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ul t Ad s sic Ba thmiapital y ly Cross Heors2011 srh Ho Septemb N MSN Dy R 7 ile y Ba

usan S

Cou rs e P l an

Two d 8 Mod ays Practi ules Geniu ce


The D ow ntow Duc n k He ro

As the Story Starts.

Something really amazing happened in Downtown Spokane this week& I had to share the story with you. Some of you may know that my brother, Joel, is a loan officer at Sterling Bank. He works downtown in a second story office building, overlooking busy Riverside Ave. Several wks ago he watched a mother duck choose the cement awning outside his window as the uncanny place to build a nest above the sidewalk. The mallard laid10 eggs in a nest in the corner of the planter that is perched over 10 ft in the air. She dutifully kept the eggs warm for wks& Monday afternoon all of her10 ducklings hatched!

ll ed a the rri l wo t how uck Joe t nigh ma d to ge momgoing ies wasse bab their , tho ely off busy an saf ch in a , urb per ntown nt to dowironme ter, enve to waically tak ich typin the wh pens s of a hap 48 hr hing. g, 1st k hatc ornin duc sday m to Tuel came atchedk Joe rk& w er duc wo moth e her the ourag the ch enc ies to he per to bab e of t intent edgh the m how wit w the ff! sho ump o to j

n rn g Tur ng Tu . ockin . ocki e nt s A Sh e nt s A Sh of Ev of Ev

The mother flew down below& started quacking to her babies above. In his disbelief Joel watched as the 1st fuzzy newborn toddled to the edge& astonishingly leapt into thin air, crashing onto the cement below. My brother couldn't watch how this might play out. He dashed out of his office& ran down the stairs the sidewalk where the 1st obedient duckling was stuporing near its mother from the near fatal fall.

Was Was yone yone ied Ever Ever ried Worr Wor

g g i n ki n i n ki n k Th k Th Quic Action Quic Action an d an d

he p. T du oke ckling l lo du Joe g 2nd gettin mp! u wasdy to j y rea quickl nder He ged u g dod awnin theile the uck wh ther d at mo cked qua & the ove. him ies ab one , babthe 2dplunge As k the ed too l jump Joe ward&with for ght it ands cau bare hhit the his ore it afe& bef ent. S set it cemnd, he r southe othe , by mma& ibling mo nned s ering stu l recov ainful stil m its p fro p.

t he y1 ies 1b ab to b ued in tin con p to jo us jum r anxio w. thei ily belo fam time h E a c hi d Joel er the t und i ng j us t awneach ou of to r e nick in th as the time ling k d uc e i t s he mad -fall. T free ntown dow walk side e to a cam dstill! stane after Tim , Joel t i me a b l e t o was h the 8 catc aining rem t them & seheir by t roving

a a Dram Dram The The s s i nu e tinue Cont Con

s oms oom er Lo ger L in Dang Again Dan Aga

At this point Joel realized the duck family had only made part of its dangerous journey. They had 2 full blocks to walk across traffic, crosswalks, curbs &pedestrians to get to the closest open water, the Spokane River. The on looking office secretaries then joined in,& hurriedly brought an empty copy paper box to collect the babies. They carefully corralled them, with the mother's approval, & loaded them up into the white cardboard container. Joel held the box low enough for the mom to see her brood. He then slowly navigated through the downtown streets toward the Spokane River, as the mother waddled behind& kept her babies in sight.

e theyhed th As eac he r t ver, er ri th & mo k overim, too sed h pas ping jum the into r, rive cking t quadly. A 's lou water the e, the edgrling ce Ste k offi Banff thene sta ed th tipp & boxped hel pherd s she babie e the ard tho tow er& t wat ir the ther r mo er thei ou aft entur advde. i

he he in g t in g t Lead Lead Way Way

g arlin d l10 lings Al it uck made d ly safe the into r& e wat led up d pad ly to . nug a duck s m e momsaid th n i Joel swam mom s, k le circ ng bac i look rd the k n a tow ing ba m bea ers, k wor dly if rou ing as p ck qua , 'See to .. y ... it! sa l d

n on n on in g I i n g I o al Clos Goal Clos th e G th e

ry & ry & Victo Victo ks! ks ! Than Than

You are probably thinking What in the world does this have to do with this class?

What Have Ducklings Got to do with Dysrhythmias?

Sometimes you can see things

coming, and sometimes you cant. Recognizing the problem is the first step and then Whats important is the action you take. In the end, you could make a big difference and even save some lives!

ing view he Re t t i on nda Fou

Module I:
A&P and Electrophysiology

Obje c tive s

Car di o Fact oi d s

Retrieved from:

Th e H ea rt

A nat omy of t h e Hea rt

i gh t atriu rece m deoxives bloo ygenat ed d. The righ pum t vent the ps the bricle lood The lungs. to left v entr pum ps th icle the rest e blood of th e bo to dy.

The A tria rece bloo ive The V d. entr icles the The r blood. pump

A nat omy of t h e Hea rt

sepaterarte from rates t rial sep he a tum the The inter ventri tria cles sept vent . vent um sepricular Righ ricles. arates t sid the e of low hear pres Pulm sure p t = o ump systnary cir Left cula side em tory pres of he sure a Syste pumrt = high p

T h e in

m syst ic circu em lat


Crank Up the Gray Matter!

What % of the blood volume of the ventricles flows right through the atria and into the ventricles before the atria even contract?

Wh o Kn ew ?

The othe 30% r fills whe n th atria e cont ract .

70% !

What is this phenomeno n known as?

ial Atr ick K

What is the typical volume of the ventricle?

150 milliliters

much of this volume is ejected on ventricular contraction ?

Normally 50% or about 7080 milliliters

What is this phenomenon volume of blood moved out of the heart known as?



What is this percentage of volume ejected out of the ventricles known as?

Ejection Fraction or EF

50% is the normal EF for an adult person. At what percentage do we say a person has impaired ventricular function?

40% or less

Di a s tole /Sys tol e

Retrieved from:

Get ti ng f rom to T he re Her e a nd Th Bac k e Co ro na ry Arte ri es

Retrieved from:

The Right Coronary Artery

Aehlert, B. (2006). ECGs Made Easy. 3rd ed. Mosby Elsevier: St. Louis. p.17.

