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ECG & Emergency Drugs For Nurses
This document provides an outline for a presentation on electrocardiography (ECG) and includes sections on the history of ECG, terminology, types of waveforms, the cardiac conduction system, cardiac action potential, ECG leads and placement, analyzing ECGs, nursing management of arrhythmias and heart blocks, and emergency drugs. It begins with an introduction to ECG and defines it as the recording of the electrical activity of the heart. Key points covered include the names and functions of different parts of the cardiac conduction system, how to analyze an ECG for rate, rhythm and blood flow information, nursing assessments and interventions for various arrhythmias, and information about common emergency drugs used to treat cardiac issues.
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- 1. Presented By: Mr.Kingsle Kishore Coumar M.F Designation: Nursing Excellence Coordinator MGMCRI
- 2. OUTLINE • Introduction • Briefhistory of ECG • Terminology • Definition • Types Of Wave Forms • Conduction system of Heart • Cardiac Action Potential • Electrocardiographic leads & placement • Analysis of ECG • Nursing management • Arrythmias and its types • Heart blocks • Emergency drugs
- 3. INTRODUCTION • ECG isderived from Greek word. • (Electro+Kardio+Graph)=(Electrical activity+heart+to write). • The prompt and skilled knowledge of identifying changes in ECG makes nurses competent enough to be the part of the health team. • It is the basic simple test that contains information about a number of cardiac diseases.
- 4. BRIEF HISTORY OFECG • Augustus Desiré Waller created the first practical ECG machine with surface electrodes. • He lectured on it in Europe and America, often using his dog “Jimmy” in his ECG demonstrations • 1917, a few years before his death, Waller published a study of over 2000 traces of heart conditions • The first human ECG, recorded by Waller, in 1887 with Lippmann’s capillary electrometer
- 5. • Willem Einthoven,a Dutch Physiologist , invented the First electrocardiogram in 1903 • Received Nobel Prize in Medicine,in 1924
- 6. Cont… • William Einthovenused a String Galvanometer for recording ECG • He assigned the letters as P,Q,R,S and T Which is used still
- 7. WHY IT NAMEDPQRST?
- 8. ANSWER • He usedABCD to indicate the waves in the uncorrected tracing, he was forced to find other letters to label his corrected curve, which he superimposed on the uncorrected tracing. He chose PQRST. • One attractive hypothesis is that Einthoven chose these letters because Descartes had used them to identify successive points on a curve.
- 9. • Descartes inventedanalytical geometry. • He was the first scientist to state the law of refraction, and he labeled some of the points on the curves he drew P and Q
- 10. TERMINOLOGY • Depolarization-Contraction • Repolarization-Relaxation •Membrane potential –Difference in electric potential between the interior and exterior of the cell due to voltage changes. • Action potential-Passing of cell from one to another, causing atria and ventricles to contract. • Resting Potential-Ions that flowed into the cell and flowed out to the cell (Resting Phase-Diastole)
- 11. DEFINITION • Electrocardiogram isthe recording of electrical events of the heart using electrodes placed on the skin (12 lead system). • It gives the broad picture of the conduction system of the heart • It gives information regarding RATE,RHYTHM, and BLOOD FLOW to cardiac muscles.
- 12. NOTE QT Duration isinversely proportional to heart rate. If HR Increases --------------------QT Interval Decreases If HR Decreases--------------------QT Interval Increases
- 13. TYPES OF WAVEFORMS WAVEFORMSEXPLANATION DURATION P Waves Atrial Depolarization <0.12sec QRS Wave Ventricular Depolarization 0.06-0.10sec T Wave Ventricular Repolarization 0.10-0.25 sec PR Interval Time period from initiation of atrial depolarization to initiation of ventricular depolarization PR Segment Isoelectric line from end of P wave to onset of QRS,depicting slowing of conduction through AV Node RR Interval Interval Between two R waves 0.6-1.0sec
- 14. CONDUCTIVE SYSTEM OFHEART
- 15. SA Node –NaturalPacemaker of the Heart. WHY?
- 16. ANSWER • SA Nodehas the Fastest automaticity – Generate impulse at 60 to 100bpm. • AV Node –Generate 40 to 50bpm • Bundle HIS –Generate 30 to 40bpm • Purkinje Fibres -Generate around 15 to 30bpm That’s why SA Node is consider Natural Pacemaker of the heart.
