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ACLS EKG Rhythms 2016 – Interpretations and managements by NIK NIKAM MD

May 5, 2019



hello ladies and gentlemen welcome to triple in media I am dr. Nick nickim a cardiologist I have been in practice for 30 plus years at the Texas Medical Center and also in Sugarland Texas let us learn something about the ACLs EKG strip interpretation and management of underlying rhythm problems so let us start before we look at a rhythm strip and determine what kind of rhythm we are looking at we need to have some basic understanding of what are the things we need to look for so let us start off with the basic electrocardiographic building block which is the QRS complex which is the P Q R st complex which is representing one heart here is the electrical system of the heart here at the junction of the superior vena cava and the right atrium we have the sinus node which originates the impulse the impulse travels through the atrium that causes the the deflection which is reflect which is represented by the P wave then it traverses through the AV node which causes this a P Q delay or the PR interval as it is called after that the impulse traverses through the Purkinje system and it activates the ventricular muscle that is reflected by the Q or as complex after that we have a stasis period and that is followed by ventricular repolarization which is reflected by the T V so when we have a strip in front of us first we need to determine the rate the rate is determined by the time that is between the R or spikes the next item we need to look at is the RR intervals or the RR intervals regular that suggest a regular rhythm if the RR intervals from one cycle to the next cycle and to the next cycle or irregular then we are dealing with and here heart rhythm we need to look at the atrial activity do we see atrial activity what kind of atrial activity do we see similarly how does the QRS complex look does it look narrow does it look wider does it look different then we go to the T waves and the SG segments of course the T waves and the ST segments reflect more in relationship to ischemia strain or infarction and we're going to look at some examples of those now here is a rhythm strip take a moment and see what this represent okay as soon as you see a rhythm strip these are the points we need to go through okay what is the rate the rate is determined by the RR interval and here are one-second marks on the ECG paper let me see if I have another slide which talks about okay here is an example of how to determine the rate in an electrocardiogram rhythm strip as I said this represents one second and each one of them is divided into five major segments like this five major segments and then each five major segments is divided into five smaller segments so the smallest segment represents 0.04 second or 40 milliseconds so this is equal to one second if a heartbeat is occurring every second then the heart rate is 60 however if it is happening at a rate of 0.8 seconds then the heart rate is 75 if it is happening at a rate of 0.6 that is equal to 100 and this comes to 1/5 if the heart rate is if one bit is happening here and the second one is happening here then the heart rate is 150 so that's how you determine the heart rate so let's go back to our first row tracing here this is a sinus rhythm here we have a atrial rate of rate of 75 and we have a regular rhythm the RR intervals are regular we have a definite P wave which is preceding each QRS complex the QRS complexes or narrow the three segments is normal and the T waves are upright so this is a normal sinus rhythm the normal sinus rhythm of course does not need any treatment of any sort so let's move to the next one we talked about how to determine the rate based on the paper speed which is 25 millimeters per one second okay here what do we have first of all okay we have P waves all right then look at the pr intervals the pr intervals are not constant so that means we have varying PR into us and there could be a dropped p wave here and it's a long pause and a new cycle begins so we have a ventricular rate which is variable and the rhythm is variable we see P waves definitely and the QRS complexes or narrow the PR intervals very we have a progressive prolongation of the PR interval here so the PR interval is short it gets longer it gets much longer and the P wave gets dropped then a new cycle begins so this is known as Venky Bach Venky Bach is a type 1 type of a a B block which rarely gives any problems most of the time it is benign we just need to watch we may see this in patients with inferior myocardial infarction but as long as we are taking care of the schema and the blood pressure oxygen level and all this it should not be a major issue okay let's look at here and here we have a rate which is less than 60 so if you look at here 1 2 3 4 5 that will be here it will be 60 here this is like 55 so rate is definitely below 60 we also have a PR interval which is about 0.2 seconds which is at the upper limit of the normal and we have of course what looks like a white cure is complet so this is an example of a bradycardia and if this bradycardia is associated with the symptoms of sweating or slight drop in blood pressure the treatment would be atropine 0.5 milligrams intravenously and repeated