ACLS CE

Part I of III
ECG STRIP INTERPRETATION

Prepared and presented by

Marc Imhotep Cray, M.D.

Review of ECG Basics

Normal ECG Morphology
Features include:
Regular rhythm at 60-100 bpm
Normal P wave morphology and
axis (upright in I and II, inverted in
aVR)
Narrow QRS complexes (< 100 ms
wide)
Each P wave is followed by a QRS
complex
The PR interval is constant
Graphic from: http://ekgenius.net/Fundamentals/nsr.html
2

EKG Paper
ECG tracings are recorded on grid
paper. The horizontal axis of the
EKG paper records time, with black
marks at the top indicating 3 second
intervals.
Each second is marked by 5 large
grid blocks. Thus each large block
equals 0.2 second. The vertical axis
records EKG amplitude (voltage).
Two large blocks equal 1 millivolt
(mV). Each small block equals 0.1
mV.

From: EKG - Practical Clinical Skills (Website).EKG Paper

Within the large blocks are 5 small

blocks, each representing 0.04
seconds.
3

Normal Sinus Rhythm

12 lead ECG in sinus rhythm

Source: http://upload.wikimedia.org/wikipedia/commons/f/f0/12_lead_generated_sinus_rhythm.JPG

Analyzing a Rhythm
Component

Characteristics

Rate

The bpm is commonly the ventricular rate.

If atrial and ventricular rates differ, as in a
3rd-degree block, measure both rates.
Normal: 60100 bpm
Slow (bradycardia): <60 bpm
Fast (tachycardia): >100 bpm
Measure R-R intervals and P-P intervals.
Regular: Intervals consistent
Regularly irregular: Repeating pattern
Irregular: No pattern
If present: Same in size, shape, position?
Does each QRS have a P wave?
Normal: Upright (positive) and uniform
Constant: Intervals are the same.
Variable: Intervals differ.
Normal: 0.120.20 sec and constant
Normal: 0.060.10 sec
Wide: >0.10 sec
None: Absent
Beginning of R wave to end of T wave Varies with
HR. Normal: Less than half the R-R interval

Regularity

P Waves

PR Interval

QRS Interval

QT Interval

Dropped beats Occur in AV blocks. Occur in sinus arrest.

Thaler MS. The Only EKG Book you'll Ever Need - 5th ed., 117-20
5

Basic Rhythm Analysis

Rate too fast or too slow?
Rhythm regular or irregular?
Is there a normal looking QRS? Is it wide or
narrow?
Are P waves present?
What is the relationship of the P waves to the
QRS complex?

ACLS Rhythm Analysis

Lethal vs non-lethal?

Shockable vs. non-shockable?

Too fast vs too slow?

Symptomatic vs. asymptomatic?

or
Unstable vs. stable?

N.B. Is the Patient Stable? How to Assess:

Hemodynamically Significant Rhythm

=Symptomatic or Unstable
Clinically, most important parameter to assess in any
patient with a cardiac dysrhythmia
is rhythm
hemodynamically "significant"
This holds true regardless of whether rhythm in
question is slow or fast
A rhythm is "hemodynamically" significant
IF it produces signs or symptoms of concern as a direct
result of the rate
8

Signs and Symptoms of Concern

(Think hypoperfusion of heart-brains-kidneys)

Signs of Concern --include hypotension (i.e.,

systolic BP 80-90 mm Hg); shock; heart
failure/pulmonary edema; and/or acute infarction
Symptoms of Concern -- include chest pain;
shortness of breath; and/or impaired mental
status

Hemodynamic stability
VT or SVT
The definition of hemodynamic stability is equally
applicable for supraventricular tachyarrhythmias (SVT) as
it is for ventricular tachycardia (VT)
patient with tachycardia who is symptomatic
(i.e., hypotensive; short of breath; confused) is in
need of immediate synchronized cardioversion
regardless of whether rhythm is VT or SVT
In contrast a trial of medical therapy is justified
IF the patient is stable!
See SVT and Tachycardia Notes.pdf
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TO SUMMARIZE
Symptomatic = unstable

Any abnormal rhythm that produces signs or

symptoms of hypoperfusion
Chest Pain/ischemic EKG changes
Shortness of Breath
Decreased level of consciousness
Syncope/pre-syncope
Hypotension
Shock - decreased Urine output, cool extremities,
etc.
Pulmonary Congestion/CHF

Treat the patient not the monitor!!!!!!

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Again Treat the patient not the monitor!!!!

