Disorders of Cardiac Conduction, Rhythm

and
Heart block
Muhammad Ismail
Lecturer ZNC, Mardan

Acknowledgment
Hanif Ullah
Lecturer, CNM BKMC

1
 OBJECTIVES
• Review the anatomy & physiology of cardiac conduction system
• Review the electrical activity of the conduction system on an
Electrocardiography (ECG) tracing.
• Describe the mechanism for dysrhythmia generation
Discuss the different types of dysrhythmias.
Discuss various heart blocks
Discuss medical, surgical and nursing management of patients with
disorders of cardiac conduction and rhythm. 2
ELECTRICAL ACTIVITY

3
 Pacemakers

60-100
• SA Node

40-60
• AV Junction

20-40
• Purkinje

4
 ECG, EKG
It is the procedure of recording the electrical activity of the heart.
The electrode combination records the potential difference at two
sites on the body. The potential differences are produced due to the
electrical activity of the heart.

Electrocardiograph is the Machine

Electrocardiogram is the Record

The characteristic shape and timing of the ECG waves are due to the
spread of wave of depolarization and repolarization associated with
each heart beat.
5
 Standard 12-Lead ECG
• Usually performed when a person is resting in the supine position.

• Composed of three bipolar limb leads: I, II, and III; three augmented voltage
leads: aVR, aVL, aVF; and six chest or precordial leads: V1 – V6.

• All limb leads lie in the frontal plane.

• V1 to V6 all six Chest leads circle heart in the transverse plane.

 V1 & V2 look at the anterior of the heart and R ventricle

 V3 & V4 = anterior and septal

V5 & V6 lateral and left ventricle

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8
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•

10
ECG Precordial Leads

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 Standard 12-Lead ECG
• Anatomical relations of leads in a standard 12 lead
electrocardiogram
• II, III, and aVF: Inferior surface of the heart
• V3 to V4: Anterior surface
• I, aVL, V5, and V6: lateral surface

V1 and aVR: right atrium and cavity of left

ventricle 12
13
Single Lead Vs 12 Lead ECG

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Basics Of ECG

15
 ECG Time & Voltage

• ECG machines can run at 50 or 25 mm/sec.

• Minor lines are 1 mm apart; at standard 25

mm/s, 1 mm corresponds to .04 seconds.

• Major grid lines are 5 mm apart; at standard 25 mm/s, 5 mm corresponds

to .20 seconds. (therefore, 30 large squares would equal 6 seconds)

• Voltage is measured on the vertical axis.

• Standard calibration is 0.1 mV per mm of deflection. 16

 ECG Paper

0.04 sec

2 large squares = 1 mV 5 large squares = 1 sec =

(1000msec)
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 Basic Electrographic Complexes
• P wave represents depolarization of atria which causes atrial

contraction and Normal P wave has amplitude of ≤2.5 mV.

• Repolarization of atria not normally detectable on an ECG

• Excitation of bundle of His and bundle branches occur in middle of

PR interval
• QRS complex reflects depolarization of ventricles

• T wave reflects repolarization of muscle fibers in ventricles

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 Explaining P, QRS and T
P wave: Atrial depolarization – About to 0.12 second in duration.
QRS complex: Ventricular depolarization - Normal measure is 0.08-0.12
second
T wave: ventricular repolarization, rounded upright - not exceed 0.2 sec of
duration
PR interval: The interval between the beginning of p wave and the beginning
of R wave - It measures between ( 0.12-0.20)
ST segment: the isoelectric line between the end of QRS and the beginning of
T wave
QT interval: the interval between the beginning of Q wave and the end of T
wave - it measures ( 0.32 – 0.40 ) second
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CompleteCardiac Cycle

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21
 Normal P-QRS-T

P Wave PR Interval QRS Complex ST Segment

Represents Atrial atrial depolarization Ventricul Interval between
depolarization and delay at the AV ar ventricular
Node (AV conduction depolariza depolarization and
time) tion repolarization
Duration < 0.11 seconds 0.11 - 0.20 seconds 0.06 - 0.12 Measure from end of
seconds QRS (J-point) to
Height < 2.5 mm Measure start of P wave Q- First beginning of T wave
to start of QRS negative
deflection In relation to iso-
Prolonged indicates a R- First electric line:
conduction block positive
Depression/Negative
Shape Smooth Shortened indicates deflection indicates ischemia
accelerated conduction S- Negative
Elevation/Positive
or junctional in origin deflection after 22
indicates injury
 Analyzing Rhythms

Should use 6 seconds ECG strips

•Step 1: Calculate rate.
•Step 2: Determine regularity.
•Step 3: Assess the P waves.
•Step 4: Determine PR interval.
•Step 5: Determine QRS duration.

