Arrythmias

• Without a regular rate and rhythm, the heart

may not perform efficiently as a pump to
circulate oxygenated blood and other life-
sustaining nutrients to all the body organs
(including itself) and tissues. With an irregular
or erratic rhythm, the heart is considered to
be dysrhythmic (sometimes called
arrhythmic).
• This has the potential to be a dangerous
condition.
 Dysrhythmias
• Dysrhythmias are disorders of the formation or
conduction (or both) of the electrical impulse within the
heart.
• These disorders can cause disturbances of the heart rate,
the heart rhythm, or both
Normal rhythm:
- Heart rate between 60 -100bpm
- Every heart rate should origin from SA node
- Cardiac impulse should propagate through normal
conduction pathway
- Cardiac impulse should pass in normal velocity
Any deviation from the normal rhythm lead to dysrhythmia
 Normal Sinus Rhythm
• Normal sinus rhythm occurs when the electrical impulse
starts at a regular rate and rhythm in the sinus node and
travels through the normal conduction pathway.
• The following are the ECG criteria for normal sinus
rhythm :
• Ventricular and atrial rate: 60 to 100 in the adult
• Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually normal, but may be
regularly abnormal
• P wave: Normal and consistent shape; always in front of
the QRS
• PR interval: Consistent interval between 0.12 and 0.20
seconds
• P: QRS ratio:1:1
 Types of Dysrhythmias

• Dysrhythmias include sinus node, atrial,

junctional, and ventricular dysrhythmias and
their various subcategories.
 SINUS NODE DYSRHYTHMIAS
• Sinus Bradycardia.
• Sinus bradycardia occurs when the sinus node
creates an impulse at a slower-than-normal rate.
• Causes include lower metabolic needs (eg,
sleep, athletic training,
hypothermia,hypothyroidism), vagal stimulation
(eg, from vomiting, suctioning, severe pain,
extreme emotions), medications (eg, calcium
channel blockers, amiodarone, beta-blockers),
increased intracranial pressure, and myocardial
infarction (MI), especially of the inferior wall
• The following are characteristics of sinus
bradycardia :
• Ventricular and atrial rate: Less than 60 in the
adult
• Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually normal, but may
be regularly abnormal
• P wave: Normal and consistent shape; always in
front of the QRS
• PR interval:Consistent interval between 0.12 and
0.20 seconds
• P: QRS ratio:1:1
Clinical manifestation:
• shortness of breath, decreased level of
consciousness, angina, hypotension
Management:
• treatment is directed toward increasing the
heart rate.
• Atropine, 0.5 to 1.0 mg given rapidly as an
intravenous (IV) bolus, is the medication of
choice in treating sinus bradycardia.
• Rarely, catecholamines and emergency
transcutaneous pacing also may be
implemented
 Sinus Tachycardia
• Sinus tachycardia occurs when the sinus node
creates an impulse at a faster-than-normal
rate.
• It may be caused by acute blood loss, anemia,
shock, hypervolemia, hypovolemia, congestive
heart failure, pain, hypermetabolic states,
fever, exercise, anxiety, or sympathomimetic
medications.
• The ECG criteria for sinus tachycardia follow:
• Ventricular and atrial rate: Greater than 100 in
the adult
• Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually normal, but
may be regularly abnormal
• P wave: Normal and consistent shape; always in
front of the QRS, but may be buried in the
preceding T wave
• PR interval: Consistent interval between 0.12
and 0.20 seconds
• P: QRS ratio:1:1
Clinical manifestation:
• Dyspnea, low BP
Management:
• Calcium channel blockers and beta-blockers
may be used to reduce the heart rate quickly
 Sinus Arrhythmia
• Sinus arrhythmia occurs when the sinus node
creates an impulse at an irregular rhythm; the
rate usually in-creases with inspiration and
decreases with expiration.
• Non respiratory causes include heart disease
and valvular disease
The ECG criteria for sinus arrhythmia follow:
• Ventricular and atrial rate:60 to 100 in the
adult
• Ventricular and atrial rhythm: Irregular
• QRS shape and duration: Usually normal, but
may be regularly abnormal
• P wave: Normal and consistent shape; always
in front of the QRS
• PR interval: Consistent interval between 0.12
and 0.20 seconds
• P: QRS ratio:1:1
 ATRIAL DYSRHYTHMIAS
Premature Atrial Complex.
• A premature atrial complex (PAC) is a single
ECG complex that occurs when an electrical
impulse starts in the atrium before the next
normal impulse of the sinus node.
