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Advanced Dysrhythmias: ECG Interpretation and Management, Exams of Advanced Education

Harvard UniversityAdvanced Education

A comprehensive overview of advanced dysrhythmias, focusing on ecg interpretation and management strategies. It covers various cardiac arrhythmias, including sinus bradycardia, sinus tachycardia, atrial fibrillation, atrial flutter, premature atrial complexes, premature junctional rhythms, and junctional rhythm. Detailed explanations of ecg characteristics, underlying causes, and treatment approaches for each dysrhythmia. It also highlights key concepts such as the systematic approach to analyzing ecgs, determining heart rate from ecg strips, and improving lead conduction.

Typology: Exams

2024/2025

Available from 03/13/2025

catejohns
catejohns 🇺🇸

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ADVANCED DYSRHYTHMIAS EXAM
GRADED A+
P dwave:
PR dinterval:
QRS dcomplex:
(ST dsegment)
T dwave:
QT dinterval: d- dcorrect danswers d-• dP dwave d- datrial ddepolarization dand dcontraction
• dPR dinterval d- dtime dof dtravel dfrom dthe dSA dnode dto dAV dnode d(.12-.2)
• dQRS d- dventricular ddepolarization dand dcontraction d(.08-.12)
- dNote: dAtrial drepolarization doccurs dduring dthis dtime, dbut dcannot dbe dseen don
dEKG
• dT dwave d- dventricular drepolarization
• dQT dinterval d- dstart dof dventricular dcontraction dto dend dof drelaxation
Systematic dApproach dto danalyzing dEKG d(7 dsteps) d- dcorrect danswers d-1.
dDetermine datrial d& dventricular drate dand drhythm.
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ADVANCED DYSRHYTHMIAS EXAM

GRADED A+

P dwave: PR dinterval: QRS dcomplex: (ST dsegment) T dwave: QT dinterval: d- dcorrect danswers d-• dP dwave d- datrial ddepolarization dand dcontraction

