Cardiac
Dysrythmias
Definition of Terms
Ablation – A technique of destruction of
heart muscle cells, usually in an attempt to
control a dysrhythmia.
Antiarrhythmic – a medication that
suppresses or prevents a dysrhythmia.
Definition of Terms
Conductivity – ability of the cardiac muscle to
transmit electrical impulses.
Defibrillation– electrical current administered
to stop a dysrhythmia.
Depolarization – process by which cardiac
muscle cells change from a more negatively
charged to a more positively charged
intracellular state.
Definition of Terms
Dysrhythmia (also referred to as arrhythmia)
– disorder of the formation or conduction (or
both) of the electrical impulse within the
heart, altering the heart rate, heart rhythm,
or both and potentially causing altered blood
flow.
Definition of Terms
Implantable Cardioverter Defibrillator (ICD) –
a device implanted into the chest to treat
dysrhythmias.
Inhibited – in reference to pacemakers term
used to describe the pacemaker with holding
an impulse (not firing).
Definition of Terms
P wave – the part of an electrocardiogram
(ECG) that reflects conduction of an electrical
impulse through the atrium; a trial
depolarization.
Paroxysmal – a dysrhythmias that has a
sudden onset and/or termination and is
usually of short duration.
Definition of Terms
PR interval- the part of an ECG that reflects
conduction of an electrical impulse from the
sinoatrial (SA) node through the
atrioventricular (AV) node.
Proarrthythmic – an agent that causes or
exacerbates a dysrhythmia.
Definition of Terms
QRS complex – the complex of an ECG that
reflects conduction of an electrical impulse
through the ventricles; ventricular
depolarization.
QT interval – the part of an ECG that reflects
the time from ventricular depolarization to
repolarization.
Definition of Terms
Repolarization – process by which cardiac
muscle cells return to a more negatively
charged intracellular condition, their resting
state.
Sinus rhythm – electrical activity of the heart
initiated by the sinoartrial (SA) node.
Definition of Terms
ST segment – The part of an ECG that reflects
the end of ventriocular depolarization (end of
the T wave).
Supra Ventricular Tachycardia (SVT) – a
rhythm that originated in the conduction
system above the ventricles.
Definition of Terms
T wave – the part of an ECG that reflects
repolarization of the ventricles.
Triggered – reference to pacemakers, term
used to described the release of an impulse in
response to some stimulus.
Definition of Terms
U wave – the part of an ECG that may reflect
purkinje fiber repolarization.
Ventricular tachycardia (UT) – a rhythm that
originated in the ventricles.
Dysrhythmias
Disorders of the formation or conduction or
both of the electrical impulse within the
heart.
Disorders can cause disturbances of the heart
rate, the heart rhythm or both.
Dysrhythmias
Dysrhythmias may initially be evidenced by
the hemodynamic effect they cause (e.g. a
change in conduction may change the
pumping action of the heart and cause
decreased blood pressure.
Dysrhythmias are diagnosed by analyzing the
electrocardiographic waveform.
Types of Dysrhythmias
Sinus node dysarythmia
Atrial dysarythmia
Junctional dysarythmia
ventricular dysrhythmias and their various
subcategories.
Sinus Node Dysrhythmias
Sinus Bradycardia – Sinus bradycardia occurs
when the sinus node creates an impulse at a
slower – than – normal rate.
CAUSES OF SINUS BRADYCARDIA
Lower metabolic needs (sleep, athletic
training, hypothermia, hypothyroidism)
Vagal Stimulation (vomiting, suctioning,
severe pain, extreme emotions)
Medications (calcium channel blockers,
amiodarone, beta-blockers
Increased intracranial pressure
Myocardial infarction (MI), especially of
the inferior wall.
Characteristicsof of Sinus
bradycardia
Ventricular & atrial rate : less than 60 in the
adult
Ventricular & atrial rhythm : regular
QRS shape & duration: Usually normal, but
may be regularly abnormal
P: QRS ration: 1:1
SINUS TACHYCARDIA
Sinus Tachycardia – Sinus tachycardia occurs
when the sinus node creates an impulse at a
faster – than – normal rate.
