07 Nov 2017 ▪ Dr.

Jude Eric Cinco

Arrhythmia 12b
CLIN ICAL ME DICIN E 02

Outline B. Normal ECG

I. Review of Concepts 1
A. Normal Cardiac Depolarization 1
B. Normal ECG 1
II. Cardiac Arrhythmias 2
III. Bradyarrhythmias 2
A. Sinus Arrhythmias 2
B. Atrioventricular (AV) Conduction Blocks 3
C. Ectopic Rhythms 5
IV. Premature Beats 6
A. Premature Atrial Contraction 6
B. Premature Ventricular Contraction 6
V. Tachyarrhythmias 7
A. Sinus Arrhythmia 7
B. Ectopic Rhythms 8
Review Questions 9
References 10
Changelog 10
Appendix 11

Abbreviation Meaning
PAC Premature Atrial Contraction
Figure 2. Parts of the ECG trace. (2020 trans)
PVC Premature Ventricular
Contraction • REMEMBER these basic concepts in the normal ECG:
IVR Idioventricular ○ There is a P wave before every QRS complex
AF Atrial Fibrillation ○ The ST segment should be isoelectric
V-tach Ventricular Tachycardia ○ The T wave should be the same direction as the QRS
V-fib Ventricular Fibrillation
Normal Sinus Rhythm
I. Review of Concepts
A. Normal Cardiac Depolarization
(1) Impulse begins in the sinoatrial (SA) node in the right atrium
(2) The impulse then travels through 3 internodal tracts:
○ Anterior
○ Middle
○ Posterior
The Bachmann’s bundle (an anterior intermodal tract) is the
preferential path for activation of the left atrium!
(3) After the 3 internodal tracts, the impulse goes to the Figure 3. Normal sinus rhythm. (Malmivuo et al., 1995)
atrioventricular (AV) node found in the interatrial septum.
(4) The impulse further travels down the Bundle of His in the
interventricular septum.
(5) Observe that the Bundle of His splits into the left and right
branches in the muscular portion of the interventricular septum to
become the terminal Purkinje fibers in the ventricular walls
Figure 4. The normal sinus rhythm. (2020 trans)

• This is what we compare all other rhythms to; each beat in this strip
comes from the depolarization of the sinus nodes
• REMEMBER these standard values:
○ Rate: 60-100 bpm
▪ A physiologic variation of 35-40 bpm is normal for well-
trained athletes.
○ Cycle length variation: <10%
○ PR interval: 0.12-0.2 secs

Determination of Heart Rate for Regular Rhythms

• We get the HR by getting the distance from an ‘R’ to another ‘R’ in
squares:
(1) Determine if you’re counting by the big (5x5) or small squares
(2) The formula is then (pick one):
▪ 300/n (big)
▪ 1500/n (small)
▪ n is equal to the number of squares between the 2 ‘R’s
Figure 1. The electrical system of the heart. (2020 trans) (3) Compute.
• Note: The ‘magic numbers’ correspond to the values using the big
square counting method
○ 300, 150, 100, 75, 60, 50, 43, 37
○ For an example, see Figure 5.

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 III. Bradyarrhythmias

Figure 5. Determining HR for regular rhythm. Using big squares: 300/n =

300/4.5 = 67 bpm. Using small squares: 1500/n = 1500/23 = 65 bpm.

Determination of Heart Rate for Irregular Rhythms

• In irregular rhythms, the spaces between the QRS complexes are
varied, so the magic number method cannot be used
• Instead:
○ Determine if you are using a 3-second or 6-second strip
○ Your formula then becomes:
▪ # of QRS complexes x 20 (for 3-second strips)
▪ # of QRS complexes x 10 (for 6-second strips)
○ For an example, see Figure 6.

Figure 8. An algorithm on differentiating the different bradyarrhythmias.

