Cardiovascular

1 small box is _____ 1 Large box is _____ 5 large boxes is equal to ____ 30 large boxes is equal to _____ Waveforms that move up the paper is called _____

0.04 seconds 0.20 seconds 1 second 6 seconds positive deflection

Sinus Tach: Clinical Symptoms - Heart rate ____ regular rhythm P wave: _____ PR interval: _____ Clinical presentation dependent on _______ May include: ______

100-150 only 1 precedes each QRS 0.12-0.20 rate and patient tolerance of rate dizziness, hypotension, angina d/t increased myocardial oxygen consumption

Describe dopamine tx for bradycardia

2nd line treatment only if atropine is not effective dosage is 2-10 mcg/kg/min infusion Increases cardiac output, increases BP and low doses increase urine output (called the renal dose)

Ventricular Tachycardia: Run of _____ Monomorphic, polymorphic, sustained, and nonsustained. Considered ________ Sustained - may be pulsatile or pulseless ALWAYS CHECK PT FOR PULSE FIRST

3 or more PVCs 150-250 bpm. Regular rhythm life threatening due to decreased CO and the possibility of deterioration ventricular fibrillation

Junctional Rhythm Accelerated Junctional Rhythm Junctional Tachycardia: Junctional rhythm: _____ Accelerated junctional rhythm: _____ Junctional Tachycardia: ______ Digitalis toxicity If symptomatic: decreased CO due to slow rate - treat with _______

40-60 bpm 60-100 bpm 100-250 bpm atropine, verapamil, propanolol, beta blockers or pacemaker insertion

Describe the normal sinus rhythm

60-100 bpm P to P interval is the same R to R interval is the same PR and QRS intervals normal Follows normal conduction pattern

Sinus Brady: Sinus node fires ______ Same criteria as normal sinus rhythm Present in normal or diseased heart Presentation: _____ Treatment: ______

<60 bpm decreased cardiac output treat IF symptomatic: Atropine, Epinephrine, Cardiac pacing, Dopamine (2-10 mcg/kg/min)

Sinus Tachy: Heart rate ______ Same NSR criteria Related to a clinical cause

>100 bpm

Supraventricular Tachycardia (SVT): Paroxysmal - abrupt onset and termination Rate - ______ Ectopic focus ______ _____ may trigger _____ may be misshapen or hidden in QRS complex _____ QRS _____ - does not change in response ot sleep, crying, exertion, etc.

>150-180 bpm above bifurcation of bundle of His PAC P wave normal regular rhythm

Represents the total absence of ventricular electrical activity No ventricular contraction (CO) occurs because depolarization does not occur Flat line

Asystole

Treatment of PVCs: ______

Based on cause of PVC oxygen therapy for hypoxia Electrolyte replacement Drugs: beta blockers, procainamide, amiodarone, lidocaine

Treatment of Pulseless Electrical Activity: ______

CPR followed by intubation and IV epi Atropine is used if the ventricular rate is slow Epi - also may consider amniodarone treatment is directed toward correction of the underlying cause

Asystole Treatment

CPR with initiation of ACLS measures (intubation, transcutaneous pacing, IV therapy with epi and atropine) Consider amniodarone

Describe the pacemaker for tx of bradycardia

Can be temporary or permanent. External (temporary) Transcutaneous - use the Zoll, set to 60. Generally painful (sedate first) Transvenous: central venous access. generally femoral sight For the patient with symptomatic brady with signs of poor perfusion, transcutaneous pacing is the tx of choice

SVT: Clinical Significance How is the patient responding?