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 Appendix 1 – Rate calculations
The simple method (Count Down Method):
1. Find a QRS complex
2. Find the next QRS complex along
3. Find the R wave in both
4. Count how many big boxes there are in between each R wave
5. With a calculator do:
300 / (number of big boxes)
6. You can make this exactly as you like ie 3.4 boxes

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Interpretation of ECG: Rate

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 Appendix 2 – Rhythm
Method: 1. Grip a piece of paper
1. Line it up horizontally across ECG lead 2 tracing
2. Make sure you can see the tips of each R wave
3. Make a vertical mark on the paper for the first 2 R waves 4. Line up 1st mark with 2nd R wave
5. Does the 2nd mark line up with 3rd R wave? 6. Carry on repeating this.
Interpretation:
• If the heart rate is regular then the distance between each QRS should be regular, and thus your marks will
line up.
• If the heart rate is irregular, then the distance between each QRS will vary, and your marks will not
always line up
R R

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 Interpretation of ECG: Rhythm
• Normal heart rhythm has consistent R-R interval.
• Mild variations due to breathing also normal.

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 Interpretation of ECG: Rhythm
Normal Sinus Rhythm
• Rate: 60-100 b/min
• Rhythm: regular
• P waves: upright in leads I, II, aVF
• PR interval: < .20 s
• QRS: < .12 s
Sinus Bradycardia
• Rate: < 60 bpm
• Rhythm: regular
Sinus Tachycardia
• Rate: > 100 bpm

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 CARDIAC ARRHYTHMIAS
Sites of Origin:
• Sinus (SA) node, Atria, Atrioventricular (AV) node or junction and Ventricles

Normal cardiac rhythm:

• Heart rate 60- 100 beats per minutes
• Origin should be from S.A node
• Cardiac impulse should propagate through normal conduction pathways.
• Impulses should follow the normal velocity

When heart is deviated from all above standards this should be considered cardiac
arrhythmias
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 What are Dysrhythmias?
• Dysrhythmias are disorders of the FORMATION or CONDUCTION
(or both) of the electrical impulse within the heart. These disorders can
cause disturbances of the heart rate, the heart rhythm, or both.

• Dysrhythmias may initially be evidenced by the hemodynamic effect

they cause (e.g. a change in conduction may change the pumping
action of the heart and cause decreased blood pressure).

• For example, an impulse that originates in the sinoatrial (SA) node

and that has a slow rate is called sinus bradycardia.

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One way of classification is on the basis of techy
arrhythmia and Brady arrhythmia
Fibrillation >400
Flutter 250-400
Paroxysmal arrhythmia 150-250

Simple tachycardia 100-150

Normal heart activity 60-100

Mild Bradyarrhythmia 40 – 60
Moderate Bradyarrhythmia 20 – 40
Severe Bradyarrhythmia <20
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 Cardiac arrhythmias classification
2. Arterial
arrhythmia
3. Junctional arrhythmia
or Nodal arrhythmia
1. Sinus
4. Ventricular
arrhythmia
arrhythmia

Supra ventricular 5. Heart block

arrhythmias
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 Types of arrhythmias

SA node Atrial arrhythmia + Ventricular Heart block

1. Sinus AV node: musculature: • SA node
arrhythmia 1. Premature atrial 1. Ventricular block
2. Sinus contraction. tachycardia • AV block
tachycardia 2. Atrial flutter 2. Ventricular
3. Sinus 3. Atrial fibrillation fibrillation
bradycardia 4. Junctional 3. Premature
arrhythmia. ventricular
contraction

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 Sinus arrhythmias
• Physiological sinus arrhythmia
• Heart is under the control of autonomic nerves system
• Specially parasympathetic out follow of Vagus nerve control the SA
and AV node.
• During inspiration the heart rate is increased and in expiration the
heart rate is decreased___