- 17. CARDIAC ACTION POTENTIAL •Two types of cells: Cardiomyocytes and cardiac pacemaker cells. • Cardiomyocytes: It makes up the cardiac muscle & enable the muscle of heart shorten and lengthen their fibres (Leads to depolarization and Repolarization in Myocardium) • Cardiac pacemaker cells: Spontaneously initiate the impulses causing beating of a heart
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- 20. S.NO PATHWAY LOCATIONFUNCTION 1 SA Node sinoatrial Node Located in right atrium Generates electrical signal or impulses to stimulate and contract atria 2 AV Node atrioventricular Node Located in the interatrial septum between atria and ventricles Screens out rapid impulses from the atria,preventing ventricles from life-threatening arrhythmia 3 Left and Right Bundle of HIS Inferior end of the interatrial septum Transmits impulses from AV node to the ventricles
- 21. WHY it isNamed Bundle of HIS?
- 22. ANSWER • Swiss cardiologistand Anatomist Wilhelm His,Jr.,Discovered this specialized muscle fibres in 1893 and therefore named after him
- 23. 4 Purkinje FibresLocated in inner ventricular walls of the heart Carry and transmit the impulse from both left and right bundle of hIS to the ventricles.
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- 25. ELECTROCARDIOGRAPHIC LEADS PLACEMENT LEADS CHESTLEADS ELECTRODE PLACEMENT V1 4th Right ICS at sternal border V2 4th Left ICS at sternal border 10 Leads V3 Mid/Halfway between V2 and V4 V4 5th ICS Midclavicular Line V5 5th ICS Anterior Axillary Line V6 5TH ICS Midaxillary Line
- 26. LEADS LIMB LEADSELECTRODE PLACEMENT aVR Right Arm aVL Left Arm aVF Left Foot N Right Foot
- 27. EINTHOVEN’S TRIANGLE BIPOLAR LEADSLEAD I LEAD II LEAD III Looking the heart electrical activity Left Side Inferior Left Inferior Right
- 30. ANALYSIS OF ECG •Determine whether rhythm is regular or irregular • Look for P wave.Are all P wave similar? • Look for QRS Complexes.All QRS are similar or they are narrow or broad? • Are PR interval are same or varying? • Look For T wave and its morphology? • Look that all waves are preceding each other in a normal sequence • Is the Rate normal?
- 33. • Large Twaves –Seen in Hyperkalemia (Symmetric and pointed wave)
- 34. • Negative InvertedT waves seen in Post Ischemia,Acute Ischmia,Cardiomyopathy (Hypertrophic) , and even in CVA.
- 35. • Flat Twaves: Hypokalemia or digitalis therapy can cause flattened T waves accompanied with a prominant U wave
- 36. • U Wave-Small,rounded deflection which is sometimes seen after T wave • Prominent U waves are characteristics of Hypokalemia.
- 37. • ST-Elevation ordepression occurs with Myocardial Infarction.
- 38. NURSING MANAGEMENT • ObtainConsent • Check electrolytes specifically K level • Administer Treatment as Prescribed for hyperkalemia or hypokalemia • Monitor ABG of the patient if hemodynamically unstable • Monitor changes in ECG
- 39. NURSING MANAGEMENT • Assesspatient for Atrial Arrhythmias (Eg:Atrial Fibrillation,Atrial Flutter) • Patient in Atrial Fibrillation are mostly on Anticoagulant therapy to prevent CVA • Teach About Importance of Anticoagulation therapy, foods • Significance of regular PT/INR
- 40. Arrhythmia • Cardiac arrhythmiarefers to any change from the normal sequence of electrical impulses.
