Transcript Document

I.Sinus Rhythms and Sinus
Arrhythmias

1.ECG of Sinus Rhythms
Sinus rhythm must originate in the sino-atrial
node.
1).Regularly recurring sequences of P waves,
QRS complexes,and T waves.P-P or R-R
interval establishes a specific interval which
should not vary more than 0.12 second.
I.Sinus Rhythms and Sinus
Arrhythmias

2).The P wave is upward in lead I,II, avF,V4-5
and downward in lead avR.
3).The PR interval>0.12 second.
4).Heart rate between 60 and 100 rates per
minute.
I.Sinus Rhythms and Sinus
Arrhythmias

2. Sinus Tachycardia
1). 1).2).and 3)
2).Heart rate exceeding 100 per minute .

Factors associated with Sinus Tachycardia:
Physiologic
Exercise
Strong emotion
Pain
Anxiety states
I.Sinus Rhythms and Sinus
Arrhythmias

Pathologic
Fever
Hyperthyroidism
Hemorrhage
Shock
Anemia
Infection
Congestive heart failure
Myocarditis
Hypoxia
I.Sinus Rhythms and Sinus
Arrhythmias
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Other factors
Drugs
Epinephrine
Atropine
Food,etc
Tea coffee
Alcohol
Tobacco
I.Sinus Rhythms and Sinus
Arrhythmias
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3.Sinus Bradycardia
1).1),2) and 3).
2).Heart rate is less than 60 per minute.
I. Sinus Rhythms and Sinus
Arrhythmias


Common causes
Physiologic bradycardia
Laborers and trained athletes
Emotional states leading to syncope
Carotid sinus pressure, eyeball
pressure,intracranial pressure
Sleep
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Pathologic
Systemic disease
Obstructive jaundice
Obstructive diseases of the intestine,kidney or
bladder
During convalescence after some diseases marked by
fever(e.g.influenza)
myxedema
myocardial infarction(inferior wall or atrial infarction)
high intracranial pressure
I.Sinus Rhythms and Sinus
Arrhythmias

Drug
Digitalis
Morphine
Quinidine
Propranolol
I.Sinus Rhythms and Sinus
Arrhythmias
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4.sinus arrhythmia
(1) 1) .2) .3)and 4)
(2) P-P or R-R interval varies in duration by
at least 0.12 second
I.Sinus Rhythms and Sinus
Arrhythmias

Common Causes
Active rheumatic fever
Infectious diseases
Atelectasis
Chronic adhesive pleuritis
Intracranial tension
Digitalization
Autonomic nerve (It is normal in children
and young adults.)
I.Sinus Rhythms and Sinus
Arrhythmias

Note:
It varies with the phases of respiration,the
Sinus rate increasing with inspiration and
decreasing with expiration.
I.Sinus Rhythms and Sinus
Arrhythmias

5.Sinus arrest
There is no sinus P wave in ECG
suddenly.The long interval is not times of P-P
interval.
II.Premature beat

The terms “premature beat”,”premature
contraction”,”premature systole”,or
“extrasystole” indicate that the atria ,AV
junction, or ventricle are stimulated
prematurely.
II.Premature beat

These premature beats are called “atrial
premature beats”when they arise in some
portion of the atria .AV junctional premature
beats arise in the AV junction. Ventricular
premature beats arise in one of the branches
of the bundle of His ,the Purkinje network ,or
the ventricular muscle.
II.Premature beat

1. Ventricular premature beats
1).The QRS complex is premature ,is
0.12second or more wide ,and is
aberrant,notched ,or slurred .It is associated
with a T wave that usually point in a direction
opposite to the main deflection of the QRS
complex.
2).The premature QRS complex is not
preceded by a P wave.
II.Premature beat

3).A ventricular premature beat is often
followed by a fully compensatory pause(the
sum of the R-R intervals including the prepremature beat and the post-premature beat
interval equals the sum of two normal R-R
intervals)
4).Multiply, ventricular premature beats that
arise from a single focus show a similar shape
and usually a similar coupling intervals
(distance from the preceding normal QRS
complex to the premature ventricular beat) in
any one lead.
II.Premature beat


