Transcript Cardiovascular Pharmacology

Cardiovascular--EKG’s / Cardiac Monitoring
Dynamic Presentation
Static Presentation
Lead II
Jerry Carley RN, MSN, MA, CNE
Digitalis pupurea (Foxglove)
University of Southern Nevada
Summer2010
Part III
Key Terms
 Arrhythmia & Dysrhythmia
 atropine
 Electrical Cardioversion
 amiodarone
 Defibrillation
 lidocaine (Xylocaine ®)
 The “Names” of all of the
 adenosine (Adenocard ®)
rhythms & dysrhythmias
 dopamine
 epinephrine
 nitroprusside (Nipride ®)
Physical Assessment:
S/S of Decreased Cardiac Output
General Method….
 General Impression
 Fast, “tight” QRS’s, fairly regular, no “FLB’s”
 Rate= ________
 Rate= 120’s
 Rhythm =_______
 Rhythm = Regular
 P Waves =_______
 P Waves = Present, upright, uniform,
 PRI=_______
w/QRS’s, (precede QRS)
 PRI = 0.16 seconds, = throughout strip
 QRS = 0.08 seconds
 QRS = _______
1:1 ratio
 General Impression
 Rate=___________
 Rhythm=_________
 Medium rate, funny-looking P’s, no
FLB’s
 100’s
 Regular
 P Waves: ________
 Present, upright, ~, biphasic,
 PRI= __________
inverted, or “s”-shaped,
QRS’s
 0.10 seconds
 0.08 seconds
 QRS = __________
1:1 w /
Normal Sinus Rhythm
RATE: 60-100
RHYTHM: Regular
P Waves: Upright, uniform (~), 1:1 with QRS Complexes
PR Interval: 0.12 – 0.20 seconds
QRS: < 0.12 sec, ~
Sinus Bradycardia
RATE: < 60
RHYTHM: Regular
P Waves: Upright, uniform, 1:1 with QRS Complexes
PR Interval: 0.12 – 0.2 seconds, uniform
QRS: < 0.12 sec, ~
Discussion: May be benign; Treatment Atropine IVP
for Symptomatic Bradycardia
Sinus Tachycardia
RATE: 100 -150
RHYTHM: Regular
P Waves: Upright, uniform (~), 1:1 with QRS
Complexes
PR Interval: 0.12 – 0.20 seconds, uniform (~)
QRS: < 0.12 sec, ~
Discussion: Etiology?
Atrial Flutter
RATE: Variable;
RHYTHM: Regular or Irregular
P Waves: Absent; Instead, heave F – Waves, or Flutter Waves
PR Interval: N/A
QRS: < 0.12 sec
Discussion: Rhythm may be regular or irregular, depending on
ventricular response. Typically expressed as a “ratio,”, e.g., the
above would be described as “Atrial flutter with a 3:1 block.”
VERY COMMON AFTER ANY TYPE OF CARDIAC SURGERY;
FREQUENTLY PROGRESSES TO ATRIAL FIBRILLATION;
MAY “BOUNCE BACK & FORTH” “A-Fib-Flutter” or “A-Flutter-Fib”
Atrial Fibrillation
RATE: Variable; Rate may indicate effect on Cardiac
Output (Loss of “Atrial Kick,” ~ 20 % C.O.)
RHYTHM: Irregular
P Waves: Absent
PR Interval: N/A
QRS: < 0.12 sec
Discussion:
-Most common dysrhythmia
-Classified as “AF with controlled ventricular response,” “AF with
rapid ventricular response,” “Uncontrolled AF.”
-Treatment: Digoxin; cardioversion
-Embolus Role in CVA & PE
CHF
DISCUSSION:
Atrial Fibrillation
Untreated or “uncontrolled Atrial fibrillation “ is a rapid and irregular heart
arrhythmia, caused by chaotic electrical impulses in the atria of the heart (the two
upper chambers). (Loss of “Atrial Kick,” i.e., ~ 20% of Cardiac Output)
In anatomical terms, the AV node and the ventricles (the two lower chambers) are
therefore bombarded with frequent, irregular electrical impulses.
As a result, the heart rate becomes fast and irregular, and the normal coordination
between the atria and the ventricles is lost.
There are several types, depending on how long the AF lasts.
When atrial fibrillation is always present, it is referred to as chronic atrial
fibrillation.
When the arrhythmia is usually present, such that episodes of normal rhythm are
infrequent or short-lived, it is referred to as persistent atrial fibrillation.
When a normal heart rhythm is usually present but occasional episodes of the
arrhythmia occur, the patient is said to have paroxysmal atrial fibrillation.
Supraventricular Tachycardia
RATE: 151 – 220+
RHYTHM: Regular
P Waves: Absent (buried in QRS)
PR Interval: N/A
QRS: < 0.12 sec
REMEMBER:
“Narrow-Complex Tachycardia”
Discussion:
C.O. is decreased due to lack of ventricular filling time.
Treatment:
Vagal Maneuvers (Carotid Massage)
Adenosine IVP
Cardioversion
Discussion:
Supraventricular tachycardias (SVT-PSVT)
The SVTs are generally benign (that is, non-life-threatening) tachycardias
that either arise in the atria (that is, “supra” the ventricles), or involve the
atria in the mechanism of the tachycardia.
Many SVTs are due to extra, abnormal electrical connections between the
atria and the ventricles. Individuals with SVT are often born with these
extra pathways. The existence of such extra pathways (often called
“bypass tracts”) allow the formation of “reentrant” arrhythmias, in which
an electrical impulse is established that spins continuously between the
atria and the ventricles, thus causing one form of SVT.
Wolff-Parkinson-White (WPW) syndrome is a common example, but there
are several other varieties of bypass tracts that can cause episodes of
SVT.
Wolf-Parkinson White Syndrome
"WPW is a form of supraventricular tachycardia
(fast heart rate originating above the ventricles).
WPW….

"WPW is a form of supraventricular tachycardia (fast heart rate originating above
the ventricles).
When you have WPW, along with your normal conduction pathway, you have extra
pathways called accessory pathways. They look like normal heart muscle, but they
may:
--conduct impulses faster than normal
--conduct impulses in both directions
The impulses travel through the extra pathway (short cut) as well as the normal
AV-HIS Purkinje system. The impulses can travel around the heart very quickly, in a
circular pattern, causing the heart to beat unusually fast.
This is called re-entry tachycardia.
Re-entry arrythmias occur in about 50 percent of people with WPW; some may have atrial fibrillation
(a common irregular heart rhythm distinguished by disorganized, rapid, and irregular heart rhythm). The greatest
concern for people with WPW is the possibility of having atrial fibrillation with a fast ventricular response that
worsens to ventricular fibrillation, a life-threatening arrhythmia,.
Junctional Rhythms
A.K.A. “AV Junctional Rhythms”
But, this rate can
be widely variable!
RATE: 40-60
RHYTHM: Regular
P Waves: Inverted, absent, or retrograde (after QRS)
PR Interval: < 0.12 sec, or absent
QRS: < 0.12 sec, ~
Discussion: Rate > 60= “Accelerated Junctional Rhythm;” Greater
than 100= “Junctional Tachycardia”
 Junctional Tachycardia
 Rate: 101
 Rhythm: Regular
 P Wave: inverted, = , ~, 1:1 w/QRS’s
 PRI = 0.08-0.10 sec, ~
 QRS = 0.06- 0.08 sec, ~
AV Blocks
The specialized conduction system is responsible for
transmitting the heart’s electrical impulses from the atria to
the ventricles.
Disease in the AV node, bundle of His, or the bundle
branches can lead to a condition called “heart block.”
Heart block occurs when the electrical impulses in the atria
are stopped from reaching the ventricles. The heart rate can
reach dangerously low levels when heart block is present.
A permanent pacemaker, however, takes care of the problem.
1st Degree AV Block
RATE: Variable
RHYTHM: Regular
P Waves: Present, upright, uniform, 1:1 ratio with QRS
PR Interval: Uniform, > 0.20 sec
QRS: < 0.12 sec
Discussion: usually benign
The above rhythm would be described as:
“Sinus Rhythm, 1st Degree AV Block, Rate=_______
 Sinus Tachycardia, 1st Degree AV Block
2nd Degree AV Block
(Mobitz I --”Wenkebach”--and Mobitz II)
RATE: Variable, usually slow
RHYTHM: Irregular
P Waves: Upright, uniform; More P waves than QRS’s
PR Interval: Variable
Type I: Gradually lengthening PRI until a QRS is dropped; then the
pattern is repeated
QRS: < 0.12 sec, ~
3rd Degree AV Block
RATE: Ventricular Rate 20 - 40
RHYTHM: Irregular
P Waves: Upright, uniform; More P waves than QRS’s; do
not correlate to QRS complexes
PR Interval: Variable
Type I: Gradually lengthening PRI until a QRS is dropped;
then the pattern is repeated
QRS: > 0.12 sec
Medical Emergency: Require Pacemaker
Ventricular Tachycardia
RATE: 200+
RHYTHM: Regular
P Waves: N/A
PR Interval: N/A
QRS: > 0.12 sec
“WIDE & BIZARRE”
Medical Emergency:
V Tach with a Pulse
Pulseless V-Tach
Synchronized Cardioversion
Antiarrhythmic such as Lidocaine IVP followed by continuous infusion
DISCUSSION
Ventricular tachycardia (VT) is a rapid heart rhythm originating within the
ventricles.