• The PAC may be caused by caffeine, alcohol,
nicotine, stretched atrial myocardium (as in
hypervolemia), anxiety, hypokalemia (low
potassium level), hypermetabolic states, or
atrial ischemia,injury, or infarction.
• Ventricular and atrial rate: Depends on the underlying rhythm
(eg, sinus tachycardia)
• Ventricular and atrial rhythm: Irregular due to early P
waves,creating a PP interval that is shorter than the others.
This is sometimes followed by a longer-than-normal PP
interval
• QRS shape and duration: The QRS that follows the early P
wave is usually normal, but it may be abnormal (aberrantly
conducted PAC). It may even be absent (blocked PAC).
• P wave: An early and different P wave may be seen or may be
hidden in the T wave; other P waves in the strip are consistent.
• PR interval: The early P wave has a shorter-than-normal PR
interval, but still between 0.12 and 0.20 seconds.
• P: QRS ratio:usually 1:1
• PACs are common in normal hearts. The patient may say,“My
heart skipped a beat.” A pulse deficit (a difference between
the apical and radial pulse rate) may exist.
 Atrial Flutter
• Atrial flutter occurs in the atrium and creates
impulses at an atrial rate between 250 and
400 times per minute.
• Because the atrial rate is faster than the AV
node, not all atrial impulses are conducted
into the ventricle, causing a therapeutic block
at the AV node.
• Atrial flutter is characterized by the following :
• Ventricular and atrial rate: Atrial rate ranges between 250
and 400; ventricular rate usually ranges between 75 and
150.
• Ventricular and atrial rhythm: The atrial rhythm is regular;
the ventricular rhythm is usually regular but may be
irregular because of a change in the AV conduction.
• QRS shape and duration: Usually normal, but may be
abnormal or may be absent
• P wave: Saw-toothed shape. These waves are referred to as
F waves.
• PR interval: Multiple F waves may make it difficult to
determine the PR interval.
• P: QRS ratio:2:1, 3:1, or 4:1
• Clinical manifestation:
chest pain, shortness of breath, and low blood
pressure
• Management :
- If patient is unstable, electrical cardioversion is
usually indicated.
- If the patient is stable, diltiazem, verapamil
beta-blockers, or digitalis may be administered
intravenously to slow the ventricular rate.
- Flecainide, ibutilide, dofetilide, quinidine,
disopyramide or amiodarone may be given to
promote conversion to sinus rhythm
 Atrial Fibrillation
• Atrial fibrillation causes a rapid, disorganized,
and uncoordinated twitching of atrial
musculature.
• Atrial fibrillation may occurfor a very short time
(paroxysmal), or it may be chronic.
• Atrial fibrillation is usually associated with
advanced age, valvular heart disease, coronary
artery disease, hypertension, cardiomyopathy,
hyperthyroidism, pulmonary disease, acute
moderate to heavy ingestion of alcohol or after
open heart surgery.
Atrial fibrillation is characterized by the following :
• Ventricular and atrial rate: Atrial rate is 300 to
600. Ventricu lar rate is usually 120 to 200 in
untreated atrial fibrillation
• Ventricular and atrial rhythm: Highly irregular
• QRS shape and duration: Usually normal, but
may be abnormal
• P wave: No discernible P waves; irregular
undulating waves are seen and are referred to
as fibrillatory or f waves
• PR interval: Cannot be measured
• P: QRS ratio: many:1
Management:
• quinidine, ibutilide, flecainide, dofetilide,
propafenone, procainamide, disopyramide, or
amiodarone
• Calcium channel blockers, beta blockers,
digoxin
• Warfarin
• Cardioversion
 JUNCTIONAL DYSRHYTHMIAS
Premature Junctional Complex
• A premature junctional complex is an impulse that
starts in the AV nodal area before the next normal
sinus impulse reaches the AV node.
• Causes of premature junctional complex include
digitalis toxicity, congestive heart failure, and
coronary artery disease.
• The ECG characteristic are: The P wave may be
absent, may follow the QRS, or may occur before the
QRS but with a PR interval of less than 0.12 seconds.
• Junctional bradycardia:
- AV nodal delay in conduction
• Ventricular and atrial rate: Ventricular rate 40
to 60; atrial rate also 40 to 60 if P waves are
discernible
• Ventricular and atrial rhythm:Regular
• QRS shape and duration: Usually normal, but
may be abnormal
• P wave: May be absent, after the QRS complex,
or before the QRS
• P-R interval : prolonged
• P: QRS ratio:1:1 or 0:1
Atrioventricular Nodal Reentry Tachycardia

• AV nodal reentry tachycardia occurs when an

impulse is conducted to an area in the AV node
that causes the impulse to be rerouted back into
the same area over and over again at a very fast
rate.
