Telemetry/EKG/Pacers
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Transcript Telemetry/EKG/Pacers
Telemetry/EKG/
Pacers
MCC NURSING
DIANA BLUM MSN
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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
Measures:
0.12-0.20
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QRS WAVE
Measures:
0.06-0.12
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QT Wave
Measures
approx 0.340.43 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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Each small box measures 0.04
1 big box (5 small boxes) is equal to a HR of 300
2 big boxes is hr of 150
3 big boxes is hr of 100
4 big boxes is hr of 75
5 big boxes is hr of 60
6 big boxes is hr of 50
7 big boxes is hr of 43
8 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
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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
AV
rhythm
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
ARTIFACT
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NSR
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Hr=
60-100 bpm
On strip it looks regular but does not map
out
PR interval= 0.12-0.20
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HR 40-60 bpm
<60 bpm is accelerated
Rhythm is regular
Pwaves not always present
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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 Adenosine
given 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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Rate is usually WNL
Rhythm is regular
Pwaves are normal in size and shape
The PR interval is prolonged (>0.20 sec) but constant
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Pwaves are normal in size and shape;
Some pwaves are not followed by QRS
PR interval: lengthens with each cycle until it appears without QRS Complex
then the cycle starts over
QRS is usually narrow
http://www.youtube.com/watch?v=G
VxJJ2DBPiQ&feature=related
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Ventricular rate is usually slow
Rhythm is irregular
Pwaves are normal in size and shape (more pwaves than QRS)
PR interval is within normal limits
QRS is usually wide
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Ventricular rate is regular but there is no correlation between pwaves and
QRS
Pwaves are normal in size and shape
No true PR interval
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Atrial Fibrillation
Erratic wavy base
Pr is not measurable
QRS 0.10 sec or less usually
http://www.youtube.com/watch?v=VKxQgjj2yVU&feature=related
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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 rate of 250-450 bpm ventricular rate varies
Atrial rhythm is regular ventricular rate is
irregular
No identifiable p waves
P wave is not measurable
Qrs: 0.10 or less usually
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Atrial fib/flutter
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Pacer spike should fall before the P wave unless a dual
Chamber pacemaker; if it does not there could be a problem
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PAC
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Extra beat
Types
uniform=go the same direction
multifocal= go in different direction
R on T=when the pvc fall on the preceding twave
couplet= 2 pvcs together
bigeminy= pvc every other beat
trigeminy=pvc every third beat
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PVCs (unifocal)
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PVCs (multifocal)
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Ventricular tachycardia
Monomorphic: beats are same size and shape
Polymorphic: different size and shape
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This is a polymorphic VT
Usually electrical imbalance in nature r/t NA+ or K+
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Ventricular Fibrillation
Rate can not be determined
because of no identifiable waves
Rapid chaotic rhythm with no
pattern
No p waves
No PR interval
No QRS
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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)
http://videos.reinolla.tv/winners/pe/
ST elevation
5 Steps to 12 Lead Interpretation
1. Assess regularity and speed
2. Look for signs of infarction
3. Present in >1 lead, but not all?
4. Assess associated conditions
5. 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
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Rhythms for Cardioversion
A-fib
A-flutter
Supraventricular
tachycardia
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.
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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
Position of the letter
Designation
1st letter
Chamber being paced (A=atrium, V=ventricle, 0=none)
2nd letter
Chamber being sensed (A=atrium, V=ventricle, 0=none)
3rd letter
Pacing Mode (O=none, I=inhibited, T=triggered,
D=dual)
4th letter
Rate Response (R=rate response is on)
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Chambers that can be paced:
Atrium
Ventricle
Dual (both atrium and ventricle)
ICD (Implantable Cardioverter Defibrillator)
Dual Paced
Atrial
Pace, Ventricular Pace (AP/VP)
AV
AP
VP
V-A
AV
AP
VP
V-A
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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
EP with Ablation
An electrophysiology study is simply a
study of the electrical function of your
heart.
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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
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 VFib/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.
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