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Nursing skills 3 > ECG, Ventilation, Blood pressure > Flashcards

ECG, Ventilation, Blood pressure Flashcards

1
Q

Electrocardiography means

A

Is the graphic representation of the electrical activity of the heart as it travels through the cardiac conduction system and heart muscle
Sinoatrial node –> internodal tracts –> atrioventricular node –>
bundle of His –> bundle branches –> Purkinje fibers

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2
Q

Why are ECGs preformed

A

1.To determine a heart rate
2. Assess cardiac rhythm
◦ You need to differentiate normal from abnormal and dangerous from harmless rhythms
3. Show conduction abnormalities
4. Aids in the treatment of cardiac arrest

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3
Q

What does a complete complex in an ECG look like

A

This complete complex represents a single heartbeat
*How long the electrical impulse takes is shown on the horizontal axis in
seconds
*The “amount” of electricity is shown on the vertical axis
* It is measured in millivolts (mv)
* The baseline is 0 mv

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4
Q

What does a normal heartbeat look like in an ECG

A

Each part of the cardiac cycle is represented by a part of the normal ECG
reading and is described by the P- QRS-T complex
The P-QRS-T complex, as
demonstrated on lead II is as follows:
P-wave: depolarization
(contraction) of the atria
QRS complex: depolarization (contraction) of the ventricles
◦ Usually positive in small animals*
◦ Negative in large animals
T-wave: repolarization
(preparation for next contraction) of the ventricles
◦ Can have either a positive (pointing up) or a negative (pointing down) wave deflection as long as it doesn’t fluctuate on the same rhythm strip

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5
Q

What is the general route of the depolarizing wave in a heart

A

◦ Cranial to caudal
◦ Right to left
◦ Dorsal to ventral

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6
Q

How do you measure a depolarizing wave

A

If the depolarizing wave is moving in one direction relative to the way it is being measured, it may be measured as positive
*If the depolarizing wave is moving in the opposite direction relative to the way it is being measured, this may be measured as negative

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7
Q

What does the vet ECG have

A

Gives a positive deflection of the P and R waves in the normal small animal ECG
*Records the strongest positive reading because it looks at the electrical activity of the heart in the direction of the wave of depolarization

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8
Q

What does the vet tech do for the ECG

A

Heart rate and rhythm are the most valuable pieces of information that can be collected from an ECG
*As a VT, you will be responsible for hooking the animal up to the electrodes and the machine, calibrating the machine, and printing the record and/or putting it in the patient file
*Like a radiograph, you need to know enough to make a judgment about whether or not you have produced a record that is of diagnostic quality or whether you need to repeat the procedure
*You will obtain the paper tracings and record all relevant patient information on the tracing (the ECG rhythm strip is part of the legal medical record)
*You do need to know if abnormalities in the tracing are due to patient abnormalities or pathologies or due to patient positioning, movement, mechanical interference etc.
*If using the ECG to monitor a patient under anesthesia, you do need to be able to calculate heart rate and to recognize a normal rhythm
*You also need to know when there is an abnormal rhythm (arrhythmia) so appropriate treatment can be started to prevent death

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9
Q

How does a 50mm/sec paper work and for what species

A

Used for smaller animals as they have faster heart rates
Spreads the complexes out so more detail can be seen
Each small box is 0.02 seconds
Each large box is 0.1 seconds

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10
Q

How does 25mm/sec paper work and is used for what species

A

Used on larger animals with slower heart rates
Compresses the complexes
Half the speed so it takes twice as
long to cover the same distance
Each small box is 0.04 seconds
Each large box is 0.2 seconds

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11
Q

How to determine the HR with a 25mm/sec paper

A

Divide 1500 by the number of small boxes between two R’s to get beats per minute
* Small box = 0.04 seconds

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12
Q

How to determine a HR using 50mm/sec paper

A
  • Divide 3000 by the number of small boxes between two R’s to get beats per minute
  • Small box = 0.02 seconds
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13
Q

how to calculate irregular rhymes using ECG paper

A
  • Calculate an average
  • Count the number of QRS complexes in a predetermined time period and multiply by the factor
  • Most common is 6 seconds
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14
Q

