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FIVE-STEP PROCESS FOR DYSRHYTHMIA INTERPRETATION

NORMAL SINUS RHYTHM Normal sinus rhythm is the normal cardiac rhythm . It begins in the SA node and has complete, regular Normal Sinus Rhythm Rules 1. Rhythm: regular 2. Heart rate: 60 to 100 bpm 3. P waves: rounded, precede each QRS complex, alike 4. PR interval: 0.12 to 0.20 seconds 5. QRS interval: 0.12 seconds

arrhythmia and dysrhythmia.

An arrhythmia is an irregularity or loss of rhythm of the heartbeat, and a dysrhythmia is an abnormal,disordered, or disturbed rhythm.

Sinus Bradycardia is a slower than normal heart rate. Sinus bradycardia has the same cardiac cycle components as a normal sinus rhythm. The only difference between the two is a slower heart rate caused by fewer impulses originating from the SA node

CAUSES.
Medications such as digoxin (Lanoxin), myocardial infarction (MI), and electrolyte imbalances can cause bradycardia. Wellconditioned athletes also can have slower heart rates because their hearts work more efficiently

SINUS BRADYCARDIA RULES 1. Rhythm: regular 2. Heart rate: less than 60 bpm 3. P waves: smoothly rounded, precede each QRS complex, alike 4. PR interval: 0.12 to 0.20 seconds 5. QRS interval: 0.12 seconds

SIGNS AND SYMPTOMS. Sinus bradycardia rarely produces symptoms unless it is so slow that it reduces cardiac output. Symptoms consist of fatigue or fainting episodes.

THERAPEUTIC INTERVENTIONS . Treatment is usually not required if the patient is asymptomatic. Oxygen and intravenous (IV) If bradycardia is due to a heart block dysrhythmia, insertion of a cardiac pacemaker If the patient is symptomatic, therapeutic interventions may include atropine sulfate, transcutaneous pacing, dopamine, epinephrine, or isoproterenol. may be required.

Sinus Tachycardia

DESCRIPTION. Tachycardia is defined as a heart rate greater than 100 beats per minute. Sinus tachycardia has the same components as a normal sinus rhythm except the heart rate is faster). More impulses originating from the SA node than normal cause this

CAUSES. Sinus tachycardia causes include physical activity; hemorrhage; shock; medications such as epinephrine, atropine, or nitrates; dehydration; fever cmpoensatory mechanism for hypoxia when more cardiac output is needed to deliver oxygen to organs and tissues.

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SINUS TACHYCARDIA RULES 1. Rhythm: regular 2. Heart rate: 101 to 180 bpm 3. P waves: rounded, precede each QRS complex, alike 4. PR interval: 0.12 to 0.20 seconds 5. QRS interval: _0.12 seconds

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SIGNS AND SYMPTOMS. Sinus tachycardia may not produce symptoms. If the heart rate is very rapid and sustained for long periods, the patient may experience angina or dyspnea. Older patients may become symptomatic more rapidly than younger patients . Patients with MI may not tolerate a rapid heart rate and have more severe symptoms since cardiac workload is increased.

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THERAPEUTIC INTERVENTIONS . Treatment depends on the cause and symptoms. Medications such as digoxin, calcium channel blockers (verapamil [Calan]), or beta blockers (propranolol [Inderal]) may be used to slow the heart rate. Oxygen may also be prescribed to ensure anadequate supply for the heart. The treatment goal is to decrease the hearts workload and resolve the cause, which then usually corrects the tachycardia

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P.A.C.may arise from a single or several foci within the atria .All P.A.C.All P.A.C. arising from a single focus will have P waves that appear the same.If P.A.C.arise from different sites,the appearance of these premature P waves will very, When P.A.C.arise from a single focus ,there is tendency for coupling interval

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compensatory pause.Measure from the R waves of the complex before the P.A.C. to the R waves of the complex after the P.A.C.This measurement will be two times the R to R interval of the underlying rhythm

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Premature Atrial Contractions


DESCRIPTION. The term premature refers to an early beat. When the atria fire an impulse before the SA node fires, a premature beat results. If the underlying rhythm is sinus rhythm, the distance between R waves is the same except where the early beat occurs. When looking at the ECG strip, a shortened R-R interval is seen where the premature beat occurs. The R wave preceding the premature atrial contraction (PAC) and the PACs R wave are close together, followed by a pause, with the next beat being regular

CAUSES. Causes of PACs include hypoxia, smoking, stress, myocardial ischemia, enlarged atria in valvular disorders, medications (such as digoxin), electrolyte imbalances, atrial fibrillation onset, and heart failure.

