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Transcript
OBJECTIVES Pediatric Cardiac Rhythm Analysis for the Non-Cardiac Nurse Amy Jo Lisanti, MSN, RN, CCRN, CCNS, PhD (candidate) Clinical Nurse Specialist, Cardiac Intensive Care Unit, The Children’s Hospital of Philadelphia CARDIAC ANATOMY But I’m not a cardiac nurse! Describe the basic anatomy and physiology of the heart. Explain cardiac electrical conduction system and its relationship to the cardiac cycle. Identify the common arrhythmias in infants and children. Recognize the nursing assessments and actions related to the arrhythmias. 7 year old Jessica presents to the ED in anaphylactic shock after stepping on a beehive and getting stung several times. Monitor – HR is 186! What else are you looking for? Figure 1 THE CARDIAC CYCLE THE CARDIAC CYCLE KEY POINT = Blood flows the path of LEAST RESISTANCE !!! Figure 2 Figure 3 Figure 4 REGULATING CARDIAC OUTPUT CARDIAC OUTPUT Cardiac Output = Stroke volume x Heart rate Therefore, CO is the amount of blood pumped out of the ventricles each minute. Stroke volume = Amount of blood pumped out of the ventricles with each beat Preload Afterload Contractility Autonomic Nervous System Intrinsic Regulation Renin-AngiotensinAldosterone System Natriuretic Peptides Baroreceptors Chemoreceptors RA stretch receptors Figure 5 SPECIAL CONSIDERATION = INFANTS!! THE ACTION POTENTIAL…. UGH! CONTRACTION Figure 6 Figure 9 THE ELECTRICAL CONDUCTION SYSTEM THE ELECTROCARDIOGRAM THE HIGHWAY OF THE HEART: SA Node AV Node Bundle of His ECG = The Graphic Representation of the Electrical Activity of the Heart ECG Picture Depends on Lead Placement Figure 8 Purkinje Fibers Figure 7 THE ELECTROCARDIOGRAM ECG PAPER QRS complex S-T Segment Voltage P-R Interval Time P wave QRS Duration T wave DEPOLARIZATION = CONTRACTION 0.2 Seconds 0.04 Seconds THE CARDIAC CYCLE THE CARDIAC CYCLE Atrial Depolarization: P-wave and PR interval QRS Complex = Ventricular Depolarization R Atria Contract and Ventricles Fill (“Atrial Kick”) Q THE CARDIAC CYCLE T Wave = Ventricular REpolarization This is the resting phase of the Cardiac Cycle. No Interruptions Allowed! S SINUS RHYTHM Determined by the SA Node – Age Dependent Electrical Impulse flows through Normal Conduction Pathway Age Ranges for Normal Sinus Rhythm (NSR) Newborn to 12 months = 100-180 1- 3 years = 90 - 150 3 - 5 years = 70 - 140 5 – 8 years = 65 – 130 8 years and older = 60 – 110 Sinus Bradycardia – Below these age ranges Sinus Tachycardia – Above these age ranges Sinus Arrhythmia – SA node fires at irregular rhythm RHYTHM ANALYSIS RHYTHM ANALYSIS • What’s Normal?? • What is my Patient’s ASSESSMENT? • What am I even looking at???? • Is my patient Hemodynamically Stable? RHYTHM ANALYSIS ECG WAVEFORM CHANGES Is the rhythm regular or irregular? Identify the waveforms Is there a P wave before every QRS complex? T wave morphology/ST segment Measurements PR interval QRS duration QT/QTc Case study 32 day old baby boy at the pediatrician’s office for his 1 month old check-up. He was born in the 75th percentile and now sits in the 10th percentile for weight. Mom says that he always seems to tire out during feeds. VS- T 36.9, HR 220, RR 52, BP 62/30 Artifact Patient Movement Loose Electrodes Improper Grounding Faulty Monitor Physiologic Hypoxia Ischemia Hypertrophy Electrolytes