ECG Made Easy with Kendall Wyatt

so this is our ECG webinar we're actually going to be broadcasting here if you're on our GoToWebinar that's great if you are on our stuff for YouTube we're actually streaming this live on YouTube so everybody always asks about their comments and I can't see the comments I can't see what's coming in if you're on the GoToWebinar side keep in mind so we have this streaming in a couple of different places so sometimes it is a little bit harder to kind of tell what where things are coming in where it's going on so I know I apologize but you can not everybody can see everything where everyone else is so if it's something I'll mention it so you're free to ask questions and type them in little question box there if you want and I encourage it if it's relevant to what we're talking about this at the time I will mention it and we will go over it and we'll go from there I'm just moving around a couple of windows here I have like three monitors and it's kind of a technological nightmare and you would think as a tech company we would be able to to do this very well but even after doing this well over a hundred times it still takes just a minute to get everything to make sure it's working because the worst thing is to get started and then figure out that something's not working correct so we've got lots of people joining in we're so great to have you today this is our ECG webinar we're going to go over a lot of the basics and a lot of different things so oops what'd I do well I must have messed up my slides here I'm on the wrong slide um so there we go so my name is dr. Kendall Wyatt I'm the academic content director epic monic now I'm the academic content director today but this is my last live webinar that I'm going to be doing with pic Manik as far as scheduled maybe in the future who knows but I'm going off to residency myself and going back to where I'm from in West Virginia and be doing web webinars and other things there so if you're looking for me you can always find me on my personal youtube but as always I'll probably be jumping you know might be jumping in the future on some Pig Manik stuff but we'll be working on lots of other things so I started out as a paramedic and then went to nursery school then went to med school and I love ACLs I think ACLs is something that's really like a huge scary thing for so many people and it shouldn't be scary and that's really that's really that point is you know ACLs shouldn't be something that's scary this when you take your first ACLs class it's 16 hours that's a lot of stuff so we're going to focus on a lot of the basics to make you good at interpreting ECGs and good at done of all the basic things and we're going to go over a lot of rhythms and then you're just going to need to practice now if you've not heard of pic Manik before what we do at pic Manik is we take all the things you need to know and we take all of the the things in medicine and we turn facts in the characters while my voice cracked I must be going to puberty again even the last time was late I guess the second time past 30 it should happen so something like bipolar should be will turn it into a bipolar bear and if you need to learn about maybe warfarin the drug you're going to be able to earn about a wharf area inside it pick money you can try it out for free if you lots of you guys are already subscribers we appreciate that you can check it out there's tons of different topics is well over 100 topics for nursing coming everything you need to know pharmacology diseases disorders and all the crazy stuff you just have so much trouble memorizing when you're in nursing school and of course every other type of medical medical degree I understand now what we're going to go over today we're going to go over just a really quick hit on some basic anatomy some high-yield points on the anatomy side but we're also most importantly is understanding the blood flow I really think so many people fail at cardiology because they just don't really understand the blood flow and how to make sure that you memorize that first super-important and understand the concept of it and I know all the instructors out there they say concept concept concept but in reality um you know that's really um really difficult to kind of grasp but what is the concept what we're going to go over concepts of this stuff today and we're going to go over how to calculate the rate in a very crude rudimentary form and then we're going to jump into some rhythms now after that we'll do some review and Q&A if you have any particular questions you can check out this recorded we'll be on pick monix YouTube it's live on there right now you can check that out on YouTube at pick Manik video just type in tucumán video or search pick Manik and YouTube what's going to pop up look at our channel would be the newest one so let's go and get started this webinar usually usually runs about an hour it usually takes me a solid hour to go through this so you know if you're not planning to hang around for an hour you can catch up and follow up later but we do hit literally every high yield point that you need to know all of the basics so really you need to know everything in this one there's not really much that I say in this webinar that's like yeah you can kind of just brush over that it's not really much here because we've already stripped all that out because we've taken really about 12 hours of what you would learn in ACLs and condensed it all down to an hour in a really rapid fire form so maybe you need to watch it a couple times maybe you need to slow it down and I understand that and I get that especially if this is your first time doing ECGs now the one of the things that's important to understand and this is just one of our pick monic images throughout the entire webinar today we've got lots of pic monic images from our system and it's not just a bunch of random images so you can go learn them all in there and check it out but this is the coronary arteries now one thing that's really important as you're learning coronary arteries is really knowing that there's the left coronary already and the right coronary artery and they really branch off the main - on the main bifurcation now a bifurcation is where something splits so it's by bifurcate bindings - so it splits and it bifurcates it creates into two so you have a left and right mark left and right coronary arteries now one thing that's really important to know is that for the understanding that basic concept is important because when you go and need to learn 12 lead EKG s when you go into actually if you're working you know you need to do some ACLs and advanced things you can really go in and learn and understand a lot of those basics of where the pathology is happening in the heart that's about all I'm going to go over with that right now now one thing that is so important and I just see so many people just brush over this they learned it in anatomy class and then they you know they they just kind of forgot it or they don't have it at the tip of their tongue is learning the blood flow through the heart it's so important now I'm not going to go through and and drill SiC rote memory tactics into getting you to memorize it but what you just you just have to understand that the you know we go from capillaries and venules and veins then into those vena cava into the right atrium now the right atrium and the right side the hearts all deoxygenated blood through that tricuspid valve or through into the right ventricle and then of course into the pulmonary artery and the lungs ah somebody wrote in real quick and so they're having trouble just seeing interest screen I think what you need to do and is you may have to I can just degree share them here because it's streaming on our YouTube so maybe let me just done we just pause this and then start it over for you so did you could you can see you surprised somebody didn't say something ahead of time there you go hopefully there you go sometimes they go to webinar system freezes on us so you can always just right in there and let us know so here you should be seeing our blood flow slide now if you're on the on the webinar side now one thing that's super important um is like I said knowing that blood flow now yes you really do need to understand all of the blood flow because then you can see the the the actual flow through the heart and understanding what's going on hello oh it's still not coming in - that's weird what on one sec let me try something else here wow there's a lot of people on you okay so it's going to go away for a second so don't forget you doo doo doo to do um waiting and waiting waiting just trying to get some technical fun things going on here um well boy got the spinning wheel of death it's definitely not my computer it's just usually software craziness we're going to get it set up just in a second sorry for the people who are on youtube that's just annoying sorry just trying to make sure we've got several hundred people on our M on our webinar panel and I'm trying to make sure that that is working now let's see let me see if I can get that fixed hmm sorry for the delay Marley's on our back up there for answering people on our youtube channel just um we are if you just joining in on YouTube it's we're just trying to fix a little problem with our GoToWebinar side we always brought broadcast live kind of to places and sometimes that doesn't always work the best for understanding just because the GoToWebinar side sometimes will fail it's not the best software which is why we've been kind of going away from it not much not a big fan but we do use um we do often do webinars from there we go it looks like getting more dinner oh look magic now okay let's see what we're looking at now mmm okay one sec okay there we go now we should be seeing more there we go okay hopefully we should be seeing on that GoToWebinar side let me just fix the borders and sorry about the craziness it just seems like no matter how many no no matter how many how many of these webinars we do and how many technological times we do this there are always something crazy that happens just seems like it was just kind of maybe we're just trying to do too many things at once maybe that's just the problem who knows hopefully on the webinar side you're able to see the slides now you should get a CV on our wonderful blood flow and feel free to just usually the little little common things goes it just going to really just fills up when something goes crazy so you should be able to see the blood flow through the heart now and do you guys on YouTube sorry about that delay so one of the things as we're going through and talking about this is like I said you really just you do have to know this you need to know it I'm not going to harp on staying on it but what is important is making sure that you know that the right atrium deoxygenated right atrium then to the right ventricle then to the lung so then the lungs then the then goes gets oxygen it goes back out to the left atrium and the left ventricle and then out the point of that is the left ventricle is the largest you know it's a large Americans got a pump out to the entire dag on body right I mean it's huge so it's got a huge and it really has to really ask to pump a lot so it's going to be a lot bigger so then if we have that left coronary artery that essentially needs to that if that if that artery gets blocked and it's that left the left coronary artery then we know that that's a that's a big problem because we're