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Cardiac Dysrhythmias Of Ventricular Origin Ectopic Ventricular Dysrhythmias Premature Ventricular Contractions (PVC’s) Ventricular Tachycardia Ventricular Fibrillation Premature Ventricular Contractions PVC’s Occur In Normal Hearts As Well As Those With Pathology People With Thousands Of PVC’s Per Day Can Be Normal PVC’s Can Also Be An Ominous Sign Of Disease Characteristics Of PVC’s Are : PVC’s Are Premature Beats The P Wave Is Absent QRS Complex Is Wide & Bizarre A Compensatory Pause Follows The PVC Premature Ventricular Contractions Premature Ventricular Contractions PVC’s May Appear Randomly PVC’s May Appear In Patterns Bigeminy Trigeminy Bigeminy Bigeminy Trigeminy Quadrigeminy Couplets Triplets Couplets Triplets Couplets Are Scary But Triplets Are Really Frightening Triplets Are A Hair’s Breath Away From Ventricular Tachycardia Multiform PVC’s Rules Of Malignancy An Ordering System For Grading The Severity Of Ventricular Ectopies From Least Severe To Most Severe Frequent Single Focus PVC’s Runs Of PVC’s Quadrigeminy Trigeminy Bigeminy Appearance Of Multifocal PVC’s RT On T Phenomenon Ventricular Tachycardia Ventricular Fibrillation RT On T Phenomenon Thought To Be Very Dangerous A PVC Occurs During Ventricular Depolarization RT On T Phenomenon Why Is It Dangerous ? • The Cardiac Cells Are Various Stages Of Depolarization - Some Have Repolarized While Others Are In Various Stages Of Repolarization • A Stimulus That Occurs Before Repolarization Is Finished Will Set Off A Disorganized Electrical Response To The Stimulus & May Set The Heart Up For A Malignant Ventricular Ectopy Like V-Tach Or V-Fib. Exercise Can I Exercise A Patient Who Is Having PVC’s ? Yes, You Can Exercise A Patient Having PVC’s. However, They Should Only Be Occasional Single Focus Single PVC’s. If The Exercise Regimen Makes The Incidence Of PVC’s Occur More Often Or If The PVC’s Become More Malignant, Exercise Should Be Terminated. A Person Should Not be Exercised When They Are Displaying Multiforme PVC’s Or Any PVC Rhythm (Bigeminy, etc.) Until Cleared By Their Cardiologist The ACSM Guidelines The ACSM Guidelines State : If There Is A “Noticeable Change In Heart Rhythm”…. ...or “Signs Of Poor Perfusion: Light Headedness, Confusion, Ataxia, Pallor, Cyanosis, Nausea, Or Cold & Clammy Skin” Then STOP THE EXERCISE !!! Table 3-10, pp 42, 5th edition Ventricular Tachycardia Ventricular Tachycardia Is Defined As A Run Of Three Or More Consecutive PVC’s The Rate Is Usually Between 100-200 BPM Short Runs Of V-Tach Will Make The Patient Feel : Dizzy Have Palpitations Feel Faint Be Short Of Breath Sustained Runs OF V-Tach Will Render The Patient Unconscious Because The Cardiac Output Is So Negatively Effected As To Decrease Perfusion To The Brain & The Heart. Ventricular Tachycardia Ventricular Tachycardia Will Degenerate Quickly Into Ventricular Fibrillation The Patient In V-Tach Must Be Supported With CPR Methods & Must Be Cardioverted Electrically Or Pharmacologically Out Of This Fatal Rhythm Both V-Tach & V-Fib Are Absolute Medical Emergencies Requiring High Level Medical Management Ventricular Fibrillation V-Fib Is Seen In Hearts That Are Dying Electrical Activity is Completely Chaotic No Meaningful Cardiac Output Is Occurring V-Fib Is Characterized By : No True QRS Complexes A Wandering Or Undulating Baseline No Recognizable Atrial Wave Forms No Recognizable T Waves The Patient Must Be Supported By CPR