EKG's made EZ

The NCLEX exam doesn't expect you to be a highly trained cardiologist, and the USMLE on average only asks 2 questions about EKGs, but recognition of important pathological rhythms is a requirement for all future nurses and physicians. One of the most important, yet daunting tasks in the nursing and medical fields is to learn to recognize, both accurately and rapidly, Electrocardiograms (ECGs). Variations from the normal p, QRS, and T waves can be completely harmless to fatal in minutes, and it is up to us in the healthcare field to be able to tell the difference, and act accordingly.

Lets take a look at these variations and see if there is a way to make this a bit easier to understand. We will divide these variations up into three groups: Bradyarrhythmias (abnormal rhythms with rate usually below 60),Tachyarrhythmias (abnormal rhythms with rate usually above 100 bpm), and Dysrhythmias (alterations to the normal sinus rhythm pattern).


Bradyarrhythmias

1.Sinus Bradycardia
–HR less than 60 requires treatment with Atropine only if symptomatic

2.AV Block
A.1st Degree•Key: PR interval above 0.2 seconds; Delay is in AV node
•Usually benign but low HR responds to Atropine


B.2nd Degree type I•Key: Progressive prolongation of PR until a P wave fails to conduct and no QRS follows a P wave; Delay is in AV node
•Usually benign condition seen with normal aging not requiring treatment, but if symptomatic with bradycardia, will respond to Atropine


C.2nd Degree type II
• Key: Normal EKG with a sudden drop of a QRS; Block usually in the His-Purkinje system usually as a result of ischemia
•Can turn into the deadly 3rd degree so temporary transcutaneous pacer may be needed until an implantable pacemaker can be inserted


D.3rd Degree
• AV dissociation often from irreversible damage to the AV node following a MI
• Key: P-P length does not equal R-R length
•Ventricles do not pump fast enough to maintain CO and requires pacemaker



Tachyarrhythmias
•Atrial impulse

A.Sinus Tachycardia•HR 100-140, may occur with exercise or anxiety, but also may be earliest indication of hypovolemia
•Usually not symptomatic until above 140 when diastolic filling time is impaired
•Count the large boxes from top of a QRS to another: 1 box = 300bpm, 2 box = 150bpm, 3 box = 100bpm, 4 box = 75bpm, 5 box = 60bpm
•TX: Eliminate cause (i.e. anemia, stimulant; fluid bolus)



B.SupraVentricular Tachycardia•A conduction signal loops and reenters the atrium causing rapid, atrial driven HR usually above 140bpm
•Atrial tachycardia results in narrow QRS complexes
•TX: Adenosine given rapid IV push



D.Atrial Flutter•One foci in atrium fires rapidly, leading to sawtooth P waves and regular QRS with HR between 75-175
•Occurs most often in COPD, but may be seen with CAD and Atrial septal defects (ASD)
•TX: Identical to AFib



•Atrial Fibrillation•Multiple atrial foci cause lack of P waves and very irregular QRS waves with widely varied HR from 75-175 bpm

•Caused by CAD, MI, HT, PE, Pericarditis, Hyperthyroidism
•Major risk for thrombotic events (CVA) so treat according to protocol
•Treatment Protocol; Determine length/onset of AFib:
• Acute: less than 48hrs
Unstable: (Hypotensive, AMS) Immediate cardioversion
Stable:
»Tachycardic: Control Rate w/ Beta Blocker (Atenolol) then electrical cardioversion
»NSR: Proceed directly to cardioversion (electrical preferred to pharmacologic; If electrical fails or is unfeasible use Amiodarone to convert)
•Acute: greater than 48 hrs or unknown duration
–Before cardioversion: If longer than 2 days must use Warfarin to anticoagulate for 3 weeks before and 4 weeks after
–Avoid the wait: Can obtain an echo to r/o thrombus and load pt with Heparin and proceed to cardioversion; Still require the 4 week Warfarin anticoagulation after
•Chronic: Under 60 with no heart disease or risk factors require no treatment; All others get Warfarin for good


Tachyarrhythmias
•Ventricular impulse

A.Ventricular Tachycardia
•Ventricular foci initiate rapid HR with wide QRS complexes
•Caused by prior MI (most common), active ischemia, hypotension, cardiomyopathy, Drugs, Electrolyte abnormalities•May initially have a pulse, but can rapidly evolve into a deadly pulseless VTach
•TX: VTach with a pulse treated with 150mg Amiodarone
•TX: Pulseless VTach treated identical to VFib with Code being called: CPR, Defibrillation, Epinephrine, Amiodarone, and Lidocaine (Alternate drugs w/ Epi being only drug you can not max out on)



B.Ventricular Fibrillation
•Ventricular foci initiates rapid rhythm which causes heart to fatigue and quiver
•Typically evolves from VTach
•Ischemic heart disease most common cause
•Always pulseless, so initiate a code as above



C.Torsades de Pointe•A polymorphic VTach with varying direction of QRS amplitude (points alternate down to up)
•Often caused by electrolyte problems and long QT, so give a trial of Mag and Calcium



D.Asystole
•Loss of electrical signal initiation so it doesn’t respond to Defibrillation (basically resets rhythm to asystole)
•Epinephrine and Atropine are only hopes



Arrhythmias
•Dysrhythmias

A.Premature Ventricular Contraction (PVC)•Abnormal Foci causes random, wide QRS contractions
•May not progress to any other rhythm and have no symptoms
•Can progress to VTach and VFib, so treat more than 6/min or if symptoms present with BBs



