Cardiac arrhythmias

subject: medicine

1. Cardiac Arrhythmias DR ABID NAEEM

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. Sinu s 1-Sinus Rythem-HR-60-100/M 2-Sinus Arrythmia-HR-60-100/M 3-Sinus Arrest- Sinus arrest- sinus stop-one beat miss 4-Sinus Bradycardia-HR-<60/M 5-Sinus Tachycardia-HR-100-160/M. >160 SVT

4. Atrial 1 - Wandering pace maker-HR-<60 2-Premature Atrial Contraction-HR-NA(Not Assessable) 3-Atrial Tachycardia-HR-160-250/m Atrial flutter-hr-250-400/m-P-regular 5-Atrial fibrillation-HR-variable=p-p-Irregular

5. (Junctional)-(AV-Node) 1-Junctional Rhythum-HR-40-60/M 2-Juctional escape-HR-40-60/M 3-Premature Contraction 4-Accelarated Junctional Rhythum-HR-60-100 5-Juntional Tachycardia-HR-100-180/M

6. BUNDLE OF HIS/RT & LF BRANCHES/ Parkinje Fibers / VENTRICULAR RHYTHUM 1-Ventricular Rhythum-HR-20-40/M 2-Ventricular Muscle-HR-10-20/M 3-Primary Ventricular Standstill-No QRS-P.wave present 4-Asystole-straight line 5-Idiopathic Ventricular-hr-20-40/M 6-Ventricular tachycardia- HR-150-250/M 7-Ventricular Flutter-HR-250-300/M 8-Ventricular Fibrillation-HR-NA

7. Heart Blocks FIRST DEGREE HEART BLOCK RATE-NORMAL=P-R INTERVAL(N-0.12 0.20/SEC=0.20/SEC 2 ND DEGREE HEART BLOCK (Mobitz Type I (Wenckebach ) PROGRESSIVE P-R PROLONGATION-TILL 01 BEAT DROP 2 ND DEGREE HEART BLOCK (Mobitz Type 2) P-R NORMAL=2,3,4 P.waves before each QRS-HR-60-100/M 3 RD DEGREE HEART BLOCK P AND QRS NAS ITS OWN RATE-HR-30-60/M

8. 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

9. SA Node Inter-noda l and inter-atria l pathways A-V Node Bundle of His Purkinje Fibers Conduction System

10. 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)

11. AV Node Located in the septum of the heart Receives impulse from inter-nodal pathways and holds the signa l before sending on to the Bundle of His Represents the PR segment of the QRS complex

12. 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

13. QRS Complex Represents the ventricles depolarizing (firing) collectively. (Bundle of His and Purkinje fibers) Origin of all ventricular rhythms Has an inherent rate of 20-40 beats per minute

14. ECG Trace Isoelectric line ( baseline ) P-wave Atria firing PR interval Delay at AV

15. ECG Trace QRS Ventricles firing T-wave Ventricles repolarizing

16. ECG Trace ST segment Ventricle contracting Should be at isoelectric line Elevation or depression may be important U wave Perkinje fiber repolarization?

17. ECG- Analysis RATE RHYTHUM AXIS WAVE FORM

18. ECG-PAPER

19. 1-RATE Calculation 300,150,100 75,60,50 1-What is the rate? Count the number of beats occurring in one minute Counting the p-waves will give the atrial rate Counting QRS will give ventricular rate

20. 2-RHYTHUM 2-Is the rhythm regular? Verify by assessing R-R interval Confirm by assessing P-P interval

21. 3-axis LEADS- I, AVF REULE OF THUMB 1- I,AVF= R ,UP= Normal axis 2- 1,AVF= R,WAVE DOWN =Extreme T-RT. Axis deviation 3- I -R=UP, AVF-R=DOWN =LT.Axis. Deviation 4-1,R =down. AVF,R=UP=RT. Axis deviation

22. Determining the Axis Predominantly Positive Predominantly Negative Equiphasic

23. Waveform Analysis Is there a P-wave for every QRS? P-waves are upright and uniform One P-wave preceding each QRS

24. Calculation 300,150,100 75,60,50 Normal Heart rate = 60 – 100 BPM SA Node discharge = 60 – 100 / min AV Node discharge = 40 – 60 min Ventricular Tissue discharge = 20 – 40/min PR interval = 0.12 – 0.20 sec QRS interval= <0.12 Summary

25. Cardiac cycle P wave = atrial depolarization PR interval = pause between atrial and ventricular depolarization QRS = ventricular Depolarization T wave = ventricular Repolarization Summary

26. Normal Sinus Rhythm Heart Rate (bpm) Rhythm P Wave PR Interval (sec) QRS (sec) 60 - 100 Regular Before each QRS, Identical 0.12 - 0.20 <0.12 Sinus Rhythms