Figure 6. Determining HR for irregular rhythm. This is a 3-second strip.
Formula to use is: (# of QRS complexes x 20) = (6 complexes x 20) = 120 bpm. A. Sinus Arrhythmias

Sinus Bradycardia
II. Cardiac Arrhythmias • Sinus rhythm with a slow heart rate
• Arrhythmia refers to any disturbance in the rate, regularity, site of • HR: <60 bpm
origin, or conduction of the cardiac electrical impulse • Can be normal or can accompany significant heart disease (Thaler,
• Abnormal cardiac rhythms can begin in 1 of 3 places: 2012)
1. The atrial muscle ○ Physiologic: resting heart rate typically of well conditioned
2. The region around the AV node (nodal/junctional region) athletes
3. The ventricular muscle ○ Pathologic: early stages of an acute myocardial infarction
• Arrhythmias are broadly categorized by their rate:
○ Abnormally slow = BRADYarrhythmia
○ Abnormally fast = TACHYarrhythmia
• Other classifications:
○ Supraventricular rhythms
▪ The depolarization wave originates from the atrial muscles
or AV node (all above the ventricle)
▫ In other sources, arrhythmias from the sinus node are
included here
▪ ECG: narrow (normal) QRS complexes
○ Ventricular rhythms
▪ Rhythms begin from points within the ventricular muscles Figure 9. Sinus bradycardia. (Malmivuo et al., 1995)
▪ ECG: wide QRS complexes
• The only exception to the rule is when there is a supraventricular
rhythm with right or left bundle branch block or the Wolff-
Parkinson-White (WPW) syndrome, where the QRS complex will
be wide

Figure 10. Sinus bradycardia. (Thaler, 2012)

Sinus Pause (Arrest)

• Note: Sinus arrest is not necessarily a slow arrhythmia. However,
Doc discussed it under this section.
• Sinoatrial node does not fire
• ECG characteristics:
○ No P wave
○ No QRST complex
• Interval between the previous beat and the next beat following the
Figure 7. ECG of WPW Syndrome. See the wide QRS complexes. (The
Medical Dictionary).
pause is less than twice the normal interval
• Doing Valsalva maneuver can induce a pause

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 ○ Any conduction block between the sinus node and the
Purkinje fibers
▪ Includes the AV node and bundle of His
3. Bundle branch block
○ Conduction block in one or both of the ventricular bundle
branches
○ Fascicular block/Hemiblock: only a part of one of the
Figure 11. Sinus arrest occurring after the fourth beat. (Thaler, 2012) bundle branches is blocked
(Not discussed; Nice to know)

• Under normal circumstances, the sinus node is the fastest

pacemaker therefore overdrives the other pacemaker cells
• In sinus arrest, other pacemakers spring into action with rescuing
beats called escape beats
○ Atrial pacemakers
▪ Discharge at a rate of 60-75 bpm
○ Junctional pacemakers
▪ Discharge at a rate of 40-60 bpm
○ Ventricular pacemakers
▪ Discharge at a rate of 30-45 bpm

Figure 14. Typical sites of the three major conduction blocks. (Thaler,
2012)

- Thaler, 2012

First Degree AV Block

• ECG characteristics:
○ PR interval > 0.2 seconds
▪ Normal duration is 0.12-0.2 seconds or 3-5 small squares
between the P and QRS
○ Normal P wave
○ Normal QRS complexes
• Formal reading:
○ “Sinus rhythm with first degree AV block”
• Mechanism:
Figure 12. Nonsinus pacemakers. (Thaler,2012) ○ There is a delay in conduction of electrical impulses through the
normal conduction pathway
• Junctional escape ▪ Delay is at the level of the AV node or bundle of His
○ Most common escape mechanism • A common finding in normal hearts
○ Depolarization originates near the AV node • Not in itself important but may be as sign of a degenerative disease
○ Most often, P wave is not seen of the conduction system, drug toxicities, or electrolyte imbalance
○ Occasionally, retrograde P wave is seen
▪ P wave is inverted in lead II and upright in lead AVR

- Thaler, 2012

Asystole
• Ventricular standstill
• Prolonged electrical inactivity
• ECG characteristics:
○ Flat line
Figure 15. First degree AV block. Note the prolonged PR interval. (Malmivuo
et al., 1995)

