ELECTROCARDIOGRAPHIC MONITORING AND CONDUCTION ABNORMALITIES Cardiac Conduction

1. Match terms with correct descriptions. P wave ___C____ PR interval ___D___ QRS complex ___E___ ST segment ____F___ T wave ____G____ QT interval ____A___ Ejection fraction ____B___ a. Interval shortens with increase in heart rate b. Ratio of stroke volume to volume of blood remaining in the ventricle at end diastole c. Atrial depolarization d. Atrial impulse conduction through AV node e. Ventricular depolarization f. Deflections indicate ventricular muscle injury g. Ventricular repolarization

Sinus Dysrhythmias
Scenario: An elderly patient presents to the emergency department with complaint of chest pain and fatigue. The cardiac monitor shows a heart rate of 35. The patients color is pale, and the skin is warm and dry. Blood pressure is 90/50, respiratory rate is 22, and temperature is 99.1F. 2. Why is this patient having symptoms? 1. The Patient is suffering from Bradycardia (HR 35), it as reduced his cardiac output, and as a consequence, he is suffering from hypotension and chest pain (Reduced O2 to his heart = Angina). Because of that, the quantity of O2 to his tissus and cells also has decrease, giving him a pale color to his skin, also his body is attempting to compensate by increasing his respiratory rate. Bradycardia can be cause by an infectious process, which would explain his fever and his warm and dry skin??? 3. What treatments should this patient receive and why? 1. He should receive first Atropine , to get his Heart Rate up, probably solve at the same time his chest pain, Hypotension, and Tachypnea. The Underlining cause of his Bradycardia should also be explored, be it an infectious disease of an atrial malfunction. An external pacemaker could also be temporarily install to prevent further bradycardia.

Atrial Dysrhythmias

Scenario: A patient presents to the doctors office with the complaint of shortness of breath. When the nurse takes the patients radial pulse, she obtains 160 beats per minute. This rate is confirmed by apical auscultation. 4. Different arrhythmias can produce a rate of 160. How will the medical team differentiate the cause? 1. First by doing an EKG, we will be able to see the kind of rhythm this is, SVT, VT, Rapid Atrial Fibrillation?? 5. What are the treatment options for SVT? 1. First, we could try the valsalva manoever, and then Adenosine is the medication of choice, it blocks for a short time the AV node conduction. Other medications that could be use are Calcium Channels blocking agents, Beta-Blockers,or Digitalis. If all fails, Electrc Cardioversion should be used. 6. List nursing responsibilities during adenosine administration. 1. First we should warn the patient about the effect of Adenosine and that he could feel like he is dying, chest pressure, facial flushing or dyspnea, but that it will pass very quickly. The patient should have a cardiac monitor. His pulse and Pressure should be monitored during the procedure, a brief periods of AV block or Pause can be observed, and should be monitored very closely.

Conduction Abnormalities
7. Complete the table. AV Block First-degree AV block Second-degree, type 1 AVB Characteristics Pr intervals greater that 0.20 seconds, rhythm is regular Pr intervals gradually lengthens until a P wave is blocked (No QRS follow). Rhythm is irregular. Atrial rate faster than ventricular rate. PR interval will be constant when P is followed be QRS. There is blocked P waves, their appearance can be variable or fixed (2:1, 3:1...) Rhythm is Treatment Options Usually not treated unless patient is symptomatic, can be medication related. Atropine, Dopamine, Epinephrine, transcutaneus pacemaker or permanent pacemaker. If related to digitalis, it will be stopped. Atropine, Dopamine, Epinephrine, Temporary or permanent pacemaker.

Second-degree, type 2 AVB

Third-degree heart block

Bundle branch block (right or left)

irregular. PR interval never constant, Rhythm is regular, but should patient is usually bradycardic, P waves are constant between them. QRS could be widened. More P waves than QRS. QRS is widened, depend on an anomaly is the His branches where the impulsion is slower on one side. Rhythm is usually regular.

Atropine, Dopamine, Epinephrine, Temporary or permanent pacemaker.

