ARRHYTHMIAS

The other name is dysrhythmias Are disorders of the formation or conduction (or both) of the electrical impulse within the heart. These disorders can cause disturbances of the HR, the heart rhythm, or both. They are diagnosed by analyzing the electrocardiographic waveform. Can either be of Sinus, Atrial, Junctional, or Ventricular in origin.

SINUS NODE ARRHYTHMIAS

Sinus bradycardia Sinus tachycardia Sinus arrhythmia

Sinus bradycardia: Occurs when the sinus node creates an impulse at a lower-than normal rate Originate in the SA node, characterized by a rate of less than 60bpm. HR:- less than 60 bpm Pacemaker site: SA node

Causes: Excessive inhibitory vagal (parasympathetic) tone on the SA node due to carotid sinus stimulation, vomiting, neurocardiogenic syncope (sudden loss of consciousness after x-treme emotional stress or prolonged standing).

 decrease in sympathetic tone on the SA node as may be caused by better blockers. administration of calcium channel blockers digitalis toxicity. Hypothyroidism

hypothermia

 Hypoxia during sleep and in trained athletes Clinical significance: With HR btn 50-59 bpm asymptomatic by itself With HR btn 30-45 bpm or less: hypotension with marked reduction in cardiac output and decreased perfusion of the brain and other vital organs.

Symptoms: Dizziness,lightheadedness, reduced level of consciousness,syncope, shortness of breath,chest pain. Hypotension,shock,pulmonary congestion, CCF, acute MI.

Sinus Tachycardia:
Occurs when the sinus node creates an impulse at a faster-than-normal rate. Arrhythmia originating in the SA node, characterized by a rate of over 100 bpm. HR: over 100bpm Pacemaker site: SA node

Causes: In adults is a normal response of heart to the demand for increased blood flow, as in exercise and exertion. Ingestion of stimulants (coffee, tea, alcohol) or smoking Increase in catecholamine and sympathetic tone resulting from excitement, anxiety, pain, stress

 Excessive dose of an anticholinergic drug(atropine) or sympathomimetic drug(dopamine,epinephrine, isoproterenol, or norepinephrine) or cocaine. CCF

Pulmonary embolism Myocardial ischaemia or acute MI Fever Thyrotoxicosis Anaemia Hypovolemia Hypoxia Hypotension or shock

Clinical significance: In healthy individual is benign arrhythmia and does not require treatment.

Sinus arrhythmia: Occurs when the sinus node creates an impulse at an irregular rhythm. Ventricular anda atrial rate is btn 60100bpm. Ventricular and atrial rhythm is irregular.

ATRIAL ARRHYTHMIAS
(a)Premature Atrial Contractions (b)Atrial Tachycardia (c ) Atrial Flutter (d) Atrial Fibrillation

(a) Premature Atrial Contractions (PACs): Occurs when an impulses starts in the atrium before the next normal impulse of the sinus node. HR: - is that of underlying rhythm, usually a sinus rhythm. Rhythm:- Irregular.

 Pacemaker site: ectopic in any part of atria outside the SA node. P waves: -Occurs earlier than the expected sinus P wave( called ectopic P wave)

Causes: Increase in catecholamine and sympathetic tone Infections Emotions Stimulants

 electrolytes imbalances
Hypoxia digitalis toxicity cardiovascular disease dilated or hypertrophied atria

sympathomimetics

Atrial Tachycardia: Arrhythmia originating in an ectopic pacemaker in the atria. It includes ectopic atrial tachycardia and multifocal atrial tachycardia (MAT).

HR:- usually 160-240bpm

-may be slower in MAT -ventricular rate usually the same as that of atria, but may be slower.

 Rhythm: -essentially regular if the AV conduction ratio is constant BUT may be irregular if a variable AV block or MAT is present. Pacemaker site: - Ectopic, in any part of the atria outside the SA node. -One that originate in a single focus is called ectopic atrial tachycardia - One that originate in three or more ectopic foci is called multifocal atrial tachycardia

 In MAT, vary in shape, size and direction in each given lead precedes each QRS complex. not easily identified because they are buried in the preceding T or U waves or QRS complexes.

