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