Section 5 : Sinus Rhythms

Sinus rhythms are those that arise from the pacemaker in the sinus node (also called the SA node). The sinus pacemaker is our heart's normal pacemaker. We have three basic rhythms that originate in the sinus node. If the heart's rate is below 60 beats/min, we call it sinus bradycardia. If the rate is above 100 beats/min, the rhythm is called sinus tachycardia. If everything is just right, the rhythm is called normal sinus rhythm (NSR). (These rates apply to human adults. Pediatrics is a whole 'nother world.) Of course, if all rhythms started in the sinus node, we probably wouldn't have a section devoted specifically to sinus rhythms. While the normal heart rhythm is of sinus origin, there are many arrhythmias that do not start in the sinus. Why is the sinus the best place to start? One reason is that an impulse that originates in the sinus node follows a certain path that allows the atria to contract before the ventricles. If the two sets of chambers contracted at the same time, the atria would push against closed valves. Because there are no valves that separate the atria from their veins (vena cava and pulmonary vein), blood would flow backwards. This often causes the jugular veins in the neck to pulse. Between the atria and the ventricles is the A.V. node. On the diagram of the firecracker (figure x-x), this node is represented by the yellow tunnel. Conduction of the electrical impulse slows down in the A.V. node, allowing the atria to completely depolarize before the ventricles so that atria may contract first. On the ECG, the isoelectric part between the P wave and the QRS complex demonstrates this pause. If the conduction through the A.V. node were slowed too much, the ECG would show this as a PR interval that is longer than 0.20 seconds.

Figure 5-1 :The match represents the sinus pacemaker. The yellow tunnel represents the AV node.

How can you tell if an ECG rhythm originates in the sinus node? One thing to do is to look at the P wave. A rounded, upright P wave is often indicative of the sinus pacemaker. (Occasionally, the amplitude of an ECG is so great that the P wave will end up looking pointed even though it is sinus. Be very careful with this.) In non-sinus (i.e. ectopic) pacemakers, the P waves are often either notched, very pointed, inverted, or absent. To know what a normal rhythm looks like, it is best to be familiar with abnormal rhythms. Don't be caught off guard by a weird looking QRS complex. Just because it doesn't look like the "textbook example" of the QRS does not mean that it is abnormal. A normal QRS is less than 0.12 seconds, but it is not limited to a single shape. Although the QRS complexes can differ from ECG to ECG, it should not be considered normal if they were to differ in the same ECG.

Normal sinus rhythm A normal sinus rhythm (NSR) is the common, everyday rhythm. It must be, of course, sinus in origin. It must be regular and have a rate between 60 - 100 per minute. It must have a normal PRI and QRS duration.

Figure 5-2 : A normal sinus rhythm

Often times, an arrhythmia is described by saying the "underlying rhythm" and adding to that anything abnormal (e.g. sinus rhythm with first degree heart block). If any abnormalities exist, do not include the word normal when designating the underlying rhythm.

Sinus bradycardia This is just like a normal sinus rhythm except that the rate is slower than 60 per minute.

Figure 5-3 : Sinus bradycardia

Remember that the limits of 60 and 100 are arbitrary. A person who has a rate of 59 beats/min would not feel much different than he would at a rate of 60 beats/min. Some people (especially athletes) have a normal resting heart rate below 60. When President (George W.) Bush passed out after choking on a pretzel, it was revealed that his normal heart rate was around 45 beats/min. Many pundits became alarmed and criticized the president for not revealing his "disease" prior to the incident. The talking cardiologist heads were quick to point out that "disease IS as disease DOES"- that a disease is based on the patient and not always on standard one-size-fits-all guidelines. Some people

may become symptomatic when there heart rate falls even though it is still above 60. We would call this relative bradycardia. This would be a good time to reiterate : treat the patient, not the machine.

Sinus tachycardia This is just like a normal sinus rhythm except that the rate is faster than 100 per minute.

