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Patrick Hegge Anatomy Heart location and size The electrocardiogram Note: Do not use this illustration for measuring PR interval. Conduction system review Consists of: Contraction of the atriums – P wave Contraction of the ventricles –QRS Complex The electrocardiogram Note: Do not use this illustration for measuring PR interval. Rhythms that if you see on the monitor you will know and can help the surgical team. Normal sinus rhythm (NSR) P waves are normal and identical P wave precedes each QRS, QRS for every P PR intervals are constant Heart rate is 60-100 bpm Sinus bradycardia Same criteria as NSR except heart rate is less than 60 bpm Sinus tachycardia Same as NSR except heart rate is between 100160 bpm. P waves are sometimes absent at higher rates. . . . . . . . . . . . A ventricular rhythm occurs when the SA and AV nodes are not firing or are too slow to be effective. RULES FOR VENTRICULAR TACHYCARDIA (V Tach) A LETHAL RHYTHM No P wave QRS > 0.12 seconds Big and wide Rate - fast > 150 PBM Usually regular but can be slightly irregular SYMPTOMS OF V TACH Chest discomfort (angina) – feels like something heavy sitting on their chest. Fainting (syncope) Light-headedness or dizziness Sensation of feeling the heart beat (palpitations) Shortness of breath (dyspnea) Note: Symptoms may start and stop suddenly. In some cases, there are no symptoms. V Tach Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM? Here’s another one Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM? IDIOVENTRICULAR 20 to 40 BPM last one Does it have a P wave? Is there a PR Interval? Do you see a QRS? (or do you see varied amplitude of possible QRS’s with no pattern) Is there any regularity – or is it chaotic? End V Fib vs V Tach Ventricular fibrillation Rapid chaotic rhythm which lacks a pattern Rate =>300 bpm (350-450 bpm – DD) Life threatening rhythm – call a code! Asystole Either a straight line EKG or chaotic imprint Life threatening – call a code! Junctional Rhythms Junctional Rhythms Junctional rhythm is an abnormal heart rhythm resulting from impulses coming from an area of the atrioventricular node the "junction" between atria and ventricles. The SA node is not working. Rules for Junctional Rhythms No P wave – or inverted P wave in lead II Not 1:1 (if no P wave) can be 1:1 if inverted P wave QRS tight ≤ 0.12 PR interval if there is one is between 0.12 and 0.20 Regular < 40 BPM Idio Junctional 40 to 60 BPM Junctional Rhythm 61 to 99 BPM Accelerated Junctional Rhythm > 100 PBM Junctional Tachycardia Question Time Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Is there a P wave? Is there an inverted P wave? If so, is it 1:1? If there is a PR interval, is it between 0.12 and 0.20 seconds? Is the QRS ≤ 0.12 seconds? Is it regular? What is the rate? Rules for Junctional Rhythms No P wave – or inverted P wave in lead II Not 1:1 (if no P wave) can be 1:1 if inverted P wave QRS tight ≤ 0.12 PR interval if there is one is between 0.12 and 0.20 Regular < 40 BPM 40 to 60 BPM 61 to 150 BPM Idio Junctional Junctional Rhythm Accelerated Junctional Rhythm or Junctional Tachycardia ATRIAL RHYTHMS Atrial rhythm resembles sinus rhythm, but originates from a different atrial focus. It can be recognized by the abnormal configuration of the p-wave. An atrial ectopic rhythm is a rhythm where the impulse formation in the atrium is coming from the wrong place. (Ectopic means out of place or from the wrong place.) We will discuss two types: Atrial Fibrillation Atrial Flutter ATRIAL FIBRILLATION Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body. During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms A number of people have no symptoms. The most common symptom in people with intermittent atrial fibrillation is palpitations, a sensation of rapid or irregular heartbeat. This may make some people very anxious. Many people also describe an irregular fluttering sensation in their chests. Some become light-headed or faint. Other symptoms include weakness, lack of energy or shortness of breath (SOB) with effort, and chest pain. The biggest complication of A Fib is a blood clot caused because the blood does not move quickly enough through the heart. RULES FOR ATRIAL FIBRILLATION (A-FIB) No P wave No PR interval QRS is ≤ 0.12 Is regularly irregular < 60 BPM still called A Fib > 100 BPM - Rapid A Fib A FIB DOESN’T ALWAYS LOOK THE SAME Let’s start by asking some questions. Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib Is there a P wave? Is there a PR interval? Is the QRS ≤ 0.12 seconds? Is it regular or regularly irregular? Don’t forget < 60 BPM still called A Fib > 100 BPM - Rapid A Fib ATRIAL FLUTTER Atrial flutter occurs when the electrical impulses take an abnormal path through the atria, typically circulating around the tricuspid valve in the right atrium. The abnormal path of the impulses makes the atria contract very rapidly. These rapid contractions are slowed when they reach the AV node often with every second or third contraction reaching the ventricle. The heart beats in a regular rhythm, but it beats rapidly. VENTRICULAR RHYTHMS A ventricular rhythm occurs when the SA and AV nodes are not firing or are too slow to be effective. RULES FOR VENTRICULAR RHYTHMS No P wave No PR interval No 1:1 QRS is wide > 0.12 Usually regular although it can be slightly irregular 20-40 BPM – Idio ventricular 40- 150 BPM - Ventricular 150- 350 BPM Ventricular tachycardia (V tach) Rules for Idioventricular Rhythms No P wave No PR interval No 1:1 QRS is wide > 0.12 Usually regular although it can be slightly irregular 20-40 BPM – Idio ventricular Ventricular Rhythm 40 – 150 BPM Ventricular Tachycardia Ventricular tachycardia (V-tach or VT) is a tachycardia, or fast heart rhythm, that originates in one of the ventricles of the heart. This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation, asystole, and sudden death. RULES FOR VENTRICULAR TACHYCARDIA (V Tach) A LETHAL RHYTHM No P wave QRS > 0.12 seconds Big and wide Rate - fast > 150 PBM Usually regular but can be slightly irregular V Tach Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM? Here’s another one Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM? Last one Does it have a P wave? Is the QRS > 0.12 seconds? Is it big and wide? Is the rate > 150 BPM? RULES FOR VENTRICULAR FIBRILLATION V FIB - A LETHAL RHYTHM No P wave Varied amplitude of QRS or indiscernible No PR interval No regularity – chaotic Time to ask some questions Does it have a P wave? Is there a PR Interval? Do you see a QRS? (or do you see varied amplitude of possible QRS’s with no pattern) Is there any regularity – or is it chaotic? More practice Does it have a P wave? Is there a PR Interval? Do you see a QRS? (or do you see varied amplitude of possible QRS’s with no pattern) Is there any regularity – or is it chaotic? Torsades de pointes Does it have a P wave? Is there a PR Interval? Do you see a QRS? (or do you see varied amplitude of possible QRS’s with no pattern) Is there any regularity – or is it chaotic? last one Does it have a P wave? Is there a PR Interval? Do you see a QRS? (or do you see varied amplitude of possible QRS’s with no pattern) Is there any regularity – or is it chaotic? End V Fib vs V Tach Any Final Questions…………………………………………