Medicine: Rapid Interpretation Rhythm

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1

what is the best tool for showing arrythmias

EKG

2

what is the intiator of pacemaker acitvity

SA node

3

what are the 3 conduction pathways of the heart (directionally)

anterior internodal tract
middle internodal tract
posterior internodal tract

4

what is another name for the anterior internodal tract

Bachman's bundle

5

what is anothe rname for the middle internodal tract

Wenckebach's bundle

6

what is another name for the posterior internodal tract

Thorel's pathway

7

what is the delay time at the AV node

1/10 second

8

what do Nodal premature beats or nodal rhythms refer to

AV node

9

after the AV node is stimulated where does it take the electrical stimulus

R and L bundle branches to ventricles

10

does the specialized nervous tissue called the AV node-bundle branch system ventricle carry electrical impulses from the ventricles rapidly or slowly

rapidly

11

does the ventricular muscle carry electrical charges quickly

NO

this is a way to find pathological impulses that originate outside the nervous conduciton ssytem in the ventricles, because they are slower

12

where are there potential/ectopic pacemakers in the heart

atria
AV node
ventricles

13

what is an ectopic focus in the heart

an area that can emit electrical impulse in the heart

14

what can the presence of impules from ectopic foci indicate

disease

15

can ectopic foci send out one or more than one electrical impuse

either

16

the normal rhythm of the heart is said to be what in nature

regular

17

what are the various categories of arrythmias

varying rhythm
extra beats and skips
rapid rhythm
heart blocks

18

what are the varying rhythm arrythmias

sinus arrythmia
wandering pacemaker
atrial fibrillation

19

do varying rhythm arrythmias have regular sequence of the ECG

yes, just in strange rythms, often changing continuously

20

do the varying rhythm arrythmias have a predictable pattern of recurrence

no

21

how do some people call the arrythmias

"irregularly irregular"

22

is the interval between the PQRST cycle always the same in varying rhythm arrythmias

no

23

what are the defining characteristics of sinus arrythmias

varying rhythm
P waves identical

24

what is sinus arrythmia from usually

a sick SA node

25

which waves are identical in each beat in sinus arrythmia

P waves

26

in sinus arrythmia, are the PQRST waves normal in size and shape

yes

27

does the rhythm of wandering pacemaker vary

yes

28

does P wave shape change in wandering pacemakerk

YES

29

does atrial fibrillation have a varying rhythm

yes

30

are there P waves in atrial fibrillation

not really, multiple ectopic atrial spikes

31

what is atrial fibrillation caused by

firing of multiple foci in atria

32

do any single impulses in atrial fibrillation depolarize the atria completely

no

33

do many atrial fibrillation electrical impulses get to the AV node

no

34

what are the arrythmias consdiered to be "extra beats and skips"

premature beats
escape beats
sinus arrest

35

what causes premature beats generally

ectopic foci

36

what morphology will premature waves show

normal or abnormal, but suddenly and early in the cycle

37

what produces an atrial premature beat

premature atrial stimulation from an atrial ectopic focus

38

will premature atrial beats look just like hte beats from the SA node (other P waves)

no

39

why does the impules from premature atrial beats look normal

because the ectopic impulse depolarizes the atria in a similar manner as the normal impulse so the AV node picks up and transmits the impulse just as if it were a normal P wave

40

where does premature nodal stimulation originate

ectopic discharge in AV node

41

how does nodal premature stimulation proceed down the bundle branch pathway

just like normal

42

what is the morphology of the premature nodal beat like on the ECG

normal QRS, but with no P wave

43

what will the nodal premature focus do occasionally

retrograde conduction sending impulse upward to stimulate atria from below

44

what can the nodal premature focus's retrograde conduction do to the P wave

create inverted P wave before or after QRS or mixed in with QRS

45

where do premature ventricular contractions (PVCs) originate

ectopic ventricular focus

46

does the impulse of the PVC follow the usual bundle branch conduction system

no

47

is the PVC impulse slow or fast

slo

48

where does the impulse of the PVC orignate

myocardium

49

what is the nervous conduction system of the heart's speed of impulse transmission

2-4 m/s

50

what does the myocardium transmit electrical impulses at

1 m/s

51

what will always follow the PVC

long compensatory pause

52

does PVC usually arise in one or both ventricles

one

53

why are the PVC deflections tall and deep

depolarization progresses differently on both sides

54

what are interpolated beats

PVCs that are sandwiched between normal beats of a tracing, making no compensatory pause and no disturbance in normal regular rhythm

