BASIC

DYSHYTHMIA INTERPRETATION

Objectives: At the conclusion of this class, the student will be able to: Describe the cardiac conduction system SA node sets rhythm, lives in upper RA, it likes a rate of 60-100doesnt like going over 150, so higher tachs are either drugs or another pacer. It conducts to the AV node, which goes to bundle of His, the L and R bundle branches, and the purkinje fibers. And a normal ECG complex has a Reg R-R, P before each QRS, and T after. A normal pr= 0.12-0.2. A normal QRS is < 0.12. P means atrial depol p-r is the codxn from SA to AV QRS is depol of vents, also repol of atria but you can't see it T is repol of vents
Electrical transmission connected with mechanical events, but conditions such as prolonged hypoxia or acidosis can cause depolarization w/o contraction

And state nursing responsibilities for a patient requiring cardiac monitoring; skin prep, put the leads in the right place. Don't throw away the wrong cord. check it if its alarming, don't trust the machine, always confirm a rhythm. Make sure the pt isn't playing w/ the leads. All pts on ekgs: you always need to know their rythym. Assess when: vs, things change, prn, after giving sensitive meds, etc. IF a pt is at risk for arrhythmis, you need to advocate that they get on EKG leads.

Identify a system for interpreting ECG patterns;

Rate: count it Rate: reg or irreg? p waves present. If not: altered or absent= other than SA node are firing pr interval: 0.12-0.20 sec; longer possible conduction delay of AV node or heart block;
present but not consistently followed by QRS complex= 2nd or 3rd degree heart block

QRS complex: is 0.10 or less; prolonged= abnormal conduction thru ventricles, Identify factors that place a person at risk for developing dysrhythmias; fluid vol def/overload. MI's. hypothermia. drugs. coffee.
Tachydysrhythmias noted in pt. w/ fluid volume deficits- HR incr. in response to diminished stroke volume Fluid volume overload= ventricular enlargement & decreased contractility= premature beats, conduction block, & abnormal HR

Myocardial factors: CAD. Alteration in myocardial perfusion & potential

ischemia; ventricles do not depolarize effectively (QRS complex) & repolarization is inefficient (T wave)= abnormal ventricular beats or blocks in conduction

Fluid volume abnormalities/shock, esp hypovolemia Electrolyte abnormalities: esp K high or lo, Mag, Ca+, these affect the heart.
hypokalemia- +ions needed to depolarize, becoming more difficult & repolarization is extended- PR interval is longer & T wave is flat, QT lengthens, extra wave follow T= bradydysrhythmias & conduction bloc; hyperkalemia- easier depolarization & short repolarization; tall T waves, QT shortens, PR interval lengthens & QRS complex widens, cell becomes too positive & cant depolarize= asystole (no heartbeat); Hypercalcemia strengthen contractility & shorten ventricular repolarization, shortening QT interval; Hypocalcemia prolongs QT interval; Hypomagnesmia increases irritability of nervous system= dysrhythmias- prominent U wave & flattening of T wave, & prolonged QT interval; Hypermagnesmia- prolonged PR interval, wide QRS complex, bradycardia, & tall, peaked T wave; Hypothermia electrical activity of heart- bradycardia (<60), prolonged of PR & QT intervals, & wide QRS complex. Summary those at risk have an alteration in tissue perfusion, imbalanced fluid

volume, or electrolytes or decreased body temp..

Hypothermia Shock: big time at risk. Medications: brady [dig, beta block, Ca channel block]; cocaine, too much K+. Diuretics lead to volume and lyte problems. Acid-Base Imbalances. Identify and describe treatment of the following common dysrhythmias: sinus rhythm: nothing sinus bradycardia, atropine, or isoproteronol [isoprenaline] sinus tachycardia, relax the pt, give pain meds, antioxylytics, O2, Ca Channel blockers and beta-blockers PACs, do nothing if not a problem, less caffeine and ETOH, betablockers [pg 282] Atrial fibrillation, handle the high rate first [pg 277] with dig, beta block, Ca Channel Block. Then the fib: amiodarone, adenosine, verapamil [ati], . If cardioverting, give anticoag and do a transesophageal echo. [ati] ventricular tachycardia, amiodarone, adenosine, verapamil ventricular fibrillation, Defibrillation soon. Amiodarone, lidocaine, and epinephrine. PVC, do nothing if not a problem, less caffeine, lidocaine [pg 282]
Lidocaine administered if PVCs are of ischemia or infarct origin; Amiodarone or procainamide if PVCs are refractory to lidocaine. Harmless unless > 6 or more/min.; life threatening if indicating ventricular irritability

