Basic dysrhythmias
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Basic Dysrhythmias. Chemeketa Paramedic Program -Basic Anatomy of the Heart -Electrical Conduction of the Heart -A System of Defining 3-Lead EKG’s. What is an:. EKG? ECG? EEG? EGG? Isn’t School Great?. Heart A & P. Location Pieces, Parts Important Vessels Electrolyte Role

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Basic Dysrhythmias

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Basic dysrhythmias

Basic Dysrhythmias

Chemeketa Paramedic Program

-Basic Anatomy of the Heart

-Electrical Conduction of the Heart

-A System of Defining 3-Lead EKG’s


What is an

What is an:

  • EKG?

  • ECG?

  • EEG?

  • EGG?

  • Isn’t School Great?


Heart a p

Heart A & P

  • Location

  • Pieces, Parts

  • Important Vessels

  • Electrolyte Role

  • Pulling apart waveforms


Basic dysrhythmias

VALVES & VESSELS


Basic dysrhythmias

FRONT


Basic dysrhythmias

BACK


Review of important vessels

Review of Important Vessels


Basic dysrhythmias

CONDUCTION SYSTEM


A system of checks balances

Baroreceptors (Pressoreceptors)

Found:

Internal carotid arteries

Aortic Arch

Chemoreceptors

Found in same places

Monitors pH, O2 & CO2

Respond by:

Stimulating sympathetic

Adrenergic response

Alpha, Beta & Dopaminergic

Norepi & Epi release

Inhibiting Parasympathetic

Acetylcholine

Cholinergic Response

Medulla

Regulatory organ

A System of Checks & Balances


Electrical conduction system

Electrical Conduction System

  • Sympathetic-Thoracic/Lumbar Nerve

    • Norepinephrine

      • HR, Contractility

  • Parasympathetic-Vagus Nerve

    • Acetylcholine

      • HR (Valsalva)

  • Chronotropic-HR

  • Inotropic-Contraction


Electrolytes conduction

Electrolytes & Conduction

  • “Excitable” cells of the Heart

  • Self-depolarizing cells (Automaticity)

  • Electrolytes of the Heart (Na+ / K+/ Ca++)


Electrolytes conduction1

Electrolytes & Conduction

  • Membrane Potential (MP)

    • Slight difference between charge inside & out

  • Threshold

    • MP becomes high enough to depolarize

  • Action Potential

    • Ability of cells at a given time

    • Difference (mV) between inside & out


The cardiac cycle

The Cardiac Cycle


Membrane potential

Membrane Potential


Sodium potassium

MP Rises

Na+ Channels Open

Rapid Influx (Fast Channels)

Cell Attains + Charge

K+ Channels Open

Outflow

The Pump

ATP Transports:

3 Na+ out & 2 K+ in

Restores Resting cellular conditions

Calcium

Slow Channels

Selective Permeability

“The Wave”

One cell contraction

Spreads

Sodium-Potassium


Electrical conduction system1

Electrical Conduction System

  • Na+ - Depolarization

  • K+ - Repolarization

    • > = < Automaticity & Conduction

    • < = > Irritability

  • Ca++ - Depolarization and Contraction

    • > = > Contractility

    • < = < Contractility, > Irritability


Electrical conduction system2

Electrical Conduction System

  • Na+ in & K+ out = Depolarization

  • K+ in & Na+ out = Repolarization

    • Imbalances in K+ or Na+

      • Effects Automaticity & Conduction

      • Hypo & hyperkalemia affects irritability

  • Ca++ - Depolarization and Contraction

    • Affects Contractility

    • Hypo & Hypercalcemia effects contractile force


I know what you re thinking who gives a @

I know what you’re thinking…Who gives a @#$% !!!

  • You are caring for a patient with a rapid heart rate. You follow protocols and administer 20mg of Diltiazem.

    • You’re patient responds by becoming:

      • Less responsive

      • Bradycardic

      • B/P drops to 72/40

      • Weak Pulse at wrist

      • Not responding to fluid, time or positioning.

  • What now???

  • Calcium Gluconate 10%

    • 500 – 1000 mg slow IV Push

@#$% = Dang


Phases

Phases

  • Phase 0 – Rapid Depolarization

    • Reached max potential -90mV

    • Fast Na+ Channels Open

    • Cell now positive +25mV

  • Phase 1 – Early Rapid Repolarization

    • Fast Na+ Channels Close

    • K+ still being lost

    • MP approaching 0mV

  • Phase 2 – Prolonged Slow Repolarization

    • Plateau Phase

    • Muscle finishing contraction

    • Beginning to relax

    • MP staying close to 0mV


Phases1

Phases

  • Phase 3 – End of Rapid Repolarization

    • K+ returns to inside

    • Cell returns to -90mV

    • Almost ready

  • Phase 4

    • Na+ - K+ Pump turns on

      • Sends Na+ out

      • Brings K+ in

  • Ready to do it all over again now 


Refractory periods excuse me i hate to interrupt again but who cares

Refractory PeriodsExcuse me!!! I hate to interrupt again, but, who cares???

