Sinus Bradycardia

CHF hypoxia PE increased temperature stress response to pain Treatment includes identification of the underlying cause and correction. Sinus Arrhythmia 45-100/bpm Rate sinus P wave normal QRS normal Conduction regularly irregular Rhythm The rate usually increases with inspiration and decreases with expiration. This rhythm is most commonly seen with breathing due to fluctuations in parasympathetic vagal tone. During inspiration stretch receptors in the lungs stimulate the cardioinhibitory centers in the medulla via fibers in the vagus nerve. The non respiratory form is present in diseased hearts and sometimes confused with sinus arrest (also known as "sinus pause"). Treatment is not usually required unless symptomatic bradycardia is present. Wandering Atrial Pacemaker

40-59 bpm sinus normal (.06-.12) P-R normal or slightly prolonged at slower rates regular or slightly Rhythm irregular This rhythm is often seen as a normal variation in athletes, during sleep, or in response to a vagal maneuver. If the bradycardia becomes slower than the SA node pacemaker, a junctional rhythm may occur. Treatment includes: treat the underlying cause, atropine, isuprel, or artificial pacing if patient is hemodynamically compromised. Sinus Tachycardia Rate P wave QRS Conduction

normal or accelerated usually have a different morphology than sinus P waves because they originate from an ectopic pacemaker normal QRS normal, however the Conduction ectopic beats may have a different P-R interval. PAC's occur early in Rhythm the cycle and they usually do not have a complete compensatory pause. PAC's occur normally in a non diseased heart. However, if they occur frequently, they may lead to a more serious atrial dysrhythmias. They can also result from CHF, ischemia and COPD. Sinus Arrest Rate P wave

101160/min sinus P wave normal QRS normal Conduction regular Rhythm or slightly irregular The clinical significance of this dysrhythmia depends on the underlying cause. It may be normal. Underlying causes include: increased circulating catecholamines Rate

variable depending on the site of the pacemaker; usually 45-100/ bpm. also variable in P wave morphology normal QRS P-R interval varies Conduction depending on the site of the pacemaker irregular Rhythm This dysrhythmia may occur in normal hearts as a result of fluctuations in vagal tone. It may also be seen in patients with heart disease or COPD. Wandering atrial pacemaker may also be a precursor to multifocal atrial tachycardia. There is usually no treatment required. Premature Atrial Contractions Rate

normal those that are present are normal normal QRS normal Conduction The basic rhythm is Rhythm regular. The length of the pause is not a multiple of the sinus interval. This may occur in individuals with healthy hearts. It may also occur with increased vagal tone, myocarditis, MI, and digitalis toxicity. If the pause is prolonged, escape beats may occur. The treatment of this dysrhythmia depends on the underlying cause. If the cause is due to increased vagal tone and the patient is symptomatic, atropine may be indicated. Sinoatrial Block Rate P wave

normal or bradycardia those present are normal normal QRS normal Conduction basic rhythm is Rhythm regular*. *In a type I SA block, the P-P interval shortens until one P wave is dropped. *In a type II SA block, the P-P intervals are an exact multiple of the sinus cycle, and are regular before and after the dropped P wave. This usually occurs transiently and produces no symptoms. It may occur in healthy patients with increased vagal tone. It may also be found with CAD, inferior MI, and digitalis toxicity. Multifocal Atrial Tachycardia Rate P wave

varies from sinus normal (unless associated with aberrant ventricular conduction). P-R interval depends Conduction on the status of AV conduction tissue and atrial rate: may be normal, abnormal, or not measurable. PAT also known as Paroxysmal Supraventricular Tachycardia (PSVT) may occur in the normal as well as diseased heart. It is a common complication of Wolfe-Parkinson-White syndrome. This rhythm is often transient and usually requires no treatment. However, it can usually be terminated with vagal maneuvers. Digoxin, antiarrhythmics, adenosine and cardioversion may be used. Frequent symptomatic episodes may require surgical intervention. When an accessory conduction pathway can be demonstrated, interventional surgery to ablate the accessory conduction pathway can be curative. Atrial Flutter QRS

located in the tissue between the inferior vena cava and the tricuspid valve, an area known as the cavotricuspid isthmus. This area is contains many intersecting fibers which may increase the chance of aberrant conduction. The conduction almost always follows in a counter-clockwise path through the isthmus and across the walls of the right atrium. Atrial flutter almost always occurs in diseased hearts but it can occur in otherwise asymptomatic hearts. The incidence of atrial flutter increases with age and medical conditions including: congestive heart failure, rheumatic valve disease, congenital heart disease, lung disease such as emphysema, or high blood pressure. Surgery involving the right atrium can increase the risk of atrial flutter due to scar formation in the atrial wall or tricuspid annulus. Treatment depends on the level of hemodynamic compromise. Synchronized electrical cardioversion is often used if: hypotensive, ischemic pain or severe CHF are present Type I antiarrhythmics like quinidine or procainamide may convert the flutter Diltiazem, verapamil, digitalis or beta-blocking agents may be used to slow ventricular rate. Verapamil and beta-blockers can increase risk of bradycardia and CHF Digoxin and other antiarrhythmic drugs can be used. Catheter ablation is often the definative treatment for eliminating recurrence Atrial Fibrillation