Left Coronary Artery: Left Anterior Descending (LAD)

Aehlert, B. (2006). ECGs Made Easy. 3rd ed. Mosby Elsevier: St. Louis. p.17.

Left Coronary Artery: Left Circumflex

Aehlert, B. (2006). ECGs Made Easy. 3rd ed. Mosby Elsevier: St. Louis. p.17.

Rate both i s af and the Sym fected Divis Parasym pathet by ions path ic Spec etic i al p . chem ressu the ical se re and c alert irculatonsors wi Nerv the Au ry syste thin t actio ous Sys onomic m tem For e n. to ta xam ke p l e, have to th we don incre asin ink abo t rate whe g our he ut pres sure n our bl art reas on. I drops f ood auto o mat ts done r any icall y for us .


Th Go e Be Th e A es O a t Ne rv o ut o n u s no m Sy ic ste m

Term s to Know

Chronotropy refers to heart rate

Slower HR = negative chronotropy Faster HR = positive chronotropy

Inotropic effect refers to a change myocardial


Positive inotropic effect = increase in contractility Negative inotropic effect = decrease in contractility

Stimulation constricts vessels in skin, cerebral and visceral circulation

Beta-receptor - 2 Types
Beta 1 Found in the heart Stimulation results in positive chronotropic effect, positive inotropic effect, and irritability of cardiac cells Beta 2 Found in lungs and skeletal muscle blood vessels Results in dilation of the smooth muscle of the bronchi and blood vessel dilation

Sy m pat (Adr h eti en er c gic) Div Fig h t or Fligh i sio n t

Located in coronary arteries, renal,

Par asy mp Fe ed Div ath a nd Bre isio et ic ed o r R n es
ta nd Di g es t

Slows the rate of firing from the SA node Slows the conduction through the AV node Decreases the strength of atrial contraction Can cause a small

stimulation primarily results in an inhibitory effect on the heart rate

Overall negative

decrease in the strength of ventricular contraction

chronotropic effect on the heart; minimal negative inotropic effect

Elec tro p hys i ol og y

s to th e cond uctio electri the hear n syste cal m of t an indu d ho c es w it myo cont card ract ility ial Two typ e cells s of ca rdiac



el l s tha whe t contra Pace n sti mula ct mak er ce ted l ls Spon tane gene ously elec rates th e t that rical imp s u work timulat lses e ing c ells the

ing c e lls C

Retrieved from:

Ca r d i ac Ac ti on P o te ntia l

Electrolytes are capable of carrying charged ions The primary electrolyte

within the cells is Potassium (K+) Sodium (Na+) is the primary electrolyte outside the cell. It is the movement of these ions across the cell membrane which creates the electrical stimulus when the ionic charges are exchanged

Card i ac A c tion Pot e ntia l

iffer ence char i ges acro n ionic cell mem ss th know e bran e is n as This volta volta ge. ge i s mea sure d by an E CG . takin g The
wa v repr eforms e chan sent the g as th es in v oltag e el e mo v e e ac ctrolyte ross s cell mem the bran es.

The d

Card i ac A c tion Pot e ntia l


hate prot eins s and the cell remain cann as th in ot p the ass ey cell mem through Thes bran e mo e le n
egat c ively ules are char ged

rest, the cell resti the nor is at the ng state mal c char ell is ne within ged. gativ ely

Polarization is when
Card i ac A Pote ction n ti al
the inside of the cell is more negatively charged as compared to the outside.

This is the normal

resting state of the cardiac cell.

Depolarization is
Ca rd iac A c tio n Po te n ti al

when the positive ions flood the cell and cause its charged state to be more positive as compared to the outside of the cell.

The P wave on an

ECG represents the depolarization of the atria.

The Q
Card i ac A Pote ction n ti al


com RS plex repr e depo sents of th larizat the ion e vent ricle s.

NOT arizato AS m THE SAn is cont yocard ME ract i al ion.

Cardiac Action Potential

is the Repolarization cell return of the

C ar d iac Pot Ac ti ent on ia l

to its normally negatively charged state.

Repolarization occurs rapidly

after the influx of positively charged ions go into the cell (depolarization).

a occu rizatio oute rs fromn inne rmost the of th rmost l to Unti e heartayers l the . repo cell cann larized is stim ot be , it ulate Th e S-T s d agai n. and e gm repr T wave ent vent esent repo ricular the larizati ECG on o n


Card i ac A Pote ction n ti al

Cardiac Action Potential

4 Resting state of the cell (Polarized) 0 - Rapid Depolarization of the cell 1 Early repolarization 2- Plateau phase permits the cardiac muscles to contract for an increased time period 3- Rapid repolarization 4 Resting state

How it looks on the ECG

Ca rd iac C ell Prop e rtie s

Automaticity Excitability (Irritability) Conductivity Contractility

Aehlert, B. (2006). ECGs Made Easy. 3rd ed. Mosby Elsevier: St. Louis. p.36.

Auto mat ic it y

The a

bility card o iac c f the gene ell to elec rate an trica l imp with out first ulse stim bein ulate g outs d fro ide i tself m .

bility card of th ia c c e resp e ond ll to to a stim ulus outs f ide i rom This tself . can chem be ele ctric ical al , mec or h an i cal i natu n re an by a ll ca d is sha rdiac red cells .

The a

Ex ci ta b i l it y

Co nd uc tiv it y

bility card o iac c f the rece ell to i ve a impu n e le tran lse and ctrical smit itsel f to it from an o t her cell All c ardia c ce this ll s c an d o

The a

The ability of the cell to

Con t ra c ti li ty

be able to shorten and cause muscle contraction

This characteristic is
specific to cardiac cells

Refr ac to rin e ss

Re fers to h ow l cells o ng n ee d afte to re the r de co v e pola and r rizat befo ion able re th e stim to respo y are ulus nd t A oa agai bsol n. ute Perio Refrac tor y d T
he c e ll s cond canno t u cont ct elec tr r how act no m icity or s stim trong th atter ulus C e orre spon ds to onse t t com of the he Q p of th lex to th RS eTw e ave peak

