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Exam 2 > EKG Rhythms > Flashcards

EKG Rhythms Flashcards

1
Q

Wolff Párkinson White (WPW)**

A
  1. Short PR Interval
  2. Delta Wave
  3. Widened QRS

Accessory conduction pathway which allows for re-entrant SVT, predisposing to cardiac symptoms and ventricular arrhythmia and SCD

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2
Q

Delta Wave**

A

Slurring of P wave into QRS complex, widening the QRS

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3
Q

Sinus Arrhythmia

A

Inspiration: HR increases
Expiration: HR decreases

Normal finding
Predictable irregularity in HR that occurs with respiration
Pronounced in adolescents
Measurement of cardiac health

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4
Q

Sinus Rhythm

A

Rhythm originates at SA Node
P wave present before every QRS complex
Normal P wave axis (0-90 degrees)

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5
Q

Sinus Bradycardia

A

SA Node & ECG complexes normal
HR lower than expected for normal age

ICP, Hypothermia, Hypoxia, Hypothyroidism, Hyperkalemia, Sedation, Sleep, Medications (Digoxin)

Treatment only if symptomatic (hemodynamic instability): Atropine, isoproterenol, cadiac pacing

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6
Q

Sinus Tachycardia

A

HR > than expected
ECG complex & intervals normal

Pain, anxiety, excitement, fever, sepsis, anemia, hypovolemia, shock, medications (albuterol, steroids)

Treatment: Underlying cause

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7
Q

Sinus Pause

A

Sinus node fails to initiate impulse
Pause is short –> No P wave or QRS recorded

Young people: common in sleep (< 2 secs only)
Hypoxia, increased vagal tone, digoxin toxicity

Treatment: Atropine, isoproterenol, cardiac pacing

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8
Q

Rhythms originating in Atrium

A

Originated outside SA node, but above Bundle of His

Atrial arrhythmias:
Unusually contoured P waves and/or
Abnormal # of P waves per QRS complex
Follow a QRS complex of NORMAL duration

Includes:
Premature Atrial Contraction (PAC)
Supraventricular Tachycardia (SVT)
Atrial Flutter
Atrial Fibrillation
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9
Q

Premature Atrial Contraction (PAC)

A

Atrial beat that occurs too early

Common in healthy children
Usually no clinical significance
CHD, digitalis toxicity, cardiac surgery,

Treatment: Only if due to digitalis toxicity

If PAC consecutive, incessant, or produce bradycardia –> abnormal electrolytes (K, Mg)

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10
Q

Supraventricular Tachycardia (SVT) **

A

Rapid HR with narrow QRS

  • Infants: HR > 220 BPM
  • Children: HR > 180 BPM

Includes any rapid rhythm occurring ABOVE the Bundle of His. Most common rhythm disturbance in pediatric patients

  1. Focal SVT
  2. Re-entrant SVT
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11
Q

Focal SVT**

A

Rapid firing of a single focus in atria
Focal is RARE

Ectopic Atrial Tachycardia (EAT)
- Most common chronic SVT in children

Leads to:
Arrhythmia - induced tachycardia (Tachycardia induced-cardiomyopahty)

Treatment:
Medication, ablation

Focal SVT resolves in predictable fashion once tachycardia is treated

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12
Q

Re-Entrant SVT **

A

2 Circuits: Normal conduction pathway (SA -> AV Node) & Accessory conduction pathway (BoH -> Purkinje Fibers)

Conduction travels down either circuit & up the other. More rapid conduction in accessory pathway

Anatomically separate accessory pathway:
WPW (delta wave)
Atrioventricular Reciprocating Tachycardia (AVRT)

or

Structurally separate accessory pathway:
Dual AV Node Pathway: Atrioventricular Nodal re-entrant tachycardia (AVNRT)

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13
Q

SVT Treatment**

A

Unstable/poor perfusion

  • Synchronized Cardioversion (0.5 - 1 J/kg, up to 2 J/kg)
  • Adenosine 0.1 mg/kg/dose (half life < 1.5 sec), CAUTION: bronchospasm in asthmatic

Stable

  • ICE
  • Valsalva maneuver

Chronic Management
- Digoxin, propanolol, nadolol, flecainide, propafenone, stoalol, amiodarone, radiofrequency cath ablation

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14
Q

Atrial Flutter**

A

Atrial Rate ~ 300 BPM
Ventricular Rate ~ 150 BPM

“sawtooth” ECG

Causes
Cardiac surgery involving atria 
Structural Heart disease 
- Atrial dilation 
- Myocarditis 
- Digitalis toxicity
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15
Q

Atrial Flutter Treatment**

A 
Rate control 
•	Digoxin 
•	Propranolol
•	Calcium channel blocks 
•	AF is difficult to rate control**

Rhythm control
• Antiarrhythmic medication

Ablation
• Class I indication for recurrent/persistent AF
o Only if over 15 kg!!

