all right welcome back everybody this is gonna be our third lesson in our series of lessons covering ECG an EKG rhythm interpretation and in this lesson we're gonna take a dive into arrhythmias [Music] oh right welcome back everybody like I said this is gonna be our third lesson in this series of lessons and for this third lesson we're gonna really start to take a dive and take a look at the different types of arrhythmias that you're gonna find your patient in for those of you who don't know my name is Eddie Watson and I'm gonna be your presenter for this lesson but before we begin here if this is your first time visiting this channel and you're interested in seeing more critical care educational content such as this video then please do subscribe down below make sure when you do that you hit that Bell icon and select all notifications that way you'll be notified as soon as our lessons become available your support truly does mean a lot to us and it really helps support this channel as well as videos like this and so for that we truly want to thank you so like I said this lesson is gonna be all about covering the different types of arrhythmias that you can find your patient in we're gonna go through all of these show you examples of them as well as kind of talk through sort of what some of those causes are what some of those key characteristics or key features of that arrhythmia in order to help you identify it are and hopefully with what we've discussed in the past two lessons you'll be able to take that knowledge and kind of understand some of the conduction issues or the issues that are going on underlying some of these rhythms that you see so I have listed out here some of the major types and there's gonna be multiple arrhythmias within some of these categories but the major types that you see here first we have our sinus arrhythmias from there we're gonna go on and talk about the different types of premature beats that you're gonna see following that up with talking about some of the bradycardic and tachycardic rhythms that you're gonna see from there we're gonna do a breakdown of either our atrial dysfunctions or junctional rhythms or some of our ventricular problems and so finally the last type of arrhythmia is that you guys are gonna see are what are called our heart blocks and in fact our next lesson is going to be a dedicated video just to those heart blocks but I did want to list them out here as they are categorized as one of the major types and so as you can see over here on the diagram of the heart on the right there's really a lot of question about what area is causing the problem and where the dysfunction is that's leading to these different types of arrhythmias so hopefully by the end of this lesson you'll have a better understanding not only of what's going on behind each arrhythmia but being able to more importantly identify them so that you can possibly intervene if need be now before we begin you guys head down into the comments we'd love to hear which of these types of arrhythmias you're most interested in hearing about alright and with that out of the way let's go ahead and start off with our first one here and for this I'm gonna bring back our six second strip paper that we have here and I'm gonna put up an example of each of these different types of rhythms for you to be able to see it and we'll kind of talk through like I said some of the the ways that you can identify this particular arrhythmia up at the top you'll notice our tick marks or our hash marks in order to identify the time breaks on here so we have the the two big hashes and the one small hash in the middle therefore we know that this strip that we're looking at is a six second strip and so the first of these arrhythmias that we're going to talk about is our sinus arrhythmia now there really are multiple different types of sinus arrhythmias that kind of fit in this category but we're gonna just for the purpose of simplicity we're just gonna talk about this generalized encompassing category and so really to start off when we say that this is a sinus arrhythmia it's because this is actually originating in the SA node and again going back to part two in this series which I will link to up above we talked about how to distinguish a normal sinus rhythm and the reason that we know that this originates in the SA node is because we have our P waves right here and along with that we've got a pretty narrow QRS complex which are our two big key indicators that this is a sinus beat and it's originating from that SA node and in fact if we count out our rhythm here using the six-second method again we talked about that in the previous lesson we see that we have one two three four five six beats here and therefore we can estimate our patient's heart rate to be 60 beats per minute now the reason we refer to this as a sinus arrhythmia is all on its own it actually has a an increasing and decreasing heart rate which hopefully should be pretty obvious as you can see our distance between these two beats compared to the distance between these two beats is quite a bit different and again it goes back and we have a shorter or quicker time between our beats here and so really our heart rate is just speeding up and slowing down and it's doing this all on its own and fortunately this is often a benign thing and so really to break this down if we have a sinus beat or a rhythm that's based off signals that are coming out of the SA node but we don't have that consistent regular heart rate then more than likely you've got a sinus arrhythmia and like I said there are different types of sinus arrhythmias but I think that's really beyond the scope of what we're hoping to achieve in this lesson but certainly once you master identifying these basic arrhythmias definitely look into some of these different things that are out there because once you've been out there and you're on the floor and you're looking at