00:01
Hi, welcome to our video
series on electrocardiograms.
00:05
In this one, we're going to talk about the
treatment plans for atrial dysrhythmias.
00:09
So we're going to treat things
like atrial fibrillation,
premature atrial contractions,
or PACs and atrial flutter.
00:18
Now,
if you're looking at the ECG,
we do things to diagnose and
assess what is really going on.
00:23
See a basic ECG strip that we're just
looking at with like maybe five leads
can give us a clue
that there's a problem.
00:31
But we're going to
take the next step
in seeing what exactly is going
on in that patient's heart.
00:37
Now, that may involve
a holter monitor,
because have you ever had the experience
where you take your car into the mechanic,
because it's making
this weird noise,
but then when you're actually
in the mechanic shop,
your car refuses to do it?
Well, the second thing
is with your heart.
00:54
Oftentimes,
patients can be having a dysrhythmia.
00:57
But it won't necessarily occur when
we have them hooked up to a monitor.
01:01
So a holter monitor
is called that
because the patient will wear it for at
least 24 hours and oftentimes even longer.
01:09
Now, they used to be big things that
you had to strap around their neck,
and they were really uncomfortable,
but they're much, much smaller now
and more comfortable and
convenient for the patient.
01:20
So the reason they wear these
for a long period of time
is because we have a
better chance of seeing
the patient experience
that dysrhythmia.
01:29
Now a cardiac stress test,
that's a whole another ballgame.
01:32
That's where we're going
to put them on a treadmill
and make them walk really fast
and then eventually even run.
01:38
So we are stressing their
cardiovascular system.
01:42
Sometimes that's a
trigger for dysrhythmias.
01:45
We'll also use it with
patients who had chest pain,
so we can watch ECG changes,
while a patient might be having
chest pain or is at least stressed.
01:54
So cardiac stress test
takes place with a physician
and some other practitioners
to observe the patient.
02:01
It usually involves a treadmill.
02:03
Unless the patient is not able to
walk on a treadmill or be mobile,
then they can use some
chemicals inserted into an IV
that will also stress the
patient's cardiovascular system.
02:15
It's not really fun for the patient
because it makes them feel all jazzed.
02:19
But it will stress the
cardiovascular system.
02:22
And that way the practitioners
and the physicians
can watch the heart under
stress and see how it responds.
02:29
Now of course,
we've got some lab work,
we're going to look at their cholesterol
and thyroid and electrolyte labs.
02:34
There's several labs
that can help us diagnose
and assess what's going
on with the heart.
02:40
Now the last one is a
transesophageal echocardiogram.
02:45
So let's start with that word at
the bottom right, echocardiogram.
02:50
We're going to get some pictures,
some images of their heart.
02:54
But transesophageal means we're
going to look through their esophagus
so we get that much
closer to the heart.
03:01
So instead of having to
go through the chest wall,
we put that camera or right down near
the heart so we can get a better picture.
03:10
And that's often
done for atrial fib.
03:13
So let's talk about atrial fib.
03:15
It is the most common type
of abnormal heartbeat.
03:19
So you'll see this
often in your practice.
03:22
Now it can become a chronic medical
condition if it isn't treated.
03:26
Sometimes we'll get patients
in and they're in atrial fib.
03:29
And they have likely been an
atrial fib for a very long time,
that's why have really good
patient history is important.
03:37
And if the patient doesn't have
it diagnosed by a physician,
ask them for more
subjective symptoms like,
what do you feel like
when this rhythm happens?
See it on the monitor.
03:49
Tell me what it feels like.
03:50
Sometimes people will say,
it feels like their heart is
gonna burst out of their chest
or it feels like
it's really fluttery.
03:56
So then you can ask them.
03:58
"Have you ever felt
that feeling before?
How long have you been
experiencing that?
Has it been just in the last few days,
the last few weeks, months or years?"
So you are the key to getting really
helpful, clinical information.
04:15
So let's talk about
these P words.
04:17
You've got paroxysmal
versus persistent.
04:20
Okay, so, the cool thing about
atrial fib is it comes and goes,
that's why a holter monitor
can sometimes be helpful.
04:27
But atrial fib can resolve itself
and go back to a sinus rhythm
or it can become
a chronic issue,
really is preferable that it
not become a chronic issue.
