Critical Care: Test One: Meds, EKG Flashcards
What is the infusion rate formula (based on patient weight)?
? ml/hr = mcg/kg/min ❎ kg ❎ 60
mcg/mL
Half-life of Nitroglycerin?
about 3-5 mins
Infusion rate (NOT based on patient weight):
? mL/hr = mg/min * 60
mg/mL
OR
? mL/hr = mcg/min * 60
mcg/mL
How often do you change IV tubing?
q72hours or by hospital policy
When do you get a new IV bag ready (while another one is currently running)?
When the current bag is at 50-100 mL
What is a side effect of long-term Heparin use?
Osteoporosis.
What is the half-life of Heparin?
about 1.5 hours
What is the antidote to Heparin?
Protamine Sulfate
What is the antidote to warfarin (Coumadin)?
Vitamin K
What is a normal INR?
2-3 usually
What do you monitor with Heparin?
PTT
What do you monitor with Coumadin (warfarin)?
PT/INR
How often do you monitor aPTT with Heparin?
q6h
How often is PT/INR monitored with Coumadin therapy?
Often monitored daily.
How is the INR calculated?
Lab calculates it by dividing patient’s PT by mean PT of individuals not on anticoagulant therapy. INR of 2-3 is therapeutic.
A substance which affects myocardial contractility =
Inotropic (positive=increased force of contraction; negative=decreased force)
A substance which affects Heart Rate =
Chronotropic (positive=increases HR; negative=decreases HR)
Where are alpha 1 receptors located?
vascular smooth muscle
Stimulation of the alpha 1 receptors results in what?
Profuse, body-wide VasoCONSTRICTION (Raises BP)
Alpha 2 receptors are located where?
centrally and peripherally (peripherally is non-signigficant)
Stimulation of alpha 2 receptors causes what?
Centrally located: removal of norep at the neuronal synaptic junctions leading to HYPOTENSION from VASODILATION. SEDATION.
Peripherally: non-significant platelet aggregation action (most meds stimulate a-2 peripherally).
Where are Beta 1 receptors located and what does their stimulation cause?
The heart; increased HR, conduction, and contractility (Pos. Inotropic & Chronotropic)
Where are Beta 2 receptors located and what does their stimulation cause?
- Smooth muscle of the bronchi and the skeletal blood vessels
- Stimulation results in:
- DILATION of the bronchi
- Activation of glycogenolysis (conversion of glycogen to glucose within the liver)=RAISES BLOOD SUGAR
- Uterine CONTRACTIONS
Albuterol is what class of drug?
Beta 2 Agonist
Where are dopaminergic receptors located?
In the coronary arteries, renal, mesenteric and visceral BV’s
You can’t give a negative chronotropic med with a HR less than ____
60
With Inotropic meds, you have to use caution in patients with _____
any heart problems.
Epinephrine stimulates what receptors?
Alpha 1, alpha 2 (peripherally), beta 1, and beta 2
Epinephrine causes vaso_______ except may cause vaso______ in the arterioles of the liver and skeletal muscles (which means increased O2/blood flow.
vasoconstriction; vasodilation
4 Uses for Epinephrine:
Severe Hypotension
Anaphylactic Shock/bronchodilation
In conjunction with local anesthetics
Mydriasis
SE/AR of Epinephrine:
Hypertensive Crisis
Cardiac dysrhythmias/Tachydysrhythmias
Angina Pectoris: Common reason taken off epinephrine
Hyperglycemia
S/s of Hypertensive Crisis:
*Headache (in unconscious person, check behavior–crying, furrow brow, agitation)
*Vision Changes (photosensitivity, diplopia)
*N/V
Change in LOC
Which receptors does Norepinephrine (Levophed) stimulate?
Alpha 1, Alpha 2 (peripherally), and Beta 1; Does NOT stimulate Beta 2=doesn’t raise blood sugar like epi can)
What type of checks are important for a person on Norepinephrine (Levophed) for a “long time” (ie 4 hours) and why?
Circulation checks because it causes profuse vasoconstriction and can lead to amputation. Aka “Leave em’ Dead” (Levophed)
What is Norepinephrine (Levophed) used for?
