ECG/EKG Review

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 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 tech monic as far as scheduled maybe in the future who knows that I'm going off to residency myself and going back to where I'm from in West Virginia and be doing what the 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 tech monic stuff but we'll be working on lots of other things so I started out as a paramedic and then went to nursing school then went to med school and I loved 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 rhythm and then you're just going to need to practice now if you've not heard of tech monic before what we do at canonic is we take all the things you need to know and we take all of the the things in medicine and we turn that into characters Wow my voice crack there must be go into puberty again even the last time is late I guess the second time past 30 it should happen so something like bipolar should be will turn it into a bi polar bear and if you need to learn about maybe war for any drug you're going to be able to learn about a wharf area inside of Kimani you can try it out for free if you like you guys are already subscribers we appreciate that you can check it out there's tons of different topics and well over a hundred nine hundred topics for nursing coming everything you need to know pharmacology to see those 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 degrees I understand now what we're going to go over today we're going to go were just a really quick hit on some basic anatomy so 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 is super important and understand the concept of it and i know all the instructors out there they say concept concept concept but in reality you know that's really really difficult to kind of grasp well what is the concept we're going to go over concepts of this stuff today 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 version will be on peconics youtube it's live on there right now you can check that out on youtube at pick monic video just type in Peconic video or search Pig Manik and YouTube that's going to pop up look at our channels even to this one so what's going it started this webinar usually usually runs about an hour it usually takes me a solid hour to get into 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 hits literally every high yield point that you need to know all of the basics so really you need to know everything in this one it's not really much that I say in this webinar that's like yeah you can kind of just brush over that not really much here because we've already stripped all that out we've taken really about 12 hours of what you would learn in ACLs and convinced 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 easy jeans now the one of the things it's important to understand this is just one of our Pig Manik images throughout the entire webinar today we've got laughing Pig Manik images from our system and it's not just a bunch of random images you can go learn them all in there and check it out but this is the coronary artery now one thing is really important as you're learning coronary arteries isn't really knowing this is the left coronary artery in the right corner and they really branch off the main - on the main bifurcation now a bifurcation is worth something split seventy-five bifurcate bindings - so it splits and it bifurcates it creates into two a left and right 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 leading edges when you go into actually if you're working you need to do this nice thing lesson advancing you can really go in and learn and understand a lot of those basics of where the pathologies happening with 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 where they don't have it at the tip of their tongue is learning the blood flow to the heart it's so important now I'm not going to go through and drilled basic rote memory tactics into getting you to memorize it but what you just you just have to understand this is yeah you know we go from capillaries and de females and veins then into those vena cava into the right atrium now the righty turn on the right side the heart salty oxygen flow through that tricuspid valve into the right ventricles and then of course into the pulmonary artery and the lungs 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 know no and 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 vendor gets oxygen 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 the largest arc it's going to pump out the entire diagon body right I'm going to huge so it's got a huge and it really has to really ask to come 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 artery gets blocked and that's that left the left corner area and we know that that's a big problem because we're essentially cutting off all of the blood slides in 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 fail 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 look 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 they have a 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 you've got these little filter kidneys here they got my orange copiers de with me 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 to this at the top of the heart so electric wretchedly comes from up here and it comes down from right there 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 card 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 let's talk about 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 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 it fires from that right atrium the SA node comes down to the right atrium down into me the AV Junction AV node is often called for the atrial ventricular Junction now the AV node is a second spot it gets electricity so it comes to the SA node to the AV node and it comes all the way down and then essentially fires throughout the rest of the heart well if the SA has failed just one thing 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 I'll be as sad properties of the heart is that they're they're automatic they can conduct themselves and if I'm energized and I'm going to cardiac cell my buddy over here in his guard xl5 electrified and shock him he's going to fire right beside me so it conducts all the way throughout the 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 when you see inverted inversions up like 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 variable if you track us so the last part is the part of Purkinje fibers so down from the AV node here out down then we have these Purkinje fibers and they go out as a ventricle the Purkinje fibers are the back up they come in at 22:40 intrinsic rate and then they're really just kind of the true backup system somebody sorry I can't pronounce your name synapse and it