55

can PVCs be coupled with normal beats

yes

56

what is it called when PVCs are coupled with another beat

bigeminy

57

if a PVC is coupled with two normal beats and the pattern repeated itself many times, what would you call this

runs of trigeminy

58

can more than one PVC originate from the same focus

yes, numerous can

59

how many PVCs a minute are considered pathological

six

60

if a PVC is identical over and over, what can we assume

they are from same focus

61

what do PVCs often indicate

heart's own blood supply is poor

62

in situations where coronary blood flow is adequate but blood is poorly oxygenatd, what will the heart do

recognize poor oxygenation and high CO2 and ventricular ectopic foci will discharge frequently

63

what is parasystole

dual rhythm caused by two pacemakers one of which is generally ectopic and ventricular in origin

64

are parasystole rhythms generally slow or fast

slow

65

what two types of rhythm combined are known as parasystole

ventricular ectopic
supraventricular

66

do ventricular ectopic beats gneerally show rhythmicity in parasystole

yes

67

are many beats dropped in parasystole

nope (protective feature)

68

if PVCs are coupled with a long series of normal beats, what should you suspect

parasystole

69

what is a run of more than 4 PVCs in rapid succession

run of ventricular tachycardia

70

what are multifocal PVCs produced by

multiple ventricular ectopic foci

71

do mutliple ventricular ectopic foci make an identical appearing PVC with each firing

yes

72

if a PVC falls on a T wave, what can result

dangerous arrythmias

73

when do PVCs normally occur

just after T wave of normal cycle

74

what can happen if a PVC falls on a T wave

the ventricular ectopic focus which is involved can discharge frequently

75

when do escape beats occur

when normal pacemaker fails to elicit a stimulus for one or more cycles, so an impatient ectopic focus fires

76

if the SA node fails to fire its normal regular stimulus, what will happen to the heart

it remains temporarily silent

77

on the ECG tracing the failure of the pacemaker to fire is free of what

waves

78

after an escaped beat, what will normally fire an impulse

ectopic focus in atria

79

after an escaped beat and ectopic focus firing, will conduction proceed down through the AV node normally?

yes

80

what is it called when an atrial ectopic focus discharges after a silent pause of more than one cycle

atrial escape beat

81

where do nodal escape beast originate

AV nodel

82

what do nodal escape beast stimulate the ventricles through

normal conduction system (yield normal QRS after the pause)

83

are QRS waves in nodal escape normal

yes

84

where do ventricular escape beats originate

ectopic ventricular foci

85

what do ventricular escape beats resemble

PVC type ventricular response after a pause in rhythm

86

how would you determiine PVC vs. ventricular escape beasts

ventricular escape would be after a pause

87

when does sinus arrest occur

when SA node's pacemaking area suddenly arrested and does not send out pacemaking stimuli

88

after the pause of sinus arrest, what takes over pacemaking activity

another new pacemaker area

89

does a new pacemaker have the same or different rate in sinus arrest

new rhythm

90

when a tracing demonstrates no evidence of P waves in all leads and a bradycardia, what should be suspected

sinus exit block

91

what treatment may sinus exit block require

implantation of an artificial pacemaker

92

what will patients with sinus exit block have occasionally

bursts of tachycardia

93

are sinus arrest and sinus exit block essentially the same thing

yes

94

which rhythms are considered rapid rythms

paroxysmal tachycardia
atrial flutter
ventricular flutter
atrial fibrillation
ventricular fibrillation

95

are rapid rhythms regular or irregular

either or

96

what does paroxysmal tachycardia mean

sudden rapid HR which usually arises from ectopic pacemaker

97

what is the HR range of paroxysmal tachycardia

250-150 beats per minute

98

what is paroxygmsal atria tachycardia caused by

sudden rapid firing of an ectopic atrial pacemaker

99

what is the rate of paroxysmal atrial tachycardia

150 to 250

100

are the foci in paroxysmal atrial tachycardia the same for each beat or different

different

101

what is a form of PAT that has more than one P to every QRS

PAT with block

102

what does PAT with block often signify

digitalis toxicity

103

what do P waves look like in PAT with block

P waves small, spiked, and up in leads II and III

104

what do ST segments look like in PAT with block

isoelectric

105

how is PAT with block recognized

each individual P wave does not have a QRS response (one or more atrial impulses blocked and does not get to AV node

106

how many spiked P waves could you see for each QRS in PAT with block

two or more (still atrial tachy)

