Med/Surg 2: Cardiac Strips
ventricular fibrillation (VF); rhythm can occur in acute MI, myocardial ischemia, heart failure, and cardiomyopathy. Can occur during a cardiac pacing procedure or a cardiac cath procedure if the catheter stimulates the ventricle in that way. Also associated with occuring after thrombolytic therapy, electric shock, hyperkalemia, hypoxemia, acidosis, and drug toxicity.
Interpretation: Causes:
6 Hs: hypovolemia, hypoxia, excess H+ (metabolic acidosis), hyperkalemia/hypokalemia, hypoglycemia, hypothermia, 6 Ts: toxins (e.g., drug overdose), cardiac tamponade, 2 thrombosis (e.g., MI, pulmonary embolus), tension pneumothorax, and trauma.
Causes of PEA (pulseless electrical activity)
ventricular tachycardia (polymorphic, Torsades de pointes); caused by a stimulus coming from ectopic focus or foci in the ventricles and the ventricles take over as pacemaker of the heart. Could be caused by electrolyte imbalance, such as low potassium, or ischemia.
Interpretation: Causes:
Junctional escape rhythm Caused when the SA node fails to fire, so the AV node becomes the pacemaker. Caused by CAD, HF, cardiomyopathy, electrolyte imbalance, inferior MI, rheumatic heart disease, also caused by drug toxicity from digoxin, nicotine, amphetamines, caffeine Symptoms: may reduce cardiac output making the patient hemodynamically unstable (hypotension etc)
Interpretation: Causes: Symptoms:
asystole; usually result of advanced cardiac disease, a severe conduction disturbance or end-stage heart failure
Interpretation: Causes: usually a result of what 3 things
ventricular fibrillation (VF); rhythm is irregular and chaotic, the waves are irregular and vary in shape and amplitude. The ventricles are quivering with no effective contraction nor cardiac output.
Interpretation: Describe rhythm:
STEMI--myocardial injury--ST segment elevation, Q and T wave inversion Can be reversible if resolve in 20 minutes, but could result in an infarct with blood flow stopping to the cardiac muscle
Interpretation: Meaning:
nSTEMI--ischemia with ST depression, T wave inversion This is reversible
Interpretation: Meaning:
atrial fibrillation; symptoms include decreased cardiac output, clots, emboli, stoke, (may have no symptoms), palpitations, SOB, fatigue, patient usually presents with an irregular pulse, very prevalence in older population **high risk for blood clots; this is most common, clinically significant dysrhythmia in regards to morbidity and mortality rates and economic impact
Interpretation: Symptoms:
atrial flutter; HR of 200-350 bpm, palpitations, SOB, dizziness, decreased CO, a thrombus may form...**Beware risk of stroke & heart failure
Interpretation: Symptoms:
premature atrial contraction (PAC); palpitations, sense heart "skipped a beat"
Interpretation: Symptoms:
premature ventricular contractions (PVC); asymptomatic in a healthy heart, symptoms in diseased heart include angina, HF, pulse deficit, palpitations, lump in throat
Interpretation: Symptoms:
sinus bradycardia; athlete would be asymptomatic; symptoms may include pale/cool skin, hypotension, weakness, angina, dizziness, syncope, confusion/disorientation, SOB
Interpretation: Symptoms:
sinus tachycardia; symptoms include dizziness, decreased cardiac output, dyspnea, SOB, hypotension, increased HR, angina/MI with CAD, anxiety, palpitations, syncope, AIR HUNGRY
Interpretation: Symptoms:
supraventricular tachycardia (SVT); symptoms include increased heart rate (often over 180 bpm), rapid pulse, hypotension from decreased stroke volume and CO, palpitations, dyspnea, SOB, angina, dizzy/faint, anxiety *can lead to congestive heart failure
Interpretation: Symptoms:
ventricular fibrillation (VF) to asystole; symptoms of asystole include unresponsive, pulseless, apneic **Lethal, requires immediate treatment
Interpretation: Symptoms:
ventricular fibrillation (VF); patient is unresponsive, pulseless, apneic state (suspension of breathing). *will not recover if not rapidly treated
Interpretation: Symptoms:
ventricular tachycardia (monophoric); stable: patient has a pulse, nonstable: patient is pulseless. Will see a severe decrease in cardiac output with symptoms of hypotension, pulmonary edema, decreased cerebral blood flow, cardiopulmonary arrest, loss of conciousness, rapid or absent pulse, syncope, angina. *VF may develop
Interpretation: Symptoms:
2nd degree AV heart block type 2, Mobitz II Symptoms include effects from decreased cardiac output: hypotension & myocardial ischemia Causes are rheumatic heart disease, CAD, anterior MI, & drug toxicity
Interpretation: Symptoms: Cause:
3rd degree AV heart block, complete heart block Symptoms stem from decreased cardiac output: ischemia, HF, shock, syncope, severe bradycardia, asystole can happen too Causes: severe heart disease (CAD, MI, myocarditis, cardiomyopathy, amyloidosis, scleroderma) & drugs (digoxin, beta blockers, and calcium channel blockers)
Interpretation: Symptoms: Causes:
2nd degree AV heart block, type 1 (Mobitz I or Wenckebach); May be asymptomatic or symptomatic with symptoms from bradycardia--hypotension, heart failure, or shock. This heart block is usually transient and well tolerated however. But it could be a warning sign of a more serious AV disturbance coming. Treated with atropine to increase heart rate or a temporary pacemaker if symptomatic (especially if patient had an MI. If the patient is asymptomatic the rhythm is closely observed, with a transcutaneous pacemaker on standby.
Interpretation: Symptoms: Treatment:
1st degree AV heart block; no treatment needed, but could continue to monitor for any new changes in rhythm & could potentially change causative agents such as fixing electrolyte imbalance or discontinuing a drug such as a beta blocker
Interpretation: Treatment:
The electrical activity on the ECG is organized, may even look normal!!! But look at your patient...they do not have a pulse. The ventricles are not moving. Just electrical current going through but it doesn't cause anything to move.
Describe what you would see on an EKG with PEA (pulseless electrical activity)
All these strips are worrisome. Once you start seeing two or more PVCs on a 6 second strip, get worried. 3+ PVCs in a row defines VENTRICULAR TACHYCARDIA. This is an ominous sign. It is now life-threatening because of decreased CO and the possible development of ventricular fibrillation, which is lethal. R-on-T phenomenon occurs when a PVC falls on the T wave of a preceding beat. This is especially dangerous because the PVC is firing during the relative refractory phase of ventricular repolarization. Excitability of the cardiac cells increases during this time, and the risk for the PVC to start VT or ventricular fibrillation (VF) is great. (Corrine explained this as a heart just going nuts, it will supersede everything else the heart is doing and just fire)
Discuss your concerns
3rd degree AV heart block, complete heart block Will put in a transcutaneous pacemaker until a temporary transvenous pacemaker can be inserted. Patient will need a permanent pacemaker ASAP. Temporary medications are used to increase heart rate and support blood pressure: atropine, dopamine, epinephrine.
Interpretation: Treatment:
Junctional rhythm Symptoms with junctional escape: atropine If drug toxicity: stop drug If not digitalis toxicity, can use beta blockers, calcium channel blockers, amiodarone for rate control DO NOT USE CARDIOVERSION
Interpretation: Treatment:
If the R is far from P, then you have a FIRST DEGREE. Longer, longer, longer, droP! Then you have a WENKEBACH. If some Ps don't get through, then you have MOBITZ II. If Ps and Qs don't agree, then you have a THIRD DEGREE.
Heart Block Poem
asystole; do CPR and then stimulate the heart with drugs such as epi/vasopressin/bicarb before you shock. You must get some wave forms before shocking.
Interpretation: Treatment:
artifact-loose electrodes
Interpretation:
artifact-muscle tremor
Interpretation:
2nd degree AV heart block type 2, Mobitz II Indicates the need for a permanent pacemaker if the patient is symptomatic. Patient may first receive a temporary pacemaker.
Interpretation: Treatment:
1st degree AV heart block; caused by MI, CAD, rheumatic fever, hyperthyroidism, electrolyte imbalance (low K+), vagal stimulation, or drugs like digoxin, beta blockers, calcium channel blockers, flecainide. *note this is asymptomatic
Interpretation: Causes:
2nd degree AV heart block, type 1 (Mobitz I or Wenckebach); may be a result from digoxin, beta blockers, CAD, or diseases that slow AV conduction. It is usually the result of myocardial ischemia or inferior MI.
Interpretation: Causes:
atrial fibrillation; caused by multiple ectopic foci in atria, may be caused by alcohol intoxication, caffeine use, electrolyte disturbance, stress, cardiac surgery; assocaited with CAD, valvular heart disease, cardiomopathy, HTN, HF, pericarditis
Interpretation: Causes:
atrial flutter; caused by drugs such as digoxin, quinidine, and epinephrine; associated with plenty of diseases including CAD, HTN, mitral valve disorders, pulmonary embolus, chornic lung disease, corpulmonale, cardiomyopathy, hyperthyroidism **Risk of stroke & heart failure
Interpretation: Causes:
premature atrial contraction (PAC); caused by emotional stress, physical fatigue, caffeine, tobacco, alcohol, hypoxia, electrolyte imbalance; associated with hyperthyroidism, COPD, CAD, & vascular disease
Interpretation: Causes:
premature ventricular contractions (PVC); caused by stimulants (caffeine, nicotine, epinephrine, isoproterenol, digoxin), alcohol, electrolyte imbalance (K+), hypoxia, fever, exercise, emotional stress, infection; associated with MI, mitral valve prolapse, HF, CAD, lung disease
Interpretation: Causes:
sinus bradycardia; may be caused by being asleep, an athlete, carotid sinus massage, Valsalva maneuver, hypothermia, increased intraocular pressure, vagal stimulation, or medications such as beta-blockers (metoprolol, propranolol, atenolol) or calcium channel blockers (amlodipine, verapamil); associated with hypothyroidism, hypoglycemia, and inferior myocardial infarction
Interpretation: Causes:
sinus tachycardia; causes may include exercise, fever, pain, hypotension, hypovolemia, hypoxia, hypoglycemia, anemia, MI, heart failure, anxiety, or medications such as epi, norepi, atropine, caffeine, theophylline, hydralazine, sudafed, asthma inhaler; associated with hyperthyroidism, anemia, hypoglycemia, heart failure **notice all the "hypos"
Interpretation: Causes:
supraventricular tachycardia (SVT); caused by dysrhythmia starting from an ectopic focus above the bundle of His, AV block, overexertion, emotional stress, deep inspiration, stimulants such as caffeine & tobacco, or electrolyte imbalance; associated with Wolff-Parkinson White syndrome, rheumatic heart disease, digitalis toxicity, CAD, cor pulmonale
Interpretation: Causes:
atrial fibrillation; main goal is to decrease ventricular response to less than 100 bpm & obtain a normal sinus rhythm--can use calcium channel blocker, beta blocker, dronedarone, or digoxin; second goal may be electrical or chemical cardioversion but MUST do warfarin therapy for 3-4 weeks if a fib. over 48 hours, might also do radiofrequency catheter ablation to destroy the ectopic tissue, and may also do a MAZE procedure (incisions made in atria & cold therapy stops signals, creates scar tissue)
Interpretation: Treatment:
atrial flutter; primary goal of treatment is to slow the ventricular response & rate to the flutter by using calcium channel blockers and beta blockers, may do electrical cardioversion (emergency or electively), may use anti-dysrhythmia drugs (amiodarone, ibutilide), book said a treatment of choice is radio-frequency catheter ablation (destroys tissue causing dysrhythmia in the atria), and COUMADIN to prevent stroke
Interpretation: Treatment:
normal sinus rhythm; no treatment needed
Interpretation: Treatment:
premature atrial contraction (PAC); *not clinically significant, withdraw source of stress & stimulation (such as caffine, sympathomimetic drugs, tobacco), can use beta-blockers
Interpretation: Treatment:
premature ventricular contractions (PVC); treat underlying cause (hypoxia with O2 therapy, hypokalemia with potassium etc); and then drug therapy such as beta-blockers, amiodarone, and lidocaine
Interpretation: Treatment:
sinus bradycardia; treat with atropine IV (increases CO & HR), transcutaneous pacing, transvenous pacing, permanent pacemaker, dopamine or epinephrine infusion, or withhold/discontinue/reduce drug dose
Interpretation: Treatment:
sinus tachycardia; treat underlying cause (pain management, antipyretics, fluids, etc.), beta-blockers (metoprolol), calcium-channel blockers (diltiazem), synchronized cardioversion, vagal maneuvers (valsalva maneuver, carotid sinus massage)
Interpretation: Treatment:
supraventricular tachycardia (SVT); IV adenosine (drug of choice), vagal stimulation (valsalva manuever, cartoid massage), beta blockers, calcium channel blockers, amiodarone, synchronized cardioversion (if pt hemodynamically unstable), or cardiac ablation (destroys area of heart causing rapid heart beat)
Interpretation: Treatment:
ventricular fibrillation (VF); treat immediately with CPR & ACLS (advanced cardiac life support) with defibrillation and definitive drug therapy including epinephrine and vasopressin
Interpretation: Treatment:
ventricular tachycardia (monophoric); VT with a pulse 1) drug therapy---identify and treat cause (oxygen, potassium for example), if monophoric give IV procainamide, sotalol or amiodarone, if Torsade de pointes give IV magnesium, isoproternol, phenytoin, and discontinue drugs that prolong the QT interval. 2) synchronized cardioversion. VT without a pulse 1) CPR and rapid defibrillation, 2) Vasopressors (epinephrine) & antidysrhythmics (amiodarone) Long term treatment: ablation or implantable cardioverter defibrillator
Interpretation: Treatment:
This is PEA, pulseless electrical activity. A heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not.
What does this mean??
pulseless electrical activity (PEA)
Name the most common dysrhythmia seen after debrillation
#1 dysrhythmia in pediatrics
SVT! Treatment is ice on their face, ice on their chest, "they just ice them"
Begins with CPR followed by drug therapy such as epinephrine and intubation. The underlying cause must be quickly identified and treated. CORRINE SAID CALL A CODE. You can shock them if they get into v-tach or v-fib
Treatment for PEA (pulseless electrical activity)