Cause:
Acute blood loss, anemia, shock,
hyperVolemia, hypovolemia congestive
heart failure, pain, hypermetabolic
states, fever, exercise,anxiety or
sympathomimetic medications
ECG criteria for sinus
tachycardia
Ventricular & atrial rate: greater then 100 in
the adult
Ventricular & atrial rhythm: regular
QRS shape & duration – usally normal, but
may be regularly abnormal
P wave: normal & consistent shape: always in
front of the QRS, but may be buried in the
preceding T wave
PR interval – Consistent interval between
0.12 & 0.20 seconds
P: QRS ratio: 1:1
Treatment for Sinus
tachycardia
Calcium channel blockers & beta-blockers
used to reduce the heart rate quickly
SINUS ARRHYTHMIA
Sinus Arrhythmia – Sinus arrhythmia occurs
when the sinus node creates an impulse at an
irregular rhythm; the rate usually increase
with inspiration and decrease with expiration
Causes:
Nonrespiratory causes include heart
disease & valvular disease, but these are
rarely seen
ECG criteria for sinus
arrhythmia
Ventricular & atrial rate: 60 to 100 in the adult
Ventricular and atrial rhythm: irregular
QRS shape & duration: usually normal, but
may be regularly abnormal
P wave: normal & consistent shape: always in
front of the QRS
PR interval: consistent interval between 0.12
and 0.20 seconds
P: QRS ratio: 1:1
ATRIAL DYSARTHMIA
PAC
ATRIAL FLUTTER
ATRIAL FIBRILLATION
PREMATURE ATRIAL
CONTRACTION
Premature atrial complex – A premature
atrial complex (PAC) is a single ECG complex
that occurs when an electrical impulse starts
in the atrium before the next impulse of the
sinus node
CAUSES
Caffeine, alcohol, nicotine, stretched
atrial myocardium (as in hyperrolemia),
anxiety, hypokalemia (low potassium
level), hepermetabolic states, or atrial
ischemia, injury or infarction
Characteristics of PAC’s
Ventricular and atrial rate: depends on the
underlying rhythm (e.g. sinus tachycardia)
PR interval: The early P wave has a shorter –
than – normal PR interval but still between
0.12 & 0.20 seconds
ECG CRITERIA FOR PAC
Ventricular and atrial rhythm: Irregular due to
early P waves, creating a PP interval that is
shorter than the others. This is sometimes
followed by a longer – than – normal PP
interval, but one that is less than twice the
normal PP interval. This type of interval is
called a non compensatory pause.
QRS shape and duration: The QRS that
follows the early P wave is usually normal, but
it may be abnormal (aberrantly conducted
PAC). It may even be absent (blocked PAC)
P wave: an early and different P wave may be
seen or may be hidden in the T wave: other P
waves in the strip are consistent.
P: QRS ratio: usually 1:1
ATRIAL FLUTTER
Atrial Flutter – atrial flutter occurs in the
atrium and creates impulses at an atrial
rate between 250 & 400 times per
minute. Because the atrial rate is faster
than the AV node can conduct, not all
trial impulses are conducted into the
ventricles, causing a therapeutic block at
the AV node.
Causes of Atrial flutter
Causes:
Similar to atrial fibrillation
ECG criteria of Atrial
Flutters
Ventricular & Atrial rate: Atrial rates ranges between 250 and 400:
ventricular rate usually ranges between 75 and 150
Ventricular and Atrial rhythm: The atrial rhythm is irregular because
of a change in the AV conduction
QRS shape and duration: usually normal, but may be abnormal or
may be absent
P wave: Saw toothed shape: These waves make it referred to as F
waves
QRS shape and duration: usually normal, but may be abnormal or
may be absent
P wave: Saw toothed shape: These waves make it referred to as F
waves
SIGNS & SYMPTOMS:
Chest pain, shortness of breath, & low blood pressure
Treatment
If patient is unstable
- electro cardioversion
If patient is stable
- Diltiazem (Cardizem)
- Verapamil(Calan, Isoptin)
- Beta-blockers or digitalis
1. -Flecainide (Tambocor)
- Ibutilide (Corvert)
- Dofetilide (Tikosyn)
- Quinidine (Cardioquin, Quinaglute)
ATRIAL FIBRILLATION
Atrial Fibrillation – Atrial fibrillation causes a
rapid, disorganized, & uncoordinates
twitching of atrial musculature. It is the most
common dysrhythmia that causes patients to
seek medical attention. It may start and stop
suddenly
ECG Criteria of Atrial
Fibrillation
Ventricular and atrial rate: Atrial rate is 300 to
600. Ventricular rate usually 120 to 200 in
untreated atrial fibrillation
Ventricular and atrial rhythm: Highly Irregular
QRS shape & duration: usually normal, but may
be abnormal
P wave: no discernible P waves: Irregular
undulating waves are seen and are referred to
as fibrillatory or F waves
PR interval: cannot be measured
P: QRS ratio: many:1
Symptoms:
irregular palpitations, fatigue, and malaise
Treatment:
Quinidine, ibutilide, flecanide, dofetilide,
propafenone
Procainamide (Pronestyl), disopyramide,or
amiodarone
Junctional Dysrhythmias
Premature Junctional Complex – A premature
junctional complex is an impulse that starts in
the AV nodal area before the next normal
sinus impulse reaches the AV node.
