ECG
for the Small Animal Practitioner
Teton NewMedia Teton NewMedia 90 East Simpson, Suite 110 Jackson, WY 83001 © 2009 by Tenton NewMedia Exclusive worldwide distribution by CRC Press an imprint of Taylor & Francis Group, an Informa business Version Date: 20140128 International Standard Book Number-13: 978-1-4822-4111-2 (eBook - PDF) This book contains in formation obtained from authentic and highly regarded sources. While al l reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liabil ity for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in thi s book by individual editors, authors or contributo rs are personal to t hem and do not necessarily ref lect the views/opinions of the publishers. The information or guidance contained in thi s book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgemen t, t heir knowledge of the patient’s medical h istory, relevant manufactu rer’s instr uctions and the appropriate best practice guidelines. Because of t he rapid advances in medical science, any in formation or advice on dosages, proced ures or diag noses should be independently verified. The reader is strongly urged to consult the drug companies’ printed instructions, and their websites, before administering any of t he drugs recommended in this book. Th is book does not indicate whether a particular treatment is appr opriate or suitable fo r a particu lar individual. Ultimately it is the sole responsibilit y of the medica l professional to make his or her own professi onal judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apol ogize to copyright holders if permission to publish in this form has not been obtained. If any copyright material ha s not been acknowledged please write and let us know so we may rectify in any futu re reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photoc opying, microfil ming, a nd recording, or in any in formation storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically f rom this work, please access w ww.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to i nfringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com and the Teton NewMedia Web site at ww w.tetonnew media.c om
Dedication To my wife Jeri, and my son Kyle, and to all my students of electrocardiography for whom this book is written.
Larry Patrick Tilley
To my mother Beryl, who continues to nurture my independent spirit and deep love of learning, and to my brother David, who shares my delight in figuring out how things work.
Naomi Lee Burtnick
3
VetMed Dr. Larry P. Tilley & Associates Suite 279 1704-B Llano Street Santa Fe, New Mexico, 87505 USA Telephone: 505-424-9731 Fax: 505-424-8752 Email:
[email protected] Within the United States: Telephone: 800-214-9760 Fax: 800-820-6815
4
Preface We take great satisfaction
in bringing the reader this convenient review of basic canine and
feline electrocardiography. It is our hope that the text will both help the practicing veterinarian meet his day-to-day needs and stimulate the interest of students in small animal electrocardiography. We feel that the conciseness and clarity of this presentation has contributed immeasurably to these ends.
We also want to acknowledge thanks to Williams and Wilkins for permission to reuse selected illustrations from my Textbook: Essentia ls of Canine and Feline Electr oca rdiogr aph y, Inter preta tion and Treatment , 3rd Edition, Lea & Febiger, 1992.
The rapid evolution of animal electrocardiography has made an easily accessible text such as this both necessary and welcome. Today’s ECG instruments have placed in the hands of the veterinarian an accurate and efficient means of recording the electrical activity of the animal’s heart. But what does the ECG tracing mean? To own an electrocardiograph is not enough; the veterinarian must use his ECG instrument correctly and interpret the ECG recording accurately.
5
Table of Contents Section
1“How To”
Introduction & Helpful Hints . . . . . . . . . . . . . . . . . . . . . . . . 9 Applications of the Electrocardiogram . . . . . . . . . . . . . . . . 10 Circulation System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Conduction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Five Physiologic Properties of Cardiac Muscle . . . . . . . . . . 13 Electrocardiogram–Definition . . . . . . . . . . . . . . . . . . . . . . . 14 What is a Lead, Anyway? . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Generation of the Electrocardiogram . . . . . . . . . . . . . . . . . 16 Electrocardiographic Recording Technique . . . . . . . . . . . . 17 ECG Paper & Standardization Calculating the Heart Rate . . . Measuring the P-QRS-T . . . . . Canine ECG Normal Values . . Feline ECG Normal Values . . .
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19 20 22 24 25
Quick & Dirty Guide to ECG Enlargements & Bundle Branch Blocks . . . . . . . . . . . . . . . . . . . . Classification of Arrhythmias . . . . . . . . . . . . . . Building Blocks for Arrhythmia Interpretation Interpreting Arrhythmias–the Easy Way . . . . . .
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2-Electrocardiographic Examples
Normal Sinus Impulse Formation Normal Sinus Rhythm . . . . . . . . . . . . . . . . . . . . . . . 34 Sinus Arrhythmia . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Disturbances of Sinus Impulse Formation Sinus Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Sinus Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . 40
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Disturbances of Supraventricular Impulse Formation Atrial Premature Complexes . . . . . . . . . . . . . Atrial Tachycardia . . . . . . . . . . . . . . . . . . . . . Atrial Fibrillation . . . . . . . . . . . . . . . . . . . . . Atrioventricular (AV) Junctional Premature Complexes &Tachycardia . . . . . . . . . . . . . . .
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Disturbances of Ventricular Impulse Formation Ventricular Ventricular Ventricular Ventricular
Premature Complexes Tachycardia . . . . . . . . . Asystole . . . . . . . . . . . Fibrillation . . . . . . . . .
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54 56 58 60
Disturbances of Impulse Conduction Sinus Arrest or Block . . . . . . . . . . . Sick Sinus Syndrome . . . . . . . . . . . . Atrial Standstill . . . . . . . . . . . . . . . . Ventricular Pre-Excitation & Wolff-Parkinson-White Syndrome . Secret to Atrioventricular Blocks . . First-Degree Atrioventricular Block
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Second-Degree Atrioventricular Block Third-Degree Atrioventricular Block . Left Bundle Branch Block . . . . . . . . . . Right Bundle Branch Block . . . . . . . .
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76 80 82 84
Escape Rhythms Junctional & Ventricular Escape Rhythms . . . . . . . 88
Miscellaneous Disturbances Pericardial Effusion (low voltage QRS complexes & electrical alternans) . . . . . . . . . . . . . . 92 ST Segment & T Wave Changes . . . . . . . . . . . . . . 94 Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Appendix Anti-Arrhythmic Drugs . . . . . . . . . . . . . . . . . . . . . 100 Recommended Textbook Readings . . . . . . . . . . . . 104
7
Section
“How To” 1
Introduction The goal of this book is to providethat youwill with fundamental information andnormal, interpretation techniques help you differentiate between abnormal, and life-threatening electrocardiographic arrhythmias in the dog and cat. Even with the advent of newer technology for assessing cardiac function, such as echocardiography, the electrocardiogram remains the definitive tool for diagnosing arrhythmias. It is to that end that we have focused this book. By carefully following the simplified techniques outlined here, you will easily build the foundation for recognizing and treating most arrhythmias.
Some Helpful Hints Scattered throughout the text you will find the following symbols to help you focus on what is really important. This is a routine feature of the subject being discussed.
We’ve tried to narrow it down, honest. This is a salient feature. If you remember anything about
this particular subject, this is it. We’ll use this selectively. It’s a key to understanding the whole process of ECG interpretation.
Stop. This doesn’t look important but it can really make a difference when trying to sort out unusual situations.
Something serious, possibly life-threatening will happen if you don’t remember this. For example, this book could blow up.
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Applications of the Electrocardiogram
Exact diagnoses of arrhythmias heard on auscultation. Acute onset of dyspnea. Shock. Fainting or seizures. Monitoring during and after surgery (for depth of anesthesia as
well as cardiac monitoring). All cardiac murmurs. Cardiomegaly found on thoracic radiographs. Cyanosis. Preoperatively in older animals. Evaluating the effect of cardiac drugs–especially digitalis,
quinidine, and propranolol.
