SA node normal rate
60-100 bpm
AV node rate as a secondary pacemaker
40-60 beats/minute
His-Purkinje system rate
20-40 beats/min
P wave represents
electrical impulse through the atrium causing atrial contraction
PR interval represents
time taken for the impulse to spread through the atria, AV node, and bundle of His
QRS complex represents time taken for depolarization (contraction) of both ventricles
time taken for depolarization (contraction) of both ventricles
ST segment represents time between ventricular depolarization and repolarization
time between ventricular depolarization and re-polarization
T wave represents
time for ventricular repolarization
QT interval represents
Time taken for entire electrical depolarization and re-polarization
Each small square on the ECG represents
0.04 seconds
Each large square represents
0.2 seconds
Stimulation of the vagus nerve does what to the SA and AV node?
Decrease rate of firing and slows impulse through AV ndoe.
What does stimulation of the sympathetic nerves do to the SA and AV node?
increases rate of firing of the SA node and increase impulse through AV node
Sinus brady is ___________ beats per minute
less than 60
What are symptoms of Sinus Bradycardia?
Fatigue, dizziness, chest pain, syncope, pale skin, hypotension, SOB, and confusion
What can cause Sinus bradycardia?
Carotid massage, valsalva maneuver, vagal stimulation
beta blockers, and calcium channel blockers
What is the treatment for Sinus Bradycardia?
Atropine,
Dopamine
Epinephrine
Sinus tachycardia is ____________ beats per minute
101-200 beats/minute
What are symptoms of Tachycardia?
dizziness, dyspnea, hypotension, angina
What is the treatment of Sinus tachycardia?
beta blockers, adenosine, calcium channel blockers
Premature Atrial Contraction (PAC)
irregular heart rhythm characterized by atrial contractions occurring before the expected time
What causes Paroxysmal Supreventricular Tachycardia?
dysrhythmias that starts anywhere above the bundle of his. It can cause a reentrant phenomenon. Termination is sometimes followed by periods of asystole
Heart rate of Paroxysmal supraventricular tachycardia?
150-220 beats per minute
Treatment for Paroxysmal supraventricular tachycardia?
vagal stimulation, IV adenosine, beta blockers, calcium channel blockers
What is the heart rate for atrial flutter?
200-350 beats per minute
What is the treatment for Atrial Flutter?
Calcium channel blockers, beta blockers, amiodarone
Cardioversion
What is the treatment for Atrial fibrillation?
calcium channel blockers, beta blockers, amiodarone, digoxin, cardioversion
What is the treatment for Junctional Dysrhythmias?
Atropine, Beta blockers, calcium channel blockers, amiodarone
Cardioversion should NOT be used
What is the characteristic of a First Degree block?
Prolonged PR interval. Greater than .20 seconds
What is the treatment for a First Degree Block?
Normally it is not a big deal and no treatment is needed. Most of the time it is asymptomatic
What is a Second Degree Block Type 1 called ?
Mobitz I or Wenchebach heart block
What is a characteristic of Second Degree Heart block type 1?
Gradual lengthening of the PR interval.
What is the treatment for Second Degree Heart block type 1?
If symptomatic, atropine
temporary pacemaker
What are characteristics of Second Degree Heart block type II?
P wave is nonconducted without progressive lengthening. It is more serious because certain number of impulses from the SA node are not conducted to the ventricles.
What is the treatment for Second degree heart block type II?
Transcutaneous pacing or the insertion of a permanent pacemaker. Atropine does not work with this block
What are the characteristics of a Three Degree Heart Block?
Complete block, No communication between atria and ventricles. No coordination. Each contract independently
What is the treatment for a a type 3 heart block?
Temporary transvenous pacemaker, dopamine and epinephrine is temporary measure to increase heart rate and support blood pressure until temporary pacing is started. The patient needs a permanent pacemaker as soon as possible. Atropine is not effective
VT without a pulse treatment
CPR and rapid defibrillation
followed by vasopressors
What is the treatment for Ventricular fibrillation?
CPR and ACLS with the use of defibrillation
Defibrillation is used for?
pulseless v tach and v fib
Cardioversion is used for?
Atrial fib and flutter, VT with pulse
Chest Tubes
...
Pneumothorax
collection of air in the pleural space
tension pneumothorax
A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side.
Pleural effusion
fluid in the pleural space
empyema
pus in the pleural cavity
What are signs and symptoms of a tension pneumothorax?
severe respiratory distress
tracheal deviation toward the unaffected side
Cyanosis
Muffled heart sounds
cardiac arrest
What is a collection of air under the skin called?
