Dysrhythmias:

Cardiac Conduction System:

Elements of the Cardiac
Conduction System:
- Sinoatrial Node (SA Node)
o Electrical impulses
o 60-100bpm
o P Wave on ECG
- AV Node
o PR Segment on ECG
o Atrial Kick
- Bundle of His/AV Bundle
- Left and Right Bundle
Branches
- Purkinje Fibers

Electrophysiological Properties:
- Automaticity
o Ability of the cardiac cells to generate an electrical impulse spontaneously and repetitively
- Excitability
o Ability of the non-pacemaker cells to respond to an electrical impulse that begins in pacemaker cells
- Conductivity
o Ability to send an electrical stimulus from cell membrane to cell membrane
- Contractility
o Ability of atrial and ventricular muscle cells to shorten their fiber length in response to electrical
stimulation causing sufficient pressure to push blood forward through heart
Electrocardiography:
ECG Complexes, Segments, and Intervals:

Electrical Conductivity of ECG Lead Electrode Placement:

- Lead I: Electrical Impulses horizontally across the heart
- Lead II: electrical impulses diagonally across the heart (MOST COMMON LEAD)
- Lead III: electrical impulses from the heart vertically
- Lead MCL1/Lead V: electrical impulses in reverse diagonal direction of the heart (use to view P waves [atrial
activity])
Lead Placement:
- White: Right Upper Chest
- Black: Left Upper Chest
- Green: Right Lower/Below Ribs
- Red: Left Lower/Below Ribs
- Brown: 4th intercostal space right sternal margin

Analyzing a ECG Strip:

Measure
Determine Determine Analyze P Measure PR QRS Examine ST Assess T Measure QT Interpret
Heart Rate Regularity Waves Interval Complex Segment Wave Interval Rhythm
Duration
STEP #1: Determining Heart Rate:

- Count the number of QRS complexes in 6 seconds

- Multiply number by 10
- Determines average/mean heart rate
- Normal Rate: 60-100bpm
o <60bpm: Bradycardia
o >100bpm: Tachycardia

STEP #2: Determine Regularity:

- Atrial Regularity
o Assessment of the PP Interval
o Place one caliper point on a P wave and the other point on the precise sport on the next P wave
 “Walk the P Waves”
o A slight irregularity in the PP intervals varying no more than three small blocks is considered essentially regular if
P waves are all the same shape
 Caused by changes in intrathoracic pressure during respiratory cycle
- Ventricular Regularity
o Assessment of the RR Interval
o Place one caliper point on a portion of the QRS complex (prominent point of deflection) and the other point on the
precise spot on the next QRS complex.
 Walk the QRS”
o A slight irregularity of no more than three small blocks is considered essentially regular if the QRS complexes are
all of the same shape

STEP #3: Analyze the P Waves:

- Are P waves present?

- Are P waves occurring regularly?
- Is there one P wave for every QRS complex?
- Are the P waves smooth, rounded, and upright in appearance, or are they inverted?
- Do all the P waves look similar?

STEP #4: Measure the PR Interval:

- Are PR Intervals >0.20 seconds?

- Are PR Intervals <0.12 seconds?
- Are PR Intervals consistent across the strip?

STEP #5: Measure the QRS Duration:

- Place one caliper point at the beginning of the QRS complex and the other at the J Point (where QRS complex ends and ST
segment begins)
o QRS Duration: 0.04-0.12 seconds
- Are QRS Intervals less than or greater than 0.12 seconds?
- Are QRS complexes similar in appearance across the strip?

STEP #6: Examine the ST Segment

- Normal ST segment begins at the Isoelectric line

- ST Depression or Elevation is signifigant if displacement is 1mm (1 small box) or more above or below the line
o Needs to be confirmed in 2 or more leads

STEP #7: Assess the T Wave:

- Note shape and height of the T wave for peaking or inversion

o Potential Etiology
 Myocardial Infarction
 Ventricular Hypertrophy
 Electrolyte Disturbance

STEP #8: Measure QT Interval:

- Normal QT Interval: less than or equal to ½ the distance of the RR interval

STEP #9: Interpret the Rhythm

Atrial Dysrhythmias:
Normal Sinus Rhythm:

Sinus Bradycardia:

Sinus Tachycardia:

Sinus Arrhythmia:

Premature Atrial Contractions:

- Non-conducted PAC
 - Conducted PAC

Atrial Tachycardia:

Atrial Flutter:

Atrial Fibrillation:

- Pathophysiology
o Chaotic rhythm
o No clear P wave
o Irregular ventricular response

- Incidence and Prevalence

o Most common dysrhythmia
o Incidence increases with age
- Assessment
o Poor Perfusion
o Anxiety
o 12 Lead ECG

- Potential Problems
o Embolus Formation
o Heart Failure

- Medications
o Antidysrhythmic Agents
o Anticoagulants

- Non-Surgical Interventions
o Cardioversion
o Ablation
o Biventricular Pacing

- Surgery
o Maze Procedure
AV Heart Blocks:
First Degree AV Block:

Second Degree AV Heart Block

Type I – Wenckebach:

Second Degree AV Heart Block

Type II – Mobitz

Third Degree/Complete Heart Block:

Junctional Dysrhythmias:
- inverted (abnormal) P wave
- absent P wave
- P wave come after the QRS complex
- PR interval is abnormally short (< 0.12 seconds)

Premature Junctional Contractions:

Junctional Escape Rhythm:

Accelerated Junctional Rhythm:

Ventricular Dysrhythmias:
Premature Ventricular Contractions:
- Couplet PVCs

- Unifocal PVCs

- Run of PVCs (5 Beat Run of VTach)

Ventricular Tachycardia:

Ventricular Fibrillation:
- Fine VF

- Coarse VF
Adult Cardiac Arrest Algorithm Shockable (pVT, VF): Follow the Left Branch: VF/pVT
Adult Cardiac Arrest Algorithm Nonshockable (PEA, Asystole): Follow the Right Branch: Asystole/PEA
Defibrillation:
- Asynchronous countershock that depolarizes critical mass of myocardium simultaneously to stop re-entry
circuit
- Allow sinus node to regain control of heart
Automated External Defibrillation:
- AEDs create an opportunity for laypersons to respond to cardiac arrest
- AEDs analyze the rhythm and shocks are delivered for
o ventricular fibrillation
o pulseless ventricular tachycardia
Idioventricular Rhythm:

Accelerated idioventricular Rhythm:

Asystole:

Ventricular Standstill: