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BasicBasic ArrythmiasArrythmias

Dr. Amban Gowda


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During the lecture time, write your questions

down on a piece of paper. Keep them until you see

the slides labeled, Check Your Pulse. These

will come up every so often and this is a pause

point for us to clarify any questions before moving

forward. Please hold questions until that point.

Thank you !


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Starting with the Basics

What are the functions of the heart?Electrical: impulse

Mechanical: pump contraction

What is the normal blood flow through

the heart?

What is the normal electrical pathway conduction?Nodes (SA, AV, Bundle)

Inherent Rates


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Electrical Conduction PathwaySA Node pacemaker of

the heart (60-100bpm)

AV Node junction of the

atria and ventricles (40-60bpm)

Bundles Bundle of His

connects the AV node to the

bundle branches (20-40bpm)


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Normal Cardiac Cycle

Systole Diastole

Electrical Depolarizationactivate

Repolarizationrecovery

Mechanical Contractempty

Relaxfill


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EKG - Electrocardiogram

An EKG is a useful tool for diagnosing a

variety of cardiac abnormalities. It displays the

activity of the hearts electrical impulse flow through

the conduction system.

What does it tell us?

the electrical conduction through the heart

areas of ischemia or myocardial damage LV Hypertrophy

electrolyte disturbances / drug toxicity


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and this Leads to . Electrodes

Positive and Negative Charges

12 Lead EKGs

Most pts in 5 leads

Where do you put those darn patches anyways? Mnemonic to remember lead placement


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What Is In Each Beat?(the cardiac cycle in waves, complexes, and intervals)

P Waveatrial contraction or depolarization, (usually upright)

QRSComplextime for ventricular contraction or depolarization(usually upright) (0.04 - 0.12sec) (delays in the bundle branches will widen the

QRS)

T Waveventricular repolarization recharging (usually upright)

PRIntervaltime between atrial depolarization to ventriculardepolarization (beginning of P wave to beginning of QRS)(0.12 - 0.20sec)

(prolonged PR = delays in the AV node conduction)

QT Intervalrepresents one complete ventricular depolarization andrepolarization (beginning of QRS to the end of the T wave) (0.32 0.44sec)

(disturbances are usually due to electrolyte disturbances or drug effects)


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EKG Tracing .

Grid Paper

Each small box = 0.04 seconds

Each large box = 0.20 seconds (5 small boxesacross)

One second is 5 large boxes

Three seconds is 15 large boxes

Six seconds is 30 large boxes

Each minute has 300 large boxes


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Reading a Rhythm Strip

What Do I Look For? Regularity - What is the R R Interval?

Rate - Is the rate normal (60-100), slow, or fast?

***Six-second strip method - (30 big boxes) &

multiply times ten

P Wave Is there a P wave before every QRS? Is itupright?

QRSComplex Is there a normal QRS complexfollowing each P wave? Wide or normal?

T wave How does your T wave look? Upright?

Measure your intervals PR Interval, QRS, QT


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Practice Strip


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Check Your Pulse


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Match the Rhythm with the Pt After assessing the EKG strip in a

systematic method, gather the information

about your pts assessment: med hx, s/sx,labs.

Does the rhythm make sense for the pt?

What is going on with the pt?2ndlevel assessment


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What is Normal?

NormalS

inus RhythmThe electrical impulse originates in the SA Node

1) Rhythm Regular (R to R Interval)

2) Rate Regular (60 100 beats/minute)

3) P wave before every QRS complex

4) QRS complex narrow, not wide (0.04-0.10sec)


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ASlight Deviation from Normal

too slow and too fast

Sinus Bradycardia1st Level Assessment

Rate? (less than 60bpm)

Symptoms? (subjective and objective)

2nd Level Assessment

Reasons? Etiology?

Nursing Interventions

Pharmacology


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Sinus Tachycardia

1st Level Assessment

Rate? (> than 100)

Symptoms? (subjective and objective)


Reasons? Etiology?

Nursing Interventions


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What is an Arrythmia anyways? Definition: a disorder of impulse formation.An

abnormal electrical conduction that changes theheart rate and rhythm.A disturbance in thehearts rhythm.

Why? Causes?

1) Classified according to their origin

2) Some are mild, asymptomatic require no treatment3) Some are catastrophic require immediate emergency

response

4) They can influence cardiac output and blood pressure


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Clinical Significance

Thousands of people suffer witharrythmias

Dysrhythmias are responsible for over44,000 deaths each year.