- Similar to epi, but does not activate Beta 2=NOT used for rescue inhaler
- Utilized with Cardiac Arrest, AV Block
- Most specifically used with HYPOTENSION or DEC. ORGAN PERFUSION
What would you do if you saw signs of decreased circulation with someone taking Norepinephrine?
Don’t turn off IV right away, but call MD ASAP
______ is often a first line drug to raise BP.
Norepinephrine
Epinephrine and Norepinephrine both stimulate the same receptors except Norepinephrine does NOT stimulate _____
Beta 2 (therefore, it doesn’t cause dilation of the bronchi (not rescue inhaler, like epi) or cause blood sugar to increase).
_____ is often a 3rd choice to raise BP.
Vasopressin
Which BP drug is not used for long periods, and is often “Last one on, First one off”?
Vasopressin
What are the uses for Vasopressin?
- Alternative or adjunct pressor to epinephrine in the tx of adult shock, refractory VF/VT
- To enhance CPR (Vasopressin-induced vasoconstriction with CPR increases blood flow to the heart/brain; improves neurological outcome (if CPR is successful))–limited studies on this so far
Which drug do you have to be careful with because it may provoke cardiac ischemia due to its potent peripheral vasoconstriction?
Vasopressin
Drug that may be used to enhance CPR because its vasoconstriction increases blood flow to the heart and brain and thus may improve neurological outcomes (if CPR is successful)?
Vasopressin
What are the 3 levels of dosages for Dopamine and which receptors does each stimulate?
LOW DOSE: 0.5mcg-2mcg; Stimulates dopaminergic receptors in kidneys causing vasodilation=inc. circ & U.O. (however, urine is not filtered in the same capacity so toxicity is possible). Don’t really use low-doses anymore.
MODERATE DOSAGE: 2-10 mcg; Mostly Beta 1= Inc. Contractility/HR/CO
HIGH DOSAGE: >10mcg; Most common; Some Beta 1 until about 15 mcg, then strictly alpha 1 from that point on; Can be third line drug to increase BP.
What is Moderate-dose Dopamine used for?
Symptomatic bradycardia after Atropine failure
What is high-dose Dopamine used for?
Hypotension with s/s of shock, usually in conjunction with epi or norepi
What drugs if taken with Dopamine, will potentiate its effects?
MAO Inhibitors
What are some precautions with Dopamine?
- Tachyarrthythmias
- If hypovolemic, replace volume first
- Do NOT mix with Sodium Bicarb
- Use with caution with cardiogenic shock
- MAO Inhibitors potentiate effects
A direct-acting sympathomimetic with strong alpha 1 adrenergic properties =
Phenylephrine (Neo-Synephrine)
Uses for Phenylephrine (Neo-Synephrine)?
- Severe Hypotension, especially related to shock states; may be used in conjunction (like 5th/6th line), or alone.
- Vascular failure with shock
- Nasal Decongestant (used to be used for this)
- May have nearby post-surgery in case of hypotension
What are some precautions with Phenylephrine (Neo-Synephrine)?
- Palpitations
- Tachycardia
- HTN
- Angina
Drug enhances sinus node automaticity and also AV conduction =
Atropine Sulfate
What is Atropine Sulfate used for?
- Symptomatic sinus bradycardia
- Asystole or PEA
What is the usual dosage of Atropine Sulfate?
1 mg! (however, some places say 0.5-1mg); every 3-5 mins; Tracheal admin=2-3mg diluted in 10 mL normal saline
What drug can you give a one-time dose of WITHOUT a written order if the patient is having SYMPTOMATIC bradycardia (ie dec. CO=hypoperfusion=dec. LOC, etc)?
Atropine sulfate
What is the half-life of Adenosine (Adenocard)?
6-10 secs
What is Adenosine (Adenocard) used for?
- First drug for most forms of narrow complex PSVT
- Mostly used for diagnostic purposes to determine underlying rhythm
Name 3 life-threatening heart rhythms:
V-tach, V-fib, Asystole
Which drug slows conduction through the AV node and interrupts the AV nodal reentry pathway?
Adenosine (Adenocard)
SE’s of Adenosine (Adenocard)?
Bradycardia
Chest pain
Ventricular ectopy
Brief periods of asystole
What does Adenosine (Adenocard) do to the Heart Rate?
Slows it.
What class of drugs is Procainamide (Pronestyl)?
