“This Patient is Trying to Die”
Life Threatening Rhythm Strips
Steve Stapczynski MD
Chair of the Emergency Department
Maricopa Medical Center
Department of Emergency Medicine
Phoenix Arizona
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About This Lecture
• A series of rhythm strips of patients with
cardiac arrest and peri-cardiac arrest
• These strips can be difficult – we do not
see these rhythms every day
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American Heart Association
Fundamentals
• Complexes show only ventricular origin
and rapidly changing morphology. The
amplitude is ≥ 200 μVpp for ≥ 5 of the
ECG complexes, and there are ≥ 12
complexes ≥ 80 μVpp within a 5-second
ECG segment.
• Ventricular Fibrillation
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American Heart Association
• Complexes show only ventricular origin
• Defined based on rate > 250 BPM and is
independent of morphology.
• Unstable or continuously changing
morphology with rate > 150 BPM.
• Ventricular Tachycardia
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American Heart Association
• Complexes show sinus origin with a rate <
100 BPM and ≥ 50 BPM. Includes bundle
branch block (BBB)
• Normal Sinus Rhythm
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American Heart Association
• Complexes show supra-ventricular origin
with a ventricular rate ≥ 100 BPM
• Includes atrial flutter and fibrillation, sinus
or junctional tachycardia, and PSVT.
• Includes bundle branch block.
• Supraventricular Tachycardia
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American Heart Association
• Complexes show a supra-ventricular origin
with a ventricular rate < 100 BPM.
• Includes atrial flutter and fibrillation, sinus
arrhythmia with or without PACs,
junctional rhythms, with or without AV
block and bundle branch block.
• Supraventricular dyrhythmia
• Organized Regular
• Organized Irregular
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American Heart Association
• Includes accelerated and non-accelerated
idioventricular rhythms.
• Complexes show only ventricular origin,
with or without uniform morphology.
• Rate is < 100 BPM and rhythm is regular
with at least 1 complex ≥ 80μVpp within a
5-second ECG segment.
• Idioventricular Rhythm
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American Heart Association
• Maximum of one complex > 80μVpp and
all complexes less than 200μVpp.
• This class may include very low amplitude
fibrillation-like complexes, or very low rate
rhythms with only one complex in a 5second segment, as well as "flatline"
cases.
• Asystole
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American Heart Association
• Complexes show supra-ventricular origin
with a rate < 50 BPM, with at least 1
complex ≥ 80uVpp within a 5-second ECG
segment. Includes bundle branch block
• Organized Bradycardia
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American Heart Association
• Low rate or low amplitude ventricular
fibrillation, or electrical activity of unknown
etiology, likely to be associated with a
pulseless asystolic patient. The rhythm
does not satisfy the criteria for Asystole,
VF, or Idioventricular classes.
• Low Rate/Low Amplitude…Agonal
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American Heart Association
Modifiers:
• Paced Rhythm
• Defibrillation attempt
• Ectopic Beats: PACs and PVCs
• Shock versus No Shock
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How to Read a Rhythm Strip
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Step 1. Regular or Irregular
Step 2. Rate? Fast, Slow or Normal
Step 3. Narrow or Wide?
Step 4. Are there P-waves?
Step 5. Are all the complexes the same?
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Determining Heart Rate on the
Rhythm Strip
• If the rhythm is regular, the heart rate is 300
divided by the number of large squares between
the QRS complexes.
• If there are 4 large squares between QRS
complexes, heart rate is 75 (300/4=75).
• Second method can be used with an irregular
rhythm: Count the number of R waves in a 6
second strip and multiply by 10.
– If there are 7 R waves in a 6 second strip, the
heart rate is 70 (7x10=70).
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The Answer Key
• These rhythm strips were independently
interpreted by three emergency physicians
• High degree of agreement
• Differences were settled via conference call
• This data set is used to program automated
defibrillators – shock versus no shock –
computer algorithm compared with human
interpretation
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CAPTCHA (Completely Automated Public Turing
Test To Tell Computers and Humans Apart) coined in 2000 by Luis von Ahn, Manuel Blum,
Nicholas Hopper and John Langford of Carnegie
Mellon University.
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Case 1
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Ventricular Fibrillation with a few
beats of Ventricular Tachycardia
Shock
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Case 2
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Ventricular Fibrillation - Shock
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Case 3
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Organized Tachycardia
No Shock
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Case 4
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Asystole or Low Amplitude
No Shock
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Case 5
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Organized Tachycardia
No Shock
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Case 6
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Ventricular Fibrillation
Shock
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Case 7
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Low Amplitude - Agonal
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Case 8
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Fine VF = Almost Asystole
Good candidate for Epi?
Shocking will probably NOT work
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Case 9
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Asystole
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Case 10
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Idioventricular Rhythm
Ectopic Beat, No Shock
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Case 11
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VT then VF then VT
Shock
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Case 12
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VF Shock
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Case 13
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Low Amplitude or Agonal
No Shock
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Case 14
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Asystole = No Shock
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Case 15
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Idioventricular Rhythm
No Shock
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Case 16
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VT Shock (Type of VT?)
Torsades
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Case 17
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Mostly VF with some VT
Shock
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Case 18
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Asystole = No Shock
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Case 19
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IV No Shock
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Case 20
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IV No Shock
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Case 21
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VF Shock (Internal Defibrillator)
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Case 22
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SVT with 4 Ectopic Beats
No Shock
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Case 23
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VF Shock
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Case 24
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VT Shock if Unstable
Could also be SVT with Aberrancy
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Case 25
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VF and VT Shock
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Case 26
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OI – No Shock – Look for
electrolyte abnormalities
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Case 27
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Junctional w/ retrograde P Wave
No Shock
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Case 28
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VF - Shock
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Case 29
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SVT = No Shock
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Case 30
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VF Pacemaker Shock
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Case 31
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VT Shock if Unstable
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Case 32
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VT Shock
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Case 33
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IV = No Shock
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Case 34
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OT = No Shock
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Case 35
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Paced with Electrical Capture
No Shock
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Case 36
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VT with Pacemaker Spikes
Shock
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Case 37
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Paced No Shock
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Case 38
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VT Shock
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Case 39
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AMI - No Shock
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Case 40
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IV - No Shock
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Case 41
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NSR - No Shock
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Case 42
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SVT versus VT
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Case 43
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Sinus Tachycardia with ST Depression,
Ectopic beats present, No shock
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Case 44
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Accelerated Junctional Rhythm with
retrograde p wave conduction with QRS
origin below the AV node – No shock
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Case 45
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Paced rhythm with electrical
capture – No shock
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Case 46
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VF Shock
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Case 47
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VF Shock – One electrical
device shock present
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Case 48
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VF Shock Pacemaker spikes
with NO electrical capture
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Case 49
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Slow junctional bradycardia
between 30-40 bpm, retrograde
p waves, No shock
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Case 50
• What happened here?
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Asystole – Epinephrine Injection
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Life Threatening Rhythm Strip Analysis
Steve Stapczynski, MD
Thank you!
Steve_Stapczynski@dmgaz.org
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