Arrhythmia Recognition: The Art of Interpretation

by Garcia, Tomas B.; Miller, Geoffrey T.

• ISBN13: 9780763722463
• ISBN10: 0763722464
• Edition: 1st
• Format: Paperback
• Copyright: 2003-11-26
• Publisher: Jones & Bartlett Learning

Summary

An American Journal of Nursing 2004 Book of the Year! Arrhythmia Recognition: The Art of Interpretation uses hundreds of four-color graphics to communicate the complex topics related to arrhythmia recognition. The text focuses on the pathophysiological mechanisms involved in the formation and maintenance of complex arrhythmias and on their clinical recognition. Each rhythm strip provides a descriptive table outlining the various abnormalities in a logical, easy-to-follow sequence. In addition, there are analytical narratives outlining what providers should consider when approaching the strip. The tables and analytical narratives are intended to formulate functional interpretative skills to consider when approaching a complex arrhythmia in a clinical situation. There are hundreds of individual rhythm strips contained within the text, each with a small descriptive table outlining the various abnormalities in a logical, easy-to-follow sequence. In addition, there are small descriptive narratives outlining the authorrs"s thought processes when approaching the strip. This table and description process is intended to formulate functional interprepative skills for the student when approaching a complex arrhythmia in a clinical situation. This text also contains over 100 test strips to sharpen students' skills in approaching unknown rhythms. Each of the test strips also contains the tables and narratives outlined above so that students can check their rationale against the authorrs"s. Arrhythmia Recognition: The Art of Interpretation is the third book in a series which covers the various levels of electrocardiographic education including 12-Lead ECGs and Arrhythmias.

Table of Contents

Introduction to Arrhythmia Recognition	p. 1
Anatomy	p. 2
Gross Anatomy	p. 2
Anterior View	p. 2
The Heart in Cross Section	p. 2
The Heart as a Pump	p. 3
Pump Function Simplified	p. 3
Cardiac Output	p. 3
Passive Pumping	p. 4
Active Pumping	p. 5
The Electrical Conduction System	p. 7
Pacemaker Function	p. 10
Pacemaker Settings	p. 11
The Sinoatrial (SA) Node	p. 11
The Internodal Pathways	p. 12
The Atrioventricular (AV) Node	p. 12
The Bundle of His	p. 13
The Left Bundle Branch (LBB)	p. 13
The Right Bundle Branch (RBB)	p. 14
The Left Anterior Fascicle (LAF)	p. 14
The Left Posterior Fascicle (LPF)	p. 15
The Purkinje System	p. 15
Chapter Review	p. 17
Electrophysiology	p. 18
Mechanics of Contraction	p. 18
Ion Movement and Polarity	p. 18
Membrane Channels and Action Potential Phases	p. 20
Introduction to the Nervous System and Cardiac Function	p. 21
Central Nervous System (CNS)	p. 21
Peripheral Nervous System (PNS)	p. 22
Chapter Review	p. 26
Vectors and the Basic Beat	p. 27
Adding and Subtracting Vectors	p. 27
The Electrical Axis of the Heart	p. 28
Electrodes and Waves	p. 28
Leads Are Like Pictures of the Heart	p. 28
Lead Placement (Where to Put the "Cameras")	p. 29
How the Machine Manipulates the Leads	p. 29