1-A anti-dysrhythmic
What drug reduces the automaticity of all pacemakers and slows intra-ventricular conduction?
Procainamide (Pronestyl)
What is Procainamide (Pronestyl) used for?
- PSVT if uncontrolled by adenosine, only if BP is stable
- Stable wide complex tachycardia of unknown origin
- One of most common anti-dysrhythmics
What is Amiodarone (Cordarone) used for?
- Used for multiple PVC’s or V-tach
- 1st line ACLS med with shock refractory VF and pulseless VT
- Wide complex tachycardia of uncertain origin
- Hemodynamically stable VT when cardioversion is ineffective
- Ectopic or multifocal atrial tachycardia with preserved LV function
- Use as adjunct to cardioversion of SVT/PSVT
- Rate control of A-fib or flutter when other therapies are ineffective
Heart Rhythms:
1) with ___, check for pulse
2) with ___, you can shock them.
3) with ____, you cannot shock them.
v-tach; v-fib; asystole
3 Precautions with Amiodarone (Cordarone):
Hypotension
May prolong QT interval
May have negative inotropic effect (decreases contractility)
_____ is an ACLS for V-tach codes
Amiodarone (Cordarone)
Amiodarone ____ the ventricles.
calms
2 common uses of Amiodarone:
Cardiac arrest and wide complex tachycardia
Drug similar to Amiodarone that also calms the ventricles, and is used for PVC’s, SVT, VT, Cardiac arrest, etc?
Lidocaine (Xylocaine)
Drug that decreases automaticity, slows conduction velocity in re-entry pathways, elevates fibrillation threshold, and may decrease energy to reverse VF =
Lidocaine (Xylocaine)
5 Indications for Lidocaine (Xylocaine)?
PVC's Cardiac arrest from VF/VT Stable VT Wide complex tachycardias of uncertain type Wide complex PSVT
What 3 things does Dobutamine (Dobutrex) do?
Vasodilation (lets heart not work as hard)
Increases Contractility (somewhat gently)
Increases Heart Rate
What is Dobutamine (Dobutrex) used for?
Pump problems (HF, Pulmonary congestion) with SBP of 70-100 and no signs of shock
_______ (drug) increases HR, but is gentler than epi, norepi, dopamine, etc.
Dobutamine (Dobutrex)
What class of drug is Nesiritide (Natrecor)?
Human B-type Natriuretic Peptide (hBNP)
What is the mechanism of action for Nesiritide (Natrecor)?
Increases urine Na+ loss (pulls fluid off body (water follows Na+))
Cardiac smooth muscle relaxation
Vasodilation
What are the uses for Nesiritide (Natrecor)?
Decompensating HF patients
HF/AMI pt’s showing dyspnea at rest or with little exertion
Which drug for HF is even gentler than Dobutamine (Dobutrex)?
Nesiritide (Natrecor)
What are two precautions for Nesiritide (Natrecor)?
SBP <90; cardiogenic shock
What is the mechanism of action for Nitroglycerin (Nitrostat)?
Relaxes vascular smooth muscle and decreases preload
What are the indications for Nitroglycerin?
Chest pain
Peri-operative HTN control
3 Precautions for Nitroglycerin:
Do NOT administer if BP <90
RV infarction
Viagra within 24 hours (causes significant hypotension)
Which drug should not be given if the patient has received Viagra within 24 hours?
Nitroglycerin
We don’t give Nitroglycerin with ____-sided infarct (MI).
Right
If someone is one a Nitroglycerin drip, monitor BP every ___
5 mins
Half-life of Nitroglycerin:
about 3-5 mins
With ____, there is no max dose. However, if systolic reaches ____, you need to titrate them off of it.
Nitroglycerin; 90
What is the fastest known anti-hypertensive?
Sodium nitroprusside (Nipride)
What levels do you have to check with sodium nitroprusside (Nipride)?
Cyanide levels
Sodium nitroprusside (Nipride) causes profuse venous and arterial _____
vasodilation
What is the drug of choice for Hypertensive Crisis?
sodium nitroprusside (Nipride)
Sodium nitroprusside (Nipride) needs to be protected from ____ at all times.
light
What med is often given in conjunction with sodium nitroprusside (Nipride) because Nipride can trigger sodium/water retention?
Lasix
What are 3 precautions with sodium nitroprusside (Nipride)?