the five minutes apart to a maximum of three milligrams you can also use epinephrine here if the patient is unstable or if the blood pressure is unstable so this is an example of a significant bradycardia rhythm strip okay here we have another example of a significantly slow heart rate if you want to really measure it this is one two three four five that's one second one two three four so that's like almost happening like less than thirty per minute so this is a situation where you can use atropine for the immediate purpose if the patient is really symptomatic again we can try atropine but if those don't work we may have to think of putting in a external or a transvenous pacemaker all right now let's look at this one again as I said we need to look at the rate the rhythm the atrial activity QRS complex ST segment and T waves in order to determine exactly what the rhythm represents here we have a rate which is like if we have three boxes the three big boxes that is 100 and this is 150 so this is between 100 and 150 it's close to 150 so I would say it would be close to like 135 it says 125 it's close to like 135 it is minor variations out of it but nonetheless we have a P wave preceding each QRS complex we have normal s DT segments the QRS or narrow this is a an example of a sinus tachycardia the sinus tachycardia rate ranges from 100 to 160 beats per it sinus tachycardia is not normal sinus tachycardia is usually due to some underlying causes such as a fever hypoxia or dehydration bleeding heart failure etc so we need to identify the underlying causes and treat them so sinus tachycardia is not something we can ignore it is something that is telling us we need to look further to determine what is causing the sinus tachycardia and treat the underlying cause here is an example of a much faster rate which is almost like a 150 to 165 rate and this is an example of a supraventricular or paroxysmal supraventricular tachycardia could be like a atrial tachycardia the rate is regular there is a PBA which is here and a narrow QRS complex and the T wave and the P waves are sort of merged together because of the rapid rate the ST segment Zaraki and the T waves are alright the treatment for the paroxysmal supraventricular tachycardia is adenosine six milligrams IV followed by a bolus and repeat the dose in a few minutes if necessary if this rhythm is associated with unstable vital signs then we may have to consider cardioversion if that is indicated if the radius like 180 and if the patient is having shortness of breath if the patient looks pale if the blood Fisher is slow then definitely a cardioversion would be in order okay here is an example of a narrow QRS the rate is 120 plus and the interesting thing is we have a QRS complex but we don't see a P wave preceding the QRS complex on the contrary we see a P wave which is following the Cure is complex so this is a P wave which is happening after the QRS complex so we are dealing with a junctional tachycardia junctional tachycardia and the ST segments and the TB okay so again junctional tachycardia is usually related to some kind of an underlying heart disease like myocardial infarction and we need to find find the underlying causes and treat the underlying causes we need to differentiate this from a sinus tachycardia where we see regular preceding PVS whereas in junctional tachycardia you see a p-wave following the QRS complexes okay here what do we have here we got three beats which looks fairly regular then here is it what looks like an atrial bit but it's coming much earlier than the expected next beat which should be somewhere here so this is a premature atrial beat this is a premature atrial beat because it resembles the sinus beat but the pv is a little bit distorted compared to the sinus P waves and it is happening it is occurring prior to the next sinus beat atrial premature bits are frequently seen in patients with chronic lung disease or in patients with the chronic heart disease and especially in an acute illness situation premature atrial beats may be a precursor of atrial flutter or fibrillation so it is very important for us to keep an eye on these premature atrial beats and make sure that our electrolytes such as potassium magnesium or normal and the hemoglobin is normal and the pH is normal so we minimize the chances for any of these beats to progress to atrial flutter of in relation here is an example which is like a normal beat and atrial premature bit this is an atrial bigeminy rhythm which is a little more advanced that's why I said we need to be observing these irregular heartbeats because they can progress to more serious types of rhythm problems such as atrial flutter or fibrillation huh talking about the more serious atrial arrhythmias so what is your diagnosis here first of all it looks like a the ventricular rate is around 75 to 80 per minute but look at the atrial based electrical activity looks like sawtooth this is called a sawtooth appearance which is classic for atrial flutter the atria radius approximately 300 beats per minute and the QRS complexes are narrow there is a four to one conduction of atrial beats it's one two three four and the QRS conducted so there is four to one conduction the ST segments cannot be seen and the TVA's cannot be actually seen in the presence of atrial flutter