Electrolyte disturbances, especially potassium abnormalities. Periocardiocentesis, for monitoring purposes. Systemic diseases that affect the heart (e.g., pyometra, pancreatitis,
uremia, neoplasia), with toxic myocarditis and resulting arrhythmias. Basis for records and consultation. Serial ECGs as an aid in the prognosis and diagnosis of cardiac disease. 10
Circulation System The body depends on the heart pumping oxygenated blood
to the tissues. Unoxygenated blood enters the right side of the heart and is
pumped to the lungs (pulmonary circulation). From the lungs, the newly oxygenated blood enters the left side
of the heart where it is pumped to the organs and tissues via the systemic circulation.
To the Body
To the Lungs
Aorta From the Lungs
Pulmonary Artery Pulmonary Veins Vena Cava
Aortic Valve Left Atrium
Pulmonic Valve
Mitral Valve Right Atrium Triscuspid Valve
Left Ventricle
Vena Cava
From the Body Right Ventricle
11
Conduction System Electrical impulses are transmitted through the heart via specialized conduction cells in the following sequence: Sinoatrial node.
Interatrial and internodal conduction tracts.
Atrioventricular (AV) node.
Bundle of His (the region of the AV node and the Bundle of
His is called the AV junction). The left and right bundle branches. Purkinje fibers.
SA Node Left Posterior Fascicle AV Node
Bundle of His
Left Anterior Fascicle
Left Septal Fibers Right Bundle Branch
Purkinje Fibers
What is depolarization and repolarization? Depolarization–heart muscle contraction in response to electrical stimulus. Occurs when electrolytes move across the cell membrane (sodium/potassium pump).
Repolarization–heart muscle relaxation occurs when the electrolytes move back across the cell membrane rendering the cell ready for the next electrical impulse. 12
Five Physiologic Properties of Cardiac Muscle Automaticity Sinoatrial node is the primary pacemaker of the heart, but any cells of the conduction system can initiate their own impulses under the right circumstances. As a rule, the further down in the conduction system the slower
the rate of automaticity.
Excitability Cardiac muscle is excited when the electrical stimulus reduces
the resting potential to the threshold potential. The degree of the resting potential within the cell determines
its excitability and obeys the “all-or-none” law.
Refractoriness Heart muscle will not respond to external stimuli during its period of contraction.
Conductivity Activation of an individual muscle cell produces activity in the
neighboring muscle cell. Conduction velocity varies in the different portions of the
specialized conduction system and muscle fibers. Velocity is greatest in the Purkinje fibers and least in the
mid-portion of the AV node. sequence is so arranged that the maximum mechanical Activation efficiency is provided from each corresponding contraction.
Contractility Occurs in response to electrical current. Remember that the ECG only measures the stimulus for
contraction–not the actual contraction itself. Echocardiography is the tool of choice for assessing contractility. 13
Electrocardiogram Definition–Graphic recording of electrical potentials produced by heart muscle during the different phases of the cardiac cycle. The voltage variations are produced by depolarization and
repolarization of individual muscle cells.
Each portion of the electrocardiogram thus arises from a
specific anatomic or physiologic area of the heart.
R
P T
Q
S
P wave–corresponds to atrial depolarization or contraction. P waves can be positive, negative, or biphasic depending on the lead (we'll explain leads just a little later).
QRS waves–correspond to ventricular depolarization or contraction. Q wave is the first negative deflection. R wave is the first positive deflection. S wave is the negative deflection that follows the R wave.
T wave –represents ventricular repolarization or relaxation. T waves can be positive, negative or biphasic.
Every QRS complex h as to have a T wave following it.
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What is a Lead, anyway? Lead systems allow you to look at the heart from different
angles. Each different angle is called a lead. The different leads can be compared to radiographs taken from different angles, such as lateral and dorsoventral thoracic radiographs taken for evaluation of cardiac chambers. Each lead has a positive and negative pole attached to the
surface of the skin, which can then be used to measure the spread of electrical activity within the heart. Upward deflection on the ECG–is produced when electrical impulses travel towards a positive electrode. Downward deflection on the ECG–is produced when electrical impulses travel towards a negative electrode. Flat line (isoelectric line)–is produced when there is no electrical spread through the heart, or if the electrical forces are equal. A
B
C
D
E
To determine the mean electrical axis (useful in assessing cardiac
chamber size) it is necessary to run the 3 standard bipolar leads as well as the 3 augmented unipolar limb leads. Lead I–right arm (-) compared to left arm (+) Lead II–right arm (-) compared to left leg (+) Lead III–left arm (-) compared to left leg (+) aVR–right arm (+) compared to a point halfway between left arm and left leg (-) aVL–left arm (+) compared to a point halfway between right arm and left leg (-) aVF–left leg (+) compared to a point halfway between left arm and right arm (-) The good news is that we only need to use lead II to assess
arrhythmias.
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Generation of the Electrocardiogram The following illustrations depict the genesis of the ECG on the basis of: Initiation of the impulse in the primary pacemaker (sinoatrial node). Transmission of theofimpulse through the specialized conduction system the heart. Activation or depolarization of the atrial and
ventricular myocardium. Recovery or repolarization of the preceding three areas.
SA Node Left Atrium Right Atrium
AV Node P
Positive Electrode
AV N ode
LBB
RBB
R
P
P
Q
Q
R
R
P
P
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Q
S
T
Q
S
Electrocardiographic Recording Technique Patient cable–a single lead or 6-lead patient cable can be attached to a hand-held recorder/monitor or any standard ECG strip chart recorder, and the ECG can be recorded with the patient in lateral or standing position. The electrode clips are attached directly to the skin and moistened with alcohol or gel to assure good contact.
Record lead II for 30-60 seconds at 25 mm/sec to assess
arrhythmias Record a brief tracing at 50 mm/sec for ease of measurement of
P-QRS-T waveforms. While the ECG is recording the following should be observed:
1. Center the recording on the paper so that both the top and bottom of the waveforms can be seen. Adjust the position control if the tracing wanders. 2. Decrease the sensitivity to 1⁄2 cm = 1 mv if the QRS complexes go off the paper. 3. Increase the length of the tracing if an arrhythmia is seen. 4. R waves should be positive on lead I. If negative, check the lead wires to determine whether they are attached to the correct limbs. If connections are correct, then a true abnormality exists. 17
Electrocardiographic Recording Technique
(continued)
Direct chest placement–a hand-held ECG recorder/monitor allows direct chest placement.
Wet the animal’s coat with alcohol or place gel on the electrode
plates, and then position the unit on the chest. The tracing is seen on the monitor and stored for printing later
with one of the following options: 1. Strip printer. 2. Printer interface to a standard inkjet printer for a plain paper printout. 3. Direct download to PC computer program.
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ECG Paper & Standardization 1 cm = 1 mv calibration signal
0.5 mv 1mm = 0.1 mv
0.02 second
0.10 second
Standardization Signal Without a standardization signal, the ECG paper is merely
graph paper. By entering a signal, you place value on each of the smallest squares. At 1 cm = 1 mv each tiny square represents 0.1 mv in height (amplitude) and 0.02 seconds in width (duration) at a paper speed of 50 mm/sec. It wouldn’t be such a bad idea to memorize this. The calibration signal can be changed, if necessary, to affect the amplitude only. If the complexes are very tall and extend beyond the margins of the paper, the signal can be reduced to 0.5 cm = 1 mv. With very small amplitude complexes, the standardization can be increased to 2 cm = 1 mv and the height of the complexes will increase accordingly. Time markings–ECG paper also has time markings in the margin every 1.5 sec at 50 mm/sec. An example of the time markings is shown in the section on calculating heart rate. All ECGs in th is b ook will be at a paper sp eed of 50 m m/sec and at a ca li bration of 1 cm = 1 mv.
