Telemetry/EKG/
Pacers
MCC NURSING
DIANA BLUM MSN
2
A
dysrhythmia is a disturbance of the
rhythm of the heart caused by a problem
in the conduction system.
 Categorized by site of origin: atrial , AV
nodal, ventricular
 Blocks are interruptions in impulse
conduction: 1st, 2nd type 1&2, 3rd or
complete heart block
5
6
P wave
Measures:
0.12-0.20
7
QRS WAVE
Measures:
0.06-0.12
8
QT Wave
Measures
approx 0.340.43 secs
Calculating Heart Rate
 Quick




Estimate: The 6-second Method
- count the # of QRS complexes in a 6 sec.
length of strip & multiply by 10
(the second mark is = to 5 large boxes)
This can be used is rhythm is reg or unreg.
11
Each small box measures 0.04
1 big box (5 small boxes) is equal to a HR of 300
2 big boxes is hr of 150
3 big boxes is hr of 100
4 big boxes is hr of 75
5 big boxes is hr of 60
6 big boxes is hr of 50
7 big boxes is hr of 43
8 big boxes is hr of 38
Large box estimate of heart rate
works with regular rhythms
 Count
small boxes between two R waves.
Divide into1500 Gives BPM
14
Atrial arrythmias
 Normal
sinus rhythm
 Sinus tachycardia
 Sinus bradycardia
 Premature atrial contraction (PAC)
 Supraventricular tachycardia
 Atrial flutter
 Atrial fibrillation
15
Ventricular arrythmias
 Junctional
 AV
rhythm
blocks
 Premature junctional rhythm
 Premature ventricular contraction (PVC)
 Ventricular Tachycardia (V-tach)
 Ventricular Fibrillation (V-Fib)
 Torsade de Pointes (TdP)
 Pulseless electrical activity (PEA)
 Asystole
ARTIFACT
17
NSR
18
 Hr=
60-100 bpm
 On strip it looks regular but does not map
out
 PR interval= 0.12-0.20
19
HR 40-60 bpm
<60 bpm is accelerated
Rhythm is regular
Pwaves not always present
20
Junctional Rhythm
21
SB
22
ST
23
Supraventricular Tachycardia
24
SVT converted with Adenosine
given rapid IV Push stimulates
vagal response.
S/E: flushing,bronchospasm,AVblock
25
AV Blocks
 First
degree block
 Second degree block Type I (Wenchebach)
 Second degree block Type II (Mobitz II)
 Third degree block
 Bundle branch block
26
Rate is usually WNL
Rhythm is regular
Pwaves are normal in size and shape
The PR interval is prolonged (>0.20 sec) but constant
27
Pwaves are normal in size and shape;
Some pwaves are not followed by QRS
PR interval: lengthens with each cycle until it appears without QRS Complex
then the cycle starts over
QRS is usually narrow
http://www.youtube.com/watch?v=G
VxJJ2DBPiQ&feature=related
29
Ventricular rate is usually slow
Rhythm is irregular
Pwaves are normal in size and shape (more pwaves than QRS)
PR interval is within normal limits
QRS is usually wide
30
Ventricular rate is regular but there is no correlation between pwaves and
QRS
Pwaves are normal in size and shape
No true PR interval
31
Atrial Fibrillation
Erratic wavy base
Pr is not measurable
QRS 0.10 sec or less usually
http://www.youtube.com/watch?v=VKxQgjj2yVU&feature=related
32
Afib causes :
 Chocolate
large amounts: contains
theobromine, a mild cardiac stimulant.
 - sleep apnea
 - athletes more prone (enlarged heart)
 - tall athletes (esp basketball players)
 - aging heart
 - men more than women
 - sleeping on left side or stomach
 etc.
33
A-fib treatment:
 ASA
not as effective as Coumadin in
preventing strokes.
 ASA less likely to cause abnorm bleeding
 **since hemorrhagic stroke increases with
age & is also increased by taking
Coumadin, some Drs. may switch older
pts from Coumadin to ASA.
34
A Fib electrical cardioversion:
 High
risk of forming clots & causing stroke
 Anticoagulants taken before treatment
and 3-4 weeks post treatment
 If life-threatening, may need Heparin IV
before cardioversion
 Best
time: recent A fib
35
Atrial rate of 250-450 bpm ventricular rate varies
Atrial rhythm is regular ventricular rate is
irregular
No identifiable p waves
P wave is not measurable
Qrs: 0.10 or less usually
36
Atrial fib/flutter
37
Pacer spike should fall before the P wave unless a dual
Chamber pacemaker; if it does not there could be a problem
38
PAC
39
Extra beat
Types
uniform=go the same direction
multifocal= go in different direction
R on T=when the pvc fall on the preceding twave
couplet= 2 pvcs together
bigeminy= pvc every other beat
trigeminy=pvc every third beat
40
PVCs (unifocal)
41
PVCs (multifocal)
42
Ventricular tachycardia
Monomorphic: beats are same size and shape
Polymorphic: different size and shape
43
This is a polymorphic VT
Usually electrical imbalance in nature r/t NA+ or K+
44
46
Ventricular Fibrillation
Rate can not be determined
because of no identifiable waves
Rapid chaotic rhythm with no
pattern
No p waves
No PR interval
No QRS
47
Vtach/Vfib
 Both
can be life threatening
 VT= V HR 100-250 bpm
 Causes: AMI, CAD, hypokalemia, dig toxic
 S/S: palpitations, dizzy, angina, <LOC
 Treatment: assess for pulse, if none, defib
 VF=Rate undeterminable Cause: same
 Treatment: CPR
48
Asystole
49
Asystole and PEA
 CPR
Oxygen
 Epinephrine 1 mg IV/IO (repeat 3-5 minutes)
 May give Vasopressin 40U IV/IO to replace

