ECG & Cardiac Monitoring II

Jessica Cheuk
Learning outcomes
After completion of this chapter, students will be able to :
1. To identify different patterns of dysrhythmias

2. To learn the assessment findings associated with each arrhythmia

3. To discuss the principles of anticipated medical treatment for different

types of cardiac dysrhythmias
Atrial dysrhythmia
• Atrial dysrhythmias refer to those dysrhythmias or complexes that
originate in the atria but outside the SA node.
• The P wave configuration will be upright but shaped differently from
the P waves originating in the SA node, as the electrical conduction
will follow a different pathway to the AV node.
➢Atrial tachycardia (AT)
➢Atrial fibrillation (AF)
➢Atrial Flutter (AF)

https://thoracickey.com/wp-
content/uploads/2016/07/C12FF5-3.gif
 Atrial Tachycardia Source: Marquette Electronics (1996). Isolated PAC. Retrieved Sept 22, 2005,
from:http://library.med.utah.edu/kw/ecg/mml/ecg_atrial_tachy.html

Impulses originates within the atria outside the SA node.

This pacemaker is sending out impulses at a faster than SA
node
Regularity Regular Causes
Rate 100-250/min ▪ It can be triggered by alcohol, nicotine, anxiety, fatigue, fever
and infectious diseases.
P waves Present, atrial P waves may appear
slightly different & may be buried ▪ It may be associated with coronary or valvular heart disease,
acute respiratory failure, hypoxia, pulmonary disease, digoxin
toxicity and certain electrolyte imbalances.
PR interval 0.12-0.2 sec, may not be seen

QRS <0.12 sec, all the same shape

➔ The rapid rate shortens diastole, resulting in loss of atrial
duration
kicks, reduced CO, reduced coronary perfusion and ischemia
myocardial changes.
 Atrial Fibrillation

Regularity irregular Causes

• It can occur following cardiac surgery, it can be caused by hypotension,
Rate Atrial rate is 350 to 600 /mins, pulmonary embolism, COPD, mitral stenosis, hyperthyroidism,
ventricular rate is variable infection, coronary artery disease, acute MI, pericarditis, hypoxia, and
P waves No consistently identifiable P atrial septal defect.
wave, fibrillary waves
PR Not measurable • The rhythm may occur in healthy person, i.e. coffee, alcohol, or
interval nicotine excess. Certain drug, aminophylline. Catecholamine release
during exercise may also trigger AF.
QRS <0.12 sec
duration
• The dysrhythmia may be paroxysmal (i.e., beginning and ending
spontaneously) or persistent (lasting more than 7 days)
 Atrial Fibrillation

Clinical Significance

• Atrial fibrillation results in a decrease in CO because of ineffective

atrial contractions or a rapid ventricular response.
• Thrombi (clots) form in the atria because of blood stasis.
• An embolized clot may develop and move to the brain, causing a
stroke. Atrial fibrillation accounts for as many as 17% of all strokes.
 Atrial flutter

Regularity Atrial regular, ventricular may be regular or irregular

Rate Atrial rate 250 to 350/mins, ventricular rate is usually slower
P waves Flutter waves

PR interval Not measurable

QRS duration <0.12 sec, unless flutter waves are buried in QRS, which make the QRS appear wider.

The rhythm is often described in terms of the number of flutter waves for each QRS
complex, for example, a 4to 1 flutter would refer to a pattern with four flutter waves for
every one QRS complex.
 Atrial flutter

Causes
It may be caused by conditions that enlarge atrial tissue and evaluate atrial pressures. It’s commonly found in patients
with several mitral valve disease, hyperthyroidism, pericardial disease and COPD. It can be triggered by alcohol,
nicotine, anxiety, fatigue, fever and infectious diseases.