The Two Lead Systems	p. 30
The Hexaxial System	p. 30
The Precordial System	p. 30
The Basic Beat	p. 31
Introduction to Basic Components	p. 31
Wave Nomenclature	p. 32
R' and S' Waves	p. 32
Individual Components of the ECG Complex	p. 32
The P Wave	p. 32
The Tp Wave	p. 33
The PR Segment	p. 33
The PR Interval	p. 33
The QRS Complex	p. 34
The ST Segment	p. 35
The T Wave	p. 35
The QT Interval	p. 36
The U Wave	p. 37
Additional Intervals	p. 38
Chapter Review	p. 39
The Rhythm Strip, Tools, and Calculating Rates	p. 40
Boxes and Sizes	p. 40
Calibration	p. 41
Temporal Relationship of Multiple-Lead Strips	p. 41
Why is Temporal Spacing Important?	p. 41
ECG Tools	p. 42
Calipers: The Clinician's Best Friend	p. 43
How to Use Your Calipers	p. 43
Comparing Widths	p. 44
ECG Rulers	p. 45
Straight Edge	p. 45
The Rate	p. 46
Establishing the Rate	p. 46
Normal and Fast Rates	p. 46
Bradycardic Rates	p. 47
Chapter Review	p. 49
Basic Concepts in Arrhythmia Recognition	p. 50
Introduction	p. 50
Artifact	p. 50
Premature Complexes	p. 51
Escape Complexes and Rhythms	p. 51
Ectopic Foci and Their Morphologies	p. 52
Ectopic Foci in the Ventricles	p. 56
Aberrancy	p. 57
Fusion	p. 59
The Isolated Electrocardiographic Type of Fusion	p. 60
Actual Fusion	p. 60
Chapter Review	p. 62
Relevant Topics in Basic Electrocardiography	p. 63
Introduction	p. 63
Basic Information	p. 63
Localizing an Area: Inferior Wall	p. 64
Localizing Other Areas	p. 64
The Electrical Axis	p. 65
How to Calculate the Electrical Axis	p. 66
Bundle Branch Blocks	p. 69
What Happens if One Side is Blocked?	p. 70
Right Bundle Branch Block (RBBB)	p. 71
Left Bundle Branch Block (LBBB)	p. 73
Chapter Review	p. 75
Arrhythmias: A Quick Review	p. 76
Major Concepts	p. 76
General	p. 76
P Waves	p. 76
QRS Complexes	p. 77
Individual Rhythms	p. 77
Supraventricular Rhythms	p. 77
Ventricular Rhythms	p. 85
Heart Blocks	p. 90
Chapter Review	p. 93
Sinus Rhythms	p. 95
Normal Sinus Rhythm	p. 96
Introduction to Sinus Rhythms	p. 96
Normal Sinus Rhythm	p. 97
The Formation of the ECG	p. 97
Regularity	p. 103
Regularly Irregular Rhythms	p. 104
Irregularly Irregular Rhythms	p. 105
ECG Strips	p. 108
Chapter Review	p. 113
Sinus Bradycardia	p. 114
When is Sinus Bradycardia Considered a Cardiac Emergency?	p. 115
ECG Strips	p. 116
Chapter Review	p. 119
Sinus Tachycardia	p. 120
A Quick Clinical Word	p. 123
Clinical Characteristics	p. 124
Rate	p. 124
ECG Strips	p. 125
Chapter Review	p. 129
Sinus Arrhythmia	p. 130
Respiratory Sinus Arrhythmia	p. 131
Nonrespiratory or Nonphasic Sinus Arrhythmia	p. 133
Some Additional Clinical Points	p. 133
ECG Strips	p. 135
Chapter Review	p. 141
Sinus Blocks, Pauses, and Arrests	p. 142
Sinus Block	p. 142
Sinus Pause and Sinus Arrest	p. 143
ECG Strips	p. 145
Chapter Review	p. 147
Section 2 Self-Test	p. 148
Section 2 Self-Test Answers	p. 155
Atrial Rhythms	p. 165
Premature Atrial Contraction	p. 166
The P Wave Axis	p. 168
PACs and the PR Interval	p. 170
The Pause	p. 171
The PAC and Aberrancy	p. 174
The Hidden PAC	p. 174
P Falling on a T	p. 175
Blocked PACs	p. 175
ECG Strips	p. 178
Chapter Review	p. 182
Ectopic Atrial Rhythm	p. 183
Diagnostic Challenges	p. 183
Hint #1	p. 184
