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Region X Cardiac SOP’s EKG Rhythms and Interventions

Region X Cardiac SOP’s EKG Rhythms and Interventions. Condell Medical Center EMS System February 2008 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider should be able to:

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Region X Cardiac SOP’s EKG Rhythms and Interventions

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  1. Region X Cardiac SOP’sEKG Rhythms and Interventions Condell Medical Center EMS System February 2008 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

  2. Objectives • Upon successful completion of this module, the EMS provider should be able to: • review identification of a variety of EKG rhythms • relate the dysrhythmia to the presentation of the patient • comprehend the Region X cardiac SOP’s as they relate to the patient’s presentation • actively participate in case review • successfully complete the quiz with a score of 80% or greater

  3. Introduction to Use of the SOP’s • Care is initiated for all patients based on your assessment • A pediatric patient is considered under the age of 16 (15 and less) • Do not delay care to contact Medical control • But, prompt communication is encouraged

  4. Cardiac SOP’s • Obtaining a history and performing an assessment can often provide valuable information • Consider underlying causes for all situations • In the cardiac SOP’s, think of the 6 H’s and 5 T’s as possible causes of the problem as you progress through assessment & treatment for the patient

  5. Hypovolemia Hypoxia Hydrogen ion - acidosis Hyper/hypokalemia (high/low potassium levels) Hypothermia Hypoglycemia Give fluids (20 ml/kg) Provide supplemental O2 Ventilate to blow off retained CO2 Difficult to determine in the field; consider in diabetic ketoacidosis & renal dialysis Attempt rewarming Check blood glucose on all altered mental status pts 6 H’s

  6. Toxins (overdose) Tamponade, cardiac Tension pneumothorax Thrombosis, coronary (ACS) or Thrombosis, pulmonary (embolism) Trauma Think “out of the box” Check for JVD,  B/P Check for JVD,  B/P, absent/decreased breath sounds, difficulty bagging Obtain 12 lead when applicable; good history taking to lead to suspicions (travel, surgery, immobility) What is history of current status? 5 T’s

  7. CPR Guidelines (2005 AHA) • If witnessed arrest, CPR until defibrillator ready • If unwitnessed or >4-5 minutes, CPR for 2 minutes then defibrillate if indicated • 30:2 compressions to ventilations for 1 and 2 man adult CPR for 2 minute periods • 5 cycles of 30:2 is 2 minutes • Once intubated, compressor does not stop; ventilator bags the patient once every 6-8 seconds via ETT

  8. AHA 2005 Guidelines • After each defibrillation attempt, immediately resume CPR • Do not look to check the rhythm • Do not stop to check for a pulse • After 5 cycles (2 minutes), stop CPR (no longer than 10 seconds) to reevaluate the rhythm • Meds are administered during cycles of CPR

  9. Securing Airway • A term used to indicate to secure the airway in whatever manner needs to be taken • Initially the airway may be secured via BVM • Insert oropharyngeal airway if needed • The patient can be intubated when time and personnel are available and after defibrillation has been performed • Whatever method is used, limit interruption of CPR to a maximum of 10 seconds when possible

  10. Regularity Rate P waves PR interval QRS complex There is no electrical activity; you observe a straight line Asystole There is no pulse, no perfusion, no blood pressure. Survival from this dysrhythmia is extremely slim. CPR is initiated in the absence of a State of Illinois DNR form.

  11. Asystole No pulse, no breathing, no B/P! You’ve got a dead patient or a lead popped off

  12. Asystole and Defibrillation • The goal in defibrillation is trying to allow the dominant pacemaker (preferably the SA node) to take over pacemaker duties • When you defibrillate a patient, you place them into asystole • So, the patient in asystole does not need defibrillation (they’re already there!) • The patient in PEA has electrical activity and defibrillation would interfere with the one thing that is working for them!

  13. PEA • A clinical situation in which there is organized electrical activity (other than VT) viewed on the monitor but there is no palpable pulse & no breathing • In the absence of a palpable pulse, the patient needs high quality CPR • Focus on the causes (6 H’s and 5 T’s) as you perform CPR and administer medications

  14. PEA <60 bpm When the underlying rate is under 60 bpm, Atropine is indicated. Remember “when they’re done, give them one” For asystole and slow PEA <60 give 1 mg Atropine IVP/IO

  15. PEA >60 bpm If the patient has no pulse, this is PEA Knowing the overall rate helps to determine if atropine is given or not Atropine not indicated if heart rate on monitor is >60

  16. SOP for Asystole/PEA • Begin CPR • Secure airway with minimal interruptions • Search for and treat causes (6 H’s, 5 T’s) • Establish IV/IO • Meds • Epinephrine 1:10,000 1 mg IVP/IO every 3-5 minutes alternated with Atropine if indicated • Asystole & slow PEA: Atropine 1 mg IVP/IO every 3-5 minutes to maximum total dose 3mg