where is the treatment the treatment if this is a paroxysmal atrial flutter we can try adenosine sometimes the beta blockers such as low-pressure may be used intravenously straw the rate so it helps in diagnosing and underlying rhythm especially if it's very rapid and if the patient's condition is unstable we can do cardioversion using low dose of 25 to be 50 watts or joules again this rhythm with treatment can go into atrial fibrillation or it can go into sinus rhythm we also need to determine the underlying causes if the patient has some electrical accessory pathway that can be treated with ablation okay this is one of the most frequent arrhythmias we see in cardiology practice here we have a narrow QRS complex the RR intervals are varying from beat to beat when you see all our intervals varying from beat to beat the best way to find the heart rate would be to measure here is 1 second 2 seconds 3 4 5 6 seconds and you take a 6 second strip and find out how many QRS complexes are there and you multiply that by 10 that will give the heart rate per minute so here we have 1 2 3 4 5 6 7 8 9 so we have 9 QRS complexes for 6 seconds duration so the rate is ninety per minute we do not see any discernible p-waves the QRS complexes are narrow it's hard to determine the status of the s T and the T wave segments and this is a classic example of atrial fibrillation with the adequate ventricular response if the rate was 130 or 140 or 180 then we would say atrial fibrillation with rapid ventricular response when a patient presents with the atrial fibrillation with a rapid ventricular response in the emergency room first we need to get the rate down then we need to work on the rhythm third we need to work on the underlying causes such as a heart failure or chronic lung disease later on we need to determine about anticoagulation and of course the quality of life so there are many things that need to be taken into consideration but in an acute situation like doing a cardiac resuscitation the most important thing is to reduce the rate and see if we can convert this to sinus rhythm if that is possible so we can start off with drugs that reduce the rate in an acute situation and the most commonly used drugs are of course Delta M 10 to 15 milligram bolus is followed by a drip we can also give a beta blocker such as low pressure intravenously in an acute situation digoxin also works fairly well you give 0.25 milligrams a bolus followed by 0.25 milligrams every six hours for a total of one milligram to load the system with digoxin we can use verapamil by mouth for chronic management of the atrial fibrillation with the rapid ventricular response and of course in an acute situation we would definitely check electrolytes such as potassium and magnesium and correct those electrolytes to minimize the effect of arrhythmias on the target organs here we have a 12-lead electrocardiogram of course the rate is approximately 75 to 80 per minute okay the most obvious thing in this particular electrocardiogram is an AR s or prime which is representative of a right bundle branch block right bundle branch block is commonly seen in patients with chronic lung disease in patients with the myocardial infarction or with the right ventricular pressure overload such as the deployment of a hypertension or for any type and generally there's no treatment needed for right bundle branch block as such okay here is an example of tall or waves in the lateral leads with deep s waves in the anterior leads associated with the ST depression and t-wave inversion this is an example of a left ventricular hypertrophy also there is a deflection of the atrial component left Hetal component of the P wave which is seen in v1 if it involves more than one small box it is suggested here for left atrial enlargement so here we have a classic example of a left ventricular hypertrophy with the strain here we see some ST elevation but that is a normal variation we see in patients with the left material hypertrophy and it doesn't necessarily suggest any evidence of an acute myocardial infarction here is an example where we have s 1 2 3 4 5 heart rate of 60 and the PR interval is almost like two major block box that is equal to almost this is the point this is 0.2 and this is 0.4 this is 0.6 and 0.8 and 1 second so this is almost point 4 or 0.38 or 380 milliseconds so we are looking at a first-degree AV block generally first-degree AV block doesn't really signify I think significant that we can manage we just need to observe this and make sure that this doesn't this does not progress to like second degree AV block something like that here we have a sinus rhythm because this is proceeding P way with each QRS complex narrow QRS complexes DT segments are normal the rate is approximately like 80 for a minute and here we see some wide QRS complex this is an example of a premature ventricular beat whenever we see premature ventricular beats we need to be concerned about especially in the presence of myocardial infarction or hypoxia or hypo because they may suggest tsukimiya and may also progress to more serious arrhythmia such as bigeminy try germany or even v-tach and when we see that we really need to determine the underlying medical underlying conditions and check potassium magnesium oxygen levels hemoglobin and if there anything