Telemetry/EKG/Pacers

MCC NURSING DIANA BLUM MSN

A dysrhythmia is a disturbance of the rhythm of the heart caused by a problem in the conduction system.

Categorized by site of origin: atrial , AV nodal, ventricular

Blocks are interruptions in impulse conduction: 1st, 2nd type 1&2, 3rd or complete heart block

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P wave

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Measures: 0.12-0.20

Measures: 0.06-0.12

QRS WAVE

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QT Wave

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Measures approx 0.34-0.43 secs

Calculating Heart Rate Quick Estimate: The 6-second Method - count the # of QRS complexes in a 6 sec. length of strip & multiply by 10 (the second mark is = to 5 large boxes) This can be used is rhythm is reg or unreg.

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TO MAP= TO DETERMINE IF REGULAR OR IRREGULAR

Each small box measures 0.041 big box (5 small boxes) is equal to a HR of 3002 big boxes is hr of 1503 big boxes is hr of 1004 big boxes is hr of 755 big boxes is hr of 606 big boxes is hr of 507 big boxes is hr of 438 big boxes is hr of 38

Large box estimate of heart rate works with regular rhythms

Count small boxes between two R waves. Divide into1500 Gives BPM

Atrial arrythmias Normal sinus rhythm Sinus tachycardia Sinus bradycardia Premature atrial contraction (PAC) Supraventricular tachycardia Atrial flutter Atrial fibrillation

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Ventricular arrythmias Junctional rhythm AV blocks Premature junctional rhythm Premature ventricular contraction (PVC) Ventricular Tachycardia (V-tach) Ventricular Fibrillation (V-Fib) Torsade de Pointes (TdP) Pulseless electrical activity (PEA) Asystole

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ARTIFACT

NSR

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SINUS ARRHYTHMIA

Hr= 60-100 bpm On strip it looks regular but does not map

out PR interval= 0.12-0.20

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JUNCTIONAL ESCAPE RHYTHM

HR 40-60 bpm<60 bpm is acceleratedRhythm is regularPwaves not always present

Junctional Rhythm

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SB

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ST

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Supraventricular Tachycardia

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SVT converted with Adenosinegiven rapid IV Push stimulates vagal response. S/E: flushing,bronchospasm,AVblock

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AV Blocks First degree block Second degree block Type I (Wenchebach) Second degree block Type II (Mobitz II) Third degree block Bundle branch block

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FIRST DEGREE HEART BLOCK

Rate is usually WNLRhythm is regularPwaves are normal in size and shape The PR interval is prolonged (>0.20 sec) but constant

27SECOND DEGREE HEART BLOCK TYPE 1

Pwaves are normal in size and shape; Some pwaves are not followed by QRSPR interval: lengthens with each cycle until it appears without QRS Complex

then the cycle starts overQRS is usually narrow

http://www.youtube.com/watch?v=GVxJJ2DBPiQ&feature=related

29SECOND DEGREE HEART BLOCK TYPE 2

Ventricular rate is usually slowRhythm is irregularPwaves are normal in size and shape (more pwaves than QRS)PR interval is within normal limitsQRS is usually wide

303RD DEGREE HEART BLOCK OF COMPLETE HEART BLOCK

Ventricular rate is regular but there is no correlation between pwaves and QRSPwaves are normal in size and shapeNo true PR interval

Atrial Fibrillation31

Erratic wavy basePr is not measurableQRS 0.10 sec or less usuallyhttp://www.youtube.com/watch?v=VKxQgjj2yVU&feature=related

Afib causes : Chocolate large amounts: contains

theobromine, a mild cardiac stimulant. - sleep apnea - athletes more prone (enlarged heart) - tall athletes (esp basketball players) - aging heart - men more than women - sleeping on left side or stomach etc.

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A-fib treatment: ASA not as effective as Coumadin in

preventing strokes. ASA less likely to cause abnorm

bleeding **since hemorrhagic stroke increases

with age & is also increased by taking Coumadin, some Drs. may switch older pts from Coumadin to ASA.

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A Fib electrical cardioversion: High risk of forming clots & causing

stroke Anticoagulants taken before treatment

and 3-4 weeks post treatment If life-threatening, may need Heparin IV

before cardioversion

Best time: recent A fib

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ATRIAL FLUTTER

Atrial rate of 250-450 bpm ventricular rate variesAtrial rhythm is regular ventricular rate is irregularNo identifiable p wavesP wave is not measurableQrs: 0.10 or less usually

Atrial fib/flutter

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PACED BEAT

Pacer spike should fall before the P wave unless a dualChamber pacemaker; if it does not there could be a problem

PAC

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39PREMATURE VENTRICULAR CONDUCTION (PVC)

Extra beat Types

uniform=go the same directionmultifocal= go in different directionR on T=when the pvc fall on the preceding twavecouplet= 2 pvcs togetherbigeminy= pvc every other beattrigeminy=pvc every third beat

PVCs (unifocal)

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PVCs (multifocal)

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Ventricular tachycardia

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Monomorphic: beats are same size and shapePolymorphic: different size and shape

