Normal sinus rhythm (ECG pattern)
Rhythm : RegularRate : 60-100P Waves : upright, identical, 1 per QRSPR Interval : .12-.20 secQRS duration : .10 sec
Sinus bradycardia (ECG pattern)
Rhythm : RegularRate : <60P Waves : upright, identical, 1 per QRSPR Interval : .12-.20 secQRS duration : .10 sec
Sinus tachycardia (ECG pattern)
Rhythm : RegularRate : 101-180P Waves : upright, identical, 1 per QRS (at high rate may blend with T-wave)PR Interval : .12-.20 secQRS duration : .10 sec
Sinus arrythmia (ECG pattern)
Rhythm : Irregular, phasic with respirationRate : Usually 60-100, but may varyP Waves : upright, identical, 1 per QRS (at high rate may blend with T-wave)PR Interval : .12-.20 secQRS duration : .10 sec
Sinoatrial (sinus) block (ECG pattern)
Rhythm : Irregular, and the pause is an EXACT MULTIPLE of the distance between two other P-P intervalsRate : Usually normal, but varies due to block P Waves : upright, identical, 1 per QRS (at high rate may blend with T-wave)PR Interval : .12-.20 secQRS duration : .10 sec
Sinus arrest (ECG pattern)
Rhythm : Irregular, more than one P-QRST complex missing and NOT SAME DISTANCE as other P-P intervalsRate : Usually normal, but varies due to blockP Waves : upright, identical, 1 per QRS (at high rate may blend with T-wave)PR Interval : .12-.20 secQRS duration : .10 sec
Wandering atrial pacemaker (ECG pattern)
Rhythm : Regular OR irregularRate : Usually normal, may be slowerP Waves : Vary in size, shape, direction across rhythm strip, with at least THREE variationsPR Interval : .12-.20 secQRS duration : .10 sec
Premature atrial complexes (ECG pattern)
Rhythm : Irregularity caused by PACRate : Underlying rhythmP Waves : P-wave associated with PAC is abnormal or hiddenPR Interval : .12-.20 sec (may be prolonged)QRS duration : .10 sec or less
Supraventricular tachycardias (atrial tachycardia) (ECG pattern)
Rhythm : RegularRate : atrial 140-250, vent. 140-250P Waves : abnormal, often pointed, may be hidden in preceeding T-wave or in the QRS complexPR Interval : not measurableQRS duration : .10 sec or less
Atrial flutter (ECG pattern)
Rhythm : Atrial is regular, vent. is irregular depending on AV blockadeRate : Atrial rate of 250-450, vent. rate is variable but usually does not exceed 180P Waves : Saw toothed, flutter wavesPR Interval : Not measurableQRS duration : .10 sec or less
Atrial fibrillation (ECG pattern)
Rhythm : IrregularRate : Atrial rate is 400-600, vent. rate is variableP Waves : Not identifieable, fibrillatory wavesPR Interval : Not measurableQRS duration : .10 sec or less
Premature ventricular complexes (ECG pattern)
Rhythm : Usually normalRate : Usually regular with premature beatsP Waves : Usually absent or after QRS of PVCPR Interval : None with PVC, the beat originates in the ventricleQRS duration : Greater than .12 sec, and is wide and bizarre
Idioventricular rhythm (ECG pattern)
Rhythm : Essentially regularRate : 20-40P Waves : Usually absent, can appear after QRS if retrograde conductionPR Interval : NoneQRS duration : Greater than .12 sec, T-wave frequently opposite QRS complex
Ventricular tachyardia (ECG pattern)
Rhythm : Essentially regularRate : 101-300P Waves : Not usually present, and if it is present it has no relationship to QRSPR Interval : NoneQRS duration : wide, greater than .12 secMonomorphic VT : QRS complexes are of same shape and amplitudePolymorphic VT : QRS complexes are variable in size, shape, and amplitude; Normal QT verus long QT or Torsades de PointesSustained VT= greater than 30 seconds
Ventricular fibrillation (ECG pattern)
Rhythm : Rapid and chaotic, no patternRate : Unable to determineP Waves : NonePR Interval : NoneQRS duration : None
First degree AV block (ECG pattern)
Rhythm : RegularRate : Usually normalP Waves : Normal, uprightPR Interval : Prolonged, >.20 sec, CONSTANTQRS duration : .10 sec or less
Second degree AV block Type I (ECG pattern)
Rhythm : atrial regular, vent. irregularRate : atrial rate > than vent. rateP Waves : Normal in configuration, more P waves than QRSPR Interval : Lengthens with each cycle until QRS is droppedQRS duration : .10 sec or less, periodically dropped
Second degree AV block Type II (ECG pattern)
Rhythm:atrial regular, vent. irregular, P's plot through time Rate : atrial rate is > than vent. rate, vent. rate is often slowP Waves : Normal in configuration, more P's than QRS'sPR Interval : WNL or slightly prolonged constantlyQRS duration : .10 sec or less, periodically dropped
Third degree AV block
Rhythm : atrial regular, vent. regular, however there is NO ASSOCIATION between the twoRate : atrial rate is > than vent. rateP Waves : Normal inconfigurationPR Interval : None; both atria and vent. beat independently of each otherQRS duration : Escape beats, depends on origin
Give 5 causes of bradycardia?
