Basic Dysrhythmia

Kamlya balgoon2009

Objectives to :-• understand the Basic ECGunderstand the meaning of

Dysrhythmiadescribe 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

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Basic ECG

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Wave ,complex & intervals P waverepresents 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

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Wave ,complex & intervals QRS complexRepresents

ventricular activation

Represent ventricular muscle depolarization

It is normal 5 mm in higher & 0,12 second in duration

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Wave ,complex & intervalsT wave represent

ventricle muscle depolarization

U wave represent

depolarization of purkinje fibers

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Wave ,complex & intervalsPR 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

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Wave ,complex & intervalsST Segment represent early

ventricle muscle depolarization

QT Interval represent total

time of ventricle muscle depolarization & depolarization

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Normal Conduction pathwaysSA Node (60 -100)AV Node (40 – 60)Ventricles (20 40)

Tachycardia >100Bradycardia < 60

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ECG - AnalysisUse a consistent method to analyze an

ECGRateRhythmAssess P waveAssess P wave to QRS ratio 1=1Interval durationIdentify abnormalities

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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 irregularkemo 2009

ArrhythmiasOriginates from the SA node = SinusOriginates from the atria = atrialOriginates from the AV node = nodal or

JunctionalOriginates from the ventricles ( high ) =

IdioventricularOriginates from the ventricles (myocardial

tissue ) = VentricularImpulse delay in the AV node = BlockNo impulse = Asystole

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Sinus Arrhythmias1- Sinus Rhythm ( the only normal one )

RegularP-R interval NormalNormal identical P wavesEach P followed by a QRSNormal QRSRate 60-100 bpm

PR interval

Normal QRS

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2-Sinus TachycardiaVentricle & a trial rate ; greater than

100Ventricle & a trial rhythm : RegularQRS shape & duration : normal P wave shape normal P-R interval normal between 0,12 & o,20

second Normal identical P wavesEach P followed by a QRSP: QRS ratio : 1:1kemo 2009

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2-Sinus Tachycardia

2-Sinus TachycardiaCauses

Normal physiologic with increase cardiac out putShock exerciseanxiety feverAnemia Medication sympathomimetic & parasympatholytic

(atropine ,epinephrine )Treatment Treat cause Medication ( antipyretics , beta blockers )

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3- Sinus BradycardiaVentricle & a trial rate : less than 60Ventricle & a trial rhythm : RegularQRS shape & duration : Normal P wave shape Normal P-R interval Normal between 0,12 &

o,20 second Normal identical P wavesEach P followed by a QRSP: QRS ratio : 1:1

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3 -Sinus Bradycardia

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3 -Sinus BradycardiaCauses

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 )

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Instant Feedback:

Sinus bradycardia is always abnormal and must be treated.TrueFalse

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Instant Feedback: Sinus tachycardia is a normal

response to pain. True

False

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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

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Sinus arrhythmiaIt occurs impulse irregular rhythm Rate increase with inspiration & decrease

with expiration It include heart disease ( valvular disease )P-R interval NormalNormal identical P wavesEach P followed by a QRSNormal QRSRate 60-100 bpm

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

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A trial dysrhythmias Premature a trial complexA trial FibrillationA trial FlutterAtrial Tachycardia

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A trial dysrhythmias 1- Premature a trial complex An electrical impulse starts in atrium

before next normal impulse of SA node

Causes Caffeine , alcohol , nicotine

Treatment Treat causes

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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 QRSP: QRS ratio : 1:1

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Premature A trial Complex ( PAC)

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2 -A trial Fibrillation Atrial fibrillation causes

rapid ,disorganized & of artial muscle

Unequal R-R = irregular

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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

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Atrial FibrillationVentricle & a trial rate : a trial rate 300 –

600 Ventricle rate 120 to 200 in untreated a

trial fibrillation Ventricle & a trial rhythm : highly irregularQRS 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 QRSP: QRS ratio : many :1

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Unequal R-R = irregular

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Atrial Fibrillation

3 -Atrial Flutter

�ٍF wave Normal QRS

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2 -Atrial FlutterCauses Heart disease ( valvular disorder ,

Rheumatic & ischemic heart disease )

Treatment Adenocard Diltazem

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Atrial FlutterIt 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

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Atrial FlutterVentricle & 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 irregularQRS 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 QRSP: QRS ratio : 2 :1 , 3 :1, 4 :1kemo 2009

Instant Feedback: In atrial flutter, instead of P waves there is

commonly a "sawtooth" pattern seen. True

False

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Instant Feedback:The hallmark sign of atrial fibrillation is:

1) An irregulary rhythm2) A sawtooth pattern

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4- Atrial TachycardiaSome times it is called

Supraventricular Tachycardia ( SVT ).

Very fast rate > 150 bpm.Normal QRS.No P wave .or very difficult discern

No P waveNormal QRS

Very fast

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4 -Atrial TachycardiaSome times it is called

Supraventricular Tachycardia ( SVT ). Very fast rate > 150 bpm.Normal QRS.No P wave.

No P waveNormal QRS

Very fast

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4 -Atrial TachycardiaCasesIschemia Hypoxia Heart failure

Treatment Adenocard Diltazem Synchronized cardioversion

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

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Ventricular Rhythms Premature Ventricular Contraction

( PVC )Ventricular Tachycardiaventricular Fibrillation ( V-tach.) No electrical Activity ( Asystole )

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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

PVCs … continued

Multifocal ( different shape )

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Premature Ventricular Contraction ( PVC )

Unifocal

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PVCs … continued

3- Couplets ,tow in arow pair

Couplets

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PVCs … continued4- Bigeminy every other beat is PVC

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PVCs … continued5- Trigeminy every third complex is PVC

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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 QRSP: QRS ratio : 0 :1 , 1 :1

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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 lethalAlways check the Pulse and BP

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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 QRSP: QRS ratio : more QRS then p wave

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Ventricular Tachycardia( V-tach.) Treatment lidocaineSynchronized cardioversion

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3- ventricular FibrillationNo P waves, No QRS, only electrical activity present.

Lethal, always check Pulse and BP

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ventricular FibrillationVentricle rate ; greater than 300 per mint

Ventricle rhythm : irregularQRS shape & duration irregular

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No electrical Activity( Asystole )

No QRS, no electrical activity, P waves may present.No heart rate ,pulse

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Instant Feedback: Treatment is usually required if

there are more than six PVCs per minute.TrueFalse

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AV BlocksAV block occur when the conduction of

impulse through AV node decrease or stop Prolonged P-R interval or more P waves

than QRSBlock means DELAY.

Causes Medication heart & valvular disease

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1 -1st Degree AV BlockIt 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 QRSNormal QRS.P-R interval is 0.20 sec or moreP: QRS ratio : 1 :1

Prolonged P-R intervalkemo 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

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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

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

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instant Feedback: In a third degree heart block, the P waves are

"married" to the QRS complexes.TrueFalse

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Instant Feedback: In first degree AV block, the P-R interval is:1-Greater than 0.20 seconds2-Between 0.12 and 0.18 seconds

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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 arrhythmiascontinuous cardiac monitoring.Assess cardiovascular, respiratory, and neurovascular status.

Possible diagnostic findings

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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.

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Nursing intervention

Nursing interventionAdminister 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.

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Any Questions ??//

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Thank youkemo 2009