ECG Interpretation Presentation PDF

Electrocardiogram Interpretation (ECG). Objectives ▪ To identify the different types of cardiac monitor ▪ To integrate the inclusion of cardiac monitoring into the holistic care of patients across the lifespan ▪ To identify the components of an ECG complex ▪ To integrate ECG reading...

Electrocardiogram Interpretation (ECG). Objectives ▪ To identify the different types of cardiac monitor ▪ To integrate the inclusion of cardiac monitoring into the holistic care of patients across the lifespan ▪ To identify the components of an ECG complex ▪ To integrate ECG readings with patient symptoms of possible cardiac issues  Cardiac Monitoring Types ▪ Display heart rhythms in actual or real time ▪ Types: ▪ 12-Lead ECG machine ▪ Defibrillator ▪ Hard-wire bedside & central monitoring ▪ Telemetry ▪ In the hospital ▪ At home  Continuous Electrocardiogram (ECG, EKG) Monitoring ▪ Graphic representation of the heart’s electrical activity over time ▪ Used to detect (as does 12-lead ECG): Rhythm irregularities (dysrhythmias, arrhythmias) Electrolyte imbalances Conduction abnormalities Injury, death, or change in the heart muscle  12-Lead Electrocardiogram (ECG) ▪ A transthoracic graphic representation of the heart’s electrical activity ▪ Reflects the intensity & direction of all electrical activity in the myocardium ▪ Provides a picture in 12 angles or views ▪ Displays overall rhythm of the heart ▪ Displays weaknesses in different parts of the heart muscle 12-Lead ECG ECG Indications ▪ Allow rapid assessment & intervention for many patient problems ▪ Diagnose arrhythmias ▪ Diagnose conduction abnormalities ▪ Diagnose heart chamber enlargement ▪ Diagnose myocardial ischemia, injury, infarction ▪ Monitors effects of cardiac or antiarrhythmic medications ▪ Monitors effects of electrolyte disturbances ▪ Hypercalcemia or hypocalcemia ▪ Hyperkalemia or hypocalcemia Bedside or Telemetry Monitoring ▪ Continuous cardiac monitoring ▪ Can see images at bedside (if bedside) & at a central cardiac monitoring station (either by ED staff or, if telemetry, by the telemetry monitor technician) ▪ 3-Lead or 5-Lead* ▪ Gives numeric heart rate average readings & a continuous cardiac waveform Electrodes ▪ Electrodes must make good contact with the skin ▪ Electrodes applied to the skin to detect electrical activity, convey it to a monitor (receiver) through a cable system ▪ The monitor converts the energy into a waveform Lead Placements Lead II ▪ P wave is upright ▪ QRS is upright ▪ Easiest to see all of the elements of the complexes ▪ Most common lead for cardiac monitoring  Electrocardiogram Graph Paper ▪ Vertical lines represent voltage or amplitude ▪ Horizontal lines represent time ▪ Horizontally small square = 0.04 sec ▪ Horizontally large square = 0.20 sec ▪ Vertical small square = 1 mm  Continuous Cardiac Monitoring 6-second Strip ▪ 6 second strip x 10 = 60 seconds (1 minute) ▪ Each 3 seconds is marked on the paper with a hash mark/vertical marker  Basic Electrocardiogram ▪ Isoelectric Line ▪ No electrical activity or weak impulses (too weak to detect) Anatomy of the ECG Complex ▪ P wave ▪ PR Interval ▪ QRS Complex ▪ ST segment ▪ T wave P Wave ▪ Atrial depolarization ▪ Impulse from the SA node, depolarization of the atria ▪ Normal is a positive deflection ▪ The impulse causes the atria to contract ▪ Can be