Subcutaneous emphysema
Where is the chest tube placed if you are trying to remove air?
what if you are trying to remove fluid?
Air - second interfcostal space
Fluid- 5th or 6th intercostal space
Chest tube size for infants and young children?
8FR-12FR
Chest tube size for children and young adults
16FR-20FR
Chest tube size for adults
24FR-32FR
Chest tube size for larger adults
36FR- 40FR
When should you see air bubbling in the water seal chamber?
When the patient cough, exhales, or there is a leak
What controls the amount of suction imposed on the patient?
The amount of water in the suction control chamber
Low water- less suction
More water- more suction
What are the advantages and disadvantages of a dry system?
Advantage: safe, high suction pressure, easier set up, quiet, absence of fluid that can evaporate
Disadvantage: does not provide the same level of patient assessment information as a wet system device
What are the steps in setting up a traditional water seal system?
1. Fill water seal chamber to 2cm mark
2. Fill suction control with sterile water to water level.
3. Connect to patient
4. Apply suction. Start with low suction level and gradually increase suction until a gentle bubbling in the suction control chamber is
What type of dressing is used for chest tubes?
Occlusive dressing
A rise in water seal indicates
negative pressure is present in the pleural space (confirms healing)
When recording intrathoacic pressure in a unit on suction- what do you do?
Add the readings of suction control chamber plus the level of water seal chamber
Bubbling in the water seal indicates
air leak
What amount of drainage should be reported the provider in an hour?
over 200 in the first hour is bad and should be reported to the provider
How should you check for leaks?
starting away from the patient and going towards the patient, check all connections
Lastly change the dressing
Blood Administration
...
Why do you only use whole blood when absolutely needed or when individual blood products components are available?
The use of whole blood has a greater effect on fluid volume than any of the components does
What do red blood cells do?
Raise the hematocrit and hemoglobin levels without significantly increasing blood volume
This component is transfused to restore or maintain adequate organ oxygenation
What is plasma?
Liquid portion of blood. 92% water and 7% plasma proteins
What does plasma do?
maintains blood pressure, provides essention proteins, vital minerals and electrolytes.
What is plasma used for?
bleeding and coagulation disorders, replace fluid volume, replace platelet aggregating inhibitors
What is albumin used for?
maintaining blood pressure and blood volume
What is Cryoprecipitate antihemophilic factor?
component prepared by slowly thawing frozen plasma and recovering the precipitate which contains coagulation factors
T or F: O has AB antigens
False, O has neighter antigen
Who are the universal donors?
Type O
Who are universal recipients?
Type AB
T or F: AB plasma donors can give to all blood types
True
T or F: RH negative individuals may donate to RH positive recipients but should only receive RH negative blood to prevent formation of anti-D antibodies
True
What specific compatibilities are needed for whole blood transfusions?
ABO & RH
What specific compatibilities are needed for Red blood cell and platelet transfusions?
ABO & Rh compatible
What specific compatibilites are needed for Fresh frozen plasma ?
ABO but no Rh
What size needle do you use for blood administration?
22 gauge
A person who has the D antigen is RH ____________
positive
How long should you remain with the patient in the beginning of the transfusion?
15 mins
The rate of the infusion in the first 15 mins should be
2mL/minute
How often should you take vitals and monitor the patient with blood administration?
Take Vitals before the transfusion
After 15 minutes
Every 30 mins up to an hour after
Infusion of blood should take no longer than _________ hours to administer
4
What is an Acute Hemolytic Reaction?
Your blood is incompatible. Antibodies in the recipient's plasma attach to antigens on transfused RBCs causing destruction
What are manifestations of Acute Hemolytic reaction
usually develops in first 15 minutes
Fever, chills, low back pain, abdominal chest or flank pain, flushing, tachycardia, dyspnea, tachypnea, hypotension vascular collpase, bleeding ]
Initial symptoms are pain at the IV site, elevated heart rate, chills, f
What should you do for acute hemolytic reaction?
maintain BP with IV colloid solutions
give diuretics as prescribed
What is a Febrile nonhemolytic reaction (most common)
Sensitization to donor WBC, platelets, or plasma protein
What are the manifestations of Febrile nonhemolytic reaction?
