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95 Cards in this Set
- Front
- Back
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S3 and S4 are heard during
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diastole
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S3
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Lub Dub Dub - Normal children and adults up to 35 or 40 years of age - Older adults - sign of significant pathophysiology
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S4
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Lub Lub Dub
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Impulse originating from SA node at a slow rate is calle
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sinus bradycardia
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SA node
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60-100 times in an adult
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Impulse travels from SA node to AV node is known as
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conduction
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The electrical stimulation of the muscles cells causes the
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atria to contract
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The AV node
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slows the electrical impulse - giving the atria time to contract and fill with blood - known as the ATRIAL KICK
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The electrical impulse then travels VERY QUICKLY through the
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1) bundle of HIS
2) R and L bundle branches 3) Purkinje fibers (located in the ventricular muscle) |
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The electrical stimulation of the muscles cells of the ventricles causes the mechanical
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CONTACTION of the ventricles (Systole).....the cells repolarize and the ventricles RELAX (diastole)
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Electrical stimulation is called
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depolarization and mechanical contraction is systole
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Electrical relaxation is called
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repolarization and mechanical relaxation is diastole
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Heart Rate influenced by the
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ANS
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The ANS consists of
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sympathetic and parasympathetic fibers
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Stimulation of the sympathetic system
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1) increase heart rate (positive chronotropy)
2) conduction through the AV node (positive dromotropy) 3) force of myocardial contraction (inotropy) |
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Sympathetic stimulation also
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1) constricts peripheral blood vessels
2) increases blood pressure |
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Parasympathetic stimulation
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1) reduces the heart rate (negatve chronotropy
2) reduces AV conduction (negative dromotropy) 3) reduce the force of atrial myocardial contraction |
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Meds to decrease dysrhthmias
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Beta-adrenergic blocking agents
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Meds that increase dysrhythmias
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1) catecholamines
2) dobutamine lline3) dopamine 4) aminophy |
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Imaginary line is called a
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lead
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Waveform represent
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the electrical current in relation to the lead
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electrophysiology study in which electrodes are placed in the heard is performed
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in the hosptial
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Standard 12 lead ECG
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10 electrodes:
6 on the chest 4 on the limbs |
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Leads placed on areas that
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are not bony and do not have significant movement
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Precordial leads
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V1-V6 placed on the chest
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First six leads: I, II, III, aVR, aVL and aVF.
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?
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A standard 12 lead ECG reflects the electrical activity in the
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LEFT VENTRICLE
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Patients with suspected R side heart damage
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R precordial leads are required to evaluate the R ventricle
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Time and rate
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horizontal axis of the graph
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Amplitude and voltage
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vertical axis of the graph
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When waveform moves toward the top of the paper it is called a
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positive deflection
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When a waveform moves toward the bottom of the paper it is called a
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negative deflection
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P Wave
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Impulse starting sinus node and spreading through the atria (atrial depolarization)
2.5 height 0.11 seconds or less in duration |
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QRS complex
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represents ventricular depolarization
Not all QRS complexes have all three waveforms Q wave - first negative deflection (<0.4) R wave - first positive deflection S wave - first negative deflection |
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When a wave is less than 5mm,
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small letters (q,r,s)
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When a wave is higher than 5mm
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capital letters (Q,R,S)
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QRS is normally less than
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0.12 seconds
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T wave represents
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ventricular repolarization (cells regain a negative charge) resting state
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U wave is thought to represent
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repolarization of the Perkinje fibers AND
PATIENTS WITH HYPOKALEMIA HYPERTENSION HEART DISEASE Smaller than the P wave |
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P-R Interval measures from the
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beginning of the P wave to the beginning of the QRS complex
0.12 to 0.20 seconds |
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ST segment (early ventricular repolarization) last from
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end of the QRS complex to the beginning of the T wave
beginning of the ST segment noted by change in thickness of the QRS complex |
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ST segment is analyzed to see if
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it is above or below the isoelectric line - may be a sign of cardiac ischemia
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QT interval represent the TOTAL time
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for ventricular depolarization and repolarization
Measured from the beginning of the QRS complex to the end of the T wave Varies with heart rate, gender and age. QT interval is 0.32-0.40 seconds if the heart rate is 65-95 bpm |
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Prolonged QT interval
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LETHAL TORSADES DE POINTES
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TP interval is measured from the
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end of the T wave to the beginning of the next P wave (Iisoelectric period)....when no electrical activity is detected, the line on the graph remains flat....isoelectric line
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PP interval is measured from
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the beginning of the P wave to the beginning of the next P wave
determines atrial rhythm and atrial rate |
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RR interval is measured from one QRS complex to the next QRS complex used to measure
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ventricular rate and rhythm
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Sinus bradycardia CAUSES
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Lower metabolic needs:
1) sleep 2) athletic training 3) vagal stimulation (vomiting, suctioning, severe pain, extreme emotiions, H's and T's: hypovolemia hypoxia hydrogen ions (acidosis) toxins tamponade tension pneumothorax thrombosis trauma |
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Sinus bradycardia MED OF CHOICE
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ATROPINE!!!!!