high-voltage, notched, inverted, missing or within the QRS complex ▪ Can be constant or variable  PR Interval ▪ Time taken for the original impulse to pass through the atria & the AV node so can move on to the ventricles ▪ PR is measured from the first upward elevation of the complex to the first deviation from the baseline (R wave) after the P wave ▪ 0.12-0.20 seconds ▪ Allows for a very slight pause to allow the mechanical event of atrial contraction to move blood through the AV valves into the ventricles ▪ If PR interval prolonged, indicates a delay in the AV node (or an atrial ventricular block) QRS Complex ▪ Ventricular depolarization ▪ 0.06 – 0.12 seconds ▪ Mechanical response is contraction of the ventricles ▪ Measured from thee first deviation from the baseline after the P wave (can be negative or positive) to where the S meets the baseline ▪ Can negatively or positively deflected ▪ Can be widened (delayed conduction) ▪ BBB (LBBB or RBBB) ▪ Ventricular pacing ▪ Hypothermia ▪ Toxin – tricyclic antidepressants  T Wave ▪ Ventricular repolarization (recovery phase) ▪ Diastole (filling of the coronary arteries & the ventricles) ▪ Can be flat, inverted, tented (peaked) ▪ Not usually measured by itself but is included in the measurement of the QT interval ▪ Varies with heart rate: inversely proportional to HR ▪ heart muscle takes longer than normal to recover ▪ Causes include congenital, MI, ↑ ICP, post-cardiac arrest, electrolyte imbalances, hypothermia, drugs/toxins ST Segment ▪ “quiet” state of the ventricles immediately after depolarization → ventricles cannot be stimulated during this time ▪ Represents the time between depolarization (QRS) & repolarization (T wave) ▪ Ventricles maintaining contracted state to push all blood out ▪ Can be an indicator of myocardial oxygenation status ▪ Usually on the baseline – an electrically neutral time ▪ Can be depressed ▪ Can be elevated ECG Interpretation: ST Segment Elevated ST: injury or infarct (MI) > 1 mm above the baseline Depressed ST: > 0.5 mm below the baseline Ischemia or old injury ST Depression: Myocardial Ischemia ST: Elevation – AMI Diagnosis by 12-Lead ECG ECG Rhythm Analysis  ECG Rhythm Analysis ▪ 1. Calculate the rate ▪ 2. Determine regularity ▪ 3. Assess the P wave ▪ 4. Determine PR interval ▪ 5. Determine QRS duration ▪ 6. Interpret the rhythm  Determine Heart Rate Measure QRS complexes in a 6 second strip and multiply X 10 (equals one minute) (works for both regular and irregular rhythms). Count from R wave to R wave This is a 6 second strip. Is it regular? (Do the QRS’s come at expected intervals?) What is the heart rate? Heart Rate Determination  Heart Rates Bradycardia 100 bpm  Determine Regularity Does the QRS come at predictable intervals? → Measure them if unsure. Slight R-R variation is normal. Identify the P wave, QRS, and T waves. Heart Rate & Regularity Assess the P Waves ▪ Should be upright in Lead II ▪ Round in shape ▪ P waves originate in the sinus node normally ▪ P waves arising from another area(s) will have a different shape, be found in an abnormal place in the complex, or will have a different polarity ▪ Is every P wave followed by a QRS complex? ▪ If the P wave is present, all with the same shape, the rhythm is referred to as a “sinus” rhythm ▪.12 -.20 seconds Assess the PR Interval ▪ Are the PR intervals normal? ▪ PR interval measured from the beginning of the P waves to the beginning of the QRS complex ▪.12-20 seconds (3-5 boxes) ▪ Are the PR intervals all the same? (all measure same) ▪ Is the rhythm regular or irregular?  