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Cardiac arrythmias

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Srinivas Sidda
Srinivas Sidda

This document provides information on cardiac arrhythmias: - It describes the normal cardiac conduction system and identifies structures involved like the SA node, AV node, Bundle of His, and Purkinje fibers. - Common arrhythmias are defined including sinus bradycardia, sinus tachycardia, premature atrial contractions, atrial fibrillation, atrial flutter, junctional rhythms, premature ventricular contractions, ventricular tachycardia, ventricular fibrillation, and asystole. - For each arrhythmia, the heart rate, rhythm, P wave presence, PR interval, and QRS duration are outlined to aid in identification. Understanding the normal cardiac cycle is essential for recognizing and

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Cardiac Arrhythmias Presenter : Dr. Srinivas sidda Guide : Dr.Nagrale ( Prof & HOD ) Anaesthesiology.
Anatomy & Physiology • Blood Flow through heart – Superior and Inferior Vena Cava – Right Atrium – Right Ventricle – Pulmonary Artery – Lungs – Pulmonary Vein – Left Atrium – Left Ventricle – Aorta – Body
Conduction System – The heart has a conduction system separate from any other system – The conduction system makes up the PQRST complex we see on paper – An arrhythmia is a disruption of the conduction system – Understanding how the heart conducts normally is essential in understanding and identifying arrhythmias
• SA Node • Inter-nodal and inter-atrial pathways • A-V Node • Bundle of His • Perkinje Fibers Conduction System
SA Node  The primary pacemaker of the heart  Each normal beat is initiated by the SA node  Inherent rate of 60-100 beats per minute  Represents the P-wave in the QRS complex or atrial depolarization (firing)
AV Node – Located in the septum of the heart – Receives impulse from inter-nodal pathways and holds the signal before sending on to the Bundle of His – Represents the PR segment of the QRS complex
AV Node – Represents the PR segment of the cardiac cycle – Has an inherent rate of 40-60 beats per minute – Acts as a back up when the SA node fails – Where all junctional rhythms originate
QRS Complex • Represents the ventricles depolarizing (firing) collectively. (Bundle of His and Perkinje fibers) • Origin of all ventricular rhythms • Has an inherent rate of 20-40 beats per minute
ECG Trace • Isoelectric line (baseline) • P-wave – Atria firing • PR interval – Delay at AV
ECG Trace • QRS – Ventricles firing • T-wave – Ventricles repolarizing
ECG Trace • ST segment – Ventricle contracting – Should be at isoelectric line – Elevation or depression may be important • U wave – Perkinje fiber repolarization?
Waveform Analysis – For each strip it is necessary to go through steps to correctly identify the rhythm 1. Is there a P-wave for every QRS? • P-waves are upright and uniform • One P-wave preceding each QRS 2. Is the rhythm regular? • Verify by assessing R-R interval • Confirm by assessing P-P interval 3. What is the rate? • Count the number of beats occuring in one minute • Counting the p-waves will give the atrial rate • Counting QRS will give ventricular rate
• Normal – Heart rate = 60 – 100 bpm – PR interval = 0.12 – 0.20 sec – QRS interval <0.12 sec – SA Node discharge = 60 – 100 / min – AV Node discharge = 40 – 60 / min – Ventricular Tissue discharge = 20 – 40 / min Summary
• Cardiac cycle – P wave = atrial depolarization – PR interval = pause between atrial and ventricular depolarization – QRS = ventricular depolarization – T wave = ventricular repolarization Summary
Normal Sinus Rhythm Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 60 - 100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
• Normal Sinus Rhythm – Sinus Node is the primary pacemaker – One upright uniform P-wave for every QRS – Rhythm is regular – Rate is between 60-100 beats per minute Sinus Rhythms
Sinus Bradycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) <60 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
• Sinus Bradycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate less than 60 beats per minute • SA node firing slower than normal • Normal for many individuals • Identify what is normal heart rate for patient • sleep & rest,cold,fright,starvation,athelets, • Hypothyroidism,raised intracranial pressure,obstructive jaundice,glaucoma, • propranolol,reserpine,digitalis,quinidine,beta blockers, • sick sinus syndrome. Sinus Rhythms
• Sinus Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
• Sinus Tachycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate is greater than 100 beats per minute • Usually between 100-160 (>160 SVT) • Can be high due to anxiety, stress, fever, medications (anything that increases oxygen consumption). • Thyrotoxicosis,fever & infetcions,alcohol,cardiac failure. • atropine,adrenaline,salbutamol. • haemorrhage & shock. • vagal pararlysis-diptheria. • Addison’s disease. • Ishaemic heart disease, Acute myocardial infarction. Sinus Rhythms
Sinus Arrhythmia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
• Sinus Arrhythmia – One upright uniform p-wave for every QRS – Rhythm is irregular • Rate increases as the patient breathes in • Rate decreases as the patient breathes out – Rate is usually 60-100 (may be slower) – Variation of normal, not life threatening Sinus Rhythms
Sinus Arrest Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
Sinus Rhythms Sinus Arrest Stop of sinus rhythm New rhythm starts Sinus pause One dropped beat is a sinus pause
sick sinus syndrome » The disease involving SA node & causing its dysfunction leading to marked sinus bradycardia. » symptoms- • dizziness. • syncope. • fatigue. • confusion. • congestive heart failure.