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Calculating the Heart Rate The heart rate (beats/minute) can be calculated easily by: 1.Using the ECG ruler on the next page. The ruler allows you to use 25 mm/sec or 50 mm/sec paper speed. 2.between Or, by counting number of beats (R-R two sets the of marks in the margin of intervals) the ECG paper (3 seconds at 50 mm/sec) and multiplying by 20.
3 seconds at 50mm/sec
Normal feline ECG: 11 beats X 20 = 220 beats/minute Regardless of which system you use it is important to know the correct paper speed!
20
r uleR
Use the enclosed ruler in the Inside Back Cover for an easy way to measure heart rate & P-QRS-T intervals
C G E 21
Measuring the P-QRS-T P wave–represents depolarization of the atria, and its duration indicates the time required for an impulse to pass from the sinoatrial (SA) node to the atrioventricular (AV) node. The normal P wave on lead II is small, positive and rounded. It is measured from the upper edge of the baseline to the top
of the P wave.
The width of the P wave is measured at its inside, from the start
to the end of the deflection from the baseline.
P-R interval–reflects activation of the AV junction. It is measured from the beginning of the P wave to the
beginning of the Q wave (R wave, if no Q wave is present).
QRS complex–represents depolarization of the ventricles. The width of QRS complex is measured from the beginning
of the first deflection to the end of the final deflection of the complex. R
Q
22
S
Measuring the P-QRS-T(continued) The height of the R wave is measured from the top edge of the
baseline to the peak of the R wave. The depth of the Q or S wave is measured from the bottom edge
of the baseline to the lowest part of the Q or S, respectively.
S-T segment–represents the time interval from the end of the QRS interval to the onset of the T wave, the early phase of ventricular repolarization. It may be above, at, or below the level of the baseline. Only significant elevations or depressions from baseline should
be considered abnormal. T
T wave–is the first major deflection following the QRS complex and represents repolarization of the ventricles. It may be positive, notched, negative, or diphasic. T wave should be less than 25 % of the QRS amplitude.
Q-T interval–is the summation of ventricular depolarization and repolarization and represents ventricular systole. Q-T interval is measured from the onset of the Q wave to the
end of the T wave. The Q-T interval alone in veterinary medicine is not often
helpful in diagnosis.
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Canine ECG Normal Values* Rate 70 to 160 beats/min for adult dogs 60 to 140 beats/min for giant breeds Up to 180 beats/min for toy breeds Up to 220 beats/min for puppies
Rhythm Normal sinus rhythm/Sinus arrhythmia Wandering sinus pacemaker
P wave Width: maximum, 0.04 sec (2 boxes wide) maximum, 0.05 sec (21⁄2 boxes wide) in giant breeds Height: maximum, 0.4 mv (4 boxes tall)
P-R interval Width: 0.06 to 0.13 sec (3 to 61⁄2 boxes)
QRS complex Width: maximum, 0.05 sec (21⁄2 boxes) in small breeds maximum, 0.06 sec (3 boxes) in large breeds Height of R wave: maximum, 3.0 mv (30 boxes) in large breeds maximum, 2.5 mv (25 boxes) in small breeds
S-T segment No depression: not more than 0.2 mv (2 boxes) No elevation: not more than 0.15 mv (11⁄2 boxes)
T wave Can be positive, negative, or diphasic Not greater than 1⁄4 amplitude of R wave
Q-T interval Width: 0.15 to 0.25 sec (7 1⁄2 - 12 1⁄2 boxes) at normal heart rate 0.1 sec.
0.02 sec.
0.5 mv
0.1 mv
Baseline
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P-R Interval
Q-T Interval
* Lead II: 50 mm/sec, 1 cm = 1 mv
Feline ECG Normal Values* Rate 120 to 240 beats/min
Rhythm Normal sinus rhythm Sinus tachycardia (physiologic reaction to excitement)
P wave Width: maximum, 0.04 sec (2 boxes wide) Height: maximum, 0.2 mv (2 boxes tall)
P-R interval Width: 0.05 to 0.09 sec (21⁄2 to 41⁄2 boxes)
QRS complex Width: maximum, 0.04 sec (2 boxes) Height of R wave: maximum, 0.9 mv (9 boxes)
S-T segment No depression or elevation
T wave
Can be positive, negative, or diphasic; most often positive Maximum amplitude: 0.3 mv (3 boxes)
Q-T interval Width: 0.12 to 0.18 sec (6 to 9 boxes) at normal heart rate 0.1 sec.
0.02 sec.
0.5 mv
0.1 mv
Baseline
P-R Interval
Q-T Interval
*Lead II: 50 mm/sec, 1 cm = 1 mv 25
Quick & Dirty Guide to ECG Enlargements & Bundle Branch Blocks R wave increased in amplitude = Left Ventricular Enlargement
R wave increased in duration = Left Bundle Branch Block
P wave increased in amplitude or duration = Atrial Enlargement
S wave increased in amplitude = Right Ventricular Enlargement
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S wave increased in duration = Right Bundle Branch Block
Classification of Arrhythmias Definition of Arrhythmias:
1. An abnormality in the rate, regularity, or site of srcin of the cardiac impulse. 2. A disturbance in conduction of the impulse such that the normal sequence of activation of the atria and ventricles is altered.
Classification of Arrhythmias
Abnormalities of impulse formation or impulse conduction are the basis for the following classification:
Normal sinus impulse formation Normal sinus rhythm Sinus arrhythmia
Disturbances of sinus impulse formation Sinus bradycardia Sinus tachycardia
Disturbances Atrial of supraventricular impulse formation premature complexes Atrial tachycardia Atrial fibrillation Atrioventricular junctional premature complexes Atrioventricular junctional tachycardia
Disturbances of ventricular impulse formation Ventricular Ventricular Ventricular Ventricular
premature complexes tachycardia asystole fibrillation
Disturbances of impulse conduction Sinus arrest or block Sick sinus syndrome Atrial standstill Ventricular pre-excitation First-degree atrioventricular block Second-degree atrioventricular block Third-degree atrioventricular block Left bundle branch block Right bundle branch block
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Building Blocks for Arrhythmia Interpretation There are two basic building blocks for placing an arrhythmia within the classification presented earlier. Recognizing the site of srcin of the abnormal beat. Recognizing deviations from the normal rate of automaticity for that site.
1. Site of origin Three different sites can be identified on lead II by the following features: Atrial–positive deflection P waves are present with a constant P-R interval and a normal duration QRS complex.*
Ectopic atrial srcin beats have all the same features as a
normally conducted SA nodal srcin beat. The primary difference lies in the timing.
Junctional–negative deflection P waves, or no P waves, with a normally conducted, short-duration QRS complex.*
–no P waves are evident. QRS complexes are wide Ventricular and bizarre appearing and may be positive or negative polarity, depending on which ventricle is the site of srcin.
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*If a bundle b ranch bloc k is pres ent , QRS compl exes will h ave prolonged duration and poor m orph ology.