Sometimes you just have to be there"

For example
despite a systolic BP of 75 mm Hg-we would not
necessarily cardiovert a patient with tachycardia who was
otherwise tolerating the rhythm well (i.e., without chest
pain, dyspnea, or confusion).
Some patients may remain stable for hours (or even
days) despite being in sustained VT

12

Lethal Rhythms
Shockable (Defibrillation)
Ventricular fibrillation
Pulseless ventricular tachycardia
Non-shockable
Asystole
Pulseless electrical activity (PEA)

13

Non-Lethal Rhythms
Too fast (tachycardias)
Sinus
Supraventricular (including a-fib/flutter)
Ventricular

Too slow (bradycardias)

Sinus
Heart block (1, 2, 3 AV block)
N.B. May have the potential to become lethal rhythms if
not treated appropriately
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The following outlined ECG strips will be reviewed

OUTLINE:
For full rationale see respective disorders at
SINUS RHYTHMS
http://emedicine.medscape.com/cardiology
SINUS RHYTHM
SINUS BRADYCARDIA
SINUS ARREST
SINUS TACHYCARDIA
ATRIAL RHYTHMS
SUPRAVENTRICULAR TACHYCARDIA
ATRIAL FIBRILLATION
ATRIAL FLUTTER
VENTRICULAR RHYTHM
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
ATRIOVENTRICULAR BLOCKS
FIRST DEGREE HEART BLOCK
SECOND DEGREE HEART BLOCK TYPE 1
SECOND DEGREE HEART BLOCK TYPE 2
THIRD DEGREE HEART BLOCK
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SINUS RHYTHMS (1)

SINUS RHYTHM

VENTRICULAR RATE/RHYTHM 60 BPM/REGULAR

ATRIAL RATE/RHYTHM 60 BPM/REGULAR
PR INTERVAL 0.20 SEC
QRS DURATION 0.06 SEC
IDENTIFICATION SINUS RHYTHM

16

SINUS RHYTHMS (2)

SINUS BRADYCARDIA

VENTRICULAR RATE/RHYTHM 58 BPM/REGULAR

ATRIAL RATE/RHYTHM 58 BPM/REGULAR
PR INTERVAL 0.20 SEC
QRS DURATION 0.08 SEC
IDENTIFICATION SINUS BRADYCARDIA

17

SINUS RHYTHMS (3)

SINUS TACHYCARDIA

VENTRICULAR RATE/RHYTHM 130 BPM/REGULAR

ATRIAL RATE/RHYTHM 130 BPM/REGULAR
PR INTERVAL 0.14 0.16 SEC
QRS DURATION 0.06 0.08 SEC
IDENTIFICATION SINUS TACHYCARDIA

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SINUS RHYTHMS (4)

SINUS ARREST

VENTRICULAR RATE/RHYTHM NONE

ATRIAL RATE/RHYTHM NONE
PR INTERVAL NONE
QRS DURATION NONE
IDENTIFICATION ASYSTOLE

19

ATRIAL RHYTHMS(1)
SUPRAVENTRICULAR TACHYCARDIA

VENTRICULAR RATE/RHYTHM 188 BPM/REGULAR

ATRIAL RATE/RHYTHM UNABLE TO DETERMINE
PR INTERVAL UNABLE TO DETERMINE
QRS DURATION 0.06 SEC
IDENTIFICATION SUPRAVENTRICULAR TACHYCARDIA (SVT)

20

ATRIAL RHYTHMS(2)
ATRIAL FLUTTER

VENTRICULAR RATE/RHYTHM 88 BPM/REGULAR

ATRIAL RATE/RHYTHM UNABLE TO DETERMINE
PR INTERVAL UNABLE TO DETERMINE
QRS DURATION 0.06 SEC
IDENTIFICATION ATRIAL FLUTTER

21

ATRIAL RHYTHMS(3)
ATRIAL FIBRILLATION

VENTRICULAR RATE/RHYTHM 55-94 BPM/IRREGULAR

ATRIAL RATE/RHYTHM UNABLE TO DETERMINE
PR INTERVAL UNABLE TO DETERMINE
QRS DURATION 0.10 SEC
IDENTIFICATION ATRIAL FIBRILLATION

22

VENTRICULAR RHYTHMS(1)
VENTRICULAR TACHYCARDIA

VENTRICULAR RATE/RHYTHM 214 BPM/REGULAR

ATRIAL RATE/RHYTHM UNABLE TO DETERMINE
PR INTERVAL UNABLE TO DETERMINE
QRS DURATION 0.14 SEC
IDENTIFICATION VENTRICULAR TACHYCARDIA, MONOMORPHIC