  17. Medications - Epinephrine • Stimulates vasoconstriction • Supports improved blood flow to the heart and brain • Can place a strain on the heart (this is adrenaline!) by  heart rate and  strength of contractility (more blood squeezed out) • Relatively short half-life so needs to be repeated frequently (every 3-5 minutes) • There is no maximum

  18. Medications - Atropine • Blocks effects of the parasympathetic nervous system that may be exerting a negative influence (decreasing heart rate) • Increases rate of discharge of impulses at the SA node • Decreases the amount of block at the AV node (lets more impulses travel through to the ventricles) • Attempts to increase the heart rate

  19. Atropine in Asystole & PEA • Asystole • “When they’re done, give them one” • 1 mg every 3-5 minutes • Max total dose is 3 mg • PEA • Only given if the rate is < 60 • If rate >60 then you don’t need the effects of Atropine to speed up the heart rate! • “When they’re done, give them one” • 1 mg every 3-5 minutes, max total 3 mg

  20. Bradycardia and Heart Blocks • When the heart rate falls, the cardiac output is affected. • The patient becomes symptomatic when the cardiac output cannot keep up with the demands of the body • Determine if the patient is symptomatic or not before administering treatment • check level of consciousness • check blood pressure

  21. Regularity Rate P waves PR interval QRS complex Regular P to P and regular R to R Less than 60 bpm Positive, upright, rounded, look similar to each other 0.12-0.20 seconds and constant <0.12 seconds Sinus Bradycardia

  22. Sinus Bradycardia Treatment indicated if the patient is symptomatic EMS needs to provide a thorough assessment to make an accurate clinical decision

  23. Regularity Rate P waves PR interval QRS complex Atria are regular, ventricular rhythm is irregular Atrial rate greater than ventricular rate Normal in shape; not all followed by QRS PR gets progressively longer until dropped QRS complex Normally <0.12 seconds Second Degree Type I - Wenckebach

  24. Second Degree Type I - Wenckebach Note characteristics of irregular rhythm, grouped beating, lengthening PR intervals, periodically dropped QRS. The P to P interval is regular and measures out in all blocks! “Type I drops one” “Wenckebach winks at you”

  25. Regularity Rate P waves PR interval QRS complex Atria regular, ventricular rhythm can be regular or not Atrial rate greater than ventricular rate which is slow Normal; more P’s than QRS’s Usually normal, constant for the conducted beats Usually <0.12 sec; periodically absent after P waves Second Degree Type II - Classical

  26. Second degree Type II - Classical This rhythm can have a variable block or can have a set pattern (ie: 2:1; 3:1, etc). The slower the heart rate, the more symptomatic the patient. Treatment with Atropine versus TCP based on width of QRS. Think “Type II is 2:1” (but know block can be 3:1,etc)

  27. Regularity Rate P waves PR interval QRS complex Atria regular, ventricular rhythm regular but independent of each other Atrial rate greater than ventricular; ventricular rate determined by origin of escape rhythm (can be slow or normal) Normal in shape & size None (no pattern) Narrow or wide depending on origin of escape pacemaker 3rd Degree - Complete

  28. 3rd degree - Complete The patient’s symptoms are based on the ventricular heart rate - the slower the heart rate the more symptomatic the patient will be. Again, P to P marches right through. Treatment with TCP versus Atropine based on width of QRS

  29. Patient Assessment in Bradycardia • The patient’s symptoms will depend on the ventricular rate which influences the cardiac output • Most reliable is to check the patient’s level of consciousness and blood pressure to help determine stability • If interventions are necessary, the goal will be to improve the heart rate to improve the cardiac output

  30. SOP for Stable Bradycardia • Patient alert • Skin is warm and dry • Systolic B/P > 100 mmHg Transport with no further intervention

  31. SOP for Unstable Bradycardia • Altered mental status • Systolic B/P < 100 mm Hg • Bradycardia or Type I second degree heart block • Includes all narrow QRS complex bradycardias • Goal: to speed up the heart rate • Atropine 0.5 mg rapid IVP • May be repeated every 3-5 minutes • Max Atropine is 3 mg • “When they’re alive, give 0.5”

  32. Transcutaneous Pacemaker (TCP) • TCP when Atropine is ineffective • Narrow QRS bradycardia not responding to dose(s) of Atropine • Wide QRS bradycardia where Atropine is not expected to be effective, TCP is tried first • TCP sends electrical charges thru the skin • TCP is uncomfortable • Valium 2 mg slow IVP over 2 minutes • May repeat Valium 2 mg slow IVP every 2 minutes to max of 10 mg for comfort

  33. TCP and Patient Assessment • Increase mA from lowest output setting until consistent capture noted on the monitor • Document settings (rate, mA) on the patient care run report • In the demand mode, if Atropine was administered and now “kicks in”, the patient’s own rate may exceed the pacemaker and put the pacemaker in stand-by (function of the demand mode!)

  34. TCP with Capture - Paced Rhythm Observed is one to one capture. Consider sedation with Valium to make the patient more comfortable.