these rhythms that your patients have a lot of times you're gonna come across things that you just don't quite know what it is and you have to often think through it or grab a friend and kind of talk over what's going on and trying to figure out what's happening all right so now that we got that one out of the way let's move on and start to talk about our premature beats that we're going to come across and there's really three kinds of premature beats that we're going to see and the first of these is what we call premature atrial complexes or P ACS as they'll often be referred to and basically a P AC is exactly what it sounds like basically it's a premature beat that originates from the SA node or essentially the atria so in this example the strip actually has two different PA C's the first one you'll find right here and the next one you'll find right here and essentially if you look at your strip you can see normally we have our beats just trucking along right at a regular rate and then all of a sudden here comes a beat sooner than we'd expect it to be these are usually pretty easy to spot because typically you'll have that normal regular rate and rhythm and then all of a sudden occasionally you'll have these beats that just seem to come a little bit earlier than you would expect them to be now these are often due to some sort of irritation of the atria and so this leads to an increase in that automaticity of the real muscle tissue now a couple of our defining characteristics in order to really be able to identify this as a PA see our first it's gonna have a narrow QRS next you're gonna have an upright P wave and finally you could possibly have a different morphology of that P wave so we'll take a look at our rhythm on the strip here again and all of these strips that we're gonna show you are gonna be in lead 2 and that's gonna be particularly important because in order to identify a P wave being upright we're gonna need to know that we're looking at lead 2 to know that the P wave should be going up so here we can see that we have our P wave and it is in fact upright we do have our narrow QRS complex so we can check these off and in this case we actually do have a different morphology of the P wave when you compare it to the other ones over here so again if we look at this one at the beginning of the strip this P wave has a different morphology than this P wave here so in this case we can check this one off to now I wouldn't rely on this different morphology because sometimes they're gonna look much like the normal P waves that you're seeing but definitely if you have this on top of everything else it should really help you easily identify that this is a P AC alright so the next premature beat that we're going to talk about is our premature junctional complex or pjc now we are going to talk about this although one thing to know is this is a pretty rare thing so it's not something that you're gonna see very often as opposed to an actual junctional rhythm which is something that we're gonna talk about a little bit later in this lesson but a pjc is not something you're gonna typically see very often so we'll just kind of blow through this one pretty quick on this trip we really just have one example of a pjc which is right here and just like with the p AC the p JC is going to be due to some sort of irritation of the AV Junction now for the PJ C the first thing that we're going to have is another narrow QRS but really the defining characteristic here is you either have an at sent or inverted p-wave so if we go back and look at our strip you can see we've got that narrow QRS complex but if you look out here at a normal P wave you see what we have going on here is this P wave is actually inverted and like I said it can either be inverted or sometimes you'll just see a flat isoelectric line before the R wave but still having that narrow QRS we can then identify this as a P JC so moving on to the last premature complex that we're going to talk about this is going to be our premature ventricular complex or PV C now these are probably the most common one that you're gonna see and I think of the premature complex is probably the easiest to identify and so on this trip here I'll go ahead and show you the PV C here and just like with the others I bet you can probably figure out this is often due to irritation of the ventricle and these are typically benign now to really talk about the defining characteristics the first and probably most notable is we're gonna have a wide QRS complex so as you can see here this is a pretty wide complex that we have here you're also gonna notice that there's not going to be a P wave again we've got nothing over here which if we think about this as a beat that's originating from the ventricle therefore you won't see a P wave because the signal didn't start in that SA node and work its way down and then finally when we talk about the T wave we're typically gonna have the T wave which is going in the opposite direction of the R wave so again we have our R wave going this way and our T wave going this way so we have that we have no P wave and quite a wide QRS therefore we can determine that this is a premature ventricular complex well hopefully those made sense for you guys I think identifying those premature beats and those different complexes is usually pretty easy so next we're gonna move on and talk about some of our basic bradycardic and tachycardic rhythms and the first of these we're going to talk about is sinus bradycardia and really the first defining characteristic of a sinus Brady rhythm is that you're gonna have a heart rate that's less than 60 so if you remember 60 to 100 is our normal rhythm that we would expect in a sinus rhythm and if we look at our strip here we see we've got one two three four beats in a six second strip meaning we have a heart rate of 40 therefore we're less than that normal range of 60 to 100 making this a