Building Blocks for Arrhythmia Interpretation (continued) 2. Intrinsic rates of automaticity Atrial, junctional, and ventricular sites each have a normal rate of automaticity (the ability to initiate impulses), but may respond in the following abnormal ways: Too fast (tachycardia) Too slow (bradycardia) Too irritable (premature) Absent (block)
Normal pacemaker rates in the dog:
Sinoatrial Node 70-160 bpm
Atrioventricular Junction (AV NodeHis bundle region) 40-60 bpm
Atrial Conduction Tissue
Ventricular Conduction Tissue (Bundle branches & Purkinje fibers) 20-40 bpm
In cats, the SA nodal/atrial intrinsic rate of automaticity is
120-240 bpm, with the normal junctional and ventricular sites having proportionately slower rates. Passive arrhythmias (escape rhythms)–
rates slower than the SA node occur because of SA nodal depression, allowing “escapes” of other pacemakers from its influence.
Active arrh yth mias–occur when a normally functioning
SA node is not able to act as the pacemaker because other pacemakers are abnormally forming impulses at a faster rate. Both passive and active arrhythmias may be intermittent or
persistent, repetitive, or occurring in varying combinations. Rule of thumb: Whichever site is fastest will drive the heart! 29
Interpreting Arrhythmias–the EasyWay Arrhythmias can be intimidating. Therefore, it is important that we find a simple approach for analyzing rhythm strips. Systematically following the five-step method outlined below has proven to be both easy and effective.
Step 1. Calculate the heart heartrate rate whether the is rapid, slow, or normal. Decide Here’s your chance to try that new ECG ruler.
Step 2. Assess the rhythm Scan the strip from left to right, noting if the R-R intervals
are regular or irregular. A caliper is a handy tool for plotting P-P and R-R intervals.
Step 3. Identify P waves Normal P wave the (positive and rounded on Lead II)–indicates that the impulse is srcinating in the SA node. P wave t h at d iffers from normal in shape and i s uprigh t– may
represent an ectopic pacemaker in the atrium. P waves th at are inv erted– on lead II, indicate that the impulse
was formed in or near the atrioventricular junction. Absence of P waves–signifies atrial fibrillation, atrial standstill,
or buried P waves in QRS complexes of AV junctional rhythms. P waves can be superim posed– on a portion of the QRS complex,
S-T segment, or T wave of the preceding cardiac cycle in various supraventricular tachycardias. 30
Interpreting Arrhythmias– the Easy Way (continued) Step 4. Assess QRS shape and duration Normal duration QRS complexes–identical to those recorded
before an arrhythmia, indicate normal activation of the ventricles. These complexes are either formed in the SA node or from an abnormal site anywhere above the bundle of His. Wide QRS complex es– with various configurations indicate an ectopic pacemaker below the bundle of His (ventricular) or a lesion in the intraventricular conduction system (bundle branch block).
Step 5. Relationship between P waves & QRS complexes Normally, there should be one P wave for every QRS complex,
with a constant P-R interval.
P waves may precede normal QRS complexes by different
time spans. Long P-R intervals– indicate an AV conduction delay (1° AV block). Sh ort P -R intervals– are seen with accessory conduction around the AV node, or in AV junctional rhythms in which the P wave is positioned close to the QRS complex. P wave n ot foll owed by a QRS comp lex – an AV block (2° AV block) has occurred. If the P-R interval lengthens gradually until a P wave occurs without a succeeding QRS complex, another form of 2° AV block has occurred. P-R in te rvals var y– in 3° AV block the relationship of the atria and ventricles is interrupted. One impulse forming site is the SA node; the other is an independent ventricular escape rhythm.
Last step: Name that arrhythmia Place the arrhythmia within the classification. The best name for an arrhythmia always identifies exactly which
part of the heart is not working properly.
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Section
2
Electrocardiographic Examples Normal Sinus Impulse Formation
Normal Sinus Rhythm Sinus Arrhythmia
Disturbances of Sinus Impulse Formation
Sinus Bradycardia Sinus Tachycardia
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•
•
m h yth R su in alS rm o go ND •
34
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ro f he t m si ot an s hc ad e erp ms al nd orm ea n od en th la si ir t m ao ht n yi hr se su th in ni S es ta ign i ore sl . pu les m i rci aic etn rad v c eh al dt rom na n ,e e do hn Tr ole.t cula yss itr n aci ve dr ior ca ta ge itn ht ai a, it itr ni a
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. esc 1.0 0 anh t ses l si sl .s a ta rv c et ni ni R m pb g.s -R 04 do ste l -2 ni la 201 vals sm d er hte na t sg ni nd od -R ta Rs in eh egr t al m pb in e h 06 on t . i n I -01 ait ee Id 7 r wa ta av tbe el n luar 10% nce eiv se ge n er iti r rs ha eff so u ta mi tss ied pre eF tyh isel ,th ase rh re tas va GehT ehT cnI wP C
.t ne ers spi tc fee d no tic ud no c r .l ual a ic rev rt t n in ave R - rtn P t in na a ts fi onc rer a azi ht b i dn wa al ed i rm o w n eb are ay exs m el esx p el p om c om S c RS -Q R P Q
E
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T 35
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la ga v cih h w ni , es eass di yr toa ri spe r ci orn ch ni .g ro do ds e ere ht b in lcia .n g o ni hp ict d e ni yc rut f hs la c bo s rm bar ya n oi ont nin wiar ti en ee er d qu ns pp frea fteo uy on Cis is bde de AS AS aesr ta yro yro nc ic art art iis os ispe ispe en s R R ot
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fo no i atr ts i ni a dm d na e urs s rep lla be ye d an su n sid toi ra :cs e udr ec rop ci n too ga v yb de t uat n cec s. a il si tia A gid S
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T 37
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ta C
. ets ar s eu rga oir e chs sa di ht la i w d rm oe nw ciat ol so eb as et en ar tf t o are ist h ,i a ts ht ac i n w , I. . m gs tn th do e rhys ede atm e u rb rt ni e d s ra rga an ulg rl noi o re fl tn is a tet m a or st nn be arr ay aw mh hic bpm w , 7-0 er d 60 ros fo i d ets gn ra yli rat er e nd Hu