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Sinus tachycardia may be a result of
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1) stress
2) acute blood loss 3) anemia 4) shock 5) hypvolemia 6) hypervolemia 7) heart failure 8) pain 9) fever 10) exercise 11) anxiety |
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Sinus tachycardia may be due to MEDS
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1) CATECHOLAMINES
2) AMINOPHYLLINE 3) ATROPINE 4) CAFFEINE 5) ALCOHOL 6) NICOTINE |
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Sinus tachycardia due to enhanced automaticity of the SA node
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with reduced parasympathetic tone is called INAPPROPRIATE SINUS TACHYCARDIA
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Sinus Tachycardia (Autonomic Dysfunction) is called
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POTS (postural orthostatic tachycardia syndrome)
Patients with POTS have TACHY without hypotension within 5-10 minutes of standing |
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Sinus Tachycardia rate
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greater than 100 but less than 120
Sinus tachy does not start or end suddenly |
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Sinus Tachy diastolic filling time
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is REDUCED
cardiac output REDUCED syncope LOW blood pressure If not corrected, pt may develop acute pulmonary edema |
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Treatment sinus tachy (meds)
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Beta Blockers
Calcium Channel Blockers but - rarely used |
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Treatment for POTS
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INCREASED fluid and sodium intake
Anti-embolism stockings |
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SINUS ARRHYTHMIA
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Sinus node creates an impulse at an irregular rhythm: rate INCREASES with inspiration and DECREASES with expiration
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SINUS ARRHYTHMIA RATE SAME AS NORMAL SINUS
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60-100 bpm
Ventricular/Atrial rhythm: Irregular |
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SINUS ARRHYTHMIA usually
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DOES NOT cause any significant hemodynamic effect and usually is NOT TREATED
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Premature Atrial Complex
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electrical impulse starts in atrium tooooo early....before time
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Premature Atrial Complex may be caused by
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1) Caffeine
2) Alcohol 3) Nicotine 4) Stretched Atrial Myocardium 5) Anxiety 6) LOW POTASSIUM 7) hypermetabolic states (pregnancy) 8) atrial ischemia 9) injury 10) infarction |
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Premature Atrial Complexes are OFTEN SEEN with
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Tachycardia
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PAC is common in
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normal hearts. The pt. may state "my heart skipped a beat"
Pulse deficit IF MORE THAN SIX A MINUTE - MAY INDICATE SERIOUS CONDITION...SUCH AS A FIB |
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PAC's have an
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irregular rhythm....early P waves....PP interval shorter....then longer than normal PP interval but one that is less than twice the normal PP interval.....NONCOMPENSATORY PAUSE
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ATRIAL FLUTTER
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1) conduction defect in the atrium
2) rapid, regular atrial rate 3) 250-400 times per minute 4) atrial rate faster than AV node can conduct 5) not all atrial impulses reach the ventricles 6) therapeutic BLOCK at the AV node 7) BLOCK is GOOD because of all impulses reached the ventricles at 250-400.....ATRIAL FIBRILLATION! |
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Atrial Flutter often occurs in patients with
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1) COPD
2) Valvular disease 3) Thyrotoxicosis (women, Grave's) 4) Following open-heart surgery 5) Repair of congenital heart defects |
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Atrial Flutter RATE
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Atrium: 250-400
Ventricles: 75-150 P wave - SAW TOOTH SHAPE......REFERRED TO AS F WAVES PR interval - multiple F waves P:QRS ratio: 2:1, 3:1, 4:1 |
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Treatment of Atrial Flutter
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1) Vagal maneuvers
2) Adenosine (slows conduction of AV node).....ALLOWS BETTER VIEW OF FLUTTER WAVES |
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Adenosine administer
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RAPIDLY IV PUSH
Followed by 20-mL saline flush ELEVATE ARM |
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Atrial Flutter Signs and Symptoms
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1) Chest Pain
2) SOB 3) Low Blood Pressure ELECTROCARDIOVERSION IS OFTEN SUCCESSFUL IN CONVERTING TO NORMAL |
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Atrial Flutter - Medications
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1) Dysrhythmia lasting longer than 48 hours
2) Transesophageal echocardiogram has NOT confirmed the absence of atrial clots NEED ADEQUATE ANTICOAGULATION 1) Beta-Blockers 2) Calcium Channel Blockers 3) Digitalis CATHETER ABLATION IS NOT THE LONG-TERM TREATMENT OF CHOICE |
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Atrial Fibrillation is an
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uncoordinated atrial electrical activation that causes a rapid, disorganized, and uncoordinated twitching of the atrial musculature.
