Cardiovascular Pharmacology

Jerry Carley RN, MSN, MA, CNEUniversity of Southern NevadaSummer2010Cardiovascular--- EKGs / Cardiac Monitoring

Digitalis pupurea (Foxglove)Lead II

Dynamic Presentation Static PresentationPart III1Note: A Power Point Presentation is designed for active viewing (or at least, this one is!). This presentation was not designed to be the template for a handout to be printed on paper. It is designed for viewing in the Slide Show Mode.Key TermsArrhythmia & DysrhythmiaElectrical CardioversionDefibrillationThe Names of all of the rhythms & dysrhythmias

atropineamiodarone lidocaine (Xylocaine )adenosine (Adenocard )dopamineepinephrine nitroprusside (Nipride )2Physical Assessment: S/S of Decreased Cardiac Output3General Method.General ImpressionRate= ________Rhythm =_______P Waves =_______

PRI=_______QRS = _______

Fast, tight QRSs, fairly regular, no FLBsRate= 120sRhythm = RegularP Waves = Present, upright, uniform, 1:1 ratio w/QRSs, (precede QRS)PRI = 0.16 seconds, = throughout stripQRS = 0.08 seconds

4General Impression

Rate=___________Rhythm=_________P Waves: ________

PRI= __________QRS = __________Medium rate, funny-looking Ps, no FLBs

100sRegularPresent, upright, ~, biphasic, inverted, or s-shaped, 1:1 w / QRSs0.10 seconds0.08 seconds

5Normal Sinus Rhythm

RATE: 60-100RHYTHM: RegularP Waves: Upright, uniform (~), 1:1 with QRS ComplexesPR Interval: 0.12 0.20 secondsQRS: < 0.12 sec, ~6Sinus Bradycardia

RATE: < 60RHYTHM: RegularP Waves: Upright, uniform, 1:1 with QRS ComplexesPR Interval: 0.12 0.2 seconds, uniformQRS: < 0.12 sec, ~

Discussion: May be benign; Treatment Atropine IVP for Symptomatic Bradycardia7Sinus Tachycardia

RATE: 100 -150RHYTHM: RegularP Waves: Upright, uniform (~), 1:1 with QRS ComplexesPR Interval: 0.12 0.20 seconds, uniform (~)QRS: < 0.12 sec, ~Discussion: Etiology?8Atrial Flutter

RATE: Variable; RHYTHM: Regular or IrregularP Waves: Absent; Instead, heave F Waves, or Flutter WavesPR Interval: N/AQRS: < 0.12 sec

Discussion: Rhythm may be regular or irregular, depending on ventricular response. Typically expressed as a ratio,, e.g., the above would be described as Atrial flutter with a 3:1 block.

VERY COMMON AFTER ANY TYPE OF CARDIAC SURGERY;FREQUENTLY PROGRESSES TO ATRIAL FIBRILLATION;MAY BOUNCE BACK & FORTH A-Fib-Flutter or A-Flutter-Fib9Atrial Fibrillation

RATE: Variable; Rate may indicate effect on Cardiac Output (Loss of Atrial Kick, ~ 20 % C.O.) RHYTHM: IrregularP Waves: AbsentPR Interval: N/AQRS: < 0.12 sec

Discussion: -Most common dysrhythmia-Classified as AF with controlled ventricular response, AF with rapid ventricular response, Uncontrolled AF.-Treatment: Digoxin; cardioversion-Embolus Role in CVA & PE

CHF10DISCUSSION: Atrial Fibrillation

Untreated or uncontrolled Atrial fibrillation is a rapid and irregular heart arrhythmia, caused by chaotic electrical impulses in the atria of the heart (the two upper chambers). (Loss of Atrial Kick, i.e., ~ 20% of Cardiac Output)

In anatomical terms, the AV node and the ventricles (the two lower chambers) are therefore bombarded with frequent, irregular electrical impulses.

As a result, the heart rate becomes fast and irregular, and the normal coordination between the atria and the ventricles is lost.

There are several types, depending on how long the AF lasts.

When atrial fibrillation is always present, it is referred to as chronic atrial fibrillation.

When the arrhythmia is usually present, such that episodes of normal rhythm are infrequent or short-lived, it is referred to as persistent atrial fibrillation.

