1. Basic Dysrhythmia
Kamlya balgoon
2009

2. Objectives to :- understand the Basic ECG
understand the meaning of Dysrhythmia
describe the normal heart conduction system.
describe the normal impulse pathways.
interpret Sinus Rhythm strips accurately.
interpret the A trial Rhythms strips accurately.
interpret AV Blocks strips accurately.
interpret the Ventricular Rhythm strips Accurately
kemo 2009

3. kemo 2009

4. kemo 2009

5. Basic ECG
kemo 2009

6. kemo 2009

7. Wave ,complex & intervals
P wave
represents a trial activation
Represents electrical impulse starting SA node & spreading through atria
P wave represent a trial muscle depolarization
It is normal 2.5 mm or less in higher & 0,11 second or less in duration
kemo 2009

8. Wave ,complex & intervals
QRS complex
Represents ventricular activation
Represent ventricular muscle depolarization
It is normal 5 mm in higher & 0,12 second in duration
kemo 2009

9. Wave ,complex & intervals
T wave
represent ventricle muscle depolarization
U wave
represent depolarization of purkinje fibers
kemo 2009

10. Wave ,complex & intervals
PR interval
Is measured from beginning of P wave to beginning of the QRS
IS time from onset of a trial activation to onset of ventricular activation
It is normal 0,12 to 0.20 second in duration
kemo 2009

11. Wave ,complex & intervals
ST Segment
represent early ventricle muscle depolarization
QT Interval
represent total time of ventricle muscle depolarization & depolarization
kemo 2009

12. kemo 2009

13. Normal Conduction pathways
SA Node ( )
AV Node (40 – 60)
Ventricles (20 40)
Tachycardia >100
Bradycardia < 60
kemo 2009

14. ECG - Analysis Use a consistent method to analyze an ECG Rate Rhythm
Assess P wave
Assess P wave to QRS ratio 1=1
Interval duration
Identify abnormalities
kemo 2009

15. Lets Have A Deal …!!!!
Normal P, normal P-R, normal QRS, normal P:QRS ratio = Sinus ……
Problem in the P wave = Atrial ………
Problem in the QRS = Ventricular ………
More P waves than QRS = 2nd or 3rd Degree AV Block.
Fibrillation = always irregular
kemo 2009

16. Dysrhythmia !!! Abnormal conduction of electrical through the heart.
It causes disturbance heart rate , heart rhythm
It named according to site of origin of impulse & conduction
kemo 2009

17. Arrhythmias Originates from the SA node = Sinus
Originates from the atria = atrial
Originates from the AV node = nodal or Junctional
Originates from the ventricles ( high ) = Idioventricular
Originates from the ventricles (myocardial tissue ) = Ventricular
Impulse delay in the AV node = Block
No impulse = Asystole
kemo 2009

18. Sinus Arrhythmias 1- Sinus Rhythm ( the only normal one ) Regular
P-R interval Normal
Normal identical P waves
Each P followed by a QRS
Normal QRS
Rate bpm
Normal QRS
PR interval
kemo 2009

19. 2-Sinus Tachycardia Ventricle & a trial rate ; greater than 100
Ventricle & a trial rhythm : Regular
QRS shape & duration : normal
P wave shape normal
P-R interval normal between 0,12 & o,20 second
Normal identical P waves
Each P followed by a QRS
P: QRS ratio : 1:1
kemo 2009

20. 2-Sinus Tachycardia
kemo 2009

21. 2-Sinus Tachycardia Causes Treatment
Normal physiologic with increase cardiac out put
Shock
exercise
anxiety
fever
Anemia
Medication sympathomimetic & parasympatholytic (atropine ,epinephrine )
Treatment
Treat cause
Medication ( antipyretics , beta blockers )
kemo 2009

22. 3- Sinus Bradycardia Ventricle & a trial rate : less than 60
Ventricle & a trial rhythm : Regular
QRS shape & duration : Normal
P wave shape Normal
P-R interval Normal between 0,12 & o,20 second
Normal identical P waves
Each P followed by a QRS
P: QRS ratio : 1:1
kemo 2009

23. 3- Sinus Bradycardia
kemo 2009

24. 3- Sinus Bradycardia Causes Treatment Slower metabolic need
( Sleep , Hypothermia , hypothyroidism )
Vagal stimulation
( vomiting , suction , sever pain )
Medication
( beta blockers , calcium channel blockers )
Eye surgery
Increase intracranial pressure
Treatment
Treat causes
Medication ( atropine ,epinephrine )
kemo 2009

25. Instant Feedback:
Sinus bradycardia is always abnormal and must be treated. True False
kemo 2009

26. Sinus tachycardia is a normal response to pain. True False
Instant Feedback:
Sinus tachycardia is a normal response to pain.
True False
kemo 2009

27. 4- Sinus arrhythmia or sinus block
Same as sinus but with a missed beat.
After missing a beat, the rhythm will continue in regularity.
A total beat missed
kemo 2009

