APPROACH TO
ACLS RHYTHMS
Dr. Jill Irene Capistrano-Sun
Dr. Miriam Roxas Timonera
Advanced Cardiac Life
Support
• Basic Life Support (BLS)
• Efficient use of Skills and equipment in
maintaining circulation and ventilation
• ECG monitoring and Arrythmia recognition
• Intravenous access and drug administration
• Emergency therapies for respiratory, cardiac
and post-cardiac arrest
• Acute coronary syndrome and stroke
management
Advanced Cardiac Life
Support
BLS
Equipment
and
Techniques
Ethical
considerations
First Aid
ACLS
ACS and
stroke
management
ECG and
Arrythmia
recognition
IV Drug
administration
Emergency
Therapies
Background: CARDIAC SYSTOLE & DIASTOLE
1-Atrial diastole
4-ventricular systole
2-Atrial systole
Atria relax and
fill with blood
Ventricles contract
And force blood
Out of heart
3-Ventricular diastole
Atria contract and
force blood into
ventricles
Ventricles relax and
fill with blood
Anatomy and Physiology
Of cardiac conduction
LA
RA
LV
RV
Anatomy and Physiology
Of cardiac conduction
Sinoatrial Node
(SA Node)
60-100 bpm
Bundle of His
(40-60 bpm)
Atrioventricular Node
(AV Node)
40-60 bpm
Bundle branches
Purkinje fibers
(20-40 bpm)
Review
Impulse Formation In SA
Node
Atrial Depolarization
Delay At AV Node
Conduction Through Bundle
Branches
Conduction Through
Purkinje Fibers
Ventricular Depolarization
Plateau Phase of
Repolarization
Final Rapid Repolarization
Basic ECG information
.08 – 0.10 sec
0.12 – 0.20 sec
0.40 – 0.43 sec
Basic ECG information
1.Rate
2.Intervals
3.Rhythm
1. Rate
Different ways to calculate a rate:
a) Locate a QRS that is close to a big line and count to
next big line: 300, 150, 100, 75, 60, 50
1 small box = .04 sec
1 small square = 5 small boxes or 0.2 sec
60 sec/ 0.2 sec = 300 /min
1 big line: 60 sec/ 0.2 sec = 300/min
2 big lines: 60 sec/ 0.4 sec = 150/min
3 big lines: 60 sec/0.6 sec = 100/min
4 big lines: 60 sec/0.8 sec = 75/min
Computation of Rate
1,500
= rate
# of small squares
3 big boxes = 15 small squares
1500 / 15 small squares = 100/min
5 big boxes = 25 small squares
1500 / 25 small squares = 60/min
How many QRS in 3 big boxes ?
1500 / 15 small squares = 100/min
How many QRS in 5 big boxes ?
1500 / 25 small squares = 60/min
1. Rate
Different ways to calculate a rate:
a) Locate a QRS that is close to a big line and count to
next big line: 300, 150, 100, 75, 60, 50
How many QRS in 5 big boxes ?
How many QRS in 3 big boxes ?
How many QRS complexes in this 6 second strip?
11 X 10 = 110 /min
Rate using 6 second strip
b) take a 6 second strip, count number of QRS complexes
and multiply by 10
1
2
3
4
5
6
7
8
9
10
11
How many QRS complexes in this 6 second strip?
