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177 Cards in this Set
- Front
- Back
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ST segment Elevation
What does it mean? |
injury
(A MI is evolving) |
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What should be done if a ST elevation is seen on an EKG?
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Call Dr.
Thrombolytics, Vasodilators should be ordered. Pt to cath lab. "30 minutes to door" |
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ST segment depression
What does it mean? |
Ischemia
(Pt had an old MI) |
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What is normal rate of impulses from the SA node?
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60-100/minute
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What is the normal rate of impulses generated from the AV node?
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40-60/minute
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What is the normal rate of impulses that can be generated from the ventricles?
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20-40/minute
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When a rhythm is said to be sinus, what does it mean?
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There is always a P wave before every QRS wave and the R-R are regular.
(Impulse is generated from SA node in R atrium) |
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When a rhythm is said to be "junctional," what does it mean?
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The impulse is generated from the AV node.(not from SA node)
P wave could be shown in any of 3 ways (see next card) |
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Name 3 ways that a P wave can appear in a junctional rhythm.
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*can be upright or inverted**
1.)Early-before the QRS but REALLY close to QRS (<.12) 2.)Mid or Buried-(missing)may occur during QRS and make the QRS wider. 3.)late-following the QRS |
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Name 2 rhythms that get their impulse from the atrium but NOT from the SA node.
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SVT (supraventricular tachycardia)
MAT (Multi-atrial tachycardia) |
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How long should the normal QRS be?
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<0.12 sec
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How long should the normal PR interval be?
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0.12-0.20 sec
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What can cause sinus bradycardia?
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(bradycardia may be normal in athletes)
vagal stimulation MI sedatives Meds: Digoxin, BB, Ca+ Channel Blockers, amiodarone severe pain sleep |
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What Sx may you see in a pt that is sinus bradycardic?
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Sx would be d/t decreased CO:
faintness SOB Healthy pts have no sx. |
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How would you treat sinus bradycardic person with sx?
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0.5-1.0mg atropine (atropine blocks vagal effect)
Possible pacer. |
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What are causes for sinus tachycardia rhythms?
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increases SNS
stress (pain) exercise stimulants: caffeine, nicotine fever anemia (low H & H) hyperthyroidism hypoxemia HG shock drugs: atropine, epinephrine, dopamine |
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What are some sx that a sinus "tachy" pt may have?
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faintness
SOB Sx d/t decreased ventricular filling time leading to decreased CO |
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What is tx for pt with sinus tachycardia?
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sedation (propethal)
O2 administration Digoxin & diuretics for HF pts. Propranolol for thyroxicosis pts. (Grave's disease) |
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What should you remember before giving Digoxin?
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Always check apical HR before giving. (Hold if HR <60!)
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Multifocal atrial tachycardia: how fast is the atrial rate
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100-150 atrial rate
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How would P waves appear in a Multifocal atrial tachycardia rhythm?
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They may vary in shape d/t impulses generated from multiple foci (There may be 3 P waves before QRS)
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Is a Multifocal atrial tachycardia rhythm regular or irregular?
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IRREGULAR d/t the variable lengths of the PR interval (remember multiple P waves before the QRS wave)
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What are some causes of MAT or Multifocal atrial tachycardia?
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**Digoxin toxicity!
elderly pts with COPD (R atrium stretched) CHF sepsis pulmonary HTN hypoxemia low K+ pH changes |
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What are some sx we may see in a pt with a multifocal atrial tachycardic rhythm?
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may lead to hemodynamic instability
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What would be done for a pt with a multifocal atrial tachycardic rhythm?
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decrease HR with a BB if necessary.
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What are some sx of digoxin toxicity?
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abdominal pain
anorexia N/V decrease HR arrythmias (ex. PSVT) |
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What is the atrial rate of Paroxysmal Supraventricular tachycardia rhythm (PSVT)?
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150-250
(faster than sinus tachycardia) |
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In what way could a (PSVT) paroxysmal supraventricular tachycardia look similar to a junctional rhythm?