causes of sick sinus syndrome • degenerative & fibrosis of SA node. • ishaemic heart disease. • digoxin, quinidine,beta blockers. • amyloidosis. • myocarditis. ★sinus syndrome associated with paraoxysmal tachycardia is called bradycardia-tachycardia syndrome. ★Anti arrythmias worsens the bradycardia, hence symptomatic patients nedd a pacemaker.
• due to increased vagal tone, Rheumatic fever or Atrial Rhythms
Premature Atrial Contraction (PAC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Premature & abnormal or hidden .12 - .20 <.12 Atrial Rhythms
– Premature Atrial Contraction (PAC) • One P-wave for every QRS – P-wave may have different morphology on ectopic beat, but it will be present • Single ectopic beat will disrupt regularity of underlying rhythm • Rate will depend on underlying rhythm • Underlying rhythm must be identified • Classified as rare, occasional, or frequent PAC’s based on frequency Atrial Rhythms
Atrial Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Wavy irregular NA <.12 Atrial Rhythms
• Atrial Fibrillation – No discernable p-waves preceding the QRS complex • The atria are not depolarizing effectively, but fibrillating – Rhythm is grossly irregular – If the heart rate is <100 it is considered controlled a-fib, if >100 it is considered to have a “rapid ventricular response” – AV node acts as a “filter”, blocking out most of the impulses sent by the atria in an attempt to control the heart rate Atrial Rhythms
• Atrial Fibrillation (con’t) – Often a chronic condition, medical attention only necessary if patient becomes symptomatic – Patient will report history of atrial fibrillation. Atrial Rhythms
Clinical features of Atrial Fibrillation • heart palpitations. • chest pain & pressure. • abdominal pain. • shortness of breath. • light headedness. • fatigue. • exercise intolerance. ✴higher risk for stroke associated with heart valve disease, heart failure, diabetes, hypertesion. ✴blood clots due to atrial fibrillation leads to storke in brain.
Atrial Flutter Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Atrial=250 – 400 Ventricular Var. Irregular Sawtooth Not Measur- able <.12 Atrial Rhythms
• Atrial Flutter – More than one p-wave for every QRS complex • Demonstrate a “sawtooth” appearance – Atrial rhythm is regular. Ventricular rhythm will be regular if the AV node conducts consistently. If the pattern varies, the ventricular rate will be irregular – Rate will depend on the ratio of impulses conducted through the ventricles Atrial Rhythms
Atrial Rhythms • Atrial Flutter – Atrial flutter is classified as a ratio of p- waves per QRS complexes (ex: 3:1 flutter 3 p-waves for each QRS) – Not considered life threatening, consult physician if patient symptomatic
• Rhythms that originate at the AV junction • Junctional rhythms do not have characteristic p-waves. Junctional Rhythms
Premature Junctional Contraction PJC Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually normal Irregular Premature, abnormal, may be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
• Premature Junctional Contraction (PJC) – P-wave can come before or after the QRS complex, or it may lost in the QRS complex • If visible, the p-wave will be inverted – Rhythm will be irregular due to single ectopic beat – Heart rate will depend on underlying rhythm – Underlying rhythm must be identified – Classify as rare, occasional, or frequent PJC based on frequency – Atria are depolarized via retrograde conduction Junctional Rhythms
Accelerated Junctional Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Regular Inverted, absent or after QRS <.12 <.12 Junctional Rhythms