1 minute = 60 seconds = 60 secs/ 6 secs = 10
11 X 10 = 110 /min
2. Intervals
We assess intervals to see where the
impulse is coming from (pacemaker beat)
Remember:
PR interval: normal is 0.12 - 0.2
QRS interval: normal is less than or
equal to 0.12
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
First degree AV block
Second degree AV block
Third degree AV block
Escape Rhythms:
Junctional Rhythm
Idioventricular Rhythm
Ventricular fibrillation
Ventricular tachycardia
Asystole
Causes of Cardiac Arrhythmias
• Disturbances in automaticity
• Disturbances in conduction
• Combinations of altered
automaticity and conduction
Firing
TACHYARRHYTHMIAS
Firing
Automaticity
of SA Node
Abnormal
Automaticity
and
Triggered
Activity
Re-entry
Physiologic
Altered
Impulse
Formation
Altered
Impulse
Conduction
Pathologic
Conduction
Blocks
Automaticity
of SA Node
Firing
BRADYARRHYTHMIAS
Firing
Mechanism of Arrhythmia Development
BRADYARRHYTHMIAS
ABNORMALITY
MECHANISM
EXAMPLES
Altered Impulse
Formation
 automaticity
Phase 4
depolarization
(e.g.cholinergic
stimulation)
Sinus Bradycardia
Altered Impulse
Conduction
 Conduction
blocks
Ischemic, anatomic
or drug-induced
impaired
conduction
1st , 2nd, 3rd degree
AV Block
Mechanism of Arrhythmia Development
TACHYARRHYTHMIAS
ALTERED IMPULSE
FORMATION
•Enhanced automaticity
•Increased phase 4 depolarization
•Sinus node
(e.g., sympathetic stimulation)
•Acquired phase 4 depolarization
•Ectopic focus
•Triggered activity
•Prolonged action potential
•Early
afterdepolarization (tissue damage or drug-induced)
•Intracellular calcium overload
•Delayed
afterdepolarization (e.g., digitalis toxicity)
ALTERED IMPULSE
CONDUCTION
•Reentry
•Unidirectional block + slowed
retrograde conduction
•Sinus tachycardia
•Ectopic atrial tachycardia
•Torsade de pointes
•PAC,PVC, digitalisinduced SVT
•Paroxysmal SVT, atrial
flutter/fibrillation, Vent.
tachycardia/fibrillation
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
(Normal) Sinus Rhythm
• 60-100 bpm
• P preceding each QRS
• Normal intervals
..\..\Basic Rhythm Edited\1.avi
Other Sinus Rhythms
• Sinus bradycardia
..\..\Basic Rhythm Edited\29.avi
– a sinus rhythm with a rate <60 bpm
Other Sinus Rhythms
• Sinus tachycardia
..\..\Basic Rhythm Edited\28.avi
– a sinus rhythm with a rate >100 bpm
2. Rhythm
What’s the rhythm?
A) Normal Sinus Rhythm
B) Sinus bradycardia
C) Sinus tachycardia
2. Rhythm
What’s the rhythm?
A) Normal Sinus Rhythm
B) Sinus bradycardia
C) Sinus tachycardia
What’s the HR?
5 x 10 = 50/min
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
SUPRAVENTRICULAR
TACHYCARDIA
Narrow complex tachycardia
SUPRAVENTRICULAR
TACHYCARDIA
•
•
•
•
•
•
Atrial Fibrillation
Atrial Flutter
Paroxysmal SVT (PSVT)
Non paroxysmal atrial tachycardia
Multifocal atrial tachycardia (MAT)
Junctional tachycardia
Supraventricular Arrhythmias
• IRREGULAR RHYTHM
•
•
•
•
Atrial fibrillation
Atrial flutter with varying AV conduction
Wandering atrial pacemaker
Multifocal atrial tachycardia
• REGULAR RHYTHM
•
•
•
•
•
•
Sinus Tachycardia
Atrial tachycardia
Junctional/atrioventricular rhythm
Atrial flutter with fixed AV conduction
AV nodal reentrant tachycardia
AV reentrant tachycardia
Atrial Arrhythmias
• ATRIAL FIBRILLATION (A-fib)
– irregular rate
– no discernable P waves
– increased risk of strokes due to clots that
might form due to fibrillation (patients are
usually on anticoagulation therapy)
Atrial Fibrillation
• Results from multiple areas of re-entry with
in the atria from multiple ectopic foci
• Atrial Rate = 400 - 700/min
• irregularly irregular; fibrillation waves
• no organized atrial activity; no P waves
Atrial fibrillation
..\..\Basic Rhythm Edited\5.avi
Atrial Arrhythmias
• Atrial flutter
– saw tooth in appearance