and paced rhythm; uhmm...leave it alone? Discuss nursing responsibilities with cardioversion get EKG strip before during and after. informed consent, IV access, sedatives, pain killers, O2 and all metallic objects off the pt. assess for complications [emboli, resp depres, dysrhthmias]. Check electrolytes for any
imbalances esp. Ca, Mg, K

and defibrillation; Defib Nursing Actions: ECG strip cont, Pad placement, correct procedure by ACLS staff, ACLS algorithms Discuss indications for and nursing implications with pacemaker Pacemakers: if the electrode is in the atria, that elicits a p wave. If theres trouble in both atria and vents, theres a second [dual chamber] signal that carries it to the vents.
Pt. teaching & education regarding device- literature, ECG strips, medicalert bracelets, know device- manuftr, model #

Margi say: Nursing Action: monitor ECG, patient education Def: pulse generator used to provide electrical stimulus to the heart when it fails to conduct or generate heart rate that maintains cardiac output Types: temporary-external and percutaneous, permanent, atrial, ventricular, dual ICDs Def: implanted cardioverter/defibrillator Indications: patients with life threatening arrhythmias that does not respond to medication Nursing Action: monitor ECG, patient education Discuss indications for pacemaker Def: pulse generator used to provide electrical stimulus to the heart when it fails to conduct or generate heart rate that maintains cardiac output Types: temporary-external and percutaneous, permanent, atrial, ventricular, dual

and implantable cardioverter/defibrillator (ICD) therapy; Def: implanted cardioverter/defibrillator Indications: patients with life threatening arrhythmias that does not respond to medication Discuss pertinent antiarrhythmic agents in terms of indications for use and action.
ADENOSINE (ADENOCARD): PSVT AMIODARONE (CORDARONE): ventricular arrhythmias and supraventricular arrhythmias, particularly with atrial fibrillation DILTIAZEM (CARDIZEM): Atrial fibrillation, atrial flutter, supraventricular tachycardia, and Prevention of reinfarction in non-Q-wave MI. ATROPINE SULFATE: For sinus bradycardia or asystole LIDOCAINE: Rapid control of ventricular arrhythmias occurring during acute MI, cardiac surgery, and cardiac catheterization and those caused by digitalis intoxication

Adenosine blocks ventricular impulse Amiodarone blocks K+ , delays repolarization Lidocaine refractory period Propranolol-beta blocker (metopropolol) Diltiazem (Cardiazem)-calcium channel blocker Nifedipine (procardia) Digoxin conduction thru AV node

SVDysrhythmia V. tach/fib PVC; v. tach/fib tachy/dysrhthmias tachy/dysrhythmias

Case Scenarios 85 yo female complaining of chest pain. Could be: Vasoconst, spasm, angina, indigestion, lung something. Her organs are old. We do: chest pain, r/o MI. Monitor shows sinus tachycardia. What interventions are indicated? Means hearts ok, run by the sinus node, its just too fast. Intervene: O2. Why? Angina is always a lack of O2 to heart. How much O2? 2 L by n/c, and then up to 4why? b/c a mask at 100% is big time overdose, shes probably already anxious. SaO2: cont. Next: run an EKG strip. In fact, get her on a 12-lead EKG. Chest pain; give her some morphine

