Complex Health Exam 1
What does a wide QRS typically mean?
- typically originates from the ventricles
What are some s/s of Premature Ventricular Complexes (PVCs)?
-"skipping a beat"
How long is 5 large boxes on EKG paper?
-1 second
What is a straight push?
-1-30 cc total volume -syringe to IV
What are some interventions for stable Ventricular Tachycardia?
-12 lead EKG -adenosine 6mg rapid IVP -antiarrhythmic bolus followed by maintenance fluids
What are the very large bore IV gauges?
-16G (grey) -14G (orange) -not commonly used in regular situations -rapid infusions, trauma, dialysis
What are the large bore IV gauges?
-18G (green) common for blood transfusions
What are the medium IV gauges?
-20G (pink) most common for adult patients
What are the smallest IV gauges?
-24G (yellow) for neonates/frail patients -22g (blue) smallest for adults, commonly for peds
What is an intraosseous vascular access?
-AKA IO -specialized hollow bore needle through the cortex of a bone into the medulliary space -no chest xray needed -"easily performed"
What does Paroxysmal Supraventricular Tachycardia (PSVT) look like?
-AKA Paroxysmal Atrial Tachycardia -regular rhythm, sudden onset and termination -P wave difficult to discern - P to QRS ration is 1:1 or 2:1
What does Torsades de Pointes look like?
-AKA Polymorphic V-Tach -usually associated with prolonged QT interval -the ribbon look
What are some causes of Ventricular Fibrillation?
-CAD to MI -untreated/unsuccessfully treated VT -cardiomyopathy -valvular heart disease -acid-base and electrolyte abnormalities -electrical shock
What are central lines?
-Central Venus Catheters (CVC) or Central Venous Port (CVP) -these can be transduced (monitoring capabilities) -inserted by MDs and mid-level providers only when specially trained -chest x-ray needed after insertion
What is a piggyback?
-IVPB -smaller volumes -usually "up high" and run through the pump and into the maintenance IVF
What information should you have when you call the provider?
-Your name/titele -Patient's name/diagnosis -MDs -Location/unit -Briefly describe what is going on
What is a port?
-a port or port-a-cath -surgically implanted into a patient's large vein located in the chest and directly underneath the skin -patients have a miniature bump on their chest -chest x-ray needed (usually in surgery)
What are some treatments for long-term Paroxysmal Supraventricular Tachycardia (PSVT)?
-ablation therapy
What is a port used for?
-administer frequent IV treatments, nutrition, fluids, chemotherapy, blood transfusions, and/or antibiotics
What are some s/s of sinus bradycardia?
-altered mental status -hypotension -chest discomfort
What are some interventions for atrial fibrillation?
-anticoagulation -rate control > calcium channel blockers, beta-blockers -conversion: anticoagulate/TEE >amiodarone, flecainide >electrical -surgical procedures >LAAO, maze procedure, ablation
Where does an atrial rhythm originate?
-atria
What are the rates for atrial fibrillation?
-atrial 300-600BPM -ventricular 120-200BPM
What is the rate of atrial flutter?
-atrial is 250-400BPM -ventricle is 75-150BPM
What are some interventions for symptomatic sinus bradycardia?
-atropine 0.5mg IV bolus, repeated q3-5 minutes until max dose of 3mg -if ineffective, apply pacing pads to skin for transcutaneous pacing -if ineffective, administer dopamine or epinephrine
What are some causes of a premature atrial complex (PAC)?
-caffeine -alcohol -nicotine -stretched atrial myocardium -anxiety -hypokalemia -hypermetabolic states (EX:pregnancy) -atrial ischemia, injury, or infarction -often seen with sinus tachycardia
What are some causes of Paroxysmal Supraventricular Tachycardia (PSVT)?
-caffeine -nicotine -hypoxemia -stress -not associated with underlying structural heart disease
What are some causes of Premature Ventricular Complexes (PVCs)?
-caffeine, nicotine, alcohol -cardiac ischemia or infarction -increased cardiac workload -digitalis toxicity -hypoxia -acidosis, electrolyte imbalance
When to call a code?
-cardiopulmonary arrest -you cannot maintain an airway -seizures that will not stop after an appropriate amount of time -uncontrolled bleeding of some kind -patient passes out but does not seem to be coming back
When should you call Rapid Response?
-changes in VS -chest pain -major changes in LOC -bleeding
What does Ventricular Fibrillation look like?
-chaotic rate and rhythm -absent P wave, QRS, PR interval
What are some s/s of atrial flutter?
-chest pain -SOB -low BP
What are some interventions for Premature Ventricular Complexes (PVCs)?