says one that they heard stitch and that's right so usually I put stitch in another room and kind of item 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 the issues so as I talked about the cardiac cells themselves they're automatic and they conduct themselves or excitedly excite themselves as well as they are contractile now that's a bunch of that's a bunch of basic stuff let's talk about ECG themselves when we talk about the ECG you got to know the parts I mean if you don't know like reading the user name 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 weight now one of them's I talked about or the pqrst and when I hear people talk about it I can remember if you can remember the alphabet you can remember the PQRS C so just remember that the P starts first now I know usually peeing a black but in this case we're going to think about the pain 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 place so we have this so this would be on the isometric line before the femur so that first deflection of filed the isometric line is the P wave 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 now we've got a wonderful big monic 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 our T trophy help your members 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 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 there start for the qbb h down to the isometric line all the way to where the s returns of the isometric line the QRS complex is ventricular depolarization so that's where the ventricle depolarize the electrical activity fires and the ventricle depolarized which essentially should equal contractions now what's interesting about ECG 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 paula source 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 causes that happens it's measured on electrical 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 Peconic 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 they're just I don't know I'm 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 end the little tiny boxes and this is a great example here but what the tintin the point is is each box breaks into smaller boxes until you've got to the tiniest little box and dresses on the next one yes I do so on the tiniest little box here right here we've 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 to 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 them but the point is if 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 nine ten two entirely correct but that's what that's enough of a concept to understand what's going on so 0.04 seconds so what happens is yeah the green paper for sure so the there what happens is the 0.04 the tiniest little boxes everything goes in multiples of five here so you got amended multiples of five so if you remember that five of the smallest boxes and you're going across right here as their evidence right here that equals 0.2 seconds 0.2 seconds so five 0.04 times five is 0.2 seconds so it's 1/5 of a second that's correct so then of course if I have five of these sets of the tiniest five small boxes then that equals one second in direction across so that's essentially 25 of the smallest boxes of point zero zero point zero four 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 zero point zero four 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 zero point two seconds what's so important about that one why is that such an important number why is it such an important number well you guys write the zero point two 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 you can always get close enough with your answer now when you look at a six second strip how do we know it's a six second strip well what's really great is see how this is one second right here what's the minimum amount of time you know we need to have to interpret a proper EKG six 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 the 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 skippable in line 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 folded inside of here so it's bolded inside of here and it's Bolden and then it counts across over the lines so that's five that's breaks it up into five and there's an even bolder darker line four and 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 the long line so there's a long line here's a long line and here's a long line so that's one and then there's to this that's three seconds in between there and then there's three seconds engineer this particular paper actually counts every one second for us with a tiny little line but just remember the longest signs the longest line so that 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 teeth the pqrst pqrst pqrst and be thrifty 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 second strip so all I have to do is take the five QRS complexes how do I then take 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 the harming a lot of you guys have jumped over to the YouTube and yes YouTube is delay its delayed a little bit so if you just haven't caught up that's good so you didn't miss anything so we put I did put a delay on YouTube the way we stream it just for Texas you know technology six there's no rule against it but it's just I don't know musical 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 it's going to give me a heart rate of about fifty so now what if I need an exact harmony well here's where the the question comes in almost all of the time unless you're literally taking an ECG class at this particular time and you're getting lots of DSG's 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 going to see an answer 70s and 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 to exactly what you can do is count the number of boxes or the amount of time between our two our interval so here's of PQ subpoena Q R this is an R wave so I can count the difference in time between the R's and and see how much time that is total I could count every little tiny box so I could count the multiples of five so there's three eight is only five ten fifteen twenty twenty-five thirty so there's thirty three I multiply 33 five times 0.04 which is going to give me one point three two seconds and then I just take sixty and divide it by 1 point 3 2 is 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 R to R they are able to identify where the R wave is and they calculate the exact difference in real time of the are waves to do an exact heart rate now one of things is well a minute so anyway looks like a couple of people are having that having some interest in iam all 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 to the YouTube and then just give me the link and you can see it there to get it I there was a new update of the software so I I don't know why it's him gently not working um so but you don't