that needs to be fixed we can fix loss if they are happening more frequently of course you know it can be treated with the most commonly used drug is of course amiodarone 200 to 400 milligrams a day given in divided doses okay here we have an example of a mobitz type 2 AV block and here we have a normal QRS complex and AP wave with a dropped QRS complex it is hard to say whether this is like a winky Bock or whether it's a type 2 mobitz block but nonetheless the underlying causes such as ischemia infarction or hypoxia hypovolemia need to be addressed okay here is an interesting example here we see P waves here's another paper here's the P wave here's the P wave is the P wave is a PV is a P wave the rate is very slow we have a ventricular type of complex with the wide QRS complex the P waves have no relationship to the QRS complexes so this is an example of a complete heart block and this is a more serious rhythm problem which needs to be treated with the external or transcutaneous pacemaker and eventually if this is a chronic condition the patient needs a permanent pacemaker in an acute situation we could use a Isuprel drip to increase the heart rate but the best thing would be to get an external pacemaker or a transvenous pacemaker so that we can stabilize the patient's condition as quickly as possible here is another example of a complete heart block because the P waves have no relationship to the QRS complexes the QRS complexes are of course narrowed so they could be arising from the AV junctional site again they have the same significance as the patients with the QRS complexes arising from the ventricular site they need to be treated pretty aggressively this is another example where we have the previous which have no relationship and a very wide QRS complex suggesting fairly sick ventricle so we need to take more aggressive step in establishing a stable rhythm in this patient which means the external pacemaker or a permanent pacemaker so that we can establish a rhythm since there is some good atrial activity we may be able to put a AV sequential pacemaker to optimise cardiac out all right now we are moving into what looks like a wild QRS tachycardia so if you look at the peaks here they are approximately two big boxes that is like 150 160 270 per minute the QRS complexes are wild we don't see any P waves the TV's seem to be okay it's hard to say since we are looking at a rhythm strip and this is an example of a ventricular tachycardia ventricular tachycardia could be stable or unstable or and they can be chronic or intermittent depending on the situation the treatment may vary a little bit if the patient is stable and if the blood pressure is normal then we may be able to just treat them with intravenous MEA drone 150 milligrams bolus over 10 minutes followed by a drip and then start on oral amiodarone however if the patient is in an ischemic State following a myocardial infarction something like that then we need a more aggressive approach where we able to administer amiodarone 300 milligrams IV and start a drip at 1 milligram per minute if the patient is really unstable we could even use epinephrine or lidocaine and definitely will check the electrolytes and correct the potassium and magnesium levels here's another example of ventricular tachycardia which is much faster here almost 180 to 190 beats per minute and again the treatment would be more in terms of unstable ventricular tachycardia because of much faster rate and much more distorted Kuras complex okay this is an example of what is commonly known as the toss at a point because the axis of the QRS complex is changing during the course of this rhythm strip and this is a highly unstable rhythm because it can very quickly degenerate into ventricular fibrillation and hence this needs to be very aggressively treated with epinephrine amiodarone lidocaine magnesium and if necessary even defibrillation if the patient's condition is unstable more than likely a patient in this rhythm would be unstable who would be hypoxic and the approach would be to stabilize medically and then treat with the defibrillation here's an example of a fine ventricular fibrillation where the undulations are very very narrow and also very the amplitudes are small this is suggestive of almost like a terminal rhythm or this is something we see following an acute to myocardial infarction that this has to be very aggressively treated with epinephrine amiodarone defibrillation here is another example of a fine ventricular fibrillation with a little more visible QRS complexes but nonetheless the prognosis in these patients is very cool and immediate treatment is of the essence in establishing stable cardiac rhythm this is what we call as agonal ventricular rhythm we see an occasional ventricular beat here and there but but for practical purposes we more or less have a flat line and this we see in in the final stages of prolonged CPR the prognosis is very poor the treatment would be similar to that of a patient with a systole talking about see asystole here's an example of a asystole there's no evidence of any QRS complex is no evidence of atrial activity we're just seeing some Wiggly waves and is practically no electrical activity in the heart and this has to be treated with epinephrine and this has to be treated with epinephrine