• Accelerated Junctional Rhythm – P-wave can come before or after the QRS complex, or lost within the QRS complex • If p-waves are seen they will be inverted – Rhythm is regular – Heart rate between 60-100 beats per minute • Within the normal HR range • Fast rate for the junction (normally 40-60 bpm) Junctional Rhythms
Junctional Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular May be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
• Junctional Tachycardia – P-wave can come before or after the QRS complex or lost within the QRS entirely • If a p-wave is seen it will be inverted – Rhythm is regular – Rate is between 100-180 beats per minute • In the tachycardia range, but not originating from SA node – AV node has sped up to override the SA node for control of the heart Junctional Rhythms
Junctional Rhythms Junctional Escape Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 40 – 60 Regular Absent, inverted or after QRS Short <.12 Normal <.12
Junctional Rhythms • Junctional Escape Rhythm – P-wave may come before or after the QRS or may be hidden in the QRS entirely • If p-waves are seen, they will be inverted – Rhythm is regular – Rate 40-60 beats per minute • The SA node has failed; the AV junction takes over control of the heart
Ventricular Rhythms Premature Ventricular Contraction (PVC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular No P waves associated with premature beat NA Wide >.12
Ventricular Rhythms • Premature Ventricular Contraction (PVC) – The ectopic beat is not preceded by a p-wave – Irregular rhythm due to ectopic beat – Rate will be determined by the underlying rhythm – QRS is wide and may be bizarre in appearance – Caused by a irritable focus within the ventricle which fires prematurely – Must identify an underlying rhythm
Ventricular Rhythm • Premature Ventricular Contraction – Classify as rare, occasional, or frequent – Classify as unifocal, or multifocal PVC’s • Unifocal-originating from same area of the ventricle; distinguished by same morphology
Ventricular Rhythm • Premature Ventricular Contraction – Classify as unifocal, or multifocal PVC’s – Unifocal-originating from same area of the ventricle; distinguished by same morphology – Multifocal-originating from different areas of the ventricle; distinguished by different morphology
Ventricular Rhythm • Premature Ventricular Contraction – Bigeminy • A PVC occurring every other beat – Also seen as Trigeminy, Quadrigeminy
Ventricular Rhythm • Dangerous PVC’s – R on T – Runs of PVC’s – 3 or more considered Vtach
Ventricular Rhythms Ventricular Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 100 – 250 Regular No P waves corresponding to QRS, a few may be seen NA >.12
Ventricular Rhythms • Ventricular Tachycardia – No discernable p-waves with QRS – Rhythm is regular – Atrial rate cannot be determined, ventricular rate is between 150-250 beats per minute – Must see 4 beats in a row to classify as v- tach
Ventricular Rhythms • Ventricular Tachycardia – THIS IS A DEADLY RHYTHM • Check patient: – If patient awake and alert, monitor patient and call physician – If patient has no vital signs, call code and start CPR » Defibrillate
Ventricular Rhythms Ventricular Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 0 Chaotic None NA None
Ventricular Rhythms • Ventricular Fibrillation – No discernable p-waves – No regularity – Unable to determine rate – Multiple irritable foci within the ventricles all firing simultaneously – May be coarse or fine – This is a deadly rhythm • Patient will have no pulse • begin CPR & resustication.
