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BasicBasic ArrythmiasArrythmias
Dr. Amban Gowda
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During the lecture time, write your questions
down on a piece of paper. Keep them until you see
the slides labeled, Check Your Pulse. These
will come up every so often and this is a pause
point for us to clarify any questions before moving
forward. Please hold questions until that point.
Thank you !
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Starting with the Basics
What are the functions of the heart?Electrical: impulse
Mechanical: pump contraction
What is the normal blood flow through
the heart?
What is the normal electrical pathway conduction?Nodes (SA, AV, Bundle)
Inherent Rates
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Electrical Conduction PathwaySA Node pacemaker of
the heart (60-100bpm)
AV Node junction of the
atria and ventricles (40-60bpm)
Bundles Bundle of His
connects the AV node to the
bundle branches (20-40bpm)
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Normal Cardiac Cycle
Systole Diastole
Electrical Depolarizationactivate
Repolarizationrecovery
Mechanical Contractempty
Relaxfill
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EKG - Electrocardiogram
An EKG is a useful tool for diagnosing a
variety of cardiac abnormalities. It displays the
activity of the hearts electrical impulse flow through
the conduction system.
What does it tell us?
the electrical conduction through the heart
areas of ischemia or myocardial damage LV Hypertrophy
electrolyte disturbances / drug toxicity
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and this Leads to . Electrodes
Positive and Negative Charges
12 Lead EKGs
Most pts in 5 leads
Where do you put those darn patches anyways? Mnemonic to remember lead placement
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What Is In Each Beat?(the cardiac cycle in waves, complexes, and intervals)
P Waveatrial contraction or depolarization, (usually upright)
QRSComplextime for ventricular contraction or depolarization(usually upright) (0.04 - 0.12sec) (delays in the bundle branches will widen the
QRS)
T Waveventricular repolarization recharging (usually upright)
PRIntervaltime between atrial depolarization to ventriculardepolarization (beginning of P wave to beginning of QRS)(0.12 - 0.20sec)
(prolonged PR = delays in the AV node conduction)
QT Intervalrepresents one complete ventricular depolarization andrepolarization (beginning of QRS to the end of the T wave) (0.32 0.44sec)
(disturbances are usually due to electrolyte disturbances or drug effects)
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EKG Tracing .
Grid Paper
Each small box = 0.04 seconds
Each large box = 0.20 seconds (5 small boxesacross)
One second is 5 large boxes
Three seconds is 15 large boxes
Six seconds is 30 large boxes
Each minute has 300 large boxes
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Reading a Rhythm Strip
What Do I Look For? Regularity - What is the R R Interval?
Rate - Is the rate normal (60-100), slow, or fast?
***Six-second strip method - (30 big boxes) &
multiply times ten
P Wave Is there a P wave before every QRS? Is itupright?
QRSComplex Is there a normal QRS complexfollowing each P wave? Wide or normal?
T wave How does your T wave look? Upright?
Measure your intervals PR Interval, QRS, QT
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Practice Strip
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Check Your Pulse
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Match the Rhythm with the Pt After assessing the EKG strip in a
systematic method, gather the information
about your pts assessment: med hx, s/sx,labs.
Does the rhythm make sense for the pt?
What is going on with the pt?2ndlevel assessment
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What is Normal?
NormalS
inus RhythmThe electrical impulse originates in the SA Node
1) Rhythm Regular (R to R Interval)
2) Rate Regular (60 100 beats/minute)
3) P wave before every QRS complex
4) QRS complex narrow, not wide (0.04-0.10sec)
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ASlight Deviation from Normal
too slow and too fast
Sinus Bradycardia1st Level Assessment
Rate? (less than 60bpm)
Symptoms? (subjective and objective)
2nd Level Assessment
Reasons? Etiology?
Nursing Interventions
Pharmacology
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Sinus Tachycardia
1st Level Assessment
Rate? (> than 100)
Symptoms? (subjective and objective)
2nd Level Assessment
Reasons? Etiology?
Nursing Interventions
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What is an Arrythmia anyways? Definition: a disorder of impulse formation.An
abnormal electrical conduction that changes theheart rate and rhythm.A disturbance in thehearts rhythm.
Why? Causes?
1) Classified according to their origin
2) Some are mild, asymptomatic require no treatment3) Some are catastrophic require immediate emergency
response
4) They can influence cardiac output and blood pressure
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Clinical Significance
Thousands of people suffer witharrythmias
Dysrhythmias are responsible for over44,000 deaths each year.
