Download Pediatric Cardiac Rhythm Analysis for the Non

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.