Figure 13. Asystole. (ekg.academy)

B. Atrioventricular (AV) Conduction Blocks

• Conduction block – can occur anywhere in the conduction system
of the heart (e.g., SA node, AV node, bundle branch)

(Not discussed; Nice to know)

There are three types of conduction blocks, defined by their

anatomic location:
1. Sinus node block Figure 16. First degree AV block. Note the prolonged PR interval. (Thaler,
○ Sinus node fires normally, but the wave of depolarization is 2012)
immediately blocked and is not transmitted into the atrial
tissue Second Degree AV Block
○ On ECG, looks like a pause in the normal cardiac cycle • ECG characteristics:
2. Atrioventricular (AV) block ○ Marked by sudden disappearance of the QRS complex, also
called the drop beat

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 ○ Drop beat: P wave without QRS complex In AV block, as long as the patient has a normal blood pressure
nd
○ Automatically labels the patient as having 2 degree AV block and no symptoms, there’s nothing to worry about. However, if the
• Pattern: patient is symptomatic, it’s usually a type II second degree AV
○ P-QRS, P-QRS, P (no QRS), P-QRS, P-QRS block.
▪ Cluster beating
• Mechanism:
○ Occasional failure of impulse from SA node to conduct to the
ventricles

Important!
• Atrial rate = P waves
• Heart rate or ventricular rate = QRS complexes

Type I
• Also known as Mobitz Type I block or Wenckebach block
• ECG characteristics:
○ Normal P wave
▪ Note: P wave may only show itself as a distortion of a T
wave (ASMPH 2020, 2016)
○ Progressive lengthening of PR interval with intermittent
dropped beats
▪ The sequence repeats itself, over and over, and often with
impressive regularity
• Mechanism: Figure 18. Type II second degree AV block. On this EKG, each third P wave is
○ Each impulse from the SA node is delayed slightly longer than not followed by a QRS complex (dropped beat). (Thaler, 2012)
the previous impulse
• Usually asymptomatic; very benign but may be a herald of 2:1 AV Block
something abnormal • Second degree AV block with a P:QRS ratio of 2:1
○ Every other beat is contracted, every other beat is dropped
• Mobitz Type I block usually has an atrio-ventricular (P:QRS) • HR: slow
conduction ratio of 4:3
○ Every fourth atrial impulse fails to stimulate the ventricles,
producing a ratio of four P waves to every three QRS
complexes.

- ASMPH 2020, 2016

Figure 19. 2:1 AV block. (www.lifeinthefastlane.com)

High Grade AV Block

• P waves present
• QRS complexes present
• Some P waves followed by QRS complexes and some are not
• Atrio-ventricular conduction ratio is 3:1 or higher
• PR interval following a QRS is constant but may be normal or
prolonged
○ May result from either Mobitz I or Mobitz II AV block
(www.lifeinthefastlane.com)
• HR: extremely slow

Figure 20. High grade AV block with 3:1 conduction ratio. Note how every
Figure 17. Type I second degree AV block. The PR intervals become third P wave is almost entirely concealed within the T wave.
progressively longer until one QRS complex is dropped. (Thaler, 2012) (www.lifeinthefastlane.com)

Type II
• Also known as Mobitz Type II block
• ECG characteristics:
○ Fixed PR interval with intermittent dropped beats
▪ Two or more normal beats with normal PR intervals and
then a P wave that is not followed by a QRS complex (a
dropped beat)
Figure 21. High grade AV block with 4:1 conduction ratio.
▪ Conduction is an all-or-nothing phenomenon
(www.lifeinthefastlane.com)
○ Ratio of conducted beats to non-conducted beats is constantly
varying, from 2:1 to 3:2 and so on (Thaler, 2012) Third Degree AV Block
• Less common than type I but more serious
• “One heart beating as two”
• Occurs without warning; more symptomatic compared to type I • Also known as a complete heart block
○ Clinically, this is more dangerous because a patient can pass
• ECG characteristics:
out from this. The heart suddenly stands still so there is no blood
○ Regularly occurring P waves and QRS complexes
supply to the brain.
○ No relationship between the P wave and the QRST complex
○ Requires a pacemaker
○ P wave beats faster than the QRS (Atrial rate > Ventricular
rate)

