Pediatric Cardiac Rhythm Analysis for the
Non-Cardiac Nurse
Amy Jo Lisanti, MSN, RN, CCRN, CCNS, PhD (candidate )Clinical Nurse Specialist, Cardiac Intensive Care U nit,
The Children’s Hospital of Philadelphia
OBJECTIVES
� Describe the basic anatomy and physiology of the heart.
� Explain cardiac electrical conduction system and its relationship to the cardiac cycle.
� Identify the common arrhythmias in infants and children.
� Recognize the nursing assessments and actions related to the arrhythmias.
But I’m not a cardiac nurse!
� 7 year old Jessica presents to the ED in anaphylactic shock after stepping on a beehive and getting stung several times.
� Monitor – HR is 186!� What else are you looking for?
CARDIAC ANATOMY
Figure 1
THE CARDIAC CYCLE
KEY POINT = Blood flows the path ofLEAST RESISTANCE !!!
Figure 2 Figure 3
THE CARDIAC CYCLE
Figure 4
CARDIAC OUTPUT
� Cardiac Output = Stroke volume x Heart rate� Therefore, CO is the amount of blood pumped out
of the ventricles each minute.
� Stroke volume = Amount of blood pumped out of the ventricles with each beat� Preload� Afterload� Contractility
REGULATING CARDIAC OUTPUT
� Autonomic Nervous System� Intrinsic Regulation
� Renin-Angiotensin-Aldosterone System
� Natriuretic Peptides� Baroreceptors� Chemoreceptors� RA stretch receptors
Figure 5
SPECIAL CONSIDERATION = INFANTS!!
THE ACTION POTENTIAL…. UGH!
Figure 6
CONTRACTION
Figure 9
THE ELECTRICALCONDUCTION SYSTEM
� THE HIGHWAY OF THE HEART:
� SA Node
� AV Node
� Bundle of His
� Purkinje Fibers Figure 7
THE ELECTROCARDIOGRAM
� ECG = The Graphic Representation of the Electrical Activity of the Heart
� ECG Picture Depends on Lead Placement
Figure 8
ECG PAPER
0.2 Seconds 0.04 Seconds
Vo
ltag
e
Time
THE ELECTROCARDIOGRAM
DEPOLARIZATION = CONTRACTION
P-R Interval
QRS Duration
S-T Segment
P wave
QRS complex
T wave
THE CARDIAC CYCLE
Atrial Depolarization: P-wave and PR interval
Atria Contract and Ventricles Fill (“Atrial Kick”)
QRS Complex = Ventricular Depolarization
THE CARDIAC CYCLE
Q S
R
THE CARDIAC CYCLE
� T Wave = Ventricular REpolarization� This is the
resting phaseof the Cardiac Cycle.
� No InterruptionsAllowed!
SINUS RHYTHM
Determined by the SA Node – Age DependentElectrical Impulse flows through Normal Conduction Pathway
Age Ranges for Normal Sinus Rhythm (NSR)Newborn to 12 months = 100-180
1- 3 years = 90 - 1503 - 5 years = 70 - 1405 – 8 years = 65 – 130
8 years and older = 60 – 110
Sinus Bradycardia – Below these age rangesSinus Tachycardia – Above these age ranges
Sinus Arrhythmia – SA node fires at irregular rhythm
RHYTHM ANALYSIS
• What’s Normal??• What am I even looking at????
RHYTHM ANALYSIS
• What is my Patient’s ASSESSMENT?• Is my patient Hemodynamically Stable?
RHYTHM ANALYSIS� Is the rhythm regular or irregular?� Identify the waveforms
� Is there a P wave before every QRS complex?
� T wave morphology/ST segment
� Measurements� PR interval� QRS duration� QT/QTc
ECG WAVEFORM CHANGES
� Artifact� Patient Movement� Loose Electrodes� Improper Grounding� Faulty Monitor
PATIENT ASSESSMENT
IS KEY!!!!
� Physiologic� Hypoxia� Ischemia � Hypertrophy� Electrolytes
� Potassium� Calcium� Magnesium
� Medications� Cardiac Surgery
Case study
� 32 day old baby boy at the pediatrician’s office for his 1 month old check-up.
� He was born in the 75th percentile and now sits in the 10th percentile for weight.
� Mom says that he always seems to tire out during feeds.
