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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

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
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
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
slide33

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
slide50
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.
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 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
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
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 fibrillation
Ventricular Fibrillation
  • Rate: No ventricular rate
  • Regularity: Irregular
  • P-Waves: No
  • P-R I: No
  • QRS: No, unorganized ventricular baseline
  • Married: No
asystole
Asystole
  • Rate: 0
  • Regularity: N/A
  • P-Waves: None
  • P-R I: N/A
  • QRS: None
  • Married: No (verify a second lead)
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)
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
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
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
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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