1. Heart Conduction System

2. Bell Work: Diagnosis of the Day
A 65 year-old male presents to his cardiologist for evaluation of recurrent episodes of lightheadedness, chest pain, and shortness of breath with exertion. One week earlier, he walking up the stairs of his house.
Vitals: HR-116, BP-164/102, RR-18. Height-68”, Weight-247 lbs
Labs: Normal Troponin level, hypercholesterolemia, hypertriglyceridemia
Imaging: Doppler echocardiogram demonstrates a significantly stenotic aortic valve and plaques within the coronary arteries.

3. Bell Work Questions
Which vital signs are abnormal? What are their normal ranges?
What is the patient’s BMI?
What is “Troponin”, and in which organ is it found?
What does this patient have too much of in his blood?
Why would having plaques in the coronary arteries cause symptoms of angina, and dyspnea, particularly on exertion?
How would you diagnose this patient?

4. Structure
1. Aorta – takes blood away from left ventricle to rest of the body
2. Superior vena cava and 3. inferior vena cava – bring deoxygenated blood to right atrium
Pulmonary artery (6) – takes blood away from right ventricle to the lungs for O2
Pulmonary veins (7) – bring oxygenated blood from lungs to left atrium

5. Chambers and Valves SEPTUM (11) divides into R and L halves
Upper chambers – RIGHT ATRIUM (4) and LEFT ATRIUM (5)
Lower chambers – RIGHT VENTRICLE (8) and LEFT VENTRICLE (9)
Four heart valves permit flow of blood in one direction

6. VALVES Tricuspid – 3 flaps or cusps – prevents backflow into R atrium
Pulmonary (12)– 3 flaps – prevents backflow into R ventricle
Mitral (bicuspid) (10) – 2 flaps – prevents backflow into L atrium
Aortic – prevents backflow into L ventricle

7. PHYSIOLOGY OF THE HEART The heart is a double pump
PHYSIOLOGY OF THE HEART The heart is a double pump. When the heart beats…
Right Heart Deoxygenated blood flows into heart from vena cava  right atrium  tricuspid valve  right ventricle  pulmonary semilunar valve  pulmonary artery  lungs (for oxygen)
Left Heart
Oxygenated blood flows from lungs via pulmonary veins  left atrium  mitral valve  left ventricle  aortic semilunar valve  aorta  general circulation (to deliver oxygen)

9. The Heart: Conduction System
The heart pumps blood through the body
This is accomplished by contraction and relaxation of the cardiac muscle tissue in the myocardium layer.

10. Conduction System Continued….
Cardiac conduction system: The electrical conduction system controls the heart rate
This system creates the electrical impulses and sends them throughout the heart. These impulses make the heart contract and pump blood.

11. CARDIAC CYCLE Creates Heart sounds Heard through stethoscope
“LUB-DUB” sound
1st sound, AKA S1 – longest and loudest (closure of atrioventricular (AV) valves)
Atrioventricular is Tricuspid and Mitral
What would Right AV valve be?
What would Left AV valve be?

12. 2nd sound – closure of aortic and pulmonary valves (AKA Semilunar Valves)
If valves do not close properly – you will hear an extra sound called a heart murmur

13. THE CARDIAC CYCLE
SYSTOLE – CARDIAC CONTRACTION THE BLOOD IS FORCED OUT OF THE HEART TO THE LUNGS FOR OXYGENATION AND TO THE BODY FOR CIRCULATION (CONTRACTION)
DIASTOLE – CARDIAC RELAXATION THE BLOOD IS RETURNED TO THE HEART FROM THE LUNGS AND THE BODY (RELAXATION)
What is this measuring?

14. Components of the Conduction System
Sinoatrial Node (Part I):
located in back wall of the right atrium near the entrance of vena cava
initiates impulses times per minute without any nerve stimulation from brain
establishes basic rhythm of the heartbeat
called the pacemaker of the heart
impulses move through atria causing the two atria to contract.
at the same time, impulses reach the second part of the conduction system

15. Components of the Conduction System Continued ….
Atrioventricular Node (Part II):
located in the bottom of the right atrium near the septum
cells in the AV node conduct impulses more slowly, so there is a delay as impulses travel through the node
this allows time for atria to finish contraction before ventricles begin contracting
Gatekeeper

16. Atrioventricular Bundle
A.K.A. “Bundle of His”
From the AV node, impulses travel through to the right and left bundle branches
These branches extend to the right and left sides of the septum and bottom of the heart.

