CARDIAC DYSRHYTHMIAS

What are Cardiac Dysrhythmias? - disturbances in the regular heart rate or rhythm due to changes in the Electrical conduction or automaticity in the heart. MUST KNOWS :

The heart has a specialized system for generating rhythmic electrical impulses and for conducting these impulses all throughout the heart

Ischemia causes damage to the structures of the heart that in turn disrupts the normal heart rhythm and conduction pathway.

What is the Main Effect of Cardiac Dysrhythmia? - Reduction Of CARDIAC OUTPUT How do dysrhythmias occur? - Dysrhythmias occur from disturbances in 3 major mechanisms:

1. 2. 3.

CONDUCTION AUTOMATICITY RE-ENTRY OF IMPULSES

Conduction Pathway of the Heart SA node Internodal Pathways AV node Bundle of His Bundle Branches

AUTOMATICITY - Used to describe problems in the heart rate produced by various pacemaker cells in the myocardium Note: - SA node has the highest automaticity (60-100bpm) - Presence of ESCAPE PACEMAKERS - Presence of ECTOPIC BEATS RE-ENTRY OF IMPULSES - Reactivation of the cardiac muscles for the second time by the same impulse initiated by the pacemaker Impulses are not extinguished but persists because of a combination of slow conduction and blocks.

PATHOPHYSIOLOGY

SIGNS AND SYMPTOMS - Palpitations, which can be skipping, pounding or fluttering in nature - Fatigue - Chest pressure or pain - Shortness of breath - Fainting, also known as syncope or near syncope - Light headedness or dizziness HOW ARE ARYTHMIAS DIAGNOSED? - Electrocardiogram - Holter Monitoring - Treadmill Testing CARDIAC DYSRYTHMIAS - Cardiac Dysrhythmias can be due: - SA node Problems - Atrial Node Problems - AV Junctional Problems

Ventricular Cell Problems

Waveforms of the ECG - P-wave o Atrial depolarization QRS complex o Atrial Repolarization and Ventricular Depolarization T- wave o Ventricular Repoarization

Points to Remember: - 1 large block in an ECG strip is equal to 0.2 sec

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1 small box in an ECG strip is equal to 0.04 sec

Remember the Normals: PR interval: 0.12-0.20 sec QRS Interval: 0.08-0.12 sec QT interval: 0.33-0.42 sec

Basic ECG Interpretation STEP 1 : Determine the RATE

Count the number of R waves in a 6 second strip and multiply it by 10 Interpretation: 9 x 10 = 90 beats STEP 1 : Calculate the RATE

Count the number of large squares between R waves. Memorize the following sequence: 300 150 100 75 60 50 Interpretation: 1 box less than 100, approximately 95 beats STEP 2 : Determine the REGULARITY

Look at the R-R distances (using a caliper or markings on a pen or paper). Regular (are they equidistant apart)? Occasionally irregular? Regularly irregular? Irregularly irregular? Interpretation : Regular

STEP 3 : Assess the P WAVES

Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS? Interpretation : Normal P waves with 1 P wave with every QRS complex STEP 4 : Determine the P-R INTERVAL

Normal: 0.12 - 0.20 seconds. (3 - 5 boxes) Interpretation : 0.12 seconds STEP 5 : Determine the Q WAVE

Look for pathological Q-waves Q waves greater than 3 mm in depth Q waves larger than 1/3 the R-wave Interpretation : Normal STEP 6 : Determine the QRS WAVE

Normal: 0.04 - 0.12 seconds. (1 - 3 boxes) Interpretation : 0.08 seconds STEP 6 : Determine the ST SEGMENT

Is the S-T segment elevated? Myocardial Infarction Is it depressed? Ischemia Interpretation : Normal STEP 7 : Determine the T WAVE

Is it inverted? Ischemia Interpretation : Normal TYPES OF DYSRHYTHMIAS http://www.skillstat.com/ECG_Sim_demo.html MANAGEMENT

CARDIOVERSION - Delivers an electrical charge to the myocardium at the peak of the R wave. - This causes depolarization of the ventricles of the heart, preventing the re-entry of ectopic focal beats allowing the SA node to regain control.

DEFIBRILLATION It involves using electrode paddles to direct an electric current through the patients heart. - Causes the myocardium to depolarize, which in turn encourages the sinoatrial node to resume control over the hearts electrical activity.

PACEMAKERS TRANSCUTANEOUS PACEMAKERS - A temporary form of pacemaker - The device works by sending electrical impulses from the pulse generator to the patients heart by way of two electrodes, which are placed on the back and the front of the patients chest. - Used only until the doctor can institute transvenous pacing TRANSVENOUS PACEMAKERS - Involves threading an electrode catheter into a vein into the patients right atrium or right ventricle - The electrode then attaches to an external pulse generator - The pulse generator can directly initiate impulse towards the myocardium

Nursing Management 1. Establish a patent IV line 2. Administer oxygen as ordered 3. Administer antiarrythmic medications as ordered 4. Monitor ECG changes 5. Monitor urinary output of less than 30 cc 6. Maintain quiet environment or stimuli free environment 7. Monitor for signs of angina and MI 8. Have emergency equipments at bedside