What is a normal HR of a dog

A

Small Dog: 80 – 140 bpm
◦ Large Dog: 60 – 120 bpm

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15
Q

What is a normal HR for felines

A

180 – 220 bpm
◦ Heart rate is usually lower at home

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16
Q

What is a normal HR for bovine

A

Bovine:
◦ Calf: 60 – 100 bpm
◦ Adult: 60 – 80 bpm

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17
Q

What is a normal HR for equine

A

Equine:
◦ Foal: 80 – 120 bpm
◦ Adult: 28 – 40 bpm

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18
Q

What should a normal rhythm look like

A

“Is there a P for every QRS and a QRS for every P?”
*Determines that the heart is:
* Depolarizing normally
* Controlled by the sinoatrial (SA) node
This is referred to as:
normal sinus rhythm

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19
Q

What does sinus arrhythmia look like

A
  • Heart rate coordinated with respirations
  • Decreases during expiration
  • Increases during inspiration
  • Normal in dogs, horses, and cattle
  • Abnormal in cats
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20
Q

Sinus bradycardia is

A

Abnormally slow HR

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21
Q

Sinus tachycardia is

A

Abnormally fast HR

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22
Q

AV block looks like

A

Delay or interruption in conduction of the electrical impulse –results in slower than normal heart rate
Three types

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23
Q

What does a first degree AV block look like

A

prolonged PR interval
◦ Can be normal in resting horses or in animals under anesthesia
◦ Also seen in animals with hyperkalemia or cardiac disease

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24
Q

What does a second degree AV block look like

A

occasional missing QRS complexes
◦ Can be normal in resting horses or in animals under anesthesia
◦ Also seen in animals with hyperkalemia or cardiac disease