Premature junctional complex include
digitalis toxicity, congestive heart failure, and
coronary artery disease.
ECG criteria
Same as for PAC’s, except for the P wave and
the PR interval. The P wave may be absent,
may follow the QRS, or may occur before the
QRS but with a PR interval of less than 0.12
seconds. Premature junctional complexes
rarely produce significant symptoms.
Treatment same as PAC.
Ventricular Dysrhythmias
PVC
Ventricular flutter
Ventricular
Ventricular Dysrhythmias
Premature Ventricular Complex – Premature
ventricular complex (PVC) is an impulsive that
starts in a ventricle and is conducted through
the ventricles before the next normal sinus
impulse – PVCs can occur in healthy people,
especially with the use of caffeine, nicotine,
or alcohol
Causes
Cardiac ischemia or infarction, increased
workload on the heart (e.g. exercise, fever,
hyperrolemia, heart failure, tachycardia),
digitalis toxicity, hypoxia, acidosis or
electrolyte imbalances, especially
hypokalemia
ECG characteristics of PVC
Ventricular & atrial rate: Depends on the
underlying rhythm (e.g. sinus rhythm)
Ventricular & atrial rhtythm: Irregular due to
early QRS, eveating one RR interval that is
shorter than the others. PP interval may be
regular, indicating that the PVC did not
depolarize the sinus node
QRS shape and Duration: Duration is 0.12
seconds or longer shape is bizarre and
Abnormal
P wave visibility of P wave depends on the
timing of the PVC: may be absent (hidden in
the QRS or T wave) or in front of the QRS
If the P wave follows the QRS, the
shape of the P wave may be different
PR interval: If the P wave is in front of
the QRS, the PR interval is less than 0.12
seconds
Causes
Similar to those for PVC
QRS shape and duration: Duration is 0.12
seconds or more bizarre; abnormal shape
P wave: very difficult to detect, so atrial rate
and rhythm may be indeterminable
Characteristics for VT
Ventricular and atrial rate: ventricular rate is
100 to 200 beats per minute: atrial rate
depends on the underlying rhythm (e.g. sinus
rhythm)
Ventricular and atrial rhythm: usually regular;
atrial rhythm may also be regular
PR interval: very irregular, if P waves seen
P: QRS ratio: Difficult to determine, but if P
waves are apparent, there are usually more
QRS complexes than P waves
P: QRS ratio: 0:1, 1:1
Ventricular Tachycardia – ventricular
tachycardia CVT) is defined as three or
more PVC’s in a row, occurring at a rate
exceeding 100 beats per minute
Treatment
Immediate defibrillation for the patient who
is unconscious and without a pulse
Ventricular Fibrillation – Ventricular
Fibrillation is a rapid but disorganized
ventricular thythm that causes ineffective
quivering of the ventricles – theres in no atrial
activity seen the ECG
Causes
Same as for Vt
Electrical shock & brugada syndrome
Characteristics of
ventricular Fibrillation
Ventricular rate: Greater than 300 per minute
Ventricular rhythm: Extremely irregular,
without specific pattern
QRS shape and duration: Irregular,
undulating waves without recognizable QRS
complexes
Treatment
immediate defibrillation and activation of
emergency services
Idioventricular Rhythm - Idioventricular
Rhythm, also called ventricular escape
rhythm, occurs when the impulse starts in the
conduction system below the AV node.