There site of origin can often lead us tothe problem area

About 15% of strokes occur in patientswith atrial arrythmias

A large majority of sudden cardiacdeaths are thought to be caused byventricular dysrhythmias.


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What is The Big Deal?

Why are we so concerned with Arrythmias?

SV x HR = CO

SV dependent on filling time, adequate volume, andmyocardial muscle function

HRdependent on electrical stimulus, Autonomic NS,Parasympathetic NS

Too Fast

Too Slow NOT GOOD!!!Too Irregular


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Some of you might be feeling a bitoverwhelmed at this time .


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Atrial Arrythmias

Atrial arrythmias occur because there are

other pacemakers in the atria competing tobe the commander

SA Node is not healthy and unable to lead


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Atrial Fibrillation

Results from disorganization of atrial electricalactivity without effective atrial contraction.Repetitive, irregular, uncontrolled depolarization.Atrial rate ~ 350-600 bpm,Ventricle - varies

No P Wave! Very jiggly baseline wave

No PR Interval

Irregular with a wavy baseline

Rate - Controlled vs. Uncontrolled Loss of Atrial Kick

Emboli Potential


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Atrial Fibrillation

1st Level Assessment


Nursing Consideration

Pharmacologic Consideration

Digoxin

Ca+ Channel Blockers Beta Blockers

Coumadin


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On Your Own .

You are responsible for reviewing pharmacology re: arrhythmias:

Please know the actions, doses, side effects, nursing

considerations, monitoring, precautions, therapeutic druglevels, s/sx toxicity for the following drugs:

Digoxin

Ca+ Channel Blockers (verapamil, diltiazem) Beta Blockers (atenolol, metoprolol)

Anticoagulants (warfarin)


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Results from the atria stimulated to contract 250-350bpm in a circuit fashion around the atrium

No true P waves F waves larger than P

waves (flutter waves) Sawtooth-shaped waves

Usually a regular rhythm D/T AV Node filter

Ventricular Rate atria to ventricle ratio (2:1 or4:1)

Assessment and treatment the same as Atrial Fib

Atrial Flutter


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The Basic Blocks

First Degree AV Block

Third Degree Block

(AKA) Complete Heart Block

Etiology, 1st and 2nd Level Assessment, Intervention


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Check Your Pulse!


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From the Bottom of My Heart

Arrythmias stemming from the ventricles. Occurs when apacemaker in the ventricles initiate a beat or a whole rhythm

PrematureVentricularContraction (PVC) FLB

QRS wide and bizarre

Ventricular Tachycardia (VTach)

3 or more ventricular ectopic complexes (PVCs)

Rate greater than 140-250bpm

QRS complex wide and aberrant


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S

ustainedV

T

ach


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Treatment for PVCs / VTach

Dependent on patients condition

How frequent are the PVCs: unifocal, multifocal,healthy heart?

Pulse? No Pulse?

Labs? Particularly K+ and Mg+ levels?

Sustained ? Non-sustained?


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Bundle Branch Block

The Road Detour

Interruption of conduction

in one of the main branches

of the Bundle of His

Normal conduction

through the bundles?

Why interruptions?

QRS wide greater than

0.12 seconds


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Dont Just Stand There!

ASYSTOLE(please, not on my shift )

AKA flatline, cardiac standstill

Etiology

Nursing Assessment and Intervention

Pharmacological Considerations


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And you may feel like all rhythms look alikeLook Closely and you will see the differences!


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STSegment Depression

Infarcted


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Check Your Pulse


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? Immediate Nursing Question ?

How does my patient look?

Do they have any symptoms? (what are symptoms of low CO?)

Do they have a normal or diseased heart?

This can buy you time!!!

(to assess and gather more information about the patients condition)


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Top Nursing Priorities

Check the patient (LOC?)

ABC airway, breathing, circulation

Oxygen administration

IVAccess / PatencyElectrode placement

Associated Symptoms? Chest pain, SOB,dyspnea, vertigo, nausea

Fluids

MonitorVS


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Fast Assessment and Identification of the

problem are key Nursing Priorities

In the cardiac world, time is

oxygen. The longer you delay

reaction to arrhythmias, the

longer the heart suffers. Dont

let your patient circle the

drain!


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Pharmacologic Considerations

Above the AV NODE (Atrial) (ABCD) Too Slow Atropine

Too Fast Beta Blockers

Calcium Channel BlockersDigoxin

Amiodarone

Below the AV NODE (Ventricular) (LAP) Too Fast Lidocaine

AmiodaroneProcainamide


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Too Slow ..

