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Skills

Invasive Procedure Requires a consent A diagnostic or therapeutic technique that requires entry of a cavity or interruption of normal body activities or functions. Noninvasive Procedure A diagnostic or therapeutic technique that does not require the skin to be broken or a cavity or organ of the body to be entered.

SERUM ANALYSIS

Serum Analysis INVASIVE Serum Electrolytes


Potassium 3.55.3 meq/L (to detect origin of cardiac dysrhythmias) Sodium 135145 meq/L (to evaluate fluid and elec and acid base balance) Calcium 4.55.5 meq/L or 8.5-10.5mg/dl (to diagnose cardiac dysrhythmias, neuromuscular, skeletal and endocrine disorders)

Serum Analysis INVASIVE


Total Cholesterol 120330 mg/dl (measures circulating free cholesterol, assess risk for Coronary Artery Disease CAD) Triglycerides 10190 mg/dl (screen hyperlipidemia, risk for CAD)

Cardiac Enzyme Studies INVASIVE


Reflects Catabolism of Normal Tissue Troponin First enzyme that will increase in MI Troponin I and T Troponin I is usually utilized for MI Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.6 ng/mL REMEMBER to AVOID IM injections before obtaining blood sample! Early and late diagnosis can be made!

Cardiac Enzyme Studies INVASIVE


Aspartate aminotransferase AST Can be found in many cells like liver, pancreas, heart kidneys and skeletal muscle (not a good indicator of MI) Creatinine kinase CK CK-MB = most specific enzyme Elevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days Normal value is 0-7 U/L CK-BB = found in nervous tissues CK-MM = found in muscle TOTAL CK = detects post MI

Cardiac Enzyme Studies INVASIVE


Lactic Dehydrogenase LDH Elevates in MI in 24 hours, peaks in 48-72 hours Normally LDH1 is greater than LDH2 MI- LDH2 greater than LDH1 (flipped LDH pattern) Normal value is 70-200 IU/L LDH1 and LDH2 = appear primarily in the heart, RBC and kidneys LDH3 = lungs LDH4 and LDH5 = liver and skeletal muscle After 710 days LDH level returns to normal

Cardiac Enzyme Studies INVASIVE


Myoglobin Rises within 1-3 hours Peaks in 4-12 hours Returns to normal in a day Not used alone Muscular and RENAL disease can have elevated myoglobin

EKG/ECG NON-INVASIVE
Electrocardiogram--graphic record produced by electrocardiograph Electrocardiograph--a device used for recording the electrical activity of the myocardium by placing leads to certain points in the chest region Electrocardiography--study of records of electric activity generated by the heart muscle

ECG

Placement of the Six (6) Electrodes V1 = 4th right intercostal space right sternal border V2 = 4th left intercostal space left sternal border V3 = halfway between V2 and V4 V4 = left mid clavicular line 5th left intercostal space V5 = left anterior axillary line halfway between V4 and V6 V6 = mid axillary line level with V4

Invasive:

angiography, Cardiac catheterization Non-invasive: ECG, Echocardiography, Stress ECG

ANGIOGRAPHY
Pretest: informed consent, allergy to dyes, seafood and iodine Intratest: Monitor VS Post-test: maintain pressure dressing over puncture site Immobilize for 6 hours

CARDIAC CATHETERIZATION (CVC)


Introduction of catheter into heart chambers Pretest: informed consent, allergy to dyes, seafood and iodine, NPO 8-12 hours Intra-test: Empty bladder, Monitor VS, explain palpitations Post-test: maintain pressure dressing over puncture site Immobilize for 6-8 hours with extremity straight

SWAN-GANZ

Blood Pressure Measurement

BLOOD PRESSURE
Measure of force exerted by blood against the wall Blood moves through vessels because of blood pressure Measured by listening for Korotkoff sounds produced by turbulent flow in arteries as pressure released from blood pressure cuff

ECHOCARDIOGRAM
Non-invasive

test that studies the structural and functional changes of the heart with the use of ultrasound No special preparation is needed

2 D-echocardiogram

EKG/ECG NON-INVASIVE
Electrocardiogram--graphic record produced by electrocardiograph Electrocardiograph--a device used for recording the electrical activity of the myocardium by placing leads to certain points in the chest region Electrocardiography--study of records of electric activity generated by the heart muscle

ECG

Placement of the Six (6) Electrodes V1 = 4th right intercostal space right sternal border V2 = 4th left intercostal space left sternal border V3 = halfway between V2 and V4 V4 = left mid clavicular line 5th left intercostal space V5 = left anterior axillary line halfway between V4 and V6 V6 = mid axillary line level with V4

ECG
Placement of Four (4) Lead Wires Lead 1 RA right arm Lead 2 LA left arm Lead 3 RL right leg Lead 4 LL left leg

ECG
Travel of an impulse From the right shoulder across the chest to the left lower rib cage.