When a normal heart rhythm is usually present but occasional episodes of the arrhythmia occur, the patient is said to have paroxysmal atrial fibrillation.11Supraventricular Tachycardia

RATE: 151 220+RHYTHM: RegularP Waves: Absent (buried in QRS)PR Interval: N/AQRS: < 0.12 sec

Discussion: C.O. is decreased due to lack of ventricular filling time.Treatment: Vagal Maneuvers (Carotid Massage) Adenosine IVP Cardioversion

REMEMBER:Narrow-Complex Tachycardia12Discussion:Supraventricular tachycardias (SVT--PSVT)

The SVTs are generally benign (that is, non-life-threatening) tachycardias that either arise in the atria (that is, supra the ventricles), or involve the atria in the mechanism of the tachycardia.

Many SVTs are due to extra, abnormal electrical connections between the atria and the ventricles. Individuals with SVT are often born with these extra pathways. The existence of such extra pathways (often called bypass tracts) allow the formation of reentrant arrhythmias, in which an electrical impulse is established that spins continuously between the atria and the ventricles, thus causing one form of SVT.

Wolff-Parkinson-White (WPW) syndrome is a common example, but there are several other varieties of bypass tracts that can cause episodes of SVT.13Wolf-Parkinson White Syndrome

"WPW is a form of supraventricular tachycardia (fast heart rate originating above the ventricles). 14WPW. "WPW is a form of supraventricular tachycardia (fast heart rate originating above the ventricles).

When you have WPW, along with your normal conduction pathway, you have extra pathways called accessory pathways. They look like normal heart muscle, but they may: --conduct impulses faster than normal --conduct impulses in both directions

The impulses travel through the extra pathway (short cut) as well as the normal AV-HIS Purkinje system. The impulses can travel around the heart very quickly, in a circular pattern, causing the heart to beat unusually fast. This is called re-entry tachycardia. Re-entry arrythmias occur in about 50 percent of people with WPW; some may have atrial fibrillation (a common irregular heart rhythm distinguished by disorganized, rapid, and irregular heart rhythm). The greatest concern for people with WPW is the possibility of having atrial fibrillation with a fast ventricular response that worsens to ventricular fibrillation, a life-threatening arrhythmia,. 15Junctional RhythmsRATE: 40-60RHYTHM: RegularP Waves: Inverted, absent, or retrograde (after QRS)PR Interval: < 0.12 sec, or absentQRS: < 0.12 sec, ~

Discussion: Rate > 60= Accelerated Junctional Rhythm; Greater than 100= Junctional Tachycardia

A.K.A. AV Junctional RhythmsBut, this rate can be widely variable!16Junctional TachycardiaRate: 101Rhythm: Regular P Wave: inverted, = , ~, 1:1 w/QRSsPRI = 0.08-0.10 sec, ~QRS = 0.06- 0.08 sec, ~

17AV BlocksThe specialized conduction system is responsible for transmitting the hearts electrical impulses from the atria to the ventricles.

Disease in the AV node, bundle of His, or the bundle branches can lead to a condition called heart block.

Heart block occurs when the electrical impulses in the atria are stopped from reaching the ventricles. The heart rate can reach dangerously low levels when heart block is present.

A permanent pacemaker, however, takes care of the problem. 181st Degree AV Block

RATE: VariableRHYTHM: RegularP Waves: Present, upright, uniform, 1:1 ratio with QRSPR Interval: Uniform, > 0.20 secQRS: < 0.12 sec

Discussion: usually benign The above rhythm would be described as: Sinus Rhythm, 1st Degree AV Block, Rate=_______19Sinus Tachycardia, 1st Degree AV Block

202nd Degree AV Block(Mobitz I --Wenkebach--and Mobitz II)

RATE: Variable, usually slowRHYTHM: IrregularP Waves: Upright, uniform; More P waves than QRSs PR Interval: VariableType I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeatedQRS: < 0.12 sec, ~

213rd Degree AV Block

RATE: Ventricular Rate 20 - 40RHYTHM: IrregularP Waves: Upright, uniform; More P waves than QRSs; do not correlate to QRS complexes PR Interval: VariableType I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeatedQRS: > 0.12 sec

Medical Emergency: Require Pacemaker22Ventricular Tachycardia

RATE: 200+RHYTHM: RegularP Waves: N/A PR Interval: N/A

QRS: > 0.12 secWIDE & BIZARRE

Medical Emergency: V Tach with a Pulse Pulseless V-TachSynchronized CardioversionAntiarrhythmic such as Lidocaine IVP followed by continuous infusion

23DISCUSSION

Ventricular tachycardia (VT) is a rapid heart rhythm originating within the ventricles.

