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Cardiac Dysrhythmias
Sinus Dysrhythmias
Bradycardia
- A Sinus Rhythm
That Is <60 BPM
Tachycardia
- A Sinus Rhythm
That Is > 100 BPM
Respiratory Arrhythmia
• During Inspiration & Expiration,
The R-R Interval Expands &
Contracts
• R-R Interval Widens During
Expiration
• R-R Interval Shortens During
Inspiration
Sinus Arrest
Sinus Arrest
Occurs Because
The Sinoatrial Node Ceases To
Fire
Sinus Arrest
Escape Or Rescue Beats
Secondary
Pacemakers Rescue
The Heart & Create Escape Or
Rescue Beats
Rescue
Beats May Have Their
Origin High Up In The Atria Or
Down Low Close To The AV
Node Or Even In The Ventricles.
If The Ectopic Pacemaker Is
Close To The SA Node, It Will Be
An Atrial Escape Beat. It Will
Have These Features :
The
Escape Beat Is Delayed
P Wave Is Irregularly Shaped
A Normal QRS Complex
Atrial Escape Or Rescue Beat
If
The Rescue Beat Is Close To
The AV Node, Then It Will
Likely Be A Junctional Escape
Beat
Characteristics Of A Junctional
Escape Beat :
A Rescue
Beat Is Delayed
No P Wave
The QRS Is Normal
Rate Will Be Slower
Junctional Rescue Or Escape Beat
If
The Rescue Beat Is Located In
The Ventricles, Then It Is A
Ventricular Pacemaker That Is
Activated To Rescue The Heart
Characteristics Of A Ventricular
Rescue Beat Are :
No
P Wave
A Rescue Beat Is A Delayed Beat
Wide Bizarre QRS Complex
Rate Will Be Very Slow
Ectopic
Pacemakers Have Their
Own Firing Rates
A Maxim : The Lower Your Go Into
The Heart To Find A Pacemaker, The
Slower The Rate
Ectopic Pacemaker Rates
Atrial
Pacemakers ~ 60-80 BPM
Junctional Pacemakers ~ 40-60 BPM
Ventricular Pacemakers ~ 30-45 BPM
What Can Cause The SA Node
To Go Into Sinus Arrest ?
Cardiovascular
Disease
Increased Vagal Tone
Infection
Drugs - Digitalis, Quinidine
Wandering Pacemaker
A Wandering Pacemaker Is A
Condition In Which You Have
Two Or More Pacemakers
Competing For Control Over
The Heart’s Rhythm
Characteristics Of A Wandering
Pacemaker :
P Waves
Have Different Shapes
PR Intervals Are Grossly Within
Normal Limits But Are Slightly
Variant From Each Other
QRS Complexes Are Normal
Wandering Pacemaker
Wandering Atrial Pacemaker
Sick Sinus Syndrome
Patient
Hx. Of Supraventricular
Tachdysrhythmias Like Atrial
Fibrillation Or Atrial Flutter
Significant Ischemic Heart Disease
Sick Sinus Syndrome
Characterized By :
Irregular
Heart Rate Deteriorating
Into Extreme Bradycardia
Episodes Of Syncope
Leads To Pacemaker Implant
Sick Sinus Syndrome
Ectopic Supraventricular
Dysrhythmias
Unsustained SVTD’s:
PAC’s
PJB’s
Or APB’s
Premature Atrial Contractions
(PAC’s Or APB’s)
Characteristics Of PAC’s :
It
Is A Premature Beat
P Wave Is Irregularly Shaped
Normal QRS
Causes Of PAC’s :
Stress
Caffeine
Tobacco
Use
Digitalis
Toxicity
Old MI’s
Low Blood Potassium Levels
Low Blood Magnesium Levels
Premature Atrial Contraction
Premature Atrial Contraction
PAC’s Can Deteriorate Into :
Atrial
Flutter
Atrial Fibrillation
Supraventricular Tachycardia
Premature Junctional
Beats (PJB’s)
PJB’s Occur from An Ectopic
Focus Close To The AV Node
Characteristics
Of PJB’s :
The Beat Is Premature
There is No P Wave
QRS Complex Is Normal
Premature Junctional Beat
Sustained Supraventricular
Dysrhythmias
Sustained SVTD’s Are :
PSVT
or PAT
Atrial Flutter
Atrial Fibrillation
PSVT Or PAT’s
Common
Dysrhythmia
Instigated Often By A Premature
Atrial Beat Or A Premature
Junctional Beat
Causes Are :
Ischemic
Heart Disease
Re-Entry Phenomenon
Stress
Drugs
Characteristics Of PSVT Are :
P Waves Are Absent
- P Waves Are
Hidden If They Are Present
Repeating Pattern Of QRS-T
Very High Heart Rates Of 150 250 BPM
Paroxysmal Atrial Tachycardia
Carotid Massage Can Bring A
Person Out Of PSVT
PSVT Can Be Stopped With
Cardioversion, Valsalva &
Coughing
Exercise
Can I Exercise A Patient With
PSVT Or SVT ?