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25
What does a third degree AV block look like
random PR intervals ◦ NOT NORMAL, requires treatment
26
What are premature complexes
Complexes that appear earlier than they should if normal conduction paths are followed
27
What does a premature supraventricular complexes look like
One or more normal QRS complexes closely following the previous QRS complex ◦ Usually have narrower, more normal-looking complexes ◦ P wave abnormalities or absent P waves https://www.youtube.com/watch?v=I1lyBZR82dQ
28
What does a premature ventricular contraction/complexes look like
Usually appear as a very wide complex closely following the previous QRS complex
29
What does atrial fibrillation look like and what causes it
Irregularly irregular ventricular rhythm * Irregular R-R intervals with no predictable pattern * QRS morphology is normal *Atria beat irregularly * Extremely rapid contraction of the atria in various small portions of the atrial wall at any one time * Normal to fast rate *Seen as fine undulations of the baseline *No P waves
30
What does ventricular fibrillation look like
Extremely rapid contraction of the ventricles in various small portions of the ventricular wall at any one time *Results in a very rapid but ineffective ventricular rate that produces NO PULSE *Will die very quickly if CPR or electrical defibrillation is not attempted immediately *Undulating baseline *Absence of QRS complexes
31
What are the common industry standards for performing an ECG on a SA
Place patient in right lateral recumbency on a non-metallic surface/mat and in a quiet room When using the ECG to monitor during surgery, procedure may dictate positioning Cats and dogs can also be placed in sternal Nearby electrical equipment should be unplugged This is to reduce 60-cycle electrical interference Limbs should be separated by a non-conductive material like a towel or paper towel Connect alligator clips to the skin Place a small amount of electrode gel or alcohol at the connection sites For long-term monitoring Clip fur and use sticky pads As in human ECGs OR Pass electrode wire directly through the skin Push a 20 G needle through skin, pass the electrode wire through needle, remove needle and secure wire with tape
32
Where should you clip each ECG lead
Clip leads to the skin in 4 places Red – left hind leg Green – right hind leg* White or Yellow – right foreleg Black – left foreleg Forelimb clips: - Attach just proximal to the olecranon Hindlimb clips: - Attach just cranial and proximal to the stifle
33
What are the most commonly placed leads and where
Although there are 6 leads, Lead II, is the most commonly used in veterinary medicine Performed in a standing position Lead placement: Many variations depending on clinician, geographical location, equipment available Most commonly used: Left arm electrode (+) – near left ventricular apex (left thorax, near elbow) Right are electrode (-) – in the lower third of right jugular furrow or over the right shoulder Ground electrode (N) – anywhere removed from the heart (ex: left shoulder, right dorsal neck area)
34
Importance of Respiratory Ventilation in Anesthesia and the Technologist
Typically, the normal alveolar respiratory ventilation is done unconsciously to maintain constant arterial blood gas tension (particularly CO2) Anesthesia and drugs can interfere with this unconscious mechanism. It is the responsibility of the person who is monitoring the patient to be able to recognise these changes and act accordingly. With a good understanding of respiratory physiology and knowledge on how the machines/systems being used work, then handling the issues interfering with the body’s unconscious mechanism can be controlled.
35
What is the Physiology of Respiration
Takes place in the medulla oblongata or “respiratory center” 2 main systems that control breathing are: Mechanical Control Chemical Control
36
What is the mechanical control of respiration
Nerve impulses that respond when the lungs are fully inflated and deflated These are autonomic pre-set levels Prevent over-inflation Ensure proper amounts of exhalation This system’s control is to maintain a normal, rhythmic, resting breathing pattern
37
What is the chemical control for respiration
There are chemical receptors within blood vessels that monitor physical and chemical characteristics of the blood The 3 characteristics that affect breathing processes are CO2 content Blood pH O2 content CO2 and blood pH work together to notify the control center Note: severe hypoxia can cause the respiratory center to fail due to neuron depression and may cause a decrease or arrest of breathing
38
What are some common resp monitors for anesthesia
Capnography Side stream Sampling Mainstream Sampling Pulse Oximetry
39
Capnography is and used for
The measurement of concentrated CO2 levels in expired gas The inspiration baseline should always be zero Upward slope indicates expiration The highest value is the end-tidal CO2 Downward slope indicates inspiration The results are displayed in millimeters of Mercury (mmHg) or percent (%) CO2
40
What would happen if ETCO2 is >45mmHg is
Hypercapnia hypoventilation
41
what does and ETCO2 of 35-45mmHg mean
Normal Eucapnia
42
What does an low ETCO2 mean
hypocapnia hyperventilation
43
What might be a patient issue with a low ETCO2
Cardiac arrest Decrease in cardiac output Hyperventilation Hypotension Air or pulmonary embolism Tidal volume too small (collapsed lung/diaphragmatic hernia)
44
what might be some monitor issues with ETCO2
Sampling line disconnected or broken Endotracheal tube cuff deflated or leaking
45
Why might the ETCO2 be 0
Patient issue - apnea - airway obstruction monitor issue - endotracheal tube disconnect - esophageal intubation - obstruction in line or ET tube
46
What might be a patient issue with high ETCO2
Hypoventilation Pneumothorax/lung disease Hyperthermia/increased metabolism Pain Shivering
47
what might be some monitor issues for high ETCO2
