Exam 2 Heart Rhythms Flashcards
Order of the heart rhythm
P-QRS-T-U
P wave
Atrial Depolarization
P-R Interval Start
Beginning of P to beginning of QRS
P-R Interval Time
0.12 to 0.20 second
Vertical small box
1mm (0.1 mV)
Vertical Large box
5 mm (0.5 mV)
Horizontal small box
.04 sec (40 m sec)
Horizontal large box
.2 sec (200 m sec)
QRS Complex
Ventricular Depolarization
QRS Interval start and end
Beginning of QRS to end of QRS
QRS Interval time
less than or equal to 0.10 seconds (0.06 to 0.10 sec)
T wave
Ventricular repolarization, follows QRS complex
QT Interval start and end
Beginning of Q wave to end of T wave
QT Interval time
0.34 to 0.43 seconds
U wave
Rare, after T wave, indicates Hypokalemia
Isoelectric Line
No electrical activity, straight line, waves upright or downward from isoelectric line
ST Segment start and end
End of QRS to beginning of T wave
ST depression with….
Ischemia
ST elevation with….
Cardiac injury
Six step process of interpretation
- R-R (regularity and rhyme)
- Heart Rate
- P wave?
- P-R interval length
- QRS Complex
- QT Interval length
Sinus Bradycardia Treatment
Oxygen
Stable: Atropine, Dopamine, Epinephrine
Unstable: Pacemaker
Sinus Tachycardia Treatment
Treat cause
-Digoxin, CCB, BB
Sinus Tachycardia Symptoms
None, angina or dyspnea, elderly more sensitive
Premature Atrial Contractions
- Rhythm: PAC interrupts
- HR: per underlying rhythm
- P waves: Early beat, abnormal shape
- P-R interval: Usually normal
- QRS: normal
PAC signs and symptoms
NONE
PAC interventions
None, treat cause, BB (lol)
Atrial Flutter Steps
- Rhythm: Atrial Rhythm regular
- HR: Varies
- P waves: None, only F waves, sawtooth
- P-R: None measurable
- QRS: Normal
Atrial Flutter S&S
Ventricular normal rate: None
Ventricular rapid rate: Palpitations, angina, dyspnea
Atrial Flutter Treatment
- Cardioversion, rapid atrial pacing, ablation
- CCB, BB, Digoxin
Atrial Fibrillation Steps
- Irregularly irregular
- HR: Atrial rate not measurable, Ventricular rate <100 controlled response, >100 rapid ventricular response
- P waves: not identifiable
- P-R: None
- QRS: normal
Atrial fibrillation S and S
Palpitations, Faint radial pulse (decreased SV and CO can lead to left HF)
A fib treatment
- Synchronized cardioversion
- Meds: Digoxin, BB, CCB, Amiodarone or Dronedarone, Warfarin, Ablation, bi-atrial pacing, implantable atrial, defibrillators, maze procedure
Supraventricular Tachycardia (SVT) Steps
- Regular, very rapid
- > 160 bpm
- No P waves
- P-R: Not measurable
- QRS: Normal
SVT S and S
Palpitations, faint radial pulse
SVT treatment
- Synchronized cardioversion
- Medications: Valsalva, Adenosine (6mg, then 12 mg IVP), CCB (diltiazem or verapamil), treat pt symptoms
Junctional rhythms steps
- Regular rhythm
- HR: < 60 (40-60 unless accelerated)
- P waves: may follow QRS, be inverted or absent
- P-R: may not be present
- QRS: Normal
Junctional rhythm treatment
- Few, rare, usually after MI
- No action needed
- Monitor for S and S and keep on telemetry
1st Degree AV block
Slowing of conduction, PR interval prolonged > 0.20 sec
2nd Degree AV block Type 1 (Wenkebach, Mobitz 1)
A progressive prolongation until a QRS is blocked, benign
2nd Degree AV block Type 2 (Mobitz 2, Classic)
More P waves than QRS’s, can deteriorate to no QRS’s=no ventricular activity
3rd Degree AV Block (Complete)
P waves and QRS’s, NO RELATIONSHIP, Ventricular rate slow
Premature Ventricular Contractions (PVC) steps
- PVC interrupts rhythm
- HR: underlying rhythm
- P waves: Absent to PVC
- P-R: None for PVC
- QRS Interval: PVCs > 0.10 seconds
PVC signs and symptoms
Palpitations, fatigue, dizziness, sever dysrhythmias
PVC interventions
- None
- Antidysrhythmics: Amiodarone (Cordarone, Pacerone) and BB
Ventricular Tachycardia Steps
- Regular
- Hr: 150-250 ventricular bpm, slow VT <150 bpm
- P waves: Absent
- P-R: None
- QRS: >0.10
Ventricular Tachycardia Signs and symptoms
Dyspnea, palpitations, light headedness, angina, cardiac arrest
V tachycardia treatments
If Pulseless then:
CPR, Defibrillation, vasopressors, anti-arrhythmics
-Amiodarone, 300 mg IVP, then 1mg/min gtt
-Lidocaine: 1-1.5 mg/kg IVP, then 1-4 mg/min gtt
If stable:
Amiodarone 150 mg over 10 min, monitor on tele
Amiodarone dose for V tachy if pulseless
300 mg IVP, then 1 mg/min gtt
Lidocaine dose for V tachy if pulseless
1-1.5 mg/kg IVP, then 1-4 mg/min gtt
Ventricular fibrillation steps
- Chaotic, extremely irregular
2-5. None
V fib signs and symptoms
Unconscious, No heart sounds, peripheral pulse or BP, respiratory arrest, cyanosis, pupil dilation
V fib Treatment (ACLS Protocol)
Immediate defibrillation
- CPR
- Epinephrine 1 mg, conc 1 to 10,000 IVP
- Amiodarone, Magnesium
- Endotracheal intubation
Asystole
Absence of ventricular activity, occasionally P waves
Asystole signs and symptoms
Unconscious, No heart sounds, peripheral pulses or BP, respiratory arrest, cyanosis, pupil dilation
Do you defib asystole?
