defining normal sinus rhythm and arrhythmias

sinus rythm

1. Regular rhythm at a rate of 60-100 bpm 2. Each QRS complex is preceded by a normal P wave 3. Normal P wave axis: P waves should be upright in leads I and II, inverted in aVR. 4. The PR interval remains constant. 5. QRS complexes are < 100 ms wide (unless a co-existent interventricular conduction delay is present)

atrial fibrillation and flutter

2 most common irregular atrial rhythms

Sinus Arrhythmia

Appearance is ALMOST NORMAL: Respiratory - Circulatory interaction Rate INCREASES with INSPIRATION (IN=IN)

sinus bradycardia (end in -lol)

Beta Blockers cause

HTN, bradycardia

Beta blockers and Ca channel blockers are used for; but can cause

slows, increases

Ca plays a role depolarization of myocytes- Ca channel blockers would ____ depolarization where as Ca ____ it

atrial; ventricular

EKG criteria on atrial flutter: rapid regular ___ contraction (220-350bpm); broad, bizarre flutter waves; usually regular ___ rate (with ratio P waves: QRS)

sinus bradycardia; not much unless symptomatic; 50 bpm

Which rhythm is this?- what do you do about it; what is the rate

hypertrophy

____ of the heart causes shift in axis, vectors and amplitudes on EKG

atrial fibrillation

age, alcohol abuse, ischemia, heart problems are all co-morbidities to

beta blockers can cause sinus bradycardia

atenolol, betalol, labetalol

>120 bpm, 70-110 bpm, <60 bpm

atrial fibrillation causes variable depolarization rates to the ventricle: rapid ventricular response is ___; controlled ventricular response is ___; slow ventricular response is ___

clots, travel (to lungs-PE)

atrial fibrillation pt are prone to form __ within the atria which can ___

rapid ventricular response

atrial fibrillation pt with ____ will have a heart rate in 200 bpm; don't have adequate profusion to body- have to be cardioverted

irregularly; variable

atrial fibrillation: fibrillation waves can look like a P wave but the ____ irregular rhythm and ____ ventricular wave should tip you off to know it is atrial fibrillation

regular

atrial flutter has ____ RR interval; circle entry, circle entry beat. circle entry, circle entry beat.

Ventricular tachycardia (V-tach)

broad complex tachycardia originating in the ventricles

sinus bradycardia

calcium channel blockers can cause

wandering atrial pacemaker

can occur, not as common, regions in atria that act as pacemaker that aren't the SA node; generates a P wave in different places in the atria

stress, fear, anxiety, mt. dew

causes of normal sinus tachycardia

electrical re-entry loop

causes short circuit in heart

Maize procedure (cardiac ablation)

cautery, burn the area of the heart- burn and block re-entry loop that is recurring

regular, 90bpm, normal P waves (no camel humping, etc), Pr interval 0.12, QRS 0.08, normal sinus rhythm

determine regularity, rate, assess P wave, determine PR interval, determine QRS duration; and what does this indicate

Arrhythmogenesis

disorders of impulse formation and disorders of impulse conduction; clinically difficult to distinguish, initiated by one mechanism, perpetrated by another

re-entry disturbance

electrical circuit malfunction that causes a basic circular, re-entry type electric pathway

atrial flutter

every wave that comes in every 4th beat comes through- "sawtooth pattern" amount of atria to amount of ventricular contraction (P:QRS) determines the amount of blockage

Supraventricular tachycardia

heart beats so fast, ventricle doesn't have time to relax, not good profusion to tissues, r on r or r on t (waves on waves)- a fatal arrhythmia can happen such as V tach or a fib

take a note card and mark QRS complexes, if they match going down the EKG it is regular, if not it is irregular

how do you determine if heart rate is regular or irregular

anticoagulants, meds, may cardiovert if applicable

how do you treat atril fib / control the rate

300, 150, 100, 75, 60, 50 (count down thick lines)

how to count the heart rate if it is a regular rhythm

atrial fibrillation

identified by irregularly irregular rhythm and absence of discernable P waves

QRS complexes, 10

if R to R cycles vary use the 6 second method where you count the number of ____ in a 6 second strip then multiply by ____

sinus tachycardia

impulse originates from SA node but at a rate greater than 100 bpm but less than 160 in adults and less than 200 in children

sinus bradycardia

impulse originates from SA node but at a rate less than 60 bpm; may be normal in conditioned athlete

220-250 bpm

in atrial flutter the rapid regular atrial contraction is in between

AV

in atrial flutter ventricular rate is determine by the ___- conduction ratio

purkinje cells

in normal sinus rhythm from the AV node the impulse travels through the bundle of His and specialized ventricular _____

AV node

in normal sinus rhythm the initiation from the SA node is propagated through specialized atrial tissue to the ____

hypertrophy

increase in cell size

fibrillation and flutter; wandering; multifocal

irregular atrial rhythms: atrial ___ and ____; ____ atrial pacemaker; ____ atrial tachycardia

