Atrial flutter is an abnormal heart rhythm where the atria beat too fast, usually between 240-340 beats per minute. It often occurs in patients with underlying heart conditions that cause enlargement or damage to the atria, such as rheumatic heart disease, congenital heart disease, or COPD. Common symptoms include palpitations, chest discomfort, and fatigue. Treatment options include medications to slow the heart rate or restore normal rhythm, cardioversion, catheter ablation, or implanting a pacemaker.
13. Pathogenesis and Inducement
of Arrhythmia
Some physical condition
Pathological heart disease
Other system disease
Electrolyte disturbance and acid-base
imbalance
Physical and chemical factors or
toxicosis
21. Clinical usage
Anti-tachycardia agents:
Ia class: Less use in clinic
1. Guinidine
2. Procainamide
3. Disopyramide: Side effect: like M-
cholinergic receptor blocker
23. Anti-tachycardia agents:
Ic class: Can be used in ventricular and/or
supra-ventricular tachycardia and
extrasystole.
1. Moricizine
2. Propafenone
24. Anti-tachycardia agents:
II class: ß-receptor blocker
1. Propranolol: Non-selective
2. Metoprolol: Selective ß1-receptor blocker,
Perfect to hypertension and coronary
artery disease patients associated with
tachyarrhythmia.
25. Anti-tachycardia agents:
III class: Potassium channel blocker,
extend-spectrum anti-arrhythmia agent.
Amioarone: Perfect to coronary artery
disease and heart failure patients
Sotalol: Has ß-blocker effect
Bretylium
26. Anti-tachycardia agents:
IV class: be used in supraventricular
tachycardia
1. Verapamil
2. Diltiazem
Others:
Adenosine: be used in supraventricular
tachycardia
28. Proarrhythmia effect of
antiarrhythmia agents
Ia, Ic class: Prolong QT interval, will cause
VT or VF in coronary artery disease and
heart failure patients
III class: Like Ia, Ic class agents
II, IV class: Bradycardia
29. Non-drug therapy
Cardioversion: For tachycardia especially
hemodynamic unstable patient
Radiofrequency catheter ablation (RFCA): For
those tachycardia patients (SVT, VT, AF, AFL)
Artificial cardiac pacing: For bradycardia,
heart failure and malignant ventricular
arrhythmia patients.
32. SINUS TACHYCARDIA
Rate: 101-160/min
P wave: sinus
QRS: normal
Conduction: normal
Rhythm: regular or slightly irregular
The clinical significance of this dysrhythmia depends on the
underlying cause. It may be normal.
Underlying causes include:
increased circulating catecholamines
CHF
hypoxia
PE
increased temperature
stress
response to pain
Treatment includes identification of the underlying cause and
correction.
33.
34. Sinus Bradycardia
Sinus rate < 60 beats/min
Normal variant in many normal and older people
Causes: Trained athletes, during sleep, drugs (ß-
blocker) , Hypothyriodism, CAD or SSS
Symptoms:
1. Most patients have no symptoms.
2. Severe bradycardia may cause dizziness, fatigue,
palpitation, even syncope.
Needn’t specific therapy, If the patient has severe
symptoms, planted an pacemaker may be needed.
35. SINUS BRADYCARDIA
Rate: 40-59 bpm
P wave: sinus
QRS: Normal (.06-.12)
Conduction: P-R normal or slightly prolonged at slower rates
Rhythm: regular or slightly irregular
This rhythm is often seen as a normal variation in athletes, during
sleep, or in response to a vagal maneuver. If the bradycardia
becomes slower than the SA node pacemaker, a junctional rhythm
may occur.
Treatment includes:
treat the underlying cause,
atropine,
isuprel, or
artificial pacing if patient is hemodynamically
compromised.
36.
37. SINUS ARRHYTHIMIA
Rate: 45-100/bpm
P wave: sinus
QRS: normal
Conduction: normal
Rhythm: regularly irregular
The rate usually increases with inspiration and decreases with
expiration.
This rhythm is most commonly seen with respiration due to
fluctuations in vagal tone.
The non respiratory form is present in diseased hearts and
sometimes confused with sinus arrset (also known as "sinus
pause").
Treatment is not usually required unless symptomatic bradycardia
is present.
38.
39. WANDERING PACEMAKER
Rate: variable depending on the site of the pacemaker; usually 45-
100/ bpm.
P wave: also variable in morphology
QRS: normal
Conduction: P-R interval varies depending on the site of the
pacemaker
Rhythm: irregular
This dysrhythmia may occur in normal hearts as a result of
fluctuations in vagal tone. It may also be seen in patients with heart
disease or COPD.
Wandering atrial pacemaker may also be a precursor to multifocal
atrial tachycardia.
There is usually no treatment required.
40.
41. Sinus Arrest or Sinus
Standstill
Sinus arrest or standstill is recognized by a
pause in the sinus rhythm.
Causes: myocardial ischemia, hypoxia,
hyperkalemia, higher intracranial pressure,
sinus node degeneration and some drugs
(digitalis, ß-blocks).
Symptoms: dizziness, amaurosis, syncope
Therapy is same to SSS
42. SINUS PAUSE, ARREST
Rate: normal
P wave: those that are present are normal
QRS: normal
Conduction: normal
Rhythm: The basic rhythm is regular. The length of the pause is
not a multiple of the sinus interval.
This may occur in individuals with healthy hearts. It may also
occur with increased vagal tone, myocarditis, MI, and digitalis
toxicity.
If the pause is prolonged, escape beats may occur.
The treatment of this dysrhythmia depends on the underlying
cause.
If the cause is due to increased vagal tone and the patient is
symptomatic, atropine may be indicated.
43.
44. Sinoatrial exit block (SAB)
SAB: Sinus pulse was blocked so it
couldn’t active the atrium.
Causes: CAD, Myopathy, Myocarditis,
digitalis toxicity, et al.
Symptoms: dizziness, fatigue, syncope
Therapy is same to SSS
45. SINOATRIAL BLOCK
Rate: normal or bradycardia
P wave: those present are normal
QRS: normal
Conduction: normal
Rhythm: basic rhythm is regular.
In a type I SA block, the P-P interval shortens until one P wave is
dropped.
In a type II SA block, the P-P intervals are an exact multiple of the
sinus cycle, and are regular before and after the dropped P wave.
This usually occurs transiently and produces no symptoms. It may
occur in healthy patients with increased vagal tone. It may also be
found with CAD, inferior MI, and digitalis toxicity.
46. Sinoatrial exit block (SAB)
Divided into three types: Type I, II, III
Only type II SAB can be recognized by
EKG.
