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ECG TRAINING MODULE 4 BY BRAD CHAPMAN RCT. OBJECTIVES 1. Arrhythmia recognition 2. Sinus 3. Atrial 4. Blocks 5. Ventricular.

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Presentation on theme: "ECG TRAINING MODULE 4 BY BRAD CHAPMAN RCT. OBJECTIVES 1. Arrhythmia recognition 2. Sinus 3. Atrial 4. Blocks 5. Ventricular."— Presentation transcript:

1 ECG TRAINING MODULE 4 BY BRAD CHAPMAN RCT

2 OBJECTIVES 1. Arrhythmia recognition 2. Sinus 3. Atrial 4. Blocks 5. Ventricular

3 ARRHYTHMIA RECOGNITION Rhythms coming from the SA node: Rhythms coming from the SA node: Normal Sinus Rhythm: Normal Sinus Rhythm: This rhythm originates from the SA node. This specialized piece of tissue generates its own impulse at a rate of 60 – 100 bpm. Sympathetic stimulation can accelerate the SA node up to a rate of 150 bpm. (Woods, 2000). P waves and QRS are usually normal and have a 1:1 ratio. This rhythm originates from the SA node. This specialized piece of tissue generates its own impulse at a rate of 60 – 100 bpm. Sympathetic stimulation can accelerate the SA node up to a rate of 150 bpm. (Woods, 2000). P waves and QRS are usually normal and have a 1:1 ratio. Rate: 60 – 100 bpm (beats per minute), Regular Rate: 60 – 100 bpm (beats per minute), Regular

4 ARRHYTHMIA RECOGNITION Sinus Bradycardia: Sinus Bradycardia: Rhythm - Regular Rate - less than 60 beats per minute Rhythm - Regular Rate - less than 60 beats per minute QRS Duration - Normal QRS Duration - Normal P Wave - Visible before each QRS complex P Wave - Visible before each QRS complex P-R Interval - Normal P-R Interval - Normal Usually benign and often caused by patients on beta blockers Usually benign and often caused by patients on beta blockers

5 ARRHYTHMIA RECOGNITION Sinus Tachycardia: Sinus Tachycardia: Rhythm - Regular Rate - More than 100 beats per minute Rhythm - Regular Rate - More than 100 beats per minute QRS Duration - Normal QRS Duration - Normal P Wave - Visible before each QRS complex P Wave - Visible before each QRS complex P-R Interval - Normal P-R Interval - Normal The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise

6 ARRHYTHMIA RECOGNITION Sinus arrhythmia: Sinus arrhythmia: The EKG is of normal pattern but the rhythm varies corresponding to respiratory cycle. The EKG is of normal pattern but the rhythm varies corresponding to respiratory cycle. This is commonly found in young people. This is commonly found in young people. P waves and QRS are usually normal and have a 1:1 ratio. P waves and QRS are usually normal and have a 1:1 ratio.

7 ARRHYTHMIA RECOGNITION Sinus Arrest: Sinus Arrest: The S.A. node fails to initiate impulses. No P waves, No QRS The S.A. node fails to initiate impulses. No P waves, No QRS

8 ARRHYTHMIA RECOGNITION Atrial Rhythms Atrial Rhythms These rhythms come from a different focus or site than the S.A. node (normal pacemaker of the heart). Usually somewhere within the wall of one of the atria. These rhythms come from a different focus or site than the S.A. node (normal pacemaker of the heart). Usually somewhere within the wall of one of the atria. The P wave is often of different shape. The QRS is usually initiated in a normal manner. The P wave is often of different shape. The QRS is usually initiated in a normal manner.

