1. Ventricular Arrhythmias

2. Ventricular Arrhythmias
The heart normally depolarizes from the top down
When the impulse originates in the ventricles, the process is reversed and the hearts’ efficiency is greatly reduced
1.. Atria contract before the ventricles in order to pump blood effectively

3. Ventricular Arrhythmias
Most serious heart arrhythmia
The ventricles are the lowest site in the conduction system
The heart has lost its effectiveness
The heart is functioning on its last level of backup support
There is no fail safe mechanism to back up a ventricular dysrhythmia

4. Ventricular Arrhythmias
There are five Ventricular Dysrhythmias
Premature Ventricular Contractions
Ventricular Tachycardia
Ventricular Fibrillation
Idioventricular Rhythm
Asystole

5. Premature Ventricular Contractions
Not a rhythm, but rather an ectopic beat originating from an irritable ventricular focus
A PVC will come earlier than expected in the cardiac cycle and will interrupt the regularity of the underlying rhythm

6. Premature Ventricular Contractions
Because PVC’s originate in the ventricles, the QRS complex will be wider than normal
There is no P wave preceding the QRS complex
Normal QRS complex is seconds.
The rhythm did not originate in the sinus node, therefore no P wave seen.

7. Premature Ventricular Contractions
The QRS complex is usually in the opposite direction of the T wave
If the QRS is negative, the T wave is positive
If the QRS is positive, the T wave is negative

8. Premature Ventricular Contractions
Compensatory pause
The extra action potential causes the SA node to become refractory to generating its next scheduled beat. Thus it must "skip a beat" and it will resume exactly 2 P to P intervals after the last normal sinus beat.
There is a compensatory pause after the PVC. The extra action potential causes the SA node to become refractory to generating its next scheduled beat. Thus it must "skip a beat" and it will resume exactly 2 P to P intervals after the last normal sinus beat. Or PVC can be interpolated. The impulse frequently does not retrograde thru the AV node so the atria are not depolarized. This leaves the sinus node undisturbed and able to discharge again at its’ expected time The PVC is followed by no pause at all but rather it squeezed itself in between two regular complexes and didn’t disturb the pattern of the sinus node at all. R to R interval remains regular

10. Premature Ventricular Contractions
Unifocal PVC’s
If a single focus in the ventricles has become irritable and is the source for the PVC’s, all the PVC’s will look the same

12. Premature Ventricular Contractions
Multifocal PVC’s
The heart is more irritable in more than one area in the ventricle
Several ventricular foci might begin to initiate ectopic beats
The PVC’s seen will have a variety of configurations
Multifocal PVC’s are more serious than unifocal PVC’s.

13. Premature Ventricular Contractions

14. Premature Ventricular Contractions
Ventricular Bigeminy

15. Ventricular Tachycardia
Ventricular tachycardia occurs when an irritable or "ectopic focus" in the ventricles overrides the higher pacemaker site and takes control of the heart.
Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

16. Ventricular Tachycardia
Ventricular tachycardia is defined as a series of three or more consecutive PVC's.
The causes are the same as PVC's:
electrolyte imbalance
overuse of caffeine or alcohol
acid-base imbalance
drug-initiated ventricular irritability

17. Key Identifying EKG Features Of Ventricular Tachycardia
Rate:
Atrial rate cannot be determined. 
Ventricular rate is beats per minute
If the rate is below 150 beats per minute is considered a slow VT.
If the rate exceeds 250 beats per minute it is called Ventricular Flutter (Really doesn't matter what you call it, the clinical significance is the same.)

18. Ventricular Tachycardia

19. Key Identifying EKG Features Of Ventricular Tachycardia
Rhythm:
Usually regular, although it can be slightly irregular

20. Key Identifying EKG Features Of Ventricular Tachycardia
P Waves:
None of the QRS complexes will be preceded by P waves.
You may see dissociated P waves intermittently across the strip (but not usually.)

21. Key Identifying EKG Features Of Ventricular Tachycardia
PR Interval:
None

22. Key Identifying EKG Features Of Ventricular Tachycardia
QRS Complex:
Wide and bizarre, measuring at least 0.12 seconds.
Often difficult to differentiate between the QRS and the T wave.

23. Key Identifying EKG Features Of Ventricular Tachycardia
T Wave:
T wave deflection is opposite than that of QRS complex.

25. Hemodynamic Considerations of VT
Ventricular Tachycardia is ALWAYS considered a worrisome arrhythmia that requires immediate attention!
There is usually a significant drop in cardiac output with this rhythm because there is loss of atrial contraction and decreased diastolic filling time related to rapid ventricular rate

26. Hemodynamic Considerations of VT
You must go to the bedside IMMEDIATELY AND RAPIDLY ASSESS THE PATIENT!
The patient can have no cardiac output or a significant drop in the cardiac output with this rhythm.
You will not know until you go to the bedside and assess your patient.

27. Ventricular Tachycardia Pt. Presentation
The symptoms seen with V-Tach depends on how much this rhythm has dropped the cardiac output in an individual patient
There are three different patient presentations with VT

28. Ventricular Tachycardia Pt. Presentation
The patient can be pulseless with this rhythm. If so, START CPR AND CALL A CODE!
Follow ACLS Pulseless Arrest Algorithm

29. Treatment for Pulseless VT
CPR until defibrillator available
Defibrillation (first line treatment)

30. Ventricular Tachycardia Pt. Presentation
The patient may still have a pulse but their blood pressure has really dropped or they have other signs/symptoms of decreased cardiac output. You would follow the treatment algorithm for SYMPTOMATIC VTACH

31. Treatment for Unstable VT
If the patient has a pulse but has symptoms of decreased cardiac output (low BP, chest pain etc.) then the first-line treatment is to start oxygen and an IV then cardiovert the patient.
Do not delay synchronized cardioversion in an unstable patient!