47.
48. Sick Sinus Syndrome (SSS)
SSS: The function of sinus node was
degenerated. SSS encompasses both
disordered SA node automaticity and SA
conduction.
Causes: CAD, SAN degeneration, myopathy,
connective tissue disease, metabolic disease,
tumor, trauma and congenital disease.
With marked sinus bradycardia, sinus arrest,
sinus exit block or junctional escape rhythms
Bradycardia-tachycardia syndrome
49. Sick Sinus Syndrome (SSS)
EKG Recognition:
1. Sinus bradycardia, ≤40 bpm;
2. Sinus arrest > 3s
3. Type II SAB
4. Nonsinus tachyarrhythmia ( SVT, AF or Af).
5. SNRT > 1530ms, SNRTc > 525ms
6. Instinct heart rate < 80bmp
50.
51. Sick Sinus Syndrome (SSS)
Therapy:
1. Treat the etiology
2. Treat with drugs: anti-bradycardia
agents, the effect of drug therapy is not
good.
3. Artificial cardiac pacing.
53. Premature contractions
The term “premature contractions” are used
to describe non sinus beats.
Common arrhythmia
The morbidity rate is 3-5%
54. Atrial premature contractions (APCs)
APCs arising from somewhere in either the left
or the right atrium.
Causes: rheumatic heart disease, CAD,
hypertension, hyperthyroidism, hypokalemia
Symptoms: many patients have no symptom,
some have palpitation, chest incomfortable.
Therapy: Needn’t therapy in the patients
without heart disease. Can be treated with ß-
blocker, propafenone, moricizine or verapamil.
55. PREAMATURE ATRIAL
CONTRACTIONS
Rate: normal or accelerated
P wave: usually have a different morphology than sinus P waves
because they originate from an ectopic pacemaker
QRS: normal
Conduction: normal, however the ectopic beats may have a
different P-R interval.
Rhythm: PAC's occur early in the cycle and they usually do not
have a complete compensatory pause.
PAC's occur normally in a non diseased heart.
However, if they occur frequently, they may lead to a more serious
atrial dysrhythmias.
They can also result from CHF, ischemia and COPD.
58. Atrial tachycardia
May occur transient; intermittent; or persistent.
Symptoms: palpitation; chest uncomfortable,
tachycardia may induce myopathy.
Auscultation: the first heart sound is variable
59. Intra-atrial reentry tachycardia (IART)
ECG characters:
1. Atrial rate is around 130-150bpm;
2. P’ wave is different from sinus P wave;
3. P’-R interval ≥ 0.12”
4. Often appear type I or type II, 2:1 AV block;
5. EP study: atrial program pacing can induce and
terminate tachycardia
60. Automatic atrial tachycardia (AAT)
ECG characters:
1. Atrial rate is around 100-200bpm;
2. Warmup phenomena
3. P’ wave is different from sinus P wave;
4. P’-R interval≥ 0.12”
5. Often appear type I or type II, 2:1 AV block;
6. EP study: Atrial program pacing can’t induce
or terminate the tachycardia
61.
62. Chaotic atrial tachycardia (CAT)
Also termed “Multifocal atrial tachycardia”.
Always occurs in COPD or CHF,
Have a high in-hospital mortality ( 25-56%).
Death is caused by the severity of the underlying
disease.
ECG characters:
1. Atrial rate is around 100-130bpm;
2. The morphologies P’ wave are more than 3
types.
3. P’-P’, P’-R and R-R interval are different.
4. Will progress to af in half the cases
5. EP study: Atrial program pacing can’t induce or
terminate the tachycardia
63.
64. Therapy
IRAT: Esophageal Pulsation Modulation, RFCA,
Ic and IV class anti-tachycardia agents
AAT: Digoxin, IV, II, Ia and III class anti-
tachycardia agents; RFCA
CAT: treat the underlying disease, verapamil or
amiodarone.
Associated with SSS: Implant pace-maker.
65. PAROXYSMAL ATRIAL
TACHYCARDIA
Rate: atrial 160-250/min: may conduct to ventricles 1:1, or 2:1,
3:1, 4:1 into the presence of a block.
P wave: morphology usually varies from sinus
QRS: normal (unless associated with aberrant ventricular
conduction).
Conduction: P-R interval depends on the status of AV conduction
tissue and atrial rate: may be normal, abnormal, or not measurable.
PAT may occur in the normal as well as diseased heart.
It is a common complication of Wolfe-Parkinson-White syndrome.
This rhythm is often transient and doesn't require treatment.
However, it can be terminated with vagal maneuvers.
Digoxin, antiarrhythmics, and cardioversion may be used.
66.
67. Atrial flutter
Etiology:
1. It can occur in patients with normal atrial
or with abnormal atrial.
2. It is seen in rheumatic heart disease
(mitral or tricuspid valve disease), CAD,
hypertension, hyperthyroidism,
congenital heart disease, COPD.
3. Related to enlargement of the atria
4. Most AF have a reentry loop in right
atrial
68.
69. Atrial flutter
Symptoms: depend on underlying
disease, ventricular rate, the patient is at
rest or is exerting
With rapid ventricular rate: palpitation,
dizziness, shortness of breath, weakness,
faintness, syncope, may develop angina
and CHF.
70. Atrial flutter
Therapy:
1. Treat the underlying disease
2. To restore sinus rhythm: Cardioversion,
Esophageal Pulsation Modulation,
RFCA, Drug (III, Ia, Ic class).
3. Control the ventricular rate: digitalis.
CCB, ß-block
4. Anticoagulation
71. Atrial fibrillation
Subdivided into three types: paroxysmal,
persistent, permanent.
Etiology:
1. Morbidity rate increase in older patients
2. Etiology just like atrial flutter
3. Idiopathic
Mechanism:
1. Multiple wavelet re-entry;
2. Rapid firing focus in pulmonary vein, vena cava
or coronary sinus.
72. ATRIAL FIBRILLATION
Rate: atrial rate usually between 400-650/bpm.
P wave: not present; wavy baseline is seen instead.
QRS: normal
Conduction: variable AV conduction; if untreated the ventricular
response is usually rapid.
Rhythm: irregularly irregular. (This is the hallmark of this
dysrhythmia).
Atrial fibrillation may occur paroxysmally, but it often becomes
chronic. It is usually associated with COPD, CHF or other heart
disease.
Treatment includes:
Digoxin to slow the AV conduction rate.
Cardioversion may also be necessary to terminate this rhythm.
73.
74.
75.
76. Atrial fibrillation
Manifestation:
Affected by underlying diseases, ventricular rate and
heart function.