Decreased cardiac output palpitations hypotension dyspnea angina

Pulseless Electrical Activity (PEA) Describe

Electrical activity observed on the ECG There is no mechanical activity of the ventricles and the patient has no pulse

Sinus Tach Facts: Occurs as a result of overly rapid firing by the SA node Usually a rapid contraction in reponse to a condition of a NORMAL heart May include: drugs, disease, pain, _____, excitement, caffeine Characterized by: Normal resting heart rate, but exaggerated postural sinus tachycardia with or without orthostatic hypotension (compensated) Decreased cardiac output

FEVER

Describe the adenosine and 2 syringe method

Give 6 mg rapid IV push of adenosine followed by immediate 20 mL NS bolus If no conversion in 1-2 minutes, give 12 mg rapid IV push followed by NS bolus Adenosine should be given as quick as possible Side effects may include flushing, chest pain/tightness, brief asystole or bradycardia

Describe 2nd degree AV block Type 1, Mobitz 1, Wenckebach

Gradual lengthening of the PR interval due to prolonged AV conduction time. Eventually a QRS is dropped. Usually block occurs at AV node, but can ocur in His-Purkinje system Longer, longer, longer, DROP, then you have a Wenckebach (Missing 1 QRS, you wink with 1 eye)

Beta Blockers reduce _____ CCBs decrease _____ Antipyretics to _____ Analgesics to _____

HR and myocardia oxygen consumption automaticity of SA node (verapamil) treat fever treat pain

Sinus Brady Clinical Symptoms: ________

Hypotension Pale, cool skin Weakness Angina Dizziness or syncope Confusion or disorientation, depressed LOC Shortness of breath

2nd Degree AV Block (Type 1, Mobitz 1, Wenckebach) Treatment includes ________ FYI: Distinguishing characteristic is that the PR interval progressively lengthens and eventually drops a beat

If symptomatic: atropine or a temporary pacemaker Asymptomatic: monitor with a transcutaneous pacemaker on standby Symptomatic bradycardia is more likely with one or more of the following: hypotension, HF, shock

VFib Continued: Unresponsive, pulseless and apneic state If not treated rapidly, death will result. What is treatment?

Immediate initiation of CPR Defibrillation ACLS measures Drug therapy: vasopressors (epi/vasopressin), anti-arrhthmic (amiodarone, lidocaine, magnesium)

SVT: Administer _______

O2 and take slow deep breaths then cough as hard as you can ice water to the face can vagal them too

_____ is affected on the EKG with atria

P wave

_____: conduction through atrium/depolarization _____: impulse time from SA node through AV node _____: conduction through the ventricles. Ventricular depolarization _____: ventricular repolarization ______: time from ventricular depolarization through repolarization _____: early repolarization. Commonly elevated in Acute MI.

P wave PR interval QRS complex T Wave QT interval ST Segment

A flutter ins and Outs: Total disorganization of atrial electrical activity due to multiple ectopic focci resulting in loss of efective atrial contraction _____ non recognizable - wavy irregular baseline can't measure PR interval Rhythm _____ Atrial rate _____ Ventricular rate _____ Most common dysrhythmia Prevelance increases with ____

P wave irregular >350 varies age

What is primary treatment of sick sinus?

Pacemaker

V Tach Treatment - Pulsatile

Precipitating causes must be identified and treated Monomorphic VT Hemodynaically stable + preseved LV function: IV Amiodarone 150 mg/D5W Lidocaine 1-1.5 mg/kg Procainamide (pronestyl) Sotalol (Betapace)

A Flutter Treatment: ____

Primary goal is to slow ventricular response by increasing AV block Drugs to slow HR: calcium channel blockers, B-adrenergic blockers antidysrhythmia drugs to convert atrial flutter to sinus rhythm or to maintain sinus rhythm (amiodarone, propafenone)

2nd Degree AV Block Type 2: Clinical significance - Often progresses to third degree AV block and is associated with a poor prognosis Reduced HR often results in decreased CO with subsequent hypotension and MI Constant P wave but no ______

QRS

Conduction of the Heart: _______: Electrical impulses stimulates and paces heart. Rate of 60-100 bpm. Impulse travels into atria. AV Node: Muscle cells of the atria contract is known as conduction. AV node has a rate of ______. Av node _______ Bundle of His: Next place electrical impulse occurs. From bundle of his, impulse travels to the _____. Electrical stimulation of the muscle cells of the ventricles in turn cause muscle contraction, known as _____ Once cells repolarize and ventricles relax you have _____

SA node 40-60; slows impulse allowing time for atria to contract and the ventricles time to fill (HR slows) bundle branches of the perkinje fibers in the ventricles systole diastole

What do they put A Fib pts on for short term coagulatiaon? Long term?