Assess QRS Complexes Are they normal in time? 0.06-0.12 sec Are they normal in shape? FLB – funny looking beat? Rabbit ears? The usual morphology shows the most efficient conduction through the ventricles. Different shapes usually take longer time, indicating an abnormal pathway. Why would an impulse take another pathway? Sinus Rhythm or Normal Sinus Rhythm  What Makes a Rhythm a Sinus Rhythm? ▪ Look at rate: ▪ Is the ventricular rate (50) 60 – 100 bpm? ▪ Look at regularity: ▪ Are the ECG complexes regular or irregular? ▪ Look at relationship between P waves & QRS complexes: ▪ Is there a P wave for each complex followed by a QRS complex? Is there something wrong with this ECG?  Sinus Rhythm ▪ Rate 60-100 beats per minute ▪ Regularity Regular ▪ P waves Normal ▪ PR Interval.12-.20 seconds ▪ QRS duration.04-.12 seconds ▪ P:QRS ratio 1:1 Sinus Tachycardia ▪ Characteristics: ▪ Ventricular & atrial rates > 100 bpm (usually < 120 bpm) ▪ Ventricular & atrial rhythm is regular ▪ QRS shape & duration normal ▪ P wave normal ▪ PR interval normal & consistent ▪ P:QRS ratio 1:1 ▪ Causes: ▪ Physiologic or psychological stress ▪ Meds that stimulate the SNS ▪ Enhanced automaticity of SA node and/or excessive sympathetic tone ▪ Hyperthyroidism  Sinus Bradycardia ▪ Characteristics: ▪ Rates < 60 bpm ▪ Rhythm is regular ▪ QRS shape & duration normal ▪ P wave normal ▪ PR interval normal & consistent ▪ P:QRS ratio 1:1 ▪ Causes: ▪ Hypoxia (especially in children) ▪ Vagal stimulation ▪ ↑ ICP ▪ Aging ▪ CAD & MI (especially inferior MI) ▪ Decompensated heart failure ▪ Infections (endocarditis, myocarditis) ▪ Hypothyroidism ▪ Electrolyte imbalances ▪ Medications that slow the conduction system ▪ Beta blockers, calcium channel blockers, amiodarone SB Management ▪ Identify & get rid of the cause** ▪ Atropine 0.5 mg IV every 3 – 5 minutes ▪ Maximum dose 3 mg ▪ Catecholamine ▪ Epinephrine, dopamine, levophed infusions ▪ Transcutaneous pacemaker ▪ May need a permanent pacemaker  Dysrhythmias or Arrhythmias ▪ Disorders of formation or conduction (or both) of electrical impulses within heart ▪ Can cause disturbances of ▪ Rate ▪ Rhythm ▪ Both rate, rhythm ▪ Potentially can alter blood flow, cause hemodynamic changes ▪ Diagnosed by analysis of electrographic waveform  ECG Essential Do’s ▪ Always check the patient ▪ Do NOT treat the cardiac monitor ▪ Check the rhythm in at least 2 leads ▪ Troubleshoot the equipment: ▪ Check the electrodes ▪ Check the monitor cables ▪ Check the monitor (especially the battery) Check the Patient!!  ECG Interpretation Objectives ▪ Identify the rhythm ▪ How does the rhythm correlate to the clinical picture? ▪ Does the rhythm’s significance result in needed interventions?  