– irregular rate
Atrial Flutter
• Atrial rate 220-350/min
• ventricular rhythm may be regular
• P waves: flutter waves resemble
SAWTOOTH or PICKET FENCE
Atrial flutter
..\..\Basic Rhythm Edited\3.avi
Atrial Fibrillation/Atrial Flutter
Treatment:
if unstable: cardiovert
if stable : digoxin
verapamil
diltiazem
-blockers
Paroxysmal Supraventricular Tachycardia
• Basic considerations
–
–
–
–
–
circus movement or reciprocating tachycardias
utilize the mechanism of reentry
Sudden onset
Stops abruptly
Usually a narrow QRS complex tachycardia
• Exceptions:
– Pre-existing conduction
– Aberrant ventricular conduction
– Pre-excitation
SUPRAVENTRICULAR
TACHYCARDIA
• Characterized by tachycardia with a narrow QRS
complex
• sudden onset and termination
• 150-250 beats/min (180 to 200 bpm in adults)
• regular rhythm
• QRS complex is normal in contour and duration
• No P waves
• P waves are generally buried in the QRS complex
• Often, P wave is seen just prior to or just after the end of
the QRS and causes a subtle alteration in the QRS
complex that results in a pseudo-S or pseudo-r
PSVT
• Regular narrow-complex
• Tachycardia without discernible P
waves (?)
• Sudden onset or cessation
SUPRAVENTRICULAR TACHYCARDIA
SUPRAVENTRICULAR
TACHYCARDIA
..\..\Basic Rhythm Edited\2.avi
2. Rhythm
..\..\Basic Rhythm Edited\4.avi
What’s the rhythm?
What’s the HR?
A) Atrial fibrillation
B) Atrial flutter
C) Supraventricular tachycardia
D) Sinus tachycardia
13 x 10 = 130/min
2. Rhythm
What’s the rhythm?
A) Atrial fibrillation
B) Atrial flutter
C) Supraventricular tachycardia
D) Sinus tachycardia
What’s the HR?
7 x 10 = 70/min
2. Rhythm
What’s the rhythm?
A) Atrial fibrillation
B) Atrial flutter
C) Supraventricular tachycardia
D) Sinus tachycardia
What’s the HR?
9 x 10 = 90/min
2. Rhythm
What’s the rhythm?
A) Atrial fibrillation
B) Atrial flutter
C) Supraventricular tachycardia
D) Sinus tachycardia
..\..\Basic Rhythm Edited\4.avi
What’s the HR?
16 x 10 = 160/min
2. Rhythm
A
B
C
D
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
First degree AV block
Second degree AV block
Third degree AV block
BRADYCARDIAS:
ATRIOVENTRICULAR
BLOCKS
Anatomical Sites of Heart Block
First Degree AV Block
• delay in passage of impulse from atria to
ventricles
• normal QRS; regular rhythm
• PR interval prolonged >0.20 sec.
Blocks
..\..\Basic Rhythm Edited\18.avi
• 1st degree AV block
– a PR interval that exceeds 0.20 sec
1st degree AV block ( PR = 0.28 sec)
Blocks
..\..\Basic Rhythm Edited\19.avi
• 2nd degree AV block (Mobitz)
– a) type I (Wenckebach)
• longer and longer PR intervals until a QRS is dropped
Blocks
..\..\Basic Rhythm Edited\20.avi
• 2nd degree AV block (Mobitz)
– a) type I (Wenckebach)
• longer and longer PR intervals until a QRS is dropped
Second Degree AV Block
• MOBITZ Type I (wenckebach)
progressive prolongation of PR
interval until an impulse is blocked
Blocks
..\..\Basic Rhythm Edited\20.avi
• 2ND DEGREE AV BLOCK (MOBITZ II)
b) type II
• P waves are regular, PR duration is constant
and then suddenly a QRS is dropped
Type II 2nd Degree AV Block
• No lengthening of PR interval before a
dropped beat
HIGH GRADE AV BLOCK
3rd degree AV block
..\..\Basic Rhythm Edited\21.avi
• P waves with a regular P to P interval
• QRS complexes with a regular R to R interval
• The PR interval will appear variable because there is no
relationship between the P waves and the QRS Complexes
Third Degree AV Block
• Complete absence of conduction between atria
and ventricles
• atrial rate is always equal to or more than
ventricular rate
• QRS may be narrow or wide depending on level
of block
3rd Degree AV Block
• level of AV Node
3rd Degree AV Block
• At ventricular level
Paced Rhythm
2. Rhythm
What’s the rhythm?
