PRASANTH.K
POST GRADUATION IN CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA HOSPITAL AND COLLEGE OF
NURSING
BANGALURU
12/6/...
PHYSIOLOGY BEHINED
THE ECG

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PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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Limb electrodes
1. Augmented limb leads/unipolar leads
2. Bipolar leads
Chest leads / precordial leads

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PRASANT...
See chest leads

V2
V3
V6
V5
V4

V1

Lead 1

aVR

aVL

Lead 2

RL(-)
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Lead 3

aVF
PRASANTH.K, CARDIOTHORACIC NUR...
Mid
clavicular
line
V3- mid way between V2
and V4

V1 fourth intercostal
space at right sternal
margin
Anterior
axillary
l...
ECG waves …

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NARAYANA HRUDAYALAYA

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ECG GRAPH PAPER

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NARAYANA HRUDAYALAYA

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paper

.1 mv

Voltage

.5 mv

.04 seconds

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Time

.20 seconds

PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUD...
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NARAYANA HRUDAYALAYA

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THE DIFFERENT PARTS OF THE ECG
ECG machines run at a standard rate of 25mm/s
5mm = 0.2 seconds
There are 5 squares / secon...
Intervals show timing of cardiac cycle
–
–
–
–

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P-P = one cardiac cycle
P-Q = time for atrial depolarization
Q-...
SEE THE TIME INTERVALS
R
ST
segment

PR
segment

T

P

U
Q
S

.12 - .20
sec

<.10
sec

.35 - .45
sec

QT
PR
QRS
interval
i...
P -1st wave of ECG
Due to atrial contraction

 Not >2-3 mm in height

 Not >0.11 sec in duration
 Shape – gently rounde...
Abnormalities of P wave
 Inverted: ectopic atrial or A-V junctional rhythm.

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Increased amplitude: atrial hypertrophy
or dilatation

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PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA...
Absence of P wave:A-V junctional
rhythm & SA block or atrial fibrilation
.

• It is an atrial fibrilation here we cannote
...
QRS– Complex- The ventricular mass is large so
there is a large deflection of the ECG when ventricles
are depolarized

 D...
Abnormalities of QRS Complex
 Duration :- More than 0.12 sec – abnormal intra
ventricular conduction

In this strip a nor...
Amplitude :- Low – diffuse coronary
disease, cardiac failure, pericardial
effusion.

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NARAYANA HRUDAYALAYA

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Amplitude :- High – Left or right
Ventricular Hypertrophy.

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PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAY...
ST segment :-. ST” ELEVATION
 Acute / post myocardial infarction
 Prinzmetal’s angina.
 Hyperkalemia.

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PRASA...
A rhythm with ST elevation

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NARAYANA HRUDAYALAYA

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T- Wave
The return of the
ventricular mass to its resting
electrical state (repolarization )
Recovery period of ventricles...
ABNORMALITIES
Inversion: myocardial ischemia

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NARAYANA HRUDAYALAYA

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Notching: Pericarditis

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NARAYANA HRUDAYALAYA

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Unusually tall T waves: Acute Myocardial
Infarction ,hyperkalemia, myocardial ischemia.

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PRASANTH.K, CARDIOTHOR...
U wave - In some ECGs an extra wave
can be seen on the end of the T wave.
Usually not seen unless patients serum
potassium...
NORMAL RHYTHM

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NARAYANA HRUDAYALAYA

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CALCULATION OF HEART RATE FROM
AN ECG STRIP

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NARAYANA HRUDAYALAYA

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The 1500 Method

• Count the number of small boxes between
two R waves and divide this number into
1500 to obtain the HR/m...
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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

‹#›
SINUS NODE DYSRHYTHMIAS

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NARAYANA HRUDAYALAYA

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SINUS BRADYCARDIA.
• Sinus bradycardia
• Relative bradycardia

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NARAYANA HRU...
CAUSES
• Lower metabolic needs
eg, sleep, athletic training,
hypothermia, hypothyroidism
• Vagal stimulation
eg, from vomi...
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NARAYANA HRUDAYALAYA

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• Ventricular and atrial rate: Less than 60 in the
adult
• PR interval: Consistent interval between 0.12
and 0.20 seconds....
Sign and symptoms
Decrease in heart rate
Shortness of breath
Decreased LOC
Angina
Hypotension
ST-segment changes
Premature...
Treatment
• Treatment is directed toward increasing the
heart rate.
• If the bradycardia is from a medication such as
a be...
SINUS TACHYCARDIA

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NARAYANA HRUDAYALAYA

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Etiology
Acute blood loss
Anemia
Shock

Hypervolemia
Hypovolemia

Congestive heart failure
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Pain
Hypermetabolic states
Fever,
Exercise
Anxiety

Sympathomimetic medications.
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PRASANTH.K, CARDIOTHORACIC NUR...
• Medicine – epinephrine, atropine,
theophilline, nifedipine , or hydralazine .

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NARAYANA HRUDAYALAYA

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1.Ventricular and atrial rate: Greater than 100 in
the adult
2.P wave: Normal and consistent shape; always
in front of the...
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NARAYANA HRUDAYALAYA

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Sign and symptoms
• Reduced cardiac output

• syncope and low blood pressure.
• Acute pulmonary edema.

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PRASANT...
Treatment
• Calcium channel blockers (reduce HR and
decrease myocardial oxygen consumption)
– Nifedipine
– Nicardipine
– V...
ATRIAL DYSRHYTHMIAS

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NARAYANA HRUDAYALAYA

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PREMATURE ATRIAL COMPLEX.

