What is the major complication involving A-Fib?
The blood moving through the fibrillating atria has a tendency to form clots, which then become emboli and block circulation elsewhere in the body.
What medications are people diagnosed with A-Fib typically taking?
Digitalis to regulate the rate of ventricular response and warfarin(coumadin) an anticoagulant to assist with clots.
which ventricle do these clots from A-fib effect?
used to convert PSVT to normal sinus, reentry SVT due to WPW, not effective in converting A-fib, A-flutter or V-tach
Point of Maximal Impulse or Apical Thrust, the thrust occurs when the hearts apex rotates forward with systole, gently beating against the chest wall and producing pulsation.
Where is PMI?
left anterior portion of the chest, mid-clavicular line, at the fifth intercostal space.
The depolarization of the atria
occurs after P wave, represents depolarization of the ventricles
represented by repolarization of the atria and ventricles
delay at the AV junction(.12-.20s)
Period between ventricular depolarization and begining of repolarization. It should be the same level as the isoelectric line.
time between 2 ventricular depolarizations
begining of the T wave
elevated or depressed ST segment
may indicate myocardial ischemia or injury.
tall or sharp peaked T waves
synch buttons on monitors
When using the cardioversion technique on a rhythm that has regular T waves, u must press the synch button so the shock will be delivered during the safest period of the ECG.
first upward deflection of the QRS, both ventricles are depolarized during the R wave.
Downward deflection after the R wave, if it is abnormally large it could mean hypertrophy
Entire heart is no longer contracting but instead quivering without any organized contracting. Most commonly seen as the rhythm adults go into during cardiac arrest. It responds well to defibrilation performed within 4 to 5 minutes. After 6 minutes or so perform CPR compressions to make the heart more susceptible to defibrilation.
How does V-Fib take place?
it occurs when many different cells in the heart become depolarized independently rather than in response to an impulse from the SA node
what 2 valves prevent backflow of blood to the ventricles?
Pulmonic Valve and aortic valve
heart sounds, indicates valves are operating properly
what are the 2 major heart sounds?
S1 and S2
what are the 2 abnormal heart sounds?
S3 and S4
occurs near the begining of ventricular contraction(systole) the closing of the tricuspid valve and mitral valve
occurs near the end of ventricular contraction(systole), when the pulmonary and aortic valves close. When the ventricles relax, these valves close because of backward flow in the pulmonary artery and aorta.
the result the end of the rapid filling period of the ventricle during diastole. GENERALLY HEARD IN CHILDREN OR YOUNG ADULTS. If heard in older adults it often signifies heart failure.
If heard, it coincides with atrial contraction at the end of venticle diastole. Patients with a Weak Left Ventricle!
What is the prefferred Anti-arrhythmic drug?
Treatable! Congestive Heart Failure, heart is unable to pump powerful enough or fast enough to empty its chambers. As a result blood backs up in the systemic circuit and pulmonary circuit.
Difficult to treat in the field! Heart is so severely damaged it can no longer pump a volume of blood sufficient enough to maintain perfussion. 40% or more of the left ventricle has been infarcted for cardiogenic shock to occur!!! HIGH MORTALITY RATE.
Signs and symptoms of cardiogenic shock
Massive peripheral vasoconstriction, patient is pale, cold skin, poor renal perfusion in minimal or absent urine. Rapid and shallow respirations, pulse is racing and thready, blood pressure will drop as compensitory mechanisms fail less then 90mmhg systolic. Goal is to identify and support the patient before blood pressure drops to the point where its irreversible.
Left sided heart failure
blood backs up in the pulmoanry veins, serum leaks out into the capilaries and alveoli. The serum mixes with air and produses foam(Pulmonary Edema). Impairs oxygenation, shortness of breath in the recumbant position
signs and symptoms of left sided heart failure
confussion, agitation, tachycardia, tachypenia, elevated BP, crackles, wheezes and frothy pink sputum..CPAP, NITRO, IV, MONITOR
Right sided heart failure
Most commonly happens as a result of left sided heart failure, right side has to work harder, eventually the right side is unable to keep up with the workload and it too fails. JVD, Edema
Plavix and Asprin
How do we treat chest pain?
End in "or"..Zocor, crestor, prestor,altacor, niacor
what is the definition of asystole?
Flat Line! entire heart is no longer contracting, but is standing still in the thorax with no organized activity.
How does asystole occur?
When many of the cells of the heart have been hypoxic for so long that they no longer have the energy for any kind of contraction.
causes of bradycardia
asymptomatic phenomenon in healthy adults, conditioned athletes, exhibited during sleep, HYPOTHERMIA, SA NODE DISEASE, AMI(which may stimulate vagul tone), INCREASED INTRACRANIAL PRESSURE AND USE OF BETA BLOCKERS, CALCIUM CHANNEL BLOCKERS, MORPHINE QUINDINE AND DIGITALIS.
First Degree Heart Block
AV node is delayed slightly longer than expected resulting in P-R interval greater than .20s, considered the least serious block. Ussually has an intrinsic rate of 60-100bpm. REGULAR RHYTHM, M,INIMUM VARIATION BETWEEN R-R INTERVALS. RARELY TREATED IN PREHOSPITAL SETTING!!!!!
