1. Cardiac monitoring
Egan’s Ch. 17, CARC Ch. 11

3. Objectives (1 of 2)
To gain an understanding of basic terminology and techniques of cardiac monitoring.
To give you the knowledge and tools you need to assist the advanced provider with the use and implementation of an ECG.
To better understand the basic anatomy and physiology of the heart.

4. Objectives (2 of 2)
Identify the components of basic cardiac arrhythmias (because many times the RTs are with the patient during the onset of the initial event).
Evaluate the rate and rhythm of a patient’s cardiovascular system, and become familiar with the normal ECG.
Familiarize yourself with and apply 4-lead electrodes and identify placements for the 12-lead systems.

5. Cardiac Monitoring
Use of 12-lead ECGs in the hospital is essential for cardiac patients.
Early identification of AMIs allows hospitals to be prepared.
The RT should know how to place electrodes and leads.

6. Electrical Conduction System (1 of 2)
A network of specialized cells in the heart
Conducts electrical current throughout the heart
The flow of electrical current causes contractions that produce pumping of blood.
VIDEO

7. The Process of Electrical Conduction
Electrical conduction occurs through a pathway of special cells.
Automaticity
Ability of heart cells to generate a spontaneous electrical impulse
Sinoatrial (SA) node: the heart’s main pacemaker
Paces at a ventricular rate of 60–100 beats/min
**Any beat that originates outside the SA node is called “ectopic”**

8. The Process of Electrical conduction
Atrioventricular Junction- electrical bridge between atria and ventricles, comprised of:
(AV) node
Bundle of His
AV node
Acts as secondary (backup) pacemaker
Paces at a ventricular rate of beats/min
Impulse is temporarily delayed here to allow better filling of the ventricles
Protects ventricles from excessively fast rates

9. The Process of Electrical conduction
Bundle branches
Purkinje fibers
Fingerlike projections that pass electrical impulses throughout myocardium to create a coordinated contraction of the ventricles

11. Electrical Conduction System (2 of 2)
VIDEO

12. Formation of the ECG (1 of 4)

13. Formation of the ECG (2 of 4)

14. Formation of the ECG (3 of 4)

15. Formation of the ECG (4 of 4)

16. Electrodes and Waves
Electrodes pick up electrical activity of the heart.

17. The ECG Complex One complex represents one beat in the heart.
Complex consists of P, QRS, and T waves.

19. ECG Paper Each small box on the paper represents 0.04 seconds.
Five small boxes in larger box represents 0.20 seconds.
Five large boxes equal 1 second.
© Steve Cole/Photodisc/Getty Images

20. Normal Sinus Rhythm Consistent P waves
Consistent P-R interval ( seconds)
60–100 beats/min
QRS < 0.12 seconds

21. Sinus Bradycardia Consistent P waves Consistent P-R interval
Less than 60 beats/min
Potential causes are: Hypoxia, hypothermia, heart disease, electrolyte imbalances(hyperkalemia), parasympathetic stimulation, hypothyroidism
Cause:
Stimulation of vagus nerve (during suctioning)
Hypothermia
Increased ICP
*Sinus bradycardia may be normal in well-conditioned athletes.
Treatment:
If accompanied by shortness of breath, hypotension, or abnormal beats, atropine is used
A pacemaker may also be indicated in symptomatic bradycardia.
Unsymptomatic – treat the cause.

22. Sinus Tachycardia Consistent P waves Consistent P-R interval
100 – 160 beats/min
Potential causes are: Fever, pain, hyperthermia, anxiety, medications, hypoxia, sympathetic stimulation
Cause:
Hypoxemia
Increased sympathetic nervous system stimulation (fear, anxiety)
Medication
Treatment:
Treat underlying cause
Administration of digitalis or beta blockers.

23. First Degree Block Impulse delayed at AV node Prolonged PR interval
There is always concern that the patient will progress to the next worse rhythm
Cause:
Complication of digoxin or beta blockers
Ischemia of the AV node
Treatment:
Atropine
Isoproterenol

24. 2nd Degree Type I (Wenckebach)
PR progressively longer until a QRS is dropped.
Cause:
Myocardial ischemia
May be a progression from 1st degree block.
Treatment:
None needed if CO is stable

25. 2nd Degree Type II (Mobitz)
Nonconducted P waves followed by conducted P waves.
Cause:
Myocardial ischemia
Treatment:
Isoproterenol
Atropine
Pacemaker
Can lead to 3rd degree block, so pacemaker needed even if patient is asymptomatic.

