Common ECG with Management

for Family Medicine Residents

Done by:

Dr. Abdulrahman Saleh Alhumaid

Dr. Saleh Saad Alsuwayt

Dr. Naif Abdullah Alomari

V1 July, 2021

‫وال تنسونا من صاحل دعائكم‬

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Index:

 Quick approach to ECG 3-4

 Atrial flutter 5
 Atrial Fibrillation 5
 AV block: 1st Degree Heart Block 6
 AV block: 2nd degree Heart Block Mobitz I block (Wenckebach phenomenon) 6
 AV block: 2nd degree Heart Block Mobitz II block (Hay Block) 7
 AV block: 3rd degree (complete heart block) 7
 Brugada Syndrome 8
 Hypocalcemia 8
 Hypercalcemia 8
 Hypokalemia 9
 Hyperkalaemia 9
 Left bundle branch block (LBBB) 9
 Right bundle branch block (RBBB) 10
 Multifocal Atrial Tachycardia (MAT) 10
 Pericarditis 11
 Pulmonary Embolism 11
 Premature atrial/ventricular complex (PAC/PVC) 12
 STEMI 13
 Supraventricular Tachycardia (SVT) 14
 Torsades de pointes 14
 Ventricular Tachycardia (VT) 15
 Ventricular Fibrillation (VF) 15
 Wolf Prkinson white sybdrome (WPW) 16
 Supplementary algorithims 17-19
 References 19

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Quick approach to ECG

Based on Rhythm

 If Narrow irregular
1. Atrial fibrillation: no p wave
2. Multifocal Atrial Tachycardia: p waves different morphology
3. Atrial flutter : p wave same appearance

 If Narrow regular
1. SVT : repeated QRS
2. Sinus tachycardia: normal tachy cycle

 Wide Irregular
1. Mobitz 1: prolonged PR (‫)يعنً كل شوي تطول البً ار من سايكل لسايكل وبعدين يصير فيى كيو ار اس دروب‬
2. Mobitz 2: Fixed PR (‫)هنا البً ار ثابتى مسافتوا لكن المشكلٌ يصير فيى دروب كيو ار اس‬

 Wide Regular (Look for P wave)

1. If single : look for PR
 If Normal sinus bradycardia
 If PR prolonged: first degree Heart block
( ‫)هنا مافيى كيو ار اس دروب بس تطول المسافٌ فً البً ار‬

2. If multi: look for number of P

 If fixed: Mobitz2
 If variable: complete heart block

 Bunle branch block

o Look for M letter in V1:
- If up + : RBBB
- If down - : LBBB

 Wolff-Parkinson-White (WPW) syndrome

- Look for delta wave before QRS

 Ventricular tachycardia (VTach)

- In ECG ٨٨٨٨
- If stable give antiarrhythmic medication (Amiodarone) every 15 mins
- If unstable : sedation then Cardioveraion 50-100 jole

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Atrial flutter

 Narrow complex tachycardia

 Regular atrial activity at ~300 bpm
 “Saw-tooth” pattern of inverted flutter waves in leads II, III, aVF

Atrial Fibrillation

 Irregularly irregular rhythm

 No P waves
 Most common sustained arrhythmia.
 Treatment:
 Assessment for anticoagulation
 Rate or rhythm control (B-blocker)
 Treatment of underlying / associated diseases
 CHA2DS2-VASc calculator via MDCalc risk of stroke to be calculated

Irregularly irregular ventricular rate without visible P waves

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AV block: 1st Degree Heart Block

 There is delay, without interruption, in conduction from atria to ventricles

 „Marked‟ first degree heart block is present if PR interval > 300ms
 Treatment:
 As an isolated finding this is a benign entity that does not cause haemodynamic
instability
 No specific treatment is required

AV block: 2nd degree Heart Block Mobitz I block (Wenckebach phenomenon)

Progressive prolongation of the PR interval culminating in a non-conducted P wave:

 PR interval is longest immediately before dropped beat

 PR interval is shortest immediately after dropped beat
 Asymptomatic patients do not require treatment
 Symptomatic patients usually respond to atropine
 Permanent pacing is rarely required

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AV block: 2nd degree Heart Block Mobitz II block (Hay Block)

A form of 2nd degree AV block in which there is intermittent non-conducted P

waves without progressive prolongation of the PR interval

 Management:
 The risk of asystole is around 35% per year
 Mobitz II mandates immediate admission for cardiac monitoring, backup
temporary pacing and ultimately insertion of a permanent pacemaker

Arrows indicate “dropped” QRS complexes (i.e. non-conducted P waves)

AV block: 3rd degree (complete heart block)

 Severe bradycardia due to absence of AV conduction

 The ECG demonstrates complete AV dissociation, with independent atrial and
ventricular rates
 Management:
 Patients with third degree heart block are at high risk of ventricular standstill and
sudden cardiac death
 They require urgent admission for cardiac monitoring, backup temporary
pacing and usually insertion of a permanent pacemaker

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Brugada Syndrome

 Risk of Sudden cardiac death.

