Arrhythmia.pptx power point presentations

Arrhythmia for Emergency and critcal care nursing students

1. ARRHYTHMIA Birhanu D(BSc, MSc EMCCN) 6/21/2024 Arrhythmia 1

2. Normal Sinus Rhythm parameters Rate 60 - 100 bpm Regularity R egular P waves Normal & followed by QRS PR interval 0.12 - 0.20 s QRS duration 0.04 - 0.12 s Any deviation from above is sinus tachycardia, sinus bradycardia or an arrhythmia 6/21/2024 Arrhythmia 2

3. Arrhythmia 6/21/2024 Arrhythmia 3 An arrhythmia is defined as any cardiac rhythm other than regular sinus rhythm. How to read ECG??? Step 1: Calculate rate. Step 2: Determine regularity. Step 3: Assess the P waves. Step 4: Determine PR interval. S tep 5: Détermine QRS duration

4. 6/21/2024 Arrhythmia 4 Classification

5. Tachyarrhythmia’s 6/21/2024 Arrhythmia 5 Heart rhythm above the normal rate. (>100BPM)

6. Approach to Tachyarrhythmia patients 6/21/2024 Arrhythmia 6 4 KEY QUESTIONS P-wave (sinus/not)…. P-wave Narrow or wide ?..... QRS<3 small box Regular or irregular?..... RR interval Stable or unstable?...... * Below *signs and symptoms of Unstable patients Altered mental status Ongoing chest pain Dyspnoea/ Tachypnea Hypotension

7. Sinus tachycardia 6/21/2024 Arrhythmia 7 Originates from the SA-node R ate >100 beats/min, T here is P wave before each QRS complex. Q RS < 0.12 sec. Regular R-R interval . Can be caused secondary to pain, fever, anxiety, PE, drug use (cocaine), alcohol withdrawal, thyrotoxicosis , volume depletion, or anemia Physiological response for exercise and stress in normal conditions.

8. 6/21/2024 Arrhythmia 8 No specific treatment for sinus tachycardia Never treat the tachycardia but treat only the causes of the tachycardia RR=150

9. 2 . Supra ventricular tachycardia( SVT) Is a rapid rhythm of the heart in which the electrical signal originates at or above the AV node . 6/21/2024 Arrhythmia 9 It’s characterized by Rate : 140 to 250 bpm Narrow QRS complex No P wave in front of QRS . Regular R-R intervals

10. Management 6/21/2024 Arrhythmia 10 Vagal manuever Carotid sinus massage Valsalva (90% success rate) Cold water immersion Adenosine 6mg rapid IVP AV nodal blocking agents Digoxin 0.5 mg IV (0.25 mg IV rpt. at 30 & 60 min) Diltiazem 0.25 mg/kg IV over 2 min; may repeat Metoprolol 5 mg IV q5 min x 3 as needed Synchronized cardioversion if ustable

11. 3 . ATRIAL FLUTTER 6/21/2024 Arrhythmia 11 Is a relatively uncommon tachyarrhythmia that develops types of heart disease or severe pulmonary disease, after cardiac surgery , and in some with no structural heart disease characteristics Rhythm Regular (unlike atrial fibrillation) Ventricular rhythm often regular No true P waves (seams like P-wave) (saw tooth). Regular R-R intervals unless there is variable blocking of the atrial impulses. Atrial rate > 300 with 2:1 block

12. 6/21/2024 Arrhythmia 12 “saw tooth pattern “is classic manifestation, Treatment Rhythm Control If unstable; Low energy cardioversion (25-50J) Rate control Diltiazem IV Metoprolol IV Digoxin IV

13. 4 . ATRIAL FIBRILLATION 6/21/2024 Arrhythmia 13 Rapid, irregular ventricular rate in which the P waves are replaced by an undulating baseline . Cardiac function usually decreases when atrial fibrillation replaces sinus rhythm. Common etiologies :mnemonic “ PIRATES” P- PE, pneumonia, pericarditis I- Ischemia (CAD and MI) R - Rheumatic heart disease, respiratory failure A- Alcohol (“holiday heart”) T – Thyrotoxicosis E - Endocrine (Ca), enlarged atria S- Sepsis, stress (fever)

14. Characteristics AF 6/21/2024 Arrhythmia 14 “ Irregularly irregular rhythm ” with the rate of 300-400 beats/min P waves:- Chaotic atrial fibrillatory waves only, PR cannot measured QRS :- Remains ≤0.10-0.12 sec. Patient can exhibit: SOB Acute pulmonary edema Drop in cardiac output and decreased coronary perfusion Irregular rhythm often perceived as palpitations Can be asymptomatic

15. 6/21/2024 Arrhythmia 15 Treatment Calcium channel blockers Beta blockers Digoxin Anti-coagulants Thrombolytic Cardio version

16. WIDE COMPLEX TACHYARRYRTRHMIAS: 6/21/2024 Arrhythmia 16 Tachyarrhythmia that originate in the ventricles which has wide QRS complex with the absence of P wave. Common wide compex tachycardia:- Monomorphic ventricular tachycardia, Polymorphic ventricular tachycardia and Ventricular fibrillation They a re severe than other tachyarrhythmia.