  35. SOP for Wide QRS Bradycardia • Typically refers to Type II second degree heart block and 3rd degree (complete) • Atropine is not effective in wide QRS complex bradycardia (origin most likely below bundle of His if QRS is wide) • Begin TCP as soon as possible • If TCP not effective, can give Atropine 0.5 mg rapid IVP and repeat every 3-5 minutes to a max of 3 mg

  36. Tachycardia and 2 Questions to Ask During Assessment: #1 - Is the patient stable or unstable? • What is the level of consciousness? • What is the blood pressure? • If patient is unstable, needs emergent cardioversion • If patient is stable, get to question #2: #2 - Is the QRS narrow or wide? • If narrow QRS think SVT • If wide QRS think VT until proven otherwise

  37. Dangers of Tachycardia • With a rapid heart beat, the heart performs inefficiently • There is not enough filling time for the ventricles • Blood flow and B/P drop • With a rapid heart beat, the work load/demand increases on the heart • Increased requirement for more oxygen with reduced blood flow to myocardium increases risk of ischemia and potential MI

  38. Tachycardia and the Patient • Signs and symptoms often depend on: • Ventricular rate • The faster the rate, the less filling time for the heart, the more symptomatic the patient is • How long the tachycardia lasts • The longer the tachycardia, the less reserve there is left and the more symptomatic the patient tends to be • General health and presence of underlying heart disease

  39. Regularity Rate P waves PR interval QRS complex Usually very regular 150 - 200 bpm None visible Not measured; if P waves seen, PR interval often abnormal Usually <0.12 seconds unless abnormal conduction Supraventricular Tachycardia - Narrow QRS SVT is a term used to describe a category of rapid rhythms that cannot be further defined because of indistinguishable P waves.

  40. Supraventricular Tachycardia - SVT This SVT is most likely atrial tachycardia due to shortened PR interval (abnormal PR interval). The heart rate (180) is too fast for sinus tachycardia. The QRS is definitely narrow!

  41. SOP for SVT (Narrow QRS) • Stable patient (alert, warm & dry, B/P >100 • Valsalva maneuver • Have patient hold breath and bear down for 10 seconds (or try to blow up a balloon or blow through a straw) • Patient at home may have tried to make self gag • Adenosine 6 mg rapid IVP • Followed immediately by rapid flush of 20 ml NS • If no response in 2 minutes, repeat Adenosine at 12 mg rapid IVP again with 20 ml flush

  42. Adenosine for SVT • Antiarrhythmic • Decreases heart rate at SA node • Slows conduction thru AV node • Does not convert atrial fibrillation, atrial flutter or VT • Short half life (10 seconds) so start IV in AC area (preferably right), must be given rapidly followed immediately with saline flush

  43. Adenosine Back-up • Diltiazem/cardizem -slows heart rate • If still in stock, can give 0.25 mg/kg IVP slowly over 2 minutes • Watch for drop in blood pressure • Verapamil/isoptin - slows heart rate • 5 mg IVP slowly over 2 minutes • Watch for drop in blood pressure • If necessary, can repeat 5 mg slow IVP in 15 minutes if B/P > 100 mmHg • Administer fluid challenge if pt hypotensive

  44. Diltiazem/cardizem • Calcium channel blocker • Slows conduction thru SA and AV nodes • Slows ventricular rate for rapid atrial fib or rapid atrial flutter • Do not use in wide QRS rhythms or in WPW • Give slowly to minimize side effects • Watch for drop in B/P • Onset in 3 minutes • As home med, treatment of chronic angina

  45. Verapamil/Isoptin • Calcium channel blocker • Slows conduction thru AV node • Controls ventricular rate in rapid atrial fib or rapid atrial flutter • Do not use with wide QRS or history of WPW • 1st dose is 5 mg slow IVP • Repeat dose in 15 minutes is 5 mg slow IVP • Watch for hypotension • As home med used for hypertension, angina

  46. Ventricular Tachycardia - VT - This is NOT a narrow QRS! Wide QRS tachycardia is ventricular tachycardia until proven otherwise. Always treat the patient for the worst case scenario first

  47. Regularity Rate P waves PR interval QRS complex Atria regular; ventricular rhythm can be regular or irregular Atrial rate 250+, ventricular rate variable No identifiable P waves; saw tooth or picket fence pattern noted Not measurable <0.12 seconds unless abnormal conduction Atrial flutter

  48. Atrial Flutter Note key characteristics of the flutter waves or the “saw toothed” appearance also called the “picket fence”

  49. Regularity Rate P waves PR interval QRS complex Irregularly irregular Atrial rate 400-600; ventricular rate variable No identifiable P waves None measured 0.12 seconds or less unless abnormal conduction Atrial Fibrillation

  50. Atrial Fibrillation Rhythm is irregularly irregular. Check for medication history of blood thinner (ie: coumadin)and digoxin (strengthens cardiac contractions). When obtaining pulse, some impulses stronger than others.

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