28. Sinus arrhythmia P-R interval Normal Normal identical P waves
It occurs impulse irregular rhythm
Rate increase with inspiration & decrease with expiration
It include heart disease ( valvular disease )
P-R interval Normal
Normal identical P waves
Each P followed by a QRS
Normal QRS
Rate bpm
kemo 2009

29. Atrial Arrhythmias General Characteristics P wave Abnormal
Multiple Foci
Regular or Irregular
Fast most of the time
Normal QRS always
kemo 2009

30. A trial dysrhythmias Premature a trial complex A trial Fibrillation
A trial Flutter
Atrial Tachycardia
kemo 2009

31. A trial dysrhythmias 1- Premature a trial complex Causes Treatment
An electrical impulse starts in atrium before next normal impulse of SA node
Causes
Caffeine , alcohol , nicotine
Treatment
Treat causes
kemo 2009

32. Premature A trial Complex ( PAC)
Ventricle & a trial rate depend on underlying rhythm
Ventricle & a trial rhythm : irregular
( due to early p wave creating a PP interval is shorter
QRS shape & duration : normal
P wave shape an early & different p wave , hidden in T wave
P-R interval Normal between 0,12 & o,20 second
Each P followed by a QRS
P: QRS ratio : 1:1
kemo 2009

33. Premature A trial Complex ( PAC)
kemo 2009

34. Unequal R-R = irregular
2- A trial Fibrillation
Atrial fibrillation causes rapid ,disorganized & of artial muscle
Unequal R-R = irregular
kemo 2009

35. 1- Atrial Fibrillation Causes Heart failure ,
artial enlargement, hypertension ,
Treatment
Digoxin , Beta blockers ( Diogxin )
Anticoagulant if rhythm present for greater 48 hours
Synchronized cardio version if rhythm present less for 48 hours
kemo 2009

36. Atrial Fibrillation Ventricle & a trial rate : a trial rate 300 – 600
Ventricle rate 120 to 200 in untreated a trial fibrillation
Ventricle & a trial rhythm : highly irregular
QRS shape & duration : normal
P wave shape : no discernible p wave , irregular undulating wave are seen are termed fibrillatory or f waves
P-R interval not can measure
Each P followed by a QRS
P: QRS ratio : many :1
kemo 2009

37. Unequal R-R = irregular
Atrial Fibrillation
Unequal R-R = irregular
kemo 2009

38. 3- Atrial Flutter ٍ
Normal QRS
F wave
kemo 2009

39. 2- Atrial Flutter Causes Treatment
Heart disease ( valvular disorder , Rheumatic & ischemic heart disease )
Treatment
Adenocard
Diltazem
kemo 2009

40. Atrial Flutter
It occur in atrium & creates impulses at an artial rate 250 to 400 times per minute
It cause serious signs ( chest pain .shortness breathing ,low blood pressure )
Treatment
Electrical Cardiovesion
kemo 2009

41. Atrial Flutter Ventricle & a trial rate : a trial rate 250 – 400
Ventricle rate 75to 150 in untreated a trial fibrillation
Ventricle & a trial rhythm : Mostly regular, but it can be irregular
QRS shape & duration : normal
P wave shape : saw –toothed shape this waves are referred to as F wave
P-R interval : multiple F wave
Each P followed by a QRS
P: QRS ratio : 2 :1 , 3 :1, 4 :1
kemo 2009

42. Instant Feedback:
In atrial flutter, instead of P waves there is commonly a "sawtooth" pattern seen.
True False
kemo 2009

43. Instant Feedback:
The hallmark sign of atrial fibrillation is: 1) An irregulary rhythm 2) A sawtooth pattern
kemo 2009

44. 4- Atrial Tachycardia
Some times it is called Supraventricular Tachycardia ( SVT ).
Very fast rate > 150 bpm.
Normal QRS.
No P wave .or very
difficult discern
No P wave
Normal QRS
Very fast
kemo 2009

45. 4- Atrial Tachycardia
Some times it is called Supraventricular Tachycardia ( SVT ).
Very fast rate > 150 bpm.
Normal QRS.
No P wave.
No P wave
Normal QRS
Very fast
kemo 2009

46. 4- Atrial Tachycardia Cases Treatment Ischemia Hypoxia Heart failure
Adenocard
Diltazem
Synchronized cardioversion
kemo 2009

47. Ventricular Rhythms General characteristics Wide QRS. NO P wave
Mostly very fast
Could be Lethal
kemo 2009

48. Ventricular Rhythms Ventricular Tachycardia
Premature Ventricular Contraction ( PVC )
Ventricular Tachycardia
ventricular Fibrillation ( V-tach.)
No electrical Activity ( Asystole )
kemo 2009

49. 1- Premature Ventricular Contraction ( PVC )
It impulse start ventricle before next normal sinus impulse
Premature = comes early with bizarre shape.
Most of the time accompany sinus rhythm.
PVCs
( early,
wide and bizarre)
kemo 2009