Medications (beta blockers, digitalis, calcium channel blockers) Hypoxia MI Hypo/Hyperkalemia Hypothyroidism
What medication is often used to treat bradycardia?
Atropine
Give 8 causes of tachycardia?
Exercise Anxiety/Fear Infection Pain Dehydration/hypovolemia Medications/Illicit drugs (Epi, dopamine, cocaine) Caffeine Nicotine
Could sinus arrythmia occur in the healthy adult?
Yes
Give three causes of sinus arrythmias?
Post MI/heart disease Increased ICP Effects of medications (Digitalis)
Treatment for sinus arrythmia?
Only necessary to treat if accompanied by slow heart rate with hemodynamic compromise; would treat with Atropine and transcutaneous pacing
Give two treatments for bradycardia?
Atropine Transcutaneous pacing
When would you treat bradycardia?
When patient is symptomatic (signs of shock, chest pain, sudden altered status, or high degree sinus block)
Give 4 causes of SA block?
Treatment for SA block?
Stable : remove causative meds if necessary and monitor patientUnstable : IV atropine, TCP, and insertion of PPM if needed
Give 4 causes of sinus arrest?
Hypoxia Myocardial ischemia/infarction Hyperkalemia Medications (beta blockers, digitalis, calcium channel blockers)
Treatment for sinus arrest?
Stable : monitorUnstable : Atropine, TCP, insertion of PPM if needed
Can wandering atrial pacemaker be seen in the healthy adult?
Yes
Give two commonly co-occurring conditions with wandering atrial pacemaker?
Underlying heart disease and digitalis toxicity
Premature atrial complexes are often common in the normal adult in response to _____, ______, _____, or ______ use?
Stress Alcohol Caffeine Tobacco
Give two causes of premature atrial complexes?
Heart disease Electrolyte disturbances
What do frequent PAC's sometimes warn of or initiate?
A more serious atrial rhythm such as tachycardia and atrial fib
What does paroxysmal mean?
Sudden onset and sudden end, but occurs greater than 50% of the day
Give 7 common causes of atrial tachycardia?
Stimulant use Infection Electrolyte imbalances MI or other heart disease (often common after bypass surgery) Hypoxia Medications WPW, abnormal accessory pathways
Give 5 common symptoms of atrial tachycardia?
Palpitations/heart "flutter" Chest pressure Dizziness Lightheadedness Dyspnea
Treatment of atrial tachycardia?
Stable: IV access O2 12 lead Vagal maneuvers Antiarrythmics *Seek expert consultation* Unstable: IV access Synchronized cardioversion Antiarrythmics (Adenosine - stops the heart; WARN THE PT!) *Seek expert consultation*
What voltage is used with synchronized cardioversion?
30-100
When is unsynchronized cardioversion used?
With LETHAL rhythms withOUT a pulse (Vfib, pulseless VT)
What should the nurse make absolutely sure of prior to administering either type of cardioversion?
That the patient is SEDATED
When is synchronized cardioversion used?
In rhythms WITH a pulse (atrial fib, atrial flutter)
True or False: Atrial flutter is usually paroxysmal and occasionally does not occur more than 24 hours - will convert to SR or atrial fibTrue False
True
Should symptomatic atrial flutter patients be cardioverted immediately, or after medication has first been administered?
IMMEDIATELY
What symptoms do you expect with high rate atrial flutter?
Weakness Dizziness Fainting Chest pain Heart flutters Difficulty breathing Nausea
When would cardioversion be contraindicated?
Digitalis toxicity Sinus tachycardia
What should be performed prior to cardioversion?
???
What is the most common arrythmia?
Atrial fib
Give 7 common causes of atrial fib?
Many heart conditions CABG surgery Systemic infection WPW (Wolfe Parkinson Syndrome) Pericarditis Pulmonary embolism Hypoxia
Treatment of atrial fib?
Control heart rate Anti-coagulation and prevention of clots Cardioversion Surgery Antiarrythmics (Amiodarone, Cardizem, sotolol)
What oral drug is used for anti-coagulation?