04:39
So let's look at paroxysmal,
first of all that means it comes and goes.
04:42
Persistent means it stays
for a very long time.
04:46
So pause the video and see if
you can recall the definition
of each of those words
without looking at your notes.
04:59
All right now that you have that
scaffold of paroxysmal and persistent,
let's look at the more
complete definitions.
05:07
So with paroxysmal atrial fib,
it's an episode that spontaneously ends.
05:12
So over seven days, it can end
we still consider it paroxysmal,
or in shorter periods of times,
it can rev up and then resolve.
05:22
But the idea with paroxysmal atrial
fib is that it resolves by itself.
05:27
We don't have to do anything for
it to go back to a sinus rhythm.
05:31
Now, persistent atrial fib
is an episode of atrial fib
that sustains itself on
longer than seven days.
05:38
So this atrial fib lasts longer than
a week or seven actual calendar days.
05:45
So this means we've
got a bigger problem.
05:48
Now it makes sense.
05:49
If someone is having episodes
of paroxysmal atrial fib,
it could turn into
persistent atrial fib.
05:56
So history,
asking your patient clear questions
that make sense to them that they can
give you the most accurate information
will help you get a better
treatment plan for them.
06:09
Now, look at our graphic here,
what is going on in the atrium?
Alright, it looks a little
spastic of there, right?
It's disorganized.
06:20
Look at the ventricle,
it's still fairly organized.
06:24
So, what's going on in your patient's
heart when they have atrial fibrillation?
It's there a disorganized
electrical signals in the heart.
06:33
And that's what causes the atrium
and we call it fibrillate or quiver
instead of pumping synchronously
with the ventricles.
06:41
Remember, what we're looking
for in a sinus rhythm heart
is atrium-ventricles,
atrium-ventricles, atrium-ventricles.
06:51
Look at the difference
in this picture.
06:52
It's a atrium-ventricles,
atrium-ventricles, atrium-ventricles.
06:58
Now, that's not going
to be an efficient way
to pump blood through
the rest of your body.
07:04
And atrial rate and atrial fib, now that
you will be able to measure it on a strip,
but think of it as being super fast,
it can be like 400-600 a minute
due to that just repeated
electrical activity.
07:17
Okay, so when we say the
atrial rate is that fast,
we just want you to have
this picture in mind.
07:24
There is no way you're
going to be able to measure
the atrial rate and
atrial fib on a strip,
because think back to
what it looked like.
07:33
It was just,
it's just kind of trashy.
07:36
There's no discernible ways
that you could measure.
07:40
So let's review the
criteria for atrial fib.
07:43
Heart rate can often
be 100-175 bpm.
07:46
That's considered a rapid
ventricular response.
07:49
However, the heart rate
can also be lower than 100
and it's still considered
atrial fibrillation
if it meets these
other criteria.
07:58
Now the rhythm is irregular like
irregularly irregular, right?
This is different than PACs.
08:04
The P wave, we don't have one
that's discernible, right?
You can't really see it,
it just kind of looks like a mess
so we can't measure
the PR interval.
08:12
But the QRS looks normal.
08:15
We just don't have a
P wave for every QRS.
08:18
Premature atrial contractions.
08:20
The name tells us a lot.
08:22
If you look at premature
that means it's early
and atrial contraction that
tells us what's going on.
08:29
Now the official definition is that
PACs or premature atrial contractions
are contractions of the atria and they're
triggered by the atrial myocardium.
08:39
But they have not
originated from the SA node.
08:44
So let's look at the criteria
for sinus rhythm with PACs.
08:48
Look at the difference
in this strip.
08:51
It looks much more organized than
the atrial fibrillation strip.
08:56
So this is sinus
rhythm with PACs.
08:59
It's fairly ordered
and structured.
09:01
Except for those few beats that
are not playing by the rules.
09:05
The heart rate is consistent.
09:07
The rhythm is regular and
a little bit irregular,
just with those
exceptional beats.
09:13
You have P waves that are
present before each QRS,
they look the same except
for those early beats.
09:19
The PR interval should be within
normal range for the sinus beats.
09:23
And the QRS is normal
less than 0.12 seconds.