Cardioversion
• Acute management if unstable
• Digoxin interaction  Malignant Ventricular Arrhythmias ***
- Avoid cardioversion in patients receiving digoxin therapy, unless the arrhythmia is life-threatening

Rapid Atrial Esophageal Pacing
• If cardioversion is contraindicated!

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16
Q

Atrial Fibrillation **

A

Atrial HR 350 – 600 BPM (very rapid)
QRS duration normal
Irregular ventricular response (Lead V1)

Causes:
Structural heart disease
Myocardial dysfunction
Previous cardiac surgeries
SVT**
• AF can develop from rapid atrial activity of SVT in as many as 30% of children
• Elimination of SVT in patients with documented AF has been shown to prevent recurrence AF

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17
Q

A Fib Treatment **

A

Unstable (hemodynamically)
• Cardioversion

Stable
• Medical management
• Observation (Recurrence, rate control, rhythm control)
• Catheter ablation

Rate Control
• Digoxin
• Propranolol
• Verapamil

Rhythm control
• Sotalol
• Amiodarone
• Reduce risk of recurrence

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18
Q

Rhythms originating in the AV Node or Junction

A

AV node (Junctional Node) assumes role of main pacemaker due to SA node dysfunction

ECGs:

  • Inverted P waves following QRS complex
  • Absent P waves, normal QRS

Rhythms

  • Junctional Rhythm
  • Junctional Ectopic Tachycardia (JET)
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19
Q

Junctional Rhythm

A

HR 40 - 60 BPM
Structurally normal heart

Causes

  • Cardiac surgical procedures involving atria
  • conditions that raise vagal tone (sleep, increased ICP)
  • Digoxin toxicity

Clinically significant only if patient is hemodynamically unstable *

20
Q

Junctional Rhythm Treatment

A

Asymptomatic:

  • Nothing
  • Except if digoxin-toxic patient

Symptomatic (poor perfusion/CO)

  • Atropine
  • Temporary pacing
21
Q

Junctional Ectopic Tachycardia (JET) *

A

ECG

  • Ventricular Rate 150 - 300 BPM
  • QRS narrow
  • Ventricular Rate is FASTER than atrial rate**
  • AV dissociation in ECG **

Type of SVT, but automatic tachycardia comes from AV Node

Most common arrhythmia occurring after cardiac surgery (< 2 years old) **

Risk Factors

  • Younger patient age
  • Longer CPB time
  • Vasoactive agent use
  • Catecholamine sensitive**
  • Type of cardiac surgery
22
Q

JET Treatment *

A 
Restore AV synchrony
- Atrial wires 
Slow ventricle rate 
- Sedation 
- Pain control 
- Electrolyte replacement (Mg)
- Minimize vasoactive agent use
- Hyperthermia avoidance
- Induce Hypothermia (cooling blanket, fan, intubated, paralyzed)

Improve CO

Amiodarone
Procainamide
Precedex
- Highly selective alpha 2 adrenoreceptor agonist (slow HR & sedation)

23
Q

Rhythms originating in Ventricle

A

Wide QRS complex
- Long in duration

QRS complex may be inconsistently related to P wave

T waves extending in opposite direction

24
Q

PVC

A

Wide QRS complex
Not preceded by P wave

Bigeminy
- PVC every other beat, alternating with normal QRS

Trigeminy
- PVC every 3rd beat, separated by 2 normal QRS

Couplet
- 2 consecutive PVCs

Unifocal PVC

  • From single focus in ventricle
  • Consistent QRS pattern in same lead

Multifocal PVC

  • Different foci in ventricle
  • Varying configuration of QRS pattern in same lead
  • OMNIOUS**
25
Q

PVC

Cause & Treatment

A 
Electrolyte imbalance
Drug toxicity 
Cardiac Injury 
Tumor 
Cardiomyopathy 
Myocarditis 
Acidosis 
Hypoxia 
CHD
Prolonged QT 
Mitral Valve Prolapse

Isolated, unifocal: No treatment

Frequent, multifocal:

  • Correct underlying cause (Hypoxia, Electrolyte imbalance, Acidosis)
  • Beta Blockers
  • Procainamide
  • Lidocaine
  • Amiodarone
26
Q

Ventricular Tachycardia (VT)**

A

Series of 3 or more PVCs + HR 120 – 200 BPM
• HR usually < 250 BPM

Sustained 
•	> 10 seconds
Non-sustained 
•	< 10 seconds 
Unifocal
Multifocal 
•	Torsade de Pointes (Undulating QRS complexes, Appear to be spiraling along an axis)
27
Q

VT

Causes/SS**

A

Cardiac surgery
• Right ventriculostomy (Early and late postoperative VT)

Torsade de Pointes causes
•	Drugs/chemicals that prolong QT interval
o	Antiarrhythmics
o	Phenothiazines 
o	Tricyclic antidepressants 
o	Antibiotics (Ampicillin)
o	Organophosphate insecticides

S/S

  • Hemodynamic compromise
  • VT can quickly deteriorate to VF ***
28
Q

VT Treatment **

A

Reversible causes

Unstable (hemodynamically) or Unconscious 
•	Synchronized Cardioversion 
o	0.5 – 1 J/Kg
Pulseless VT
•	Immediate Defibrillation 
o	2 – 4 J/kg 
Uncontrollable VT 
•	ECMO

Stable, conscious patient
• Amiodarone
• Sotalol
• Lidocaine

29
Q

Torsade de Pointes

Treatment*

A

Shorten the QT Interval by increasing HR
• Cardiac Pacing
• Isoproterenol gtt

Unstable (hemodynamically)
• IV Magnesium

30
Q

VT +CHD

Treatment **

A

Implantable cardioverter-defibrillator (ICD)
Ablation procedures

For patients with 
•	Cardiomyopathy
•	LQTS
•	Life-threatening VT
•	Resuscitated patients following sudden cardiac death
31
Q

Ventricular Fibrillation **

A

ECG
- Bizarre, wavy ventricular pattern with varying sizes and configurations of the QRS complex

Results from erratic firing of multiple foci within the ventricles
- Leads to infective circulation, pulselessness, death

Causes

  • Hypoxia
  • Hyperkalemia
  • Digoxin toxicity
  • Quinidine Toxicity
  • MI
  • Myocarditis
  • Cardiothoracic surgery complications

Acute Management

  • CPR
  • Defibrillation following PALS guidelines
32
Q

1st Degree Heart Block **

A

ECG
• NSR (P wave present before every QRS complex, QRS normal in duration and appearance)
• 1:1 Conduction (No dropped beats)

Prolonged PR Interval
• Due to abnormal delay in conduction through AV node

Can occur in healthy children

33
Q

1st Degree Heart Block

Causes & Treatment **

A 
Causes
•	Conduction disturbance
•	Rheumatic Fever Cardiomyopathies 
•	Congenital Heart Defects
o	ASD
o	Ebsteins Anomaly 
o	Endocardial Cushion Defect 
•	Myocarditis 
•	Digoxin Toxicity*
o	First degree AV block is a sing of digoxin toxicity 
o	Most common cause in pediatric patients** 
•	Lyme Disease*
o	PR Interval > 280 seconds**

Signs and Symptoms
• Increased Vagal Tone
• Usually asymptomatic & hemodynamically stable

Treatment
• None
• Unless digoxin toxicity

34
Q

2nd Degree Heart Block**

A

ECG
• Some P waves are followed by QRS complex
o Dopped Beats

Mobitz Type I
Mobitz Type II

35
Q

2nd Degree Heart Block**

Mobitz Type I

A

PR interval becomes progressively prolonged until 1 QRS complex is eventually dropped –> Missed beat
o Dysfunction of AV node, but does not progress to complete heart block

Causes
o	CHD
o	Myocarditis
o	MI
o	Cardiomyopathy 
o	Drug Toxicity (Digoxin, BB, CCB, Quinidine)
o	Cardiac Surgery

Can occur in healthy children (11%)
o Sleep

Symptoms
o No hemodynamic compromise

Management
o Underlying cause (toxicity)
o Otherwise, treatment unnecessary

36
Q

2nd Degree Heart Block**

Mobitz Type II

A

Characteristics can be one of the following
o 1. Normal AV conduction with normal PR Interval
o 2. Conduction is completely blocked - Ventricular rate depends solely on number of conducted atrial impulses, AV block at the level of Bundle of His