Reflex tachycardia will occur usually
Severe hypotension
Not good for bad hearts–will stress them
What class of drug is Verapamil (Calan, Isoptin)?
Calcium Channel Blocker
What is the mechanism of action for Verapamil and Diltiazem?
Slows inward flux of Na and Ca
Reduces myocardial O2 consumption
Decreases HR
Decreases contractility
Indications for Verapamil?
PSVT with adequate BP and preserved LV function
Control of Ventricular response of A-fib, A-flutter.
What do calcium channel blockers do?
Coronary dilation
decrease automaticity=Dec. HR
Vasodilation in periphery=Dec. BP
Calcium channel blockers (ie Verapamil) cannot be used in those with ______
Wolff Parkinson White Syndrome
5 Precautions for Verapamil:
Avoid in WPW (Wolff Parkinson White Syndrome)
Expect BP drop
May decrease myocardial contractility
Concurrent use of Beta Blockers can cause severe hypotension
Diltiazem (Cardizem) is a ______
Calcium Channel Blocker
2 Indications for Diltiazem (Cardizem)?
A-Fib/Flutter with rapid ventricular response
PSVT with narrow QRS and adequate BP
Precautions with Diltiazem (Cardizem)?
Avoid in those with WPW
Expect BP drop
Avoid in tachycardias due to overdose or poisoning
Concurrent use of Beta Blockers can cause severe hypotension
Metoprolo (Lopressor) is a _______
Beta Blocker
Most beta blockers are ______ (block beta 1 and 2).
non-selective
It is recommended to prescribe ______ after someone has an MI
Beta Blockers
Indications for Beta Blockers (ie Metoprolol):
MI and unstable angina
Emergent antihypertensive therapy
Tachydysrhythmias
Mechanism of action for Beta Blockers (ie Metoprolol):
Blocks catecholamine’s by blocking their ability to bind to Beta adrenergic receptors
Precautions for Beta Blockers (ie Metoprolol):
Avoid if receiving CCB’s
Contra if HR <60, BP <100, hypoperfusion
Administer slowly
Monitor BP
What is the mechanism of action for Dexmedetomidine hcl (Precedex):
Stimulates alpha 2 in the CNS causing inhibition of the SNS of the brain
Use for Dexmedetomidine Hcl (Precedex):
Initial sedation of newly intubated patients
Precaution with Precedex?
Hypotension
Dexmedetomidine Hcl (Precedex) is what class of drugs?
Sedative/Hypnotic; acts as Alpha 2 agonist
Half-life of Dexmedetomidine Hcl (Precedex)?
6 mins (short half-life=good control of sedation)
Dexmedetomidine Hcl (Precedex) is not recommended to infuse longer than ___ and you may need to decrease the dose for those with _____
24 hours; renal/hepatic failure
_____ has a rapid onset sedation within 40 seconds.
Propofol (Diprivan)
_____ causes potentiation of GABA, the main inhibitory neurotransmittter.
Propofol (Diprivan)
Uses for Propofol (Diprivan):
Conscious sedation
Effective with continuous sedation with rapid recovery
Med that is an emulsion med (lipid-based) which means that you have to use it all within 6 hours/replace bottle, prepare with strict sterile technique, it can cause emboli issues, and you don’t want to instill lipids on top of it:
Propofol (Diprivan)
Propofol is good because it doesn’t cause as many problems with _____
hypotension
What is the most potent Diuretic on the market?
Mannitol
Mannitol is a ____
osmotic diuretic. Most potent diuretic out there.
Mannitol is used to decrease ______&____
ICP; Intraocular pressure
What is Mannitol’s effect on electrolytes?
No significant effect on the excretion of electrolytes.
What is the mechanism of action for Mannitol?
Creates an osmotic force w/in the lumen of the nephron; undergoes minimal reabsorption which allows more of the med to remain within the nephron and enhances renal preservation. Inhibits passive reabsorption of water=Increased UO.
The pacemaker of the heart=
SA node
The ____ side of the heart is more anterior (frontal impact/trauma would affect it more).
Right
What is the second spot of electrical conduction in the heart?
AV node
What is the “atrial kick”?
.
