Download - Name That Rhythm EMT-Intermediate W06
![Page 1: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/1.jpg)
Name That Rhythm
EMT-Intermediate
W06
![Page 2: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/2.jpg)
![Page 3: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/3.jpg)
![Page 4: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/4.jpg)
![Page 5: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/5.jpg)
![Page 6: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/6.jpg)
![Page 7: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/7.jpg)
![Page 8: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/8.jpg)
![Page 9: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/9.jpg)
And you thought we wouldn’t review…..
![Page 10: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/10.jpg)
Heart A & P
• Location• Pieces, Parts• Important
Vessels• Electrolyte Role• Pulling apart
waveforms
![Page 11: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/11.jpg)
Valves & Vessels
![Page 12: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/12.jpg)
Review of Important Vessels
![Page 13: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/13.jpg)
The Components
• SA Node• Internodal
Pathways• AV Junction• AV Node• Bundle of His• L & R Bundle
Branch• Purkinje Network• Purkinje Fibers
![Page 14: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/14.jpg)
The Route
![Page 15: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/15.jpg)
Sino Atrial Node
• The Natural “Pacemaker”– Connects directly
to atrial fibers
• Fires 60-100 times per minute
• Wavelike Atrial Depolarization• The P-Wave
P-Wave
P-R Interval
Q-Wave
.04 Sec .04 Sec .04 Sec .04 Sec .04 Sec
0.20 Seconds per 5 Boxes
![Page 16: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/16.jpg)
AV Junction
• Receives impulses from SA Node via the Atrial Cells– An electrical funnel– Impulses hit at various times– Causes delay
• PR-I
– Susceptible to blockage
• Path from A to V– Delivers impulse to the AV
Node
![Page 17: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/17.jpg)
Atrio-Ventricular Node
• Lies between the Atria and Ventricles
• Collects impulses from above
• Stimulates Ventricles
• If unstimulated– Intrinsic rate 40-60
![Page 18: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/18.jpg)
Bundle of His / Left and Right Bundle
Branches• Distributes Impulses from
the Node• “The Ventricular
Messengers”
![Page 19: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/19.jpg)
Purkinje Network/Fibers
• Direct connection with ventricular tissue
• Intrinsic rate 20-40 if unstimulated
P-Wave
P-R Interval
QRS Complex
T-Wave
![Page 20: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/20.jpg)
Electrical Conduction System
• Sympathetic-Thoracic/Lumbar Nerve
– Norepinephrine
• HR, Contractility
• Parasympathetic-Vagus Nerve
– Acetylcholine
• HR (Valsalva)
• Chronotropic-HR
• Inotropic-Contraction
![Page 21: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/21.jpg)
Electrical Conduction System
• Na+ in & K+ out = Depolarization• K+ in & Na+ out = Repolarization
– Imbalances in K+ or Na+
• Effects Automaticity & Conduction• Hypo & hyperkalemia affects irritability
• Ca++ - Depolarization and Contraction– Affects Contractility– Hypo & Hypercalcemia effects contractile
force
![Page 22: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/22.jpg)
Phases
• Phase 0 – Rapid Depolarization– Reached max potential -90mV– Fast Na+ Channels Open– Cell now positive +25mV
• Phase 1 – Early Rapid Repolarization– Fast Na+ Channels Close– K+ still being lost– MP approaching 0mV
• Phase 2 – Prolonged Slow Repolarization– Plateau Phase– Muscle finishing contraction– Beginning to relax– MP staying close to 0mV
![Page 23: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/23.jpg)
Phases
• Phase 3 – End of Rapid Repolarization– K+ returns to inside– Cell returns to -90mV– Almost ready
• Phase 4– Na+ - K+ Pump turns on
• Sends Na+ out
• Brings K+ in
• Ready to do it all over again now
![Page 24: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/24.jpg)
Refractory PeriodsExcuse me!!! I hate to interrupt again, but, who
cares???
• Absolute Refractory Period– Polarity of cell prohibits
depolarization• Relative Refractory Period
– Cell is returning to ready state for depolarization
– Impulse now is BAD!!!