Usually not treated unless it is indicatory of another more important problem (ex: MI)

Case Study
Scenario: Eleanor, an 86-year-old retired nurse, presents to the emergency department with complaints of chest pain and shortness of breath. She is immediately placed on a cardiac monitor where it shows ventricular tachycardia, rate 160. Her blood pressure is 70/50, respiratory rate is 22 and rapid. An IV is started, oxygen is administered via face mask, and a 12-lead EKG is obtained. 8. Identify immediate treatment options for Eleanor. 1. Electrical cardioversion During synchronized cardioversion, Eleanor becomes unresponsive. The nurse cannot palpate a carotid pulse. 9. Identify immediate treatment options. 1. Pas sur ici, faut-il y rpondre avec toutes les manoeuvres, ou les mdicaments? Reanimation procedure should be started, physician should be at the side of patient, patient should be monitored to assess if there is a rhythm (Asystolia or Ventricular Fibrillation) Massage should be initiated followed by defibrillation, vitals should be tried to be taken, and medications could be given appropriately. Eleanors rhythm returns as a result of swift resuscitative action. Her new rhythm is atrial fibrillation with multifocal PVCs. Eleanor will require an in-depth cardiac workup to identify the cause of her cardiac problems. Immediately, numerous labs are drawn: CPK, troponin levels, CRP (C reactive protein), CBC, electrolytes, magnesium, renal panel, and coagulation studies. Chest x-ray shows clear lung fields. An echocardiogram is ordered. The physician also requests immediate consult for ICD placement. ( Implantable Cardio Defibrillator) 10. Identify immediate treatment options for continual PVCs during post-resuscitation.

1. Patient has to be under constant cardiac monitoring, Amiodarone should be started and also heparin because of the atrial fibrillation. Electrolytes results should be checked as soon as they come back and corrected if needed. 11. Provide reasons for obtaining specified lab and diagnostic tests. CPK: CPK is an indicator of muscle damage, in our case, it is the damage to the heart muscle that interest us. It can be an indication of Myocardial Infarction. They have a rapid onset, (4 hours) but usually disappear in one or two days. Troponins : Troponin are similar to CPK but are specific to the heart and damage done to it. They take a little longer to appear (4-6 hours) but take around 4 days to disappear. CRP: CRP is usually an indicator of an inflammatory process but can also be used to evaluate patient with MI, it usually follows the levels of CPK but takes 1 to 3 days to attain it's maximum levels, if it stays elevated, it can be an indication of continuing damage to the heart. CBC : Complete Blood count, will give us a basic understanding of bloods cells, anemia or malnutrition could cause chest pain, Electrolytes: Electrolytes are very important to the conduction of electricity in the heart, and low or elevated levels can cause significant changes in electrical pattern of the heart. We should be especially careful about the potassium levels, and they should be corrected immediately. Magnesium : Magnesium is also an electrolyte, but it is not normally dosed and must be taken appart, low level can cause as potassium all kinds of arrythmia, also it is closely related to the level of potassium, so a low level of magnesium will likely also cause a low level of potassium, it must also be quickly corrected. Renal Panel :A decrease renal function could cause and increase in electrolytes, for example Potassium at level greater than 5.5. The creatinine and Bun level could help us determined the actual renal function. (il me semble que l'on pourrait rajouter des choses...) Coagulation studies : MI could be caused by increase coagulation levels, also if patient is now in atrial fibrillation anticoagulant therapy will be started, and we need to assess the starting point of patient. (Ici pas sur sur non plus) 12. Why is an ICD being considered as a treatment option for Eleanor? 1. Multifocal PVC's are arrhythmias that can induced other more dangerous arrhythmias. For example if a PVC goes on during the refractory period of a normal QRS, it could induce Ventricular tachycardia or even worst Ventricular fibrillation. Multifocal PVC are more dangerous, because they come from different ectopic center within the ventricules. Furthermore, a newly diagnosed AF, could also induced theses kinds of arrhythmias. An ICD could prevent theses complications by shocking as soon has theses rhythm appear.