ECG
How are waveforms produced? Electrical impulses are generated by the: SA to AV to HIS BUNDLE to PURKINJE

ECG
SA node (70-80 bpm) Bachmanns bundle Internodal pathways Anterior Middle (wenckebachs) Posterior (thorels) DEPOLARIZATION OF ATRIA TAKES PLACE

ECG
AV node (30-60 bpm) His bundle Right and Left bundle Purkinje fibers Depolarization of ventricles takes place

ECG
0.04sec/small square 0.20sec/big square 300/150/100/75/60/50 R-R wave 25 small boxes for 1 big box

ECG
NSR (normal sinus rhythm) Sinus Tachycardia and Sinus Bradycardia (considered normal rhythm) Arrhythmias (abnormal rhythm)

ECG
Atrial Arrhythmias: Premature Atrial Contraction (PAC) Atrial Flutter Atrial Fibrillation

ECG
Ventricular Arrhythmias: Premature Ventricular Contraction (PVCs) Ventricular Tachycardia (vtach) Ventricular Fibrillation (vfib)

Atrioventricular or AV Block First Degree AV block (prolonged P wave followed by QRS) Second Degree AV block Type I Wenckebachs PR interval gradually lengthens then drops Type II PR interval is constant and one or more beats are non conduction or dropped Third Degree AV block (complete heart block) atria and ventricles are beating independently or P wave have no relationship to the QRS complex . Pacemaker is necessary

Possible ECG results: Elevation of ST segment = MI Peaked or inverted T wave = MI Pathological Q wave = MI Prolonged P-R interval = 1st degree heart block Widened QRS complex = delayed conduction to purkinje fiber Flattening of T wave = hypo K Depression of ST segment = hypo K Long QT interval = hypocalcemia (torsades de pointes) Prolonged QT interval = hypermagnesemia

P Q
S

P WAVE ATRIAL DEPOLARIZATION(PR INTERVAL =0.12-.2 SEC)

P Q
S

PR SEGMENT EARLY REPOLARIZATION OF THE ATRIA

P Q
S

QRS SEGMENT VENTRICULAR DEPOLARIZATION (0.05-0.10 SEC)

P Q
S

ST SEGMENT EARLY REPOLARIZATION OF THE VENTRICLES

Sinus Rhythm

Sinus Rhythm

Normal Sinus Rhythm


Look at the p waves:
rate is 60-100/min cycle length do not vary by 10% PR interval is 0.12 sec. or more
Lead II

Normal Sinus Rhythm


Look at the p waves:
same contour in same lead? Upright in I, II, aVF & left precordial leads followed by QRST?
Lead II

Sinus Bradycardia
Regularly occurring PQRST Rate < 60 / min Rate = 48/min

Rate = 48/min

56/min

Sinus Bradycardia

Sinus Tachycardia
Regularly occurring PQRST Rate > 100 / min
Rate = 111/min Rate = 111/min Rate = 111/min

105/min

Sinus Tachycardia

Sinus Arrhythmia
Identical but irregularly occurring PQRST longest PP or RR > the shortest by 0.16 sec or more
Rate = 71/min Rate = 94/min Rate = 79/min Rate = 94/min

Sinus Arrhythmia

Premature Atrial Contraction


Prematurely occurring PQRTS complex P wave different in configuration from the sinus beat. PR interval often long. QRS narrow.

Paroxysmal Supraventricular Tachycardia

(N) AVN Conduction

AVN Conduction with unilateral block

pathway

pathway

pathway pathway

AV NODE

Atrial Flutter

Atrial Flutter
Atrial rate = 220-300/min ( P as flutter waves ) Variable degree of AV block ( irregular RR interval )

Atrial Fibrillation
No discernible P waves Irregular RR interval

Atrial Fibrillation

Junctional Rhythm
Impulses from the AV node P wave inverted or buried w/in QRS or follows the QRS Rate slow QRS narrow

Atrioventricular Blocks

R P Q S T

First Degree Atrioventricular Blocks

R P T

Q
Do you have a normal P wave? Do you have a normal PR segment? Do you have a normal PR interval? Do you have a normal QRS-T?