May develop embolism in left atrial. Have high
incidence of stroke.
The heart rate, S1 and rhythm is irregularly irregular
If the heart rhythm is regular, should consider about
(1) restore sinus rhythm; (2) AF with constant the
ratio of AV conduction; (3) junctional or ventricular
tachycardia; (4) slower ventricular rate may have
complete AV block.
80. PREMATURE JUNCTIONAL
CONTRACTION
Rate: normal or accelerated.
P wave: as with junctional rhythm.
QRS: normal
Conduction: P-R interval < .12 secs if P waves are
present.
Rhythm: PJC's occur early in the cycle of the baseline
rhythm. A full compensatory pause may occur.
PJCs may occur in both healthy and diseased hearts. If
they are occasional, they are insignificant. If they are
frequent, junctional tachycardia may result.
Treatment is usually not required.
81.
82. JUCTIONAL TACHYCARDIA
Rate: faster than 60/bpm
P wave: as with junctional rhythm.
QRS: normal or widened with aberrant ventricular conduction.
Conduction: P-R interval usually < .12 seconds if present
Rhythm: usually regular
The clinical significance of this rhythm depends upon the basic
rhythm disturbance. If the ventricular rate is rapid, cardiac output
may decrease.
Treatment includes:
finding and correcting the underlying cause,
vagal maneuvers,
verapamil, and
cardioversion.
83.
84. Nonparoxysmal AV junctional tachycardia
Mechanism: relate to hyper-automaticity
or trigger activity of AV junctional tissue
Etiology: digitalis toxicity; inferior MI;
myocarditis; acute rheumatic fever and
postoperation of valve disease
ECG: the heart rate ranges 70-150 bpm or
more, regular, normal QRS complex, may
occur AV dissociation and wenckebach AV
block
85. Nonparoxysmal AV junctional tachycardia
Therapy:
Treat underlying disease; stopping
digoxin, administer potassium,
lidocaine, phenytoin or propranolol.
Not for DC shock
It can disappear spontaneously. If had
good tolerance, not require therapy.
86. JUNCTIONAL ESCAPE RHYTHM
Rate: 40-60/bpm
P wave: inverted in leads where they are normally upright; this
happens when the atrial depolarization wave moves towards a
negative (-) lead.P waves may occur before, during or after the QRS,
depending on where the pacemaker is located in the AV junction.
QRS: normal
Conduction: P-R interval < .12 seconds if present.
Rhythm: irregular as a result of the escape beats.
The most common cause of this rhythm in healthy individuals is sinus
bradycardia.
It may also be seen in the presence of a high degree or complete AV
block. If the ventricular rate is slow, hemodynamic compromise may
occur.
Treatment depends upon the underlying cause and the baseline
dysrhythmias.
Atropine or a pacemaker may be used to increase
the ventricular rate.
87.
88. Paroxysmal tachycardia
Most PSVT (paroxysmal supraventricular
tachycardia) is due to reentrant mechanism.
The incidence of PSVT is higher in AVNRT
(atrioventricular node reentry tachycardia) and
AVRT (atioventricular reentry tachycardia), the
most common is AVNRT (90%)
Occur in any age individuals, usually no structure
heart disease.
89. Paroxysmal tachycardia
Manifestation:
Occur and terminal abruptly.
Palpitation, dizziness, syncope,
angina, heart failure and shock.
The sever degree of the
symptom is related to
ventricular rate, persistent
duration and underlying disease
90. Paroxysmal tachycardia
ECG characteristic of AVNRT
1. Heart rate is 150-250 bpm, regular
2. QRS complex is often normal, wide QRS
complex is with aberrant conduction
3. Negative P wave in II III aVF, buried into or
following by the QRS complex.
4. AVN jump phenomena
91. Paroxysmal tachycardia
ECG characteristic of AVRT
1. Heart rate is 150-250 bpm, regular
2. In orthodromic AVRT, the QRS complex
is often normal, wide QRS complex is
with antidromic AVRT
3. Retrograde P’ wave, R-P’>110ms.
92. Paroxysmal tachycardia
Therapy:
AVNRT & orthodromic AVRT
1. Increase vagal tone: carotid sinus massage,
Valsalva maneuver.if no successful,
2. Drug: verapamil, adrenosine, propafenone
3. DC shock
Antidromic AVRT:
1. Should not use verapamil, digitalis, and
stimulate the vagal nerve.
2. Drug: propafenone, sotalol, amiodarone
RFCA
93. Pre-excitation syndrome
(W-P-W syndrome)
There are several type of accessory
pathway
1. Kent: adjacent atrial and ventricular
2. James: adjacent atrial and his bundle
3. Mahaim: adjacent lower part of the AVN
and ventricular
Usually no structure heart disease, occur
in any age individual
94. WPW syndrome
Manifestation:
Palpitation, syncope, dizziness
Arrhythmia: 80% tachycardia is AVRT,
15-30% is AFi, 5% is AF,
May induce ventricular fibrillation
95. WPW syndrome
Therapy:
1. Pharmacologic therapy: orthodrome AVRT
or associated AF, AFi, may use Ic and III
class agents.
2. Antidromic AVRT can’t use digoxin and
verapamil.
3. DC shock: WPW with SVT, AF or Afi produce
agina, syncope and hypotension
4. RFCA
99. PVCs
Therapy: treat underlying disease, antiarrhythmia
No structure heart disease:
1. Asymptom: no therapy
2. Symptom caused by PVCs: antianxiety agents, ß-
blocker and mexiletine to relief the symptom.
With structure heart disease (CAD, HBP):
1. Treat the underlying diseas
2. ß-blocker, amiodarone
3. Class I especially class Ic agents should be avoided
because of proarrhytmia and lack of benefit of
prophylaxis
101. Ventricular tachycardia
Torsades de points (Tdp): A special type of
polymorphic VT,
Etiology:
1. congenital (Long QT),
2. electrolyte disturbance,
3. antiarrhythmia drug proarrhythmia (IA or IC),
4. antianxiety drug,
5. brain disease,
6. bradycardia
102. Ventricular tachycardia
Accelerated idioventricular rhythm:
1. Related to increase automatic tone
2. Etiology: Often occur in organic heart
disease, especially AMI reperfusion
periods, heart operation, myocarditis,
digitalis toxicity
103. VT
Manifestation:
1. Nonsustained VT with no symptom
2. Sustained VT : with symptom and
unstable hemodynamic, patient may feel
palpitation, short of breathness,
presyncope, syncope, angina,
hypotension and shock.
