reading ekg paper with measurements
artifacts
patient movement
loose or defective electrodes
improper grounding
faulty ekg apparatus
Normal sinus rhythms
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Sinus bradycardia
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Factors associated with sinus bradycardia
During sleep and in athletes------ Normal
acute right inferior wall MI
As a reperfusion rhythm after coronary angioplasty
Vagal stimulation from vomiting, bearing down or carotid sinus pressure
Vasovagal reaction
Carotid sinus hypersensitivity syndrome
De
Sinus tachycardia
...
Sinus arrythmia
associated with respirations
Sinus arrest
atrial kick
extra push of blood to the ventricles
atrial flutter
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atrial fibrillation
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SVT
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junctional arrhythmias
p waves may be inverted ,absent or follows after a QRS
junctional escape rhythm
rate 40 - 60 beats/min
accelerated junctional rhythm
rate 60-100
junctional tachycardia
rate 100-180
Atrioventricular heart blocks
there is a delayed conduction or failed conduction of impulses through the av node into the ventricles
ist degree AV block
schlerosis/dig toxicity/certain meds
MI/infarction
valvular heart disease/myocarditis
2nd degree type 1 (Mobitz 1 or Wenckebach)
same as 1st degree etiology
2nd degree type 2 (Mobitz II)
same as 1st degree etiology
3rd degree av block (complete heart block)
new MI-acute inferior wall MI
increased vagal tone/Digoxin/age
2nd degree progressed/hyperkalemia/conduction problems
pacemaker indications
av blocks,brady and tachy arrthmias
hypersensitive carotid stimulus
pacemaker parts
pulse generator
pacing leads
electrodes
3 adjustable parameters on the pulse gen
output(mA) ,rate,sensitivity (mV)
temporary pacemakers
transcutaneous,transvenous( RIJ or L subclavian)
epicardial
permanent pacemakers
single chamber,dual chamber,biventricular
modes of pacing
fixed-rate mode
demand mode
TCP nursing care
sedation and analgesia
skin inspection
CPR may be performed on top
ensure capture is maintained
TVP nursing care
cxr post procedure to r/o pneumothorax
monitor sensing and pacing
do not attempt to reposition pacing electrodes
keep atropine and pads at bedside
plastic bag the pulse gen
complete bedrest!
PPM nursing care
immobilize 24-48h
no lifting or raising arm above the head 4-6 weeks
keep incision clean
keep pads/paddles 2 inches away from device
interrogate after defib
DO NOT TOY Twiddler Syndrome-displace leads
ICD nursing care
magnet over ICD during compressions or intubation
VVIR
DDDR
ventricular is paced,ventricle is sensed,inhibited pacing,rate responsive
dual paced,dual sensed,dual response,tate responsive
Atrial paced rhythm
ventricular paced rhythm
dual paced rhythm
failure to fire
pacer turned off
battery depletion
disconnection
fracture of lead
electromagnetic interference
failure to capture
mA output is too low
lead is out of position or lying in infarcted tissue(turn pt to his L side)
electrolyte imbalance(high K+)
Ventricular rhythms
originate in the ventricles
V tach
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V fib
...
IVR -idioventricular rhythm
P wave-none
rhytm-regular
rate 20-40
accelerated IVR
rate 40-100
asystole
agonal rhythm
if rate if IVR < 20 and qrs is indistinguishable waveform
PEA pulseless electrical activity
Check H's and T's
hypoxia,hydrogen ion,hypo or hyperkalemia,hypothermia,hypovolemia
tension pneumothorax,tamponade,toxins,thrombus
TTM- Targeted temperature management n(therapeutic hypothermia)
cooling the patient to slow metabolism preserving brain function after cardiac arrest
PVC's
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PAC's
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PJCs (Premature Junctional Contractions)
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EKG leads:
bipolar leads
Bipolar limb leads (r arm l arm l leg)
EKG leads
augmented leads
avr avl avf
Precordial leads
10 electrodes = 12 leads
...
ST Elevation Myocardial Infarction (STEMI)
st elevation > 1mm
st depression >0.5 mm
new LBBB
dynamic T wave inversion
pronounced j point
Reciprocal leads
Drugs
absorption,disctribution,metabolization,elimination
Pharmacodynamics
what the drug does to the body-effect and side effects
Pharmacokinetics
what the body does to the drug- oral/digested/absorbed in the small intestine,broken down and exreted -liver and kidneys
half-life
the time it takes for plasma concentration of a drug to fall to half of its original value
postive inotropes
stimulate and increase heart contraction
dig,dopamine,dobutamine
negative inotropes
decreases strength of a contraction
betablockers- metoprolol/calcium channel blockers (cardizem,verapamil)
chonotropic drugs (+ drugs)
increase heart rate - Atropine,dopamine,epi
chonotropic drugs (- drugs)
decrease heart rate-dig,calcium channel blockers(cardizem)
preload
the amount of blood in the ventricle before it contracts
Afterload
how hard the heart has to push to get blood out
vt/v fib
amiodarone300mg iv then 150 after 3-5 mins
procainamide
lidocaine
SVT
adenosine 6mg iv rapid + 20 ml nss push/elevate arm
rpt 12 mg in 1-2 mins if needed
rate control
cardizem 15-20 mg iv bolus over 2 mins
bradycardia/vagolytic
atropine .5 mg iv every 3-5 mins x 6 doses = 3mg
vasoactive meds
positive or negative that affects the contractility of the heart
used for hypotension, low cardiac output and shock
vasodilator
widening of the blood vessels for increase blood flow
reduces afterload
used to prevent angina
nitro,nimpride
vasopressors/fvasoconstrictor
to increase blood pressure
Levophed- regitine to treat extravasation
neosyneprine-treat sepsis-treat with phentolamine for extravasation
epi-1mg every 3 mins in cardiac arrest
inotrope
dopamine -for hypotension,treat with phentolamine for extravasation
dobutamine-for CHF
alpha/beta adrenergic
Labetolol 20mg iv over 2 mins
calcium channel blocker
cardene for hypertension
CHF
natrecor,dobutamine,lasix
hyperkalemia
calcium chloride
sodium bicarb 50mg
glucose 25gms
regular insulin 10 units
nebulized albuterol 20mg over 15 mins
anaesthesia/sedation
Diprivan