Asystole Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) None None None None None
Asystole • No p-waves • No regularity • No Rate • This rhythm is associated with death – Check patient and leads – No pulse • Begin CPR
Heart Block First Degree Heart Block Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. Regular Before each QRS, Identical > .20 <.12
Heart Block – First Degree Heart Block • P-wave for every QRS • Rhythm is regular • Rate may vary • Av Node hold each impulse longer than normal before conducting normally through the ventricles • Prolonged PR interval – Looks just like normal sinus rhythm
Heart Block Second Degree Heart Block Mobitz Type I (Wenckebach) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. can be slow Irregular Present but some not followed by QRS Progressively longer <.12
Heart Block • Second Degree Heart Block • Mobitz Type I (Wenckebach) – Some p-waves are not followed by QRS complexes – Rhythm is irregular • R-R interval is in a pattern of grouped beating – Rate 60-100 bpm – Intermittent Block at the AV Node • Progressively prolonged p-r interval until a QRS is blocked completely
Heart Block Second Degree Heart Block Mobitz Type II (Classical) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually slow Regular or irregular 2 3 or 4 before each QRS, Identical .12 - .20 <.12 depends
Heart Block • Second Degree Heart Block • Mobitz Type II (Classical) – More p-waves than QRS complexes – Rhythm is irregular – Atrial rate 60-100 bpm; Ventricular rate 30-100 bpm (depending on the ratio on conduction) – Intermittent block at the AV node • AV node normally conducts some beats while blocking others
Heart Block Third Degree Heart Block (Complete) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 30 – 60 Regular Present but no correlation to QRS may be hidden Varies <.12 depends
Heart Block • Third Degree Heart Block (Complete) – There are more p-waves than QRS complexes – Both P-P and R-R intervals are regular – Atrial rate within normal range; Ventricular rate between 20-60 bpm – The block at the AV node is complete • There is no relationship between the p-waves and QRS complexes
CAUSES » FIRST DEGREE & SECOND DEGREE BLOCK • normal variant • increased vagaltone. • athelets. • sick sinus syndrome. • acute carditis. • ishaemic heart disease. • hypokalemia • lyme disease. • digoxin • beta blockers • calcium channel blockers.
COMPLETE HEART BLOCK » CAUSES- • Idiopathic / conduction tissue fibrosis. • congenital. • ischaemic heart disease. • Associated with Aortic valve calcification. • cardiac surgery & trauma. • digoxin intoxication. • bundle interruptions by tumors, parasites,granulomas, injury, abscess.
Left bundle branch block
Bundle branch block » Right bundle branch block.
Study resources – Understanding ECG ,6th edition, P.J.Mehta’s. – A Primer of ECG , K.P.Misra. – The ECG in Practice, 6th edition, Jhon R.Hampton. – www.skillstat.com/6sECG_rdm.html – www.gwc.maricopa.edu/class/bio202/cyberheart/ ekgqzr2.htm – http://www.randylarson. rhythmst.htmlcom/acls/master/ – Rapid Interpretation of EKG’s, Dale Dubin.

More Related Content

Cardiac arrythmias

  • 1. Cardiac Arrhythmias Presenter : Dr. Srinivas sidda Guide : Dr.Nagrale ( Prof & HOD ) Anaesthesiology.
  • 2. Anatomy & Physiology • Blood Flow through heart – Superior and Inferior Vena Cava – Right Atrium – Right Ventricle – Pulmonary Artery – Lungs – Pulmonary Vein – Left Atrium – Left Ventricle – Aorta – Body
  • 3. Conduction System – The heart has a conduction system separate from any other system – The conduction system makes up the PQRST complex we see on paper – An arrhythmia is a disruption of the conduction system – Understanding how the heart conducts normally is essential in understanding and identifying arrhythmias
  • 4. • SA Node • Inter-nodal and inter-atrial pathways • A-V Node • Bundle of His • Perkinje Fibers Conduction System
  • 5. SA Node  The primary pacemaker of the heart  Each normal beat is initiated by the SA node  Inherent rate of 60-100 beats per minute  Represents the P-wave in the QRS complex or atrial depolarization (firing)
  • 6. AV Node – Located in the septum of the heart – Receives impulse from inter-nodal pathways and holds the signal before sending on to the Bundle of His – Represents the PR segment of the QRS complex
  • 7. AV Node – Represents the PR segment of the cardiac cycle – Has an inherent rate of 40-60 beats per minute – Acts as a back up when the SA node fails – Where all junctional rhythms originate
  • 8. QRS Complex • Represents the ventricles depolarizing (firing) collectively. (Bundle of His and Perkinje fibers) • Origin of all ventricular rhythms • Has an inherent rate of 20-40 beats per minute
  • 9. ECG Trace • Isoelectric line (baseline) • P-wave – Atria firing • PR interval – Delay at AV
  • 10. ECG Trace • QRS – Ventricles firing • T-wave – Ventricles repolarizing
  • 11. ECG Trace • ST segment – Ventricle contracting – Should be at isoelectric line – Elevation or depression may be important • U wave – Perkinje fiber repolarization?