  • Absolute Refractory Period

    • Polarity of cell prohibits depolarization

  • Relative Refractory Period

    • Cell is returning to ready state for depolarization

    • Impulse now is BAD!!!

  • R on T Phenomenon

    • Causes VT & VF

    • Treated with defibrillation

      • Can be caused by:

        • Frequent FLB’s

        • EMT-P not pushing the “sync” button


The electrocardiograph ecg ekg

The Electrocardiograph (ECG, EKG)

  • Electrical Activity

    • Not Heart Action

  • Records + and – impulses

  • Paper runs at 25mm/s

  • Counting Rates

    • 300-150-100-75-60-50

    • 6 second strip x 10

    • 10 Second Strip x 6

    • The little number on the monitor 


Lead considerations

$25,000 mVoltmeter

Lead Views:

1 – Lateral

2 – Inferior

3 – Inferior

Lead Considerations


The components

The Components

  • SA Node

  • Internodal Pathways

  • AV Junction

  • AV Node

  • Bundle of His

  • L & R Bundle Branch

  • Purkinje Network

  • Purkinje Fibers


Ode to a node

Ode to a Node

  • Have a heart, and have no fear,The SA node is over here.Beating at a constant rate,60 – 100 is really great.The AV node can make a show,If SA node has gone too slow.40 – 60 is not too badIf it’s all you’ve got, you will be glad.Should the whole thing drop it’s speed,His and bundle branches will take the lead.And that, my friend is the whole and part,Of the conduction system of your heart.

    • Flip and See ECG, Cohn/Gilroy-Doohan


Sino atrial node

0.20 Seconds per 5 Boxes

.04 Sec

.04 Sec

.04 Sec

.04 Sec

.04 Sec

P-Wave

Q-Wave

P-R Interval

Sino Atrial Node

  • The Natural “Pacemaker”

    • Connects directly to atrial fibers

  • Fires 60-100 times per minute

  • Wavelike Atrial Depolarization

  • The P-Wave


Av junction

AV Junction

  • Receives impulses from SA Node via the Atrial Cells

    • An electrical funnel

    • Impulses hit at various times

    • Causes delay

      • PR-I

    • Susceptible to blockage

  • Path from A to V

    • Delivers impulse to the AV Node


Atrio ventricular node

Atrio-Ventricular Node

  • Lies between the Atria and Ventricles

  • Collects impulses from above

  • Stimulates Ventricles

  • If unstimulated

    • Intrinsic rate 40-60


Bundle of his left and right bundle branches

Bundle of His / Left and Right Bundle Branches

  • Distributes Impulses from the Node

  • “The Ventricular Messengers”


Purkinje network fibers

T-Wave

P-Wave

P-R Interval

QRS Complex

Purkinje Network/Fibers

  • Direct connection with ventricular tissue

  • Intrinsic rate 20-40 if unstimulated


Basic dysrhythmias

T-Wave

P-Wave

P-R Interval

QRS Complex

R

PRI

Baseline

Q

S


The six step approach

The Six Step Approach

  • What is the Rate?

  • Is the Rhythm Regular?

  • Are there P-Waves?

  • Is the P-R Interval Normal?

  • Is the QRS Complex Normal?

  • Is There a P-Wave for Every QRS?


Step 1 rate

Step 1 = Rate

  • Is the rate between 60-100 (Sinus)

  • Between 40-60 (Junctional/Bradycardic)

  • Above 100 (Tachycardic)

  • Between 20-40 (Ventricular)


Step 2 regularity

Step 2 = Regularity

  • At-a-glance: Does it look regular?

  • Are the P-Waves evenly spaced?

  • Are the QRS Complexes evenly spaced?


Step 3 p waves

Step 3 = P-Waves

  • Are P-Waves present?

  • Are they upright and rounded?

  • Are they irregular in any way: Notched / Peaked / Depressed…?

  • Are they all the same?


Step 4 p r interval

Step 4 = P-R Interval

  • Is the P-R Interval between 0.12-0.20?

  • Is it too long / too short? (Block)

  • Is it the same on every conduction?

  • Is it absent?


Step 5 qrs complex

Step 5 = QRS Complex

  • Is it there?