Figure 5-4 : Sinus tachycardia

Sinus tachycardia is common in everyone. If you are a paramedic or EMT, you will probably find plenty of patients in sinus tachycardia simply because they are nervous or excited. In more serious cases, a person in the early stages of shock may have a fast heart rate to compensate for the would-be-fall in blood pressure. Sinus tachycardia in itself is not always a bad thing; treatment should be aimed at the underlying cause.

Sinus arrhythmia Sinus arrhythmia is similar to normal sinus rhythm except that it the rate is irregular. It often matches the patient's breathing pattern, speeding up when the patient inhales and slowing down when the patient exhales. Sinus arrhythmia can be relatively common in young and is often asymptomatic. How irregular is irregular? The criterion used by many is that the longest R-R interval should differ from the shortest by at least 0.16 seconds.

Figure 5-5 : Sinus arrhythmia

Section 6 : Atrial Rhythms

Atrial rhythms are rhythms that originate in the atria. The atrial rhythms that fall under the category of PSVT are mentioned elsewhere. What is the difference between an electrical beat originating in the sinus and one originating in the atria? For one, the P wave tends to be a different shape. Sinus P waves tend to be rounded, upright, etc. while atria P waves tend to be weird shaped. Sometimes they are pointy, sometime flat. They can have a notch running down the middle of them. Some are diphasic, which means that one part is above the isoelectric line while one part is below it.

Premature atrial complex When you feel your heart has "skipped a beat," it very well may have been due to a PAC. A premature atrial complex (PAC) describes a wave or set of waves caused by an atrial pacemaker that interrupts the underlying rhythm. Figure 6-1 shows a sinus rhythm that is twice interrupted by PACs. The PACs shown consist of an atrial P wave along with a normal QRS complex and a normal T wave. Compare the P waves on both the sinus complexes and the PACs. Premature describes the fact that the beat occurred before the regular one would have. In figure 6-1, you can imagine that the sinus pacemaker was firing along at a regular rhythm until it was unexpectedly (and rudely) interrupted by the atrial pacemaker. The atrial pacemaker causes the wave of depolarization that resets the sinus node. Look at the R-R intervals. The ones from the sinus to the following atrial complexes are shorter than the others.

Figure 6-1 : A sinus rhythm with two premature atrial complexes

When an atrial pacemaker fire prematurely, it is entirely possible that the AV node is still refractory. In these situations, you might find a single atrial P wave without the QRS complex and T waves. We describe this as non-conducted. When these impulses conduct, you may see either a normal QRS or a wide QRS. The wide QRS in this case is due to what is called aberrancy. This is often due to one of the bundle branches still being refractory. PACs are also covered in Section 10 : Premature Complexes.

Atrial fibrillation Atrial fibrillation (often called "a-fib") is relatively common among the elderly. It occurs when the electricity in the atria follows a seemingly random and repetitive path, causing the atria to quiver. (The word fibrillation means quivering.) Because the atria are quivering, they are unable to pump blood. The ventricles are still functional, but are depolarized at irregular intervals. This rhythm can last for years and is not always symptomatic. There are a few reasons why this rhythm is bad. Some of them are : The ventricles may be depolarized at too high a rate. The atria are unable to perform their normal function. Clots may form in the left atrium, predisposing the patient to a stroke. The old saying "a rolling stone gathers no moss" might be applied to blood. Instead of gathering moss, stagnant blood tends to form thrombi (clots).

Figure 6-2 : Atrial fibrillation

One of the major questions that doctors are asking themselves is : is it better to control or convert?