� VS- T 36.9, HR 220, RR 52, BP 62/30
� Premature Atrial Contractions (PACs)� Paroxysmal Atrial Tachycardia (PAT/SVT)� Atrial Flutter� Atrial Fibrillation
ATRIAL ARRHYTHMIAS
PREMATURE ATRIAL CONTRACTION (PAC)
PAROXYSMAL ATRIAL TACHYCARDIA (PAT/SVT)
ATRIAL FLUTTER
ATRIAL FIBRILLATION
� Premature Ventricular Contraction (PVC)
� Ventricular Tachycardia (V-tach)
� Ventricular Fibrillation (V-fib)
VENTRICULAR ARRHYTHMIAS
PVCsPVCs
Wide QRS Complex
No P-Wave
V-TACH
TORSADE DE POINTES
Figure 10
VENTRICULAR FIBRILLATION
� Cardiac Muscle is quivering!� No Coordinated Contraction!
� NO Cardiac Output!� CPR and DEFIB STAT!
PROLONGED QT
� RISK =SUDDEN DEATH
� QT Interval changes with Heart Rate
� QTc is the “Corrected”QT Interval� Adjusted for the Heart Rate (R-R Interval)
� Prolonged QT:� QTc is greater than 0.42 sec in men� QTc is greater than 0.44 sec in women
Case Example
� 14yo male with osteosarcoma in his right distal femur.
� Treatment: Doxorubicin, Cisplatin, Methotrexate� Zofran q8 hours for nausea and vomiting� Pre-chemo ECHO and ECG were normal� Ordered another ECHO and ECG prior to next
dose of Doxorubicin. QTc=0.52
HEART BLOCKS� First-degree AV Block� Second degree AV Block
� Mobitz Type I (aka Wenckebach)� Mobitz Type II
� Third degree AV Block
FIRST-DEGREE AV BLOCK
Figure 10
MOBITZ I - WENCKEBACH
MOBITZ Type II
COMPLETE HEART BLOCK
ASYSTOLE
� NO ELECTRICAL ACTIVITY� NO PACEMAKER TO INITIATE ACTIVITY
� LETHAL ARRHYTHMIA� Very Resistant to Resuscitation Efforts
REVIEW
� Most Common Arrhythmias in Children:� Bradycardia (most often related to Hypoxia)� Sinus Arrhythmia (changes in vagal tone from
inspiration and expiration, benign)� Asystole (can follow bradycardia if untreated)� Supraventricular Tachycardia
� Children with Congenital Heart Defects may present with any arrhythmia.
� Children with other chronic illnesses on certain medications may develop arrhythmias.
Thank you for your attention!
References
� Hebbar, A. & Hueston, W. (2002). Management of common arrhythmias: Part I. Supraventricular Arrythmias. American Family Physician, 65, 2479-2486.
� Morelli, P., Biancaniello, T., Chandran, L. (2007). The essentials of pediatric ECGs. Contemporary Pediatrics, 24(9), 49-60.
� Mowery, B. & Suddaby, E. (2001). ECG interpretation: What is different in children? Pediatric Nursing, 27, 224, 227-231.
� Urden, L., Stacy, K., Lough, M. (2006). Thelan’s Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby Elsevier.
Figures� Figure 1: Retrieved July 10, 2008, from
http://www.medicalook.com/diseases_images/heart-dis eases1.jpg� Images 2-4: Retrieved July 10, 2008, from
http://en.wikipedia.org/wiki/Cardiac_cycle� Figure 5: Retrieved July 10, 2008, from
http://www.themdsite.com/graphics/ION_14a.jpg� Figure 6: Retrieved July 10, 2008, from
http://virtuallyshocking.com/wp-content/uploads/2006/10/CepBasicsPresentation.011-0 01.png
� Figure 7: Retrieved July 10, 2008, from http://www.uptodate.com/patients/content/images/car d_pix/Heart_conduction_system.jpg
� Figure 8: Retrieved July 10, 2008, from http://nobelprize.org/educational_games/medicine/ec g/ecg-readmore.html
� Figure 9: Retrieved April 16, 2010, from http://www.carolguze.com/images/cellorganelles/acti n-myosin.jpg
� Figure 10: Retrieved April 16, 2010, from http://www.lond.ambulance.freeuk.com/ecg/1degavbk.j pg
� Cullen, J. (2008). Color ECG tracing pictures, used with permission.