Semilunar valves =
Pulmonic and Aortic
AV valves =
Tricuspid & Mitral (Bicuspid)
During atrial diastole (filling), the ___ valves are closed
AV (tri and bi)
During atrial systole, the ___ valves are open
AV (tri and bi)
During ventricular diastole (filling), the ___ valves are closed.
semi-lunar (pulmonic and aortic)
During ventricular systole (contraction), the ____ valves are open.
semi-lunar (pulmonic and aortic)
Electrical Conduction System:
1) SA node: pacemaker of heart
2) Internodal conduction and interatrial conduction tracts
3) AV junction (AV node and Bundle of His)
4) Right and left bundle branches
5) Perkinje network
Inherent rates:
1) SA node/atrial: ____ bpm
2) AV node: ___ bpm
3) Ventricular: ____ bpm
60-80; 40-60; 20-40
Which refractory period of the heart do you NOT want to give a signal during?
Absolute refractory period.
EKG leads usually come in __, ___, or ___ (#’s) leads. Electricity runs from ___ to ____.
3, 5, or 12; Negative to positive;
What are some ways to improve contact of the electrode to the body?
- Remove extra hair in the area (DON’T shave them–increased risk of infection; clip them).
- Cleanse with soap/H20
- Abrade the skin (dry with ETOH)
- Press electrode firmly on skin
- Change q24h
What are the locations of the electrodes for an EKG?
- WHITE to upper RIGHT (around 2nd ICS, Mid-Clavicular)
- Snow over trees=GREEN under WHITE (around 7-8th ICS)
- Smoke over fire=BLACK on upper left and RED below that (Black=left,2nd ICS/Midclavicular, Red= left, 7-8th ICS)
- Chocolate (BROWN) is close to the heart= (4th ICS at sternum)
- *ICS’s are approximate
“V-leads” look at ________; V__&___ leads look at the right side of the heart while V-leads _______ look at the left.
Look at the right to left ventricle; V1&2; V3 through V6
EKG paper shows ___ activity, NOT ____ movement.
electrical; mechanical
The ____ line of the EKG paper is voltage while the ____ line is time.
vertical; horizontal.
EKG paper:
Time: Dark vertical lines=___seconds
Light vertical lines=___seconds
Voltage: Dark horizontal lines= ____mm
Light horizontal lines=____mm
Time: dark vertical=.2; light vertical=.04
Voltage: Dark=5mm; light=1mm
Most EKG strips are ____ seconds in length
6
3 ways to determine Heart Rate on EKG strip:
- *1) Count # of small squares between 2 consecutive R waves and divide into 1500 (use only with regular rhythm).
- *2) Count # of R waves in a 6 second strip and multiply by 10 (use for IRREGULAR; can be used for Regular, but it’s more of a guesstimate).
3) Count # of large squares between 2 consecutive R waves and divide into 300 (only with regular rhythm).
Flat line on the EKG paper that represents the resting membrane potential of cardiac cells =
Isoelectric Line
EKG wave that represents Atrial depolarization/systole/contraction =
P Wave
One “complex” on an EKG represents what?
Ventricular filling through contraction
What is the first wave in a normal EKG complex?
P wave
The amplitude of the P wave should not exceed more than ___ mm; the average duration is _____
2.5 (almost 3 boxes vertically)
Peaked P waves may indicate what? Inverted P waves? Varying P waves? Missing P waves?
Peaked=Right atrial hypertrophy; Inverted=SA node not the pacemaker; Varying=Impulse origin varies; Missing=Junctional or AV block rhythm
Part of EKG that represents activity from the beginning of atrial depolarization (systole/contraction) to the beginning of ventricular depolarization =
PR interval
Part of EKG that extends from the beginning of the P wave to the beginning of the QRS complex =
PR interval
Which part of the EKG measures the “Atrial Kick”?
PR interval
Average duration for the PR interval =___ seconds
.12-.20 (3-5 small boxes wide).
For the P wave, what do you need to focus on? (3)
Location, Configuration, and deflection
What do you need to focus on with the PR Interval?
Duration (.12-.20 seconds; 3-5 boxes)
A shortened PR interval may indicate what? Prolonged PR interval?
SA node not the pacemaker; Impulse delayed through AV node
What do you need to focus on with the QRS complex?
Duration (.06-.12) and configuration
Which part of the EKG represents ventricular depolarization (systole/contraction) & atrial repolarization (diastole/relaxation)?
