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NURS 420 > EKG/Sinus & Atrial Dysrythmias > Flashcards

EKG/Sinus & Atrial Dysrythmias Flashcards

Cardiac Probs

1
Q

5 Leads ECG Placements

A
  • White on the Right
  • Clouds over Grass
  • Smoke over Fire
  • I Heart Chocolate

White on Right side
Green RL
Black on Left side
Red LL
Brown in Middle

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2
Q

ECG Paper

A

Horizontal axis = time
Small square: 0.04 sec
Large square: 0.20 sec
5 Large sqaures: 1 sec
x30 Large squares: 6 sec
x1500 small square: 1 min
x 300 large squares: 1 min
Vertical axis = Voltage
Height of one small square = 0.1 millivolt in mm

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3
Q

Calculating Heart Rate

A

6 sec intervals
x7 R-R interval in 6 sec
* 7 x 10= 70 bpm

or
1500/ # small boxes in one R-R
300/ # big boxes in one R-R

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4
Q

QRS Complex

A

Time for delpolarization of both ventricles (systole)
Duration: < .10
Firing of AV node
* **Atrial repolarization also occurs, just can’t see it **

What I should ask myself: 3 R’s
Regularity: Are the QRS complexes occuring the same regularity (R-R wave)
Rate: Artial and Ventricular rate should be 60-100/min, count in the 6 sec strip (multiple 10) to get rate
Resemblance: Do they resemble a QRS complexes, is there one present after each P wave? Only 1 P wave/ QRS, Are they round and pointing up, less than 0.12 ( 3 small cubes)

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5
Q

P Wave

A

Electrical impulse starting in SA node + spreading through the atria
* Represents: atrial depolarization
* Duration: 0.06-0.12 ( Longer -> delays conduction -> could affect CO)
* Good contraction does not equal good CO (relies on good refill)

What I should ask myself: 3 R’s
Regularity: Are the P waves occuring the same regularity and the consecutive P waves on the EKG? ( Marching)
Rate: Artial should be 60-100/min, count in the 6 sec strip (multiple 10) to get rate
Resemblance: Do they resemble a P wave? Only 1 P wave/ QRS, Are they round and pointing up, less than 0.12 ( 3 small cubes)

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6
Q

PR Interval

A

Represents time taken for impulse to spread through atria, before ventricular contraction
* measured from beginning of P wave to the beginnning of QRS complex
* Full atrial depolarization -> starts of ventricular depolarization
* Duration: 0.12-0.20 (longer -> delays form SA node -> AV node ( AV node prob)

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7
Q

ST segment

A

Time between ventricular deloparization and reploarization
Measures S wave and T wave
Duration: 0.12
**Needs to be isoelectric (flat) **
End of vent. ctxs -> beginning of vent. refill

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8
Q

T wave

A

time for vent. repolarization
Duration: 0.16

What I should ask myself:
It should come after each QRS complex and be round and upright

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9
Q

Isoelectric Line

A

The heart at rest
No depolarization, no repolarization
“baseline”
No 02 req

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10
Q

QT Interval

A

Time form entire electrical depolarization + repolarization of vent.
Duration: 0.32-0.40

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11
Q

Normal Sinus Rhythm

A

Rate: 60-100 bpm
Rhythm: atrial + venticular reg
P waves: uniform, upright, one preceding each QRS
PR interval: 0.12-0.2 sec
QRS: 0.10 sec or less
1:1 atrial: vent ctxs => sinus rhythm

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12
Q

Sinus Tachycardia

A

Ventricular + Atrial rate > 100 bpm
Rhythm: reg
P wave: uniform, upright, one preceding each QRS
PR interval: 0.12 - 0.2 sec
QRS: 0.10 sec or less

