Transcript
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Name That Rhythm

EMT-Intermediate

W06

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And you thought we wouldn’t review…..

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Heart A & P

• Location• Pieces, Parts• Important

Vessels• Electrolyte Role• Pulling apart

waveforms

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Valves & Vessels

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Review of Important Vessels

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The Components

• SA Node• Internodal

Pathways• AV Junction• AV Node• Bundle of His• L & R Bundle

Branch• Purkinje Network• Purkinje Fibers

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The Route

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Sino Atrial Node

• The Natural “Pacemaker”– Connects directly

to atrial fibers

• Fires 60-100 times per minute

• Wavelike Atrial Depolarization• The P-Wave

P-Wave

P-R Interval

Q-Wave

.04 Sec .04 Sec .04 Sec .04 Sec .04 Sec

0.20 Seconds per 5 Boxes

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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

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Atrio-Ventricular Node

• Lies between the Atria and Ventricles

• Collects impulses from above

• Stimulates Ventricles

• If unstimulated– Intrinsic rate 40-60

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Bundle of His / Left and Right Bundle

Branches• Distributes Impulses from

the Node• “The Ventricular

Messengers”

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Purkinje Network/Fibers

• Direct connection with ventricular tissue

• Intrinsic rate 20-40 if unstimulated

P-Wave

P-R Interval

QRS Complex

T-Wave

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Electrical Conduction System

• Sympathetic-Thoracic/Lumbar Nerve

– Norepinephrine

• HR, Contractility

• Parasympathetic-Vagus Nerve

– Acetylcholine

• HR (Valsalva)

• Chronotropic-HR

• Inotropic-Contraction

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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

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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

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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

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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 PVC’s– EMT-P not pushing the

“sync” button

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QRS Complex

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Lead Considerations

• $25,000 mVoltmeter– Lead Views:

• 1 – Lateral• 2 – Inferior• 3 – Inferior

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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?

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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)

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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

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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

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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

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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

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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

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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)

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(Paroxysmal) Supra Ventricular Tach

Rate: 140-220 Regularity: Regular P-Waves: Usually falls within the QRS-T

complex (not visible) P-R I: Shorter than 0.12, or absent QRS: 0.04-0.12 sec and Normal Married: Undeterminable

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SVT

• WPW– Usually based on Hx.– Delta wave on Q– Shortened PR-I– No Verapamil – Accessory Path use

increase

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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

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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

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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

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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.

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Complete Heart Block

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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

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Junctional

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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

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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

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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

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Ventricular Tachycardia

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Ventricular Fibrillation

Rate: No ventricular rate Regularity: Irregular P-Waves: No P-R I: No QRS: No, unorganized ventricular baseline Married: No

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Ventricular Fibrillation

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Asystole

Rate: 0 Regularity: N/A P-Waves: None P-R I: N/A QRS: None Married: No (verify a second lead)

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Asystole

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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)

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Idioventricular

• Less regular than this!

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Exceptions / Disruptions

• Premature Ventricular Contractions

• Premature Atrial Contractions

• Bundle Branch Blocks

• Pacer Considerations (Atrial, Ventricular or Both)

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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

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PVC’s

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PAC’s

• P-QRS Complex appearing in an unexpected location

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

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PJC

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Bundle Branch Block

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

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Paced Rhythms

• Patients may have various types of pacemakers

• Atrial

• Ventricular

• Both

• Vertical spike on monitor is an indicator

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Paced Rhythms Various

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Artifact

• 60 Cycle Interference

• Loose Leads/Moving Ambulance

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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!!!

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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