Coronary Artery DiseaseCoronary Artery DiseaseComplicationsComplications
Cardiac Cardiac Arrhythmias/DysrhythmiArrhythmias/Dysrhythmi
asas Conduction SystemConduction System
Four Properties of Cardiac TissueFour Properties of Cardiac Tissue AutomaticityAutomaticity – ability to initiate an impulse – ability to initiate an impulse ContractilityContractility – ability to respond – ability to respond
mechanically to an impulsemechanically to an impulse ConductivitConductivity – ability to transmit an y – ability to transmit an
impulse along a membrane in an orderly impulse along a membrane in an orderly mannermanner
ExcitabilityExcitability – ability to be electrically – ability to be electrically stimulatedstimulated
Cardiac Conduction Cardiac Conduction SystemSystem
Specialized neuromuscular tissueSpecialized neuromuscular tissue
PR IntervalPR Interval::SA Node – upper R atrium through SA Node – upper R atrium through
Bachman’s BundleBachman’s BundleAV Node – internodal pathwayAV Node – internodal pathwayBundle of His Bundle of His
QRS ComplexQRS Complex: : Right and Left Bundle BranchesRight and Left Bundle BranchesPurkinje FibersPurkinje Fibers
Cardiac ConductionCardiac Conduction
Cardiac MonitoringCardiac MonitoringPQRS ComplexPQRS Complex
Cardiac Action Cardiac Action PotentialPotential
Calculating Heart RateCalculating Heart Rate EKG paper is a grid where time is measured along the horizontal axis. EKG paper is a grid where time is measured along the horizontal axis. Each small square is 1 mm in length and represents 0.04 seconds. Each small square is 1 mm in length and represents 0.04 seconds. Each larger square is 5 mm in length and represents 0.2 seconds. Each larger square is 5 mm in length and represents 0.2 seconds. Voltage is measured along the vertical axis - 10 mm is equal to 1mV in voltage. Voltage is measured along the vertical axis - 10 mm is equal to 1mV in voltage. Heart rate can be easily calculated from the EKG strip:Heart rate can be easily calculated from the EKG strip: Heart rate can be easily calculated from the EKG strip:Heart rate can be easily calculated from the EKG strip:
• When the rhythm is regular:When the rhythm is regular:
• the heart rate is 300 divided by the number of large squares between the QRS complexes.the heart rate is 300 divided by the number of large squares between the QRS complexes. • e.g., if there are 4 large squares between regular QRS complexes, the heart rate is 75 (300/4=75).e.g., if there are 4 large squares between regular QRS complexes, the heart rate is 75 (300/4=75).
• The second method can be used with an irregular rhythm to estimate the rate:The second method can be used with an irregular rhythm to estimate the rate:
• Count the number of R waves in a 6 second strip and multiply by 10. Count the number of R waves in a 6 second strip and multiply by 10.
• e.g., if there are 7 R waves in a 6 second strip, the heart rate is 70 (7x10=70).e.g., if there are 7 R waves in a 6 second strip, the heart rate is 70 (7x10=70).
