Name That Rhythm EMT-Intermediate W06

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Text of Name That Rhythm EMT-Intermediate W06

  • Name That RhythmEMT-IntermediateW06

  • And you thought we wouldnt review..

  • Heart A & PLocationPieces, PartsImportant VesselsElectrolyte RolePulling apart waveforms

  • Valves & Vessels

  • Review of Important Vessels

  • The ComponentsSA NodeInternodal PathwaysAV JunctionAV NodeBundle of HisL & R Bundle BranchPurkinje NetworkPurkinje Fibers

  • The Route

  • Sino Atrial NodeThe Natural PacemakerConnects directly to atrial fibersFires 60-100 times per minuteWavelike Atrial DepolarizationThe P-Wave

  • AV JunctionReceives impulses from SA Node via the Atrial CellsAn electrical funnelImpulses hit at various timesCauses delayPR-ISusceptible to blockagePath from A to VDelivers impulse to the AV Node

  • Atrio-Ventricular NodeLies between the Atria and VentriclesCollects impulses from aboveStimulates VentriclesIf unstimulatedIntrinsic rate 40-60

  • Bundle of His / Left and Right Bundle BranchesDistributes Impulses from the NodeThe Ventricular Messengers

  • Purkinje Network/FibersDirect connection with ventricular tissueIntrinsic rate 20-40 if unstimulated

  • Electrical Conduction SystemSympathetic-Thoracic/Lumbar NerveNorepinephrine HR, ContractilityParasympathetic-Vagus NerveAcetylcholine HR (Valsalva)Chronotropic-HRInotropic-Contraction

  • Electrical Conduction SystemNa+ in & K+ out = DepolarizationK+ in & Na+ out = RepolarizationImbalances in K+ or Na+Effects Automaticity & ConductionHypo & hyperkalemia affects irritabilityCa++ - Depolarization and ContractionAffects ContractilityHypo & Hypercalcemia effects contractile force

  • PhasesPhase 0 Rapid DepolarizationReached max potential -90mVFast Na+ Channels OpenCell now positive +25mVPhase 1 Early Rapid RepolarizationFast Na+ Channels CloseK+ still being lostMP approaching 0mVPhase 2 Prolonged Slow RepolarizationPlateau PhaseMuscle finishing contractionBeginning to relaxMP staying close to 0mV

  • PhasesPhase 3 End of Rapid RepolarizationK+ returns to insideCell returns to -90mVAlmost readyPhase 4Na+ - K+ Pump turns onSends Na+ outBrings K+ in

    Ready to do it all over again now

  • Refractory PeriodsExcuse me!!! I hate to interrupt again, but, who cares???Absolute Refractory PeriodPolarity of cell prohibits depolarizationRelative Refractory PeriodCell is returning to ready state for depolarizationImpulse now is BAD!!!

    R on T PhenomenonCauses VT & VFTreated with defibrillationCan be caused by:Frequent PVCsEMT-P not pushing the sync button

  • QRS Complex

  • Lead Considerations$25,000 mVoltmeterLead Views:1 Lateral2 Inferior3 Inferior

  • The Six Step ApproachWhat 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?

  • Describe What Youve 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 RhythmRate: 60 - 100Regularity: VeryP-Waves: Present and NormalP-R I: 0.12-0.20 secQRS: 0.04-0.12 sec and NormalMarried: 1 P: 1 QRS, no extras or shortages

  • Sinus ArrhythmiaRate: 60 - 100Regularity: IrregularP-Waves: Present and NormalP-R I: 0.12-0.20 secQRS: 0.04-0.12 sec and NormalMarried: 1 P: 1 QRS, no extras or shortages

  • Sinus TachycardiaRate: Over 100Regularity: RegularP-Waves: Present and NormalP-R I: 0.12-0.20 secQRS: 0.04-0.12 sec and NormalMarried: 1 P: 1 QRS, no extras or shortages

  • Sinus BradycardiaRate: Less than 60Regularity: RegularP-Waves: Present and NormalP-R I: 0.12-0.20 secQRS: 0.04-0.12 sec and NormalMarried: 1 P: 1 QRS, no extras or shortages

  • Atrial FibrillationRate: Usually tachyRegularity: Irregular (Irregularly irregular)P-Waves: Not DiscernibleP-R I: UndeterminableQRS: 0.04-0.12 secMarried: Undeterminable

  • Atrial FlutterRate: Usually tachyRegularity: Atria Regular Ventricles May be IrregularP-Waves: Sawtooth Pattern 2:1, 3:1, 4:1...P-R I: 0.12-0.20 sec on conducting beatQRS: 0.04-0.12 secMarried: P-waves outnumber QRS(Picket fence)

