iein engineer so let's go ahead and move on now we already talked about PA C's premature atrial contractions that we're gonna do is we're gonna determine how to determine the rate and rhythm for PVCs so premature ventricular contraction so how to notice them how to determine the rate how to determine if there's a specific pattern to them alright so let's imagine again just like we saw with the ectopic atrial focus that we saw up and within the atria there could be some type of irritable focus right in the same way you could have some type of irritable focus within the ventricles and this little dude he can be a little agitated what can a j't eight this ventricular focus so let's say here's our ectopic focus right so there's a little irritated tissue what irritates this little dude it could be hypoxia right so obviously low oxygen within the blood whether that be because our red blood cells are decreasing so it's anemia whether it be due to some type of lung issue like COPD asthma pneumonia pneumothorax who knows or whether it be due to car decreases in cardiac output maybe congestive heart failure cardiogenic shock obstructive shock something like that where you're not getting enough oxygen flowing through the blood for whatever reason that can cause this little dude to become irritated into fire action potentials off okay what else it could be due to electrolyte abnormalities so sometimes certain types of electrolytes maybe potassium maybe calcium sometimes is there's fluctuations within these cations there can be agitation to these cells and they can fire okay undesirably it could also be due to increased sympathetic nervous system activity so anything that really increases your sympathetic nervous system so your flight or flight system right and that's going to increase your epinephrine and norepinephrine activity on those beta adrenergic receptors right and that's gonna add you take those dudes what else could it be it also could be stimulants so in the same way these are some paths oh my medic this could be due to cocaine right so cocaine it could be due to a VHD medications like methylphenidate or methamphetamines it could be multiple different things right but basically this is one of the reasons why these little irritable folk focuses can actually fire off these action potentials another reason we didn't talk about it with the atria but kind of go off of it it could also be due to infarcted tissue or another way we can kind of say this is scar tissue so let me explain what I mean by this let's say here in the myocardium there's this little infarcted tissue right there right and it's trying to you know basically you want to conduct action potentials and so here's this action potential moving along the ventricles right so when up the bundle break down the bundle branches it's going through the Purkinje system and it encounters this infarct a tissue well it can't go through it because it this infarct this issue doesn't conduct action potential so it has to go around it what happens is whenever it this kind of stuff happens it can create a reentrant circuit and these reentrant circuits can actually kind of let action potentials flow off of them and generate heart rates that are extremely high and this is what can make it very dangerous so one thing I want you to remember is these can create what's called re-entrant circuits and again we'll get into more detail in this when we get into the more pathophysiology of this stuff just introducing you to this stuff all right cool so that we got a kind of an idea of what the heck these PVCs are what triggers them and basically how they're generating these things alright let's go ahead and knock these things out then what do we do rate let's count all the are waves or s waves in this case here's an R wave this is an S wave okay our wave s wave or wave s wave our wave s wave and again an R wave so we have one two three four five six seven eight nine so it's going to be nine this is a six and rhythm strip so you multiply it by ten that's equal to 90 beats per minute okay so that's gonna be the rate on this dude all right next thing we do we determine the R to our interval okay with this situation here again you're kind of going off of this this PVC here so let's imagine here we kind of take it from this point here and we go to this guy so one two maybe a half then we go to the next one so we're gonna go to this point about here so we're gonna have one two three oh it's already off right so that's definitely off we move to the next one you go from here you got one two and you got about a half then you got one two three and again I got about a half here as well okay so we're definitely throwing kind of a irregular R to R interval here or we can actually say R to s and then again R to ask interval here's but again we're kind of showing the same kind of thing here as you move along this is definitely irregular in nature so we have an irregular rhythm here alright so let's go ahead and move on here so do we see P waves P waves here's a P wave but then before the QRS complex is there P wave I don't really see one okay it might not be a P wave there here's another P wave I can't really see a P wave here before this QRS complex it's a P wave there again I don't really see a P way here before this QRS complex P wave okay so is it seems here there is some P waves but again if we kind of follow this and this kind of answers our next question here there's not a P wave for every QRS there is