essentially cutting off all of the blood slides with blood supply to the to the biggest part of the heart that's pumping and that's what's really really becomes a problem now when you think about this this is great when you go and you think about heart failure which we've got videos on all that stuff and all the other things heart failure and all of the other diseases as well you can think about how some you know something as simple as a myocardial infarction can essentially cause then maybe cause a lot of problems it can cause them and you can think about the pathology that goes along with it so I like to think about this with my wonderful fish tank method whoops Before we jump into this so I just think of the body as a fish tank these all go together the pipes or the veins and arteries the pump itself the heart which is what we're talking about for electrical rhythms the aerator and every great fish tank you need something to pump oxygen in there so we've got our lungs and then the tank in the fluid is just like the fish tank itself with water which of course is the actual body keeping everything together in the blood and then everything needs a great filter like the kidneys and we've got these little filter kidneys here it got my orange copier today with me um so my mouth gets dry so I always have to take a little drink now let's jump into EKG stuff now we're finally going wow system that's painful so one of things I want to talk about are of the electrical physiology of the heart now when we talk about the electrical physiology we know that we have to talk about the sinoatrial node we've got this sinus sinus atrial sinoatrial node here we've got our little little spark plug and that's what's really important until it's at the top of the heart so electro wretchedly comes from up here and it comes down from the right side all the way down to the left ventricle it comes from the sinoatrial node to the AV node we've got our little aviator wearing heart and then of course it goes to the bundle of His and we've got our hissing snakes and then down to the Purkinje fibers and out to the rest of the heart now when you think about this conduction system what you really need to know is that each one does different speeds and this is important concept again to think about because what happens is it's really like a backup system you know it's like having a buddy system and if one fails then the other one's going to step in and help out so what happens is the sinoatrial node they all have different rates which they kind of kick in it and that's really the concept to think about so when you think about somebody who then has a heart block which we're not going to go into the ECG of heart blocks but they have a heart block so they have blocked the electrical system that person is not going to have a fast rate right they're going to have a very slow rate so let's talk through them so if you talk about the SA node the sinoatrial node it has a regular beat of an intrinsic rate of 60 to 100 beats a minute that's essentially essentially a sign a sinus rhythm right sinus rhythm is intended and matches a sinoatrial node firing from the sinoatrial node because it's essentially firing from the normal place and firing correctly and that's really what you can think about so that fires from that right atrium the SA node comes down to the right atrium down into the the AV Junction the AV node it's often called or the atrial ventricular Junction now the AV node is the second spot it gets electricity so it comes to the SA node to the AV node then it comes all the way down and then essentially fires throughout the rest of the heart well if the SA node fails if something happens and you have a heart block a blocked conduction pathway essentially what happens is the AV node can take over it can work all by itself because that's one of the great properties but sometimes albeit bad properties of the heart is that they're they're automatic they can conduct themselves and if I'm energized and I'm at a cardiac cell my buddy over here his guard xl5 electrified and a shocked him he's going to fire right beside me so it conducts all the way throughout the heart tissue as well and that's one of the great things so that the AV node can essentially fire in the middle of the heart and that's where you see all those weird problems where you see inverted inversions up like the the QRS complex because it looks weird that's because of a probable problem and there's very identifiable patterns that we see on the ECG were able to track up um so um the last part is the are the Purkinje fibers so down from the AV node here out down then we have these Purkinje fibers and they go out to the ventricles the Purkinje fibers are the backup they come in at 20 to 40 intrinsic ring and then they're really just kind of the true backup system somebody sorry I can't pronounce your name Donets tinnitus says they heard stitch and that's right so since usually I put stitch in another room and kind of hide him off to the side but he's a he's here with me today so if he does bark I'm sorry but he kind of has dependency issues so as I talked about the cardiac cells themselves they are automatic and they conduct themselves they're excited they excite themselves as well as they are contractile now that's a bunch of that's basic stuff let's talk about ECGs themselves when we talk about the ECG you got to know the parts I mean if you don't know it's like reading the user manual you have to know the basics before you can really just dive in otherwise you're destined to fail so let's talk about this so we have the P way now one of them's I talked about or the pqrst and when I hear people talk about like I can't remember if you can remember the alphabet you can remember the pqrst so just remember that the P starts first now I know usually peeing is last but in this case we're going to think about the P first so when we talk about the P wave what happens the P wave is the first deflection above this isometric line the isometric line is essentially this imaginary line of wherever the ECG kind of resonates to a base so we have this so this would be on the isometric line before the P wave so that first deflection above the isometric line is the P way and then we've got the Q which is usually the QRS complex which we're going to talk about again in a sec and then the last is the T wave or the T and that's the deflection after the QRS complex and we need to know what each of them do hmm oh my goodness poor gotowebinar just as a complete fail today that's not cool I am actually going to change over something here - we should be seeing the EKGs you see ECG piece of skies maybe on the river side nope okay [Music] you you now I'm going to just change some stuff here [Music] sorry about that [Music] okay let's see then we can um yeah so somebody did write in maybe we could just watch on YouTube yeah you could do that you can also kind of pause and replay on YouTube that's one option but there's so many people in America you let's see here - this on Sony oh boy sorry about the delay for the lots of people watching on YouTube again just a little love loving technical problems oh is actually there's several of you guys on the on YouTube we appreciate it start to the delay but we are going to be I'm just trying to fix something here on the the GoToWebinar software you know YouTube software never messes up unless I push the wrong button I'm just saying let's see fix is just gonna have to just annoying okay one second you you [Music] so many people in your - is crazy okay so we should be working maybe now I hope and you're more than welcome to jump over to YouTube because it doesn't mess up over there so let me just um Marley if you actually paste the link into GoToWebinar and you click send to all it'll that way everyone can see it so um you can jump in over there if it messes up again because I'm not going to fix it again I don't know why I don't why it's breaking it's out of my control it's not something I can control fortunately so sorry about that um I am sorry actually because I just noise me and it just adds an extra five minutes of boring audio nobody likes that he likes to watch me it's like super hot in my house today so anyway so uh as we're talking about the the ECG pieces like I said pqrst you've got to know all the pieces now we've got a wonderful big Manik to help you with this you can go check it out we've got a little Queen and then our rocket our little s for shooting down and then of course arty trophy to help you remember pqrst as well as learning now one of the things you've really got to know is you just got to understand what's going on with each of the pieces of the ECG so the P wave essentially is atrial depolarization what does that mean well that means the atria are depolarizing right well that means they are discharging and essentially that's the electrical contraction of the electrical activity that's causing contraction depolarization and of course it creates a little indentation and then the QRS complex itself so from the start for the Q deviates down the isometric line all the way to where the s returns an isometric line the QRS complex is ventricular depolarization so that's where the ventricles depolarize the electrical activity fires and the ventricles depolarize which essentially should equal contraction now what's interesting about ECGs is that just because there's electrical activity that does not necessarily mean that the actual muscle is doing an ECG is only measuring the electrical activity so of course we have something called pulseless electrical activity right where it looks like there's a heart rhythm but there's actually no heartbeat there's no pulse and that's really important because it's just sporadic electrical activity cause that happens that's measured on electric on an ECG because that's exactly what an ECG does so you can go in and again check out those different pieces here's just an example of the pig monic how we talk about atrial depolarization ventricular depolarization and then repolarization of the ventricles now here's where you really just need to make sure that you understand this concept the ECG paper itself is super important to know how it works and you've got to really understand to be able to calculate the heart rate it's actually really simple so many people get caught up on math with this and they just get so confused and then just I don't you know not sure what to do or I can't really get it all you have to do is essentially then we have to you have to look at the the little tiny boxes and this is a great example here but what the tip and the point is is each box breaks into smaller boxes until you've got to the tiniest little box if you end up with something next one yep I do so on the tiniest little box here right here we got the tiny little box you need to remember that one and that's it you need to remember 0.04 seconds that's what you've got to memorize if you memorize that you can build off of that too all of the times and how the the ECG measures because when you have the printout of ECG paper you may have green paper or blue paper or maybe you have I don't know rainbow paper good for you I'd like to see something but the point is it's usually you know it all looks the same it's all the same grid and inside of here from left to right it measures time in seconds and then measuring the height is essentially measuring we can say maybe the intensity as a generalized term yes I know that's not if you're if you're if you're super nerdy