03.04 Atrial Flutter

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Hey guys, my name is Brad, and welcome to nursing.com. And in today's video, what we're going to be doing is we're going to be discussing atrial flutter, also known as a-flutter. I think it's going to be important to discuss some of the physiology behind a-flutter, as well as some signs and symptoms the patient may experience, how we may treat a patient experiencing a-flutter, and most importantly, for this course, how to identify it on an EKG exam. Let's dive in. 

So in atrial flutter, this is causing the atria to beat rapidly in unison, right? So atrial flutter, before I continue, is very, very similar to a-fib. We're going to see that from the signs and symptoms the patient expresses to how we treat them to also the physiology.  Make sure you go check out our course on atrial fibrillation as well, to help bring better clarity to the concept of a-flutter. 

But essentially what we're seeing is, instead of a normal physiological homeostatic electrical conduction system where we originate at this SA node in our electrical conduction, goes down to the AV node and all the way down to the Purkinje fibers. Instead we have SA node dysfunction, where our sinus rhythms, where our normal electrical impulse originates, we actually have a dysfunctional SA node. And so, as a result, what's going to happen is instead of our electrical impulses originating in that SA node, going down to the AV node, our electrical impulses actually come from these atrial tissues themselves, which causes a very rapid cyclical, like a firing of electrical impulses that rapidly go around and around inside of that atrial tissue, pretty much producing an atrial rate of approximately 300 beats per minute. Again, remember that that AV node here actually acts as a filter, filtering out a lot of those electrical impulses, because we don't want 300 beats per minute to actually reach these ventricles. Because if our ventricles were beating at 300 beats per minute, that's not conducive or compatible with life. So the AV node acts as a filter filtering out those 300 beats per minute down to approximately 150 beats per minute that we're going to see ventricularly.. 

Now, the way that I like to think about this, and one of the ways in which this is actually different from a A-fib is that it is in unison. It is a coordinated, although very rapid, atrial firing occurring in a coordinated manner. And so the way that I like to think about this is a flock of birds, right? Ignore my drawing. I know it's amazing. We're an artist over here. I like to think about a flock of birds, right? A-flutter, birds flying in this “A” pattern, right? And their wings all fluttering together. And you can imagine a flock of birds flying together. They're all doing so in unison, this is different from a-fib, which is rapid and uncontrolled. This is actually a controlled, although rapid beating of the atrium. 

So again, a lot of the causes and other things that we're going to see in a-flutter are very similar to a-fib, right? The older you are, the more weak that the conduction system gets. But ischemia, right, lack of perfusion to the heart itself is actually going to end up resulting in these electrical abnormalities, such as a-flutter. 

Now regarding assessment findings. Of course, if our atria are rapidly beating at a rate of 300 beats per minute, palpitations are absolutely going to occur, right? A patient's heart is just going to be beating away. This is going to cause things such as anxiety, patients feeling anxious, patients feeling like they can't catch their breath. We have an impaired electrical conduction system, therefore we have an impaired contraction system. Remember the electrical impulses actually cause the contraction, right? If our electrical conduction system is impaired, so is our contraction. And patients could experience shortness of breath. And if that LV is impaired and unable to pump blood out of the heart, as effectively as it normally would, our blood pressure is going to drop as well, which can end up resulting in syncope. 

Now, again, a lot of the therapeutic managements that we're going to see in a-flutter are very, very similar to what we're going to see in AFib, right? Again, either physical or mechanical cardioversion. And remember what this is, is essentially we have an incredibly rapid, rapidly firing atria. We need to stop that and restore normal electrical conductivity. We can do that either through physical means such as cardioversion, where we actually place the defibrillation pads connected to a defibrillating machine, normally used in a code, but instead we reduce the amount of power that we hit the patient's chest with, so to speak, in an attempt to mechanically convert a patient back to a normal rhythm. And chemically, we could use antiarrhythmic medications, such as amiodarone.  Rhythm stabilizers to stabilize this erratic rhythm. Negative chronotropes, again, chronotropes being medications that affect heart rate, negative meaning that it decreases your heart rate. A-flutter, incredibly rapid, rapidly firing heart. We want to decrease that heart rate.  And anticoagulation.  Again, this is something that's very similar to a-fib, and I didn't mention it in our initial slide here for a-flutter. But remember if we have this cyclical firing of electrical impulses throughout the atrial tissue at approximately 300 beats per minute, what is happening is these atria are quivering, right? Our atria are quivering instead of contracting right now. Why is that important? As these atria quiver, blood just sits there and that atria stagnant, not moving, not being ejected properly. And as blood sits here, stagnated, that causes clots to form within these atria. And should this clot travel down to a ventricle and then be ejected out of the body, we're talking about a clot now traveling throughout the body, possibly hitting the brain, causing a stroke, the lungs causing a PE or the heart causing an MI. So anticoagulation adherence is definitely going to be important in a-flutter. 

