1/29/2009

1 Cardiac Dysrhythmias
Gwen Stewart-Woods, RN,MSN
2
EKG tracing is evidence of electrical activity of the heart only and gives no direct information
about the mechanical action of the heart.
3 Terms associated with electrical activity of the heart
1  Depolarize/Depolarization
 Repolarize/Repolarization
 Pacemaker
 SA node
 AV node/AV Junction
 Supraventricular
 Ventricular
 Ectopy/ectopic
 Automaticity
 Conductivity
 Contractility
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2  Dysrhythmia/arrhythmia
 Synchronization
 Cardioversion
 Defibrillation
 Bigeminy
 Couplet
 Unifocal
 Multifocal
 Premature contraction
 Bradycardia
 Tachycardia

4 EKG Components
1  P wave
 PR Interval
 QRS complex
 ST segment
 T wave
 U wave
 R-R Interval
5
6 Cardiac Truths
 Electrical changes: Action Potential
 Depolarization: Electrical firing – Electrolytes shift
 Repolarization: Electrical recharging – Electrolytes re-shift
7 Refractory Period

2  Absolute Refractory: Unresponsive to stimulus

 Relative Refractory: Depolarized by strong stimulus
 “R-onT” Phenomenon
8 Electrolyte Effects:

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Hyperkalemia (pp319 – 322)

1  Hyperkalemia: >4.5
 Causes: Excess, Renal failure, Rhabdomyolysis, ARBs, ACE-I, K-sparing diuretics
 EKG changes: Tall Peaked Ts, prolonged PR, lost P, wide QRS, wide QRS tach, V-Fib,
cardiac standstill
 Treatment: IV insulin-glucose, Kayexalate, hemodialysis
 Treat coexisting low Na, Ca, or pH

9 Hypokalemia
 Hypokalemia: <3.5
 Causes: GI loss, diuretics, chronic steroid therapy
 ECG changes: PVCs, U wave, VT, VF
 Treatment: Replacement; “high-alert medication”;
 Treat low magnesium
10 Hypercalcemia
 Hypercalcemia: >4.8mg/dl/1.3mmol/L – ionized Ca; > 10.5mg/dl /2.6mmol/L – serum
 Causes: excess bone tumors, primary hyperparathyroidism, renal failure; intake
 ECG changes: short QT, bradycardia, Hrt block, BBB;
 CV effects: HTN, dig toxicity
11 Hypocalcemia
 Hypocalcemia: Ionized Ca <4mg/dl/ 1.05mmol/L
 Causes: Citrate chelation Blood transfusion & Phosphate; Metabolic alkalosis coexists
 CV effects: dec CO, contractility & BP
 EKG effects: brady, VT, asystole, prolonged QT (torsades de pointes)
 Tx: *Ca Cl/ Ca gluconate
12 Hypomagnesemia
1  Hypomagnesemia <1.5mEq/L; Associated w/ other electrolyte imbalances
Causes: Insufficient intake, GI loss, ETOH, loop diuretic, citrate chelation
Cardiac effects: HTN, vasospasm, MI, VT, VF,
EKG changes: prolonged PR & QT, U waves, flat T wave, wide QRS, SVT, VT, VF, Torsades
TX: Replacement – TOC for Torsades

13 Antidysrhythmic Agents (pp 552-555)
 Class I: Na channel blocker Prolongs Absolute Refrac
IA. Supraventricular & Vent
IB. Ventricular
IC. Supraventricular & Vent
 Class II: Beta Blocker Slows HR. Supraventric
 Class III: Potassium channel blocker- Prolongs PR, QRS, QT. Ventric or Supraventric
 Class IV: Calcium channel blocker- slows Sinus & AV conduction, decreases contractility.
Supraventric
14 Frequently Used Emergency Med
15 Cardiac Conduction System
“The Heart’s Highway”
2  The Electrical Conduction System
 Pacemaker cells
1. Sinoatrial Node: 60 – 100 b/m
2. AV Junction: 40 – 60 b/m
3. Ventricle: 20 – 40 b/m
 “Atrial Kick”
16 The Basics of Rhythm Analysis
17 Cardiac Leads

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 Senses & records electrical activity

 5 Lead & Electrode Placement
 Lead II & V
18 ECG Recording
1 ECG graph paper
Small square: 0.04 sec
Large square: 0.20 sec
15 large squares = 3 seconds
30 large squares = 6 seconds
19 EKG Components
20 P Wave & PR Interval
1  Sinus Node
 Round & Smooth
 Atrial Depolarization
 AV Node & Bundle of His conduction
 0.12 - .20 sec