Cardiac MonitoringCardiac MonitoringCardiac RateCardiac Rate
Cardiac MonitoringCardiac MonitoringAmplitude / DurationAmplitude / Duration
12 Lead EKG12 Lead EKG
EKG LeadsEKG Leads
12-Lead EKG12-Lead EKG
Reciprocal EKG Reciprocal EKG ChangesChanges
Cardiac MonitoringCardiac MonitoringChest Lead PlacementChest Lead Placement
Cardiac Monitoring- Cardiac Monitoring- MCLMCL
Cardiac MonitoringCardiac MonitoringNormal Sinus RhythmNormal Sinus Rhythm
Cardiac MonitoringCardiac MonitoringPQRS ComplexPQRS Complex
Cardiac MonitoringCardiac MonitoringCardiac Rhythm Cardiac Rhythm
AnalysisAnalysis Analyze the P waves – rate/rhythmAnalyze the P waves – rate/rhythm Analyze the QRS complexes – Analyze the QRS complexes –
rate/rhythmrate/rhythm Determine the heart rateDetermine the heart rate Measure the PR IntervalMeasure the PR Interval Measure the QRS durationMeasure the QRS duration Interpret the rhythm Interpret the rhythm Clinical significance? Hemodynamic Clinical significance? Hemodynamic
status?status? Appropriate TxAppropriate Tx
Cardiac Monitoring Cardiac Monitoring Normal Sinus RhythmNormal Sinus Rhythm
Cardiac MonitoringCardiac MonitoringNormal Sinus RhythmNormal Sinus Rhythm
EKG / Heart SoundsEKG / Heart Sounds
Cardiac MonitoringCardiac MonitoringNormal Sinus RhythmNormal Sinus Rhythm
Atrial & Ventricular rhythmsAtrial & Ventricular rhythms: : regularregular
RateRate: 60-100 beats/min: 60-100 beats/min P wavesP waves: present consistent : present consistent
configuration, one P wave prior to configuration, one P wave prior to each QRS complexeach QRS complex
PR intervalPR interval: .12 – .20 sec and : .12 – .20 sec and constantconstant
QRS durationQRS duration: -.04 to .10 sec and : -.04 to .10 sec and constantconstant
Cardiac MonitoringCardiac MonitoringSinus DysrhythmiasSinus Dysrhythmias
Cardiac MonitoringCardiac MonitoringSinus BradycardiaSinus Bradycardia
SA Node discharges < 60 beats/ minSA Node discharges < 60 beats/ min
EtiologyEtiology: >parasympathetic stimulation / : >parasympathetic stimulation / vagus nervevagus nerve
AssessAssess: LOC, Orientation, VS, PO, pain, : LOC, Orientation, VS, PO, pain, escaped ventricular ectopyescaped ventricular ectopy
TxTx: If patient is symptomatic – raise legs : If patient is symptomatic – raise legs up, move patient, Atropine – ACLS up, move patient, Atropine – ACLS BradycardiaBradycardia
Cardiac MonitoringCardiac MonitoringSinus Tachycardia Sinus BradycardiaSinus Tachycardia Sinus Bradycardia
Cardiac MonitoringCardiac MonitoringSinus TachycardiaSinus Tachycardia
SA Node discharge > 100 beats/ minSA Node discharge > 100 beats/ min
EtiologyEtiology: Sympathetic stimulation – : Sympathetic stimulation – normal or abnormal responsenormal or abnormal response
TxTx: Treat underlying cause: Treat underlying causeCardiac Supply ProblemsCardiac Supply ProblemsCardiac Demand ProblemsCardiac Demand Problems
E.g., hypovolemia, hypoxemia, anxiety, pain, E.g., hypovolemia, hypoxemia, anxiety, pain, anemia, anginaanemia, angina
Regular Narrow QRS - AdenosineRegular Narrow QRS - Adenosine
Sustained Sustained Tachy / Brady Tachy / Brady DysrhythmiasDysrhythmias Chest discomfort, or pain, radiation to jaw, back, Chest discomfort, or pain, radiation to jaw, back,