Now regarding the six step method used to solve for a-flutter, what are we going to see in an EKG strip whenever we see a-flutter? Now, heart rate, we'll recall atrially, we're going to see approximately 300 beats per minute and ventricular rate. Regularity. Now, one of the differentiators between AFib and A-flutter is in AFib. we're seeing an uncontrolled, uncoordinated cyclical firing of electrical impulses within that atrial tissue. Instead in a-flutter, remember we have those birds, that flock of birds in “A” flutter beating away in unison. But normally what we will see here is indeed R to R regularity that we'll usually check out. 

P to QRS interval. Again, same with a-fib, there are no distinguishable P waves. We just really won't be able to see that in a-flutter. Instead, the key massive thing that you're going to use to differentiate a-flutter from anything else is this “saw-tooth” like pattern. You're going to see what appears to be a “saw-tooth” like pattern. We'll see that better in our next slide whenever we actually take a look at an example question. But you can almost see that “saw-tooth” morphology on an EKG strip and know without looking at any of the other six steps that what we're dealing with is a-flutter. That's how clinically important and differentiating that morphology is.

PR interval. Because there is no distinguishable P wave, you will not be able to see a PR interval length. And QRS length, remembering that the normal was 0.06 to 0.12 seconds. This is indeed what we're going to see with a-flutter. Let's go ahead and dive into an example question and close this out. 

So taking a look at a practice question and using the six step method that we use to solve for EKG, the sixth being the solve, let's actually take a look and implement this. Okay. Now let's take a look at the heart rate here. Again. What we have is a six second strip. So let's count each individual QRS complex and multiply by ten. 1, 2, 3, 4, 5, 6, 7, 8.  So we have eight times 10 giving us a heart rate of 80 (8 X 10 = 80) right? Now, 80 beats per minute. I've already said that typically what we would see, ventricularly is a heart rate of 150 beats per minute. We can see here, this is actually an example, where that does not always meet the bill, right? But again, this massive differentiator that you can see right from the strip is this “saw-tooth” like pattern, right? All throughout this actual “saw-tooth” appearance, morphology, of this rhythm, you can almost see that and immediately know that what we have is a-flutter. 

The second thing’s going to be that R to R our interval. Again, we're basically looking at the measurements between, our distances between, our R to R intervals. Again, not always going to be the same. You can see this is a little bit shorter. This is longer. Not always going to be regular, but usually is going to be regular. So in this instance, another instance in this example where we are in a-flutter, but we're not regular, right? It doesn't always fit the bill, but morphology is so important. 

So again, P to QRS ratio, is there one P for every QRS? No. Because we cannot see the P wave. Instead, we are positive for this “saw-tooth” morphology. 

Now our PR interval. We cannot see a P wave. So cannot measure a PR interval. 

And regarding our QRS length, we would actually measure the individual lines in between our QRS complex. So we would say we would go, 1, 2 small boxes 0.04 times two equals 0.08 seconds (0.04 X 2 = 0.08). And this is indeed a normal QRS length. 

So to summarize some of our key points associated with a-flutter, remember in a-flutter, the atria are beating rapidly, but they're beating rapidly in unison. Try and remember the flock of birds fluttering together in unison. As far as the heart rate is concerned, we're going to see that atrial rate of approximately 300 beats per minute being filtered out by that AV node. Remember this regularity with the R to R interval. Usually we will see a regular R to R interval because those birds are fluttering in unison, right? But not always the case as we saw with our example. Again, you're not gonna be able to see a PR interval length, nor are you going to be able to see any P waves at all associated with QRS complexes because the atria are beating too rapidly for those P waves to even be identifiable. And with the QRS complex length, this will still remain normal. 

If you need a little additional clarity regarding a-flutter, make sure that you also check out our lesson on a-fib as these two rhythms are very similar to one another. Guys, go out there and be your best selves today. And as always, happy nursing.

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