VT tends to disrupt the orderly contraction of the ventricular muscle, so that the ventricles ability to eject blood is often significantly reduced. That, combined with the excessive heart rate, can reduce the amount of blood actually being pumped by the heart during VT to dangerous levels.

Consequently, while patients with VT can sometimes feel relatively well, often they experience in addition to the ubiquitous palpitations extreme lightheadedness, loss of consciousness, or even sudden death.

In general, there are two kinds of VT: VT with a Pulse and VT without a pulse24Ventricular Fibrillation

RATE: Ventricular Rate 0RHYTHM: IrregularP Waves: PR Interval: N/AQRS: N/A

Medical Emergency: Cardiac Arrest

GREATEST CHANCE OF SURVIVAL= IMMEDIATE DEFIBRILLATIONFine Ventricular fibrillation25DISCUSSION:

Ventricular fibrillation (VF) is a rapid, chaotic ventricular arrhythmia that immediately brings to a halt all meaningful ventricular contractions.

Blood (Cardiac Output) therefore immediately stops flowing, and loss of consciousness occurs within seconds.

Unless cardiopulmonary resuscitation measures are initiated within a few minutes of the onset of VF, death will occur.

Electricity is the answer!26

ACLS

Advanced CardiacLifeSupport27Coarse Ventricular Fibrillation

28PACED RHYTHMS

29100% AV-Paced, 1st Degree AV BlockRate:Rhythm: P Waves + ~ =PRI=0.22 secQRS= ~ = 0.08 sec

30Asystole

31Artifact

32ECTOPY

PVC (Premature Ventricular Contraction)Identification: Irregular Rhythm -Ventricular depolarization Occurs earlier than predicted -QRS Wide & Bizarre, > 0.12 seconds -Uniform or multiform -Unifocal or multifocal -Frequent PVCs = More than 6 PVCs per minute -2 or more PVCs in a row (couplets, triplets, more)>>Unsustained V-Tach -PVC Patterns: PVC every other complex = BIGEMINY Increasing presence / severity PREDISPOSES TO V TACH V FIBBIGEMINYPharmacologic Treatment:Lidocaine IVPLidocaine Gtt;Amiodarone IVP & gtt33SR w/ PJC

Rate: 60sRhythm : IrregularP Waves: +, upright, ~ not 1:1 with QRSPRI = 0.18 secQRS = 0.06-0.08 sec34

35What Rhythm is This?NO !Check the Patient!It isnt any rhythm until you correlate it with the patients clinical condition and cardiac output !

36PEA P. E. A. Pulseless Electrical ActivityANY RHYTHM NORMALLY ASSOCIATED WITH A PULSE,WHERE NO PULSE IS PRESENT

( so if monitor shows Asystole, VF, or VT it is NOT P.E.A., since these rhythms Are NOT normally associated with a pulse).

CAUSES: Cardiac TamponadeOthers 37Sinus Tachycardia w/ BBB; PJC or PAC converting to Sinus Tachycardia w/ Ventricular AsystoleP Waves: = ~ 150 / minuteQRS = 0.12 sec (BBB) ~ until stopPRI = unable to measure

38Atrial Fibrillation w/ Ventricular Pacing (& PVC)

39VT Versus SVT

Narrow versus Wide40Diagnostic TestsSerial Cardiac Enzymes--CK-MB--Myoglobin--TroponinSerial EKGs

Pagana & Pagana, p. 322NormalRange2X3X4X5X246810121416DAYS AFTER INFARCTIONCK MBTROPONINMyoglobinChest PainCARDIAC MARKERSCARDIAC ENZYMESa.k.a. isoenzymesSerum Levels Over Time:

Rapid diagnosis in E.R.: ~15-20 minutesSXEKG changesMARKERS41REMEMBER:At the end of the day,ITS ALL ABOUTCardiacOutput!C.O. = H R & R x S V

B.P. = C.O. X P V R S V R** Tissue perfusion of vital organsand everything else.Correlate Monitor Waveforms to the Patients Condition !!!Is it a perfusing rhythm?Is the Patient PERFUSING ?!42Work On Your Own (and/or in groups)Practice Strips 1-29Determine Rate, Rhythm, P Waves, PR Interval, QRS IntervalGeneral Impression (Out to the side) Rate = #Rhythm = Regular vs IrregularP Waves: Presence (?) , Upright (?), ~ Similarity / Uniformity (?) ,1:1 w /QRSs (?)PRI = Measure & Assess: 0.12 0.2seconds ?QRS = Measure & Assess; < 0.12 seconds ? Comment: Normal or abnormal ? Cardiac Output?43