- 41. ARRHYTHMIAS BRADY ARRHYTHMIA HEART RATE< 60 BPM TACHY ARRHYTHMIA HEART RATE >100 BPM VENTRICULAR ARRTHYMIAS ATRIALARRTHYMIAS SICK SINUS SYNDROME AV BLOCK ATRIAL TACHYCARDIA ATRIAL FIBRILLATION PSVT ATRIAL FLUTTER VENTRICULAR FIBRILLATION VENTRICULAR TACHYCARDIA TORSADE DE POINTES
- 42. Early CPR matters;what about early defibrillation? First important to understand different cardiac arrest rhythms: Ventricular fibrillation – heart rhythm in chaos Ventricular tachycardia – heart rhythm very fast Ventricular fibrillation (VF) and ventricular tachycardia (VT) are both shockable rhythms – that is, they need defibrillation
- 43. Early CPR matters;what about early defibrillation? First important to understand different cardiac arrest rhythms: Pulseless electrical activity (PEA) – electrical recording can look normal, but no blood flow Asystole – also known as “flatline” – no electrical activity at all PEA and asystole are not shockable rhythms – defibrillation does not treat these cardiac arrest rhythms
- 44. Cardiac arrest heartrhythms summary ventricular ventricular pulseless asystole fibrillation tachycardia electrical activity Shockable rhythms; need to defibrillate VF and VT are very common for cardiac arrest in the home or in public places Non-shockable rhythms; do not defibrillate PEA and asystole are more for cardiac arrest among hospitalized patients
- 45. ECG WAVEFORMS P Wave •Saw Tooth Shape P wave in Atrial Flutter • No P waves in or fibrillatory P waves in atrial Fibrillation
- 47. CPR in theworkplace Friday, June 13, 2008 Tim Russert, TV correspondent, had cardiac arrest at work had known coronary disease suffered heart attack that quickly led to cardiac arrest Attempted resuscitation (CPR and defibrillation) failed Unknown how long until AED was applied Resuscitation in the media
- 48. CPR in thehome Friday, June 25, 2009 Michael Jackson had cardiac arrest at his home; physician performed CPR Presumed respiratory arrest from drug overdose Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed – not a hard surface Resuscitation in the media
- 49. NURSING MANAGEMENT • Assessthe patient-Are they symptomatic • Give O2 and monitor oxygen saturation • Monitor blood pressure and heart rate • Start IV if not already established • Closely monitor the patient • Maintain records and reports • Teach the patient regarding pacemaker and various do’s and don’t’s
- 50. Cont… • Vagal Maneuvers(Valsalva’s maneuver or Carotid Sinus Massage) • Make sure Resuscitative equipment is readily available. • Prepare cardioversion • Educate patient regarding self management if on anticoagulant therapy. • Obtain 12 lead ECG and interpret the findings • Promote bed rest with head of the bed elevated to 45 degree • Teach Family members about FAST-Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services.
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- 57. EMERGENCY DRUGS • Adrenaline •Lidocaine • Amiodarone • Calcium gluconate • Frusemide • Atropine • Dopamine • Noradrenaline • Adenosine • Metoprolol • Dobutamine • Chlorphenaramine • Dexamethasone • Hydrocortisone • Midazolam • Tramadol • Sodium bicarbonate
- 58. ADRENALINE • α-adrenergic- vasoconstriction(which can also reduce bleeding) and mydriasis. • β2-adrenergic - bronchial relaxation • Proper labelling • Continuous monitoring • Check q5min B/P, pulse rate • After giving flush it immediately with 3-5 ml of NS. • Ensure rhythm and watch carefully • 1ml – 1 mg • Onset: 3-5 minutes (quick) • Cardiac arrest every 3- 5 mins • If anaphylaxis: 0.5ml IM Mechanism of action: Dose Nurses responsibility Indications • Cardiac arrest • Anaphylaxis • Acute asthmatic attacks
- 59. ADENOSINE • Anti-arrhythmic •Slows conduction time through the A-V node, can interrupt the re-entry pathways through the A-V node, and can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardia • 2ml – 6mg • Onset: 20-30 seconds and the duration of action is < 10 seconds. • Max dose: 12 mg Mechanism of action: Dose Nurses responsibility • Don’t administer through central line (may cause asystole). • Don’t give more than 12 mg Adenosine as a single dose. • After administering adenosine , flush I.V. line immediately and rapidly with normal saline solution to drive drug into bloodstream. • Monitor heart rhythm for new arrhythmias after administering dose Indications • Supra Ventricular Tachycardia
- 60. ATROPINE • Anti-arrhythmic, Anticholinergic(anti- muscarinic) • These actions increase cardiac output & heart rate, decrease by blocking vagal stimulations in heart • Blocks the acetylcholine receptors to dries the secretions • 1ml – 0.6mg • Onset: immediately • Max dose: 3 mg • If OP poisoning : 4mg or more Mechanism of action: Dose Nurses responsibility Indications • Bradycardia < 40-50 bpm • AV heart block • Biliary surgery • I/O chart must to check urinary retention • Continuous ECG monitoring • Assess GI functions • Check for any dryness of mucous membrane
- 61. FUROSEMIDE Inhibit reabsorptionof sodium and chloride at proximal and distal tubule and in loop of henle • 1ml –10 mg • First dose-20-80mg • Second dose after 6th hour of 1st dose • Onset: 2-3 min • Max dose: 600-800 mg Mechanism of action: Dose Nurses responsibility Indications • Pulmonary oedema • Hepatic failure • Nephrotic syndrome • Ascites • Hypertension • I/O chart must to check fluid loss • Assess for hypokalaemia & hypotension • If high doses check for tinnitus or hearing loss
- 62. CALCIUM GLUCONATE • 10ml –10% • Ensure 10:10:10 • Max dose: 3 gram • Slow IV Mechanism of action: Dose Nurses responsibility Indications • Prevention and treatment of hypocalcaemia • Hyper-magnesemia • Hyperkalaemia • Continuous cardiac monitoring • ECG: check for the reverse of QT and T waves • Check for calcium levels • Calcium needed for maintenance of nervous, muscular & skeletal functions • Mainly cardiac contractibility
- 63. 2%LIDOCAINE Type 1antiarrhythmic: decreases diastolic depolarization, decreasing automaticity of ventricular cells • 1ml – 20mg • 50-100mg (25-50mg/min) • Repeat q3-5 min • Max 300mg / hr Mechanism of action: Dose Nurses responsibility Indications • Ventricular dysrhythmias • Digoxin toxicity • Continuous cardiac monitoring for dysrhythmia • ECG: if increases PR & QRS Segments stop or reduce rate.