Causes:
Exercise, pain, shock
Fever, increase TH (?), anxiety, Hypoxia

Treatment:
Treat underlying cause (decrease caffeine intake, fever pain etc) Perfusion ( cap. refill 1-2 sec, distal pedal , warm, pink)
Vagal maneuvers, blow through straw
Beta Blockers, Ca channel blocker works at the AV node, decrease BP
Catheter ablation: SA node reviving

check the electrod to make sure they are in the right position

Shorter filling time ( decrease CO)
Shorter isoelectric

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13
Q

Sinus Bradycardia

A

Rate: less than 60 bpm
Rhythm: atrial and vent reg
P waves: uniform, upright, one preceding each QRS
PR interval: 0.12-0.20 sec
QRS: 0.10 sec or less

Causes:
Trained athletes, medicine, OD, decrease TH, extreme cold, use of med (BB, CCB, amiodarone), vagal stim, Hypothryoid, MI (Ischemia), Hypoxia

Treatment:
Eliminate cause
increase HR if symptomatic (1st s/s: neuro changes-lethargy)
1st choice Atropine 0.5-1 mg Q3-5 mins (total 3 mg, IV push)
* if not effective (2nd choice) **Transcutaneous pacing **
3rd choice Catecholamines: epi or dopamine drip
Emergency transcutaneous pacing

Hemodynamic- Hypotension, mental status, SOB angina, PVCs

atropine is a anticholingeric that blocks vagal effects on the SA and AV nodes

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14
Q

Atrial Tachycardias

A
  • Varied group of dysrhythmias that originate from an ectopic focus in the atria somewhere other than the SA node. HR>150
  • Ectopic atrial focus generates impulses faster than AV node can handle. Ventricles may not respond to each one.
  • Does not require the AV junction, accessory pathway, or vent tissue for it initiation
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15
Q

Supraventicular Tachycardia (SVT)

A

Atrial tachycardia
Narrow complex
Dysrhythmia orginating in atria that overrides SA node (singular ectopic beat)
T wave overrides P wave ( 0:1 ratio = atrial dysrhthmia)
Equal R-R = reg

Causes/Risk Factors:
Unrelieved sinus tach can -> SVT
Female < 40, caffeine, nictoine, Hypoxia, Stress, CAD, Cardiomyopathy

Hemodynamic Effect ( if sustained):
Palpitation, weakness, fatique, SOB, anxiety, hypotension, syncope!, angine, decrease LOC

Treatment:
**Assess the pt’s **: ABC’s, O2, IV access
Can resolve on its own, eliminate cause
Vagal maneuvers! (first try for adults, children (ice water, face in, shock, Baby (ICE pack two to cheek)
1 st choice AdenSoine - (6mg, 12 mg), fast IV push, stops the heart, short half life, follow w/ saline, arm up
* Pts must be attached to code cart
* 2nd choice, if 12 mg doesn’t work Amiodarone ( antidysrthmic) ,
* Beta Blocker, Ca channel blockers to slow rate (AV node)
* 3RD CHOICE sync cardioversion if the rhythm is resistant to drugs, wait for the QRS, it has to learn the rhythmm
* Defib- doesnt wait for the QRS
* Catheter ablation later, not emegerncy phase. (burn hyperexcitable cells)

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16
Q

Hemodynamic: Yes or No

A

Yes, do the treatments in order
No, skip straight to synchronized cardiodiversion

17
Q

Adenosine

A

Stop the heart and allow it to rebutt, fast, follwed by flush, Half life of 10 sec.
within 1-2 sec, give close to heart as possible

18
Q

Paroxysmal Supraventricular Tachycardia (PSVT)

the in SVT then autocorrect

A

Not a sustained SVT
Sudden onset and termination
Rate: >150
Regularity: reg
P wave: present or abnormally shaped
PR interval: may be normal or prolonged
QRS shape and duration: 0.06 - 0.10

19
Q

Atrial Fibrillation

If unsure how long pt has been in Afib, pt must have work up for a clot ! put pt on anticoag before coverting to NST

A

Multiple ectopic foci-> ineffective atrial ctx
* + irregular ventricular response ( compromised vent. filling + decrease SV)