ECG criteria for
idioventricular rhythm
Ventricular rate: ranges between 20 and 40; if
the rate exceeds 40, the rhythm is known as
accelerated idioventricular rhythm CAIVR)
Ventricular rhythm: regular
QRS shape & duration: Bizarre, abnormal
shape duration is 0.12 seconds or more
Ventricular Asystole – Commonly called
flatline, ventricular asystole is characterized
by absent QRS complexes, although P waves
may be apparent for a a short duration in two
different leads. There is no heartbeat, no
palpable pulse, and no respiration
Causes
hypoxia, acidosis, severe electrolyte
imbalance, drug overdose or hypothermia
Treatment
Cardiopulmunary Resuscitation & emergency
services are necessary to keep the patient
alive
Conduction Abnormalities – When assessing
the rhythm strip, the nurse takes first to
identify the underlying rhythm (e.g. sinus
rhythm, sinus arrhythmia) Then the PR
interval is assessed for the possibility of an AV
block. AV block occur when the conduction of
the impulse through the AV nodal area
decreased or stopped.
First – degree Atrioventricular Block – 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
Causes
hemodynamic effect
Causing a decrease in perfusion to vital organ,
such as the brain, heart, kidneys, lungs, & skin
Characteristics of First
degree
Ventricular and atrial rate: Depends on the
underlying rhythm
Ventricular and atrial rhythm: Depends on
the underlying rhythm
QRS shape and duration: usually normal, but
maay be abnormal
P wave: In front of the QRS complex: shows
sinus rhythm, regular shape
PR interval: Greater than 0.20 seconds: PR
interval measurement is constant
P: QRS ratio 1:1
Second – degree atrioventricular Block, type I
– Second – degree, type I heart block occurs
when all but one of the atrial impulses are
conducted through the AV node into the
ventricles.
Each atrial impulse takes a longer time for
conduction than the one before, until one
impulse is fully blocked. Atrial impulse, the
AV node has time to fully repolarize, so that
the next atrial impulse can be conducted
within the shortest amount of time.
Characteristics of 2nd –
degree
Ventricular and atrial rate: Depends on the
underlying rhythm
Ventricular and atrial rhythm: The Pp interval
is regular if the patient has an underlying
normal sinus rhythm: the RR interval
characteristically reflects a pattern of change.
Starting from the RR that is the longer, the
RR interval gradually shortens until there is
another long RR interval again
QRS shape & duration – usually normal, but
may be abnormal
P wave: In front of the QRS complex, shape
depends in underlying rhythm
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, creating a pattern in the
irregular PR interval measurements.
P: QRS ratio: 3:2, 4:3, 5:4 and so forth
Second – Degree Alrioventicular 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.
Characteristics of 2nd
degree Av block, type II
Ventricular & atrial rate: Depends on the
underlying rhythm
Ventricular & atrial rhythm: The PP interval is
regular if the patient has an underlying
normal sinus rhythm. The RR interval is
usually regular but may be irregular,
depending on the P: QRS ratio
QRS shape & duration: usually abnormal, but
may be normal
P wave: In front of the constant for those P
waves just before QRS complexes
P: QRS ratio: 2:1, 3:1, 4:1, 5:1, and so forth
Third – Degree Atrioventicular Block – Third
degree heart block occurs when no atrial
impulse is conducted through the AV node
into the ventricles. In third – degree heart
block, two impulses stimulate the heart: one
stimulates the ventricles, represented by the
QRS complex, & one stimulates the atria,
represented by the P wave.
P waves may be seen, but the atrial electrical
activity is not conducted down into the
ventricles to cause the QRS complex, the
ventricular electrical activity this is called AV
dissociation
Characteristics of 3rd
degree AV block
Ventricular & atrial rate: Depends on the
escape and underlying Rhythm
Ventricular and atrial rhythm: The PP interval
is regular & the RR interval is regular:
however, the PP interval is not equal to the
RR interval
QRS shape & duration: Depends on the
escape rhythm; in junctional escape, QRS
shape & duration are usually normal, and
inventricular escape, QRS shape & duration
are usually abnormal
P wave: Depends on underlying rhythm
PR interval: Very irregular
P: QRS ratio: more P waves than QRS
complexes
Treatment
directed toward increasing the heart rate to
maintain a normal cardiac ouput
If the patient is stable and has no symptoms,
treatment is indicated other than decreasing
or evadicating cause
If the patient does not respond to atrophine
or has an acute m1, transcutaneous pacing
should be stared
Thank you