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PREMATURE ATRIAL CONTRACTIONS RULES


1. Rhythm: premature beat interrupts underlying rhythm where it occurs 2. Heart rate: depends on the underlying rhythm; if normal sinus rhythm (NSR), 60 to 100 bpm 3. P waves: early beat is abnormally shaped 4. PR interval: usually appears normal, but premature beat could have shortened or prolonged PR interval 5. QRS interval: _0.12 seconds (indicates normal conduction to ventricles

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SIGNS AND SYMPTOMS . Premature atrial contractions can occur in healthy individuals, as well as in the patient with a diseased heart. No symptoms are usually present. If many PACs occur in succession, the patient may report the sensation of palpitations.

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THERAPEUTIC INTERVENTIONS . PACs are usually not dangerous, and often no treatment is required other than correcting the cause. Frequent PACs indicate atrial irritability, which may worsen into other atrial dysrhythmias. Quinidine or procainamide can be given to a patient having frequent PACs to slow the heart rate.

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Atrial flutter Atrial flutter occurs when a single irritable site in the atria initiates many electrical impulses at a rapid rate .The electrical impulses are conducted throughout the atria so rapidly that normal P waves are not produced .instead of Pwaves ,flutter waves are found Flutter waves have a typical saw tooth on the rhythm strips

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During atrial flutter,the atria usually depolarize more rapidly than normal ,while the ventricular usually depolarize at a normal rate.Therefore ,every atrial impulse cannot be conducted to the ventricular ,and a QRS complex is not present for every F wave The ventricular usually depolarize and repolarize at regular intervals,allowing them to responed to the atrial impulses at a regular rate,which may result in a regular ventricular rhythm
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QRS complex typically measure less than 0.12 second and usually occur at regular intervals.the ventricular rate is usually 60-100 electrical impulses per minutes,However ,the atrial rate usually ranges from 250-350 impulses per minutes When an atrial flutter has a ventricular rate of less than 60 impulse per minutes ,it is called atrial flutter with a slow ventricular response When an atrial flutter has a ventricular rate is 100-150 impulse per minutes ,it is called atrial flutter with a rapid ventricular response
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The ratio of flutter waves to each QRS complex further describes the dysrhythmias .Itis important to determine the number of flutter waves for every QRS Example Two F waves with one QRS =2:1block

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If the number of flutter waves is the same before every QRS complex ,the R to R interval throughout and the rhythm is regular,when the number of Fwaves before each QRS complex,the Rto Rinterval is irregular and the rhythmis called atrial flutter with variable ventricular response

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Atrial Flutter the atria contract, or flutter, at a rate of 250 to 350 bpm. The very rapid P waves appear as flutter, or F waves, on ECG and appear in a sawtoothed pattern. Some of the impulses get through the AV node and reach the ventricles, resulting in normal QRS complexes. There can be from two to four F waves between QRS complexes. If impulses pass through the AV node at a consistent rate, the rhythm is regular . The classic characteristics of atrial flutter are more than one P wave before a QRS complex, a saw-toothed pattern of P waves, and an atrial rate of 250 to 350 bpm. 30

CAUSES. Causes of atrial flutter include rheumatic or ischemic heart diseases, congestive heart failure (CHF), hypertension, pericarditis, pulmonary embolism, and postoperative coronary artery bypass surgery. Many medications can also cause this dysrhythmia.

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ATRIAL FLUTTER RULES 1. Rhythm: atrial rhythm regular; ventricular rhythm regular or irregular depending on consistency of AV conduction of impulses 2. Heart rate: ventricular rate varies 3. P waves: flutter or F waves with saw-toothed pattern 4. PR interval: none measurable 5. QRS complex: _0.12 seconds
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SIGNS AND SYMPTOMS . The presence of symptoms in atrial flutter depends on the ventricular rate. If the ventricular rate is normal, usually no symptoms are present. If the rate is rapid, the patient may experience palpitations, angina, or dyspnea

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Pharmacologic management of these arrhythmias typically involves diltiazem or verapamil as well as betablocking agents such as atenolol. The decision to use electrical cardioversion depends heavily on the hemodynamic stability of the presenting patient; in general those patients who are unable to sustain their systemic functions are electrically converted although conversion to a normal sinus rhythm can be performed with amiodarone .

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THERAPEUTIC INTERVENTIONS
. The ventricular rate and cardiac output guide treatment. The goal is to control the ventricular rate and convert the rhythm. A rapid ventricular rate or symptoms of decreased cardiac output require cardioversion (electrical shock). If the rate is greater than 150 bpm, immediate cardioversion is needed. Medications that may be used to control the rate include calcium channel blockers and beta blockers. For rhythm conversion, digoxin can be used to slow conduction through the AV node and increase cardiac contractility. Other medications, such as quinidine, procainamide, or propranolol, can also be used to slow the heart rate.
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atrial fibrillation
An increased irritability of all cardiac cells in the atria exists .Because of this increased atrial irritability.many sites within the atria attempt to initiate electrical impulse many electrical impulse are initiated,most of the impulses are not conducted,therefor,the atria is not completely depolarized with each impulses .The atrial muscle does not contract forcefully only movement (fibrillating waves ) occurs.