shoulder or upper armshoulder or upper arm Restlessness, anxiety, nervousnessRestlessness, anxiety, nervousness Dizziness, syncopeDizziness, syncope Change in pulse strength, rate, rhythmChange in pulse strength, rate, rhythm Pulse deficitPulse deficit Shortness of breath, dyspneaShortness of breath, dyspnea Tachypnea, OrthopneaTachypnea, Orthopnea Pulmonary ralesPulmonary rales S3 or S4 heart soundsS3 or S4 heart sounds Jugular vein distentionJugular vein distention Weakness, fatigueWeakness, fatigue Pale, cool skin, diaphoresisPale, cool skin, diaphoresis Nausea, vomitingNausea, vomiting Decreased urine outputDecreased urine output HypotensionHypotension
Cardiac MonitoringCardiac MonitoringPSVTPSVT
Cardiac MonitoringCardiac MonitoringParoxysmal Supraventricular Paroxysmal Supraventricular
Narrow QRS Tachycardia Narrow QRS Tachycardia (PSVT)(PSVT)
SA Node rate 100-280 beats/min - MSA Node rate 100-280 beats/min - Mean 170 ean 170 beats/minbeats/min
Etiology:Etiology: Pre-excitation syndrome, e.g., Wolff- Pre-excitation syndrome, e.g., Wolff-Parkinson White (WPW) SyndromeParkinson White (WPW) Syndrome
AssessAssess: Weakness, fatigue, chest pain, chest : Weakness, fatigue, chest pain, chest wall pain, hypotension, dyspnea, nervousnesswall pain, hypotension, dyspnea, nervousness
TxTx: Valsalva maneuvers: bearing down, : Valsalva maneuvers: bearing down, gagging, ocular pressure, vomiting, carotid sinus gagging, ocular pressure, vomiting, carotid sinus massage, massage, Meds: AdenosineMeds: Adenosine
Cardiac MonitoringCardiac MonitoringInterferenceInterference
Cardiac MonitoringCardiac MonitoringAtrial Flutter / Atrial Flutter /
FibrillationFibrillation
Cardiac MonitoringAtrial Flutter / Fibrillation
Cardiac MonitoringCardiac MonitoringAtrial FibrillationAtrial Fibrillation
Most Common dysrhythmia in the USMost Common dysrhythmia in the US Multiple rapid impulses from many Multiple rapid impulses from many
atrial foci, rate of 350-600/min—atrial foci, rate of 350-600/min—depolarize the atrial in a disorganized depolarize the atrial in a disorganized and chaotic manner – atrial quiverand chaotic manner – atrial quiver
ResultsResults: : No P wavesNo P wavesNo atrial contractsNo atrial contractsNo atrial kick No atrial kick Irregular ventricular responseIrregular ventricular response
Cardiac MonitoringCardiac MonitoringAtrial FibrillationAtrial Fibrillation
EtiologyEtiology: MI, RHD with Mitral Stenosis, : MI, RHD with Mitral Stenosis, CHF, COPD, Cardiomyopathy, CHF, COPD, Cardiomyopathy, Hyperthyroidism, Pulmonary emboli, Hyperthyroidism, Pulmonary emboli, WPW Syndrome, Congenital heart WPW Syndrome, Congenital heart diseasedisease
** ** Mural Thrombi – increased risk for Mural Thrombi – increased risk for pulmonary & systemic pulmonary & systemic thromboemboli to brain & peripherythromboemboli to brain & periphery
AssessAssess: VS, PO, Pulse Deficit, chest : VS, PO, Pulse Deficit, chest pain, syncope, hypotensionpain, syncope, hypotensionSymptoms worsen with increased Symptoms worsen with increased
ventricular responseventricular response
Cardiac MonitoringCardiac MonitoringAtrial FibrillationAtrial Fibrillation
Tx:Tx: TEE – Trans-esophageal echocardiogramTEE – Trans-esophageal echocardiogram
Identifies thrombi on valvesIdentifies thrombi on valvesMedications to decrease the ventricular Medications to decrease the ventricular
response - Metoprolol (Lopressor)response - Metoprolol (Lopressor)OxygenOxygenProphylactic anticoagulation Prophylactic anticoagulation
Lovenox - Coumadin – long termLovenox - Coumadin – long termCardioversionCardioversion
Cardiac MonitoringCardiac MonitoringAtrial FibrillationAtrial Fibrillation
Tx:Tx: Medications to decrease the ventricular response Medications to decrease the ventricular response