need any kind of login or anything to view the live webinar you just need a link you just go to our page and click there so it looks like most of people are jumped over to there as well so the link is there you should be able to see it Marlene can jump on and give you the link and Marley will help you out so one of the things in extinct is let's try an example of our heart rate screen here so here's our six seconds of ECG what's the heart rate what's the heart rate here what do you think of her it is well what you got to do well what you have to do is you have to count those and you could count the distance between yard our but that takes too long we need to be fast and you only get a minute 20 seconds on these questions when you're taking your words right so I mean what what do you need to do when you need to count the how many our QRS complexes are one two seven eight 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 me too much into the intervals themselves just because running behind I don't know if it's because I'm talking so much urge because the the gotowebinar mess-ups distracting me but um 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 you again remember those five tiny blocks the five block of five that's 0.2 seconds - that's five blocks and what happens is that the delay in conduction speed from the atria going down to the ventricles from the SA node to the AV node is a delay and women delay this delay because it's blocked oh my god somebody was so smart it's out of this stuff right but it just makes sense so this is delay that's called a heart lock 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 greater than 0.2 seconds now we've got our QRS complex which needs to be less than 0.1 2 seconds or 0.1 but I like to use 0.2 just because it's so it's 3 boxes again and again you can see more than three blocks boxes in there that means it's delayed and it's going slow time you see the depolarization process is going slow throughout the brick vegetables that happens often because of conduction problems and other injuries and myocardial infarctions and when up we've got the the QT interval the QT interval is from the Q to the T so it's essentially it be essentially the distance from the time that the heart depolarizes to the time the heart repolarize to the ventricle honey 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 while they are 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 it causes this abnormality and that's where we get sudden death that's when 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 it 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 FT segment is the most common thing of course that's from the s QRS to the where the team begins to deflect above the isometric line the ST segment and of course septum that particular segment is where you can measure basically cardiac injury essentially that's what we see that cardiac injury ischemia or death now there's a couple of other important ones and you really gotta know these I've just got the most important ones in here I talked about that for long QT already but what about a new way where do we see a you wave I didn't even mention letter U yet it's like it's like I'm mom oh goodness what is it guys like let's talk about the letter U let's look the you well the you wave is pqrst and then you essentially is another wave out here after the T wave another one there's another little ways 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 involved happens and exactly in the opposite this tall peaked it involves a location so hypokalemia and I do remember that you way the shaped like a year so it's you know decreasing decreasing potassium now when we talk about the t way there's tall peaks T with this one you're going to see off very often as well and here's a great example so I got my my P is right here kind of hard to sing QRS now your there's giant T wave I mean 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 of toll Peaks t way number one sign of hyperkalemia and the toll peach tea ways and that's really important to make sure that you know a tall peak T way so just make sure you know that stuff those are two ones that they're so commonly tested but also if you have a patient that's just fidgeting you know or twitching out of control and they're having problems and you're a renal patient then you find out that you know the tall peach tea way well that's because you know you're going to see that on Eugene you're like wow that person may have hyperkalemia look how tall with it t way that's crazy I mean of course then you can treat that but remember that calcium is a very very very cardiac cerium affects the cardiac system a lot it's the effects of heart and imbalances are the cards very sensitive for those imbalances that's why we can see it on the ECG and of course it causes arrhythmias all very easy so here just our potassium big - you can go check that out a month 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 ST segment this segment right in here this between the s T we know that the ST segment essentially can be can be 1 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 our cardiac injury answers 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 they 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 reflection 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 s tmdb st segment deviation these are important to knowing in them in barchan here's some examples so here we've got under the B here here we see this PQRS what 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 it's there means you get 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-wayne so if somebody asked about them will the t way be obvious Stephanie and how BIG's the T way going to be in hyperkalemia and the changes it really just depends on the severity of the potassium imbalance we could be huge it could be like the example that you see there we're probably going to see other types of symptoms it may not be obvious but what it may not be is it may not be a beautiful round it may look like DP may not be very big but it looks like a TV and that's because it's literally rapidly depolarizing straight up and straight down they look very pointed and that's why we call it tall and peaked T wit and you can there's you know there are algorithms email check the t way to the QRS complex that's the physiology stuff I'm gonna go into that but what we're going to talk about now now when 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 into genes so there's just some example so they can always look differently well 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 q r s t QRS G then we got a q r s t you get a q r s t so it's going to look different and it's based on the m excuse me the evolution of the myocardial infarction itself so all of that lots of basics