Clinical Significance
• The high ventricular rates (greater than 100 beats/minute) and loss of the atrial “kick” will decrease CO.
• serious consequences such as HF, especially in the patient with underlying heart disease.
• Patients with atrial flutter have an increased risk of stroke because of the risk of thrombus formation in the
atria from the stasis of blood.
 AV nodal reentrant tachycardia (AVNRT)

Regularity Regular
Rate 140-250 bpm
P waves Inverted in Lead II, III, aVF
preceding / follow/ buried
by QRS
PR interval Not measurable
QRS duration <0.12 sec,
http://washingtonhra.com/wp-
content/uploads/2015/05/AVNRT-animation.gif
Paroxysmal Supraventricular Tachycardia
(PSVT)
• Paroxysmal atrial tachycardia (PAT)
• Paroxysmal nodal or junctional tachycardia
• AV nodal reentrant tachycardia
✓An atrial premature beat often initiates the rhythm
✓The tachycardia begins & terminates abruptly.
✓In response to a vagal maneuver, such as carotid sinus
massage, it is either unaffected or reverts to a normal sinus
rhythm

** sinus tachycardia response slowly to vagal maneuver**

Atrioventricular blocks
 Atrioventricular blocks
• AV blocks is the conductivity problems of the heart.
• An AV block exists when the electrical conduction through the AV
node or bundle of His is delayed or blocked.
• The blocks are differentiated by their level of severity or degree of
block, becoming more acute with each additional degree:

✓first-degree AV block;
✓type I second-degree AV block,
✓type II second-degree AV block
✓third-degree AV block (complete heart block)
 First degree Heart block
Source:
https://www.unm.edu/~l
kravitz/Extras2/first.gif

Impulse is conducted to the ventricles but the time of AV conduction is

prolonged

Regularity Regular
Rate Usually normal, but depends on the underlying rhythm
P waves normal
PR interval Constant, > 0.2 sec
QRS duration <0.12 sec, unless there is conduction delay
 First degree Heart block
Causes
• may be normal.
• Associated with MI, CAD, rheumatic
fever, hyperthyroidism, electrolyte
imbalances (e.g., hypokalemia),
vagal stimulation, and drugs such as
digoxin, β-adrenergic blockers,
calcium channel blockers
Source:
https://www.unm.edu/~l
kravitz/Extras2/first.gif
Clinical significance
First-degree AV block is usually not
serious but can be a sign of higher
degrees of AV block. Patients
with first-degree AV block are
asymptomatic.
 Second degree Heart Block (Mobitz type I)
Source
https://www.unm.edu
/~lkravitz/Extras2/mo
bitz1.gif

A gradual lengthening of the PR interval. It occurs because of a prolonged AV

conduction time until an atrial impulse is nonconducted and a QRS complex is
blocked (missing).
Regularity Irregular
Rate Atrial rate> ventricular rate due to the dropped QRS complex
P waves normal
PR interval Lengthens with each cycle until a P wave is not followed by a QRS
complex
QRS duration <0.12 sec
 Second degree Heart Block (Mobitz type I)
Source
https://www.unm.edu/~lkra
vitz/Extras2/mobitz1.gif

Causes
• caused by AV nodal ischemia from Clinical significance
occlusion to the right coronary • usually asymptomatic
artery, from acute inferior wall MI, • or develop hypotension if the
or from increased parasympathetic rhythm is low
stimulation. It is usually transient
and rarely progresses to second-
degree AV block, type II, or third-
degree AV block.
 Second degree heart block (Mobitz type II) Source:
http://www.medicine-
on-
line.com/html/ecg/e000
1en_files/image120.png

Regularity Regular
Rate Atrial rate >ventricular rate due to dropped QRS complex
P waves normal
PR interval Constant, < 0.2 sec
QRS duration <0.12 sec, unless there is conduction delay
 Second degree heart block (Mobitz type II)
Source:
http://www.medicine-
on-
line.com/html/ecg/e000
1en_files/image120.png