104. VT
ECG characteristics:
1. Monomorphic VT: 100-250 bpm, occur and
terminate abruptly,regular
2. Accelerated idioventricular rhythm: a runs of 3-10
ventricular beats, rate of 60-110 bpm, tachycardia
is a capable of warm up and close down, often seen
AV dissociation, fusion or capture beats
3. Tdp: rotation of the QRS axis around the baseline,
the rate from 160-280 bpm, QT interval prolonged
> 0.5s, marked U wave
105. Treatment of VT
1. Treat underlying disease
2. Cardioversion: Hemodynamic unstable VT
(hypotension, shock, angina, CHF) or
hemodynamic stable but drug was no
effect
3. Pharmacological therapy: ß-blockers,
lidocain or amiodarone
4. RFCA, ICD or surgical therapy
106. Therapy of Special type VT
Accelerated idioventricular rhythm:
usually no symptom, needn’t therapy.
Atropine increased sinus rhythm
Tdp:
1. Treat underlying disease,
2. Magnesium iv, atropine or isoprenaline, ß-
block or pacemaker for long QT patient
3. temporary pacemaker
107. Ventricular flutter and fibrillation
Often occur in severe organic heart disease:
AMI, ischemia heart disease
Proarrhythmia (especially produce long QT and
Tdp), electrolyte disturbance
Anaesthesia, lightning strike, electric shock,
heart operation
It’s a fatal arrhythmia
108. Ventricular flutter and fibrillation
Manifestation:
Unconsciousness, twitch, no blood
pressure and pulse, going to die
Therapy:
1. Cardio-Pulmonary Resuscitate (CPR)
2. ICD
109. Cardiac conduction block
Block position:
Sinoatrial; intra-atrial; atrioventricular;
intra-ventricular
Block degree
1. Type I: prolong the conductive time
2. Type II: partial block
3. Type III: complete block
110. Atrioventricular Block
AV block is a delay or failure in transmission of
the cardiac impulse from atrium to ventricle.
Etiology:
Atherosclerotic heart disease; myocarditis;
rheumatic fever; cardiomyopathy; drug
toxicity; electrolyte disturbance, collagen
disease, lev’s disease.
111. AV Block
AV block is divided into three categories:
1. First-degree AV block
2. Second-degree AV block: further subdivided
into type I and type II
3. Third-degree AV block: complete block
112. AV Block
Manifestations:
First-degree AV block: almost no symptoms;
Second degree AV block: palpitation, fatigue
Third degree AV block: Dizziness, agina, heart
failure, lightheadedness, and syncope may cause
by slow heart rate, Adams-Stokes Syndrome may
occurs in sever case.
First heart sound varies in intensity, will appear
booming first sound
113. FIRST DEGREE A-V HEART
BLOCK
Rate: variable
P wave: normal
QRS: normal
Conduction: impulse originates in the SA node but has prolonged
conduction in the AV junction; P-R interval is > 0.20 seconds.
Rhythm: regular
This is the most common conduction disturbance. It occurs in both
healthy and diseased hearts.
First degree AV block can be due to:
inferior MI,
digitalis toxicity
hyperkalemia
increased vagal tone
acute rheumatic fever
myocarditis.
Interventions include treating the underlying cause and observing for
progression to a more advanced AV block.
114.
115. SECOND DEGREE A-V BLOCK
MOBITZ TYPE I (WENCKEBACK)
Rate: variable
P wave: normal morphology with constant P-P interval
QRS: normal
Conduction: the P-R interval is progressively longer until one P
wave is blocked; the cycle begins again following the blocked P
wave.
Rhythm: irregular
Second degree AV block type I occurs in the AV node above the
Bundle of His.
It is often transient and may be due to acute inferior MI or digitalis
toxicity.
Treatment is usually not indicated as this rhythm usually produces
no symptoms.
116.
117. SECOND DEGREE A-V BLOCK
MOBITZ TYPE II
Rate: variable
P wave: normal with constant P-P intervals
QRS: usually widened because this is usually associated with a
bundle branch block.
Conduction: P-R interval may be normal or prolonged, but it is
constant until one P wave is not conducted to the ventricles.
Rhythm: usually regular when AV conduction ratios are constant
This block usually occurs below the Bundle of His and may
progress into a higher degree block.
It can occur after an acute anterior MI due to damage in the
bifurcation or the bundle branches.
It is more serious than the type I block.
Treatment is usually artificial pacing.
118.
119. THIRD DEGREE (COMPLETE)
A-V BLOCK Rate: atrial rate is usually normal; ventricular rate is usually less than
70/bpm. The atrial rate is always faster than the ventricular rate.
P wave: normal with constant P-P intervals, but not "married" to the QRS
complexes.
QRS: may be normal or widened depending on where the escape pacemaker
is located in the conduction system
Conduction: atrial and ventricular activities are unrelated due to the
complete blocking of the atrial impulses to the ventricles.
Rhythm: irregular
Complete block of the atrial impulses occurs at the A-V junction, common
bundle or bilateral bundle branches.
Another pacemaker distal to the block takes over in order to activate the
ventricles or ventricular standstill will occur.
May be caused by:
digitalis toxicity
acute infection
MI and
degeneration of the conductive tissue.
Treatment modalities include:
external pacing and atropine for acute, symptomatic episodes and
permanent pacing for chronic complete heart block.
120.
121. AV Block
Treatment:
1. I or II degree AV block needn’t
antibradycardia agent therapy
2. II degree II type and III degree AV block
need antibradycardia agent therapy
3. Implant Pace Maker
123. Intraventricular Block
Etiology:
Myocarditis, valve disease, cardiomyopathy,
CAD, hypertension, pulmonary heart disease,
drug toxicity, Lenegre disease, Lev’s disease
et al.
Manifestation:
Single fascicular or bifascicular block is
asymptom; tri-fascicular block may have
dizziness; palpitation, syncope and Adams-
stokes syndrome
124. Intraventricular Block
Therapy:
1. Treat underlying disease
2. If the patient is asymptom; no treat,
3. bifascicular block and incomplete trifascicular
block may progress to complete block, may
need implant pace maker if the patient with
syncope
125. RIGHT BUNDLE BRANCH
BLOCK
Rate: variable
P wave: normal if the underlying rhythm is sinus
QRS: wide; > 0.12 seconds
Conduction: This block occurs in the right or left bundle branches
or in both. The ventricle that is supplied by the blocked bundle is
depolarized abnormally.
Rhythm: regular or irregular depending on the underlying rhythm.
Left bundle branch block is more ominous than right bundle
branch block because it usually is present in diseased hearts. Both
may be caused by hypertension, MI, or cardiomyopathy. A
bifasicular block may progress to third degree heart block.