  • (Paroxysmal) Supra Ventricular TachRate: 140-220Regularity: RegularP-Waves: Usually falls within the QRS-T complex (not visible)P-R I: Shorter than 0.12, or absentQRS: 0.04-0.12 sec and NormalMarried: Undeterminable

  • SVTWPWUsually based on Hx.Delta wave on QShortened PR-INo Verapamil Accessory Path use increase

  • 1st Degree Heart BlockRate: 60 - 100Regularity: VeryP-Waves: Present and NormalP-R I: Longer than 0.20 secQRS: 0.04-0.12 sec and NormalMarried: 1 P: 1 QRS, no extras or shortages

  • 2nd Degree Heart Block (Type 1) WenkebachRate: Can be Normal, or usually bradyRegularity: IrregularP-Waves: Present and NormalP-R I: Lengthens until beat is droppedQRS: 0.04-0.12 sec and NormalMarried: P-wave present on conducting beats, increased delay causes missed QRS

  • 2nd Degree Heart Block (Type 2)Mobitz IIRate: Less than 60Regularity: IrregularP-Waves: Present, 2:1, 3:1, 4:1P-R I: 0.12-0.20 sec on conducting beatQRS: 0.04-0.12 sec, may begin to widenMarried: P-wave for every QRS and extras depending on conduction ratio

  • 3rd Degree Heart Block (CHB)Complete Heart BlockRate: Ventricular Rate 40-60Regularity: Atria-Regular Vent-RegularP-Waves: Present and NormalP-R I: Atria independent of VentriclesQRS: Usually greater than 0.12 secMarried: P-waves completely unrelated to QRS Complexes.

  • Complete Heart Block

  • Junctional RhythmRate: 40-60Regularity: RegularP-Waves: Inverted, Retrograde or AbsentP-R I: Shortened or absentQRS: 0.04-0.12 secMarried: P-wave for every QRS, sometimes not visible

  • Junctional

  • Junctional Accelerated RhythmRate: 60-100Regularity: RegularP-Waves: Inverted, Retrograde or AbsentP-R I: Shortened or absentQRS: 0.04-0.12 secMarried: P-wave for every QRS, sometimes not visible

  • Junctional TachycardiaRate: 100-140Regularity: RegularP-Waves: Inverted, Retrograde or AbsentP-R I: Shortened or absentQRS: 0.04-0.12 secMarried: P-wave for every QRS, sometimes not visible

  • Ventricular TachycardiaRate: 100-220Regularity: RegularP-Waves: NoneP-R I: NoneQRS: Greater than 0.12 secMarried: NOWell look at Torsades de Pointes in Lab

  • Ventricular Tachycardia

  • Ventricular FibrillationRate: No ventricular rateRegularity: IrregularP-Waves: NoP-R I: NoQRS: No, unorganized ventricular baselineMarried: No

  • Ventricular Fibrillation

  • AsystoleRate: 0Regularity: N/AP-Waves: NoneP-R I: N/AQRS: NoneMarried: No (verify a second lead)

  • Asystole

  • Agonal / IdioventricularRate: 20-40Regularity: IrregularP-Waves: NoneP-R I: N/AQRS: Wider than 0.12 secMarried: NO (a dying heart)

  • IdioventricularLess regular than this!

  • Exceptions / DisruptionsPremature Ventricular ContractionsPremature Atrial ContractionsBundle Branch BlocksPacer Considerations (Atrial, Ventricular or Both)

  • Premature Ventricular ContractionsWide, Bizarre QRS ComplexAlways identify the underlying rhythm firstCan appear in couplets, triplets, short runs of V-Tach, bigeminy and trigeminyCan be uni-focal or multi-focalCaused by random firing within the ventriclesNot accompanied by a P-wave

  • PVCs

  • PACsP-QRS Complex appearing in an unexpected locationCaused by a stimulus from within the Atria, but not from the SA Node

  • PJC

  • Bundle Branch BlockAny rhythm having a BBB will have a widened twin peaked R-Wave

  • Paced RhythmsPatients may have various types of pacemakersAtrial VentricularBothVertical spike on monitor is an indicator

  • Paced Rhythms Various

  • Artifact60 Cycle Interference

    Loose Leads/Moving Ambulance

  • In SummaryReally Cool Physiology!!!GENERAL RULES to InterpretationApplicable to 3 lead monitoringPractice, Practice, PracticeRemember the rules, NOT how it looks coming from one patient or one rhythm generator!!!

  • Sources In order of preferenceMany of the pictures and info from:Flip and See ECG, 2nd EditionCohn/Gilroy-DoohanA great resourceParamedic Paramedic Textbook, Revised 2nd EditionMick J. Sanders, MosbyECGs Made Easy, 2nd EditionBarbara Aehlert, RN, MosbyBasic Dysrhythmias, Interpretation and Management, 3rd EditionRobert J. Huszar, Mosby