A) First degree AV block
B) Second degree AV block
C) Third degree AV block
2. Rhythm
What’s the rhythm?
A) First degree AV block
B) Second degree AV block
C) Third degree AV block
A. Mobitz I (Wenckebach)
B. Mobitz II
2. Rhythm
Mobitz I or Wenchebach
Non conducted p
Mobitz II
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
First degree AV block
Second degree AV block
Third degree AV block
Escape Rhythms:
Junctional Rhythm
Idioventricular Rhythm
Junctional Complexes
• conducting tissue near AV node has
taken over the pacemaker of the
heart
• rate 40-60
• usually with retrograde P waves
Junctional Rhythm
Junctional Rhythm
•Impulses from the AV node
•P wave inverted or buried w/in
QRS or follows the QRS
•Rate slow
•QRS narrow
..\..\Basic Rhythm Edited\6.avi
•Impulses from the AV node
•P wave inverted or buried w/in QRS or follows the QRS
•Rate slow
•QRS narrow
Idioventricular Rhythm
Impulse ventricular in origin
Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to QRS
Rate < 40 / min
Rate < 48 / min
ACLS PHILHEART CENTER
Accelerated Idioventricular Rhythm
Impulse ventricular in origin
Absence of (N), upright P wave
associated with QRS complexes
QRS > 0.10 sec
T wave opposite in direction to QRS
Rate = 40-120 / min
Rate = 40-120 / min
ACLS PHILHEART CENTER
Accelerated Junctional Rhythm
•Impulses from the AV node
•P wave inverted or buried w/in
QRS or follows the QRS
•Rate 60-100 bpm
•QRS narrow
Idioventricular Rhythm
..\..\Basic Rhythm Edited\7.avi
Idioventricular Rhythm
•Impulse ventricular in origin
•Absence of (N), upright P wave
associated with QRS complexes
•QRS > 0.10 sec
•T wave opposite in direction to QRS
•Rate < 40 / min
Rate < 40 / min
Accelerated Idioventricular Rhythm
•Impulse ventricular in origin
•Absence of (N), upright P wave
associated with QRS complexes
•QRS > 0.10 sec
•T wave opposite in direction to QRS
•Rate = 40-100 / min
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
First degree AV block
Second degree AV block
Third degree AV block
Escape Rhythms:
Junctional Rhythm
Idioventricular Rhythm
Ventricular fibrillation
Ventricular tachycardia
VENTRICULAR
TACHYCARDIA
Wide complex tachycardia
Premature Ventricular Contraction
•
•
•
•
•
•
•
Prematurely occurring complex.
Wide, bizarre looking QRS complex.
Usually no preceding P wave.
T wave opposite in deflection to the QRS
complex.
Complete compensatory pause following
every premature beat.
