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GE Healthcare Technologies

Arrhythmia Recognition

Cardiac Conduction System ECG Components Electrical and Mechanical Events

Sinoatrial Node RIGHT ATRIUM Atrioventricular Node Right Bundle Branch RIGHT VENTRICLE Left Bundle Branch LEFT ATRIUM HIS Bundle

LEFT VENTRICLE

1 Small Square = 1 mm (0.1 mV) 1 Small Square = .04 sec (40 msec)

VERTICAL AXIS

1 Large Square = 5 mm (0.5 mV) 2 Large Squares = 1 mV

HORIZONTAL 1 Large Square = .2 sec (200 msec) AXIS

5 Large Squares = 1 sec (1000 msec)

Mid Diastole

Atrial Contraction

Isovolumic Ventricular Contraction

Ventricular Ejection

Isovolumic Ventricular Relaxation

Sinus Rhythms

Normal Sinus Rhythm

Supraventricular Rhythms

Premature Atrial Complexes -- PACs Atrial Tachycardia

Conduction Defects

Right Bundle Branch Block

P Wave Heart Rate 60 ­ 100 bpm Rhythm Regular P Wave Before each QRS, identical PR Interval

(in seconds)

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics RSR' in V1

QRS

(in seconds)

Heart Rate Heart Rate N/A Rhythm Irregular P Wave Premature and abnormal. May be hidden PR Interval

(in seconds)

Rhythm Regular

P Wave Abnormal P before each QRS (difficult to see)

PR Interval

(in seconds)

QRS

(in seconds)

Before each QRS, identical

0.12 to 0.20

0.12

0.12 to 0.20

< 0.12 QRS

(in seconds)

140 ­ 250 bpm

0.12 to 0.20

< 0.12

Left Bundle Branch Block

0.12 to 0.20

< 0.12

Sinus Arrhythmia

Atrial Flutter Premature Atrial Complex -- Isolated PAC

P Wave Before each QRS, identical Heart Rate Usually 60 ­ 100 bpm Rhythm Irregular P Wave Before each QRS, identical PR Interval

(in seconds)

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics QS or rS in V1 and V2 ST elevation

0.12 to 0.20

0.12

QRS

(in seconds)

0.12 to 0.20

< 0.12

Heart Rate N/A

Rhythm Irregular

P Wave Premature and abnormal. May be hidden

PR Interval

(in seconds)

QRS

(in seconds)

Heart Rate A: 240 ­ 350 bpm V: Varies with conduction ratio

Rhythm

P Wave

PR Interval

(in seconds)

QRS

(in seconds)

Pre-excitation Syndrome

0.12 to 0.20

< 0.12

A: Regular Flutter (F) waves V: Regular, usually the negative group beating component of the or variable flutter wave in II, III, aVF and positive in V1

N/A

< 0.12

Sinus Tachycardia Premature Atrial Complexes (Atrial Bigeminy) Every other beat is a PAC Atrial Fibrillation

P Wave Heart Rate > 100 bpm Rhythm Regular P Wave Before each QRS, identical PR Interval

(in seconds)

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics Delta wave distorts initial QRS

QRS

(in seconds)

0.12 to 0.20

< 0.12

Before each QRS, identical Heart Rate Heart Rate Rhythm Irregular P Wave Premature and abnormal. May be hidden PR Interval

(in seconds)

< 0.12

Usually > 0.10

Rhythm Irregular

P Wave Absent Fibrillatory (f) waves

PR Interval

(in seconds)

QRS

(in seconds)

QRS

(in seconds)

A: 350 ­ 650 bpm V: Slow to rapid

N/A

< 0.12

First-Degree AV Block

Sinus Bradycardia

N/A

0.12 to 0.20

< 0.12

Junctional Rhythm

Premature Atrial Complex with Aberrancy

P Wave Heart Rate < 60 bpm Rhythm Regular P Wave Before each QRS, identical PR Interval