that's 9/10 entirely correct but that's that's enough of a concept to understand what's going on so 0.04 seconds so what happens is yeah that the green paper for sure so the there what happens is the 0.04 the tiniest little boxes everything goes in multiples of 5 here so you gotta remember the multiples of 5 so if you remember that five of the smallest boxes in here going across right here as their evidence right here that equals 0.2 seconds 0.2 seconds so 5 0.04 times 5 is 0.2 seconds so it's 1/5 of a second that's correct so then of course if I have 5 of these sets of the tiniest 5 small boxes then that equals 1 second in duration across so that's essentially 25 of the smallest boxes of point zero 0.04 seconds and when I say that out loud and everybody hears it for the first time they think wow that's that's confusing and I know it sounds like a lot of numbers thrown at once but it's essentially 0.04 seconds of the smallest one now whoever thought of this man they're super smart people because what happens is we need to know what what's so important that we need to know about what what is so important about this 0.2 seconds what's so important about that one why is that such an important number why is it such an important number well that's right the 0.2 seconds is where we measure heart blocks we're measuring that period of time and that measures heart blocks and that's exactly right so with that moving on there the biggest thing you've got to do next is be able to calculate the heart rate the heart rate essentially now I like to use just a simple example and yes I am simplifying this no it's not going to work 100% of the time but it's going to get you so close that you can always get close enough with your answer now when you look at a 6 second strip how do we know it's a 6 second strip well what's really great is see how this is one second right here what's the minimum amount of time we really know need to have to interpret a proper EKG six seconds right so what's really cute is that inside of these at the bottom of every paper there are lines there are lines that jettison down to the bottom and then usually little black lines now there's variations in this yes but the point is that these variations insect in in in these little lines are usually at three second intervals so they're usually three second intervals and then they jump over so there's three and then that's three seconds and then that's three seconds so if I count one two three lines or in between two and skipable online that's a distance of six seconds now what you don't want to do is waste your time and try to count all the tiny little boxes inside here well how can you do that well see these bolded lines all of the ECG paper is bolded inside of you so it's bolded inside of here and it's bolded and then it counts across over the lines so that's five that breaks it up into five and then there's an even bolder darker line for another multiple of five and that's absolutely correct so you can just go over here and then go over to the nether the other multiple of five so that's which is where it works but what we need to get is a six second strip so if you know your ECG you know the basics pqrst then we can identify here look at these blonde these long line so there's a long line here's a long line and here's a long line so that's one then there's to this that's three seconds in between there and then there's three seconds in between year this particular paper actually counts every one second for us with a tiny little line but just remember the longest signs ah the longest line so that's that's three seconds and this is three seconds so we've got a six second strip well how do we get a heart rate speed literally super simple all you have to do is identify the QRS complexes and count those multiply it by ten that's it so let's look at this so here we've got a P a QRS and a tea the pqrst pqrst pqrst and vigorous tea so here's one there's two there's three there's four and there's five so there are five QRS complexes in this six seconds trip so all I have to do is take the five QRS complexes how do I then take know the heart rate I multiply that by ten and that means I've got a heart rate of about fifty here on this example now I say about because I can also there's another way I can measure I can measure the heart rate a lot too you guys have jumped over to the YouTube and yes YouTube is delayed it's delayed a little bit so if you just haven't caught up that's good so you didn't miss anything so we putting I put a delay on YouTube the way we stream it just protect yeah technology city there's no rule against it but it's just I don't know seems like fun so if I look at this six second strip so there I've got one two three four five so I've got about a heart rate of fifty because I multiply that by ten and that's absolutely correct so I can multiply that by five and that's going to give me a heart rate of about fifty so now what if I need an exact heart rate well here's where the the question comes in almost all the time unless you're literally taking an ECG class at this particular time and you're getting lots of ECGs and getting just literally drilled on them the quick method always works it's going to get you close enough almost always you're going to get answers they're going to be far away I'm you're going to see an answer that's forty you know fifteen you're going to see an answer seventy see any answers thirty and see an answer that's you know twenty-six so it's very close which one's the closest is most likely to be your answer but if you need an exact answer what you can do is count the number of boxes or the amount of time between the r2r interval so here's a P Q 2 P Q R this is an R wave so I can count the difference in time between the R's and and and see how much time that is total I could count every little tiny box or I could count the multiples of 5 so there's 3 8 or 8 5 10 15 20 25 30 so there's 33 I multiply 33 pipes times 0.04 which is going to give me one point three two seconds and then I just take 60 and divide it by one point three two and it's going to give me the exact heart rate of 45 all of the ECG monitors and all the heart monitors out there what they do is they actually count from the - are they are able to identify where the R wave is and they calculate the exact difference in real time of the are waves to give you an exact heart rate now one of the things that well I'm going so anyway looks like a couple of people are having that having some interesting troubles there on the still on the gotowebinar thing I can't keep like freezing it I don't know I can't fix it unfortunately I don't know that it's anything maybe out of my control but the one thing is important you can jump over the you tube and then just you just need to link and you can see it there to get it I there was a new update in the software so I I don't know why it's um definitely not working um so but you don't need any kind of login or anything to view the live webinar you just need the link you just go to our page and click there so it looks like most the people have jumped over to there um as well so the link is there you should be able to see it Marlene you can jump on and give you the link and Marley will help you out um so one of the thing the next things is let's try an example of our heart rate speed here so here's our six second ECG what's the heart rate what's the heart rate here what do you think the her it is well what do you got to do well what you have to do is you have to count those and you could count the distance between the art are but that takes too long we need to be fast I mean you only get a minute 20 seconds on these questions when you're taking your boards right so I mean what's what do you need to do when you need to county.the how many our QRS complexes is over 1 2 3 4 5 6 7 8 there's about eight so this heart rate is about eighty and almost all the time literally almost every single time you're going to be able to know exactly what's here and then you're going to be able to see if that's a heart a slow rate or a fast rate we're going to talk about that so I'm not going to go into the too much into the intervals themselves just because running behind enter know if it's because I'm talking so much or because the the gotowebinar mess-ups distracting me but we talked about the p-wave itself there's something called the PR interval and we know the PR interval needs to be less than 0.2 seconds now what does that match to again remember those five tiny blocks the five block of five that's 0.2 seconds so that's five blocks and what happens is that's a delay in conduction speed from the atria going down to the ventricles from the SA node to the AV node it's a delay and when that delay is it's delayed because it's blocked oh my god somebody really so smart to thought of this stuff right because it just makes sense so this is delayed that's called a heart block and there are lots of different types of heart blocks but essentially the number one sign of a heart rate is a heart block sorry is a delayed PR interval which means it's greater than 0.2 seconds now we've got our QRS complex which needs to be less than 0.1 two seconds or 0.1 but I like to use 0.2 just because it's so it's three boxes again and again if you can see more than three block boxes in there that means it's delayed and it's going slow that means the the depolarization process is going slow throughout the brick ventricles that happens often because of conduction problems and other injuries and myocardial infarctions and one-up we've got the the QT interval but QT interval is from the Q to the T so it's essentially it's the essentially the distance from the time that the heart depolarizes to the time the heart repolarizes or the ventricles I mean why is that so important well when we think about that what happens is we can have something called R on T phenomenon and what happens is our on T well the R is on the T and the heart is trying to depolarize and repolarize it exactly the same the right time it is because that time gets stretched out and then it causes this abnormality and that's where we get sudden death that's where you that's why one of the reasons why we have these type of phenomenons are one of the reasons why we have defibrillators in every single school and every single thing now because of this abnormality and then of course it needs to be shocked and a goes back into rhythm that's just you know and then of course it a lots of drugs out there that cause QT prolongation that you need to know about the ST segment is the most common thing of course that's from the s a QRS to the where the T begins to deflect above the isometric line the ST segment and of course that that particular segment is where you can um measure basically a cardiac injury essentially that's where we see that cardiac injury ischemia or death now there's a couple of other important ones and you really got to know these I've just got the most important ones in here I talked about that prolonged QT already but what about au wave where do we see a you wait I didn't even mention what are you yet there's like it's like I'm mom oh goodness what is that guys like let's talk about the letter U hmm what'swhat's the you well the you wave is pqrst and then you essentially it's another wave out here after the T wave it's another one there's another little wave it's not another P wave and I don't want you concern it for that because it's really difficult to be able to identify anyway most commonly you're