Sudden chills, rigors, fever (rise in temperature of > 1 degree celcius), headache, flushing, anxiety, vomiting, muscle pain
What is the management of Febrile nonhemolytic reaction?
antipyretics
Avoid aspirin in thrombocytopenic patients
What are manifestations of Circulatory overload?
cough, dyspnea, pulmonary congestion, adventitious breath sounds, headache, hypertension, tachycardia, distended neck veins
What is the management for Circulatory overload?
Place patient upright with feet in dependent position, obtain chest xray stat is ordered, administer prescribed diuretics, O2 and morphone
What are the manifestations of Sepsis?
Rapid onset of chills
High fever
vomiting
diarrhea
Hypo-tension or shock
What is the classic sign of Sepsis?
Hypotension
What is Transfusion Related Acute Lung Injury?
reaction between transfused antileukocyte antibodies and recipient's leukocytes causing pulmonary inflammation and capillary leak.. Can han happen anytime and up to 6 hour after
What are manifestations of TRALI?
Fever
chills
hypotension
tachypnea
frothy sputum
dyspnea
hypoemia
respiratory failure
noncardiogenic pulmonary edema
What is the management of TRALI?
Draw blood for arterial blood gases and HLA
Obtain Chest x-ray STAT
Provide o2 and administer corticosteroids as ordered
When should you suspect a TRALI reaction?
patient has difficulty breathing or the onset of pulmonary edema in the absence of fluid overload or cardiac dysfunction
What should you monitor for a Massive Blood Transfusion?
RBC transfusion does not contain clotting factors, albumin or platelets. We need to monitor clotting status and electrolyte levels.
What are manifestations of Massive Blood Transfusion?
hypothermia, dysrhythmias, hypocalcemia, hyperkalemia
What are some signs of a delayed hemolytic reaction?
Fever, mild jaundice, decrease hemoglobin
occurs as early as three days or as late as several months
T or F: Delayed hemolytic reaction generally does not need treatment
True
What is graft vs host disease?
When T lymphocytes in the transfused component attack and react against tissue antigens in the recipient.
What are the manifestations of Graft versus host diease?
skin rash, fever, jaundice, bone marrow suppression.
Pacemakers
...
When do you use a pacemaker?
Heart blocks (3rd degree or 2nd degree advanced)
Symptomatic Bradycardia,
tachycardia (less common)
What are the four types of pacemakers?
Transcutaneous
Temporary Epicardial
Temporary Endocardial (transvenous)
Permanent
What are symptoms for symptomatic bradycardia that needs pacing?
Dizziness, lightheadedness, SOB, Hypotensive, diaphoretic
symptoms should go away with pacing
What is the post procedure care for someone with a permanent pacemaker?
up and moving around but limit arm and shoulder activity
arm will be in a sling
What is the post procedure care for someone with a temporary pacemaker?
we don't really want them moving a whole lot
Medications for:
Sinus Bradycardia
Atropine
Pacemaker
Medications for:
Sinus Tachycardia
Vagal Maneuver
Beta blockers (metoprolol)
Medications for:
Premature Atrial Contraction
Beta blockers (metoprolol)
Medications for:
Paroxysmal Superventricular Ventricular Tachycardia
Vagal stimulation
IV adenosine
IV beta blockers
Amiodarone
Cardioversion
Medications for:
Atrial Flutter
Calcium channel blockers
Beta blockers
Convert a flutter to normal sinus = ibutilide
Maintain normal sinus rhythm - amiodarone
cardioversion
radiofrequency ablation
Medications for:
Atrial Fibrillation
Amiodarone
Ibutilide
Cardioversion
Anticoagulation
Radiofrequency ablation
Cryoblation, Dig
Medications for:
Junctional Dysrhythmia
Atropine for escape rhythm
Beta blockers
Calcium channel blockers
Amiodarone
Medications for:
First degree heart block
No treatment
Medications for:
2 degree heart block type I
Symptomatic
- atropine
- pacemaker
asymptomatic
- monitor
Medications for:
2 degree heart block type II
permanent pacemaker
Medications for:
Third Degree
Trancutaneous pacemaker till temporary transvenous pacemaker then permanent
Dopamine and Epinephrine
Medications for:
PVC
Beta blockers
Procainamide
Amiodarone
Medications for:
VT with pulse
antidysrhythmics
cardioversion
Medications for:
VT without pulse
CPR
rapid defibrillation
vasopressors - epinephrine
Amiodarone
Medications for:
Ventricular Fibrillation
CPR
Defibrillation
epinephrine
vasopressin
Medications for:
Asystole
CPR
Defibrillation
Epinephrine
Vasopressin
Intubation