Coumadin
How often should INR be assessed in the pt undergoine anti-coagulation therapy, and what should the level be to be therapeutic?
Give 2 most common complications of ablation of pathways?
Hematoma at the introduction site AV block
Give three tachyarrythmias that ablation of pathways may be used?
When are PVCs worrisome?
Frequent (>6 per minute) Coupled or paired, trigeminy Multiform (coming in from several different areas) During an AMI On the T-wave
What do you do when your patient's rhythm begins to include worrisome PVCs?
Give the patient LIDOCAINE
What treatment does accelerated idioventricular rhythms require?
Usually none, unless symptoms are associated
How do you identify vent. tachycardia?
Big, wide QRS complex with a heart rate > 100
What are the symptoms of vent. tachy?
Heart fluttering Pt doesn't feel well
If a patient has sustained ventricular tachycardia, what will happen?
If sustained, the pt will code
What is ventricular tachycardia often associated with? Give 3.
Underlying heart disease (valve disease, ACS, cardiomyopathy, CHF, trauma to the heart, Long QT syndrome)
What is the FIRST thing you do when you see VT on the heart monitor?
Check the patient Determine if stable or unstable
What three types of meds would you give a pt with unstable vent. tachycardia?
Amiodarone Lidocaine ACLS drugs
What are some drugs that can lengthen QT interval?
Give 5 causes of vent. fibrillation?
Heart disease (ACS, CHF, arrythmias, Long QT syndrome) Electrolyte disturbances (hypo/hyperkalemia, hypomagnesemia) Electrocution (usually during the ST cycle) Drugs (anti-arryrythmics, digitalis) Vagal stimulation
If you a pt who has vent. fibrillation and there is NO pulse, what should be done for the pt?
CARDIOVERSION
What is the difference between Monophasic and Biphasic defibrillators?
Biphasic is NEWER Biphasic currents go BOTH ways Biphasic currents use less energy (200 instead of 300)
Give 4 main points in administering cardioversion?
Make sure there is no pulse Attach pads correctly Use gel Call an "all clear"
Is asystole shockable with cardioversion?
NO
What do you do if the pt goes into asystole after the first shock of cardioversion?
Perform CPR Administer epinephrine or atropine Try to get shockable rhythm
What is the first thing you do if you find a pt with PVCs and underlying sinus rhythm?
Check for a pulse
Is a sinus rhythm with PVCs a shockable rhythm?
NO
Is pulseless electrical activity a possible cause of PVCs?
Yes
How do you treat PEA?
Treat the underlying cause
What are the 11 underlying causes of PEA? (Hs and Ts)
Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hypo-Hyperkalemia Hypoglycemia Hypothermia Toxins-drugs Tamponade (cardiac) Tension pneumo Thrombosis Trauma
How do you treat cardiac tamponade?
Blood has pooled around the heart and the heart cannot pump anymore, so treat this by removing fluid from around the heart with a huge needle
How do you treat a tension pneumo?
Insert a chest tube
How does heart disease lead to AV block?
Heart disease causes damage to the AV node via the fibers/muscles that carries the impulse
Give 2 common causes of AV block?
Heart disease (AMI, particullary to the right coronary artery!)
When dealing with any type of block, what is the first thing that you need to know?
Whether or not the pt is symptomatic!
Is first degree AV block usually symptomatic or asymptomatic?
Asymptomatic
What is the treatment for AV block?
Asymptomatic/first degree and second degree Type I: usually just monitor
Give 6 indications for the insertion of a pacemaker?
Symptomatic heart blocks Post AV node ablation Sick sinus syndrome Frequent pauses To control CHF To control arrythmias
What are the three temporary pacemakers?
Transcutaneous Epicardial Transvenous
What is the permanent pacemaker called?
Permanent implantable device or PPM
How do you know what the PM is pacing at?
The pt should have a card with them or you can call the rep for the company and they can tell you
What is an AICD?
Automated internal cardio defibrillator - it turns the pacemaker off; may only be needed to shock
Demand vs. fixed rate PM?
Demand: set to kick on when HR drops to set parameters
What do you anticipate doing for a HB patient?
What is a common neurological sign of tension pneumo?
Anxiety
Post-operative instructions for a pt who has recently undergone PM implantation?
Avoid lifting arm up (because leads take several weeks to adhere) NO MRI! (magnet turns PM off!) Can continue to take coumadin Monitor HR
What is a common sign of lead dislodgement?
Frequent episodes of dizziness
What do you do to assess the function of the PM?
Hook the pt up to a heart monitor
