Heart Blocks 7/ 2005

Hi all. Yet another one, which occurred to me that I should do about two weeks ago, when a patient was doing some pretty strange things on the monitor. As usual, please remember that this is not meant to be an official reference, but is supposed to represent the information that a preceptor would pass on to a new orientee in the unit. Please get back to me if things aren’t clear, have been left out, or are just plain wrong, and I’ll fix them up right away. Thanks!

1- What is a heart block? 2- What exactly is being “blocked” in heart block? 2-1- The key idea: all of the time, some of the time, none of the time… 2-2- It can not be that simple… 3- Why do heart blocks happen? 4- What are the three types, or degrees of heart block? What is a “dropped beat”? 4-1- A normal rhythm for reference. 4-2- First degree heart block. 4-3- Second degree heart block. 4-3-1- Second degree, type 1: Wenckebach/ Mobitz 1 4-3-2- Second degree, type 2: Mobitz 2 4-4- How I tell them apart? 4-5- Third degree (complete) heart block. 5- A puzzler… 6- What is the treatment for heart block? 7- Where can I learn more about pacemakers?

1- What is a heart block?

Heart block is a kind of arrhythmia, usually caused by ischemia or an MI. There are three kinds, or degrees of heart block, and although sometimes people get confused about them, actually they’re pretty simple to understand.

2- What exactly is being “blocked” in heart block?

The signal from the SA node is trying to get to the AV node, and it’s being slowed down, or blocked altogether – it’s having a hard time getting through. The result is that the SA signal going through the atria makes a normal P wave, but if that signal doesn’t trigger a response from the AV node, no QRS gets produced – so you’ll see a P wave that isn’t followed by a QRS. The QRS represents ventricular depolarization – so what? So what is: no depolarization, no contraction, no blood pressure!

The signal is trying to get from here…

To here…

www.arrhythmia.org/ general/whatis/

2-1- Here’s the key idea - the signal is either getting through:

1- All the time (but taking a little longer than usual). 2- Some of the time. 3- None of the time.

Got that? All, some, or none of the time. And see, those are the three kinds, or degrees of heart block: first, second, and third degree. All, some, or none.

2-2- It can not be that simple…

Sure it can. This is one of those things that people get scared of, and they build it up in their heads as if it were this enormous mysterious thing, like running a nuclear reactor. (When she learns about something new, Jayne always says: “Well, is it easier or harder than a ventilator?”)

3- Why do heart blocks happen?

Heart blocks usually happen when the patient is having ischemia, or an MI. The blood supply to the nodes is interrupted, or reduced, and they become unhappy – but at least in this regard, they do it in recognizable ways.

CCU nurses – what kind of MI or ischemia commonly produces heart blocks?

4- What are the three types, or degrees of heart block? What is a “dropped beat”?

4-1- First of all, here’s a normal strip for reference:

[pic]

Right – a quick bit of review. See the P wave? Now, see where it meets the QRS? Actually, that first upright part of the QRS is the R wave - there’s no Q-wave here. (There’s more about Q waves and what they mean in the faq on “Reading 12-lead EKGs” – basically you don’t want to see them, because they mean the patient has gotten into the tissue necrosis stage of an MI.)

So – no Q waves here. Ok… so the first, upright move of the QRS complex is the R wave, right? So the measurement from the beginning of the P wave, until it hits the R wave, is called (surprise) the P-R interval. A normal PR interval is supposed to be no more than .20 seconds – which is five little boxes, or one big box on the EKG paper. Calipers definitely help here.

Now. Remember what the PR interval actually is? That’s to say, not how long it is, but what it actually means? It shows the movement of an electrical depolarization signal along the path through the atria, from the SA node in the right atrium, to the AV node at the atrioventricular junction.

Say what?

Remember, the signal is trying to travel from the SA node to the AV node, and from there it goes on southward to make the QRS complex as it goes through the ventricles.

If the PR interval is normal, then the signal is travelling from the SA node to the AV node in a normal amount of time.

Okay so far? Onwards…

4-2- First degree heart block.

[pic]

Right – here we are in first-degree heart block. Look at the PR interval now – see how long it is? Longer than .20 seconds, anyway. So that means that it’s taking a longer-than-normal time for the signal to go from node to node: SA to AV. It gets there every time, and goes on through the AV node to make a QRS – and therefore a ventricular contraction - but it takes longer than it’s supposed to.

4-3- Second degree heart blocks:

This is where a lot of the confusion comes in. It really isn’t all that hard. Look at the P-waves in the wenckebach strip below. Some of them have no QRS after them. This is what’s meant by a “dropped beat”. The SA node fires off a signal down the conduction path to the AV node, but the AV node doesn’t respond by starting a QRS – in fact, nothing happens. The SA node just continues shooting off signals at it’s own rate, and some of the time the signals get through the AV, and some of the time they don’t. If you’re lucky, enough of the beats are conducted to the ventricles that your patient can still make a blood pressure. If you’re not lucky…what would you do for that patient?