bradycardia now sometimes the sinus bradycardia can be a normal thing a prime example of this is gonna be our athletes if you think about they built up that strong cardiac muscle and have that real strong contraction and cardiac output therefore the body just doesn't need to beat as often because you're gonna get adequate perfusion as a result of that really strong heart and so sometimes you'll see some bradycardia rhythms and these people but this could also be a pathological thing this could be something related to our nervous system and that nervous system not telling the heart to speed up this could also be the result of some sort of damage or disease think of things like sick sinus syndrome or just damage that results or disease processes that result over time in older people and finally this could be the result of some sort of medication prime example of this are our beta blockers which if they've just happened to have too much of the beta blocker in them this could cause their rate to slow down outside of the normal range like we had talked about you're gonna have a heart rate less than 60 in addition to that you're gonna have your narrow QRS and your upright P wave we already identified our heart rate at being 40 see we've got our narrow QRS here and yep that P wave is upright therefore we meet all the criteria here and we can identify this as a sinus bradycardia now on to the flip side of sinus bradycardia next we're going to talk about our sinus tachycardia so once again we know our normal heart rate is sixty to a hundred therefore in order to have a sinus tachycardia we're gonna have to have a heart rate that's greater than 100 so in this example we've got 1 2 3 4 5 6 7 8 9 10 11 12 13 14 beats in a six second strip meaning we have a heart rate of a hundred and forty and that's definitely over 100 typically our causes for a sinus tachycardia is usually going to be the result of some sort of increased sympathetic response so these can be things like your patients in pain they have a fever they have an increased oxygen demand or even things more serious like hypovolemia now once again we're calling this a sinus beat therefore we're gonna have that narrow QRS and of course an upright P wave so again if we look at our example we do have that narrow QRS and lo and behold our P wave is upright and we already talked about our heart rate of 140 is over a hundred therefore we can say this is a sinus tachycardia so moving deeper into the territory of our tachycardias the next one we're going to talk about is our supraventricular tachycardia or often times you'll hear this one referred to as SVT and really for SVT our first defining characteristic is going to be a heart rate that is greater than 150 so in this example if we count out these here we see that we actually have 16 beats here therefore we know we've got a heart rate of a hundred and sixty so we are past that 150 mark but sometimes with these SVT's you can see rates as high as 300 just crazy to think about now you might really be thinking how is this any different than a sinus tachycardia why do we have this distinction of 150 and typically the reason for that is at this point you're going to end up with an indistinguishable P wave and really what we mean by that is the rate is happening so fast that we can't really tell if this is the T wave or the P wave is there a P wave in there is there not we can't really tell but we can see that we have a narrow QRS which you can see here and therefore we know that this is coming from at least the AV node or higher because those signals are going quickly through the ventricles giving us that quick QRS complex and that's where we get the name super ventricular from is it's somewhere above the ventricle but oftentimes we're just not able to tell because that rate is happening so fast finally one last defining characteristic that you're gonna have here is that you're gonna have a pretty regular rhythm there's gonna be some fluctuation in it with its speed but for the most part you're gonna be right around in the same area and you can see that with our rhythm strip here these are waves are coming at a pretty regular rate now just the hit on the causes real quick really the causes of our SVT are going to be very similar to sinus tachycardia and it's primarily due to that increased sympathetic response but here for this example heart rate of 160 s greater than 150 can't really tell if there's a P wave in there we do have that narrow QRS and a regular rhythm therefore we can say that this is a SVT alright I've always really kind of enjoyed those tacky rhythms especially the the SVT it's pretty interesting when you actually see a patient that has that and so with that said I'm actually going to go ahead and stop this lesson at this point before this particular one gets too long and to kind of conclude in this lesson we talked about sinus arrhythmia the three different types of premature complexes that you'll see in your patients as well as the Brady and tachycardia rhythms that you're often going to see and so in the next lesson we're gonna pick up where we left off and we're gonna talk about all the different atrial junctional and ventricular rhythms that are out there and with that said I truly want to thank you guys for watch I hope that you found this lesson talking about some of the basic arrhythmias to be of benefit to you and if you did please go down below and leave us a like because it really does help to support this video and the channel and if you haven't already please subscribe to the channel below as well that way as soon as our next lesson covering the atrial junctional and ventricular beats become available that you'll get notified of that as well in the meantime though feel free to check out our most recent series of lessons which we covered arterial blood gases and so with that said I want to thank you guys for watching and we'll see in the next lesson