[sometimes ER will withhold meds so that they can diagnose]. Assess her head to toe. Find why shes in tach: pain, low O2, temp, etc. If her tach is too high: amidarone or cardizem. Her heart cant handle this for longget that HR down. Get her on an NTG drip. 66 yo male admitted with syncope, takes digoxin and lasix for CHF. Monitor shows sinus bradycardia, 45, BP 78/40. What interventions are indicated? 58 yo male admitted with AMI, complaining of 8/10 cp. Monitor shows sinus rhythm with frequent PVCs. What interventions are indicated? 57 yo nurse who faints at her yoga class. In ED, monitor shows sinus bradycardia, rate 44. What interventions are indicated? Where EKG: during procedures, ER, tele, ICU, etc. Dysrrythmia means abn. Arrhythmia: no rhythym. I. Cardiac Conduction Components SA node: usually the pacemaker, RA, why? Because it beats faster than all the other pacemaker cellsthe fastest pacer always manages the overall conduit. Automaticity: beats on its own without any extra signals. Beats 60100 bpm. Doesnt like to go over 150so if youve got a higher tach, think drugs or supravent-tach. AV node: next stop. Sends impulse to bundle of His, R/L bundle brances, purkinjes. Right after the depolarization, theres a contraction. BB, purkinje fibers Intervals Rate: Margi says usually getting the rate is silly b/c its a machine, but.its a machine, so do it anyway.

P wave means: atrial depolarizing PR interval: beginning of P to beginning of Q: too slow means blocked at AV node. Normal less than 0.20 QRS duration: vents depol, artia repol but you dont see it. Q is 1st neg deflection. R is first pos deflection, etc. QRSs look different but it doesnt mean they are badhas to do with the leads. 0.04-0.12. Margi says: 0.08 to 0.12 is normal in practice. Book says less than 0.10. Whatever. ST segment T: vents repol QT interval II. Nursing Responsibilities if your pt is on a monitor Means you better have a clean strip to put in the recorddont want one with artifact from the cables moving around. Accurate waveform skin prep: Sometimes you have to make the pt hold perfectly still so you can have a good strip. Shave hairy men, dry sweaty people. accurate lead placement Alarms: go off all the time for no good reason, and if you dont play with the cable it will not make so much noise. Patient education: about alarms, what leads do, that you have to move slow, dont play with them. What does this dysrhythmia mean to this patient? III. Lead Systems A. 12-lead EKG: 12 pictures of electrical activity of the heart: gets all over the chest and the limbs. B. Common Monitoring Leads: 1. Lead II: negative electrode under right clavicle, positive electrode left midaxillary line, 5th ICS 2. MCL1: negative electrode below left clavicle, positive electrode

4th ICS, right sternum border 3. 3 lead cables: positive, negative, ground 4. 5 lead cables: right and left leg, right and left arm and chest lead IV. Characteristics of Cardiac Monitoring A. ECG recording: 1. horizontally: *small box=0.04 sec. *large box=.20 seconds 2. vertically: mm/small box B. Electrical Events: NEED TO KNOW 1. P wave: 2. PR Interval: normal:=/<0.20 seconds 3. QRS complex: normal:=/< 0.10 seconds 4.ST segment: 5. T wave: QT interval: V. Rhythm Interpretation A. System for strip interpretation: 1.Measure heart rate. 2. Examine the R-R interval. 3. Examine the P wave. 4. Measure the PR interval. Determine if each P wave is followed by a QRS complex. Examine the QRS complex. B. Rate determination techniques: VI. Risk Factors for Development of Dysrhythmias

