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DYsrhythmia.pptx
- 1. Dysrhythmia Prepared by Ms PoojaPrakash Cardio-vascular and thoracic nursing
- 2. • A normalsinus rhythm is the usual heart rhythm that begins in the sinoatrial (SA) node, is between 60 and 100 beats/min, and has normal intervals and no aberrant or ectopic beats. • Dysrhythmias are disorders of the heart rhythm. • is the disturbance in the electric cycle of the heart. • is a disorder of the formation or conduction (or both) of the electrical impulses within the heart.
- 3. • Sites oforigin of Dysrythmias - Sinoatrial Node - Atria - Atrioventricular Node - Ventricles
- 4. • Common causesof Dysrhythmia # Cardiac condition - Cardiomypathy - Conduction defects - Myocardial cell degeneration - Accessory pathways - Myocardial infraction - Heart failure Valve disease # Other conditions - Acid-base imbalance - Alcohol - Caffeine, tobacco - Connective tissue disorder - Drug effects (antidysrhythmic drugs, stimulants, beta- adrenergic blockers) - Electric shock - Electro imbalances - Emotional crisis
- 5. • Mechanism ofconduction - Normal - Bradycardia - Tachycardia - Flutter - Fibrillation - Premature complexes - blocks
- 6. PATHOPHYSIOLOGY • The significanceof all dysrhythmias is their effect on cardiac output and therefore cerebral and vascular perfusion. • CO=SV*HR • Co: Cardiac output • SV: Stroke volume • HR: Heart rate
- 7. DYSRHYTHMIA 1. Rhythms originatingin sinoatrial (SA) node - Sinus bradycardia - Sinus tachycardia - Sinus arrest 2. Rhythms originating in atria - Premature atrial contraction - Atrial tachycardia - Paroxysmal supraventricular tachycardia - Supraventricular tachycardia 3. Rhythms originating in atrioventricular junction - Premature jugular complex - Junctional rhythm - Junctional tachycardia 4. Rhythms originating in ventricles - Premature ventricular contraction - Ventricular tachycardia - Ventricular fibrillation 5. Conduction abnormalities - First degree atrioventricular block - Second degree atrioventricular block = Mobitz I = Mobitz II - Third degree atrioventricular block
- 8. • Conduction pathwayis same as sinus rhythm but SA node fires at a rate less than 60 beats/min. • ECG characteristics: - Rate : <60B/min - Rhythm: regular - P wave: precede every QRS complex, consistent in shape - PR interval: Normal (0.12- 0.20 sec) - QRS complex: Normal (0.04 – 0.010 sec) - Conduction: Normal through atria, AV node, bundle branches, ventricles • Treatment: - Anticholinergic drugs, atropin - Pacemaker therapy may be required
- 9. • Conduction pathwayis same as sinus rhythm but SA node fires at a rate more than 100 beats/min. • ECG characteristics: - Rate : >100B/min - Rhythm: regular - P wave: precede every QRS complex, consistent in shape - PR interval: Normal (0.12- 0.20 sec) - QRS complex: Normal (0.04 – 0.010 sec) - Conduction: Normal through atria, AV node, bundle branches, ventricles • Treatment: - Treatment of hypovolemia - Adenosine and beta- adrenergic blockers
- 10. • Decreased Sinusnode automaticity • Impulses are not generated • Absence of p wave, QRS complex and no electrical activity for 3 sec • ECG characteristics: - Rate : Atrial normal or bradycardia, ventricular normal or bradicardia - Rhythm: Irregular due to absence of sinus node discharge - P wave: present when sinus node is firing and absent during periods of sinus arrest - PR interval: Usually normal when p waves are present - QRS complex: usually Normal but absent during sinus arrest - Conduction: at the time of sinus arrest there is no conduction • Treatment: - Atropin 0.5 to 1 mg IV may increase the rate - Pacemaker therapy may be required
- 11. Premature Atrial Contraction •Contraction originating from an ectopic focus in the atrium, other than SA node. • Ectopic signal may originates in the left or right atrium and travels across the atria by an abnormal pathway creating a distorted p wave. • ECG characteristics: - Rate : Normal - Rhythm: usually regular, PAC results in early beat - P wave: distorted P wave - PR interval: normal or prolonged on premature beat - QRS complex: may be normal, wide, absent depends on prematurity of beat - Conduction: normal - Treatment: - Beta-adrenergic blockers to decrease prematurity of beat.