  • 12. Waveform Analysis – For each strip it is necessary to go through steps to correctly identify the rhythm 1. Is there a P-wave for every QRS? • P-waves are upright and uniform • One P-wave preceding each QRS 2. Is the rhythm regular? • Verify by assessing R-R interval • Confirm by assessing P-P interval 3. What is the rate? • Count the number of beats occuring in one minute • Counting the p-waves will give the atrial rate • Counting QRS will give ventricular rate
  • 13. • Normal – Heart rate = 60 – 100 bpm – PR interval = 0.12 – 0.20 sec – QRS interval <0.12 sec – SA Node discharge = 60 – 100 / min – AV Node discharge = 40 – 60 / min – Ventricular Tissue discharge = 20 – 40 / min Summary
  • 14. • Cardiac cycle – P wave = atrial depolarization – PR interval = pause between atrial and ventricular depolarization – QRS = ventricular depolarization – T wave = ventricular repolarization Summary
  • 15. Normal Sinus Rhythm Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 60 - 100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  • 16. • Normal Sinus Rhythm – Sinus Node is the primary pacemaker – One upright uniform P-wave for every QRS – Rhythm is regular – Rate is between 60-100 beats per minute Sinus Rhythms
  • 17. Sinus Bradycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) <60 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  • 18. • Sinus Bradycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate less than 60 beats per minute • SA node firing slower than normal • Normal for many individuals • Identify what is normal heart rate for patient • sleep & rest,cold,fright,starvation,athelets, • Hypothyroidism,raised intracranial pressure,obstructive jaundice,glaucoma, • propranolol,reserpine,digitalis,quinidine,beta blockers, • sick sinus syndrome. Sinus Rhythms
  • 19. • Sinus Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  • 20. • Sinus Tachycardia – One upright uniform p-wave for every QRS – Rhythm is regular – Rate is greater than 100 beats per minute • Usually between 100-160 (>160 SVT) • Can be high due to anxiety, stress, fever, medications (anything that increases oxygen consumption). • Thyrotoxicosis,fever & infetcions,alcohol,cardiac failure. • atropine,adrenaline,salbutamol. • haemorrhage & shock. • vagal pararlysis-diptheria. • Addison’s disease. • Ishaemic heart disease, Acute myocardial infarction. Sinus Rhythms
  • 21. Sinus Arrhythmia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  • 22. • Sinus Arrhythmia – One upright uniform p-wave for every QRS – Rhythm is irregular • Rate increases as the patient breathes in • Rate decreases as the patient breathes out – Rate is usually 60-100 (may be slower) – Variation of normal, not life threatening Sinus Rhythms
  • 23. Sinus Arrest Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms
  • 24. Sinus Rhythms Sinus Arrest Stop of sinus rhythm New rhythm starts Sinus pause One dropped beat is a sinus pause
  • 25. sick sinus syndrome » The disease involving SA node & causing its dysfunction leading to marked sinus bradycardia. » symptoms- • dizziness. • syncope. • fatigue. • confusion. • congestive heart failure.
  • 26. causes of sick sinus syndrome • degenerative & fibrosis of SA node. • ishaemic heart disease. • digoxin, quinidine,beta blockers. • amyloidosis. • myocarditis. ★sinus syndrome associated with paraoxysmal tachycardia is called bradycardia-tachycardia syndrome. ★Anti arrythmias worsens the bradycardia, hence symptomatic patients nedd a pacemaker.
  • 27. • due to increased vagal tone, Rheumatic fever or Atrial Rhythms
  • 28. Premature Atrial Contraction (PAC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Premature & abnormal or hidden .12 - .20 <.12 Atrial Rhythms
  • 29. – Premature Atrial Contraction (PAC) • One P-wave for every QRS – P-wave may have different morphology on ectopic beat, but it will be present • Single ectopic beat will disrupt regularity of underlying rhythm • Rate will depend on underlying rhythm • Underlying rhythm must be identified • Classified as rare, occasional, or frequent PAC’s based on frequency Atrial Rhythms
  • 30. Atrial Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Wavy irregular NA <.12 Atrial Rhythms
  • 31. • Atrial Fibrillation – No discernable p-waves preceding the QRS complex • The atria are not depolarizing effectively, but fibrillating – Rhythm is grossly irregular – If the heart rate is <100 it is considered controlled a-fib, if >100 it is considered to have a “rapid ventricular response” – AV node acts as a “filter”, blocking out most of the impulses sent by the atria in an attempt to control the heart rate Atrial Rhythms
  • 32. • Atrial Fibrillation (con’t) – Often a chronic condition, medical attention only necessary if patient becomes symptomatic – Patient will report history of atrial fibrillation. Atrial Rhythms
  • 33. Clinical features of Atrial Fibrillation • heart palpitations. • chest pain & pressure. • abdominal pain. • shortness of breath. • light headedness. • fatigue. • exercise intolerance. ✴higher risk for stroke associated with heart valve disease, heart failure, diabetes, hypertesion. ✴blood clots due to atrial fibrillation leads to storke in brain.