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oCnicrea n de :an ta gci ic oloi os syh sP A
din ni qu, si la ti g di, lo ol n rpa rpo ,s thy icd end inez p poy m et im ai h s ht a,i :sy na on cf e m re gi og hp s. ht olo in :s er op th rn gu ck y a a r ol h P w Db
s. no is el m ystes su ov .ai er m n ael l rat kre en py CH
de e b olw y lo a f m e V I ni de ht .e etr na tar si B t ni or- ar e dm a l.P ph eb ufp ud l dl eh ee p ou to so hs n t et si pl al en eh ror ip ya .ev yp tor m ti o a e ce ylc fi nil fef ge ro ni atu rsi mb nie tau ter eth po b r ta r oo c a,t rd eni g )e ol ll nic sp o hy a al ner po -ps lo e e u c otr h no ro p .T e ss osi tn vsn e a .d en fo m tr k rei ea no ega a uq w si n ht re st( nfu m a w i ley ix i m gn e Vr i arr sn Is te- ac t si gi uo g pl n e etn acsl tuni lnor aitr a m ta tmae cinli onc dof thg er rT fI yb esu iR
le n an hc uim cl ca d n s,ac it e ht se an d na e, ni hp ro m ,e
T
39
aid ra cy hc a suT ni og SD 40
at C
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ai dr ac yc h a T s u n i S
m bp 06 1 > et ar s. t rta ca en ha im in bp g0 ni 4 tl 2 u> ers dn . ,e a la ) art ds rve e t gre reb ni a hc tn R si ai R d g ni l a 0in ion m or 41 tai n d ra tis an v d, t no ise gih l eyb pp sa u ed p hit o ni w n la 02 lby rit ,s2 sis ao d o . e p t in e , n se tesh yobrt gulare staon r fo ni rs sc u ta noi 80 im ila eF rta s1( thy vret e ecl og erh in GAc nid hT R-P C
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. iax op y ,h urel afi tr .) ae g h ni e rdo tvi s ecr ge n G oc C ,n E o as tic .) n ch ef o su( in, nsi se ai et ru m op d ne yh s.t ec ,a s( ac ro ck ro p d t o t na ni sh ail , d s gso rsate sim soa n oi dni rro irdo ven, ti ai ni yh ir d m pa tre hp hryth cse,i ,hyp peine on Cra rex rev ,e de no :e :ef inp ta mm cig gci rot ic oc oilo ool :as os ost shy tah rgu s MP P D
. cok hs dr oc l cai rt c lee g, ni ons poi e ne hp roo l hc xae H
A
orf ot ni eu xog di si d, ai er ardc iluaf y tr cah ae t h e ve ht ti fI se . gn ess oc auc ot e eu ht d g is ni t rolt eif; t . onc ra de t d rta cia na e d g he in ni h is yf t y ti w c ne ol ne s id lli cifi fo f wu tss erz sni si il c onc uiq diar yl rna ca p t smi at, gni n e tne tne ylred m ta tmae timec nue er rT xe ht
T
41
Section
2
Electrocardiographic Examples Disturbances of Supraventricular Impulse Formation
Atrial Premature Complexes Atrial Tachycardia Atrial Fibrillation Atrioventricular Junctional Premature Complexes Atrioventricular Junctional Tachycardia
43
se xe lp m o
44
C rue ta m e Prl ira g to AD
at C
arl uc rit env a pur s yb sedu ac er a
ail tra fo tiy ci at m tuo ain sae . er ai cm ni th n yh A rr .) as i doe ht n rof As Sm s an i thr anhc ee ht m o( e r tie tai s u ail cir r c at t cn poi atr t n ec ree na el g om rf asin gr ni o at res ni b gi rio fla se rdi s a ulp oc y m i m
)s C P A ( s xel p m o C er u ta m er P la ir t A
.l el. l a ta vr ycc ro ta airt e ev e f th a th tni ti h k e d vea R . iso tst ool sua na w Ps )es p, se ot p ai P u x e er e dr ci ins lep tiv d eye ht ca p e ga na r ht hy tco ht m o e e uo i c er na scu ben odn nyi dw e ltaa ut ht sni y su ar ni irt a re f a ni T b a . m g m m er no aot tI se tsa oc tos p lr h .s ht e ,t ro t b e ht os sa eav gse de ah rsu c ot ga e w ar tc .T ta er u h m P n eu o as s sc d e p d l ( u i nbe ra sa n sni de oc su th lu yll oit e sl yl oi er ge au ra th up al ev sa rr su ug f m r rp C i m is lis nfi toa e. ali no eh A P m va ocl th av rta eik tfo .m . h r w ci lt e e m yt et am m o po su va th he rh in ro fr T s e R n pe ou cet jk w tch ty th cP fo a iv e oo T ca tfi d . ip y sh er h l eh u n o lla nt p T a,n m ey t oy edi t . h ht hc o e c al ty e suu eer th C P e u pl t f rom hr eht is dif no A su ot eh nt n vae ip xe a d teh aec lyd dl tar yl w hs lp as es s b e ou o la n h o w s tc h p ser issu rlPma aletio Scom veaw irmpe oflo oismt npexe -S,sT itimsi r R p y te no S Q P us lla ysa tu R u a ta tr he R ed ci ro su e ah Qe so,n e ear stt -PQ tal ctpo ,ci sue era tse hst tio F h up he er e sa au s av w all h C oi GeTh idsr Itn ehT eTh pib Ap AP wP llof rbif
C E
.) y ht pao y om di arc , cy ein ci ff us ni alr ti m .,g e.( t enm ger al ne la rit a h s tiw n oi ylla ti us d su, cat on d Cna de sg ta od ic in os nee sS
A
tih w e ulr i fatr ea h ev i ste .r g oti no b ci g hni ni ye rle ym d zn un eg any tinr t e ear vn o .eT c ci nis on hc et fo io t agn ne d m ta an ret tci e er thn iud et of f t ois aegs n e inx doe ot m ta gid airp er –sg orp ToD pa
d tea l di tih actsw ro f ni xo gi d es U .l o ol n tea or m zea tli id es u y ht a opy oim dr ca ic poh rt re y. py ht h ap ht yo i m w –s io ta dr C ac 45
46
aid ra cy hc a laT ir g to AD
ta C
.e do n su ni s eh t n hta re thoe ist la ir at an om fr ngi t nai gi or hm ty rh ra lu ge r idp ar a si
hc m iur ih ta w e, ht rae ni al su an co oit f c tica jun V m ot A au dna al mm u. or irt sel nb a c a e ir n th tne nv .A ai ee e ht dr w ac etb ot chya uitc asp t ir d la c n ir a a ta y, m eb tnr riu ot ree at de si eth erd sm et is i la no nah u i c ec tm er m es a r s her to C P ot esl An er A up o e. m i m us e or ac ht s ere ne w h os llo Ti a
ai dr ycah ca T la ir t A
ya m ey h T .s ev a w sPu ni . s la e vr h .s tf te uo o ni u ta -R ni th P t onc na deg .) r th n o t ol m pb )l enr or a ep f 40 sm fi ro 2 roxy atd tea ,s> ta pa hw rr ( a ;c tn em lcu pbm tet soy itr i n 08 rm all ve 1- te er st n na 610 ir eg ef > he si ht sg, iet es of od e av se ( by w u a
se rpidas r iet u ta rat eF rea
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a ePh ecb m iad tf ee ra o s no yc tio yt hc a s r a ta ug e la fi be rit on t o A Cn
C E
of sue ac eb er ra zi b nda ed i w ro s)e xe lp m co su n si e th as .n e oit asm tai ( c la xe -e r rm op n ra yl ul alu ci su rt si nev nr atior cko u lo ifg b no hc cn S rba Re Q dl en hu Tb
.r cuc o anc kc ol b V A of se er g de su o ria v se rat gih h yr ev t A t. na ts onc yl alu ius alv r te ni -R P e h T