Second Degree Heart Block:Type 1(Wenckebach)
Occurs when an impulse reaching the AV node is occasionally prevented from proceeding to the ventricles and causing a QRS complex. type 1 occurs when each successive impulse is delayed a little longer, until finally one impulse is not allowed to continue. 60-100bpm, RHYTHM IS IRREGULAR PR INTERVAL STARTS WITHIN NORMAL LIMITS 0.12-.20s, THEN GRADUALLY GETS LONGER TIL ITS NOT FOLLOWED BY A QRS COMPLEX. TREATED ONLY WHEN ASSOCIATED WITH BRADYCARDIA!
Second Degree Heart Block: Type 2 (Classical)
Rhythm may be regular with every other P wave blocked, or irregular witha prolonged R-R interval before the last QRS complex before the blocked P wave. TREATED IN THE PREHOSPITAL SETTING ONLY WHEN ASSOCIATED WITH BRADYCARDIA!
Third Degree Heart Block
Occurs when all impulses reaching the AV Node are prevented from proceeding to the ventricles and causing a QRS complex. As a result its also called a complete heart block. Ventricles then develop there own pacemaker to continue circulation of the blood at a greatly reduced rate! Ventricular rate will be less than 60bpm. R-R intervals march out and P-P intervals march out, however, theres no consistancy to how they present. ALSO TREATED IN THE PREHOSPITAL SETTING WHEN ASSOCIATED WITH BRADYCARDIA.
PSVT reffers to the rhythms tendency to begin and end abruptly. Paroxysmal(occurs in spasms) SupraVentricular Tachycardia. TO CALL THIS AN ARRHYTHMIA IT NEEDS TO BE WITNESSED!!
Signs and symptoms of hypertension
Headache is the most common symptom directly related to blood pressure elevation, other signs include dizziness, weakness, epistaxis(nosebleeds) and blurring of the vision.
6 second method of determining rate
count the QRS complexes on a 6 second strip, multiply that number by 10 and you get your heart rate
Sinoatrial Node, located in the right atrium. SA Node receives blood from the RCA. If the RCA is occluded the SA node will become Ischemic, which will inturn prevent the SA node from firing.
What is the fastest and primary pacemaker in the heart?
The SA Node, electrical impulses generated in this node spread across 2 atria through internodal pathways which causes atrial tissue to depolarize as they pass.
Atrioventricular Node, serves as a gatekeeper to the ventricles and secondary pacemaker of the heart.
ST Elevation is shown in how many boxes?
1 or 2 boxes!
V1 and V2
look at the right ventricle
V3 and V4
see the interventricular septum
V5 and V6
see the anterior and lateral left ventricle
what leads can inferior infarction be seen?
II, III and AVF
what leads can anterioseptal infarction be seen?
V1 and V3
what leads can anterolateral infarction be seen?
V4 to V6
what leads can extensive anterior wall infarction be seen?
V1-V6, I and AVL
what leads can posterior wall infarction be seen?
V1 to V2(tall R waves; reciprocal changes)
fourth intercostal space at right sternal border
fourth intercostal space at left sternal border
equidistant between V2 and V4
fifth intercostal space in left midclavicular line
anterior axillary line, same horizontal plane as V4
Mid axillary line, same horizontal plane as V4
How does syncope occur?
Occurs when CO suddenly declines, leading to a reduction in CEREBRAL PERFUSION
how do we recognize hyperkalemia on an ECG?
peaked T waves
parasympathetic nervous system
concerned primarily with vegetative functions, "rest and digest", send messages through the vagus nerve.
how can the vagus nerve be stimulated?
pressure on the carotid sinus, straining against a closed glottis(VALSALVA MANEUVER) and distention of a hollow organ(bladder or stomach)
How does the vagus nerve help slow the heart down?
The brain sends a signal via the vagus nerve right to the SA node, the electrical impulse causes the release of ACH, which also acts on the AV node slowing the heart rate.
What is the only drug that interacts directly with the parasympathetic nervous system?
What is an AMI?
Acute Myocardial Infarction, or heart attack, it occurs when a portion of the cardiac muscle is deprived of coronary blood flow, long enough that portions of the muscle die(undergo necrosis).
what needs to decrease when a person is having an AMI?
Oxygen demand on the heart needs to decrease.
what is the most common cause of cardiac arrest?
Plaque in the carotid arteries
Caution has to be taken with these patients, there hypertensive and present as stroke patients but if that plaque breaks free it could very easily cause ischemic stroke
pain is gradual, Chest pain, reffered to as heavy, squeezing, crushing or tightness, can be relieved
Aortic Aneurism Pain
Maximal pain and abrupt, Chest Pain, described as the worst pain ever experienced! Ripping, tearing, sharp or like a knife, dose not stop once started. Must take BP in both arms!
What is the true indicator of Hypertension
Persistent elevation of the diastolic pressure, by contrast, is the indicative of hypertensive disease. ^90
What position do we check for JVD?
Place the patient in a semisitting position(45 degree angle) with the head slightly rotated away from the jugular vein you are examining.