27. 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

28. Sinus Bradycardia Heart Rate (bpm) Rhythm P Wave PR Interval (sec) QRS (sec) <60 Regular Before each QRS, Identical 0.12 - 0.20 <0.12 Sinus Rhythms

29. 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 Sinus Rhythms

30. Sinus Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) >100 Regular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms

31. 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) Sinus Rhythms

32. Sinus Arrhythmia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms

33. 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

34. Sinus Arrest Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) NA Irregular Before each QRS, Identical .12 - .20 <.12 Sinus Rhythms

35. Sinus Arrest Sinus Rhythms Stop of sinus rhythm New rhythm starts

36. Sinus Pause Sinus Rhythms One dropped beat is a sinus pause Beats walk through

37. Atrial Rhythms

38. 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

39. 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

40. Atrial Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Irregular Wavy irregular NA <.12 Atrial Rhythms

41. 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

42. 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

43. Atrial Tachycardia Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 140 – 250 Irregular Abnormal and present but may be hidden on ST segment or T wave Not measure-able <.12 but may be wide Atrial Rhythms

44. Atrial Flutter Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Atrial=250 – 400 VentricularVar. Irregular Sawtooth Not Measur-able <.12 Atrial Rhythms

45. Atrial Flutter More than one p-wave for every QRS comple x Demonstrate a “saw tooth” 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

46. 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 is patient symptomatic

47. Rhythms that originate at the AV junction Junctional rhythms do not have characteristic p-waves . Junctional Rhythms

48. 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

49. 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

50. Junctional Rhythms

51. Accelerated Junctional Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Var. Regular Inverted, absent or after QRS <.12 <.12 Junctional Rhythms

52. 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 invert ed 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

53. Junctional Rhythms

54. 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

55. 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 spread up to override the SA node for control of the heart Junctional Rhythms

56. Junctional Rhythms

57. 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

58. 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

59. Junctional Rhythms

60. 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

61. 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

62. 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

63. 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

64. Ventricular Rhythm Multifocal -originating from different areas of the ventricle ; distinguished by different morphology

65. Ventricular Rhythm Premature Ventricular Contraction Bigeminy A PVC occurring every other beat Also seen as Trigeminy , Quadrigeminy

66. Ventricular Rhythm Dangerous PVC’s R on T Runs of PVC’s 3 or more considered Vtach

67. Idioventricular Rhythm Ventricular Rhythm

68. Ventricular Rhythm

69. Ventricular Rhythms Ventricular Flutter Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) 150 – 300 Regular No P waves NA Wide >.12

70. Ventricular Rhythms Ventricular Flutter “Extreme V-Tach” Call code Begin CPR

71. Ventricular Rhythms Ventricular Flutter “Extreme V-Tach” Call code Begin CPR

72. 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

73. Ventricular Rhythms Ventricular Tachycardia No discernable p-waves with QRS Rhythm is regular Atrial rate cannot be determined, ventricular rate is between 1 50-25 0 beats per minute Must see 4 beats in a row to classify as v-tach

74. 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

75. Ventricular Rhythms Ventricular Fibrillation Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Chaotic None NA None

76. 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 Call a code and begin CPR

77. Ventricular Rhythms

78. Ventricular Standstill Primary ventricular standstill Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) No QRS No QRS Present NA None

79. Asystole Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) None None None None None

80. Asystole No p-waves No regularity No Rate This rhythm is associated with death Check patient and leads No pulse Begin CPR

81. Heart Block First Degree Heart Block Heart Rate Rhythm P Wave PR Interval (sec.) QRS (Sec.) Norm. Regular Before each QRS, Identical > .20 <.12

82. 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

83. Heart Block

84. 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

85. 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

86. Heart Block

87. 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

88. 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

89. Heart Block

90. 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

91. 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

92. Heart Block

93. ECG-READING 1-RATE 2-RYTHEM 3-AXIS-1,AVF 4-LEADS V1-V2=RT.CHEST LEADS V3-V4=SEPTAL LEADS V1-V4=ANTERIOR CHEST LEADS V5-V6=LATERAL CHEST LEADS 1,AVL,V1-V6=ANTROLATERAL CHEST LEADS 11,111,AVF-INFERIOR LEADS

94. 5-MYOCARDIAL INFARCTION ANTERIOR,ANTROLATRAL,INFERIOR ACUTE MI-T-INVERSION, ST-ELEVATION 6-CONDUCTIONS DEFECTS RBBB-T.WAVE-V1-V2= M -PATTERN RBBB V5 V6 W PATTERN LBBB-T.WAVE-V5-V6= M -PATTERN LBBB V1 V2 W PATTERN

95. 7-CCF,PERICARDIAL EFFUSION,OBESE-LOW VOLTAGE ECG.