LECTURE 13: ECG READING & EMERGENCY NURSING

BUNDLE OF HIS
Between the right and left ventricles DYSRHYTHMIAS
PROBLEM
PURKINJE FIBERS
site: ventricular muscles ATRIAL P wave + N QRS
VENTRICULAR QRS + absent p wave
SA P Wave
PREMATURE ATRIAL CONTRACTION
• Prob: P wave – early (not consecutive)
• Mgt
o Does not require TX
o Avoid caffeine

ATRIAL TACHYCARDIA
• Prob: p wave – fast/early (consecutive)
• Atrial rate: 150-250 bpm
• Mgt
o Vagal stimulation
▪ Carotid massage
STEPS ▪ Stimulate vaguse nerve
1. RHYTHM ▪ Decrease HR/BD
• measure R wave to R wave o DRUGS
• determine: regular or irregular ▪ CLASS 2
2. RATE • Beta blockers – “olol”
• Determine: o Propanolol
• Normal, tachycardic, or bradycardic o Decreases HR
• Normal – 60-100 ▪ CLASS 4
• Tachy >100 • CCB
• Bradycardic <60 • Relaxes the heart
• Decrease HR
• Method: count the number of R
o Verapamil
waves on 6 second strip and multiply ATRIAL FLUTTER
by 10 • Prob: P Wave: saw tooth pattern
• Result normal – 60-100 (6-10 R/ • QRS: normal
QRS) • Atrial rate: 250-350 bpm
• Mgnt
o Drugs
A. SINUS BRADYCARDIA ▪ A. if stable
• RATE: <60 • Class 2 –
• DOC: atropin sulfate betablockers
• Dose 0.5 – 1mg • Class 4 ccb
• Digoxin (lanoxin) –
B. SINUS TACHYCARDIA
• Rate:>100 miscellaneous drug
o ( - )
• DOC: Beta blocker
chronotropic –
• Action: decreased HR
decrease
• Ccb: verapamil & diltiazem heart rate
• Action: decrease HR ▪ B. Prolong relaxation
(unstable)
3. P WAVE • Class 3 – amiodorone
• Iddentify the p wave *
• Ask: o Prolongs
• Is there p wave before each QRS relaxation
complex? YES • Class 1 –
• Are the p waves similar in sixe, procainamide
shape & position? YES o S l o w s
• Are the p wave normal in conduction
(activity) of
appearance? Y
heart
4. PR INTERVAL
• Normal: 0.12 to 0.20 second •
• Ask:
• Is the PERI consistently the same
ATRIAL FIBRILLATION
length? yes
• Is the PRI Normal? yes
5. QRS COMPLEX
• Normal QRS duration: <0.10/0.12
sec
• If more than 0.12 sec – ventricular
problem
o Widen QRS (abn)

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 LECTURE 13: ECG READING & EMERGENCY NURSING

VENTRICULAR TACHYCARDIA

• Prob: p wave – disorganized, chaotic,

irregular, (+) wavy lines
• QRS: normal
• Rate: >350 bpm
• S/S
o Pulse rhym – irregular (R to R • Prob: QRS – fast/early – consecutive
o Decreased CO o 3 or more consecutive PVCs
• Compliatio risk:clot formation o QRS – widen – more thant >0.12
• Mgt secs
o CARDIOVERSION o P wave: absent
▪ Set mode: synchronous/ • Rate: 150
synchronized counter shock • Mgt
▪ Shock is delivered during the o Treatment – 1st initial: assess LOC,
patient’s R wave check pulse
o If conscious:
▪ DRUGS
• L – LIDOCAINE
• A – AMIODARONE
• P – PROCAINAMIDE
▪ COUGH CPR
• Inhale deeply &
cough forcefully
o If unconscious + no pulse: pulseless
v-tach
▪ Defibrillation
o DRUGS: VENTRICULAR FIBRILLATION
1. All classes except CLASS 1-B – for
ventricular problem. LIDOCAINE
i. C L A S S 1-A -
PROCAINAMIDE
ii. CLASS 1-C
iii. CLASS 2 – BETABLOCKER
DECREASED HEART RATE
iv. CLASS 3 – AMIODARONE –
PROLONGS RELXATION
v. C L A S S 4 – C C B –
DECREASE HR (BY
RELAXING THE HEART) • Cause: untereated v -tach
2. ANTICOAGULANTS • QRS
i. IV: Heparin o Disorganized, chaoric, irregular
ii. Px is risk for clot formation o (+) coarse wavy lines
• v-rate: >300
PREMATURE VENTRICULAR CONTRACTION • treatment:
(PVC) o defibrillation – best managmenet
• Prob: QRS early QRS (instead of pwave) ▪ 1st shock: 200 joules
o not consecutive ▪ 2nd shock: 300 joules
o Widen QRS ▪ 3rd shock: 360 joules
o Duration: >0.12 secs o If no defibrillator: CPR
• MGT
o 1. CLASS 1 -B WITNESS
▪ DOC: lidocaine D – DEFIB
• Initial IV bolus: 50mg C – CPR
• Continuous IV : 2mg/ E – EPINEPHRINE
min A – AIRWAY MANAGEMENT
▪ ALERT
• If more then 6 PVCs UNWITNESS
per minute notify C – CPR
doctor D – DEFIB
• High risk of V tach E – EPI
fomation A – AIRWAY MGT
• Give: lidocaine
•

