00:01
Now with
Dysrhythmia and Conduction System.
00:03
What are the two
ends of the spectrum?
Either too slow or too fast.
00:10
With the bradyarrhythmia
our topic will bring us to
heart blocks.
00:15
With this most common type of blocks
that we will take a look at
AV nodal block,
first-degree, second-degree.
00:21
With second degree
will then divide that into mobitz.
00:24
But want to take a look at
type one and type two.
00:27
and then we'll walk into our
third-degree AV block.
00:30
On the other end of the spectrum
to quick.
00:34
I'll quickly walk you through now
press it reinforcement
so that you feel comfortable
with arrhythmia.
00:39
As soon as your atria --
well, what exactly are you going
to be looking at, or interpreting
so that you can figure out that
your patient has an arrhythmia?
How about an EKG?
Would that come in handy?
Sure it would.
00:50
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's say that you add a fib.
01:01
Okay, not a fib where you're lying
to yourself about anything
but a fib in the sense of
a fibrillation.
01:09
A fibrillation is one in which
that wave has disappeared.
01:13
Is that clear?
Or has become wavy.
01:16
Difficult to identify obscure.
01:18
Can we agree upon that?
I hope so.
01:21
So if you have atrial fibrillation,
what wave is this?
The P wave is now become
very obscure to identify.
01:27
Let's continue.
01:28
Atrial flutter.
01:29
You pay attention the two T's
in the middle of flutter, okay.
01:33
And the reason for that
is because
you want to think of
a saw tooth type of appearance
of your P wave.
01:41
Why P wave?
Atria.
01:43
Multifocal Atrial Tachycardia
(MAT)
This once again would be
an issue with your atrium.
01:50
So what does the P waves look?
They look abnormal.
They look bizarre.
01:53
The P waves do.
It doesn't touch the QRS complex.
01:56
Is that clear?
And then we have WPW,
Wolff-Parkinson-White Syndrome.
02:02
What is this?
It's an accessory pathway.
02:04
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.
02:13
Why do you need that delay
at the AV node?
Well, you need that delay
so that you have just enough time
as I squeezed the blood
from the atria to the ventricle,
right?
You need just enough time
and a delay
in which you have enough time
to properly fill up the ventricle.
02:28
Correct?
Who is going to provide that delay?
I believe it's called the
atrioventricular node, the AV node.
02:35
Okay, that's perfectly normal,
physiologic conduction.
02:39
What if you accidentally,
inherently,
ended up having
an accessory pathway
anywhere along the interatrial
or should I say
between
the atrial and the ventricle?
Alright, so if you had
some type of accessory pathway
on the septum or the wall, between
the atrial and the ventricle,
well, this will not provide a delay.
03:00
This is that accessory pathway
that you're referring to.
03:02
And so therefore,
we'll talk about this
what's called as an AV nodal
re entry type of arrhythmia.
03:08
Not good, not good.
03:09
And the particular characteristics
that are very important for you
to clinch WPW as diagnosis.
03:16
Okay, so that's the atria.
03:17
But in general, what's going on?
Tachy.
03:21
To fast.
03:22
what's normal beats per minute?
60-100.
03:26
Okay, 60 to 100
is normal beats per minute.
03:30
So if it's tachy, greater than 100,
by definition, automatically tachy.
03:35
Less than 60 automatically brady.
Is that clear?
So this is all
greater than 100.
03:40
Ventricular.
03:41
What are you going to affect?
What wave are you going
to affect here
with ventricular issues?
Hopefully you're telling me,
QRS.
03:50
Correct.
03:50
The QRS complex represents
the activity of the ventricle.
03:55
So therefore, let's say that you
have twisting around your point.
04:00
How do you say that in French?
"To saw the point."
You know,
probably saying more Italian
when I said it.
04:05
But it's French.
04:06
It is to saw the point,
you're twisting around the point.
04:10
Who is? The QRS complex.
04:12
Wow, that's dangerous, isn't it?
What predisposed to this?
Most likely, maybe some kind of
Long QT issue.
04:22
Alright.
04:23
So when the QT becomes
more and more prolonged,
Why?
Oh, maybe drugs,
such as antibiotics,
such as antipsychotics,
such as quinidine.
04:32
You have a bunch of drugs that may
result in a Secondary Long QT.
04:38
Inherently, you can have
genetic diseases.