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PSVT would have P waves that can appear in either of 3 ways (early, buried or late (retrograde)) because the impulse is not from the SA node.
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paroxysmal supraventricular tachycardia are often initiated by?
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a Premature atrial contraction (PAC)which is an ectopic atrial impulse.
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What are some causes of a paroxysmal superventricular tachycardia? (PSVT)
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Can happen in normal hearts d/t: emotions, tobacco, alcohol, caffeine.
rhuematic heart disease acute MI Digoxin toxicity |
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What are some sx in a pt experiencing a PSVT rhythm?
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pt w/o hx of heart disease: palpitations
lightheadedness Pt w/hx of heart disease: dyspnea angina HF (d/t decreased vent filling time & decreased CO) |
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What is tx for PSVT?
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unstable pt:
CONTROL RATE & CONVERT RHYTHM cardioversion overdrive pacing stable Pt: sedation vagal manuevers(carotid massage done by Dr, vasalva manuever) adenosine (decrease HR) BB if normal heart amiodarone radiofrequency ablation |
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What exactly is a PAC? (premature atrial contraction)
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an early beat w/in a sinus rhythm that makes it irregular
pt may feel a "skipped beat" |
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What can cause a PAC?
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Healthy pt: caffeine
emotion, alcohol,tobacco rhuematic heart disease (irritated atria by HF or PE) COPD HF hyperthyroidism mitral stenosis low K+, low Mag+ Meds: atropine, epinephrine, dopamine |
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Why are we concerned when we see a PAC appear in a rhythm?
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Because it may lead to atrial tachycardia, afib, atrial flutter.
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What do we do when we see a PAC in a rhythm?
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Nothing! Just monitor!
Can tell pt to decrease stimulants. maybe digoxin or antirhythmic if pt has sx. We would tx underlying conditions: COPD, HF |
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What is the atrial rate of an atrial flutter rhythm and where is it generated?
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250-350. (faster than PSVT)
is generated by ectopic impulse. Not SA node. |
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What is characteristic of atrial flutter rhythm when you look at it?
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"sawtooth" or "picket fence" pattern.
*think of a butterly fluttering its wings on a picket fence. |
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What makes the atrial flutter look the way it does?
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because the AV node is acting as a gatekeeper. only allows every 2nd, 3rd or 4th atrial impulse to reach ventricles. (would call it a 2:1, 3:1 or 4:1 flutter block)
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Which pts may you see an atrial flutter rhythm?
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CAD, CHF
Cor pulmonale, MI PE COPD rheumatic heart disease Would NOT see in normal hearts |
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Why would a Dr order vagal manuevers in a pt he suspects as having an atrial flutter rhythm?
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vagal manuevers increase the AV block and allows the Dr's to see the atrial wave better.
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Why would anticoagulants be used in a pt with atrial flutter?
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Because there is lack of "atrial kick." (leads to decrease CO)
*There is no full atrial contractions. (can lead to increased thrombi which leads to increased strokes) |
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What would tx be in a stable pt with atrial flutter?
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anticoagulate if rhythm longer than 72 hours,
*Sedate then DCCV if INR 2.0-3.0. Follow with 2-3 weeks of anticoagulation. Meds: amiodarone radiofrequency ablation (ablate AV node) Pacing in older pts. |
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What would tx be in an unstable pt with atrial flutter?
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FIRST:
TEE (to R/O thrombus)don't want to dislodge thrombus! anticoagulate then DCCV |
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Is atrial flutter regular or irregular?
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Regular
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What are some sx in a pt experiencing a PSVT rhythm?
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pt w/o hx of heart disease: palpitations
lightheadedness Pt w/hx of heart disease: dyspnea angina HF (d/t decreased vent filling time & decreased CO) |
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What is tx for PSVT?