  • dPR dinterval d- dtime dof dtravel dfrom dthe dSA dnode dto dAV dnode d(.12-.2)
  • dQRS d- dventricular ddepolarization dand dcontraction d(.08-.12)
  • dNote: dAtrial drepolarization doccurs dduring dthis dtime, dbut dcannot dbe dseen don dEKG
  • dT dwave d- dventricular drepolarization
  • dQT dinterval d- dstart dof dventricular dcontraction dto dend dof drelaxation Systematic dApproach dto danalyzing dEKG d(7 dsteps) d- dcorrect danswers d-1. dDetermine datrial d& dventricular drate dand drhythm.
  1. dIdentify dP dwaves dand dshape, dand dif dthere dare dP dwaves dfor devery dQRS.
  2. dDetermine dPR dinterval d(0.12-.2), dand dif dconsistent, dirregular dbut dwith dpattern dto dirregularity, dor djust dirregular.
  3. dDetermine dQRS dduration, dconsistency, dand dshape. d(<0.12)
  4. dIdentify dT dwave dand dshape.
  5. dIdentify dST dsegment, dand dany delevation/depression.
  6. dIdentify dany dectopic dbeats doccurring doutside dunderlying drhythm. Determining dHR dfrom dEKG dstrip d- dcorrect danswers d-Typical dheart drhythm dstrips dwill dcontain d 6 dseconds d(30 dbig dboxes)
  • dRates din da d 6 dsecond dstrip dcan dbe dobtained dby
  • dVentricular drate d= dQRS d(QRS dto dQRS-the dgaps) dx d 10
  • dAtrial drate d= dP dwaves dx d 10 OR dVentricular drate d= d 1500 d/ d# dof dsmall dboxes dbetween d 2 dQRS; dAtrial drate d= d 1500 d/ d# dof dsmall dboxes dbetween d 2 dP dwaves
  • d 1 dsmall dbox d= d.04sec, d 5 dboxes/large dbox d= d0.2sec; d 5 dlarge dboxes d= d 1 dsecond, d 15 dlarge d= d3sec To dimprove dlead dconduction... d(4) d- dcorrect danswers d-- dClean dand ddry dskin dwith dsoap dand dwater
  • dRemove dexcess dhair
  • dGentle dabrasion dof dskin dwith dclean dgauze dto dexpose depidermis d(dry dgauze, dnot dalcohol dwhich dacts das dbarrier, dskin dis da dnatural dconductor)
  • dHave dpatient dremain dstill dand dsupine Normal dSinus dRhythm d- dcorrect danswers d-• dVentricular dand datrial drate: d 60 dto d 100 dbpm
  • dVentricular dand datrial drhythm: dRegular
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dregularly dabnormal
  • dP dwave: dNormal dand dconsistent dshape; dalways din dfront dof dthe dQRS
  • dPR dinterval: dConsistent dinterval dbetween d0.12 dand d0.20 dseconds
  • dP:QRS dratio: d1: Sinus dBradycardia d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: d< d 60 dand dregular
  • dP dwave: dNormal dand dconsistent dshape; dalways din dfront dof dQRS
  • dPR dinterval: dConsistently dbetween d0.12 dand d0.2 dseconds
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dregularly dabnormal
  • dConcern d- ddecreased dcardiac doutput dand dtissue dperfusion Etiology dof dSinus dBrady d(causes) d- dcorrect danswers d-• dLower dmetabolic dneeds d- dSleep, dAthletes, dHypothyroidism
  • dVagal dstimulation d(triggers dparasympathetic) d- dVomiting, dSuctioning, dPain
  • dMedications d- dCCB, dBB, dAmiodarone
  • dIdiopathic dsinus dnode ddysfunction
  • dIncreased dintracranial dpressure
  • dP dwave: dEarly/different dP dwave dmay dbe dseen; dothers dmay dbe dconsistent
  • dPR dinterval: dConsistently dbetween d0.12 dand d0.2 dseconds
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dregularly dabnormal
  • dmostly dbenign, dnormal-short-long d(varying) dintervals dfrom dP dto dP Etiology dof dPACs d- dcorrect danswers d-• dCaffeine, dalcohol, dnicotine d(remove)
  • dStretched datrial dmyocardium
  • dAnxiety d(tx d- dcoping dmechanisms, deducation, dmeds dif dneeded)
  • dHypokalemia
  • dHypermetabolic dstates Management dwill ddepend don dfrequency dof dPACs d(treat dmanifestations das dneeded) Atrial dFibrillation d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: dAtrial drate dis d300-600; dventricular drate d120-200 dif duntreated; dboth dirregular drhythm d(irregularly dirregular)
  • dP dwave: dNo dP dwaves
  • dPR dinterval: dCannot dbe dmeasured
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dabnormal
  • dPatho d- dMultiple dectopic dfoci dlead dto duncoordinated dcontractions din dthe datria. dThe dloss dof datrial dkick dreduces dcardiac doutput dby d25-30%, dwhile dthe dpooling dof datrial dblood dleads dto dan dincreased drisk dof dclot dformation.
  • dacute dvs. dchronic d- dwhat dis dthe dperson dfeeling d(SOB, dfatigue, ddizziness, dHA, dpalpitations, dchest dpain)
  • dw/ drapid dventricular dresponse d(RVR) d- dventricular drate dis d110, datrial drate d300- 600; drate dsustained dabove d 140 doverworks dthe dheart d- dgoal dis dto ddecrease dHR Atrial dFlutter d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: dAtrial drate d250-400; dventricular drate d75-150; dboth dusually dregular drhythm
  • dP dwave: dSaw-toothed dpattern dknown das dF dwaves
  • dPR dinterval: dF dwaves dmake dit ddifficult dto dobtain
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dabnormal
  • dcaused dby done dectopic dstimulant d- dwhich dis dwhy dit dis dregularly dirregular d(unlike dafib dwhich dis dirreg. dirreg. dbc dstimulus dcomes dfrom ddifferent dplaces) A drapid, dregular datrial dimpulse drate dbtw d250-400; dAV dnode dcannot dconduct dall dimpulses d(which dis dwhy dV drate dis dlower) Treatment dof dA dfib dand dflutter d(5) d- dcorrect danswers d-• dAnticoagulation d(Aspirin, dwarfarin d(Coumadin), dNOAC
  • dNovel danticoagulants d- dXarelto/rivaroxaban, dEliquis
  • dRate dcontrol d- dBeta dblockers, dCalcium dchannel dblockers d(also dused dfor dRVR)
  • dRhythm dcontrol d- dClass dIC d- dsodium dchannel dblocker, dClass dIII d- dpotassium dchannel dblocker
  • dAntidysrhythmic ddrugs dcan dcause dmore ddysrhythmias
  • dRhythm dTherapy d- dCatheter dablation, dMaze/Mini-Maze, dConvergent
  • dLeft datrial dappendage docclusion

Non-paroxysmal dJunctional dTachycardia d- dcorrect danswers d-• dcaused dby denhanced dautomaticity din dthe djunctional darea; drhythm dsimilar dto djunctional drhythm dexcept drate dof d70-120bpm

