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Ventricular Rhythms - BMH/Tele

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Ventricular Rhythms - BMH/Tele

  1. 1. Ventricular Rhythms <ul><li>Electrical impulses that originate from the ventricular conduction system. </li></ul>
  2. 2. Ventricular Rhythms Bundle Branch Blocks (BBB) & Hemiblocks Premature Ventricular Contractions (PVC) Ventricular Escape Beat Idioventricular Rhythm & AIVR Ventricular Tachycardia Ventricular Fibrillation Ventricular Standstill Asystole
  3. 3. Wide, Bizarre QRS’s <ul><li>Sequential Depolarization </li></ul><ul><li>The electrical impulse originates from an ectopic site within one of the ventricles stimulating that side first, then depolarizes the other ventricle </li></ul><ul><li>Conduction time is slower than normal causing a wide, bizarre QRS complex </li></ul><ul><li>( > 0.12 sec) </li></ul>
  4. 4. Bundle Branch Block (BBB) A bundle branch block refers to an obstruction in the transmission of the electrical impulse through one branch (either right or left) of the bundle of His.
  5. 5. Hemiblocks A bundle branch block that occurs farther down the left bundle branch is called a hemiblock Left Posterior Fascicular Block Left Anterior Fascicular Block
  6. 6. Bundle Branch Block (BBB) In a bundle branch block, the impulse travels down the unaffected bundle branch and then from one myocardial cell to the next to depolarize the ventricle Because this cell-to-cell conduction progresses much more slowly than the conduction along the specialized cells of the conduction system, ventricular polarization is prolonged
  7. 7. Bundle Branch Block (BBB)
  8. 8. BBB: Analyzing a Strip Rhythm: Regular Rate: 60 – 100 bpm P waves: Upright & uniform. PRI: 0.12 – 0.20 sec QRS: > 0.12 sec; notched or “bunny ears”. ***Interpretation: NSR w/ BBB & ST-segment depression
  9. 9. Premature Ventricular Contraction (PVC) A PVC is a premature, ectopic impulse that originates in either the right or left ventricle. Electrical impulse originating from ventricle depolarizes only one ventricle at a time (resulting in sequential depolarization). This results in a wide, bizarre-looking QRS complex. May be unifocal or multifocal.
  10. 10. PVC’s <ul><li>The ST segment and T wave slope in the opposite direction from the main deflection of the QRS complex </li></ul><ul><li>If depolarization is abnormal, then repolarization will be abnormal </li></ul>
  11. 11. Compensatory Pause <ul><li>Occurs because the SA node isn’t depolarized by the ectopic ventricular beat, the discharge timing of the sinus node remains unchanged and the underlying rhythm will resume on time after the PVC </li></ul>
  12. 12. Unifocal PVC’s
  13. 13. Multifocal PVC’s
  14. 14. Patterned PVC’s <ul><li>Bigeminy, Trigeminy, Quadrigeminy </li></ul>
  15. 15. Premature Ventricular Contraction (PVC) Causes: Electrolyte Imbalances Hypokalemia, Hyperkalemia, Hypomagnesemia, Hypocalcemia Metabolic Acidosis Hypoxia Myocardial Ischemia Drug Intoxications Cocaine, amphetamines, TCA’s LV Enlargement Increased Sympathetic Stimulation Myocarditis
  16. 16. Premature Ventricular Contraction (PVC) Treatment: If asymptomatic, no treatment may be required Antiarrhythmics such as amiodarone (Cordarone), lidocaine, or procainamide (Pronestyl), propafenone (Rythmol)
  17. 17. PVCs: Analyzing a Strip Rhythm: Premature ectopic beat causes slight irregularity Rate: Overall HR depends on rate of underlying rhythm P waves: Ectopic beat is not preceded by a P wave. PRI: None; impulse originates from a lower focus QRS: Wide and bizarre; different from underlying QRS complexes. T wave is frequently in the opposite direction from the QRS complex.