-correcting the cause
What are some causes of premature junctional complexes (PJCs)?
-digitalis toxicity -HF -CAD
What are some causes of Junctional Tachycardia?
-digitoxin toxicity (60% of cases) -inferior MI -hypokalemia -open-heart surgery -COPD
What are some s/s of sinus tachycardia?
-dizziness -palpitations -SOB -Nausea -lightheadedness -chest pain -syncope
What does a premature junctional complex look like?
-early P waves, shorter PP interval (sometimes followed by longer PP interval) -irregular rhythm -PR interval short
What is the treatment for Junctional Tachycardia?
-eliminate or treat underlying cause
What are central lines used for?
-giving large volumes -trauma -poor venous access (hard stick patients) -certain surgeries -vasoactive medications -TPN
What are some causes of a Junctional Rhythm?
-hypokalemia -MI -cardiac surgery -digitalis toxicity -sinus node dysfunction -post AV node ablation -side effect of medications
What are some causes of Ventricular Tachycardia?
-hypoxemia -acid-base imbalance -ischemic heart disease -cardiomyopathy -electrolyte imbalances -valvular disease -genetic abnormalities -QT prolongation
What are leads?
-imaginary lines formed between two electrodes -records the voltage shifts as the waves of electrical activity sweep over the heart -each lead provides a different view -appearance of ECG varies based on lead
What are some treatments for unstable Paroxysmal Supraventricular Tachycardia (PSVT)?
-immediate synchronized cardioversion
What are some interventions for unstable Ventricular Tachycardia?
-immediate synchronized cardioversion if available for monomorphic VT
What are some causes of atrial fibrillation?
-increasing age -HTN -diabetes -obesity -valvular heart disease -HF -obstructive sleep apnea -alcohol abuse -hyperthyroidism -MI -smoking -exercise -cardiothoracic surgery -increased pulse pressure -European ancestry -family history
What is intraosseous vascular access used for?
-infusion of medical therapy and laboratory tests -used in ED, trauma, and peds
What do Premature Ventricular Complexes (PVCs) look like?
-irregular rhythm -P wave may or may not be visible -0.12 or longer, bizarre QRS
What are some s/s of a Junctional Rhythm?
-lightheadedness -palpitations -activity intolerance -chest heaviness -neck tightness or pounding -SOB -weakness
What are some causes of sinus bradycardia?
-lower metabolic needs >sleep, athletic training, hypothermia -vagal stimulation >vomiting, suctioning, bowel movements -medications >calcium channel blockers, beta-blockers -other > increased intracranial pressure, coronary artery disease, inferior wall MI, decompensated HF
What are some interventions for Torsades de Pointes?
-magnesium sulfate (IV) -isoproterenol -atrial pacing (shorten QT interval) -antiarrhythmics can be considered, but often ineffective and sometimes harmful
When should you call the provider?
-major changes in your patient's status -changes in vitals -changes in LOC -Bleeding
What are some s/s of atrial fibrillation?
-may be asymptomatic -may experience palpitations and clinical manifestations of HF >SOB, hypotension, dyspnea on exertion, fatigue
What are some s/s of Ventricular Tachycardia?
-may or may not have pulse -hypotension
What does atrial fibrillation look like?
-no discernable P waves, irregular undulating waves are referred to as fibrillatory or f waves -many p waves : 1 QRS -rhythm highly irregular -absent PR interval
How does defibrillation work (compared to cardioversion)?
-not synchronized -for cardiac arrest, VT, VF -higher energy joules -not used for patients who are conscious with a pulse
What is an IV drip?
-on a pump at a very controlled rate
What are some s/s of premature atrial complexes (PACs)?
-patient may say "my heart skipped a beat) -a pulse deficit (a difference between apical and radial pulse) may exist
What are the difference IV routes?
-peripheral intravenous lines -central line -peripherally inserted central catheter (PICC) -a port (or port-a-cath) -Intraosseous (IO) vascular access
What are PICC lines?
-peripherally inserted central catheter line -a thin, soft, long catheter that is inserted into a vein in the arm, leg, or neck -the tip of catheter sits in a large vessel -only performed by trained professionals like RNs/invasive radiologists -usually no chest x-ray is needed since it is done under fluoroscopy
What are some causes of sinus tachycardia?
-physiological >acute blood loss, anemia, shock, hypervolemia, hypovolemia, HF, pain, hypermetabolic states, fever, exercises -Psychological stress -medications >cold meds (pseudoephedrine, NSAIDs), bronchodilators (albuterol), ADHD (Ritalin, Adderall), antidepressants (Cymbalta), thyroid meds (synthroid), antibiotics (zithromax, levaquin) -stimulants >caffeine, nicotine -illicit drugs >amphetamines, cocaine, ecstasy -autonomic dysfunction >POTS
What are some s/s of Premature Junctional Complexes (PJCs)?