. m si . di no or y m ht re om py ct h so r yo em h tah s.) gt po go ni y d eb d t m ido an ne ra st m c ac eg ht n ar i il ln wa e st ti l ac ne iar ni gn ta o g and (ce usin sae om ca sie rd oes d yn h tr s t ae te ,s h ih C er W PA s vsee o-ns hti n oi hit rink swla ti ws aP m d g -f in olf saa on nido W Cne hit tne de esy w mla ta nlo tde ngi ic m cia es os om sos ma s CAS
A
la ir at d in t re y arn ets lla t i r ne ni o d ert adm ret a s ni be ni y i m re a m t m ad lye inx be vi og n t i a efc rd lc fe o ol , o s. n es ay m m eaz eta ac e)r itli ro de t srue il,d loo olas p mn i su ap ar ni ni are por de s vps di , d u t e nn roa sni a ee c o ni b ro en ox sa ra ad dgi he lu ,l r ta co ol o, n o oc m dl m i s ez lu (m re useo dltiai egni vu en d di n t aen vatr nan Qui n e mla .nIa oxi o.n i gi m ta agV adr .iD ant er –sg cyh lyw bim ToD cat ols oc
. ni oxg id ro ol, o ent ,a m ez ai lti D –s ta C
47
no it lla ir b iFl ai rt og AD 48
ta C
g ni dr ab m ob yl t ne que r esfs upl m i la ir at edz i ang r sio d us ero m u n yb d sue ac si
n oi ta l rilb i F.e lado ir Vn t eA Aht
e si ob t tea se r v ra a lu w c ry rit ot n la vee rilbi h ff To et. re ar b r m lau un ci de tr ti env m il da an lyn la o i s atr ow alr lla geu no r i ir tc yl un atl rj ot al d cui an rtn de. pia ov lse r ri ci at r s at se ohan sehet vhene r ti ua t u ta allri ecb dot eF ibf ral cte la u u i gd GtAr erir nco
C E
el d ubn ot ued er r
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zaib d na ed i w ro ) no tia urg fi n .) oc aves nisus we (f h s ts . oin ea on t it lla m a at cis s( ci o al ex by m ro rpe de n r c s a lap i lcu er noi ir are rat ent se giu vr va fn ok w oc co P Sl la R b Q hc m ro e na h N T rb
.e du ti pl m a in yr av etn of se x ple m co S R Q la m or N
tne m eg .e r s la aes en id la c rit dai a ra ht c i of we dc tea en cio sab sas the nn iot ri id u no cco cy ht a i m w s sta tnoi n oi cdn alrli ti as fbi d go ail dni A tr on Cen hy. de yse tap ta lon oy ic m oim os mo rda s Cc
A
an ht ss le ot et ar
e ht fo a g ne in h w ol w s yln l arte naio doe h it at edc ht da id n ceu if iis . de m k ts r izea co ix o lt hs es Ti l n d se. r ai gis su ol rd l ac ol co ica re on rep nil h ra c ot rop ith enh or p w nw rue by ois d ial ed re na f w ov sg rta lol id ur eor d h ,f ca ot dl vie er aci ev ste ets rt si g iin cel no no E p cm .y rse d g a ar n rlyine isni sec suie d ox en ta t une gid, esi rral n e tht inm rtar ucir a/ t m ta erT aste alcu nve er –sg b0 itrn di ToD 61 ev par
. ni oxg id dd a h ig h s ni ae m r et ra t are h e ht If. lo ol n tea ro m zea tli id es u y ht a opy oim dr ca ic poh rt re py h ht i w – st a C
49
er u ta m er lP a n o tci n ai Ju rd )V cay A ( h ca alr T u ci & r s te ex n e l vp iro mg t oo ACD 50
xe lp m o C rue ta m re P la no tic nu J
a dir ac y cha T al n iot c n Ju
e xe lp m o
se k ta exl p e mn co ina .a er c i u t dr at en ac r rem e h p ni chyat la e r no ht al i u ct na cirt ujn ht ne a ret va ne as pr h ef us wbd s t e ucr su m re t oc m te s
C er u ta m er P la ion tc n u J V A
aidraetrah imemet ra he oS cyTt. m.p aer b h ca heh -6004 t Tfor tfeo la ake ra la cem oni pa ct ion tc ary jun nimpr alur u J hste inctr a ve Verv oitr Ao a
, er riat S rm ut a R te a e Qe m th l h rpe ot am t,s e )e ron uc th da a of yb rg g ci d or ni p usea (ret rate ctoe c d n la er ar eg itr a w s, a cak elc w b tir ol sd n a a ev d rpe e na s hs es to cuo lu t f p e) la im rad oin e hT roge nctu su. nt aj co a( n f rd ee la a w tw oin rfo be ct nu sal hsi j el gu ra w n . i ulc sa ist rde rit ,e dt ref v e en a no pr riovt ePw can tne a e fo ci tvi w s po ag se ri tc ne ua al e a ce uci na g B rt fo int x.e en g are lp arv irn ne m p if g oc us
–s
–
tp ur e d si ht n d w a at oll edi ht o se fr w r o o av ,n )s w o e P d xel e e tura osp m po c m erm ire us p p n e us is .t ht e e n b he of ,e ts ser e d ap usa ec e si e m ecb rp as( oin r ya n tat lau m . oi i ge e su tar cxe r av c u sir w P cfoip nofig prer . m II ot c la thy d ec la ciu a ro tnr rh le eh m e nt ne th oe fo a vr ubt ivt no hit o, ,l ga ita w kc a e c er ol n lo u b rm o .m sy he at hc n a t mn ea yl thy w l al no pr br suau erh ost nig isx led si va m l d el un et w as enp p bf ar Pl ei e om i tr a av d c rer m S S ea ro w R R zia Hn P Q Qb
se– elx p m se eCor r tu u ta aem eFrPl an Goitc Cnu EJ
. is ve et ob ra a tr de ae ot hn e se hx ,gt el op ed om ht ce r In. uta uso m e u rp ni l t a onc ino ro tc ,) nuj st s s a urb e m rto sas t. hs ex ne ( el se la p rp m m s yl yx oC la o . us ra m u pr ht si e y es hti hr ua e ra p be ul ryo na rge nsate a–cid tiha p ra w c , m oc yh pm c on aT b0 n l 6 A an er v oit o cn uJ
.) s C P A ( s no i ractt no c er u at m er p la ir at es acu hatt s no it id onc e am S
g. rud e ht eu int onc si ,ds ts ix e y ictx ot si l tai gi d If. s C P A ro f sa e a sm e h t t si n e tne m ta amte er rT
s n oi ti d on Cy.ti de icx ta ots ic liat os igi sD A T 51
52
Section
Electro2 cardiographic Examples Disturbances of Ventricular Impulse Formation
Ventricular Premature Complexes Ventricular Tachycardia Ventricular Asystole Ventricular Fibrillation
53
se xe plm o C er u atm er P ra l ricut ne g o VD 54
ta C
e . in av noi ht h s i s uf w r de C Pe ta V rp tii .ry oo ni tn pf e o ess er se l d pum an caue . i y bh ca cit s tea id it m d a e arc m syt ne os d rae atu er ud s )s esd hto dn a a Cecr nsot ,pe Pni ce oc ed ff n V ( ul rye y,s esx incsm daonc ncera el si es elo p ahn th tin ce iw e m o Mm sric Ce.d est xe er on yrs ,es s as u ta nisu uslc naek a mhte vio ew re adof ceard wdith P ra tes ht eta l sin no ioc u ci ciel cest sas rt tnr ffe era e t s n e veh rice CP Vt d V
. .rer s. seu a zia eex p b l yr d pm ot an co asn ed S e i Rp w m o yl Q la he ac c t piy m by t o d er rf ew a ed ol esr pxesel scoiats yllfol i a u ta moc red uus e SR sea Csi F Q va P GehT wP VA
s. / er csh oni sr ni p ot . na ci sit tr i m re .m sa rad b s gc oD ido se,a yom d ry sie d an htr d na sr e e , va xeo yph lav isa b h ci pl yl it n eo la w o n ic st rh c e a c ai sep cn ,)s rd ,y i is ac ht ne on y,t ap es tes ci yo lya rict toxi m iod noi oa lsi s a acr ac yll gti c ai ht ;o cie d, i y p) w s s sg ath e( go s od pyo ctse d(si d n oi ree moid efdl tidr ti eb ar at ac d gar ch ein oy it ong itcm inl w on t Cen sa ch am de eys nic tiw aur ta lno no ne ,ts ic m m es uul os om om ols vlo s C C Av