Narrow QRS irreg rhythm–diltiazem; beta-blockersNarrow QRS irreg rhythm–diltiazem; beta-blockers Wide QRS reg rhythm – amiodaroneWide QRS reg rhythm – amiodarone Wide QRS irreg rhythm – digoxin, diltiazem, Wide QRS irreg rhythm – digoxin, diltiazem,
verapermil, amiodaroneverapermil, amiodarone
OxygenOxygenProphylactic anticoagulation Prophylactic anticoagulation CardioversionCardioversion
Cardiac MonitoringCardiac MonitoringAtrial FibrillationAtrial Fibrillation
CardioversionCardioversionSynchronized countershock Synchronized countershock
50 – 100 Joules 50 – 100 Joules Avoids delivering shock during Avoids delivering shock during
repolarizationrepolarization Patent intravenous linePatent intravenous line Patient sedated – VersedPatient sedated – Versed OxygenationOxygenation ABCABC Assess: VS, PO, Monitor cardiac rate - Assess: VS, PO, Monitor cardiac rate -
rhythmrhythm Administer antidysrhythmic medicationAdminister antidysrhythmic medication
Cardiac MonitoringCardiac MonitoringJunctional Escape Junctional Escape
RhythmRhythm
Cardiac MonitoringCardiac MonitoringJunctional Escape Junctional Escape
RhythmRhythm Impulse generated from AV nodal Impulse generated from AV nodal
cells at the AV Junctioncells at the AV Junction
Escape pacemakerEscape pacemaker
Rate 40-60 beats/ minRate 40-60 beats/ min
Transient Transient
Assess: Patient hemodynamic Assess: Patient hemodynamic stabilitystability
Cardiac MonitoringCardiac MonitoringPremature Ventricular Premature Ventricular
ContractionsContractions
Cardiac MonitoringCardiac MonitoringNSR – V. Tach – V. NSR – V. Tach – V.
FibrillationFibrillation
Cardiac MonitoringCardiac MonitoringVentricular Ventricular TachycardiaTachycardia
Cardiac MonitoringCardiac MonitoringVentricular Ventricular
DysrhythmiasDysrhythmias
Cardiac MonitoringCardiac MonitoringPremature Ventricular Premature Ventricular
ContractionsContractions
Cardiac MonitoringCardiac MonitoringPremature Ventricular Premature Ventricular Contractions (PVCs)_Contractions (PVCs)_
Early ventricular complexesEarly ventricular complexesFollowed by compensatory pauseFollowed by compensatory pauseFit between two NSR beats - interpolated Fit between two NSR beats - interpolated
Unifocal, multifocal, couplet, triplets, Unifocal, multifocal, couplet, triplets, bigeminy, trigeminy, quadrigeminybigeminy, trigeminy, quadrigeminy 3+ = ventricular tachycardia3+ = ventricular tachycardia
EtiologyEtiology: myocardial ischemia, <K+, : myocardial ischemia, <K+, CHF, metabolic acidosis, airway CHF, metabolic acidosis, airway obstructionobstruction
Cardiac MonitoringCardiac MonitoringPremature Ventricular Premature Ventricular
Contractions (PVCs/ Contractions (PVCs/ Ventricular Tachycardia Ventricular Tachycardia
with Pulsewith Pulse AssessAssess: LOC, hemodynamic : LOC, hemodynamic
status-- continuous cardiac status-- continuous cardiac monitoring of rhythm & rate, VS, monitoring of rhythm & rate, VS, PO, peripheral perfusionPO, peripheral perfusion
TxTx: Underlying cause + Oxygen, : Underlying cause + Oxygen, Amiodarone IV bolus / InfusionAmiodarone IV bolus / Infusion
V. Tachycardia/V. FibrillationV. Tachycardia/V. FibrillationPulselessPulseless
TX: TX: CPR BLS - Airway, Breathing, CirculationCPR BLS - Airway, Breathing, Circulation Shockable Rhythm VT/VF: Defibrillate – 120-200 JoulesShockable Rhythm VT/VF: Defibrillate – 120-200 Joules
CPR x 5 cyclesCPR x 5 cycles
Check rhythm – shockable?Check rhythm – shockable? Defibrillate (biphasic 200 J / monophasic 360 JDefibrillate (biphasic 200 J / monophasic 360 J
Resume CPR Resume CPR