• R on T Phenomenon– Causes VT & VF– Treated with defibrillation
• Can be caused by:– Frequent PVC’s– EMT-P not pushing the
“sync” button
![Page 25: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/25.jpg)
QRS Complex
![Page 26: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/26.jpg)
Lead Considerations
• $25,000 mVoltmeter– Lead Views:
• 1 – Lateral• 2 – Inferior• 3 – Inferior
![Page 27: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/27.jpg)
The Six Step Approach
• What is the Rate?
• Is the Rhythm Regular?
• Are there P-Waves?
• Is the P-R Interval Normal?
• Is the QRS Complex Normal?
• Is There a P-Wave for Every QRS?
![Page 28: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/28.jpg)
Describe What You’ve Found!!!
• IN GENERAL (underlying rhythms)!!!• What are the abnormalities?• Does it originate in the Sinus Node?• Does it follow through from the Atria
to the ventricles? Are there abnormal delays?
• What are the exceptions to the underlying rhythm? (Describe those also)
![Page 29: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/29.jpg)
Normal Sinus Rhythm
• Rate: 60 - 100• Regularity: Very• P-Waves: Present and Normal• P-R I: 0.12-0.20 sec• QRS: 0.04-0.12 sec and Normal• Married: 1 P: 1 QRS, no extras or shortages
![Page 30: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/30.jpg)
Sinus Arrhythmia
Rate: 60 - 100 Regularity: Irregular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages
![Page 31: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/31.jpg)
Sinus Tachycardia
Rate: Over 100 Regularity: Regular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages
![Page 32: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/32.jpg)
Sinus Bradycardia
Rate: Less than 60 Regularity: Regular P-Waves: Present and Normal P-R I: 0.12-0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages
![Page 33: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/33.jpg)
Atrial Fibrillation
Rate: Usually tachy Regularity: Irregular (Irregularly irregular) P-Waves: Not Discernible P-R I: Undeterminable QRS: 0.04-0.12 sec Married: Undeterminable
![Page 34: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/34.jpg)
Atrial Flutter
Rate: Usually tachy Regularity: Atria Regular
• Ventricles May be Irregular
P-Waves: Sawtooth Pattern 2:1, 3:1, 4:1... P-R I: 0.12-0.20 sec on conducting beat QRS: 0.04-0.12 sec Married: P-waves outnumber QRS
(Picket fence)
![Page 35: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/35.jpg)
(Paroxysmal) Supra Ventricular Tach
Rate: 140-220 Regularity: Regular P-Waves: Usually falls within the QRS-T
complex (not visible) P-R I: Shorter than 0.12, or absent QRS: 0.04-0.12 sec and Normal Married: Undeterminable
![Page 36: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/36.jpg)
SVT
• WPW– Usually based on Hx.– Delta wave on Q– Shortened PR-I– No Verapamil – Accessory Path use
increase
![Page 37: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/37.jpg)
1st Degree Heart Block
Rate: 60 - 100 Regularity: Very P-Waves: Present and Normal P-R I: Longer than 0.20 sec QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or
shortages
![Page 38: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/38.jpg)
2nd Degree Heart Block (Type 1) Wenkebach
Rate: Can be Normal, or usually brady Regularity: Irregular P-Waves: Present and Normal P-R I: Lengthens until beat is dropped QRS: 0.04-0.12 sec and Normal Married: P-wave present on conducting beats,
increased delay causes missed QRS
![Page 39: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/39.jpg)
2nd Degree Heart Block (Type 2)Mobitz II
Rate: Less than 60 Regularity: Irregular P-Waves: Present, 2:1, 3:1, 4:1 P-R I: 0.12-0.20 sec on conducting beat QRS: 0.04-0.12 sec, may begin to widen Married: P-wave for every QRS and extras
depending on conduction ratio
![Page 40: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/40.jpg)
3rd Degree Heart Block (CHB)Complete Heart Block
Rate: Ventricular Rate 40-60 Regularity: Atria-Regular
• Vent-Regular P-Waves: Present and Normal P-R I: Atria independent of Ventricles QRS: Usually greater than 0.12 sec Married: P-waves completely unrelated to QRS
Complexes.
