Name That Rhythm

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Name That Rhythm

• EMT-Intermediate
• W06

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And you thought we wouldnt review..
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Heart A P

• Location
• Pieces, Parts
• Important Vessels
• Electrolyte Role
• Pulling apart waveforms

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Valves Vessels
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Review of Important Vessels
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The Components

• SA Node
• Internodal Pathways
• AV Junction
• AV Node
• Bundle of His
• L R Bundle Branch
• Purkinje Network
• Purkinje Fibers

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The Route
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Sino Atrial Node

• The Natural Pacemaker
• Connects directly to atrial fibers
• Fires 60-100 times per minute
• Wavelike Atrial Depolarization
• The P-Wave

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AV Junction

• Receives impulses from SA Node via the Atrial
  Cells
• An electrical funnel
• Impulses hit at various times
• Causes delay
• PR-I
• Susceptible to blockage
• Path from A to V
• Delivers impulse to the AV Node

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Atrio-Ventricular Node

• Lies between the Atria and Ventricles
• Collects impulses from above
• Stimulates Ventricles
• If unstimulated
• Intrinsic rate 40-60

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Bundle of His / Left and Right Bundle Branches

• Distributes Impulses from the Node
• The Ventricular Messengers

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Purkinje Network/Fibers

• Direct connection with ventricular tissue
• Intrinsic rate 20-40 if unstimulated

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Electrical Conduction System

• Sympathetic-Thoracic/Lumbar Nerve
• Norepinephrine
• HR, Contractility
• Parasympathetic-Vagus Nerve
• Acetylcholine
• HR (Valsalva)
• Chronotropic-HR
• Inotropic-Contraction

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Electrical Conduction System

• Na in K out Depolarization
• K in Na out Repolarization
• Imbalances in K or Na
• Effects Automaticity Conduction
• Hypo hyperkalemia affects irritability
• Ca - Depolarization and Contraction
• Affects Contractility
• Hypo Hypercalcemia effects contractile force

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Phases

• Phase 0 Rapid Depolarization
• Reached max potential -90mV
• Fast Na Channels Open
• Cell now positive 25mV
• Phase 1 Early Rapid Repolarization
• Fast Na Channels Close
• K still being lost
• MP approaching 0mV
• Phase 2 Prolonged Slow Repolarization
• Plateau Phase
• Muscle finishing contraction
• Beginning to relax
• MP staying close to 0mV

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Phases

• Phase 3 End of Rapid Repolarization
• K returns to inside
• Cell returns to -90mV
• Almost ready
• Phase 4
• Na - K Pump turns on
• Sends Na out
• Brings K in
• Ready to do it all over again now ?

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Refractory PeriodsExcuse me!!! I hate to
interrupt again, but, who cares???

• Absolute Refractory Period
• Polarity of cell prohibits depolarization
• Relative Refractory Period
• Cell is returning to ready state for
  depolarization
• Impulse now is BAD!!!
• R on T Phenomenon
• Causes VT VF
• Treated with defibrillation
• Can be caused by
• Frequent PVCs
• EMT-P not pushing the sync button

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QRS Complex
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Lead Considerations

• 25,000 mVoltmeter
• Lead Views
• 1 Lateral
• 2 Inferior
• 3 Inferior

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The Six Step Approach

• What is the Rate?
• Is the Rhythm Regular?
• Are there P-Waves?
• Is the P-R Interval Normal?
• Is the QRS Complex Normal?
• Is There a P-Wave for Every QRS?

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Describe What Youve Found!!!

• IN GENERAL (underlying rhythms)!!!
• What are the abnormalities?
• Does it originate in the Sinus Node?
• Does it follow through from the Atria to the
  ventricles? Are there abnormal delays?
• What are the exceptions to the underlying rhythm?
  (Describe those also)

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Normal Sinus Rhythm

• Rate 60 - 100
• Regularity Very
• P-Waves Present and Normal
• P-R I 0.12-0.20 sec
• QRS 0.04-0.12 sec and Normal
• Married 1 P 1 QRS, no extras or shortages

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Sinus Arrhythmia

• Rate 60 - 100
• Regularity Irregular
• P-Waves Present and Normal
• P-R I 0.12-0.20 sec
• QRS 0.04-0.12 sec and Normal
• Married 1 P 1 QRS, no extras or shortages

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Sinus Tachycardia

• Rate Over 100
• Regularity Regular
• P-Waves Present and Normal
• P-R I 0.12-0.20 sec
• QRS 0.04-0.12 sec and Normal
• Married 1 P 1 QRS, no extras or shortages

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Sinus Bradycardia

• Rate Less than 60
• Regularity Regular
• P-Waves Present and Normal
• P-R I 0.12-0.20 sec
• QRS 0.04-0.12 sec and Normal
• Married 1 P 1 QRS, no extras or shortages

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Atrial Fibrillation

• Rate Usually tachy
• Regularity Irregular (Irregularly irregular)
• P-Waves Not Discernible
• P-R I Undeterminable
• QRS 0.04-0.12 sec
• Married Undeterminable

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Atrial Flutter

• Rate Usually tachy
• Regularity Atria Regular
• Ventricles May be Irregular
• P-Waves Sawtooth Pattern 21, 31, 41...
• P-R I 0.12-0.20 sec on conducting beat
• QRS 0.04-0.12 sec
• Married P-waves outnumber QRS
• (Picket fence)