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unstable pt:
CONTROL RATE & CONVERT RHYTHM cardioversion overdrive pacing stable Pt: sedation vagal manuevers(carotid massage done by Dr, vasalva manuever) adenosine (decrease HR) BB if normal heart amiodarone radiofrequency ablation |
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What exactly is a PAC? (premature atrial contraction)
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an early beat w/in a sinus rhythm that makes it irregular
pt may feel a "skipped beat" |
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What can cause a PAC?
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Healthy pt: caffeine
emotion, alcohol,tobacco rhuematic heart disease (irritated atria by HF or PE) COPD HF hyperthyroidism mitral stenosis low K+, low Mag+ Meds: atropine, epinephrine, dopamine |
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Why are we concerned when we see a PAC appear in a rhythm?
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Because it may lead to atrial tachycardia, afib, atrial flutter.
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What do we do when we see a PAC in a rhythm?
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Nothing! Just monitor!
Can tell pt to decrease stimulants. maybe digoxin or antirhythmic if pt has sx. We would tx underlying conditions: COPD, HF |
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What is the atrial rate of an atrial flutter rhythm and where is it generated?
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250-350. (faster than PSVT)
is generated by ectopic impulse. Not SA node. |
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What is characteristic of atrial flutter rhythm when you look at it?
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"sawtooth" or "picket fence" pattern.
*think of a butterly fluttering its wings on a picket fence. |
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What makes the atrial flutter look the way it does?
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because the AV node is acting as a gatekeeper. only allows every 2nd, 3rd or 4th atrial impulse to reach ventricles. (would call it a 2:1, 3:1 or 4:1 flutter block)
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Which pts may you see an atrial flutter rhythm?
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CAD, CHF
Cor pulmonale, MI PE COPD rheumatic heart disease Would NOT see in normal hearts |
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Why would a Dr order vagal manuevers in a pt he suspects as having an atrial flutter rhythm?
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vagal manuevers increase the AV block and allows the Dr's to see the atrial wave better.
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Why would anticoagulants be used in a pt with atrial flutter?
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Because there is lack of "atrial kick." (leads to decrease CO)
*There is no full atrial contractions. (can lead to increased thrombi which leads to increased strokes) |
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What would tx be in a stable pt with atrial flutter?
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anticoagulate if rhythm longer than 72 hours,
*Sedate then DCCV if INR 2.0-3.0. Follow with 2-3 weeks of anticoagulation. Meds: amiodarone radiofrequency ablation (ablate AV node) Pacing in older pts. |
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What would tx be in an unstable pt with atrial flutter?
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FIRST:
TEE (to R/O thrombus)don't want to dislodge thrombus! anticoagulate then DCCV |
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Is atrial flutter regular or irregular?
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Regular
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What is the atrial rate of an atrial fibrillation rhythm?
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rapid ectopic 350-500
faster than atrial flutter |
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What is characteristic to afib rhythm?
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chaotic atrial activity with NO definable P waves.
(appear small & quivering) |
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When a higher number of impulses go through AV node in an atrial fibrillation, the ventricular response is said to be?
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a rapid ventricular response
(may have decreased CO) |
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When a lower number of impulses go through AV node in an atrial fibrillation, the ventricular response is said to be?
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a slow ventricular response
(may have decreased CO) |
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What can cause afib?
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may be no underlying disease.
MI PE COPD CHF, HTN dehydration open heart surgery spinal cord or brain trauma (increases vagal or adrenergic tone) |
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What is tx for afib?
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anticoagulate: heparin or coumadin
Meds: BB, Ca+ Channel blockers, Digoxin, antiarrhtymic: amiodarone, sotalol cardiovert: if >48 hrs in afib, anticoagulate for 3-4 weeks, synchronized cardiovert AV node ablation surgical: MAZE |
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What are causes of AV junctional?
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MI
Drug toxicities: Digoxin (Dig increases automaticity of SA node), BB, Ca+ Channel Blockers cardiac surgery hypoxia increased vagal tone (athletes) |
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What are sx of a pt with an AV junctional rhythm?
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SOB
anxious systolic BP <90 angina Dig tox sx: N/V, abd pain |
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What is tx for a pt with an AV junctional rhythm?