 Asymptomatic patients with a type 1 ECG pattern.
 Treatment = ICD insertion & screening 1st degree relatives

 Brugada sign (Type 1 ECG)

 Saddle back ST segment “pseudo RBBB” (Type 2 ECG)
 Either type 1 or type 2, but with <2mm of ST segment elevation (Type 3 ECG).

Hypocalcemia

 Hypocalcaemia causes QTc prolongation primarily by prolonging the ST

segment
 The T wave is typically left unchanged
 Hypomagnesemia , same ecg finding of hypocalcemia “QT Prolongation”

Hypercalcemia

 The main ECG abnormality seen with hypercalcaemia is shortening of the QT

interval

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Hypokalemia

 Increased P wave amplitude

 Prolongation of PR interval
 Widespread ST depression and T wave flattening/inversion
 Prominent U waves (best seen in the precordial leads V2-V3)

Hyperkalaemia

 Peaked T waves
 P wave widening/flattening, PR prolongation

Push -pull effect

Left bundle branch block (LBBB)

 QRS duration > 120ms

 Dominant S wave in V1
 Absence of Q waves in lateral leads
 Prolonged R wave peak time > 60ms in leads V5-6

LBBB: Left Bundle Branch Block, V1: Dominant S wave, V6: broad, notched („M‟-shaped) R wave

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Right bundle branch block (RBBB)

 QRS duration > 120ms

 RSR‟ pattern in V1-3 (“M-shaped” QRS complex)
 Wide, slurred S wave in lateral leads (I, aVL, V5-6)

Multifocal Atrial Tachycardia (MAT)

A rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria.

 Most commonly seen in patients with severe COPD or congestive heart failure.
 Heart rate > 100 bpm (usually 100-150 bpm; may be as high as 250 bpm).
 Irregularly irregular rhythm with varying PP, PR and RR intervals.
 At least 3 distinct P-wave morphologies in the same lead.

3 distinctive P-wave morphologies (arrows)

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Pericarditis

 Widespread concave ST elevation and PR depression throughout most of the

limb leads (I, II, III, aVL, aVF) and precordial leads (V2-6)
 Reciprocal ST depression and PR elevation in lead aVR (± V1)
 Sinus tachycardia is also common in acute pericarditis due to pain and/or
pericardial effusion

Pulmonary Embolism

Non specific nor sensitive

 T-wave inversion is commonly associated with acute coronary syndrome (ACS).

Both ACS and PE can present with elevated troponin.

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Premature atrial/ventricular complex (PAC/PVC)

 Frequent PACs may cause palpitations and a sense of the heart “skipping a beat”
 PACs & PVCs s are a normal electrophysiological phenomenon not usually
requiring investigation or treatment

PAC ECG

This rhythm strip displays the typical pattern of frequent PACs (arrows) separated by post extrasystolic pauses

PVC ECG

 Sinus rhythm with PVCs of two different morphologies (arrows)

 Note the appropriately discordant ST segments / T waves
 The pause surrounding the PVC is equal to double the preceding R-R interval (= a full compensatory
pause

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 STEMI

The different infarct patterns are named according to the leads with maximal ST
elevation:

 Septal = V1-2
 Anterior = V2-5
 Anteroseptal = V1-4
 Anterolateral = V3-6, I + aVL
 Extensive anterior / anterolateral = V1-6, I + aVL

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 Supraventricular Tachycardia (SVT)

 Narrow complex tachycardia at ~ 150 bpm

 No visible P waves
 Associated with Mitral valve prolapse (MVP)

Supraventricular tachycardia (SVT): Rhythm strip demonstrating a regular, narrow-complex tachycardia

Torsades de pointes

 For TdP to be diagnosed, the patient must have evidence of both Polymorphic
ventricular tachycardia (PVT) and QT prolongation.
 Bidirectional VT is another specific type of of PVT, most commonly associated
with digoxin toxicity
 TdP is often short lived and self terminating, however can be associated with
haemodynamic instability and collapse.
 TdP may also degenerate into ventricular fibrillation (VF).

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 Ventricular Tachycardia (VT)

 Broad complex tachycardia originating in the ventricles.

 There are several different varieties of VT — the most common
being Monomorphic VT.
 Ventricular tachycardia may impair cardiac output with consequent hypotension,
collapse, and acute cardiac failure.
 Management:
 Anti-arrhythmia (eg, amiodarone, lidocaine, and procainamide) if stable.
 Cardioversion if unstable.

 Ventricular tachycardia

Ventricular Fibrillation (VF)

 Chaotic irregular deflections of varying amplitude
 No identifiable P waves, QRS complexes, or T waves
 Rate 150 to 500 per minute
 Management:
 Cardioversion: External electrical defibrillation

 Typical rhythm strip of ventricular fibrillation

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Wolf Prkinson white sybdrome (WPW)

 Sinus rhythm with a very short PR interval (< 120 ms)

 Broad QRS complexes with a slurred upstroke to the QRS complex — the delta
wave
 Long-term management: ablation of bypass tract

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Supplementary algorithims

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References

1. FASTLANE ECG https://litfl.com/ecg-library/diagnosis/

2. American Heart Association (AHA)

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