Treatment is artificial pacing for a bifasicular block that is
associated with an acute MI.
126.
127. PVC BIGEMNY
Rate: variable
P wave: usually obscured by the QRS, PST or T wave of the PVC
QRS: wide > 0.12 seconds; morphology is bizarre with the ST segment and the T wave
opposite in polarity. May be multifocal and exhibit different morphologies.
Conduction: the impulse originates below the branching portion of the Bundle of His;
full compensatory pause is characteristic.
Rhythm: irregular. PVC's may occur in singles, couplets or triplets; or in bigeminy,
trigeminy or quadrigeminy.
PVCs can occur in healthy hearts. For example, an increase in circulating
catecholamines can cause PVCs. They also occur in diseased hearts and from
drug (such as digitalis) toxicities.
Treatment is required if they are:
associated with an acute MI,
occur as couplets, bigeminy or trigeminy,
are multifocal, or
are frequent (>6/min).
Interventions include:
lidocaine,
pronestyl, or
quinidine.
128.
129. VENTRICULAR
TACHYCARDIA Rate: usually between 100 to 220/bpm, but can be as rapid as 250/bpm
P wave: obscured if present and are unrelated to the QRS complexes.
QRS: wide and bizarre morphology
Conduction: as with PVCs
Rhythm: three or more ventricular beats in a row; may be regular or
irregular.
Ventricular tachycardia almost always occurs in diseased hearts.
Some common causes are:
CAD
acute MI
digitalis toxicity
CHF
ventricular aneurysms.
Patients are often symptomatic with this dysrhythmia.
Ventricular tachycardia can quickly deteriorate into ventricular fibrillation.
Electrical countershock is the intervention of choice if the patient is
symptomatic and rapidly deteriorating.
Some pharmacological interventions include lidocaine, pronestyl, and
bretylium.
130.
131. TORSADE DE POINTES
Rate: usually between 150 to 220/bpm,
P wave: obscured if present
QRS: wide and bizarre morphology
Conduction: as with PVCs
Rhythm: Irregular
Paroxysmal –starting and stopping suddenly
Hallmark of this rhythm is the upward and downward deflection of the QRS
complexes around the baseline. The term Torsade de Pointes means
"twisting about the points."
Consider it V-tach if it doesn’t respond to antiarrythmic therapy or treatments
Caused by:
drugs which lengthen the QT interval such as quinidine
electrolyte imbalances, particularly hypokalemia
myocardial ischemia
Treatment:
Synchronized cardioversion is indicated when the patient is unstable.
IV magnesium
IV Potassium to correct an electrolyte imbalance
Overdrive pacing
132.
133. VENTRICULAR
FIBRILLATION
Rate: unattainable
P wave: may be present, but obscured by ventricular waves
QRS: not apparent
Conduction: chaotic electrical activity
Rhythm: chaotic electrical activity
This dysrhythmia results in the absence of cardiac output.
Almost always occurs with serious heart disease, especially acute
MI.
The course of treatment for ventricular fibrillation includes:
immediate defibrillation and ACLS protocols.
Identification and treatment of the underlying cause is also needed.
134.
135. IDIOVENTRICULAR RHYTHM Rate: 20 to 40 beats per minute
P wave: Absent
QRS: Widened
Conduction: Failure of primary pacemaker
Rhythm: Regular
Absent P wave
Widened QRS > 0.12 sec.
Also called " dying heart" rhythm
Pacemaker will most likely be needed to re-establish a normal heart rate.
Causes:
Myocardial Infarction
Pacemaker Failure
Metabolic imbalance
Myoardial Ischemia
Treatment goals include measures to improve cardiac output and establish a
normal rhythm and rate.
Options include:
Atropine
Pacing
Caution: Supressing the ventricular rhythm is contraindicated because that rhythm
protects the heart from complete standstill.
136.
137. VENTRICULAR STANDSTILL
(ASYSTOLE)
Rate: none
P wave: may be seen, but there is no ventricular response
QRS: none
Conduction: none
Rhythm: none
Asystole occurs most commonly following the termination of
atrial, AV junctional or ventricular tachycardias. This pause is
usually insignificant.
Asystole of longer duration in the presence of acute MI and CAD
is frequently fatal.
Interventions include:
CPR,
artificial pacing, and
atropine.
138.
139. normal ("sinus") beats
sinus node doesn't fire leading
to a period of asystole (sick
sinus syndrome) p-wave has different shape
indicating it did not originate in
the sinus node, but somewhere
in the atria. It is therefore called
an "atrial" beat
QRS is slightly different but still narrow,
indicating that conduction through the
ventricle is relatively normal
Atrial Escape Beat
Recognizing and Naming Beats & Rhythms
140. there is no p wave, indicating that it did
not originate anywhere in the atria, but
since the QRS complex is still thin and
normal looking, we can conclude that the
beat originated somewhere near the AV
junction. The beat is therefore called a
"junctional" or a “nodal” beat
Junctional Escape Beat
QRS is slightly different but still narrow,
indicating that conduction through the
ventricle is relatively normal
Recognizing and Naming Beats & Rhythms
141. actually a "retrograde p-wave may sometimes be
seen on the right hand side of beats that
originate in the ventricles, indicating that
depolarization has spread back up through the
atria from the ventricles
QRS is wide and much different ("bizarre") looking
than the normal beats. This indicates that the beat
originated somewhere in the ventricles and
consequently, conduction through the ventricles did
not take place through normal pathways. It is
therefore called a “ventricular” beat
Ventricular
Escape Beat
there is no p wave, indicating that the beat
did not originate anywhere in the atria
Recognizing and Naming Beats & Rhythms
142. Ectopic Beats or Rhythms
• beats or rhythms that originate in places other than the SA node
• the ectopic focus may cause single beats or take over and pace
the heart, dictating its entire rhythm
• they may or may not be dangerous depending on how they affect
the cardiac output
Recognizing and Naming Beats & Rhythms
Causes of Ectopic Beats or Rhythms
• hypoxic myocardium - chronic pulmonary disease, pulmonary embolus
• ischemic myocardium - acute MI, expanding MI, angina
• sympathetic stimulation - nervousness, exercise, CHF, hyperthyroidism
• drugs & electrolyte imbalances - antiarrhythmic drugs, hypokalemia,
imbalances of calcium and magnesium
• bradycardia - a slow HR predisposes one to arrhythmias
• enlargement of the atria or ventricles producing stretch in pacemaker cells
143. Fast Conduction Path
Slow Recovery
Slow Conduction Path
Fast Recovery
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms
Electrical Impulse
Cardiac
Conduction
Tissue
Tissues with these type of circuits may exist:
• in microscopic size in the SA node, AV node, or any type of heart tissue