- 64. TRAMADOL Binds toopioid receptors inhibit reuptake of norepinephrine, serotonin Weak opioid analgesics • 1ml –50mg • 1ml diluted with 9 ml ns • If 100 mg dilute with 100 ml ns • Max dose: 400 mg/day Mechanism of action: Dose Nurses responsibility Indications • Moderate pain or severe pain • Chronic pain • Frequently check for the pain status • Check for the dizziness, headache, confusion, nausea, Vomiting • Document the pain score properly by using pain scale
- 65. METOPROLOL Anti-hypertensive Lowers B/Pby beta blocking effects • 1ml –1mg • Max dose: 400 mg/day • Slow IV Mechanism of action: Dose Nurses responsibility Indications • Mild to moderate hypertension • NYHA class II, III heart failure • Cardiomyopathy • Monitor B/P for every 5 mins • Before administration check for the manual B/P and pulse rate if significant changes or PR <50bpm
- 66. MIDAZOLAM Sedative, anti anxiety, hypnotic Depresssubcortical levels in CNS • 1ml –1mg • Max dose: 15 mg/day Mechanism of action: Dose Nurses responsibility Indications • Pre operative sedation • Sedation for diagnostics • Endoscopic procedures • Intubation • anxiety • Monitor B/P, pulse, respiration. • Keep crash cart near by • Assist with ambulation until drowsy periods end
- 67. AMIODARONE • Anti-dysrhythmic •It works on cardiac cell membrane and relax the smooth muscles of myocardium • 1ml –50mg • 150 mg for 1st dose • 360 mg for next 6 hours • Maintenance 540 mg for remaining 18 hours Mechanism of action: Dose Nurses responsibility Indications • Unstable ventricular tachycardia • Ventricular fibrillation • Atrial flutter • Monitor ECG continuously • BP for hypo/hypertension • Check for any dyspnoea, fatigue, cough, fever and chest pain if persist discontinue
- 68. DOBUTAMINE • Adrenergicdirect acting cardia stimulant • Increased cardiac contractibility, • Increase cardiac output without increase heart rate • 1ml - 50mg • SS-5ml+45ml ns • DS-10 ml+40ml ns • Administer only by IV infusion. Mechanism of action: Dose Nurses responsibility Indications • Cardiac surgeries • Short-term treatment of adults with Cardiac decompensation • Assess for hypovolemia and correct • Check for bp, chest pain, LOC • If bp increases titrate the value • Check for electrolyte and urine output • Titrate on the basis of the patient's homodynamic/renal response.