Relative Refractory Period Some cells have

Ref r act orin es s

repolarized while others havent Vulnerable period where a strong stimulus can cause the cells to depolarize again Represented by the down slope of the T wave on the ECG

k norm er tha d n stim al caus ulus ca to d e the c n agai epolariz ells e Arrhy n thm initia ias c Is the te here an start period end ing at wav of the the R on T e on ECT G phen ome non

Super norm A wea al perio

Refr ac to rin e ss

M ain Stru ct ur th e Con es o d uc f Sys t tio n em

The Sinoatrial node (SA) The Atrioventricular node

(AV) The Atrioventricular Junction The Bundle of His The Right and Left Bundle Branches The Purkinje Fibers

The SA
Retrieved from:

Nod e

Located in the
Nod e The SA

upper posterior right atrium Known as the hearts pacemaker because it has the fastest firing rate in the system Intrinsic rate is 60100 bpm

Paraathetic inne sympa and Heart rvation thetic normrate duri ally sl o If the ng sleep ws SA N to p erfo ode fa area rm o ils hear s of the ther over t can t pace the ake func maker will tion bu slowbe at a t it er ra te


The SA

Nod e

Th e AV No de
Retrieved from:

of th atriu e ri g m be ht the tricu hind v al v spid Blood e from supply is RCA mos t pe i n and ople the circu left Intrins mflex ic fir rate ing is 40 bpm -60


The AV

Nod e

s the just belo small ar node w th ea cond where e AV impu ucting the fibe rs lse a the Thin re sm k of aller high it as a way 6 lan . mer ge in trying t e high way to a 4 lao it ta kes and the ne This t help o do tha time t. cond s slow the uction t a cont tria to o allow f vent racting inish befo ricle r s co ntra e the ct

This i

Atrio ve nt ricu Ju nc l ar t ion

Bun dl e o f

the ed at th sept interve e top o ntric f um Intri ular nsic bpm rate of 40 It is -60 the to th only c the e vent onnec Dua atria ricles f tion rom l b lo L AD o d s u desc and Le pply fr endi ft po om AKA His-P ng art sterior (incl e udes urkinje ry left/ B and right buundle osystem Pur fH nd


H is


le br is, fiber anche s) s

Righ t a nd B und le Br L eft anc h es

Ri ght Bun dle B inne Vent rvates t ranch he R ricle Le ight ft Bu inne ndle Br Vent rvates t anch he L ricle B eft r
eaks bran into 3 m inne ches to ore entir rvate th e T hese e left ve ntric are le fasc icles called A
nt P erior os S terior epta l

Pu rk in je Fib er s

Both Bundle Branches continuously divide

into smaller and smaller branches known as Purkinje Fibers These are most prevalent as the branches move downwards towards the apex of the heart web-like presence The fibers eventually become continuous with the muscle fibers Intrinsic firing rate of 2040 bpm

Dys r hyth m ias

mal hear rhyt hm t Thre e po tent reas ia l ons Incre to occu ased r
Auto Trigg maticity ered Activ Reen ity try

Inc r e ase Auto d mat ic it y

ac c ells not norm that a re pace a lly m begi aker c ells n to spon depo tane lariz A si t e e oth ously er th SA n an t ode its fi incre he r in g than rate ases faste norm r al


Pot ent ia l C au s Incr es of Au t eas om ed atic ity

rma impu l elec som lses thatrical repo etimes o t lariz The ationccur dur abno i ng rma com es fr l impu othe r thaom som lse This impu n the S ewhere A No l se c near de ause by c depo el l s s to l ar i z once e afte more t impu l s e r a s i n g h an C an le occu vent r in th ricle e atr Ca n s i a or occu time r one s in o succ r more essi on


Tr igg ered Acti v it y

Tr igg ered Acti v it y

or m cons ore ecut are c ive b alled eats Whe a ru n th n beat e abno rma cont l seve inue ral b s for seco eats n , it is ds, or m refe rred inutes sus to as taine d


Ca u s es o Tr igg f ered Acti v it y

Ree n try

Is the spread of an

impulse through tissue that has already been stimulated by that same impulse

Ree nt ry

Normal Pathway

Ree ntr y

Recirculates or Loops

Ree n try

Partial Block in Circuit

Re e ntr y

Delayed Conduction Through Circuit

Cau s es o f Ree n try

C om mo n to D ys rh issue y th m s ias





I! E


Plea se r e tu r n to sea ts in 15 m y o u r LET inut es S TA


for ave cture e w e Pi Th g th

ettin G

II: ule od M ms

Obje c tive s

Part s of th e E CG Wa v efor ms

P wav QRS C e T wav omplex U wav e Interv e

PR i n QT in terval
gme n
terv al



Represents the spread of depolarization across the atria Normal characteristics include: Smooth and rounded No more than 2.5 mm in height No more than 0.11 mm in duration Positive in leads I, II, aVF, and V2 V6

P P The The e ve Wav Wa

Turn to page 16

to K n ow Go o d



Made up of 3 separate waves In some cases not all 3 waves will be always present - e.g. The Q wave is not always seen

QRS QRS plex plex Com Com

The Q wave is always negative

The R wave is the first positive deflection above the baseline in the complex -- the R wave is always positive

The S wave follows the R wave and deflects negatively

Normal duration is 0.060.10 sec

A normal Q wave is less

Remain on page 16

An interval is a waveform and a segment

va l rval nter Inte PR I PR

Represents the time it takes for the impulse to travel through a part of the conduction system

The PR interval will decrease as HR increases

Usually measures between 0.12-.020 sec in adults

A conduction problem above the level of the bundle branches will usually be reflected in the P and PR interval

Page 16

R R Inte rv al

Represents the repolarization of the Ventricles The direction of the T wave is usually the same direction as the QRS complex that it follows. The absolute refractory period is still in play until the peak of the T wave Slightly asymmetric Usually 0.5mm or more in height in leads I and II Usually 5mm or less in limb leads Usually greater than 10mm in chest leads

ve ave T Wa TW
Turn to page 22

Low amplitude T waves can be seen in Hypokalemia Tall pointed T waves are indicative of Hyperkalemia

T lT rmal orma Abno Abn es es Wav Wav

ent ent egm egm ST S ST S

See page 20

See page 23

Q-T Inte rv a l

See page 25

Not commonly seen Usually small, round & measures < 1.5 mm in amplitude Can be seen with hypokalemia, hypomagnesmia Some medications: Quinidine Procainamide Disopyramid e Amiodarone Digitalis Phenothiazin es

U wa ve

Putt i ng i t A ll How Toge to E valu ther ate a Rh

ythm Strip

Identifying wave forms and segments --- pp. 26-28

1.Is it regular or irregular in nature?

