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.