Control refers to controlling the rate. Keeping the rate of ventricular contraction under 100/min. often minimizes the symptoms of this rhythm. This is usually done with medication. When the rate of QRS complexes (and thus ventricular depolarizations) exceeds 100, we call this rhythm uncontrolled atrial fibrillation. Convert refers to converting the rhythm into a sinus rhythm. You might think this would be the obvious choice. The problem is, however, that someone who has been in atrial fibrillation for a while has a high chance of "throwing clots" in the left atrium. These thrombi (clots) are thought to form in the atria when they are fibrillating. In the process of conversion to a sinus rhythm, the thrombi may become dislodged from the atrium. They are then likely to be sent through the left ventricle, the aorta, and into the arteries that supply the brain. This could lead to a stroke. Patients who undergo this "cardioversion" are often put on anticoagulants for weeks before the procedure. There are usually two readily apparent things in an ECG of atrial fibrillation. 1. There is an extremely irregular QRS rate. The R-to-R values often differ with each beat with no visible pattern to their timing. 2. There are no easily discernible P waves. Instead, the baseline usually appears chaotic. It may have an appearance ranging from coarse (large and jagged) to fine (relatively smooth). This is the atrial contribution to the ECG. The PRI cannot be measured.

Atrial flutter The buzzword that everyone loves to use when describing atrial flutter is "saw tooth." The term is used for good reason : the P waves often looks like the teeth of a saw when viewed in Lead II. These P waves are often called "flutter waves." In atrial flutter, the atria are depolarizing at an extremely rapid rate. The AV node will normally only conduct impulses up to a rate around 220 per minute. In atrial flutter, the atria are depolarizing about 250 - 350 times per minute. This means that not all of the impulses will be conducted. The conduction ratio (P:QRS ratio) is often relatively constant at 2:1 or 4:1, although it can also vary.

With 2:1 conduction, the ventricular rate is usually about 150. Unlike atrial fibrillation, atrial flutter QRS complexes tend to appear at regular intervals.

Figure 6-3 : Atrial flutter (2:1 conduction)

Section 7 : Junctional Rhythms

Junction here refers to the AV junction, the area around the AV node and the bundle of His. The exact definition of the AV junction often varies, depending on who you ask. As I've mentioned before, the AV node is an electrically conducting path that connects the atria to the ventricles. Emerging from the AV node is the bundle of His (also called the AV bundle). Because the "anatomy people" seem to disagree on where the AV node starts and stops, the "physiology people" call the general area the AV junction. This would include the AV node and at least part of the bundle of His.

Figure 7-1 : A firecracker showing the firing of a junctional pacemaker

What is a junctional rhythm? A junctional rhythm is one that starts in the AV junction. Figure 7-1 illustrates what happens when a pacemaker in the junction fires. The match lights the fuse, causing the fire to travel both ways. In the atrial part of the fuse, the activation travels in the reverse direction (from right to left on the diagram). We know that when it travels "forward" it produces an upright P-wave. When it travels retrograde (which is a snooty, polysyllabic way of saying "backward"), the P wave is inverted (i.e. upside down, below the isoelectric line).

Thus, an inverted P wave strongly indicates that the electrical impulse originated in the AV node or beyond. In addition to being upside-down, the junctional P wave may not be before the QRS. When the sinus fires, the atria are depolarized before the ventricles, and thus the P wave is first. In figure 7-1, the atrial explosives are lit before those of the ventricles. While simply looking at the figure, however, it is hard to predict which set of explosives will be ignited first. Perhaps they will be ignited at the same time. The ignition of the explosives in the atria (i.e. atrial depolarization) is the P wave while the ignition of the ventricular explosives (i.e. ventricular depolarization) is the QRS complex. In a junctional rhythm, the P wave may occur before, during, or after the QRS complex. This depends on the exact location of the pacemaker, which may vary. When two waves occur at the same time, they add together. Anything above the isoelectric line counts as positive, below negative. Because the P wave in this case is negative, it will subtract from whatever the QRS is.

Premature Junctional Complex A premature junctional complex (PJC) is not a rhythm but rather denotes a complex caused by a junctional pacemaker that interrupts the underlying rhythm.

