Lesson Description

1
Lesson Description

• Identify basic anatomy and physiology of the
  electrophysiological cardiac cycle
• Demonstrate correct electrode placement for the
  continuous ECG monitoring.
• Describe and perform steps in ECG rhythm strip
  analysis.
• Recognize rhythms according to ACLS guidelines
  for rhythms that are too fast from the atria, too
  fast from the ventricles, too slow, and pulseless.

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Lesson Description

• Associate nursing implications to each described
  dysrhythmia.
• Apply treatment options according to ACLS
  guidelines for rhythms that are
• too fast from the atria,
• too fast from the ventricles,
• too slow,
• pulseless.
• Prioritize pharmacological treatment and medical
  management to each scenario.

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ECGElectrocardiogram

• Placement of leads

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• SODIUM (Na) - Normal Adult Range 135-145 mEq/L
• Sodium is the most abundant cation in the blood
  and its chief base. It functions in the body to
  maintain osmotic pressure, acid-base balance and
  to transmit nerve impulses.
• Very Low value seizure and neurologic signs and
  symptoms. When replacing sodium, raising the NA
  not more than 1mEq/L per hour is typical as to
  not cause neurologic changes.
• Low Na (hyponatremia) Occurs when sodium intake
  is low but fluid intake is not. Can cause edema
  (fluid in body tissues), headache (fluid in brain
  tissue), and muscle cramps.
• High Na (hypernatremia) Caused by high sodium
  intake or excessive fluid loss via persistent
  vomiting or diarrhea. Symptoms include extreme
  thirst (thus temptation to drink a lot of fluid),
  confusion, seizures, and coma in severe cases.
• POTASSIUM (K) - Potassium is the major
  intracellular cation. Elevated-will decrease
  heart rate and bradyarrythmias. Decreased-will
  cause tachyarrythmias.
• Normal Range 3.5 - 5.5 mEq/L
• Low K (hypokalemia) caused by severe diarrhea,
  vomiting, urination, or insulin intake. Symptoms
  include fatigue, feeling of weakness in muscles,
  changes in heart function.
• High K (hyperkalemia) most common cause is
  dietary intake or inability to urinate or have a
  bowel movement. Also it can occur as a result of
  infection, or of taking certain medications.

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Electrolytes

• CALCIUM (Ca) - Calcium is needed for normal
  muscle action and bone structure.
• Normal Ca 9-11 mg/dl Ionized Ca- 4.25-5.25mg/dl
• Low Ca Results from malnutrition (i.e.,
  inadequate calcium intake), or failure to take
  phosphorus (PO4) binders. Calcium is bound to
  albumin and it is the ionized calcium that is
  needed by the body. A certain amount of ionized
  calcium must be circulating in the blood for
  normal cardiac contractions to take place.
  Symptoms of low calcium include muscle twitching,
  cramping or, in extreme cases, generalized
  seizures.
• High Ca Can result from taking too high a dose
  of calcium-containing phosphate binders or
  certain malignant neoplasms. High calcium can
  cause a wide variety of symptoms loss of
  appetite, nausea and vomiting, weakness, fatigue,
  lethargy, confusion, irritability, even coma.
• Regulated by parathyroid.
• MAGNESIUM (Mg) Magnesium is most plentiful in
  the cells. As with K, Na, and Ca, Mg is needed
  for neuromuscular activity. Magnesium influences
  the use of K, Ca, and protein, and is found in
  most foods, so people that maintain a normal diet
  should not have a problem keeping their Mg up.
• Normal Adults 1.8-3 mg/dl
• Low Mg Results from malnutrition, malabsorption,
  cirrhosis of the liver, alcoholism, hypokalemia,
  diuretics, and insulin.
• High Mg Results from severe dehydration, renal
  failure, leukemia, diabetes mellitus and antacids
  or laxatives that contain Mg.

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• Regularity of Rhythm
• is it regular
• is it irregular
• are there any patterns to the irregularity
• are there any extra beats
• Rate
• what is the rate
• is the Atrial rate the same as the Ventricular
  rate

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• Count the number of R waves in a 6 second strip
  and multiply by 10.
• Count the number of large squares between two
  consecutive R-waves and divide into 300.
• OR memorize this
• 1 large square 300 bpm
• 2 large squares 150 bpm
• 3 large squares 100 bpm
• 4 large squares 75 bpm
• 5 large squares 60 bpm
• 6 large squares 50 bpm
• Count the number of small squares between two
  consecutive R-waves and divide into 1500.