107

what is paroxysmal nodal tachycardia caused by

ectopic pacemaker in AV node

108

what is the potential pace of paroxysmal nodal tachycardia

150-250 bpm

109

can paroxysmal nodal tachycardia proceed by retrograde conduction? how will this appear

inverted P wave eitehr immediately before or just after each QRS of tachycardia

110

what are paroxysmal nodal and paroxysmal atrial tachycardial known together as

supraventricular tachycaridas

111

is differentiation between PAT and PNT important

not really, sometimes P waves run into prior T wave

112

what is paroxysmal ventricular tachycardia initiated by

ventnricular ectopic pacemaker

113

does PVT have a characteristic pattern

yep

114

what does PVT rate look like

150-250

115

what do sudden runs of PVTs look like

PCs

116

can an atrial impulse break from above and stimulate a normal appearing complex during ventricular tachycardia

yes

117

why do only a few atrial impulses stimulate the AV node in ventricular tachycardia

because the AV node is only vulnerable to a stimulus from above at certain times during VT

118

when AV node is stimulated by atrial depolarization from above during VT, the impulse follows the normal BB pathway; a neartly normal looking QRS results, but then it fuses with what to create a fusion beat

PVC like complex

119

if a breakthrough atrial depolarization gets past the AV node and makes it to completion, what is this called

capture beat (presence captures or fusions makes VT the diagnosis for sure)

120

what may runs of VT signify

coronary artery disease

121

what does PVT appear like

run of PVCs

122

where does atrial flutter originate from

atrial ectopic focus

123

what happens in atrial flutter

P waves in rapid succession and each identical to the next

124

how fast does ectopic atrial focus fire in atrial flutter

250-350

125

are the P waves different in atrial flutter

identical

126

does every P wave have in atrial flutter have a QRS sequence

no, few do

127

when in doubt about atrial flutter, what may be very helpful

inverting the tracing

128

what is the rhythm with a "saw tooth" appearnce

atrial flutter

129

is there a flat baseline between beats in atrial flutter

no

130

what produces ventricular flutter

single ventricular ectopic focus firing at a rate of 200-300 per minute

131

what type of wave does ventricular flutter look like

smooth sine wave

132

what does ventricular flutter turn into

deadly arrythmias

133

what does ventricular flutter almost always turn into

vetricular fibrillation

134

is there any filling in ventricular flutter

almost none, so there is no cardiac output and v fib resulsts as many ventricular ectopic foci try to compensate

135

what is atrial fibrillation caused by

many ectopic atrial foci firing at differen rates causing a chaotic, irregular atrial rhythm

136

how much of atria is depolarized by an ectopic impulse in atrial fibrillation

very small portion

137

what does atrial fibrillation appear as on the ECG

irregular baseline without P waves

138

are QRS complexes regular in atrial fibrillation

not regular

139

is QRS in atrial fibrillation rapid or slow

either

140

what is ventricular fibrillation created by

stimuli from many ventricular ectopic foci causing a chaotic twitching of the ventricles

141

is there effective cardiac pumping in ventricular fibrillation

no

142

what are the types of cardiac arrest

v fib
asystole

143

where can heart blocks occur

SAn node
AV node
BB system

144

what should you ALWAYS check for on tracings

heart blocks

145

what does SA node block cause the pacemaker to do

temporarily stop for at least one cycle, but then pacemaker resumes pacing activity

146

after an SA block will the heart change its rhythm

usually not, back to old speed

147

where does AV node block create a delay

at AV node, makes a longer than normal pause before stimulating the ventricles

148

what is thus lengthened in AV block

PR interval

149

how much does an AV block prolong the PR interval

more than 0.2 (large square) on EKG

150

what does an "interval" on a tracing usually include

wave

151

what are "segments" generally considered

poritons of bsseline

152

what does the PR interval include

P wave and baseline that follows it up to the ponit where the QRS complex begins

153

where is the PR interval measured from

beginning of P wave to beginning of QRS complex

154

how long should the PR interval measure less than

one large square or 0.2 seconds

155

if PR interval is larger than one large square, what is present

AV block

THIS IS SO IMPORTANT TO MEASURE EVERY TIME

156

what is first degree AV block characerized by

PR interval greater than 0.2 seconds but P-QRS-T sequence is normal

157

when is a second degree AV block present

takes 2 or more atrial impulses to stimulate the ventricular (QRS) response (2:1 or 3:1 AV block)

158

what is the wenckebach phenomemon

PR interval becomes progressively longer until AV node is not stimulated (no QRS)

159

what type of heart block is wenckebach

second degree heart block

160

what is another name for wenckebach phenomenon

mobitz I

161

what would we call this if without lengthening of a PR interval, a QRS is dropped

mobitz II

162

what is another name for a third degree heart block

complete block

163

what happens in a complete block

none of the atrial impulses stimulate the AV node and vetnricles muscle be paced indepently

