythm Premature Atrial Complexes – PACs Atrial Tachycardia Right Bundle Branch Block

P Wave PR Interval QRS Characteristics (in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS Heart Rate Rhythm P Wave PR Interval QRS Before each QRS, 0.12 to 0.20 ≥ 0.12 RSR’ in V1 (in seconds) (in seconds) (in seconds) (in seconds) identical 60 - 100 bpm Regular Before each 0.12 to 0.20 < 0.12 140 - 250 bpm Regular Abnormal P 0.12 to 0.20 < 0.12 QRS, identical Heart Rate Rhythm P Wave PR Interval QRS before each QRS Left Bundle Branch Block (in seconds) (in seconds) N/A Irregular Premature and 0.12 to 0.20 < 0.12 abno rmal. Sinus Arrhythmia May be hidden Atrial Flutter

Premature Atrial Complex – Isolated PAC

P Wave PR Interval QRS Characteristics (in seconds) (in seconds) Before each QRS, 0.12 to 0.20 ≥ 0.12 QS or rS in V1 & V2 identical ST elevation

Heart Rate Rhythm P Wave PR Interval QRS Pre-excitation Syndrome Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) (in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) A:240-350 bpm A: Regular Flutter (F) waves N/A < 0.12 60 - 100 bpm Irregular Before each 0.12 to 0.20 < 0.12 V: Varies with V: Regular usually the ne gative QRS, identical N/A Irregular Premature and 0.12 to 0.20 < 0.12 conduction group beating component of

abnormal. ratio or variable May be hidden in II, III, aVF and positive in V1 Sinus Tachycardia Premature Atrial Complexes (Atrial Bigeminy) Atrial Fibrillation Every other beat is a PAC

P Wave PR Interval QRS Characteristics (in seconds) (in seconds) Before each QRS, < 0.12 Usually > 0.12 Delta wave Heart Rate Rhythm P Wave PR Interval QRS identical distorts initial QRS (in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS > 100 bpm Regular Before each 0.12 to 0.20 < 0.12 (in seconds) (in seconds) First-Degree AV Block QRS, identical A:350-650 bpm Irregular Abs ent N/A < 0.12 V: Slow to rapid Fibrillatory Heart Rate Rhythm P Wave PR Interval QRS (f) waves (in seconds) (in seconds) Sinus Bradycardia N/A Irregular Premature and 0.12 to 0.20 < 0.12 abnormal . Junctional Rhythm May be hidden

Premature Atrial Complex with Aberrancy P Wave PR Interval QRS Characteristics (in seconds) (in seconds) Before each QRS, > 0.20 < 0.12 Regular rhythm identical Heart Rate Rhythm P Wave PR Interval QRS Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) (in seconds) (in seconds) Second-Degree AV Block – Type I > 60 bpm Regular Before each 0.12 to 0.20 < 0.12 40 - 60 bpm Regular Inverted in inferior < 0.12 < 0.12 (AV Wenckebach or Mobitz type I) QRS, identical leads; before, du ring or after the QRS; may be absent Sinus Arrest or SA Block Accelerated Junctional Rhythm

Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) P Wave PR Interval QRS Characteristics N/A Irregular Premature and 0.12 to 0.20 < 0.12 (in seconds) (in seconds) abnormal. Abnormal May be hidden Shape Conduction Increasingly < 0.12 QRS dropped in a intermittent prolonged repeating pattern Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) Heart Rate Rhythm P Wave PR Interval QRS Second-Degree AV Block–Type II 40 - 100 bpm Irregular Identical before 0.12 to 0.20 < 0.12 Nonconducted Premature Atrial Complex (in seconds) (in seconds) each QRS. (Mobitz type II) P to P interval 60 - 100 bpm Usually AV May be sinus < 0.12 < 0.12 dissociation P wave before and after because of (AV dissociation) the pause digitalis toxicity P Wave is buried in the T Wave. NOTE: Notch is not present in other T waves Junctional Tachycardia

P Wave PR Interval QRS Characteristics Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) (in seconds) (in seconds) Sinus Usually normal Broad Some P waves N/A Irregular Premature and None Absent and identical ≥ 0.12 are not conducted abnormal. (before and after a May be hidden blocked impulse)

Second-Degree AV Block – 2 :1 AV Block

Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) Usually Regular Inverted, < 0.12 < 0.12 < 140 bpm Absent or after QRS