Causes: digitalis toxicity metabolic abnormalities electrolytes disturbances Hypoxemia chronic lung dse rheumatic heart dse

Clinical significance: depend on the presence of heart dse,nature of the heart dse, Ventricular rate, duration of the arrhythmia. symptomatic atrial tachycardia must be treated promptly to reverse the consequences of reduced CO and increased workload of the heart and to prevent occurrence of serious ventricular arrhythmias.

Atrial Flutter:
An arrhythmia arising from an ectopic pacemaker or the site of a rapid reentry circuit in the atria. The atrial rate becomes faster than the AV node can conduct, hence not all atrial impulses are conducted into the ventricles. Characterized by rapid abnormal flutter waves with a saw tooth appearance and usually a slower, regular ventricular response.

 HR: usually btn 240 and 360 Rhythm: -atrial rhythm typically regular but may be irregular Causes: advanced rheumatic dse coronary or hypertensive heart dse cardiomyopathy atrial dilation

Thyrotoxicosis Digitalis toxicity Hypoxia Acute or chronic cor pulmonale CCF Damage to SA node or atria bse of pericarditis or myocarditis Alcoholism

Atrial Fibrillation: An arrhythmia arising from multiple ectopic pacemakers of rapid reentry circuits, irregular, often rapid ventricular response. HR:atrial rate 350-600 f waves per minute. Ventricular rate commonly btn 160-180 bpm.

 Rhythm:- atrial rhythm irregularly (grossly) irregular. -ventricular rhythm is almost always irregularly irregular. Pacemaker site: multiple ectopic foci.

Causes - advanced rheumatic heart dse -hypertensive or coronary heart dse -thyrotoxicosis -cardiomyopathy -acute myocarditis and pericarditis - chest trauma -pulmonary dse -digitalis toxicity

VENTRICULAR ARRHYTHMIAS
Premature Ventricular Contractions Ventricular Tachycardia Ventricular Fibrillation Ventricular Asystole

Premature Ventricular Contractions(PVC):

Is an impulse that starts in a ventricle and is conducted through the ventricles before the next normal sinus impulse.
An extra ventricular contraction consisting of an abnormally wide and bizarre QRS complex that originates in an ectopic pacemaker in the ventricles.

 HR: is that of the underlying rhythm. Rhythm: irregular Pacemaker site: ectopic, in the ventricles.

P waves: may be present or not and follows the QRS complex.

Causes:

Increase in catecholamine and sympathetic tone Stimulants (coffee, alcohol, tobacco) Myocardial ischaemia or acute MI. CCF Excessive administration of digitalis or sympathomimetic drugs. Increased workload on the heart e.g fever, hypervolemia, exercise, heart failure, tachycardia.

Increase in vagal tone Hypoxia Acidosis Hypokalemia Hypomagnesaemia

Ventricular Tachycardia:
Arrhythmia originating in an ectopic pacemaker in the ventricles with a rate of 110 to 250 bpm. QRS complexes are abnormally wide and bizarre May also defined as three or more PVCs in a row, occurring at a rate exceeding 100bpm.

 Rhythm: may be slightly irregular Pacemaker site: ectopic,in the bundle branches,purkinje network, or ventricular myocardium. P wave:- may present or absent. usually no relation with QRS complex

Causes: significant heart dse digitalis toxicity QT interval prolongation from various causes (excessive administration of quinidine, brady arrhythmias, thirddegree AV block).

-hypokalemia -liquid protein diets -central nervous system disorders). Clinical significance: -life-threating arrhythmia,often initiating into VF or asystole. - VT and its underlying causes must be treated immediately.