lots of things to understand I get it you don't understand all of the basic stuff I recommend making sure you really know that but number one you've clearly got to know how you can calculate a good rate that's what's super important you got to go to the calculator lake you got to be able to know how to get the rate correct and make sure that that is indeed working and that is that's definitely one of the things you just have to know so let's actually we're going to go through some rhythms but first thing when you learn anything I think when you're learning any type of new skill and I I'm not somebody usually harps on so many basic things but you've got to learn a process it's just like baking a cake doing easy Jesus 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 for you if you learn you see G's 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 a 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 the 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 this 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 there's so many people with ECGs they missed those they missed the basic stuff and if you're saying it's not what 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 is 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 and I think that's really am use my learning example don't just you know don't don't build what I do so we're going to talk about first we're going to go through looking at the weight 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 the heart going to bastards going as well 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 if it's regular ordered irregular then we're going to fit directly they're going to break that down we're going to say is it doing the same thing every time or is it do 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 on 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 going to are so much and basically all the last one is like is it wide or is it short right is it greater than here I like to say three boxes just for simplicity sake and you see some variation in the text on on 0.1 second second whew let's look for 18-foot for you and then 0.12 seconds but you're going to see that and then I get really just in my mind think three boxes I know 390 boxes of 0.04 seconds apiece times 3 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 really 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 the hard ones yep you'll get so let's talk about a sinus rhythm okay I'm not going to 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 DDR turned on YouTube so you can actually pause it and stop me and I'm just still going to be playing on YouTube and you can stop me and make some notes and then you can push play against all there I'm pretty sure I turn on the DVR things one of great things are level 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 sinus sinoatrial node and traveled down through the right path to the AV node and then out sinoatrial node running that originated from the sinoatrial node of 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 you look at this here's the same pattern you're going to notice this exact same thing rate rhythm p-waves peer in a volt purist it's going 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 December talk I had to cut it out of this because there's just too much stuff but one of the things so you got the right rhythm p-waves PR interval QRS and it's 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 it it should make like a chain to eight so it's about eight actually this is the same rhythm I just showed you a minute ago yeah I just realized one so the rate is about 80 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 first time I'm going to explain it to you with the perfect one and then when we get into the harder one you're going to have to you're going to have to fit where it's to do some something you're 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 if I look at the r2r interval so here's the are there's not there's an element there's an honest there's not usually you get the point right and then you have to say are they regular now I might use the thumb method here this is my beautiful them 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 an ECG monitor whether it's on anything I literally just summit 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 variation thanks duck but 3 3 8 5 great name by the way thanks for that some-some compliment can you guys on gotowebinar duck bust me 385 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 one farther apart that would be maybe not regular and we're going to talk about that well you don't just have to look at the yard ours to truly say that it's regular you have to look at the p2 p2 you got to look at the p2p so you're going to be able to identify so there's the P so p q r s t right so there's my p and there's my other p c c to pee 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 their hand out you can always 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 to mine round and then it has the answers but as far as I hand out 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 some in the world I mean I know some this is there's no comic better than this one magical thumbs then I take it and I put it down there and I'm looking at the disc 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 the indicate 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 ring in a normal healthy individual 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 sliders so I don't maybe I shouldn't talk about but one of the things that changes your heart rate is breathing if I sit 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 interest into a thoracic cavity I caused pressure increased pressure my heart then can't fail as easily so my heart rate need to speed up a little bit and that's called an original sinus arrhythmia it's a little beat this is going to be a little bit off place it's perfectly normal if you're seeing it slowly speed up just a little bit over a couple of beats perfectly normal you're like okay now looking at the rest of it the rest of it is super easy I look at the p-waves and I say or the upright normal is a one before every single key RS yes yes yes yes yes yes yes there is then I was 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 QRF there's not a chance literally just even glancing at it is there more than three boxes in between that Kira's 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 then it's 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 yeah 50 right the rate is approximately 50 approximately now 50 is that between 60 to 100 now is it faster slump it's slow just low rate it's approximately 50 it's a braided kartik rhythm now is the rhythm regular oh I get a little bit bigger thumbs for this look all