1. Sinus rhythm
2. Sinus tachycardia
3. Sinus bradycardia

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 Normal Sinus Rhythm
• Normal sinus rhythm occurs when the electrical impulse starts at a regular rate
and rhythm in the sinus node and travels with normal conduction pathway.
• The following are the ECG criteria for normal sinus rhythm
Ventricular and atrial rate: 60 to 100 in the adult
Ventricular and atrial rhythm: Regular
QRS shape and duration: Usually normal, but may be regularly abnormal
P wave: Normal and consistent shape; always in front of the QRS
PR interval: Consistent interval between 0.12 and 0.20 seconds
P: QRS ratio: 1:1

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 Sinus tachycardia
• Sinus tachycardia occurs when the sinus node creates an impulse at a faster-
than-normal rate.
• It may be caused by acute blood loss, anemia, shock, hypervolemia,
congestive heart failure, pain, fever, exercise, anxiety. The ECG findings of
sinus tachycardia:

0.20 and 0.12 seconds

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 Sinus bradycardia
• Sinus Bradycardia. Sinus bradycardia occurs when the sinus node creates an impulse at a
slower-than-normal rate.
• Causes include lower metabolic needs (eg, sleep, athletic training, hypothermia,
hypothyroidism), vagal stimulation (eg, from vomiting, suctioning), medications (eg,
calcium channel blockers, beta-blockers) and (MI).
• Ventricular and atrial rate: Less than 60 in the adult Ventricular and atrial rhythm: Regular
• QRS shape and duration: Usually
normal, but may be regularly abnormal
• P wave: Normal shape, and consistent
in front of the QRS
• PR interval: Consistent interval
• P: QRS ratio: 1:1
•

• Atropine, 0.5 to 1.0 mg (IV) or bolus. Rarely, emergency transcutaneous pacing also may
be implemented 38
 ATRIAL DYSRHYTHMIAS

Basically has following types

1. Premature Atrial Contraction (PAC)

2. Arterial flutters - 250 – 350 beats per minute
3. Arterial fibrillation - 350 beats per minute

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 Premature Atrial Contraction (PAC)
• PACs) are extra heartbeats that start in the upper chambers of your heart. The
premature, or early, signal tells the heart to contract.
• Premature beats or extra beat frequently appear following a normal sinus rhythm
• Caused by caffeine, alcohol, nicotine, stretched atrial myocardium (as in hypervolemia),
atrial ischemia or injury.
 Impulse is activated in ectopic side of atrium instead of SA node
 P wave has unusual, non sinus morphology.
 Ventricular and atrial rhythm: Irregular due to early P waves, PP interval shorter.
 QRS shape and duration: The QRS that follows the early P wave is usually normal
 P wave: Early P wave may be hidden or merged in the T wave; other P waves in strip consistent.

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 Atrial Flutter
• Atrial flutter: An atrial arrhythmia caused by one or more rapid circuits in the
atrium. Usually more organized and regular than atrial fibrillation.
• Occurs in the atrium and creates impulses at an atrial rate 250 and 400 bpm.
not all atrial impulses are conducted into the ventricle, causing a therapeutic
block at the AV node. Causes are similar to that of atrial fibrillation.
characterized by the following:
• Heart rate: 250 and 400 bpm

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 Cont..
• Ventricular and atrial rate: Atrial rate ranges between 250 and 400;
ventricular rate usually ranges between 75 and 150.
• Ventricular and atrial rhythm: The atrial rhythm is regular; the
ventricular rhythm is usually regular but may be irregular because of a
change in the AV conduction.
• P wave: Saw-toothed shape. These waves are referred to as F waves.
• PR interval: Multiple F waves may make it difficult to determine the
PR interval.
• P: QRS ratio: 2:1, 3:1, or 4:1