Treatment forSymptomatic Bradycardia

is Atropine (check your patient first)

Classification: Antidysrhythmic/Anticholinergic

Common dose: 0.5mg 1.0mg up to 2mg IVP

How to give: given every 3-5 minutesSE: hypotension, angina, tachycardia, PVCs, dry mouth


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Too Fast

Uncontrolled Atrial Fibrillation

- Beta Blockers (Lopressor, Labetolol)

- Calcium Channel Blockers (Cardizem,

Verapamil)

- Glycosides/Inotropes (Digoxin)

Ventricular Arrhythmias

- Antiarrythmics (Lidocaine, Procainamide,

Amiodarone)


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Practice on your Own

Antiarrhythmic IV Drips

Lidocaine bolus of 50-100mg (1mg/kg) over 2-3 minutes

IV Drip: (1gm/250ccs) or (2Gm/500ccs) to run at1-4mg/min

How to figure that in ml/hr for a pump ..

Know nursing considerations / monitoring and

s/sx of toxicity


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Non Pharmacologic Treatment

Electroshock Cardioversion

Unstable tachy rhythms

Ablation

Defibrillation (and internals)

Nursing Consideration and Care

***Look at Patient Teaching in Table 35-9


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Pacemakers

I. External Pacing noninvasivetemporary with patches on chest wall

II. Internal Pacing invasive

temporary internal through the femoral

arteriesIII. Permanent Pacemaker inserted through the chest

wall open heart

IV. Modes: Demand or Override

*** Review Pt Teaching with a pacemaker


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Case Study ExampleMrs. Taylor has become more forgetful lately.

She has trouble managing her medications. Sheis supposed to take (1) Digoxin in the morning,but sometimes she takes one at night. As aresult, her Digoxin level has reached toxiclevels. She comes to the ER with nausea,vomiting, fatigue, vision changes. You put heron the EKG monitor and she is in 3rd degree

heart block with a HR of 32. Her blood pressureis 70/40. The ER doctor orders for you to puther on an external pacemaker. She will remainon this pacemaker to maintain an adequate HR

and CO until her Dig toxicity resolves.


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We are done for the day!


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Additional References

http://medlineplus.gov

http://www.nurse411.com

click on: educational links

click on: basic EKG tutorial, put in your name,and push play

Adams, M., Josephsen, D., Holland, L. (2005).Pharmacology for Nurses: A pathophysiologicapproach. New Jersey: Prentice Hall.


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FurtherStudy on Your Own

Taking it a step further ..

Challenge yourself


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The Health of the Heart Walls

The heart is composed of four walls and each

of the walls is fed oxygen through direct

and indirect blood flow.

This blood flow is delivered by coronary

arteries and through collateral circulation.


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Heart Walls

Anterior Wall

Includes most of the left ventricle, the intraventricular

septum

Inferior Wall

Includes most of the right ventricle and some of the

left ventricle, extends down to the apex

Lateral WallLocated on the left side of the heart (no right heart

involvement)

Posterior WallLies along the back of the heart


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Coronary Artery Supply

Right Coronary Artery Left Main Coronary Artery

Left Circumflex Coronary Artery

Left Anterior Descending

Right Coronary Artery


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Right Coronary Artery

feeds the right atrium and ventricle

inferior wall

posterior wall

SA Node and AV Node (in most people)

Left Anterior Descending

anterior wall and intraventricular septum

apex of the heart

papillary muscles

bundle branches

Circumflex

lateral and posterior wall of L Ventricle


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How Does This Tie To The EKG?

When one looks at an EKG and

notices disturbances or problems

in certain areas of the heart, it

is useful to understand whichcoronary artery supplies that

area. This can help you identify

the vessel where blood supply is

possibly compromised

(arteriosclerotic changes)


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ExampleA patient that came into the hospital with SickSinusSyndrome (SA Node is not feeling well) and was inSymptomatic Sinus Bradycardia may go for a CoronaryAngiogram. During this procedure, the MD may find that

they have atherosclerotic changes and blocks in their RightCoronary Artery that feeds blood supply (and O2) to thatnode. Without proper blood supply, that area is unable to

perform normal electrical conduction and begins to showdisturbances (arrhythmias). This patient may need to have

an angioplasty or stent placement or CABG to open up thatarea to better blood supply.


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Additional References

http://medlineplus.gov

http://www.nurse411.com

click on: educational links

click on: basic EKG tutorial, put in your name,and push play

Adams, M., Josephsen, D., Holland, L. (2005).Pharmacology for Nurses: A pathophysiologicapproach. New Jersey: Prentice Hall.

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