• Each time the impulse is conducted through this
area, it is also conducted down into the
ventricles, causing a fast ventricular rate
• Causes: caffeine, nicotine,hypoxemia, and stress,
coronary artery disease and cardiomyopathy
• The ECG criteria are as follows:
• Ventricular and atrial rate: Atrial rate usually
ranges between 150 to 250; ventricular rate
usually ranges between 75 to 250
• Ventricular and atrial rhythm: Regular; sudden
onset and termination of the tachycardia
• QRS shape and duration: Usually normal, but
may be abnormal
• P wave: Usually very difficult to discern
• PR interval: If P wave is in front of the QRS, PR
interval is less than 0.12 seconds
• P: QRS ratio:1:1, 2:1
• Symptoms are: restlessness, chest pain, shortness
of breath, pallor, hypotension, and loss of
consciousness
• Management :
- Carotid sinus massage, gag reflex, breath holding,
and immersing the face in ice water, increase
parasympathetic stimulation, causing slower
conduction through the AV node and blocking the
reentry of the rerouted impulse.
• If the vagal maneuvers are ineffective, the patient
may then receive a bolus of adenosine, verapamil,
or diltiazem.
• Cardioversion
 VENTRICULAR DYSRHYTHMIAS
Premature Ventricular Complex
• Premature ventricular complex (PVC) is an impulse
that starts in a ventricle and is conducted through
the ventricles before the next normal sinus
impulse.
• PVCs can occur in healthy people, especially with
the use of caffeine, nicotine, or alcohol. They are
also caused by cardiac ischemia or infarction,
increased workload on the heart (eg, exercise,
fever, hypervolemia, heart failure, tachycardia),
digitalis toxicity, hypoxia, acidosis, or electrolyte
imbalances, especially hypokalemia.
• PVCs have the following characteristics on the ECG:
• Ventricular and atrial rate: Depends on the underlying rhythm
(eg, sinus rhythm)
• Ventricular and atrial rhythm: Irregular due to early QRS, creating
one RR interval that is shorter than the others. PP interval may be
regular, indicating that the PVC did not depolarize the sinus node.
• QRS shape and duration: Duration is 0.12 seconds or longer;
shape is bizarre and abnormal
• P wave: Visibility of P wave depends on the timing of the PVC;
may be absent (hidden in the QRS or T wave) or infront of the
QRS. If the P wave follows the QRS, the shape of the P wave may
be different.
• PR interval: If the P wave is in front of the QRS, the PR interval is
less than 0.12 seconds.
• P: QRS ratio:0: 1; 1:1
• Lidocaine (Xylocaine) is the medication most commonly used for
immediate, short-term therapy
Ventricular Tachycardia
• Ventricular tachycardia (VT) is defined as three
or more PVCs in a row, occurring at a rate
exceeding 100 beats per minute.
• VT is an emergency because the patient is
usually (although not always) unresponsive
andpulseless.
• VT has the following characteristics
• Ventricular and atrial rate:Ventricular rate is 100 to 200
beats per minute; atrial rate depends on the underlying
rhythm (eg, sinus rhythm)
• Ventricular and atrial rhythm: Usually regular; atrial rhythm
may also be regular.
• QRS shape and duration:Duration is 0.12 seconds or
more;bizarre, abnormal shape
• P wave:Very difficult to detect, so atrial rate and rhythm may
be indeterminable
• PR interval: Very irregular, if P waves seen.
• P: QRS ratio: Difficult to determine, but if P waves are
apparent, there are usually more QRS complexes than P
waves.
• Cardioversion may be the treatment of choice, especially if
the patient is unstable.
• Defibrillation
Ventricular Fibrillation
• Ventricular fibrillation is a rapid but
disorganized ventricular rhythm that causes
ineffective quivering of the ventricles. There is
no atrial activity seen on the ECG.
• Ventricular fibrillation has the following
characteristics:
• Ventricular rate: Greater than 300 per minute
• Ventricular rhythm: Extremely irregular, without
specific pattern
• QRS shape and duration: Irregular, undulating
waves without recognizable QRS complexes
• Absence of an audible heartbeat, a palpable
pulse, and respirations.
• Defibrillation and anti arrhythmic drugs are
effective.
Ventricular Asystole
• Commonly called flat line, ventricular asystole
is characterized by absent QRS complexes,
although P waves may be apparent for a short
duration in two different leads.