A single or multiple non-conducted P wave in a face of rhythm with a

constant PR interval. The P : QRS ration varies
Causes
• associated with rheumatic
heart disease, CAD, anterior
MI, and drug toxicity.
Clinical significance
• It often progresses to third-degree AV block
• reduced HR lead to hypotension myocardial
ischemia.
• It is an indication for therapy with a
permanent pacemaker.
Second degree heart block (Mobitz type II)
Source:
https://medschooljourn
al.files.wordpress.com/2
010/11/picture9.jpg
 Third degree heart block Source: http://en.my-
ekg.com/arrhythmias/arrhythmi
as.html

(complete heart block)

Regularity Atrial regular, ventricular regular, there is no relationship between 2

rhythms
Rate Atrial rate> ventricular rate
P waves normal
PR interval None, as the atria & ventricles beat independently of each other
QRS duration <0.12 sec indicates a junctional pacemaker
>0.12 sec indicates a ventricular pacemaker
 Third degree heart block Source: http://en.my-
ekg.com/arrhythmias/arrhythmi
as.html

(complete heart block)

None of the impulses from the atria are conducted through the AV junction
to the ventricles.
The atria and ventricles beat independently of each other and referred to as
“AV dissociation.”
 Third degree heart block
(complete heart block)
Causes
• caused by medications such as
digitalis toxicity and by
degenerative heart disease.
• It may also be caused by acute MI
and myocarditis.
Source: http://en.my-
ekg.com/arrhythmias/arrhythmi
as.html
Clinical significance
Third-degree AV block usually results
in reduced CO with subsequent
ischemia, HF, and shock.
Syncope from third-degree AV block
may result from severe bradycardia or
even periods of asystole.
Atrioventricular dysrhythmias
Atrioventricular dysrhythmias

• AV junctional dysrhythmias are those dysrhythmias that originate from

the AV node or bundle of His.
• The AV junction may take over as the primary pacemaker of the heart if
➢the SA node fails to discharge an impulse,
➢the impulse is blocked and does not reach the AV node,
➢the SA node is pacing slower than the impulse generation of the AV
node.
Atrioventricular dysrhythmias

• When the AV node paces the heart, the impulse generated may travel
backward to depolarize the atria and forward to depolarize the ventricles.
• The P wave may be inverted and appear before the QRS complex, it may
be buried in the QRS complex, or it may be inverted and appear after the
QRS complex.
➢Junctional escape rhythm
Junctional escape rhythm

Regularity Regular except for the premature beats

Rate 40-60/mins
P waves the P waves of the early beat may occur
before, during, or after the QRS and may be inverted
PR interval usually normal or shorter than normal, or may not be able to
be measured if the P wave does not appear before the QRS
QRS duration <0.12 sec, unless there is conduction delay
 Junctional Escape Rhythm
Simultaneous absent of P wave

The junctional escape beat is an example of this compensatory

mechanism. Because it prevent ventricular standstill, they should
never be suppressed.

Marquette Electronics (1996). Junctional Escape Rhythm. Retrieved Sept 22,

2005, from http://medstat.med.utah.edu/kw/ecg/mml/ecg_junctional.html

27
 Junctional escape rhythm

Causes Clinical significance

• acute MI, valvular disease, SA • Asymptomatic
node disease, • Or hypotension because of slow HR
• post-cardiac surgery,
• Patient taking digoxin, beta
blockers, and calcium channel
blockers.
Premature complex
Premature complex
• Premature complexes are early beats, the rhythm is regular except for
the premature beats occurring earlier.
• A pause usually occurs following the premature complex and
represents the time delay during which the SA node resets its rhythm
for the next beat.
• Noncompensatory pauses usually follow a premature atrial complex,
and compensatory pauses usually follow a premature ventricular
complex (PVC).
Premature complex
• To distinguish between the compensatory or noncompensatory
pauses, the distance between three normal beats is measured.
• Then measure the distance between three beats that includes the
premature complex.
• Compensatory pauses➔ the distance are the same
• Noncompensatory pauses➔ the distance of the 3 complex with
premature complex will be less than the measurement containing the
three normal beats.
Premature Atrial Contractions (PACs)
Source: Marquette Electronics
(1996). Isolated PAC. Retrieved
Sept 22, 2005, from
http://medstat.med.utah.edu/kw/ec
g/mml/ecg_isolated.html