going to be told about a new wave and then you need to know that it involves potassium and exactly in the in the opposite this tall peaked arm it involves a low potassium so hypokalemia and i just remember that you wave is shaped like a u so it's you know a decreasing decreasing potassium now when we talk about the t way this tall peaks T waves this one you're going to see out very often as well and here's a great example so I got my my P is right here kind of hard to see QRS look at this giant T wave I mean it almost looks like a QRS complex it's bigger than but it's after the QRS and it's a giant T wave it's at all Peaks T wave number one sign of hyperkalemia and the tall peaks T wave and that's really important to make sure that you know um at our peak T way so um just make sure that you know that stuff those are two ones that they're so commonly tested but also if you have a patient it's just fidgeting you know or twitching out of control and they're having problems and they're a renal patient then you find out that you know the tall peaks T wave well that's because you know you're going to see that on an ECG and you're like wow that person may have hyperkalemia look how tall look at t way that's crazy I mean the course then you can treat that but remember that potassium is very very very um cardia it's very effective cardiac system a lot it affects the heart and imbalances are the cars very sensitive to those imbalances that's why we can see it on the ECG and of course it causes arrhythmias all very easy so here's just our potassium pickmonz you can go check that out of your mom so I'm just going to kind of skip I kind of already talked about each one of these but I want to talk about s T the ST segment so as we look at the the the ST segment this segment right in here this between the s T we know that the ST segment essentially can be um can be one what is the ST segment well the ST segment you're thinking your thing about cardiac injury yes that's absolutely right so you think about cardiac injury the answer is yes it's not dumb it can be cardiac ischemia and then cardiac infarction so ischemia just means oxygen starvation so it just means that the you know it's oxygen deprived whereas ischemia actually means cell death so we have cardiac ischemia we may see a depressed ST segment but if we have cardiac ischemia a true you know infarction that's where we see that ST segment elevation and that's absolutely absolutely right so that's where you'll see that and that's just really important to make sure that you know those here's our little STD B ST segment deviations these are important to knowing in them in embarking here's some examples so here we've got under the B here here we see this P QR s but the s doesn't ever go back to the isometric line well that's because we got our s the s is almost gone but today I mean it's you got to understand it's going to be where it comes down and starts deviating back to the new isometric line what it thinks it is and then we got coming over to the T and then back all the way down opposite of that over here under our C example we've got our PQRS and then it comes way down below the isometric line before coming back above to the T wave so somebody asked about will the T wave be obvious Stefanie and how BIG's the T wave going to be in hyperkalemia and the changes it really just depends on the severity of the potassium and balance it could be huge it could be like the example that you see there you're probably going to see other types of symptoms it may not be obvious but what it may not be it may not be a beautiful round it may look like a teepee may not be very big but it looks like a teepee and that's because it's literally rapidly depolarizing straight up and straight down may look very pointed and that's why we call it tall and peaked t-waves um and you can there's you know there are algorithms being check the t way to the QRS complex that's a physiology stuff I'm gonna go into that but what we're going to talk about now now we look at a myocardial infarction the St elevation that you see could be very different and I don't want you to focus on trying to always identify St elevation I see so many people learning ECG in the beginning and they're just so focused on trying to find St elevation that they're not focused on making sure that they're just good at reading EC genes so there's just some example so they can always look differently look how this one looks different from this one this one looks different from this one these are all ST segment elevation so there's no P wave in any of these that's on purpose but QRS t q r s t then we got a q r s t negative q r s t so it's going to look different and it's based on the evidence gives me the evolution of the myocardial infarction itself so all of that lots of basics lots of things to understand I get it if you don't understand all of the basic stuff I recommend making sure you really know that but number one you've really got to know how you can calculate a good rate that's what's super important you've got to be on the calculator rate you got to be able to know how to get the rate correct make sure that that is indeed working and that is that's definitely one of the things you just have to know um so let's actually we're going to go through some rhythms but first thing um when you learn anything I think when you're learning any type of new skill and I I'm not somebody who usually harps on so many basic things but you've got to learn a process it's just like baking a cake doing ECGs it's like doing anything you've got to follow a very certain pattern otherwise you're guaranteed to make mistakes because then you're going to just keep ending up with what do I do now this one looks weird ooh that's not what you really that's what's going to happen if you don't follow the pattern and we got a pattern here for you if learned ECGs in a little bit different order that's probably okay so you don't have to follow my order exactly but it is a set order that it does equal success every single time and then there's the weird crap at the other you know the end world there's a few anomalies that you just have to know and we'll talk about some of those as we go through so one of them as we go through this is what everything we're going to run through today we're going to go through if anything making sure you're a master of the process because that's what's going to make you be able to understand what's going on and just not make any of that what I want to call basic mistakes right the things we like oh my god I can't believe I missed that because that's where so many people with with ECGs they miss those they miss the basic stuff and I if you're saying it's not one of you want you're not that person I'm telling you I worked as a paramedic for a long time and that's one of the big paramedic skills of doing ECGs oh I was so bad I didn't realize how bad I was until I relearned it and always follow the same process now and I think that's really um use my learning example don't just you know don't don't don't do what I do so we're going to talk about first we're going to go through looking at the rate and we're going to run through this each one we're going to look at the rate and we're going to determine the rate that's the most important thing because then you know is it is the heart going to faster is going to slow we're going to look at the rhythm of what's going on we're going to see if it's doing the same thing because if it's regular or if it's irregular then we're going to if it's already they're going to break that down we're going to say is it doing the same thing every time or is it doing a bunch of weird crap after that we're going to look at the p-waves and we're going to say three questions we're going to say is there one before every single QRS are the upright are they consistent upright rounded and consistent then we're going to look at that PR interval making sure that it's less than 0.2 seconds for what hard block yes and then we're going to look at the QRS complex itself we're a little QR someone's and basically all the last one is like is it wide or is it short right is it greater than zero I like to say three boxes just for simplicity sake and you see some variation in the text on on 0.1 second seconds whoo there's a little Freudian flip for you and then 0.12 seconds you're going to see that and then I just always just in my mind think three boxes because I know three tiny boxes of 0.04 seconds a piece times three 0.12 mainly because I'm a math nerd now we're going to look through this and we're going to run through these examples and we're actually going to run through this together so if you didn't catch all this don't freak out I didn't intend for you to I did intend to harp on this giant list because we're literally going to run through this every single one and as we start with the basics a basic regular rhythm we're going to build each one and we're going to go through it and we want to see how we're building through the process because if you can get the easy ones then you can move the harder ones and the harder ones and hard ones yep you'll get it so let's talk about a sinus rhythm okay I'm not going to go I'm not going to read all of this crap to you because I think it's a waste of time you can watch this later you can scribble it down I think I've got the DVR turned on YouTube so you can actually pause it and stop me and I'm still going to be playing on YouTube and you can stop me and make some notes and then you can push play again it's all there it each hour turn on the DVR think it's one of the great things I love on there but what's really important is a sinus rhythm well what is a sinus rhythm mean well a sinus rhythm means it originated hopefully from the sign it sinoatrial node and traveled down through the right path to the AV node and then out sinoatrial node so that means that originated from the sinoatrial node sinus rhythm that's where that comes from sinus doesn't mean your nose sinus it means normal regular expected all those whatever synonyms now when we look at this here's the same pattern you're going to notice this exact same thing rate rhythm P waves PR interval QRS it's going with the same way on every single one of these we look at you don't have to go into the details on each one and when I talk about the leads and all this stuff I don't even worry about that stuff when you're starting out I mean I think you need to know lead placement and that's a separate separate talk I had to cut it out of this because it's just too much stuff um but one of the things so you got the rate rhythm P waves PR interval QRS in a sinus rhythm let's look at the rate first what is the rate let's say this is a six-second rhythm what's the right here someone tell me the rate so somebody can I can't count you should make like a cheat sheet from some point eight so it's about eight actually this is the same rhythm I just showed you a minute ago so now I just realized that so the rate is about eighty right now when I say the rate when I talk about fast and slow what's a normal heart rate you got to know that one 60 to 100 beats in an adult 60 to 100 is it faster than 100 or lower than 60 no it's normal that means it's a normal rate rate regular now rhythm here's where it gets a little tricky rhythm you've got to be able to say is this doing the same thing over and over and over and over and over and over and over yes or no how do we do that now the first time I'm going to explain it to you with the perfect one