Dr.Binoy Skaria 13/07/15

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1 Dr.Binoy Skaria 13/07/15

2 Acknowledgement Medtronic, Google images & Elsevier for slides Natalie Ryan, Events Manager, HEFT- for organising the event and inviting me to speak

3 30 minutes followed by discussion Basics of ECG Common ECGs/ rhythm strips & their basis Some common & less common conditions

4 Cardiac Conduction: Cycle Initiation

5 P Wave

6 AV Node

7 Bundle Branches

8 Purkinje Fibers

9 QRS Complex

10 Plateau Phase

11 T-Wave

12 ECG Complex

13 Rate P-P Regularity R-R Regularity Less than 60bpm Regular Regular P wave P:QRS Ratio 1:1 Present PR Interval QRS Width Normal Normal

14 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Greater than 100bpm, Gradual onset Regular Regular Present 1:1, associated Normal, gradually shortens with HR increase Normal

15 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width bpm Irregular Irregular Present 1:1, associated Normal Normal

16 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Varies Irregular Irregular Present, except during pause 1:1, associated Normal Normal

17 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width bpm, Sudden onset Regular Regular Morphology will differ from sinus p-wave 1:1, associated Interval of ectopic focus will differ from sinus PR Normal, but can develop aberrant (wide) complexes

18 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Greater than 100bpm Irregularly irregular Irregularly irregular At least 3 different p-wave morphologies 1:1, associated Varies Normal

19

20 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Varies Chaotic atrial activity Irregularly irregular Usually No discernable p-waves None None Normal, but can develop aberrant (wide) complexes

21 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width 40-60bpm None, or Regular if antegrade or retrograde Regular Variable (none, antegrade, or retrograde) None, or 1:1 if antegrade or retrograde None, short, or retrograde Normal

22 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width 20-40bpm None Regular None None None Wide complex (>/= 0.12sec).

23 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width bpm Variable Regular Dissociated atrial rate Variable None Wide complex (>/= 0.12sec).

24 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Depends on underlying rhythm Regular Regular Present, Normal 1:1, associated Prolonged, > 0.20sec Normal

25 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Depends on underlying rhythm Regular Regularly irregular Present Variable; 2:1, 3:2, 4:3, etc Variable, gradually lengthens until dropped Normal

26 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Depends on underlying rhythm Regular Regularly irregular Present Variable; 2:1, 3:2, 4:3, etc Normal for conducted beats Normal

27 Atrial Rate Ventricular Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Atrial rate is the underlying rhythm (i.e, Sinus, Atrial Fib, etc.) Ventricular rate is from the dissociated escape rhythm Regular Regular Present Variable, dissociated Variable, No pattern Normal (Junctional escape rhythm) Wide (Ventricular escape rhythm)

28 Rate P-P Regularity R-R Regularity P wave P:QRS Ratio PR Interval QRS Width Depends on the underlying Atrial Fibrillation, Ventricular rate can be fast or slow. Chaotic atrial activity Irregularly irregular Usually absent None None Wide (>0.12ms)

29 Identify the Rhythm: A. Ventricular Tachycardia B. Sinus Bradycardia C. Complete Heart Block D. Atrial Fibrillation E. Ventricular Fibrillation

30 Identify the rhythm A. Ventricular Tachycardia B. Sinus Bradycardia C. Complete Heart Block D. Atrial Fibrillation E. Ventricular Fibrillation

31 Identify the Rhythm: A. Ventricular Tachycardia B. Sinus Bradycardia C. Complete Heart Block D. Atrial Fibrillation E. Ventricular Fibrillation

32 Identify the Rhythm: A. Ventricular Tachycardia B. Sinus Bradycardia C. Complete Heart Block D. Atrial Fibrillation E. Ventricular Fibrillation

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42 Micro re-entry : AVNRT

43

44 Macro re-entry : Type 1 flutter

45

46 WPW- macro re- entrant

47 Concealed WPW

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54 Polymorphic VT

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56 Arrhythmia in LQTS

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