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 rd
▪ Means that a person with a 3 degree AV block will always
have a slow heart rate (because the QRS beats slower
than the P wave)
○ Note: A third degree block is not obviously visible, you have to
look at the PR interval in all the leads
• Mechanism:
○ Complete AV dissociation:
▪ The atrium is beating on its own, and the ventricle is beating
on its own, without communication
○ Absence of impulse conduction between atria and ventricles
○ Atrial conduction is normal but no beats are conducted to the
ventricles
○ Impulses originate at both SA node and at the subsidiary
pacemaker below the block

Criteria
• No recognizable consistent or meaningful relationship between atrial
and ventricular activity
• Atrio-ventricular dissociation
• QRS complexes often abnormal in shape, duration, and axis
(occasionally normal)
• QRS morphology constant
• QRS rate constant (15-60 beats/min)
• Any form of atrial activity seen (most commonly sinus initiated)
Figure 24. Comparison of the different degrees of AV block. A, First degree
nd nd
AV block; B, Type I 2 degree AV block; C, Type II 2 degree AV block; D, 2:1
rd
block; E, 3 degree AV block. (The Six Second ECG, 2005).

C. Ectopic Rhythms

Supraventricular Arrhythmias
• Characterized by narrow QRS complex

Slow Atrial Fibrillation

• Atrial muscle fibers contract independently
• ECG characteristics:
Figure 22. Third-degree AV block. The P waves appear at regular intervals, as
do the QRS complexes, but they have nothing to do with one another. The QRS ○ No P wave
complexes are wide, implying a ventricular origin. (Malmivuo et al., 1995) ○ Flat or slight undulation at the baseline (grounded-appearance)
called fibrillation waves
○ Narrow QRS complex
○ Irregularly irregular (R-R interval) rhythm
• Mechanism:
○ AV node is continuously subjected to various depolarizing
waves of varying strengths, which spreads at irregular intervals
down the His bundle
• HR: <60 bpm
○ AF with Slow Ventricular Response (SVR)
• Dangerous because blood isn’t mobilized and becomes static, which
may cause an embolic stroke

Types based on HR
• Atrium
○ >400 bpm and almost indiscernible
• Ventricular
○ >100: AF with Rapid Ventricular Response (RVR)
○ 60-100 bpm: AF with Controlled Ventricular Response (CVR)
○ <60 bpm: AF with Slow Ventricular Response (SVR)

Figure 23. Third-degree AV block. The P waves appear at regular intervals, as

do the QRS complexes, but they have nothing to do with one another. The QRS
complexes are wide, implying a ventricular origin. (Thaler, 2012)

Figure 25. Slow atrial fibrillation. Notice the ground-like appearance of

fibrillation waves between 2 QRS complexes. (Thaler, 2012)

Junctional Rhythm
• Impulses arising close to or in the AV node
• ECG characteristics:
○ P waves
▪ Inverted in inferior leads (I, II, and aVF) and positive in lead
of aVR
▪ After a QRS complex or buried under it
○ Narrow QRS complex
• Mechanism:
○ Occurs after sinus arrest and junction takes over

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 ○ Impulse from the AV node travels down the ventricle to generate ▪ Different contour from the sinus beat
a narrow QRS complex then up the atrium to generate a P wave ▪ Premature timing
○ P wave is inverted because the depolarization wave comes from ○ Compensatory pause
the atrium and not the sinus node ▪ A period of delay to reset the heart back to its original sinus
rhythm
Table 1. Comparison based on P wave ○ Long PR interval
rd
Junctional 3 Degree Sinus Junctional ○ Narrow QRS complex
Rhythm AV Block Bradycardia Escape • Mechanism:
Inverted P P wave is Normal Only occurs ○ Atrial premature beat originates at an atrial site distant from the
wave walking orientation of after a sinus sinus node
through the P wave pause ○ Sources of premature beat:
▪ SA node – premature atrial beat
▪ AV node – premature junctional beat
• Can be normal due to factors such as caffeine and emotional
provocation