• in a “macroscopic” structure such as an accessory pathway in WPW
144. Fast Conduction Path
Slow Recovery
Slow Conduction Path
Fast Recovery
Premature Beat Impulse
Cardiac
Conduction
Tissue
1. An arrhythmia is triggered by a premature beat
2. The beat cannot gain entry into the fast conducting
pathway because of its long refractory period and
therefore travels down the slow conducting pathway only
Repolarizing Tissue
(long refractory period)
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms
145. 3. The wave of excitation from the premature beat
arrives at the distal end of the fast conducting
pathway, which has now recovered and therefore
travels retrogradely (backwards) up the fast
pathway
Fast Conduction Path
Slow Recovery
Slow Conduction Path
Fast Recovery
Cardiac
Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms
146. 4. On arriving at the top of the fast pathway it finds the
slow pathway has recovered and therefore the wave of
excitation ‘re-enters’ the pathway and continues in a
‘circular’ movement. This creates the re-entry circuit
Fast Conduction Path
Slow Recovery
Slow Conduction Path
Fast Recovery
Cardiac
Conduction
Tissue
The “Re-Entry” Mechanism of Ectopic Beats & Rhythms
147. Atrial Re-entry
• atrial tachycardia
• atrial fibrillation
• atrial flutter
Atrio-Ventricular Re-entry
• Wolf Parkinson White
• supraventricular tachycardia
Ventricular Re-entry
• ventricular tachycardia
Atrio-Ventricular Nodal Re-entry
• supraventricular tachycardia
Re-entry Circuits as Ectopic Foci and Arrhythmia Generators
148. Recognizing and Naming Beats & Rhythms
Clinical Manifestations of Arrhythmias
• many go unnoticed and produce no symptoms
• palpitations – ranging from “noticing” or “being aware” of ones heart
beat to a sensation of the heart “beating out of the chest”
• if Q is affected (HR > 300) – lightheadedness and syncope, fainting
• drugs & electrolyte imbalances - antiarrhythmic drugs, hypokalemia,
imbalances of calcium and magnesium
• very rapid arrhythmias u myocardial oxygen demand r ischemia
and angina
• sudden death – especially in the case of an acute MI
149. Recognizing and Naming Beats & Rhythms
Premature Ventricular Contractions (PVC’s, VPB’s, extrasystoles):
• A ventricular ectopic focus discharges causing an early beat
• Ectopic beat has no P-wave (maybe retrograde), and QRS complex is "wide and bizarre"
• QRS is wide because the spread of depolarization through the ventricles is abnormal (aberrant)
• In most cases, the heart circulates no blood (no pulse because of an irregular squeezing motion
• PVC’s are sometimes described by lay people as “skipped heart beats”
M u lt if o c a l
P V C 's
C o m p e n s a t o r y p a u s e
a fte r t h e o c c u r a n c e o f a P V C
R o n T
p h e n o m e m o n
150. Recognizing and Naming Beats & Rhythms
Characteristics of PVC's
• PVC’s don’t have P-waves unless they are retrograde (may be buried in T-Wave)
• T-waves for PVC’s are usually large and opposite in polarity to terminal QRS
• Wide (> .16 sec) notched PVC’s may indicate a dilated hypokinetic left ventricle
• Every other beat being a PVC (bigeminy) may indicate coronary artery disease
• Some PVC’s come between 2 normal sinus beats and are called “interpolated” PVC’s
Interpolated PVC – note the sinus
rhythm is undisturbed
The classic PVC – note the
compensatory pause
151. PVC's are Dangerous When:
• They are frequent (> 30% of complexes) or are increasing in frequency
• The come close to or on top of a preceding T-wave (R on T)
• Three or more PVC's in a row (run of V-tach)
• Any PVC in the setting of an acute MI
• PVC's come from different foci ("multifocal" or "multiformed")
These dangerous phenomenon may preclude the occurrence of deadly arrhythmias:
• Ventricular Tachycardia
• Ventricular Fibrillation
Recognizing and Naming Beats & Rhythms
sinus beats
Unconverted V-tach r V-fib
V-tach
“R on T phenomenon”
time
The sooner defibrillation takes place,
the increased likelihood of survival
152. Recognizing and Naming Beats & Rhythms
Notes on V-tach:
• Causes of V-tach
• Prior MI, CAD, dilated cardiomyopathy, or it may be idiopathic (no known cause)
• Typical V-tach patient
• MI with complications & extensive necrosis, EF<40%, d wall motion, v-aneurysm)
•V-tach complexes are likely to be similar and the rhythm regular
• Irregular V-Tach rhythms may be due to to:
• breakthrough of atrial conduction
• atria may “capture” the entire beat beat
• an atrial beat may “merge” with an ectopic ventricular beat (fusion beat)
Fusion beat - note p-
wave in front of PVC and
the PVC is narrower than
the other PVC’s – this
indicates the beat is a
product of both the sinus
node and an ectopic
ventricular focus
Capture beat - note that
the complex is narrow
enough to suggest normal
ventricular conduction.
This indicates that an
atrial impulse has made it
through and conduction
through the ventricles is
relatively normal.
153. Recognizing and Naming Beats & Rhythms
Premature Atrial Contractions (PAC’s):
• An ectopic focus in the atria discharges causing an early beat
• The P-wave of the PAC will not look like a normal sinus P-wave (different morphology)
• QRS is narrow and normal looking because ventricular depolarization is normal
• PAC’s may not activate the myocardium if it is still refractory (non-conducted PAC’s)
• PAC’s may be benign: caused by stress, alcohol, caffeine, and tobacco
• PAC’s may also be caused by ischemia, acute MI’s, d electrolytes, atrial hypertrophy
• PAC’s may also precede PSVT
PAC
Non conducted PAC Non conducted PAC
distorting a T-wave
154. Premature Junctional Contractions (PJC’s):
• An ectopic focus in or around the AV junction discharges causing an early beat
• The beat has no P-wave
• QRS is narrow and normal looking because ventricular depolarization is normal
• PJC’s are usually benign and require not treatment unless they initiate a more serious rhythm
Recognizing and Naming Beats & Rhythms
PJC
155. Recognizing and Naming Beats & Rhythms
Atrial Fibrillation (A-Fib):
• Multiple ectopic reentrant focuses fire in the atria causing a chaotic baseline
• The rhythm is irregular and rapid (approx. 140 – 150 beats per minute)
• Q is usually d by 10% to 20% (no atrial “kick” to ventricular filling)
• May be seen in CAD (especially following surgery), mitral valve stenosis, LV hypertrophy, CHF
• Treatment: DC cardioversion & O2 if patient is unstable
• drugs: (rate control) & Ca++
channel blockers, digitalis, to d AV Conduction
• amiodarone to d AV conduction + prolong myocardial AP (u refractoriness of myocardium)
•The danger of thromboembolic events are enhanced due to d flow in left atrial appendage
• Treatment: anticoagulant drugs (Warfarin / Coumadin)
• International Normalized Ratio (INR – normalized PT time) should be between 2 and 3.