There site of origin can often lead us tothe problem area
About 15% of strokes occur in patientswith atrial arrythmias
A large majority of sudden cardiacdeaths are thought to be caused byventricular dysrhythmias.
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What is The Big Deal?
Why are we so concerned with Arrythmias?
SV x HR = CO
SV dependent on filling time, adequate volume, andmyocardial muscle function
HRdependent on electrical stimulus, Autonomic NS,Parasympathetic NS
Too Fast
Too Slow NOT GOOD!!!Too Irregular
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Some of you might be feeling a bitoverwhelmed at this time .
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Atrial Arrythmias
Atrial arrythmias occur because there are
other pacemakers in the atria competing tobe the commander
SA Node is not healthy and unable to lead
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Atrial Fibrillation
Results from disorganization of atrial electricalactivity without effective atrial contraction.Repetitive, irregular, uncontrolled depolarization.Atrial rate ~ 350-600 bpm,Ventricle - varies
No P Wave! Very jiggly baseline wave
No PR Interval
Irregular with a wavy baseline
Rate - Controlled vs. Uncontrolled Loss of Atrial Kick
Emboli Potential
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Atrial Fibrillation
1st Level Assessment
2nd Level Assessment
Nursing Consideration
Pharmacologic Consideration
Digoxin
Ca+ Channel Blockers Beta Blockers
Coumadin
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On Your Own .
You are responsible for reviewing pharmacology re: arrhythmias:
Please know the actions, doses, side effects, nursing
considerations, monitoring, precautions, therapeutic druglevels, s/sx toxicity for the following drugs:
Digoxin
Ca+ Channel Blockers (verapamil, diltiazem) Beta Blockers (atenolol, metoprolol)
Anticoagulants (warfarin)
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Results from the atria stimulated to contract 250-350bpm in a circuit fashion around the atrium
No true P waves F waves larger than P
waves (flutter waves) Sawtooth-shaped waves
Usually a regular rhythm D/T AV Node filter
Ventricular Rate atria to ventricle ratio (2:1 or4:1)
Assessment and treatment the same as Atrial Fib
Atrial Flutter
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The Basic Blocks
First Degree AV Block
Third Degree Block
(AKA) Complete Heart Block
Etiology, 1st and 2nd Level Assessment, Intervention
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Check Your Pulse!
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From the Bottom of My Heart
Arrythmias stemming from the ventricles. Occurs when apacemaker in the ventricles initiate a beat or a whole rhythm
PrematureVentricularContraction (PVC) FLB
QRS wide and bizarre
Ventricular Tachycardia (VTach)
3 or more ventricular ectopic complexes (PVCs)
Rate greater than 140-250bpm
QRS complex wide and aberrant
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S
ustainedV
T
ach
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Treatment for PVCs / VTach
Dependent on patients condition
How frequent are the PVCs: unifocal, multifocal,healthy heart?
Pulse? No Pulse?
Labs? Particularly K+ and Mg+ levels?
Sustained ? Non-sustained?
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Bundle Branch Block
The Road Detour
Interruption of conduction
in one of the main branches
of the Bundle of His
Normal conduction
through the bundles?
Why interruptions?
QRS wide greater than
0.12 seconds
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Dont Just Stand There!
ASYSTOLE(please, not on my shift )
AKA flatline, cardiac standstill
Etiology
Nursing Assessment and Intervention
Pharmacological Considerations
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And you may feel like all rhythms look alikeLook Closely and you will see the differences!
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STSegment Depression
Infarcted
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Check Your Pulse
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? Immediate Nursing Question ?
How does my patient look?
Do they have any symptoms? (what are symptoms of low CO?)
Do they have a normal or diseased heart?
This can buy you time!!!
(to assess and gather more information about the patients condition)
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Top Nursing Priorities
Check the patient (LOC?)
ABC airway, breathing, circulation
Oxygen administration
IVAccess / PatencyElectrode placement
Associated Symptoms? Chest pain, SOB,dyspnea, vertigo, nausea
Fluids
MonitorVS
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Fast Assessment and Identification of the
problem are key Nursing Priorities
In the cardiac world, time is
oxygen. The longer you delay
reaction to arrhythmias, the
longer the heart suffers. Dont
let your patient circle the
drain!
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Pharmacologic Considerations
Above the AV NODE (Atrial) (ABCD) Too Slow Atropine
Too Fast Beta Blockers
Calcium Channel BlockersDigoxin
Amiodarone
Below the AV NODE (Ventricular) (LAP) Too Fast Lidocaine
AmiodaroneProcainamide
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Too Slow ..
