EKG Monitoring

Types of EKG Monitoring Critical Care 24 hours/day Immediate recognition of problems Cardiac stepdown Immediate response 12 Lead EKG When needed Specific order or standing order

Continuos Monitoring 3 to 5 electrodes are placed on chest Must change pads prevent irritation according to policy Monitor tech watches for changes Can determine rate, rhythm and changes

12 Lead EKG Used to determine both new and old heart problems Electricity is conducted differently over injured heart muscle Determines rate, rhythm and changes from previous EKG Looks at heart in 12 directions Usually done by trained personnel Current flows from a negative to a positive lead The lead placement determines the direction of the deflection of the QRS complex

Lead Placement

Interpretation of an EKG Graph paper divided into small and large squares Each small square represents 0.04 seconds on the horizontal axis and I mm on the vertical axis Each large square contains 5 small squares and represents 0.20 seconds and 5 mm The electrical activity is recognized by upward and downward deflections of the wave forms The baseline is called the isoelectric line

EKG Graph

Interpretation of an EKG, cont. P Wave- represents atrial depolarization and is the 1st deflection and indicates the results of the SA node firing PR interval – represents time required for atrial repolarization and the time it takes for the impulse to travel from the atria to the ventricles (normal is 0-.12 to 0.20 seconds) QRS complex – represents ventricular depolarization (normal is 0.06 to 0.10 seconds) T Wave– represents ventricular repolarization

Interpretation of an EKG, cont EKG is evaluated for Rate – done on EKG by using the 6 second strip from R wave to R wave (normal is 60-100) Regularity – measure for consistency P waves – look for a P wave before each QRS complex PR interval – must fall in the normal range QRS complexes – must be normal or may be problem in the conduction system T waves – should be rounded, upright and same shape and size (not inverted ) Rate can be done by finding R on heave line and counting next R as 300, 150, 100, 75, 60, 50, 43, 37 Also by counting number of small squares between 2 R waves and divide 1500 by the number of squares

Systematic Review of EKG Strip Determine rate and regularity Is there a P wave before each QRS complex Are P waves rounded and upright Measure the QRS and do they look alike Look at the T wave. Is it upright or inverted

Normal Strip

Common Dysrhythmias Sinus dysrhythmias Atrial dysrhythmias Sinus tachycardia – greater than 100 Sinus bradycardia – less than 60 Sinus arrest Atrial dysrhythmias PAC SVT Atrial fibrillation Atrial flutter

Common Dysrhythmias, cont. Atrioventricular blocks 1st degree, 2nd degree, and 3rd degree AV block Ventricular dysrhythmias V-tache V-fib PVC’s Idioventricular Ventricular asystole

PVC

V-Tache

SVT

Mobitz II

Treatment Based on severity of the problem Lethal dysrhythmias are treated immediately Asystole – Atropine, Epinephrine V-tache – lidocaine, Pronestyl, mag sulfate, amiodarone V-fib – defibrillation with drugs Some may cause severe symptoms while others do not

Drug Treatment of Dysrhythmias Quinidine Pronestyl Lidocaine Mexitil Tonocard Tambocor Rythmol Adenocard Magnesium sulfate Inderal Brevibloc Betapace Cordarone Covert Verapamil Cardizem Lanoxin Atropine

Pacemakers Used to restore regular rhythm and improve cardiac output Types Temporary Permanent Transcutaneous Transvenous Implantable

Modes of Delivery Single chamber Duel chamber Fixed rate Demand rate AV sequential

Care of Pacemaker Vitals on return from OR Check insertion site and provide care as needed Monitor for: rhythm pacemaker spike PVC’s or other abnormal beats Usually on bedrest for 24 hours , off the side of insertion Gradually increase activities Patient must carry ID card Instruct patient to take pulse daily Notify physician both in hospital and after home of: Dyspnea Syncope Dizziness Weakness Fatigue Chest pain

Implantable Cardioverter/Defibrillator Used to treat life threatening rhythm problems Senses heart rate and wave form and delivers a shock to return heart function to a regular rhythm Recognizes V-tach and V-Fib If rhythm does not return to NSR, can continue Newer models can also recognize tachyarrhythmias and bradyarrhythmias Implanted in the sub-q tissue over the pectoralis muscle Causes some anxiety to patient when shock delivered Family and patient need education and support Wears ID bracelet Should avoid heavy magnetic fields (MRI, metal detectors)