5).occasionally, a ventricular premature beat
will occur simultaneously with the apex of the
preceding T wave,This is R on T
phenomenon.
When this occurs ,it may be a precursor of a
ventricular tachycardia.
Note: multifocal ventricular prematyre
beat (VPB) and multiformed VPB
II.Premature beat

2.Atrial premature beats
1).A premature P wave is present .It may be
surperimposed on the preceding T wave because it is
premature.The premature P wave is usually followed
by a QRS complex and a T wave.Occasionally, it is
not followed by a QRS complex and a T
wave .(blocked atrial premature beat).
2).The QRS and T waves that follow the premature
P waves usually resemble the other QRS and T waves
in the lead.
II.Premature beat

3).The P-R interval of the atrial premature beat is
usually longer than the normal PR intervals in the
ECG.
4).An atrial premature beat is often followed by a
noncompensatory pause.
5).The ventricular complex is usually normal but may
be aberrant in from if the premature atrial beat
coincides with the refractory phase of the previous
ventricular beat .The aberrant QRS is called aberrant
conduction.
II.Premature beat
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3. AV Junctional premature beats
1).A premature AV junction P wave is followed by a
QRS and T wave.
2).The AV junction P waves in aVR become
upward .The P waves in II,III, and aVF is
downward.The PR interval is usually less than
0.12second ,if the P waves is before the QRS
complexes. The P waves may appear after the QRS
complexes or may be hidden within the QRS complex.
3).An AV junctional premature beat is followed by a
fully compensatory.
Ⅲ.Ectopic tachycadia

It is more common to paroxysmal tachycardia.
The paroxysmal tachycardia can be divided
into two main groups.
① Paroxysmal Supraventricular tachycardia
② Paroxysmal ventricular tachycardia
Ⅲ.Ectopic tachycadia

1.paroxymal supraventricular tachycardia
ECG
1).Heart rate is regular rhythm with a rate o f
160-250/minute.
2).The QRS complex in form is usually
normal.
3).The P wave in not easy to see.
4).With abrupt onset and abrupt terminal.
Ⅲ.Ectopic tachycadia

2. paroxysmal ventricular tachycardia
1).The QRS complex are 0.12 second or more
wide ,are aberrant ,and are followed by aberrant ST
segments and T waves.
2) Ventricular rate is between 140 and 200/minute
and regular rhythm or slightly irregular.
3).The P waves have no relation to the QRS
complexes.
4).Fusion beats or ventricular capture are present.
5).Sometimes, P-P interval >R-R interval.but the P-R
is no relation.
Ⅳ.Flutter and Fibrillation

The flutter and fibrillation arise from excitable
ectoptic focus in the atria and ventricle and
with a rapid rate and appropriate conduction
block. Thus ,They are easily caused by a
reentry.
Ⅳ.Flutter and Fibrillation

1. Atrial Flutter
ECG:
1).There are no P waves in ECG
2).Presence of saw-tooth flutter wave.
3).F waves always uniform in size ,shape and
frequency.
4).Regular atrial rhythm with a rate of 250-350
5).Ventricular response of 1:1,2:1,3:1,4:1,or higher.
6).Absence of isoelectric line.
Ⅳ.Flutter and Fibrillation

2. Atrial Fibrillation
ECG:
1).Absence of P waves
2).P waves replaced by f waves.
3).f waves : irregular in size ,shape ,and
spacing.
Rate between 350 and 600
4). Irregularly irregular ventricular rhythm,
best seen in Ⅱ,Ⅲ,Avf,V1 or V2.
Ⅴ.Atrio –ventricular block(AVB)