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 LECTURE 13: ECG READING & EMERGENCY NURSING

CARDIOVERSION DEFIBRILLATION o 0.24------/-------0.24------/-------0.24

o s/s: decreased LOC, dizziness,
MODE synchronous asynchronous fainting/syncope
CONSCIOUS (+) or sedated unconscious 3RD DEGREE AV BLOCK
• impulse/signal: completely blocked
ENERGY Low High
• no impulse communication
50-100J 200
• s/s: decreased HR: <40, dizziness,
<200 300
360 syncope, faintness + chest pain DOB
sedation
INDICATED Atrial fibrillation v - t a c h • Mgt:
(pulseless) 1. Identify underlying causes
v-fibrillation ▪ MI – (+) necrosis
▪ Electrolyte imbalances
2. Treatment
NURSING MANAGEMENT
a. Atropine – 0.5-1mg
1. ADVANCE DIRECTIVES
b. Transcutaneous pacing –
2. NOT DNR – ensure
emergency thru electrodes
3. APPLY: conductive agents (gels paste) to
on the skin
prevent electrocution
c. Permanent pacing – there is
4. Say “CLEAR” – 3x
a device implanted :
5. Correct placement:
pacemaker
a. 1st pad: 2nd ICS, R sternal border
b. 2nd pad: 5th ICS, L MCL, MAL/AAL
PACEMAKER
6. Pressure: 20-25 lbs • I n d i c a t e d : AV b l o c k ( h e a r t b l o c k ) ,
bradycardia
• Minor surgery
• Actions
o To control the abnormal heart rhythm
o Uses electrcial impulse
• Parts
o Battery (5-10 yrs)
o Computerized generators
o Wires with sensors
o Health teachings
1. Avoid vigorous exercises – avoid
lifting >3lbs
2. Report malfunction S/S
• Irregular pulse –
check pulse daily
(apical)
• Decreased CO
o Decreased
AV BLOCK (heart block)
• Causes urine output
o Edema
o Fibrosis – scarirng
o DOB
▪ Ischemia (decreased O2, o Hiccups – sign
heart muscles)
of pacemaker
▪ Infarction: (+) necrosis – MI malfunction
▪ Impaired condction 3. Avoid close contact with strong
• Blocked
• Partial: 1st and 2nd magnetic fields devices – MRI
• Okay microwave
degree AV block
• Complete: 3rd degree 4. Medic alert bracelet
o A prolongs
• Impulses – cannot
reach the ventricles

1ST DEGREE AV BLOCK

• Impulse: slowed, still makes it
• PR Interval: prolonged – >0.20 secs
(consistent)

2nd DEGREE AV BLOCK

• Type 1 – mobitz 1 (Wenchebach)
o Pr interval: prolonged – >0.20 secs
o Progressively longer
o 0.22----0.25----0.27----0.30
o S/s: decreased LOC, dizziness,
fainting/syncope
• Type 2 (mobitz 2)
o Pr interval: prolonged >0.20 secs
o Intermittent (but consistent 0.24)

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 LECTURE 13: ECG READING & EMERGENCY NURSING

DISASTER & EMERGENCY NURSING Ready to eat

•
DISASTER – catastrophic events that can lead to an pagkain
destruction Damit
•
Kumot
•
Kapote
•
TYPES Tsinelas
•
1. HUMAN MADE Id na may
•
• war/riots (civil unrest) bloodtype
• transportation accidents • M g a
• structural collapse – manmade bc of imporanteng
corruption XD, substandard materials dokumento
• Pollution – chemical spills, factories b i r t h
• Fire certificate,
• Explosion/bombing (terrorist related) lisensya at
2. NATURAL DISASTER passport
• Flood • Sanitary items
• Earthquake s a b o n ,
• Volcanic eruption toothbrush at
• Hurricane toothpaste,
• Tsunami toilet paper,
• Landslide napkin
• Mudflow (lahar) o Early warning – PAGASA,
• CD outbreak? PHILVOCS
OFFICIAL WATER LEVEL MONITORINGG
PHASES OF DISASTER MANAGEMENT
ALARM AIRING WATER COMMAND
1. MITIGATION
• Eliminating threats (disaster LEVEL
occurrence) 1ST One min 15m alert
• Long term planning YELLOW continuous
• Measures:
o Land use planning – plan 2ND 2 mins 16m prepare
ahead ORANGE intermittent
o Orientation: policies and
3RD 5 mins 17m evacuate
procedures
o Safety codes RED continuous
4TH 5 mins 18m Force
MAROON continuous evacuation

o Mass prophylaxis
2. PREPAREDNESS
• Planning how to respond – short
term planning
• Measures:
o Drills and trainings – red
cross, 911 NDRRMC – National Disaster Risk Reduction &
Management Council

