EKG like a BOSS Part 3 - Abnormal Heart Rhythms

now as we go through these abnormal rhythms what I want you to pay close attention to is not the full criteria but what's abnormal okay so the two easiest ones we can go through are the ones that only have one thing wrong that's sinus bradycardia and sinus tachycardia so when we look at sinus bradycardia sinus bradycardia is exactly the same as normal sinus rhythm except it's slow so you're gonna have a rate less than sixty beats per minute in this case fifty it's too slow that's the only thing that's different your regular you've got a normal sized QRS you've got a normal size PR interval and you've also got a one to one ratio on your PD QRS so everything's normal except it's too slow so if you find that you know you've got sinus bradycardia sinus tachycardia the other end it's exactly the same as normal sinus rhythm except it's too fast so you've got a regular rhythm you've got a rate over 100 beats per minute you've got a one-to-one p2 QRS ratio you've got a narrow normal QRS complex and a normal PR interval the only thing different is it's too fast now with sinus bradycardia and sinus tachycardia typically we just want to treat the cause figure out what's wrong with the patient what caused their heart rate to be too slow or too fast and if we can treat that it typically resolves on its own now if the patient's unstable we might actually do some different interventions but for the most part we're just going to treat the cause now we know that in the heart the signal is supposed to originate in the SA node go to the AV node and spread throughout the ventricles but what happens when you get random signals from other places in the atria it starts to kind of take over that electrical signal from the SA node right so that's when you get what we call atrial dysrhythmias with an atrial dysrhythmia which part of the EKG waiver you're gonna start to see problems with the P way right the P wave represents your atrial depolarization so if the atria are doing crazy things you're gonna have problems with your P way everything else should look normal the other thing is if we have other parts of the atria that are firing randomly and not in sync with the SA node are we going to have a Euler rhythm probably not right so the biggest signs of atrial dysrhythmias are going to be irregularity and p-wave problems so you have two major atrial different dysrhythmias atrial fibrillation and atrial flutter so let's talk about how they're different in atrial fibrillation the atria have multiple places that are just firing and doing random things on their own so the atria are just quivering you're not really getting any kind of coordinated electrical signal at all so you're going to see no consistent P waves instead you're gonna see a wavy baseline you're going to see evidence that the atria are just kind of doing whatever and they're completely uncoordinated so using the five step method regularity like I said this tends to be irregular it's very rare to have a true atrial fibrillation that's regular because there's no coordination going on so we have an irregular rhythm as far as rate most of the time it's normal now you could have this problem where the AV node over reacts to all of these electrical stimuli and you get what's called rapid ventricular response in which case you might see a faster rate so it's just really important to know what's going on with your patient could be normal could be fast third step p2 QRS ratio do we have P waves we really don't do we so can we check our p2 QRS ratio not really basically we don't have good P waves we've got a wavy baseline that's a problem now our QRS complex is most often normal it's gonna be narrow unless there's something else going on but in pure afib normal QRS PR interval we don't have P waves we can't check it okay so again our big things that are abnormal in atrial fibrillation is you have an irregular rhythm and you have a wavy baseline with no coordinated P waves okay so when we check for atrial flutter and when we compare the two here's the difference instead of having multiple sites all over the atria they're just making the atria quiver you have one or two sites that are actually stimulating contractions in the atria and they're stimulating that much faster than what the SA node would luckily our AV node is our gatekeeper to our ventricles and it's kind of protecting the ventricles from overreacting to every single signal from atria so what you're going to see the atria alone contracting at a very very high rate 120 150 sometimes even 2 to 300 beats per minute so you're gonna see not one P way for every QRS but multiple P waves P wave puf puf QRS P wave P wave P wave P wave QRS right so what the classic sign of atrial flutter is is what we call a sawtooth baseline it looks jagged like a saw so if we use our five steps regularity it's usually irregular it is possible to have a consistent three to one and end up with a regular rhythm but for the most part it's usually irregular you might have three P's and a QRS and then five peas in a QRS so usually it's irregular rate again usually normal but if we do start to see that AV node overreact to those signals we're gonna get what's called rapid ventricular response or RDR so it could also be fast p2 QRS ratio we actually have more peace than qrs's we've got lots and lots and lots of P waves on our baseline our QRS complex usually normal because there's nothing wrong with the ventricles in pure a flutter and then our PR interval you can't really measure because it's not consistent it's not coordinated we can't really measure it so the big things that are classic for a flutter is an irregular rhythm and a sawtooth baseline now you'll notice on this strip that the top and bottom lead look quite different from each other and the bottom lead it's way easier to tell that you have a sawtooth baseline right so if you're ever unsure what