  • 34. Atrial Flutter Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Atrial=250 – 400 Ventricular Var. Irregular Sawtooth Not Measur- able <.12 Atrial Rhythms
  • 35. • Atrial Flutter – More than one p-wave for every QRS complex • Demonstrate a “sawtooth” appearance – Atrial rhythm is regular. Ventricular rhythm will be regular if the AV node conducts consistently. If the pattern varies, the ventricular rate will be irregular – Rate will depend on the ratio of impulses conducted through the ventricles Atrial Rhythms
  • 36. Atrial Rhythms • Atrial Flutter – Atrial flutter is classified as a ratio of p- waves per QRS complexes (ex: 3:1 flutter 3 p-waves for each QRS) – Not considered life threatening, consult physician if patient symptomatic
  • 37. • Rhythms that originate at the AV junction • Junctional rhythms do not have characteristic p-waves. Junctional Rhythms
  • 38. Premature Junctional Contraction PJC Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually normal Irregular Premature, abnormal, may be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
  • 39. • Premature Junctional Contraction (PJC) – P-wave can come before or after the QRS complex, or it may lost in the QRS complex • If visible, the p-wave will be inverted – Rhythm will be irregular due to single ectopic beat – Heart rate will depend on underlying rhythm – Underlying rhythm must be identified – Classify as rare, occasional, or frequent PJC based on frequency – Atria are depolarized via retrograde conduction Junctional Rhythms
  • 40. Accelerated Junctional Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Regular Inverted, absent or after QRS <.12 <.12 Junctional Rhythms
  • 41. • Accelerated Junctional Rhythm – P-wave can come before or after the QRS complex, or lost within the QRS complex • If p-waves are seen they will be inverted – Rhythm is regular – Heart rate between 60-100 beats per minute • Within the normal HR range • Fast rate for the junction (normally 40-60 bpm) Junctional Rhythms
  • 42. Junctional Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular May be inverted or hidden Short <.12 Normal <.12 Junctional Rhythms
  • 43. • Junctional Tachycardia – P-wave can come before or after the QRS complex or lost within the QRS entirely • If a p-wave is seen it will be inverted – Rhythm is regular – Rate is between 100-180 beats per minute • In the tachycardia range, but not originating from SA node – AV node has sped up to override the SA node for control of the heart Junctional Rhythms
  • 44. Junctional Rhythms Junctional Escape Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 40 – 60 Regular Absent, inverted or after QRS Short <.12 Normal <.12
  • 45. Junctional Rhythms • Junctional Escape Rhythm – P-wave may come before or after the QRS or may be hidden in the QRS entirely • If p-waves are seen, they will be inverted – Rhythm is regular – Rate 40-60 beats per minute • The SA node has failed; the AV junction takes over control of the heart
  • 46. Ventricular Rhythms Premature Ventricular Contraction (PVC) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular No P waves associated with premature beat NA Wide >.12
  • 47. Ventricular Rhythms • Premature Ventricular Contraction (PVC) – The ectopic beat is not preceded by a p-wave – Irregular rhythm due to ectopic beat – Rate will be determined by the underlying rhythm – QRS is wide and may be bizarre in appearance – Caused by a irritable focus within the ventricle which fires prematurely – Must identify an underlying rhythm
  • 48. Ventricular Rhythm • Premature Ventricular Contraction – Classify as rare, occasional, or frequent – Classify as unifocal, or multifocal PVC’s • Unifocal-originating from same area of the ventricle; distinguished by same morphology
  • 49. Ventricular Rhythm • Premature Ventricular Contraction – Classify as unifocal, or multifocal PVC’s – Unifocal-originating from same area of the ventricle; distinguished by same morphology – Multifocal-originating from different areas of the ventricle; distinguished by different morphology
  • 50. Ventricular Rhythm • Premature Ventricular Contraction – Bigeminy • A PVC occurring every other beat – Also seen as Trigeminy, Quadrigeminy
  • 51. Ventricular Rhythm • Dangerous PVC’s – R on T – Runs of PVC’s – 3 or more considered Vtach
  • 52. Ventricular Rhythms Ventricular Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 100 – 250 Regular No P waves corresponding to QRS, a few may be seen NA >.12
  • 53. Ventricular Rhythms • Ventricular Tachycardia – No discernable p-waves with QRS – Rhythm is regular – Atrial rate cannot be determined, ventricular rate is between 150-250 beats per minute – Must see 4 beats in a row to classify as v- tach
  • 54. Ventricular Rhythms • Ventricular Tachycardia – THIS IS A DEADLY RHYTHM • Check patient: – If patient awake and alert, monitor patient and call physician – If patient has no vital signs, call code and start CPR » Defibrillate
  • 55. Ventricular Rhythms Ventricular Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 0 Chaotic None NA None
  • 56. Ventricular Rhythms • Ventricular Fibrillation – No discernable p-waves – No regularity – Unable to determine rate – Multiple irritable foci within the ventricles all firing simultaneously – May be coarse or fine – This is a deadly rhythm • Patient will have no pulse • begin CPR & resustication.
