ecg lecture: sinus arrest, sinoatrial exit block, av block and escape rhythms

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Sinus arrest, Sinoatrial exit block, AV blocks, Escape Rhythms Dr. Michael-Joseph F. Agbayani, MD FPCP FPCC @HeartRhythmMD

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Simple ECG lecture about sinus arrest, sinoatrial exit block, AV block and escape rhythms. Slideshow was made with an audience of medical professionals in mind.

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Page 1: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Sinus arrest, Sinoatrial exit block, AV blocks, Escape Rhythms

Dr. Michael-Joseph F. Agbayani, MD FPCP FPCC

@HeartRhythmMD

Page 2: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Images used are mine or under a creative commons license or public domain.

Page 3: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 4: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 5: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

SA node: 60 to 100 bpmSA node: 60 to 100 bpm

AV Junction: 40 to 60 bpmAV Junction: 40 to 60 bpm

Ventricle: <40 bpmVentricle: <40 bpm

Page 6: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 7: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 8: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Sinoatrial Exit Block

• Sinus node still firing• Impulse fails to conduct beyond SA node• Degrees– First degree SA exit block– Second degree SA exit block (Type 1 and type 2)– Third degree SA exit block

Page 9: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

First degree sinoatrial block

• First degree– Delay in conduction of sinus impulse– Not evident in a surface ECG

Page 10: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Second degree sinoatrial block

• Intermittent failure of the sinus impulse to exit the node

• Type 1– Progressive delay in sinus impulse resulting in

non-conducted impulse– Group beating (Wenckebach periodicity)

Page 11: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Second degree sinoatrial block type 1

Page 12: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Second-degree sinoatrial block

• Type 2– Failed conduction of sinus impulse without

progressive prolongation of sinoatrial conduction time

– Pause is a multiple of baseline P-P interval

Page 13: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 14: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Third-degree sinoatrial block

• None of the sinus node impulses are able to exit the node

• Absence of p waves• Indistinguishable from sinus arrest

Page 15: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Sinus Pause / Sinus Arrest

• Sinus node doesn’t fire• P-P interval of the pause not a multiple of the

baseline P-P interval• Usually said to be abnormal if > 3 seconds

Page 16: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 17: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 18: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

First degree AV block

• PR interval is > 200 ms and is constant• Each p wave is followed by QRS complex• Marked first degree is >300 ms• May be symptomatic

Page 19: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 20: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Second Degree AV Block

• One non-conducted p wave• Mobitz Type 1 (Wenckebach Block)• Mobitz Type 2• 2:1 AV block

Page 21: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Mobitz Type 1 (Wenckebach)

• Gradual prolongation of PR interval until non-conducted p wave

• RP-PR reciprocity• Lengthening of the PR interval at progressively

shorter decrements• Progressively shorter R-R intervals and group beating• Shortening back to baseline PR interval after the

blocked cycle

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Mobitz Type 2

• No change in PR before non-conducted P wave

• Usually associated with His-Purkinje disease

Page 25: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
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2:1 AV block

• Second degree AV block• Every other beat is conducted• PR interval in conducted beats is usually

constant

Page 29: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

2:1 AV block

• Classifying into Mobitz Type 1 or type 2 is discouraged

• Clues to level of block– Narrow vs wide complex– Long or short PRs in conducted beats– PR and RP relationship– Presence of Mobitz Type 1 block– Response to Atropine or exercise

Page 30: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

2:1 AV block

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Page 32: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

High Grade AV Block

• At least 2 consecutive non-conducted P waves (3:1 AV Block)

• Also called “advanced second-degree heart block”

• Look at the PR interval of conducted beats: should be constant

Page 33: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

4:1 AV block

Page 34: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

3rd Degree or Complete Heart Block

• None of the P waves are conducted• P waves and QRS complexes occur

independently of each other• R-R intervals are usually regular (junctional or

ventricular escape rhythm)

Page 35: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

SA node: 60 to 100 bpmSA node: 60 to 100 bpm

AV Junction: 40 to 60 bpmAV Junction: 40 to 60 bpm

Ventricle: <40 bpmVentricle: <40 bpm

Page 36: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 37: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

• R-R intervals are usually regular (escape rhythm)

• “PR” intervals are not constant / no pattern• Escape rhythm can be junctional or ventricular

Page 38: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Escape Rhythms

• Atrial escape rhythm (<60 bpm)– P wave morphology abnormal

• Junctional rhythm (40 to 60 bpm)– Narrow QRS– Retrograde P waves shortly before or after QRS, if

any

• Ventricular rhythm (<40 bpm)– Wide, “bizarre” QRS complexes

Page 39: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 40: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

SA node: 60 to 100 bpmSA node: 60 to 100 bpm

AV Junction: 40 to 60 bpmAV Junction: 40 to 60 bpm

Ventricle: <40 bpmVentricle: <40 bpm

Page 41: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
Page 42: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
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Images• Heart image with conduction system: Public Domain image from Gray’s Anatomy • QRS complex: Public Domain image from Wikipedia user

http://en.wikipedia.org/wiki/User:Agateller• Road Block sign: http://en.wikipedia.org/wiki/File:Road_block.jpg• Traffic: http://en.wikipedia.org/wiki/File:Traffic_jam_on_Phu_Nhuan_district.JPG• Sinoartial exit block: http://commons.wikimedia.org/wiki/User:Jer5150• First degree AV block: http://www.flickr.com/photos/popfossa/• Second Degree AV block Mobitz Type 1:

http://commons.wikimedia.org/wiki/User:Jer5150• Mobitz type 2 and 2:1: http://commons.wikimedia.org/wiki/User:Jer5150• Complete heart block: http://commons.wikimedia.org/wiki/User:Jer5150• Complete heart block strip: http://en.wikipedia.org/wiki/User:MoodyGroove• Junctional rhythm: http://www.flickr.com/photos/nottinghamvets/

Page 45: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Images• Sinus pause: http://commons.wikimedia.org/wiki/User:Stevenfruitsmaak• Mobitz Type 1 with escape: Michael Rosengarten BEng, MD.McGill

(ecgpedia.org)• SCT with Pause: Michael Rosengarten BEng, MD.McGill (ecgpedia.org)• Mobitz type 1 and type 2 strips: Munther Homoud,

M.D.(http://ocw.tufts.edu/)• Mobitz Type II: http://lifeinthefastlane.com/author/edward-burns/• High Grade AV block: http://lifeinthefastlane.com/author/edward-burns/• Ventricular Escape rhythm: http://lifeinthefastlane.com/author/edward-

burns/• Fixed ratio blocks: http://lifeinthefastlane.com/author/edward-burns/

Page 46: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

ECG EXERCISESA exit block, Sinus Arrest, AV Blocks and Escape Rhythms

Page 47: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms
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Page 56: ECG Lecture: Sinus arrest, sinoatrial exit block, AV block and escape rhythms

Images• First Degree AV block: http://www.flickr.com/photos/popfossa/• 4:1 AV block: http://www.flickr.com/photos/popfossa/• Mobitz type 1: http://www.flickr.com/photos/popfossa/• First Degree AV block: http://www.flickr.com/photos/popfossa/• Type II Sinoatrial exit block: http://lifeinthefastlane.com/author/edward-burns/• Mobitz type 1: http://lifeinthefastlane.com/author/edward-burns/• Complete Heart Block; http://lifeinthefastlane.com/author/edward-burns/• Sinus arrest: http://lifeinthefastlane.com/author/edward-burns/• High grade Av block and Mobitz Type 2:

http://lifeinthefastlane.com/author/edward-burns/

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