 Hi, welcome to Nursing School Explained. This video is in the EKG interpretation series about atrial rhythms and we'll discuss atrial flutter, also known as A-flutter. If you haven't already done so, I highly recommend that you watch my other videos that discuss basic electrophysiology and EKG interpretation the basics about how to read the EKG paper and determine the heart rate as well as the normal intervals and rules to remember for every EKG rhythm strip interpretation. Whenever we are discussing atrial rhythms, it means that the impulse originates in the atria. Usually the P-wave is represented or represents atrial depolarization and contraction. So when we now have an atrial dysrhythmia, that means that the impulse originates from any location in the atria other than the normal SA node. So the conduction pathway will be initiated by an irritable or excitable focus or cell in the atria and it does have a positive P-wave because it comes from the atria but it might have a different shape than the usual impulse that comes from the SA node because of this different conduction pathway the conduction is taking now due to this irritable focus being located in a different spot than the SA node. Particularly in atrial flutter the irritable focus depolarizes very regularly and extremely rapidly. So for atrial flutter we can see here the rules are to first determine the rate and the rate for atrial flutter is usually quite high which will be 250 to 450 beats per minute and remember that is the atrial rate only the ventricular rate would probably be a little bit different. So looking at this and our rules we would apply counting the QRS complexes 3, 4, 5, 6, 7 which gives us the ventricular rate of 70 but if you're looking at the P-waves or the atrial rate these P-waves look very different from our normally shaped P-wave in normal sinus rhythm. So these P-waves let's just jump over here to number three here they have this classical shaped sawtooth or flutter wave appearance as you can see they're kind of jaggedy they're not really round as the normal P-wave usually appears so if I would count these P-waves I would get quite a large amount here 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 so we'll have about 15 beats on this three second strip or 14 beats which would give us 28 in a six second strip so that would mean that the atrial rate is 280 now because this irritable focus comes from the atria and does not come from the SA node we the ventricles don't respond so the ventricular rate is still normal at 70 but because we have this additional beat now that's trying to kind of cause some problems here we see these sawtooth or flutter waves that are so typical of atrial flutter and then the rhythm can be regular or irregular the atrial rate may be regular and the ventricular rate may be irregular depending on the AV conduction or blockage so we'll discuss that shortly here we already so this was number two regularity number three we already discussed and the P-waves are not really identifiable because they don't have this classic look of the surrounded P-wave they have these sawtooth or flutter wave appearances that we already discussed therefore we can't really measure the PRI because we have way too many P-waves to look at the PRI and then the QRS and atrial flutter is usually normal which is the less than 0.12 and if I look at this find a good Q-wave look in Q-wave here that starts at a thicker box so that would be one two in our case that would be 0.10 0.08 which makes the QRS complex normal and then down here you see I've labeled this here as atrial flutter with 421 conduction and that basically means that there's four atrial or conductions or P-waves or flutter waves for every QRS so we have one two three four P-waves to every QRS and that just means that this is an atrial flutter with a 421 conduction here here's a bigger picture of this atrial flutter rhythm strip and again like I said very classical these sawtooth appearances here you really can't miss that atrial flutter causes is usually PACs or premature atrial contractions that I'm discussing in a different video so please go back to that if you're interested chronic atrial flutter however is unusual because it usually converts either back to normal sinus rhythm or it'll progress to atrial fibrillation which can be a chronic condition also again discussed in a different video atrial flutter signs and symptoms will depend on the rate and duration so if the patient has been in atrial flutter for a day they might have signs and symptoms they might feel a little bit lightheaded or dizzy they might feel a little short of breath they might be anxious because they're feeling that the heart is skipping a beat or the complaint of palpitations they might have a syncopal event they might faint or they might complain of chest pain or pressure with this this rhythm looking at interventions for atrial flutter we will have to distinguish whether the patient is stable and asymptomatic or symptomatic and unstable and if the definition of symptomatic and unstable are usually these two criteria here which means a change in level of consciousness and hypotension which by acls protocol guidelines is defined as a systolic blood pressure less than 90 so if the patient is stable and asymptomatic we can direct them to perform a vagal maneuver meaning that they can either hold their breath and bear down or blow into a straw or blow into their own thumb which increases the intra thoracic pressure and stimulates the vagus nerve and we know that the vagus nerve is in charge of the parasympathetic nervous system that will then hopefully slow everything down including the patient's heart rate and maybe convert back to normal sinus rhythm then certain medications can be used for patients in atrial flutter and those are calcium channel blockers beta blockers digoxin as well as anti arithmetics but if the patient is symptomatic and unstable again with a change in level of consciousness or systolic blood pressure less than 90 we need to treat the underlying cause and follow advanced cardiac life support protocol which means that the patient might need synchronized cardioversion and I will be discussing synchronized cardioversion and compared to defibrillation in a different video here are some references and credits please refer to practical clinical skills and medic tests for any additional rhythm strips you would like to practice please also watch the other videos in my EKG interpretation playlist particularly the other atrial rhythms referring back to PACs atrial fibrillation as well as supraventricular tachycardia thanks for watching nursing school explain please leave comments and subscribe to my channel so you can stay up to date with the latest videos thank you very much see you next time