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if pt has no sx: WATCH!
Pt with sx: atropine (increases HR) blocks parasympathetic system Correct toxicity: Digiband for Digoxin tox, Glucagon for BB OD, Ca+ for Ca+ Channel blockers tox |
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What is rate of accelerated junctional rhythm?
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60-100, impulses not from SA node. impulse from secondary pacemaker in AV node.
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What are causes of accelerated junctional rhythm?
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Digoxin toxicity
MI HF rhuematic fever myocarditis valvular heart disease |
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What are sx of accelerated junctional rhythm?
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Digoxin toxicity sx: N/V, abd pain
dysrhytmias |
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What is tx for accelerated junctional rhythm?
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NO ATROPINE FOR THIS PT! d/t pt already having a normal pulse!
Tx for digoxin toxicity: Digibind, DigiFab |
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What is rate of junctional bradycardia?
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<40
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What are causes of junctional bradycardia?
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MI
Drug Toxicities: Digoxin, BB, Ca+ Channel Blockers |
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What is tx for junctional bradycardia?
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Assess HR
atropine (Increases HR) correct toxicity (Digibind, Glucagon for BB, Ca+ for Ca+ channel blockers) Temporary pacemakers |
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What is rate of junctional tachycardia?
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100-150
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What causes junctional tachycardia? (aka Paroxysmal Junctional Tachycardia)
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Digoxin toxicity
MI HF rhuematic fever myocarditis valvular heart disease/surgery |
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What are sx of unstable pt with junctional tachycardia?
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angina
SOB Neuro changes |
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What is tx for stable pt with junctional tachycardia?
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pt w/o angina & not SOB)
vagal manuevers (cough, bear down, carotid massage) adenosine rapid IV push (blocks impulse at AV node to decrease HR, asystole, then HR returns) 1st-6mg, 2nd-12mg, 3rd-12mg BB or Ca+ Channel Blockers IV |
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What is tx for unstable pt with junctional tachycardia?
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Unstable pt (angina, SOB, neuro changes)
UNSTABLE PT NEVER GETS ADENOSINE!!!! electrical synchronized cardioversion (sync R waves) |
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What is a premature junctional contraction?
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Is a contraction that can occur in a Normal sinus rhythm. P waves may be one of 3 ways. R-R waves irregular.
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What can cause a premature junctional contraction?
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Digoxin toxicity
CAD HF electrolyte imbalances (K+, Mag+) |
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What is good to do if you know a pt is prone to premature junctional contractions?
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Check labs regularly.
Replace K=, Mag+ as needed. |
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What happens in an AV block?
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The impulse is delayed or fails to be conducted in the AV node.
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What is a 1st degree AV block?
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The sinus impulse conducted to AV node is delayed prior to conduction to ventricles.
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What do you see different in a 1st degree AV rhythm?
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The PR interval will be longer than >.20 because the impulse is delayed. The QRS may be narrow at times.
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What are causes of a 1st degree AV rhythm?
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Toxicity of Digoxin, BB, Ca+ Ch Blockers
Increased vagal tone high K+ acute MI degeneration of AV pathways *may see in pts in recovery room as anesthesis is wearing off. |
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What is good to do before giving K+ supplements to pts?
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look for a longer PR interval. (a longer PR interval can indicate hyperkalemia)
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What sx would a pt have with a 1st degree AV block?
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Typically no sx!
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What would you do for a pt with a 1st degree AV block?
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No tx if pt has no sx. "Not worried yet."
Document and notify Dr! Would verify cardiac meds with Dr since 1st AV blocks may progress to more serious heart blocks. if sx: atropine 0.5-1.0mg IV) |
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What happens in a 2 degree AV block Type 1 (aka Mobitz 1)?
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the impulse traveling from atria is interrupted at the AV junction, slowing conduction of inpulse to ventricles. eventually the message doesn't get through. Old man Mobitz 1 is walking slow, slower and eventually can't get through.
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What is Mobitz 1 or a 2 degree AV block Type 1 also known as?