Multifocal Atrial Tachycardia (MAT)

irregular rhythm like atrial fib; but will have a P wave greater than 100 bpm

wandering atrial pacemaker

irregular rhythm like atrial fib; but will have a P wave less than 100 bpm

respiration

irregularity of sinus arrhythmias vary with ___

atrial fibrillation

irregularly irregular rhythm

Atrial Fibrillation (A-Fib)

irregularly irregular; not a great contraction of atria; shakes like jelly/ quivers which is why people form blood clots in the atria

atrial fibrillation

most common irregular atrial rhythm

COPD

multifocal atrial tachycardia is associated with ill patients with ____

atrial fibrillation

multiple electrical foci/ epicenters cause atria to contract; not good communication between atria and ventricles, some signal is getting into ventricles; not good atrial contractions; pt put on blood thinners, watch for heart failures; can be slow (less than 100); or with RVR (hr in 200); no atrial preload to heart

atrial fibrillation

multiple irritable foci throughout atrial myocardium

Atrial Fibrillation (A-Fib)

multiple stimulus; no definite contraction- jelly effect- causing blood to become stasis which can cause clots, and pulmonary emboli

work-up

new onset atrial fibrillation can indicate they have something else going on-- do a good ___ on the pt; they may need to be admitted; to see if it just happened or some co-morbidity that did this that we do not know about

p, 250-250 bpm

no ___ waves. flutter waves instead "sawtooth pattern" at a rate of ____

atrial fibrillation

no p wave

pacemaker (P cells)

normal sinus rhythm implies that the heart's depolarization is initiated by ____ cells located in the SA node

60-100

normal sinus rhythm is _____ bpm

60-100bpm, regular, before each QRS, 0.12-0.20, <12 second

normal sinus rhythm: heart rate =____; rhythm=_____; P wave=_____; PR interval _____; QRS ____

atrial flutter

only some impulses are conducted through the AV node and into ventricles (usually every other impulse)

right

pulmonary HTN is on ___ side

Multifocal Atrial Tachycardia (MAT)

rate is greater than 100 bpm; P wave varies in morphology (P'), must have 3 different P' waves; irregular rhythm; associated with very ill patients with COPD

sinus tachycardia

rate is over 100; there is a P, QRS complex are normal

wandering atrial pacemaker

rate varies but usually less than 100 bpm; P wave varies in morphology (P'), rhythm irregular, if rate accelerates> 100 bpm, it becomes multifocal atrial tachycardia

100 bpm, irregularly irregular, none, none, 0.06 s, atrial fibrillation, controlled ventricular response (70-110)

rate, regularity, p waves, pr interval, QRS duration, interpretation with what kind of ventricular response

atrial flutter

re-entry circuit; comes and goes (paroxysmal); or persistent

structural; previous MI

re-entry disturbances are caused by ___ defect and ___ ___

atrial fibrillation

results from random, rapid depolarization waves in the atria that are transmitted variably to the ventricle: rapid, controlled, or slow ventricular repsonses

60-100 bpm; preceded;

sinus rate = ____; each QRS complex is ___ by a p wave; P waves should be upright in leads ____, ____, and should be inverted in ___, the PR interval remains ____,

pulmonary embolism (PE)

sinus tachycardia can be a soft indicator of what

sinus arrhythmia

slight heart pause

160; 200

supra-ventricular tachycardia is a heart rate above ___ in adults and ___ in children

4:1 (P:QRS)

this atrial flutter has a ___:___ blockage

Sinus Arrhythmia (note the QRS complexes are nearly identical)

this indicates?

similar; stable

tx atrial fibrillation and atrial flutter is ___; atrial flutter is more __ than fib

control the rate

tx of atrial fibrillation

atrial flutter

type of supraventricular tachycardia caused by re-entry circuit within the right atrium

irregular, escape, premature, tachy

types of arrhythmias include: ___ rhythms, ___ rhythms, ___ beats, ____ arrhythmias

atrial flutter

usually in presence of other heart disease, macro-reentrant rhythm, may be paroxysmal/persistent, frequently becomes atrial fibrillation

Atrial Fibrillation (A-Fib)

variable ventricular rate

ventricular tachycardia

ventricles will lose ability to profuse blood and get subsequent hypotension, collapse and acute cardiac failure; some can be stable

ventricular arrhythmias

ventricular tachycardia, ventricular fibrillation, supraventricular tachycardia, wolf-parkingson white syndrome, asystole are all ___ and life threatening

it gets larger when it has to work harder

what causes hypertrophy of the heart

early, pre-sinus node depolarization beat

what do these Premature Atrial contractions indicate

anticoagulants; blood clots

what medications do pt with atrial fibrillation take long term to prevent ____ from flicking from the heart into the lungs (causing PE)

normal, left, right, interdeterminate

when determining an axis of the heart: there is ___, ____, ____, ____

pulseless, pulse

when you diagnose pt with V tach; first identify if they are ____ Vtach or do they have a____

athletes (with normal BP); when we lost CO from low HR (when BP is abnormal)

who has sinus bradycardia, when does it become an issue

expected management of symptoms

why do PAC and PVC matter

Atrial Fibrillation (A-Fib)

you can live with ___ but it is better to live without it