42
 Atrial fibrillation (Af)
• It is the most common dysrhythmia that causes patients to seek medical
attention. It may start and stop suddenly. This happens when many impulses
begin and spread through the atria, competing for a chance to travel through
the AV node.
• Small electrical activity shows fluctuations but not shows the p wave.
• Af may occur for a very short time (paroxysmal), or it may be chronic.
• Usually associated with advanced age, valvular heart disease, coronary artery
disease, hypertension, cardiomyopathy, hyperthyroidism, pulmonary disease,
acute moderate to heavy ingestion of alcohol or the after open heart surgery.
• This results in a disorganized rapid and irregular rhythm.
• Because the impulses are traveling through the atria in a disorderly fashion,
there’s a loss of coordinated atrial contraction.
• P wave is not actually the p wave. 43
 Cont..
• Ventricular and atrial rate: Atrial rate is 400 to 600. Ventricular
rate is usually 120 to 200 in untreated atrial fibrillation.
• Ventricular and atrial rhythm: Highly irregular
• QRS shape and duration: Usually normal, but may be abnormal
• P wave: No discernible P waves; irregular undulating waves are seen and
are referred to as fibrillatory or f waves.
• PR interval: Cannot be measured.
• P: QRS ratio: many:1

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 Junctional Arrhythmias

• Atrioventricular Nodal Reentry Tachycardia: When impulse is conducted to an area

in the AV node that causes the impulse to be rerouted back into the same area over and
over again at a very fast rate.
• Each time the impulse is conducted through this area, it is also conducted down into the
ventricles, causing a fast ventricular rate.
 Junctional Arrhythmias
• AV nodal reentry tachycardia that has an abrupt onset and an abrupt
cessation with a QRS of normal duration had been called paroxysmal atrial
tachycardia (PAT).
• Factors associated with the development of AV nodal reentry tachycardia
include caffeine, nicotine, hypoxemia, and stress. Underlying pathologies
include coronary artery disease and cardiomyopathy.

Wolff Parkinson white syndrome 46

Cont..

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 Ventricular arrhythmias
• Ventricular arrhythmias are abnormal heartbeats that originate in
your lower heart chambers, called ventricles. These types of
arrhythmias cause your heart to beat too fast, which prevents oxygen-
rich blood from circulating to the brain and body and may result in
cardiac arrest.

• Types includes

1. Premature ventricular contraction

2. Ventricular tachycardia VT or v tach
3. Ventricular fibrillation

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 Premature ventricular complex (PVCs)
• PVC is an impulse that starts in a ventricle and is conducted through the
ventricles before the next normal sinus impulse.
• PVCs can occur in healthy people, especially with the use of caffeine,
nicotine, or alcohol & also caused by cardiac ischemia or infarction,
increased workload on the heart (e.g. exercise, fever, hypervolemia, heart
failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances,
especially hypokalemia.

• In the absence of disease, PVCs are not

serious, TREATED only if symptomatic
with beta-blockers or In patients with an
acute MI need therapy.
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PVC’s

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 Premature ventricular complex (PVCs)
ECG shows wide and bizarre QRS complex
Ventricular and atrial rhythm: Irregular due to early QRS, creating one RR
interval that is shorter than the others.
P wave: Visibility of P wave depends on the timing of the PVC; may be absent
(hidden in the QRS or T wave) or in front of the QRS.
 PR interval: If the P wave is in front of the QRS, the PR interval is less than
0.12 seconds.
P: QRS ratio: 0:1, 1:1

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 Ventricular Arrhythmias
Ventricular tachycardia (VT or V-tach): A condition in which an electrical signal is
sent from the ventricles at a very fast but often regular rate.
• VT is defined as three or more PVCs in a row, occurring at a rate exceeding 100
beats per minute.
• VT is usually associated with coronary artery disease and may precede ventricular
fibrillation. VT is an emergency because the patient is usually unresponsive and
pulseless. VT has the following characteristics
Ventricular and atrial rate: Ventricular rate is 100 to 200 beats per minute;
Rapid ventricular rhythm with broad abnormal QRS complexes (often 0.14s or
more).
P wave: Very difficult to detect, so atrial rate and rhythm may be indeterminable.
PR interval: Very irregular, if P waves seen.
P: QRS ratio: Difficult to determine, but if P waves are apparent, there are
usually more QRS complexes than P waves. 52
 Ventricular Tachycardia
• Treatment: in hemodynamically compromised patients, emergency DC
cardioversion may be required.
• If the blood pressure and cardiac output are well maintained, intravenous
therapy with class I drugs or amiodarone is usually used.
• First-line drug treatment consists of lidocaine (50-100 mg i.v. over 5
minutes) followed by a lidocaine infusion (2-4 mg i.v. per minute).
• DC cardioversion is necessary if medical therapy is unsuccessful.