ECG Essential’s! ▪ Always check the patient ▪ Do NOT treat the cardiac monitor ▪ Check the rhythm in more than 1 lead ▪ Troubleshoot the equipment ▪ Check the electrodes ▪ Check the monitor cables ▪ Check the monitor (especially the battery)  What is Artifact? ▪ Noise!!!! ▪ originating from sources outside the patient ▪ Electrostatic sources, electromagnetic sources or radiofrequency interference ▪ “noise” originating from the patient ▪ Muscle artifact (shivering, seizure, difficulty breathing) ▪ “noise” originating from patient-electrode contact ▪ Dried out electrode, poor skin contact  ECG Rhythm Analysis—Remember? ▪ 1. Calculate the rate ▪ 2. Determine regularity ▪ 3. Assess the P wave ▪ 4. Determine PR interval ▪ 5. Determine QRS duration ▪ 6. Interpret the rhythm  Conduction Abnormalities: Dysrhythmias = Arrhythmias ▪ Disorders of the formation or conduction (or both) of the electrical impulse within the heart ▪ Can cause disturbances of the heart rate, the heart rhythm, or both ▪ Rate dysrhythmias ▪ Tachycardia = heart rate > 100 bpm ▪ Bradycardia = heart rate < 50 – 60 bpm ▪ Irregular rhythm ▪ Inherent pacemaker (SA node) malfunctions ▪ Other pacemakers supersede the SA node ▪ Blocks ▪ Atrial depolarization not always in sequence with ventricular depolarization ▪ Ventricular block → ventricles contract sequentially (one side first, then the other)  Dysrhythmias: Fibrillation ▪ Unsynchronized electrical activity ▪ Atrial or ventricular ▪ Multiple small groups of cardiac muscle cells trying to act as the heart’s impulse generator all at once ▪ Quivering, chaotic electrical & muscular activity ▪ Does NOT generate enough chamber output to measure Atrial Fibrillation Ventricular Fibrillation  Sinus (SA Node) Dysrhythmias ▪ Occur due to an imbalance of sinoatrial node discharge ▪ Can be a normal response ▪ Can be a pathologic response due to disease or toxins (including prescribed medication) ▪ Types of sinus dysrhythmias: ▪ Sinus bradycardia ▪ Sinus tachycardia ▪ Sinus arrhythmia  Supraventricular Tachycardia ▪ If cannot determine whether the tachycardia arises from the atria or the AV junction, the dysrhythmia is referred to as supraventricular or above the ventricles ▪ It is often difficult to diagnose some tachycardias as it is often difficult to discern the abnormal P waves or the PR intervals in the abnormal rhythm because the ventricular rate is too fast ▪ Abnormal P waves are buried in the T wave of the preceding beat  Supraventricular Tachycardia ▪ HR > 150 (adult) ▪ Vagal maneuvers ▪ Adenosine 6 mg rapid IVP + 20 ml NS rapid IVP ▪ May repeat in 1 – 3 minutes at 12 mg doses ▪ Beta blockers or calcium channel blockers may be considered  Atrial Dysrhythmias ▪ Premature atrial contraction ▪ Atrial flutter ▪ Atrial fibrillation  Premature Atrial Beats (funny little beats) ▪ Early atrial beats that originate outside of the SA node ▪ SA node fires an impulse, then an irritable focus quickly jumps in, firing its own impulse before the SA node fires again ▪ The P to P and R to R intervals are shorter with a PAC ▪ A PAC is usually followed by a pause in the normal rhythm ▪ An abnormality that occurs within an underlying rhythm ▪ Can be unifocal or multifocal ▪ Most common cause is excessive use of caffeine, nicotine, alcohol, or with anxiety, fatigue, or fever ▪ Usually benign and asymptomatic (or may feel “palpitations”) ▪ If are frequent or with the presence of heart disease, may put person at risk for development of serious atrial dysrhythmias  Atrial Flutter (assess the P waves) ▪ Do you see p waves? ▪ This saw-tooth baseline is typical of ▪ atrial flutter, a re-entry abnormality. ▪ AV junction blocks some of the impulses ▪ may be 2:1 or 3:1 ▪ rate is normally tachycardic ▪ affects filling of ventricles and cardiac output ▪ Seen with organic heart problems ▪ What could patient symptoms be with this rhythm?  