Epinephine 1 mg IV (repeat q3-5 mins) / VasopressinEpinephine 1 mg IV (repeat q3-5 mins) / Vasopressin CPR x 5 cyclesCPR x 5 cycles
Check rhythm – shockable?Check rhythm – shockable? Defibrillate (biphasic 200 J / monophasic 360 JDefibrillate (biphasic 200 J / monophasic 360 J
Resume CPR Resume CPR
Antiarrhythmics: amiodarone/lidocaineAntiarrhythmics: amiodarone/lidocaine Magnesium – torsades de pointesMagnesium – torsades de pointes
Advanced Cardiac Life SupportAdvanced Cardiac Life Support Defibrillation – V Fib / pulseless & polymorphic V tach Defibrillation – V Fib / pulseless & polymorphic V tach
Meds:Meds:
Cardiac MonitoringCardiac MonitoringV Fib - Agonal RhythmV Fib - Agonal Rhythm
Common Causes of Common Causes of DysrhythmiasDysrhythmias
CardiacCardiacAccessory pathways, conduction defects, Accessory pathways, conduction defects,
congestive heart failure, left ventricular congestive heart failure, left ventricular hypertrophy, myocardial cell hypertrophy, myocardial cell degeneration, myocardial infarctiondegeneration, myocardial infarction
Other ConditionsOther Conditions Acid-base imbalances, alcohol, coffee, tea, Acid-base imbalances, alcohol, coffee, tea,
tobacco, connective tissue disorders, drug tobacco, connective tissue disorders, drug effects or toxicity, electric shock, electrolyte effects or toxicity, electric shock, electrolyte imbalances, emotional crisis, hypoxia, shock, imbalances, emotional crisis, hypoxia, shock, metabolic disorders (e.g. thyroid), near-metabolic disorders (e.g. thyroid), near-drowning, poisoningdrowning, poisoning
Cardiac MonitoringCardiac MonitoringHeart Block Heart Block
11stst, 2, 2ndnd Types I & II Types I & II
Cardiac Monitoring Cardiac Monitoring Heart BlocksHeart Blocks
Cardiac Monitoring Cardiac Monitoring First Degree AV BlockFirst Degree AV Block
First Degree AV BlockFirst Degree AV Block: all sinus : all sinus impulses eventually reach ventriclesimpulses eventually reach ventricles
Prolonged PR Interval >.20Prolonged PR Interval >.20EtiologyEtiology: AV nodal ischemia – right coronary : AV nodal ischemia – right coronary
artery (inferior MI); hypokalemia, increased artery (inferior MI); hypokalemia, increased beta-blockers or calcium channel blockers, beta-blockers or calcium channel blockers, narcotics, excessive vagal stimulationnarcotics, excessive vagal stimulation
AssessAssess: Hemodynamically stable: Hemodynamically stable
TxTx: withhold offending medication; : withhold offending medication; oxygen; atropine, notify physician; oxygen; atropine, notify physician; observeobserve
Cardiac Monitoring Cardiac Monitoring Second Degree AV Block Second Degree AV Block
Mobitz Type I - Mobitz Type I - WenckebachWenckebach
Each impulse takes progressively longerEach impulse takes progressively longer Progressive lengthening of PR IntervalProgressive lengthening of PR Interval Followed by a dropped beat (missing QRS complex) & a Followed by a dropped beat (missing QRS complex) & a
pausepause May need temporary transvenous pacerMay need temporary transvenous pacer
Etiology: Etiology: Often transient following anterior / Often transient following anterior / inferior wall MI – may revert to 1inferior wall MI – may revert to 1stst Degree AV Block Degree AV Block
Assess: Assess: Hemodynamic stabilityHemodynamic stability
TxTx: Atropine / May require Temporary : Atropine / May require Temporary Transcutaneous Pacemaker / CPR / ACLS ProtocolTranscutaneous Pacemaker / CPR / ACLS Protocol
Cardiac Monitoring Second Degree AV Block
Mobitz Type I - Wenckebach
Cardiac Monitoring Cardiac Monitoring Second Degree AV Block Second Degree AV Block