Premature – term refers to the
incompleteness of the electrical
activity from the SA node
The P...
PAC is a single ECG
complex that occurs when an
electrical impulse starts in the atrium
before the next normal impulse of ...
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NARAYANA HRUDAYALAYA

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Etiology
1. Alcohol
2. Nicotine
3. Stretched atrial myocardium (as in hypervolemia)
4. Anxiety
5. Hypokalemia (low potassi...
ECG characteristics
Ventricular and atrial rate: Depends on the

underlying rhythm (eg, sinus tachycardia)
Ventricular a...
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NARAYANA HRUDAYALAYA

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P wave: An early and different P wave may be
seen or may be hidden in the T wave
PR interval: The early P wave has a sho...
Sign and symptoms
• PACs are common in normal hearts. The
patient may say,“My heart skipped a beat.”
• A pulse deficit may...
Treatment
• If PACs are infrequent, no treatment is
necessary.
• Caffeine or sympathomimetic drugs may be
warrented.
• Tre...
ATRIAL FLUTTER.
Atrial flutter occurs when the
atrium creates impulses at rate of 250 - 400
times per minute.
Here atrial ...
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NARAYANA HRUDAYALAYA

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The atrial rate is
faster than the AV node can
conduct, not all atrial impulses
are conducted into the
ventricle, causing ...
• There will be single recurring saw toothed
waves which originates from a single ectopic
focus in the right atrium.

12/6...
Etiology
•
•
•
•
•
•
•
•

CAD
HTN
Mitral valve disorders
Pulmonary embolus
Cor pulmonale
Cardiomyopathy
Hyperthyroidism
Dr...
7. Pulmonary disease

8. Acute moderate to heavy ingestion
of alcohol (“holiday heart”
syndrome)

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NARAYANA HRUDAYALAYA

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ECG characteristics
1.Atrial rate -220 - 430;
2.ventricular rate -75 – 150
(< 300).
3. QRS shape and duration:
Usually nor...
4. P wave: Saw-toothed shape.
(F waves.)
5.PR interval: Multiple F

waves may make it difficult
to determine the PR

inter...
Sign and symptoms
• Chest pain
• Shortness of breath
• Low blood pressure.

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PRASANTH.K, CARDIOTHORACIC NURSING,...
Treatment
• For unstable patient - electrical cardioversion .
• For stable patient –
Diltiazem ,verapamil
beta-blockers, o...
ATRIAL FIBRILLATION.
Atrial fibrillation causes
a rapid, disorganized ,and
uncoordinated twitching of atrial
musculature ....
Etiology
•
•
•
•
•
•

Causes are similar to atrial flutter.
Cardiomyopathy
RHD
HTN
HF
Pericarditis

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PRASANTH.K,...
•
•
•
•
•
•
•

Thyrotoxication
CAD
Alcohol intoxication
Caffeine use
Electrolyte disturbence
Stress
Cardiac surgery

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NARAYANA HRUDAYALAYA

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ECG characteristics
1. Atrial rate is 350 to 650.
2. Ventricular rate - slow to rapid.
3. Ventricular and atrial rhythm: H...
Treatment
• Usually converts to sinus rhythm within 24 hours

without treatment.
• Calcium channel blocker. - ditiazem

• ...
• Antidysrhythmia medication- propafenone,
procainamid,amiodarone.
• HF/LV dysfunction<40% - amiodarone, DC
cardioversion....
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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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• Radiofrequency catheter ablation
(MAZE procedure)
cryoablation
High intensity ultrasound

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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NARAYANA HRUDAYALAYA

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JUNCTIONAL DYSRHYTHMIAS

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NARAYANA HRUDAYALAYA

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JUNCTIONAL RHYTHM
Junctional or idionodal
rhythm occurs when the AV node,
instead of the sinus node, becomes
the pacemaker...
ETIOLOGY
• RHD
• IWMI
• Electrolyte imbalance
• CAD
• Drugs
Digoxin,amphetmines,caffeine,nicotine.
• Cardiomyopathy
12/6/2...
SA node failed
to produce
AV node start
acting as the
natural pace
maker

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PRASANTH.K, CARDIOTHORACIC NURSING,
N...
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NARAYANA HRUDAYALAYA

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ECG characteristics
1.Ventricular rate 40 to 60; atrial rate also 40
to 60
2.P wave: May be absent, after the QRS
complex,...
Sign and symptoms
• Junctional rhythm may produce signs and
symptoms of reduced cardiac output

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PRASANTH.K, CAR...
Treatment
The treatment is the same as for sinus
bradycardia.
 Emergency pacing may be needed.

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PRASANTH.K, C...
• Accelerated junctional rhythm and junctinal
tachycardia –digoxin toxycity
With held Digoxin

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PRASANTH.K, CARD...
ATRIOVENTRICULAR NODAL
REENTRY TACHYCARDIA.