(in seconds)

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics Regular rhythm

QRS

(in seconds)

Before each QRS, identical Heart Rate 40 ­ 60 bpm Rhythm Regular P Wave Inverted in inferior leads; before, during or after the QRS; may be absent PR Interval

(in seconds)

> 0.20

< 0.12

0.12 to 0.20

< 0.12

QRS

(in seconds)

< 0.12

< 0.12

Second-Degree AV Block -- Type I (AV Wenckebach or Mobitz type I)

P P P P P P P

Sinus Arrest or SA Block Accelerated Junctional Rhythm

Heart Rate N/A PR Interval

(in seconds)

Rhythm Irregular

P Wave Premature and abnormal. May be hidden

PR Interval

(in seconds)

QRS

(in seconds)

0.12 to 0.20

< 0.12 Abnormal shape

P Wave Conduction intermittent

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics QRS dropped in a repeating pattern

Heart Rate 40 ­ 100 bpm

Rhythm Irregular

P Wave Identical before each QRS. P to P interval may be fixed before and after the pause

QRS

(in seconds)

0.12 to 0.20

< 0.12

Increasingly prolonged

< 0.12

Nonconducted Premature Atrial Complex

Heart Rate 60 ­ 100 bpm Rhythm P Wave Usually AV May be sinus P wave dissociation (AV dissociation) because of digitalis toxicity

PR Interval

(in seconds)

QRS

(in seconds)

< 0.12

< 0.12

Second-Degree AV Block -- Type II (Mobitz type II)

P Wave is buried in the T Wave.

NOTE: Notch is not present in other T Waves present in other T Waves

Heart Rate N/A

Rhythm Irregular

P Wave Premature and abnormal. May be hidden

PR Interval

(in seconds)

QRS

(in seconds)

Junctional Tachycardia

P Wave Sinus PR Interval

(in seconds)

QRS

(in seconds)

Characteristics Some P waves are not conducted

None

Absent

Usually normal and identical (before and after a blocked impulse)

Broad 0.12

Second-Degree AV Block -- 2:1 AV Block

Heart Rate Usually <140 bpm

Rhythm Regular

P Wave Inverted, absent or after QRS

PR Interval

(in seconds)

QRS

(in seconds)

< 0.12

< 0.12

P Wave Sinus

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics 2:1 AV conduction

Normal or prolonged

Narrow or broad

Third-Degree (Complete) AV Block

Arrhythmia Recognition (poster 1 of 2)

This is part one of two posters to assist healthcare professionals in recognizing basic arrhythmias. According to the Practice Standards for Electrocardiographic Monitoring in Hospital Settings (Circulation. 2004;110:2721-2746) in general, the mechanisms of arrhythmias are the same in both adults and children. However, the ECG appearance of the arrhythmias may differ due to developmental issues such as heart size, baseline heart rate, sinus and AV node function, and automatic innervation. ECG terminology and diagnostic criteria often vary from text to text and from one teacher to another. There are often several terms describing similar findings (for example: Premature Atrial Contraction, Atrial Premature Complex, Atrial Extrasystole, Supraventricular Ectopic Beat, etc.) It is important to correlate the ECG interpretation with the clinical observation of the patient.

0­1d Heart Rate/Min PR Interval Lead II (Seconds) QRS Interval Lead V5 (Seconds) 94 -155 (122) 1­3d 91 - 158 (122)

Normal ECG Standards for Children by Age

3­7d 90 - 166 (128) 7 ­ 30 d 106 - 182 (149) 1 ­ 3 mo 120 - 179 (149) 3 ­ 6 mo 105 - 185 (141) 6 ­ 12 mo 108 - 169 (131) 1­3 y 89 - 152 (119) 3­5y 73 - 137 (109) 5­8y 65 - 133 (100) 8 ­ 12 y 62 - 130 (91) 12 ­ 16 y 60 - 120 (80)

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 (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) 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 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07)