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- 13. • Atrial tachycardia -Rapid firing of an ectopic atrial focus or to an atrial re-entery circuit allows an impulse to travel rapidly and repeatedly around pathway in the atria. • ECG characteristics: - Rate : 120 to 125 b/m - Rhythm: regular unless there is variable block at AV node - P wave: differ in configuration from sinus P waves because they are ectopic. Precede each QRS complex, but may be hidden in preceding T- wave. When block is present, more than P wave appears before each QRS complex. - PR interval: may be shorter or prolonged but often difficult to measures because of hidden P- waves. - QRS complex: usually normal, but may be wide if aberrant conduction is present. - Conduction: usually normal through the AV node and into ventricles - Treatment: - Sedation - Cardioversion - Beta-blockers, verapamil and diltiazem - Digitalis - Antiarrhythmic drugs - Radiofrequency catheter ablation of the ectopic focus
- 14. Paroximal Supraventricular Tachycardia •Originating in an ectopic focus anywhere above the bifurcation of the bundle of his. • Paroxysmal refers to an abrupt onset and termination • ECG characteristics: - Rate : 100 to 300 b/min - Rhythm: regular or slightly irregular - P wave: often hidden in the preceding T wave, but if seen may be abnormal in shape - PR interval: may be shorter or normal - QRS complex: usually normal - Treatment: - IV adenosine - IV beta adrenergic blockers - Calcium channel blockers - Amiodarone - Digitalis - Catheter ablation therapy
- 15. Supraventicular Tachycardia • Originatingin an ectopic focus above the bundle of his • ECG characteristics: - Rate : 100 – 300 b/min - Rhythm: regular - P wave: usually not visible, burried in T-wave - PR interval: not measurable - QRS complex: usually narrow, may be wide - Conduction: through atria varies depending on the mechanism of tachycardia. Atria may depolarize in a retrograde direction in AV nodal re-entry tachycardia. Through ventricle is normal. - Treatment: - IV adenosine - IV beta adrenergic blockers - Calcium channel blockers - Amiodarone - Digitalis - Catheter ablation therapy
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- 17. • Originates fromsingle ectopic focus in the right atrium, identified by recurring regular sawtooth- shaped flutter (F-Waves) • ECG characteristics: - Rate : Atrial rate varies 250- 350 b/min; ventricular rate is in normal range - Rhythm: Atrial rhythm is regular. Ventricular rhythm may be regular or irregular - P wave: replaced by F- waves - PR interval: not measurable - QRS complex: usually narrow, aberration may occur - Conduction: usually normal through AV nodes and ventricles - Treatment: - IV beta adrenergic blockers - Calcium channel blockers - Amiodarone - Digitalis - Catheter ablation therapy - Cardioversion
- 18. Atrial fibrillation • Originatesfrom multiple ectopic focus in the atrium, identified by fibrillatory (f) waves • ECG characteristics: - Rate : Atrial rate 400-600b/min or more; ventricular rate varies depends on amount of block at the AV node - Rhythm: regular - P wave: replaced by F-waves - PR interval: not measurable - QRS complex: usually normal, aberration is common - Conduction: disorganized and irregular - Treatment: - IV beta adrenergic blockers - Calcium channel blockers - Amiodarone - Digitalis - Cardioversion
- 19. • Irritable focusin the AV junction • ECG characteristics: - Rate : 60-100 b/min - Rhythm: irregular because of early beats - P wave: may occur before, during or after the QRS complex and inverted - PR interval: short usually 0.10 sec or less - QRS complex: usually normal but may be aberrant - Conduction: retrograde through atrai , normal through ventricle - Treatment: - No treatment needed
- 20. • Occurs ifsinus node rate falls below the automatic rate of AV junctional pacemaker or in the presence of digitalis toxicity. • Rate: Junctional rhythm (40-60b/min), Accelerated Junctional rhythm (60-100b/min), Junctional tachycardia (100-250 b/min) • Rhythm: regular • P waves: may proceed or follow QRS • PR interval: short, 0.10 sec or less • QRS complex: usually normal • Conduction: retrograde • Treatment : atropine, beta-adrenergic blockers calcium channel blockers, amiodarone, cardioversion
- 21. Premature ventricular contraction •Originating in ectopic focus in the ventricles. It is the premature occurrence of a QRS complex which is wide and distorted in shape. • Rate: 60-100 b/min • Rhythm: irregular because of early beats • P waves: not related to PVCs • PR interval: absent before most PVCs, if present PR interval is short • QRS complex: wide, bizarre, usually greater than 0.12 sec • Treatment : beta-adrenergic blockers, procianamide, amiodarone, lidocaine
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- 23. • Run ofthree or more PVCs occurs. • Ectopic foci fire repetitively and the ventricle control takes control as the pacemaker • Rate: ventricular rate is usually 100- 220 b/min • Rhythm: usually regular but may be slightly irregular • P waves: buried in QRS complex or T wave. VT may conduct retrograde to the atria and p-wave can be seen after each QRS. • PR interval: not measurable • QRS complex: wide, bizarre, usually greater than 0.12 sec. Can be monomorphic, polymorphic Torsado de pointes. • Conduction: impulse originates in one ventricles and spreads by muscle cell to cell conduction through both ventricles. Retrograde conduction • Treatment :1. Hemodynamically stable (with pulse), Amiodarone, Lidocaine • 2. Hemodynamically unstable (with pulse), Cardioversion • 3. Pulseless VT, Defibri;ation • Others: Radiofrequency ablation, implantable cardioverter defibrilator
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- 25. • Severe derangementof the heart rhythm characterized on ECG by irregular undulations of varying shapes and amplitude. • Represents the firing of multiple ectopic foci in the ventricle. • ECG Characteristics: - Rate: Rapid, uncoordinated, ineffective - Rhythm: Choatic, irregular - P-wave: not seen - QRS complex: no formed QRS complex seen; rapid, irregular undurations without any specific pattern. This erratic electrical activity can be coarse or fine - Conduction: multiple ectopic foci firing simultaneously in ventricles and depolarizing them irregularly and without any organized pattern. Ventricles are not contracting. • Treatment: immediate CPR and advanced cardiac life support measures with the use of defibrillation and definitive drug therapy.
