THE ECG:

RECOGNIZING CARDIAC
ARRHYTHMIAS

OOI PHAIK MUI

22 APRIL 2016
 To interpret an ECG:
a. Determine the rate of QRS activity
b. Determine the pattern of the rhythm
(regular, irregular etc.)
c. Measure the width of the QRS
d. Determine atrial activity and relationship
of P's to QRS's
e. Measure PR interval
f. You are now ready for an overall
interpretation of the rhythm strip
PMOOI 2010 2
Cardiac Conduction

PMOOI 2010 3
 Classification of Arrhythmias

Sinus rhythm
and its variants

Atrial Arrhythmias

AV block
Junctional
Arrhythmias

Ventricular
Arrhythmias

PMOOI 2010 4
 Sinus rhythm
and its variants

PMOOI 2010 5
 Sinus Rhythm
Heart Rate 60 - 100 / min
Rhythm Regular
P Present
PR interval 0.12 – 0.20 sec
P:QRS 1:1
PMOOI 2010 6
 Sinus bradycardia
Heart Rate <60 / min
Rhythm Regular
P Present
PR interval 0.12 – 0.20 sec
P:QRS 1:1
PMOOI 2010 7
 Atrial
Arrhythmias

PMOOI 2010 8
 Sinus Tachycardia
Heart Rate 100 - 150 / min
Rhythm Regular
P Present
PR interval 0.12 – 0.20 sec
P:QRS 1:1
PMOOI 2010 9
 Sinus Arrhythmia
Heart Rate Varies; ↑ with respiration & ↓
with expiration
Rhythm Irregular
P Present
PR interval 0.12 – 0.20 sec
P:QRS 1:1
PMOOI 2010 10
 Premature atrial contractions (PAC's)
Heart Rate Depends on underlying rate
Rhythm Irregular when PAC
P Present & different shape in PAC
PR interval Normal & varies in PAC
P:QRS 1:1
PMOOI 2010 11
Premature junctional contractions (PJC's)
Heart Rate Depends on underlying rate
Rhythm Irregular when PJC
P Present & absent / inverted in PJC
PR interval Normal & none in PJC
P:QRS 1:1
PMOOI 2010 12
 Atrial Tachycardia
Heart Rate 150-250/min
Rhythm Regular
P Superimposed P and T
PR interval
P:QRS 1:1

PMOOI 2010 13
 Atrial Flutter
Heart Rate Atrial 250 – 350 / min
Rhythm regular
P Absent; Flutter wave (Sawtooth appearance)
PR interval Not measurable
P:QRS Not every P wave conducted thru AV
junction; ventricular rate slower
i.e. 2 P : 1 QRS or 3:1 or 4:1

PMOOI 2010 14
PMOOI 2010 15
 Atrial Fibrillation
Heart Rate Atrial > 350 / min
Ventricular varies
Rhythm Irregularly Irregular
P None; Fibrillating wave
PR interval none
P:QRS No relationship between P:QRS
R to R intervals irregular

PMOOI 2010 16
Junctional
Arrhythmias

PMOOI 2010 17
If the ectopic focus is high up in the AV
node, the depolarization wave reaches
the atria before the ventricles and atrial
activation precedes ventricular
activation. As a result, the P wave is in
front of the QRS complex.

PMOOI 2010 18
 Pacemaker @ center
& travel equally but
conduction down the
His bundle and
bundle branch is
very fast, so the P
wave is buried within
PMOOI 2010
the QRS complex 19
If the ectopic focus is
low down in the AV
node, ventricular
activation precedes
atrial activation and
the P wave follows the
QRS complex.
PMOOI 2010 20
 Junctional Bradycardia
Heart Rate < 40/min
Rhythm Regular
P Absent, inverted or P after QRS
PR interval Not applicable
P:QRS No relationship

PMOOI 2010 21
 Junctional Rhythm
Heart Rate 40 – 60 / min
Rhythm Regular
P Absent, inverted or P after QRS
PR interval Not applicable
P:QRS No relationship

PMOOI 2010 22
 Accelerated Junctional Rhythm
Heart Rate > 60 - 100
Rhythm Regular
P Absent, inverted or P after QRS
PR interval Not applicable
P:QRS No relationship

PMOOI 2010 23
 Junctional Tachycardia
Heart Rate 100 - 150 /min
Rhythm Regular
P Absent, inverted or P after QRS
PR interval Not applicable
P:QRS No relationship

PMOOI 2010 24
Ventricular
Arrhythmias

PMOOI 2010 25
 Premature Ventricular Contraction (PVC)
Heart Rate Varies with underlying rhythm
Rhythm Irregular
P Present expect PVC
PR interval 0.12 – 0.20 sec except PVC
P:QRS 1:1 except PVC