the way my arse yes I look at my P 2 P P 2 P 2 P VP all the way across beautiful very consistent is there 1 P wave P Q R st p for SGP or seen people are c concourses yes beautiful 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 just forgot to mention this on the last one I know that this is it's not a sinus rhythm because there's a p-wave there it's there before every QRS that means it's positive it's upright it's upright and is one before we can write 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 there's one before every QRS that means it's probably called it right yes and that means then that that's a sinus bradycardia so that means originated from sine h now research sorry my stitchers here is about to say I have a moment I think I know one in the bark 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 maybe you're answering something because there's a little bit of it away 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 made me that's what we get into something called junctional rhythms junctional because of the aid AV Junction that means it didn't originate from the SA node if there's no P wave that means it's junctional actually the side note we'll talk about that in here in second so I put a BIST once someone tell me the rate 13 13 right 13 130 their 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 you really turn into them 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 they're right here PN T and as we're going to get faster it's harder to see the P wave yes that's it right like it's like having the top of the stitches feels like Xiaomi 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 way there's a 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 math and that's what means it's attack cardiac rhythm so you say tachycardia first then when you look and you say you say regular yes when we say P waves there's one before every QRS that means it's sinus tachycardia so then we've added times already now we say it's sinus tachycardia 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 zero points using so from here to here to know 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 if there's three boxes in between there right no there's not that means it's QRS is perfectly fine so 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 reasons that are too fast now these are some 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 them sinus tachycardia itself is is difficult and the point is you know it going in this example it says 101 to 180 beats now that doesn't mean after 100 maybe it's not sinus tachycardia but we have other names for it that's right so let's talk about these them these two facets images screw back stitches sitting on the lap 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 tachy this review so we talked about tachy dysrhythmias we can talk about ones that are too bad like supraventricular tachycardia we're talking about tachycardia right so what is supraventricular tachycardia means well that means that the the heart the the electrical activity I came and talked to Nelson the electrical activity arises above ventricles that means the electrical activity rises above the ventricles and is a super ventricular so what happens is it causing the cat tachycardia needs 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 and you know nicotine stress lots of different things into 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 in treating any type of rhythm itself what we need to know is is the patient's symptomatic I mean any time we have a ACG abnormality so even sinus bradycardia we may you 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 heart so their heart speak slower they're normally bradycardia and of course will be normally slowed down to the next to them they're going to be normally slow and then of course you want to treat them you don't just start giving atropine to everyone because they have a slow heart rate does it make me normal so we treat symptomatic patients sing with SVT so let's look at a couple leaves a couple it is also a way we'll be happy before ever again mult reentry SVT so it 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 yeah over a stimulation so I love this term paroxysmal paroxysmal supraventricular tachycardia Wow what if I work right say that ten times fast there are small super ventricular tachycardia or PSP T or SVT PSB t means paroxysmal that means that it's 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 Nicole on on youtube thinks about stitches drunk he made he made me drunk guiding them so paroxysmal means that it comes on and it goes away so how do we check this and look at his rhythm most of you owner if you're not really comfortable with EG geez you've got a little bit 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 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 check around great if I literally if you took your hand and you covered up if you covered up this section you're you know from here back and you look at just those 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's just normal but what happens is when we look look at the the you know the steps what's the rate so Jack's an overachiever and apparently already counted 15 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 okay that's way too fast well is it is it regular is what's going on here regular is what's happening here regular well I'm going to get my beautiful thumbs and I put them up there and I look I'm like wow I got a big space right here well there's my red pointer I got a big space I get another space the same then it gets smaller smaller the miniatures Lily just turns out hey oh yeah stitch the stitch is everywhere we've got in a day and not not having the best day he's not happy so then I have a tiny place tinyface tinyface tinyface tinyface tinyface right across here that's in 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 away really fast rate right but then what happens well then somewhere right along this space it gets normal again there's no it looks just like it's the same as it did before so we're doing something normal it did some craziness in the middle and then it just got back normal again we see this again but we're going to talk about a particular rate what happens is it was doing great then it got to just got drunk here in the middle and then again big crazy stuff it's going to regress and then it went back I wasn't talking about usage that was one of them you to seasonally 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 scientist sometimes sometimes stitch goes a little crazy I don't know why I think he has Tourette's I mean it's going to be honest I I can always tell what he's about to do it that's why I pulled him up here can we just like looking around like he's just about ready to yell sorry okay so