and then when we get into the harder ones you're going to have to you're going to have to we're going to do some some finger motion I like to use my thumb so when we look at the rhythm the way you tell if the rhythm is regular what you actually have to do is you have to check between you have to look at the our two our interval so here's the are there's an arm there's an honor there's an arm there's an arm usually you get the point right and then you have to say are they regular now I like to use the thumb method here this is my my people thumb I have the most beautiful thumbs that anybody has ever had these are the best thumbs and I know thumbs okay so I like to just literally every time whether it's on a ECG monitor whether it's on anything I literally just thumb it and I take my thumb and I really just put my thumb right up there and I angle it to where it's about right and I just eyeball it and I'm like yep it's almost the same distance all the way across there's no wide variations thanks duck but 3 3 8 5 great name by the way thanks for the thumb the thumb compliment few guys on gotowebinar duck but 3 3 8 5 just gave me a compliment about my mom so what you need to do is see if it's regular as it isn't the same distance what you're looking for is you want to see if one scrunched together or ones farther apart that would be maybe not regular and we're going to talk about that but you don't just have to look at the yardarms to truly say that it's regular you have to look at the p2 peas too so you got to look at the p2 peas so you're going to be able to identify so there's the P so PQRS tea right so there's my pee and there's my other P P P P P P and I'm doing this one slowly on purpose because you're going to have to be able to do this and it gets harder of course it gets harder that's the whole point that's why this is a difficult subject but what what the important thing here is is that you've got to be able to understand the basics so this is the normal rhythm I'm telling you it's normal when we look at harder ones then you're going to have to be able to figure it out somebody asked is there is there a handout you can always um you can always check this out on YouTube you can I do have a PDF of some sample rhythms for you to try and I'll post it in the link of the video afterwards or I'll send it out in the email it's just a rough set of rhythms and you can just try them on your own and then it has the answers but as far as a handout you just kinda have to watch the YouTube but um getting back to our regular look at our piece so I take my beautiful thumb again the best thumb in the world I mean I know thumbs this is there's no thumb but better than this one ah magical thumbs then I take it and I put it down there and I'm looking at the distance again so I'm looking at the distance and of course when I look all the way across they're very close now when I say close I mean we put if it's if it's one one box away two boxes away perfectly normal we're not trying to micro scrutinize this this is a rough thing and then it's you know it's supposed to be because what is one thing that will create a variation in a heart rate in a normal healthy individual and you got to know about this for real life on the test they're not going to give it to you but actually I think I have a slide on so I don't maybe I shouldn't talk about it but one of the things that changes your heart rate is breathing if I bet take a big deep breath what happens if I hold that big deep breath in or I took a big giant big deep breath I've increased the pressure in my heart or in my intro intra thoracic cavity caused pressure increased pressure my heart then can't fill as easily so my heart rate needs to speed up a little bit and that's called an original sign is arrhythmia it's a little beat this is going to be a little bit off place that's perfectly normal if you're seeing it slowly speed up just a little bit over a couple of beats perfectly normal I think I have an example you're late look at now looking at the rest of it the rest of it is super easy for this I look at the p-waves and I say are the upright normal is there one before every single key RS yes yes yes yes yes yes yes there is then I look at the PR interval all the way across beautiful I mean there's no way I've got five boxes in between them not a chance then I look at the QRS there's not a chance literally just even glancing at it is there more than three boxes in between that QRS not a chance I don't even need to look at all of them and tell you all the way across absolutely not so when you kind of condition yourself you quickly get the basics and we're still basic stuff then when we start doing these faster we're going to faster and faster and faster and faster investors right that's the idea so let's look at this one tell me what the rate is this is a six second strip you have just a few seconds what's the rate the rate is about 50 right the rate is approximately 50 approximately now 50 is that between 60 to 100 now is it fast or slow it's slow it's a slow rate it's approximately 50 it's a braided cardiac rhythm now is the rhythm regular oh I get a little bit bigger thumbs for this one look all the way my heart ours yes I look at my p2p s P - P - P P P all the way across beautiful very consistent is there 1p way P Q R st p q r st p q r s t p q st p q st yes beautiful um so if i look at that and then i look at this rhythm when I look at the P wave how do I know that this is a sinus rhythm I'd forgot to mention this on the last one I know that this is a snap a sinus rhythm because there's a P wave there it's there before every QRS that means it's and it's positive it's upright it's upright and is one before every QRS that P wave right there that little nugget that P wave tells me that that originated from the sinoatrial node meaning it's a sinus bradycardia so it's originating from the sinus the sinoatrial node is one before every QRS that means it probably caused it right yes and that means then that a sinus bradycardia so that means originated from the sinoatrial mouth wastage sorry my stitchers here is about to to have a moment I think I know one in the bargain so the so that's how I know that that's a sinus bradycardia so Jack for you just important to make sure you know and maybe you're answering something because there's a little bit of a delay but what's important to think about when you when you say bradycardia make sure you're always saying sinus bradycardia because if it's not sinus bradycardia then you know that it may be that's where we get into something called junctional rhythms junctional because of the ABE AV Junction that means it didn't originate from the SA node if there's no P wave that means it's junctional that's just a side note we'll talk about that in here in second so let's look at this one someone tell me the rate 13 13 right 13 130 the rates about 130 beautiful now let's look at the rhythm you got to have really tiny thumbs for this one and I don't have tiny thumbs I have big beautiful thumbs but if you have tiny thumbs wow I couldn't imagine if your honor if you're on a mobile device and you really try and use your thumbs but if you look there it's regular the art are all the way across is beautiful the p2p now I know it's hard to see those P ways but they're there look there right there P P and as the rhythms get faster it's harder to see the P waves yes it's absolutely right it's like it's like having the toddler just stitch it he's like Charlie um so that's absolutely right and it's regular and the art are also regular so are are all the way across now there's a P wave is the one before every QRS yes is it up right yes that means this is a fast rate right because 130 is above 100 that's right we did Matt and that's it means it's a tachycardic rhythm so you say tachycardia first then when you look at and you say you say regular yes then we say P waves there's one before every QRS that means it's sinus tachycardia so then we've added tachycardia now we say it's sinus regarding and that's how we know exactly what it is PR interval of course on us on a fast rate it's really hard to see a true hard block so we're going to look here there's no way there's any of those are greater than 0.2 seconds so from here to here no there's literally one one or two boxes in between there right and that's how we know it's sinus tachycardia QRS just glancing at those you know there's no chance that there's three boxes in between there right no there's not that means it's QRS is perfectly fine so um not a problem at all so this is a sinus tachycardia all the way across beautiful now let's talk about some tacky dysrhythmias rhythms that basically lots of different rhythms that are too fast now these are some of the ones that people have trouble with because sinus tachycardia itself is a toughy and I'm surprised somebody didn't didn't point this out but sinus tachycardia itself is is difficult and the point is um you know it only in this example it says 101 to 180 beats now that doesn't mean after 180 it's not sinus tachycardia but we have other names for it that's right so let's talk about these um these two fast rhythm come into scoot back stitch is sitting on the lab piece um so first off first of all I want to talk about so we're talking about things that are too fast we're going to talk about tacky dysrhythmias so we talked about tacky dysrhythmias we can talk about ones that are too fast like supraventricular tachycardia we're talking about tactic Aria right so what is supraventricular tachycardia mean well that means that the heart the the electrical activity I can't even talk to bouncing the electrical activity arises above our ventricles that means the electrical activity rises above the ventricles and is a supraventricular so what happens is it causes a tachycardia there's a couple different kinds I'm not going to talk about each one of them but essentially what happens most commonly is either over excitation of the SA node from things like caffeine um and you know nicotine stress lots of different things but the big one you know caffeine is a huge trigger for what we call a super ventricular tachycardia or SVT and of course you know whenever we look at treating rhythms and treating any type of rhythm itself what we need to know is is the patient's symptomatic I mean any time we have a ECG abnormality so even sinus bradycardia we make we don't have to treat sinus bradycardia unless it's symptomatic because we know athletes which I'm not an athlete category they have big strong hearts so their heart speeds slower they're normally bradycardic and of course would be normally slow down stitching an exonym they're going to be normally slow and then of course um you don't have treat them you don't just start giving atropine to everyone because they have a slow heart rate because it made me normal so we treat symptomatic patients sing with SVT so let's look at a couple of these a couple it there's also a way we'll be happy before I forget mult reentry SVT so it's essentially can be caused by other accessory pathways that basically here's a good example right here in this one so atrial tachycardia which we have a slide on and then them just react citation of that AV node causing causing you over a stimulation so I love this term paroxysmal paroxysmal supraventricular tachycardia wow what a fun work right say that ten times fast paroxysmal supraventricular tachycardia or PS VT or SVT PS v t means paroxysmal that means that it's uh that means it's transient right just