ACLS PHILHEART CENTER
Premature Ventricular Contraction
in Couplets
Two Premature ventricular
contractions occurring consecutively
ACLS PHILHEART CENTER
Premature Ventricular Contraction
in Bigeminy
Alternating normal sinus beat and
a PVC
ACLS PHILHEART CENTER
Premature Ventricular Contraction
in Trigeminy
PVC’s regularly occurring every
third beat
ACLS PHILHEART CENTER
Multifocal Premature Ventricular
Contraction
PVC’s coming from different foci in
the ventricle
PVC’s assuming different polarities
in a single lead
PVC’s of different morphology and
coupling interval
ACLS PHILHEART CENTER
Premature Ventricular Contraction
R on T Phenomenon
R or Q of the PVC occurring at the
T wave of the preceding sinus beat
Most dangerous PVC
ACLS PHILHEART CENTER
Ventricular tachycardia (V-tach)
• impulse originates in the ventricle
• always has a wide QRS complex
ACLS PHILHEART CENTER
Ventricular Tachycardia
•At least 3 consecutive PVC’s
•Rapid, bizarre, wide QRS complexes
(> 0.10 sec)
•No P wave (ventricular impulse
origin)
Rate > 100 / min
ACLS PHILHEART CENTER
ACLS PHILHEART CENTER
Ventricular Tachycardia
ACLS PHILHEART CENTER
Ventricular Tachycardia
• Nonsustained
• Sustained
• Monomorphic
• Polymorphic
• Torsades pointes
• ..\..\Basic Rhythm Edited\9.avi
Accelerated Idioventricular Rhythm
With 2 foci of ventricular activity
ACLS PHILHEART CENTER
Pre excitation : WOLFF PARKINSON WHITE
Rhythm is sinus except during pre excited tachycardia
Short PR interval
QRS distorted by delta wave
ACLS PHILHEART CENTER
Pre excited tachycardia
ACLS PHILHEART CENTER
Torsades de Pointes
• A form of polymorphic VT
• Electrical tracing appears to be twisted into a helix
• This form of ventricular tachycardia degenerates relatively
often into ventricular fibrillation
ACLS PHILHEART CENTER
Torsades de Pointes
ACLS PHILHEART CENTER
Ventricular Tachycardia
Treatment:
lidocaine
procainamide
amiodarone
sotalol
if unstable:
electrical cardioversion or defibrillation
for torsades de pointes:
Magnesium Sulfate
overdrive pacing
ACLS PHILHEART CENTER
Ventricular Fibrillation
Associated with coarse or fine chaotic
undulations of the ECG baseline
No P wave
No true QRS complexes
Indeterminate rate
Coarse Fibrillation
Fine Fibrillation
Ventricular fibrillation
– complete breakdown of all rhythm
Ventricular Fibrillation
• single most important rhythm for an ACLS
provider to recognize
• no organized ventricular depolarization
• no EFFECTIVE cardiac output
• may be coarse or fine
Coarse Ventricular Fibrillation
Fine Ventricular Fibrillation
Ventricular Fibrillation
Ventricular Fibrillation
Management
Only DEFIBRILLATION
provides definitive therapy
2. Rhythm
What’s the rhythm?
A) Ventricular fibrillation
B) Ventricular tachycardia
A) Monomorphic
B) Polymorphic
C) Torsade de Pointes
2. Rhythm
Most commonly encountered rhythms:
Normal Sinus Rhythm
Sinus bradycardia
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
First degree AV block
Second degree AV block
Third degree AV block
Escape Rhythms:
Junctional Rhythm
Idioventricular Rhythm
Ventricular fibrillation
Ventricular tachycardia
Asystole
Ventricular Asystole
• total absence of ventricular electrical
activity
• FLAT LINE PPROTOCOL :
• check 2 leads on the monitor
perpendicular to each other to make sure
patient is in asystole
• Check all connections of patient to monitor
• Adjust gain/sensitivity
Asystole
• Pulseless
..\..\Basic Rhythm Edited\15.avi
ASYSTOLE
• absence of ventricular electrical activity
• sometimes p waves or ventricular
escape beats (agonal beats) may occur
ASYSTOLE
Treatment:
epinephrine
atropine
search for reversible cause
CPR
2. Rhythm
What’s the rhythm
A) Ventricular fibrillation
B) Asystole
Ventricular fibrillation changing to Asystole