17. Atrioventricular Bundle Continued….
These branch a lot to form the Purkinje fibers that transmit the impulses to the myocardium (muscle tissue)
The bundle of His, bundle branches and Purkinje fibers transmit quickly and cause both ventricles to contract at the same time
Like a “phone tree”

18. Atrioventricular Bundle Continued….
As the ventricles contract, blood is forced out through the semilunar valves into the pulmonary trunk and the aorta.
After the ventricles complete their contraction phase, they relax and the SA node initiates another impulse to start another cardiac cycle.

19. Septum

21. 1 - Sinoatrial node (SA node)
2 - Atrioventricular node (AV node)
3 – Bundle of His
4 - Right & Left Bundle Branches
which lead to Purkinje Fibers

22. THE CONDUCTION SYSTEM SINO-ATRIAL (SA) NODE ATRIAL IMPULSES
ATRIO-VENTRICULAR (AV) NODE
BUNDLE OF HIS
BUNDLE BRANCHES
PURKINJE FIBERS

23. EKG

25. USES OF AN EKG
TO DIAGNOSE
FOR MONITORING
IN DEFIBRILLATORS

26. INDICATIONS FOR AN EKG FUNCTION OF HEART
ELECTRICAL PROBLEMS
CHANGES IN THE HEART
ROUTINE PRE-OP
PART OF A COMPLETE Physical exam AFTER AGE 40
EVALUATION OF CARDIAC CONDITIONS
STAT – USUALLY IN AN EMERGENCY

27. EKG PREPARATION PHYSICIAN’S ORDER PATIENT’S WEIGHT AND HEIGHT
PATIENT’S DATA
LOCATION, DATE, AND TIME
PATIENT’S AGE, SEX AND CARDIAC MEDS
PATIENT’S WEIGHT AND HEIGHT
ANY SPECIAL CONDITION OR POSITION OF PATIENT DURING PROCEDURE

28. WHAT THE EKG WILL SHOW HEART RATE RHYTHM SIGNS OF CARDIAC ENLARGEMENT
HEART DISEASE
MYOCARDITIS
SIGNS OF HEART INJURY (MI)
ELECTROLYTE ABNORMALITY
PULMONARY EMBOLISM
DRUG TOXICITY

29. EKG BASICS
ELECTRODES – SENSORS PLACED ON THE PATIENT TO PICK UP ELECTRICAL ACTIVITY
LCD DISPLAY – LIQUID CRYSTAL DIODE AREA FOR PATIENT DATA ENTRY
ECG/EKG – RECORDING OF ELECTRICAL ACTIVITY ONTO GRID PAPER
LEADS – WIRES ATTACHED TO ELECTRODES

30. PATIENT PREPARATION REMOVE CLOTHING FROM THE WAIST UP
REMOVE JEWELRY THAT MAY INTERFERE
PROVIDE DRAPE FOR PRIVACY
CLEAN SKIN WITH ALCOHOL
APPLY LEADS TO NON-HAIRY AREA
SHAVE AREA ONLY IF NECESSARY

31. APPLYING ELECTRODES
COMPLETE EKG CONSISTS OF 12 LEADS but only 10 go on the patient.
LIMB LEADS ARE APPLIED TO ARMS AND LEGS
CHEST LEADS ARE APPLIED TO THE CHEST

32. CHEST LEADS 12 Leads V4 – 5TH INTERCOSTAL SPACE AT MID-CLAVICULAR LINE
V5 – SAME LEVEL AS 4 AT LT ANT. AXILLARY LINE
V6 – SAME LEVEL AS 4 AT LT MIDAXILLARY LINE
V1 – 4TH INTERCOSTAL SPACE RT OF STERNUM
V2 – 4TH INTERCOSTAL SPACE LT OF STERNUM
V3 – MIDWAY BETWEEN V2 & V4

33. LIMB LEADS RA - FLESHY OUTER AREA OF UPPER RIGHT ARM
LA – FLESHY OUTER AREA OF UPPER LEFT ARM
RL – FLESHY PART OF LOWER RIGHT LEG
LL – FLESHY PART OF LOWER LEFT LEG

34. THREE LEAD TRACING RA- RIGHT OF STERNUM (white)
LA – LEFT OF STERNUM (black)
LL LEFT LOWER RIB AREA (red)
Can have 5 lead tracing – see all leads