21 QRS Complex
2  Ventricular Depolarization
 0.06 – 0.10 (1.5 – 2.5 small squares)
 *0.10 – 0.12 = IVCD
 >0.12 “widened & bizarre” = PVC

22 QRS Complex Variations
1  May not have all 3 components
 Usually Positive
 May be Negative
23 T Wave, ST Segment & QT Interval
 T wave: Repolarization of the ventricles.
 QT interval: Vent depol & repol.
 U wave: Probably Repolarization of the Purkinje system.
 ST Segment: Norm flat. Elevated = injury / pericarditis; Depressed = ischemia

24 Rhythm Regularity
25 Rhythm Regularity
1  Regular but Regularly irregular
“interrupted”
26 Calculating the Heart Rate
27 Calculating HR using “X 10” method
28 Calculating HR using “1500” / Small Squares method
29 EKG Waves, Complexes & Intervals
 P wave: Atrial depolarization.
 PR interval: Conduction through the atria, AV junction & bundle of His.
 QRS Complex: Ventricular depolarization
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30
31 Implications: Assessing the Client
 How does the rhythm effect the heart as a pump?
 Could the rhythm lead to worse rhythms?

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 Is the client alert?

 How does he or she feel?
 If unconscious, is there a pulse?
 What is the client’s blood pressure?
 Is immediate treatment required?

32 Putting It All Together
Basic Rhythm Analysis
33 Dysrhythmia Interpretation:
A Systematic Approach
 Identify the waveforms & complexes. Is there a relationship?
 Determine Regularity
 Calculate the HR
 Measure PR Interval, QRS Duration & QT
 Identify the “Pacemaker”
 Add additional components
 State analysis
34 Types of Dysrhythmias
1  Supraventricular
1. Sinus
2. Atrial
3. Junctional
2  Ventricular
35 The Gold Standard:
Normal Sinus Rhythm
 Impulse originate in SA node
 60 – 100 b/m
 1 P for each QRS
 PR interval & QRS duration are normal
 Regular rhythm
 Tx: None

36 Sinus Bradycardia
 Same as NSR except HR < 60
 Athlete; Sleeping
 Vagal, ICP, BB or Dig, Ischemia
 TX: none unless symptomatic. Atropine 0.5-1mg q 3-5 mins. Up to a total of .03-.04mg/kg;
Transcutaneous pacing ASAP; IV access for meds; Dopamine Epinephrine, Isoproterenol
37 Sinus Tachycardia
 Same as NSR except HR > 100
 Exercise, pain, T, hemorrhage, cocaine, “ecstasy”, dopamine, atropine, epi
 Can dec SV & CO
 TX: correct cause, CCBs, BBs
38 Sinus Arrhythmia
 Cyclic irregularity coinciding with respirations
 Increase with inhalation & decrease with exhalation
 Usually seen in children & young adults
 TX: none usually
39 Supraventricular Tachycardia (SVT)
 Tachy rythms originating above ventricles: Sinus, Atrial, Junctional. P waves often not seen,
QRS usu <0.12 (*can be >0.12 if BBB or Aberrant)
 Cause: Med, caffeine, tobacco, hypoxia, hrt dz

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 TX: Dig, ibultilide, CCBs, BBs, O2

 Can casue dec CO due to rapid HR
40 Paroxysmal Supraventricular Tachycardia (PSVT)
 “Starts & Stops” abruptly; regular rhythm; P wave usu not seen; Norm QRS unless aberrant
 Cause same as PACs; Can result in dec CO
 TX: Vagal maneuver, Carotid massage, Adenosine 6mg – 12 mg (avoid asthmatics),
Amiodarone, Cardizem, Cardioversion
41 Atrial Dysrhythmias
Premature Atrial Contraction (PAC)
2  Isolated, early beats: different P; PR interval usually different; QRS usu norm / wide
 Emotional upheaval, nicotine, caffeine, and digitalis . Mitral valve prolapse, heart failure
 TX: treat cause and monitor for future problems, admin. Digitalis or Quinidine, consider 02

42 Atrial Flutter
1  Sawtooth “Flutter” waves;Atrial rate 250–350b/m
 Reg rhythm if conduction ratio is constant; irregular if ratio varies
 Cause: Hrt dz, PE, COPD, MI, Card/Lung Surg
 TX: Convert: *Ibultilide, flecainide, sotalol, procainamide, Amio; Cardioversion, overdrive
pacing; If>48hr anticoagulant
 Slow HR: CCBs, BBs, Dig; RFA