  18. 18. Run of PVC’s 3 or more consecutive PVC’s Occurs within an underlying rhythm Spontaneously resumes back to underlying Symptomatic or Asymptomatic Result of R-on-T Phenomenon Amiodarone (Cordarone), lidocaine, or procainamide (Pronestyl)
  19. 19. Run of PVCs: Analyzing a Strip Atrial Fibrillation (controlled) with a 5-beat run of PVCs (run of V-Tach or burst of PVCs) & ST-segment depression
  20. 20. Ventricular Escape Beat <ul><li>A ventricular beat that occurs as a result of a pause in an underlying rhythm </li></ul><ul><li>Likely occur due to increased vagal effect on the SA node rather than because of enhanced automaticity </li></ul><ul><li>A protective mechanism – preventing slow heart rates </li></ul>
  21. 21. Ventricular Escape Beat <ul><li>How does this beat differ from a junctional escape beat??? </li></ul><ul><li>Interpretation: NSR w/ ventricular escape beat following a pause converting back to NSR </li></ul>
  22. 22. Idioventricular (Escape) Rhythm
  23. 23. Idioventricular (Escape) Rhythm Idioventricular rhythms occur when all pacemakers fail to function or when SV impulses can’t reach the ventricles because of a block in the conduction system
  24. 24. Idioventricular (Escape) Rhythm Causes: Accompanied by Complete Heart Block Myocardial Ischemia MI Digoxin Toxicity Pacemaker Failure Metabolic Imbalances
  25. 25. Idioventricular (Escape) Rhythm Treatment: Pacemaker (Temporary – Permanent) Treat Underlying Cause
  26. 26. IVR: Analyzing a Strip Rhythm: Regular; can slow down as heart dies. Rate: No atrial rate; ventricular rate 20 – 40 bpm P waves: None; impulse originates from a lower focus PRI: None; impulse originates from a lower focus QRS: Wide and bizarre; equal to or > 0.12 sec. T wave not visible Interpretation: Idioventricular Rhythm (IVR)
  27. 27. Accelerated Idioventricular Rhythm <ul><li>Rate: 41 - 100 </li></ul><ul><li>Wide, bizarre QRS complexes </li></ul><ul><li>No P waves </li></ul>
  28. 28. Accelerated Idioventricular Rhythm <ul><li>How is AIVR distinguished from accelerated junctional rhythm??? </li></ul>
  29. 29. Ventricular Tachycardias Monomorphic, Polymorphic, Torsades de Pointes
  30. 30. Ventricular Tachycardia Ventricular tachycardia usually results from increased myocardial irritability, which may be triggered by enhanced automaticity or reentry within the Perkinje system or by PVC’s initiating the R-on-T phenomenon
  31. 31. Ventricular Tachycardia Causes: Myocardial ischemia MI CAD Valvular heart disease Heart failure Cardiomyopathy Electrolyte imbalances Drug intoxication – digoxin, procainamide, quinidine, or cocaine
  32. 32. Ventricular Tachycardia <ul><li>Non-sustained: </li></ul><ul><li>Paroxysmal bursts lasting less than 30 seconds </li></ul><ul><li>Sustained: </li></ul><ul><li>Stable, Unstable, or Pulseless </li></ul>
  33. 33. Ventricular Tachycardia Three Types of ACLS Algorithms for V-Tach: Stable Ventricular Tachycardia Unstable Ventricular Tachycardia Pulseless Ventricular Tachycardia
  34. 34. Monomorphic VT: Analyzing a Strip <ul><li>Rhythm: Regular; sometimes slightly irregular </li></ul><ul><li>Rate: no atrial rate; ventricular rate 150 – 250 bpm </li></ul><ul><li>P waves: No P waves present </li></ul><ul><li>PRI: None </li></ul><ul><li>QRS: Wide and bizarre; Uniform; </li></ul><ul><li>0.12 sec. </li></ul><ul><li>T wave opposite direction of QRS </li></ul><ul><li>***Interpretation: Ventricular Tachycardia (VT) </li></ul>