here's another example of what is like a flatline we can treat with epinephrine if there's no response we I would say maybe we have reached the end of an unsuccessful cardiopulmonary resuscitation now this is an example of a left ventricular hypertrophy with the strain and which we already saw previously so let's move on to the next one and here is an example of a wide QRS complex and the PR interval is almost non-existent here we have the P waves and immediately there is what we call the delta wave and then the QRS becomes apparent so this is an example of a WPW and patients with the WPW have accessory pathways patients who have WP UW are more prone for teki arrhythmias these tech aided Mears are tricky because the only drugs that you would really want to use in these arrhythmias to block the accessory pathway would be better block is amiodarone or procainamide using any other drugs such as lidocaine it may make this arrhythmia so worse that's one thing to keep in mind so when you see a patient with WPW with the rapid ventricular response then always consider beta blockers or even procainamide this is an example of an acute inferior and lateral wall myocardial infarction here we have a regular sinus rhythm narrow QRS complexes but we have significant ST elevation this is the ST elevation in two three a VF v5 and v6 so this is representing the inflow lateral region so this is an example of an acute myocardial infarction and of course this is an emergency these patients can be either taken to the cardiac catheterization lab for acute a coronary intervention but mandolins the treatment from the emergency room would include oxygen aspirin nitroglycerin morphine FRIB no lytx urgent PCI and long-term beta blocker okay here is an example of an anterior myocardial infarction where this ST elevation in v2 v3 v4 v5 so along with the right bundle branch block left atrial enlargement so the treatment for this would also be very similar to the one we saw in the previous slide so this is the case of an acute extensive anterior myocardial infarction with right bundle branch block which carries a more serious prognosis compared to patients with the just anterior myocardial infarction without right bundle branch block this is an example of a be sequential pacemaker because we see a spike here followed by a p-wave and then we see a second spike which is followed by a wide QRS complex so this is a classical this is a classic example of a be sequential pacemaker which seems to be working properly then the early course of this presentation we saw cases of the right bundle branch block and even two slides before we saw a case of a right bundle branch block in the presence of anterior myocardial infarction this is an example of a left bundle branch block and here we have a wide QRS complex in one ABL and in the lateral chest leads associated with deep wild s waves in the anterior leads so this is an example of a left bundle branch block and finally we have one more item that we need to cover and that is these negative TVs which are known as the giant negative T waves these are suggesting of a left ventricular ischemia they may also be seen in patients with cerebral vascular accidents and this is something we have to treat like an acute coronary syndrome and take appropriate steps to diagnose the extent of the underlying coronary artery disease or cerebral vascular problems again this is an example of the left bundle branch block which we just saw a few minutes ago here is an example of a sinus bradycardia and associated with that there is a long pause here after almost regular cycle for three beats and when we see something like this we need to be worried about a blocked P AC which is not maybe buried in the T wave or it could be a sinus arrhythmia since these T waves are similar these t ways this T wave looks a little bit different from the other t ways you may assume this could be a blocked PA see if all the tables were identical then you would worry about sinus arrhythmia but the P or our interval is too long for sinus arrhythmia to be represented in this rhythm step so that's how we we come up with a diagnosis by a process of elimination okay to summarize ladies and gentlemen when you're looking at a rhythm strip for an ACLs test first you need to look at the RR intervals make sure what the rate is then you look at the rhythm by measuring by looking at the RR intervals in the whole rhythm strip look for the atrial activity determine what type of retail activity you are seeing look at the QRS complex and see whether it is supraventricular or ventricular then you look at the STT segments to determine any evidence of ischemia strain infarction or ventricular ischemia and then you come up with a most plausible diagnosis okay ladies and gentlemen I hope this presentation has been helpful to you if there are so many mistakes or typos please make a comment in the comment section and hopefully we can correct those in the future videos and please do subscribe to our YouTube channel where we bring you all these types of educational programs and we would also like it to visit our Facebook page which is the triple-n media where we keep you abreast of what's happening in and around the Houston area and please do leave your comments below and subscribe to our YouTube channel thank you

