we can integrate a lot of topics.
Now, with dysrhythmia, a conduction system.
What are the two ends of the spectrum? Either
too slow or too fast. With the bradyarrhythmia,
our topic will bring us to heart blocks. With
this, most common type of blocks that we will
take a look at, AV nodal block. First degree,
second degree. With second degree, we will
then divide that into Mobitz. But we will
only take a look at type 1 and type 2 and
then we will walk into our third degree AV
block. On the other end of the spectrum. Too
quick. I will quickly walk you through, now
passive reinforcement so that you feel comfortable
with arrhythmia. As soon as your atria,
well what exactly are we going to be looking
at or interpreting so that you can figure
out that your patient has an arrhythmia. How
about an EKG? Will that come in handy? Short
one. So if you have an atrial type of arrhythmia,
what kind of wave are you automatically looking
at, please? The P wave right. Now let us say
that you add afib okay. That afib where you
are lying to or anything, but afib in the
sense of afibrillation. Afibrillation is
one in which that wave has disappeared.
Is that clear? Or has it become wavy. Difficult
to identify, obscure. Can we agree upon that?
I hope so. So if you have atrial fibrillation,
what wave is this? The P wave has now become
very obscure to identify. Let us continue.
Atrial flutter. You pay attention to two 'T's
in the middle of flutter okay and the reason
for that is because you want to think of a
sawtooth type of appearance of your P wave.
Why P wave? Atria. Multifocal atrial tachycardia,
MAT. This once again will be an issue with
your atria. So what does the P wave look? They
look abnormal. They look bizaare. The P waves
do. It doesn't touch the QRS complex, is that
clear? And then we have WPW, Wolf-Parkinson-White
syndrome. What is this? It is an excessory
pathway. "What does that even mean, Dr. Raj?"
It means that remember the proper conduction
of an impulse is going to be from the SA node,
you have to go to a delay. Why did you need
that delay at the AV node? You need that delay
so that you have just enough time. As you
squeeze the blood from the atria to the ventricle,
right. You need just enough time in a delay
in which you have enough time to properly
fill up the ventricle. Correct? Who is going
to provide that delay? I believe it is called
the atrioventricular node. The AV node okay. That
is perfectly normal physiologic conduction.
What if you accidentally, inheritently ended
up having an accessory pathway anywhere along
the intraatria or shall I say between the
atria and the ventricle? So if you had some
type of accessory pathway on the septum or
the wall between the atria and the ventricle,
well this will not provide a delay. This is
that accessory pathway that you are referring
to. And so, therefore, we will talk about what
is called as a AV nodal reentry type of arrhythmia.
Not good. And the particular characteristics
that are very important for you to clinch
WPW as a diagnosis. Okay. So that is the atria.
But in general, what is going on? Tachy, too
fast. What are normal beats per minute? 60 to 100
okay. 60to 100 is normal beats per minute. So
if it is tachy, greater than 100, by definition
automatically tachy. Less than 60, automatically
brady. Is that clear? So this is algorithm
100. Ventricular, what are you going to effect?
What wave are you going to affect here with ventricular
issues? Hopefully, you are telling me QRS
correct. The QRS complex represents the activity
of the ventricle. So, therefore, let us say
that you have twisting around your point.
How do you say that in French? Torsades de
pointes. You are twisting
around a point. Who is? The QRS complex. Wow!
That is dangerous, isn't it? What predisposed
of this? Most likely, maybe some kind of long
QT issue. So when the QT becomes more and
more prolonged, why? Maybe drugs such as
antibiotics, such as antipsychotics, such
as quinidine, a bunch of drugs may result
in a secondary long QT. Inheritently you can
have genetic diseases. You have heard of romano-ward
right, in which there is no deafness. You have
heard of things such as Lange-Nielsen. So
these are the inheritent type of long QT syndromes.
What does that even mean? The more that you
prolong your QT, the QRS complex doesn't know
how to behave so, therefore, it starts twisting
around the point, is that clear? So understand
the most common predisposing factors. And once
you do, things become a heck of a
lot easier. Ventricular fibrillation,
you should feel
very comfortable with the term fib, fibrillation.
What does that mean? A disappearance or obscure
type of wave. Can't tell you how to identify. But
in this case, the ventricular. So it is difficult
to identify the QRS complex. Oh! My goodness.
Picture this. The QRS complex is difficult
to identify. It is wavy. It is almost like
a flat line. What does flat line mean to you?
You are sleeping forever. You are dead. So
ventricular fibrillation. You are worried
about death, aren't you? You'd never want to
get to that point. In fact, whenever you have
any type of arrhythmia and if it is originating
in atria known as supraventricular arrhythmias
right. Whenever you have supraventricular
tachycardias, what is your number one mission?
What is your objective? You do everything
in your power to prevent that arrhythmia from
going into the ventricle because if it does
oh! My goodness take a look at this ventricular
fibrillation. You are going crazy, who is?
The ventricles are. What does that mean? You
can’t properly fill up your ventricles with
blood. How in the world are you supposed to
have cardiac output? You don't. Is your patient
going to die? Yes. Are you putting things
together? I hope so. Ventricular tachy.
Well, all these mean that
the QRS complex, this band between them is
getting very short. The R wave to R wave.
Think about R wave, major pulse deflection.
The R wave to R wave is going to shorten.
You might have heard of mnemonics or paramedics
or what not and they talk about 300, 150, 100
and 75, 60, 50. It's like a phone number and what
does that mean is that the fact the lines
as I should show you an EKG. The lines when they
are closer together, is that tachy or is that
brady, please? Tachy okay. I will show you
that. If you missed it, that is okay. Don't
worry. I am just introducing. What I like
to do as you know is to bring information
from before and then introduce information
to be had. But ultimately, reinforcement.
Let us begin. So now with vascular disease,
the only other category here with arrhythmia
where let us say that she had a myocardial infarction
okay. Once again let us say in left anterior
descending, you will find an ST elevation,
in which leads would you find ST elevation
if your left anterior was undergoing infarction?
A major embolic obstruction. Got it? Good. What is
it? V1 through V4. Are you picturing in this?
Good. So left anterior descending, there is
a myocardial infarction, you'll ST elevation
in V1 through V4. So that's your intraventricular
area and may be anteroapical and that is some
point well, this used to be called the widow
maker, why? Because if the patient had an
LAD type of MI, chances are they are not coming
back and it ends up where the spouse is lost,
right. That is unfortunate. My point is this,
though. If there is myocardial infarction
and the wall is not working properly, could
it result in arrhythmias? Sure it can. Venous
insufficiency, peripheral vascular disease,
peripheral arterial disease. Any one of these
could result in decreased perfusion to the
heart and some may result in arrhythmia.
Aortic dissection. This itself let us that
you have an issue such as Marfan disease.
What is that called when you have little bit
of tear and there is accumulation of fluid
from the intima into the media? Cystic medial
necrosis may result in eventually aortic dissection,
with vascular diseases. Once again if there
isn’t proper blood supply to the heart and
you have origination of your arrhythmia. Interesting,
isn't it? So you can have these inheritent
causes that we just walk through or vascular
diseases, but you have to take a look at the
body in totality for you to truly make sense
of this. Let us continue.
So what we have here, quickly is an EKG. I