PMOOI 2010 26
PMOOI 2010 27
 Couplet PVC

Short run of VT / non sustain VT

PMOOI 2010 28
 Idioventricular rhythm
Heart Rate 20 - 40 bpm
Rhythm Regular
P Absence
PR interval None
P:QRS None

PMOOI 2010 29
 Accelerated Idioventricular rhythm
Heart Rate 50 - 100 bpm
Rhythm Regular
P Absence
PR interval None
P:QRS None

PMOOI 2010 30
Ventricular Tachycardia
Rate 100 – 250 / bpm
Rhythm Regular
P May present &
swamped by the wide
QRS
PR AV dissociation
QRS > 0.12 sec; broad &
bizarre
PMOOI 2010 31
 Torsade De Pointes
Heart Rate 200 - 250 / bpm
Rhythm Regular @ slightly irregular
P AV Dissociation
PR interval None
QRS > 0.12 sec; wide & bizarre. QRS
constantly changing & twisting.
P:QRS AV Dissociation
PMOOI 2010 32
 Coarse VF

Ventricular Fibrillation
Rate too rapid and
unable to count
Rhythm Irregular; Chaotic
baseline
P, PR & None
QRS

PMOOI 2010 Fine VF 33

Natural history of VF

34
Agonal Rhythm

Asystole

PMOOI 2010 35
 AV block

PMOOI 2010 36
 First Degree Heart Block
Heart Rate 60 – 100/ min
Rhythm Regular
P Present
PR interval > 0.20 sec (delay in conduction at
the AV node or the bundle of His.)
P:QRS 1:1
PMOOI 2010 37
 ↓

Second Degree HB – Type 1 (Wenkebach)

Heart Rate Atrial 60 – 100; Ventricular slower
Rhythm Regularly irregular
P Present
PR interval Progressive lengthening of PR
interval until a dropped beat (QRS)
QRS ≤ 0.12 sec
PMOOI 2010 38
 Second Degree HB – Type 2
Heart Rate Atrial 60 – 100 / min
Ventricular slower
Rhythm Irregular
P Present
PR interval 0.12 – 0.20 sec except dropped beat
QRS ≤ 0.12 sec / broad
PMOOI 2010 39
 Third Degree HB (CHB)
Heart Rate Atrial 60 – 100 / min
Ventricular varies (20 – 60 / min)
Rhythm Irregular
P Present
PR interval Not measureable. AV Dissociation
QRS ≤ 0.12 sec / broad
P:QRS AV dissociation
PMOOI 2010 40
PMOOI 2010 41
 Paced Rhythm
Ventricular
Paced Rhythm

Atrial Paced
Rhythm

Duel chamber
Paced Rhythm
PMOOI 2010 42
 Artifact

Electrical Interference

Muscle Artifact

Loose Leads

Wandering Baseline

PMOOI 2010 43
 Following will help to
diagnose arrhythmia

1. Determine the rate

2. Determine the pattern of the rhythm
(regular, irregular etc.)
3. Are P waves present?
4. Measure PR interval
5. Determine relationship of P's to QRS's

PMOOI 2010 44
Recognition
of ECG

45
 ECG analysis
Three simple questions:
(1) Is there a normal looking QRS complex ?

(2) Is there a P wave ?

(3) What is the relationship between the P wave

and QRS complexes ?

46
SINUS RHYTHM

47
SINUS BRADYCARDIA

48
SINUS TACHYCARDIA
49
ATRIAL FLUTTER

50
ATRIAL FIBRILLATION

51
ATRIAL FIBRILLATION

52
PAROXYSMAL ATRIAL
TACHYCARDIA
53
PAROXYSMAL ATRIAL
TACHYCARDIA

54
JUNCTIONAL TACHYCARDIA

55
JUNCTIONAL RHYTHM
56
JUNCTIONAL RHYTHM
I

57
JUNCTIONAL RHYTHM
58
JUNCTIONAL TACHYCARDIA
59
1ST DEGREE A-V BLOCK

60
2ND DEGREE A-V BLOCK- TYPE I
61
2ND DEGREE A-V BLOCK- TYPE II

62
2ND DEGREE A-V BLOCK- TYPE II
63
2ND DEGREE A-V BLOCK- TYPE II
64
3RD DEGREE A-V BLOCK (CHB)
65
3RD DEGREE A-V BLOCK (CHB)
66
IDIOVENTRICULAR RHYTHM
67
 ACCELAERATED
IDIOVENTRICULAR RHYTHM
68
VENTRICULAR FIBRILLATION
69
VENTRICULAR FIBRILLATION
70
VENTRICULAR FIBRILLATION (FINE)