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(Paroxysmal) Supra Ventricular Tach

• Rate 140-220
• Regularity Regular
• P-Waves Usually falls within the QRS-T complex
  (not visible)
• P-R I Shorter than 0.12, or absent
• QRS 0.04-0.12 sec and Normal
• Married Undeterminable

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SVT

• WPW
• Usually based on Hx.
• Delta wave on Q
• Shortened PR-I
• No Verapamil Accessory Path use increase

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1st Degree Heart Block

• Rate 60 - 100
• Regularity Very
• P-Waves Present and Normal
• P-R I Longer than 0.20 sec
• QRS 0.04-0.12 sec and Normal
• Married 1 P 1 QRS, no extras or shortages

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2nd Degree Heart Block (Type 1) Wenkebach

• Rate Can be Normal, or usually brady
• Regularity Irregular
• P-Waves Present and Normal
• P-R I Lengthens until beat is dropped
• QRS 0.04-0.12 sec and Normal
• Married P-wave present on conducting beats,
  increased delay causes missed QRS

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2nd Degree Heart Block (Type 2)Mobitz II

• Rate Less than 60
• Regularity Irregular
• P-Waves Present, 21, 31, 41
• P-R I 0.12-0.20 sec on conducting beat
• QRS 0.04-0.12 sec, may begin to widen
• Married P-wave for every QRS and extras
  depending on conduction ratio

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3rd Degree Heart Block (CHB)Complete Heart Block

• Rate Ventricular Rate 40-60
• Regularity Atria-Regular
• Vent-Regular
• P-Waves Present and Normal
• P-R I Atria independent of Ventricles
• QRS Usually greater than 0.12 sec
• Married P-waves completely unrelated to QRS
  Complexes.

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Complete Heart Block
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Junctional Rhythm

• Rate 40-60
• Regularity Regular
• P-Waves Inverted, Retrograde or Absent
• P-R I Shortened or absent
• QRS 0.04-0.12 sec
• Married P-wave for every QRS, sometimes not
  visible

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Junctional
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Junctional Accelerated Rhythm

• Rate 60-100
• Regularity Regular
• P-Waves Inverted, Retrograde or Absent
• P-R I Shortened or absent
• QRS 0.04-0.12 sec
• Married P-wave for every QRS, sometimes not
  visible

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Junctional Tachycardia

• Rate 100-140
• Regularity Regular
• P-Waves Inverted, Retrograde or Absent
• P-R I Shortened or absent
• QRS 0.04-0.12 sec
• Married P-wave for every QRS, sometimes not
  visible

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Ventricular Tachycardia
Well look at Torsades de Pointes in Lab

• Rate 100-220
• Regularity Regular
• P-Waves None
• P-R I None
• QRS Greater than 0.12 sec
• Married NO

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Ventricular Tachycardia
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Ventricular Fibrillation

• Rate No ventricular rate
• Regularity Irregular
• P-Waves No
• P-R I No
• QRS No, unorganized ventricular baseline
• Married No

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Ventricular Fibrillation
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Asystole

• Rate 0
• Regularity N/A
• P-Waves None
• P-R I N/A
• QRS None
• Married No (verify a second lead)

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Asystole
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Agonal / Idioventricular

• Rate 20-40
• Regularity Irregular
• P-Waves None
• P-R I N/A
• QRS Wider than 0.12 sec
• Married NO (a dying heart)

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Idioventricular

• Less regular than this!

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Exceptions / Disruptions

• Premature Ventricular Contractions
• Premature Atrial Contractions
• Bundle Branch Blocks
• Pacer Considerations (Atrial, Ventricular or Both)

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Premature Ventricular Contractions

• Wide, Bizarre QRS Complex
• Always identify the underlying rhythm first
• Can appear in couplets, triplets, short runs of
  V-Tach, bigeminy and trigeminy
• Can be uni-focal or multi-focal
• Caused by random firing within the ventricles
• Not accompanied by a P-wave

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PVCs
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PACs

• P-QRS Complex appearing in an unexpected location
• Caused by a stimulus from within the Atria, but
  not from the SA Node

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PJC
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Bundle Branch Block

• Any rhythm having a BBB will have a widened twin
  peaked R-Wave

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Paced Rhythms

• Patients may have various types of pacemakers
• Atrial
• Ventricular
• Both
• Vertical spike on monitor is an indicator

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Paced Rhythms Various
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Artifact

• 60 Cycle Interference
• Loose Leads/Moving Ambulance

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In Summary

• Really Cool Physiology!!!
• GENERAL RULES to Interpretation
• Applicable to 3 lead monitoring
• Practice, Practice, Practice
• Remember the rules, NOT how it looks coming from
  one patient or one rhythm generator!!!

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Sources In order of preference

• Many of the pictures and info from
• Flip and See ECG, 2nd Edition
• Cohn/Gilroy-Doohan
• A great resource
• Paramedic Paramedic Textbook, Revised 2nd Edition
• Mick J. Sanders, Mosby
• ECGs Made Easy, 2nd Edition
• Barbara Aehlert, RN, Mosby
• Basic Dysrhythmias, Interpretation and
  Management, 3rd Edition
• Robert J. Huszar, Mosby