156. Recognizing and Naming Beats & Rhythms
Atrial Flutter:
• A single ectopic macroreentrant focuses fire in the atria causing the “fluttering” baseline
• AV node cannot transmit all impulses (atrial rate: 250 –350 per minute)
• ventricular rhythm may be regular or irregular and range from 150 –170 beats / minute
• Q may d, especially at high ventricular rates
• A-fib and A-flutter rhythm may alternate – these rhythms may also alternate with SVT’s
• May be seen in CAD (especially following surgery), VHD, history of hypertension, LVH, CHF
• Treatment: DC cardioversion if patient is unstable
• drugs: (goal: rate control) Ca++
channel blockers to d AV conduction
• amiodarone to d AV conduction + prolong myocardial AP (u refractoriness of myocardium)
• The danger of thromboembolic events is also high in A-flutter
157. Recognizing and Naming Beats & Rhythms
Multifocal Atrial Tachycardia (MAT):
• Multiple ectopic focuses fire in the atria, all of which are conducted normally to the ventricles
• QRS complexes are almost identical to the sinus beats
• Rate is usually between 100 and 200 beats per minute
• The rhythm is always IRREGULAR
• P-waves of different morphologies (shapes) may be seen if the rhythm is slow
• If the rate < 100 bpm, the rhythm may be referred to as “wandering pacemaker”
• Commonly seen in pulmonary disease, acute cardiorespiratory problems, and CHF
• Treatments: Ca++
channel blockers, blockers, potassium, magnesium, supportive therapy for
underlying causes mentioned above (antiarrhythmic drugs are often ineffective)
Note IRREGULAR
rhythm in the tachycardia
Note different P-wave
morphologies when the
tachycardia begins
158. Recognizing and Naming Beats & Rhythms
Paroxysmal (of sudden onset) Supraventricular Tachycardia (PSVT):
• A single reentrant ectopic focuses fires in and around the AV node, all of which are conducted
normally to the ventricles (usually initiated by a PAC)
• QRS complexes are almost identical to the sinus beats
• Rate is usually between 150 and 250 beats per minute
• The rhythm is always REGULAR
• Possible symptoms: palpitations, angina, anxiety, polyuruia, syncope (d Q)
• Prolonged runs of PSVT may result in atrial fibrillation or atrial flutter
• May be terminated by carotid massage
• u carotid pressure r u baroreceptor firing rate r u vagal tone r d AV conduction
• Treatment: ablation of focus, Adenosine (d AV conduction), Ca++
Channel blockers
Note REGULAR rhythm
in the tachycardiaRhythm usually begins
with PAC
159. ECG ARTIFACT
Artifact occurs when something causes a
disruption in monitoring.
Some common causes are:
AC interference -causes 60 cycle artifact
Muscle tremors
Respiratory artifact-wandering baseline
Loose electrode
Broken lead wire
167. PREMATURE VENTRICULAR CONTRACTION
(PVC)
CLINICAL SIGNS:
DEPEND ON FREQUENCY
PVC SHORT DIASTOLIC FILLING TIME
C.O.
FREQUENT PVC – SENSATION OF
PALPATIONS, SKIPPED BEATS
BIGEMINY – PVC EVERY OTHER BEAT
TRIGEMINY – PVC EVERY 3RD
BEAT
168. PREMATURE VENTRICULAR CONTRACTION
(PVC)
TREATMENT:
TREAT IMPAIRED HEMODYNAMICS
ANTIARRHYTHMICS
OXYGEN
MONITOR FOR PVC LANDING ON
T-WAVE
OBSERVE FOR UNIFOCAL (VS) MULTIFOCAL
169. Ventricular Arrhythmias
VENTRICULAR TACHYCARDIA
3 OR MORE PVC’s
QRS IS WIDE/ BIZARRE
EXTREMELY SERIOUS
MAY LEAD TO LETHAL RHYTHMS
ETIOLOGY: SAME CAUSES AS PVC,
ALSO CARDIOMYOPATHY,
MYOCARDIAL IRRITABILITY
173. V-fib
ETIOLOGY:
SAME AS VT, PVC
SURGICAL MANIPULATION OF HEART
FAILED CARDIOVERSION
CLINICAL SIGNS:
SAME AS CARDIAC ARREST
EKG SHOWS DISORGANIZED
RHYTHM
175. SCREAM for Vfib and
Pulseless VTach
1.Shock360J* monophasic, 1st and
subsequent shocks.(Shock every 2
minutes if indicated)
2.CPR After shock, immediately begin
chest compressions followed by
respirations (30:2 ratio) for 2 minutes.
3.Rhythm check after 2 minutes of CPR
(and after every 2 minutes of CPR
thereafter) and shock again if indicated.
Check pulse only if an organized or non-
shockable rhythm is present.
177. CARDIAC ARREST
VENTRICULAR ASYSTOLE
80 – 90% DUE TO V-fib
TOTAL ABSENCE OF ELECTRICAL AND
MECHANICAL ACTIVITY
ETIOLOGY
TRAUMA
OVERDOSE
MI
CLINICAL SIGNS
ASYSTOLE or V-fib
NO DEFINABLE WAVE FORMS
ABSENCE OF VITAL SIGNS
178. Ventricular Asystole
Acronym Comments
T Transcutaneous
Pacemaker
Only effective with early
implementaion
E Epinephrine 1 mg IV q3-5 min
A Atropine 1 mg IV q3-5 min
179. PEA- Pulseless Electrical
Activity
Asystole Algorithm
P E A
Problem search
Epinephrine – 1mg IV/IO q3-5min
Atropine- with a slow HR, I mg IV/IO q3-
5min
Consider termination of efforts if
asystole persists despite appropriate
interventions.
180. CARDIAC ARREST
Review ACLS Guidelines
2005TREATMENT: IMMEDIATE CPR
A. AIRWAY/ ADVANCED AIRWAY
CONTROL
B. BREATHING/ POSITIVE PRESSURE
VENTILATION
C. CIRCULATION/ CPR, START IV
D. DEFIBRILLATE (V-fib, V-tach ONLY)
E. DRUGS-Antidysrhythmic tx
181. CARDIAC ARREST
EPINEPHRINE 1:10,000 IV PUSH
REPEAT Q 5 MIN.