50. Multifocal ( different shape )
PVCs … continued
Multifocal ( different shape )
kemo 2009

51. Premature Ventricular Contraction ( PVC )
Unifocal
kemo 2009

52. PVCs … continued
3- Couplets ,tow in arow pair
Couplets
kemo 2009

53. PVCs … continued
4- Bigeminy every other beat is PVC
kemo 2009

54. PVCs … continued
5- Trigeminy every third complex is PVC
kemo 2009

55. Premature Ventricular Contraction ( PVC )
Ventricle & a trial rate : depend on rhythm
Ventricle & a trial rhythm : irregular due to early QRS creating PR interval is shorter
QRS shape & duration : duration 0.12 second or more . Bizarre , abnormal shape
P wave shape : visibility p wave depend time of PVC may absent or in front QRS
P-R interval : less than 0,12 second
Each P followed by a QRS
P: QRS ratio : 0 :1 , 1 :1
kemo 2009

56. 2- Ventricular Tachycardia ( V-tach.)
It three or more PVC in arow
A whole strip with PVCs.
No P waves.
If there is no pulse, it is lethal
Always check the Pulse and BP
kemo 2009

57. Ventricular Tachycardia ( V-tach.)
Ventricle & a trial rate : ventricle rate 100 – 200beats /m
QRS shape & duration : duration 0.12 second or more .
P wave shape : very difficult to detect
P-R interval : very irregular if see p wave
Each P followed by a QRS
P: QRS ratio : more QRS then p wave
kemo 2009

58. Ventricular Tachycardia ( V-tach.)
Treatment
lidocaine
Synchronized cardioversion
kemo 2009

59. 3- ventricular Fibrillation
No P waves, No QRS, only electrical activity present.
Lethal, always check Pulse and BP
kemo 2009

60. ventricular Fibrillation
Ventricle rate ; greater than 300 per mint
Ventricle rhythm : irregular
QRS shape & duration irregular
kemo 2009

61. No electrical Activity ( Asystole )
No QRS, no electrical activity,
P waves may present.
No heart rate ,pulse
kemo 2009

62. Instant Feedback:
Treatment is usually required if there are more than six PVCs per minute. True False
kemo 2009

63. AV Blocks
AV block occur when the conduction of impulse through AV node decrease or stop
Prolonged P-R interval or more P waves than QRS
Block means DELAY.
Causes
Medication
heart & valvular disease
kemo 2009

64. Prolonged P-R interval
1- 1st Degree AV Block
It artial impulse conduct through AV node into ventricle are rate slower than normal
It looks like the sinus rhythm but with prolonged P-R interval..
Normal and identical P waves.
Each P is Followed by a QRS
Normal QRS.
P-R interval is 0.20 sec or more
P: QRS ratio : 1 :1
Prolonged P-R interval
kemo 2009

65. 2- 2nd Degree AV Block a- Mobitz I
Normal QRS.
Identical P waves.
P-R interval progressively prolongs until there is P not followed by a QRS
P without QRS
kemo 2009

66. 2- 2nd Degree AV Block a- Mobitz II
Identical P waves, Not every P is followed by a QRS.
When there is a QRS, it has to be preceded by a P wave
Atrial rate is regular.
Check BP immediately.
Every QRS preceded by a
P waves
Identical P waves
kemo 2009

67. 4- 3rd Degree AV Block ( Complete Heart Block )
No relationship between P waves and QRS complexes
Check the BP immediately
kemo 2009

68. instant Feedback:
In a third degree heart block, the P waves are "married" to the QRS complexes. True False
kemo 2009

69. In first degree AV block, the P-R interval is:
Instant Feedback:
In first degree AV block, the P-R interval is:
1-Greater than 0.20 seconds
2-Between 0.12 and 0.18 seconds
kemo 2009

70. Possible diagnostic findings
ECG: changes in heart rate, rhythm.
*Blood chemistry: electrolyte imbalance.
Nursing intervention:
Monitor pulse for irregular pattern or abnormally rapid or slow rate.
Observe for arrhythmias
continuous cardiac monitoring.
Assess cardiovascular, respiratory, and neurovascular status.
kemo 2009

71. Nursing intervention
Initiate cardiopulmonary resuscitation (CPR), if indicated, until other advanced cardiac life support
measures are available and successful.
Perform defibrillation early for ventricular tachycardia and ventricular fibrillation.
kemo 2009

72. Nursing intervention
Administer medications, oxygen, and I.V fluids, as needed.
Prepare for procedures, such as cardioversion
Monitor for predisposing factors (such as fluid and
electrolyte imbalance) and signs of drug toxicity, especially digoxin.
Monitor and record vital signs.
Maintain prescribed diet.
Maintain bed rest, until patient is stable.
Provide support to the patient and family.
kemo 2009

73. Any Questions ??//
kemo 2009

74. Thank you
kemo 2009