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28 Comments

  • Reply dalmar slam May 5, 2019 at 9:33 pm

    Dr:Nik Nikam..the 30minute..i Think it's Complete LBBB?

  • Reply Gulf Students May 5, 2019 at 9:33 pm

    thank you very much sir . you make my life easy . im working in Emergency medicine room

  • Reply Dan Negoita May 5, 2019 at 9:33 pm

    Are you kidding!?? When the patient has ASYSTOLE you must first do CPR and THEN give adrenaline. You must emphasize CPR. Adrenaline (or any other drug) DOES NOT improve the chances of survival without neurological sequeli

  • Reply Janet Li May 5, 2019 at 9:33 pm

    thank you for explaining in detail. helps me understand the waves in detail

  • Reply madina zamani May 5, 2019 at 9:33 pm

    Thank you so much very good review hoping to pass my ECG exam test tomorrow

  • Reply marra donna May 5, 2019 at 9:33 pm

    Thank you, Sir, for sharing. God bless

  • Reply John Fullard May 5, 2019 at 9:33 pm

    very good explanation of EKG

  • Reply Gulu Gulu May 5, 2019 at 9:33 pm

    Should we avoid using beta blockers in WPW syndrome?

  • Reply Cherry Blossom May 5, 2019 at 9:33 pm

    Thanks!

  • Reply Raza Ali May 5, 2019 at 9:33 pm

    Disply picture ofECG

  • Reply Curly Spoon Designs May 5, 2019 at 9:33 pm

    Thank you! I feel like I can interpret ECGs better now

  • Reply k Das May 5, 2019 at 9:33 pm

    Thanks

  • Reply alex koukou May 5, 2019 at 9:33 pm

    i think that amiodarone is contraindicated in WPW syndrome patients!!!

  • Reply Vijay Yadav May 5, 2019 at 9:33 pm

    very much informative.please continue

  • Reply Dr Bhavna Sharma May 5, 2019 at 9:33 pm

    Simply & beautifully explained

  • Reply Five Stars May 5, 2019 at 9:33 pm

    I don’t understand Indian accent 👎

  • Reply Biji Anto May 5, 2019 at 9:33 pm

    Amazing video….

  • Reply Angelo Gagliano May 5, 2019 at 9:33 pm

    Wenkebach is classified as Second degree AV Block, Type I. Thanks for presenting.

  • Reply rajan mathew May 5, 2019 at 9:33 pm

    Thank you sir ….gbu

  • Reply Mangala Pk May 5, 2019 at 9:33 pm

    Great job thanks

  • Reply Emily L May 5, 2019 at 9:33 pm

    I believe that Adenosine's second dose is 12 mg, not 6 mg for SVT. As per the ACLS manual: "The first dose of adenosine should be 6 mg administered rapidly over 1-3 seconds followed by a 20 ml NS bolus. If the patient’s rhythm does not convert out of SVT within 1 to 2 minutes, a second 12 mg dose may be given in similar fashion."

  • Reply Joel Hernandez May 5, 2019 at 9:33 pm

    MI CIELITO IS THE ONLY PRINCESA EN MI VIDA ! !!!!!!!!!!!!!!!!!!!!!!

  • Reply Joel Hernandez May 5, 2019 at 9:33 pm

    SE

  • Reply mustafa naji May 5, 2019 at 9:33 pm

    Thank you so much for this video

  • Reply Isabel And Andrea May 5, 2019 at 9:33 pm

    Very easy to understand. Thank you!

  • Reply Josh Vlogger May 5, 2019 at 9:33 pm

    Good job sir.,

  • Reply Tamara Richards May 5, 2019 at 9:33 pm

    This is a fantastic overview; thank you so much for the thorough information!!

  • Reply Kosal Chin May 5, 2019 at 9:33 pm

    Great lecture

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