27. 3rd Degree Heart Block
Ventricles and atria beat independently of one another.
There is no relationship between the P waves and QRS complexes
The patient will need a pacemaker
Usually a temporary pacer (TCP) until a permanent one can be inserted
Cause:
Myocardial ischemia
AV node damage
Treatment:
Pacemaker

28. Atrial Flutter Rapidly firing ectopic site in atria
Characteristic “sawtooth” pattern
At risk for thrombi
Rate: beats/min
May progress to atrial fibrillation
Cause:
Hypoxia
Arteriosclerotic heart disease MI
Treatment:
Cardioversion
Carotid artery massage
Procainamide
Digitalis

29. Atrial Fibrillation Multiple ectopic sites within atria
Atrial rate > 350 beats/min
Decrease in ventricular filling
Cause:
Hypoxia
Arteriosclerotic heart disease
Mitral stenosis
Valvular heart disease
Treatment:
Cardioversion
Propranolol
Digitalis

32. PVC’s Occasional PVC is ok but > 6/min is a sign of irritability
Wide and bizarre QRS complex is the most distinguishing feature
No P wave prior to PVC
Bigeminyand trigeminy
Unifocal and Multifocal
Multifocal is more concerning because there are multiple irritated areas in the ventricles
Occasional PVC is ok but > 6/min is a sign of irritability
May progress to ventricular tachycardia
Treatment
Lidocaine (decreases ventricular irritability)
Find the problem and fix it!

33. PVC’s Cause: Ventricular irritability caused by hypoxia
Acid-base disturbances
Electrolyte abnormalities
CHF
Coronary artery disease
Treatment:
Lidocaine IV
Lido decreases ventricular irritability

34. Supraventricular Tachycardia (SVT)
Impulse moves from atria – ventricles – atria (circular)
Rate: beats/min
P waves may be unidentifiable, normal QRS
Treatment
If stable and narrow complex can try adenosine or vagal maneuvers
If unstable, then immediate cardioversion
Treatment:
Immediate cardioversion (unstable)
Carotid artery massage (stable)
Valsalva maneuver

36. Ventricular Tachycardia
Three or more PVC’s in a row
Rate: beats/min
No distinguishable P waves
Precedes or follows V-fib
Treatment
If stable, treat with amiodarone
If unstable with a pulse, then cardioversion
Pulseless VT is treated with CPR and defibrillation just like VF
Cause:
Arteriosclerotic heart disease
Coronary artery disease
Myocardial ischemia
Mitral valve prolapse
Hypertensive heart disease
Treatment:
Lidocaine
Amiodarone (stable)
If unstable….Defibrillation if pulseless, otherwise cardioversion

37. Ventricular Fibrillation
Rapid, completely disorganized rhythm
Deadly arrhythmia that requires immediate treatment
A new onset is coarse and will progress to fine VF which is harder to defibrillate
Fine VF can be confused with asystole
Treatment is CPR and immediate defibrillation
No effective CO. If not reversed death with ensue.
If fine v-fib is present (harder to defib), epinephrine can increase the force of contractions and convert the rhythm into coarse v-fib.
Cause:
Coronary artery disease
Hypertensive heart disease
Acute MI
Treatment:
Defibrillation
CPR

38. Pulseless Electrical Activity (PEA)
Pattern does not generate a pulse.
May show normal QRS complexes
Can be any kind of a pattern from NSR to one or two complexes
Treatment is CPR and identify the cause (H’s and T’s)
PEA is not common but is associated with cardiac trauma, tension pneumothorax, severe electrolyte disturbances, and severe acid-base imbalances.
Treatment:
CPR

39. Asystole Complete absence of electrical cardiac activity
Patient is clinically dead.
Decision to terminate resuscitation efforts depends on local protocol.

41. Cardiac Monitors May be 3-, 4-, or 12-lead system
Compact, light, portable
Many monitors now combine functions beyond ECG.

42. 4-Lead Placement Four leads are called limb leads.
Leads must be placed at least 10 cm from heart.

43. 12-Lead ECG Used to identify possible myocardial ischemia
Studies show 12-lead acquisition takes little extra time.
Early identification of acute ischemia and accurate identification of arrhythmias

44. 12-Lead Placement Limbs leads placed at least 10 cm from heart.
Chest leads must be placed exactly.
Lead
Location
View V1
4th intercostal space, right sternal border
Ventricular septum V2
4th intercostal space, left sternal border V3
Between V2 and V4
Anterior wall of left ventricle V4
5th intercostal space, midclavicular line V5
Lateral to V4 at anterior axillary line
Lateral wall of left ventricle V6
Lateral to V5 at midaxillary line

45. Holter monitoring Portable, battery powered recording device
Done over 24 hours
Useful in patients experiencing irregular heart beats on an inconsistent basis.

46. Troubleshooting
Clean skin.
Use benzoin.
Shave hair.