An ectopic focus within the atria fires before the next sinus node
impulse is expected
Regularity Irregular
Rate Usually 60-100/mins
P waves One P per each QRS,
may be upright,
flattened, notched, or lost in the preceding T wave
PR interval 0.12-0.2 sec or prolonged in the PAC
QRS duration 0.12 sec
Premature Atrial Contractions (PACs)
Source: Marquette Electronics
(1996). Isolated PAC. Retrieved
Sept 22, 2005, from
http://medstat.med.utah.edu/kw/ec
g/mml/ecg_isolated.html

Causes
▪ It can be triggered by alcohol, nicotine, anxiety, fatigue, fever and
infectious diseases.
▪ It may be associated with coronary or valvular heart disease, acute
respiratory failure, hypoxia, pulmonary disease, digoxin toxicity and certain
electrolyte imbalances.
▪ PAC is rarely dangerous in patient.
Premature Atrial Contractions (PACs)
Source: Marquette Electronics
(1996). Isolated PAC. Retrieved
Sept 22, 2005, from
http://medstat.med.utah.edu/kw/ec
g/mml/ecg_isolated.html

Clinical Significance
• It cause no symptoms and can go unrecognized for years. The patient may
perceive PACs as normal palpitations.
• In persons with heart disease, frequent PACs may indicate enhanced
automaticity of the atria or a reentry mechanism. Such PACs may warn of or
start more serious dysrhythmias ( e.g. SVT)
 Premature Ventricular Contraction (PVC)
Source:
http://medlibes.com/uploa
ds/Screen%20shot%202010
-07-
06%20at%209.47.50%20PM
.png

Ectopic beats originate in the ventricles resulting in wide & bizarre QRS
complexes
Regularity Depends on underlying rhythm, interrupted by PVC
Rate Underlying rhythm
P waves None
PR interval None
QRS duration >0.12 sec, wide & bizarre
 Premature Ventricular Contraction (PVC)
Causes
Emotional stress, anxiety,
exercise, MI, alcohol, caffeine,
tobacco, hypokalemia,
hypomagnesemia, acidiosis,
heart failure, cocaine
Source:
http://medlibes.com/uploa
ds/Screen%20shot%202010
-07-
06%20at%209.47.50%20PM
.png
Clinical significance
The presence of PVCs is a sign of
ventricular myocardial irritability and,
in some patients, may lead to VT or
ventricular fibrillation
(VF).
Ventricular Dysrhythmias
Ventricular Dysrhythmias
• Electrical impulse initiated from any site in the ventricles below
the Bundle of His
• QRS complex is wider than normal (prolonged conduction time
through the ventricles)
• The T wave and the QRS complex deflect in opposite directions
because the difference in the action potential during ventricular
depolarization and repolarization.
• P wave is absent (atrial depolarization does not occur)
Ventricular Dysrhythmias (QRS > 0.12 SEC)
Ventricular dysrhythmias are those dysrhythmias that originate in the
ventricles. The ventricles may take over as the primary pacemaker of the
heart if:
a. the SA node fails to discharge an impulse
b. the impulse is blocked and does not reach the ventricles
c. the SA node and AV node are pacing slower than the impulse generation
of the ventricles
d. an irritable site in one of the ventricles produces a rapid rhythm
• Premature ventricular complexes (PVC),
• ventricular tachycardia (VT),
• ventricular fibrillation (VF),
• ventricular asystole,
• PEA.
 Sources:

Ventricular Tachycardia http://media.clinicaladvisor.com/i

mages/dsm/ch4594.fig1.png

• A run of three or more PVCs

• When an ectopic focus or foci fire repeatedly and the ventricle takes control as
the pacemaker
Regularity Regular
Rate 110 to 250/mins
P waves Absent
PR interval none
QRS duration >0.12 sec, wide & bizzare