Table 2. Comparison between conducted and non-conducted PAC

Conducted PAC Non-conducted PAC
Ventricular conduction through Conduction is blocked
Figure 26. ECG of a junctional rhythm. (2020 trans, 2016) AV node is normal
Ventricular Arrhythmias No QRS after a PAC
Difficult to distinguish from an SA
block
Idioventricular Rhythm
• Impulse originates from the ventricular muscle pacemakers
○ Occurs when the SA and AV nodes are either not firing or are
firing slower than the ventricular pacemaker rate
• Also known as ventricular escape rhythm
• ECG Characteristic:
○ No P wave since sinus node is not functioning
○ Wide QRS complex
▪ >0.10 seconds (≥2.5 small squares)
○ T wave deflects in opposite direction to QRS complex Figure 29. The third beat is an atrial premature beat. Note how the P wave
contour of the premature beat differs from that of the normal sinus beat. (Thaler,
• Absence of normal, upright P wave associated with QRS complexes 2012)
○ If P wave is present, it is usually not associated with the QRS
complex B. Premature Ventricular Contraction
• Mechanism: • Prematurely occurring complex
○ The sinus node stops depolarizing so no P waves are observed
• ECG Characteristic:
but the resulting QRS is wide and very slow because the
○ Wide, bizarre looking QRS complex
subsidiary AV node pacemaker also did not depolarize normal
○ Usually no preceding P wave
• Note: There is also an accelerated type of idioventricular usually ○ T wave deflected opposite to QRS complex
falling in the range of 50-100bpm ○ Complete compensatory pause following every premature
beat
• May occur singly, in pairs (couplet), or in clusters

Figure 27. Idioventricular ECG shows a slow heart rate in sinus rhythm,
without a P wave and wide, bizarre QRS complex (SkillStat Learning Inc.,
2005).

Figure 30. Premature ventricular contraction. (Malmivuo et al., 1995)

Figure 28 . Idioventricular rhythm ECG with abnormal T wave, absent P
wave, but with regular ventricular rhythms. (Winter, 2016)
rd
Differentiating IVR from PVC and 3 degree AV block
• Different from PVC due to:
○ Absence of junction beat in idioventricular rhythm
○ You just see a wide QRS complex
rd
• Different from 3 degree AV block because:
Figure 31. ECG showing a PVC rhythm with wide, bizarre QRS complex and
○ AV block must have complete dissociation of atrial and a compensatory pause following a premature beat (SkillStat Learning Inc.,
ventricular contraction which is not necessarily seen in IVR 2005).
○ But IVR may be seen in a third degree AV block
Important!
IV. Premature Beats • Not all pauses seen on the ECG are identified as compensatory
Note: We decided to discuss this in a separate section since they’re ○ Compensatory pause only applies on PVC or PAC because
not necessarily slow or fast arrhythmia, and to understand the of their premature nature
succeeding sections on ventricular arrhythmias.

A. Premature Atrial Contraction

• “Extra beat”
• ECG characteristics:
○ Abnormal P wave

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Figure 32. ECG showing a PVC rhythm with wide, bizarre QRS complex and
a compensatory pause following a premature beat and before the next beat
(SkillStat Learning Inc., 2005). Figure 39. ECG showing a PVC that falls on the T wave (2019 trans,
2015).

Figure 33. ECG showing a PVC rhythm with wide, bizarre QRS complex and Figure 40. ECG showing a PVC that falls on the T wave of the second sinus
a compensatory pause following a premature beat and before the next beat
beat showing how PVC R on T can initiate V-tach (Clinical Skills
(Clinical Skills Education LLC, 2016). Education LLC, 2016).

Different presentations of PVC Important!