32. Ventricular Tachycardia Pt. Presentation
The patient has a pulse, blood pressure is stable and they have no other serious signs and symptoms of decreased cardiac output
you would follow the treatment algorithm for
STABLE VENTRICULAR TACHYCARDIA

33. Treatment for Stable VT
If the patient is stable (their BP is stable and they are not having chest pain or other symptoms of decreased cardiac output), then first-line treatment will be to start oxygen and an I.V. and to give the patient an antiarrhythmic medication (eg. Amiodorone, Lidocaine, Procainamide)

34. Ventricular Tachycardia Pt. Presentation
The bottom line with this rhythm is that YOU DON'T KNOW HOW YOUR PATIENT IS DOING BY LOOKING AT THE MONITOR.
YOU HAVE TO GO TO THE BEDSIDE TO ASSESS THE PATIENT!!!

35. Cath lab patient in VT

36. Sally was orienting a new nurse, Margaret, to the CCU
Sally was orienting a new nurse, Margaret, to the CCU. Sally had to leave the unit for a little while and asked Ginny to watch out for Margaret while she was gone. Of course, no sooner had Sally left the unit until Margaret called to Ginny, "Hey Ginny, my patient is doing something funny on the monitor." Ginny thought, "Well, OK, something funny. It could be movement artifact or it could be something serious." Ginny, not wanting to sound worried, said "OK, Margaret, what does it look like to you?" Margaret said, "Well it looks like ghosts holding hands to me." Ginny immediately got this vivid picture in her mind of Ventricular Tachycardia. She knew she had something to worry about and jumped right on it!
This is a true story that will help you remember what Ventricular Tachycardia looks like. However, let me warn you: if you see Ventricular Tachycardia in the clinical setting, and say "Hey that patient has ghosts holding hands" everyone and I mean EVERYONE will think you are crazy and will NOT KNOW WHAT YOU ARE TALKING ABOUT! (You may have to use your imagination a little to identify with this story :-)

37. Polymorphic VT Torsades de pointes Twisting of the points
Wide complex ventricular tachycardia
Antiarrhythmic of choice is magnesium
Torsades de pointes-a form of polymorphic VT known as "torsade de pointes". It has a striking visual appearance with a fast, wide-complex rhythm originating from the ventricles, with undulation or twisting about a baseline. The real danger and resultant sudden cardiac death occurs when this arrhythmia is sustained and degenerates into ventricular fibrillation with hemodynamic collapse.

38. Torsades de pointes

39. Ventricular Fibrillation
Severest form of ventricular irritability
No identifiable complexes
Pattern chaotic and irregular
Disorganised electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is indicated. This condition may occur during or after a myocardial infarct.

41. Treatment for Ventricular Fibrillation
CPR until defibrillator available
Defibrillation (first line treatment)
Follow ACLS Pulseless Arrest Algorithm

43. Ventricular Fibrillation

45. Idioventricular Rhythm
Ventricular rhythm produced as an escape rhythm
The heart is depolarized at the inherent rate of the ventricles which is 20-40bpm.
PVC’s, VT, and VF are all produced by ventricular irritability, Idioventricular rhythm is produced as an escape mechanism.
If a higher pacemaker fails, a ventricular focus can step in to take over pacemaking responsibility

46. Idioventricular Rhythm
No P wave seen
Rhythm usually regular
QRS complex will be wide
Rate will be less than 40
No p wave usually seen since the ventricles took over when the atrial pacemaker site failed

47. Idioventricular Rhythm

48. Asystole Rhythm - Flat Rate - 0 Beats per minute QRS Duration - None
P Wave - None
Straight line indicates absence of all electrical activity

49. Asystole Confirm all leads are correctly attached to patient
Confirm that machine is functioning properly
Confirm rhythm in two different leads

50. Asystole

51. Name that rhythm!!

52. Ventricular Tachycardia (VT) Abnormal
Rhythm - Regular
Rate Beats per minute
QRS Duration - Prolonged
P Wave - Not seen
Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

53. Slide A Multifocal PVC’s
Slide B 8 beat run VT

54. VF
Rhythm - Irregular
Rate , disorganised
QRS Duration - Not recognisable
P Wave - Not seen
This patient needs to be defibrillated!! QUICKLY

55. Rhythm - Regular
Rate - Normal
QRS Duration - Normal
P Wave - Ratio 1:1
P Wave rate - Normal and same as QRS rate
P-R Interval – Normal
Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in response to a signal within the ventricles.(unifocal PVC's as they look alike)

56. Idioventricular rhythm

57. VT

58. 2 odd waveforms, these are the ventricles depolarising prematurely in response to a signal within the ventriclesdiffered in appearance they would be called multifocal PVC's

59. Rhythm - Flat
Rate - 0 Beats per minute
QRS Duration - None
P Wave - None
Carry out CPR!!

60. VT

61. VT shown in two different patients

62. VT

63. Ventricular standstill

64. VF

65. Frequent Unifocal PVC’s

67. Asystole