as we look here this is why we call it characters noise normal it comes and then it goes away so before I talk about that what somebody already mentioned it once but when we talk about SVT very important to know that SVG paradoxes paroxysmal SPG 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 is transient ischemic attacks T is they come and they go and they come and go and you're all fine so you get the big one right and then it doesn't go away it does favorite PSU G if you're somebody who is drinking caffeine like me and you're you know doing crazy stuff like me and what happens is Ben you you have an SVT luckily I don't have PSP team but then you end up you know you have bouts of PSP t what happens is eventually you go into SPG and your body's not able to convert any time we go to irregular rhythm to normal with me call that conversion your body's not able to convert back to a regular normal sinus rate since you're going to be like the corner look like what the point is it what happens is then 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 X we team their NFC team 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 leaders said earlier I think that's right so you've got to give identity 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 restart it's the funnest drug to give ever if you're going to do it I recommend getting a theater you just see a patient at least usually for a second on the flatline it's the only medication really that you need to give as rapidly as possible because it didn't seem only as a half-life of just seconds so it comes it's there it's gone just like my subscribe anyway for that joke I have 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 our sign well we know their sign is 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 way 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 rigidity from below yes a knows usually in the AV node of the atrioventricular Junction so if I look at his rhythm what's the rate down here so let's follow the same pattern let's not skip ahead 1 2 12 I got 12 my other school so so I've got 12 here so at rate of 12 so that's 120 so 120 or so I mean that's escalate yes but it's fast that's the point 2 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 away across the our Tarzana P 2 P oh well the art ARS are great right so the art ARS regular and then you look at the next one you look down and you say the P wait is there a P wave there before every QRS no there's no P wait what's this there's no P that's not the peanut that's over here so we're when we're looking at pqrst people are seeing them just a madness down here right it's not um it's actually the P wave is actually occurring that's what this is actually the P wave done but when you when you look at these so many people get confused I 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 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 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 PQ RC but there's no P waves there's no P before the QRS that's all you got to know before the QRS therapy is an upright and is 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 QRF usually is always fine but you still do it the widened QRS there's only one box between albums which means 0.04 seconds now here just said this again just because I like to are abundant junctional rhythms you know just think about that that junctional rhythm needs to happen 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 they're chose they never appear the same way 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 here what's the rate what is the rate about eight right the ventricular rate is about a 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 guess 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 you 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 is 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 the little weird ways what are these these are really here well you see only look almost like sharp teeth like a shark tooth or a saw like if you ever use a saw in West Virginia so I've seen lots of saws so the important thing here is the knowing that these great right and looks like a salty they're called waterways now you there isn't there's as much in the VCG is that you can just memorize but every time you see one QRS complex and this little book all the way across in beautiful harmony those are almost always salted ways 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 two each QRS complex 1 2 3 sirs but about none is actually whether 3 or 4 to each QRS you can see that that atrial rates much faster than the ventricular rate so when you look at the rhythm is this freedom regular irregular well if it's regular that means there's 1 P before every QRS the art are ours and the p2p are a 1 to 1 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 I couldn't cut it and write 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 here for me when I see I'm so used to layer GoToWebinar stuff and other things and it has like a name on there and whatever it has whatever you type in and then YouTube it shows that whatever the weird name is when you sign up so it's funny for me so it's on people's names Dec but so anyway you can see that this is irregularly irregular p-waves well you can't really tell if it there but those are those characteristics all twos waves flutter waves that's why we call this atrial flutter and of course this can be very fast and you can have wait-wait crazy rate 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 they've been tricked the ventricles or the atria relax what happens when that happens while they fill with blood if the atria contract and contracting the dragony contracting which I think attracts really fast they never slow down to catch a breath and fill with blood to be able to pump blood into the ventricles so what happens is they just go in in a fast rate right I can't I can't do this at the right speed and correlation but the point is the H we had never stopped contracting at this fast rate so the ventricles are enabled and never able to actually the atrium ever able to fill completely blood so they can't pump enough blood to the to the to the ventricles and then of course you have decreased cardiac output which then yours 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 pointing waves like the last one but they are very characteristically regularly flutter waves there all the way across the board here is a two to one ratio so there's two the one here's a three and four to one so four to one ratio so four to one ratio you can kind of see the difference there and how the cardiac output is different and how it how you'd have problem 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 ask we 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 a token well let's look at the