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Heart Blocks

Heart Blocks

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Published by Mark Hammerschmidt

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Published by: Mark Hammerschmidt on Aug 01, 2008
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05/03/2013

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Heart Blocksfrom
 Mark Hammerschmidt, RN
Hi all. Yet another one, which occurred to me that I should do about two weeks ago, when apatient was doing some pretty strange things on the monitor. As usual, please remember that thisis not meant to be an official reference, but is supposed to represent the information that apreceptor would pass on to a new orientee in the unit. Please get back to me if things aren’t clear,have been left out, or are just plain wrong, and I’ll fix them up right away. Thanks!1-What is a heart block?2-What exactly is being “blocked” in heart block?2-1- The key idea: all of the time, some of the time, none of the time…2-2- It can not be that simple…3-Why do heart blocks happen?4-What are the three types, or degrees of heart block? What is a “dropped beat”?4-1- A normal rhythm for reference.4-2- First degree heart block.4-3- Second degree heart block.4-3-1- Second degree, type 1: Wenckebach/ Mobitz 14-3-2- Second degree, type 2: Mobitz 24-4- How I tell them apart?4-5- Third degree (complete) heart block.5-A puzzler6-What is the treatment for heart block?7-Where can I learn more about pacemakers?
1-What is a heart block?
Heart block is a kind of arrhythmia, usually caused by ischemia or an MI. There are three kinds,or degrees of heart block, and although sometimes people get confused about them, actuallythey’re pretty simple to understand.
2-What exactly is being “blocked” in heart block?
The signal from the SA node is trying to get to the AV node, and it’s being slowed down, or blocked altogether – it’s having a hard time getting through. The result is that the SA signal goingthrough the atria makes a normal P wave, but if that signal doesn’t trigger a response from the AVnode, no QRS gets produced – so you’ll see
a P wave that isn’t followed by a QRS
. The QRSrepresents ventricular depolarization – so what? So what is: no depolarization, no contraction, noblood pressure!
 
The signal is trying to get from here…To here…
www.arrhythmia.org/ general/whatis/
2-1- Here’s the key idea - the signal is either getting through:
1-Allthe time (but taking a little longer than usual).2-Some of the time.3-None of the time.Got that? All, some, or none of the time. And see, those are the three kinds, or degrees of heartblock: first, second, and third degree. All, some, or none.
2-2- It can not be that simple…
Sure it can. This is one of those things that people get scared of, and they build it up in their heads as if it were this enormous mysterious thing, like running a nuclear reactor. (When shelearns about something new, Jayne always says: “Well, is it easier or harder than a ventilator?”)
3-Why do heart blocks happen?
Heart blocks usually happen when the patient is having ischemia, or an MI. The blood supply tothe nodes is interrupted, or reduced, and they become unhappy – but at least in this regard, theydo it in recognizable ways.CCU nurses – what kind of MI or ischemia commonly produces heart blocks?
4-What are the three types, or degrees of heart block? What is a “dropped beat”?
4-1- First of all, here’s a normal strip for reference:Right – a quick bit of review. See the P wave? Now, see where it meets the QRS? Actually, thatfirst upright part of the QRS is the R wave - there’s no Q-wave here. (There’s more about Q
2
 
waves and what they mean in the faq on “Reading 12-lead EKGs” – basically you don’t want tosee them, because they mean the patient has gotten into the tissue necrosis stage of an MI.)So – no Q waves here. Ok… so the first, upright move of the QRS complex is the R wave, right?So the measurement from the beginning of the P wave, until it hits the R wave, is called (surprise)the P-R interval. A normal PR interval is supposed to be no more than .20 seconds – which isfive little boxes, or one big box on the EKG paper. Calipers definitely help here.Now. Remember what the PR interval actually is? That’s to say, not how long it is, but what itactually means? It shows the movement of an electrical depolarization signal along the paththrough the atria, from the SA node in the right atrium, to the AV node at the atrioventricular  junction.Say what?Remember, the signal is trying to travel from the SA node to the AV node, and from there it goeson southward to make the QRS complex as it goes through the ventricles.If the PR interval is normal, then the signal is travelling from the SA node to the AV node in anormal amount of time.Okay so far? Onwards…
4-2- First degree heart block.
Right – here we are in first-degree heart block. Look at the PR interval now – see how long it is?Longer than .20 seconds, anyway. So that means that it’s taking a longer-than-normal time for thesignal to go from node to node: SA to AV. It gets there every time, and goes on through the AVnode to make a QRS – and therefore a ventricular contraction - but it takes longer than it’ssupposed to.
4-3- Second degree heart blocks:
This is where a lot of the confusion comes in. It really isn’t all that hard. Look at the P-waves inthe wenckebach strip below. Some of them have
no QRS
after them.
This is what’s meant by a“dropped beat”.
The SA node fires off a signal down the conduction path to the AV node, but theAV node doesn’t respond by starting a QRS – in fact, nothing happens. The SA node justcontinues shooting off signals at it’s own rate, and some of the time the signals get through theAV, and some of the time they don’t. If you’re lucky, enough of the beats are conducted to theventricles that your patient can still make a blood pressure. If you’re not lucky…what would youdo for that patient?Next confusing bit: there are two kinds of second degree heart block. And just to make thingsreally interesting, the first of the two kinds has two different names. But only the first. Just in caseit wasn’t complicated enough already.
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