Ventricular Tachycardia
Causes
• associated with MI, CAD, significant
electrolyte imbalances
cardiomyopathy, mitral valve
prolapse, long QT syndrome, drug
toxicity, and central nervous system
disorders.
• It can be seen in patients who have
no evidence of cardiac disease.
Sources:
http://media.clinicaladvisor.com/i
mages/dsm/ch4594.fig1.png
Clinical significance
VT can be stable (patient has a pulse)
or unstable (patient is pulseless).
Sustained VT causes a severe
decrease in CO because of decreased
ventricular diastolic filling times and
loss of atrial contraction➔ hypotension
R - on - T Phenomenon
▪ A cardiac event in which a ventricular stimulus causes
premature depolarization of cells that have not completely
repolarized. It is noted on the electrocardiogram as a
ventricular depolarization falling somewhere within a T
wave. The R-on-T phenomenon may result in ventricular
tachycardia or ventricular fibrillation.

43
 Ventricular Fibrillation (V-Fib) Source:
http://medlibes.com/uploads/Screen
%20shot%202010-07-
06%20at%209.54.11%20PM.png

• V-Fib is chaotic depolarization of the ventricles caused by

increased automaticity of multiple ventricular ectopic foci.
• Lead to arrested cardiac pump function and immediate death.
• V-Fib can only be treated by immediate debrillation.

▪ No contraction & no cardiac output

 Ventricular Fibrillation Source:
http://medlibes.com/uploads/Screen
%20shot%202010-07-
06%20at%209.54.11%20PM.png

Regularity Irregular, chaotic fibrillary waves

Rate Unable to determine, no identifiable wave patterns
P waves Undetectable
PR interval none
QRS duration Undetectable
 Ventricular Fibrillation Source:
http://medlibes.com/uploads/Screen
%20shot%202010-07-
06%20at%209.54.11%20PM.png

Causes Clinical significance

• Electrolyte imbalances, such as
hypokalemia, hyperkalemia and VF results in an unresponsive, pulseless,
hypercalcemia
• Untreated VT
and apneic state.
• Acid and base imbalance
• Sever hypoxia
• Myocardial ischemia & infarction
• Drug toxicity, i.e. digoxin
• Electric shock
• Severe hypothermia
 • Source:

Asystole
https://ekg.aca
demy/ecgLesso
ns/ventricularA
ssets/v121.gif

Asystole represents the total absence of ventricular electrical activity.

Regularity None
Rate None
P waves None
PR interval None
QRS duration None
 • Source:

Asystole
https://ekg.aca
demy/ecgLesso
ns/ventricularA
ssets/v121.gif

Flat line protocol

Asystole represents the total absence of ventricular electrical activity.
• Check lead attachment
Regularity None
• Check lead selection
Rate None
• Check the gain/adjust
P waves None
PR interval
sensitivities
None
• Check power on/off
QRS duration None
References
• Drew, B. J. (2007). Pulling it all together. AACN Adv Crit Care, 18, 305-317.
• Hinkle, J. (2014). Clinical handbook for Brunner & Suddarth's textbook of medical-
surgical nursing. (Edition 13th ed.). Philadelphia: Wolters Kluwer Health/Lippincott
Williams & Wilkins.
• Houghton, A., Gray, D. (2014). Making Sense of the ECG. Boca Raton: CRC Press.
• Lewis, S. M. (2017). Medical-surgical nursing : assessment and management of clinical
problems (10th ed.). St. Louis, Missouri: Elsevier.
• Morton, P., & Fontaine, D. (2013). Critical care nursing : A holistic approach (10th ed.).
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
• Perrin, K., & MacLeod, C. (2013). Understanding the essentials of critical care nursing
(2nd ed.). Boston: Pearson.
• Urden, L., Stacy, K., & Lough, M. (2018). Critical care nursing : Diagnosis and
management (8th ed.). Maryland Heights, Missouri : Elsevier.
Thank you!