I had ACLS recert last week. The week before, I did BLS, which was awful. I sat in a class of 30 people watching videos. They have gotten much better but, oh man! They tested each person one at time as we ALL watched and waited. It was b-r-u-t-a-l.
Yesterday I was watching my 8-year-old’s tournament baseball tryouts. At the end, the coaches lined all of the kids up on the pitcher’s mound. Then, one at time, they have them each throw 15 pitches. The same awful feeling swelled inside of me. Can we please do something? Anything?
Anyway, I was not looking forward to ACLS. And it just so happened to fall on my birthday. No big deal, I just didn’t want to be stuck there all day, dying of boredom. Thankfully, my instructor was fantastic!! I wish I had her last name but from here on out, we’ll call her ACLS Kathy. She was in EMS for 100 years and has been teaching ACLS for 80 years. She knew what to teach and how to teach it so that you might remember it in the field one day.
We didn’t comb through the book discussing minutia. We cooked along, and I remember more from that course than anything I’ve been through before. Part of her plan was cut it down in a way that you don’t get lost. Which is something I love! But that’s not what I want to talk about today.
Today I want to talk about ACLS Kathy’s heart block analogy that will save you from ever getting these questions wrong ever again. You’ll be looking forward to them and smiling when you see them.
Here we go.
First degree is easy. Everyone remembers that one. The signal is delayed through the AV node, but it is consistent. The P wave is always just a little too far from the QRS because it’s slow getting in. Think of the checkout line– Normal line vs line with little old lady behind the register. She moves everyone through, but it takes a little longer (that analogy isn’t Kathy’s, it’s mine).
Second degree is where it gets complicated, but it really isn’t.
Second degree WILL ALWAYS HAVE A DROPPED BEAT!
This is something I never realized until this course. Just never made the connection. If it doesn’t drop a beat, it’s either 1st or 3rd degree, which makes it SO much easier. This was the single biggest takeaway for me.
2nd degree, type 1 = Wenckebach or Mobitz I
Here are two little sayings that may help you remember 2nd degree type 1:
“Longer longer longer drop, now you have a Wenckebach” (this comes from Carol Sadley, a professor at Rutgers that does the cardio section of that program)
“Wencky Wencky Wencky — Bach” (from ACLS Kathy)
Here, the P wave gets slower and slower and slower… then doesn’t get through at all. Then starts up again. (ok, the p wave itself doesn’t get slower. The signal slows down after the p wave through the AV node so there is a delay between the p wave and QRS.)
Kathy’s analogy here was sending your new assistant out for coffee. Day one you get this great idea that your assistant could go out to Starbucks and get real coffee for the both of you. On day one, he comes back in 15 minutes. Day two- he stops and gets himself a magazine on the way and it takes him 30 minutes. Day 3 is a beautiful day so he decides that walking would be better than driving and it takes him 45 minutes. Day 4, he leaves with your coffee money and never comes back.
longer, l o n g e r, l o n g e r , drop
2nd degree type 2 or Mobitz II
P wave stays constant, but some beats get dropped. Imagine standing outside a club and the bouncer lets the three people in front of you in and then kicks you and your friend out of line. Then lets the next three people in and kicks the 4th and 5th dudes out line.
Third degree
P waves have no relationship to QRS, but remember: There are also no dropped QRS’s. They are each just going at their own rate and don’t communicate at all with each other.
The day turned out to be really good. Passed my class and got to my baseball game on time. 🙂
This discussion about heart blocks alone was worth me attending the whole day. I hope you see the value here. It can save you hours of studying and lots of missed points. Every few years, I relearn this for one reason or another; this time, it’s mine forever.
You can test how well you know it using The Final Step.
🙂
Brian