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Wenckebach
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What do you see when you look at a Mobitz 1 or a 2 degree AV block rythym strip?
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*Progressively longer PR interval with each QRS complex until a dropped or absent QRS complex occurs.
(1 P wave before each QRS complex) |
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What can cause a Mobitz 1 or Wenckebach rhtyhm?
2 degree AV block |
acute MI
drug toxicities(dig, BB, Ca+ channel blockers) AV node ischemia high K+ rhuematic fever myocarditis |
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What sx would you see in a pt with a Mobitz 1?
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Typically no sx.
You would notify Dr but just watch this pt! |
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What would you do for a pt with a Mobitz 1?
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If pt is unstable:
atropine IV push(increase HR) If pt stable: Notify Dr. Use caution with meds! Hold all meds that will decrease HR (Dig, BB, Ca+ Ch Bl) |
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What happens in a 2 degree AV block Type 2 (aka Mobitz II)?
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impulse is interrupted below the AV junction in either the Bundle of His or the Bundle Branches. (something is blocking the impulses of these pts. QRS dropping)
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How does a Mobitz II look different than a Mobitz I rhythm?
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The PR intervals are consistently the same length on conducted beats in Mobitz II. (In Mobitz I, the PR interval are progressively longer until a QRS is dropped.)Mobitz II is NOT a progressive block!
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So, what is the hallmark of a Mobitz II rhythm?
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sudden dropping of a QRS complex
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What do we know about the P waves and QRS complexes in a Mobitz II?
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We may see 2 or 3 P waves before each QRS complex. (atrial & ventricular rates vary) P>QRS
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Why are we worried when we see a Mobitz II?
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Because Mobitz II can QUICKLY become a complete heart block or asystole! Is usually irreversible!
"sweat on the forehead time!" |
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What can cause Mobitz II?
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acute MI
myocarditis severe CAD degeneration of electrical conduction system |
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What is done when we see a Mobitz II?
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IMMEDIATE temporary pacer is needed!
Then, permanent pacemaker usually required. **CAUTION with atropine! (has a parodoxical effect! Can slow HR down!) |
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What is a 3 degree AV block (aka Complete heart block)?
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Complete absence of conduction between atria & ventricles. (no relationship between atria & ventricle activity)
atria dancing hip hop & ventricles dancing the waltz. |
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What do we know about the P waves and the QRS in a Complete heart block (or 3 degree AV block)?
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There is no relationship between P waves and QRS.
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What happens in a 2 degree AV block Type 1 (aka Mobitz 1)?
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the impulse traveling from atria is interrupted at the AV junction, slowing conduction of inpulse to ventricles. eventually the message doesn't get through. Old man Mobitz 1 is walking slow, slower and eventually can't get through.
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What is Mobitz 1 or a 2 degree AV block Type 1 also known as?
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Wenckebach
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What do you see when you look at a Mobitz 1 or a 2 degree AV block rythym strip?
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*Progressively longer PR interval with each QRS complex until a dropped or absent QRS complex occurs.
(1 P wave before each QRS complex) |
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What can cause a Mobitz 1 or Wenckebach rhtyhm?
2 degree AV block |
acute MI
drug toxicities(dig, BB, Ca+ channel blockers) AV node ischemia high K+ rhuematic fever myocarditis |
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What sx would you see in a pt with a Mobitz 1?
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Typically no sx.
You would notify Dr but just watch this pt! |
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What would you do for a pt with a Mobitz 1?
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If pt is unstable:
atropine IV push(increase HR) If pt stable: Notify Dr. Use caution with meds! Hold all meds that will decrease HR (Dig, BB, Ca+ Ch Bl) |
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What happens in a 2 degree AV block Type 2 (aka Mobitz II)?
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impulse is interrupted below the AV junction in either the Bundle of His or the Bundle Branches. (something is blocking the impulses of these pts. QRS dropping)
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How does a Mobitz II look different than a Mobitz I rhythm?
