ECG #2

[Cardiac Dysrhythmias]



SA
NODE
AV
NODE
RIGHT BUNDLE
BRANCH
LEFT BUNDLE
BRANCH
PURKINJEE
FIBERS
ELECTRICAL CONDUCTION OF THE HEART
Common Pediatric Arrhythmias
Most common dysrhythmias in children are:
Supraventricular tachycardia
Bradycardia
Sinus arrhythmia

Atrial fibrillation
Atrial flutter
Ventricular tachycardia and fibrillation
Rarely found in children.

However! Children with congenital heart disease may present
with any arrhythmia!
Abnormal rhythms specifically related to their heart disease or
damage caused by surgical repair are the arrhythmias most
usually seen. [Blocks!]
A Quick Note About Dominance
and T Waves
Right ventricular dominance determined
by analyzing a 12-lead ECG
Larger portion of the QRS waveform in V1.
With right ventricular dominance, the R
wave is larger than the S wave in V1.

Also T Wave inversion in V1-V3 Normal
Before we start looking at the
rhythms
Why do people have arrhythmias?

What is the difference between a bad
arrhythmia and a not-so-bad arrhythmia?

What do we look at when reading
rhythms
Assess the rate
Assess rhythm/regularity
Identify and examine P waves
Assess intervals (evaluate conduction)
PR interval, QRS duration, QT interval
Evaluate overall appearance of the rhythm
ST segment elevation/depression
T wave inversion
Interpret rhythm and evaluate clinical significance

Rhythm/Regularity
When analyzing a rhythm strip, determine:
Atrial (P-P intervals) rhythm
Ventricular (R-R intervals) rhythm

If rhythm is regular, R-R intervals (or P-P
intervals if assessing atrial rhythm) are
same
Plus or minus 10% acceptable
Sinus Dysrhythmias

Sinus Rhythm
Rate 60-100 beats/min
Rhythm
Regular

P waves
Uniform in appearance, positive (upright) in lead II, one
precedes each QRS complex
PR
interval
0.12-0.20 second and constant from beat to beat
QRS 0.10 second or less
Sinus Rhythm
Sinus Bradycardia
Rate

Less than 60 beats/min

Rhythm

Regular

P waves

Uniform in appearance, positive (upright) in lead II, one
precedes each QRS complex

PR interval

0.12-0.20 second and constant from beat to beat

QRS
0.10 second or less

In adults a rate less than 60
But variability in heart rates in pediatric
patients For example, heart rate of 80 in a
newborn infant would be considered sinus
bradycardia.
Sinus bradycardia is a common rhythm of
children in severe distress.
Cardiovascular system response to
hypoxia and certain drugs.

Sinus Tachycardia
Rate

101 - 180 beats/min

Rhythm

Regular

P waves

Uniform in appearance, positive (upright) in lead II, one
precedes each QRS complex; at very fast rates it may be
difficult to distinguish a P wave from a T wave

PR interval

0.12-0.20 second and constant from beat to beat

QRS
0.10 second or less


Sinus Arrhythmia
Rate

60 - 100 beats/min

Rhythm

Irregular

P waves

Uniform in appearance, positive (upright) in lead II, one
precedes each QRS complex; at very fast rates it may be
difficult to distinguish a P wave from a T wave

PR interval

0.12-0.20 second and constant from beat to beat

QRS
0.10 second or less

Atrial Dysrhythmias

Premature Atrial Complexes
Rate

Usually within normal range, but depends on underlying rhythm

Rhythm

Regular with premature beats

P waves

Premature (occurring earlier than the next expected sinus P
wave), positive (upright) in lead II, one precedes each QRS
complex, often differ in shape from sinus P waves may be
flattened, notched, pointed, biphasic, or lost in the preceding T
wave

PR interval

May be normal or prolonged depending on the prematurity of
the beat

QRS Usually less than 0.10 second but may be wide (aberrant) or
absent, depending on the prematurity of the beat. The QRS of
the PAC is similar in shape to those of the underlying rhythm
unless the PAC is abnormally conducted.

Premature Atrial Complexes
(PACs)
Wandering Atrial Pacemaker
Rate

60-100 bpm

Rhythm

Irregula
P waves

P waves vary in shape depending on site of impulse origin. May
be upright, inverted, or biphasic. Must see three (3) different P
wave shapes to diagnose WAP.
PR interval

0.12-0.20 seconds (variable)
QRS Usually less than 0.10 second.

