CHART 389

Dysrhythmia First-degree AV block

AV Block Dysrhythmias: Etiology, Physical Assessment, and Treatment

Etiology May occur without any underlying heart disease May occur in athletes Occurs in about 13% of the population Drug reactions to digoxin, betablockers, and CA channel blockers Cardiac related causes include: Ischemia Myocardial infarction Rheumatic heart disease Coronary artery disease Conduction delay within the AV node Most commonly associated with AV nodal ischemia secondary to occlusion of the right coronary artery Other causes may be: Myocardial infarction Inferior/right ventricular structural heart disease or an anatomical abnormality Myocarditis Transient side effect of open heart surgery Increased vagal activity Drug toxicity, e.g., digoxin Septal wall necrosis Acute inferior or right ventricular MI Myocarditis Advanced coronary artery disease (general ischemia) Electrolyte imbalance Digitalis toxicity Reaction to amiodarone, betablockers, or calcium channel blockers Physical Assessment Pulse: Within normal limits BP: Within normal limits Treatment This is not a dangerous rhythm in itself and usually is asymptomatic. May progress to a more advanced heart block, especially in the presence of a myocardial infarction. Observe closely and place on an ECG monitor to detect additional signs and symptoms.

Mobitz I / Wenckebach/ Type I seconddegree heart block

Pulse: Irregular BP: May be decreased with frequently dropped beats due to decreased cardiac output. If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present, although rare. Pulse: slow and typically irregular, depending on ventricular response BP: Decreased due to low cardiac output If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present. Pulse: Slow and usually irregular BP: Lower than usual If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present.

This is often a transient rhythm and will revert to normal rhythm without treatment. Usually asymptomatic because the ventricular rate often remains nearly normal and cardiac output is not significantly affected. If symptomatic, and is a result of medications, they should be withheld. If the heart rate is slow and serious clinical manifestations such as low BP, angina, shortness of breath, occur, atropine or temporary pacing is considered. When occurs in conjunction with acute myocardial infarction, observe for increasing AV block. Often considered an emergent situation. The health care provider should be notified at once. May progress to a third-degree AV block and ventricular asystole, thus, a standby cardiac pacemaker is indicated for asymptomatic patients, and temporary cardiac pacing is required for symptomatic patients. For sustained permanent block, a permanent pacemaker is inserted.

Mobitz II second-degree AV block

Third-degree AV block (complete)

Ischemic damage Septal wall necrosis Acute inferior or right ventricular MI due to the effect of vagal tone and ischemia on the AV node Acute anterior MI Myocarditis Coronary artery disease Cardiomyopathies Cardiac muscle diseases Rheumatic heart disease Drug toxicity, reaction to amiodarone, beta-blockers, or calcium channel blockers Electrolyte imbalance Rheumatic heart disease Congenital condition usually located at the level of the AV junction

Treatment is essential as third-degree block is potentially lethal. If an AV junctional or ventricular escape pacemaker does not take over following a sudden onset of third-degree AV block, asystole will occur. Clinical manifestations depend on the ventricular heart rate, especially for slow rates. If the QRS is narrow and the patient is symptomatic, initial management is atropine and/or transcutaneous pacing. If the QRS is wide and the patient is symptomatic, transcutaneous pacing is started. A temporary pacemaker is inserted, and may be followed by a permanent pacemaker.

CHART 389
Dysrhythmia Bundle branch block (BBB)

AV Block Dysrhythmias: Etiology, Physical Assessment, and TreatmentContinued

Etiology Causes vary depending on whether it is the right or left BBB Right BBB may be present in healthy individuals with apparently normal hearts without any apparent underlying cause Common pathological causes include: Coronary artery disease Cardiac tumors Cardiomyopathy Myocarditis Atrial septal defect Cardiac surgery Congenital RBBB Acute anterioseptal MI Acute pulmonary embolism or infarction Acute heart failure Unlike RBBB, LBBB always indicates a diseased heart and generally is more common in individuals with diseased hearts Common causes include: Hypertensive heart disease Cardiomyopathy Myocarditis Syphilitic, rheumatic, and congenital heart disease Cardiac tumors Idiopathic degenerative disease of the electrical conduction system Aberrant ventricular conduction associated with supraventricular premature contractions and tachycardia Physical Assessment Pulse: Within normal limits BP: Within normal limits Treatment Specific treatment usually is not indicated if it is present alone and is not the result of an acute MI. Temporary cardiac pacing is indicated for the treatment of a right or left bundle branch block under the following conditions: results from an acute MI is complicated by a first- or second-degree AV block, or both, especially in the setting of an acute MI if the block progresses to a complete AV block.