rhythm you're looking at check a different lead or ask for a 12 lead and that will help clarify okay so let's talk about SVT or supraventricular tachycardia what the heck does that mean supra means above right so this is tachycardia that originates above the ventricles in other words in the SA node or the atria now the big classic sign of super ventricular tachycardia versus just a sinus tachycardia is that it's extremely fast and what happens is it's so fast that the electrical activity of repolarization covers the electrical activity of the atrial depolarization in other words the P wave gets hidden in the previous T wave so you're not actually gonna be able to see specific P waves you're only going to see one large wave after every QRS that's the classic sign of SVT now by definition a lot of people will say it's a 150 or higher but I've seen an SVT in the 130s or 140 s so don't get caught up on the rate specifically but make sure that you understand that it's this P wave getting hidden in the previous QRS that actually calls it SVT now in this rhythm if you do the 1500 method and you count the number of boxes it's actually about 187 beats per minute so you don't even have to think about the rate for this one so let's do our five-step method number one regularity it's typically regular you can have an atrial fibrillation that causes SVT but it goes so fast it almost looks regular so for the most part you're usually gonna see it being regular the rate again over 150 or just extremely fast p2 QRS ratio you're not actually gonna see your P waves your P waves are gonna be missing and they're assumed to be up in that T wave your QRS complex typically narrow or normal so less than point one two PR interval again you can't really measure because we can't really see our P waves so those are your five steps so the classic sign of SVT is a super fast rate and a P wave that is hidden in a T wave now no one can survive with a heart rate of 187 for very long their heart will give out so we still have to do something about this for them so we'll give meds like calcium channel blockers we might give adenosine to try to restart the electrical signal their heart we might even do a synchronized cardioversion it just depends on how stable they are so we've talked about atrial dysrhythmias that start above the ventricles in the SA node of the atria so now let's talk about ventricular dysrhythmias remember the ventricles are responsible for pumping the blood out to the body so if we have a dysrhythmias ear that's not good that means we're having trouble pumping blood to the body so these are the deadly rhythms that I was talking about okay if we have ventricular problems which part of the EKG are we looking at the QRS complex now one thing I want you to realize is you should be able to recognize both of these two rhythms I'm about to show you like that on site you should not have to go through a five-step process for these you should see them from across the room on the monitor and go running okay because these are deadly rhythms so the first one is v-tach this is a classic ventricular tachycardia what you're gonna see is a fast rate and a wide QRS complex you're probably not gonna see any P waves in fact you're not gonna see any P waves you're not gonna see any T waves you're just going to see a wide complex in fact sometimes it's actually called wide complex tachycardia now here's the thing about ventricular tachycardia it can actually have a pulse or not so the most important thing you can do when you see this on a monitor is check your patient if they don't have a pulse please call a code and start CPR if they do similar interventions like SVT calcium channel blockers adenosine possibly synchronized cardioversion I've even seen people use amiodarone lidocaine whatever you can do because if they have a pulse with ventricular tachycardia it's not gonna last long because it's not a coordinated pumping effort I actually had a patient once who was in v-tach with a pulse for four hours before we were able to get him converted back to a normal sinus for them it was crazy super nerve-wracking but we tried everything and it just took a long time for his heart to respond the last min tricular dysrhythmia we're gonna talk about is ventricular fibrillation if you remember from atrial fibrillation fibrillation means quivering so if we have our ventricles quivering are they pumping no they're not pumping at all ventricular fibrillation never has a pulse I need you to know that ventricular fibrillation is a pulseless rhythm so if you see this on the monitor you need to go running check that patient call a code and start CPR now why check the patient if it never has a pulse well you could see some artifact or some movement on the EKG so make sure it's real but either way you need to understand if you see that on a monitor there is no way that that patient has a pulse so again ventricular tachycardia ventricular fibrillation I need you guys to be able to see this from across the room recognize it immediately without going through your five steps and act quickly to take care of that patient so those are the most common rhythms you're going to see there's a couple of things you'll need to know like premature atrial contraction premature ventricular contraction then of course your heart blocks so if you jump on over to and our SMG comm there's a full EKG course with dedicated lessons on every single rhythm as well as lessons on the EKG waveforms and how to calculate heart rate so I hope this in any lesson was helpful for you I hope you feel a little bit more confident with interpreting EKGs with that five-set method so you can do it quickly and like a boss so jump on over to NRS ng calm and start your trial remember you're not alone in this we've got you happy nursing

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Id: kVhnNGlgIOU

Length: 11min 35sec (695 seconds)

Published: Thu Oct 31 2019