Good morning

ATRIO –VENTRICULAR
BLOCK (AVB)
AV block, or heart block, exists
when conduction of the stimulus
from the atria to the ventricle
through the AV node is slowed or
blocked.
The AV block may be transient
,intermittent ,or permanent .It may be
incomplete or complete.
Atrioventricular Blocks
Impulse is delayed within the AV
node, bundle of His or His-Purkinje
HEART
CORONARY VASCULATURE
A heart block
can be a
blockage at any
level of the 
electrical conduc
tion system of th
e heart
.
Types of heart block
SA nodal blocks
AV nodal block
Intraatrial block
Intraventricular block
Bundle branch blocks
TYPES ACCORDING TO SEVERITY
• First degree AV block
• Second degree AV block
–Type I second degree AV block
(Mobitz I) / Wenckebach block
–Type 2 second degree AV block
(Mobitz II)
• Third degree AV block (Complete
heart block)
 FIRST DEGREE HEART BLOCK(Ⅰ ゜

AVB)
I゜ AVB is prolongation of the atrio-ventricular

conduction time and is also referred to as first degree A-V

block.


The electrical impulse moves through the AV node more

slowly than normal


Heart rate and rhythm are normal
Generally, no treatment is necessary for first-degree heart block.

• ECG: Prolonged
P-R interval:
• longer than
0.20sec in adults
and >0.22s in old
adults.
• PR Interval > 0.2
seconds (>5
small sq) but
constant
The difference of
P-R interval
between two
times is more
than 0.04 second.
SECOND-
DEGREE
HEART
BLOCK
 SECOND-DEGREE HEART BLOCK

Some signals from the atria don't

reach the ventricles
Causes "dropped beats
There are two types:
 Type I second-degree heart block, or Mobitz Type
I, or Wenckebach's AV block
 Type II second-degree heart block, or Mobitz
Type II
 Mobitz Type I, or Wenckebach's
AV block
• Electrical impulses are
delayed more and more with
each heartbeat until a beat
is skipped

• Level of block is at AV node

• ECG:
(1) The P-R interval
becomes longer and
longer
(2) RHYTHM: irregular
3:2 CONDUCTION RATIO
Mobitz Type II
Failure of conduction of one or
more sinus beats to the ventricle
 More serious
 An abnormally slow heartbeat
may result
Level of block is below AV node
There is a fixed numerical relationship
between atrial and ventricular impulses,which
may be 2:1 or 3:1 or 4:1
Mobitz Type II
 MOBITZ TYPE I MOBITZ TYPE II

•PR interval •PR interval consant;

lengthens; Preceding the pause
Preceding the pause is same as that after
is longer than that the pause
after the pause
•Level of block: is
•Level of block: is at below AV node
AV node
•QRS -wide
•QRS - Normal
 THIRD-DEGREE OR COMPLETE
HEART BLOCK!
• Heart's electrical signal doesn't
pass from the upper to the lower
chambers.
• This can precipitate VT/VF
• Ventricles end up producing their
own electrical signals (called the
escape rhythm)
• Some part of conducting system will take over as
pacemaker
• The escape pacemaker can be in the AV node Or it
can be in the His bundle or even distal to it
• It usually results in a very slow heartbeat
(bradycardia) and can cause a heart attack.
LEVEL OF BLOCK

