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Dysrrhythmia, major arrhythmias and management, bascs of ECG.
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  • 1. PRASANTH.K POST GRADUATION IN CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA HOSPITAL AND COLLEGE OF NURSING BANGALURU 12/6/2013 1
  • 2. PHYSIOLOGY BEHINED THE ECG 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 2
  • 3. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 3
  • 4. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 4
  • 5. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 5
  • 6. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 6
  • 7. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 7
  • 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. 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. 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. ECG waves … 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 11
  • 12. ECG GRAPH PAPER 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 12
  • 13. paper .1 mv Voltage .5 mv .04 seconds 12/6/2013 Time .20 seconds PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 13
  • 14. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 14
  • 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. 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. 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. 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. Abnormalities of P wave  Inverted: ectopic atrial or A-V junctional rhythm. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 19
  • 20. Increased amplitude: atrial hypertrophy or dilatation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 20
  • 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. 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. 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. Amplitude :- Low – diffuse coronary disease, cardiac failure, pericardial effusion. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 24
  • 25. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 25
  • 26. Amplitude :- High – Left or right Ventricular Hypertrophy. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 26
  • 27. ST segment :-. ST” ELEVATION  Acute / post myocardial infarction  Prinzmetal’s angina.  Hyperkalemia. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 27
  • 28. A rhythm with ST elevation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 28
  • 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. ABNORMALITIES Inversion: myocardial ischemia 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 30
  • 31. Notching: Pericarditis 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 31
  • 32. Unusually tall T waves: Acute Myocardial Infarction ,hyperkalemia, myocardial ischemia. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 32
  • 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. NORMAL RHYTHM 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 34
  • 35. CALCULATION OF HEART RATE FROM AN ECG STRIP 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 35
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 37
  • 38. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 38
  • 39. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA ‹#›
  • 40. SINUS NODE DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 40
  • 41. SINUS BRADYCARDIA. • Sinus bradycardia • Relative bradycardia 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 41
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 43
  • 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. 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. 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. SINUS TACHYCARDIA 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 47
  • 48. Etiology Acute blood loss Anemia Shock Hypervolemia Hypovolemia Congestive heart failure 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 48
  • 49. Pain Hypermetabolic states Fever, Exercise Anxiety Sympathomimetic medications. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 49
  • 50. • Medicine – epinephrine, atropine, theophilline, nifedipine , or hydralazine . 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 50
  • 51. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 51
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 53
  • 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. 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. ATRIAL DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 56
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 59
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 62
  • 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. 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. 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 67
  • 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. • 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. 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 72
  • 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. 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. Sign and symptoms • Chest pain • Shortness of breath • Low blood pressure. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 75
  • 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. 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. Etiology • • • • • • Causes are similar to atrial flutter. Cardiomyopathy RHD HTN HF Pericarditis 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 78
  • 79. • • • • • • • Thyrotoxication CAD Alcohol intoxication Caffeine use Electrolyte disturbence Stress Cardiac surgery 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 79
  • 80. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 80
  • 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. 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. • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 84
  • 85. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 85
  • 86. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 86
  • 87. • Radiofrequency catheter ablation (MAZE procedure) cryoablation High intensity ultrasound 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 87
  • 88. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 88
  • 89. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 89
  • 90. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 90
  • 91. JUNCTIONAL DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 91
  • 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. ETIOLOGY • RHD • IWMI • Electrolyte imbalance • CAD • Drugs Digoxin,amphetmines,caffeine,nicotine. • Cardiomyopathy 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 93
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 95
  • 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. 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. 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. • Accelerated junctional rhythm and junctinal tachycardia –digoxin toxycity With held Digoxin 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 99
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 101
  • 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. 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. 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. 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. 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. 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. • 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. • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 110
  • 111. VENTRICULAR DYSRHYTHMIAS 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 111
  • 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. • 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. • 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. • • • • Multifocal Unifocal Bigeminy Trigeminy 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 115
  • 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. 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. 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. In a rhythm called bigeminy, every other complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 119
  • 120. Trigeminy is a rhythm in which every third complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 120
  • 121. Quadrigeminy is a rhythm in which every fourth complex is a PVC. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 121
  • 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. 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. 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. 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. 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. ETIOLOGY Causes are similar to PVC Usually associated with coronary artery disease 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 127
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 129
  • 130. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 130
  • 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. • Monomorphic + hemodynamicaly stable + preserved left ventricular function – IV procainamide Sotalol Amidarone lidocaine 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 132
  • 133. • Hemodynamically unstable + poor left ventricular function – IV amiodarone/lidocaine Cardioversion 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 133
  • 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. • 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. • 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. • VT with out pulse Life tretening situation CPR Rapid defibrillation Epinephrine. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 137
  • 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. ETIOLOGY • • • • • Wolff parkinson- white (WPW)/preexcitation Overexertion Emotional stress Deep inspiration Stimulants 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 139
  • 140. • • • • • • Caffeine Tobacco RHD Digitalis toxicity CAD Cor pulmonale 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 140
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 143
  • 144. Etiology • Causes of ventricular fibrillation are the same as for VT 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 144
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 146
  • 147. Treatment CPR ACLS measures Defibrillation 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 147
  • 148. VENTRICULAR ASYSTOLE/COMMONLY CALLED FLATLINE 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 148
  • 149. ETIOLOGY • Advanced cardiac disease • End stage HF • Severe conduction system disturbences 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 149
  • 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. Sign and symptoms • There is no heartbeat, no palpable pulse, and no respiration 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 151
  • 152. Treatment A fatal condition. • Cardiopulmonary resuscitation • Transcutaneous pacing 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 152
  • 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. CONDUCTION ABNORMALITIES 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 154
  • 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. 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. AV block 1st degree 3RD degree 2nd degree M1 12/6/2013 M2 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 157
  • 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 159
  • 160. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 160
  • 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. 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 164
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 167
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 170
  • 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. 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. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 173
  • 174. 12/6/2013 PRASANTH.K, CARDIOTHORACIC NURSING, NARAYANA HRUDAYALAYA 174