  35. 35. Ventricular Tachycardia A.K.A. – Monomorphic V-Tach
  36. 36. Polymorphic VT: Analyzing a Strip Rhythm: Regular; sometimes slightly irregular Rate: no atrial rate; ventricular rate 150 – 250 bpm P waves: No P waves present PRI: None QRS: Wide and bizarre; Varied morphology; > 0.12 sec. T wave opposite direction of QRS ***Interpretation: Polymorphic VT
  37. 37. Torsades de Pointes <ul><li>Causes: </li></ul><ul><li>Usually reversible </li></ul><ul><li>Drugs that lengthen QT interval (amiodarone, ibultilide, erhythromycin, haloperidol, sotalol, levafloxicin) </li></ul><ul><li>Myocardial ischemia </li></ul><ul><li>Hypokalemia, hypomagnesemia, hypocalcemia </li></ul>
  38. 38. Torsades de Pointes Treated by correcting the underlying cause: Mechanical overdrive pacing Magnesium sulfate Electrical cardioversion
  39. 39. Torsades de Pointes: Analyzing a Strip Rhythm: Irregular; sometimes slightly irregular Rate: no atrial rate; ventricular rate 150 – 250 bpm P waves: No P waves present PRI: None QRS: Wide and bizarre; Varied morphology; > 0.12 sec. T wave opposite direction of QRS ***Interpretation: Torsades de pointes
  40. 40. Ventricular Fibrillation (VF) A chaotic pattern of electrical activity in the ventricles in which electrical impulses arise from many different foci. No effective myocardial contraction = No CO Untreated V-fib causes most cases of sudden cardiac death in people outside of the hospital
  41. 41. Ventricular Fibrillation Causes: Myocardial ischemia MI Untreated Ventricular Tachycardia Underlying HD Acid-Base Imbalance Electric Shock Severe Hypothermia Electrolyte imbalances Hypokalemia, hyperkalemia, hypercalcemia
  42. 42. Ventricular Fibrillation <ul><li>Fine or Coarse </li></ul>
  43. 43. VF: Treatment Defibrillatory Shocks CPR Vasopressors Antidysrhythmics Determine Underlying Cause
  44. 44. Defibrillation What Does Defibrillation Do? The electrical current causes the myocardium to depolarize, which, in turn, encourages the SA node to resume normal control of the heart’s electrical activity RESETS THE ELECTRICAL CONDUCTION!
  45. 45. VF: Analyzing a Strip Rhythm: Chaotic Rate: Cannot be determined; no discernible waves P waves: No P waves PRI: None QRS: No discernible QRS complexes ***Interpretation: Ventricular Fibrillation (VF)
  46. 46. Ventricular Standstill <ul><li>SA node intact, so P waves are present </li></ul><ul><li>No ventricular conduction due to a preceding advanced AV block </li></ul>
  48. 48. Asystole Treatment: CPR Epinephrine Atropine
  49. 49. TIME TO WORKOUT!!!
  50. 50. References <ul><li>Beverage, D. Haworth, K., Labus, D. Mayer, B. H., & Munson, C. (2005). ECG interpretation made incredibly easy, (3 rd ed.). Ambler, PA: Lippincott, Williams, & Wilkins. </li></ul><ul><li>Chernecky, C., et al. (2002). Real world nursing survival guide: ECG’s & the heart. United States of America: W. B. Saunders Company. </li></ul><ul><li>Huff, J. (2006). ECG workout: Exercises in arrhythmia interpretation (5 th ed.). United States of America: Lippincott, Williams & Wilkins. </li></ul><ul><li>Walraven, G. (1999). Basic arrhythmias (5 th ed.). United States of America: Prentice-Hall, Inc. </li></ul><ul><li>www.madsci.com/manu/ekg_rhy.htm </li></ul>
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