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• P-waves top part of the heart, the atria
• are the p-waves regular
• is there a p-wave for every QRS complex
• are there more p-waves than QRS complexes
• PR Interval
• what is the PRI (normal 0.12 0.20 sec.)
• is each one the same distance from the QRS
  complex
• is there a pattern to the irregularity
• QRS Complex the bottom part of the heart, the
  ventricles
• what is the QRS complex (normal 0.04 -
  0.12 sec.)
• are they all consistent
• are there any extra beats and do they all
  look the same

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Know these Concepts and how to treat!

• Too fast tachycardias gt 100 bpm,
• is it the atrias (narrow QRS lt 0.12) or
• is it ventricles (wide QRS gt 0.12)
• Too slow bradycardias lt 60 bpm,
• is it a block 1st Degree PRI gt 0.20,
• 2nd Degree Type I (PRI increases until it drops a
  QRS complex, 2nd Degree Type II (PRI consistent,
  but drops many QRS complexes),
• 3rd degree AV Block (p to p wave is equal distant
  and R to R wave is equal distant, but they have
  no relationship to one another), or junctional
  (inverted or absent p-wave).
• Dead Rhythms
• Asystole,
• V. Tach. (Ventricular Tachycardia without a
  pulse),
• V. Fib. (Ventricular Fibrillation),
• PEA (Pulseless Electrical Activity) any rhythm
  with no pulse.

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• So, with this strip, we see that the rhythm is
  regular, meaning that the R to R is regular.
• Next, we see that there is a discernable p-wave
  with every QRS complex. Therefore, we can say at
  this point, it is a regular sinus rhythm.

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• The rate in this six second strip is 7 Rs X 10
  70 bpm.
• Or take two Rs and count the small boxes between
  them and divide into 1500.
• 1500/22 68 bpm. Is the HR within normal limits
  60-100 bpm? Yes, therefore. We can say it is a
  normal sinus rhythm.

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• Next, we can count the PRI at 4 boxes or 4 x 0.04
  0.16 seconds. Is that WNL? Yes.
• Next we can count the QRS at 2 boxes or 2 x 0.04
  0.08 seconds. Is that WNL? Yes.
• We would write on the strip SR 70 P0.16 Q0.08
  as an abbreviated form, date, time, sign and put
  what lead it was in, in this case, lead II.

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• Within the group of sinus rhythms, we have sinus
  rhythm with PACs (Premature atrial contraction).
  
• We know its coming from the atria because of the
  p-wave and narrow QRS. lt 0.12 sec.
  

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• Also, we have sinus rhythm with PVCs (Premature
  Ventricular Complexes).
• We know its coming from the ventricles because
  the QRS complex is gt 0.12 sec.

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• Rhythms that are too fast with narrow complex
  QRS
• Lets do the same analysis with the rhythm.
  Sinus Tachycardia, what is the rate, the PRI, and
  the QRS?
• Regular, p-wave is present. Not normal because
  HR is gt 100, but is sinus because there is a
  p-wave with every QRS. What is the HR? PRI?
  QRS?

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• Irregular, p-wave is abnormal, saw toothed
  appearance. Not normal because HR is gt 100 and
  not sinus because of the abnormal p-wave. HR is
  irregular about 110 bpm counting just the Rs.
  PRI-unable to calculate because of flutter wave.
• QRS 0.08. Because it is lt 0.12 we know the
  origin is in the top part of the heart, the
  atria.
• This is atrial flutter, but really all we need to
  know if the patient has a pulse and it is atrial.

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• Irregular, no discernable p-wave. Not normal
  because HR is gt 100 and not sinus because no
  discernable p-wave. HR is irregular about 120 bpm
  counting just the Rs.
• PRI-unable to calculate because no discernable
  p-wave. QRS 0.08. Because it is lt 0.12 we
  know the origin is in the top part of the heart,
  the atria.
• This is atrial fibrillation, but really all we
  need to know if the patient has a pulse and if it
  is atrial.

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• Image from http//en.wikipedia.org/wiki/ImageSVT_
  Lead_II.JPG public domain.
• Regular, no discernable p-wave. Not normal
  because HR is gt 100 and not sinus because no
  discernable p-wave. HR is regular about 180 bpm
  counting just the 18 Rs in six seconds of the
  strip. PRI-unable to calculate because no
  discernable p-wave.
• QRS 0.08-0.10. Because it is lt 0.12 we know
  the origin is in the top part of the heart, the
  atria.
• This is Supraventricular Tachycardia or SVT, but
  really all we need to know if the patient has a
  pulse, and it is atrial in origin.

