The Electric Company
What is the pacemaker of the heart?
The SA node (sinoatrial node)
Regular, Rate less than 60, P Waves: uniform, normal; one for every QRS. QRS is less than 0.12 second, PR Interval: 0.12-0.20 second
Sinus Bradycardia
What rhythm produces progressively lengthening PR Intervals until a dropped QRS complex, then the cycle repeats?
Second Degree Type I (Mobitz 1, Wenkeback)
What is the term for early beats that occur within the patient's own rhythm and are caused by irritability? They are followed by a compensatory pause.
Ectopic Beats = Early Beats
A&O x3, HR 58, Regular rate, slightly dizzy, O2 Sats 90% on room air. No comorbidities, Negative PMX or PSX, no visible signs of bleeding or trauma.
What would you do?
Plan for: IV fluids, oxygen via Nasal Cannula at low flow (2 Liters), risk for falls IPOC, plan possible expert consult, labs
What is the name of the electrical pathway within the right and left ventricles?
The Purkinje Fibers
Irregularly Irregular. Rate varies with conduction: Less than 100 if controlled, greater than 100 if uncontrolled. No P waves, chaotic baseline, QRS is less than 0.12 second, PR Interval not discernable
Atrial Fibrillation (A Fib)
What rhythm is characterized by a prolonged delay in conduction at the AV node, recognized by a consistent PR Interval greater than 0.20 seconds.
First Degree AV Block
How would you refer to 7 fast wide QRSs that occur in a row? Bonus 100 points: If 2 beats of VT are a couplet, what are 3 beats called?
7 beats of Vtach
Bonus-2 beats are a couplet, 3 beats are a run of VT
New admission with SR on tele develops dizziness and chest pain. No previous cardiac HX or rhythms issues. Patient is panicked and tachypenic with O2 sats dropping to 89%. What can you do without an order? What orders can you expect?
Empathic communication, provide support/calm environment.
If hemodynamically stable, attempt Vagal Maneuvers. If unsuccessful: plan for Adenosine administration and/or synchronized cardioversion
What is the gatekeeper of the electrical system that buffers electrical impulses between the atria and ventricles?
The Atrioventricular (AV) Node
Regular rhythm, rate varies, QRS complexes similar 0.12-0.20 second, PR Interval consistent, No pulse
Pulseless Electrical Activity (PEA)
In which rhythm do the PR intervals vary completely, as there is no association between the atria and the ventricles?
Third Degree Heart Block (complete heart block)
How do you document the patient's rhythm when you see sinus rhythm and then occasional early beats that have a normal QRS and a p wave in front of them?
Sinus with PACs (Premature Atrial Contractions)
My patient is in V Fib, what do I do?
Confirm it IS VF by check for a pulse. If no pulse present, immediately begin compressions and call a code 99. First line treatment for VF is early defibrillation, pads must be placed quickly and attached to Zoll Defibrillator. Follow ALS algorithm and providers orders (if provider present).
What does the T wave represent in terms of electricity passing through the heart?
Ventricular Repolarization
Irregular, rate not measurable, P Wave not discernable, QRS complex chaotic/not discernable, PR Interval not discernable
Ventricular Fibrillation
We see this occur when the patient demonstrates a particular rhythm (like Sinus, or Afib) and instead of the QRS measuring normal, it is widened or greater than 0.12?
a Bundle Branch Block
If narrow complex Tachyarrhythmia does not convert with vagal maneuvers and chemical conversion, what is the next step?
Cardioversion- narrow complex (regular) dose is 50-100 joules, narrow complex (irregular) dose is 120-200 joules, Wide complex (regular) 100 joules
Life support measures continue on a patient with established advanced airway, ETcO2 monitoring shows a poor waveform and a ETcO2 value of 9? What needs to happen?
Team leader in the code event must recognize this and encourage the compressor to increase the quality of compressions. 10 mmHg or less indicate poor quality compressions and decreased perfusion. 15-20 mmHg indicate quality life support measures.
What does the QT interval represent?
This encompasses the time from the beginning of ventricular depolarization to the end of ventricular repolarization.
Regular or irregular, Rate greater than 200 bpm, P wave not discernable, QRS complex > 0.12 second; variable in shape; twisting, PR Interval not discernable
Torsades de Pointes
or Multifocal V Tach
What is the rhythm that has a fixed PR Interval with set pattern of dropped QRS complexes?
Second Degree AV Block Type 2 (Mobitz 2)
What are the treatment goals for a person in Atrial Fibrillation/Flutter?
1. Rate Control 2. Rhythm control 3. Anticoagulation
During a code situation, the teams and providers are evaluating for cause of the event. What are they looking for?
Bonus 100 points- can you name them?
Hs & Ts
Hypovolemia, Hypoxia, Hydrogen ion excess (acidosis), Hyper/hypokalemia, Hypothermia, Hyper/hypoglycemia
Toxins, Tamponade, Tension PTX, Thrombosis (PE), Thrombosis (MI)