• At AV nodal – Junctional rhythm with

narrow QRS complex
• At His-Purkinje level - Ventricular
escape rhythm with wide QRS
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– It can be bullet points or description.
• ECG:
• Atrial rate : normal
• Ventriuclar rate : less than 45bpm
• P wave: dissociated from QRS
• There is no P-R to QRS relationship
• QRS : normal/ wide
• Regular P-P interval .
Rugular R-R interval
SUMMARY :
1º : Prolongation of PR Interval
2º : Mobitz I – Increasing PR Interval until
dropped beat is seen
Mobitz II – Constant PR Interval with
more P waves to QRS
2 : 1 – Constant PR Interval with more P
waves to QRS
3º : Complete pathological block at the AV
node Complete dissociation between P
waves
 CAUSES
• Can be either congenital or acquired
– autoimmune diseases
• Causes of acquired complete heart block
 include the following:
• Drugs or toxins
– Beta-blockers
– Calcium channel blockers
– Digoxin or other cardiac glycosides
 Causes
ctd.....
• coronary artery disease
• Profound hypervagotonicity
• MI - anterior wall MI
• Cardiomyopathy
• Sclerosis (Aortic)
• Acute rheumatic fever
• Metabolic disturbances, Eg, severe
hyperkalemia
•PATHOPHYSIOLOGY
• Duration of the escape QRS complex depends on the site
of the block and the site of the escape rhythm pacemaker.
• Pacemakers above the His bundle produce a narrow QRS
complex escape rhythm, while those at or below the His
bundle produce a wide QRS complex.
• When the block is at the level of the AV node, the escape
rhythm generally arises from a junctional pacemaker with
a rate of 45-60 beats per minute. Patients with a
junctional pacemaker frequently are hemodynamically
stable and their heart rate increases in response to
exercise and atropine.
• When the block is below the AV node, the escape rhythm
arises from the His bundle or the bundle-branch Purkinje
system at rates less than 45 beats per minute. These
patients generally are hemodynamically unstable and
their heart rate is unresponsive to exercise and atropine.
SIGNS AND SYMPTOMS
• Bradycardia
• Chest pressure or pain
• Fainting, also known as
 syncope
• Fatigue
• Lightheadedness or dizziness
• Palpitations, which can be skipping,
fluttering or pounding in the chest
• Shortness of breath
• In patients with concomitant
myocardial ischemia or
infarction,
–Chest pressure or pain
–Dyspnea
–nausea or vomiting
–Signs of anxiety such as agitation or
unease
–Diaphoresis
–Pale complexion
–Tachypnea
• Patients may have signs of
hypoperfusion
–Altered mental status
– seizures, caused by not enough oxygen getting to
the brain
–Hypotension
–Lethargy
–Chest pain
–.
• Stokes Adams syndrome
–A condition involving sudden fainting which usually
lasts for less than a minute and may include
seizures. Before the attack the patient becomes
pale and during recovery the patient often feels hot
and flushed. The fainting occurs when there is a
lack of oxygen to the brain due to heart rhythm
 problems involving slowing of the heart. The
condition has a high mortality ratewithout
treatment which often involves a pacemakeror
medication
Symptoms of Stokes Adams syndrome
• Fainting
• Blackouts
• Sudden loss of consciousness
• Fainting when seated - several other types of fainting rarely
occur when seated
• Recurrent attacks of fainting
 DIAGNOSES
 Laboratory Studies
Serum electrolytes levels
Digoxin level
Lyme titers
Cardiac enzymes 
a complete blood count

 12-lead electrocardiogram
 Imaging Studies
 A chest radiograph
 If myocarditis or a pericardial effusion is
a concern, an
echocardiogram should be performed
• angiogram
 TREATMENT
Emergency department care
• Administering oxygen, maintenance of an
intravenous line, frequent monitoring of blood
pressures, and continuous cardiac monitoring.
• Anti-ischemic therapy
• Transcutaneous pacemaker
• Transvenous pacemaker
• Arrange for permanent pacemaker insertion
MEDICATIONS Anticholinergic
agents

Catecholamines

Antidotes

Antiarrhythmic
drugs
 Medications

• Anticholinergic agents
These agents improve conduction through the AV node by
reducing vagal tone via muscarinic receptor blockade.
• Catecholamines
These agents improve hemodynamics by acting on the beta-
adrenergic receptors to increase the heart rate and
contractility, and by acting on the alpha-adrenergic
receptors to increase the systemic vascular resistance.
• Sympathomimetic agents
These agents act on beta-adrenergic receptors and increase
heart rate and contractility
• Digoxin immune Fab (Digibind)
WHAT IS A PACEMAKER?
•
The Pacemaker is a battery-powered
implantable devices that function to
electrically stimulate the heart to
contract and thus to pump blood
through out the body. These devices
are used to help patients with very
slow heart beats. A regular
pacemaker weighs about an ounce,
band has and area of 30cm2. 
DIFFERENT KINDS OF
PACEMAKER.