 No !! This Patient Has An
Uncontrolled Atrial Dysrhythmia
Atrial Flutter
Atrial Flutter Is Also Known As
The Sawtooth Pattern
Characteristics Of Atrial Flutter :
High
Rate Of P Wave Appearance
Of 250-350
QRS Complex Is Followed By A
Regular Pattern Of P Waves - 2:1,
3:1 or 4:1 Block
QRS
Complexes Are Normal
& Regular
No Visible T Waves
No Visible S-T Segment
No Visible PR Interval
Causes Of Atrial Flutter :
Ischemic
Heart Disease
PAC’s
Re-Entry
Phenomenon
Pulmonary
Emboli
Stress
MI’s
Cor
Pulmonale
Valvular Heart Disease
Atrial Flutter
Exercise
Can I Exercise A Patient With
Atrial Flutter ?
 No !! This Patient Has An
Uncontrolled Atrial Dysrhythmia
Atrial Fibrillation
Some Causes Are :
MI’s
Pulmonary
Embolism
Hypertension
CAD
Heart Valve Disease
Characteristics Are :
High
Rates Of Atrial Discharge Of
Between 350-500 BPM
Flat Or Undulating Baseline
Absent P Waves
Irregularly Timed Normal QRS
Complexes
Atrial Fibrillation
Atrial Fibrillation
Exercise
Can I Exercise A Patient In Atrial
Fibrillation ?
 NO !! - The Patient Has An
Uncontrolled Atrial Dysrhythmia
Symptoms
What Will The Patient Feel With A
Supraventricular Tachydysrhythmia ?
Lightheadedness
Dizziness Or Syncope
Shortness Of Breath
Palpitations
Angina
Can A Patient Chronically Live
With These Dysrhythmias ?
Yes,
But There Are Some
Inherent Dangers !
Inherent Dangers
 Supraventricular Tachydysrhythmias
Can Cause The Formation Of Blood
Clots In The Atria.