-rarely produces symptoms
What does Junctional Tachycardia look like?
-regular rhythm -P wave can be absent, inverted, or before/after QRS
What does a Junctional Rhythm look like?
-regular rhythm -P waves may be absent, before/after QRS, or inverted - 1:0 or 1:1 P to QRS
What does atrial flutter look like?
-regular rhythm -saw-toothed P waves, referred to as F waves -P to QRS ratio is either 2:1, 3:1, or 4:1
What does a premature atrial complex (PAC) look like?
-rhythm irregular due to early P waves, creating a PP interval that is shorter -not necessarily an extra P, but an early one
What are some interventions for Premature Junctional Complexes (PJCs)
-same as PACs -treat the underlying cause
What are some interventions for a symptomatic Junctional Rhythm?
-same as bradycardia -atropine -emergency pacing
What is a 9cardiac) ectopy?
-stimuli generated outside of the normal conduction pathway
How does cardioversion work (compared to defibrillation)?
-synchronized on the QRS wave -for tachydysrhythmias (unstable) -lower energy joules -used in unstable patients
How do you measure PR interval?
-the beginning of the P wave to the beginning of the QRS complex
How do you measure a QRS complex?
-the beginning of the Q to the end of the S
What does a narrow QRS complex mean?
-typically originates from the SA or AV node
What are PICC lines used for?
-used for long-term IV antibiotics, nutrition, medications, and blood draws
What does Ventricular Tachycardia look like?
-usually regular rhythm -difficult to detect P waves -0.12 or more, bizarre QRS
What are some treatments for stable Paroxysmal Supraventricular Tachycardia (PSVT)?
-vagal maneuvers -adenosine (6mg/12mg/12mg rapid IVP) -IV calcium channel blocker, IV beta-blocker, IV digoxin -consider synchronized cardioversion
What are some interventions for atrial flutter?
-vagal maneuvers -adenosine trial -anticoagulation -rate control -conversion >medications >electrical -surgical procedures >LAAO >maze procedure >catheter ablation therapy
What are some interventions for a hemodynamically unstable sinus tachycardia?
-vagal maneuvers >carotid massage, gagging, valsalva maneuver, coughing, face in ice, straw/bubbles -adrenocard (Adenosine) >6mg, 12mg, 12mg RAPID IVP -synchronized cardioversion
Where do ventricular rhythms originate?
-ventricles
What is the rate of a junctional rhythm?
-ventricular rate of 40-60BPM -atrial rate of 40-60BPM
What is the rate of Junctional Tachycardia?
-ventricular rate of 70-120BPM -atrial rate of 70-120BPM
Why do you call rapid response?
-when you feel something is wrong -you got the MD but the patient is still not better - OOOOOR you can't get MD
Where do you place 5-lead electrodes?
-white on right -cloud over grass -smoke over fire -chocolate at heart :)
What are the s/s of Junctional Tachycardia?
-will depend on cause -symptoms of digoxin toxicity may be present
How long is one small box on EKG paper?
0.04 seconds
What is a normal QRS complex?
0.04-0.12 seconds
What is a normal PR interval?
0.12-0.20 seconds
How long is one large box on EKG paper?
0.20 seconds
What is the rate of the Bundle Branches?
25-40BPM
What is the rate of the Purkinje Fibers?
25-40BPM
What is the rate of the Bundle of HIs?
40-55BPM
What is the rate of the AV node?
40-60BPM
How long is 30 large boxes on EKG paper?
6 seconds
What is the rate of the SA node?
60-100BPM
Where do junctional rhythms originate?
AV node
What are some managements of sinus tachycardia?
CORRECT THE CAUSE -give fluids -blood products -pain medications -reduce anxiety -remove meds/simulants
What are some managements of sinus bradycardia?
CORRECT THE CAUSE -stop meds -warm -stop N/V
What are some interventions of premature atrial complexes (PACs)?
ELIMINATE UNDERLYING CAUSES -reduce/eliminate caffeine intake -correct hypokalemia
What is the acronym for cardioversion?
Oh, Say It Isn't So -O2 monitoring -Suction equipment -IV access -Intubation supplies -Sedation, analgesics, and signed consent
Where does a sinus rhythm originate?
SA node
What are the s/s of Paroxysmal Supraventricular Tachycardia (PSVT)?
decreased CO can cause -restlessness -chest pain -SOB -pallor -hypotension -LOC