VT tends to disrupt the orderly contraction of the ventricular muscle, so that the
ventricle’s ability to eject blood is often significantly reduced. That, combined with
the excessive heart rate, can reduce the amount of blood actually being pumped
by the heart during VT to dangerous levels.
Consequently, while patients with VT can sometimes feel relatively well, often they
experience – in addition to the ubiquitous palpitations – extreme lightheadedness,
loss of consciousness, or even sudden death.
In general, there are two kinds of VT: VT with a Pulse and VT without a pulse
Ventricular Fibrillation
RATE: Ventricular Rate 0
RHYTHM: Irregular
P Waves:
PR Interval: N/A
QRS: N/A
“Fine” Ventricular fibrillation
Medical Emergency: “Cardiac Arrest”
GREATEST CHANCE OF SURVIVAL= IMMEDIATE DEFIBRILLATION
DISCUSSION:
Ventricular fibrillation (VF) is a rapid, chaotic
ventricular arrhythmia that immediately brings to a
halt all meaningful ventricular contractions.
Blood (Cardiac Output) therefore immediately stops
flowing, and loss of consciousness occurs within
seconds.
Unless cardiopulmonary resuscitation measures are
initiated within a few minutes of the onset of VF,
death will occur.
“Electricity is the answer!”
“ACLS”
Advanced
Cardiac
Life
Support
 “Coarse” Ventricular Fibrillation
PACED RHYTHMS
 100% AV-Paced, 1st Degree AV Block
 Rate:
 Rhythm:
 P Waves + ~ =
 PRI=0.22 sec
 QRS= ~ = 0.08 sec
Asystole
“Artifact”
“ECTOPY”
BIGEMINY
PVC (Premature Ventricular Contraction)
Pharmacologic
Identification: Irregular Rhythm
Treatment:
-Ventricular depolarization Occurs earlier than predicted
Lidocaine IVP
-QRS “Wide & Bizarre,” > 0.12 seconds
Lidocaine Gtt;
-Uniform or multiform
Amiodarone IVP
-Unifocal or multifocal
& gtt
-“Frequent PVC’s” = More than 6 PVC’s per minute
-2 or more PVC’s in a row (couplets, triplets, more…)>>Unsustained VTach
-PVC Patterns: PVC every other complex = BIGEMINY
Increasing presence / severity PREDISPOSES TO V TACH V FIB
 SR w/ PJC
Rate: 60’s
Rhythm : Irregular
P Waves: +, upright, ~
not 1:1 with QRS
PRI = 0.18 sec
QRS = 0.06-0.08 sec
What Rhythm is This?
 NO !
 Check the Patient!
 It isn’t any rhythm until you correlate
it with the patient’s clinical condition
and cardiac output !
PEA
P. E. A.
“Pulseless Electrical Activity”
ANY RHYTHM NORMALLY ASSOCIATED WITH A PULSE,
WHERE NO PULSE IS PRESENT
( so if monitor shows
Asystole, VF, or VT it is NOT P.E.A., since these rhythms
Are NOT normally associated with a pulse).
CAUSES: Cardiac Tamponade
Others
 Sinus Tachycardia w/ BBB; PJC or PAC converting to Sinus
Tachycardia w/ Ventricular Asystole
 P Waves: = ~ 150 / minute
 QRS = 0.12 sec (BBB) ~ until stop
 PRI = unable to measure
 Atrial Fibrillation
 w/ Ventricular Pacing (& PVC)
VT Versus SVT
“Narrow versus Wide”
SX
Diagnostic Tests
•Serial Cardiac Enzymes
MARKERS
EKG changes
CARDIAC MARKERS
CARDIAC ENZYMES
•--CK-MB
•--Myoglobin
•--Troponin
•Serial EKG’s
a.k.a. “isoenzymes”
CK MB
Serum Levels Over Time:
TROPONIN
5X
Myoglobin
Pagana & Pagana, p. 322
Rapid diagnosis in E.R.: ~15-20 minutes
4X
3X
2X
Normal
Range
2
Chest Pain
4
6
8
10
DAYS AFTER INFARCTION
12
14
16
REMEMBER:
At the ‘end of the day,’
IT’S ALL ABOUT
C.O. =
HR&R x SV
B.P. = C.O. X P V R
SVR
*
*
Tissue perfusion of vital organs…and everything else….
Work On Your Own (and/or in groups)…
 Practice Strips 1-29
 Determine Rate, Rhythm, P Waves, PR Interval, QRS Interval
 General Impression (Out to the side)
 Rate = #
 Rhythm = Regular vs Irregular
 P Waves: Presence (?) , Upright (?), ~ Similarity / Uniformity (?)
,1:1 w /QRS’s (?)
 PRI = Measure & Assess: 0.12 – 0.2seconds ?
 QRS = Measure & Assess; < 0.12 seconds ?

Comment: Normal or abnormal ? Cardiac
Output?