Cardiac Monitoring Notes

Patient Care III

MI 211c

Cardiac Monitoring

 Cardiac Conduction Cycle

- Provides electrical stimulus to cause the heart muscle to continually
 Contract (systole)
 Relax (diastole)
- SA node
- AV node
- Bundle of His
- Bundle Branches
- Purkinje Fibers
- Electrical impulses cause each myocardial cell to:
1) Change from a resting (polarized) state
2) To a state of contraction (depolarized)
3) Back to a resting state by recharging (repolarized)

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  Cardiac Conduction Cycle Electrophysiology
- Heart cells (myocytes) are capable of conductivity, excitability, contractility, and
automaticity
- Myocytes influenced by Na+, Ca2+, and K+
- At rest – cells polarized
 Cell interior negatively charged
 Charge builds up until threshold is reached
- Na+ ions flood into the cell, followed by Ca2+ ions – cells depolarized
 Cell interior becomes more positive than outside
 Followed by mechanical event = contraction
- K ions move out of the cell – cells repolarized
+

 Interior cell charge transitions to be more negative

Cardiac Conduction Cycle

 Electrocardiogram
- An electrical picture of the heart measured externally
 Ability to do so discovered in mid-1880’s
- ECG vs. EKG
 Dr. Willem Einthoven, 1901
- Labeled with letters
 P, Q, R, S, T, U
 Letters correspond to events in the cardiac cycle

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 Electrocardiogram

 Cardiac Cycle Waves

- P-wave
- QRS complex
- T-wave
- U-wave

Cardiac Cycle Waves Description Image

Atrial depolarization -
Contraction
Location - Precedes the QRS
complex
Amplitude - Not more than
0.25 mV (2-2.5 boxes)
Duration - 0.06-0.11 seconds
P-Wave
Appearance - Rounded and
upright

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 Ventricular depolarization -
Contraction
Location - Follows the PR
interval
Amplitude - Variable with
ECG lead
QRS Complex Duration - <0.12 seconds
Appearance - 3 waves

Ventricular repolarization -
Return to resting state
Location - Follows the S wave
Amplitude - 0.5 mV or less
Duration - Not measured
Appearance - Rounded and
smooth
T-Wave

His-Purkinje repolarization -
Return to resting state
Location - Follows the T wave
Amplitude - Not measured
Duration - Not measured
U-Wave Appearance - Upright and
rounded

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  Cardiac Cycle Waves
- PR Interval
 Beginning of the P-wave to the beginning of the QRS complex.
• Beginning of atrial depolarization to the beginning of ventricular
depolarization
• 0.12 - 0.2 sec duration
- ST segment
 End of the S-wave to the beginning of the T-wave
 Represents the end of ventricular depolarization and the beginning of
ventricular repolarization
 Duration
- Not Measured QT Interval
 Beginning of the Q wave to the end of the T Wave
 Time from ventricular depolarization to ventricular repolarization
 Duration
• 0.36 - 0.44 seconds duration
- RR Interval
 Distance from one R-wave to the next
 Used to determine if rhythm is regular

Cardiac Cycle Waves

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  Interpreting Rhythm Strips
a. Step 1:
 Determine the rates
• Atrial rate = P waves per 6s x 10
• Ventricular rate = QRS complex (R waves) per 6s x 10
b. Step 2:
 Assess regularity of rhythm (20 – 30 s)
• Atrial = P wave to P wave
• Ventricular = R wave to R wave
c. Step 3:
 Assess atrial activity
• Compare appearance and configuration of P waves
o Present?
o Normal shaped?
o Position?
d. Step 4:
 Determine the duration of the PR interval
• Is it WNL?
o 0.12 - 0.20 sec
• Is there one P wave for each QRS complex?

e. Step 5:
 Determine the duration of the QRS complex
• Size and shape
• Duration (0.04 - 0.11 sec)
• Distance from T-wave
• Point in same direction

f. Step 6:
 Evaluate the T-wave
• Present
• Size and Shape
• Point in same direction as QRS complex
g. Step 7:
 ST segment flat on isoelectric line

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Part II

 What is expected of you?

- Recognize normal sinus rhythms
- Be observant for signs and symptoms
- Respond appropriately
 Calm, reassuring attitude
 Assess vital signs
 Elevate patient’s head
 Be prepared to administer oxygen
 Be prepared for IV drug administration
 Be prepared to call a CODE

 Recognize Common ECG Abnormalities

- Sinus Bradycardia -Ventricular Fibrillation
- Sinus Tachycardia - Atrial Fibrillation
- Ventricular Tachycardia - Atrial Flutter
- Premature Ventricular Contractions (PVCs) - Heart Block

 Bradycardia vs. Tachycardia

- Bradycardia
 Slow heart rate
 <60 beats/min
- Tachycardia
 Fast heart rate
 >100 beats/min

Bradycardia

Tachycardia

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  Ventricular Tachycardia
- Hear rate between 150-250 bpm
- Low Cardiac output
 Pt. lose consciousness
 Becomes hypotensive
- Solution:
 Amiodarone via IV
 May need to use defibrillator

 Premature Ventricular Contractions

- PVCs
 A ventricular contraction preceding the normal impulse initiated by the SA
node.
 May occur singly, in pairs or in threes
- ECG Characteristics
 Rhythm: irregular
 P-wave: Absent
 QRS complex
• Bizarre configuration
• Occurs early
- Causes:
 Caffeine, tobacco, alcohol ingestion, exercise, scarring from MI’s, foreign
body ‘tickling’ the heart
- Signs/Symptoms:
 Asymptomatic
 Palpitations
 Decreased cardiac output

 Ventricular Fibrillation
- Chaotic, irregular contractions of the
ventricles
- Waves are jagged
- Life threatening
- Ventricles fail to pump blood
- Leads to asystole and death
- ECG Characteristics:
 normal parameters not measurable
- Causes:
 Acute MI
 Electric Shock
 Untreated Tachycardia
 Electrolyte Imbalance
 Hypothermia
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  Ventricular Fibrillation CONT.
- Symptoms
 Absent Pulse and BP
 Loss of Consciousness
 Cyanosis
- Treatment
 CPR
 Defibrillation
 Epinephrine

 Atrial Fibrillation
- Both atria and ventricles contracting
rapidly
- Atrial and ventricular rhythms
irregular
- May lead to PE or stroke
- Symptoms
 Palpitations
 Nausea
 Weakness & Fatigue
- Treatment
 Slow the ventricular response.
 Increase cardiac output

 Atrial Flutter
- Rapid, but regular contractions of the
atria
- Waves are rounded
- Atrial rate 250 – 400 beats/minute
- ECG Characteristics
 P-wave: Absent
• Flutter waves are present
 QRS complex: < 0.12 seconds
- Causes:
 Valve Disorder
 Infection
 Alcoholism
 Hyperthyroidism
- Symptoms
 Chest pain
 SOB
 Hypotension

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  Heart Block
- An interference of the
normal electrical
conduction of the heart
- Defined by the location of
the block
 A-V Heart Block
- Symptoms
 SOB
 Chest pain
 Hypotension & lightheadedness

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