04:41
You've heard of Romano-Ward, right,
in which there's no deafness.
04:46
You've heard of things such as
Lange-Nielsen
So these are the inherent type of
Long QT syndrome.
04:52
What does that even mean?
The more that you prolong your QT,
the QRS complex doesn't know
how to behave.
04:59
So therefore, it starts twisting
around the point.
05:01
Is that clear?
So understand the most common
predisposing factors,
and once you do
things become a heck
of a lot easier.
05:08
Ventricular fibrillation.
05:09
Ah, you should feel
very comfortable
with the term fib.
05:13
Fibrillation.
05:14
What does that mean?
An disappearance or obscure
type of wave can talk to identify.
05:21
But in this case,
if ventricular
so it's difficult to identify
the QRS complex.
05:25
Oh, my goodness.
Picture this.
05:28
That QRS complex is difficult
to identify. It's wavy.
05:32
That's almost like a flat line.
What flat line mean to you?
You're sleeping forever.
You're dead.
05:38
So ventricle fibrillation, you
worried about death, aren't you?
You don't ever want
to get to that point.
05:43
In fact, whenever you have
any type of arrhythmia,
and if it's originating in atria
known as supraventricular
arrhythmias, right.
05:52
Whenever you have
supraventricular tachycardia is,
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're going crazy.
06:09
Who is? The ventricles are.
What does that mean?
You can't properly fill up
your ventricles with blood
How on the world are you
supposed to have cardiac output
you don't.
06:17
Is your patient going to die?
Yes.
06:19
Are you putting
things together?
I hope so.
06:22
Ventriclar tachy.
06:24
Well, just all this means that the
QRS complex,
the span between of them
is getting very, very short.
06:29
The R wave to R wave,
think about R wave,
major positive deflection,
the R wave to R wave
is it going to shorten.
06:36
You might have heard of mnemonics
or paramedics or whatnot there
and they talk about 300
and 150, 100 and 75, 60, and 50.
06:44
Alright? It's like a phone number.
06:46
And what that means is the fact that
the more number -- the lines,
as I should show you an EKG,
the lines
when they're closer together,
is that tachy, or is that brady?
Please.
06:56
Tachy. Okay. And with that,
I'll show you that coming up.
06:59
If you've missed it, that's okay.
Don't worry.
07:01
I'm just introducing,
what I like to do, as you know,
is to bring information from before
and then introduce information
to be head,
but ultimately, reinforcement.
Let's begin.
07:12
So now, with vascular disease,
the only other category here
with arrhythmia,
where let's say that you had a
myocardial infarction, okay?
Once again, let's say
left anterior descending,
you find an ST elevation.
07:22
And which leads
would you find ST elevation,
if your left anterior descending
was undergoing infarction,
A major, major
embolic obstruction.
07:34
Got it. Good. What isi it?
V1 through a V4.
Are you picturing this?
Good, so left anterior descending,
and there's a myocardial infarction
upon ST elevation in V1 to V4.
07:45
Okay, so that's your
interventricular area,
and maybe anterior apical.
07:49
And at some point, wow, this used
to be called the widow-maker. Why?
Because if the patient had
an LAD top MI,
chances are
they're not coming back.
07:57
And it ends up
where the spouse is lost.
08:01
Right? That's unfortunate.
08:02
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.
08:10
Other cardiac disorders
that can cause arrhythmias include
cardiomyopathy and the conduction system
abnormalities that we just discussed.
08:17
Noncardiac disorders can also cause
arrhythmias COPD
is associated
with multifocal atrial tachycardia or METI
hyperthyroidism can cause
atrial fibrillation
channel properties and stimulants
can cause taki arrhythmias.
08:30
And as strange as it sounds,
antiarrhythmic medications
can cause arrhythmias
and even be pro arrhythmic in some cases.
08:37
Aortic Dissection.
08:39
This itself, let's say that you have
an issue such as Marfan disease
what's that called,
when you have a little bit of tear
and there's accumulation of fluid
from the into the media,
cystic medial necrosis
may result in eventually,
aortic dissection
with vascular diseases,
once again, if there is a proper
blood supply to the heart,
and you have origination
of your arrhythmia.
09:08
Interesting, isn't it?
Interesting.
09:10
So you can have these inherent
causes
that we just walked through,
or vascular diseases,
but you have to take a look
at the body and totality
for you to truly make sense of this