conduction disturbances

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Slide 1:

Part - I Part - I Part - I Conduction disturbances

Normal ECG pattern :

Normal ECG pattern P wave – atrial depolarization or activation PR segment – AV conduction system activation PR interval – onset of atrial depolarization to ventricalar depolarization QRS complex – depolarization of ventricle ST – T – ventricular repolarization or recovery U wave – repolarization of purkinje J point – junction between QRS and ST segment

ECG:

ECG

ECG Parts:

ECG Parts

NORMAL ECG:

NORMAL ECG Paper speed 25mm/sec Squares – one small square (1mm)– 0.4 sec One big square – 5 mm – 0.2 sec Five big squares – 25 mm - 1.0 sec

ECG Paper:

ECG Paper Squares – one small square (1mm)– 0.4 sec One big square – 5 mm – 0.2 sec Five big squares – 25 mm - 1.0 sec

ECG:

ECG

Intrinsic Rates :

Intrinsic Rates A. Atria : 75 B. AV Node: 60 C. Ventricle : 40 Normal rate 60-100 beats / mt Bradycardia - < 60 Tachycardia > 100 Supraventricular tachycardia = 140-220

RATE:

RATE 300 / large squares in between 2 R waves 1500 / small squares in between 2 R waves

Calculate Rate:

Calculate Rate

Calculate Rate in irregular rhythm:

Calculate Rate in irregular rhythm 6 second method – in irregular rhythm No. of R waves in 6 seconds multiplied by 10 = No of R waves in 60 seconds

Calculate Rate:

Calculate Rate

Bradycardia – :

Bradycardia –

Sinus bradycardia.:

Sinus bradycardia. Impulses originate at the SA node at a slow rate. All complexes are normal, evenly spaced; rate <60/min. PR interval 120 - 200 msec.

SINUS BRADYCARDIA Impuses originate at S-A node at slow rate:

SINUS BRADYCARDIA Impuses originate at S-A node at slow rate All complexes normal, evenly spaced Rate < 60 - 100/min

BRADYCARDIA:

BRADYCARDIA 2 types Relative bradycardia (every 1 deg. Rise in temp elevates 10 beats normally) this response is blunted eg..Typhoid fever Absolute bradycardia - causes – non cardiac cardiac

Absolute bradycardia:

Absolute bradycardia Athletes,Sleep,Hypothermia Vasovagal,Obstructive jaundice ICT , K+ Betablocker,CCB,Digoxin Heart blocks, Sick Sinus Syn

BRADYCARDIA TREATMENT:

BRADYCARDIA TREATMENT Treatment – Q2 inhalation Inj atropine 0.5 – 1.0 mg IV, Transcutaneous pacing , dopamine 5- 20 mcg / kg ./ mt Epinephrine 2-10 mcg/min Isoproteronol – 2-10 mcg/min Trans venous pacing Permanent pacing

ATRIAL FIBRILLATION Impuses have chaotic, random pathways in atria:

ATRIAL FIBRILLATION Impuses have chaotic, random pathways in atria Baseline irregular, ventricular response irregular

AF :Causes:

AF :Causes RHD-Mitral IHD HHD CHD-ASD Cardiomayopathy Thyrotoxicosis,Alcohol,COPD,Pul.Emboli Lone AF

Atrial fibrillation:

Atrial fibrillation

AF -Clinical:

AF -Clinical Palpitation Irregularly irregular /Varying pulse Pulse deficit Varying 1 st HS Absence of a wave in JVP

Management:

Management Control rate – BB,CCB,Digoxin Pharmacological CV – Quinidine Amiodarone Anticoagulation DC cardioversion Abelation + Pacemaker

ATRIAL FLUTTER Impulses travel in circular course in atria:

ATRIAL FLUTTER Impulses travel in circular course in atria Rapid flutter waves, ventricular response irregular

Atrial Flutter:

Atrial Flutter

Multifocal Atrial Tachycardia– different P waves in same lead. :

Multifocal Atrial Tachycardia– different P waves in same lead . Rate 100-250/bpm P wave two or more ectopic P waves with different morphologies QRS normal Conduction P-R intervals vary Rhythm irregular COPD is the most common underlying cause.