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 Ventricular fibrillation (VF)
• Ventricular fibrillation is a rapid but disorganized ventricular rhythm in
which electrical signals are sent from the ventricles at a very fast and erratic
rate. As a result, the ventricles are unable to fill with blood and pump. There
is no atrial activity seen on the ECG.

• Causes of ventricular fibrillation are the same as for VT, and may result from
untreated or unsuccessfully treated VT, electrical shock, has a structurally
normal heart, and a family history of sudden cardiac death.

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 Ventricular Fibrillation
• This rhythm is life-threatening because there may no pulse and
complete loss of consciousness.
Ventricular rate: Greater than 300 per minute
Ventricular rhythm: Extremely irregular, without specific pattern
QRS shape and duration: Irregular, undulating waves without
recognizable QRS complexes

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 Heart block
• DEFINITION: Heart block, nodal block, junctional block and also called AV
block - When the electrical signal that controls your heartbeat is partially or
completely blocked. OR
• Heart block is an abnormal heart rhythm where the heart beats too slowly
(bradycardia). In this condition, the electrical signals that tell the heart to contract
are partially or totally blocked between the upper chambers (atria) and the lower
chambers (ventricles).

• They are further classified as:

1. First-degree heart block (first-degree AV block)

2. Second-degree heart block (second-degree AV block)

3. Third-degree heart block (third-degree AV block)

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 FIRST-DEGREE HEART BLOCK
• First-degree atrioventricular block (AV block), or PR prolongation, is a
disease of the electrical conduction system of the heart in which the PR
interval is lengthened beyond 0.20 seconds.
• Most common causes of first-degree AV block:
Acute myocardial infarction (inferior wall MI), myocarditis, electrolyte disturbances
(hypokalemia), drugs (especially that increase the refractory time of the AVN,
thereby slowing conduction).
SA Node – normal
Normal P wave
AV Node conducts more slowly
than normal - Prolonged PR Interval
Rest of conduction is normal -
Normal QRS
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 Significance
• Clinical significance - None

• Treatment -None

• Note – this can progress to 2º or 3º heart block

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 Second Degree Heart Block (2º)
• Mobitz Type - I (Wenkebach)

• Mobitz Type - II

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 Second Degree Heart Block (2º) Mobitz Type I
(Wenkebach)
• Conduction through the AV Node – progressively delayed until a drop
beat is seen
• Second-degree atrioventricular (AV) block, or second-degree heart block,
is characterized by disturbance, delay, or interruption of atrial impulse
conduction through the AV node to the ventricles.
CAUSES
• Drugs (beta-blockers, calcium channel blockers, amiodarone)
• Rheumatic fever, myocarditis varicella-zoster virus infection
• Hypoxia, hypothyroidism, inferior wall myocardial infarction etc.

60
 Second Degree Heart Block (2º) Mobitz Type I
(Wenkebach)
Findings on ECG
• PR Interval prolongs with each beat
until a dropped beat is seen
• The PR Interval is NOT constant
• After each dropped beat, the PR interval
is normal and the cycle starts again

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 Significance
Clinical Significance
• Slight symptoms e.g.. Lethargy, Confusion

Treatment
• Pacemaker if symptoms persistent

Note – this can progress to 3º Heart Block

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 Second Degree Heart Block (2º) Mobitz Type II
• Conduction through the AV node is constant.
• PR interval is normal and constant
• Occasionally a dropped beat is seen
• P wave are normal and QRS complex is usually not always wide.
• PR interval always the same duration.
• There are dropped beats
• The block is below the AV node generally in the His – Purkinji system
• concomitant bundle branch block

63
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 Significance
• Clinical significance – this is a more significant disease

• Treatment – pacemaker

• Note – this can progress to 3º Heart Block

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 Third Degree Heart Block (3º) (Complete)
• Complete failure of the AV Node
• No impulses from Sinus Node will pass through to the ventricles
• Some part if the conducting system (ventricular) will take over as
pacemaker of the heart (even a myocardial cell 10-15 bpm).
• Third-degree atrioventricular (AV) block, also referred to as third-degree
heart block or complete heart block, is a disorder of the cardiac conduction
system where there is no conduction through the atrioventricular node.