AV nodal re-entry tachycardia
occurs when an impulse is
conducted to an area ...
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NARAYANA HRUDAYALAYA

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Each time the impulse
is conducted through this area,
it is also conducted down into
the ventricles, causing a fast
ventri...
AV nodal reentry tachycardia. In
yellow, is evidenced the P wave that
falls after the QRS complex.
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PRASANTH.K, ...
ECG CHARACTERISTICS
1.Atrial rate - 150 to 250; ventricular rate - 75 to
250
2.QRS shape and duration: normal or abnormal
...
Sign and symptoms
 Palpitations

 Restlessness
 Chest pain
 Shortness of breath
 Pallor
 Hypotension

 Loss of cons...
Treatment
• Treatment is aimed at breaking the reentry of the

impulse.
• Vagal maneuvers.
• If the vagal maneuvers are in...
VAGALMANEUVERS
• Valsalva maneuver
The Valsalva maneuver or Valsalva manoeuvre
is performed by moderately forceful
attempt...
• It works by increasing intra-thoracic pressure
and affecting baro-receptors (pressure
sensors) within the arch of the ao...
• Holding ones breath for a few seconds,
coughing, plunging the face into cold water,
(via the diving reflex), drinking a ...
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NARAYANA HRUDAYALAYA

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VENTRICULAR DYSRHYTHMIAS

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NARAYANA HRUDAYALAYA

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PREMATURE VENTRICULAR
COMPLEX
(PVC) is an impulse that starts in a ventricle and
is conducted through the ventricles befor...
• Normally impulses pass through both
ventricles almost simultaneously, the
depolarisation waves of the two ventricles
par...
• However, when a PVC occurs the impulse
nearly always travels in one direction
therefore there is no neutralisation effec...
•
•
•
•

Multifocal
Unifocal
Bigeminy
Trigeminy

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NARAYANA HRUDAYALAYA

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PHYSIOLOGICAL EXPLANATIONS FOR
PREMATURE VENTRICULAR
CONTRACTIONS:
• Re-entrant signaling
or
• Enhanced automaticity in so...
ETIOLOGY
1.Caffeine, nicotine, or alcohol.
2. Cardiac ischemia or infarction.
3.Digitalis toxicity.
4.Hypoxia.
5.Acidosis....
ECG characteristics
• (1) more frequent than 6 per minute,AV nodal reentry

tachycardia in lead II.
• (2) multifocal or po...
In a rhythm called bigeminy, every
other complex is a PVC.

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NARAYANA HRUDAY...
Trigeminy is a rhythm in which every
third complex is a PVC.

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NARAYANA HRUD...
Quadrigeminy is a rhythm in which
every fourth complex is a PVC.

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PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA ...
1.QRS -Duration is 0.12 seconds or longer;
shape is bizarre and abnormal

2.P wave: Visibility of P wave depends
3.PR inte...
Sign and symptoms
The patient may feel a “skipped heart beat.”
Complaints of angina and heart failure

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PRASANTH...
Treatment
• Initial treatment is aimed at correcting the
cause.
• Beta adrenergic blockers
• Lidocaine - as short-term the...
VENTRICULAR TACHYCARDIA.
Three or more PVCs in a row, occurring at a rate
exceeding 100 beats per minute.

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PRAS...
MONOMORPHIC VT

POLYMORPHIC VT(torsades de
points)

QRS complex are same in Different shape direction
shape, size and dire...
ETIOLOGY
Causes are similar to PVC
Usually associated with coronary artery disease

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PRASANTH.K, CARDIOTHORACIC ...
ECG CHARACTERISTICS

1.Ventricular rate - 100 to 200 beats per minute
2.QRS : Duration is 0.12 seconds or more;
bizarre, a...
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NARAYANA HRUDAYALAYA

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Treatment
• VT is an emergency because the patient is
usually unresponsive and pulseless.

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PRASANTH.K, CARDIOTH...
• Monomorphic + hemodynamicaly stable +
preserved left ventricular function –
IV procainamide
Sotalol
Amidarone
lidocaine
...
• Hemodynamically unstable + poor left
ventricular function –
IV amiodarone/lidocaine
Cardioversion

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PRASANTH.K...
• Hemodynamically unstable + polymorphic VT
+ nomal base line QT intervl
Beta adrenergic blockers
Lidocaine
Amidarone
Proc...
• Hemodynamically unstable + polymorphic VT
+ nomal base line QT intervl
Beta adrenergic blockers
Lidocaine
Amidarone
Proc...
• Polymorphic VT + prolonged baseline QT
interval
IV magnesium
Isoproterenol
Phenytoin
Lidocaine
Antitachycardia pacing
ca...
• VT with out pulse
Life tretening situation
CPR
Rapid defibrillation
Epinephrine.

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PRASANTH.K, CARDIOTHORACIC ...
PAROXYSMAL SUPRAVENTRICULAR
TACHYCARDIA.
• PSVT originates in an ectopic focus anywhere
above the bifurcation of the bundl...
ETIOLOGY
•
•
•
•
•

Wolff parkinson- white (WPW)/preexcitation
Overexertion
Emotional stress
Deep inspiration
Stimulants

...
•
•
•
•
•
•

Caffeine
Tobacco
RHD
Digitalis toxicity
CAD
Cor pulmonale

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PRASANTH.K, CARDIOTHORACIC NURSING,
NAR...
TREATMENT
•
•
•
•
•
•
•
•

Vagal maneuvers – valsalva and coughing
IV adenosine(Half life – 10sec)
IV adrenergic blockers
...
VENTRICULAR FIBRILLATION.
Rapid but disorganized ventricular rhythm
Causes ineffective quivering of the ventricles.
Wit...
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NARAYANA HRUDAYALAYA

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Etiology
• Causes of ventricular fibrillation are the same
as for VT