QRS complex
Which part of the QRS complex do you have to have while the other 2 may be optional?
The “R”=if you don’t have it, then there’s no ventricular contraction.
Which part of the EKG follows the P wave?
PR interval
What follows the PR interval?
QRS complex
What is the duration of the QRS complex?
.06-.12 seconds
A ___ wave that is 1/3 to 1/2 the size of the ___ wave can mean a past MI.
Q; R
A widened QRS greater than ___ seconds indicates: (4)
.12 (3 boxes); Bundle Branch Block, Slow impulse conduction, V-Tach, or PVC (premature ventricular contraction)
“QRS’s VP is BS!”
A second positive waveform in the QRS complex is called ___; what can this indicate?
R prime; aka “Rabbit Ears”; Bundle Branch Block (right and left ventricles aren’t contracting simultaneously; don’t necessarily need treatment).
What do we focus on with the ST segment?
Deflection
What part of the EKG is one of the most diagnostic pieces for a current MI (one of the first things looked at in the ER)?
ST segment (a deviation off of the isoelectric line by greater than 1mm can be bad).
What part of the EKG represents the end of ventricular depolarization (systole/contraction) and beginning of ventricular repolarization (diastole/relaxation)?
ST segment
Where does the ST segment extend to and from?
Extends from the end of the S wave to the beginning of the T wave
We don’t want the ST segment to extend ___ mm above or below the isoelectric line.
1 mm or more
If someone is “throwing tombstones”, they are having what on the EKG?
ST elevation
A change in the _____ (part of an EKG) may indicate myocardial injury.
ST segment
What do we need to focus on with the T wave?
Amplitude, Configuration, and Deflection.
What part of the EKG represents ventricular repolarization (diastole/relaxation)?
T wave
Depolarization =
Systole (Contraction)
Repolarization =
Diastole (Relaxation)–“Re and Re”
The amplitude of the T wave should be ___ mm or less
5 mm (one big box)
A peaked T wave may indicate what? Notched T wave? Inverted T wave?
Peaked=Hyperkalemia; Notched= Pericarditis/P wave in T wave; Inverted=Myocardial ischemia (give the patient O2)
If there’s a peaked T wave, you should check ____
K+ levels
What should you focus on with the QT Interval?
Duration
What part of the EKG represents the time needed for the ventricular depolarization-repolarization cycle?
QT interval
Where does the QT interval extend to and from?
From the beginning of the QRS complex to the end of the T wave
What is the usual duration for the QT interval?
0.36-0.44 seconds
A prolonged _____ (part of EKG) can result from too much Type 1 Antiarrhythmic medications (ie Procainamide or Quinidine).
QT interval
If there’s a prolonged QT Interval, what should you check?
If the patient is on antidysrhythmics (Type 1’s (ie Procainamide or Quinidine) can cause prolonged QT interval). If so, hold drug, draw levels of drug, and call MD.
A shortened QT interval can mean what?
Hypercalcemia
Cardiac Glycoside Toxicity (ie Digoxin)
Fast Heart Rate
What is a systematic way to interpret an EKG?
1) Determine Rhythm Regularity
2) Determine Rate
3) Evaluate P wave
4) Determine PR Interval
5) Evaluate QRS complex
6) Evaluate T wave
7) Determine the QT interval
8) Interpret
9) Evaluate significance
10) Consider treatments, if needed (always at least put CTM (continue to monitor))
11) Every rhythm change (good and bad) should be reported.
Rhythm, Rate, P waves, PRI, and QRS for Normal Sinus Rhythm?
Rhythm: Regular Rate: 60-100 P waves: Present, uniform, 1 present for every QRS PRI: 0.12-0.20 seconds QRS: 0.04-0.12 seconds
*Can have some ST segment depression possible
Rhythm, Rate, P waves, PRI, and QRS for Sinus bradycardia:
Rhythm: Regular Rate:< 60 P waves: Present, uniform, 1 present for every QRS PRI: 0.12-0.20 seconds (3-5 boxes) QRS: 0.04-0.12 seconds
*HR will be below 60 and possible ST segment involvement are only 2 abnormals.
Treatment for NSR (Normal Sinus Rhythm) with ST depression?
O2 (for ST depression)
Cardiac consult
CTM (continue to monitor).