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The nursing implication of someone with a rapid
heart rate

• We need to determine the symptoms the patient is
  exhibiting.
• If this rapid rate is too fast, HR gt 150, or if
  the heart rate is causing other symptoms such as
  low blood pressure, chest pain, diaphoresis,
  palpitations, then we need to treat this patient
  as having a critical problem.
• If the patient has a heart rate gt 150 or has any
  of the above serious signs and symptoms related
  to the rapid rate, then that person needs to be
  cardioverted. A brief trial of medications might
  be considered, first.

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The medications that we would consider are

• Beta Blockers
• Beta blockers are effective in the treatment of
  angina because they reduce the heart's need for
  oxygen by reducing its workload. Heart rate is
  decreased and heart contraction is less vigorous.
• Beta-blockers include (propranolol, nadolol,
  pindolol, atenolol, metoprolol, timolol) are also
  used for treating high blood pressure and
  arrhythmias (irregular heartbeats).
• Potential side effects include lethargy, fatigue,
  slow heartbeats, low blood pressure. It is
  contraindicated in heart block, bradycardias, and
  respiratory diseases.

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The medications that we would consider are

• Calcium Channel Blockers
• Calcium channel blockers prevent the normal flow
  of calcium into the cells of the heart and blood
  vessels. This causes the blood vessels to relax
  and increases the supply of blood and oxygen to
  the heart.
• Verapamil and diltiazem (Cardizem) commonly are
  used in treating atrial dysrhythmias.
• Potential side effects include low blood
  pressure, dizziness, lightheadedness, flushing,
  headaches, and ankle swelling. Diltiazem
  (Cardizem) is the drug of choice for treating
  Atrial fibrillation and Atrial flutter.

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The medications that we would consider are

• Cardiac Glycosides
• Cardiac glycosides are compounds that have a
  powerful effect on the heart muscle, increasing
  the force of its contractions. These drugs
  strengthen the pumping capacity of the heart and
  improve irregular heartbeat activity. This
  improves blood circulation and helps eliminate
  excess fluid from the body. It is also useful in
  managing arrhythmias.
• Digoxin (Lanoxin) is a common cardiac glycoside.
• Potential side effects include low heart rate,
  fatigue, loss of appetite, nausea, vomiting,
  diarrhea, and visual disturbances. It is
  important to auscultate an apical pulse for 1
  minute and make sure the heart rate is at the
  normal rate for that patient before
  administering. (If it is a new dose then be
  cautious if HR is too low).

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The medications that we would consider are

• Amiodarone 150mg over 10minutes, then hang a
  drip.
• It is a sodium and potassium and calcium blocking
  agent that also effects alpha and beta adrenergic
  blocking and is effective in treating atrial
  dysrhythmias.
• It can drop the blood pressure. And, although it
  has been shown to be effective, we are now seeing
  some negative side effects as well, like liver
  toxicity and thyroid dysfunction and visual
  disturbances when patients are on oral dosages
  for long periods of time.

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Other medications

• Adenosine (6mg, repeat at 12mg, repeat at 12mg)
  Must use an antecubital or higher vessel and a
  flush. I recommend using a 3-way stop-cock to
  push the drug and the flush rapidly. Adenosine is
  a naturally occurring and has a 10 second
  half-life. It is will produce asystole, which
  will hopefully allow the normal SA node to
  restart its cycle. It is the treatment of
  choice for SVT.
• Sotalol (Betapace) Potassium Channel Blocker,
  also has beta blocking properties. 1-1.5mg/kg,
  then 10mg/min to treat A. fib. or A. flutter.

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• Regular, not sinus because no p-wave. HR about
  130 bpm. Tachycardia because gt 100.
• PRIunable to determine because no p-wave.
  QRS0.16, wide because gt0.12. The origin is
  ventricular because QRS complex is wide.
• We call this Ventricular Tachycardia. First
  thing you want to do is check a pulse. If no
  pulse, then it would be a lethal arrhythmia
  requiring defibrillation. If the patient has a
  pulse, then we consider some medications.

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Wide Complex Tachycardia

• Amiodarone 150mg over 10minutes, then hang a
  drip. It is a sodium and potassium and calcium
  blocking agent that also effects alpha and beta
  adrenergic blocking and is effective in treating
  ventricular dysrhythmias. It can drop the blood
  pressure. And, although it has been shown to be
  extremely effective, we are now seeing some
  negative side effects as well, like liver
  toxicity and thyroid dysfunction and visual
  disturbances when patients are on oral dosages
  for long periods of time.
• Procainamide Sodium Channel Blocker (Give as a
  bolus infusion 20mg/min up to max of 17mg/kg, a
  maintenance drip of 1-4mg/min.). Studies have
  shown this to be more effective is terminating
  spontaneous occurring V. Tach. Stop the drip if
  arrhythmia subsides, if hypotension, or if QRS is
  prolonged more than 50 from its original
  duration.