- 26. Asystole • Total absenceof ventricle electrical activity. • Occasionally P-wave can be seen • No ventricular contraction occurs because depolarization doesn’t occur • Rate: None • Rhythm: None • P-wave: may be present if the sinus node is functioning • PR-interval: None • QRS complex: None • Conduction: Atrial conduction may be normal if the sinus node is functioning. No conduction in the ventricle • Treatment: CPR with initiation of ACLS measures which intubation, transcutaneous pacing and IV therapy with epinephrine and atropine.
- 27. Conduction Abnormalities/Disorders Heart Block •Mobitz II heart block • Type I/ Mobitz I/ Wenckebach heart block First degree AV block Second degree AV block Third degree AV block
- 29. First degree AtrioventricularBlock • Every impulse is conducted to the ventricles, but the duration of AV conduction is prolonged. • ECG Characteristics • Rate: Can occur at any sinus rate, usually 60-100 b/min • Rhythm: regular • P wave: Normal, precede every QRS • PR-interval: Greater than 0.20 sec • QRS complex: usually normal, unless bundle of branch block exists. • Conduction: Normal through the atria, delayed through the AV node, normal through the ventriccles. • Treatment: No treatment required for first degree AV block.
- 31. Second degree AVblock Type I • Type I second degree AV block also termed as Mobitz I or Wenckebach heart block • Includes a gradual lengthening of the PR interval followed by missed or blocked beat • ECG characteristics - Rate: Atrial rate is normal, but ventricle rate may be slower as a result of nonconducted or blocked QRS complex - Rhythm: Irregular unless 2:1 conduction is present - P-Waves: Normal. Some P waves are not conducted to the ventricles, but only one at a time fails to conduct. - PR- interval: Gradually lengthening of PR interval in consecutive beats. - QRS complex: Usually normal unless there is associated bundle branch block - Conduction: normal through the atria, progressively delayed through the AV node until an impulse fails to conduct. Ventricular conduction is normal. - Treatment: if the patient is symptomatic, atropine is used to increase HR or temporary pacemaker may be needed. - In case of asymptomatic, the rhythm should be closely observed with a transcutaneous pacemaker on standby.
- 33. Second degree AVblock Type II • Type II second degree AV block also termed as Mobitz II heart block • PR interval is constant and is greater than 0.20 sec, followed by missed or blocked beat • ECG characteristics - Rate: Atrial rate is usually normal, but ventricle rate depends on intrinsic rate and the degree of AV block - Rhythm: Atrial rhythm is regular, but ventricle rhythm may be irregular - P-Waves: usually Normal and precede each QRS. Periodically a P wave is not followed by a QRS complex. - PR- interval: constant (prolonged greater than 0.20 sec), before all conducted beats. - QRS complex: Almost always wide because of association bundle branch block. - Conduction: normal through the atria and AV node, but intermittently blocked in the bundle branch system and fails to reach the ventricles. Conduction ratios can vary from 2:1 to only occasional blocked beats. - Treatment: Pacemaker implatation
- 34. Second degree AVblock Type II
- 35. Third degree AVblock • Third degree AV block or Complete heart block constitutes one form of AV dissociation in which no impulses from the atria are conducted to the ventricles. • The atria are stimulated and contract independently of the ventricles. The ventricular rhythm is an escape rhythm and the ectopic pacemaker may be above or below the bifurcation of the bundle of his. • ECG charachteristics • Rate: Atrial rate is 60-100 b/min. the ventricular rate is 40-60b/min • Rhythm: regular • P-wave: Normal, but dissociative from QRS complexes • QRS-complex: Normal if ventricles controlled by a Junctional pacemaker, wide if controlled by a ventricular pacemaker • Conduction: Normal through atria. All impulses are blocked at the AV node or in the bundle of branches, so there is no conduction to the ventricles. Conduction through the ventricles is normal if a junctional escape rhythm occurs and is abnormally slow if a ventricular escape rhythm occurs. • Treatment: Pacemaker implantation.
- 36. Third degree AVblock
- 37. Management of ARHYTHMIA •Antiarrhythmic drugs • Defibrilation • Implantable cardioverter defibrilators • Cardioversion • Pacemaker • Radiofrequency catheter ablation therapy