  • Is it between 0.04 - 0.12?

  • Does it have any abnormalities? (Notched / Rabbit Eared / Wide / Bizarre)


Step 6 p qrs married

Step 6 = P-QRS Married?

  • Is there a P-wave for every QRS?

  • Are there more P-Waves than QRS?

  • Are the P-Waves after or within the QRS?


Describe what you ve found

Describe What You’ve Found!!!

  • IN GENERAL (underlying rhythms)!!!

  • What are the abnormalities?

  • Does it originate in the Sinus Node?

  • Does it follow through from the Atria to the ventricles? Are there abnormal delays?

  • What are the exceptions to the underlying rhythm? (Describe those also)


Normal sinus rhythm

Normal Sinus Rhythm

  • Rate: 60 - 100

  • Regularity: Very

  • P-Waves: Present and Normal

  • P-R I: 0.12-0.20 sec

  • QRS: 0.04-0.12 sec and Normal

  • Married: 1 P: 1 QRS, no extras or shortages


Sinus arrhythmia

Sinus Arrhythmia

  • Rate: 60 - 100

  • Regularity: Irregular

  • P-Waves: Present and Normal

  • P-R I: 0.12-0.20 sec

  • QRS: 0.04-0.12 sec and Normal

  • Married: 1 P: 1 QRS, no extras or shortages


Sinus tachycardia

Sinus Tachycardia

  • Rate: Over 100

  • Regularity: Regular

  • P-Waves: Present and Normal

  • P-R I: 0.12-0.20 sec

  • QRS: 0.04-0.12 sec and Normal

  • Married: 1 P: 1 QRS, no extras or shortages


Sinus bradycardia

Sinus Bradycardia

  • Rate: Less than 60

  • Regularity: Regular

  • P-Waves: Present and Normal

  • P-R I: 0.12-0.20 sec

  • QRS: 0.04-0.12 sec and Normal

  • Married: 1 P: 1 QRS, no extras or shortages


Atrial fibrillation

Atrial Fibrillation

  • Rate: Usually tachy

  • Regularity: Irregular (Irregularly irregular)

  • P-Waves: Not Discernible

  • P-R I: Undeterminable

  • QRS: 0.04-0.12 sec

  • Married: Undeterminable


Atrial flutter

Atrial Flutter

  • Rate: Usually tachy

  • Regularity: Atria Regular

    • Ventricles May be Irregular

  • P-Waves: Sawtooth Pattern 2:1, 3:1, 4:1...

  • P-R I: 0.12-0.20 sec on conducting beat

  • QRS: 0.04-0.12 sec

  • Married: P-waves outnumber QRS

    • (Picket fence)


  • Paroxysmal supra ventricular tach

    (Paroxysmal) Supra Ventricular Tach

    • Rate: 140-220

    • Regularity: Regular

    • P-Waves: Usually falls within the QRS-T complex ( sometimes not visible)

    • P-R I: Shorter than 0.12, or absent

    • QRS: 0.04-0.12 sec and Normal

    • Married: Undeterminable


    Basic dysrhythmias

    WPW

    Usually based on Hx.

    Delta wave on Q

    Shortened PR-I

    No Verapamil – Accessory Path use increase

    SVT


    1st degree heart block

    1st Degree Heart Block

    • Rate: 60 - 100

    • Regularity: Very

    • P-Waves: Present and Normal

    • P-R I: Longer than 0.20 sec

    • QRS: 0.04-0.12 sec and Normal

    • Married: 1 P: 1 QRS, no extras or shortages


    2nd degree heart block type 1 wenkebach

    2nd Degree Heart Block (Type 1) Wenkebach

    • Rate: Can be Normal, or usually brady

    • Regularity: Irregular

    • P-Waves: Present and Normal

    • P-R I: Lengthens until beat is dropped

    • QRS: 0.04-0.12 sec and Normal

    • Married: P-wave present on conducting beats, increased delay causes missed QRS


    2nd degree heart block type 2 mobitz ii

    2nd Degree Heart Block (Type 2)Mobitz II

    • Rate: Less than 60

    • Regularity: Irregular

    • P-Waves: Present, 2:1, 3:1, 4:1

    • P-R I: 0.12-0.20 sec on conducting beat

    • QRS: 0.04-0.12 sec, may begin to widen

    • Married: P-wave for every QRS and extras depending on conduction ratio


    3rd degree heart block chb complete heart block

    3rd Degree Heart Block (CHB)Complete Heart Block

    • Rate: Ventricular Rate 40-60

    • Regularity: Atria-Regular

      • Vent-Regular

  • P-Waves: Present and Normal

  • P-R I: Atria independent of Ventricles

  • QRS: Usually greater than 0.12 sec

  • Married: P-waves completely unrelated to QRS Complexes.