Short: heparin (IV), lovenox (SC) Coumadin

Non Pharm Treatment for A flutter:

Synchronized cardioversion may be used to convert the atrial flutter to sinus rhythm emergently and electively Radiofrequency catheter ablation can be curative therapy for a flutter - used if constantly in a flutter. Cauterize area of the heart

12 Lead Measurements: 12 electrical views of heart using 10 electrodes Six leads measure electrical forces in the frontal place (leads I, II, III, aVR, aVL, and aVF) Six leads (V1-V6) measure the electrical forces in the horizontal plan (precordial leads) Can help determine electrical axis of heart; atrial and ventricular enlargement; patterns of ischemia, injury or infarction. Prefer the EKG to be in view _____ EKG is taking pictures of all angles of the heart

V2

Treatment for SVT

Vagal maneuvers IV adenosine (always have crash cart in the room) Verapamil If vagal maneuvers and/or drug therapy is ineffective and/or patient becomes hemodynamically unstable, direct current (DC) cardioversion should be used

Sinus Brady Facts - Decreased Cardiac Output is characterized by: ______

Weakness Fatigue Decreased UOP Edema Chest pain Syncope

Atrial Fibrillation: Clinical associations are the same as flutter Often acutely caused by _____

alcohol intoxication caffeine use electrolyte disturbance (potassium and magnesium) cardiac surgery

A FiB: For some patients, conversion to sinus rhythm may be considered Antidysrhthmic drugs for conversion: _______ DC cardioversion may be used to convert atrial fibrillation to normal sinus rhythm If patient has been in a fib for >48 hours, anticoagulation therapy with warfarin is recommended for ________ before cardioversion and _____ after succesful cardioversion

amiodarone, propafenone 3-4 weeks before 4-6 weeks after

Junctional Dysrhythmias: Originates in the ______ _____ has failed to fire or impulse has been blocked at the _____ Rate _____ may or may not have a _____ Understand that the AV node has _______. The SA node has failed to fire or the AV node is going too fast and takes over Can see that the ______

area of the AV node SA node; AV node 40-60 BPM P wave taken over as the primary pacemaker p wave merges into the QRS

Maze Procedure: The maze procedure is surgery performed to treat _____. During the procedure, a number of incisions are made on the left and right atrium to form scar tissue, which does not conduct electricity and disrupts the path of abnormal electrical impulses. The scare tissue also prevents erratic electrical signals from recurring. After the incisions are made, the atrium is sew together to allow it to hold blood and contract to push blood into the ventricle.

atrial fibrillation

Atrial Flutter Clinical Significance: High ventricular rates and loss of the ______ can _____ Risk for ______

atrial kick can decrease CO and precipitate HF, angina stroke due to risk of thrombus formation in the atria (blood is pooling in atria without kicking into ventricles) C/O chest pain if first time

A flutter usually occurs with _______: CAD Alcoholism Pericarditis Hypertension Mitral valve disorders Pulmonary embolus Chronic lung disease Cardiomyopathy Hyperthyroidism Drugs: digoxin, quinidine, epinephrine

atrial stretching

If someone has A fib, they will stay on a _______

blood thinner

Describe Epi for bradycardia

can be used as an equal alternative to dopamine when atropine is not effective. Dosage is 2-10 mcg/min

VTach Treatment Pulseless: Life threatening situation ______

cardiopulmonary resuscitation (CPR) and rapid defibrillation Epinephrine or Vasopressin if defibrillation is unsuccessful Consider amniodarone or lidocaine