Ste a R Ana ps to lyz i hy t hm ng S tr ip

a. Measure R-R interval b. Measure P-P interval

2.What is the rate? 3.Find the P wave

a. Right place b. Right number

4.Measure the parts and pieces

a. P wave b. QRS complex c. PR interval d. QT interval

pp. 40-44

Ste ps t a R o An hy t aly z hm i ng Str i p

5.Evaluate the overall appearance of the rhythm

a. S-T Segment b. T wave

6.Interpret the rhythm and evaluate the clinical significance

How to Measure Rate on a Rhythm Strip

Version 1:

6 Seconds Count QRS Complexes between the hash marks on the Rhythm strip and multiply by 10.

How to Measure Rate on a Rhythm Strip

Version 2:
R-R interval

Count the large boxes between consecutive R waves (R-R) And divide into 300. Best used on a regular rhythm.

8 45-4 s Page



!! II

Speaking of hot dog its time for lunch!


f Li mo hyth he R T

orm N The ms yth e Rh f

III: ule od M al

Obje c tive s

or m al S in u s Rhy t hm

Sinus rhythms originate at the SA node and conduct through the intended pathway of the conduction system

Characteristics Of NSR
Rate Rhythm P waves PR interval QRS duration 60-100 beats per minute P-P interval regular R-R interval regular Positive (upright) in lead II One precedes each QRS complex P waves look alike 0.12-0.20 seconds Constant from beat to beat 0.10 seconds or less

Si nu s Rhy th m

Sinu s Br ad y car di a

Characteristics of Sinus Bradycardia

Rate Rhythm P waves PR interval QRS duration

Less than 60 beats per minute P-P interval regular, R-R interval regular (upright) in lead II Positive One precedes eachand constant from 0.12-0.20 seconds QRS complex P waves look alike beat to beat 0.10 second

S inu T ch a y s card ia

Characteristics of Sinus Tachycardia Rate 101-180 beats per minute Rhythm P-P regular, R-R interval regular P waves Positive (upright) in lead II PR interval 0.12-0.20 seconds (may shorten with faster One precedes each QRS QRS 0.10 second or less rates) look alike P waves duration Constant beat to it may At very fast ratesbeat be difficult to tell between P and T waves

Sinu s Ar rh y th m ia

Characteristics of Sinus Arrhythmia Rate Rhythm Usually 60-100 bpm, but may be slower or faster Irregular Coordinated with respiration
HR increases gradually during inspiration (R-R intervals shorten) HR decreases with expiration (R-R intervals lengthen)

P wave

Positive (upright) in lead II One precedes each QRS P waves look alike

PR interval 0.12-0.20 second Constant beat to beat QRS duration 0.10 second or less

Valid a

Prac ti n g tice! wh a t you ve l e

arne d

Pages 58-65

ia s thm p rhy l Ar At The To t ri a i n g A rt


IV: ule od M s


A n at a rhrial arr orig ythm hythm ia is atri inatesthat a SA n , b u t w i t h i n T he P ode. not at t the he look waves that like t do no from are g he P w t A the enera aves tr i a SA n t e d l arr ode be c h yt h with aused mias . trig automby iss can g reen ered aticit ues N acti y ot u try. vity , , or s thre ually the ateninlifearrh result g unle ss card ythmi ant as a iac outp ffec t ut.

Atri a l Arr h yth m ias

Prem atu re A C om tr ial ple xes (PA C s)

Issues with: Automaticity or Reentry; comes before its expected

The P wave may be buried in preceding T wave, may be notched, or even biphasic depending on its origin in the atria. It could even look similar to the P wave that comes from the SA node if it originates close to the node. Page 94 Retrieved from

Orig in o f

I mpu ls e
Retrieved from

Characteristics of PACs
Rate Rhythm P waves Usually within a normal range but is dependent on underlying rhythm Not a rhythm; but a feature of a rhythm. Underlying rhythm is usually regular with Premature; positive in Lead II; usually differ in premature beats shape from SA node P waves: Flattened, notched, pointed, biphasic, or lost in the preceding T wave May be normal or prolonged depending on when it occurs Usually 0.10 sec or less May be wide (aberrant) or absent depending on when it happens Usually normally shaped unless the PAC is abnormally conducted

PR Interval QRS duration

Abe rran t PA Cs
Retrieved from:

Non con d uc t ed PA C s
Retrieved from:


/ ntal tional / Me mo E sical Phy ue or fatigss stre s or easeders of Dis isor t d h e ar th e

ation edic cts M effe lis

CHF ACS Atrial gem a enlt r en r lvulaase Va dise

olyte c lectr alan E imb es yroi erth Hypism d n ts a imul ffeine St Ca

igita D


Tobacco Cocaine

e t thrlying Treande ot n u use! allyd by er e ca Gen otic uals n ivid e duc ss nd a i ftenissue Re stre ing or g to Mos enign c n b ent PACs edu minati ts R eliimulan qu Fre an F c ccasionally st g CH 0 iate of n it des eati ing in so i Trorrecttrolytes ep rial lation c At fibril r C elebalance te flut rial im At mal

n t Ca a Wh n ppe Ha

Int ns

o enti erv


ys nt arox prave P Su i lar ricuhycard Tac SVT) a (P

e pacens whe cell makin n the area shifts frg of the with om a P wa in th rea ves to e at diffe will l ria. rent ook othe r; so ly from even m beat etime each Not to b s co m eat mon In o r der calle for it be a d this, to be that t least there m othe differ f 3 P wa ust v r r in a strom eac es h ip

H ap p

Mul ti for m ed Atri Rh yt al hm

(For mer ly kn o wn a Pa ce s Wand mak erin g At e r) ri al

s ost affec cardiac or fa ted by outpu st ra eithe t is If th te is r e ca not a slow use be a resu is susp treated toxic ity, hlt of dig ected notif y MD old th italis to If ra e me . te > d, beco 100 th and me ca en it c u is trethe und se for an ated erly conc Vaga ing c ern . l ma ause nece neuv alon ssary t ers mig g wi o th m slow r ht be edic ate ation s.

