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Select Dysrhythmias and Therapeutic Modalities J.O. Medina, NP Education Specialist Nurse Practitioner Nurse Practitioner Critical Care & Emergency Services.

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Presentation on theme: "Select Dysrhythmias and Therapeutic Modalities J.O. Medina, NP Education Specialist Nurse Practitioner Nurse Practitioner Critical Care & Emergency Services."— Presentation transcript:

1 Select Dysrhythmias and Therapeutic Modalities J.O. Medina, NP Education Specialist Nurse Practitioner Nurse Practitioner Critical Care & Emergency Services California Hospital Medical Center

2 Premature Atrial Contractions (PACs) Rateusually within normal range but depends on underlying rhythm Rhythmregular with premature beats P wavespremature (occurring earlier than the next sinus P wave), positive in lead II, one precedes each QRS complex, often differ in shape from sinus P waves : may be flattened, notched, pointed, biphasic, or lost in preceding T wave

3 Premature Atrial Contractions (PACs) PR intervalmay be normal or prolonged, depending on prematurity of beat QRS Durationusually less than 0.10 sec but may be wide (aberrant) or absent, depending on the prematurity of the beat; the QRS of the PAC is similar in shape to those of the underlying rhythm unless the PAC is aberrantly conducted

4 Premature Atrial Contractions (PACs) PAC is not an entire rhythm - it is a single beat. Therefore identify the underlying rhythm and the ectopic beat(s) Types –non-conducted or blocked PAC only P wave with no QRS after it appearing as pause –conducted PAC

5 Premature Atrial Contractions (PACs) PAC Patterns: –pairs (couplet) : two sequential PAC –“runs” or “bursts” : three or more sequential PACs often called: paroxysmal (sudden) atrial tachycardia (PAT) paroxysmal SVT (PSVT) –atrial bigeminy –atrial trigeminy –atrial quadrigeminy

6 Premature Atrial Contractions (PACs) Clinical Significance –very common –presence does not imply underlying cardiac disease

7 Atrial Tachycardia Rate beats/min Rhythmregular P wavesone positive P wave precedes each QRS complex in lead II but the P waves differ in shape from sinus P waves; with rapid rates, it is difficult to distinguish P waves from T waves

8 Atrial Tachycardia PR interval may be shorter or longer than normal and may be difficult to measure because P waves may be hidden in T waves QRS duration0.10 sec or less unless an interventricular conduction delay exists

9 Atrial Tachycardia Clinical Significance –rapid ventricular rate may decrease cardiac output

10 Atrial Flutter Rateatrial rate / min, typically 300 / min; ventricular rate variable determined by AV blockade Rhythmatrial regular ; ventricular regular or irregular P wavesno identifiable P waves; saw- toothed “flutter”, “picket fence” PR interval non measurable QRSusually < 0.10 sec

11 Atrial Flutter Clinical Significance –is accompanied by a rapid ventricular rate, there is decreased cardiac output; may deteriorate to atrial fibrillation

12 Atrial Fibrillation Rateatrial rate usually greater than beats/min; ventricular rate variable Rhythmventricular rhythm usually irregularly irregular P wavesno identifiable P waves; fibrillatory waves present; erratic, wavy baseline PR intervalnot measurable QRS durationusually< 0.10 sec but may be widened if an intraventricular conduction delay exists

13 Atrial Fibrillation Types : –controlled –uncontrolled

14 Atrial Fibrillation Clinical Significance –if accompanied by a rapid ventricular rate, there is decreased cardiac output, increased stroke risk

15 Junctional Rhythms AV node –a group of specialized cells located in the lower portion of the right atrium, above the base of the tricuspid valve Bundle of His –cardiac fibers located in the upper portion of the interventricular septum; connects the AV node with the two bundle branches AV junction –the AV node and the nonbranching portion of the bundle of his

16 Premature Junctional Complex (PJC) Rate usually within normal range but depends on underlying rhythm Rhythmregular with premature beats P wavesmay occur before, during or after the QRS ; if visible, the P wave is inverted in leads II, III, and aVF

17 Premature Junctional Complex (PJC) PR intervalif P wave occurs before the QRS, the PR interval will usually be less than or equal to 0.12 sec; if no P wave occurs before the QRS, there will be no PR interval QRS durationusually 0.10 sec or less unless an interventricular conduction delay exists

18 Premature Junctional Complex (PJC) May occur in patterns : –couplets –bigeminy –trigeminy –quadrigeminy

19 Premature Junctional Complex (PJC) Clinical Significance –most individuals with PJCs are asymptomatic; lightheadedness, dizziness, and other signs of decreased cardiac output may be evident if PJCs are frequent; if the patient is taking digitalis, check digoxin level Clinical Significance –signs and symptoms of decreased cardiac output may be present because of underlying bradycardic rate and/or SA node dysfunction; if the patient is taking digitalis, check digoxin level

20 Junctional Tachycardia Rate beats / min Rhythmregular P wavesmay occur before, during, or after the QRS; if visible, the P wave is inverted in lead II, III, and aVF PR intervalif P wave is present before the QRS, usually less than or equal to 0.12 sec; if no P wave occurs before the QRS complex, there will be no PR interval

