Topic: Cardiovascular Nursing, &
EKG Monitoring, part 3
Module: 2.4

Block 7.0 Module 2.4
Digitalis pupurea (Foxglove)
Dynamic Presentation
Static Presentation
Lead II

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Arrhythmia & Dysrhythmia
Electrical Cardioversion
Defibrillation
The “Names” of all of the rhythms & dysrhythmias
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 atropine amiodarone lidocaine (Xylocaine ®) adenosine (Adenocard ®) dopamine epinephrine nitroprusside (Nipride ®)
Block 7.0 Module 2.4

Block 7.0 Module 2.4

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General Impression
Rate= ________
Rhythm =_______
P Waves =_______
PRI=_______ 
QRS = _______
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Fast, “tight” QRS’s, fairly regular, no “FLB’s”
Rate= 120’s
Rhythm = Regular
P Waves = Present, upright, uniform, 1:1 ratio w/QRS’s, (precede QRS)
PRI = 0.16 seconds, = throughout strip
QRS = 0.08 seconds

 General Impression
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Rate=___________
Rhythm=_________
P Waves: ________
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PRI= __________
QRS = __________
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 Medium rate, funny-looking P’s, no
FLB’s
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100’s
Regular
Present, upright, ~, biphasic, inverted, or “s”-shaped, 1:1 w /
QRS’s
0.10 seconds
0.08 seconds

RATE: 60-100
RHYTHM: Regular
P Waves: Upright, uniform (~), 1:1 with QRS Complexes
PR Interval: 0.12 – 0.20 seconds
QRS: < 0.12 sec, ~
Block 7.0 Module 2.4

RATE: < 60
RHYTHM: Regular
P Waves: Upright, uniform, 1:1 with QRS Complexes
PR Interval: 0.12 – 0.2 seconds, uniform
QRS: < 0.12 sec, ~
Discussion: May be benign; Treatment Atropine IVP

RATE: 100 -150
RHYTHM: Regular
P Waves: Upright, uniform (~), 1:1 with QRS
Complexes
PR Interval: 0.12 – 0.20 seconds, uniform (~)
QRS: < 0.12 sec, ~
Block 7.0 Module 2.4

RATE: Variable;
RHYTHM: Regular or Irregular
P Waves: Absent; Instead, heave F – Waves, or Flutter Waves
PR Interval: N/A
QRS: < 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;
MAY “BOUNCE BACK & FORTH” “A-Fib-Flutter” or “A-Flutter-Fib”

RATE: Variable; Rate may indicate effect on Cardiac
Output (Loss of “Atrial Kick,” ~ 20 % C.O.)
RHYTHM: Irregular
P Waves: Absent
PR Interval: N/A
QRS: < 0.12 sec
Discussion:
-Most common dysrhythmia
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Classified as “AF with controlled ventricular response,” “AF with rapid ventricular response,” “Uncontrolled AF.”
-Embolus Role in CVA & PE
CHF

DISCUSSION: 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
Block 7.0 Module 2.4
arrhythmia occur, the patient is said to have paroxysmal atrial fibrillation.

RATE: 151 – 220+
RHYTHM: Regular
P Waves: Absent (buried in QRS)
PR Interval: N/A
QRS: < 0.12 sec
REMEMBER:
“Narrow-Complex Tachycardia”
Discussion:
C.O. is decreased due to lack of ventricular filling time.
Treatment:
Vagal Maneuvers (Carotid Massage)
Adenosine IVP

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.
Block 7.0 Module 2.4

"WPW is a form of supraventricular tachycardia
(fast heart rate originating above the ventricles).
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"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,.
Block 7.0 Module 2.4

A.K.A. “AV Junctional Rhythms”
But, this rate can be widely variable!
RATE: 40-60
RHYTHM: Regular
P Waves: Inverted, absent, or retrograde (after QRS)
PR Interval: < 0.12 sec, or absent
QRS: < 0.12 sec, ~
Discussion: Rate > 60= “Accelerated Junctional Rhythm;” Greater than 100= “Junctional Tachycardia”
Block 7.0 Module 2.4

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Junctional Tachycardia
Rate: 101
Rhythm: Regular
P Wave: inverted, = , ~, 1:1 w/QRS’s
PRI = 0.08-0.10 sec, ~
QRS = 0.06- 0.08 sec, ~
Block 7.0 Module 2.4