for these normal ones but whenever we get to these abnormal like PVCs there's no P wave so there is some AV disassociation here dissociation okay and again why is that is because we I don't really see a P wave before we're going into the QRS complexes for these PVCs okay so that's important thing to realize all right cool what about the QRS complexes are these suckers wide or narrow we remember PVCs these things are firing from these little act up these ectopic areas that could be a reinsurance circuit or it could be an irritable ectopic focus when they fire they're not going to go through your normal bundle branch system right so they're not going to be going from the SA node they're not going to be going through the AV node it's not going to be going through the bundle of hiss and then to the right bundle branch and left bundle branch it's going to be traveling in an abnormal way so because of that let's go ahead and take here at this point here and we're going to go to about this point here and we're going to count the boxes so 1 2 3 I'm in about 4 boxes so if I'm around 4 boxes maybe 3 3 or 4 boxes little boxes that is obviously a wide QRS complex so these suckers are definitely wide and again I could try to do another one over here about there to about there and again 1 2 3 and again about 4 so about four little boxes that's definitely going to be greater than equal to three little boxes so this is definitely a wide QRS complex now this should be something that you need to remember the wide QRS complex is because these PVCs that we see this one right here this is our PVC this is a PVC they're not going through your normal conduction system they're coming from either an irritable focus or from a reentrant circuit and they're not going through your normal conduction system if they don't go through the normal conduction system in other words SA node to AV node to the bundle of hiss I want to put BH there to the bundle branches to your perc in G's then it's not going to have that normal narrow QRS complex so if it's coming from some other site this ventricular focus or this reentrant circuit here it's going to generate these wide and abnormally appearing QRS complexes okay so remember that this is an abnormal QRS complex that's wide that's because it's not coming from this normal conduction system here all right so before I move on to this next EKG remember I told you guys that this is weird that these are kind of these QRS waves are actually going belike negative to end deflection go back to the basics remember this is lead to negative electrode here positive electrode here right and then we create like this kind of axis of this lead remember the QRS vector we the mean you want it to point towards the positive electrode well what if in this case this ectopic focus is firing and when it fires it actually usually if it's firing it might be firing this way from the left ventricle moving over into the right ventricle and so it might actually be moving and towards the right ventricle away from this positive electrode if it's moving this positive charge is moving from the left ventricle towards the right ventricle away from the positive electrode what kind of deflection do you get you should get a negative deflection so again that's one thing that's something if you really are interested in you can determine if an ectopic focus where it is based upon the direction of the QRS complexes look at your leads use that basic stuff that we talked about to determine your vectors and which way they are pointing in association with your lead so according to lead to this most likely is going to be an ectopic focus in your left ventricle moving towards the right ventricle okay and maybe even kind of lower within the ventricles as well all right so let's move on to the next EKG here all right so for the next EKG let's count up our rate 1 2 3 4 5 6 7 8 9 10 11 12 12 times 10 is 120 beats per minute that's our rate let's go ahead and determine our art our intervals oh my gosh we don't even have to keep going here it's obviously all frakked-up okay so this is definitely not a regular art our intervals they're all jacked up so this is definitely irregular this is super obvious okay next go to the P waves are they normal do you have P waves here's a P wave okay this is a T wave here I don't really see my P wave at all there's no p-wave if it is maybe it's kind of hidden within my QRS complex it might be like hidden in here but I don't see it okay so no p-wave there then I go again and I'm gonna have another P way of a normal one and I have a T wave then I have another P wave okay cool QRS complex and then again I go over here I got a T wave and oh I don't see a P wave again all right well remember I told you any time you see these wide QRS complexes and they're coming early so this is definitely coming earlier than it should and it doesn't look like a normal QRS complex in other words it's really wide and it's abnormal up hearing this is a PVC that's a PVC this is a PVC that's a PVC huh well these PVC seem to be coming after every two normal P QRS complexes right so if it's coming after every - this is called ventricular trigeminal well let's go up for a second - that one that we just did before let's look at this son of a gun we have a PVC and it's occurring in between each normal P QRS complex we call that ventricular bigeminy it's the same concept as before all right cool we know that we have wide QRS complexes right and these are definitely