100-250/bpm two or more ectopic P waves with different morphologies normal QRS P-R intervals vary Conduction irregular Rhythm Multifocal atrial tachycardia (MAT) may resemble atrial fibrillation or flutter. It almost always occurs in seriously ill, elderly individuals. COPD is the most common underlying cause. Treatment depends upon the underlying cause. Paroxysmal Atrial Tachycardia Rate P wave

Rate

P wave

atrial 160-250/min: may conduct to ventricles 1:1, or 2:1, 3:1, 4:1 into the presence of a block. morphology usually

atrial 250-350/min; ventricular conduction depends on the capability of the AV junction (usually rate of 150-175 bpm). not present; usually a P wave "saw tooth" pattern is present. normal QRS 2:1 atrial to ventricular Conduction most common. usually regular, but can be Rhythm irregular if the AV block varies. palpitations, rapid heart Symptoms rate, chest pain, shortness of breath, lightheadedness, fatigue, and low blood pressure. Atrial flutter is the second most common tachyarrhythmia, after atrial fibrillation. It is usually confined to tissue of the right atrium, only rarely passing through the atrial septum to effect the left atrium. It results from an aberrant conduction circuit typically Rate

Rate P wave QRS

Conduction

Rhythm

Symptoms

atrial rate usually between 400-650/bpm. not present; wavy baseline is seen instead. usually normal, a wide QRS may indicate conduction by accessory pathway. variable AV conduction; if untreated the ventricular response is usually rapid. irregularly irregular with abscence of P waves. (This is the hallmark of this dysrhythmia). palpitations, chest pain, dyspnea, fatigue, lightheadedness, or syncope.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. AF increases the risk hemodynamic impairment and thromboembolic events. It may occur

paroxysmally, but it often becomes chronic. Signs of acute atrial fibrillation are: hypotension, myocardial ischemia, decreased perfusion of vital organs and acute congestive heart failure (CHF). Chronic atrial fibrillation increases the risk of atrial mural thrombus and embolus. Some conditions associated with atrial fibrillation are: mitral stenosis, lung disease, heart disease, sepsis, hyperthyroidism and cardiac surgery.

Treatment is directed at rate control, antithrombotic therapy and correction of rhythm. Slowing the ventricular rate by increasing the AV node refractory period. Digoxin, beta-adrenergic blockers, calcium channel blockers may be used to reduce the rate of AV conduction to 80-100 beats/minute. Patients with chest pain, ischemia, congestive heart failure, mitral stenosis or hypotension may require intravenous verapamil, digoxin or a combination to quickly control the ventricular rate. In appropriate patients cardioversion either chemical, electrical or a combination may be required to convert this arrhythmia to normal sinus rhythm. Premature Junctional Contractions

rhythm. normal or widened with aberrant ventricular conduction. P-R interval usually < Conduction .12 seconds if present usually regular Rhythm The clinical significance of this rhythm depends upon the basic rhythm disturbance. If the ventricular rate is rapid, cardiac output may decrease. Treatment includes: finding and correcting the underlying cause, vagal maneuvers, verapamil, and cardioversion. Junctional Escape Beats and Rhythm QRS

variable normal morphology with constant P-P interval normal QRS the P-R interval is Conduction progressively longer until one P wave is blocked; the cycle begins again following the blocked P wave. irregular Rhythm Second degree AV block type I occurs in the AV node above the Bundle of His. It is often transient and may be due to acute inferior MI or digitalis toxicity. Treatment is usually not indicated as this rhythm usually produces no symptoms. Third Degree AV Block or Complete AV Block Rate P wave

normal or accelerated. as with junctional rhythm. normal QRS P-R interval < .12 secs Conduction if P waves are present. PJC's occur early in Rhythm the cycle of the baseline rhythm. A full compensatory pause may occur. PJCs may occur in both healthy and diseased hearts. If they are occasional, they are insignificant. If they are frequent, junctional tachycardia may result. Treatment is usually not required. Junctional Tachycardia Rate P wave

variable normal normal impulse originates in the SA node but has prolonged conduction in the AV junction; PR interval is > 0.20 seconds. regular Rhythm This is the most common conduction disturbance. It occurs in both healthy and diseased hearts. First degree AV block can be due to: inferior MI, digitalis toxicity hyperkalemia increased vagal tone acute rheumatic fever myocarditis. Interventions include treating the underlying cause and observing for progression to a more advanced AV block. Second Degree AV Block (Mobitz type I, Wenkebach) Rate P wave QRS Conduction