71
ASYSTOLE
72
TORSADE DE POINTES
73
TORSADE DE POINTES
74
AGONAL RHYTHM
75
NSR + UNIFOCAL PVCs
76
NSR + UNIFOCAL PVCs
77
NSR + COUPLETS (UNIFOCAL) PVCs

78
NSR + UNIFOCAL PVCs (BIGEMINY)
79
NSR + MULTIFOCAL PVCs
80
NSR + MULTIFOCAL PVCs
81
NSR + UNIFOCAL PVCs
(QUADRIGEMINY)
82
NSR + TRIPLETS PVCs (SALVOS)
83
NSR + COUPLETS + SHORT RUN
OF VT
84
VENTRICULAR TACHYCARDIA
(SUSTAINED VT)
85
VENTRICULAR TACHYCARDIA
(SUSTAINED VT)
86
NSR + PACs
87
NSR + PJCs
88
NSR + PJCs
89
VENTRICULAR PACED RHYTHM
90
NON CAPTURED PACING
91
ARTIFACT (AC LINE INTERFERENCE)

92
ARTIFACT (MUSCULAR TREMORS)

93
ARTIFACT (DUE TO LOOSE LEADS)

94
Each student to answer 2 ECG strips

IDIOVENT.

VT
95
PAT (SVT)

JT

96
 NSR + UNIFOCAL
PVCs

NSR + PJCs

97
NSR + MULTIFOCAL PVCs

VF
98
T. D. P

ARTIFACT
99
BIGEMINY PVCs

VF
100
 VT

V. PACED RHYTHM
101
NSR + PACs

2ND DEG. II
102
NSR + PJCs

VF
103
2ND DEG. H/B II

NSR + PJCs
104
 1ST DEG H/B

ATRIAL FLUTTER
105
SLOW AF

SVT - JT
106
S.TACHY

SVT
107
 ASYSTOLE

TRIGEMINY PVCs
108
CHB

SVT
109
 IDIOVENT.

2ND DEG. H/B II

110
S.BRADY +PACs

AF

111
NON SUSTAINED VT – NSR+UNIF. PVCs-
SUSTAINED VT

112
NSR+UNIFO. PVCs

113
ASYSTOLE

NSR
114
 1ST DEG. H/B

BIGEMINY PVCs
115
NSR + UNIFO. PVCs (TRIGEMINY)

ARTIFACT
116
 NSR

ATRIAL FLUTTER
117
AF

CHB
118
1ST DEG. H/B

S.TACHY
119
 2ND DEG.H/B I
2ND DEG H/B II + MULTIFOCAL PVCs

120
2ND DEG. H/B
BIGEMINY PACs

121
R ON T

J. TACHY 122
 AF

NSR+COUPLETS
123
SHORT RUN OF VT > NSR+UNIFO. PVCs > SUSTAINED VT

124
 S.BRADY

JUNCTIONAL RHYTHM
125
NSR + PACs
NSR + PJCs

126
2ND Deg. H/B I

NSR + PJCs
127
S. RHYTHM

CHB
128
S. BRADY

VF
129
PAT

PAT
130
NSR + UNIFO. PVCs

ARTIFACT (AC LINE INTERFERENCE)

131
NSR + PACs

NSR + PJC
132
Recognition of ECG

Ms. Tan Ah Hong SRN, PJM.

Penang CPR Society

133
SINUS RHYTHM

134
 ECG analysis
Three simple questions:
(1) Is there a normal looking QRS complex ?

(2) Is there a P wave ?

(3) What is the relationship between the P wave

and QRS complexes ?

135
SINUS BRADYCARDIA

136
SINUS TACHYCARDIA

137
ATRIAL FLUTTER

138
ATRIAL FIBRILLATION

139
ATRIAL FIBRILLATION

140
PAROXYSMAL ATRIAL
TACHYCARDIA
141
PAROXYSMAL ATRIAL
TACHYCARDIA
142
JUNCTIONAL TACHYCARDIA

143
JUNCTIONAL RHYTHM
144
JUNCTIONAL RHYTHM
I

145
SINUS RHYTHM TO JUNCTIONAL
RHYTHM
146
JUNCTIONAL RHYTHM
147
JUNCTIONAL TACHYCARDIA
148
1ST DEGREE A-V BLOCK

149
2ND DEGREE A-V BLOCK- TYPE I
150
2ND DEGREE A-V BLOCK- TYPE II
151
2ND DEGREE A-V BLOCK- TYPE II
152
2ND DEGREE A-V BLOCK- TYPE II
153
3RD DEGREE A-V BLOCK (CHB)
154
3RD DEGREE A-V BLOCK (CHB)
155
IDIOVENTRICULAR RHYTHM
156
 ACCELAERATED
IDIOVENTRICULAR RHYTHM
157
VENTRICULAR FIBRILLATION
158
VENTRICULAR FIBRILLATION
159
VENTRICULAR FIBRILLATION (FINE)