 Patients
Can Auto-Embolize
Organ Systems If The Heart
Spontaneously Converts Out Of
The Dysrhythmia
 Patients
Must First Be AntiCoagulated & Then Converted
Out Of The Dysrhythmia
Ectopic Ventricular
Dysrhythmias
Premature Ventricular
Contractions (PVC’s)
Ventricular Tachycardia
Ventricular Fibrillation
Premature Ventricular
Contractions
PVC’s
Occur In Normal Hearts As
Well As Those With Pathology
People With Thousands Of PVC’s
Per Day Can Be Normal
PVC’s Can Also Be An Ominous
Sign Of Disease
Characteristics Of PVC’s Are :
PVC’s Are
Premature Beats
The P Wave Is Absent
QRS Complex Is Wide & Bizarre
A Compensatory Pause Follows
The PVC
Premature Ventricular Contractions
Premature Ventricular Contractions
PVC’s May Appear Randomly
PVC’s May Appear In Patterns
Bigeminy
Trigeminy
Bigeminy
Bigeminy
Trigeminy
Quadrigeminy
Couplets
Triplets
Couplets
Triplets
Couplets Are Scary But Triplets
Are Really Frightening
Triplets Are A Hair’s Breath Away
From Ventricular Tachycardia
Multiform PVC’s
Rules Of Malignancy
An Ordering System For
Grading The Severity Of
Ventricular Ectopies
From Least Severe To
Most Severe
Frequent
Single Focus PVC’s
Runs Of PVC’s
Quadrigeminy
Trigeminy

Bigeminy
Appearance
Of Multifocal PVC’s
RT On T Phenomenon
Ventricular Tachycardia
Ventricular Fibrillation
RT On T Phenomenon
Thought To Be Very Dangerous
A PVC Occurs During
Ventricular Depolarization
RT On T Phenomenon
 Why
Is It Dangerous ?
• The Cardiac Cells Are Various
Stages Of Depolarization - Some
Have Repolarized While Others
Are In Various Stages Of
Repolarization
• A Stimulus That Occurs Before
Repolarization Is Finished Will Set
Off A Disorganized Electrical
Response To The Stimulus & May
Set The Heart Up For A Malignant
Ventricular Ectopy Like V-Tach Or
V-Fib.
Exercise
Can I Exercise A Patient Who Is
Having PVC’s ?
Yes, You Can Exercise A Patient
Having PVC’s. However, They
Should Only Be Occasional
Single Focus Single PVC’s.
If The Exercise Regimen Makes
The Incidence Of PVC’s Occur
More Often Or If The PVC’s
Become More Malignant,
Exercise Should Be Terminated.
A Person Should Not be
Exercised When They Are
Displaying Multiforme PVC’s Or
Any PVC Rhythm (Bigeminy,
etc.) Until Cleared By Their
Cardiologist
The ACSM Guidelines
The ACSM Guidelines State :
If There Is A “Noticeable Change
In Heart Rhythm”….
...or “Signs Of Poor Perfusion:
Light Headedness, Confusion,
Ataxia, Pallor, Cyanosis, Nausea,
Or Cold & Clammy Skin” Then
STOP THE EXERCISE !!!
Table 3-10, pp 42, 5th edition
Ventricular Tachycardia
Ventricular Tachycardia Is
Defined As A Run Of Three Or
More Consecutive PVC’s
The Rate Is Usually Between
100-200 BPM
Short Runs Of V-Tach Will
Make The Patient Feel :
Dizzy
Have
Palpitations
Feel Faint
Be Short Of Breath
Sustained Runs OF V-Tach Will
Render The Patient Unconscious
Because The Cardiac Output Is
So Negatively Effected As To
Decrease Perfusion To The Brain
& The Heart.
Ventricular Tachycardia
Ventricular Tachycardia Will
Degenerate Quickly Into
Ventricular Fibrillation
The Patient In V-Tach Must Be
Supported With CPR Methods &
Must Be Cardioverted Electrically
Or Pharmacologically Out Of This
Fatal Rhythm
Both V-Tach & V-Fib Are
Absolute Medical Emergencies
Requiring High Level Medical
Management
Ventricular Fibrillation
V-Fib Is Seen In Hearts That
Are Dying
Electrical Activity is Completely
Chaotic
No Meaningful Cardiac Output
Is Occurring
V-Fib Is Characterized By :
No True QRS Complexes
A Wandering Or Undulating Baseline
No Recognizable Atrial Wave Forms
No Recognizable T Waves
The Patient Must Be Supported
By CPR Methods & Must Be
Electrically Cardioverted Out Of
This Rhythm Or Death Ensues
Ventricular Fibrillation
Exercise
Exercise Cannot be Sustained In
Patients With V-Tach Or V-Fib
Because 99.99 % Of The Time
They Will Be Unconscious Exercise Is Never An Option
Atrioventricular Blocks
First Degree AV Blocks
Second Degree AV Blocks
• Mobitz Type I (Wenckebach Block)
• Mobitz Type II
Third Degree AV Blocks
First Degree AV Blocks
Characterized By :
• Prolonged PR Interval > 5 mm
• Every QRS Is Preceded By A P Wave
• Every QRS Is Normal
• No Dropped Beats
First Degree AV Block
First Degree AV Block
Causes :
Drug
Toxicity
Ischemic Heart Disease Of The
Heart’s Conduction System
Myocarditis
First Degree AV Block Does
Appear In Healthy Individuals
As Well As In Those With
Ischemic Heart Disease
Exercise
Can I Exercise A Patient In First
Degree AV Block ?