Hint #2	p. 184
ECG Strips	p. 187
Chapter Review	p. 190
Ectopic Atrial Tachycardia	p. 191
ECG Strips	p. 194
Chapter Review	p. 197
Ectopic Atrial Tachycardia with Block	p. 198
Diagnostic Criteria	p. 198
P Waves in EAT with Block	p. 199
The Problem with Lead II	p. 200
ECG Strips	p. 203
Chapter Review	p. 206
Wandering Atrial Pacemaker	p. 207
Wandering Atrial Pacemaker: The Classical Definition	p. 207
Wandering Atrial Pacemaker: A Clinical Variation	p. 208
ECG Strips	p. 211
Chapter Review	p. 214
Multifocal Atrial Tachycardia	p. 215
Clinical Scenario	p. 217
ECG Strips	p. 218
Chapter Review	p. 221
Atrial Flutter	p. 222
General Overview	p. 222
The Making of the Saw-Tooth Pattern	p. 222
AV Nodal Conduction Rates	p. 225
Atrial and Ventricular Rates	p. 225
Recognizing Atrial Flutter	p. 226
Atrial Flutter and Wide-Complex Tachycardias	p. 228
ECG Strips	p. 231
Chapter Review	p. 235
Atrial Fibrillation	p. 236
General Information	p. 236
How f Waves Are Created	p. 236
Ventricular Response	p. 238
Clinical Implications	p. 239
Regular Ventricular Response in Atrial Fibrillation	p. 239
The Morphology of the Complexes in Atrial Fibrillation	p. 240
ST Segments and T Waves	p. 241
ECG Strips	p. 243
Chapter Review	p. 248
Section 3 Self-Test	p. 249
Section 3 Self-Test Answers	p. 256
Junctional Rhythms	p. 267
Introduction to Junctional Rhythms	p. 268
A Closer Look at the AV Node	p. 268
The Junction as a Pacemaker	p. 269
Junctional Rhythms: An Overview	p. 272
Chapter Review	p. 274
Junctional Rhythm	p. 275
Junctional Escape Complexes and Rhythms	p. 275
ECG Strips	p. 277
Chapter Review	p. 281
Premature Junctional Contraction	p. 282
ECG Strips	p. 286
Chapter Review	p. 290
Rapid Junctional Rhythms	p. 291
Pseudo-S and Pseudo-R' Waves	p. 292
ECG Strips	p. 294
Chapter Review	p. 298
AV Nodal Reentry Tachycardia	p. 299
General Overview	p. 299
General Concepts in AV Nodal Reentry	p. 299
Reentry and AVNRT	p. 304
Identifying the Arrhythmia	p. 308
ECG Strips	p. 310
Chapter Review	p. 316
AV Reentry Tachycardia	p. 317
Normal Conduction Through an Accessory Pathway	p. 317
AVRT Reentry Circuits	p. 318
Orthodromic AVRT	p. 318
The P Wave and AVRT	p. 319
Other Important Clinical Facts	p. 320
Antidromic AVRT	p. 321
ECG Strips	p. 323
Chapter Review	p. 326
How to Approach a Narrow-Complex Tachycardia	p. 327
The Hemodynamic Consequences of a Tachycardia	p. 327
Heart Rate and Hemodynamics	p. 327
A Few Extra Seconds...	p. 330
Focused Treatment Requires Focused Identification	p. 330
What to Look for in an SVT	p. 330
Rate	p. 330
Regularity	p. 331
The P Wave	p. 331
The P-QRS Relationship	p. 332
The Company It Keeps	p. 333
A Final Word	p. 334
Chapter Review	p. 335
Section 4 Self-Test	p. 336
Section 4 Self-Test Answers	p. 343
Ventricular Rhythms	p. 353
Introduction to Ventricular Rhythms	p. 354
Morphology	p. 354
The Ventricle as a Pacemaker	p. 358
The P Wave in Ventricular Rhythms	p. 358
P Wave Morphology in Ventricular Rhythms	p. 358
The P:QRS Relationship in Ventricular Rhythms	p. 358
Ventricular Rhythms: General Overview	p. 362
Chapter Review	p. 363
Premature Ventricular Contraction	p. 364
General Overview	p. 364
Coupling Interval	p. 365