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PRASANTH.K, CARDIOTHORACIC NURSING,
NARAY...
ECG CHARACTERISTICS
1. Ventricular rate: Greater than 300 per minute

2. Ventricular rhythm: Extremely irregular, without
...
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Treatment
CPR
ACLS measures
Defibrillation

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VENTRICULAR
ASYSTOLE/COMMONLY CALLED
FLATLINE

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ETIOLOGY
• Advanced cardiac disease
• End stage HF
• Severe conduction system disturbences

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PRASANTH.K, CARDIOT...
ECG CHARACTERISTICS
• Absent QRS complexes
• P waves may be apparent for a short duration

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PRASANTH.K, CARDIOTH...
Sign and symptoms
• There is no heartbeat, no palpable pulse, and
no respiration

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PRASANTH.K, CARDIOTHORACIC NU...
Treatment
A fatal condition.
• Cardiopulmonary resuscitation
• Transcutaneous pacing

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PRASANTH.K, CARDIOTHORACI...
• A bolus of intravenous epinephrine should be
administered and repeated at 3- to 5-minute
intervals
Followed by 1-mg bolu...
CONDUCTION ABNORMALITIES

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AV BLOCKS
AV blocks occur when the conduction of the
impulse through the AV nodal area is decreased
or stopped.

12/6/2013...
COMMON ETIOLOGICAL
FACTORES
• Medications like digitalis, calcium channel
blockers, beta-blockers.
• Myocardial ischemia a...
AV block

1st degree

3RD degree
2nd degree

M1
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M2
PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA

15...
first-degree AV block
• rarely causes any hemodynamic effect.
• First-degree heart block occurs when all the
atrial impuls...
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NARAYANA HRUDAYALAYA

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ECG characteristics
• PR interval: Greater than 0.20 seconds
• P: QRS ratio: 1:1

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PRASANTH.K, CARDIOTHORACIC NU...
SECOND-DEGREE
ATRIOVENTRICULAR BLOCK
• Type I. Second-degree,
•

type I heart block occurs when all but one

of the atrial...
type1
• The RR interval reflects a pattern of change.
• Starting from the RR that is the longest, the
RR interval graduall...
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NARAYANA HRUDAYALAYA

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• PR interval: PR interval becomes longer
with each succeeding

• ECG complex until there is a P wave not
followed by a QR...
SECOND-DEGREE
ATRIOVENTRICULAR BLOCK,
TYPE II.
• Second-degree,type II heart block occurs when
only some of the atrial imp...
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NARAYANA HRUDAYALAYA

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ECG characteristics
• PR interval: PR interval is constant for those P
waves just before QRS complexes.
• P: QRS ratio: 2:...
THIRD-DEGREE ATRIOVENTRICULAR
BLOCK.
• No atrial impulse is conducted through the AV
node into the ventricles.
• P waves m...
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CHARACTERISTICS
• PR interval: Very irregular

• P: QRS ratio: More P waves than QRS
complexes

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PRASANTH.K, CAR...
1st degree HB

•No treatement
•Modifications
to causative
medications
•Continuous
montoring

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2nd degree HB

MOR...
12/6/2013

PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA

173
12/6/2013

PRASANTH.K, CARDIOTHORACIC NURSING,
NARAYANA HRUDAYALAYA

174
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Dysrrhythmia, major arrhythmias and management, bascs of ECG.

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Transcript of "Dysrrhythmia, major arrhythmias and management, bascs of ECG. "