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TORSADES DE POINTE

This is a polymorphic VTUsually electrical imbalance in nature r/t NA+ or K+

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Ventricular Fibrillation

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Rate can not be determined because of no identifiable wavesRapid chaotic rhythm with no patternNo p wavesNo PR intervalNo QRS

Vtach/Vfib Both can be life threatening VT= V HR 100-250 bpm Causes: AMI, CAD, hypokalemia, dig

toxic S/S: palpitations, dizzy, angina, <LOC Treatment: assess for pulse, if none,

defib VF=Rate undeterminable Cause: same Treatment: CPR

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Asystole

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Asystole and PEA CPR

Oxygen Epinephrine 1 mg IV/IO (repeat 3-5 minutes) May give Vasopressin 40U IV/IO to replace 1st or 2nd dose of epinephrine Consider Atropine 1 mg IV/IO Repeat every 3 to 5

min (up to 3 doses)

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http://videos.reinolla.tv/winners/pe/

ST elevation

5 Steps to 12 Lead Interpretation1. Assess regularity and speed2. Look for signs of infarction3. Present in >1 lead, but not all?4. Assess associated conditions5. Correlate with clinical condition

Normal EKG

MI

Polymorphic VT

VFIB

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http://nursebob.com/

http://www.usfca.edu/fac_staff/ritter/ekg.htm

http://ems-safety.com/12-lead-ekg.htm

Rhythms for Cardioversion A-fib A-flutter Supraventricular tachycardia

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Post cardioversion care: 1. generally the care for a patient tells

cardioversion is the same as for the fibrillation. 2. If it is a elective procedure, digoxin is usually

withheld for 48 hours prior to cardioversion to prevent dysrhythmias after the procedure.

3. Airway patency should be maintained and the patient state of consciousness should be evaluated.

Indications for pacemaker Temporary: -symptomatic bradycardia (not

controlled by meds) - ant MI - drug overdose (dig, beta blocker) Permanent: - 2nd degree Mobitz Type II - 3rd degree Block - symptomatic bradycardia, arrhythmias - suppress tachyarrythmias

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Position of the letterDesignation1st letterChamber being paced (A=atrium, V=ventricle, 0=none)

2nd letterChamber being sensed (A=atrium, V=ventricle, 0=none)

3rd letterPacing Mode (O=none, I=inhibited, T=triggered, D=dual)

4th letterRate Response (R=rate response is on)

Chambers that can be paced:AtriumVentricleDual (both atrium and ventricle)ICD (Implantable Cardioverter

Defibrillator)

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AP VP AP VP

V-AAV V-AAV

Dual Paced

Atrial Pace, Ventricular Pace (AP/VP)

ICD - prevents sudden cardiac death due to V-tach or V-fib. Pt can feel the shock -defib felt like “kick in the chest” that lasts 1 second - cardiovert feels like “thump in

chest - pt doesn’t feel pacing

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Operative failures with pacers: Pneumothorax Pericarditis Infection Hematoma Lead dislodgement (seen on X-ray) Venous thrombosis (rare but would see unilateral edema to arm on same

side as pacer)

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Pt Education: 1. carry ID card (Xray code seen in standard chest Xray) 2. not allowed to drive for 1 month 3. no metal detectors or no longer than nec. 4. MRI interrupts pacing-can’t get one for some time if

new 5. No power generators (welding) 6. microwave questionable 7. radiotherapy (may damage circuits) The pacer may need to be surgically moved if in path of radiation field. 8. TENS (transcutaneous electrical stimulation) interferes may need reprogramming 9. Cell phone use in opposite ear of pacer and store away from side of pacer

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EP with Ablation

An electrophysiology study is simply a study of the electrical function of your heart.

Bundle Branch Blocks: Diagnosed with 12 lead EKG: most common cause: acute MI

Right bundle branch block: - impulse travels through left ventricle

first, then activates right ventricle (gives am “M” shaped complex

Left bundle branch block: --impulse first depolarizes right side

of heart then the left ventricle (gives deep, wide “V” shaped complex

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Hyperkalcemia

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Intro to ACLS

Primary Survey Airway: Open airway, look, listen, and

feel for breathing Breathing: If not breathing slowly give

2 rescue breaths. If breaths go in continue to next step.

Circulation: Check the carotid artery (Adult) for a pulse. If no pulse begin CPR.

Defibrillation: Search for and Shock V-Fib/Pulseless V-Tach

Adult ACLS Secondary Survey ABCDs (abbreviated)

Airway: Intubate if not breathing. Assess bilateral breath sounds for proper tube placement.

Breathing: Provide positive pressure ventilations with 100% O2.

Circulation: If no pulse continue CPR, obtain IV access, give proper medications.

Differential Diagnosis: Attempt to identify treatable causes for the problem.

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http://acls.net/quiz/mi_stroke_1.htm

stress Common responses can include:

Feeling a sense of loss, sadness, frustration, helplessness, or emotional numbness

Experiencing troubling memories from that day Having nightmares or difficulty falling or

staying asleep  Having no desire for food or a loss of appetite Having difficulty concentrating  Feeling nervous or on edge

Teaching to cope Reach out and talk. Express yourself. Watch and listen. Stay active. Stay in touch with family.    Take care of yourself.

ANY QUESTIONS?Let’s Practice