SVT
Usually less than 0.10 second QRS
Not measurable PR interval
No identifiable P waves P Waves
Ventricular regular or irregular depending on AV conduction/blockade Rhythm
Atrial rate is unknown. Ventricular rate is 150-180 beats/min determined
by AV blockade.
Rate
Most common arrhythmia seen in children.
It includes a variety of rhythms that emanate from the
sinus, atrial, or junctional areas of the heart.
By definition, all but ventricular rhythms are considered
supraventricular.
Supraventricular tachycardia is differentiated from sinus
tachycardia by the unusually fast rate and the patient's
presentation.
It can occur in normal healthy infants, children, and
adolescents with an accessory pathway such as Wolf-
Parkinson-White syndrome (WPW). [L to R in atria]
Px
Effect on the child must be assessed.
Can be asymptomatic or in extreme distress.
Child- asymptomatic should be continually monitored
and treated by a pediatric cardiologist.
Rapid rate decreases diastolic filling time, the child
also can have evidence of low cardiac output and poor
systemic perfusion.
If the child is showing signs of poor perfusion, the
rhythm should be treated promptly with IV adenosine.
If the child has inadequate blood pressure, then he or
she should undergo synchronized cardioversion
Atrial Tachycardia
Usually less than 0.10 second QRS
0.12-0.20 seconds PR interval
Abnormal morphology, often perky P Waves
Ventricular regular or irregular depending on AV conduction/blockade Rhythm
Atrial rate is unknown. Ventricular rate is 150-180 beats/min determined
by AV blockade.
Rate
Atrial Fibrillation
Usually less than 0.10 second but may be widened if an intraventricular
conduction delay exists
QRS
Duration
Not measurable PRI
No identifiable P waves; fibrillatory waves present. Erratic, wavy baseline. P Waves
Ventricular rhythm usually irregularly irregular Rhythm
Atrial rate usually greater than 400-600 beats/min; ventricular rate variable Rate
Atrial Fibrillation
Atria are depolarized at a rate of 400 to
600 beats/min
the muscles of the atria to quiver (fibrillate)
Results in:
Ineffectual atrial contraction
Subsequent decrease in cardiac output
Loss of atrial kick
Atrial Fibrillation
Atrial Flutter
Usually less than 0.10 second but may be widened if flutter waves are
buried in QRS complex or an intraventricular conduction delay exists.
QRS
Not measurable PRI
No identifiable P waves; saw-toothed flutter waves are present P Waves
Atrial regular, ventricular regular or irregular depending on AV
conduction/blockade
Rhythm
Atrial rate 250-350 beats/min, typically 300 beats/min; ventricular rate
variable determined by AV blockade. The ventricular rate will usually not
exceed 180 beats per minute due to the intrinsic conduction rate of the AV
junction.
Rate
Atrial Flutter
Premature Junctional Contractions
[PJCs]
Usually less than 0.10 second but may be wide (aberrant) or absent,
depending on the prematurity of the beat. The QRS of the PJC is similar in
shape to those of the underlying rhythm unless the PJC is abnormally
conducted.
QRS
Absent or less than 0.12 seconds PR interval
Absent or inverted P Waves
Irregular Rhythm
Atrial rate 250-350 beats/min, typically 300 beats/min; ventricular rate
variable determined by AV blockade. The ventricular rate will usually not
exceed 180 beats per minute due to the intrinsic conduction rate of the AV
junction. 60-100 bpm
Rate
Junctional Rhythm
Usually less than 0.10 seconds QRS
Absent or less than 0.12 seconds PR interval
Absent or inverted P Waves
Regular Rhythm
40-60 bpm Rate
Accelerated Junctional Rhythm
Usually less than 0.10 seconds QRS
Absent or less than 0.12 seconds PR interval
Absent or inverted P Waves
Regular Rhythm
60-100 bpm Rate
Junctional Tachycardia
Usually less than 0.10 seconds QRS
Absent or less than 0.12 seconds PR interval
Absent or inverted P Waves
Regular Rhythm
Greater than 100 bpm Rate
Blocks

First-Degree AV Block
Rate

Usually within normal range, but depends on underlying rhythm

Rhythm

Regular

P waves

Normal in size and shape, one positive (upright) P wave before each
QRS in leads II, III, and aVF

PR interval

Prolonged (greater than 0.20 second) but constant

QRS duration

Usually 0.10 sec or less unless an intraventricular conduction delay
exists

First-Degree AV Block
Second-Degree AV Block,
Type I - Wenkebach
Rate Atrial rate is greater than the ventricular rate
Rhythm Atrial regular (Ps plot through); ventricular irregular
P waves Normal in size and shape. Some P waves are not followed by a
QRS complex (more Ps than QRSs).
PR interval Lengthens with each cycle (although lengthening may be very
slight), until a P wave appears without a QRS complex. The PRI
after the nonconducted beat is shorter than the interval preceding
the nonconducted beat.
QRS Usually 0.10 second or less but is periodically dropped
Second-Degree AV Block, Type
I
Second-Degree AV Block,
Type II
Rate Atrial rate is greater than the ventricular rate. Ventricular rate is often
slow.
Rhythm Atrial regular (Ps plot through). Ventricular irregular.
P waves Normal in size and shape. Some P waves are not followed by a QRS
complex (more Ps than QRSs).
PRI Within normal limits or slightly prolonged but constant for the conducted
beats. There may be some shortening of the PR interval that follows a
nonconducted P wave.
QRS Usually 0.10 second or greater, periodically absent after P waves