A Fib: Radiofrequency catheter ablation Maze procedure Modifications to the maze procedure: use of ____ and _____ The MAZE proceudre is an "open heart" procedure requiring cardiopulmonary bypass. Accordingly, it carries risk of stroke, kidney failure, other organ fialure and death. Success rates vary by center, but are generally reported in the range of 80-100%

cold (cryoablation) and use of heat (high-intensity ultrasound)

Describe a premature atrial contraction (PAC)

contraction originating from ectopic focus in atrium in location other than SA node Travels across atria by abnormal pathway, creating distorted P wave May be stopped, delayed, or conducted normally at the AV node

Describe PVCs

contraction originating in ectopic focus of the ventricle

A Fib: Can result in _____ ______ may form

decrease in CO due to ineffective atrial contractions (loss of atrial kick) and rapid ventricular response thrombi may form as a result of blood stasis - embolus may develop and travel to the brain, causing a stroke

Goal of A fib treatment is ______

decrease ventricular response and prevent embolic stroke

A Flutter Medication Treatments: B Adrenergic blockers Dilitizaem Propafenone Amiodarone Flecainide Clonidine Meds to _______

decrease ventricular response and slow AV block

What are drugs for A Fib rate control?

digoxin, B-adrenergic blockers, calcium channel blockers

Describe the 1st degree AV block

every impulse is conducted to the ventricles, but duration of AV conduction is prolonged (>0.20) Each P wave has a QRS PR interval is constant **An increase in the time it takes for impulses from the atrium to reach the ventricles. Patients usually have no symptoms, seen in athletes

PVC's Continued: PVCs are ____ which occur from an ectopic focus on the ventricle wall This focus is usually below the _______ In the normal person, these may be caused by smoking, alcohol, or coffee ingestion. They usually are rare and inconsequential in normal persons. PVCs may also, and more frequently, occur as the result of an ______ This irritable spot on the myocardium sends out a powerful electrical impulse which spreads across the ventricles, causing them to contract out of proper sequence. In other words, the ventricles contract before they have had a chance to completely fill with blood from the contraction of the atria. In heart disease, PVCs may decrease _____ ______ must be monitored.

extra beats bifurcation of the bundle of his MI or due to arteriosclerotic heart disease CO and precipitate angina and HF Patient's response to PVCs

Sick Sinus Symptoms: Most people initially have few or no symptoms. In some cases, symptoms may come and go When they do occur, sick sinus symptoms may include: _______

fatigue slower than normal pulse (bradycardia) dizziness or lightheadedness fainting or near fainting SOB chest pains palpitations Many of these signs and symptoms are caused by reduced blood flow to the brain when the heart beats too fast or too slow

Supraventricular Tachycardia: Clinical Associations Paroxysmal SVT is a regular, fast heart rate that begins and ends suddenly and originates in _____ Most people have _______ Episoes can often be stopped by maneuvers that stimulate the _____ Sometimes, people are given drugs to stop the episode Paroxysmal SVT is most common among ______

heart tisue other than the ventricles uncomfortable palpitations, shortness of breath, and chest pain vagus nerve, which slows the heart rate young people and is more unpleasant than dangerous

Meds for A flutter: _____

heparin coumadin eloquis Anything for clots

Normal Sinus Rhythm facts: With normal sinus rhythm, beats will continue to be regular without changes Will not change when patient has ______ Can range anywhere from ________

inspiration or non-strenuous movement 60-100 beats per minute

Sick Sinus Syndrome: Results in _______ May have coexisting rapid _____ May require ______

marked sinus bradycardia, SA block or sinus arrest atrial dysrhythmias such as atrial flutter or atrial fibrillation that alternate with SA depression implanted pacemaker to control bradycardia