P Wave PR Interval QRS Characteristics Normal ECG Standards for Children Age This poster includes Premature Ventricular Conduction, Pacemaker Lead (in seconds) (in seconds) Arrhythmia Recognition (poster 1 of 2) 0 - 1 d 1 - 3 d 3 - 7 d 7 - 30 d 1 - 3 mo 3 - 6 mo 6 - 12 mo 1 - 3 y 3 - 5 y 5 - 8 y 8 - 12 y 12 - 16 y Placement, ST Segment Depression, Ventricular Rhythms, Pacemaker Rhythms, Sinus Normal or Narrow or broad 2:1 AV conduction Heart 94 - 155 91 -158 90 - 166 106 - 182 120 - 179 105 - 185 108 - 169 89 - 152 73 - 137 65 - 133 62 - 130 60 - 120 Full Compensatory Pause and ECG Artifact. The ECG rhythm strips display lead II prolonged This is part one of two posters to assist healthcare professionals in recognizing Rate/Min (122) (122) (128) (149) (149) (141) (131) (119) (109) (100) (91) (80) as the top waveform and lead V1 as the bottom waveform. Classic examples are basic arrhythmias. According to the Practice Standards for Electrocardiographic PR Interval 0.08 - 0.16 0.08 - 0.14 0.07 - 0.15 0.07 - 0.14 0.07 - 0.13 0.07 - 0.15 0.07 - 0.16 0.08 - 0.15 0.08 - 0.16 0.09 - 0.16 0.09 - 0.17 0.09 - 0.18 Monitoring in Hospital Settings (Circulation. 2004;110:2721-2746) in general, the Lead II (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) shown for each rhythm to provide basic visualization and avoid complexities. (seconds) Third Degree (Complete) AV Block mechanisms of arrhythmias are the same in both adults and children. However, The intended use of this poster is to complement a text and /or course – in QRS Interval 0.02 - 0.07 0.02 - 0.07 0.02 - 0.07 0.02 - 0.08 0.02 - 0.08 0.02 - 0.08 0.03 - 0.08 0.03 - 0.08 0.03 - 0.07 0.03 - 0.08 0.04 - 0.09 0.04 - 0.09 Lead V5 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07) addition to a reference guide for arrhythmia recognition such as heart size, baseline heart rate, sinus and AV node function, and (seconds) automatic innervation. All values 2nd – 98th percentile; numbers in parentheses, means. Adapted fromPe diatr Cardiol. 1979;1:123. The most common ECG rate, interval, and duration measurements Are from the following publications: ECG terminology and diagnostic criteria often vary from text to text and from • Clinical Electrocardiography (Post Graduate Institute for Medicine). • Understanding Electrocardiography (Mary Boudreau Conover). (for example: Premature Atrial Contraction, Atrial Premature Complex, Atrial • How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis). Extrasystole, Supraventricular Ectopic Beat, etc.) It is important to correlate the • Principles of Clinical Electrocardiography (M. J. Goldman). ECG interpretation with the clinical observation of the patient. P Wave PR Interval QRS Characteristics • Basic Dysrhythmias Interpretation and Management (Robert Huszar). (in seconds) (in seconds) • An Introduction to Electrocardiography (Leo Shamroth). Normal but not N/A Narrow or broad AV dissociation • Interpretation of Arrhythmias (Emanual Stein). related to QRS

Premature Ventricular Conduction Pacemaker Lead Placement ST Segment Depression Pacing Lead Pacing Lead

v1 v1

J point Atrial Ventricular AV Sequencial Pacing Pacing Pacing Downsloping ST Upsloping ST Horizontal ST The pacing lead is The pacing lead is The pacing lead is The J point occurs at the end of the QRS complex. inserted into the inserted into the inserted into the The ST segment begins at the J point and extends to a user-defned interval. Right Ventricular PVC Left Ventricular PVC atrium to cause ventricle to cause both the atrium and atrial depolarization. ventricular ventricle stimulating depolarization. at set intervals.

Ventricular Rhythms Pacemaker Rhythms

Premature Ventricular Complex - PVC Ventricular Fusion Beat Electronic Pacemaker Spikes Failure to Capture Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) N/A Irregular with N/A N/A ≥ 0.12 PVCs

Unifocal PVCs: Identical shapes

Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) Electrical stimuli delivered by the electronic pacemaker to the N/A N/A Present Same as sinus ≥ 0.12 endocardium are seen as a spike on the surface ECG. rhythm or shorter The pacemaker generates a pacemaker spike but does not cause an intrinsic beat (P wave or QRS). Ventricular Escape Beat Ventricular Pacemaker (single chamber) Failure to Sense

Multifocal PVCs: More than one shape

Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) Single spike producing a wide QRS complex < 40 bpm Irregular Absent Absent ≥ 0.12 (ventricular capture). Idioventricular Rhythm Atrial Pacemaker (single chamber) The pacemaker does not recognize the intrinsic beats and generates an unnecessary pacemaker spike.