• PVC in Couplet • Commotio Cordis
○ Sudden arrhythmic death as a result of a blunt chest wall
blow
○ Also known as cardiac concussion
▪ Doc Cinco’s example was a ninja giving a punch to the
chest

Figure 34. PVC in couplet (2019 trans, 2015).

V. Tachyarrhythmias
• PVC in Bigeminy
○ Ratio is one normal sinus beat to one PVC
○ Alternating normal sinus beat and a PVC (i.e., PQRST, PVC,
pause, PQRST, PVC, pause, and so on)

Figure 35. PVC in bigeminy (2019 trans, 2015).

• PVC in Trigeminy
○ PVC’s appear every third beat

Figure 41. An algorithm on differentiating the different tachyarrhythmias.

Figure 36. PVC in trigeminy (2019 trans, 2015).
A. Sinus Arrhythmia
• PVC in Quadrigeminy
Sinus Tachycardia
○ PVC’s recurring every fourth beat
• Sinus rhythm with a fast heart rate
• HR: >100 bpm
• Can be normal or can accompany significant heart disease (Thaler,
2012)
○ Physiologic: accelerated heart rate in strenuous exercise
Figure 37. PVC in quadrigeminy (2019 trans, 2015). ○ Pathologic: congestive heart failure, severe lung disease,
hyperthyroidism
• Multifocal PVC
○ PVC from different foci in the ventricle
○ Assuming different polarities in a single lead
○ Different morphology and coupling interval

Figure 38. Multifocal PVC (2019 trans, 2015).

Figure 42. Sinus tachycardia. (Malmivuo et al., 1995)
- 2019 trans, 2015

PVC R-on-T Phenomenon

• R or Q wave of the PVC occurs at the T wave of the preceding sinus
beat
○ The PVC occurs so early that it falls on the T wave of the
preceding beat
• Most dangerous PVC
• PVC R on T may cause V-tach and/or V-fib because the cells have
not fully repolarized Figure 43. Sinus tachycardia. (Thaler, 2012)

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 B. Ectopic Rhythms

Supraventricular Arrhythmias
• Characterized by narrow QRS complex

Generic Supraventricular Tachycardia (SVT)

• Also known as paroxysmal generic supraventricular tachycardia
○ Paroxysmal due to sudden onset and termination Figure 46. AF with RVR (LITFL, 2017).
• ECG characteristics:
○ No P wave Multifocal Atrial Tachycardia (MAT)
▪ Impulse is faster than the P wave • Most common rhythm in the ICU
○ Narrow QRS complex • ECG characteristics:
○ Fast and regular rhythm (thus “generic”) ○ Varying P waves, PR and PP and R-R intervals
• HR: 150-250 bpm ○ P waves should at least have 3 different morphologies
• Mechanism: ▪ If <3, it is just premature atrial contraction
○ The origin that is causing the SVT is so fast that it takes over ▪ Followed by a QRS complex
• Normal ○ Narrow QRS complex
○ As long as BP is within normal range • Mechanism:
○ Give a beta-blocker and they return to normal ○ Foci in the atrium from varying sources are firing and race
towards the AV node to be able to conduct first.
○ Cause by a hyper-sympathetic drive
• Treatment:
○ Give oxygen, fluids or sedation to relax the patient
○ Don’t give anti-arrhythmia

Figure 44. SVT. There is an absence of P waves before each narrow QRS
(Thaler, 2012).

Atrial Flutter
• ECG characteristics:
○ No P wave, but flutter waves (f-waves) are present Figure 47. Multifocal atrial tachycardia. Note that (1) the P waves vary
▪ “Saw-tooth” appearance dramatically in shape; (2) the PR intervals vary; and (3) the ventricular rate is
▪ Can be regular (same number per interval) or irregular irregular. (Thaler, 2012)
(different number per interval)
○ Narrow QRS complex
○ Rhythm can be both be regular and irregular
• HR: 250-350 (average 300)
• Mechanism: Figure 48. Notice that the encircled P waves are/have irregular
○ With every conduction, there is a QRS complex morphologies and have irregular intervals. (Ecg rhythms)
○ Without conduction, a flutter is generated
• Calculating HR: Ventricular Arrhythmias
○ 300 bpm and QRS are proportional to each other • Also known as "wide" tachyarrhythmias
▪ 2:1 flutter = 300/2 = 150 bpm • Ventricular arrhythmias are rhythm disturbances arising below the
▪ 3:1 flutter = 300/3 = 100 bpm AV node
○ Remember: Count HR by the QRS not the flutter • Usually no P wave and with wide, bizarre QRS complex