This poster includes Premature Ventricular Conduction, Pacemaker Lead Placement, ST Segment Depression, Ventricular Rhythms, Pacemaker Rhythms, Full Compensatory Pause and ECG Artifact. 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. The intended use of this poster is to compliment a text and/or course -- in addition to a reference guide for arrhythmia recognition

The most common ECG rate, interval, and duration measurements are from the following publications: · Clinical Electrocardiography (Post Graduate Institute for Medicine). · Understanding Electrocardiography (Mary Boudreau Conover). · How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis). · Principles of Clinical Electrocardiography (M. J. Goldman). · Basic Dysrhythmias Interpretation and Management (Robert Huszar). · An Introduction to Electrocardiography (Leo Shamroth). · Interpretation of Arrhythmias (Emanual Stein).

P Wave Normal but not related to QRS

PR Interval

(in seconds)

QRS

(in seconds)

Characteristics AV dissociation

All values 2nd ­ 98th percentile; numbers in parentheses, means. Adapted from Pediatr Cardiol. 1979;1:123.

N/A

Narrow or broad

PN: 05­9712

www.gehealthcare.com

GE Healthcare Technologies

Arrhythmia Recognition

Premature Ventricular Conduction

V1 V1

Pacemaker Lead Placement

Pacing Lead Pacing Lead

ST Segment Depression

Atrial Pacing

The pacing lead is inserted into the atrium to cause atrial depolarization.

Ventricular Pacing

The pacing lead is inserted into the ventricle to cause ventricular depolarization.

AV Sequential Pacing

The pacing leads are inserted into both the atrium and ventricle stimulating at set intervals.

J Point

Downsloping ST

Upsloping ST

Horizontal ST

Right Ventricular PVC

Left Ventricular PVC

The J point occurs at the end of the QRS complex. The ST segment begins at the J point and extends to a user-defined interval.

Ventricular Rhythms

Premature Ventricular Complex ­ PVC

Heart Rate N/A Rhythm Irregular with PVCs P Wave N/A PR Interval

(in seconds)

Pacemaker Rhythms

Ventricular Fusion Beat Electronic Pacemaker Spikes Failure to Capture

QRS

(in seconds)

N/A

0.12

Unifocal PVCs: Identical shapes

Heart Rate N/A

Rhythm N/A

P Wave Present

PR Interval

(in seconds)

QRS

(in seconds)

Same as sinus rhythm or shorter

0.12

Electrical stimuli delivered by the electronic pacemaker to the endocardium are seen as a spike on the surface ECG. 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 Multifocal PVCs: More thanone shape

Heart Rate < 40 bpm

Rhythm Irregular

P Wave Absent

PR Interval

(in seconds)

QRS

(in seconds)

Absent

0.12

Single spike producing a wide QRS complex (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 20 ­ 40 bpm Rhythm Regular P Wave Absent or not related PR Interval

(in seconds)

QRS

(in seconds)

AV Sequential Pacemaker (dual chamber)

N/A

0.12

Accelerated Idioventricular Rhythm (AIVR)

R on T Phenomenon: PVC occurs at the peak of the of T wave of the preceding beat of the preceding beat

The pacemaker does not generate a pacemaker spike when it is needed. First spike followed by a paced P wave (atrial capture) followed by a second spike producing a wide QRS complex (ventricular capture).

Paced Fusion Beat

ECG Artifact

Any waveform on the ECG that is not related to the patient's cardiac events

Heart Rate

Rhythm Regular

P Wave Absent, not related or retrograde conduction

PR Interval

(in seconds)

QRS

(in seconds)

Calibration Pulses

Ventricular Bigeminy: Every other beat is a PVC

40 ­ 100 bpm

N/A

0.12

Ventricular Tachycardia (3 or more consecutive ventricular complexes)

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

Full Compensatory Pause vs. Noncompensatory Pause

Ventricular Trigeminy: Every third beat is a PVC

Heart Rate > 100 bpm Rhythm Regular P Wave Absent, not related, or retrograde conduction 1:1, 2:1, or VA Wenckeback PR Interval

(in seconds)

AC Interference (60 cycle)

QRS

(in seconds)

N/A

0.12

Ventricular Fibrillation

Sixty even, regular spikes in a one-second interval caused by electrical current near the patient.