Atrial Fibrillation (Assess the P waves!) ▪ Do you see p waves? ▪ Atria are fibrillating, not helping the ventricles to fill ▪ note the disorganized base-line, no consistent P wave ▪ note irregularly irregular (no pattern to R waves) ▪ impulses get to AV node randomly ▪ Loss of atrial “kick” means loss of 25% to 30% of cardiac output ▪ What are patient symptoms? ▪ AV flutter often deteriorates to atrial fib  Atrial Fibrillation—Controlled or Uncontrolled Rate ▪ May be intermittent or chronic ▪ Controlled or uncontrolled ▪ Ventricular rate can be < 60 bpm or > 100 bpm ▪ RVR is an emergent situation ▪ Requires prompt treatment ▪ Symptoms of poor perfusion  Can you Interpret?.  Symptoms: Atrial Fibrillation & Atrial Flutter ▪ Fatigue ▪ Weakness ▪ Shortness of breath ▪ Dizziness ▪ Anxiety ▪ Syncope or near syncope ▪ Chest discomfort/pain ▪ Palpitations ▪ Hypotension  Treatment: Atrial Fibrillation & Atrial Flutter ▪ Drug therapy ▪ beta blockers ▪ amiodarone hydrochloride ▪ verapamil ▪ diltiazem ** ▪ digoxin ▪ May try adenosine ▪ Cardioversion  Ventricular Dysrhythmias ▪ Premature ventricular contractions or complexes ▪ Ventricular tachycardia ▪ Ventricular fibrillation  PVCs ▪ Assess QRS complexes for uniformity & regularity ▪ Seen as early ventricular complexes followed by a pause ▪ FLB’s are usually PVCs ▪ Impulse arises early (before next expected beat) ▪ Compensatory pause (SA node rhythm unaffected) ▪ Usual cause in hospitalized patient?** ▪ Rare PVCs common in everyone ▪ Skipped beat when pulse checked (does not perfuse) ▪ Too many PVCs → cardiac output falls  Assessing PVCs on a rhythm strip ▪ What is the underlying rhythm? ▪ Are the abnormal beats PVCs? How do you know? Unifocal versus Multifocal. Repetitive PVCs Sequential PVCs  Management: PVCs ▪ Usually not serious ▪ What is most common cause? How to you treat? ▪ If frequent & persistent, amiodarone or sotalol ▪ Lidocaine 50-100 mg bolus, infusion at 2-4 mg/min (Class 1b) ▪ Procainamide (Pronestyl) 500-600 mg IV bolus over 30 min, infusion at 2-6 mg/min (Class 1a) ▪ Eliminate cause—what is the most common cause?  Ventricular Arrhythmias ▪ Ventricular Tachycardia ▪ Pulse or pulseless? Why is this important? ▪ Ventricular Fibrillation  Ventricular Tachycardia: Assess QRS Complex ▪ Is it regular? ▪ Rate? ▪ usually high >170 bpm, can be over 300! ▪ At rates this high, no time for ventricular filling ▪ P waves? PR interval? ▪ QRS? Normal morphology? ▪ V-tach ▪ Is this a problem? ▪ What would patient symptoms be? ▪ Death  V Tach Causes Treatment Ischemic heart disease MI ▪ Stable or Unstable??? Cardiomyopathy ▪ What does stable look like? Hypokalemia Hypomagnesemia ▪ What does unstable look like? Valvular heart disease Heart failure Drug toxicity Hypotension Ventricular aneurysm Hypoxia  Treatment: V. Tach with a Pulse Stable Unstable ▪ Medications ▪ Cardioversion!!! ▪ Amiodarone 150 mgs over 10 minutes ▪ Lidocaine ▪ Electrolyte replacement (magnesium)  V. Tach--Pulseless ▪ Treatment is the same as for ventricular fibrillation  Ventricular Fibrillation: Assess QRS Complex ▪ Disorganized ventricular activity ▪ No systole—do you have a pulse? ▪ No cardiac output ▪ Death  V. Fib ▪ Course ▪ Fine  Management: Ventricular Rhythms ▪ Always an emergency ▪ Is the result of electrical chaos due to impulses from many foci firing in a disorganized pattern ▪ No