1. Welcome to ASATT Region 7 Educational Meeting
Patrick Hegge

2. Anatomy
Heart location and size

3. The electrocardiogram
Note: Do not use this illustration for measuring PR interval.

5. Conduction system review

6. Consists of:
Contraction of the atriums – P wave
Contraction of the ventricles –QRS Complex

7. The electrocardiogram
Note: Do not use this illustration for measuring PR interval.

8. Basic arrhythmia recognition
Rhythms that if you see on the monitor you will know and can help the surgical team.

9. Normal sinus rhythm (NSR)
P waves are normal and identical
P wave precedes each QRS, QRS for every P
PR intervals are constant
Heart rate is bpm

10. Sinus bradycardia
Same criteria as NSR except heart rate is less than 60 bpm

11. Sinus tachycardia
Same as NSR except heart rate is between bpm.
P waves are sometimes absent at higher rates.

12. A ventricular rhythm occurs when the SA and AV nodes are not firing or are too slow to be effective.

13. RULES FOR VENTRICULAR TACHYCARDIA (V Tach)
A LETHAL RHYTHM
  No P wave
QRS > seconds
Big and wide
Rate - fast > 150 PBM
Usually regular but can be slightly
irregular

14. Chest discomfort (angina) – feels like something heavy sitting on their chest.
Fainting (syncope)
Light-headedness or dizziness
Sensation of feeling the heart beat (palpitations)
Shortness of breath (dyspnea)
Note: Symptoms may start and stop suddenly. In some cases, there are no symptoms.
SYMPTOMS OF V TACH

15. V Tach
Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM?

16. Does it have a P wave? Is the QRS > 0.12 seconds?
Here’s another one
Does it have a P wave?
Is the QRS > 0.12 seconds?
Is it big and wide?
Is the rate > 150 BPM?

17. IDIOVENTRICULAR 20 to 40 BPM

18. last one Does it have a P wave? Is there a PR Interval?
Do you see a QRS?
(or do you see varied amplitude of possible QRS’s with no pattern)
Is there any regularity – or is it chaotic?

19. End
V Fib vs V Tach

20. Ventricular fibrillation
Rapid chaotic rhythm which lacks a pattern
Rate =>300 bpm ( bpm – DD)
Life threatening rhythm – call a code!

21. Asystole Either a straight line EKG or chaotic imprint
Life threatening – call a code!

22. Junctional Rhythms

23. Junctional Rhythms

24. Junctional rhythm is an abnormal heart rhythm resulting from impulses coming from an area of the atrioventricular node the "junction" between atria and ventricles.
The SA node is not working.

25. Rules for Junctional Rhythms
No P wave – or inverted P wave in lead II
Not 1:1 (if no P wave) can be 1:1 if inverted P wave
QRS tight ≤ 0.12
PR interval if there is one is between 0.12 and 0.20
Regular
< 40 BPM Idio Junctional
40 to 60 BPM Junctional Rhythm
61 to 99 BPM Accelerated Junctional Rhythm
> 100 PBM Junctional Tachycardia

26. Question Time
Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

27. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

28. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

29. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

30. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

31. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

32. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

33. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

34. Is there a P wave?
Is there an inverted P wave? If so, is it 1:1?
If there is a PR interval, is it between 0.12 and 0.20 seconds?
Is the QRS ≤ 0.12 seconds?
Is it regular?
What is the rate?

35. Rules for Junctional Rhythms
No P wave – or inverted P wave in lead II
Not 1:1 (if no P wave) can be 1:1 if inverted P wave
QRS tight ≤ 0.12
PR interval if there is one is between 0.12 and 0.20
Regular
< 40 BPM Idio Junctional
40 to 60 BPM Junctional Rhythm
61 to 150 BPM Accelerated Junctional Rhythm or Junctional Tachycardia

36. ATRIAL RHYTHMS

37. Atrial rhythm resembles sinus rhythm, but originates from a different atrial focus.
It can be recognized by the abnormal configuration of the p-wave.
An atrial ectopic rhythm is a rhythm where the impulse formation in the atrium is coming from the wrong place. (Ectopic means out of place or from the wrong place.)
We will discuss two types:
Atrial Fibrillation
Atrial Flutter

38. ATRIAL FIBRILLATION
Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body.
During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles)
of the heart.