Treatment forSymptomatic Bradycardia
is Atropine (check your patient first)
Classification: Antidysrhythmic/Anticholinergic
Common dose: 0.5mg 1.0mg up to 2mg IVP
How to give: given every 3-5 minutesSE: hypotension, angina, tachycardia, PVCs, dry mouth
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Too Fast
Uncontrolled Atrial Fibrillation
- Beta Blockers (Lopressor, Labetolol)
- Calcium Channel Blockers (Cardizem,
Verapamil)
- Glycosides/Inotropes (Digoxin)
Ventricular Arrhythmias
- Antiarrythmics (Lidocaine, Procainamide,
Amiodarone)
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Practice on your Own
Antiarrhythmic IV Drips
Lidocaine bolus of 50-100mg (1mg/kg) over 2-3 minutes
IV Drip: (1gm/250ccs) or (2Gm/500ccs) to run at1-4mg/min
How to figure that in ml/hr for a pump ..
Know nursing considerations / monitoring and
s/sx of toxicity
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Non Pharmacologic Treatment
Electroshock Cardioversion
Unstable tachy rhythms
Ablation
Defibrillation (and internals)
Nursing Consideration and Care
***Look at Patient Teaching in Table 35-9
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Pacemakers
I. External Pacing noninvasivetemporary with patches on chest wall
II. Internal Pacing invasive
temporary internal through the femoral
arteriesIII. Permanent Pacemaker inserted through the chest
wall open heart
IV. Modes: Demand or Override
*** Review Pt Teaching with a pacemaker
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Case Study ExampleMrs. Taylor has become more forgetful lately.
She has trouble managing her medications. Sheis supposed to take (1) Digoxin in the morning,but sometimes she takes one at night. As aresult, her Digoxin level has reached toxiclevels. She comes to the ER with nausea,vomiting, fatigue, vision changes. You put heron the EKG monitor and she is in 3rd degree
heart block with a HR of 32. Her blood pressureis 70/40. The ER doctor orders for you to puther on an external pacemaker. She will remainon this pacemaker to maintain an adequate HR
and CO until her Dig toxicity resolves.
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We are done for the day!
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Additional References
http://medlineplus.gov
http://www.nurse411.com
click on: educational links
click on: basic EKG tutorial, put in your name,and push play
Adams, M., Josephsen, D., Holland, L. (2005).Pharmacology for Nurses: A pathophysiologicapproach. New Jersey: Prentice Hall.
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FurtherStudy on Your Own
Taking it a step further ..
Challenge yourself
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The Health of the Heart Walls
The heart is composed of four walls and each
of the walls is fed oxygen through direct
and indirect blood flow.
This blood flow is delivered by coronary
arteries and through collateral circulation.
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Heart Walls
Anterior Wall
Includes most of the left ventricle, the intraventricular
septum
Inferior Wall
Includes most of the right ventricle and some of the
left ventricle, extends down to the apex
Lateral WallLocated on the left side of the heart (no right heart
involvement)
Posterior WallLies along the back of the heart
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Coronary Artery Supply
Right Coronary Artery Left Main Coronary Artery
Left Circumflex Coronary Artery
Left Anterior Descending
Right Coronary Artery
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Right Coronary Artery
feeds the right atrium and ventricle
inferior wall
posterior wall
SA Node and AV Node (in most people)
Left Anterior Descending
anterior wall and intraventricular septum
apex of the heart
papillary muscles
bundle branches
Circumflex
lateral and posterior wall of L Ventricle
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How Does This Tie To The EKG?
When one looks at an EKG and
notices disturbances or problems
in certain areas of the heart, it
is useful to understand whichcoronary artery supplies that
area. This can help you identify
the vessel where blood supply is
possibly compromised
(arteriosclerotic changes)
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ExampleA patient that came into the hospital with SickSinusSyndrome (SA Node is not feeling well) and was inSymptomatic Sinus Bradycardia may go for a CoronaryAngiogram. During this procedure, the MD may find that
they have atherosclerotic changes and blocks in their RightCoronary Artery that feeds blood supply (and O2) to thatnode. Without proper blood supply, that area is unable to
perform normal electrical conduction and begins to showdisturbances (arrhythmias). This patient may need to have
an angioplasty or stent placement or CABG to open up thatarea to better blood supply.
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Additional References
http://medlineplus.gov
http://www.nurse411.com
click on: educational links
click on: basic EKG tutorial, put in your name,and push play
Adams, M., Josephsen, D., Holland, L. (2005).Pharmacology for Nurses: A pathophysiologicapproach. New Jersey: Prentice Hall.