ventricular contractions ▪ May be first manifestation of CAD ▪ Patients with AMI are at increased risk for developing ▪ Causes ▪ Electrolyte abnormalities: hypomag, hypoK ▪ Hemmorrhage ▪ Hypoxia ▪ Shock, surgery, trauma  Management of V. Fib ▪ Call code ▪ CPR 2 minutes ▪ Defibrillation ▪ CPR 2 minutes ▪ Epinephrine 1 mg of 1:10,000 evert 3-5 min ▪ CPR 2 minutes ▪ Defibrillation ▪ CPR 2 minutes ▪ Amiodarone 300 mg bolus; may repeat bolus at 150 mg ▪ CPR 2 minutes ▪ Defibrillation  Other Rhythms ▪ Asystole ▪ Pulseless electrical activity ▪ Pacemaker Rhythm ▪ Third degree heart block  Asystole ▪ No heart activity, no cardiac output ▪ Check in 2 leads ▪ Or…is a lead off? Check the patient ▪ Death… is usually fatal ▪ Management: ▪ CPR ▪ Epinephrine 1 mg of 1:10,000 mix IV every 3-5 minutes ▪ Oxygenation ▪ Treat reversible causes (H’s & T’s)  Pulseless Electrical Activity (PEA) ▪ Is a condition, not a true rhythm ▪ May resemble SR, ST, sinus bradycardia ▪ Organized electrical rhythm on the ECG monitor that looks like it will initiate heart muscle contractions but does not ▪ Unconscious, no pulse, no respiration, no cardiac output ▪ Causes: ▪ Severe heart disease ▪ Reversible causes (H’s & T’s) ▪ The electrical activity is organized in the heart but fails to generate effective cardiac muscle contraction Management: PEA ▪ Management: ▪ CPR ▪ Epinephrine 1 mg of 1:10,000 mix IV ▪ Oxygenation ▪ Treat reversible causes (H’s & T’s)  Causes of Cardiac Arrest/Lethal Arrhythmias ▪ H’s ▪ T’s ▪ Hypovolemia ▪ Toxins ▪ Hypoxia* ▪ Tamponade (cardiac) ▪ Hydrogen ion (acidosis) ▪ Tension pneumothorax ▪ Hyper-/Hypokalemia ▪ Thrombosis (coronary & ▪ Hypoglycemia pulmonary) ▪ Hypothermia ▪ Trauma  Third Degree AV Block: Complete Heart Block ▪ Impulses from the atria are completely blocked at the AV node & not conducted to the ventricles ▪ 2 impulses ▪ Potentially life-threatening due to ↓ in cardiac output ▪ Atrial beats march out, ventricular beats march out but there is no discernable pattern  Nursing Care of Patients with Dysrhythmias ▪ Decreased cardiac output ▪ Alterations in tissue perfusion ▪ Anxiety related to fear of the unknown or debilitation or morbidity/mortality ▪ Knowledge deficits  Planning & Goals of Nursing Care ▪ Decrease or eliminate dysrhythmias ▪ Maintain cardiac output ▪ Decrease cardiac workload ▪ Decrease oxygen consumption ▪ Decrease anxiety ▪ Increase knowledge  Dysrhythmias: Interventions ▪ Symptomatic care ▪ Pharmacologic ▪ Electrical ▪ Vagal maneuvers ▪ Cardioversion ▪ Defibrillation ▪ Pacemaker (temporary, permanent)  Management: Stable Unstable ▪ What does a stable patient ▪ What does an unstable patient look like? look like? Treatment? Treatment?  Electrical Therapy: Synchronized Cardioversion ▪ Delivery of electrical energy that is synchronized to the QRS complex so that the energy is delivered during systole to avoid the T wave* and the electrically vulnerable period of ventricular repolarization → the energy is not discharged until the defibrillator senses a QRS complex ▪ Synchronized cardioversion is used to terminate (stop): ▪ Supraventricular and ventricular tachycardias ▪ Atrial flutter with rapid ventricular response (RVR) ▪ Atrial fibrillation with rapid ventricular response (RVR) ▪ Sustained monomorphic ventricular tachycardia (VT) with a pulse  Synchronized Cardioversion ▪ A-P placement of the hands-free