ecg training module 4

ECG TRAINING MODULE 4ECG TRAINING MODULE 4

BYBY

BRAD CHAPMAN RCTBRAD CHAPMAN RCT

OBJECTIVESOBJECTIVES

1.1. Arrhythmia recognitionArrhythmia recognition

2.2. SinusSinus

3.3. AtrialAtrial

4.4. BlocksBlocks

5.5. VentricularVentricular

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION Rhythms coming from the SA node:Rhythms coming from the SA node:

Normal Sinus Rhythm: Normal Sinus Rhythm: This rhythm originates from the SA node. This specialized piece of This rhythm originates from the SA node. This specialized piece of

tissue generates its own impulse at a rate of 60 – 100 bpm. tissue generates its own impulse at a rate of 60 – 100 bpm. Sympathetic stimulation can accelerate the SA node up to a rate of Sympathetic stimulation can accelerate the SA node up to a rate of 150 bpm. (Woods, 2000). P waves and QRS are usually normal 150 bpm. (Woods, 2000). P waves and QRS are usually normal and have a 1:1 ratio.and have a 1:1 ratio.

Rate: 60 – 100 bpm (beats per minute), RegularRate: 60 – 100 bpm (beats per minute), Regular

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION

Sinus Bradycardia:Sinus Bradycardia: Rhythm - Regular Rate - less than 60 beats per minute Rhythm - Regular Rate - less than 60 beats per minute QRS Duration - Normal QRS Duration - Normal P Wave - Visible before each QRS complexP Wave - Visible before each QRS complex P-R Interval - Normal P-R Interval - Normal Usually benign and often caused by patients on beta blockersUsually benign and often caused by patients on beta blockers


Sinus Tachycardia:Sinus Tachycardia: Rhythm - Regular Rate - More than 100 beats per minute Rhythm - Regular Rate - More than 100 beats per minute QRS Duration - Normal QRS Duration - Normal P Wave - Visible before each QRS complex P Wave - Visible before each QRS complex P-R Interval - Normal P-R Interval - Normal The impulse generating the heart beats are normal, but they are The impulse generating the heart beats are normal, but they are

occurring at a faster pace than normal. Seen during exerciseoccurring at a faster pace than normal. Seen during exercise


Sinus arrhythmia:Sinus arrhythmia: The EKG is of normal pattern but the rhythm varies corresponding The EKG is of normal pattern but the rhythm varies corresponding

to respiratory cycle.to respiratory cycle. This is commonly found in young people.This is commonly found in young people. P waves and QRS are usually normal and have a 1:1 ratio.P waves and QRS are usually normal and have a 1:1 ratio.


Sinus Arrest:Sinus Arrest:The S.A. node fails to initiate impulses. The S.A. node fails to initiate impulses.

No P waves, No QRSNo P waves, No QRS


Atrial RhythmsAtrial Rhythms These rhythms come from a different focus or These rhythms come from a different focus or

site than the S.A. node (normal pacemaker of site than the S.A. node (normal pacemaker of the heart). Usually somewhere within the wall of the heart). Usually somewhere within the wall of one of the atria.one of the atria.

The P wave is often of different shape. The The P wave is often of different shape. The

QRS is usually initiated in a normal manner.QRS is usually initiated in a normal manner.

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION Atrial Flutter:Atrial Flutter: The waves are very rapid (300 bpm) – usually saw tooth in pattern. The waves are very rapid (300 bpm) – usually saw tooth in pattern.

The A-V node cannot transmit every impulse to the ventricle. The The A-V node cannot transmit every impulse to the ventricle. The ventricle will respond to every second, third, fourth etc. flutter wave.ventricle will respond to every second, third, fourth etc. flutter wave.

Rhythm - Regular Rate - Around 110 beats per minute Rhythm - Regular Rate - Around 110 beats per minute QRS Duration - Usually normal QRS Duration - Usually normal P Wave - Replaced with multiple F (flutter) waves, usually at a ratio P Wave - Replaced with multiple F (flutter) waves, usually at a ratio

of 2:1 (2F - 1QRS) but sometimes 3:1 of 2:1 (2F - 1QRS) but sometimes 3:1 P Wave rate - 300 beats per minute P Wave rate - 300 beats per minute P-R Interval - Not measurable As with SVT the abnormal tissue P-R Interval - Not measurable As with SVT the abnormal tissue

generating the rapid heart rate is also in the atria, however, the generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this caseatrioventricular node is not involved in this case