9 ARRHYTHMIA RECOGNITION Atrial Flutter: Atrial Flutter: The waves are very rapid (300 bpm) – usually saw tooth in pattern. The A-V node cannot transmit every impulse to the ventricle. The ventricle will respond to every second, third, fourth etc. flutter wave. The waves are very rapid (300 bpm) – usually saw tooth in pattern. The A-V node cannot transmit every impulse to the ventricle. The ventricle will respond to every second, third, fourth etc. flutter wave. Rhythm - Regular Rate - Around 110 beats per minute Rhythm - Regular Rate - Around 110 beats per minute QRS Duration - Usually normal QRS Duration - Usually normal P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but sometimes 3:1 P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but sometimes 3:1 P Wave rate beats per minute P Wave rate beats per minute P-R Interval - Not measurable As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case P-R Interval - Not measurable As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case

10 ARRHYTHMIA RECOGNITION Atrial fibrillation: Atrial fibrillation: There are no consistent P waves. Because the irritable focus is so rapid (more than 350 bpm) There are no consistent P waves. Because the irritable focus is so rapid (more than 350 bpm) You see wavy series of fib waves. The ventricular response is totally irregular. You see wavy series of fib waves. The ventricular response is totally irregular. Rhythm - Irregularly irregular Rhythm - Irregularly irregular Rate - usually beats per minute but slower if on medication Rate - usually beats per minute but slower if on medication QRS Duration - Usually normal QRS Duration - Usually normal P Wave - Not distinguishable as the atria are firing off all over P Wave - Not distinguishable as the atria are firing off all over P-R Interval - Not measurable P-R Interval - Not measurable The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

11 ARRHYTHMIA RECOGNITION AV NODE RHYTHMS AV NODE RHYTHMS When the pacemaker of the heart shifts down to the A.-V. node, the P waves are altered. This causes the P waves to be inverted. Because the focus is so close to the ventricle, the atria and ventricle contract at about the same time. The P wave occurs just before, after or buried in the QRS complex. When the pacemaker of the heart shifts down to the A.-V. node, the P waves are altered. This causes the P waves to be inverted. Because the focus is so close to the ventricle, the atria and ventricle contract at about the same time. The P wave occurs just before, after or buried in the QRS complex. Nodal rhythm: Nodal rhythm: The rhythm is regular but the P wave occurs just before the QRS, after or is buried in the QRS. Your P wave can also be inverted. The rhythm is regular but the P wave occurs just before the QRS, after or is buried in the QRS. Your P wave can also be inverted. Nodal Tachycardia: Nodal Tachycardia: The rate is usually between 100 and 150 bpm. Since conduction beyond the A-V node is normal, we usually get a QRS complex which is normal. Inverted P waves are seen. The rate is usually between 100 and 150 bpm. Since conduction beyond the A-V node is normal, we usually get a QRS complex which is normal. Inverted P waves are seen.

12 ARRHYTHMIA RECOGNITION 1 st Degree AV Block: 1 st Degree AV Block: Prolonged AV conduction time. If the pacemaker is normal and in the S.A. node the P wave will be normal in shape. But because of defective (slow) conduction in the A.V. node, the PR interval exceeds the upper limit or normal. The heart rate and rhythm are unaffected. Prolonged AV conduction time. If the pacemaker is normal and in the S.A. node the P wave will be normal in shape. But because of defective (slow) conduction in the A.V. node, the PR interval exceeds the upper limit or normal. The heart rate and rhythm are unaffected. Your PR interval is greater than.20 sec. (200) Your PR interval is greater than.20 sec. (200) Rhythm - Regular Rhythm - Regular Rate - Normal Rate - Normal QRS Duration - Normal QRS Duration - Normal P Wave - Ratio 1:1 P Wave - Ratio 1:1 P Wave rate - Normal P Wave rate - Normal P-R Interval - Prolonged (>5 small squares) P-R Interval - Prolonged (>5 small squares)

13 ARRHYTHMIA RECOGNITION 2nd Degree Block Type 1 (Wenckebach) 2nd Degree Block Type 1 (Wenckebach) Here, there is a progressive lengthening of the PR interval to the point where an impulse does not reach the ventricle and a beat is dropped. Here, there is a progressive lengthening of the PR interval to the point where an impulse does not reach the ventricle and a beat is dropped. Rhythm - Regularly irregular Rhythm - Regularly irregular Rate - Normal or Slow Rate - Normal or Slow QRS Duration - Normal QRS Duration - Normal P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. P Wave rate - Normal but faster than QRS rate P Wave rate - Normal but faster than QRS rate P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped

14 ARRHYTHMIA RECOGNITION 2nd Degree Block (Mobitz Type II) 2nd Degree Block (Mobitz Type II) This is characterized by an occasional or cyclic block of conduction of an impulse without previous lengthening of conduction time. This is characterized by an occasional or cyclic block of conduction of an impulse without previous lengthening of conduction time. Rhythm - Regular Rhythm - Regular Rate - Normal or Slow Rate - Normal or Slow QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 P Wave rate - Normal but faster than QRS rate P Wave rate - Normal but faster than QRS rate P-R Interval - Normal or prolonged but constant P-R Interval - Normal or prolonged but constant

15 ARRHYTHMIA RECOGNITION 3 rd Degree AV Block: 3 rd Degree AV Block: Usually called a complete heart block. There is a delay before the idioventricular pacemaker goes in action. During this time there is no ventricular contraction (no QRS) and often times the patient may faint. There is no impulse from the atria that is reaching the ventricle. Usually called a complete heart block. There is a delay before the idioventricular pacemaker goes in action. During this time there is no ventricular contraction (no QRS) and often times the patient may faint. There is no impulse from the atria that is reaching the ventricle. Rhythm - Regular Rhythm - Regular Rate - Slow (Ventricular rate 20 – 40 bpm) Rate - Slow (Ventricular rate 20 – 40 bpm) QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Unrelated P Wave P Wave - Unrelated P Wave rate - Normal but faster than QRS rate rate - Normal but faster than QRS rate P-R Interval - Variation P-R Interval - Variation Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm

16 ARRHYTHMIA RECOGNITION Right and Left Bundle Branch Blocks: Right and Left Bundle Branch Blocks: When the conduction through the right and left bundles are impaired, the impulse must travel through non specialized tissue. This prolongs depolarization producing a longer QRS complex. When the conduction through the right and left bundles are impaired, the impulse must travel through non specialized tissue. This prolongs depolarization producing a longer QRS complex.

17 ARRHYTHMIA RECOGNITION The Criteria for a LBBB: The Criteria for a LBBB: -Wide QRS complex greater than.12 seconds -Wide QRS complex greater than.12 seconds -Upright, possibly notched QRS complex (RSR’) in lead I, V5 and V6. -Upright, possibly notched QRS complex (RSR’) in lead I, V5 and V6. -Predominantly negative QRS in V1. -Predominantly negative QRS in V1. Rhythm - Regular Rhythm - Regular Rate - Normal Rate - Normal QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Ratio 1:1 P Wave - Ratio 1:1 P Wave rate - Normal and same as QRS rate P Wave rate - Normal and same as QRS rate P-R Interval - Normal P-R Interval - Normal

18 ARRHYTHMIA RECOGNITION The Criteria for a RBBB: The Criteria for a RBBB: - Wide QRS of at least.11 seconds - Wide QRS of at least.11 seconds -An RSR’ in V1 and V2 -An RSR’ in V1 and V2 -Wide S wave in leads I and V6. -Wide S wave in leads I and V6.

19 ARRHYTHMIA RECOGNITION Ventricular rhythms: Ventricular rhythms: These impulses are coming from the wall of the ventricles. These impulses are coming from the wall of the ventricles. Ventricular tachycardia: Ventricular tachycardia: This is a dangerous rhythm which requires immediate attention and prompt correction. This is a dangerous rhythm which requires immediate attention and prompt correction. Rhythm - Regular Rhythm - Regular Rate Beats per minute Rate Beats per minute QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Not seen Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse P Wave - Not seen Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

20 ARRHYTHMIA RECOGNITION Ventricular fibrillation: Ventricular fibrillation: The pattern is bizarre with no rhythm of any sort. You usually have no palpable or audible pulse. The pattern is bizarre with no rhythm of any sort. You usually have no palpable or audible pulse. Rhythm - Irregular Rhythm - Irregular Rate , disorganised Rate , disorganised QRS Duration - Not recognisable QRS Duration - Not recognisable P Wave - Not seen P Wave - Not seen This patient needs to be defibrillated!! QUICKLY This patient needs to be defibrillated!! QUICKLY

21 REVIEW No questions will be asked for this module as it is for information only and you will not be expected to know these blocks. No questions will be asked for this module as it is for information only and you will not be expected to know these blocks.


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