Second Degree AV Block (Mobitz
type II)

Complete AV Block
Rate Atrial rate is greater than the ventricular rate. The ventricular rate is
determined by the origin of the escape rhythm.
Rhythm Atrial regular (Ps plot through). Ventricular regular. There is no
relationship between the atrial and ventricular rhythms.
P waves Normal in size and shape.
PR interval None the atria and ventricles beat independently of each other, thus
there is no true PR interval.
QRS Narrow or wide depending on the location of the escape pacemaker
and the condition of the intraventricular conduction system. Narrow =
junctional pacemaker, wide = ventricular pacemaker.
Complete AV Block
Ventricular Dysrhythmias

Premature Ventricular Contractions
(PVCs)
Rate Depends on underlying rhythm
Rhythm
Irregular
P waves Not present before most PVCs
PR interval Generally not present
QRS duration Greater than 0.12 seconds
Idioventricular Rhythm
Rate Less than 40 beats/minute
Rhythm
Essentially regular
P waves May be present or absent. If present, they have no set relationship to the
QRS complexes appearing between the QRSs at a rate different from
that of the IR.
PR interval Variable
QRS duration Greater than 0.12 second; often difficult to differentiate between the
QRS and T wave
Accelerated Idioventricular Rhythm
Rate Less than 40-100 beats/minute
Rhythm
Essentially regular
P waves May be present or absent. If present, they have no set relationship to the
QRS complexes appearing between the QRSs at a rate different from
that of the IR.
PR interval Variable
QRS duration Greater than 0.12 second; often difficult to differentiate between the
QRS and T wave
Ventricular Tachycardia (VT)
Rate 101-250 beats/minute
Rhythm
Essentially regular
P waves May be present or absent. If present, they have no set relationship to the
QRS complexes appearing between the QRSs at a rate different from
that of the VT.
PR interval None
QRS duration Greater than 0.12 second; often difficult to differentiate between the
QRS and T wave
Ventricular Tachycardia
Torsades de Pointes (TdP)
Ventricular Fibrillation (VF)
Rate

Cannot be determined because there are no discernible
waves or complexes to measure

Rhythm

Rapid and chaotic with no pattern or regularity

P waves

Not discernible

PR Not discernible

QRS
Not discernible

Ventricular Fibrillation (VF)
Ventricular Fibrillation
This dysrhythmia results in the absence of
cardiac output
The course of treatment for ventricular fibrillation
includes:
immediate defibrillation and ACLS protocols
Identification and treatment of the
underlying cause is also needed

Asystole
Rate
Ventricular usually not discernible but atrial activity may be
observed (P-wave asystole)
Rhythm Ventricular not discernible, atrial may be discernible
P waves Usually not discernible
PRI Not measurable
QRS Absent
Asystole
Pulseless Electrical Activity
PEA Causes
Hypovolemia
Hydrogen Ions
Hypoxia
Hypothermia
Hypo-/hyperkalemia
Hypoglycemia
Tension Pneumothorax
Tamponade
Thromboemboli (PE, MI)

Toxins - Drug overdose / accidents (cyclic antidepressants,
calcium channel blockers, beta-blockers, digoxin)
Trauma
What do we look at when reading
rhythms
Assess the rate
Assess rhythm/regularity
Identify and examine P waves
Assess intervals (evaluate conduction)
PR interval, QRS duration,
Evaluate overall appearance of the rhythm
ST segment elevation/depression
T wave inversion
Interpret rhythm and evaluate clinical significance

What do we need to remember
as Critical Care Nurses?
Lets start with what I don't need you to
know
Ability to recognize funky weird rhythms
Ability to read all rhythms

OK now that we have establish
what you don't have to know
what do I expect you to know?

Every shift print off rhythm strip and place
in chart
Identify
Reg/irreg, PR interval, rate and rhythm
SR, SB, A. Fib, A. flutter, VT and VF A
MUST
Something is wrong rhythms the rest
Know enough to get some help reading them
Remember
Not always able to name an abnormal
rhythm, but:
Know normal rhythms

Know fatal rhythms

Report these rhythms