Muscle Tremor (Somatic) Ventricular Quadrigeminy: Every fourth beat is a PVC

Heart Rate 300 ­ 600 bpm Rhythm Extremely irregular P Wave Absent PR Interval

(in seconds)

QRS

(in seconds)

Absent

Absent

Ventricular Asystole To measure a Full Compensatory Pause:

1. Mark off three normal cycles. 2. Place the first mark on the P wave of the normal cycle preceding the premature complex. 3. The third mark should fall exactly on the P wave following the premature complex to be called a compensatory pause.

Electrical interference caused by the patient's tensed muscles.

Heart Rate Absent

Rhythm Absent

P Wave Absent or present

PR Interval

(in seconds)

QRS

(in seconds)

Wandering Baseline (Drift)

Absent

Absent

Arrhythmia Recognition (poster 2 of 2)

This is part two of two posters to assist healthcare professionals in recognizing basic arrhythmias. According to the Practice Standards for Electrocardiographic Monitoring in Hospital Settings (Circulation. 2004;110:2721-2746) in general, the mechanisms of arrhythmias are the same in both adults and children. However, the ECG appearance of the arrhythmias may differ due to developmental issues such as heart size, baseline heart rate, sinus and AV node function, and automatic innervation. ECG terminology and diagnostic criteria often vary from text to text and from one teacher to another. There are often several terms describing similar findings (for example: Premature Atrial Contraction, Atrial Premature Complex, Atrial Extrasystole, Supraventricular Ectopic Beat, etc.) It is important to correlate the ECG interpretation with the clinical observation of the patient.

0­1d Heart Rate/Min PR Interval Lead II (Seconds) QRS Interval Lead V5 (Seconds) 94 -155 (122) 1­3d 91 - 158 (122)

Normal ECG Standards for Children by Age

3­7d 90 - 166 (128) 7 ­ 30 d 106 - 182 (149) 1 ­ 3 mo 120 - 179 (149) 3 ­ 6 mo 105 - 185 (141) 6 ­ 12 mo 108 - 169 (131) 1­3 y 89 - 152 (119) 3­5y 73 - 137 (109) 5­8y 65 - 133 (100) 8 ­ 12 y 62 - 130 (91) 12 ­ 16 y 60 - 120 (80)

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 (0.107) (0.108) (0.102) (0.100) (0.098) (0.105) (0.106) (0.113) (0.119) (0.123) (0.128) (0.135) 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 (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.05) (0.06) (0.06) (0.06) (0.06) (0.07)

This poster includes Premature Ventricular Conduction, Pacemaker Lead Placement, ST Segment Depression, Ventricular Rhythms, Pacemaker Rhythms, Full Compensatory Pause and ECG Artifact. 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. The intended use of this poster is to compliment a text and/or course -- in addition to a reference guide for arrhythmia recognition

The most common ECG rate, interval, and duration measurements are from the following publications: · Clinical Electrocardiography (Post Graduate Institute for Medicine). · Understanding Electrocardiography (Mary Boudreau Conover). · How to Quickly and Accurately Master Arrhythmia Interpretation (Dale Davis). · Principles of Clinical Electrocardiography (M. J. Goldman). · Basic Dysrhythmias Interpretation and Management (Robert Huszar). · An Introduction to Electrocardiography (Leo Shamroth). · Interpretation of Arrhythmias (Emanual Stein).

All values 2nd ­ 98th percentile; numbers in parentheses, means. Adapted from Pediatr Cardiol. 1979;1:123.

An undulating baseline with waveform present.

PN: 05­9712

www.gehealthcare.com

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