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? Bigeminy - 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 Cardiology “Drive your car” Aortic stenosis Dilated cardiomyopathy 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 heart disease Causes •Rheumatic heart disease •Myocarditis 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 Heart Block 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, ischemia 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 Tachycardia 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 lidocaine 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 “palpitations” 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: Sinus tachycardia with borderline st elevation in V1, V2 with one PVC EMS says… Then goes into torsades…. Is shocked at 200 j once, brief CPR Post shock in ER .