PATIENT ASSESSMENT IS KEY!!!! Potassium Calcium Magnesium Medications Cardiac Surgery ATRIAL ARRHYTHMIAS Premature Atrial Contractions (PACs) Paroxysmal Atrial Tachycardia (PAT/SVT) Atrial Flutter Atrial Fibrillation PREMATURE ATRIAL CONTRACTION (PAC) ATRIAL FLUTTER ATRIAL FIBRILLATION PVCs Wide QRS Complex No P-Wave PAROXYSMAL ATRIAL TACHYCARDIA (PAT/SVT) VENTRICULAR ARRHYTHMIAS Premature Ventricular Contraction (PVC) Ventricular Tachycardia (V-tach) Ventricular Fibrillation (V-fib) V-TACH TORSADE DE POINTES VENTRICULAR FIBRILLATION Cardiac Muscle is quivering! No Coordinated Contraction! NO Cardiac Output! CPR and DEFIB STAT! Figure 10 PROLONGED QT RISK = SUDDEN DEATH QT Interval changes with Heart Rate QTc is the “Corrected” QT Interval Adjusted for the Heart Rate (R-R Interval) HEART BLOCKS FIRST-DEGREE AV BLOCK First-degree AV Block Second degree AV Block 14yo male with osteosarcoma in his right distal femur. Treatment: Doxorubicin, Cisplatin, Methotrexate Zofran q8 hours for nausea and vomiting Pre-chemo ECHO and ECG were normal Ordered another ECHO and ECG prior to next dose of Doxorubicin. QTc=0.52 QTc is greater than 0.42 sec in men QTc is greater than 0.44 sec in women Prolonged QT: Case Example Mobitz Type I (aka Wenckebach) Mobitz Type II Third degree AV Block Figure 10 MOBITZ I - WENCKEBACH COMPLETE HEART BLOCK MOBITZ Type II ASYSTOLE NO ELECTRICAL ACTIVITY NO PACEMAKER TO INITIATE ACTIVITY REVIEW Most Common Arrhythmias in Children: LETHAL ARRHYTHMIA Very Resistant to Resuscitation Efforts Thank you for your attention! Children with Congenital Heart Defects may present with any arrhythmia. Children with other chronic illnesses on certain medications may develop arrhythmias. Figures References Hebbar, A. & Hueston, W. (2002). Management of common arrhythmias: Part I. Supraventricular Arrythmias. American Family Physician, 65, 2479-2486. Morelli, P., Biancaniello, T., Chandran, L. (2007). The essentials of pediatric ECGs. Contemporary Pediatrics, 24(9), 49-60. Mowery, B. & Suddaby, E. (2001). ECG interpretation: What is different in children? Pediatric Nursing, 27, 224, 227-231. Urden, L., Stacy, K., Lough, M. (2006). Thelan’s Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby Elsevier. Bradycardia (most often related to Hypoxia) Sinus Arrhythmia (changes in vagal tone from inspiration and expiration, benign) Asystole (can follow bradycardia if untreated) Supraventricular Tachycardia Figure 1: Retrieved July 10, 2008, from http://www.medicalook.com/diseases_images/heart-diseases1.jpg Images 2-4: Retrieved July 10, 2008, from http://en.wikipedia.org/wiki/Cardiac_cycle Figure 5: Retrieved July 10, 2008, from http://www.themdsite.com/graphics/ION_14a.jpg Figure 6: Retrieved July 10, 2008, from http://virtuallyshocking.com/wpcontent/uploads/2006/10/CepBasicsPresentation.011-001.png Figure 7: Retrieved July 10, 2008, from http://www.uptodate.com/patients/content/images/card_pix/Heart_con duction_system.jpg Figure 8: Retrieved July 10, 2008, from http://nobelprize.org/educational_games/medicine/ecg/ecgreadmore.html Figure 9: Retrieved April 16, 2010, from http://www.carolguze.com/images/cellorganelles/actin-myosin.jpg Figure 10: Retrieved April 16, 2010, from http://www.lond.ambulance.freeuk.com/ecg/1degavbk.jpg Cullen, J. (2008). Color ECG tracing pictures, used with permission.