Pop-off valve closed Improper ventilation Valves sticking in rebreathe system
48
Why might he capnography baseline be high
Patient issue - rapid and shallow breaths Monitor issues - large dead space apparatus - exhausted CO2 absorbent - bain system incorrectly assembled
49
What is a side stream sampling for ventilation
Extracts a sample of the respiratory gas between the endotracheal tube and the anesthetic hose and diverts it back to a measuring chamber
50
What are some pros for a side stream sampling for ventilation
Small, lightweight Can be used in remote monitoring (MRI) Can be used in non-anesthetized patients
51
What are some cons for a side stream sampling for ventilation
Can produce falsely low ETCO2 in small patients with high oxygen flow 2 to 3 second delay for results on monitor Sample tubes can be occluded with moisture/condensation build up Attachments can become lost or broken easily
52
What is a main stream sampler for ventilation
Device that locally analyzes the respiratory gases between the endotracheal tube and anesthetic hoses but produces instant results
53
What is a pro for mainstream sampling for ventilation
Less moisture/condensation build up then side-stream No disposable supplies to lose or break
54
What is a con for mainstream sampling for ventilation
Heavy Prone to accidental disconnection, leaks Dropping damage Tendency to kink tubes
55
What is a pulse oximeter and what is it used for
Is the measurement of haemoglobin oxygen saturation It is a non-invasive method of continuous measurement It is abbreviated to SpO2 meaning the method of measuring saturated oxygen in the blood stream Light-emitting diodes (LEDs) in red and infrared wavelengths penetrate the tissue and measure the light absorption spectra of the haemoglobin Will also pick up the pulse signal (heart rate) Valuable information to detect early decrease in oxygen saturation before respiratory or cardiovascular failure occurs Greatly reduces the odds for anesthetic related deaths
56
What are the normal values of SpO2 and what should you do if they're slightly off
The normal percentage of SpO2 to sustain life and properly perfuse all the internal organs is over 95% Some monitors will read slightly low around 93% It is very important to detect hypoxia rather than an exact measurement reading Compare with the color of the mucous membranes if concerned
57
Where can you place an SpO2 monitor
Needs to be on an area for 30 seconds before it can be assumed accurate For quality control the HR needs to match the monitor reading Can be placed on: Ear Tongue Paw pads Lip Prepuce and/or vulva
58
What can affect the SpO2 readings
Pigment of skin Amount of hair Movement of patient Peripheral vasoconstriction Thickness of tissue
59
When do you measure BP
Part of minimum baseline ER, ICU, anesthesia Patients with known or suspected hypertension or hypotension
60
What does BP measure
Systemic vascular resistance (the smooth muscle tone of the blood vessels) Cardiac output (pumping action of the heart) Circulating arterial blood volume (body water volume) Required to drive tissue perfusion --> oxygenation
61
What should the vet nurse do for BP
Have the technical skills to accurately assess blood pressure Understand the advantages and disadvantages of different monitoring techniques Recognize abnormal values and understand their implications Know when to alert the clinician who is managing the patient
62
What are the blood pressure values actually measuring
Systolic Arterial Pressure (SAP) - When left ventricle contracts, blood is pushed into the aorta and this creates SAP Diastolic Arterial Pressure (DAP) - As the left ventricle fills again, the aortic pressure falls; the residual (resting) pressure in the aorta is the DAP Mean Arterial Pressure (MAP) - Is calculated from systolic and diastolic pressures: MAP = DAP + 1/3(SAP-DAP)
63
What is a normal range for systolic arterial pressure in dogs
80-140mmHg
64
What is a normal range for systolic arterial pressure in cats
80-140mmHg
65
What is a normal range for diastolic arterial pressure in dogs
54-80mmHg
66
What is a normal range for diastolic arterial pressure in cats
55-75mmHg
67
What is a normal range for mean arterial pressure in dogs and cats
60-100mmHg
68
When should you report BP
Need to allow a 10 mmHg window for time to respond Report if: Systolic <90 mmHg Mean <70 mmHg Diastolic <55 mmHg Acceptable pressures under general anesthesia are lower due to the nature of the drugs that cause vasodilation and cardiac depression
69
How do you diagnose hypotension
Is made based on the patient’s presentation, physical examination, and blood pressure measurement In dogs and cats, MAP is the preferred value used for making a diagnosis of hypotension Patient is considered hypotensive when: MAP is < 60 mmHg SAP is < 80 to 100 mmHg Follow with brief physical assessment of the patient Notify clinician of patient’s status Note: renal perfusion is compromised with MAP < 65 mm Hg
70
How do you diagnose hypertension
Can be primary or secondary There are many secondary causes including underlying disease (kidney disease, Cushing’s, heart disease, drugs) Diagnosis is based on sustained high BP readings on 3 separate occasions Dogs: SAP/DAP >150/90 mmHg Cats: SAP > 150 mmHg Follow with brief physical assessment of the patient Notify clinician of patient’s status
71
Why can hypertension by falsely diagnosed
Caused by stress, anxiety, fear The car ride Vet office scents “White coat” Handling This results in sympathetic response Can result in a false diagnosis of hypertension, elevated HR and RR
72
How to eliminate chances of false hypertension
Calm patient in a quiet exam room for 5 to 10 min Get pet to become familiar with you Treats and GENTLE play Only measure BP after patient has acclimatized to clinic setting Measure heart rate at same time as BP reading Presence of tachycardia in association with hypertension should prompt consideration of white coat hypertension Once ready, take 3 readings and average them Repeat 3 more readings if possible