•
There are many different sorts of pacemaker. I will tell you about some of them. A
single-chamber pacemaker has one lead while a dual-chamber has two leads.
Dual chamber pacemakers have two leads: one in the atrium and one in the
ventricle. Dual-chamber pacemakers are more complex and sophisticated than
single-chamber pacemakers. A dual chamber pacemaker can receive signal from
both the ventricle and the atrium. It can also coordinate the signals and
contractions of the atria and the ventricles to help the heart beat more efficiently.
There is an external pacemaker for people with small abnormalities in their heart
rhythm. The body normally has a pacemaker when you are born but some
peoples stop working so that is where the man made pacemaker comes in. 
Pacemaker systems are often implanted under local anaesthesia in a cardiac
catheterization laboratory. Implantation of a pacemaker is considered a minor
procedure. Some hospitals with electrophysiology laboratories implant
pacemakers there. A pacemaker is implanted just below the collarbone in a
procedure that takes about two hours. Each pacemaker can last up to around
ten years without a change. 
A unipolar
   A bipolar
circuit circuit
 Pacing sites
• Temporary transvenous pacemaker
– involves a pulse generator, which is externally connected to
2 electrode wires, threaded through a large vein (generally
the subclavian or internal jugular) into either the right
atrium or the right ventricle.These wires directly contact the
endocardium within the heart .

• Temporary epicardial pacemaker

– involves directly stimulating the epicardium. This type of
pacing is initiated after cardiac surgery.Postoperatively,
electrodes are lightly sutured to the epicardium before the
thorax is closed. These pacing wires are pulled through the
skin and secured to the external chest wall, ready for
attachment to a temporary pacing generator as needed
Temporary Dual Chamber Sequential Pacing Temporary Single
Box    Chamber Pacing
Box
 Base Level Pacing Controls

ON and OFF
• The device is turned on by
pressing the ON key. The device is
turned off by pressing the ON and
OFF keys simultaneously.
RATE
• This dial is used to set the rate, in
pulse per minute [ppm]), at which
pacing pulses are delivered. It
allows continuous adjustment of
the rate from 30 to 180 min-1
(ppm)
Base Level Pacing Controls ctd….

OUTPUT
• This dial is used to set the amplitude, in
milliamperes (mA), of the pacing pulse.
It allows continuous adjustment of the
stimulus current amplitude from 0.1 to
20 mA. If both the atrium and the
ventricle are paced, a separate output
setting is required for each chamber.
• The output amount is the level of energy
delivered by the pulse generator to the
heart to initiate depolarization.
• Output is then slowly increased until
capture is obtained .
.
 SENSITIVITY

• Sensing merely refers to the ability of  Repositioning the patient on his or

her left side may improve contact
the generator to detect and
between the electrode and the
recognize the impulses the
myocardium. If the response is still
myocardial tissue is generating on
inadequate, then the sensitivity
its own.
must be increased.
• This dial is used to enable and
 This increase is accomplished by
adjust the sensitivity, in millivolts
turning down the millivoltage,
(mV), of the sensing circuitry. When
allowing the generator to detect
enabled, the sensitivity can be
beats that occur at lower
adjusted from 0.5 to 20 mV. Initially
millivolt levels. Conversely, if the
set at about 2 to 5 mv.
pacemaker is detecting beats that
• To synchronize the beats, the
are not actually occurring
generator first analyzes the intrinsic (inappropriate sensing), then the
rhythm and then stimulates the heart sensitivity threshold must be
only as needed. increased to block out artifact. This
• The most common cause of failure increase is accomplished by
to sense is displacement of the turning up the millivoltage
electrode.
 CAPTURE

Electrical capture, the ability of the electrical impulse to

initiate a cardiac response, is detected by examining an
electrocardiogram. Capture is both an electrical and a
mechanical event.
Electrical capture is indicated by a pacer spike followed by
a corresponding P wave or QRS complex, depending on
which chamber is being paced .If the atrium is paced, the
spike appears before the P wave. If the ventricle is paced,
the spike occurs before the QRS complex
Failure to capture occurs when a pacer spike is present but is
not followed by a corresponding waveform (P wave or QRS
complex)
• Atrial pacer
–a pacer spike (Ap) followed by a
corresponding P wave.

• ventricular pacer
• pacer spike (Vp) followed by a
corresponding, widened QRS complex.
NURSING DIAGNOSIS

• Acute pain related to an imbalance in

oxygen supply & demand.
• Decreased cardiac output related to
myocardial ischemia.
• Knowledge deficit related to unfamiliarity
with the procedure.
• Anxiety related to surgical procedure.
• Activity intolerance related to decreased
cardiac output.
• Sleep pattern disturbance related to
environmental changes
• Constipation related to decreased activity
level of patient.