Yes, But The Rhythm Must Not
Degenerate During Exercise To
Second Degree AV Block.
Also, The Rhythm Had To Have
Been Present Before Exercise
Started. If A Patient Is Normal
On Their EKG Before Exercise
& Degenerates Into First Degree
AV Block, Exercise Must Stop !!
First Degree AV Block Is
Generally Not Considered To Be A
Highly Malignant Dysrhythmia
Second Degree AV Block
Mobitz Type I Or A
Wenckebach Block
Second Degree AV Block Or A
Mobitz Type I AV Block Is
Characterized By :
•
•
•
•
Progressively Lengthening PR Interval
A Sudden Dropped QRS Complex
Return Of A Normal Rhythm
A Repeating Cycle
Mobitz Type I
Exercise
Can I Exercise A Patient In A
Mobitz Type I Second Degree AV
Block ?
Yes, Providing The Dysrhythmia
Does Not Degenerate During
Exercise.
 The Patient Must Also Have
Been Cleared For Exercise
A Problem Does Exist With A
Mobitz Type I AV Block !!
You Have To Be Concerned That
It Will Degenerate Into A Mobitz
Type II AV Block
Second Degree AV Block
Mobitz Type II
Characteristics Are :
A Series
Of Normal Beats
All PR Intervals Are Normal Duration
Sudden Dropped Beat - No QRS
Normal Rhythm Re-Established
Cycle Begins Again
Mobitz Type II
Mobitz Type II
Mobitz Type II AV Block Is A
Dangerous Dysrhythmia Because
Of The High Likelihood That It
Will Convert To A Third Degree
AV Block.
Exercise
Can I Exercise A Patient In A
Mobitz Type II AV Block ?
No. The Risk Is Too High That
The Patient Will Convert To
Third Degree AV Block.
A Patient With A Mobitz Type II
AV Block Is Going Eventually
Convert To A Third Degree
Block & Is A Candidate For A
Surgically Implanted Pacemaker
Third Degree AV Block
This Is A Serious Condition In
Which There Is No Communication
Of The SA Node With The AV Node.
It Is Also Called Complete Heart
Block.
The Atria Beat At Their Own
Rate While The Ventricles Beat
At Their Own Rate
The P Waves Appear & Are Not
Connected To Any QRS Complex
The QRS Are Abherrantly Wide
Ultimate Ventricular Rate Is
Often Very Bradycardic
3rd Degree AV Block
Most Patients In Third Degree
AV Block Require The
Implantation Of A Pacemaker.
Bundle Branch Blocks
 Right
Bundle Branch Block
RSR’ (Bunny Ears) In V1-V4
Loss Of The R Wave Progression
ST Segment Depression In V1 - V4
T Wave Inversion In V1 - V4
Wide QRS Complexes
 Can
you exercise a patient in
RBBB ?
 Yes
as long as they have been
cleared by their physician.
 Left
Bundle Branch Block
Loss of the R wave progression
Huge S waves in V1 - V4
RSR’ in V4 - V6
Wide QRS complexes
ST segment depression in V4 - V6
T Wave inversion in V4 - V6
 Can
you exercise a person in
LBBB ?
 Yes,
as long as the patient has
been cleared by their physician.