Causes
o Same as Mobitz Type I

Treatment
o Asymptomatic - Prophylactic pacemaker therapy (Risk for complete heart block)
o Symptomatic - Pacemaker therapy

37
Q

3rd Degree Heart Block**

A 
ECG
•	P waves regular
o	Normal R-R interval 
o	Slower rate than normal for age 
•	Congenital 
o	QRS duration & impulse normal appearing 
o	Ventricular rate higher: 50 – 80 BPM 
•	Acquired 
o	QRS duration prolonged 
o	Ventricular rate slower: 40 – 50 BPM 
o	May appear as PVC

Complete Heart Block
• Complete failure of impulse conduction from Atria to Ventricles
• Atria and Ventricles beat independently from each other

38
Q

3rd Degree HB **

Causes, Treatment

A

Causes - Congenital
o With or without structural heart disease
o Maternal Lupus
o L Transposition of the great arteries

Causes - Acquired
o Cardiac surgical complications (VSD, TOF)
o Rheumatic Fever
o Lyme Disease

Signs & Symptoms
•	Low CO 
o	Fatigue 
o	Dizziness 
o	Syncope 
o	Exercise intolerance
•	Infants
o	CHF
Treatment
•	CHB
o	Permanent pacemaker 
•	Surgically induced post-op CHB
o	Temporary pacing 
o	Permanent pacemaker (If CHB > 7 days)
39
Q

LQTS**

A

ECG

Prolongation of QT Interval - Delayed ventricular repolarization

Corrected QT Interval (QTc) Measurements
• Normal QTc = < 440 ms
• Long QT Syndrome: QTc > 460 ms

T Wave
• Abnormal
• Notched, Biphasic

40
Q

LQTS Diagnosis

A

Diagnosis requires ALL of the following:

ECG Findings
• May sometimes have normal QT interval*

Symptoms

Family history
• Positive family history for LQTS or premature, sudden death reported in 60% of patients*

Genetic testing (sometimes)
• All blood relatives of patients with congenital LQTS should have screening ECG in addition to genetic testing**
o Regardless of symptoms

41
Q

LQTS Causes

A 
Congenital
•	Jervell & Lange-Nielsen Syndrome 
o	Congenital deafness (Autosomal recessive)
•	Romano-Ward Syndrome
o	No deafness (Autosomal dominant) 
Acquired 
•	Antibiotics 
•	Antidepressants 
•	Antipsychotics
•	Electrolyte disturbances 
•	Hypokalemia 
•	Hypocalcemia 
•	Hypomagnesemia 
•	Hypothyroidism 
•	Anorexia nervosa
•	Head trauma
42
Q

LQTS

S/S & Risks

A

Signs and Symptoms

  • Syncope
  • Palpitations
  • Dizziness
  • Cardiac arrest
  • Most symptoms coincide with exercise, emotion, or sudden auditory stimuli** (doorbell, alarm)

Risk
-Ventricular Arrhythmias (High risk)
-Sinus bradycardia (Frequently associated with Long QT syndrome )
-Sudden Death
• QTc Interval > 500 msc = 5 – 8 x increased risk of cardiac event **

43
Q

LQTS Treatment

A

Reduce sympathetic activity

Beta Blockers
•	Propanolol 
o	2 – 4 mg/kg/day
•	Atenolol 
o	0.5 mg/kg/day

Cardiac Pacemaker

ICD
• Only if high risk
• Previous cardiac arrest
• Failed medication therapy

Left cardiac sympathetic denervation surgery

LQTS + VT or Torsade de Pointes
•	IV Magnesium 
o	20 – 50 mg/kg 
o	Max 2 g
•	Serum electrolytes
•	Toxicology screen
44
Q

WPW

Causes/Diagnostics

A

Congenital Diseases accompanied with

  • Ebstein’s Anomaly
  • L-TGA (corrected transposition)
  • Hypertrophic Cardiomyopathy
Diagnostic
- ECHO
- Evaluation if 
•	Syncope with WPW
- Risk Stratification
•	Exercise Treadmill Testing 
o	Monitor loss of pre-excitation with increased heart rates 
•	Electrophysiology study 
o	Evaluate accessory pathway with potential ablation therapy
45
Q

WPW Risks

A

At risk for

  • Sudden death 48% children
  • A Fib –> VF
  • A Flutter –> VF
  • Intermitted pre-excitation or SVT

Contraindications

  • Digoxin
  • Verapamil
  • Both medications shorten refractory period of WPW accessory pathway

Restrictions
-Competitive Sports

Exam 2 (5 decks)

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