C E A
itl nu tyi itv ac tc rit s re t ient ap itc a m o pt m sy e th ro .lF ai s erv rto onc si t n iet ap ict a d. el om tp lo r m tn asy sco ei th ai t of mh n e etn ythr m ta tmaer rae e T ht
r T
fi erk co blat be a hit w gsu rd su .str oi so evr ert p as el inb sa e m o on r C . a inet iod el am i r ex ol m ol or, at ed sor i e nd aic si ot no ,e C ni ss.t di is nr qui, peia ed m i th m a yh ian rra ocr tn p– ta sg ro o pm Di
.s gu rd edr re f rep e ht er a lo lo tena ro lo lo anr opr p–
st a C 55
56
ai dr a ych ca T ra l icur t ne g o VD
ta C
es no u cea tia ul d.e bs n ic m im st ait lo tes s by m or us tea sr f ro m e g ) r ht nl o ultis sam seoa no er yx es ts o id ce orw par la ffe a t( dri yr ni n a a s tte co dn C i y oc P mm V re tn es er nt a ht o i rt iw m eb op , m or ya m e i et reth am i ingy syr si dar fin al cy gi uc s s cah yll va t o ra asu ird ulc ,u ac rit ai he mt en ht no Vy s.u hrr rea co ga st f nc lar nie fee ciu ate tc tr hr rie . nt n ve ef .D ois c il t u poi yl en fre l p cet ait m eg r o n na et an op or of P de of
ai dr ac y h ca T ral u ci rt n e V
m pb hti w 010 ly n 0-6 o m ne m e oc w t r bea ocu id s ra ex yc lep hc a m T oc ra re ulc ut ir pa t ne cd n V . an m oi h hryt fusr ra al u ulg cir er nt e a V ht . i re w ar . z m pb hm bi t 05 hy nd 1 rr ea . > si ula di ai ser arter erictn rsewa ardcy al v xe ch u ta uci doii pel tar e ertn de mo clua F v mr c itr S GehT esit RQ env
C E
eb ,e de ecr p ya m s vea w P e h T .s ev a w P e ht d na s ex pl m . co se Sx R elp Qm eo th cS ne R eQ e tw be ht ip w h ol nso fol tia ro erl i,n oh n tiw si e ne er dd hi Th
.s er csh ni p na m er obD d an sr xeo b y lla ic e sep .s ,y C P ht a V r yop efo s om id oh t acr as e ht i m w as sg e s ddo hetr n oi ere san ti -be oit d rg id ilan ast onc on Cne cn tde de sey in aic ta oln mo sosa ic m mo re os mo cn th s CUO
.e bil sso p sa oon s sa eginb d t olu n e hysp m ta ahre eT
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IV ev .r re r it ot ts o es al i , ni ed ng di i o os m da nia cg va ,s oc ni d li t yl an af ,e er ,r n inea id dun biito co in ta h u ild q, reT nie fI ed s. m .e i sit zy cm a s n oi in rpe eg hc a n fo ocr ai irt t p me ne la tyh vn r ho m ta ort rra cn er at fi is t s n teh le,b erkc teoig is ast blo n ) n - a, no e at c i siu h eb te f Wa ur in . ht id m by ht iw fo y ed hr sg ega us w llo su dr od of ni su e se so oi tai s t vr luo vert pre rop bnep V o ni pa (I co bm ht et oi n w aci edi .C er od m en ul il an ti ifa –s ai eil t go oc xe ra e D rp m h
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el ot s ys A ral u ci rt n e V
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Section
2
Electrocardiographic Examples Disturbances of Impulse Conduction
Sinus Arrest or Block Sick Sinus Syndrome Atrial Standstill Ventricular Pre-Excitation First-Degree Atrioventricular Block Second-Degree Atrioventricular Block Third-Degree Atrioventricular Block Left Bundle Branch Block Right Bundle Branch Block
63
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k co l B r o t esr r A s u n i S
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et ,e oyl sa rt es ecl di e, tr se ae a h sei ed ativr arte eh nc gee its d, la p gea eo s n as ai, s.i ms H su alp fo ni oe s n .g eld d tio cla do . nbu a.f f e e r iv ,ca cer deso om r het ndr er dn fo ob noi ro t b y is tia icc ci ss os ear la u n t rr ra hp sni tes ah ail oh t t cye kci yar sd eg ot hc s ti n ryn ry s ar to edr ouh ha da d n oi bni eso heh ch gp, onc ti ng psi ti aoc nih se d id de ws n gu ve lfina dprs pug atio s.ta ,co ners on Cetn ree edr aml cn niot aug de dic gb reb nd in alu vf ta ni od up id mo mit on ic al ni in ret mo sl toi os mro nee nee ope nc gaa artir s N S S R U Vi
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.t en tm era t ot ev is no espr un s al m i na in d ree di s no c e nba c re ka m cea p la i .c iifc it rt a a n om tp A . me sya usac is g l n t mia riyl n e naif den u m ta eno eta er N rT
T 65
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s G gn uni C s its s Eui f e es sni xe os ht e o d fo ht w ce ior . o se tih ls va ep lli tii w gni h gn tds la se y so o n s lr la l a orm nb cayn uden esas theg staic a a e ce in dr G .Mht m ru ca C k o si E oc to dr D fo l n n se. tlu b oi y h s erb us tdi ss cn er ni d un ar e m u es na is eb ht; n re i k l tr a a ci d a ot vse ird sf nu he daob env an cy yt ro hte gi iad chta orij nad/ cea r a m etr ac alr m on op a dya icu eh ict lst si r r T n i bt . a su ne )e uj) rf v V ke ins ar om r Aa er pus dn r( m e vee of ys ual cap s s a c g de rdi rit al n a n dui soi yc evn oit l p c nci nte tach- atrio jun ed re ai e V o rcu rd ht A ne a f t ) r c on A ve yda se eta (S a br tili el ail sh ( a ht tar eg hm m r ,k o na yt on co ins hc hr ba lb
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The Secret to Atrioventricular Blocks First-Degree AV Block— “All” of the beats go through the AV node (but with delay ed cond uctio n)
Second-Degree AV Block— “Some” of the beats go through
Third-Degree AV Block— “None” of the beats go through
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s A
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T 85
Section
2
Electrocardiographic Examples Escape Rhythms
Junctional Escape Rhythms Ventricular Escape Rhythms
87
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kc ol B V A et el p m o C ht i w m ythh R ep cas E ra ulc rit en V
e th, ee er th ht ht ek yl fo n a la s i m ee suu noi us ca ( g ap yt er pa aic ic r r d i e r at ow l afte ca otm eh m eht ua t th f ts of hyr oe ey l hg tiv tar or i ti e e h c h ht ea er th er ht ve thi ak se os ue wm re cea ces atk r ak pc ,se yli cem ap nsitr iclrt raop n e ni e m ht e ev te h r en .T hrt ek hs oa wp n m e urc ost toi ca . co ro c p m ny h n uj rai ty ) d rh ow V ibs e dA s ( u ap w o r s sc resl ciula hetf aen ht tr I s ei ne .m na )e vo th w do itr y on n ae rht sk la h n i rit t, an m ao tr i ht y ni ae m s h do hr