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The PR intervals are consistently the same length on conducted beats in Mobitz II. (In Mobitz I, the PR interval are progressively longer until a QRS is dropped.)Mobitz II is NOT a progressive block!
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So, what is the hallmark of a Mobitz II rhythm?
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sudden dropping of a QRS complex
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What do we know about the P waves and QRS complexes in a Mobitz II?
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We may see 2 or 3 P waves before each QRS complex. (atrial & ventricular rates vary) P>QRS
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Why are we worried when we see a Mobitz II?
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Because Mobitz II can QUICKLY become a complete heart block or asystole! Is usually irreversible!
"sweat on the forehead time!" |
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What can cause Mobitz II?
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acute MI
myocarditis severe CAD degeneration of electrical conduction system |
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What is done when we see a Mobitz II?
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IMMEDIATE temporary pacer is needed!
Then, permanent pacemaker usually required. **CAUTION with atropine! (has a parodoxical effect! Can slow HR down!) |
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What is a 3 degree AV block (aka Complete heart block)?
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Complete absence of conduction between atria & ventricles. (no relationship between atria & ventricle activity)
atria dancing hip hop & ventricles dancing the waltz. |
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What do we know about the P waves and the QRS in a Complete heart block (or 3 degree AV block)?
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There is no relationship between P waves and QRS.
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How does the PR intervals look in a complete heart block?
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May appear to constantly change in length but are not progressive. (no rhyme or reason to length of PR interval)
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How may a QRS complex look in a temporary and permanent 3 degree AV block?
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temporary heart block: QRS may be narrow.
permanent heart block: QRS may be wide & bizarre. No relationship with P waves. |
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What can cause a temporary heart block?
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Acute MI
increased vagal tone drog tox: dig, BB, Ca+ Ch Blockers high K+ myocarditis rheumatic fever |
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What can cause a permanent complete heart block (3 degree AV Block)?
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acute MI
chronic degenerative disease of the conduction system. |
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When may a pt have sx of a complete heart block?
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When they have <40 bpm. (decreased CO)
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What is done for pts with complete heart blocks?
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Immediate pacer for pt w/sx.
(hip hop dancer & waltz dancer got a divorce, now need a peacemaker.) atropine may be effective in temporary heart blocks (narrow QRS complex-<.08) Use caution with all meds. (Hold all meds that decrease HR!) |
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What is a Bundle Branch Block? (BBB)
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an interruption in the transmission of the impulse through either the right or left bundle branches. is a sequential contraction in ventricles.
*can see this in any rhythm. |
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How can you see a Bundle Branch Block on a rhythm strip?
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May look like a single notch on the QRS complex or most likely a widened QRS >.12.
(because the blocked ventricle contracts slightly later than the unblocked ventricle.) |
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What can cause a Bundle Branch Block?
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CAD
MI acute PE congenital abnormality degenerative disease of the conduction system |
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What do we for a person with a Bundle Branch Block?
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12 lead EKG is required to determine which bundle branch is blocked.
Typically no sx is required. |
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What is a ventricular rhythm?
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the SA node and the AV node fail to initiate an impulse or the ventricles fire spontaneously from an ectopic impulse. will see sequential depolarizations (wide QRS in all vent dysrhytmias) if atria contract, they contract with ventricles so P waves are hidden.
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What is a PVC (premature ventricular contraction)?
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a random QRS complex or ventricular contraction
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Are PVCs counted in total # of R waves?
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YES
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How may a QRS complex look in a PVC?
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wide & bizarre (>.12)
QRS complexes will look the same if they are unifocal. (impulse coming from one area of ventricle) QRS will look different if they are multifocal. (impulses coming from different area of ventricle.) |
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Would a rhythm with PVCs be regular or irregular?
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Irregular. The R-R intervals vary. P-P vary as well.
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What do you call 2 PVCs not separated from underlying complexes?
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a PVC couplet
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What do you call 3 PVCs in a row?
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a run of Ventricular tachycardia (a run of Vtach)
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What does it mean when you see bigeminy PVCs (a PVC with every 2nd QRS)?