35. Cardiac Stations Blood Flow (4 people)
Lead placement on manikins (4 people)
Blood pressure (6 people)
Heart Rate, Respirations, 02 sat (4 people)
Heart model (anatomy) 2 people

36. Day 2

37. Bell work
1. How do you prepare a patient for an EKG? 2. Name three items an EKG could show 3. Put the following terms in order of correct cardiac conduction: Bundle of HIS SA Node Purkinje Fibers L/R Bundle Branches AV Node

38. Objective
Understand Repolarization and Depolarization as it relates to the PQRST wave Identify arrhythmias

39. EKG

40. Polarization
Depolarization and Repolarization 1. Cardiac cells at rest are considered polarized, meaning no electrical activity takes place 2. The cell membrane of the cardiac muscle cell separates different concentrations of ions, such as sodium, potassium, and calcium. This is called the resting potential.

41. Polarization
3.  Electrical impulses are generated by automaticity of specialized cardiac cells
4.  Once an electrical cell generates an electrical impulse, this electrical impulse causes the ions to cross the cell membrane and causes the action potential, also called depolarization
5.  The movement of ions across the cell membrane through sodium, potassium and calcium channels, is the drive that causes contraction of the cardiac cells/muscle

42. Polarization
6.  Depolarization with corresponding contraction of myocardial muscle moves as a wave through the heart
7.  Repolarization is the return of the ions to their previous resting state, which corresponds with relaxation of the myocardial muscle

43. Polarization
8.  Depolarization and repolarization are electrical activities which cause muscular activity
9.  The action potential curve shows the electrical changes in the myocardial cell during the depolarization – repolarization cycle
10.  This electrical activity is what is detected on ECG, not the muscular activity.

44. EKG COMPONENTS
P WAVE – Indicates Atrial Depolarization causing atrial contraction
QRS COMPLEX – Indicates Ventricular Depolarization causing Ventricular Contraction
Atria are repolarizing (relaxing)
T WAVE – Indicates Ventricular Repolarization, causing ventricles to relax

46. How To Read EKG
EKG paper is a grid where time is measured along the horizontal axis.
Each small square is 1 mm in length and represents 0.04 seconds.
Each larger square is 5 mm in length and represents 0.2 seconds
In order to correctly identify heart rhythms, you will need to print off 6 second strips

47. EKG Intervals P-R interval = 0.12-0.20 seconds
QRS Complex = Seconds

48. How to Read EKG Can determine HR from EKG strip
Each strip is 6 seconds
To determine HR:
Count R waves and multiply by 10

49. EKG Analysis – 8 steps Rhythm – Regular or Irregular Heart Rate
Is there a P Wave?
Is there a PR – interval?
Is there a QRS?
Is there a T wave?
Is there a Q-T interval
Is there an ST segment

50. REGULAR HEART RHYTHMS NORMAL SINUS RHYTHM (NSR) SINUS TACHYCARDIA
between 60 – 100 BPM, regular rhythm
SINUS TACHYCARDIA
> 100 BPM, regular rhythm
SINUS BRADYCARDIA
< 60 BPM, regular rhythm

51. Normal Sinus Rhythm
60 – 100 Beats per minute

52. Sinus Tachycardia
 A fast heart rhythm with a rate of more than 100 beats per minute.

53. Sinus Bradycardia
A slow heart rhythm with a rate below 60 beats per minute.

54. Arrhythmias
Abnormal heart rhythms that can be mild to life threatening.
Atrial
Junctional
Ventricular
Heart Blocks

55. Irregular Rhythm

56. Review

57. Arrhythmias ATRIAL PREMATURE ATRIAL CONTRACTION (PAC) ATRIAL FLUTTER
ATRIAL FIBRILLATION (A-FIB)
VENTRICULAR
PREMATURE VENTRICULAR CONTRACTION (PVC)
VENTRICULAR TACHYCARDIA (V-TACH)
VENTRICULAR FIBRILLATION (V-FIB)
SUPRAVENTRICULAR TACHYCARDIA (SVT)
ASYSTOLE

58. PAC Premature atrial contraction (PAC)
Can occur in anyone but usually goes unnoticed.
Most common forms of arrhythmias. 
the premature discharge of an electrical impulse in the atrium, causing a premature contraction. 
A PAC is premature, because the it occurs earlier than the next regular beat should have occurred.