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Wide Complex Tachycardia

• Sotalol (Betapace) Potassium Channel Blocker,
  also has beta blocking properties. 1-1.5mg/kg,
  then 10mg/min to treat sustained V. Tach.
• Lidocaine Sodium Channel Blocker (Bolus dose
  0.5mg/kg up to 1.5mg/kg q 5-10 minutes to a max
  dose of 3mg/kg/, a maintenance drip of
  1-4mg/min.).

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• Rhythms that are too slow
• And the same analysis with the rhythm, Sinus
  Bradycardia, what is the rate, the PRI, and the
  QRS?

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• 1st Degree AV block
• 2nd Degree, Type I AV block
• 2nd Degree Type II AV block
• 3rd Degree AV block
• 2nd Degree, type II and 3rd degree AV blocks are
  critical because they can progress to asystole
  rapidly.

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The nursing implication of someone with a slow
heart rate

• We need to determine the symptoms the patient is
  exhibiting.
• If this slow rate is too slow, HR lt 60,
• or if the heart rate is relatively low and is
  causing other symptoms such as low blood
  pressure, chest pain, diaphoresis, palpitations,
• then we need to treat this patient as having a
  critical problem.

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The treatments that we would consider are

• Transcutaneous pacing is always appropriate in
  bradycardia.
• Atropine parasympatholytic (shuts off the
  parasympathetic nervous system, 0.5mg IV push,
  may repeat q 3-5 min to a max dose of 3mg). Will
  not work on denervated hearts (heart
  transplants).
• Dopamine drip (2-10 mcg/kg/min) increases heart
  rate and cardiac output.
• Epinephrine drip (2-10 mcg/min) affects
  sympathetic nervous system We never give IV
  push Epi to a patient with a pulse. Notice this
  is in a drip.

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ACLS

• Advanced Cardiac Life Support
• American Heart Association
• World Consensus and Studies to Support Treatment
• Treat by Algorithms diagrams that walk through
  the treatment of a disease or problem by
  predefined standards

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Dead

• Ventricular Fibrillation
• Pulseless Ventricular Tachycardia

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Assess Responsiveness, Call 911Begin CPR
Primary Survey
A- Airway, open itB- Breath for the patientC-
Circulation, check, perform chest compressions
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Primary Survey ABCD

• D is for defibrillate. Check
• for a shockable rhythm. Only 2 rhythms to
  defibrillate. V. Fib / Pulseless V. Tach.
• Defibrillate 360J (monophasic) or
• 120-200J (biphasic) 1 X only

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Secondary Survey ABCD

• A Airway, secure the airway by intubating
• B Breath for the patient, bag-valve-mask,
  ventilatation
• C Circulation check, establish IV and give
  medications based on the rhythm
• D - Differential Diagnosis

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Differential Diagnosis

• Hypovolemia, Toxins (or
  tablets for drug overdose)
• Hypoxia, Tamponade,
  cardiac
• Hydrogen Ion (acidosis), Tension Pneumothorax
• Hypo/Hyperkalemia, Thrombosis, coronary
  (MI) or pulmonary (PE)
• Hypoglycemia, Trauma
• Hypothermia

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• Epinephrine 1mg IV push q 3-5minutes or
• Vasopressin 40 Units IV push (replace Epis 1st
  or 2nd dose)
• Amiodarone 300mg IV push, repeat at 150mg IV push
• Lidocaine 1-1.5mg/kg, then 0.5-0.75mg/kg to max
  of 3mg/kg
• Consider, Magnesium Sulfate 1-2 grams IV over
  5-20 minutes if pulseless and a hypomagnesium
  state.

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• Any rhythm without a pulse except V.fib/pulseless
  V.Tach is PEA (Pulseless Electrical Activity)
• Consider the causes 6Hs and 5Ts
• Hypovolemia, Toxins
  (or tablets for drug overdose)
• Hypoxia,
  Tamponade, cardiac
• Hydrogen Ion (acidosis), Tension
  Pneumothorax
• Hypo/Hyperkalemia,
  Thrombosis, coronary (MI) or pulmonary (PE)
• Hypoglycemia, Trauma
• Hypothermia
• epinephrine 1mg IV push q 3-5minutes
• or
• vasopressin 40 Units IV push (replace 1st or 2nd
  dose of epinephrine)
• Then atropine 1mg IV if HR is lt 60 bpm, push q
  3-5minutes to max dose of 3mg. In this case the
  rate is 100bpm, so no atropine.