  • 57. Asystole Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) None None None None None
  • 58. Asystole • No p-waves • No regularity • No Rate • This rhythm is associated with death – Check patient and leads – No pulse • Begin CPR
  • 59. Heart Block First Degree Heart Block Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. Regular Before each QRS, Identical > .20 <.12
  • 60. Heart Block – First Degree Heart Block • P-wave for every QRS • Rhythm is regular • Rate may vary • Av Node hold each impulse longer than normal before conducting normally through the ventricles • Prolonged PR interval – Looks just like normal sinus rhythm
  • 61. Heart Block Second Degree Heart Block Mobitz Type I (Wenckebach) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. can be slow Irregular Present but some not followed by QRS Progressively longer <.12
  • 62. Heart Block • Second Degree Heart Block • Mobitz Type I (Wenckebach) – Some p-waves are not followed by QRS complexes – Rhythm is irregular • R-R interval is in a pattern of grouped beating – Rate 60-100 bpm – Intermittent Block at the AV Node • Progressively prolonged p-r interval until a QRS is blocked completely
  • 63. Heart Block Second Degree Heart Block Mobitz Type II (Classical) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Usually slow Regular or irregular 2 3 or 4 before each QRS, Identical .12 - .20 <.12 depends
  • 64. Heart Block • Second Degree Heart Block • Mobitz Type II (Classical) – More p-waves than QRS complexes – Rhythm is irregular – Atrial rate 60-100 bpm; Ventricular rate 30-100 bpm (depending on the ratio on conduction) – Intermittent block at the AV node • AV node normally conducts some beats while blocking others
  • 65. Heart Block Third Degree Heart Block (Complete) Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 30 – 60 Regular Present but no correlation to QRS may be hidden Varies <.12 depends
  • 66. Heart Block • Third Degree Heart Block (Complete) – There are more p-waves than QRS complexes – Both P-P and R-R intervals are regular – Atrial rate within normal range; Ventricular rate between 20-60 bpm – The block at the AV node is complete • There is no relationship between the p-waves and QRS complexes
  • 67. CAUSES » FIRST DEGREE & SECOND DEGREE BLOCK • normal variant • increased vagaltone. • athelets. • sick sinus syndrome. • acute carditis. • ishaemic heart disease. • hypokalemia • lyme disease. • digoxin • beta blockers • calcium channel blockers.
  • 68. COMPLETE HEART BLOCK » CAUSES- • Idiopathic / conduction tissue fibrosis. • congenital. • ischaemic heart disease. • Associated with Aortic valve calcification. • cardiac surgery & trauma. • digoxin intoxication. • bundle interruptions by tumors, parasites,granulomas, injury, abscess.
  • 70. Bundle branch block » Right bundle branch block.
  • 71. Study resources – Understanding ECG ,6th edition, P.J.Mehta’s. – A Primer of ECG , K.P.Misra. – The ECG in Practice, 6th edition, Jhon R.Hampton. – www.skillstat.com/6sECG_rdm.html – www.gwc.maricopa.edu/class/bio202/cyberheart/ ekgqzr2.htm – http://www.randylarson. rhythmst.htmlcom/acls/master/ – Rapid Interpretation of EKG’s, Dale Dubin.