All pts on ekgs: you always need to know their rythym. Assess when: vs, things change, prn, after giving sensitive meds, etc. IF a pt is at risk for arrhythmis, you need to advocate that they get on EKG leads. Myocardial factors: CAD Fluid volume abnormalities/shock, esp hypovolemia Electrolyte abnormalities: esp K high or lo, Mag, Ca+, these affect the heart. Hypothermia Shock: big time at risk. Medications: brady [dig, beta block, Ca channel block]; cocaine, too much K+. Diuretics lead to volume and lyte problems. Acid-Base Imbalances. VII. Common Arrhythmias all atrial dysrythmias have a lack of P-Waves A. Normal Sinus rhythm: 60-100; regular; P before every QRS; normal intervals B. Sinus bradycardia: SR with rate <60 Atropine is for symptomatic Brady C. Sinus tachycardia: SR with rate >100 D. Atrial fibrillation: irregularly irregular; irregular ventricular rate; wavy baseline; narrow QRS. NTK. Very common arrhythmia. Irreg irreg means goes thru AV node sporadically. Usually looks like you cant distinguish a P-Wave, or the p-waves arent always there. unequal R-R= irreg. atria arent getting filled therefore poor CO. These pts are fainty and tired dont bother finding P waves, they are not behaving. QRS is okits skinny. Inverted t wave

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E. PACs: early, before QRS, P looks different from sinus P. need to know difference btwn this and PVC or a fib. Means the atria are ctx a little early [premature atrial ctxjust wants to jump right in]. Theres a P still there, before a extra long R-Rso the rate isnt perfectly regular in one spot. Usually r/t coffee, nerves. QRS is normal.

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QuickTime and a decompressor are needed to see this picture.

F. PVCs: early, wide and bizarre, no P before it. The QRS should look weird b/c it comes from the ventricle, right? QRS is wide and bizarre and usually a bit early compared to the other beats. Sometimes the QRS inverts on these long bizarre QRSs. Common in previous MI of some sort. This is irritable tissue. Chart; sinus rhythm w/ occasional PVC. Dont freak out or treat it.

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Ventricular badness is the most likely to make you keel over. Ventricular tachycardia: wide and bizarre, regular, rate very fast, no P

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Atrial Flutter: rare, doubt itll be on exam

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H. Ventricular fibrillation: no QRS, wavy baseline: dead person, full code, the guy on the golf course who dies is usually a v-f arrest. Usually the cause of cardiac arrestwhy we have defibrillators. Defib them, hopefully the SA node will get back on top of it.

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Rules for Ventricular Fibrillation (V-Fib) Regularity: There is no regularity to the rhythm because there are no complexes or waves present that are able to be analyzed. Rate: There is no measurable rate. P WAVE: There are no P waves present. PRI: PRI is unable to be measured due to no P waves being present. QRS: There are no QRS complexes present.

Paced rhythm: ventricular, atrial or both

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VIII. Antiarrhythmic Agents: goal to suppress dysrhythmia Class I: fast sodium channel blockers Class IA: procainamide Class IB: lidocaine Class IC: flecainide Class II: block effects of catecholamines: slow AV conduction; beta blockers Class III: block potassium channels; amiodarone Class IV: calcium channel blockers; verapamil Nursing action before giving these drugs: assess vital signs assess ECG physical assessment infusion pump with IV drugs patient education: reason for drug; report any dizziness, palpitations IX. Cardioversion, Defibrillation, and Pacemakers Cardioversion: Def: delivery of electrical shock synchronized with patients heart rhythm; Indications: treat SVT, atrial fibrillation, & ventricular tachycardia in an unstable patient; sx hypotension, chest pain, diaphoresis, SOB, CHF,

MI Nursing Actions: ECG strip before, during, and after procedure, VS, informed consent, IV access, conscious sedation, oxygen pad placement, assess for complications Defibrillation: Def: emergency procedure to treat ventricular tachycardia in unresponsive patient and ventricular fibrillation; unsynchronized Indications: cardiac arrest Nursing Actions: ECG strip cont, Pad placement, correct procedure by ACLS staff, ACLS algorithms Pacemakers: if the electrode is in the atria, that elicits a p wave. If theres trouble in both atria and vents, theres a second [dual chamber] signal that carries it to the vents. Def: pulse generator used to provide electrical stimulus to the heart when it fails to conduct or generate heart rate that maintains cardiac output Types: temporary-external and percutaneous, permanent, atrial, ventricular, dual ICDs Def: implanted cardioverter/defibrillator Indications: patients with life threatening arrhythmias that does not respond to medication Nursing Action: monitor ECG, patient education