Treatment for SB (Sinus Bradycardia) with ST depression?
O2 (for ST depression)
If symptomatic, give Atropine; without S/s, CTM (continue to monitor).
Rhythm, Rate, P waves, PRI, and QRS for Sinus Tachycardia (ST):
Rhythm: Regular Rate: 101-150 P waves: Present, uniform, 1 present for every QRS PRI: 0.12-0.20 seconds QRS: 0.04-0.12
*Rates can be so fast that the P wave can be hidden in the previous T wave
Treatment for ST (Sinus Tach) with ST depression and peaked T wave?
Check K+ (for peaked T wave)
O2 (for ST depression)
Beta-Blocker/CCB (Slow HR)
CTM (Continue to monitor).
If it was just plain Sinus Tach, treatment could say “Possible treatments for increased HR: BB, CCB, etc, CTM”
Some common causes of ST (Sinus Tach)?
Normal response to exercise and conditions in which catecholamine release is enhanced–flight, fright, anger, or stress (fever, hypotension, sepsis, anemia, anxiety, pheochromocytoma, etc).
Rhythm, Rate, P waves, PRI, and QRS for Sinus Dysrhythmia or arrhythmia:
Rhythm: Irregular (often corresponds with respiratory cycle bc lungs compress heart; common in young children, but can be in adults too)
Rate: 60-100
P waves: Present, uniform, 1 present for every QRS
PRI: 0.12-0.20
QRS: 0.04-0.12
**Only thing wrong is that the rhythm is irregular
What is the treatment for Sinus dysrhythmia/arrhythmia:
Unless symptomatic, don’t do anything. If they have a peaked T-wave or something, you can give O2. Always at least put CTM (continue to monitor).
For plain “Sinus Arrhythmia”, she put under treatment: “No treatment at this time, continue to monitor.”
What do you check for with a peaked T-wave?
Check K+ levels. Can mean Hyperkalemia.
What treatment is given for peaked/depressed ST segment?
give O2
What is treatment for Sinus arrest?
O2
A sinus arrest is no electrical activity for greater than ____ seconds. A sinus pause is no electrical activity for less than ___ seconds.
3; 3
Rhythm, Rate, P waves, PRI, and QRS for Sinus Arrest/pause:
Rhythm: Regular then irregular Rate: Varies P waves: Present, uniform, 1 present for every QRS PRI: 0.12-0.20 QRS: 0.04-0.12
*There’s an elongated time frame with no electrical activity. Sinus arrest=no activity for >3 seconds; Sinus pause=no activity for <3 seconds
Rhythm, Rate, P waves, PRI, and QRS for PAC’s (Premature Atrial Contractions):
Rhythm: Regular (NSR), with premature beat (s)
Rate: Determined by underlying rhythm
P waves: -For underlying rhythm: Present, uniform, 1 present for every QRS
-For premature beat: P wave will be different shape
PRI: 0.12-0.20
QRS: 0.04-0.12
Usually followed by a non-compensatory pause.
Looks just like others except the premature complex parts.
What is the treatment for PAC’s (Premature Atrial Contractions)?
Often nothing. Can give O2 if ST segment is involved too. Always put CTM (Continue to monitor).
Treatment for SB (sinus bradycardia) with peak T wave, ST segment elevation, and Sinus Arrest?
O2 (for ST elevation & Sinus Arrest)
Check K+ levels (because of T wave)
With symptoms, give Atropine; without symptoms, CTM
Treatment for Sinus Bradycardia?
With symptoms, give Atropine; without s/s, CTM (continue to monitor)
Treatment for NSR with ST elevation and 2 PAC’s @5th and 8th complexes:
O2 and continue to monitor
2 PAC’s next to each other is called a ____
couplet; they are bad.
Rhythm, Rate, P waves, PRI, and QRS for Wandering Atrial Pacemaker:
Rhythm: Usually Irregular Rate: 60-100 (not >100) P waves: 1 present for every QRS; ***Vary in size and shape (minimum of 3 different shapes)*** PRI: 0.12-0.20 seconds (these vary) QRS: 0.04-0.12
**Varying P waves and underlying rhythm usually irregular
Treatment for WAP with varying P waves:
CTM (continue to monitor)
Rhythm, Rate, P waves, PRI, and QRS for Multi-focal Atrial Tachycardia:
Rhythm: usually irregular Rate: >100 P waves: 1 present for every QRS, but vary in size/shape (at least 3 different shapes) PRI: 0.12-.20 QRS: 0.04-0.12
Same as WAP (wandering atrial pacemaker) except that the rhythm is greater than 100
Happens almost exclusively in COPD patients
Which EKG rhythm happens almost exclusively in COPD patients?