160
ASYSTOLE
161
 VENTRICULAR FIBRILLATION

SINUS > R ON T >VF

VF – DEFIBRILLATE- NSR

162
Natural history of VF

163
TORSADE DE POINTES
164
TORSADE DE POINTES
165
TORSADE DE POINTES
166
AGONAL RHYTHM
167
NSR + UNIFOCAL PVCs
168
NSR + UNIFOCAL PVCs
169
NSR + COUPLETS (UNIFOCAL) PVCs

170
NSR + UNIFOCAL PVCs (BIGEMINY)
171
NSR + MULTIFOCAL PVCs
172
NSR + MULTIFOCAL PVCs
173
NSR + UNIFOCAL PVCs
(QUADRIGEMINY)
174
NSR + TRIPLETS PVCs (SALVOS)
175
NSR + COUPLETS + SHORT RUN
OF VT
176
VENTRICULAR TACHYCARDIA
(SUSTAINED VT)
177
VENTRICULAR TACHYCARDIA
(SUSTAINED VT)

178
NSR + PACs
179
NSR + PJCs
180
NSR + PJCs
181
VENTRICULAR PACED RHYTHM
182
NON CAPTURED PACING
183
ARTIFACT (AC LINE INTERFERENCE)

184
ARTIFACT (MUSCULAR TREMORS)

185
ARTIFACT (DUE TO LOOSE LEADS)

186
ARTIFACT (BIOTELEMETRY)

187
188
Cycle Artifact

189
Wandering Baseline Artifact

190
Muscle Tremor Artifact

191
Each student to answer 2 ECG strips

IDIOVENT.

VT
192
PAT (SVT)

JT

193
 NSR + UNIFOCAL
PVCs

NSR + PJCs

194
NSR + MULTIFOCAL PVCs

VF
195
T. D. P

ARTIFACT
196
BIGEMINY PVCs

VF
197
 VT

V. PACED RHYTHM
198
NSR + PACs

2ND DEG. II
199
NSR + PJCs

VF
200
2ND DEG. H/B II

NSR + PJCs
201
 1ST DEG H/B

ATRIAL FLUTTER
202
SLOW AF

SVT - JT
203
S.TACHY

SVT
204
 ASYSTOLE

TRIGEMINY PVCs
205
CHB

AT 206
 IDIOVENT.

2ND DEG. H/B II

207
S.BRADY +PACs

AF

208
NON SUSTAINED VT – NSR+UNIF. PVCs-
SUSTAINED VT

209
NSR+UNIFO. PVCs

210
ASYSTOLE

NSR
211
 1ST DEG. H/B

BIGEMINY PVCs
212
NSR + UNIFO. PVCs (TRIGEMINY)

ARTIFACT
213
 NSR

ATRIAL FLUTTER
214
AF

CHB
215
1ST DEG. H/B

S.TACHY
216
 2ND DEG.H/B I
2ND DEG H/B II + MULTIFOCAL PVCs

217
2ND DEG. H/B
BIGEMINY PACs

218
R ON T

J. TACHY 219
 AF

NSR+COUPLETS
220
SHORT RUN OF VT > NSR+UNIFO. PVCs > SUSTAINED VT

221
 S.BRADY

JUNCTIONAL RHYTHM
222
NSR + PACs
NSR + PJCs

223
2ND Deg. H/B I

NSR + PJCs
224
S. RHYTHM

CHB
225
S. BRADY

VF
226
PAT

PAT
227
NSR + UNIFO. PVCs

ARTIFACT (AC LINE INTERFERENCE)

228
NSR + PACs

NSR + PJC
229
PMOOI 2010 230
PMOOI 2010 231
232
PMOOI 2010 233
234
If the ectopic focus is high up in the AV
node, the depolarization wave reaches
the atria before the ventricles and atrial
activation precedes ventricular
activation. As a result, the P wave is in
front of the QRS complex.

PMOOI 2010 235

 Pacemaker @ center
& travel equally but
conduction down the
His bundle and
bundle branch is
very fast, so the P
wave is buried within
PMOOI 2010
the QRS complex 236
If the ectopic focus is
low down in the AV
node, ventricular
activation precedes
atrial activation and
the P wave follows the
QRS complex.
PMOOI 2010 237
 Pacemaker @ center &
travel equally but
conduction down the His
bundle and bundle branch is
very fast) and the P wave is
buried within the QRS
PMOOI 2010
complex 238