65
 Third Degree Heart Block (3º) (Complete)
• P wave rate – normal
• Ventricular rate – slow
• Ventricular complex may be broad
Idioventricular rhythm
• Complete dissociation between P waves & QRS
• PR interval: Very irregular
• P: QRS ratio: More P waves than QRS complexes

66
 Significance
Clinical significance
• Symptoms LOC, Confusion, Dizziness, Low BP
• Can lead to standstill, VT or VF (stokes Adams)
Treatment - pacemaker

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 Asystole
•Rhythm - Flat
•Rate - 0 Beats per minute
•QRS Duration - None
•P Wave - None

Total absences of any electrical activity, straight line appear

69
Summarization

70
 PACEMAKER
• Electronic device that provides electrical stimuli to the heart muscle.
• Used when a patient has a slower-than-normal impulse formation or a
conduction disturbance that causes symptoms or used to control some
tachydysrhythmias that do not respond to medication therapy.

• Biventricular (both ventricles) pacing may be used to treat advanced heart

failure that does not respond to medication therapy.
• Pacemakers can be permanent or temporary.
 Permanent pacemakers are used most commonly for irreversible complete heart
block.
 Temporary pacemakers are used (eg, after MI, after open heart surgery) to support
patients until they improve or receive a permanent pacemaker. 71
 Cont..
A pacemaker has two parts:
• Pulse generator. This small metal container houses a battery and the
electrical circuitry that controls the rate of electrical pulses sent to the
heart.
• Leads (electrodes). One to three flexible, insulated wires are each placed
in one or more chambers of the heart and deliver the electrical pulses to
adjust the heart rate. However, some newer pacemakers don't require
leads. These devices, called leadless pacemakers, are implanted directly
into the heart muscle.

72
 Indications for Pacemaker
• Sinus node dysfunction with documented symptomatic Sinus node dysfunction with
documented symptomatic bradycardia
• Symptomatic chronotropic incompetence (failure to Symptomatic chronotropic
incompetence (failure to increase HR with exercise or increased metabolic demand)
• 3° and advanced and advanced 2° AV block associated with any of the AV block
associated with any of the following:
Arrhythmias that require drugs resulting in symptomatic bradycardia
Sinus pauses > Sinus pauses > 3 seconds
Asymptomatic escape rate < Asymptomatic escape rate < 40bpm while awake bpm while
awake.
• 3° or 2° AV block with associated symptomatic AV block with associated
symptomatic bradycardia
• Type II Type II 2° AV block with wide QRS, regardless of AV block with wide QRS,
regardless of symptoms
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74
 Complications of Pacemaker Use
• Infection near the site in the heart where the device is implanted
• Swelling, bruising or bleeding at the pacemaker site, especially if you take
blood thinners
• Blood clots (thromboembolism) near the pacemaker site
• Damage to blood vessels or nerves near the pacemaker
• Collapsed lung (pneumothorax)
• Blood in the space between the lung and chest wall (hemothorax)
• Movement (shifting) of the device or leads, which could lead to cardiac
perforation (rare).

75
 Special precautions
• It's unlikely that your pacemaker would stop working properly because of electrical interference.
• Cellphones. It's safe to talk on a cellphone, but keep your cellphone at least 6 inches (15
centimeters) away from your pacemaker.
• Security systems. Passing through a metal detector, avoid remaining near or leaning against a
metal-detection system. Carry an ID card stating that you have a pacemaker.
• Medical equipment. Certain medical procedures, such as MRI, CT scans, and shock wave
lithotripsy to break up large kidney stones or gallstones could interfere with your pacemaker.
• Power-generating equipment. Stand at least 2 feet from welding equipment, high-voltage
transformers or motor-generator systems.
• If you work around such equipment, ask your doctor about arranging a test in your workplace to
determine whether the equipment affects your pacemaker.
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77
 NURSING MANAGEMENT
• Assess the high-risk patients

• Monitor ECG of the patient

• Assess the family history of heart disease

• Assess the history of smoking and alcoholism

• Monitor lab values frequently, especially serum cholesterol levels.

• Assess for CAD

• Monitor vital signs

• Instruct to avoid high fat and oil-rich diet

78
THANK
YOU
79
Reference:
• Medical-Surgical Nursing, 10th edition - Brunner & Suddarth page
number (762-773)

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