  • dgenerally ddoesn't dhave dhemodynamic deffect, dbut dmay dindicate dunderlying dcondition d(digitalis dtoxicity, dmyocardial dischemia, dhypokalemia, dCOPD)
  • dbc dit dis dcaused dby dincreased dautomaticity, dcardioversion dis dnot dan deffective dtx Junctional dRhythm d- dcorrect danswers d-• doriginates dwithin dAV dnodal dtissue d- drate dwill dbe dat dAV dpace, d40-60bpm d(issue dwith dSA dnode dor dissue dw/ dconduction dbetween dSA dand dAV)
  • dAtrial/ventricular drate dand drhythm: dAtrial/ventricular drate d40-60 dwith dregular drhythm
  • dP dwave: dMay dbe dabsent, dafter dQRS, dor dbefore dQRS; dmay dalso dbe dinverted
  • dPR dinterval: dF dwaves dmake dit ddifficult dto dobtain
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dabnormal
  • dp dwave dinverted dbc dit dgoes dfrom dAV dnode, dup dto datria, dand ddown dto dventricles dor dsometimes dwill dnot dhave dp dwave
  • dTreatment dis dsame das dsinus dbradycardia d+ demergency dpacing dif dneeded Premature dJunctional dRhythms d- dcorrect danswers d-• dAn dimpulse dthat dstarts din dthe dAV dnodal darea dbefore dthe dnext dnormal dsinus dimpulse dreaches dthe dAV dnode; dless dcommon dthan dPACs
  • dCauses: ddigitalis dtoxicity, dHF, dCAD
  • dECG dcriteria dare dsame das dPACs dexcept dthe dP dwave dand dPR dinterval d- dp dwave dmay dbe dabsent, dmay dfollow dQRS, dor dmay doccur dbefore dQRS dbut dwith dPR dof dless dthan d0.
  • drarely dproduces dsignificant dsymptoms; dtx dis dsame das dfrequent dPACs Atrioventricular dNodal dReentry dTachycardia d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: dAtrial drate d150-250; dventricular drate d120-200; dregular dwith dsudden donset dand dtermination dof dtachycardia
  • dP dwave: dMay dbe ddifficult dto ddiscern
  • dPR dinterval: dIf dP dwave dis ddiscerned, dusually dless dthan d0.12 dseconds
  • dQRS dshape dand dduration: dUsually dnormal, dbut dmay dbe dabnormal
  • dTreatment d- dtreating ds/s dand dbreaking dreentry dof dimpulse dthrough dcatheter dablation *SVT d- dan dumbrella dterm d- dtachycardia ddue dto dsomething dabove dthe dventricle
  • dIf dP dwaves dcannot dbe didentified, dthe dAVNRT dmay dbe dcalled dsupraventricular dtachycardia d(SVT), dand dmay dbe dtreated dwith drapid dIVP d 6 dmg dadenosine. *if dp dwaves dappear dwhen dadenosine dis dgiven, dit dis dAVNRT d- dslows dAV dconduction dso dwill ddetermine dthe dcause Premature dVentricular dComplex d(PVC) d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: dRate dwill ddepend don dunderlying drhythm; dPVC drhythm dis dirregular ddue dto dearly dQRS
  • dQRS dshape dand dduration: dBizarre, dabnormal dshape; dduration d0.12 dseconds dor dmore d(widened)
  • dneither dSA dor dAV dare dworking; dpurkinje dfibers dtake dover d(20-40bpm, dcompromised doutput) Aystole d- dcorrect danswers d-• dAtrial/ventricular drate dand drhythm: dNo dheartbeat
  • dP dwave: dMay dbe dapparent dfor dshort dduration
  • dPR dinterval: dCannot dmeasure
  • dQRS dshape dand dduration: dAbsent treatment d- dcorrection dof dHs/Ts dand duse dof depinephrine dwith dhigh dquality dCPR d(assessment dfirst, dnot dcpr) check dpatient, dcheck dleads 1˚ dAV dBlock d- dcorrect danswers d-*prolonged dPR dinterval)
  • dAtrial/ventricular drate dand drhythm: dDepends don dunderlying drhythm
  • dP dwave: dIn dfront dof dQRS dcomplex; dshows dsinus drhythm, dregular dshape
  • dPR dinterval: d> d0.20 dseconds d(greater dthan d3-5 dboxes) dconsistently
  • dQRS dshape dand dduration: dUsually dnormal, dmay dbe dabnormal
  • doften dnot dtreated, dmust dconsider dpossibility dof dfurther ddevelopment d- dtreat dsymptoms, dsuch das dlow dBP, ddizziness d(fluid dbolus, dreassess, datropine dif dlow dHR) 2˚ dAV dBlock dType d 1 d- dcorrect danswers d-**PR dgets dlonger duntil dQRS dfinally ddrops, drepeats)