NOO!
Asystole interventions
- CPR, Endotracheal intubation
- Epi 1 mg. 1 to 10,000 every 3-5 mins
- Vasopressin
Pacemaker Education
- Incision care
- Take radial pulse
- ID Card
- Avoid magnets and ungrounded appliances and metal detectors
- Periodic pacemaker checks
What wave does synchronized cardioversion sync to?
R waves
Do you sedate for cardioversion?
YES! with Versed
Aminophylline
Bronchodilator, can cause PVCs
Leads II, III, aVF
Inferior MI
Leads V1, V2
Septal
Leads V3, V4
Anterior
Leads I, aVL, V5, V6
Lateral
Drug of choice for Prinzmetal’s angina
Nifedipine (CCB)
and nitrates
Cardiac marker that rises first in response to cardiac damage?
Myoglobin
Cardiac marker that stays present the longest after cardiac injury?
Troponin
What order does blood flow through the valves?
Tricuspid, Pulmonic, Mitral, Aortic
Put the measurements of the cardiac cycle in order
- 0.12-0.2
- 0.6-0.1
- 0.34-0.43
- Varies
Name the conduction pathway
SA node, AV node, Bundle Branches, Purkinje fibers
Follow the blood flow through the heart
Right ventricle, Pulmonary artery, Pulmonary vein, Left ventricle
Beta blocker antidote
IV Glucagon
Calcium channel blockers antidote
Calcium Gluconate IV
Nipride antidote
Sodium thiosulfate
Norepi, dopamine, epi, dobutamine, vasopressin antidote
Phentolamine
Heparin antidote
Protamine sulfate
Warfarin antidote
Vitamin K
Digoxin toxicity signs and symptoms
N/V, vision changes (diplopia, blurred, photophobia, green/yellow halos), bradycardia
Digoxin antidote
Digoxin immune fab (Digibind)
Normal digoxin levels
0.8 to 2.0 ng/mL
Who do we use TTM (therapeutic temperature management) on?
Comatose adults with ROSC (return of spontaneous circulation) after cardiac arrest (Vfib/pulseless VT, “nonshockable”)
TTM temp range
32-36 degrees C
TTM for how long?
24 hours at 32-36 degrees C
Does TTM require sedation?
Yes!
How long during TTM should you passively rewarm?
Over 12 hours once cooling period is complete
Is TTM ever contraindicated?
No
If someone is actively or rapidly warming should they have TTM?
No
Would you rather lose the left or right side of the heart?
Right because the RN can drive it with a pacer
Non modifiable CAD risk factors
Age, gender (more common in men), ethnicity, genetic predisposition and family history
C reactive Protein
Produced by the liver, nonspecific marker of inflammation
Troponin levels
- Elevated 4-6 hours after damage
- Peaks in 10-12 hours
- Remains elevated for 10-14 days
Creatine Kinase (CK)
CK-MB is in cardiac muscles
- Rise 4-6 hours after damage
- Peaks at 12-18 hours
- Normal within 24-36 hours
Myoglobin
Not site specific, indicates damage before CK MB
-Levels rise 1 hour after damage
Blood lipids in cardiac blood studies
- Triglycerides
- Cholesterol
- Phospholipids
Electrocardiogram
Records electrical activity
Echocardiogram
Records motion
-Heart structures, valves, size, shape, position
Cardiac tamponade symptoms (triad)
- Narrow pulse pressure
- JVD
- Muffled heart tones
Hallmark sign of an MI
Chest pain that is sever, immobilizing, and not relieved by interventions
Prinzmental’s Angina
Rare form of chest pain that occurs at rest, usually response to a spasm of the major coronary artery
PQRST method for angina
- Precipitating events
- Quality of pain
- Radiation
- Severity of pain
- Timing
Coronary artery disease (CAD) definition
Coronary arteries become narrow and hardened
Acute Coronary syndrome
Prolonged ischemia to the coronary arteries (STEMI and NSTEMI)
ACS treatments
- Oxygen
- ACE inhibitors (PRIL)
- ARB’s (TAN)
- BB (LOL)
- Diuretics (check electrolytes)
- Inotropes (Glycosides/Digoxin)
- Vasodilators (Nitro)
ACS signs and symptoms
- Angina
- SOB
- Pain in jaw, neck , back
- Dizzy
- Nausea
- Sweating
Acute HF
- Happens suddenly,
- PINK FROTHY SPUTUM
Heart failure signs and symptoms
Weakness, faintness, orthopnea, edema, palpitations, weight gain, irregular heart beat, JVD, crackles/rales