Yes No Prolonged (> 0.20 sec) Yes

Criteria for First Degree Heart Block


P waves present QRS complexes present P waves morphology and axis usual for the subject QRS complexes morphology and axis usual for the subject One P wave to each QRS complex P-R interval constant

P-R interval must be prolonged ( i.e. > 0.20 sec )

FIRST DEGREE AV BLOCK


PR interval > 0.20 sec

0.28 sec

0.28 sec

0.28 sec

FIRST DEGREE AV BLOCK

Second Degree Atrioventricular Blocks


Do you have a normal P wave? Yes Do you have a normal PR segment? No Do you have a normal PR interval? No Will there be intermittent P waves not followed by QRS complex? Yes (dropped beats)

Degree Atrio-Ventricular Block (Wenckebach)


Longest P-R interval is the one immediately before the dropped beat. Shortest P-R interval is the one associated with the first conducted beat after the dropped beat. P-R interval before the blocked beat increase and do so by progressively decreasing amounts so that the consecutive R-R intervals before the blocked beat actually progressively shorten.

SECOND DEGREE AV BLOCK MOBITZ I


Progressive lengthening of PR interval w/ intermittent drop beats .

0.20 sec

0.28 sec

0.20 sec

Degree Atrio-Ventricular Block (Mobitz II)

Within period of observation, one P wave is not followed by a QRS complex. No change in P-R interval before the transient failure of atrio-ventricular conduction. n P waves to (n-1) QRS complexes for each example of transient type II block. (n will be 3 or more*)

SECOND DEGREE AV BLOCK MOBITZ II


Fixed PR interval w/ intermittent drop beats .

BLOCK AT THE Bundle of His


Bilateral bundle branches

Trifascicle

0.18 sec

0.18 sec

0.18 sec

SECOND DEGREE AV BLOCK MOBITZ II

2 : 1 AV BLOCK

Criteria for High-Grade Atrio-Ventricular Block


P waves present QRS complexes present P wave morphology and axis usual for the subject QRS morphology and axis usual for the subject and the lead

Criteria for High-Grade Atrio-Ventricular Block


Some P waves followed by QRS complexes and some are not Atrio-ventricular conduction ratio is 3:1 or higher P-R interval following a QRS is constant but may be normal or prolonged

HIGH GRADE AV BLOCK

THIRD DEGREE AV BLOCK


Complete atrioventricular block Impulses originate at both SA node and at the subsidiary pacemaker below the block Do you have regularly occurring P waves and QRS complexes? Yes Are the P waves related to the QRST complexes? No Is the atrial rate < = > ventricular rate? greater
Ventricular rate = 83 BPM Ventricular rate = 83 BPM

Atrial rate = 100 BPM

Atrial rate = 100 BPM

Atrial rate = 100 BPM

THIRD DEGREE AV BLOCK WITH SUPRAVENTRICULAR ESCAPE RHYTHM

THIRD DEGREE AV BLOCK WITH VENTRICULAR ESCAPE RHYTHM

AV Dissociation w/o 3o AV Block


Impulses originate at both SA node and at a subsidiary pacemaker below that is firing at the same rate (acchrocage) or even faster than that of the SA node
Do you have regularly occurring P waves and QRS complexes? Yes Are the P waves related to the QRST complexes? Most of the time, NO Sometimes yes Is the atrial rate < = > ventricular rate? Less than or equal

Normal Cardiac Depolarization

Premature Ventricular Contraction


Prematurely occurring complex. Wide, bizarre looking QRS complex. Usually no preceding P wave. T wave opposite in deflection to the QRS
complex. Complete compensatory pause following every premature beat.

Premature Ventricular Contraction in Couplets


Two Premature ventricular
contractions occurring consecutively

Premature Ventricular Contraction in Bigeminy


Alternating normal sinus beat and
a PVC

Premature Ventricular Contraction in Trigeminy


PVCs regularly occurring every
third beat

Premature Ventricular Contraction in Quadrigeminy


PVCs regularly occurring every
fourth beat

Multifocal Premature Ventricular Contraction


PVCs coming from different foci in
the ventricle PVCs assuming different polarities in a single lead PVCs of different morphology and coupling interval

Premature Ventricular Contraction R on T Phenomenon


R or Q of the PVC occurring at the
T wave of the preceding sinus beat Most dangerous PVC

Ventricular Tachycardia
At least 3 consecutive PVCs Rapid, bizarre, wide QRS complexes
(> 0.10 sec) No P wave (ventricular impulse origin) Rate > 140 / min

Ventricular Tachycardia

Ventricular Tachycardia

Ventricular Fibrillation

Ventricular Fibrillation

Idioventricular Rhythm
Impulse ventricular in origin Absence of (N), upright P wave
associated with QRS complexes QRS > 0.10 sec T wave opposite in direction to QRS Rate < 40 / min Rate < 40 / min

Intraventricular Conduction Delay


Supraventricular rhythm with
associated BBB

Wide QRS complexes

Agonal Rhythm
Extreme sinus bradycardia with irregular, idioventricular rhythm and occasional atrial activity

Pacemaker Rhythm
No P wave (ventricular impulse origin) Wide QRS complex (>0.10 sec) Pacemaker spike precede the wide
QRS complexes

Thank you

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