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Atrial fibrillation may be
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transient, starting and stopping suddenly and occurring for a very short time.....PROXYSMAL DYSRHYTHMIA
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Atrial fibrillation usually occurs in people of
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1) advanced age
2) structural heart disease 3) mitral/tricuspid 4) DM 5) Obesity 6) Hyperthyroidism 7) "Holiday Heart" syndrome 8) Acute to heavy ingestion of alcohol |
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Atrial fibrillation RATE:
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Atria: 300-600
Ventricles: 120-200 NO DISCERNABLE P WAVES (irregular undulating waves) PR Interval: CANNOT BE MEASURED P:QRS ratio: MANY:1 |
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Atrial fibrillation rapid and irregular ventricular response results in
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smaller stroke volume
atrial "kick" is lost irregular palpitations SOB Fatigue Exercise intolerance Malaise |
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Atrial fibrillation - patients may present with
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1) asymptomatic
2) hypotension 3) chest pain 4) pulmonary edema 5) altered LOC (esp. if they have hypertension) 6) mitral stenosis |
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Atrial fibrillation usually presents with a
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pulse deficit (difference between apical and radial pulse)
short diastole - no time to send blood to coronary artery - increased risk of MI with onset of chest discomfort erratic atrial contraction and the atrial myocardial dysfunction promote the formation of thrombi - especially within the atria - increasing the risk for an embolic event |
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Clinical Evaluation Atrial Fibrillation
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1) History and physical
2) 12-lead EKG (ventricular hypertrophy, history of MI, cardiac chamber size, thickness, function) 3) Blood tests - thyroid, renal, and hepatic 4) Chest x-ray 5) Exercise test 6) Holter monitor |
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In many patients, atrial fibrillation converts to a normal sinus rhythm and
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no treatment is necessary
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Electrical cardioversion is indicated for
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patients with atrial fibrillation that is unstable unless they have digitalis toxicity or hypokalemia
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Because of high risk for an embolism in the atria, cardioversion should be avoided
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if longer than 48 hours duration unless the patient has received Warfarin (Coumadin) for the past 3 to 4 weeks prior to cardioversion
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Alternatively, the absence of a mural thrombus can be confirmed by transesophageal echocardiogram and
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heparin can be administered immediately prior to cardioconversion
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After atrial conversion
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warfarin is indicated for at least 4 weeks
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Torsade de pointes
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a ventricular tachycardia
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Wolff-Parkinson-White Syndrome
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QRS wide, ventricular rhythm very fast and irregular, atrial fibrillation with an accessory pathway should be suspected.
An accessory pathway is congenitaltissue between the atria, His bundle, AV node, Purkinje fibers or ventricular myocardium |
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Electrical cardioversion is the treatment of choie for atrial fibrillation in the presence of
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WPW syndrome - NO DIGOXIN OR VERAPAMIL, CARDIZEM
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To control the heart rate in atrial fibrillation, give
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IV beta blocker
nondihydropyridine calcium channel blocker (diltiazem and verapamil) |
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Atrial Fibrillation - DO NOT GIVE MEDS
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DO NOT GIVE MEDS
AV BLOCK BRONCHOSPASM IMPAIRED VENTRICULAR FUNCTION |
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Atrial fibrillation - GIVE MEDS
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GIVE MEDS
PATIENTS WITH HEART FAILURE PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION BUT NO ACCESSORY PATHWAY |
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Pregnant Women - Atrial Fibrillation - Meds
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Give Pregnant Women Digoxin (Beta-Blocker) or Nondihydropyridine (Calcium Channel Blocker)
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Recurrence of Atrial Fibrillation
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Pre-operative administration of a beta-blocker or amiodarone is the most successful
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Atrial Fibrillation Therapy
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Risks of stroke and bleeding
1) Warfarin (older than 75), HTN, DM, HF or history of stroke 2) If immediate control is necessary, place on Heparin until Warfarin level is therapeutic (INR between 2-3) 4) If during therapy, an ischemic stroke or embolization (increase INR to 3.0-3.5) 5) Hypersensitive to Warfarin - Aspirin may be substituted but Warfarin is preferred |
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Atrial Fibrillation Patient that needs any type of surgery
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Withhold warfarin for a week, if more than a week - heparin may be given
Paient's with a STENT - give PLAVIX an antiplatelet agent PLUS WARFARIN for 1-12 months following the procedure |