  1. 1. PRASANTH.K POST GRADUATION IN CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA HOSPITAL AND COLLEGE OF NURSING BANGALURU 12/6/2013 1
  2. 2. PHYSIOLOGY BEHINED THE ECG 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 2
  3. 3. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 3
  4. 4. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 4
  5. 5. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 5
  6. 6. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 6
  7. 7. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 7
  8. 8. Limb electrodes 1. Augmented limb leads/unipolar leads 2. Bipolar leads Chest leads / precordial leads 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 8
  9. 9. See chest leads V2 V3 V6 V5 V4 V1 Lead 1 aVR aVL Lead 2 RL(-) 12/6/2013 Lead 3 aVF PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA Show lead placement from 9 beginning
  10. 10. Mid clavicular line V3- mid way between V2 and V4 V1 fourth intercostal space at right sternal margin Anterior axillary line V4 fifth intercostal space at mid clavicular line Mid axillary line V2 fourth intercostal space left sternal margin V6 mid axillary line horizontal level of V4 and V5 V5 anterior axillary line at 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA horizontal level of lead 4 10
  11. 11. ECG waves … 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 11
  12. 12. ECG GRAPH PAPER 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 12
  13. 13. paper .1 mv Voltage .5 mv .04 seconds 12/6/2013 Time .20 seconds PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 13
  14. 14. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 14
  15. 15. THE DIFFERENT PARTS OF THE ECG ECG machines run at a standard rate of 25mm/s 5mm = 0.2 seconds There are 5 squares / seconds = 300/mnt 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 15
  16. 16. Intervals show timing of cardiac cycle – – – – 12/6/2013 P-P = one cardiac cycle P-Q = time for atrial depolarization Q-T = time for ventricular depolarization T-P = time for relaxation PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 16
  17. 17. SEE THE TIME INTERVALS R ST segment PR segment T P U Q S .12 - .20 sec <.10 sec .35 - .45 sec QT PR QRS interval interval width PRASANTH.K, CARDIOTHORACIC NURSING, 12/6/2013 NARAYANA HRUDAYALAYA 17
  18. 18. P -1st wave of ECG Due to atrial contraction  Not >2-3 mm in height  Not >0.11 sec in duration  Shape – gently rounded 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 18
  19. 19. Abnormalities of P wave  Inverted: ectopic atrial or A-V junctional rhythm. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 19
  20. 20. Increased amplitude: atrial hypertrophy or dilatation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 20
  21. 21. Absence of P wave:A-V junctional rhythm & SA block or atrial fibrilation . • It is an atrial fibrilation here we cannote identify any P waves. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 21
  22. 22. QRS– Complex- The ventricular mass is large so there is a large deflection of the ECG when ventricles are depolarized  Duration - 0.05 to 0.1 sec 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 22
  23. 23. Abnormalities of QRS Complex  Duration :- More than 0.12 sec – abnormal intra ventricular conduction In this strip a normal QRS complex is followed by and abnormal QRS complex ,that is widened . 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 23
  24. 24. Amplitude :- Low – diffuse coronary disease, cardiac failure, pericardial effusion. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 24
  25. 25. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 25
  26. 26. Amplitude :- High – Left or right Ventricular Hypertrophy. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 26
  27. 27. ST segment :-. ST” ELEVATION  Acute / post myocardial infarction  Prinzmetal’s angina.  Hyperkalemia. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 27
  28. 28. A rhythm with ST elevation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 28
  29. 29. T- Wave The return of the ventricular mass to its resting electrical state (repolarization ) Recovery period of ventricles. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 29
  30. 30. ABNORMALITIES Inversion: myocardial ischemia 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 30
  31. 31. Notching: Pericarditis 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 31
  32. 32. Unusually tall T waves: Acute Myocardial Infarction ,hyperkalemia, myocardial ischemia. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 32
  33. 33. U wave - In some ECGs an extra wave can be seen on the end of the T wave. Usually not seen unless patients serum potassium level is low. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 33
  34. 34. NORMAL RHYTHM 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 34
  35. 35. CALCULATION OF HEART RATE FROM AN ECG STRIP 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 35
  36. 36. The 1500 Method • Count the number of small boxes between two R waves and divide this number into 1500 to obtain the HR/min. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 36
  37. 37. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 37
  38. 38. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 38
  39. 39. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA ‹#›
  40. 40. SINUS NODE DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 40
  41. 41. SINUS BRADYCARDIA. • Sinus bradycardia • Relative bradycardia 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 41
  42. 42. CAUSES • Lower metabolic needs eg, sleep, athletic training, hypothermia, hypothyroidism • Vagal stimulation eg, from vomiting, suctioning, severe pain, extreme emotions • Medications eg, calcium channel blockers, amiodarone, beta-blockers • Increased intracranial pressure. • Myocardial infarction (MI), especially of the inferior wall. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 42
  43. 43. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 43
  44. 44. • Ventricular and atrial rate: Less than 60 in the adult • PR interval: Consistent interval between 0.12 and 0.20 seconds. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 44
  45. 45. Sign and symptoms Decrease in heart rate Shortness of breath Decreased LOC Angina Hypotension ST-segment changes Premature ventricular complexes. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 45
  46. 46. Treatment • Treatment is directed toward increasing the heart rate. • If the bradycardia is from a medication such as a beta-blocker, the medication may be with held. • Atropine, 0.5 to 1.0 mg given rapidly as an intravenous (IV) bolus. • Pace make therapy may be required. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 46
  47. 47. SINUS TACHYCARDIA 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 47
  48. 48. Etiology Acute blood loss Anemia Shock Hypervolemia Hypovolemia Congestive heart failure 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 48
  49. 49. Pain Hypermetabolic states Fever, Exercise Anxiety Sympathomimetic medications. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 49
  50. 50. • Medicine – epinephrine, atropine, theophilline, nifedipine , or hydralazine . 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 50
  51. 51. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 51