59. PAC
This rhythm strip displays the typical pattern of frequent PACs (arrows) separated by post-extrasystolic pauses.
Causes: related to stress, too much caffeine or nicotine, or exercise

60. Premature Ventricular Contraction (PVC)
Early, extra heartbeats that originate in the ventricles. Most of the time, PVCs don’t cause any symptoms or require treatment. This type of arrhythmia is common and can be related to stress, too much caffeine or nicotine, or exercise. They can be also be caused by heart disease or electrolyte imbalance.

61. Atrial Flutter
atria beat faster (about beats per minute) than the ventricles of your heart.
Slows down at AV node but patient has tachycardia

62. A-Flutter Saw Tooth p-waves
Unstable patients: chest pain, severe SOB, altered level of consciousness, or hypotension.

63. Atrial Fibrillation No P Wave
impulses begin and spread through the atria competing for a chance to travel through the AV node.
disorganized, rapid and irregular.
loss of coordinated atrial contraction

64. Supraventricular Tachycardia SVT
cardiac arrhythmia characterized by very rapid or erratic Tachycardia above 150 BPM
heart racing/palpitations, dizziness or light-headedness, chest pain, breathlessness

65. Ventricular Tachycardia
A rapid heartbeat that originates in the ventricles. The rapid rhythm keeps the heart from adequately filling with blood, and less blood is able to pump through the body. V-tach can be serious, especially in people with heart disease.

66. Ventricular Fibrillation
An erratic, disorganized firing of impulses from the ventricles.
ventricles quiver and cannot generate an effective contraction, which results in a lack of blood being delivered to the body.
This is a medical emergency that must be treated with cardiopulmonary resuscitation (CPR) and defibrillation (delivery of an energy shock to the heart muscle to restore a normal rhythm) as soon as possible.

67. Asystole
Asystole is defined as a cardiac arrest rhythm in which there is no discernible electrical activity on the ECG monitor. 

68. Artifact

69. Rhythm Analysis

70. DAY 3
Treatment

71. Bell Work – Diagnosis of the Day
A Caucasian male, 68 y/o, presents to the emergency department c/o of increasing SOB, dizziness, and the sensation of heart racing. He has hx of hypertension, CAD and recently two stents placed in the cath lab. Vitals are: BP: 100/60 HR: 160 bpm RR: 26 breaths pm Oxygen saturation: 96%. Troponin and Cardiac Serum Enzymes are Negative. Patient has elevated cholesterol. A 12-lead ECG shows a narrow QRS complex tachycardia and absence of P wave.

72. Bell Work Questions
What vital signs are abnormal. Write the normal range.
What arrhythmia would you say the patient is having?
Since the patient has high cholesterol, choose two foods that have low cholesterol that you could suggest to the patient.
You may use your phones to help you.

73. Treatment Options for Arrhythmias
Cardioversion
Ablation
Medication
Calcium channel blockers ( lower BP and reduces force of contraction)
Beta-blockers (slow heart rate and lower BP)
Anticoagulants (blood thinners)

74. Cardioversion
Cardioversion send electric shocks to your heart through electrodes placed on your chest. It's also possible to do cardioversion with medications.
scheduled procedure in a hospital.
should be able to go home the same day as your procedure.
For most people, cardioversion quickly restores a normal heart rhythm.

75. Cardioversion AKA Synchronized Cardioversion
LOW ENERGY SHOCK
synchronized with the peak of the QRS complex (the highest point of the R-wave).
When the “sync” option is engaged on a defibrillator and the shock button pushed, there will be a delay in the shock. During this delay, the machine reads and synchronizes with the patients ECG rhythm.
This occurs so that the shock can be delivered with or just after the peak of the R-wave in the patients QRS complex

76. Cardiac Ablation
Catheter ablation is a procedure that uses radiofrequency energy (similar to microwave heat) to destroy a small area of heart tissue that is causing rapid and irregular heartbeats. Destroying this tissue helps restore your heart’s regular rhythm. The procedure is also called radiofrequency ablation.
Treats SVT, Aflutter and AFIB

77. How To Read EKG
EKG paper is a grid where time is measured along the horizontal axis.
Each small square is 1 mm in length and represents 0.04 seconds.
Each larger square is 5 mm in length and represents 0.2 seconds
In order to correctly identify heart rhythms, you will need to print off 6 second strips

78. Bell Work
In the PQRST Wave – Describe when the atrial and ventricles are contracting/depolarizing
What is abnormal rhythm called?