Figure 7-2 : Sinus rhythm with a PJC

See Section 10 : Premature Complexes.

Junctional escape

We have talked about the "backup" pacemakers in the heart. There happens to be one of these pacemakers in the AV junction. This junctional pacemaker's intrinsic rate is between 40 and 60 times/min. Remember the rule, "the fastest pacemaker calls the shots"? That means that the sinus pacemaker (usually around 75/min) will normally prevent the junctional pacemaker from firing. What might happen if the sinus rate were to fall to, let's say, 30 times/minute? Well, the junctional pacemaker may start calling the shots. We call this type of "backup rhythm" an escape rhythm. Junctional escape will often have a rate between 40 and 60 beats/min.

Figure 7-3 : Junctional escape

Junctional tachycardia (I am using the term junctional tachycardia to refer specifically to the type caused by a junctional pacemaker. The type of junctional tachycardias caused by reentry are dealt with in the PSVT section.) Let's suppose an ectopic pacemaker in the AV junction decides to overtake the sinus node. This is equivalent of a coup, led by the a trouble maker in the AV junction. If the rate is faster than 100, we call this junctional tachycardia.

Figure 7-4 : Junctional tachycardia

Accelerated junctional rhythm Occasionally, an ectopic pacemaker in the AV junction will have a rate that is too fast to be considered junctional escape but too slow to be considered junctional tachycardia. We call this an accelerated junctional rhythm.

Figure 7-5 : Accelerated junctional rhythm

Section 8 : Supraventricular Tachycardias

The term supraventricular tachycardia (SVT) has at least two different meanings that are commonly in use. 1. MORE GENERAL : Any tachycardia that originates in or depends on parts above the ventricles. In other words, any tachycardia that is not from the ventricles. This is mostly used in the context of describing an unknown tachycardia. All tachycardia will fall under the categories of ventricular or supraventricular. Under this definition, sinus tachycardia is a type of supraventricular tachycardia. 2. MORE SPECIFIC : This group of rhythms is often called "paroxysmal SVT", or PSVT. A group containing certain tachycardia rhythms (of supraventricular origin) which all have a similar appearance. Some in the rhythms in this group are AV nodal reentrant tachycardia, unifocal atrial tachycardia, and sinus reentry tachycardia. The different rhythms of this group are usually classified under the term SVT because they cannot be easily distinguished from one another. The term American is similar in that it has two meanings : in its most general sense, it refers to people and things of North America and South America. In the more specific sense of the word, it is used to refer to people and things of the U.S.

Paroxysmal supraventricular tachycardia (PSVT) We will focus on the second definition of SVT (top of page) right now. This definition includes a number of rhythms- knowledge of each of the individual rhythms is not usually required for someone learning basic ECG interpretation. Instead, be familiar with this group. These rhythms tend to be between the rates of 150-250 and are paroxysmal.

The word paroxysmal means sudden; when used with arrythmias, it denotes one that begins and ends suddenly. This means that someone can go from a normal sinus rhythm to a PSVT with a rate of 180 in only second.

Figure 8-1 : A supraventricular tachycardia (SVT)

AV nodal reentrant tachycardia (AVNRT) This is the most common type of PSVT. As the name suggests, this rhythm is due to a reentrant impulse at the site of the AV node. Because the mechanism depends on the AV node, we can reason that if we were to temporarily disable the AV node, this rhythm might "break," that is, convert to a sinus rhythm. Vagal maneuvers (e.g. carotid sinus massage, breathing against a closed glottis) will often slow conduction down at the AV node to the point that this rhythm breaks. Adenosine is a drug that temporarily blocks conduction in the AV node, also causing this rhythm to break. If it is your job to offer treatment, then check with your local protocols on how to proceed.