21 Junctional Tachycardia QRS durationusually 0.10 sec or less unless an intraventricular conduction delay exists

22 Junctional Tachycardia Clinical Significance –the more rapid the rate, the greater the incidence of symptoms caused by increased myocardial oxygen demand –signs of decreased cardiac output if patient taking digitalis, check digoxin level

23 Ventricular Rhythms : Overview Ventricles are efficient pacemaker the ventricles assumed the pacing responsibility of the heart if : –SA node fails to discharge –impulse from SA node is generated but blocked as it exits the SA node –rate of discharge of SA node is slower than that of the ventricles –irritable site in either ventricle produces an early beat or rapid rhythm

24 Premature Ventricular Complexes (PVCs) Rateusually within normal range but depends on underlying rhythm Rhythmessentially regular with premature beats; if the PVC is an interpolated PVC the rhythm will be regular P wavesusually absent or with retrograde conduction to the atria, may appear after the QRS (usually upright in the ST segment or T wave)

25 Premature Ventricular Complexes (PVCs) PR intervalnone with the PVC because the ectopic beat originates in the ventricle QRS durationgreater than 0.12 sec, wide and bizarre, T wave frequently in opposite direction of the QRS complex

26 Premature Ventricular Complexes (PVCs) PVCs may occur in patterns: –Pairs (couplets) –“runs” or “bursts” –bigeminal PVCs –trigeminal PVCs –quadrigeminal PVCs Uniform PVCs Multiform PVCs Interpolated PVCs R on T PVCs

27 Premature Ventricular Complexes (PVCs) Clinical Significance –May or may not produce palpable pulses; may be asymptomatic or complain of palpitations, a “racing heart”, skipped beats, or chest or neck discomfort

28 Ventricular Tachycardia Monomorphic Polymorphic –Long QT syndrome (LQTS) acquired (iatrogenic) congenital (idiopathic) –Normal QT

29 Monomorphic Ventricular Tachycardia Rate /min Rhythmessentially regular P wavesmay be present or absent; if present, they have no set relationship to the QRS complexes, appearing between the QRSs at a rate different from that of the VT PR intervalnone

30 Monomorphic Ventricular Tachycardia QRS duration> 0.12 sec; often difficult to differentiate between the QRS and T wave Clinical significance –palpitations –SOB –chest pain –LOC if VT prolonged or sustained

31 Torsades De Pointes (TDP) Rate beats/min; typically beats/min Rhythmmay be regular or irregular P wavesnone PR intervalnone QRS duration> 0.12 sec; gradual alteration in amplitude and direction of QRS complexes

32 Torsades De Pointes (TDP) Clinical significance –palpitations –syncope –dizziness

33 Ventricular Fibrillation Ratecan not be determined because there are no discernible waves or complexes Rhythmrapid, chaotic with no pattern or regularity P wavesnot discernible PR intervalnot discernible QRS durationnot discernible

34 Ventricular Fibrillation Types –coarse –fine Clinical significance –unresponsive –pulseless –apneic

35 Atrioventricular (AV) Blocks : Overview AV junction –area of specialized conduction tissue that provides electrical links between the atria and the ventricle delay or interruption in impulse conduction within the AV node, bundle of his, or his purkinje system is called AV blocks classification –according to degree of block –according to site of block

36 First Degree AV Block Rateusually within normal range but depends on underlying rhythm Rhythmregular P wavesnormal in size and shape PR Intervalnormal in size and shape, one positive upright before each QRS QRS durationusually 0.10 sec or less unless an interventricular conduction delay exists

37 First Degree AV Block Clinical significance –patient usually asymptomatic –first degree AV block that occurs with acute MI should be monitored closely for increasing heart block

38 Second Degree AV Block Type I Rateatrial rate is greater than the ventricular rate Rhythmatrial regular; ventricular irregular P wavesnormal in size and shape, some P waves are not followed by a QRS complex

39 Second Degree AV Block Type I PR intervallengthens with each cycle until a P wave appears without a QRS complex; the PRI after the nonconducted beat is shorter than the interval preceding the nonconducted beat QRS durationusually 0.10 sec or less but is periodically dropped

40 Second Degree AV Block Type I Clinical significance –usually asymptomatic

41 Second Degree AV Block Type II Rateatrial rate is twice the ventricular rate Rhythm atrial regular; ventricular regular P wavesnormal in size and shape; every other P wave is followed by QRS complex PR intervalconstant

42 Second Degree AV Block Type II QRS durationwithin normal limits if the block occurs above the bundle of his (type I); wide if the block occurs below the bundle if his (type II); absent after every other P wave Clinical significance –may rapidly progress to complete AV block without warning

43 Complete AV Block Rateatrial rate is greater than ventricular rate; the ventricular rate is determined by the origin of the escape rhythm Rhythmatrial regular; ventricular regular; there is no relationship between atrial and ventricular rhythms

44 Complete AV Block P wavesnormal in size and shape PR intervalnone - the atria and ventricles beat independently of each other; thus there is no true PR interval

45 Complete AV Block QRS duration narrow or wide, depending on the location of the escape pacemaker and the condition of the interventricular conduction system; narrow indicates junctional pacemaker; wide indicates ventricular pacemaker

46 Complete AV Block Clinical significance –signs and symptoms will depend on the origin of escape pacemaker and patient’s response to ventricular rate

47 Questions? Thank You !


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