Degrees of AV Block Ventricular Tachycardia

• 2:1 block – 2 flutters / QRS complex • ECG characteristics:
• 3:1 block – 3 flutters / QRS complex ○ Rapid, wide, bizarre QRS complexes that are very fast and
mostly regular following one after another
▪ >0.10 sec
○ At least 3 PVCs occurring consecutively without pause
○ No P wave
• HR: 120 to 200 beats per minute
• Mechanism:
○ In pathologies where there is decreased ventricular filling, V-
Figure 45. Atrial Flutter with appearance of saw-tooth f waves varying in tach results as a compensation
number per heartbeat (Thaler, 2012). ▪ Sustained V-tach is an emergency, presaging cardiac arrest
and requiring immediate treatment
The AV node cannot handle the extraordinary number of atrial
impulses bombarding it – it simply doesn't have time to repolarize
in time for each ensuing wave-and therefore, not all of the atrial
impulses pass through the AV node to generate QRS complexes.
Some just bump into a refractory node, and that is as far as they
get.
Figure 49. ECG showing a PVC rhythm with wide, bizarre QRS complex and
a compensatory pause following a premature beat and before the next beat.
- Thaler, 2012 (SkillStat Learning Inc., 2005)

Rapid Atrial Fibrillation

• Similar description to slow AF, but tachycardic
• HR: >100 bpm
○ AF with Rapid Ventricular Response (RVR)

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 Figure 52. ECG showing ventricular fibrillation. There are no distinguishable
Figure 50. ECG showing ventricular tachycardia with wide, bizarre QRS
P waves and QRS complexes. (Clinical Skills Education LLC, 2016)
complex and a compensatory pause following a premature beat and before
the next beat. (Clinical Skills Education LLC, 2016)
Review Questions
Not discussed thoroughly: 1. Marie, a 22 y/o medical student, was walking to CoCo after their
• Types of VT exam when she suddenly fainted. Her friends rushed her to the
○ Sustained: VT lasting longer than 30 seconds hospital. She has a BMI of 18.5 and had no family history of
○ Non-sustained: VT terminates within 30 seconds hypertension or diabetes. What is your diagnosis of her condition
○ Monomorphic: PVCs look the same based on her ECG results below?
○ Polymorphic: PVCs are different from one another

Polymorphic Ventricular Tachycardia

A. Premature atrial contractions

Figure 51. ECG showing polymorphic ventricular tachycardia where there B. Sinus node block
are multiple PVCs with multiple origins vs. monomorphic with uniform C. First degree AV block
pattern. (Winter, 2016) D. Wenckebach block
E. Mobitz Type II Second degree AV block
Torsades de Pointes
• Literally “twisting of the points” 2. Your patient’s ECG results are as follows. Describe the graph.
• A variation of ventricular tachycardia where QRS complexes spiral
around the baseline, resulting in changes in both axis and amplitude
○ Doc Cinco compared it to a spring being twisted
• ECG characteristics:
○ No P wave
○ Wide QRS complex
○ T wave not discernable
○ Prolonged QT interval
• A variation of polymorphic v-tach that may be due to a metabolic
condition involving potassium or magnesium A. Prolonged PR interval
• Treatment: magnesium (DOC) B. Progressive lengthening of interval with intermittent drop
• Contraindicated: amiodarone beats
C. Fixed PR interval with intermittent drop beats
D. P wave beats faster than the QRS complex

3. True of this slow arrhythmia:

Figure 52. ECG showing Torsades de Pointes. (2020 trans, 2016)