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At irregular intervals ,one electrical impulse is conducted through the AV junction and ventricular. resulting in ventricular depolarization and a QRS complex. QRS complexes usually remain within the normal range of less than 0.12 second and the R to R intervals are irregular throughout the rhythm strip. Although the atrial heart rate is usually 350-500 or more electrical impulses per minute.the ventricularheart rate within the normal limits of 60-100 impulses per minute.this dysrhythmias is known as atrial fibrillation

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60atrial fibrillation with a ventricular rate of less than impulses per minutes is called atrial fibrillation with a slow ventricular response ,when this dysrhythmia has impulses per minutes is 150to 100 aventricular rate of called atrial fibrillation with rapid ventricular response,when this dysrhythmia has aventricular rate of impulses per minutes is called un 150greater than controlled atrial fibrillation

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Atrial Fibrillation
the atrial rate is extremely rapid and chaotic. An atrial rate of 350 to 600 bpm can occur. However, the AV node blocks most of the impulses, so the ventricular rate is much lower than the atrial rate. There are no definable P waves because the atria are fibrillating, or quivering, rather than beating effectively. No P waves can be seen or measured. A wavy pattern is produced on the ECG. Because the atrial rate is so irregular and only a few of the atrial impulses are allowed to pass through the AV node, the R waves are irregular. The ventricular rate varies from normal to rapid.
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CAUSES.
Causes of atrial fibrillation include aging, rheumatic or ischemic heart diseases, heart failure, hypertension, pericarditis, pulmonary embolism, and postoperative coronary artery bypass surgery. Medications can also cause this dysrhythmia.

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ATRIAL FIBRILLATION RULES

1. Rhythm: irregularly irregular 2. Heart rate: atrial rate not measurable; ventricular rate under 100 is controlled response; greater than 100 is rapid ventricular response 3. P waves: no identifiable P waves 4. PR interval: none can be measured because no P waves are seen 5. QRS complex: 0.06 to 0.10 seconds

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SYMPTOMS.
With atrial fibrillation, most patients feel the irregular rhythm. Many describe it as palpitations or a skipping heartbeat. When checking a patients radial pulse, it may be faint because of a decreased stroke volume (volume of blood ejected with each contraction). If the ventricular rhythm is rapid and sustained, the patient can go into left ventricular failure

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Rate control: accept atrial fibrillation and focus on symptom relief and prevention of tachycardias. Typically with beta-blockers and digoxin. Target rate is < 100 bpm . Rhythm control: trying to keep the patient in normal sinus rhythm. Typically with anti-arrhythmics like amiodarone, flecainide, and sotalol, or electrical cardioversion, or with radiofrequency catheter ablation . In both cases anti-coagulants are needed to prevent embolic stroke .

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THERAPEUTIC INTERVENTIONS . Treatment is based on the patients stability. If the patient is unstable,cardioversion is done immediately to try to return the heart to normal sinus rhythm. If the patient is stable, medications to restore and maintain a normal sinus rhythm and control the ventricular rate may be used. The ventricular rate may be controlled with such medications as digoxin, beta blockers, or calcium channel blockers. Medications approved by the Food and Drug Administration to convert atrial fibrillation and maintain a normal sinus rhythm include dofetilide, quinidine, flecainide, propafenone, and ibutilide IV.
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Anticoagulant therapy (aspirin for low-risk patients, warfarin for those at high risk), which can be long term or lifelong, is given to reduce thrombi. International normalized ratio (INR) and prothrombin time levels must be carefully monitored for patients on warfarin. Chemical or electrical cardioversion may be performed to convert the rhythm after sufficient anticoagulation (about 3 weeks). If known, the underlying cause of the atrial fibrillation should also be treated

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Dual-chamber pacing for those with sinus node problems or biatrial pacing, as well as pacemaker recognition of atrial fibrillation, helps to prevent this dysrhythmia. Implantable cardioverter defibrillators (ICDs) can deliver a shock activated by the physician or patient to end the atrial fibrillation. Because this is a planned event, medications for comfort can be taken by the patient before the shock. For patients with atrial fibrillation who do not respond to medications, ablation procedures may be performed A surgical procedure can be performed if other treatments fail. The maze procedure was first done as open heart surgery, but a percutaneous, nonsurgical catheter maze procedure may be used to eliminate the risks of open heart surgery.

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