Where’s the

PAC?  A junctional premature contraction (JPC) is a beat that originates prematurely in the AV node.  It can occur sporadically or in a grouped pattern. Junctional  If PR interval is present, it does NOT represent atrial stimulation of Premature the ventricles. Contraction (JPC) PVC What is this called?  - every other beat  Trigeminy - every third beat  Quadrigeminy - every fourth beat Just how mad  Couplets - two in a row are you??  Triplets - three in a row  V-Tach - 5 or more PVC’s

 Multifocal – More than one focus PVC Couplet

Multifocal

Bigeminy Trigeminy Quadrageminy BBB Hemiblock

 You are driving into the EKG.  You need to turn.  You signal. Right or left.

Bundle Branch

BLOCKS

 J point: the junction between the end of the QRS segment and the beginning of the ST segment Turn signal theory

- Courtesy of Mike Taigman Advanced Field “Drive your car”  Dilated LBBB AMI/Extensive CAD Causes Primary disease of the cardiac electrical conduction system Long standing hypertension leading to aortic root dilatation = aortic regurgitation

•RVH / Cor pulmonale •PE RBBB •Ischemic disease Causes •Rheumatic heart disease • or cardiomyopathy •Degeneration of conduction system

“Drive your car” AV Blocks What is actually blocked? A vessel? Is something really “blocked?” Heart Blocks Defined by PR Interval First-Degree Regularity: Regular P wave: Normal PR interval: Prolonged >0.20 sec QRS width: Normal

Syncopal episode – is this the culprit?  First degree AV block is a constant and prolonged PR interval  Insult to AV node, hypoxemia, Inferior MI, dig st toxicity, of the conduction system and 1 Degree AV increased vagal tone Block  Criteria Rhythm: Regular PRI: > .20 Degree 2nd Regularity: Regularly irregular

AV Block - P wave: Present Type I PR interval: Variable QRS width: Normal Dropped beats: Yes, patterned

Long, Longer, Longest, DROP! Rinse and repeat. - Wenchebach 2nd Degree AV  Wenkebach: Long, longer, longest….drop. Block, Type I  Same causes as 1st degree AV block Wenkebach  Criteria Rhythm: Irregular PRI: Progressive lengthening of PRI until dropped beat  QRS's appear to occur in groups. Mobitz II Second- Degree Heart Regularity: Regularly irregular Block P wave: Normal PR interval: Normal QRS width: Normal Dropped beats: Yes 2nd Degree AV Block  Can lead to third degree AV block Type II  AV conduction normal…then drop. Mobitz  Criteria PRI: Constant on conducted complexes until a sudden block of AV conduction Rate: Separate rates for underlying (sinus) rhythm and escape rhythm Regularity: Regular, but P rate and QRS rates are different P wave: Present P-QRS ratio: Variable Third-Degree PR interval: Variable, no pattern Heart Block QRS width: Normal or wide Grouping/dropped beats: None

3rd Degree AVB Complete  Caused by:  Acute MI  Dig Toxicity  Conduction System Disease Something wicked this way comes Ventricular Rate: 100–200 BPM Regularity: Regular PR interval: None (VTach) QRS width: Wide, bizarre

Dead? Defib

VT

Alive? Synch

 Rate: Generally 100 to 220 bpm  Width of QRS>0.12 sec

Rhythm: Regular Ventricular  Stable = treated with or Amiodarone Tachycardia  Hemodynamically unstable VT (with a pulse) is cardioverted  VT without a pulse is defibrillated

 Three or more beats of ventricular origin (PVCs) in succession at a rate greater than 100 beats per minute

. “I think you need to go to the ER” 30 y/o female “”

Torsade de Rate: 200–250 BPM Pointes Regularity: Irregular P wave: None QRS: Changing polarity Grouping: Variable sinusoidal pattern

Prolonged ______can cause torsades.

Torsades

How do we treat this?  Felt unwell “like the water ran out of me”  Under stress  HX: HTN, psyche, chronic neck pain  Drank alcohol, etoh, did cocaine Case

Called 911…

 “Had an episode of urinary incontinence, pt felt weak”  Dizzy, dyspnea, chest discomfort  Field EKG: with borderline in V1, V2 with one PVC EMS says…  Then goes into torsades….

Is shocked at 200 j once, brief CPR Post shock in ER