• There is no heartbeat, no palpable pulse, and
no respiration. Without immediate treatment,
ventricular asystole is fatal.
• Cardiopulmonary resuscitation and emergency
services are necessary to keep the patient
alive
• Intubation and establishment of intravenous
access are the first recommended actions.
Transcutaneous pacing may be attempted.
• A bolus of intravenous epinephrine should be
administered and repeated at 3- to 5-minute
intervals, followed by 1-mg boluses of
atropine at 3- to 5-minute intervals.
 Heart blocks
• AV blocks occur when the conduction of the
impulse through the AV nodal area is decreased
or stopped. These blocks can be caused by
medications (eg, digitalis, calcium channel
blockers, beta-blockers), myocardial ischemia
and infarction, valvular disorders, or myocarditis
First-Degree Atrioventricular Block
• First-degree heart block occurs when all the
atrial impulses are conducted through the AV
node into the ventricles at a rate slower than
normal.
• This conduction disorder has the following
characteristics :
• Ventricular and atrial rate: Depends on the underlying
rhythm
• Ventricular and atrial rhythm: Depends on the
underlying rhythm
• QRS shape and duration: Usually normal, but may be
abnormal
• P wave: In front of the QRS complex; shows sinus
rhythm, regular shape
• PR interval: Greater than 0.20 seconds; PR interval
measurement is constant.
• P: QRS ratio:1:1
Second-Degree Atrioventricular Block, Type I.
• Second-degree,type I heart block occurs when
all but one of the atrial impulses are
conducted through the AV node into the
ventricles.
• Each atrial impulse takes a longer time for
conduction than the one before, until one
impulse is fully blocked.
• Ventricular and atrial rate: Depends on the underlying rhythm
• Ventricular and atrial rhythm: The PP interval is regular if the
patient has an underlying normal sinus rhythm; the RR interval
characteristically reflects a pattern of change. Starting from the
RR that is the longest, the RR interval gradually shortens until
there is another long RR interval.
• QRS shape and duration: Usually normal, but may be abnormal
• P wave: In front of the QRS complex; shape depends on
underlying rhythm
• PR interval: PR interval becomes longer with each succeeding
ECG complex until there is a P wave not followed by a QRS. The
changes in the PR interval are repeated between each
“dropped” QRS, creating a pattern in the irregular PR interval
measurements.
• P: QRS ratio:3:2, 4:3, 5:4
Second-Degree Atrioventricular Block, Type II.
• Second-degree, type II heart block occurs when only some of
the atrial impulses are conducted through the AV node into the
ventricles.
• Second-degree AV block, type II has the following
characteristics :
• Ventricular and atrial rate: Depends on the underlying rhythm
• Ventricular and atrial rhythm:T he PP interval is regular if the
patient has an underlying normal sinus rhythm. The RR interval
is usually regular but may be irregular, depending on the PQRS
ratio.
• QRS shape and duration: Usually abnormal, but may be normal
• P wave: In front of the QRS complex; shape depends on
underlying rhythm.
• PR interval: PR interval is constant for those P waves just before
QRS complexes.
• P: QRS ratio:2:1, 3:1, 4:1, 5:1, and so forth
Third-Degree Atrioventricular Block
• Third-degree heart block occurs when no atrial
impulse is conducted through the AV node into the
ventricles.
• In third-degree heart block, two impulses stimulate
the heart: one stimulates the ventricles(eg,
junctional or ventricular escape rhythm),
represented by the QRS complex, and one
stimulates the atria (eg, sinus rhythm, atrial
fibrillation), represented by the P wave.
• P waves may be seen, but the atrial electrical
activity is not conducted down into the ventricles
to cause the QRS complex, the ventricular electrical
activity. This is called AV dissociation.
• Complete block (third-degree AV block) has the
following characteristics:
• Ventricular and atrial rate: Depends on the escape
and underlying atrial rhythm
• Ventricular and atrial rhythm: The PP interval is
regular and the RR interval is regular; however, the PP
interval is not equal to the RR interval.
• QRS shape and duration: Depends on the escape
rhythm; in junctional escape, QRS shape and duration
are usually normal, and in ventricular escape, QRS
shape and duration are usually abnormal.
• P wave: Depends on underlying rhythm
• PR interval: Very irregular
• P: QRS ratio: More P waves than QRS complexes
• Management :
• Intravenous bolus of atropine is the initial
treatment of choice.
• If the patient does not respond to atropine or
has an acute MI, transcutaneous pacing
should be started.
• A permanent pacemaker may be necessary if
the block persists