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Introducing the Ventricular Rhythms

Understand ventricular rhythms, including origins, components, and characteristics. Learn to identify and differentiate various rhythms like PVC, VT, VF, and asystole on EKG. Clinical implications discussed.

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Introducing the Ventricular Rhythms

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  1. 10 Introducing the Ventricular Rhythms

  2. Introducing the Ventricular Rhythms • Objectives • Discuss the origin of the ventricular rhythms • Review specific components of the electrical conduction system of the heart • Identify premature ventricular contractions, including EKG characteristics • Identify idioventricular rhythm, including EKG characteristics • Differentiate idioventricular rhythm and accelerated idioventricular rhythm

  3. Introducing the Ventricular Rhythms • Objectives (continued) • Identify ventricular tachycardia, including EKG characteristics • Identify ventricular fibrillation, including EKG characteristics • Identify ventricular asystole, including EKG characteristics • Discuss pulseless electrical activity • Discuss the clinical significance of the ventricular rhythms

  4. Origin of the Ventricular Rhythms • The rhythms are classified according to the heart structure in which they begin, or theirsite of origin • The sinoatrial (SA) node or the AV junctional tissues fails to generate an impulse • If this failure develops,the VENTRICLES will assume the role of pacing the heart

  5. Origin of the Ventricular Rhythms • Rhythms that are initiated in the area of the ventricular are called ventricular rhythms • Ventricular rhythms are the least efficient of the heart’s pacemakers; you should recall thatpatient assessmentis the most important indicator of clinical significance

  6. Components of Electrical Conduction System of the Heart

  7. Origin of the Ventricular Rhythms • Impulses that are ventricular in origin begin in the lower ventricular musculature • Impulse may travel in retrograde (backward) direction to depolarize the atria • Impulse may travel antegrade (forward) to depolarize the ventricles • Either way, the normal conduction pathway is bypassed

  8. Origin of the Ventricular Rhythms • Due to bypass, ventricular rhythms will display QRS complexes that are wide (greater than or equal to 0.12 seconds)and bizarre in appearance • Absence of P waves because they are hidden or buried in QRS complex • Remember that QRS complexes of supraventricular rhythms are commonly less than 0.12 seconds in duration

  9. Premature Ventricular Complexes (Contractions) (PVC) • Individual complexes rather than an actual rhythm • Singleectopic(out-of-place)complex that occurs earlier then the next expected complex • Arises from an irritable site in the ventricles • The significance of PVCs is based entirely upon the patient’s clinical condition

  10. Premature Ventricular Complexes (Contractions) (PVC) Premature Ventricular Complexes (Contractions) (PVC) • The underlying cadence of SA node is not interrupted by a PVC nor is SA node depolarized • PVC is usually followed by acompensatory pause • Presence of compensatory pause, coupled with wide, bizarre, and premature QRS complex’s are highly suggestive indicators of PVCs

  11. Compensatory Pause

  12. Premature Ventricular Complexes (Contractions) (PVC) Premature Ventricular Complexes (Contractions) (PVC) • PVC may fall between two sinus beats without interfering with the rhythm • Referred to as aninterpolated beat • PVCs appear in many different patterns and shapes • The morphology, or shape, of the PVC is based on the site of origin of the ectopic focus

  13. PVC Patterns of Occurrence

  14. Premature Ventricular Complexes

  15. Premature Ventricular Complexes - Unifocal

  16. Premature Ventricular Complexes - Multifocal

  17. Premature Ventricular Contractions (Complexes) OR PVCs • PVCs often indicate myocardial irritability; multifocal PVCs are more serious then unifocal PVCs • Salvos • Runs of ventricular tachycardia • Any indication of increased myocardial irritability dictates that the patient be carefully evaluated and managed

  18. Ventricular Bigeminy and Couplet PVCs

  19. Ventricular Bigeminy

  20. Ventricular Trigeminy

  21. R on T

  22. Idioventricular Rhythms • Also termedventricular escape rhythms,considered a last-ditch effort of the ventricles to try to prevent cardiac standstill • Means SA node and AV node have failed • Rate usuallyless than 40 bpm,and cardiac output is usually compromised

  23. Agonal Rhythm • Agonal rhythmis when the idioventricular rhythm fallsbelow 20 bpm • Frequentlymay be seen as the last-ordered semblance of a heart rhythm when eitherresuscitation is unsuccessfulor aftersuccessful defibrillation

  24. Idioventricular Rhythms • Causesinclude extensive myocardial damage, secondary to acute myocardial infarction, or failure of higher pacemakers • Is consideredalethal rhythmand treatment must beimmediate and aggressive

  25. Idioventricular Rhythms

  26. Accelerated Idioventricular Rhythm • May occur when the rate of the ectopic pacemaker exceeds40 bpm • Commonly accepted rate is40-100 bpm • There are no P waves or PR intervals noted

  27. Accelerated Idioventricular Rhythm

  28. Accelerated Idioventricular Rhythm • May occur in conjunction with myocardial ischemia • Can be mistaken for ventricular tachycardia • Imperative that you remember toalways assess and treat the patient,rather than the monitor or EKG strip

  29. Ventricular Tachycardia Rhythms • This rhythm is one in whichthree or more PVCs arise in sequence at arate greater than100 bpm • This rhythm commonly overrides the normal pacemaker of the heart • Often occurs rapidly and isinitiated by a PVC or by PVCs occurring in rapid succession

  30. Ventricular Tachycardia Rhythms • If rhythm is sustained, patient’s clinical condition may rapidly deteriorate • A sustained rhythm is one that lasts for more than 30 seconds • If lasts forless than 30 seconds,it is anonsustained rhythm,or simplya run of V tach

  31. Ventricular Tachycardia

  32. Ventricular Tachycardia • Is classified (based on assessment of the patient’s clinical presentation)as either pulseless V tach or V tach with a pulse • Immediate treatment is based on the presence or absence of a palpable pulse • Pulseless V tach • Immediate defibrillation

  33. Ventricular Tachycardia • Treatment of V tach with a pulse is based on patient’s clinical picture • Hemodynamically unstable • (Low blood pressure, shortness of breath, etc.)Immediate cardioversion is considered • Hemodynamically stable • ( Normal blood pressure, absence of chest pain, and no notable change in mental status )Drug intervention is appropriate

  34. Ventricular Tachycardia • Causes may include • Myocardial ischemia, hypoxia, electrolyte imbalances, increased anxiety or physical exertion, and underlying heart disease

  35. Ventricular Tachycardia Rhythm

  36. Torsades De Pointes • Similar to ventricular tachycardia • Morphology of QRS complexes showsvariations in width and shape • Resembles aturning aboutor twisting motionalong base line • May result from • Hypokalemia, hypomagnesemia, tricyclic antidepressant drug overdose, use of antidysrhythmic drugs, or combination of these

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