MAT:

MAT

WANDERING PACEMAKER Impuses originate from varying points in atria:

WANDERING PACEMAKER Impuses originate from varying points in atria Variation in P-wave contour, P-R and P-P interval and therefore in R-R intervals

Sinus Pause or Arrest :

Sinus Pause or Arrest

Heart blocks:

Heart blocks First degree block Second degree block Third degree block Bundle branch Block

Causes of Heart Blocks:

Causes of Heart Blocks Congenital Acquired Ischemia,cardiac surgery Digitoxicity,Betablocker Endocarditis,carditis Degeneration/calcification of conduction system Collagen vascular diseases Infiltrative disease – sarcoid, Amyloid

Clinical features:

Clinical features Symptomatic bradycardia Syncope Stokes-Adams attacks(Mobitz 2) Irregular cannon waves on JVP

Conduction system:

Conduction system

PR Interval:

PR Interval PR Interval – Onset of P to onset of QRS Normal – 120 –200msec or 3 –5 small squires Atrial Depolarisation

A-V BLOCK, FIRST DEGREE:

A-V BLOCK, FIRST DEGREE A-V BLOCK, FIRST DEGREE Atrio-ventricular conduction lengthened P-wave precedes each QRS-complex but PR-interval is > 0.2 s

First degree block:

First degree block 1st Degree AV Block The normal PR interval is 0.12 - 0.20 sec, or 120 -to- 200 ms. 1st degree AV block is defined by PR intervals greater than 200 ms. This may be caused by drugs, such as digoxin; excessive vagal tone; ischemia; or intrinsic disease in the AV junction or bundle branch system

First degree block:

First degree block PR – 200 ms

First degree block:

First degree block

A-V BLOCK, SECOND DEGREE:

A-V BLOCK, SECOND DEGREE A-V BLOCK, SECOND DEGREE Sudden dropped QRS-complex Intermittently skipped ventricular beat

Second-degree heart block: Mobitz I or Wenchebach. Progressive lengthening of the PR interval with intermittent dropped beats :

Second-degree heart block: Mobitz I or Wenchebach . Progressive lengthening of the PR interval with intermittent dropped beats

Second degree block:

Second degree block

Mobitz II 2nd Degree AV Block:

Mobitz II 2nd Degree AV Block

Mobitz II 2nd Degree AV Block:

Mobitz II 2nd Degree AV Block

Slide 46:

A-V BLOCK, THIRD DEGREE Impulses originate at AV node and proceed to ventricles Atrial and ventricular activities are not synchronous P-P interval normal and constant, R-R interval normal and constant No Relationship between P & QRS QRS complexes normal, rate constant, 20 - 55 /min

Third degree block:

Third degree block

Blocks:

Blocks First degree Second degree – Mobitz I Second degree – Mobitz II Third degree

Management:

Management Treat primary condition Avoid rate limiting drugs Inj.Atropine Pacemaker

Diagnosis ?:

Diagnosis ?

Diagnosis ?:

Diagnosis ?

Diagnosis ?:

Diagnosis ?

RIGHT BUNDLE-BRANCH BLOCK QRS duration greater than 0.12 s Wide S wave in leads I, V5 and V6:

RIGHT BUNDLE-BRANCH BLOCK QRS duration greater than 0.12 s Wide S wave in leads I, V 5 and V 6 Fig. 19.5.A Right bundle-branch block.

RBBB:

RBBB

RBBB:

RBBB

LEFT BUNDLE-BRANCH BLOCK QRS duration greater than 0.12 s Wide S wave in leads V1 and V2, wide R wave in V5 and V6:

LEFT BUNDLE-BRANCH BLOCK QRS duration greater than 0.12 s Wide S wave in leads V 1 and V 2 , wide R wave in V 5 and V 6 Fig. 19.5.B Left bundle-branch block

LBBB:

LBBB

LBBB:

LBBB

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