23

VENTRICULAR RHYTHMS(2)
VENTRICULAR FIBRILLATION

VENTRICULAR RATE/RHYTHM UNABLE TO DETERMINE

ATRIAL RATE/RHYTHM UNABLE TO DETERMINE
PR INTERVAL UNABLE TO DETERMINE
QRS DURATION UNABLE TO DETERMINE
IDENTIFICATION VENTRICULAR FIBRILLATION

24

ATRIOVENTRICULAR BLOCKS(1)
FIRST DEGREE HEART BLOCK

VENTRICULAR RATE/RHYTHM 68 BPM/REGULAR

ATRIAL RATE/RHYTHM 68 BPM/REGULAR
PR INTERVAL 0.28 SEC
QRS DURATION 0.06 SEC
IDENTIFICATION FIRST-DEGREE AV BLOCK

25

ATRIOVENTRICULAR BLOCKS(2)
SECOND DEGREE HEART BLOCK TYPE 1

VENTRICULAR RATE/RHYTHM 38-75 BPM/IRREGULAR

ATRIAL RATE/RHYTHM 75 BPM/REGULAR
PR INTERVAL LENGTHENING
QRS DURATION 0.06 0.08 SEC
IDENTIFICATION SECOND-DEGREE AV BLOCK, TYPE 1

26

ATRIOVENTRICULAR BLOCKS(3)
SECOND DEGREE HEART BLOCK TYPE 2

VENTRICULAR RATE/RHYTHM 48 - 83 BPM/IRREGULAR

ATRIAL RATE/RHYTHM 167 BPM/REGULAR
PR INTERVAL 0.24 SEC
QRS DURATION 0.12 SEC
IDENTIFICATION SECOND-DEGREE AV BLOCK, TYPE 2

27

ATRIOVENTRICULAR BLOCKS(4)
THIRD DEGREE HEART BLOCK

VENTRICULAR RATE/RHYTHM 45 BPM/REGULAR

ATRIAL RATE/RHYTHM 115 BPM/REGULAR
PR INTERVAL VARIES
QRS DURATION 0.16 SEC
IDENTIFICATION THIRD-DEGREE AV BLOCK

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ACLS Case Scenarios

Supplement to Part I- ECG STRIP INTERPRETATION

Name the rhythm & its

management

63 yo man with a witnessed collapse

while mowing the lawn

What is the rhythm?

What is the management?
NB: Go through step-by-step analysis of rhythm rate, rhythm,
qrs, p waves, intervals etc.
30

Ventricular Fibrillation

Rapid and irregular

No normal P waves or QRS complexes

31

VF / Pulseless VT
Secondary Survey - ABC

Primary Survey - ABC

32

ACLS Algorithm

Primary Survey
Shock 360 J
Secondary Survey
Vasopressor - Epi or Vasopressin IV
Shock 360J
Antiarrhythmic Amiodarone, Lidocaine or
Magnesium Sulfate IV
Shock 360J
NB: Dont forget CPR in between shocks dont stop CPR for anything
except to assess patient (no longer than 10 seconds) or shock resume CPR
*immediately* after the shock for 5 cycles *without* checking a rhythm until
after 5 cycles of 30/2 CPR
33

79yo man s/p NSTEMI

What is the rhythm?

What is the management?

34

Ventricular Tachycardia (1)

Rapid and regular

No P waves
Wide QRS complexes
35

Ventricular Tachycardia (2)

Monomorphic VT

http://www.txai.org/edu/irregular/ventricular_tachyarrhythmias.htm

Polymorphic VT

http://www.txai.org/edu/irregular/ventricular_tachyarrhythmias.htm

Note: Polymorphic is often associated with electrolyte

abnormalities or toxicities
36

Ventricular Tachycardia (3)

Assume any wide complex tachycardia is VT
until proven otherwise
SVT with aberrant conduction may also have wide
QRS complexes

Attempt to establish the diagnosis

Ischemia risk and VT go together

37

Treatment of VT (1)
If pulseless - follow VF algorithm
If stable try anti-arrhythmics
Amiodarone
Lidocaine
Procainamide?

If patient has a pulse, but is unstable or not

responding to meds - shock

38

Treatment of VT (2)
Anti-arrhythmics are also pro-arrhythmic
One antiarrhythmic may help, more than one
may harm
Anti-arrhythmics can impair an already
impaired heart
Electrical cardioversion should be the second
intervention of choice

39

60yo diabetic man with chest pain

What is the rhythm?

