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EKG findings and Arrhythmias

Heart Blocks:

First-degree AV block – normal sinus rhythm with PR interval ³ 0.2ms

Second-degree, type 1 (Weckenbach) block – PR interval elongates from beat to beat until a PR is dropped

Second-degree, type 2 (Mobitz) block – PR interval fixed but there are regular non-conducted P-waves leading

to dropped beats

Third-degree block – no relationship between P waves and QRS complexes. Presents with junctional escape

rhythms or ventricular escape rhythm

 

Atrial Fibrillation

• The most common chronic arrhythmia

• From ischemia, atrial dilatation, surgical history, pulmonary diseases, toxic syndromes

• Classically, the pulse is irregularly irregular

 

Signs and Symptoms:

•

Chest discomfort• Palpitations

• Tachycardia,

• Hypotension + syncope

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Treatment :

• Control rate with b-blockers, CCB’s, and digoxin (not acutely)

• If fibrillations last >24hr then should anticoagulate with warfarin for at least 3 weeks before

cardioversion (prevents embolisms)

• If you cannot convert to normal sinus rhythm, the patient will require long-term anticoagulation.1st line is warfarin, 2nd line is aspirin

Cardioversion to convert to normal rhythm:

1st line – IV procainamide, sotalol, amiodarone

Electrical à shock of 100-200J followed by 360J

 

Atrial Flutter

• Less stable than Afib • The rate is slower than that of atrial fibrillation (approximately 250-350bpm) 

• Ventricular rate in atrial flutter is at risk of going too fast, thus atrial flutter is considered to be moredangerous (medically slowing this rate can cause a paradoxical increase in ventricular rates) 

• Classic rhythm is an atrial flutter rate of 300bpm with a 2:1 block resulting in a ventricular rate of 150bpm 

• Signs and symptoms similar to those of atrial fibrillation 

• Complications include syncope, embolization, ischemia, heart failure 

Classic EKG finding is a “sawtooth” pattern:

 

Treatment :

• If patient is stable, slow the ventricular rate with CCB’s or b-blockers (avoid procainamide because itcan result in increased ventricular rate as the atrial rate slows down)

• If cardioversion is going to take place be sure to anticoagulate for 3 weeks

• If patient is unstable must cardiovert à start at only 50J because is easier to convert to normal sinusrhythm than atrial fibrillation

 

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Multifocal Atrial Tachycardia (MFAT)

• An irregularly irregular rhythm where there are multiple concurrent pacemakers in the atria.

• Commonly found in pts with COPD

EKG shows tachycardia with ³ 3 distinct P waves

 

Treatment :

• Verapamil

• Treat any underlying condition

 

Supraventricular Tachycardia

• Many tachyarrhythmias originating above the ventricle

• Pacemaker may be in atrium or AV junction, having multiple pacemakers active at any one time

• Differentiating from ventricular arrhythmia may be difficult if there is also the presence of a bundlebranch block

Treatment :

• Very dependent on etiology

• May need to correct electrolyte imbalance

• May need to correct ventricular rate [digoxin, CCB, b-blockers, adenosine (breaks 90% of SVT)]

• If unstable requires cardioversion

• Carotid massage if patient has paroxysmal SVT

 

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Ventricular Tachycardia

• VTach is defined as ³ 3 consecutive premature ventricular contractions

• If sustained, the tachycardic periods last a minimum of 30s.

• Sustained tachycardia requires immediate cardioversion due to risk of going into ventricular fibrillation

 

Treatment :

• If hypotensive or no pulse existent do emergency defibrillation (200, then 300, then 360J)

• If patient is asymptomatic and not hypotensive, the first line treatment is amiodarone or lidocainebecause it can convert rhythm back to normal

 

Ventricular Fibrillation

• Erratic ventricular rhythm is a fatal condition.

• Has no rhyme or rhythm

 

Signs and Symptoms:

• Syncope

• Severe hypotension

• Sudden death

Treatment :• 1st line – Emergent cardioversion is the primary therapy (200-300-360J), which converts to normalrhythm almost 95% of the time

• Chest compressions rarely work

• 2nd line – Amiodarone or lidocaine

If treatment isn’t given in a timely matter, patient experiences failure of cardiac output and this progresses to

death.