  • Complete heart block

    Complete Heart Block


    Junctional rhythm

    Junctional Rhythm

    • Rate: 40-60

    • Regularity: Regular

    • P-Waves: Inverted, Retrograde or Absent

    • P-R I: Shortened or absent

    • QRS: 0.04-0.12 sec

    • Married: P-wave for every QRS, sometimes not visible


    Junctional

    Junctional


    Junctional accelerated rhythm

    Junctional Accelerated Rhythm

    • Rate: 60-100

    • Regularity: Regular

    • P-Waves: Inverted, Retrograde or Absent

    • P-R I: Shortened or absent

    • QRS: 0.04-0.12 sec

    • Married: P-wave for every QRS, sometimes not visible


    Accelerated junctional

    Accelerated Junctional


    Junctional tachycardia

    Junctional Tachycardia

    • Rate: 100-140

    • Regularity: Regular

    • P-Waves: Inverted, Retrograde or Absent

    • P-R I: Shortened or absent

    • QRS: 0.04-0.12 sec

    • Married: P-wave for every QRS, sometimes not visible


    Junctional tachycardia1

    Junctional Tachycardia


    Ventricular tachycardia

    Ventricular Tachycardia

    • Rate: 100-220

    • Regularity: Regular

    • P-Waves: None

    • P-R I: None

    • QRS: Greater than 0.12 sec

    • Married: NO

    We’ll look at Torsades de Pointes in Lab


    Ventricular tachycardia1

    Ventricular Tachycardia


    Ventricular fibrillation

    Ventricular Fibrillation

    • Rate: No ventricular rate

    • Regularity: Irregular

    • P-Waves: No

    • P-R I: No

    • QRS: No, unorganized ventricular baseline

    • Married: No


    Ventricular fibrillation1

    Ventricular Fibrillation


    Asystole

    Asystole

    • Rate: 0

    • Regularity: N/A

    • P-Waves: None

    • P-R I: N/A

    • QRS: None

    • Married: No (verify a second lead)


    Asystole1

    Asystole


    Agonal idioventricular

    Agonal / Idioventricular

    • Rate: 20-40

    • Regularity: Irregular

    • P-Waves: None

    • P-R I: N/A

    • QRS: Wider than 0.12 sec

    • Married: NO (a dying heart)


    Idioventricular

    Less regular than this!

    Idioventricular


    Exceptions disruptions

    Exceptions / Disruptions

    • Premature Ventricular Contractions

    • Premature Atrial Contractions

    • Bundle Branch Blocks

    • Pacer Considerations (Atrial, Ventricular or Both)


    Premature ventricular contractions

    Premature Ventricular Contractions

    • Wide, Bizarre QRS Complex

    • Always identify the underlying rhythm first

    • Can appear in couplets, triplets, short runs of V-Tach, bigeminy and trigeminy

    • Can be uni-focal or multi-focal

    • Caused by random firing within the ventricles

    • Not accompanied by a P-wave


    Pvc s

    PVC’s


    Pac s

    PAC’s

    • P-QRS Complex appearing in an unexpected location

    • Caused by a stimulus from within the Atria, but not from the SA Node


    Basic dysrhythmias

    PJC


    Bundle branch block

    Bundle Branch Block

    • Any rhythm having a BBB will have a widened twin peaked R-Wave


    Paced rhythms

    Paced Rhythms

    • Patients may have various types of pacemakers

    • Atrial

    • Ventricular

    • Both

    • Vertical spike on monitor is an indicator


    Paced rhythms various

    Paced Rhythms Various


    Artifact

    60 Cycle Interference

    Loose Leads/Moving Ambulance

    Artifact


    In summary

    In Summary

    • Really Cool Physiology!!!

    • GENERAL RULES to Interpretation

      • Applicable to 3 – lead monitoring

    • Practice, Practice, Practice…

    • Remember the rules, NOT how it looks coming from one patient or one rhythm generator!!!


    Sources in order of preference

    Sources – In order of preference

    • Many of the pictures and info from:

      • Flip and See ECG, 2nd Edition

        • Cohn/Gilroy-Doohan

          • A great resource

      • Paramedic Paramedic Textbook, Revised 2nd Edition

        • Mick J. Sanders, Mosby

      • ECG’s Made Easy, 2nd Edition

        • Barbara Aehlert, RN, Mosby

      • Basic Dysrhythmias, Interpretation and Management, 3rd Edition

        • Robert J. Huszar, Mosby


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