Junctional Premature Contraction (JPC)

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1 Where s the PAC?

2 Junctional Premature Contraction (JPC) A junctional premature contraction (JPC) is a beat that originates prematurely in the AV node. It can occur sporadically or in a grouped pattern. If PR interval is present, it does NOT represent atrial stimulation of the ventricles.

3 PVC

4 What is this called?

5 Just how mad are you?? Bigeminy - every other beat Trigeminy - every third beat Quadrigeminy - every fourth beat Couplets - two in a row Triplets - three in a row V-Tach - 5 or more PVC s Multifocal More than one focus

6 PVC Couplet

7

8 Multifocal

9 Bigeminy

10 Trigeminy

11 Quadrageminy

12 BBB Hemiblock

13 You are driving into the EKG. You need to turn. You signal. Right or left. Bundle Branch BLOCKS J point: the junction between the end of the QRS segment and the beginning of the ST segment

14 Turn signal theory - Courtesy of Mike Taigman Advanced Field Cardiology

15 Drive your car

16 LBBB Causes Aortic stenosis Dilated cardiomyopathy AMI/Extensive CAD Primary disease of the cardiac electrical conduction system Long standing hypertension leading to aortic root dilatation = aortic regurgitation

17 RBBB Causes RVH / Cor pulmonale PE Ischemic heart disease Rheumatic heart disease Myocarditis or cardiomyopathy Degeneration of conduction system

18 Drive your car

19 AV Blocks What is actually blocked? A vessel? Is something really blocked?

20 Heart Blocks Defined by PR Interval

21 First-Degree Heart Block Regularity: Regular P wave: Normal PR interval: Prolonged >0.20 sec QRS width: Normal Syncopal episode is this the culprit?

22 1 st Degree AV Block First degree AV block is a constant and prolonged PR interval Insult to AV node, hypoxemia, Inferior MI, dig toxicity, ischemia of the conduction system and increased vagal tone Criteria Rhythm: Regular PRI: >.20

23 2nd Degree AV Block - Type I Regularity: Regularly irregular P wave: Present PR interval: Variable QRS width: Normal Dropped beats: Yes, patterned Long, Longer, Longest, DROP! Rinse and repeat. - Wenchebach

24 2 nd Degree AV Block, Type I Wenkebach Wenkebach: Long, longer, longest.drop. Same causes as 1 st degree AV block Criteria Rhythm: Irregular PRI: Progressive lengthening of PRI until dropped beat QRS's appear to occur in groups.

25 Mobitz II Second- Degree Heart Block Regularity: Regularly irregular P wave: Normal PR interval: Normal QRS width: Normal Dropped beats: Yes

26 2 nd Degree AV Block Type II Mobitz Can lead to third degree AV block AV conduction normal then drop. Criteria PRI: Constant on conducted complexes until a sudden block of AV conduction

27 Third-Degree Heart Block Rate: Separate rates for underlying (sinus) rhythm and escape rhythm Regularity: Regular, but P rate and QRS rates are different P wave: Present P-QRS ratio: Variable PR interval: Variable, no pattern QRS width: Normal or wide Grouping/dropped beats: None

28 3rd Degree AVB Complete Caused by: Acute MI Dig Toxicity Conduction System Disease

29 Something wicked this way comes

30 Ventricular Tachycardia (VTach) Rate: BPM Regularity: Regular PR interval: None QRS width: Wide, bizarre

31

32 Dead? Defib VT Alive? Synch

33 Rate: Generally 100 to 220 bpm Width of QRS>0.12 sec Ventricular Tachycardia Rhythm: Regular Stable = treated with lidocaine or Amiodarone Hemodynamically unstable VT (with a pulse) is cardioverted VT without a pulse is defibrillated Three or more beats of ventricular origin (PVCs) in succession at a rate greater than 100 beats per minute.

34 I think you need to go to the ER

35 30 y/o female palpitations

36 Torsade de Pointes Rate: BPM Regularity: Irregular P wave: None QRS: Changing polarity Grouping: Variable sinusoidal pattern Prolonged can cause torsades.

37 Torsades How do we treat this?

38 Felt unwell like the water ran out of me Under stress HX: HTN, psyche, chronic neck pain Drank alcohol, etoh, did cocaine Case Called 911

39 EMS says Had an episode of urinary incontinence, pt felt weak Dizzy, dyspnea, chest discomfort Field EKG: Sinus tachycardia with borderline st elevation in V1, V2 with one PVC Then goes into torsades. Is shocked at 200 j once, brief CPR

40 Post shock in ER

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