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION Atrial fibrillation:Atrial fibrillation: There are no consistent P waves. Because the irritable focus is so There are no consistent P waves. Because the irritable focus is so

rapid (more than 350 bpm)rapid (more than 350 bpm) You see wavy series of fib waves. The ventricular response is You see wavy series of fib waves. The ventricular response is

totally irregular.totally irregular. Rhythm - Irregularly irregular Rhythm - Irregularly irregular Rate - usually 100-160 beats per minute but slower if on medicationRate - usually 100-160 beats per minute but slower if on medication QRS Duration - Usually normal QRS Duration - Usually normal P Wave - Not distinguishable as the atria are firing off all over P Wave - Not distinguishable as the atria are firing off all over P-R Interval - Not measurable P-R Interval - Not measurable The atria fire electrical impulses in an irregular fashion causing The atria fire electrical impulses in an irregular fashion causing

irregular heart rhythmirregular heart rhythm

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION AV NODE RHYTHMSAV NODE RHYTHMS

When the pacemaker of the heart shifts down to the A.-V. node, the P waves When the pacemaker of the heart shifts down to the A.-V. node, the P waves

are altered. This causes the P waves to be inverted. Because the focus is so are altered. This causes the P waves to be inverted. Because the focus is so close to the ventricle, the atria and ventricle contract at about the same time. close to the ventricle, the atria and ventricle contract at about the same time. The P wave occurs just before, after or buried in the QRS complex. The P wave occurs just before, after or buried in the QRS complex.

Nodal rhythm:Nodal rhythm: The rhythm is regular but the P wave occurs just before the QRS, after or is The rhythm is regular but the P wave occurs just before the QRS, after or is

buried in the QRS. Your P wave can also be inverted.buried in the QRS. Your P wave can also be inverted. Nodal Tachycardia:Nodal Tachycardia: The rate is usually between 100 and 150 bpm. Since conduction beyond the The rate is usually between 100 and 150 bpm. Since conduction beyond the

A-V node is normal, we usually get a QRS complex which is normal. Inverted A-V node is normal, we usually get a QRS complex which is normal. Inverted P waves are seen.P waves are seen.

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION 11stst Degree AV Block: Degree AV Block: Prolonged AV conduction time. If the pacemaker is normal and in Prolonged AV conduction time. If the pacemaker is normal and in

the S.A. node the P wave will be normal in shape. But because of the S.A. node the P wave will be normal in shape. But because of defective (slow) conduction in the A.V. node, the PR interval defective (slow) conduction in the A.V. node, the PR interval exceeds the upper limit or normal. The heart rate and rhythm are exceeds the upper limit or normal. The heart rate and rhythm are unaffected.unaffected.

Your PR interval is greater than .20 sec. (200)Your PR interval is greater than .20 sec. (200) Rhythm - Regular Rhythm - Regular Rate - Normal Rate - Normal QRS Duration - Normal QRS Duration - Normal P Wave - Ratio 1:1 P Wave - Ratio 1:1 P Wave rate - Normal P Wave rate - Normal P-R Interval - Prolonged (>5 small squares)P-R Interval - Prolonged (>5 small squares)

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION2nd Degree Block Type 1 (Wenckebach)2nd Degree Block Type 1 (Wenckebach) Here, there is a progressive lengthening of the PR interval to the Here, there is a progressive lengthening of the PR interval to the

point where an impulse does not reach the ventricle and a beat is point where an impulse does not reach the ventricle and a beat is dropped.dropped.

Rhythm - Regularly irregular Rhythm - Regularly irregular Rate - Normal or Slow Rate - Normal or Slow QRS Duration - Normal QRS Duration - Normal P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0. P Wave rate - Normal but faster than QRS rate P Wave rate - Normal but faster than QRS rate P-R Interval - Progressive lengthening of P-R interval until a QRS P-R Interval - Progressive lengthening of P-R interval until a QRS

complex is dropped complex is dropped


2nd Degree Block (Mobitz Type II)2nd Degree Block (Mobitz Type II) This is characterized by an occasional or cyclic block of conduction of This is characterized by an occasional or cyclic block of conduction of

an impulse without previous lengthening of conduction time.an impulse without previous lengthening of conduction time. Rhythm - Regular Rhythm - Regular Rate - Normal or Slow Rate - Normal or Slow QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 QRS Duration - Prolonged P Wave - Ratio 2:1, 3:1 P Wave rate - Normal but faster than QRS rate P Wave rate - Normal but faster than QRS rate P-R Interval - Normal or prolonged but constantP-R Interval - Normal or prolonged but constant