Mul t i foca l Atr ial Rh y t hm

Benig n peop condit Unles le ion in m

Wha t it L oo ks L ike
Retrieved from

Characteristics of Multiformed Atrial Rhythms Rate Usually 60-100 bpm, but may be slower; If > 100 bpm called multifocal atrial tachycardia May be irregular due to varying pacemaker sites Size, shape and direction may change from beat to beat; must have at least 3 different P wave shapes in the same lead

Rhythm P Waves

PR Interval Variable due to area of conduction QRS duration 0.10 sec unless there is a ventricular conduction delay

hing heir g Cou ing t e ag Hold eath inus Eng : br d s ose i e urp arot ssag nly!) a C ma s o P he f athe t (MDation o lus ymp to s mu plic stiface Para vision al Ap cold e g di tic to th ld shcloith e va s d r crea y Co wia peaten n i dpw b i ce ne ( ing intra o t s r va crea ic salneuve wn in alMa c V do hora re) and t earke g a i B lhavin essu pr M e of

P lt

u Res / ose urp


ues hniq

l l Vaga Vaga rs rs euve euve Man Man

s elea lcholine r y acet lows S ult: ction s Re ondu e c h th g

g ggin Ga

B g thin gh a a Brethrou w stra

Wha t to Ha v the Be ds e at Va ga i de f l Ma or ne u ve rs

STAT team or MD Code Cart, Oxygen, Suction Adenosine 6 mg for rapid IV push
2 syringe method: Adenosine -> Saline right after Use site most proximal to patient

12 Lead EKG on patient Continuous monitoring of ECG is essential

Tele or hardwire monitoring is not enough

Generally, vagal maneuvers should not continue for greater than 10 seconds at a time

Atri a l Tach y car d ia

Retrieved from

Issue with automaticity or triggered activity Origin is outside of the SA node in the atria This rapid impulse overrides the SA node impulse Usually every impulse is transmitted to the ventricles P waves look different than SA node P waves Can start with a PAC Can be paroxysmal Retrieved from or sustained

f in of in o Orig Orig lse ulse Impu Imp

Characteristics of Atrial Tachycardia Rate Rhythm P wave

100-250 bpm Regular One positive P wave precedes QRS complex in lead II; P waves differ in shape from sinus P waves; An isoelectric baseline is usually present between P waves

PR Interval QRS duration

May be shorter or longer than normal 0.10 sec or less an interventricular conduction delay exists

ptom Asym tions se s a Cau alpit ng P ri nt ula feine luttensation e F Stim Caf r se l Albutero line es s u r es t P h yl Theop Ch a e Cocain spne Dy n e atigu ss or d io t F e Infec lyte e Electro alances izzinhthead D ig l ith imb ss w e ness or illn ive e Acut xcess olamine cope e ch Syn ear cateess n cope exc syn ial

a nd ns ms Sig o mpt Sy atic

l l Atria Atria d ia d ia ycar ycar Tach Tach

rd yocaarction M inf

man work euve rate but ma rs rare wha enough y slow ly tach t kind of to see Som ycardia etim i es A s active (effe cts a denos Med in e s ab icati o bloc ons lik ve) kers chan , cal e beta ci u m n el b Poss l o ck ib ly ers card synch Poss ioversio ronized ib ly n RF a blati on


Inte rve n tion s

At r ia l

flutte s; class r proble is a ree ic ntry m Healt hy AV preve n nts a ode condu ction 1:1 impul of ses Atrial a highra te can b s 450 e as Ratio bpm of Atr Ventr icle ial : contra typica ctions a and s lly 2:1, re ometi 4:1, mes 6 :1

Two type

Flu tt er

100 cular ra d V1 con are cal tes < Ventri trolledled >10 cular ra unc0 are c tes also ontroll alled know ed rap id v e n as resp onse ntricul RVR ar , or

Best s II, III een in e Ventri , aVF, aln ads

Atria l Flu tte r

Wha t it L ook s Like

Atria l F lu t ter Ori g in

Retrieved from

Characteristics of Atrial Flutter

Rate Atrial rates from 250-450 bpm; Usually 300 bpm Ventricular rate variable depends on AV blocking Ventricular rate will not usually be >180 bpm Atrial regular; ventricles regular or irregular due to the AV node conduction potential depending on AV conduction and blocking No identifiable p waves, just sawtooth flutter waves Not measurable 0.10 seconds or less; may be widened dependent on how impulse is conducted through ventricles

Rhythm P wave PR Interval QRS duration

re here Whe sW ions ition ndit ond e Co eC r ur Som Som ccu Occ ht O ight Mig AF M AF

al o r i d Mitr usp Tric alve is xia V ypo H n os g ry lmona m Ste gur Pu r Re olis o e mb a on i ronic Ch eu m lung e Pn I s at h isea d M ardiomyop C y eart ic h m sche ase I dise oidis thyr yper H m

I nte rven t io ns

Signs and symptoms vary widely in severity Treatment is initiated with signs of heart failure or decompensation is noted Medications
Beta blockers Calcium channel blockers Amiodarone

Synchronized Cardioversion
Anticoagulants may be initiated if AF has occurred longer than 48 hours Started 2-3 weeks before cardioversion

RF Ablation if necessary

Atri al F i bri l (A-F lat ion i b)

Relates to an issue

of automaticity from several sites in the atria Multiple sites generate impulses between 400-600 bpm Resultant impulses cause atria to quiver vs. contract

A tria l Fib rilla t io n (A-Fi b)

an r esul decr t in ease card d iac o as a utpu trial t kick a b se is nt Pers ons with fib a Are at incre ased of st risk roke

This c

Retrieved from

A tria l Fib rilla t io n Ori g in

Wha t it l oo ks like

Fibrillatory waves, no P waves

y rger st-su s Po e abet o i Di tens yper tress e S H n ffein Ca a e mi c poxi emia Isch eart Hy h e okal emi as Hyp dise d c ogly ce Hyp dvan A ge a a pa s myo io e ps i S Card y th CHF inus ick s drome S yn s s rditi d a Peric thyroi yper H m is

ons ions nditi ndit h Ae Co e Co th A Som ed wit Fib d wi Fib Som ciate ciat Asso Asso

Characteristics of Atrial Fibrillation

Rate Rhythm
Atrial rate usually 400-600 bpm; ventricular rate variable Ventricular rhythm is irregularly irregular (no pattern of irregularity)

P waves PR Interval QRS duration

None; Only fibrillatory waves; Not measurable 0.10 sec or less; but may be widened if conduction is delayed


Inte rve n tion s

d at co n t vent rollin ricul Medi ar rate g catio


o ag u l an t s prev form ent thro to mb u ation If he s art f an is ailure to co sue, me become dica s ntro tions l it

n Corr e c t in s imba g elec t lanc Card es rolyte iove rsion Abla tion

Valid a

Prac ti n g tice! wh a t you ve l e

arne d

Pages 107-114

End of Day 1 !