Mobitz Type IIMobitz Type II
EtiologyEtiology: Infranodal block in one of the : Infranodal block in one of the bundle branchesbundle branches Dropped QRS complex without progressive Dropped QRS complex without progressive
lengthening of PR intervallengthening of PR interval P wave with no QRS complex followingP wave with no QRS complex following Random blockRandom block May progress to 3May progress to 3rdrd Degree AV Block – need for Degree AV Block – need for
permanent pacerpermanent pacer
AssessAssess: Hemodynamic stability: Hemodynamic stability
TxTx: Atropine / Transcutaneous pacemaker / : Atropine / Transcutaneous pacemaker / CPR / ACLS ProtocolCPR / ACLS Protocol
Cardiac Monitoring Cardiac Monitoring Third Degree AV BlockThird Degree AV Block
No sinus impulses conduct to the ventriclesNo sinus impulses conduct to the ventricles AV dissociation – rate: 40/minAV dissociation – rate: 40/min PR interval not constant – no relationship with P PR interval not constant – no relationship with P
and QRS complexand QRS complex Ventricular pacemaker – may abruptly fail Ventricular pacemaker – may abruptly fail
causing ventricular asystolecausing ventricular asystole
EtiologyEtiology: Anterior Wall MI; hypoxemia, : Anterior Wall MI; hypoxemia, electrolyte disturbances, cardiac surgeryelectrolyte disturbances, cardiac surgery
Cardiac Monitoring Cardiac Monitoring Third Degree AV BlockThird Degree AV Block
AssessAssess: Hemodynamic stability: Hemodynamic stability
TxTx: :
CPR CPR ACLS Protocol ACLS Protocol Pacemaker Pacemaker
Cardiac MonitoringCardiac MonitoringPaced RhythmPaced Rhythm
Cardiac MonitoringCardiac MonitoringPaced RhythmPaced Rhythm
Indications for Indications for Permanent PacemakerPermanent Pacemaker
Chronic atrial fibrillation with slow Chronic atrial fibrillation with slow ventricular responseventricular response
Fibrosis or sclerotic changes of the cardiac Fibrosis or sclerotic changes of the cardiac conduction systemconduction system
Hypersensitive carotid sinus syndromeHypersensitive carotid sinus syndrome Sick sinus syndromeSick sinus syndrome Sinus node dysfunctionSinus node dysfunction TachydysrhythmiasTachydysrhythmias Third-degree AV blockThird-degree AV block
Cardiac MonitoringCardiac MonitoringVentricular StandstillVentricular Standstill
Pulseless AsystolePulseless Asystole
CPRCPR
ACLS ProtocolACLS Protocol
Tx: Atropine, Epinephrine, Tx: Atropine, Epinephrine, dopamine dopamine
Pulseless AsystolePulseless Asystole
Shockable Rhythm? No – BLS/CPRShockable Rhythm? No – BLS/CPR Epinephrine 1 mg IV (may repeat q3-5 Epinephrine 1 mg IV (may repeat q3-5
mins)mins)
(or one dose of Vasopressin)(or one dose of Vasopressin) AtropineAtropine 5 cycles of CPR5 cycles of CPR Shockable rhythm? NO - CPRShockable rhythm? NO - CPR Yes – Pulseless V FibYes – Pulseless V Fib
Cardiac DysrhythmiasCardiac Dysrhythmias
ASSESS THE PATIENTASSESS THE PATIENT Treat the underlying causeTreat the underlying cause Support hemodynamicallySupport hemodynamically
Emergency Cardiac MedicationEmergency Cardiac MedicationCPRCPRTranscutaneous/Transvenous Transcutaneous/Transvenous
pacemakerpacemaker Information and emotional support Information and emotional support
to patient & familyto patient & family
New Cardiac AdvancesNew Cardiac Advances
Implantable cardioverter – Implantable cardioverter – defibrillator (AICD)defibrillator (AICD)
Automatic external defibrillator (AED)Automatic external defibrillator (AED)ABCDABCD
Cardiac Ablation TherapyCardiac Ablation Therapy
BLSBLS ACLSACLS