  52. 52. 1.Ventricular and atrial rate: Greater than 100 in the adult 2.P wave: Normal and consistent shape; always in front of the QRS, but may be buried in the preceding T wave 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 52
  53. 53. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 53
  54. 54. Sign and symptoms • Reduced cardiac output • syncope and low blood pressure. • Acute pulmonary edema. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 54
  55. 55. Treatment • Calcium channel blockers (reduce HR and decrease myocardial oxygen consumption) – Nifedipine – Nicardipine – Verapamil • beta-blockers -propanolol - Atenolol • I/V- Adenosine 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 55
  56. 56. ATRIAL DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 56
  57. 57. PREMATURE ATRIAL COMPLEX. Premature – term refers to the incompleteness of the electrical activity from the SA node The P wave can form premature and early Some time P wave will be hidden also. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 57
  58. 58. PAC is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 58
  59. 59. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 59
  60. 60. Etiology 1. Alcohol 2. Nicotine 3. Stretched atrial myocardium (as in hypervolemia) 4. Anxiety 5. Hypokalemia (low potassium level) 6. Hypermetabolic states, or atrial ischemia, injury, or infarction. 7. Often seen with sinus tachycardia. 8. COPD 9. CAD 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 60
  61. 61. ECG characteristics Ventricular and atrial rate: Depends on the underlying rhythm (eg, sinus tachycardia) Ventricular and atrial rhythm: Irregular due to early P waves, creating a PP interval that is shorter than the others. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 61
  62. 62. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 62
  63. 63. P wave: An early and different P wave may be seen or may be hidden in the T wave PR interval: The early P wave has a shorterthan-normal PR interval, but still between 0.12 and 0.20 seconds. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 63
  64. 64. Sign and symptoms • PACs are common in normal hearts. The patient may say,“My heart skipped a beat.” • A pulse deficit may exist. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 64
  65. 65. Treatment • If PACs are infrequent, no treatment is necessary. • Caffeine or sympathomimetic drugs may be warrented. • Treatment is directed toward the cause. • Beta adrenergic blockers may be used to decrease PACs. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 65
  66. 66. ATRIAL FLUTTER. Atrial flutter occurs when the atrium creates impulses at rate of 250 - 400 times per minute. Here atrial rate is faster than the AV node can conduct so not all atrial impulses are conducted into the ventricle causing a therapeutic block at the AV node. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 66
  67. 67. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 67
  68. 68. The atrial rate is faster than the AV node can conduct, not all atrial impulses are conducted into the ventricle, causing a therapeutic block at the AV node. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 68
  69. 69. • There will be single recurring saw toothed waves which originates from a single ectopic focus in the right atrium. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 69
  70. 70. Etiology • • • • • • • • CAD HTN Mitral valve disorders Pulmonary embolus Cor pulmonale Cardiomyopathy Hyperthyroidism Drugs- digoxine, quinidine, epinephrine. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 70
  71. 71. 7. Pulmonary disease 8. Acute moderate to heavy ingestion of alcohol (“holiday heart” syndrome) 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 71
  72. 72. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 72
  73. 73. ECG characteristics 1.Atrial rate -220 - 430; 2.ventricular rate -75 – 150 (< 300). 3. QRS shape and duration: Usually normal/ but may be abnormal /may be absent 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 73
  74. 74. 4. P wave: Saw-toothed shape. (F waves.) 5.PR interval: Multiple F waves may make it difficult to determine the PR interval. 6.P: QRS ratio: 2:1, 3:1, or 4:1 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 74
  75. 75. Sign and symptoms • Chest pain • Shortness of breath • Low blood pressure. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 75
  76. 76. Treatment • For unstable patient - electrical cardioversion . • For stable patient – Diltiazem ,verapamil beta-blockers, or digitalis I/V - to slow the ventricular rate. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 76
  77. 77. ATRIAL FIBRILLATION. Atrial fibrillation causes a rapid, disorganized ,and uncoordinated twitching of atrial musculature . It may start and stop suddenly. Atrial fibrillation may occur for a very short time (paroxysmal), or it may be chronic. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 77
  78. 78. Etiology • • • • • • Causes are similar to atrial flutter. Cardiomyopathy RHD HTN HF Pericarditis 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 78
  79. 79. • • • • • • • Thyrotoxication CAD Alcohol intoxication Caffeine use Electrolyte disturbence Stress Cardiac surgery 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 79
  80. 80. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 80
  81. 81. ECG characteristics 1. Atrial rate is 350 to 650. 2. Ventricular rate - slow to rapid. 3. Ventricular and atrial rhythm: Highly irregular 4. P wave: irregular undulating waves referred as fibrillatory waves (f waves) 5. PR interval: Cannot be measured 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 81
  82. 82. Treatment • Usually converts to sinus rhythm within 24 hours without treatment. • Calcium channel blocker. - ditiazem • Beta adrenergic blockers.- metoprolol, • Digoxin • Cardioversion. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 82
  83. 83. • Antidysrhythmia medication- propafenone, procainamid,amiodarone. • HF/LV dysfunction<40% - amiodarone, DC cardioversion. • Trans esophageal echocardiogram • >48 hrs – warferin-3-4 weeks before cardioversion 4-6 hrs after cardioversion 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 83
  84. 84. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 84
  85. 85. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 85
  86. 86. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 86
  87. 87. • Radiofrequency catheter ablation (MAZE procedure) cryoablation High intensity ultrasound 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 87
  88. 88. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 88
  89. 89. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 89
  90. 90. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 90
  91. 91. JUNCTIONAL DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 91
  92. 92. JUNCTIONAL RHYTHM Junctional or idionodal rhythm occurs when the AV node, instead of the sinus node, becomes the pacemaker of the heart. When the sinus node slows or when the impulse cannot be conducted through the AV node , the AV node automatically discharges an impulse. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 92
  93. 93. ETIOLOGY • RHD • IWMI • Electrolyte imbalance • CAD • Drugs Digoxin,amphetmines,caffeine,nicotine. • Cardiomyopathy 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 93