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• Asystole-confirm in a 2nd lead
• Consider the causes 6Hs and 5Ts
• Hypovolemia, Toxins
  (or tablets for drug overdose)
• Hypoxia,
  Tamponade, cardiac
• Hydrogen Ion (acidosis), Tension
  Pneumothorax
• Hypo/Hyperkalemia,
  Thrombosis, coronary (MI) or pulmonary (PE)
• Hypoglycemia, Trauma
• Hypothermia
• epinephrine 1mg IV push q 3-5minutes
• or
• vasopressin 40 Units IV push (replace 1st or 2nd
  dose of epinephrine)
• Then atropine 1mg IV push q 3-5minutes to max
  dose of 3mg.
• Consider termination of efforts.

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Questions

• 1. Which of the following is the most important
  step to restore oxygenation and ventilation for
  the unresponsive, breathless submersion
  (near-drowning) victim?
• a. attempt to drain water from breathing passages
  by performing the Heimlich maneuver
• b. begin chest compressions
• c. provide cervical spine stabilization because a
  diving accident may have occurred
• d. open the airway and begin rescue breathing as
  soon as possible, even in the water

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• 2. Which of the following choices lists in
  correct order the major steps of CPR and
  defibrillation operation for an unresponsive
  adult victim?
• a. send someone to phone 911, check for pulse,
  attach the defibrillator electrode pads, open the
  airway, provide 2 breaths if needed, then turn on
  the defibrillator.
• b. wait for defibrillator and barrier device to
  arrive, then open the airway, provide 2 breaths
  if needed, check for pulse, and if no pulse is
  present, attach the defibrillator and follow the
  proper sequence
• c. send someone to phone 911 and get the
  defibrillator, open the airway, provide 2 breaths
  if needed, check for pulse, and if no pulse is
  present, perform CPR, attach the defibrillator
  and follow the proper sequence
• d. provide 2 breaths, check for a pulse, call for
  the defibrillator, provide chest compressions
  until the defibrillator arrives, attach the
  defibrillator.
• 3. The patient has no pulse and continues in
  V.fib. One shock was given, and still cannot
  convert the patient. What intervention would you
  do next?
• a. Secure the airway by intubating the patient.
• b. Give IV fluids rapidly, stat.
• c. Place patient in trendelenburg position.
• d Give IV Lasix, now.

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• 4. The patient was bradycardic, intubated on a
  ventilator. Suddenly, the patient becomes
  asystolic. The code team is called, CPR is
  begun. What is the first medication that should
  be given after intubation and IV placement?
• a. Give amiodarone 300mg IV push.
• b. Give lidocaine 1 to 1.5 mg/kg IV push.
• c. Give diltiazem 20mg IV push.
• d. Give epinephrine 1mg IV push.
• 5. A patient has a pulse and has an unstable
  tachycardia heart rate of 180s. What
  intervention would be appropriate?
• a. Give atropine 1mg IV push.
• b. Give epinephrine 1mg IV push.
• c. Prepare for synchronized cardioversion.
• d. Give vasopressin 40 Units IV push.

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• 6. The patient is unresponsive a code team is
  providing CPR. You are ready to move to your
  secondary assessment. What should be done first?
• a. Place an IV for epinephrine 1mg IV push.
• b. First get a set of vital signs, and then
  proceed.
• c. Secure the airway by intubating the patient.
• d. First get a chest x-ray so you know whats
  going on.
• 7. The last step of the secondary assessment is
• a. Defibrillate
• b. Transcutaneous Pacing
• c. Intubation
• d. Determine the cause

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• 8. A sixty year old is unresponsive, pulseless,
  intubated being ventilated with a bag-valve mask,
  and CPR is being performed. What is the next
  most appropriate intervention.
• a. Place an IV.
• b. Get a ventilator.
• c. Place a Foley catheter.
• d. Consult a cardiologist
• How can you tell if it is an unstable tachycardia
  or bradycardia?
• What drugs would you give to treat
  A.fib/A.flutter? SVT?
• And bradycardia?
• What are the characteristics of V.Tach? What
  would you want to check if you saw this?
• What treatments would you do for this?
• What is the difference between Cardioversion and
  Defibrillation?
• What two rhythms can you defibrillate?
• What are the characteristics of asystole? What
  do you want to confirm? How do you treat it?