A Br Befo ief Re view re B egin ni ng

ias t hm le rhy l Ar he Midd It ona Of cti In T Jun ling Fee

V: ule od M


Ju nc tion al R h yt hm

AV junction takes
over the pacemaker function of the heart if the SA node fails to generate or conduct an impulse to the junction.

t res earc dete h ha rmin s AV n ed t h at ode the mad itsel f is n e of cells pace ot , cells but tha maker t the just Bun dle o prior to If th the f His e AV are. junc paci tion ng t is he h the eart elec , trica impu lse m l back ward ust trav atria el s up them to depo the lariz . e


J unc Arrh tio nal y th m ias

The P wave will be

inverted in leads II, III, & aVF If the atria depolarize prior to the ventricles the P wave will precede the QRS complex If not, it will follow If the atria depolarize concurrent to the ventricles P waves may be absent as they are hidden in the QRS Less common than other premature complexes like PACs or PVCs

Jun ctio na l Rhy thm

The AV junction fires an

Pre ma Com tur e Ju p le xe s nct io n al or PJ C s

impulse prior to the SA node which interrupts the sinus rhythm The QRS complex is usually within normal limits and can be followed by a short pause This is meant to reset the sinus rhythm from the SA node The difference between a PAC and a PJC is the direction of the P wave in leads II, III.

PACs will be upright PJCs will be flipped

Wha t it Lo ok s Like
No P wave

Characteristics of Rate Usually within normal Premature Junctional Complexes range but depends on rhythm
Rhythm Not a rhythm, but a feature of the underlying one. Underlying rhythm usually regular with premature beats May occur before, during or after QRS complex If visible P wave is inverted in leads II, III, and aVF

P wave

PR Interval QRS duration

If a P wave before QRS its usually < 0.12 secs; If no P wave before, no PR interval Usually0.10 seconds unless there is a conduction delay

So m e Ca use s of PJCs

PJCs sust a aine re not a d rh but ythm a sin g le c they o inter rarely re mplex vent quir How e io n ever linke , if PJC s are d to agen a ca usal beco t and it m prob es lema agen t t sho ic that mini mize uld be d


Inte rve n tion s

r to PJCs that exce they LAT E in happen pt stea early d of Hap pen wou after y ld ex ou norm pect a al si Prev nus ents beat card stan iac dstil l an d resu l t is prot as a ectiv e


Junc tion Es ca al pe B eats

Wha t it L oo ks L ike

Narrow QRS complexes

Characteristics of Junctional Escape Beats

Rate Rhythm P wave 40-60 bpm Very regular May be before, during or after QRS complex If visible, inverted in leads II, III, aVF

PR Interval

If P before QRS complex < 0.12 seconds; If not no PR interval 0.10 seconds unless conduction delay

QRS duration

Inte rve n tion s

d if s sym i ptom gns and decr ease s of outp d ca ut o rdiac Atro ccur pine . and tran scut aneo paci ng us On f loors team , call S TAT


Junc tion Rhy t a l hm

Junctional Rhythms are usually 40-60 bpm If rate drops below this, it is known as a Junctional Bradycardia While Junctional Rhythms are bradycardic by sinus standards, Junctional Bradycardia is slower than the normal junctional rate

J unc Br ad tio nal y car d ia

Ac c e ler Jun c a ted t io n al Rh y thm

Junction fires at a rate of 61-100 bpm Increased automaticity at the AV junction The only difference between a junctional rhythm and the accelerated junctional rhythm is rate

uses Ca italis y Dig icit tox I te M Acu c rdia ry Ca urge s D a COP lemi poka Hy

ntion rve Inte s r onito nt for M patie f o s/sx ac i card pen ecom d ati o n s

ed ted lerat lera al Acce Acce tional t io n Junc hm Junc thm Rhyt R hy

Increased automaticity at the Bundle of His Fires at a rate of 101-180 bpm Again, the only difference between an Accelerated Junctional Rhythm and a Junctional Tachycardia is the rate

Junc tion Tach al y car d ia

e dep nt tme ow the es s rea C au T on h nt is he e pati rating t ticity a utom tole hm n, A yt yge x rh CHF hylline ter o ccess nis dmi in IV a ontrol eop i c i ty h A ga T italis tox ry h oc a es t throug g i ur D te coron e eas e rate M th s Acu yndrom ke s s a med neuver if ay m tters ed ma M ma se r gal y be us a wo V ma n o f i ase orig ycardia Incre eart e h g tachnot be ama d can rmined ce ioge Indu rd dete
Ca nic ck sho ce indu icul Mayventr ar rhyth dys s ia

ntion rve Inte s nds

l al tiona t io n Jun c Jun c dia dia ycar ycar Tach Tach

END of Module V !!

