Basic Dysrhythmia Kamlya balgoon 2009

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

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Basic ECG kemo 2009

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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

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

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

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

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

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

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

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

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

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

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 60-100 bpm Normal QRS PR interval kemo 2009

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

2-Sinus Tachycardia kemo 2009

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

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

3- Sinus Bradycardia kemo 2009

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

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

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

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

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 60-100 bpm kemo 2009

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

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

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

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

Premature A trial Complex ( PAC) kemo 2009

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

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

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

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

3- Atrial Flutter ٍ Normal QRS F wave kemo 2009

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

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

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

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

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

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

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

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

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

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

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

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

Premature Ventricular Contraction ( PVC ) Unifocal kemo 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Any Questions ??// kemo 2009

Thank you kemo 2009