  94. 94. SA node failed to produce AV node start acting as the natural pace maker 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 94
  95. 95. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 95
  96. 96. ECG characteristics 1.Ventricular rate 40 to 60; atrial rate also 40 to 60 2.P wave: May be absent, after the QRS complex, or before the QRS; may be inverted, 3.PR interval: If P wave is in front of the QRS, PR interval is less than 0.12 second. 4.P: QRS ratio: 1:1 or 0:1 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 96
  97. 97. Sign and symptoms • Junctional rhythm may produce signs and symptoms of reduced cardiac output 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 97
  98. 98. Treatment The treatment is the same as for sinus bradycardia.  Emergency pacing may be needed. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 98
  99. 99. • Accelerated junctional rhythm and junctinal tachycardia –digoxin toxycity With held Digoxin 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 99
  100. 100. ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA. AV nodal re-entry tachycardia occurs when an impulse is conducted to an area in the AV node that causes the impulse to be rerouted back into the same area over and over again at a very fast rate. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 100
  101. 101. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 101
  102. 102. Each time the impulse is conducted through this area, it is also conducted down into the ventricles, causing a fast ventricular rate. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 102
  103. 103. AV nodal reentry tachycardia. In yellow, is evidenced the P wave that falls after the QRS complex. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 103
  104. 104. ECG CHARACTERISTICS 1.Atrial rate - 150 to 250; ventricular rate - 75 to 250 2.QRS shape and duration: normal or abnormal 3.P wave: Usually very difficult to discern 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 104
  105. 105. Sign and symptoms  Palpitations  Restlessness  Chest pain  Shortness of breath  Pallor  Hypotension  Loss of consciousness. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 105
  106. 106. Treatment • Treatment is aimed at breaking the reentry of the impulse. • Vagal maneuvers. • If the vagal maneuvers are ineffective, a bolus of adenosine, verapamil, or diltiazem. • Cardioversion for the unstable or unresponsive patient. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 106
  107. 107. VAGALMANEUVERS • Valsalva maneuver The Valsalva maneuver or Valsalva manoeuvre is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 107
  108. 108. • It works by increasing intra-thoracic pressure and affecting baro-receptors (pressure sensors) within the arch of the aorta. It is carried out by asking the patient to hold their breath and try to exhale forcibly as if straining during a bowel movement, or by getting them to hold their nose and blow out against it 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 108
  109. 109. • Holding ones breath for a few seconds, coughing, plunging the face into cold water, (via the diving reflex), drinking a glass of ice cold water, and standing on one's head. • Carotid sinus massage, carried out by firmly pressing the bulb at the top of one of the carotid arteries in the neck, is effective but is often not recommended due to risks of stroke in those with plaque in the carotid arteries. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 109
  110. 110. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 110
  111. 111. VENTRICULAR DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 111
  112. 112. PREMATURE VENTRICULAR COMPLEX (PVC) is an impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 112
  113. 113. • Normally impulses pass through both ventricles almost simultaneously, the depolarisation waves of the two ventricles partially cancel each other out in the ECG. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 113
  114. 114. • However, when a PVC occurs the impulse nearly always travels in one direction therefore there is no neutralisation effect which results in the high voltage QRS wave in the electrocardiograph. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 114
  115. 115. • • • • Multifocal Unifocal Bigeminy Trigeminy 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 115
  116. 116. PHYSIOLOGICAL EXPLANATIONS FOR PREMATURE VENTRICULAR CONTRACTIONS: • Re-entrant signaling or • Enhanced automaticity in some ectopic focus. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 116
  117. 117. ETIOLOGY 1.Caffeine, nicotine, or alcohol. 2. Cardiac ischemia or infarction. 3.Digitalis toxicity. 4.Hypoxia. 5.Acidosis. 6.Electrolyte imbalances, especially hypokalemia. 7.Valve prolapse 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 117
  118. 118. ECG characteristics • (1) more frequent than 6 per minute,AV nodal reentry tachycardia in lead II. • (2) multifocal or polymorphic (having different shapes) • (3) occur two in a row (pair). • (4) Occur on the T wave have not been found to be precursors of VT 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 118
  119. 119. In a rhythm called bigeminy, every other complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 119
  120. 120. Trigeminy is a rhythm in which every third complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 120
  121. 121. Quadrigeminy is a rhythm in which every fourth complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 121
  122. 122. 1.QRS -Duration is 0.12 seconds or longer; shape is bizarre and abnormal 2.P wave: Visibility of P wave depends 3.PR interval: If the P wave is in front of the QRS, the PR interval is less than 0.12 seconds. 4.P: QRS ratio: 0:1; 1:1 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 122
  123. 123. Sign and symptoms The patient may feel a “skipped heart beat.” Complaints of angina and heart failure 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 123
  124. 124. Treatment • Initial treatment is aimed at correcting the cause. • Beta adrenergic blockers • Lidocaine - as short-term therapy . 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 124
  125. 125. VENTRICULAR TACHYCARDIA. Three or more PVCs in a row, occurring at a rate exceeding 100 beats per minute. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 125
  126. 126. MONOMORPHIC VT POLYMORPHIC VT(torsades de points) QRS complex are same in Different shape direction shape, size and direction and size. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 126
  127. 127. ETIOLOGY Causes are similar to PVC Usually associated with coronary artery disease 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 127
  128. 128. ECG CHARACTERISTICS 1.Ventricular rate - 100 to 200 beats per minute 2.QRS : Duration is 0.12 seconds or more; bizarre, abnormal shape 3.P wave: Very difficult to detect, so atrial rate and rhythm may be indeterminable 4.PR interval: Very irregular. 5.P: QRS ratio: Difficult to determine 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 128
  129. 129. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 129
  130. 130. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 130
  131. 131. Treatment • VT is an emergency because the patient is usually unresponsive and pulseless. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 131