Next confusing bit: there are two kinds of second degree heart block. And just to make things really interesting, the first of the two kinds has two different names. But only the first. Just in case it wasn’t complicated enough already.

1- Second Degree Heart Block, Type 1: Wenckebach/Mobitz 1

Here’s the first kind. This rhythm is called Wenckebach. It’s also called Mobitz 1. Why it should have these two names, I have no idea – anybody know? Co-discovered, probably.

[pic]

See the dropped beats? The signal is getting through to the AV node some of the time. Mobitz 1 is actually considered pretty benign – you see it in some patients in and around the time that they’re having an MI, but it turns out that the rhythm usually disappears after the event, and doesn’t cause much problem. Not the one to worry about. (I worry anyway, but hey, I’m old.)

Here’s Karel Wenckebach himself. Doesn’t look very happy. Missed out on Mobitz 2… poor guy.

2- Second Degree Heart Block, Type 2/ Mobitz 2

Now, here we are in second degree, type 2, “Mobitz 2”. This one only has one name. Where was Dr. Wenckebach for this one? I bet his kids are really jealous of those Mobitz kids – they have two named after dad! Or was it mom?

[pic]

http://www.grundkurs-ekg.de/rhythmus/e_av_block_2_mobitz.jpg

This is the kind of second degree that you don’t want to see – it turns out that
Mobitz 2 frequently progresses to the big bad heart block – namely: complete, or third degree heart block.

So – if the first kind is (relatively) good, and the second kind is bad, (really bad) – it becomes pretty important to be able to tell them apart.

4-4- How do I tell them apart?

It’s all about the PRs… look at the PR intervals of the beats leading up to the dropped one. In Mobitz 1, the PRs do what? - they get longer, longer, longer, and then there’s a dropped beat.

Now look at Mobitz 2. What do those PRs do? They stay the same, the same, then a beat gets dropped.

See? Not so hard. It’s either: “longer longer longer, drop” – or, “the same, the same, the same, drop”.

“Longer” comes first, so that’s type 1.

“The same” is second – that’s type 2.

If you say “Longer, longer, longer, drop”, and then “The same, the same, the same, drop”, in the car, or the shower a few times, you’ll never forget it again. What were we talking about? My wife looks at me strangely in the car…

5- Third degree – complete heart block.

This is the big bad one. This time, none of the P-waves are conducted to the AV node. Once again, luck and the condition of the patient come into it – if the patient still has a functioning AV node, and if the goddesses are smiling, the AV node will generate a rate by itself : a “nodal”, or “junctional” rhythm – remember the intrinsic rates? SA node is what?: 60 to 100 beats per minute, AV node is 40 to 60. But – you wouldn’t be having a heart block problem if the AV node were still functioning reasonably, would you? So the AV node may just sit there, probably ischemic, either unable to do anything or only generating an occasional beat. In that case, you wind up with something like this:

[pic]

Ack! Can this patient generate a blood pressure? Nuh-uh! And the P-waves are only coming at a rate of about 60 – this is a very bad situation. But of course you were ready – what would you do in this situation?

5- A Puzzler:

Here’s a puzzler: what’s this one?
[pic]

Well, are the P-waves being conducted? Some of them are, right?- not every P is followed by a QRS - so this has to be a type 2; a second -degree heart block. What kind is it? (Do you see that this was a trick question?)

You can’t tell what kind of second-degree this is. You need a series of PR intervals to look at to be able to tell, remember? – either “longer, longer, longer”, or “the same, the same, the same” before a dropped beat. There are certainly dropped beats here – lots of P-waves with no QRS’s after them. But there’s no series of PRs to look at that will tell you which of the Mobitzes this is. So it could be the nice one, or it could be the bad one – you can’t tell. So which do you prepare for?

6-What is the treatment for heart block?

Again, it depends on which degree your patient is having. First degree I’ve never seen treated just because it’s there – but if it’s there because of something like a high digoxin level, or because the patient has been started on a combination of cardiac meds that might combine to block conduction – then maybe you need to think about those meds. Combining blockades can definitely produce these rhythms.

Second degree – still depends. Type one – watch it carefully, because it’s probably associated with an MI process. Type 2- watch it really carefully, because that’s the one that progresses to third degree. Have atropine nearby, have a Zoll/external pacemaker nearby… I’d go ahead and put the pacing pads on the patient, and you would actually do well to go ahead and figure out what the capture threshold is for the patient. Notify the team, and make sure that someone is thinking about taking the patient to the cath lab for a temporary pacing wire.

Third degree – emergently, you may have to call a code. You probably will have to call a code. If you even think that the patient has a chance of going into third degree/complete heart block, get the equipment ready as in Mobitz 2, make sure the team is well aware, have the transvenous pacing kit ready at the bedside along with the external pacer. Test the external pacer, make sure it’s capturing, and leave it on in demand mode. Get the code cart into the room, and make sure that the cardiology people are coming, either to place the wire at the bedside, or in the cath lab if the situation allows for it.

7- Where can I learn more about pacemakers?

There’s lots more on pacers, both internal and external, in the “Pacemakers” FAQ.