Methods & Must Be Electrically Cardioverted Out Of This Rhythm Or Death Ensues Ventricular Fibrillation Exercise Exercise Cannot be Sustained In Patients With V-Tach Or V-Fib Because 99.99 % Of The Time They Will Be Unconscious Exercise Is Never An Option Atrioventricular Blocks First Degree AV Blocks Second Degree AV Blocks • Mobitz Type I (Wenckebach Block) • Mobitz Type II Third Degree AV Blocks First Degree AV Blocks Characterized By : • Prolonged PR Interval > 5 mm • Every QRS Is Preceded By A P Wave • Every QRS Is Normal • No Dropped Beats First Degree AV Block First Degree AV Block Causes : Drug Toxicity Ischemic Heart Disease Of The Heart’s Conduction System Myocarditis First Degree AV Block Does Appear In Healthy Individuals As Well As In Those With Ischemic Heart Disease Exercise Can I Exercise A Patient In First Degree AV Block ? Yes, But The Rhythm Must Not Degenerate During Exercise To Second Degree AV Block. Also, The Rhythm Had To Have Been Present Before Exercise Started. If A Patient Is Normal On Their EKG Before Exercise & Degenerates Into First Degree AV Block, Exercise Must Stop !! First Degree AV Block Is Generally Not Considered To Be A Highly Malignant Dysrhythmia Second Degree AV Block Mobitz Type I Or A Wenckebach Block Second Degree AV Block Or A Mobitz Type I AV Block Is Characterized By : • • • • Progressively Lengthening PR Interval A Sudden Dropped QRS Complex Return Of A Normal Rhythm A Repeating Cycle Mobitz Type I Exercise Can I Exercise A Patient In A Mobitz Type I Second Degree AV Block ? Yes, Providing The Dysrhythmia Does Not Degenerate During Exercise. The Patient Must Also Have Been Cleared For Exercise A Problem Does Exist With A Mobitz Type I AV Block !! You Have To Be Concerned That It Will Degenerate Into A Mobitz Type II AV Block Second Degree AV Block Mobitz Type II Characteristics Are : A Series Of Normal Beats All PR Intervals Are Normal Duration Sudden Dropped Beat - No QRS Normal Rhythm Re-Established Cycle Begins Again Mobitz Type II Mobitz Type II Mobitz Type II AV Block Is A Dangerous Dysrhythmia Because Of The High Likelihood That It Will Convert To A Third Degree AV Block. Exercise Can I Exercise A Patient In A Mobitz Type II AV Block ? No. The Risk Is Too High That The Patient Will Convert To Third Degree AV Block. A Patient With A Mobitz Type II AV Block Is Going Eventually Convert To A Third Degree Block & Is A Candidate For A Surgically Implanted Pacemaker Third Degree AV Block This Is A Serious Condition In Which There Is No Communication Of The SA Node With The AV Node. It Is Also Called Complete Heart Block. The Atria Beat At Their Own Rate While The Ventricles Beat At Their Own Rate The P Waves Appear & Are Not Connected To Any QRS Complex The QRS Are Abherrantly Wide Ultimate Ventricular Rate Is Often Very Bradycardic 3rd Degree AV Block Most Patients In Third Degree AV Block Require The Implantation Of A Pacemaker. Bundle Branch Blocks Right Bundle Branch Block RSR’ (Bunny Ears) In V1-V4 Loss Of The R Wave Progression ST Segment Depression In V1 - V4 T Wave Inversion In V1 - V4 Wide QRS Complexes Can you exercise a patient in RBBB ? Yes as long as they have been cleared by their physician. Left Bundle Branch Block Loss of the R wave progression Huge S waves in V1 - V4 RSR’ in V4 - V6 Wide QRS complexes ST segment depression in V4 - V6 T Wave inversion in V4 - V6 Can you exercise a person in LBBB ? Yes, as long as the patient has been cleared by their physician.