![Page 41: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/41.jpg)
Complete Heart Block
![Page 42: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/42.jpg)
Junctional Rhythm
Rate: 40-60 Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS, sometimes not
visible
![Page 43: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/43.jpg)
Junctional
![Page 44: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/44.jpg)
Junctional Accelerated Rhythm
Rate: 60-100 Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS,
sometimes not visible
![Page 45: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/45.jpg)
Junctional Tachycardia
Rate: 100-140 Regularity: Regular P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent QRS: 0.04-0.12 sec Married: P-wave for every QRS,
sometimes not visible
![Page 46: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/46.jpg)
Ventricular Tachycardia
Rate: 100-220 Regularity: Regular P-Waves: None P-R I: None QRS: Greater than 0.12 sec Married: NO
We’ll look at Torsades de Pointes in Lab
![Page 47: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/47.jpg)
Ventricular Tachycardia
![Page 48: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/48.jpg)
Ventricular Fibrillation
Rate: No ventricular rate Regularity: Irregular P-Waves: No P-R I: No QRS: No, unorganized ventricular baseline Married: No
![Page 49: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/49.jpg)
Ventricular Fibrillation
![Page 50: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/50.jpg)
Asystole
Rate: 0 Regularity: N/A P-Waves: None P-R I: N/A QRS: None Married: No (verify a second lead)
![Page 51: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/51.jpg)
Asystole
![Page 52: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/52.jpg)
Agonal / Idioventricular
Rate: 20-40 Regularity: Irregular P-Waves: None P-R I: N/A QRS: Wider than 0.12 sec Married: NO (a dying heart)
![Page 53: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/53.jpg)
Idioventricular
• Less regular than this!
![Page 54: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/54.jpg)
Exceptions / Disruptions
• Premature Ventricular Contractions
• Premature Atrial Contractions
• Bundle Branch Blocks
• Pacer Considerations (Atrial, Ventricular or Both)
![Page 55: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/55.jpg)
Premature Ventricular Contractions
• Wide, Bizarre QRS Complex• Always identify the underlying rhythm
first• Can appear in couplets, triplets, short
runs of V-Tach, bigeminy and trigeminy
• Can be uni-focal or multi-focal• Caused by random firing within the
ventricles• Not accompanied by a P-wave
![Page 56: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/56.jpg)
PVC’s
![Page 57: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/57.jpg)
PAC’s
• P-QRS Complex appearing in an unexpected location
• Caused by a stimulus from within the Atria, but not from the SA Node
![Page 58: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/58.jpg)
PJC
![Page 59: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/59.jpg)
Bundle Branch Block
• Any rhythm having a BBB will have a widened twin peaked R-Wave
![Page 60: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/60.jpg)
Paced Rhythms
• Patients may have various types of pacemakers
• Atrial
• Ventricular
• Both
• Vertical spike on monitor is an indicator
![Page 61: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/61.jpg)
Paced Rhythms Various
![Page 62: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/62.jpg)
Artifact
• 60 Cycle Interference
• Loose Leads/Moving Ambulance
![Page 63: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/63.jpg)
In Summary
• Really Cool Physiology!!!
• GENERAL RULES to Interpretation– Applicable to 3 – lead monitoring
• Practice, Practice, Practice…
• Remember the rules, NOT how it looks coming from one patient or one rhythm generator!!!
![Page 64: Name That Rhythm EMT-Intermediate W06](https://reader035.vdocuments.net/reader035/viewer/2022081514/56649e4c5503460f94b40d85/html5/thumbnails/64.jpg)
Sources – In order of preference
• Many of the pictures and info from:– Flip and See ECG, 2nd Edition
• Cohn/Gilroy-Doohan– A great resource
– Paramedic Paramedic Textbook, Revised 2nd Edition
• Mick J. Sanders, Mosby
– ECG’s Made Easy, 2nd Edition• Barbara Aehlert, RN, Mosby
– Basic Dysrhythmias, Interpretation and Management, 3rd Edition
• Robert J. Huszar, Mosby