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e h . T . tu evi no tp at ne uo su a m o cai .C ne dr t hp ca en m ry gn ta dan ain tre oc tn gu se ai dr a o. si rm tt de o m f ant uni ht sm si t yi s n hr na er co ep hc is sid e ai e cas m m b e ty h dl t e ef y u ht a h o s r h usea sia are ,sc h k.c ecb sti tf tie ol i b ai a, g ths V m edt nic ne ht a a a A y er pl ro d hr t a , na ra e ic lo ai s dr e bt tifi lo ht o r n n ac oi yd of ldn A. apro ti ra se uo eta pr d bs acu sh rlo ,n nuis gni hm yrp oxi on y f Co ler yhtr ocyl dgi, de sseu t dn ep gr sa ua oh ta ac n e e cs en cu ic eh mhtt el ip s,s os tll ta rae cuat ort gur s A er T a A d A T 89
90
Section
2
Electrocardiographic Examples Miscellaneous Disturbances
Pericardial Effusion (low voltage QRS complexes and electrical alternans) ST Segment and T Wave Changes Artifacts
91
S R Q eg at ol V) s w o na L( n r
onis telAl uf cira f tc Eel la E s & rdia xee ci lp re mo g o PC D 92
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nadl s na nr et al alc rit elc E
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s n a n re tl lA ac ir tc el E & s xel p m o C S R Q gea tl o V w o L
.) go d e ht ni I dIa el on V m 5. 0 < ( n. sd oi ae tc l re lla id ni or xese ight e pl h ni m co et due nar ti et pl al s m a xe e olw pl m oc s— xe S se mople QR— r c sn u ta SR nra e Qge tlae Fat al l Gvo citr Cow lec EL E
la id ra ocy m , m als p eon vie t rat ifl ni ( y h atp oy m oi rad .a n,c i io no tc r m ue fan i pn ail r d ,ao rca yo em sy m hp ,g. .e , em , e . m a ag sim ed am di e dl o y a yr anr idr .) tho o ca iss py m lu yo orb H P Mif
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.a id ycar hc ta alr ciu tr ne v rap su or kc blo hc n rba e dl un B
g ca ni y dir rle ca dn el u be sis th ot hpt eda i t w ce no ri siu de f b ef dl eu rga oh l s a tn s e tea m ci ta d er ni T lya ed. us ta u icd no in siu n f e ef tfo la s id is arc ise rei tn t. p ce ne ni iod se s r rp an rica is ert eP en al .e ofi t lac da ,r n e crit pon edor e m t lE amt isd
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93
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n e m ta er T 95
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o S 97
Appendix Anti-Arrhythmic Drugs Recommended Textbook Readings
99
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rndab ra lu ict arp a gn tis li by dn a t isx e 103
Recommended Textbook Readings 1. Allen, D.G., and Kruth, S.A.: Small Ani mal Ca rdiopulmonary Medicine. Toronto, B.C. Decker, 1988. 2. Bonagura, J.D. (Ed.): Contemporary Issues in Small Animal Practice; Cardiology. Volume 7. New York, Churchill Livingstone, 1987. 3. Burtnick, N.L., and Degernes, L.A.: Electrocardiography on fifty-nine anesthetized convalescing raptors. In Raptor Biomedicine. Chapter 20. Edited by P.T. Redig, J.D. Remple, and D.B. Hunter. Minneapolis, University of Minnesota Press, 1993. 4. Chung, E.K.: Manual of Ca rdiac A rrh yth mi as. New York, York Medical Books, 1986. 5. Collet, M., and LeBobinnec, G.: Elec trocar diagra ph ie et rhythmologie canines. Paris, Editions du Point Veterinaire, 1991. 6. Detweiter, D.K.: The dog electrocardiogram: A critical review. In Compre hensive Electrocardiography: Theory and Practice in Health and Disease. Edited by P.W. MacFarland and T.D.V. Lawrie. New York, Pergamon Press, 1988. 7. Edwards, N.J.: Bolton's Handbook of Canine and Feline Electrocardiography. 2nd Edition. Philadelphia,W.B. Saunders,1987. 8. Ettinger, S.J., and Suter, P.F.: Cani ne Cardiol ogy. Philadelphia, W.B. Saunders, 1970. 9. Fish, C.: Elect roca rdiogra ph y of Arrh yth mias . Philadelphia, Lea & Febiger, 1990. 10. Fox, (Ed.): CaninLivingstone, e and Feli ne 1990. Cardiolog y . New P.S. York, Churchill 11. Friedman, H.H.: Diagnostic Electrocardiography and Vectorcardiography. 3rd Edition. New York, McGraw-Hill, 1985. 12. Gompf, B., Tilley, L.P., and Harpster, N. (Eds.): Nomenclature and Cr it eria in Diseas es of th e Hear t and Vessels ( Sm all An im al Medicine). Denver, American Animal Hospital Association and The Academy of Veterinary Cardiology, 1986.
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13. Hamlin, R.L. (Guest Ed.): Effic acy of cardiac t h erapy . Vet. Clin. North Am. (Small Anim. Pract.), 21(5): 1991.
14. Horwitz, L.N.: Current Management of Arrhythmias. Philadelphia, B.C. Decker, 1991. 15. Liu, S-K., Hsu, F.S., and Lee, R.C.T.: An Atlas o f Cardiovascular Pathology. Taiwan, Wonder Enterprise, 1989. 16. Mandel, W.J.: Cardiac Arrhythmias: Their Mechanisms, Diagno sis, and Manage me nt. Philadelphia, J.B. Lippincott, 1987. 17. Marriott, H.J.L., and Conover, M.B.: Advanced Concepts i n Arrh yth mias. 2nd Edition. St. Louis, C.V. Mosby, 1989. 18. Miller, M.S., Tilley, L.P., and Detweiler, D.K.: Cardiac elec troph ysio lo gy. In Duke 's Ph ysio lo gy. 11th Edition. Edited by M.J. Swenson. Ithaca, N.Y., Cornell University, 1993. 19. Murtaugh, R.J, and Kaplan, P.M.: Veterin ary Emerge ncy and Criti cal Ca re Medici ne. St. Louis, Mosby Yearbook, 1991. 20. Pick, A., and Langendorf, R.: Interpr etation o f Complex Arrh yth mias. Philadelphia, Lea & Febiger, 1979. 21. Tilley, L.P., Miller, M.S., and Smith, F.W.K.: Canine and Feline Cardiac Arrhythmias-Self Assessment , Philadelphia, Lea & Febiger, 1993. 22. Tilley, L.P. (Guest Ed.): Cardiopulmon ary diagnostic tec h niques. Vet. Clin. North Am. (Small Anim. Pract.) 13(2): 1983. 23. Tilley, L.P.: Essen ti als of C anine and Fel in e Ele ct rocar di ograph y. Interpret ation and Treatm ent . 3rd Edition. Philadelphia, Lea & Febiger, 1992. 24. Tilley, L.P. (Guest Feline cardiology. Vet. Clin. North Am. (Small Anim.Ed.): Pract.), 7(2): 1977. 25. Tilley, L.P., and Owens, J.M.: Manual of Small Animal Cardiology. New York, Churchill Livingstone, 1985. 26. Tilley, L.P., Smith, F.W.K., and Miller, M.S.: Cardiology Pocket Reference. 2nd Edition. Denver, American Animal Hospital Association, 1993. 27. Tilley, L.P., and Smith, F.W.K., (Eds.): DiagnosticsElectrocardiography. In The 5 Min ute Vete rinar y Consult. Baltimore, Williams & Wilkins, 1997.
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