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION 33rdrd Degree AV Block: Degree AV Block: Usually called a complete heart block. There is a delay before the Usually called a complete heart block. There is a delay before the

idioventricular pacemaker goes in action. During this time there is no idioventricular pacemaker goes in action. During this time there is no ventricular contraction (no QRS) and often times the patient may faint. There ventricular contraction (no QRS) and often times the patient may faint. There is no impulse from the atria that is reaching the ventricle.is no impulse from the atria that is reaching the ventricle.

Rhythm - Regular Rhythm - Regular Rate - Slow (Ventricular rate Rate - Slow (Ventricular rate 20 – 40 bpm)20 – 40 bpm) QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Unrelated P Wave P Wave - Unrelated P Wave rate - Normal but faster than QRS rate rate - Normal but faster than QRS rate P-R Interval - Variation P-R Interval - Variation Complete AV block. No atrial impulses pass through the atrioventricular node Complete AV block. No atrial impulses pass through the atrioventricular node

and the ventricles generate their own rhythmand the ventricles generate their own rhythm


Right and Left Bundle Branch Blocks:Right and Left Bundle Branch Blocks:When the conduction through the right and When the conduction through the right and

left bundles are impaired, the impulse left bundles are impaired, the impulse must travel through non specialized tissue. must travel through non specialized tissue. This prolongs depolarization producing a This prolongs depolarization producing a longer QRS complex. longer QRS complex.

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITIONThe Criteria for a LBBB:The Criteria for a LBBB: -Wide QRS complex greater than .12 seconds-Wide QRS complex greater than .12 seconds -Upright, possibly notched QRS complex (RSR’) in lead I, V5 and -Upright, possibly notched QRS complex (RSR’) in lead I, V5 and

V6.V6. -Predominantly negative QRS in V1.-Predominantly negative QRS in V1. Rhythm - Regular Rhythm - Regular Rate - Normal Rate - Normal QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Ratio 1:1 P Wave - Ratio 1:1 P Wave rate - Normal and same as QRS rate P Wave rate - Normal and same as QRS rate P-R Interval - NormalP-R Interval - Normal


The Criteria for a RBBB:The Criteria for a RBBB: --Wide QRS of at least .11 secondsWide QRS of at least .11 seconds -An RSR’ in V1 and V2-An RSR’ in V1 and V2 -Wide S wave in leads I and V6.-Wide S wave in leads I and V6.

ARRHYTHMIA RECOGNITIONARRHYTHMIA RECOGNITION Ventricular rhythms:Ventricular rhythms:

These impulses are coming from the wall of the ventricles.These impulses are coming from the wall of the ventricles. Ventricular tachycardia:Ventricular tachycardia: This is a dangerous rhythm which requires immediate attention and prompt This is a dangerous rhythm which requires immediate attention and prompt

correction.correction. Rhythm - Regular Rhythm - Regular Rate - 180-190 Beats per minute Rate - 180-190 Beats per minute QRS Duration - Prolonged QRS Duration - Prolonged P Wave - Not seen Results from abnormal tissues in the ventricles generating a P Wave - Not seen Results from abnormal tissues in the ventricles generating a

rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse is unconscious and without a pulse


Ventricular fibrillation:Ventricular fibrillation: The pattern is bizarre with no rhythm of any sort. You usually have The pattern is bizarre with no rhythm of any sort. You usually have

no palpable or audible pulse.no palpable or audible pulse. Rhythm - Irregular Rhythm - Irregular Rate - 300+, disorganised Rate - 300+, disorganised QRS Duration - Not recognisable QRS Duration - Not recognisable P Wave - Not seen P Wave - Not seen This patient needs to be This patient needs to be defibrillated!! QUICKLYdefibrillated!! QUICKLY

REVIEWREVIEW

No questions will be asked for this module No questions will be asked for this module as it is for information only and you will not as it is for information only and you will not be expected to know these blocks.be expected to know these blocks.

ecg training module 4

Documents

p wave rate

consistent p waves

node normal pacemaker

minute pr interval

normal sinus rhythm

normal pattern

normal manner

rhythm regular rate