Poor forward movement of blood
* stagnation -> clots -> stroke, MI, DVT, PE
* Blood thinner !
Rate: Atrial > 350-600 bpm, ventricular (controlled < 100, uncontrolled > 100)
* irreg vent. rhythm ( irreg. R-R)
* unidentifiable P wave ( hunreds) 400:1 ratio
Cause:
80 + y.o, HF, Valvular disease, CHD,CAD, MI, HTN, cardiomypathy, increase TH, pulmon disease, OSA, moderate -> heavy alcohol, post open heart surgery
Hemodynamic Effects
Losse of atrial kick (25% -30% of CO) -> decrease vent. filling -> decrease SV
Thrombus formation ! (risk of CVA , peripheral emboli)
Dementia, increased risk of stroke, premature death

Treatment:
1. rhythm conversion ( cardioversion IF < 48 hr, sychronized cardioversion, heparin)
2. If > 48hrs pt must have anticoagulant b/4 converting to NSR due to risk of emboli
3. Rate control (for uncontrolled) ( ca channel blockers , beta blockers, digoxin, amiodarone

Med: Ibutilide, amiodarone

20
Q

Chads 2 Score

A

Screening criteria to predict stroke in A-Fib
A higher score is assoicated w/ higher risk of embolic stroke
Score: 0-6
0= no treatment or aspirin
1= aspirin or warfarin
2-6= warfarin

21
Q

Anticoagulation A-FIB

A

Heparin (to start) -> then Warfarin (need Qweekly, INR monitored)
Dabigatran (thrombin inhibitor)
Apixaban (factor Xa inhibitor)
Rivaroxaban (“ “)

revisible agent:
Coumadin- Vit. K
Dabigatarn- Idarucizumab
Apixaxaban & rivaroxaban ( adaxxa)

22
Q

Atrial Flutter

A

Atrial tachydysrhythmia w/ reg saw toothed waves
Originates from single ectopic focus in atrium
Associated w/: CAD, HTN, PE, mitral valves disorder, lung disease, drugs - dig, epi
Reg R-R
P waves eat up T wave

Treatment:
Treat underlying causes, electrocardioversion, atrial override pacing
Pharm cardioversion: ibutilide
antidysrhythmics, catheter ablation

23
Q

Ventricular Dysrhythmias

Premature Venticular Contractions

A

Ectopic beat fires before AV node
HR varies, irreg rhythm
QRS: wide, disorted, > 0.12 secs
P wave rarely visible, PR interval = unmeasurable
PVC’s w/ same slope = unifocal
Treatment:
O2, correct cause- electrolyte imbalances, AMI (cardiac outputs)
IV therapy: Beta blockers, ( if not a run of PVC’s) or Amiodarone (potassium blockers) , Lidocaine

Causes:
Caffiene, nicotine, alcohol, ischemia/ infarction, exercise, tachy, hypervolemia, heart failure, digitalis toxicity, hypoxia, acid/base imbalance, electrolyte imbalance - decrease K - marathon runners

24
Q

Ventricular Dysrhthmias

Ventricular Tachycardia

A

1: check carotid pulse

unable to detemine atrial rate
vent. rate: 100-250 bpm
vent. rhythm = reg
no PR interval
QRS > 0.12 secs

Causes:
ACS, tricyclic OD, dig toxicity, cocaine abuse, mitral valve prolapse, acid-base imbalances, trauma

#2: call code (no pulse)
#3: CPR/defibrillate

Pulse present, unstable SBP < 100, HR > 150
* O2, IV access , amiodarone, cardioversion (sedate pt if conscious), pre-prodcedure sedation ( if awake and time permits)

Pulse present, stable, SBP > 100, HR >150
* Amiodarone, lidocaine

3-5 mins epi amodarone

Pulseless VT: START CPR/Defib

25
Q

Ventricular Dysrhythmias

Torsade DE Pointes

Polymorphic V TACH

A

Unable to determine atrial rate
vent. rate 100-250
irreg venticular rhythm
P wave, PR = nonexistant
QRS: spindle node pattern