B.ST Elevation
•Usually an ominous sign of actual myocardial infarction
•Treat with ACS protocol including ECG and Enzymes
•If present in all 12 leads may suggest Pericarditis

C.T wave Inversion
•An ominous sign of cardiac ischemia, can precede B
D.Q wave
•If deeper than ½ of QRS, suggests a prior infarction, Follows B

E.U wave
•Suggestive of hypokalemia
F.ST Depression
•Often a sign of ischemia, use MONA, ECG, Enzymes

G.Peaked T wave•Suggestive of hyperkalemia

H.Prolonged QT
•QT width is more than ½ the width of QRS-QRS
•Often caused by low Mg or Ca, as well as many drugs that effect these electrolytes
•TX: Withdrawal medication that caused and check/treat electrolyte abnormalities

Diagnostic Tests made EZ

I remember trying to answer questions about the care of patients before, during and after certain diagnositic tests, and having no clue, mainly because I didn't really know what the test really was. So I am posting some pictures with a common point or two related to that test, that the NCLEX and the USMLE frequently asks. Hope you find this makes it a bit EZer to grasp.


Bronchoscopy (BAL)

• Definitive diagnosis of TB


• Lidocaine used intraoperatively to numb gag and cough receptors so assure patient has gag reflex back before feeding or giving fluids

Chest Xray

• Xray can be used for multiple diseases, and can be focused on chest, abdomen, cervical spine, extremeties, etc


• Portable xrays are frequently used for many respiratory complaints so prepare to see this ordered when you pass the boards and become an RN


• In any female inquire if there is any possibility they are pregnant, as xray is contraindicated if so


• Remove jewelry as will show up on xray and cover possible results
  
  

Thoracentesis

• In this procedure, a needle is inserted into the pleural space (membrane surrounding lungs) to draw out fluid


• May be a one time withdrawal, or may leave a drain in place


• Used for Pleural Effusions, Empyema, etc.


• Patient often placed on affected side, to allow good lung freedom to breathe


• Cardiocentesis, is similar procedure used for fluid around heart (Tamponade)

Pulmonary Angiography

• Definitive test used as gold standard diagnosis of Pulmonary Embolism


• Contrast material is inserted via a catheter, directly into lung vasculature (often entered through Femoral vein) and the flow of contrast is seen under fluoroscopy


• Expensive and time to test is often greater than desired, so CT or VQ scan often replace for PE


• Contrast material is used, so caution for allergies or kidney failure. As a general rule patients should receive more than normal fluids for 24 hours after contrast to help flush it ouf of system.

Arterial Blood Gas

• ABGs are often requested when acute respiratory or metabolic issues are occuring


• You may be on a unit very soon that will require you to perform this task


• Remember to do an Allen Test first (occlude radial/ulnar arteries, and release one then the other observing return of blood flow to hand in between)


• Do not suggest if your plan of care would not change with result possibilities


• When analyzing ABGs, look at pH first! High is alkalosis, low is acidosis. Then simply see if bicarb or CO2 has changed to determine what type is present (bicarb is metabolic, CO2 is respiratory)
  
  

Circular CT

• The most common type of test used for diagnosing Pulmonary Embolism, as well as a host of other diseases. This test produces picture slices through the body, like you were sliced in half.


• Contrast is usually used for circular CT, and can be seen in picture above as white material. Large circle on bottom of picture is the Aorta, and the smaller circles to the right are pulmonary arteries. Notice the dark circle in middle that resembles a donut? That is an embolus in the lung (PE)


• Remember all issues with contrast (allergies, kidney failure, patient on Metformin?)


• See pic below for what a circular CT looks like
  
  
  

MRI (magnetic resonance imaging)

• Similar results to a CT, but much prettier pictures. Due to the improved clarity are becoming gold standard for many diseases


• But test can take hours to perform, so not the best choice for rapidly deteriorating conditions.


• Since the test uses magnets, the patient can not have metallic heart valves or cochlear implants


• Contrast may also be used


• See below for image obtained by MRI, noticing the various slices we are able to obtain and use

CT (computerized tomagraphy)

• While the picture may not be as clear as an MRI, these images are actually better at seeing fluids, such as blood, and thus are usually first line for possible hemorrhagic strokes and other diseases


• Notice in picture above, to the right, contrast has been used which allows certain areas to become much brighter. In these pictures, the large tumor on the right is enhanced by contrast.


• All of the issues of contrast must be considered however


• See below for pic of CT,,,again

Lumbar Puncture


LP Indications
• Diagnosis of Meningitis
• Diagnosis of Subarachnoid bleed
• Diagnosis of Multiple Sclerosis
• Diagnosis of Malignancy
• Introduction of contrast or anesthetics

• LPs are taken with patient in fetal position (on side, legs drawn up, head on chest)
• Be on the alert for severe headache post procedure from drawing too much CSF out

Myelogram

• In this procedure, an LP is performed, and dye is injected under fluoroscopy.
• Xrays are then taken to measure flow of CSF and look for constrictions
• Dye may be oil or water based
• If an oil-based dye was used, the patient is kept flat in bed for approximately 8 hours
• If a water-soluble dye was used, bed rest is maintained, with the head of the bed elevated 30 degrees for 6 to 8 hours

OK...hope that helped a bit with getting a picture of certain diagnostics you will run across commonly in the hospital or on the NCLEX. Good luck!