like my thought right at the moment it's transient it was there and then I lost it um Nicole on on youtube thinks I'm stiches drunk he may he may be drunk I don't know so paroxysmal means that it comes on and it goes away so how do we check this and look at this rhythm most of you on the rhythms if you're not really comfortable with ECGs you're going to look at this when you're like I have no idea what's going on but anytime you're looking at a rhythm if you get one that you just really can't tell and you're able to get a longer portion of a rhythm a bigger bigger section that's great that's what you should do because what you want to do is see what was happening like things are chugging along great so look at this rhythm here this rhythm checking out and great if I literally if you took your hand and you covered up if you covered up this section of your you know from here back and you looked at just this rhythm and imagine you did that same thing for six seconds everything's great I mean it's a great rhythm so you know that that's normal but what happens is when we look at the the you know the steps what's the rate here so Jack's an overachiever and apparently already counted 15 across here so I'm just going to believe you so that rate right now and during this six seconds was about 150 beats a minute and that's okay that's way too fast but is that is it regular is what's going on here regular is what's happening here regular well I'm gonna get my beautiful thumbs and I put them up there and I look I'm like wow I got a big space so right here well there we go there's my red pointer I got a big space I get another space the same then it gets smaller smaller but then it's just literally just tiny star hey come on oh yeah stitch stitch is definitely seven a day is not not having the best days he's not happy so then I have a tiny space tiny space-time space-time spaced any space tiny space right across here that's and that's absolutely right so it gets but it's regular in the middle but it's too fast if you just took this section and you multiply it times two then you've got a way really fast rate right but then what happens well then somewhere right along this space it gets normal again and as normal it looks just like the same as it did before so it was doing something normal it did some craziness in the middle and then it just got back normal again we see this again when we're going to talk about a ventricular rate but what happens is it was doing great then it got to just it got drunk here in the middle and then you're gonna did crazy it's gonna regret and then it went back to I wasn't talking about you stitch that was one of the YouTube people monkey um and then it goes back to being normal again but that's the point there's just this madness in the middle and that's what we call paroxysm um sorry Francis sometimes sometimes stitch goes a little crazy I don't know why I think he has Tourette's I mean it's gonna be honest I I can always tell when he's about to do it that's why I pulled him up here because he's just like looking around like he's just about ready to yell um sorry okay so um as we look here that's why we call it paroxysmal it's normal it comes and then it goes away so before I talk about that what somebody already mentioned once but when we talk about SVT it's really important to know that SVT pair oxwas paroxysmal SVT anything that's randomly coming and going is usually a sign for something that's going to come and stay and be very problematic this is the same when you think about T IAS transient ischemic attacks T IAS they come and they go and they come and go and you're all fine until you get the big one right and then it doesn't go away it's the same with PSV T if you're somebody who is drinking caffeine like me and you're you know doing crazy stuff like me and what happens is then you have an SVT luckily I don't have P SVT but then you end up you know you have bouts of P SVT what happens is eventually you go into SVT and your body's not able to convert anytime we go to irregular rhythm to a normal rhythm we call that conversion your body's not able to convert back to a regular normal sinus rate so she's giving me like the corner look right now um what the point is um it what happens is that eventually you're in sustained SVT and those patients you can't stay in SVT for very long some patients can and yes they have runs of SVT and they're in SVT for a long time and they you know then they have to be treated but what's the drug we need to give for SVT this is really high yield you got to know this drug what's the drug somebody said earlier I think that's right so you've got to give identity um you've got to give adenosine for sustained SVT adenosine interrupts the channels in the heart and essentially stops the ability for the heart to contract electrically temporarily and then what happens is it basically just restarts it's the funnest drug to give ever if you're going to do it I recommend getting to see it because you just see a patient at least usually for a second on your flatline it's the only medication really that you need to give as rapidly as possible because adenosine only has a half-life of just seconds so it comes it's there and it's gone just like my sex life anyway it's more than that joke I had today so another one I want to talk about I talked about what happens how do we know that things are sinus right how do we know things are sinus well we know there's sinus because we've got those beautiful wonderful P waves right there right there before every QRS and what do we call something when there's no P wave we call that a junctional rhythm Anna junctional rhythm happens whenever we have a rhythm that doesn't have a P wave that's original Ridge knitting from below the SA node usually in the AV node or the aim atrial ventricular junction so if I look at this rhythm what's the rate down here so let's follow the same pattern let's not skip ahead one to twelve I got 12 my hope is gone so um so I've got 12 here so at rate of 12 so that's 120 so 120 or so I mean that's estimated yes but it's fast that's the point so tachycardia so then when we look at the rhythm I'm just going to tell you right now if you didn't already look it's beautiful its regular all the way across the our tarzana p2p well the art are is it great right so the art are is regular and then you look at the next one you look down and you say the P waves is there a P wave there before every QRS hmm no there's no P wait what's this there's no P that's not the peanuts that's over here so we're when we're looking at pqrst people than just some madness down here right it's not um it's actually the p-wave is actually occurring that's this is actually the p-wave dunya but when you when you look at these so many people get confused they get hung up right you get hung up and you get confused like well which one's the P what you should be able to do is identify the QRS right if you identify the QRS then you know that the the P should be right before it and the T should be after right so you just have to kind of um sometimes it requires a little bit of guesswork but you just end up getting the hang of it of just understanding that you've got well there should be a P wave right here causing this maybe you would say that little notches no so there's the QRS and then remember coming back above the isometric line T here's our T wave so this this is just a pqrst this is actually a hidden P wave down here in at the same time of the s that's really bad so then we got a pqrst but there's no P waves there's no P before the QRS that's all you got to know before the QRS is there P is an upright and it's visible no so then if it's not there then that means it's a junctional rhythm the rhythms originated from the AV AV node so that's a pqrst that's how we know PR interval there is no PR interval so it doesn't matter you don't have to you don't have to calculate that because you can't do it qrs usually is always fine but you still do it the widened QRS there's only one box between all bones which means it's 0.04 seconds beautiful now here just said this again just because I like to harp on it junctional rhythms you know just think about that that junctional rhythm means it happens at the junction or below the junction that's what's important that's why we call sinus rhythms sinus now let's talk about some fun fun arrhythmias here these are fun when we talk about the irregularities the weird ones these are ones that are hard these are ones that are so hard to really get down because their jaw they never appear the same one you're going to get a rhythm and it's going to look different but you just follow the process and you'll get it so let's look at atrial flutter human what's the rate what is the rate about eight right the ventricular rate is about 80 ventricular rate because the QRS is the ventricular rate well can you just said all you have to do is count the QRS complexes to get the rate yeah I did but now we're making it harder that's the whole point so you know that the P waves themselves the P waves are essentially atrial depolarization which should ideally electric the electrical activity is connected to the muscle tissue and working in harmony every time a P wave happens that's atrial depolarization so then we can tell we can count P waves to count the amount of atrial depolarization or the atrial rate so what's the atrial rate here well you could just literally count all the way across again and then multiply by 30 right but the what you want to do is you want to see how many cute how many there are to each QRS complex how many it's called we we call it the how many there are to each one so it's like a 1 3 2 1 a 2 2 1 a 4 2 1 so there are these little weird waves what are these these are really weird when you see all these look almost like shark teeth like a shark tooth or a saw like if you ever use a saw in from West Virginia so I've seen lots of saws so the important thing here is um the knowing that these rate right it looks like a saw - they're called flutter waves now you can there isn't there isn't much in with ECGs that you can just memorize but every time you see one QRS complex in this little group of all the way across in beautiful harmony those are almost always sawtooth waves they're called flutter waves and when you see those these are essentially not P waves but what happens is these are atrial depolarization and you can see how many there are - each QRS complex 1 - 2 3 so this is about none is actually whether 3 or 4 to each QRS so you can see that that atrial rates much faster than the ventricular rate so when you look at the rhythm is this rhythm regular irregular well if it's regular that means there's one P before every QRS the art are ours and the P two peas are a one to one ratio and it's correct so it's an irregular rate and this is where it gets confusing is it doing the same thing over and over is it regularly irregular or is it doing literally there's no pattern whatsoever well if I folded this into an origami set and like you know took it and cut it and laid them all over top of each other it's doing the same thing over and over and over people would be very cautious to call this regular well it's irregular but it's regularly irregular it's doing the same thing wrong over and over and over again so that's regularly regular that's right it's always weird for me when I see I'm so used to layer GoToWebinar stuff and other things in it it has like a name on there and whatever it has whatever you type in and then