Rate P wave

faster than 60/bpm as with junctional

atrial rate is usually normal; ventricular rate is usually less than 70/bpm. The atrial rate is always faster than the ventricular rate. normal with constant P wave P-P intervals, but not "married" to the QRS complexes. may be normal or QRS widened depending on where the escape pacemaker is located in the conduction system atrial and ventricular Conduction activities are unrelated due to the complete blocking of the atrial impulses to the ventricles. irregular Rhythm Complete block of the atrial impulses occurs at the A-V junction, common bundle or bilateral bundle branches. Another pacemaker distal to the block takes over in order to activate the ventricles or ventricular standstill will occur. May be caused by: digitalis toxicity acute infection Rate

MI and degeneration of the conductive tissue. Treatment modalities include: external pacing and atropine for acute, symptomatic episodes and permanent pacing for chronic complete heart block. Premature Ventricular Contractions

Ventricular Tachycardia

Caused by:

Treatment:

drugs which lengthen the QT interval such as quinidine electrolyte imbalances, particularly hypokalemia myocardial ischemia Synchronized cardioversion is indicated when the patient is unstable. IV magnesium IV Potassium to correct an electrolyte imbalance Overdrive pacing Idioventricular Rhythm

usually between 100 to 220/bpm, but can be as rapid as 250/bpm obscured if present P wave and are unrelated to the QRS complexes. wide and bizarre QRS morphology as with PVCs Conduction three or more Rhythm ventricular beats in a row; may be regular or irregular. Ventricular tachycardia almost always occurs in diseased hearts. Some common causes are: CAD acute MI digitalis toxicity CHF ventricular aneurysms. Patients are often symptomatic with this dysrhythmia. Ventricular tachycardia can quickly deteriorate into ventricular fibrillation. Electrical countershock is the intervention of choice if the patient is symptomatic and rapidly deteriorating. Some pharmacological interventions include amiodarone and lidocaine. Torsade de Pointes Rate

variable usually obscured by the QRS, PST or T wave of the PVC wide > 0.12 seconds; QRS morphology is bizarre with the ST segment and the T wave opposite in polarity. May be multifocal and exhibit different morphologies. the impulse originates Conduction below the branching portion of the Bundle of His; full compensatory pause is characteristic. irregular. PVC's may Rhythm occur in singles, couplets or triplets; or in bigeminy, trigeminy or quadrigeminy. PVCs can occur in healthy hearts. For example, an increase in circulating catecholamines can cause PVCs. They also occur in diseased hearts and from drug (such as digitalis) toxicities. Treatment is required if they are: associated with an acute MI, occur as couplets, bigeminy or trigeminy, are multifocal, or are frequent (>6/min). Interventions include: lidocaine, pronestyl, or quinidine. Rate P wave

Rate P wave QRS Conduction

usually between 150 to 220/bpm, obscured if present P wave wide and bizarre QRS morphology as with PVCs Conduction Irregular Rhythm Paroxysmal starting and stopping suddenly Hallmark of this rhythm is the upward and downward deflection of the QRS complexes around the baseline. The term Torsade de Pointes means "twisting about the points." Consider it V-tach if it doesnt respond to antiarrythmic therapy or treatments Rate

Rhythm Absent P wave Widened QRS > 0.12 sec. Also called " dying heart" rhythm Pacemaker will most likely be needed to re-establish a normal heart rate. Causes: Myocardial Infarction Pacemaker Failure Metabolic imbalance Myoardial Ischemia Treatment goals include measures to improve cardiac output and establish a normal rhythm and rate. Options include: Atropine Pacing Caution: Suppressing the ventricular rhythm is contraindicated because that rhythm protects the heart from complete standstill. Asystole/Ventricular Standstill