  • dAtrial/ventricular drate dand drhythm: dDepends don dunderlying drhythm; dventricular drate dlower dthan datrial drate; dPP dinterval dregular dwith dRR dinterval dgradually dshortening duntil danother dlong dRR dinterval
  • dP dwave: dIn dfront dof dQRS dcomplex; dshape ddepends don dunderlying drhythm
  • dPR dinterval: dBecomes dlonger dwith dsucceeding dEKG dcomplex duntil dthere dis da ddropped dQRS dwith dpattern drepeating dafter deach ddrop
  • dQRS dshape dand dduration: dUsually dnormal, dmay dbe dabnormal
  • dMostly dasymptomatic, dgive datropine dif dHR dneeds dto dbe dincreased 2˚ dAV dBlock dtype d 2 d- dcorrect danswers d-*regular dP dbeats, ddropped dQRS dbeats d- dirregular dRR
  • dAtrial/ventricular drate dand drhythm: dDepends don dunderlying drhythm; dventricular drate dlower dthan datrial drate; dPP dinterval dregular dwith dRR dinterval dusually dregular, dbut dmay dbe dirregular ddepending don dP:QRS dratio
  • dP dwave: dIn dfront dof dQRS dcomplex; dshape ddepends don dunderlying drhythm
  • dPR dinterval: dPR dinterval dis dconstant dfor dP dwaves djust dbefore dQRS dcomplexes
  • dQRS dshape dand dduration: dUsually dabnormal, dmay dbe dnormal 3˚ dAV dBlock d- dcorrect danswers d-two dseparate dpacemakers, datria dand dventricles dpumping dto ddifferent dsignals)
  • dAtrial/ventricular drate dand drhythm: dRate ddepends don dthe descape drhythm dand datrial drhythm; dventricular drate dlower dthan datrial drate; dPP dinterval dis dregular dand dRR dinterval dis dregular, dbut dthey dare dnot dequal dto deach dother
  • dP dwave: dDepends don dunderlying drhythm
  • dPR dinterval: dVery dirregular
  • dQRS dshape dand dduration: dDepends don descape drhythm *analyze dentire dstrip, dsynchronized dbeat dis donly da dcoincidence; dmay dneed dpacing dfor dlow dHR Treatment dfor d3˚ dAV dBlock d- dcorrect danswers d-see dbradycardia dalgorithm
  • dTranscutaneous dpacing dperformed dby dmost ddefibrillators. dDue dto dimpulse dtravel, dcan dcause dsignificant ddiscomfort d(analgesics, dnot dlong dterm, dwill dneed dtransvenous dpacing) Treatment dfor dBradycardia d(modified) d- dcorrect danswers d-1 d- dMaintain dpatent dairway, dassist dbreathing das dneeded d( dO2, dECG, dBP, doximetry, dIV daccess)
  1. dPromote dadequate dperfusion d(observe d+ dmonitor)
  2. dSigns dof dpoor dperfusion d(AMS, dshock, dchest dpain)
  • dPrepare dfor dtranscutaneous dpacing; duse dw/o ddelay dfor dhigh-degree dblock d(type dII d2˚ dand d3˚)
  • dConsider datropine d0.5mg dIV dwhile dawaiting dpacer. dMay drepeat dto da dtotal ddose dof d3mg; dif dineffective, dbegin dpacing
  • dConsider depi d(2-10mcg/min) dor ddopamine d(2-10mcg/kg/min) dinfusion dwhile dawaiting dpacer dor dif dpacing dineffective
  1. dprepare dfor dtransvenous dpacing, dtreat dcontributing dcauses, dconsider dexpert dconsultation Treatment dfor dadult dtachycardia d- dcorrect danswers d-1. dAssess dappropriateness dfor dclinical dcondition
  2. dIdentify dand dtreat dunderlying dcause d- dmaintain dpatent dairway, dO2 dprn, dcardiac dmonitor d(rhythm, dBP, doximetry)
  3. dIf dcausing dhypotension, dAMS, dsigns dof dshock, dischemic dchest ddiscomfort, dacute dHF d- dsynchronized dcardioversion d- dConsider dsedation; dif dregular dnarrow dcomplex, dconsider dadenosine d(slows dAV dconduction)
  4. dNo dS&S dbut dWide dQRS? d(>0.12) d= dIV daccess dand d12-lead dECG, dconsider dadenosine d(if dregular dand dmonomorphic), dconsider dantiarrhythmic dinfusion, dconsider dexpert dconsultation
  • dStable dwide d- dprocainamide, damiodarone, dsotalol
  1. dNo dWidened dQRS: dIV daccess dand d12-lead dECG, dvagal dmaneuvers, dadenosine d(if dregular), dBB dor dCCB, dconsider dexpert dconsultation Treatment dof dVentricular dFibrillation d(w/ dpulseless darrest) d- dcorrect danswers d-• dDefibrillation dfor dpulseless dventricular dtachycardia/fibrillation duses dhigher dvoltage