  132. 132. • Monomorphic + hemodynamicaly stable + preserved left ventricular function – IV procainamide Sotalol Amidarone lidocaine 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 132
  133. 133. • Hemodynamically unstable + poor left ventricular function – IV amiodarone/lidocaine Cardioversion 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 133
  134. 134. • Hemodynamically unstable + polymorphic VT + nomal base line QT intervl Beta adrenergic blockers Lidocaine Amidarone Procainamide sotalol 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 134
  135. 135. • Hemodynamically unstable + polymorphic VT + nomal base line QT intervl Beta adrenergic blockers Lidocaine Amidarone Procainamide sotalol 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 135
  136. 136. • Polymorphic VT + prolonged baseline QT interval IV magnesium Isoproterenol Phenytoin Lidocaine Antitachycardia pacing cardioversion 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 136
  137. 137. • VT with out pulse Life tretening situation CPR Rapid defibrillation Epinephrine. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 137
  138. 138. PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA. • PSVT originates in an ectopic focus anywhere above the bifurcation of the bundle of his. • Reentrant phenomenon 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 138
  139. 139. ETIOLOGY • • • • • Wolff parkinson- white (WPW)/preexcitation Overexertion Emotional stress Deep inspiration Stimulants 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 139
  140. 140. • • • • • • Caffeine Tobacco RHD Digitalis toxicity CAD Cor pulmonale 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 140
  141. 141. TREATMENT • • • • • • • • Vagal maneuvers – valsalva and coughing IV adenosine(Half life – 10sec) IV adrenergic blockers Calcium channel blockers – diltiazem Digoxin Amidarone (WPW) If not again stable – DC cardioversion Radiofrequency catheter ablation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 141
  142. 142. VENTRICULAR FIBRILLATION. Rapid but disorganized ventricular rhythm Causes ineffective quivering of the ventricles. With out any atrial activity on the ECG. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 142
  143. 143. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 143
  144. 144. Etiology • Causes of ventricular fibrillation are the same as for VT 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 144
  145. 145. ECG CHARACTERISTICS 1. Ventricular rate: Greater than 300 per minute 2. Ventricular rhythm: Extremely irregular, without specific pattern 3. QRS shape and duration: Irregular, undulating waves without recognizable QRS complexes 4. This dysrhythmia is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 145
  146. 146. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 146
  147. 147. Treatment CPR ACLS measures Defibrillation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 147
  148. 148. VENTRICULAR ASYSTOLE/COMMONLY CALLED FLATLINE 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 148
  149. 149. ETIOLOGY • Advanced cardiac disease • End stage HF • Severe conduction system disturbences 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 149
  150. 150. ECG CHARACTERISTICS • Absent QRS complexes • P waves may be apparent for a short duration 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 150
  151. 151. Sign and symptoms • There is no heartbeat, no palpable pulse, and no respiration 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 151
  152. 152. Treatment A fatal condition. • Cardiopulmonary resuscitation • Transcutaneous pacing 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 152
  153. 153. • A bolus of intravenous epinephrine should be administered and repeated at 3- to 5-minute intervals Followed by 1-mg boluses of atropine at 3- to 5minute intervals. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 153
  154. 154. CONDUCTION ABNORMALITIES 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 154
  155. 155. AV BLOCKS AV blocks occur when the conduction of the impulse through the AV nodal area is decreased or stopped. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 155
  156. 156. COMMON ETIOLOGICAL FACTORES • Medications like digitalis, calcium channel blockers, beta-blockers. • Myocardial ischemia and infarction • Valvular disorders, or myocarditis. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 156
  157. 157. AV block 1st degree 3RD degree 2nd degree M1 12/6/2013 M2 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 157
  158. 158. first-degree AV block • rarely causes any hemodynamic effect. • First-degree heart block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 158
  159. 159. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 159
  160. 160. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 160
  161. 161. ECG characteristics • PR interval: Greater than 0.20 seconds • P: QRS ratio: 1:1 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 161
  162. 162. SECOND-DEGREE ATRIOVENTRICULAR BLOCK • Type I. Second-degree, • type I heart block occurs when all but one of the atrial impulses are not conducted through the AV node into the ventricles. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 162
  163. 163. type1 • The RR interval reflects a pattern of change. • Starting from the RR that is the longest, the RR interval gradually shortens until there is another long RR interval. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 163
  164. 164. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 164
  165. 165. • PR interval: PR interval becomes longer with each succeeding • ECG complex until there is a P wave not followed by a QRS. • The changes in the PR interval are repeated between each “dropped” QRS. • P: QRS ratio: 32, 43, 54, and so forth 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 165
  166. 166. SECOND-DEGREE ATRIOVENTRICULAR BLOCK, TYPE II. • Second-degree,type II heart block occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 166
  167. 167. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 167
  168. 168. ECG characteristics • PR interval: PR interval is constant for those P waves just before QRS complexes. • P: QRS ratio: 2:1, 3:1, 4:1, 5:1, and so forth 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 168
  169. 169. THIRD-DEGREE ATRIOVENTRICULAR BLOCK. • No atrial impulse is conducted through the AV node into the ventricles. • P waves may be seen, but no QRS complex. This is called AV dissociation. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 169
  170. 170. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 170
  171. 171. CHARACTERISTICS • PR interval: Very irregular • P: QRS ratio: More P waves than QRS complexes 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 171
  172. 172. 1st degree HB •No treatement •Modifications to causative medications •Continuous montoring 12/6/2013 2nd degree HB MORBITZ 1 SYMPTOMATIC PATIENT/MI Atropine ASYMPTOMATIC PATIENT Close observation with subcutaneous pace maker stand by 3rd degree HB MORBITZ 2 Temporary transcutaneous / transvenous pacing SYMPTOMATIC PATIENT Transcutaneous pase maker untll transvenous pase maker Permanent pace Atropine maker epinephrine adenosin PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 172
  173. 173. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 173
  174. 174. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 174

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