43 Atrial Fibrillation
 Most common dysrhythmia; Fibrillatory waves, Irregular rhythm, QRS usu norm
 Risk factors; Male, HTN, HF, MI
 Adverse effect: Dec CO, Blood clots
 TX: Cardioversion (if early), Rate control- CCBs, BBs, Dig;
 Rhythm control: Amio, Ibutilide; Long term; Amio, quinidine, sotalol, dofetilide,
*Anticoagulate; Atrial pacing, Cox-Maze III

44 Junctional Rhythms
 Simultaneous Retrograde & Antegrade conduction
 P wave precede, hidden or follow QRS
 Short PR interval
 PJC, Escape beat
 Accelerated 60-100
 Tachycardia >100
 TX: tx cause; atrop; BBs,CCBs, O2
45 Ventricular Ectopy
2  QRS >0.12
 PVC, Unifocal, Multifocal, Couplet, Bigeminy, Trigeminy,
 Cause: Ischemia, hypokalemia, hypoxemia, acidosis, hrt dz, irritation, dig, Class I antidys
 TX: Cause, BBs, Temp pace

46 Ventricular
Tachycardia
 Rate >100b/m usually Reg
 QRS>0.12
 Hr dz, MI, electrolyte cardiomyopathy, antidysrhythmics
 Loss of atrial kick, dec CO, can deteriorate to VFib
 TX: Amio, lidocaine, procainamide, overdrive pacing; immediate defib
47 Ventricular
Fibrillation

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3  Chaotic electrical ventricular activity

 No P, QRS, or T;
 No pulse
 Causes: acute MI, deteriorating ventricular dysrhythmias, drowning, drug overdoses,
accidental electric shock
 Significance: Lethal!
 Treatment: immediate defibrillation, CPR, Amio epinephrine, Lidocaine, Procainamide, 02

48 R on T
Phenomenon
 PVC during Relative Refractory
 Torsades de Pointes
 Ischemic tissue
 Prolonged QT: Electrolyte imbalance, Dig tox, Class Ia & III
 Tx: Magnesium, Inc HR

49 AV Conduction Defects;
1st Degree AV Blocks
 Prolonged PR >0.20
 Cause: Dig tox, BBs, Amio, Ischemia
 TX: Usually none required
50 2nd Degree AV Block I / Mobitz I
 Gradually prolonged PR until QRS is dropped, Irregular
 Cause: dig toxicity, inferior MI, medication s/e
 Significance: usually benign; resolves if ischemia is resolved
 Treatment: Usually none; temp pace as precaution
51 2nd Degree AV Block II / Mobitz II
 Second degree AV block (Type II) – More serious
 Constant PR interval; more Ps than QRS
 Causes: Same as Mobitz I; MI, conduction system lesion, med. s/e, hypoxia
 Tx: atropine only palliative usually needs pacemaker temporary until permanent

52 3rd Degree AV Block /

Complete Heart Block
1  Atrial impulse is blocked at AV Junction
 PR interval varies; Underlying rhythm is junction or ventricular
 Significance: dec. CO sec to slow ventr. rate
 Causes: same as other heart blocks
 Tx: brady temporary pacemaker until permanent one can be done; atropine; epinephrine
or dopamine; 02, correct cause
53 Pulseless Electrical Activity (PEA)

 Electrical activity with no mechanical response; no pulse; may see any pattern on monitor
and eventually deteriorates into asystole. Usually fatal
 Cause: Hypovolema, hypoxia, acidosis, tension pneumo, cardiac tamponade, PE,
hypothermia, hyperkalemia, MI, Drug OD ie tricyclic antidepressants
 TX: CPR, epi, atropine
54 Asystole
1  Ventricular standstill No pulse, will result in death if left untreated
 Cause: Hypoxia, hyperkalemia, hypokalemia, preexisting acidosis, hypothermia
 TX: CPR, pacing, atropine, O2

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55 Cardioversion/Defibrillation
1  Cardioversion – synchronized to pt’s rhythm
 Defibrillation for vfib and pulseless vtach

56 Nursing Management: Cardioversion
NPO
Check Dig level
Explain procedure
Select appropriate Lead
Turn on Sync button
Sedate client
Apply gel pad & paddles
Select desired energy level
Press charge button confirming sync markers
Call out clear ; Discharge
57 Nursing Management: Defibrillation
 Immediate intervention
 Apply gel pads & paddles
 Select energy
 No sync
 Charge defibrillator
 Call clear
 Discharge
58 Automatic External Defibrillator
(AED)