Multi-Focal Atrial Tachycardia
Rhythm, Rate, P waves, PRI, and QRS for SVT (Supraventricular Tachycardia) (or Atrial Tachycardia):
Rhythm: Regular
Rate: 150+
P waves: Present, uniform, 1 present for every QRS–may be hidden
PRI: 0.12-0.20 seconds; often not measurable
QRS: 0.04-0.12
- Paroxysmal Atrial Tachycardia (PAT) if onset and termination are abrupt–can lead to probs such as AV Blocks
- Can be called Paroxysmal SVT with abrupt onset and termination
Treatment for SVT with peaked T wave and peaked P wave?
O2
Check K+ levels (because of T wave)
CCB or BB (slow the heart rate)
Heart rate of 101-149=_______; Heart Rate above 150=________
Sinus Tachycardia; SVT (supraventricular tachycardia/Atrial tachycardia)
Rhythm, Rate, P waves, PRI, and QRS for Atrial Flutter:
Rhythm: Atrial : regular
Ventricular=regular or irregular
Rate: Atrial=250-350 usually
Ventricular=1/4,1/3, or 1/2 of atrial rate
P waves=resemble “saw tooth” or “picket fence” or “shark fin”*******: Put “Immeasurable” on the test
PRI: Immeasurable
QRS: 0.04-0.12
*Hard to determine presence of T-wave; only skilled docs possibly can
Treatment for A-Flutter 3:1 (3 p for every 1 QRS):
Determine with Heart Rate: if okay (above 60), then CCB’s or Digoxin
if really low, may need Atropine
CTM
Rhythm, Rate, P waves, PRI, and QRS for A-fib:
Rhythm: irregularly irregular
Rate: Varies; Atrial 350-500 (cannot determine); Ventricular 60-250
P waves: *****absent–squiggly, chaotic line
PRI: Immeasurable
QRS: 0.04-0.12
- *Controlled A-Fib= <100 bpm; Uncontrolled A-Fib=>100; HAVE TO SPECIFY WHICH ONE.
- *Big Precaution of PE or stroke! Can also lead to SVT.
EKG rhythm that can often lead to PE’s or Stroke =
A-fib
Treatment for A-Fib:
O2
*Anti-Coagulants
Antidysrhythmics (including CCB’s (diltiazem), BB’s and Digoxin–with HR’s over 60)
Occur when the AV Node takes over as the site of origin for the pacemaker =
Junctional Rhythms
Junctional rhythms may also be referred to as _____
Ectopic (means out of the normal place)
AV nodal tissue as an intrinsic beat of ____ (this is “normal” rate for AV tissue).
40-60
Rhythm, Rate, P waves, PRI, and QRS for PJC (Premature Junctional Contraction):
Rhythm: Underlying rhythm normal–with premature beat
Rate: Determined by underlying rhythm
P wave: Normal for underlying rhythm; P wave for PJC may occur before (inverted), during (absent), or after (usually upright) QRS
PRI: If P present and before QRS <0.12
QRS: 0.04-0.12
Non-compensatory pause noted
Same as PAC except P wave is different (absent or inverted)*
Treatment for SB with ST depression, Peaked P wave, & PJC @ 4th complex?
O2
Symptomatic=Atropine; Not s/s=CTM
Rhythm, Rate, P waves, PRI, and QRS for Junctional (Escape) or Nodal Rhythm:
Rhythm: Regular
Rate: 40-60 (this is normal when the AV Node has taken over as pacemaker)
P wave: May occur before, during, or after QRS
PRI: If P wave present and before QRS <0.12
QRS: 0.04-0.12
P waves absent or inverted**
Have to say if it’s Junctional (40-60), Accelerated Junctional (61-100) or Junctional Tachycardia (101-180)
Treatment for Junctional Rhythm:
If symptomatic, Atropine; If not, CTM.