YouTube it shows up who whatever the weird name is when you sign up so it just it's funny for me us with some people's names duck but so anyway um you can see that this is irregularly irregular p-waves well you can't really tell that there but those are those characteristic sawtooth waves flutter waves so that's why we call this Adriel flutter and of course this can be very fast I mean you can have wait-wait crazy rates what's wrong with all of these atrial arrhythmias the atrial arrhythmias have problems because what happens is if the when you know when when the bentrik the ventricles or the atria relax what happens when that happens well they fill with blood if the atria contract and contract even dragna contracting contracting contract really fast they never slow down to catch a breath and fill with blood to be able to pump blood into the ventricles so happens is they just go in in a fast rate right and I can't do this at the at the right speed and correlation but the point is the atria never stopped contracting at this fast rate so the ventricles are naval never able to actually the atrium ever able to fill completely blood so then they can't pump enough blood to the to the to the ventricles and then of course you have decreased cardiac output which then is further exacerbates the problem here's a couple of examples of flutter waves and this is important because this is one that I feel like you can try to identify very easy but the waves always kind of look like this sawtooth pattern these are not pointy waves like the last one but they are very characteristically they're Lily flutter waves they're all the way across the board here is a two-to-one ratio so there's two to one here's a three and then four to one so four to one ratio so four to one ratio so you can kind of see the difference there and how the cardiac output is different and how it how you'd have problems with cardiac output if you had four to one versus two to one and that's absolutely right because you would have a lot decreased blood flow now the most high-yield one that you absolutely have got to be able to identify and I feel like it's the one curveball that comes out of nowhere that so many people have trouble with is is atrial fibrillation so how do we identify atrial fibrillation how do we identify atrial fibrillation how do we how do I identify atrial fib well let's look at the right follow the exact same process don't skip ahead so how many there's a QRS right here by the way right behind this little atrial heart alarm clock who is freaking out for fibrillation so how many how many what's the speed here 1 2 3 5 6 7 8 9 9 right sorry so there's nine so the the ventricular rates about ninety now okay let's just go with that for now what's the rhythm what's the rhythm will get your beautiful thumbs out and take a look well it's wide its wide then it's short then it's wider than its shorter than its wide then it's really sure if it's wider than its really wide it's not doing the same thing there's no distance between any of these is the same well why would that distance be changing well what causes the QRS complex to fire the QRS the QRS complex but the QRS complex fires because of an atrial impulse right the firing from the SA node goes down to the AV Junction then BAM causes the QRS complex to fire the atrial depolarization so is this regular or irregular well it's irregular right so if it's irregular then is it irregularly regular irregularly irregular or irregularly irregular well there's no discernable pattern there's no discernible pattern whatsoever and if you tried to go ahead and try to find the P to P you can you can't find the P to P because where are the P waves well here's where you you have the difference between what we would call junctional rhythm and fibrillation fibrillation the Aprilia tory waves are just imagined quivering rank equivalent quivering quivering fire quivering quivering craving fire would revive over fire it's like it's really just like being being electrocuted I guess you know or tased at just a random interval because you're like freaking out and then you just fire fire but it's no pattern to it whatsoever and that's exactly what fibula Tory waves are so where's the P wave well um let's just start right here so that that might be a P wave no qrst no P wave QRS t there's a P wave right there right and QRS see nothing curiousity curious - QRS - nothing there's no P waves there's no discernible P wait and you can tell it it it's getting regular all over the place and how we can tell that this is irregularly irregular and every time you get an irregularly irregular rhythm and you have QRS complexes that are changing distance over time it's very likely that it's atrial fibrillation unless you don't have a decent if you have wide QRS complexes that's obviously a much more serious problem but that's where you should always have on the tip of your tongue atrial fibrillation because you're always going to get this thrown at you because it's so common as people age and they end up with them atrial you know atrial atrial fib what's a big problem with that we worry about because the atria are just quivering and the ventricles are contracting and the atria quivering and contract and then randomly and they're not working in unison that means again the blood flow from the atria are not going to the ventricles and the ventricles aren't able to filled and it's not going out to the rest of the body that's absolutely right so what what do we do for this well there's lots of things we can do for atrial fibrillation but you've got to worry about the long term problems because you can develop blood clots in the right atrium in the atrium and those can travel out to the body and cause strokes and other problems and that's really the big worry with with afib so they're probably going to be put on coagulation therapy and of course we can cardiovert those patients as well we can give medications to help slow their heart rate down calcium channel blockers like diltiazem or cortisone that's great so here's a good example just a little a weird one that sometimes I didn't want to mention this because I hear it all the time um atria thr fibrillation with rbr you've probably heard that I remember when I heard that the first time I didn't know what the heck I didn't I didn't know what the heck that was it means as a rapid ventricular response that means essentially the atria were misfiring and fibrillating what happened was at some point those a the ventricle ventricles um got a rapid ventricular response and started beating in a super fast rate so it's a very high ventricular tachycardia that's very irregular and this is very difficult to determine the difference between rapid atrial fib with rbr versus super ventricular tachycardia it's very difficult to distinguish and that's why you need to get a 12-lead to be able to get the difference um and that's definitely I'm definitely a thing um - yeah so we'll move on so let's talk about the cardiac arrest algorithms here just just so we can go over these before we finish up so monomorphic v-tach now first off there's Monte morphic and monomorphic rather and polymorphic mono means one morphic means changes so one change then tricular tachycardia so it's going to look like the same every time so first off what's the rate here well I can tell you that these are giant QRS complexes and this is pretend you see something like this if you see something like a you know big giant Y is probably a could be a PVC or it's a giant QRS complex how many other 18 I mean I counted real quick so there's about 18 of those QRS complexes across there so maybe there's 79 so there's 18 the point is very fast it's a very fast rate very fast way too fast for the six second strip and that means about 180 beats a minute now what's the rhythm what's the rhythm looking across all of those Peaks there it's pretty regular it's pretty regular but is it regularly is it is it a regular rhythm or is it your regularly irregular well it's a regular because there's no P what p2p and r2 are in synchrony because you can't see a p2p but what there is is it's doing the same thing the whole time literally looks the same all the way across and that makes it's doing the same thing over and over so it's irregularly regular or regularly Eirik how have you even put it I always say those them and I swap swap the words so it means the same so anyway look at P Wix there's none here there's no P waves there's no there's no we P waves present you can't see anything you see nothing but giant ventricular contractions because these giant QRS is the PR interval of course then means it's absent and the QRS here is giant so where is the QRS are there more than three boxes in between all of this yes there's five six seven boxes of QRS in between you so 7 times 4 is 28 so point you eight seconds of a of a QRS complex it's very wide tachycardia why tachycardias are often ventricular tachycardia is usually what it means what do I do with this rhythm what's the treatment here give them a hug right let's give my hug so the first thing you want to do is always if you see a rhythm like this check the patient check the patient what do you need to check the patient for you need to check their pulse because you can have ventricular tachycardia and be talking walking just fine now you can't do that for very long but you can't do it and that's what's that's what's really important it doesn't work forever but you can do it and that's it that's right um you know you can see that definitely the important thing is that it it's you got a check for that pulse because if they don't have it you the ACLS algorithms with this one this is just a trick question that always pops up it's a big paramedic nursing medical school all of them what's the first thing you do check the patient one because it's easy to you know look like it's they have v-tach if the patient is moving if they're on the monitor number two pulseless v-tach is treated differently versus v-tach without a pulse if you don't have a policy you need CPR and defibrillation if you have v-tach with a pulse you have to be cardio burn so you need to be electrically cardioverted synchrony using a synchronous cardioversion meaning just works good timing so I hope you know the difference of those so I just got those three different some differences here of what the things you need to do differently I'm not going to go over in big detail because I am running way behind so for polymorphic v-tach is just different now this is where you have traces the point and I'm sure I butchered that French name but is the point in Prasad's is that we call it polymorphic v-tach well what is polymorphic mean that means it's changing it's multiple changes in ventricular tachycardia but let's not skip the process what's the rate super fast to the end right what's the rhythm well it's irregular and it's irregularly irregular now what was the other irregularly irregular rhythm that we had atrial fibrillation right well this one else who is irregularly irregular polymorphic v-tach now polymorphic v-tach look for those P waves no P waves is it junctional no just v-tach I mean technically is type of junctional but it's it's it's v-tach ventricular tachycardia PR interval is gone but reason it's v-tach as we look at that QRS interval and it's why every single one of these ugly QRS complexes are really wide I mean if you can put your whole thumb in there if you had tiny thumbs thank goodness out tiny thumbs all the way across here you can