Sympathetic nervous system stimulation involving the myocardium
epinephrine, a special hormone also called adrenaline commands the heart to speed up
Used in the treatment of symptomatic bradycardia, dose is 0.5mg, IV push every 3-5mins not to exceed 3mg,
0.02mg/kg max of 0.5mg
Standardized graph paper, distance on the graph paper represents a given time. Height(amplitude) is measured in millimeters and width is measured in Milliseconds
What does 1 small box on ECG paper represent?
What does 1 large box on ECG paper represent?
5 small boxes, .20 seconds
How many large boxes in a 6 second strip?
Paroxymal Nocturnal Dyspnea
What is PND?
an acute episode of shortness of breath in which the patient suddenly awakens from sleep with a feeling of suffocation, often times the patient will report going to a window to get more air or move from a bed to a recliner.
What is PND a classic sign of?
Left sided heart failure but also can occur in chronic lung disease
What do PDN patients always need?
12 Lead ECG!
these patients reglularly have a low heart rate, they could be hypovolemic, give them fluids, THEY DONT NEED ATROPINE!
younger patient, history of allergies, unproductive cough, recent respiratory infection. Hyperinflated, hypersonant chest. On albuterol, atrovent inhalers
Left Sided Heart Failure
older patient, history of heart problems, dyspnea worse when lying down, cough with watery, foamy sputum, crackles, distended neck veins, edema. On Digitalis, Lasix, Methahydrine,etc..
40 units, 1 time, cardiac arrest
True third degree heart block
The QRS complex is wide!
How long could ST elevation on a 12 lead ECG take to transmit?
minutes to hours, if you think that patient is having an MI take them to the appropriate facility.
Chest pain time frame to be given thrombolytics?
<12 hours, greater than 12 hours the cardiologist makes the call!
Stroke time frame to be given thrombolytics?
Treatment for CHF?
aimed at improving oxygenation and decreasing the workload of the heart and forcing fluid from the Alvoli. CPAP, Sit the patient up with feet dangling to encourage venous pooling in the legs, IV keep vein open, Heart monitor,NITRO
what is CPAP?
Continuous Possitive Airway Pressure, drives fluid out of the Alveoli, Patient must be able to tolerate it!
set the synch button, start at 50j, The machine will monitor the R waves of the QRS complexes and delivers the shock at a time when the R-on-T phenominon is least likely to occur. V-TACH and SVT
Not synchronized, You shock a person who is in witnessed V-Fib or Pulseless V-Tach at 200j
1mg, cardiac arrest, repeat every 3-5mins
In patients with arteriosclerosis, will there pulse pressure be increased or decreased?
Pulse pressure will be increased, the arterial walls are stiffened.
Patients who are experiencing an MI of the right ventricle may already be hypotensive, what is the treatment?
1-2 liters of saline before administering any nitroglycerine
Calcium Channel blockers relieve angina in 2 ways?
preventing spasm of coronary arteries and weakening cardiac contraction thereby decreasing myocardial oxygen demand, Hypotension is a side effect
Calcium Channel Blockers
Diltizem(Cardizem),Nefedipine(Adalat, Procardia), Verapamil(Calan,Isoptin)
operate in a high pressure system and carry blood away from the heart, have thick walls, carry oxygen rich blood(except pulmonary arteries), BP is constriction and dilation of arteries.
operate in a low pressure system, carry blood to the heart, have thin walls, carry oxygen poor blood(except pulmonary veins),Veins contain valves
What system regulates cardiac contraction?
Central nervous System
Acute Coronary Syndrome, its a term used to describe any group of the clinical symptoms consistant with myocardial ischemia.
Coronary Artery Disease
Ventricular filling happens as a result of the atrium contracting, its the amount of blood kicked in by the atrium.
What percentage of blood flow comes from the atrial kick?
20%, the other 80% comes from the gets in passively via gravity
Thoracic Aortic Aneurism
presents with back pain or tearing pain, BLOOD PRESSURE ON BOTH SIDES MUST BE TAKEN
abdominal aortic aneurism
become symptomatic when they present with pressure, complain of feeling like they have to ****, extremities are cold because the lack circulation because of the pressure put on the colon from the abdominal aorta.
part of an ECG where the QRS ends and the ST segment begins, It represents the end of depolarization and the apparent beginning of repolarization. In the case of an AMI the J point will be easier to identify the ST segment when looking for elevation.
Torsades de Pointes
When the QRS complex varies in height and alternating pattern, its known as polymorphic V-Tach. Prolonged Q-T interval
What type of patients can Torsades de Pointes be normal in?
those induced by drugs or medications such as quinidine.
Which is worse Monomorphic V-Tach or Polymorphic V-Tach?
Polymorphic is and it ussually converts itself back to normal rhythm or degenerates to V-Fib
How do you confirm if proper lead placement is done on a 12 lead?
Possitive P wave in lead 1, Inverted P wave in AVR
V1 and V2
look at the septum
V3 and V4
anterior wall of the left ventricle
V5 and V6
lateral wall of the left ventricle
No history of ischemia, symptomatic
History of ischemia