ECG & Emergency Drugs For Nurses

1. Presented By: Mr. Kingsle Kishore Coumar M.F
Designation: Nursing Excellence Coordinator
MGMCRI

2. OUTLINE
• Introduction
• Brief history 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 is derived 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 OF ECG
• 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 Einthoven used a String
Galvanometer for recording ECG
• He assigned the letters as
P,Q,R,S and T Which is used still

7. WHY IT NAMED PQRST?

8. ANSWER
• He used ABCD 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 invented analytical
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 is the 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 is inversely proportional to heart rate.
If HR Increases --------------------QT Interval Decreases
If HR Decreases--------------------QT Interval Increases

13. TYPES OF WAVEFORMS
WAVEFORMS EXPLANATION 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 OF HEART

15. SA Node –Natural Pacemaker of
the Heart.
WHY?

16. ANSWER
• SA Node has 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

18. CARDIAC ACTION POTENTIAL

20. S.NO PATHWAY LOCATION FUNCTION
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 is Named Bundle of
HIS?

22. ANSWER
• Swiss cardiologist and Anatomist
Wilhelm His,Jr.,Discovered this
specialized muscle fibres in 1893
and therefore named after him

23. 4 Purkinje Fibres Located in inner ventricular
walls of the heart
Carry and transmit the impulse from both left and
right bundle of hIS to the ventricles.

24. ELECTROCARDIOGRAPHIC LEADS

25. ELECTROCARDIOGRAPHIC LEADS PLACEMENT
LEADS
CHEST LEADS
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 LEADS ELECTRODE PLACEMENT
aVR Right Arm
aVL Left Arm
aVF Left Foot
N Right Foot

27. EINTHOVEN’S TRIANGLE
BIPOLAR LEADS LEAD 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 T waves –Seen in
Hyperkalemia (Symmetric and
pointed wave)

34. • Negative Inverted T waves seen
in Post Ischemia,Acute
Ischmia,Cardiomyopathy
(Hypertrophic) , and even in
CVA.

35. • Flat T waves: 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 or depression
occurs with Myocardial
Infarction.

38. NURSING MANAGEMENT
• Obtain Consent
• 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
• Assess patient 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 arrhythmia refers 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 heart rhythms 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 the workplace
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 the home
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
• Assess the 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.

51. HEART BLOCKS

56. EMERGENCY
DRUGS

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 reabsorption of
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 1 antiarrhythmic:
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 to opioid 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/P by 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
Depress subcortical
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 • Adrenergic direct
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 • Adrenergic agent
• 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 • Adrenergic agent
• 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-22.75 mg
• 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 • OPIOID analgesics
• 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 • Coronary vasodilator
• 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 Associated with
Drug Administration
•Consult references/pharmacist
•Observe for ADR’s
•Report drug reactions
•Record observations
•Withhold drug if needed - notify provider

81. Medication Orders
• The nurse 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
• Controlled substances
- 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 Rights of Medication Administration
• Right drug
• Right dose
• Right patient: name and birth date
• Right time
• Right route
• Right documentation
• Patient’s right to refuse