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 OBJECTIVES 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. But I’m not a cardiac nurse! 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? CARDIAC ANATOMY Figure 1 THE CARDIAC CYCLE KEY POINT = Blood flows the path of LEAST RESISTANCE !!! Figure 2 Figure 3 THE CARDIAC CYCLE Figure 4
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Pediatric Cardiac Rhythm Analysis for the
Non-Cardiac Nurse
Amy Jo Lisanti, MSN, RN, CCRN, CCNS, PhD (candidate )Clinical Nurse Specialist, Cardiac Intensive Care U nit,
The Children’s Hospital of Philadelphia
OBJECTIVES
� 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.
But I’m not a cardiac nurse!
� 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?
CARDIAC ANATOMY
Figure 1
THE CARDIAC CYCLE
KEY POINT = Blood flows the path ofLEAST RESISTANCE !!!
Figure 2 Figure 3
THE CARDIAC CYCLE
Figure 4
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
REGULATING CARDIAC OUTPUT
� Autonomic Nervous System� Intrinsic Regulation
� Renin-Angiotensin-Aldosterone System
� Natriuretic Peptides� Baroreceptors� Chemoreceptors� RA stretch receptors
Figure 5
SPECIAL CONSIDERATION = INFANTS!!
THE ACTION POTENTIAL…. UGH!
Figure 6
CONTRACTION
Figure 9
THE ELECTRICALCONDUCTION SYSTEM
� THE HIGHWAY OF THE HEART:
� SA Node
� AV Node
� Bundle of His
� Purkinje Fibers Figure 7
THE ELECTROCARDIOGRAM
� ECG = The Graphic Representation of the Electrical Activity of the Heart
� ECG Picture Depends on Lead Placement
Figure 8
ECG PAPER
0.2 Seconds 0.04 Seconds
Vo
ltag
e
Time
THE ELECTROCARDIOGRAM
DEPOLARIZATION = CONTRACTION
P-R Interval
QRS Duration
S-T Segment
P wave
QRS complex
T wave
THE CARDIAC CYCLE
Atrial Depolarization: P-wave and PR interval
Atria Contract and Ventricles Fill (“Atrial Kick”)
QRS Complex = Ventricular Depolarization
THE CARDIAC CYCLE
Q S
R
THE CARDIAC CYCLE
� T Wave = Ventricular REpolarization� This is the
resting phaseof the Cardiac Cycle.
� No InterruptionsAllowed!
SINUS RHYTHM
Determined by the SA Node – Age DependentElectrical Impulse flows through Normal Conduction Pathway
Age Ranges for Normal Sinus Rhythm (NSR)Newborn to 12 months = 100-180
1- 3 years = 90 - 1503 - 5 years = 70 - 1405 – 8 years = 65 – 130
8 years and older = 60 – 110
Sinus Bradycardia – Below these age rangesSinus Tachycardia – Above these age ranges
Sinus Arrhythmia – SA node fires at irregular rhythm
RHYTHM ANALYSIS
• What’s Normal??• What am I even looking at????
RHYTHM ANALYSIS
• What is my Patient’s ASSESSMENT?• Is my patient Hemodynamically Stable?
RHYTHM ANALYSIS� Is the rhythm regular or irregular?� Identify the waveforms
� Cardiac Muscle is quivering!� No Coordinated Contraction!
� NO Cardiac Output!� CPR and DEFIB STAT!
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)
� Prolonged QT:� QTc is greater than 0.42 sec in men� QTc is greater than 0.44 sec in women
Case Example
� 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
HEART BLOCKS� First-degree AV Block� Second degree AV Block
� Mobitz Type I (aka Wenckebach)� Mobitz Type II
� Third degree AV Block
FIRST-DEGREE AV BLOCK
Figure 10
MOBITZ I - WENCKEBACH
MOBITZ Type II
COMPLETE HEART BLOCK
ASYSTOLE
� NO ELECTRICAL ACTIVITY� NO PACEMAKER TO INITIATE ACTIVITY
� LETHAL ARRHYTHMIA� Very Resistant to Resuscitation Efforts
REVIEW
� Most Common Arrhythmias in Children:� 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
� Children with Congenital Heart Defects may present with any arrhythmia.
� Children with other chronic illnesses on certain medications may develop arrhythmias.
Thank you for your attention!
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.
Figures� Figure 1: Retrieved July 10, 2008, from
http://www.medicalook.com/diseases_images/heart-dis eases1.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