Compensatory vs. Noncompensatory Pauses	p. 367
Unifocal vs. Multifocal PVCs	p. 367
Bigeminy, Trigeminy, and More	p. 367
Couplets, Triplets, and Salvos	p. 369
The P Wave and PVCs	p. 370
Fusion Complexes	p. 371
ECG Strips	p. 373
Chapter Review	p. 378
Ventricular Escape and Idioventricular Rhythms	p. 379
General Overview	p. 379
Ventricular Escape Complexes	p. 379
Idioventricular Rhythm	p. 380
Accelerated Idioventricular Rhythm	p. 381
Capture Beats	p. 382
ECG Strips	p. 385
Chapter Review	p. 391
Ventricular Tachycardia	p. 392
General Overview	p. 392
Reentry and Other Possible Mechanisms	p. 393
The presence of an electrical circuit with at least two pathways	p. 393
The two pathways must have different properties	p. 394
An area of slowing in one of the circuits--just enough to allow the rest of the circuit to get over its refractory period	p. 395
General Characteristics of VTach	p. 397
Morphology of the Complexes and Arrhythmia Recognition	p. 397
Regularity	p. 398
AV Dissociation	p. 398
Similar Morphology to PVCs	p. 399
Nonsustained Monomorphic Ventricular Tachycardia	p. 400
Sustained Monomorphic Ventricular Tachycardia	p. 401
Ventricular Flutter	p. 402
ECG Strips	p. 403
Chapter Review	p. 409
Polymorphic Ventricular Tachycardia and Torsade de Pointes	p. 410
General Overview	p. 410
Polymorphic Ventricular Tachycardia	p. 410
Torsade de Pointes	p. 411
Onset of Torsade de Pointes	p. 412
The Turning of the Points	p. 413
Causes of Torsade de Pointes	p. 415
ECG Strips	p. 417
Chapter Review	p. 420
How to Approach a Wide-Complex Tachycardia	p. 421
General Overview	p. 421
The Approach	p. 422
AV Dissociation	p. 422
Capture Beats	p. 424
Fusion Complexes	p. 424
P Waves	p. 426
Regular or Irregular?	p. 427
Morphology	p. 428
Electrical Axis in the Extreme Right Quadrant	p. 433
Concordance in the Precordial Leads	p. 434
History	p. 434
Physical Examination	p. 436
Case Discussion	p. 437
Physical Examination	p. 437
What do you think of the patient's history?	p. 437
What do you think of this patient's physical examination?	p. 438
What do you think of this patient's rhythm?	p. 439
How can you put it all together?	p. 441
Chapter Review	p. 442
Ventricular Fibrillation and Asystole	p. 443
Ventricular Fibrillation	p. 443
Asystole	p. 446
Agonal	p. 447
ECG Strips	p. 448
Chapter Review	p. 450
Section 5 Self-Test	p. 451
Section 5 Self-Test Answers	p. 458
Additional Rhythms and Information	p. 469
Atrioventricular Block	p. 470
General Overview	p. 470
First-Degree AV Block	p. 472
Second-Degree AV Block	p. 477
Second-Degree AV Block or Wenckebach	p. 477
Mobitz I Second-Degree AV Block: A Final Word	p. 484
Second-Degree AV Block	p. 487
Untypable or 2:1 Second-Degree AV Block	p. 492
High-Grade or Advanced AV Block	p. 495
Complete or Third-Degree AV Block	p. 497
Chapter Review	p. 506
Artificially Paced Rhythms	p. 507
General Overview	p. 507
Pacemaker Code	p. 507
The Pacemaker Spike	p. 509
QRS Morphology in a Paced Rhythm	p. 510
Popular Pacemaker Modes	p. 510
Atrial Demand Pacemaker	p. 511
Ventricular Demand Pacemaker	p. 512
AV Sequential	p. 512
Automatic Pacemaker	p. 512
ECG Strips	p. 514
Chapter Review	p. 520
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