Magnesium Sulfate for prolonged QT interval, 1-2 grams diluted in 10 ml

26
Q

Ventricular Dysrhythmias

Ventricular Fibrillation

A

irregular waveforms of varying shapes and amplitudes
multiple ectopic foci firing
no CO! quivering (lethal)

Treatment:
1. assess pt
2. CPR + defibrillation (ACL’s meds)
3. Intubation (airway and correct imbalance)

Causes:
1. V TACH -> V Fib
2. increase sym nervous system stim, vagal stim, electrolyte imbalances, electrocution, ACS, HF, meds

27
Q

Ventricular Dysrhythmias

Asystole

A

Pulseless, no depolarization
Can’t shock
Interventions:
assess pt, ABCs
Check a second lead
immediate CPR
O2, IV access, pacing , meds

28
Q

Pulseless Electrical Activity (PEA)

A

EKGs shows a little electrical activity, but pt w/ no pulse
poor prognosis
Can’t shock ( no enough electrical activity)
CPR, O2
causes: severe hypovolemia, hypoxia, MI, tension pnemo, cardiac tamponade, massive PE

might see a slow hr 40-50

29
Q

6 H’s and T’s

A

Hyperkalemia Tamponade (cardiac)
Hypoxia Tension pneumothorax
Hypothemia Thrombosis (pulm embolus)
Hydrogen ion access (acidosis) Thrombosis (MI)
Hypovolemia Toxins and Trauma
Hypoglycemia

30
Q

Heart Blocks

A

Causes of AV Blocks
Temporary: MI, Dig Toxicity, Myocarditis, Ca Channel Blocker, Beta Blockers, Cardiac surgery
Permanent: Aging, congential abnorm, MI, Cardiac surgery, Cardiomyopathy

31
Q

Heart Block

First Degree AV Block

PR interval is prolonged

A

conduction does occur, it just take longer ( least dangerous)
PR interval > 0.20 sec
Treatment:
treat underlying casues ( reduces med dose or hold)
observe for progression of block

32
Q

Heart block

Second Degree Type 1 AV Block

AKA: Mobitz Type 1

A
  • Each successive impulse from the SA node is delayed slightly longer than the previous impulse
    (pattern continues impulse to vent. fails, then cycle repeats)
  • Atrial rhythm= norm ( SA node unaffected)
  • PR interval get longer until P wave fails to conduct to ventricles ( vent rhythm = irreg)
  • usually asymptomatic (otherwise, low CO s/s: hypoTN, light-headed
  • Asymptomatic: no treatment
  • Symptomatic: atropine, temporary pacemaker
33
Q

Heart Block

Second Degree Type 2 AV Block

AKA: Mobitz type 2

A

Occasional impulses from SA node fail to conduct to the ventricles
* PR interval remains the same
* consistent AV node conduction
* Occasional dropped beat

Problematic b/c slower/ abn ventricular rate -> decrease CO

Symptoms: hypotensive, light-headed, chest pain, palpitations

Treatment: Atropine, dopamine, epi, premanent pacemaker

34
Q

Heart Block

Third Degree AV Block

AKA: Complete Heart Block

A

Impulse from atria are completely blocked at the AV node -> cannot be conducted to the ventricles
* Atrial/ SA node rate = 60-100
* Ventricular/ AV node rate = 40-60
* Purkinje Fibers rate = 20-40

Strip appearance: lots of P waves laid independtly over a strip of QRS:
* P wave does not conduct following QRS
* Some P waves are burried in QRS or T’s
* P-P = Reg
* R-R = Reg

Very Symptomatic: Severe fatigue, dyspnea, chest pain, change in mental status, hypotension, pallor, bradycardia

Treatment: Atropine, dopamine, epi, pacemaker

35
Q

Artifact

A

No rhythm that is basline, usually w/ pt that have hairy chest.

36
Q

Conduction System

A

SA Node -> AV Node -> Bundle of HIS -> Bundle Branches -> Purkinje Fibers

37
Q

Dysrhythmias

A

Abnormal conductions of the heart + cardiac rhythm

Dysrhythmias does not equal abnorm heart rate

NURS 420 (10 decks)

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