What is the management?

40

Normal Sinus Rhythm

Regular rate and rhythm

Normal P waves and QRS
Evaluate for cause of chest pain and monitor for
change in rhythm
41

40 yo woman found down, pulseless and

apneic

What is the rhythm?

What is the management?

42

Pulseless Electrical Activity (PEA)

Any organized (or semi-organized) electrical
activity in a patient without a detectable pulse
Non-perfusing

Treat the patient NOT the monitor

Find and treat the cause!!!!!

43

PEA and Asystole

Secondary Survey - ABCD

Primary Survey - ABC

44

PEA
Primary Survey

Secondary Survey

Search for and Treat Causes

Epinephrine 1 mg IVP
repeat every 3-5 minutes

Atropine 1 mg IVP
if PEA is slow
45

Find and Treat the Cause

Remember Non-shockable rhythms include:
Asystole
Pulseless electrical activity (PEA)
The most effective treatment is to find and fix
the underlying problem

46

Causes of PEA?
#1 cause of PEA in adults is hypovolemia
#1 cause in children is hypoxia/respiratory
arrest

Other causes? The Hs and Ts (Next Slide)

47

The Hs and Ts

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hyper-/hypokalemia
Hypothermia
Hypoglycemia (rare)

Toxins
Tamponade
Tension pneumothorax
Thrombosis (coronary
or pulmonary)
Trauma

N.B. There are now actually 6 Hs hypoglycemia added on AHA

guidelines BUT only a few anecdotal reports of actually causing PEA
and usually in association with underlying chronic cardiac dysfunction
(severe heart failure)
48

Treat the Hs and Ts

Busy slide the point is to TREAT whatever the problem is

Hypovolemia
Volume IVF, PRBCs
Hypoxia
Oxygenate/Ventilate
Hydrogen ion (acidosis)
Sodium bicarbonate
Hyperventilation
Hyper-/hypokalemia
Sodium bicarbonate
Insulin/glucose
Calcium
Hypothermia
Warm -- invasive
Hypoglycemia
Dextrose

Toxins
Check levels
Charcoal
Antidotes
Tamponade
pericardiocentesis
Tension pneumothorax
Needle decompression
Tube thoracostomy
Thrombosis (coronary or
pulmonary)
Thrombolytics
OR/cath lab
Trauma
49

19 yo man with palpitations

What is the rhythm?

What is the management?

50

Supraventricular Tachycardia

Rapid (usually 150-250 bpm) and regular

P waves cannot be positively identified
QRS narrow
Note: P waves either merge with preceding T waves or are buried in QRS
complexes so the differentiation between atrial and junctional
tachycardia is impossible.
P waves buried in T wave or QRS or not present cant differentiate
supraventricular from junctional most are supraventricular
51

Treatment of Stable SVT (1)

Consider vagal maneuvers
Carotid sinus massage
Valsalva
Eyeball massage
Ice water to face
Digital rectal exam

Adenosine
6 mg, 12 mg, 12 mg
NB: Carotid massage - Turn head, Locate maximal impulse of carotid
artery. Massage up and down massage for 5-10 seconds.
One side at a time. Do not do in someone you suspect carotid disease
52

Treatment of Unstable SVT (2)

Electrical Cardioversion
Cardioversion is not defibrillation
Use defibrillator in sync mode
prevents delivering energy in the wrong part of
the cardiac cycle (R on T phenomenon)
NB: Heart is not fibrillating

53

Electrical Cardioversion (1)

Energy level somewhat controversial
100 J200J300J360J
Atrial flutter may convert with lower energy
50J

For polymorphic VT start with 200J

54

Electrical Cardioversion (2)

Be prepared
Patient on monitor, IV, Oxygen
Suction ready and working
Airway supplies ready

Pre-medicate whenever possible

Conscious sedation
Electrical shocks are painful!

55

Tachycardia
Evaluate Patient
Stable?

Unstable?

Lots of options
based on rhythm

Shock

Treat the patient NOT the monitor!!!

56

Stable Tachycardias
Narrow complex?
Regular rhythm
Sinus tachycardia
SVT
AV nodal reentry
Irregular rhythm
Atrial fibrillation
Atrial flutter

Wide complex?
Uncertain rhythm
assume VT
Narrow complex
tachycardia with
aberrancy
Ventricular tachycardia
Monomorphic or
polymorphic

57

56 yo woman with shortness of breath and

chest pain

What is the rhythm?