! O O O O H A Y

From Not So Bad to Terrible

rB cula ntri ove Atri

VII: u le od M cks lo

Obj ecti ves

e l ay or d cond isrup ucti nod e, B on to th tion in und Hisle of e AV Purk His, i nje its c syst or alled The an A em PR i V bl nter key ock to d val is t eter wha m in he t kin in g The d of QRS AV b co m loc k esse plex ntia is dete l to r bloc mining k is loca where t he ted

If a d

Atri o ven t ric ul ar B lo c ks

r st D Atri egr ov en ee tri c ular Bl o c k 1 AV B

Node es from dela to AV n SA ye d o de Usua lly o ccur the l s at e ve l AV n o f th ode e Know n as inco an mple t e bl oc k


Wha t it L oo ks L ike

Characteristics of First Degree AVB

Rate Usually within normal range; depends on underlying rhythm

Rhythm P wave PR Interval QRS duration

Regular Normal in size and place >0.20 seconds but constant Usually < 0.10 seconds

Some causes:

1st Degree AVB

Sec KA o nd De gre Wen e AV ken b ac B Ty h o pe 1 r M o bi t z I

a t es leve at t h l of t he S e node A Takes long long er a nd er f o wav rP e im puls to p e ass Incom AV nod e plete bloc k


Wha t it L oo ks L ike

Cha r acte ris tic s

Characteristics of Second Degree AVB Type 1 ate R Atrial rate > ventricular rate Rhythm Atrial regular (p waves march P wave out); ventricular irregular Normal size and shape; Some do not have aLengthens with PR Variable; QRS following Interval successive beats QRS Normal; but is periodically duration dropped

atic ly sual mptom te U asy mmedia s es s Ca u so i ention s v n inter ot alway ctio n onduay are ed C el e h d need gh t of hrouode sult ns, t n e re If th edicatio AV s m med lated or e then d be CA r hemia l R sc shou eld n i io h of with arct ympat f in tting r s se the inferio Para etic in h e If acutleMI shoulid ton y n wal ve with ut a m ease l b reso hours cr in 2 48-7 for as alanc h watc ning AV mb curs i e wors age o c en e we k bloc bet nd ble, it a path nsta ine and u d Sym If Atropng shouled r etic aci

Int ns

ntio erve

ac h ac h kenb kenb Wen Wen

Sec o nd D AV B eg re Ty pe e Mo II o r bitz I I

le of H Less is c QRS ommon w narr ill rema Bun ow in dl

rs be node lo w the AV Bund

mm ill be on More 0.10 serio seco > freq nd s uen us


e Br More anches co

to co tl mpley progr bloc te h esses k eart

Wha t it L oo ks L ike

Characteristics of Mobitz II
Rate Rhythm P wave

Atrial rate> Ventricular rate; Ventricular rate is usually slow Atrial regular (march out); Ventricular irregular Normal size and duration; Some not followed by a QRS; More Ps than QRS complexes Constant between beats; may be slightly longer than normal preceding QRS

PR Interval

QRS duration Normal; may be absent after some P waves

l tricumains n If ve te re es s o ra C au al, n t norm men a orn i t hemrctio trea be sc fa I In ociated may ssary ass the nece r rate la with tricu , Ven rops Left onary r d r re fo a Co ry prep ng e Art . paci .g nterio I E A NO R OP

ntion rve Inte s ar

i t z II i t z II Mo b Mo b

r MI

is cute ocardit f A my ypes o t her rt a Ot hesease di



2:1 A VB

Variant of Mobitz II block 2 Ps to every QRS; Frequently dropped QRS Depending where the block occurs in the conduction system, QRS may get wider

lete disa of th e P w ssocia QR S t com aves to ion Co m plex the plete es AV b P wa lock ves cond are NO T ucte the AV n d throug Ps m ode h arch out QR S on o com wn plex out es m on o arch wn a com p nd inde letely pend ent o f P s


Thi r d De gree AVB

Wha t it L oo ks L ike

Characteristics of 3rd Degree AV Block or Complete AV Disassociation

Rate Atrial rate > Ventricular rate; Rate determined by escape rhythm

Rhythm P wave

Atrial regular; Ventricular regular; No relationship between two Normal in size and duration

PR Interval None QRS duration Depends on location of escape rhythm. Could be wide or narrow

ntion rve Inte s uses Ca

t , bu I ior M solve r Infe ay re ek m in a we ht with MI- mig ly r erio sudden Ant art rs st hou 4 12-2r acute afte emia isch

e to th lar rate Due ntricu ve cape t s the e it is no of ythm on for rh m ncom ts to u n ly patie e rapid ecom le b b t nsta u tmen a l tre e Initia uld b sho ed with t direc ine and s u p Atro cutaneo s tran g. n paci

B B e AV e AV egre egre d 3rd D 3r D

Pages 156 - 176

End of Module VII!!!!


!! ! S


Hitting the Low Point

VI : ule od M lar

ricu ent V ias thm rhy Ar


the ventricles Occur when the pacemaker take over

Ven tric u A rrh la r ythm ias

function Least efficient Fires at a rate of 20-40 bpm If injured or infarcted, the ventricles can become irritable and ectopic beats can form

If beats are generated outside the normal

conduction system the QRS complex can be very wide T waves will deflect in an opposite direction

Pre m a tur e Ve C om n tr i pl e xes c ul a P V r Cs

Issue of automaticity
or reentry

Ectopic beat not a


Occurs sooner than

expected in the underlying rhythm

Typica T wav

seco lly lasts loca nds due > 0.12 genetion of im to ratio puls n e

e oppo deflec ts in site direc tion Can l ook diffe from each rently mor othe e th r if to lo an o impucation o ne due f lse g ener ation

P VC s

Wha t T he y Lo ok Like .

PVCs fired from a single source Note T waves in opposite direction from QRS Widened QRS This pattern is known as bigeminy

Characteristics of Premature Ventricular Complexes Usually within normal range; depends on Rate
underlying rhythm Rhythm P wave PR interval Basically regular but with some premature beats; Some PVC types do not interfere with the underlying rhythm None None

QRS duration > 0.12 seconds, wide and bizarre; T wave in opposite direction


casi occu onal is ge r, no trePVCs nera atm As v lly re ent entr quire irrita icular d bility (dem onst increas incre asin rated a es of PV s g fre mor Cs) risk quenc e y vent lethal for incre ricular r hyth ase The ms unde rlyin is th g ca en a use ddre ssed

As oc


What are the Gems of PVCs?

A single incident is known as PVC A PVC which occurs with every other sinus beat is known as bigeminy (or two) Every 3rd beat is trigeminy Every 4th beat is quadrigeminy



Which one of these is more concerning?