The specialized conduction system is responsible for transmitting the heart’s 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 .
Block 7.0 Module 2.4

st
RATE: Variable
RHYTHM: Regular
P Waves: Present, upright, uniform, 1:1 ratio with QRS
PR Interval: Uniform, > 0.20 sec
QRS: < 0.12 sec
Discussion: usually benign
The above rhythm would be described as:
“Sinus Rhythm, 1 st Degree AV Block, Rate=_______
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 Sinus Tachycardia, 1 st Degree AV Block
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2 nd Degree AV Block
(
Mobitz I --”Wenkebach”--and Mobitz II)
RATE: Variable, usually slow
RHYTHM: Irregular
P Waves: Upright, uniform; More P waves than QRS’s
PR Interval: Variable
Type I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeated

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RATE: Ventricular Rate 20 - 40
RHYTHM: Irregular
P Waves: Upright, uniform; More P waves than QRS’s; do not correlate to QRS complexes
PR Interval: Variable
Type I: Gradually lengthening PRI until a QRS is dropped; then the pattern is repeated
QRS: > 0.12 sec
Block 7.0 Module 2.4
Medical Emergency: Require Pacemaker

RATE : 200+
RHYTHM : Regular
P Waves : N/A
PR Interval : N/A
QRS : > 0.12 sec
“WIDE & BIZARRE”
Medical Emergency :
V Tach with a Pulse
Pulseless V-Tach
Antiarrhythmic such as Lidocaine IVP followed by continuous infusion

DISCUSSION
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 ventricle’s 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 pulse
Block 7.0 Module 2.4

RATE: Ventricular Rate 0
RHYTHM: Irregular
P Waves:
PR Interval: N/A
QRS: N/A
Medical Emergency: “Cardiac Arrest”
“Fine” Ventricular fibrillation
GREATEST CHANCE OF SURVIVAL= IMMEDIATE DEFIBRILLATION
Block 7.0 Module 2.4

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!”
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Advanced
Cardiac
Life
Support
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 “Coarse” Ventricular Fibrillation
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100% AV-Paced, 1 st Degree AV Block
Rate:
Rhythm:
P Waves + ~ =
PRI=0.22 sec
QRS= ~ = 0.08 sec
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BIGEMINY
PVC (Premature Ventricular Contraction)
Pharmacologic
Identification: Irregular Rhythm
Treatment:
-Ventricular depolarization Occurs earlier than predicted
Lidocaine IVP
QRS “Wide & Bizarre,” > 0.12 seconds
Lidocaine Gtt;
-Uniform or multiform
Amiodarone IVP
-Unifocal or multifocal
& gtt
“Frequent PVC’s” = More than 6 PVC’s per minute
2 or more PVC’s in a row (couplets, triplets, more…)>>Unsustained V-
Tach
-PVC Patterns: PVC every other complex = BIGEMINY
Block 7.0 Module 2.4
Increasing presence / severity PREDISPOSES TO V TACH V FIB

 SR w/ PJC
Rate: 60’s
Rhythm : Irregular
P Waves: +, upright, ~ not 1:1 with QRS
PRI = 0.18 sec
QRS = 0.06-0.08 sec
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NO !
Check the Patient!
It isn’t any rhythm until you correlate it with the patient’s clinical condition and cardiac output !
Block 7.0 Module 2.4

PEA P. E. A.
“Pulseless Electrical Activity”
ANY 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 Tamponade
Others
Block 7.0 Module 2.4

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Sinus Tachycardia w/ BBB; PJC or PAC converting to Sinus
Tachycardia w/ Ventricular Asystole
P Waves: = ~ 150 / minute
QRS = 0.12 sec (BBB) ~ until stop
PRI = unable to measure
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Atrial Fibrillation w/ Ventricular Pacing (& PVC)
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Block 7.0 Module 2.4

SX
• --CK-MB
• Serial Cardiac Enzymes
MARKERS
EKG changes
• --Myoglobin
• --Troponin
• Serial EKG’s a.k.a. “isoenzymes”
CK MB
Serum Levels Over Time: Pagana & Pagana, p. 322
TROPONIN
5X
Rapid diagnosis in E.R.: ~15-20 minutes
Myoglobin 4X
3X
2X
Normal
Range
Block 7.0 Module 2.4
2
Chest Pain
4 6 8 10 12 14 16
DAYS AFTER INFARCTION

At the ‘end of the day,’
C.O. = H R & R x S V
B.P. = C.O. X P V R
S V R
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Tissue perfusion of vital organs…and everything else….

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Practice Strips 1-29
Determine Rate, Rhythm, P Waves, PR Interval, QRS Interval
General Impression (Out to the side)
Rate = #
Rhythm = Regular vs Irregular
P Waves: Presence (?) , Upright (?), ~ Similarity / Uniformity (?)
,1:1 w /QRS’s (?)
PRI =
Measure & Assess: 0.12 – 0.2seconds ?
QRS = Measure & Assess; < 0.12 seconds ?
Output?
Comment: Normal or abnormal ? Cardiac
Block 7.0 Module 2.4