Professional Documents
Culture Documents
Learning Objectives:
This syllabus is designed to fill the needs of students who desire the
ability to interpret the resting normal and abnormal ECG, as well as
provide an overview of heart anatomy, function and neurophysiology.
This should be considered to be an introduction to
electrocardiography that will provide a basis for continuing study of
this subject. This Arrhythmia syllabus is a supplement to the Lilly
textbook.
1. Review of the heart anatomy and the cardiac cycle as they relate
to the electrical conducting system
2. An understanding of cardiac muscle contraction
3. A comprehensive overview of EKG interpretation involving the
recognition of the most common arrhythmias
NOTE: Many changes of serious abnormalities (e.g. ST elevation)
can be caused by less serious conditions (e.g. early repolarization).
The ECG can only react in a limited number of ways to innumerable
clinical conditions. Therefore, we always interpret the ECG in the
clinical context at hand.
Arrhythmia Review
What is an arrhythmia?
The idea that helped me the most in actually understanding what
arrhythmias do to people was correlating, or maybe I should say
learning to visualize in my head, what the heart was actually doing
during one arrhythmia or the other. Each part of the normal cardiac
cycle has a specific mechanical event associated with it, and if you
can get a mental image in your head of what is, or isnt happening,
then the effects of the arrhythmias become much clearer.
The Nodes:
Take a look at the diagram that follows.
Remember these? These are the intrinsic pacemakers. Not too
hard theres only two of them. First is the sino-atrial node which
lives in the right atrium and is the one that generates P-waves. Pwaves travel from the SA to the AV, or Atrioventricular node, which
lives at the place where the atria and the ventricles join. As the
signal travels through the RA (and LA), both atria contract.
This is the key thing: as the signal goes through its part of the
heart, that same part of the heart responds mechanically, with
movement.
What is ectopy?
Ectopic means: something occurring where it isnt supposed to.
Pregnancy anywhere in the body but the uterus is ectopic
pregnancy. Seizures result from ectopic electrical activity in the
brain. If the signal that starts a heartbeat originates from
someplace other than its supposed to, its also called ectopic.
PAT is a very rapid supraventricular rhythm that comes from the atria
usually it runs at a very rapid rate, about 250-300bpm. You
sometimes see young people have short bursts of this rhythm, which
doesnt last more than a couple of seconds. How much caffeine did
they drink today? This strip shows the PAT breaking spontaneously
to NSR.
Here are some nice premature atrial contractions. That is, we assume
that the heart is contracting in response to these signals. Anyhow, if
you look at the early beat 5th complex, right? youll see that it has
a different P-wave morphology, meaning that it comes from
someplace other than the normal sinus node. The other thing youll
notice is that it comes too soon its premature. Coming sooner than
the normal SA node impulse, the PAC captures the heart, just for that
one beat then that ectopic source (an ectopic pacemaker is often
called a focus) shuts off again, and the regular sinus rhythm comes
back.
Continuing southwards
Working our way south from the SA node, the next source of
arrhythmias is the AV node, otherwise called the junction or just
the node, as in producing nodal rhythms.
Heres a rhythm you see once in a while see how the p-waves have
a number of different morphologies? The idea here is that the atrial
focus shifts from the SA node to the atrial tissue, in various places,
each of which generates its own signal, which goes on to capture. If
the rate is less than 100, they call it Wandering atrial pacemaker
(WAP) if its over 100, the name changes to Multifocal Atrial
Tachycardia.
2-11: What if the atria and the ventricles arent talking to each
other? How can I tell?
2-11-1: What is AV dissociation?
You all know complete heart block when you see it? Look at all those
p-waves floating around, lonely, on an empty isoelectric sea with no
QRSs to talk to. Heres how to tell if your patients atria and ventricles
arent communicating: it has to do with the relative rates. Whats the
atrial rate here? Lets count boxes going to the right from the p-wave
just above the ? in the first line of this paragraph: 300-150-100-70
somewhere in the sixties. How about the ventricular rate? --wicked
slow. somewhere around 20. And irregular, at that. The SA and AV
nodes arent communicating very often, if at all, and the AV node isnt
doing much, although it seems to be trying.
Is there:
- A) Any kind of visible relationship between the ps and the
qrss that you can see?
- B) are the ps just sort of appearing in amongst the QRSs
at random? Id say b. And is there any kind of
predictable ratio between the ps and the qrss? Such as
2:1, or even 8:1, or some varying number? Not really.
The arrows show that the p-waves are actually popping up all over
the place. Even though the last complex looks normal, thats actually
just a lucky hit the atria are doing their thing, and the ventricles are
doing theirs, but theyre not on speaking terms. Also notice the
constant P-P interval, constant R-R interval and variable P-R interval.
3-3: VT
Heres another big scary one. For this one you want to shock them as
soon as possible.
This is a weird one, and a bit rare, but you should know about it.
Torsades is an unusual kind of VT. In Torsades ( polymorphic VT ),
the axis actually rotates as the arrhythmia goes along it swings,
rotating around the heart, as though around a pin stuck in the middle
of the heart.
Misc:
Quiz Questions
1- This is:
abcd-
supraventricular tachycardia,
supraventricular bradycardia
WPW
sinus bradycardia
2- This is:
a- sinus bradycardia
b- ventricular bradycardia
c- wide-complex tachycardia, probably VT
3- This is:
abcd-
sinus rhythm
ventricular tachycardia
ventricular fibrillation
supraventricular tachycardia
4- This is:
abcd-
Answers:
1. D
2. C
3. C
4. D