What is the management?

58

Atrial fibrillation/flutter

May be rapid
Irregular (fib) or more regular (flutter)
No P waves, narrow QRS
59

Atrial fibrillation/flutter
Treatment based on patients clinical picture
Unstable = Immediate electrical cardioversion
Stable
Control the rate
Diltiazem
Esmolol (not if EF < 40%)
Digoxin

Provide anticoagulation

Treat the patient NOT the monitor!!!

60

78yo man found down, pulseless and

apneic, unknown duration

What is the rhythm?

What is the management?

61

Asystole

Is it really asystole?
Check lead and cable connections.
Is everything turned on?
Verify asystole in another lead.
Maybe it is really fine v-fib?

62

68 yo woman with h/o hypertension

presents with dizziness

What is the rhythm?

What is the treatment?

63

Sinus Bradycardia

Slow and regular

Normal P waves and QRS complexes

64

Bradycardias (1)
Many possible causes
Enhanced parasympathetic tone
Increased ICP.
Hypothyroidism
Hypothermia
Hyperkalemia
Hypoglycemia
Drug therapy
65

Bradycardias (2)
Treat only symptomatic bradycardias
Ask if the bradycardia causing the symptoms

Recognize the red flag bradycardias

Second degree type II block
Third degree block

66

Transcutaneous pacing (1)

Class I for all symptomatic bradycardias

Always appropriate
Doesnt always work
Technique
Attach pacer pads
Set a rate to 80 bpm
Turn up the juice (amps) until you get capture

Painful may need sedation / analgesia

67

Transvenous Pacing (2)

Invasive
Time-consuming to establish
Skilled procedure
Better long-term than transcutaneous
May have better capture than transcutaneous
pacing

68

Bradycardia Treatment
Medications
Vagolytic
Atropine

Adrenergic
Epinephrine
Dopamine

69

29 yo asymptomatic female

What is the rhythm?

What is the management?

70

1 AV block

Regular rate and rhythm

Normal P wave with long PR interval (>0.2msec/1 big
box)
Normal QRS
Note: No emergent treatment needed (asymptomatic)
Follow bradycardia algorhitm if unstable

71

58yo asymptomatic woman

What is the rhythm?

What is the management?

72

2 AV Block - Type I

aka Wenckebach
Regular rate and rhythm
Normal P waves and QRS complexes
Increasing PR interval until QRS dropped
May be bradycardic. No ACLS interventions indicated
(asymptomatic)

73

80 yo man with syncope

What is the rhythm?

What is the management?

74

2 AV Block Mobitz Type II

Regular atrial rate with normal P wave

Consistent PR interval
Random QRS dropped
Note: Follow bradycardia algorithm prepare for pacing even if
asymptomatic as this block can worsen
75

Another 80 yo man with syncope

What is the rhythm?

What is the management?

76

3 AV Block

Normal P waves
Normal QRS
No relationship between P and QRS
aka complete heart block
NB: Follow bradycardia algorithm. Will need to be paced.
May also have wide complexes if escape rhythm is present
77

Know When To Stop

With return of spontaneous circulation
No ROSC during or after 20 minutes of
resuscitative efforts
Possible exceptions include near-drowning, severe
hypothermia, known reversible cause, some
overdoses

DNR orders presented

Obvious signs of irreversible death
N.B. For out-of-hospital providers also include
transfer of care, danger to providers, etc

78

Take Home Points

Assess and manage at every step before
moving on to the next step
Rapid defibrillation is the ONLY effective
treatment for VF/VT
Search for and treat the cause
Treat the patient not the monitor
Reassess frequently
Minimize interruptions to chest compressions
79

End of ACLS CE Part I

THANK YOU FOR YOUR ATTENTION
Reference resources and further study:
ACLS Study Guide - ECG STRIP INTERPRETATION.pdf
ACLS Rhythms for the ACLS Algorithms.pdf
http://acls-algorithms.com/ Website, including Megacode simulator

To follow:
Part II
ACLS in Acute Coronary Syndromes / Cardiac Arrest
Importance of CPR / BLS in most current (2010) AHA ACLS
Relationship of the chain of survival to successful resuscitation of the
cardiac arrest patient
Discuss the interventions required to ensure good outcomes with
Return of Spontaneous Circulation (ROSC)
Part III
Defibrillation and ACLS Drug Therapy
80