1st or 2nd dose of epinephrine
 Consider Atropine 1 mg IV/IO Repeat every 3 to 5
min (up to 3 doses)
 http://videos.reinolla.tv/winners/pe/
ST elevation
5 Steps to 12 Lead Interpretation
1. Assess regularity and speed
2. Look for signs of infarction
3. Present in >1 lead, but not all?
4. Assess associated conditions
5. Correlate with clinical
condition
Normal EKG
MI
Polymorphic VT
VFIB
57
58
59
60

http://nursebob.com/

http://www.usfca.edu/fac_staff/ritter/ekg.htm

http://ems-safety.com/12-lead-ekg.htm
62
Rhythms for Cardioversion
 A-fib
 A-flutter
 Supraventricular
tachycardia




Post cardioversion care:
1. generally the care for a patient tells
cardioversion is the same as for the fibrillation.
2. If it is a elective procedure, digoxin is usually
withheld for 48 hours prior to cardioversion to
prevent dysrhythmias after the procedure.
3. Airway patency should be maintained and
the patient state of consciousness should be
evaluated.
64
Indications for pacemaker
 Temporary:

-symptomatic
bradycardia (not
controlled by meds)

- ant MI

- drug overdose (dig, beta blocker)
 Permanent:

- 2nd degree Mobitz Type II

- 3rd degree Block

- symptomatic bradycardia,
arrhythmias

- suppress tachyarrythmias
Position of the letter
Designation
1st letter
Chamber being paced (A=atrium, V=ventricle, 0=none)
2nd letter
Chamber being sensed (A=atrium, V=ventricle, 0=none)
3rd letter
Pacing Mode (O=none, I=inhibited, T=triggered,
D=dual)
4th letter
Rate Response (R=rate response is on)
66
Chambers that can be paced:
Atrium
Ventricle
Dual (both atrium and ventricle)
ICD (Implantable Cardioverter Defibrillator)
Dual Paced
 Atrial
Pace, Ventricular Pace (AP/VP)
AV
AP
VP
V-A
AV
AP
VP
V-A
68
ICD
-
prevents sudden cardiac death due to
 V-tach or V-fib.
 Pt can feel the shock

-defib felt like “kick in the chest”

that lasts 1 second

- cardiovert feels like “thump in chest

- pt doesn’t feel pacing
69
Operative failures with pacers:
 Pneumothorax
 Pericarditis
 Infection
 Hematoma
 Lead
dislodgement (seen on X-ray)
 Venous thrombosis (rare but would see

unilateral edema to arm on same side

as pacer)
70
Pt Education:













1. carry ID card (Xray code seen in standard chest Xray)
2. not allowed to drive for 1 month
3. no metal detectors or no longer than nec.
4. MRI interrupts pacing-can’t get one for some time if new
5. No power generators (welding)
6. microwave questionable
7. radiotherapy (may damage circuits) The
pacer may need to be surgically moved if in
path of radiation field.
8. TENS (transcutaneous electrical stimulation) interferes
may need reprogramming
9. Cell phone use in opposite ear of pacer and store away
from side of pacer
EP with Ablation
An electrophysiology study is simply a
study of the electrical function of your
heart.
72
Bundle Branch Blocks:
Diagnosed with 12 lead EKG:
most common cause: acute MI
 Right
bundle branch block:
 - impulse travels through left ventricle
first, then activates right ventricle (gives
am “M” shaped complex
 Left bundle branch block:

--impulse first depolarizes right side of
heart then the left ventricle (gives deep,
wide “V” shaped complex
73
74
Hyperkalcemia
Intro to ACLS
Primary Survey
 Airway:
Open airway, look, listen, and feel
for breathing
 Breathing: If not breathing slowly give 2
rescue breaths. If breaths go in continue
to next step.
 Circulation: Check the carotid artery
(Adult) for a pulse. If no pulse begin CPR.
 Defibrillation: Search for and Shock VFib/Pulseless V-Tach
Adult ACLS Secondary Survey
ABCDs (abbreviated)
.
 Airway:
Intubate if not breathing. Assess
bilateral breath sounds for proper tube
placement.
 Breathing: Provide positive pressure
ventilations with 100% O2.
 Circulation: If no pulse continue CPR,
obtain IV access, give proper
medications.
 Differential Diagnosis: Attempt to identify
treatable causes for the problem.
 http://acls.net/quiz/mi_stroke_1.htm
stress

Common responses can include:






Feeling a sense of loss, sadness, frustration,
helplessness, or emotional numbness
Experiencing troubling memories from that day
Having nightmares or difficulty falling or staying
asleep
Having no desire for food or a loss of appetite
Having difficulty concentrating
Feeling nervous or on edge
Teaching to cope
 Reach
out and talk.
 Express yourself.
 Watch and listen.
 Stay active.
 Stay in touch with family.
 Take care of yourself.
ANY QUESTIONS?
Let’s Practice