Failure to Fire Paired PVCs (Couplet) Single spike producing paced P wave (atrial capture) followed by an intrinsic QRS complex. Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) 20 - 40 bpm Regular Absent or not related N/A ≥ 0.12 AV Sequential Pacemaker (dual chamber)

Accelerated Idioventricular Rhythm (AIVR)

The pacemaker does not generate a pacemaker spike when it is needed. R on T Phenomenon: PVC occurs at the peak of the of T wave of the preceding beat First spike followed by a paced P wave (atrial capture) followed by a second spike producing a wide QRS complex (ventricular capture). ECG Artifact Paced Fusion Beat Any waveform on the ECG that is not related to the patient’s cardiac events

Heart Rate Rhythm P Wave PR Interval QRS Calibration Pulses (in seconds) (in seconds) 40 - 100 bpm Regular Absent, not related N/A ≥ 0.12 Ventricular Bigeminy: Every other beat is a PVC or retrograde conduction

Ventricular Tachycardia (3 or more consecutive ventricular complexes) The electronic pacemaker and the patient’s own cardiac rhythm occurs simultaneously producing a combination Deliberate artifact caused to show the interpreter the of a paced beat and an intrinsic beat. relationship of the complexes with a known electrical stimulus (standardization procedure).

AC Interference (6 0 cycle) Full Compensatory Pause vs. Noncompensatory Pause

Ventricular Trigeminy: Every third beat is a PVC

Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) > 100 bpm Regular Absent, not related N/A ≥ 0.12 or retrograde conduction 1:1. 1:2, Sixty even, regular spikes in a one-second interval or VA Wencheback caused by electrical current near the patient.

Ventricular Fibrillation Muscle Tremor (Somatic)

Full Compensatory Pause Ventricular Quadrigeminy: Every fourth beat is a PVC Heart Rate Rhythm P Wave PR Interval QRS (in seconds) (in seconds) 300 - 600 bpm Extremely Absent Absent Absent irregular

Ventricular Asystole Noncompensatory Pause Electrical interference caused by the patient’s tensed muscles. To measure a Full Compensatory Pause: Wandering Baseline (Draft)

Heart Rate Rhythm P Wave PR Interval QRS preceding the premature complex. (in seconds) (in seconds) 3. The third mark should fall exactly on the P wave following Absent Absent Absent or present Absent Absent the premature complex to be called a compensatory pause.

Normal ECG Standards for Children Age Arrhythmia Recognition (poster 2 of 2) 0 - 1 d 1 - 3 d 3 - 7 d 7 - 30 d 1 - 3 mo 3 - 6 mo 6 - 12 mo 1 - 3 y 3 - 5 y 5 - 8 y 8 - 12 y 12 - 16 y The most common ECG rate, interval, and duration measurements Heart 94 - 155 91 -158 90 - 166 106 - 182 120 - 179 105 - 185 108 - 169 89 - 152 73 - 137 65 - 133 62 - 130 60 - 120 are from the following publications: This is part two of two posters to assist healthcare professionals in Rate/Min (122) (122) (128) (149) (149) (141) (131) (119) (109) (100) (91) (80) • Clinical Electrocardiography (Post Graduate Institute for Medicine). recognizing basic arrhythmias. According to the Practice Standards for PR Interval 0.08 - 0.16 0.08 - 0.14 0.07 - 0.15 0.07 - 0.14 0.07 - 0.13 0.07 - 0.15 0.07 - 0.16 0.08 - 0.15 0.08 - 0.16 0.09 - 0.16 0.09 - 0.17 0.09 - 0.18 Electrocardiographic Monitoring in Hospital Settings (Circulation. Lead II (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) • Understanding Electrocardiography (Mary Boudreau Conover). (seconds) 2004;110;2721-2746) in general, the mechanisms of arrhythmias are the QRS Interval 0.02 - 0.07 0.02 - 0.07 0.02 - 0.07 0.02 - 0.08 0.02 - 0.08 0.02 - 0.08 0.03 - 0.08 0.03 - 0.08 0.03 - 0.07 0.03 - 0.08 0.04 - 0.09 0.04 - 0.09 • How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis). Lead V same in both adults and children. However, the ECG appearance of the 5 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07) • Principles of Clinical Electrocardiography (M. J. Goldman). (seconds) An undulating baseline • Basic Dysrhythmias Interpretation and Management (Robert Huszar). baseline heart rate, sinus and AV node function, and automatic All values 2nd – 98th percentile; numbers in parentheses, means. Adapted fromPe diatr Cardiol. 1979;1:123. with waveform present. Innervation. • An Introduction to Electrocardiography (Leo Shamroth). This poster includes Premature Ventricular Conduction, Pacemaker Lead Placement, ST Segment • Interpretation of Arrhythmias (Emanual Stein). ECG terminology and diagnostic criteria often vary from text to text and Depression, Ventricular Rhythms, Pacemaker Rhythms, Full Compensatory Pause and ECG Artifact. from one teacher to another. There are often several terms describing The ECG rhythm Strips display lead II as the top waveform and lead V1 as the bottom waveform. Classic examples are shown for each rhythm to provide basic visualization and avoid complexities. Premature Complex, Atrial Extrasystole, Supraventricular Ectopic Beat, The intended use of this poster is to complement a text and/or course – in addition to a reference etc.) It is important to correlate the ECG interpretation with the clinical guide for arrhythmia recognition observation of the patient.