AV reentrant tachycardia (with accessory pathway) Like AVNRT, this type also depends on reentry. However, it involves an accessory pathway. An accessory pathway (in this case) is an abnormal connection between the atria and ventricles. Patients who are prone to this type of PSVT tend to have two pathways : the AV node and this accessory pathway. Circus movement tachycardia, while sometimes applied to any tachycardia involving a loop, is often used to specifically refer to this rhythm.

Atrial tachycardia Atrial tachycardia is usually considered a type of PSVT; it can be subdivided even further based on its mechanism. It can be caused by a intra-atrial reentrant circuit or by automaticity (i.e. ectopic pacemaker). The important thing to note is that these tachycardias are not dependent on the AV node for their survival.

Section 9 : Ventricular Rhythm

Figure 9-1 : A firecracker showing a number of potential ventricular pacemaker locations. Note that the fuse representing the ventricular septum is a "slow fuse".

Several matches have been drawn in figure 9-1 to represent some of the possible locations of the ventricular pacemaker. These are all portions of the Purkinje system. Pick one of the matches and predict the path the impulse (fire) would follow. Perhaps can now imagine why impulses that originate in the ventricles produce wide QRS complexes. In a normal sinus beat, the impulse forks at the bundle of His. It covers both ventricles simultaneously. It generally depolarizes the ventricles in less than 0.10 seconds. If you imagine that the impulse starts where the bottom match is lighting the fuse, you can see it now has to cover both ventricles. The "slow fuse" is where the impulse can travel through the ventricular septum and into the other ventricle. This should explain why ventricular pacemakers cause a QRS complex longer than 0.10 s. What else might cause a QRS to last longer than 0.10 seconds? Imagine that one of the bundle branches were blocked. (The bundle branches start at the fork, just after the A.V. node.) An impulse that originates in the sinus node would be normal up until it reaches the block. If the impulse could only travel down ONE of the branches, it would have to cut over through the ventricular septum ("slow fuse") to depolarize the other ventricle. You can see why this

would take longer. Not everything that glitters is gold, and not every QRS that is wide is caused by a ventricular pacemaker. All QRS complexes of ventricular origin are wide (> 0.12 s). Does it logically follow that all wide QRS complexes are ventricular? No, it does not. In fact, it is the case that NOT ALL WIDE QRS COMPLEXES ARE FROM THE VENTRICLES. On the other hand, virtually all narrow complex QRS complex are supraventricular (i.e. not from the ventricles). If this didn't "click," you might want to reread this paragraph. Let's say we can put all rhythms in one of two categories : supraventricular or ventricular. Supraventricular QRS complexes : NARROW or WIDE Ventricular QRS complexes : WIDE only

Premature Ventricle Complex Premature ventricular complex (PVC) is a term that originally was called premature ventricular contraction. Because the mechanical contraction of the ventricles cannot be inferred from the ECG, the word complex has replaced contraction. These are also referred to as : premature ventricular beats (PVB), VPBs, and VPCs. PVCs tend to be compensating (i.e. they don't travel back and reset the underlying pacemaker). In these cases, the distance from the normal P wave before the PVC to the P wave after the PVC is twice the underlying P-P interval. Unlike the other three rhythms in this section, PVCs frequently occur in normal healthy hearts and often go unnoticed. They also may give a person the feeling of having "skipped a beat". On the other hand, PVCs in an unhealthy heart may be a bad omen.

Figure 9-2 : Sinus rhythm with a unifocal PVC

PVCs are also covered in Section 10 : Premature Complexes.