pads is preferred as less energy is required and the success rate is higher when the delivered energy travels through the short axis (anteroposterior) of the chest ▪ An additional 3-Lead monitoring cable (and the hands-free pads) from the defibrillator in order for the machine to sense the QRS complexes ▪ Cardioversion is usually an elective procedure performed with moderate sedation ▪ May be performed urgently if the patient is hemodynamically unstable ▪ Follow the manufacturer’s instructions for the defibrillator for cardioversion  Unsynchronized Electrical Therapy: Defibrillation ▪ Delivery of unsynchronized electrical energy to the myocardium to stop ventricular fibrillation (VF) and pulseless ventricular tachycardia (pVT). ▪ The defibrillating shock depolarizes all cells in the myocardium at the same time → all electrical activity is stopped thus allowing the sinus node to resume its function as the normal cardiac pacemaker ▪ The defibrillating shock is measured in joules (J) or watt-seconds ▪ Energy can be delivered as monophasic (delivers energy in one direction) or biphasic (delivers initial energy in one direction & the last portion in the opposite direction)  Unsynchronized Cardioversion ▪ Biphasic**: ▪ 120j – 200j ▪ Monophasic: ▪ 200j – 360j ▪ Internal defibrillation paddles ▪ 20j – 50j ▪ Automatic implantable cardioverter defibrillator (AICD) ▪ 20j – 34j Electricity Cardioversion Defibrillation ▪ Low energy ▪ High energy ▪ Synchronized ▪ Unsynchronized ▪ Patient has a pulse ▪ Patient has NO pulse*  Electrical Therapy: Pacemakers ▪ Transcutaneous pacing (TCP) ▪ External – temporary ▪ Pacing pads through the skin ▪ Transvenous pacing (temporary pacing) ▪ External – temporary ▪ Pacing wires through venous system to heart ▪ Permanent transvenous pacing (PPM) ▪ Internal – permanent ▪ Fixed or demand ▪ Single or Dual chamber (right atria & right ventricle paced) ▪ Biventricular (both ventricles)  Pacemaker Functions ▪ Pacing ▪ When electrical signals are sent through the pacing wires to the heart tissue(s) ▪ Sensing ▪ The pacer wires also send information back to the pacemaker generator, allowing the pacemaker not to interfere with a natural, healthy heart beat  Pacemaker Rhythm ▪ May be fixed rate or demand ▪ Fixed rate preset ▪ Does not change or respond to native rhythm ▪ Demand senses native rhythm and activates when the native heart rate falls below a preset rate. ▪ Pacemaker inhibits (stops) when native rhythm increases above preset rate. ▪ Pacemaker spike = fire ▪ QRS after spike = capture ▪ Assess rhythm for fire and capture ▪ Assess patient CV status Paced Rhythm Strips  Patient Care and Management ▪ Daily pulse check. ▪ Lift no more than 5-10 lbs. ▪ Do not raise arms above shoulder level for a long time (2-3 months). ▪ Microwave/electric blanket OK. ▪ Use cell phone on opposite side (do not place against the chest). ▪ No magnetic tests (MRI). ▪ MRI compatible now available. ▪ Carry ID pacemaker card. ▪ Teach patient to do a daily pulse rate check → Why?  Dysrhythmias: Emergency Interventions ▪ Assessment ▪ Patient condition/status ▪ Rhythm identification ▪ ABCs ▪ Alive? Quality of airway? LOC? Pulse? Blood pressure? ▪ Dead? CPR → ACLS algorithms based on rhythm ▪ Defibrillation if indicated ▪ Breathing? Yes, supplemental oxygen; No, ambu bag ▪ IV access – medications ▪ Monitor ▪ Call physician Questions?