 Pulseless VT should be treated the same as VF(i.e cardiac arrest). Ventricular Fibrillation: - an arrhythmia arising in numerous ectopic pacemakers in the ventricles. -characterized by very rapid abnormal waves and no QRS complexes

 HR:- no coordinated ventricular beats. ventricles contracts from 300-500 bpm in an unsynchronized, uncoordinated, and haphazard manner. Fibrillating ventricles are described as bag of worms

 Pacemaker site: -ectopic, multi-foci in the purkinje fibres and ventricular myocardium PR-Intervals: absent R-R Intervals: absent QRS complexes: -absent Rhythm:-grossly (totally) irregular

Causes: -significant heart dse -cardiac, medical,and traumatic conditions as terminal events - excessive dose of digitalis. - hypoxia.

acidosis electrolyte disturbances(hypo/hyper-kalemia during anaesthesia, cardiac and noncardiac operations,cardiac catheterization and cardiac pacing following cardioversion or accidental electrocution

 Clinical significance: -Life-threatening -VF resemble ventricular asystole, therefore must be correctly identified using at least two ECG leads.

 ECG artifacts should be ruled out by checking pts pulse immediately after the ECG- indicated onset of VF to confirm the arrhythmia before treating the pt for cardiac arrest.

Ventricular Asystole (Cardiac standstill): -Is the absence of all electrical activity in the ventricles. HR:-absent
Causes: when the dominant pacemaker fails to generate impulses. when impulses are blocked from entering the ventricles VT VF Pulseless electrical activity Ventricular escape rhythm

CONDUCTION ABNORMALITIES
When assessing the rhythm, nurses takes care first to identify the underlying rhythm(e.g sinus rhythm, sinus arrhythmia) Then the PR interval is assesed for the possibility of an AV block. AV block occurs when the conduction of an impulse through the AV nodal area is decreased or stopped.

 These blocks can be caused by medications like digitalis, calcium channel blockers, beta blockers. If the AV block is caused by increased vagal tone (like suctioning, pressure on large vessels, anal stimulation), it is commonly accompanied by sinus bradycardia.

 The clinical signs and symptoms of heart blocks vary with the resulting ventricular rate and the severity of any underlying disease process. Where the first-degree AV block rarely causes any hemodynamic effect, the other blocks may in result in decreased heart rate, causing a decrease in pefusion to vital organs, such as the brain, heart, kidneys, lungs, and skin. Treatment is based on the haemodynamic effect of the rhythm. Always keep in mind to treat the patient and not the rhythm.

First-degree AV block: Occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. PR interval is greater than 0.2secs and measurement is constant. P:QRS ratio: 1:1

Causes: -Acute inferior or right ventricular MI -ischemic heart dse. -excessive inhibitory vagal tone -Digitalis toxicity -electrolyte imbalance -acute rheumatic fever or myocarditis

Second-degree AV block, Type I: Occurs when all but one of the atrial impulses are conducted through the AV node to the ventricles. Each atrial impulses take longer time for conduction than the one before, till one impulse is fully blocked. PR interval becomes longer with each succeding ECG complex till there is a P wave not followed by a QRS. P: QRS ratio: 3:2, 4:3, 5: 4 Causes is the same first-degree block.

Second- degree AV block, Type II: Occurs when only some of the atrial impulses are conducted through the AV node into the ventricles. PR interval is constant for those P waves just before QRS complexes. P: QRS ratio: 2:1, 3:1, 4:1, 5:1

Third-degree AV block(Complete block): Occurs when no atrial impulse is conducted through the AV node into the ventricle. In third-gree heart block, two impulses stimulate the heart: one stimulate the ventricles(e.g junctional or ventricular escape rhythm), represented by the QRS complex, and one stimulates the atria(e.g sinus rhythm, atrial fibrillation), represented by the P wave.

 PR interval: very irregular. P:QRS ratio: More P waves than QRS complexes. Causes: acute inferior or ventricular MI ishaemic heart dse Excessive inhibitory vagal tone digitalis toxicity

 Administration of some drugs e.g bitter blockers, amiodarone or calcium channel blokers electrolyte imbalance (hyperkalemia) acute anterior MI. acute rheumatic fever or myocarditis chronic degenerative changes in the bundle branches.