Ventricular fibrillation Ventricular fibrillation ("v-fib", often abbreviated VF) describes the electrical activity associated with the quivering of the ventricles. When Don Corleone is shot, quivering Fredo is unable to successfully wield a gun. Quivering ventricles are about as effective as quivering Fredo- they cannot pump blood. I mentioned earlier that, while functional atria are a prerequisite for playing tennis or jogging, functional ventricles are a prerequisite for staying alive. Thus, untreated v-fib can progress to death within minutes. You can understand why v-fib is one of the evil rhythms. When someone suddenly drops dead from a cardiac arrest, v-fib is likely to blame. The pattern for ventricular fibrillation is... well, there really is no pattern. It is random electrical activity. Sometimes the amplitude of the waves is large (coarse VF), while other times the amplitude is so small (fine VF) that the rhythm is almost asystole. It has almost a "kindergarten artwork" quality to it. As the minutes pass, cells in the body become damaged due to the lack of oxygenated blood. Among these are cells of the heart. As the heart dies, it loses its ability to conduct electricity. Coarse v-fib will turn into fine v-fib, and fine v-fib will transition into asystole.

Figure 9-3 : Ventricular fibrillation (coarse)

Figure 9-4 : Ventricular fibrillation (fine)

Ventricular tachycardia Ventricular tachycardia (V-tach, often abbreviated VT) refers to a rhythm that arises from the ventricles causing the heart to beat at a rate faster than 100 beats per minute. The ventricular rate is usually above 120 beats/min and may exceed 250 beats/min. At some point, the ventricles may beat so frequently that there is not adequate time for the blood to refill. A patient in ventricular tachycardia MAY or MAY NOT have a pulse. A heart in VT is vulnerable to going into ventricular fibrillation. In fact, the common sequence of arrhythmias in patients who die in this rhythm is: V-tach to V-fib to asystole. The QRS complex will be wider than 0.12 seconds. Figure 9-5 shows the stereotypical V-tach, but not all cases look like this. Unless you have been trained to distinguish a ventricular QRS complex from a wide QRS of non-ventricular origin, then you should call a tachycardia with wide QRS complexes a "wide complex tachycardia."

Figure 9-5 : Ventricular tachycardia

Ventricular escape Ventricular escape, often called idioventricular escape, is when an ectopic "backup" pacemaker in the ventricles kicks in. A few things can cause this : 1. The sinus and junctional pacemakers have failed 2. There is a block that prevents impulses of the sinus (or junctional) pacemaker from reaching the ventricles. Although it is considered a "backup" rhythm, it is only slightly more compatible with life than asystole. The intrinsic rate of a ventricular pacemaker is 20 - 40 times/minute. In other words, this is a very bad rhythm.

Figure 9-6 : Idioventricular rhythm

Asystole Asystole is not a ventricular rhythm. It is the "flat-line"; subsequently, it is the easiest rhythm to recognize. Because it has no electrical activity, asystole does

not readily belong into any of the other groups of arrhythmias. I have included in this section because it is often the end result of ventricular fibrillation. Pronounced uh-SIS-toe-lee. Always make sure the equipment is connected to the patient. Also, check more than one lead to confirm that the rhythm is asystole. If an electrically active heart has all of its activity perpendicular to a given lead, very little will show on that lead's ECG. In these cases, another lead (pointing a different direction) should pick up on this hidden activity.

Figure 9-7 : Asystole

Section 10 : Premature Complexes

I'm frequently asked if there is some way that I can explain the concept of the human heart's premature ectopic complexes using waterfowl. In response to these requests, I have put together in this section an extended metaphor that addresses the topics common to premature atrial, junctional, and ventricular complexes.

The normal mallard rhythm Figure 10-1 shows a number of mallards marching along. Each mallard represents the ECG complex above it. Let's assume there exists some commander of the ducks (who is not shown in the diagram). He is very picky when it comes to marching, and he requires that each duck maintain a specified distance between himself and the duck before him. This distance is the length of a single ruler (shown below ducks).

Figure 10-1 : Sinus ducks marching. Each duck is ordered to maintain a ruler's length distance between the duck ahead of it and itself.