20 to 40 beats per minute Absent Widened Failure of primary pacemaker Regular

Rate P wave

none may be seen, but there is no ventricular

response none QRS none Conduction none Rhythm Asystole occurs most commonly following the termination of atrial, AV junctional or ventricular tachycardias. This pause is usually insignificant. Asystole of longer duration in the presence of acute MI and CAD is frequently fatal. Interventions include: CPR, 100% oxygen, IV intubation transcutaneous pacing epinephrine 1.0 mg., IV push, q3-5 minutes atropine Import terms in Logic & Mathematical Statements Original Statement Today is monday. That was fun. Negation Indicates the opposite, usually employing the word not. The symbol to indicate negation is : ~ Conjunction In logic, a conjunction is a compound sentence formed by using the word and to join two simple sentences. The symbol for this is . (whenever you see read 'and') When two simple sentences, p and q, are joined in a conjunction statement, the conjunction is expressed symbollically as p q. Simple Sentences Compound Sentence : conjunction p: Joe eats fries. p q : Joe eats fries, and maria drinks q: Maria drinks soda. soda. Negation of statment Today is not monday. That was not fun.

either statement is true or if both statements are true! In other words, the statement 'The clock is slow or the time is correct' is a false statement only if both parts are false! Likewise, the statement 'Mr. G teaches Math or Mr. G teaches Science' is true if Mr. G is teaches science classes as well as math classes! The Conditional

In logic, a conditional statement is compound stentence that is usually expressed with the key words 'If....then...'. Using the variables p and q to represent two simple sentences, the conditional "If p then q" is expressed symbollically as p q. Simple Sentences Compound Sentence : Conditional p: You are absent p q : If you are absent, then you q: You have a make up have a make up assignment to assignment to complete. complete. Note: The word 'then' is optional, and a conditional will often not include 'then'. The example above could have been expressed: If you are absent, you have a make up assignment to complete. Truth values of Conditionals The only time that a conditional is a false statement is when a true "if" clause leads to a false "then" clause. For example, the conditional "If you are on time, then you are late." is false because when the "if" clause is true, the 'then' clause is false. THEREFORE, the entire statement is false. Example of a false conditional If Clause Then clause Entire Statment p q p q you are late you are on If you are late, then you are on time time. When p is true then q is false The entire statment is false True False False

the truth values of both facts are exactly the same -- BOTH TRUE or BOTH FALSE. Biconditionals are often used to form definitions. Definition: A triangle is isosceles if and only if the triangle has two congruent (equal) sides. The "if and only if" portion of the definition tells you that the statement is true when either sentence (or fact) is the hypothesis. This means that both of the statements below are true: If a triangle is isosceles, then the triangle has two congruent (equal) sides. (true) If a triangle has two congruent (equal) sides, then the triangle is isosceles. (true) REMEMBER: IF AND ONLY IF is TRUE when both facts are T or both facts are F..

Carbonara: Ingredients: 1 lb spaghetti cup heavy cream 4 eggs lb bacon, cut into -inch dice 1 tsp extra virgin olive oil 2 Tbsp chopped Italian parsley Kosher salt and freshly ground black pepper, to taste cup freshly grated pecorino-romano cheese (parmesan may be substituted) Preparation: 1. Fill a large soup pot with cold water and add a handful or so of Kosher salt. Stir and taste; it should taste like seawater. Cover the pot and heat the water until it boils. 2. Add the diced bacon to a cold saut pan and cook slowly over a low heat for 10 to 15 minutes or until crisp. Remove bacon from pan and drain on paper towels. 3. Drop the spaghetti into the boiling salted water and cook according to package instructions, about 6 to 9 minutes or until al dente, or tender but still firm to the bite. 4. While the pasta cooks, combine the eggs, cheese, cream and olive oil in a bowl and beat with a whisk until completely mixed. 5. Drain pasta, toss with the egg and cream mixture, then add the cooked bacon and chopped parsley. Serve right away, with additional grated cheese if desired.

In logic, a disjunction is a compound sentence formed by using the word or to join two simple sentences. The symbol for this is . (whenever you see read 'or') When two simple sentences, p and q, are joined in a disjunction statement, the disjunction is expressed symbollically as p q. Pneumonic: the way to remember the symbol for disjuntion is that, this symbol looks like the 'r' in or, the keyword of disjunction statements. Simple Sentences Compound Sentence : disjunction p: The clock is slow. p q : The clock is slow, or the time is q: The time is correct. correct. Warning and caveat: The only way for a disjunction to be a false statement is if BOTH halves are false. A disjunction is true if

Warning and Caveat The opposite situation does not lead to a false statement. A false 'if' clause and a true 'then' clause creates a true statement. (Seems counterintuitive at first!) See the table below for an example. If Clause Then clause Entire Statment p q p q a human is then squares have If a human is a cat, then a cat corners squares have corners. When p is q is true The entire statment is true. false False True True Explanation: The if clause is always false (humans are not cats) , and the then clause is always true (squares always have corners). And the entire statement is true In logic, a biconditional is a compound statement formed by combining two conditionals under "and." Biconditionals are true when both statements (facts) have the exact same truth value. A biconditional is read as "[some fact] if and only if [another fact]" and is true when