AMIODORONE:
ATROPINE:
VASOPRESSIN:
CONSIDER ANTIARRHYTHMICS
USE ACLS ALGORITHMS
182. CARDIAC ARREST
TREATMENT: POST CARDIAC ARREST
MONITOR -
CARDIAC STATUS
RESPIRATORY STATUS
TREAT UNDERLYING CAUSE
EMOTIONAL SUPPORT
SAFE ENVIRONMENT
183. DEFBRILLATION (vs)
CARDIOVERSION
DEFIBRILLATION
ASYNCHRONOUS ELECTRICAL DISCHARGE
THAT CAUSES DEPOLARIZATION OF ALL
MYOCARDIAL CELLS AT ONCE.
THIS ALLOWS (HOPEFULLY) THE SA NODE TO
RESTORE ITS PACEMAKER FUNCTION AND
DICTATE A REGULAR SINUS RHYTHM.
USED FOR PULSELESS V-tach AND V-fib
VOLTAGE: 200 – 360 joules (“stacked shock”)
or AED
184. CARDIOVERSION (aka)
SYNCHRONIZED
CONVERSION
ELECTRICAL IMPULSE IS DISCHARGED
DURING QRS (VENTRICULAR
DEPOLARIZATION)
USUALLY TIMED /W CARDIAC MONITOR TO
PREVENT SHOCK ON
T-WAVE
USED FOR RAPID A-fib, V-tach /W PULSE AND
PERSISTENT PAT / PSVT
VOLTAGE: 50 – 100 joules
185. EQUIPMENT REVIEW
DEFIBRILLATOR
SELECT ENERGY LEVEL, THEN CHARGE
PADDLES
USE 25 POUNDS OF PRESSURE WHEN APPLIED TO
CHEST, Placed 2nd
RICS and 5th
LAAS
CONDUCTING AGENT
GEL OR PAD WHICH ESTABLISHES SKIN CONTACT,
REDUCES SKIN BURNS
JOULES
MEASUREMENT OF ELECTRICAL ENERGY
DISCHARGES
NO ONE SHOULD COME IN CONTACT WITH PATIENT
OR BED DURING DISCHARGE
186. HEART BLOCK
DEPRESSED CONDUCTION OF IMPULSE
FROM ATRIA TO VENTRICLES
AV NODE BECOMES DEFECTIVE AND
IMPULSES (P-WAVES) ARE BLOCKED FROM
BEING TRANSMITTED TO VENTRICLES
FIRST DEGREE
SECOND DEGREE
TYPE I
TYPE II
THIRD DEGREE
187. 1° HEART BLOCK
PR INTERVAL > 0.20 SECONDS
CAUSES: MAY BE NORMAL VARIANT
INFERIOR WALL MI
DRUGS: DIGOXIN
VERAPAMIL
TREATMENT:
MONITOR
OBSERVE FOR SYMPTOMS
189. 2° HEART BLOCK
ONE OR MORE P-WAVES ARE NOT
CONDUCTED THROUGH THE VENTRICLE
HEART RATE - VENTRICULAR RATE
SLOW TO NORMAL
ATRIAL RATE MAY BE 2 – 4 X’s
FASTER THAN VENTRICULAR
190. 2° HEART BLOCK
CAUSES: ORGANIC HEART DISEASE
MI, Dig toxicity, B and Ca Channel
Blockers
DIGOXIN TOXICITY
SYMPTOMS
Tx:
Monitor HR
Atropine
Temporary pacemaker
Avoid meds that decrease conductivity
2 TYPES OF 2° HEART BLOCK
MOBITZ TYPE I- Wenkeback
MOBITZ TYPE II
191. Second Degree Heart Block
Mobitz I
PRI becomes progressively longer until
drops QRS
192. Second Degree Heart Block
Mobitz Type II
PRI constant and regular, but in a 2:1 ,
3:1 pattern
193. 3° HEART BLOCK
(COMPLETE HEART BLOCK)
ATRIAL IMPULSES & VENTRICULAR RESPONSE
ARE IN TOTAL DISASSOCIATION
P-WAVES ARE SEEN & ARE IRREGULAR
QRS COMPLEX ARE SEEN & ARE IRREGULAR
(ESCAPE RHYTHM)
NO CORRELATION BETWEEN P-WAVES & QRS
(RATE IS SLOW) – independent rhythms
194. 3° HEART BLOCK
(COMPLETE HEART BLOCK)
CAUSES
ORGANIC HEART DISEASE
MI
DRUGS
ELECTROLYTE IMBALANCE
EXCESS VAGAL TONE
SIGNS & SYMPTOMS
EXTREME DIZZINESS
HYPOTENSION
SYNCOPE
S/S OF C.O.
ALTERED MENTAL STATUS
197. PACEMAKER
Indications: Speed up a slow HR or Slow down
a rapid HR
ELECTRICAL DEVICE THAT DELIVERS
CONTROLLED ELECTRICAL STIMULUS
THROUGH ELECTRODES PLACED IN CONTACT
WITH HEART MUSCLE
2 PIECES
PULSE GENERATOR IMPLANTED IN CHEST
WALL UNDER R CLAVICLE
PACEMAKER ELECTRODES IMPLANTED IN
MYOCARDIAL TISSUE
200. Types of Pacemakers
Use a 5 letter code
system, first 3 used
more often:
1. Chamber being
paced: A, V, D
2. Chamber being
sensed: A, V, D, O
3. Type of response
by the PM to the
sensing: I, T, D, O
201. PATIENT TEACHING
Carry PM ID card
MEDI ALERT BRACELET
Avoid swimming, golf and weight
lifting
AVOID MRI
Check PM q3-6 mos.
PACEMAKER SURVEILANCE
Monitor pulse rates
Don’t hold cell phones over
generators
202. AUTOMATIC IMPLANTABLE
CARDIOVERSION DEFIBRILLATOR
(AICD)
PROVIDES INTERNAL SHOCKS WHEN
SERIOUS ARRHYTHMIA IS DETECTED (V-
tach OR V-fib)
Has a pulse generator and a sensor that
monitors the heart
If pt has dysrhythmia it delivers a shock
which the pt will feel
USEFUL WHEN ARRHYTHMIA IS
UNRESPONSIVE TO MEDS OR SURGICAL
ABLATION OR IRRITABLE MYOCARDIAL
TISSUE