40. Atrial fibrillation symptoms
A number of people have no symptoms. The most common symptom in people with intermittent atrial fibrillation is palpitations, a sensation of rapid or irregular heartbeat. This may make some people very anxious.
Many people also describe an irregular fluttering sensation in their chests.
Some become light-headed or faint. Other symptoms include weakness, lack of energy or shortness of breath (SOB) with effort, and chest pain.
The biggest complication of A Fib is a blood clot caused because the blood does not move quickly enough through the heart.

41. RULES FOR ATRIAL FIBRILLATION
(A-FIB)
No P wave
No PR interval
QRS is ≤ 0.12
Is regularly irregular
< 60 BPM still called A Fib
> 100 BPM - Rapid A Fib

42. A FIB DOESN’T ALWAYS LOOK THE SAME

43. Let’s start by asking some questions. Is there a P wave
Let’s start by asking some questions. Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib

44. Is there a P wave. Is there a PR interval. Is the QRS ≤ 0. 12 seconds
Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib

45. Is there a P wave. Is there a PR interval. Is the QRS ≤ 0. 12 seconds
Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib

46. Is there a P wave. Is there a PR interval. Is the QRS ≤ 0. 12 seconds
Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib

47. ATRIAL FLUTTER
Atrial flutter occurs when the electrical impulses take an abnormal path through the atria, typically circulating around the tricuspid valve in the right atrium.
The abnormal path of the impulses makes the atria contract very rapidly.
These rapid contractions are slowed when they reach the AV node often with every second or third contraction reaching the ventricle.
The heart beats in a regular rhythm, but it beats rapidly.

48. VENTRICULAR RHYTHMS

49. A ventricular rhythm occurs when the SA and AV nodes are not firing or are too slow to be effective.

50. RULES FOR VENTRICULAR RHYTHMS
No P wave
No PR interval
No 1:1
QRS is wide > 0.12
Usually regular although it can be slightly irregular
BPM – Idio ventricular
BPM - Ventricular
BPM Ventricular tachycardia (V tach)

51. Rules for Idioventricular Rhythms
No P wave
No PR interval
No 1:1
QRS is wide > 0.12
Usually regular although it can be slightly irregular
BPM – Idio ventricular

52. Ventricular Rhythm 40 – 150 BPM

53. Ventricular Tachycardia
Ventricular tachycardia (V-tach or VT) is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart.
This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death.

54. RULES FOR VENTRICULAR TACHYCARDIA (V Tach)
A LETHAL RHYTHM
  No P wave
QRS > seconds
Big and wide
Rate - fast > 150 PBM
Usually regular but can be slightly
irregular

55. V Tach
Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM?

56. Does it have a P wave? Is the QRS > 0.12 seconds?
Here’s another one
Does it have a P wave?
Is the QRS > 0.12 seconds?
Is it big and wide?
Is the rate > 150 BPM?

57. Does it have a P wave? Is the QRS > 0.12 seconds?
Last one
Does it have a P wave?
Is the QRS > 0.12 seconds?
Is it big and wide?
Is the rate > 150 BPM?

58. RULES FOR VENTRICULAR FIBRILLATION
V FIB - A LETHAL RHYTHM
 No P wave
Varied amplitude of QRS or indiscernible
No PR interval
No regularity – chaotic

59. Time to ask some questions
Does it have a P wave?
Is there a PR Interval?
Do you see a QRS?
(or do you see varied amplitude of possible QRS’s with no pattern)
Is there any regularity – or is it chaotic?

60. More practice Does it have a P wave? Is there a PR Interval?
Do you see a QRS?
(or do you see varied amplitude of possible QRS’s with no pattern)
Is there any regularity – or is it chaotic?

61. (or do you see varied amplitude of possible QRS’s with no pattern)
Torsades de pointes
Does it have a P wave?
Is there a PR Interval?
Do you see a QRS?
(or do you see varied amplitude of possible QRS’s with no pattern)
Is there any regularity – or is it chaotic?

62. last one Does it have a P wave? Is there a PR Interval?
Do you see a QRS?
(or do you see varied amplitude of possible QRS’s with no pattern)
Is there any regularity – or is it chaotic?

63. End
V Fib vs V Tach

64. Any Final Questions…………………………………………