17. 5. monomorphic achycardia :- 6/21/2024 Arrhythmia 17 Ventricular tachycardia in which the QRS complexes have a uniform morphology Etiology chronic coronary heart disease( common) Cardiomyopathy Drug ( tricyclic antidepressants, procainamide , digoxin , some long-acting antihistamines) Rheumatic heart disease, or other cardiac conditions

18. Characteristics 6/21/2024 Arrhythmia 18 The same morphology, or shape , is seen in every QRS complex Rate: ventricular rate >100 bpm ; typically 120 to 250 bpm Rhythm: no atrial activity seen , only regular ventricular beat PR: non-existent P waves: seldom seen but present QRS complex: wide and bizarre complexes >0.12 sec

19. 6/21/2024 Arrhythmia 19 Recommended Therapy For normal heart : For impaired heart : Lidocaine , Amiodaron Amiodaron , Lidocaine Sotalol DC cardioversion if persists Procainamide

20. 6 . Polymorphic Ventricular Tachycardia 6/21/2024 Arrhythmia 20 It is an uncommon tachyarrhythmia distinguished by the changing morphology of its QRS complexes Etiology is similar to monomorphic v . tac , Defining Criteria per ECG Marked variation and inconsistency seen in the QRS complexes Rate: ventricular rate >100 bpm ; typically 120 to 250 bpm . Rhythm: irregular PR: non existent P waves: seldom seen but present

21. 6/21/2024 Arrhythmia 21 Clinical manifestation : Rare: asymptomatic polymorphic VT Majority of times: symptoms of decreased CO Tends toward rapid deterioration to pulseless VT or VF

22. Recommended therapy 6/21/2024 Arrhythmia 22 Review most recent ECG (baseline) Measure QT interval just prior to polymorphic v. tac . Threat ischemia Correct electrolyte abnormality if exist Beta blocker Amoidarone Lidocain Procanamide Sotalol DC cardio version if persist and patient has unstable manifestation

23. 7 . VENTRICULAR FIBRILLATION 6/21/2024 Arrhythmia 23 Patients who die suddenly in cardiac arrest usually succumb to ventricular fibrillation The arrhythmia that most frequently causes cardiac arrest and the setting for at least 80% of those who die suddenly outside the hospital. Cardiac arrest occurs more frequently in patients who are awake , active or highly active , cigarette smokers , obese , less educated, or have survived previous cardiac arrests.

24. Etiology 6/21/2024 Arrhythmia 24 Coronary heart disease , often involving three vessels, Previous myocardial infarction and reduced ventricular function. Defining criteria of ECG Chaotic activity of the ventricles No effective cardiac output or coronary perfusion Life-threatening - death occurs within 4 min.

25. 8. Asystole Commonly called flat line, Characteristics of ECG Absent QRS complexes There is no heartbeat , no palpable pulse No respiration. It is non- shockable rhythm (as pulseless electrical activity). 6/21/2024 Arrhythmia 25 Rx - AED, CPR

26. 6/21/2024 Arrhythmia 26 Treatment: Immediate defibrillation CPR Lidocaine , bretylium . epinephrine

27. 9. Sinus bradycardia: SA node discharge rate falls below 60 beats/min. AV conduction remains intact with a constant PR interval . Normal SA node–initiated P waves Normal PR interval 1:1 atrioventricular conduction: Rate <60 beats/min and regular 6/21/2024 Arrhythmia 27

28. Cont…… Treatment usually does not require specific treatment unless the heart rate is slower than 50 beats/min and there is evidence of hypo perfusion. Correct underlying causes. Use atropine in the unstable patient , followed by transcutaneous cardiac pacing and Infusions of dopamine or epinephrine if there is no response to atropine 6/21/2024 Arrhythmia 28

29. 10. AV block Based on severity of block AV block classified as 1 st degree AV block 2 nd degree AV block 2 nd degree motize type I 2 nd degree motize type II 3 rd degree AV block 6/21/2024 Arrhythmia 29 Benign Malignant

30. First-Degree AV Block 6/21/2024 Arrhythmia 30 PR interval > 200 ms (constant PR prolongation with no QRS escape) • Delayed conduction through the AV Node Usually treatment not is required. Close monitoring in the patient with acute myocardial ischemia is indicated due to the potential for progression to complete heart block

31. Second-Degree AV Block – Mobitz I 6/21/2024 Arrhythmia 31 Progressive prolongation of the PR interval until there is failure to conduct and a ventricular beat is dropped • often transient and usually associated with an inferior myocardial ischemia, medication toxicity, or myocarditis • Specific treatment is usually not necessary • If hypo perfusion, atropine

32. Second-Degree AV Block – Mobitz II 6/21/2024 Arrhythmia 32 Constantly prolonged PR until QRS drop Regularly dropped ventricular beats • It imply structural damage to the infranodal conducting system • usually permanent , & may progress complete heart block, • Treatment trans cutaneous pacing . • Atropine can be tried but the effect is inconsistent

33. Third-Degree AV Block Complete Heart Block 6/21/2024 Arrhythmia 33 No impulse conduction from the atria to the ventricles – Complete A – V disassociation – Treatment: monitoring and admission, medication/atropine and pacing

34. 6/21/2024 Arrhythmia 34

35. Reference 6/21/2024 Arrhythmia 35 1. Tinitinallis emergency medicine 8 th edition 2. Harrinson principles of internal medicine 19 th edion 3. Uptodate 21.6 4. Internet source ( google ) 5. Gyton medical physiology 11 th edition

36. . 6/21/2024 Arrhythmia 36 THANK YOU