right follow the exact same process don't skip ahead so how many there's a QRS right about there right behind this little atrial heart alarm clock he was freaking out for fibrillation so how many how many what's the speed is one five six seven six nine nine right sorry there's nine so there the ventricular rates about 90 now okay let's just go with that for now what's the rhythm what's the rhythm look at your beautiful thumbs out and take a look what's wide it's wide and it's short that it's wider than its shorter than its wide then it's really sure if it's wider then it's really why it's not doing the same thing there's nothing 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 that firing from the SA node goes down the AV Junction and 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 your regularly regular regularly irregular or irregularly irregular well there's no discernible pattern there's no discernible pattern whatsoever and if you tried to go ahead and try to find the p2p you can you can't find a p2p because where are the teammates well here's where you you have the difference between what we've called junctional rhythm and fibrillation fibrillation simply Latorre waves are just imagined quivering right equipment quivering quickly fire quivering quivering waving fire would require a quiver fire it's like it's really just like being being electrocuted I guess you know it pays that just a random interval because you're like freaking out and you just fire fire but it's no pattern to it whatsoever and that's exactly what fibula tori ways are so where's the p-wave well um let's just start right here so that's that might be if you had no qrst no P wave QRS T there's a P wave right there right and keira see nothing QT Kira's tooth you're see nice there's no P waves there's no discernible P waves and you can tell it it it's getting regular all over the place that's 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 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 some atrial you know atrial atrial fib what's the big problem or that we worry about because the atria are just quivering and the ventricles are contracting and it's a tree 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 are 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 of the body and cause strokes and other problems and that's really the big worry with with afib so they probably going to put on coagulation therapy and of course we can cardiovert those patients as well we can give them medications to help slow their heart rates down calcium channel blockers like gum still chiasm or carded them this way 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 atria atria fibrillation was far beyond we probably heard that I remember when I heard that first time I didn't know what the heck I didn't I didn't know what that guy was it means there's a rapid ventricular response that means essentially the atria were misfiring and fibrillating what happened was at some point there's a the ventricles ventricles 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 very difficult to distinguish and that's why you need to get a 12-lead to be able to get the difference and that's definitely am definitely a thing to do yeah so we'll move on let's talk about the cardiac arrest algorithms here just just so we can go over the knees before we finish up so monomorphic v-tach now first off there's monomorphic and monomorphic rather and polymorphic mono means one more bit means changes so one change ventricular tachycardia so it's going to look like the same every time so first off what's the rate well I can tell you that these are giant QRS complexes remember then you see something like this if you see something like a you know big giant wise probably a could be a PVC or it's a giant to rest 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 very fast rate very fast way too fast with a 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 what is it regularly is it a regular rhythm or is it your regularly irregular well it's a regular because there's no P with P to P and R 2 are in synchrony because you can't see a P - P but what there is is it's doing the same thing the whole time Lily 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 having input I always say those them and I swap swap the words so it means the same so anyway look at P wicks 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 of the giant QRS is the PR interval of course then means axon and the QRS here is giant so where is the Q X are there more than three boxes in between all of this yes there's five six seven boxes of QRS in between here so seven times four is 20 so 0.28 seconds of a of a QRS complex is very wide tachycardia why tachycardia are often ventricular tachycardia is usually what it means what do I do it this rhythm what's the treatment you give them a hug great let's get my hug so the first thing you want to do is always if you see a rhythm like this check the patient's check the patient's what do you need to check the patient's ball 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 that's what's really important it doesn't work forever but you can do it and that's it that's right you know you can see that definitely the important thing is that it is it's you've got a check for that pulse because if they don't have a 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 a happy jacket the patient is moving if they're under maunder number two Poliquin v-tach is treated differently versus v-tach without a pulse you don't have a pulse you need CPR and defibrillation if you have v-tach where the pulse you have to be cardio work so you need to be electrically cardioverted synchronizing a synchronous cardioversion meaning just work you're coming 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 and not going to go over and big detail because I am breast way behind so for polymorphic v-tach is just different now this is where you have Prasad's the point and I'm sure I butchered that French name but um the point in the Prasad's is in the Colin 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 at 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 me tag ventricular tachycardia PR interval is gone but we even attack and 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 stem in there if you have tiny film and get it down turn them all the way across here you can see you can see the big giant some big giant wide QRS complexes so you can see that's greater than 0.1 two second story 0.10 either way three boxes big what are we worried about this well polymorphic v-tach is often torsades to point to them can be caused by several different things because by is 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 needs 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 whether it 