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It means there is increased irritability. not good.
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Would it be better or worse to have either trigeminy or quadrigeminy PVCs than bigeminy?
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Better, since the ventricles are less irritable. You'll see PVCs with every 3rd or 4th complex instead of every other QRS.
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What can cause PVCs?
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acute MI
CHF hypoxia, hypercapnia, acidosis **electrolyte imbalances stimulants: caffeine, amphetamines, Red Bull drug induced: dopamine, dobutamine stress, anxiety |
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What can nurses do to decrease future PVCs in a pt?
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If we see an increase in PVCs, check labs!!!!
(K+ and Mag+) |
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What is a "R on T" phenomenon?
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R wave of the PVC falls on the T wave of the previous complex. (During the T wave, the ventricle is vulnerable to contract again easiet) Could lead to lethal dysrythmia like V tach.
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What is the priority tx for pts with PVCs?
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K+ & Mag+ replacement (3.5-5.0 norm K+) (1.6-2.3 norm Mag+)
amiodarone BB, Ca+ Ch Blockers Correct susprected cause: give O2 for hypoxia, decrease caffeine, look at meds pt is taking, maybe dopamine needs to be decreased. Monitor pt closely! |
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What is ventricular tachycardia? (V tach)
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ventricular contractions without ANY P waves. (impulses generated from ventricles)
rate is 100-250bpm. R-R intervals are regular! QRS compleses are wide (as in any vent dysrhytmias .12) |
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Is V tach life threatening?
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YES NEEDS IMMEDIATE TX!
(As HR increases, ventricles do not have time to fill, therefore CO decreases and perfusion to vital organs decrease) |
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What can cause V tach?
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myocardial ischemia & MI
hypoxia & acidosis electrolyte imbalances (K+, Mag+) R on T phenomenon CAD drug induced-dopamine, dobuatmine mechanical stimulation (PA catheter insertion, pacemaker insertion) |
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What do we do for pts with stable V tach with a pulse?
(don't really see this often) |
Call condition C
amiodarone 150 mg bolus, then maintenance infusion (or lidocaine 1-1.5mg/kg IV bolus - old school) Procainamide infusion for pts who go in and out of V tach. If pt does not respond to meds, then cardiovert |
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What do we do for pts with unstable V tach with a pulse?
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Condition C
cardiovert then amiodarone 150mg IV bolus, then maintenance infusion, then later PO amiodarone. |
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What do we do for pts with unstable VT and NO pulse?
(pt unconscious) |
SCREAM
S=shock at 360J q2min as needed C=CPR (30:2) R=Rhythm w/2 leads(reassess q2min after CPR and q2min) E=Epinephrine 1mg IV push q3-5min (or vasopressin 40Units IV x 1) A=amiodarone (300mg IV-dose is doubled because pt is dead) M=Mag+ (or other med lidocaine) |
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What is Torsades de Pointes (aka polymorphic tachycardia)?
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rhythm with large, bizarre polymorphous QRS complexes by varying height and direction. (resembles twisting & turning motion along baseline.) QRS>.12. R-R may be regular or irregular
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What can cause Torsades de Pointes rhythms?
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R on T phenomenon
Drugs that cause prolonged PR interval: amiodarone, quinidine, sotolol, procainamide) psych meds: haldol, antidepressants, antiemetics electrolyte imbalances-K+, Mag+ bradycardia & heart blocks |
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What is drug of choice for Torsades de Pointes?
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MagSO4 IV bolus.
We don't give amiodarone until we can R/O that isn't a cause for the Torsades. |
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What else can we do for Torsades if Torsades not corrected with MagSO4?
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Overdrive pacing-
Cardiovert or debrillate (pt sedated first!) |
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What is ventricular fibrillation?
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Impulses generated from many different sites in ventricles. Cannot measure rate. No P-P or R-R intervals. This pt would NOT have a pulse!
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Is V fib life threatening?
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YES! (pt has NO pulse!) No perfusion! No CO!