Ventricular Fibrillation
• Electrical impulses come from multiple ectopic pacemakers in the A. Prolonged P wave due to late depolarization
ventricles B. Prolonged QRS wave is due to abnormal depolarization of
• Indeterminate rate and rhythm pacemaker
• ECG characteristics: C. QRS does not exceed 2 small boxes
○ No P wave D. Occurs when the SA and AV nodes are firing faster than the
○ No true QRS complexes pacemaker
○ Associated with coarse or fine chaotic undulations of the ECG
baseline 4. Your patient’s ECG results are as follows. What is your diagnosis?
○ Looks like grounded electrical activity
• Mechanism:
○ A patient in V-fib is automatically arrested because the
ventricles are not contracting à no cardiac output

Figure 53. ECG showing ventricular fibrillation. There are no distinguishable

P waves and QRS complexes (SkillStat Learning Inc., 2005) A. Mobitz Type II block
B. Atrial fibrillation
C. Ventricular fibrillation
D. Sinus bradycardia

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5. Identify. References
(1) ASMPH 2019. (2015). Arrhythmia [Trans].
(2) ASMPH 2020. (2016). Arrhythmia [Trans].
(3) Cinco, J.E. (2017). Arrhythmia [Lecture slides].
(4) Ekg.Academy. Ventricular Rhythms: Asystole. Retrieved from
https://ekg.academy/ecgLessons/ventricularAssets/v121.gif
(5) Life in the FastLane. (2017). “AV block: 2nd degree, “high-grade” AV block”.
Retrieved from https://lifeinthefastlane.com/ecg-library/basics/high-grade-
block/
(6) Malmivuo, Jaakko & Plonsey, Robert. (1995). 19. The Basis of ECG
Diagnosis. 437-457.
(7) Mehta, R. S. (2014). ECG & Arrhythmias. Retrieved from
https://www.slideshare.net/rsmehta/ecg-arrhythmias
th
(8) Thaler, M.S. (2012). The Only EKG Book You’ll Ever Need (7 ed.).
(9) SkillStat Learning Inc. 2005. The Six Second ECG (Application)
(10) Winter, J.2016. ECG Characteristic educator. https://ecg-
educator.blogspot.com/2016/02/ventricular-rhythms.html

A. PAC
B. MAT
Changelog
C. Fast AF
D. Junctional Rhythm Changes in v02
(1) P9, Review Questions. Removed the redundant statements in question #3.
(2) P9, Ventricular Tachycardia. A variation of polymorphic v-tach that may be
6. Identify. due to a metabolic condition involving potassium or magnesium.

A. PAC
B. Slow AF
C. Junctional Rhythm
rd
D. 3 degree AV block

7. Identify.

A. Sinus tachycardia
B. Sinus bradycardia
C. Sinus arrest
D. Normal

8. Question 2: In sinus arrest, P wave is normal. True or False?

9. An ECG tracing is shown to you in the clinics, and through closer

inspection you suspect that this arrhythmia originates above the
ventricle. You then proceed to look for a:

A. Prolonged QT interval
B. Elevated ST segment
C. Narrow QRS complex
D. Wide PR interval

10. Dr. Sais gives you a quiz on normal ECG tracing. He loves his trick
questions, and shows you what seems to be a normal sinus
rhythm. Among the following arguments, which would help you
prove that it is indeed normal?

A. The P wave comes immediately after the QRS complex.

B. The PR interval comes to a value of 0.19.
C. The PT segment is the point of isoelectric reference.

Answer Key: 1e, 2d, 3b, 4c, 5b, 6c, 7b, 8f, 9c, 10b

05.12b Arrhythmia 10 / 11
VERSION 02
 Appendix

Figure 53. First Degree AV Block. (Mehta, 2014)

Figure 54 Type I Second Degree AV Block. (Mehta, 2014)

Figure 55. Type II Second Degree AV Block. (Mehta, 2014)

Figure 56. Third Degree AV Block. (Mehta, 2014)

05.12b Arrhythmia 11 / 11
VERSION 02