73
What are the two types of BP monitoring
Direct arterial pressure monitoring Indirect arterial pressure monitoring
74
What is direct bleed pressure monitoring
Gold standard Most accurate Much more invasive Higher risk Specialized equipment and abilities needed
75
What is indirect arterial blood pressure monitoring
Non-Invasive Blood Pressure (NIBP) Measure pressures in a peripheral artery Doppler or oscillometric Less accurate Tends to underestimate actual BP
76
How do you preform a direct arterial blood pressure
DABP measurement is the most accurate method Placement of catheter into an artery Palpate for pulse Most common locations: Dorsal pedal artery Femoral artery Catheter is connected to monitor via transducer equipment (saline filled tubing) Transducer converts mechanical fluctuations in the fluid to an electrical signal Monitor displays pulse waveform as well as SAP, DAP, and MAP Catheter needs to be flushed slowly and regularly to prevent clot formation Need to be careful detachment of equipment does not occur This would result in very rapid and severe blood loss Particularly dangerous in small animals
77
What are the limitations of direct arterial BP monitoring
Technically difficult Specialized equipment required Requires sedation/anesthesia to place arterial catheter Easier if in surgery Constant monitoring Risk of Infection Thromboemboli Serious hemorrhage if catheter dislodged
78
What is the doppler method when taking BP
Indirect method NIBP Relies on detecting blood flow past a pressurized cuff Doppler crystal is placed over artery and used to detect blood flow distal to the pressure cuff
79
How do you use a doppler to measure BP
Clip fur over artery Ventral digital artery or tail artery MUST be distal to the cuff Ultrasound gel is placed on the coupling surface of crystal Gel and crystal are placed over the artery Crystal is taped in place Crystal converts the pulsatile flow signal to an audible sound delivered via the Doppler speaker Listen for the sound of the blood moving against the blood vessel Add sphygmomanometer and cuff Place cuff proximal to carpus/tarsus/base of tail Inflate cuff so pressure in cuff is greater than the SAP The flow signal will be lost (no sound) As the pressure in the cuff is slowly released, the flow signal returns First audible sound corresponds with the SAP   Can also use to count pulses; should match a manual pulse
80
When can you take accurate BP with a doppler and when can you not
Accurate SAP readings > 100 mmHg If SAP is less than 100 mmHg, the readings may actually correlate better with the MAP** Very poor estimate for DAP (or readings <80 mmHg) Hair and poor surface contact interferes with coupling Can be difficult to place over artery Can be errors if tachycardia or arrhythmia More labour intensive
81
Oscillometric BP is measured how
Indirect NIBP “Hands-free” devices Less labour intensive Accurate for MAP, DAP; may underestimate SAP
82
Where are common areas to put a doppler crystal
Caudal aspect of Front and hind limb Base of tail
83
How do you use a oscillometric BP device
Cuff is placed around a limb or the tail over an artery and connected to the monitor As the cuff inflates and deflates, oscillation of the arterial pulse in the cuff is detected electronically The monitor then calculates and displays the heart rate, systolic BP, diastolic BP, and calculates MAP Always compare the heart rate reading with auscultation If the two are similar, the BP readings are more accurate Use average of 5 readings Eliminate highest and lowest Use mean of remaining 3 readings Note: if there is more than 40 mmHg variation, it is not correct
84
What are the limitations of oscillometry
Less accurate than Doppler if hypotensive Time (takes several minutes per measurement) Increased margin of error as BP increases Easily affected by arrhythmia and motion (including shivering) More reliable in dogs than in cats
85
Where do you place a BP cuff
Most common errors in measuring BP are related to cuff selection and placement Select area with minimal bone, cylindrical shaped Room for cuff to not be bent; not over joint Preferred placement: Around the forelimb Above or below the carpus Around the hindlimb Above or below the tarsus Around the base of the tail ie: In Dachshunds; cats Cuff is ideally at (or close to) level of the heart
86
How do select a BP cuff size for a dog
Width of cuff should be 40% of limb circumference Circumference x 0.4
87
how do you select a BP cuff for a cat
Width of cuff should be 30% of limb circumference Circumference x 0.3
88
What do you do if BP cuff is not the right size
Measure circumference with a measuring tape If cuff size is between what is available, use wider of the two options Most common errors in BP measurement are related to poor cuff sizing
89
What happens if a BP cuff is too large
Too large cuff = falsely decreased the BP reading
90
What happens if a BP cuff is too small
Too small cuff = falsely elevated the BP reading
91
What happens if a BP cuff is too loose
Too loose = falsely elevated reading
92
What happens if you do not place the BP cuff in the right area
If placed too proximal on limb, may slide down and become loose If placed over a joint, the artery may not be compressed at all and there is no disappearance of Doppler flow signal --> gives ridiculously high readings
93
94
What happens to the body if co2 increases
CO2 increases  blood pH becomes more acidic  triggers the respiratory center to increase rate and depth of breaths  CO2 eliminated
95
What happens to the body when co2 decreases
CO2 decreases blood pH becomes more basic  triggers the respiratory center to decrease rate and depth of breaths  allows CO2 to increase This can also occur while “bagging” our patients under anesthesia and can take awhile for animal to breath on its own due to low levels of CO2 O2 decreases (hypoxia)  triggers respiratory center to increase rate and depth of breaths

Nursing skills 3 (5 decks)

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