2nd Degree AV Block (Type 1, Mobitz 1, Wenckebach) Clinical Associations: Drugs - Digoxin, beta blockers CAD and other diseases that slow AV conduction Clinical significance: Usually a result of ______ Almost always transient and well tolerated May be a warning signal of a more serious AV conduction disturbance

myocardial ischemia or infarction

Atrial Flutter Clinical Symptoms include _____

palpitations decreased cardiac output and CHF

2nd Degree AV Block Type 2: Treatment If symptomatic, ________

permanent pacemaker If one cannot be inserted, temporary transvenous or transcutaneous pacemaker works

Ventricular Fibrillation: Emergent Situation!!!! Rapid, ineffective _____ Severe derangement of the heart rhythm characterized on ECG by _______ No pulse No effective contraction or CO occurs

quivering of ventricles irregular waveforms, varying contour and amplitude

Atrial Flutter: Atrial tachydysrhytmia - recurring, regular _______ Atrial rate of ____ Originates from a ____ Ventricular rate may be regular or irregular - may conduct in a 1:1, 2:1 or 4:1 pattern QRS is _____

saw tooth shaped flutter waves 250-350 bpm (AV node can only handle 200 - conducts every other one) single ectopic focus normal

PAC Treatment: _________ Depends on symptoms - B Adrenergic blockers Dilitazem (Cardizem) Propafenone (Rhythmol) Amiodarone (Cardaron/Pacerone) Flecainide (Tambacor) Clonidine (Catapres) Magnesium Reduce or eliminate caffeine

slow conduction through the AV node

Monomorphic Vtach: With monomorphic VT all of the QRS waves will be ______. Each ventricular impulse is being generated from the same place in the ventricles thus all of the QRS waves look the same. Treatment of monomorphic VT is _______

symmetrical dependent upon whether the patient is stable or unstable. Expert consultation is always advised, and if unstable, the ACLS tachycardia algorithm should be followed

Describe Atropine for tx of bradycardia

the first drug of choice or symptomatic bradycardia. Dose in the bradycardia ACLS algorithm is 0.5 mg IV push and may repeat up to a total dose of 3 mg Given as quick IV push, considered emergency drug in the ICU (don't need to order)

A person with sick sinus syndrome may have heart rhythms that are _______. Sick sinus syndrome is relatively uncommon, but the risk of developing sick sinus increases with age. Can't document sinus rhythm or tach in these patients. All over the board.

too fast, too slow, punctuated by long pauses - or an alternating combo of all of these rhythm problems.

Sinus Tach Treatment: Treatment is determined by ______ What do you treat with?

underlying cause (treat first) Beta blockers Calcium channel blockers Antipyretics Analgesics

An elevated T wave can indicate _____

unstable potassium, or an MI if ST segment involved

Torsades De Pointes: Abnormal _____ Acquired or congenital Preceded by a _____ Immediate treatment required Check for any _____ _______ med treatment

vent repolarization prolonged QT interval electrolyte imbalance magnesium or isoproterenol (Isuprel)_

Prematrue Ventricular Contractions (PVC's): Premature occurence of a _____ QRS complex May be followed by a _____ P wave _____ Multifocal, unifocal, ventricular bigeminy, ventricular trigeminy, couplets, triplets, R on T phenomena

wide and distorted (aberrant) compensatory pause usually not visible

Polymorphic V Tach: With polymorphic ventricular tachycardia, the QRS waves ________. This is because each ventricular impulse can be generated from a different location. On the rhythm strip, the _______ One commonly seen type of polymorphic ventricular tachycardia is _____. These are advanced rhythms which require additional expertise and expert consulation is advised Drugs of choice: _______ If polymorphic VT is stable the ACLS tachycardia algorithm should be used to treat the patient. Unstable polymorphic ventricular tachycardia is treated with _____

will not be symmetrical QRS might be somewhat taller or wider beta blockers, lidocaine, amioderone, and MAGNESIUM unsynchronized shocks (defibrillation)