Idi ov en tr ic ula Rh y t hm r IVR

Overall rate is about

20-40 bpm, & at least 3 consecutive beats No atrial kick Decreased cardiac output

sign ts will show sym s & decoptoms Consi mpensof escdered ation ape an Preve rhythm cardnts tot al stan iac Not ve dstill effic ry Requi ient immres trea ediate tme nt



Wha t it L oo ks L ike

Characteristics of Idioventricular Rate 20-40 bpm Rhythm

Rhythm P wave PR Interval QRS duration Basically regular None None > 0.12 seconds; T wave frequently opposite to QRS complex; must have at least 3 consecutive beats at IVR rate

ntion rve Inte s e: puls uses Ca

r cular icula entri entr Idiov Rhythm Idiov Rhythm

a o re is scutaneng the ran If paci T

e of thion re Failu onduct c tem sys ve the to abo tricles r ven erate o gen duct an con trical elec ulse > ic imp intrins the of the rate tricles h ven r wi t cu y oc Ma MI ic

us ss acce IV gen Oxy nd nd aeat Fi tr l yi n nder se u u g ca

no e is and the er If thpulse t no pt is thing brea PEA R

ol etab balanc M im e talis Digi toxicity

CP ay Airw ss acce IV gen Oxy reat nd trlyin a Find unde e us g ca

Idio Acce lera ven t ed tr i c ular AI V R hy t hm R

he s ame mor phol o gy Rate as I V is 4 1 R -100 3 or mor bpm beat e cons ecut s Usua ive ll y la sts a seco few nds Occu to a minu rs w hen te firin sinu g sl o s ws

Has t

Wha t it L oo ks L ike

Characteristics of Accelerated Idioventricular Rhythm

Rate Rhythm P wave 41-100 bpm Basically regular None

PR Interval None QRS duration > 0.12 seconds; T wave in opposite deflection; must have at least 3 consecutive beats

ntion rve Inte s uses Ca

gn beni after ly sual d seenthe U an I in rs a n M 1 2 ho u first on omm c Very fter sion a erfu rep rapy the in s een s be tali icity Can Digi

sa lly active t Usua rote shor p t hm , rhy uration is in d tment ary trea necess not pt er ifsigns of ev How hows nce to s ra ntolehythm ot i r ng n the paci cula

tox i ne Cocatoxicity oi d achnrrha r Subahemo ge dit e Acut myocar is e ns i v erte rt Hyp hea as e dise d

ait nd w a atchusually W it nt nsie tra

AV ventri r s to ag Med encour ode N e SA to rdrive ove tricula ven pulse r im . (e.g pine) Atro s


Puls ele ss E lec t Act ric a ivity PE l A

o k li ke a rhyt hm b regu no p lar ut th ulse ere i Only s elec impu trical and lses hap no c peni ontr of ca actil ng ity ACLS rdiac m uscl algo e rithm to tr eat s us NO P ed ACIN G

Can lo

Ven tri cu la r T V-Ta ac h y car c h o r V di a T

cons r more at a recutive P ate > VCs < 30 100 seco dura nds tion= nons ustai > 30 ned seco dura nds sustation= ined Can origin ectop a te a s an ic b e at

Three o

the they all sam l ook plac e= e= sam mon e When omorphic diffe they loo VT rent sam ly = k e pla not poly ce = Rarely morphic V T occu the hea rs in hear lthy t


VT c a h

Wha t it L oo ks L ike
Classic V-Tach = monomorphic

Wha t it C an A l so L ook Like

From a sinus rhythm to VT

Polymorphic Ventricular Tachycardia

Characteristics of Ventricular Tachycardia

Rate Rhythm P wave PR Interval 101 250 bpm Basically regular If present, not related to QRS and at a different rate (very uncommon) None

QRS duration > 0.12 seconds; often difficult to differentiate between QRS and T waves

Some Causes

ar ar ricul ricul Vent Vent d ia d ia ycar ycar Tach Tach


ACLS algorithms if hemodynamically

unstable Treat underlying causes

Can be congenital or acquired Can cause a lethal polymorphic VT

AKA Torsades des Pointes Congenitally
Sudden fright Some physical activities Medications

Can be caused

Long QT Syndrome


Environmental exposure to pesticides Liquid protein diets! Electrolyte abnormalities Hypo- kalemia, magnesmia, calcemia Hypothyroidism Subarachnoid hemorrhage Myocarditis

Begins in the
Ven tricu lar F ibril latio n V-f ib

ventricles No organized waveforms or contractions of the ventricles Ventricles quiver Requires immediate treatment

al de 10% crea minu with ev ses pass te that ery es a not corr nd its Artifac ected V-fib t can m ; ALW imic chec k the AYS befo re in patien trea tme itiating t TREAT nt NOT THE PT ., THE MON ITOR !



Wha t it L oo ks Like

Fine V-fib

Coarse V-fib

Characteristics of V-Fib
Rate Rhythm No discernible rate No discernible rhythm; rapid and chaotic

P wave PR Interval QRS duration

None None No discernible QRS complex

C a I u n s t e e s r

V-Fib V-Fib

v e n ti o n s

ACLS Algorithms

CPR Meds Defibrillation

As ys t o le

lete cess elec ation trica l i mp to th of e ve u No h ntric lses eart les beat Not , out com pu t patib life le w ith


Wha t it L oo ks Like

P-wave Asystole

Complete Asystole

Cha r acte ris tic s

Characteristics of Asystole Rate None Rhythm None P wave None PR None Interval None QRS duration

A s y st ol e

C a u s e s I n t e r v e n ti o n s

Same etiologies as for PEA May occur briefly after tachy

rhythms are reset

Practice Session
Pages 208-218

! OW W
END of Module VI!!!

wry Go A ings Th hen W

III: e V dul Mo ia l rd ca yo M tio rc nfa /I n ia em ch Is

Is ch e m ia

Ischemia drops the ST segment and flips T waves in some leads Ischemia and Infarction can found by looking at the ST be segment and T waves

vs. vs. ction ction Inf a r Inf a r m ia emia Ische Isc h

Bot h

Clinically significant changes are evident when the ST segment

is at least 2 small boxes away from the isoelectric line
In fa rc ti on

Infarction raises the ST segment

Wha t No rma Loo k l s L ik e


W he re the D an ge r Lies .

W ha t Is c Lo ok he mia s Lik e


Wha t I n fa Lo ok rctio n s Lik e


End of Module VIII!!




!! Y