164

in complete heart block what will be the pacemaker

some ectopic pacemaker

165

if the complete heart block's QRS's are normal, what is said of the rhythm

idionodal

166

if the complete heart block's QRSs are wide and bizarre, what is the rhythm said to be

idioventricular

167

if in complete heart block you see a pace of 60, what is it probably being paced by

AV node

168

if in complete heart block you see a rate of 30-40 what is it probably being paced by

ventricular ectopic pacemaker

169

what is the slower ventricular (QRS) rate and certain atrial rate being separate from one another in complete heart block called

AV dissociation

170

how are very slow rates calculated in ECGs

take cycles per six second strip and multiply by 10

171

if a person in third degree heart block loses consciousness, what is this called

stokes-adams syndrome

172

what is a bundle branch block caused by

block of impulse of right or left bundle branch

173

are both ventricles normally depolarized simultaneously

yes

174

what happens electrically in BBB to the ventricles

one ventricle fires before the other, leading to "joined QRS"

175

what does a widened QRS look like

joined QRS

176

how are the peaks in the wide QRS noted

R and R'

177

how wide is the QRS in BBB

3 small squaares or greater

178

how many R waves are seen in right BBB

R and R'

179

how is diagnosis of right BBB made mainly

by widened QRS

180

should you check in every ECG the width of the QRS

yes

181

will typiclly the chest or limb leads have a wider QRS

chest

182

if a patient with BBB develops supraventricular tachycardia, what will the widened QRSs imitate

v tach

183

which ventricle fires late in LBBB

left

184

what ventricle fires late in RBBB

right

185

what should you notice immediately in BBB's

widened QRS, then R-R' configuration

186

if there is a RBBB, what leads should be checked for the R-R'

V1 and (right)

187

if there is a LBBB, what leadas should be checked for the R-R'

V5 and V6 (left)

188

during what siutaitons can there be aberrrant conduction that imitates BBB

refractory period varies between ventricls so that during rapid rates or after early (premature) atrial beats the AV nodal stimulus may be carrierd to one ventricle and there is a slight delay

189

where will there be a R-R' if there is RBBB

V1 or V2

190

in RBBB which ventricle is depolarizng slightly later

right

191

where will there be a R-R' if there is a LBBB

left chest leads V5 or V6

192

how can R-R' sometimes appear in LBBB in V5 or V6

notch in wide QRS

193

how long in duration must QRS be for BBB

0.12

194

what is the certain rapid rate at which BBB becomes evident

"critical rate"

195

what would an R-R' in a QRS of normal duration be called

incomplete BBB

196

what is improtant about LBBB

infarct cannot be accurately diagnosed on ECG

197

what types of waves cannot be identified in LBBB

Q waves

198

what should always be checked first when evaluating rhythm

PR interval
QRS complex

199

if PR interval is extended, what should you be thinking

AV block

200

if QRS is prolonged what should you be thinking

BBB

201

can mean QRS vector and ventricular hypertroophy be accurately calculated in presence of BBB

no

202

what does the mean QRS vector represent

general direction of simulatenous depolarzation of ventricles

203

why can't you represent mean QRS vector in BBB

, very difficult to represnt such a vector in BBB because ventricles firing out of plane and there are really two

204

what are the criteria for ventricular hypertrophy based on

normal QRS

205

why does BBB produce large QRS deflections

because each ventricle does not have usual simultenaous electrical oppositon by depolarization from other ventrcile

206

in presence of BBB can atrial hypertrophy be diagnosed as normal

yes

207

in presence of BBB can ventricular hypertrophy be diagnosed as normal

no

208

what happens in some people that screws up electrical activity of the heart in wolff-parkinson white syndrome

accessory pathway short circuits the usual delay of ventricular stimulation causing premature ventricular depolarization represented as a delta wave

209

what accessory bundle is said to provide ventricular pre-excitation in wolf-parkinson white syndrome

bundle of kent

210

what does the delta wave cause in WPW syndrome

shortened PR interval and lengthened QRS

211

what does delta wave represent in WPW syndrome

premature stimulation of a portion of the septum

212

what are the two mechanisms through which people can have paroxysmal tachycardia

re=entry
rapid conduction

213

what happens in re-entry paroxysmal tachycardia

ventricular depol may immedaitely re-stimulate the atria (and AV node) via this pathway in retrograde fashion

214

what is another name for retrograde re-stimulation of atrium

circus re-entry

215

what is rapid conuction's mechanism of paroxysmal tachycardia

supraventricular tachycardias can be rapidly conducted to ventricles 1:1 throught this pathway