Enter the goose Now let's look at the duck-duck-goose patterns. In figure x-x, you see that a goose (representing a ventricular complex) has joined the parade. He took ("stole") the place of one of the "regularly scheduled" ducks. In addition to this, the goose is following a little too closely (much like bad drivers do). Thus, we call this goose premature. Remember, each of the ducks was originally given the order to march at a distance of one ruler's length behind the duck directly in front of him. This puts the duck that follows the goose in a dilemma. He has two options : 1. The duck can ignore the goose and follow one ruler's length behind where the missing duck would have been. This is the equivalent of following the length of two rulers behind the previous mallard (the one before the goose). Compensating for the too-short distance before the goose, the distance after the goose would be longer than a ruler. This "distance" is called a compensatory pause. 2. The duck could march at a distance of one ruler's length behind the goose. This would mean that the goose has shifted the entire marching formation behind him a little bit more forward than they would have been. There is no compensatory pause.

Figure 10-2 : A premature waterfowl (followed by a compensatory pause). Even though the

goose takes the place of one of ducks, it does not alter the overall spacing of the group. This is exhibited by the compensatory pause following the goose.

Figure 10-3 : Premature waterfowl (no compensatory pause). Notice how the overall pattern is reset by the blue-headed (premature) ducks. The red rulers indicate a distance that is too short. The mallards that follow the premature ducks are basing their position on these blue-headed troublemakers.

In the heart, the "option" is usually decided by where the premature complex originates. Those complexes that cause a compensatory pause are those whose impulse does not reach the normal (sinus) pacemaker. Lack of the compensatory pause is generally attributed to the impulse from the premature complex conducting retrograde towards the sinus node and resetting it. Although this is by no means a fixed rule, PACs (and PJCs) tend to reset the sinus while PVCs tend not to reset the sinus. Thus, if a premature complex is followed by a compensatory pause, you should suspect a PVC.

Interpolated complexes Sometimes, a goose may be able to squeeze between two ducks without messing with their pattern at all. When this happens with an PVC, we call it an interpolated PVC. An interpolated complex is a premature complex that is early enough so that no complex is skipped. Thus, in figure 10-4, there are no missing ducks.

Figure 10-4 : An interpolated goose. This is a premature goose who, rather than take the place of one of the ducks, has managed to squeeze between two ducks without altering their pattern. No ducks have gone missing.

Unifocal versus multifocal Remember the following generalization : different shape means different origin. The QRS shape often reflects where the impulse entered the ventricular conduction system. As far as the ventricles are concerned, pacemakers in the sinus node, atria, and the junction (normally) all share the same path. Thus a sinus complex, a PAC, and a PJC are all likely to have similarly shaped QRS complexes. Pacemakers in the ventricular conduction system are not limited to one location; they can occur in a variety of places. These different places should produce different QRS complexes. For example, in figure 10-5, we see two different PVCs. We should assume, because of their dissimilarity, that these PVCs each originated from a different part of the ventricular conduction system. Thus, we designate them multifocal. If all of the PVCs had the same general shape, we would refer to them as unifocal.

Figure 10-5 : Mallard rhythm with multifocal geese.

Patterns of premature beats These terms describe how often the premature complexes appear. If their appearance seems random, none of the following terms are applicable. Bigeminy : every other beat Trigeminy : every third beat Quadrigeminy : every fourth beat

Multiple premature beats

Paired complexe s (also called couplets) A salvo of complexe s (also called a run) The term salvo (as in barrage) is used to describe the occurrence of multiple premature complexes in a row. (Many consider "multiple" in this case to mean three or more.) When many premature complexes occur in a row, you should probably start looking at them less in terms of premature complexes and more in terms of tachycardia.

Section 11 : AV Heart Blocks

Atrioventricular heart blocks (referred to simply as heart blocks from here on) is the name given to conditions in which electrical conduction at the AV node is somehow affected. We generally speak of three broad types (or degrees) of heart blocks. In a nutshell, they are : 1st degree heart block : AV conduction is (excessively) slowed 2nd degree heart block : AV conduction is incompletely (i.e. occasionally) blocked 3rd degree heart block : AV conduction is completely blocked Before you continue, stop and predict what each type of heart block will look like. Use what you already know about P waves, QRS complexes, and the space between them. If AV conduction is slowed, how will this appear on an ECG? If conduction is completely blocked, will QRS complexes follow P waves?