AV block, or heart block, exists when
conduction of the stimulus from the atria to
the ventricle through the AV node is slowed
or blocked.The AV block may be
transient ,intermittent ,or permanent .It may
be incomplete or complete. A patient may
show various types of AV block in one ECG.
AVB
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1. First degree heart block(Ⅰ゜AVB)
I゜AVB is prolongation of the atrio-ventricular
conduction time and is also referred to as first degree
A-V block.
ECG:prolonged P-R interval:longer than 0.20sec in
adults and >0.22s in old adults.
The difference of P-R interval between two times is
more than 0.04 second.
Note:P-R interval varies with heart rate and age.
AVB
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2.II゜AVB (second degree heart block)
1).Mobitz Type I(Wenckeback phenomenon)
(1)The P-R interval becomes longer and
longer
(2)The R-R interval gets shorter and shorter,
until there is a blocked or nonconducted
ventricular beat with a long pause, then an
escape rhythm or beat resumes.
AVB
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2).II゜II type(mobity type II AV block)
Mobity II is characterized by failure of conduction of
one or more sinus beats to the ventricle .There is a
fixed numerical relationship between atrial and
ventricular impulses,which may be 2:1 or 3:1 or
4:1 .Mobitz II blocks become progressive worse until
a complete heart block is established.Thus ,mobitz
Type II require a pacemaker,whereas mobitz I does
not require a pacemaker,since it does not progress to
complete heart block.
AVB
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3.III゜AVB(Complete heart block)
(Third degree A-V Block)
ECG:
1).The atrial and the ventricular rhythms are absolutely
independent of one another .
2).There is no P-R to QRS relationship.
3).The atrial rate is more rapid than the ventricular rate.
4).regular P-P interval .
5).rugular R-R interval
AVB
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6).QRS is 0.12sec or greater.
VR is 36 beats per minute or less.(20-40
beats/mim)
QRS is less than 0.12sec.
VR is 36 to 60 beats per min(40-60beats/min)
Ⅵ.Bundle branch block

The ventricular conduction system is
composed of two major divisions.
①the right bundle branch
②the left bundle branch
Ⅵ.Bundle branch block

1. Right Bundle Branch Block(RBBB)
ECG:
1).QRS 0.12 sec or wider
2).Rsr’(M)pattern in V1 and V2 and deep ,wide S wave
in Ⅰ,V5-6.
3).The ST segment is slight depressure with negative
T waves
When incomplete RBBB is present ,the pattern is
similar, but the QRS width is less than 0.12sec.
Ⅵ.Bundle branch block

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2. Left Bundle Branch Broch,(LBBB)
ECG: 1). QRS 0.12sec or more .
2)absent q waves in I,V5 and V6
3).wide ,notched,or slurred R waves in V5-6 with
depressed ST segments,downward T waves.
4).wide QS or rS patters with elevated ST segments
and upward T waves in V1-2.
When incomplete LBBB in present ,the pattern is
similar ,but the QRS width is less than 0.12 second.
Ⅵ.Bundle branch block


3. Left anterior fascicular block (LAH)
ECG criteria
1).Left axis deviation (-30゜to -45゜or greater)
2).Small q wave in lead I
3).Deep s wave in lead II
4).Decper S wave in lead III
5).S wave in aVF and V6
Ⅵ.Bundle branch block

4.left posterior fascicular block(LPH) (left
posterior hemiblock)
ECG criteria
1).Right axis deviation of +120゜ or greater
2).Large S wave in lead I
3).Tall R waves in lead II and III.
7.Wolff-Parkinson-White Syndrome
(W.P.W)

ECG criteria:
1.Short P-R interval (less than 0.10 sec to 0.12 sec
2.prolonged QRS complex , 0.12 sec or greater
3.Delta wave in the lower third of the ascending limb
of the R wave
4.Type A is characterized by dominantly upright QRS
complexes in the right precordial leads, resulting in
tall delta-R waves in leads V1-2.
Wolff-Parkinson-White Syndrome(W.P.W)

5.Type B is characterized by dominantly negative QRS
complexes in the right precordial leads ,with tall
delta-R wave in leads V5-6
Conditions associated with wpw syndrome
① Atrial fibrillation
② Atrial flutter
③ Atrial tachycardias
Reciprocal tachycardias