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What is coarse Vfib and is it better than Vfib with fine waves?
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coarse waves are high in amplitude. tells us that the cardiac cells are still able to respond to shock tx. may progress to fine vfib where few cardiac cells are viable and will not respond to tx as well.
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What would you do for a pt in V fib?
"you have to defib to live in V fib!" |
SCREAM
S=Shock (360J)q2min as needed C=CPR R=rhythm (reasses q2min) E=epinephrine (1mg IV push or vasopressin 40U IV x 1) A=amiodarone 300mg IV) M=Mag+ (or meds-lidocaine) |
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What can cause V fib?
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myocardial ischemia, MI
sudden cardiac death cardiac trauma (MVA) hypoxia, acidosis electrolyte imbalances (K+ either too high or too low, Mag+ too low) electrical shock (lightening) cocaine toxicity |
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What is idioventricular/agonal (dying heart)?
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ventricle contractions are <30-40 and are slow & ineffecctive.
R-R may be regular or irregular QRS becomes progressively wider to asystole. |
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What can cause an agonal "dying heart"?
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advanced heart disease
dying heart appearance of final arrythmia prior to asystole. |
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What do we do for an idioventricular/agonal heart?
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pacemaker (also can pace with defibrillator
atropine epinephrine dopamine **wouldn't do these if pts on a "dying wean." |
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what is accelerated idioventricular rhythm?
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same as the idioventricular or agonal rhythm but rate is between 40-100.
(The monitor may read "V tach" but not really since this rate is slower than V tach.) |
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What can cause an accelerated idioventricular rhythm?
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acute MI
reperfusion after thrombolytic tx ("reperfusion arrhthmia") |
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Is an accelerated idioventricular rhythm life threatening?
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NO. this rhythm is self-limiting and will go away on its own.
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What is asystole? (aka ventricular standstill)
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absence of all electrical activity in ventricles
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What are common causes of aystole & PEA?
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6 Hs:
hypoxia-intubate, give O2 hypovolemia-pt in shock H+ (acidosis)-give Sod Bicarb hyper(give insulin)/hypokalemia (renal pts) hypothermia-warm fluids hypoglycemia-D5W 6Ts: toxins(narcotic, opoids)give Narcan tamponade-chest tube (check Beck's triad after surgery) tension pneumothorax thrombosis (coronary) thrombosis (pulmonary) PE trauma |
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What do you NOT do for a person in asystole?
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DO NOT DEFRILLATE! (it would suppress any viable cardiac cells.)
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What would you do for a pt in asystole if you don't defibrillate?
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DO PEA!
P=search for probable cause E=epinephrine 1mg IV q 3-5min or vasopressin 40U IV x 1 dose A=atropine 1mg IV q3-5min "Push fast, Push hard!" |
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What is PEA and what is tx?
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Pulseless electrical activity. Heart has some electrical activity but not fully contracting so there is no pulse. Tx is same as for asystole.
P=search for probable cause E=epinephrine 1mg IV q3-5min A=atropine 1mg IV q3-5 min |
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When is adenosine used?
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conversion of paroxysmal supraventricular tachycardia (PSVT) to normal sinus rhythm when vagal stimulation is unsuccessful.
Also used in stable pt with junctional tachycardia, not unstable pts! |
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How does adenosine work?
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slows conduction time through AV node.
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Which pts would adenosine be contraindicated in?
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pt with 2nd or 3rd degree AV blocks or unstable junctional tachycardic pt.unless a functional artificial pacemaker is present.
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What is the usual dose for adenosine?
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6mg rapid IV bolus then 1-2 minutes later,
12mg rapid IV bolus then, 12mg rapid IV bolus |
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When is atropine used?
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in sinus bradycardia and heart blocks
*use caution in mobitz II because may cause parodoxical effect. |
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What is the goal of pacing?
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To maintain adequate CO.
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What are some situations requiring a pacer?
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asystole
complete heart block severe bradycardia cardiac arrest after surgery terminate rapid SVTs |