see you can see the big giant big giant wide QRS complexes so you can see that's greater than 0.1 two seconds or 0.10 either way three boxes big what do we worry about this well polymorphic v-tach is often torsades to point ism can be caused by several different things it be caused by um there's a conduction defect that can cause torsades there's our on T phenomenon can cause torsades but what's important to know about this is that it amides immediate defibrillation right these patients are in big trouble now you could have a bout of this a short paroxysmal bout but remember what we know about anything that's paroxysmal you need to be worried about it so these patients usually have an impending cardiac arrest or is it well this is cardiac arrest but um you know that usually it doesn't go well after this so we need to make sure we're worried about these what's the medication we give people with this what's the medication hmm there was only a medication that relaxed muscles oh yeah I don't know just can't think of it right these patients are often going to be given magnesium right you know get end up getting magnesium to them to calm the muscles down especially because they're very irritated just like any time things something's fibrillated it's just twitching all over the place twitch which which are accumulating fibula Tory waves now I already got this Arrington all the slides in the skin well maybe I mean yeah I did sorry now the next one I want talk about some ventricular fibrillation so ventricular fibrillation this is something I just want you to really not just guess every time you just see a squiggly line you just guess we fit please don't do that because it's pretty easy to be able to tell um let's look at the right here what's the rate I can't tell the rate Kendyl that's absolutely right great answer what's the rhythm it's a bunch of chaotic mess I can't tell absolutely right good answer where are the P waves look what am i a magician I don't see any P waves what's the PR interval this is not funny and that's right you there's no nothing is discernible but what's important here is is that there is nothing to certify at all ever there's no discernible pattern now when I look back if I go backwards and look differently a polymorphic v-tach look at these giant beautiful waves I mean these are look these are beautiful giant v-tach waves v-tach waves always look like this well not always they can be a little shorter I mean and I think they get upset when they're the shorter ones they're a usually look like these these waves right here these short ones these little short fat ones or these big beautiful tones and that's not a discrimination joke against short fat people I was right I'm short in fact anyway the point is I'm going to get so many hate comments for this so I guess it's a good thing it's my last topic monic webinars day huh yes the point is there's no discernable pattern whatsoever it's literally just just you know quivering all over the place it's not doing any kind of if I was to isolate this and throw it into a normal rhythm it's nothing that would look like anything of a QRS complex right it's not really anything that I can tell and that's absolutely what is important now as you go through this and you look at this is like well what's the difference since with this innate them well this is not a atrial fibrillation because atrial fibrillation is usually very very short very fine waves whereas ventricular fibrillation is a lot of larger waves look at the isometric line it's literally goes all the way when I can't move my cursor on the way across but it's literally if a beautiful line all the way across middle and there's literally deflections above and below then atrial fibrillation is just going to be little tiny deflections above because those are P waves which go above the isometric line this is going above and below but not in giant beautiful waves and it's very chaotic there's no pattern that's ventricular fibrillation now there's a difference one of the things of we we do call this sometimes course v-fib which is what I just showed you and then there is something technically called fine ventricular fibrillation which is literally just a whole bunch of nothing all the way across here you may see people sometimes you know treat this like an eight assist alehrer them or whatnot or try to call asystole fine v-fib and shock it I think that's a debatable thing and you know this is fine v-fib debatably um and that's just where it's because it's not as tall now the last one asystole a means without in medical terminology one of the biggest things you need to learn in medicine is making sure you know medical term so you can get all of this stuff correct a means without systole means systole so they're contraction without without contraction cardiac standstill so what happens well there's nothing the end we're done right there's the what's the rate there's no rate now there may be P waves there that's what's really important you can happen systole and you could still have some P waves in here maybe there's just one little blip of a P way and that's one of the biggest things I struggled with when I when I first became a paramedic was really being able to say okay well what's the dealy or you know being able to you know there's still electrical activity we should do something well it's still asystole unfortunately because there's still electrical firing maybe happening in the atria which could cause um you know atrial depolarization but heart may not actually be responding so there's nothing absolutely dependable there's no nothing going on and that is asystole and that's really all you have to know about I think it's the easiest one to know because it's just nothing right here's a good example of our P wave assist alee so there's still an electrical activity firing at the SA node but there's nothing going on elsewise it's all done went to sleep and it's just on p-wave and there is nothing else and that's what you need to know one really important one and don't you miss this trick is pulseless electrical activity peña right look at this rhythm what's the rhythm here this is beautiful what's this person's pulse rate pulse rates zero but the heart rate the electrical heart rate is measured and it's probably 120 I know it's beautiful it's a good nice beautiful rate but the thing of it is is you may have electrical activity in the cardiac monitor but the patient may actually not have a pulse that's where you always need to make sure you have that rule of check your patient treat your patient not the maunder because this one could get you in trouble I don't see beautiful peña that often maybe more than once in my entire life that's like at a rate of like 50 that I thought was sustainable for life but that was just because there were so many drugs given that the electrical activity I felt like had to at least be going on but unfortunately the heart muscle just wasn't as fun so here's our same review of going over what you need to know follow this same process just do it what's the rate is it slow is it regular or is it fast is it and what's the rhythm doing is it doing the same thing over and over or is it just doing a bunch of crap all over the place what's the p-waves one before every QRS is the most important and then of course each one they need to be upright and consistent they need to look the same all the way across what's that PR interval less than 0.2 seconds super important to make sure that PR interval is less than 0.2 seconds and then looking at the QRS last which is depending on what book you look at it's zero point one zero two zero point one two seconds or less or three small block boxes if you see n things that are wide curious those usually ventricular rhythm ventricular arrhythmias and that's just what you know and as I think Jack mentioned earlier we give after after any kind of arrhythmia contributor with Mia after the fact we usually give lidocaine that's right so guys that's all we have in here for our webinar today I'm glad you could join us I'm so sorry for the problems that we had with our if you are under GoToWebinar side get a jumped on youtube so you can join us duck butt three three eight five I am NOT going over the heart box today and I am sorry but I can't tell you I do make lots of videos myself you can follow us on YouTube at picnic video you can look on YouTube for my channel if you want and follow me myself because I make I've been making lots of videos myself and will be making some one heart blocks just because I have a lot of really bad corny jokes for that and I think it would be a lot of fun but I am this is actually my last webinar with pic Manik aside from any kind of guest appearances that I'll be doing in the future because I am going off to residency so you'll have to find me otherwise so I'm sorry about that but maybe I'll be in as a guest maybe in the future I don't know I can't guarantee anything but what I do know is this definitely my last one if you have any questions specifically you want to check out pick Manik I absolutely recommend it and love peg Manik you should check it out go to pick app came and talk checkout pick Manik for free on the website pick Manik calm you can also email if you have any questions you can go to go in there and actually email them feedback feedback a pic Manik video as well you can follow me on Twitter at big Manik Kindle and then you can also sign up and you can just messages straight from our site in the back background we've got Marley who is our who is our master nursing scholar who also has been answering lots of your guys's questions on YouTube as well as GoToWebinar and taking care of a lot of the details I don't see any big questions aside from just asking about more more content and where we're going to be but definitely I'm appreciate you joining in with us stitch is always with me and I'm not sure what we're going to do for the hospital stuff the mystic is just me being moody now now he's not in the mood for doing anything but we're going to be going to oh we're actually moving back to West Virginia from Phoenix so you'll find us at I'm actually going to be at Charleston Area Medical Center doing residency there for internal medicine so it'd be lots of fun still be doing lots of teaching and lots of nursing education which is one of my passions definitely definitely lots of fun I hope you learned something today guys I know is a little slow to get started I went literally 20 minutes longer than I expected and that was not on purpose so thanks for sticking around lots of people here like I said you can follow pic Manik on YouTube at big Manik video recommend it you should check out pic Manik for free if you haven't because you're hurting yourself if you haven't checked it out and then if you wanted to follow me on youtube you can follow myself just go on there just search Kendall Wyatt on YouTube you'll find my channel it's right there I think it's Kendall Wyatt nd maybe as this V is the link but I honestly don't even know it's um I should probably I should probably for them but anyway thanks for joining in and for everyone and especially hats off to all of my favorite webinar listeners like Junie and my new favorite duck but 3385 oh god I don't see too many other questions but other than that guys we appreciate it and as always good luck to study

Channel: PicmonicVideo

Views: 38,994

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Id: 5p_1kirq_S4

Length: 97min 0sec (5820 seconds)

Published: Thu May 04 2017