1st degree heart blocks : This occurs when conduction at the AV node is slowed beyond the normal amount. This is manifested as a PRI that is longer than 0.20 seconds. This PRI will generally remain constant. (If the PRI is changing from beat to beat, you may a second degree heart block.) When you see a rhythm with a first degree heart block, you generally name the rhythm according to this pattern : <underlying rhythm> with a first degree heart block. For example, if you were to see a case of sinus bradycardia but the PRI consistently measures 0.22, you would call the rhythm : sinus bradycardia with a first degree heart block.

Figure 11-1 : Sinus rhythm with a first degree heart block

2nd degree heart blocks : The most confusing thing about second degree heart blocks is that there are two subtypes and they are called a variety of names. Whenever you see Mobitz, think 2nd degree heart block. Therefore, Mobitz I is the same thing as 2nd degree heart block type I. 2nd degree heart block type I : This rhythm is also called Mobitz I. It is also called Wenckebach. It consists of the PRI getting longer with each electric beat until eventually a P wave occurs but the QRS never shows (essentially skipping a beat). The process is then repeated. This is like showing up for work Monday an hour late, on Tuesday two hours late, and so on until Friday comes around and you don't even show up at all. The following Monday, you start the same cycle again. You could call this behavior "pulling a Wenckebach" but nobody would get it and people would just think you're weird. (There would be an gradual-increasing PR intervals until it disappears/skips.)

Figure 11-2 : Second degree heart block type I (Wenckebach)

2nd degree heart block type II : This rhythm is also called Mobitz II. This occurs when a QRS suddenly fails to show up after a P wave. It usually makes an appearance the next wave. This rhythm lacks the increasing PRI that is seen with the Wenckebach type. It would be as if you showed up 30 minutes late Monday through Thursday, but failed to show up Friday. I have always considered this the "duck duck goose" rhythm because it maintains a relatively constant PRI until it skips.

Figure 11-3 : Second degree heart block type II

It is important to recognize the two subtypes of 2nd degree heartblocks. The second subtype tends to be much worse than the first subtype (Wenckebach). Note : For second degree heart blocks, it is common to specify the ratio of P waves to QRS complexes. This is the conductance ratio. In a second degree heart block with a 2:1 conductance, there will be only one PRI. It will be impossible to distinguish between the two subtypes of 2nd degree heart blocks using only the ECG.

3rd degree heart blocks : These are also called complete heart blocks. This is when the atria and the ventricles are essentially divorced. If no electricity travels through the AV node for a little while, the ventricle's backup pacemaker starts calling the shots. The atria are being controlled by one pacemaker, the ventricles by another. This often manifests itself on an ECG as P waves occuring at regular intervals with QRS complexes occuring at regular intervals, but no apparent relationship between any P wave or QRS complex. Sometimes it may look like a P wave follows a QRS, sometimes vice-versa, but they don't seem to affect each other.

Figure 11-4 : Third degree heart block

In figure x-x, you may have to play "Where's Waldo?" with the P waves. The first two are clearly visible. The last two are hiding in QRS complexes. Compare the shape of the QRS complexes. You should notice a slight difference where you expect the P wave to be. In the middle QRS, the P wave is evident at the very end. In the last QRS complex, it is at the very beginning. To be considered a true third degree heart block, the ventricles should be in an escape rhythm. Why? There are many situations in which the atria and ventricles can be completely independent when there is no "true block" between the atria and ventricles. If a ventricular ectopic pacemaker were firing at such a rate that the sinus and ectopic impulses meet head-on somewhere in the junction, you would see these two impulses cancel each other out; the atria and ventricles would be doing their own thing despite no real problem with AV conduction.