our PVCs and it's definitely a regular we have some P waves but some P waves aren't there so there's some P waves and because some P waves aren't there in other words there's not a P wave for every QRS complex there's no AV Association so this is av dissociation next thing QRS complexes are these suckers wide or narrow this is obviously a wide QRS complex okay and again we determined the PVCs have a very specific pattern to them they're occurring every after every two normal P QRS complexes pqrst complexes okay so if it triggered the trigeminal it's after every normal pqrst complex it's ventricular bigeminy all right we have here let's count up our guy here 1 2 3 4 5 6 7 8 8 times 10 equals 80 80 beats per minute all right our to our interval look at that and look at this this oh my gosh this thing's all over the place right there's no consistency in these are our intervals all right there might be some consistency here in here but between this one and this one there's no consistency between this one and this one there's no consistency so this is definitely irregular all right cool p-wave do we get a p-wave got a p-wave here we got a p-wave here I don't see a P way before the QRS complex I don't really see another P way before that QRS complex I don't see another P way before that QRS complex okay again there's some P waves and then some of them are not there so we're gonna put some P waves so because of that because there's not a P wave for every QRS complex what does that mean is there association between the atria and the ventricles every single time no so there is some AV dissociation now here's what I want you to remember a V disassociation means that there's again not every action potential is going through the AV node into the ventricles all right so it's not going s a node all the way down to pork in G's and again that is why you're getting B's little PVC so I got a PVC here a PVC here and the PVC here and it happens three in a row now here's the thing PVCs can cause palpitations right and sometimes we're going to get to another rhythm which we're gonna talk about this son-of-a-gun looks a lot like something called v-tach so whenever you have something that is again look at the r2 our interval here is it about the same yeah so what would you call this it's one two one two if something is about the same art our interval what is that it's regular if you have something that is actually regular and wide QRS complexes but it's moving at a very fast rate well when we say our rate is here well it's gonna be three hundred and 150 anything greater than 100 is tachycardic so this is why complex tachycardia but we say whenever you have more than greater than or equal to three PVCs this is now v-tach and v-tach is pathological so you can have PVCs but PVCs can be completely normal it could just because you have too much caffeine yet a lot of with too much coffee or maybe you're you know you're taking your ADHD medication it's an increasing your heart rate right so it's causing an increase in sympathetic activity so these can be completely normal but whenever you have three of these in a row it is now considered to be pathological and we call it v-tach there's actually a special like name for this one they actually call it a three beat salvo sometimes they call it a PVC triplet but again now this is basically considered to be pathological so whenever you have three or more PVCs in a row it's considered to be v-tach and we'll talk a little bit more about that later so again what's our QRS complexes here why we already kind of talked about this how was wide complex regular an interval regular rhythm and tachycardic and we call that v-tach and these all look the same that's another thing if your PVCs all look the same that means it's coming from one act topic focus so only one irritable cell in the ventricles is firing if you have some that are different in appearance so in other words let's say that this woman was pointing upwards but had another one that was maybe point this one was pointing downwards then that would be a different type right so this would be another ectopic focus and sometimes we can call that polymorphic and we'll talk about a specific type of polymorphic v-tach and a little called torsades de pointes which is a very dangerous one okay so again in this what I want you guys to be able to recognize is how to find PVCs how to find pa C's on the EKG how to determine if those PVCs and pa CS have a particular pattern in other words is it bigeminy or is it trigeminal and most importantly do I see three or more PVCs in a row if I do this is now considered v-tach and that could be a medical emergency see I hope it made sense I hope you guys really did like it and enjoy it if you guys did hit that like button comment down the comment section and please subscribe also if you guys won go down in our description box we have links to our Facebook our Instagram even our patreon account if you guys have the opportunity and you would like to donate even a dollar we would really appreciate that helps us to continue to make videos for you guys as enjoyment in the next video what we're gonna do is we're gonna talk some more about how to determine the rate and rhythm for EKGs representing things like torsades two points how to determine if something is v-tach and how to determine if someone is in v-fib and we'll talk about what you do in those scenarios okay so again as always a ninja nerds we love you and until next time [Music]