- 69. DOPAMINE • Adrenergicagent • Vasoconstrictor & inotropic effect Causes increased cardiac output, renal flood flow and sodium excretion • 1ml-40mg • 5ml-200mg • Ss-5ml+45ml ns • DS-10ml+40ml ns Mechanism of action: Dose Nurses responsibility Indications • Shock • Hypotension • Cardiogenic or septic shock • Assess for hypovolemia and correct • Check for bp, chest pain, LOC • Administer only by IV infusion no bolus • Only administer by large veins • More prone to get extravasation
- 70. NORADRENALINE • Adrenergicagent • Vasoconstrictor • BP, heart rate, cardiac output increases • 1ML-1MG • SS -4 ml+46ml 5D • DS- 8ml+42ml 5D Mechanism of action: Dose Nurses responsibility Indications • Acute hypotension • Shock • Continuous monitoring for BP every 5 mins • If BP increases may titrate the dose • Notify if urine output <30ml/hr
- 71. DEXAMETHASONE • Corticosteroid,Anti inflammatory, Immuno- suppressant • Decrease inflammation by suppression of poly- morpho nuclear leucocytes • 1ml- 4mg • Initially 0.5–20 mg Mechanism of action: Dose Nurses responsibility Indications • Any inflammations • Allergies • Cerebral oedema • Septic shock • Monitor for hypo/hyper glycaemia • Potassium level need to assess • Frequently take BP, monitor body weight (signs of Na+ & H2O retention). • Assess for signs of infections
- 72. CHLORPHENARAMINE • Antihistamine • 1ml-22.75mg • Max dose 40mg/ day • Taken only for short time dose Mechanism of action: Dose Nurses responsibility Indications • Allergic Rhinitis • Cold Symptoms • Urticaria • Allergic Reaction • Check for sign and symptoms of CNS depressant • Check for nausea, vomiting and constipation
- 73. HYDROCORTISONE • Corticosteroid •Anti-inflammatory, • Immunosuppressive and salt-retaining (mineralocorticoid) • 100–500 mg, • 3–4 times in 24 hours Mechanism of action: Dose Nurses responsibility Indications • Severe inflammation • Adrenal insufficiency • Ulcerative colitis • Asthma • COPD • Check for hypokalaemia & hyperglycaemia • Plasma cortisol level if long term • Check for any signs of infection with WBC counts • Ensure antacids are there or not
- 74. SODIUM BICARBONATE • Alkanilizer •Reverse acidosis • 10ml-7.5% • If severe acidosis, 50 ordered means 5 ampoules have to administer Mechanism of action: Dose Nurses responsibility Indications • Metabolic acidosis • Salicylate poisoning • Check ABG every 4 hours if infusion ongoing • Check for the serum electrolytes • Asses respiratory status, pulse rate if abnormal notify
- 75. MORPHINE SULPHATE • OPIOIDanalgesics • Depress pain impulses transmission at the spinal cord • 1ml- 2mg • > 50kg 2.5 to 15 mg every 2-6 hours as needed Mechanism of action: Dose Nurses responsibility Indications • Moderate to severe pain • Assess the pain characteristics. • Check bowel status • I/O chart must • Check for CNS changes (dizziness, drowsiness, LOC, pupillary reactions)
- 76. NITROGLYCERINE • Coronaryvasodilator • Antianginal • Decreases preload and afterload • 1ml- 5mg Mechanism of action: Dose Nurses responsibility Indications • Chronic stable angina pectoris • CHF • Acute MI • Assess the pain characteristics. • check for orthostatic B/P Before & after administration
- 77. • Anti-coagulant • Antithrombotic •1ml-1000 IU Mechanism of action: Dose Nurses responsibility Indications • Prevention of DVT • MI • Heart surgeries • Disseminated intravascular clotting syndrome • Assess the pain characteristics. • check for orthostatic B/P Before & after administration INJ.HEPARIN
- 78. Inj.PotassiumChloride (KCL) • Electrolyte,mineral replacement • 1ml- 20 Meq Mechanism of action: Dose Nurses responsibility Indications • Prevention and treatment of hypokalemia • Check the potassium level • Assess for any signs of arrythmias • Determine hydration status • Check cardiac status
- 80. Nursing Implications Associatedwith Drug Administration •Consult references/pharmacist •Observe for ADR’s •Report drug reactions •Record observations •Withhold drug if needed - notify provider
- 81. Medication Orders • Thenurse must ensure the patient receives the correct medication • Orders should include the following: • Name Date/time Drug name Dose Route Time/frequency administration Prescriber’s signature • Controlled substances - Opioids, barbiturates, ect. double-locked - Keys with charge nurse - Log administration of drugs - End-of-shift count - Waste controlled substance with witness
- 82. Medication Orders • Controlledsubstances - Opioids, barbiturates, ect. double-locked - Keys with charge nurse - Log administration of drugs - End-of-shift count - Waste controlled substance with witness • Types of orders - Standing orders - pre-written, no call - Verbal orders
- 83. The Seven Rightsof Medication Administration • Right drug • Right dose • Right patient: name and birth date • Right time • Right route • Right documentation • Patient’s right to refuse