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 mean there was only a medication that relaxed muscles oh yeah I don't know I can't think of it right these patients are often going to be given magnesium right here you end up getting magnesium to them to calm the muscle stem especially because they're very irritated just like anything something's fibrillated it's just twitching all over the place which which which is accumulating fibula tori ways now where you got this or even skip oh maybe he I did sorry now the next one I will talk about some ventricular fibrillation so then tricular fibrillation this is something I just want you to really not just guess every time you just see a squiggly line you just get me fit please don't do that because it's pretty easy to be able to tell let's look at the rate here what's the rate I can't tell the rate in well 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-wave look what am i a magician I don't see any period what's up irritable this is not funny that's right there's no nothing is discernable but what's important here is is that there is nothing to certify at all ever there's no discernable pattern now when I look back if I go backwards and look differently a polymorphic v-tach look at these giant beautiful ways these are look either 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 there's a shorter one there is bigger they look like these these waves right here these short ones these little short that one or these big beautiful Tolan and that's not a discrimination joke against short fat people of I'm short and fat 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 webinar space the point is there's no discernible pattern whatsoever it's literally just just you know quivering all over the place it's not doing any kind of if I were 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 is this in a sense well this is not a atrial fibrillation because atrial fibrillation is usually very very short very fine with whereas ventricular fibrillation is a lot of larger ones look at the isometric line literally goes all the way like move my cursor on the gospel it is a beautiful line on the way across the middle and there's literally deflections above and below the atrial fibrillation is this 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 been tricular fibrillation now there's a difference one of the things up we we do call this sometimes course of the afib which will be forward to show 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 is just deliver 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 and that's just where it's because it's not at all 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 terms so you can get all of this stuff correct a means without Cicilline systole so the contraction without without contraction cardiac standstill so what happens well there's nothing the end well 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 have basically and you could still have some P waves in here maybe there's one little blip of a P wave and there's one of the biggest things I struggled with when I when I first began as paramedic was really being able to say okay well what's the deal here you know being able to you know there's still electrical activity we should do something well still asystole unfortunately because there's still electrical firing that may be happening in the atria which could cause you know atrial depolarization but the heart may not actually be responding so there's nothing actually dependable there's no nothing going on and that is a fiscally and that's really all you have to know about it I think it's the easiest one to know because it's just nothing right here's our a good example of our P way basically so there's still an electrical activity firing at the SA node but there's nothing elsewise it's all done went to sleep and it's just gone P wave and there's nothing else and that's what needs it now one really important one and don't you miss this trick is Paul source of electrical activity peña right relive is rhythm what's the revenue this beautiful what this person's pulse rate pulse rates zero but the heart rate the electrical heart rate is measured and it's probably what in time is money enter 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 can 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 were just wasn't as fun so your very same review of going over what you need to know follow this same process to do it what's the rate is as well is it regular or is it fast is it and what what's the rhythm doing is it doing the same thing over and over or didn't just do it 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 and you 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 for less for three small blocks boxes your cm things that are wide QRS is so here we've been trickier rhythm ventricular arrhythmia and that's just what you know and that is I think Jack mentioned earlier we give up after after any kind of arrhythmia particular arrhythmia after the fact we usually give lidocaine and 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 on our go-to webinar side we'll get in terms of mutant so you can join us duck buck 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 axe o'clock video you can look on YouTube for my channel if you want and follow me myself because I make 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 efficacy a lot of fun but I am this is actually my last webinar with Beck Manik aside from any kind of guest appearances that I'll be giving in the future because I am going off to residency so you'll have to find me otherwise so 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 it's definitely my last one if you have any questions specifically you want to check out pick monic i absolutely recommend it and love peg Manik you should check it out go to app Canyon talk checkout pick Manik for free on the website if Manik calm you can also email if you have any questions you can go to go in there and actually email them feedback feedback at the clonic video as well you can follow me on twitter aspect Manik Kindle and then you can also sign up and you can just messages straight from our site in the back deep 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 but other than that guys we appreciate it and as always good luck studying

Channel: PicmonicVideo

Views: 129,030

Rating: 4.8173518 out of 5

Keywords: rn, nclex, picmonic, nursing, nursing school, nursing student, nclex questions, nclex style questions, answer nclex questions, nclex-rn, nclex-lpn, nclex review, nclex review questions, nursing pharmacology, pharmacology, ecg, ekg, electrocardiogram, arrhythmia, dysrhythmia, heart, blood flow, blood flow through the heart, bradycardia, tachycardia

Id: mDWYA0zE6PM

Length: 85min 3sec (5103 seconds)

Published: Mon May 22 2017