3. RESPONSE
• Actions to minimize the hazards
• Measures
o Emergency planning o Activate Emergency Plan
▪ Public education (ER)
▪ Emergency bag o Search and rescue
• Tubig
o Triaging
• Flashlight
o In case of fire:
• Kandila at
posporo (balot ▪ R – RESCUE
sa plastic ▪ A – ALARM
• Pito ▪ C – CONFINE –
• Firs aid kit CONTAIN THE FIRE
• Gamot ▪ E – EXTINGUISH,
• Maliit na de EVACUATE
4. RECOVERY
abteryand • Aka: DEACTIVATION
radyo • Returning the community to normal
• Measures:

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 LECTURE 13: ECG READING & EMERGENCY NURSING

o Rehabilitation o Pneumothorax
o Reconstruction • Circulation
o Relief goods o Cardiac arrest
o Rescue services o Angina & MI
o Shock
TRIAGE – sorting out o Hemorrhage – massive
• Indication: mass casualty bleeding (major amputation –
• Initial steps arm and leg)
o SAFETY – survey the scene
o Rapid assessment 2. DELAYED
▪ START method: • AKA: urgent
• Simple • Color: yellow
• Triage • Can wait: within 2 hrs
• And • Without threat to limb or life
• Rapid • Closed head injury – concussion/
• Treatment contusion
▪ If pedia: JUMPSTART • Abdominal wounds – w/o hemorrhage
o Prioritization • Fracture – open/compound, lower
▪ Base on survival extremities
▪ Situation • Amputation – minor (finger and toes)
▪ If SCENE
• Increase chance of 3. MINIMAL
survival (red, yello, • AKA: non-urgent
green) • Color: green
• last: decreased • Can wait: for hours to days
chance of survival – • Sprain (injury to the ligaments),
black • Strain (overstretched muscles and
• case to case basis tendons) & fracture (upper extremities)
o if ongoing: eg • Walking wounded
fire • Abrasion
▪ 1 s t : • Minor burns
walkin • Small wound – lacerations, incision,
g puncture
(green)
4. EXPECTANT
4 CATEGORIES • Color: black
• Unlikely chance of survival – DOA
• Pulse and RR – absent V/S
• Pupil: fixed and dilated – sign of
impending death
• Penetrating head injury
• Abrasion - >90% (deep)
• Burns: >60%
• Spinal cord injury – cervical/neck area

FIRST AID

CHOKING
• S/S
oclutching/grasping the neck - Classic
sign
oCan’t speak, breathe or cough
oCyanosis
oCollapse – late sign
oStridor – very high pitched sound
(epiglottitis, and choking)
• Management
o Assessement
1. IMMEDIATE
• AKA: EMERGENT ▪ Ask the pt to speak: “are you
• Color: RED choking?”
• Life threatening but survivable ▪ Maneuver adult - Heimlich
• Airway maneuver
o facial burn (singed nasal hair) 1. Stand behind the victim
o facial fracture 2. Place arms around the victim’s waist
o bronchospasm – 3. Make a fist
anaphylaxis, r/t smoke / 4. Place the thumb side of the fist
o Site: between xyphoid and umbilcus
fume, status asthmaticus
• Breathing 5. Perform 5 quick thrusts: inward and upward
o If <10 RR or >30 RR
o Chest trauma
o ARDS & Atelectasis

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 LECTURE 13: ECG READING & EMERGENCY NURSING

• Mgt
o Position
▪ Sit down
▪ Lean forward – prevent
aspiration
o Apply pressure – to control bleeding
▪ Pinch the anterior (nose
bridge) nose (5-10 mins)

FACIAL BURNS
• S/S
o Singed nasal hair/mustache/beard
o Sooty nose
• Mgt
o Priority: airway
o O2 – humidified O2: 100%
o Portable oxygen
o Do not overcrowd the patient

SHOCK
• Inadequate tissue perfusion
• Decrease O2 delivery to the cells
o Metabolism: anaerobic
o Product: lactic acid
o Ph imbalance: metabolic acidosis

CAUSE EFFECT
CARDIOGENIC MI - m o s t Heart unable
INFANT: back blows (back thrust) thumps/slaps common to pump
• Use heel of the hand
Angina adequate
CAD blood
CHF
HYPOVOLEMIC Hemorrhage D e c r e a s e d
Decreased (blood loss) blood volume
volume of the - t r a u m a /
blood in the accidents
blood vessels - P U D
(bleeding
ulcer)
-(+) surgery
- l a b o r &
delivery
-Excessive
menstruation

causes effect
PREGNANT/OBESE: chest thrust
Site: thrust – middle of the sternum distributive
anaphylactic Allergy Bronchus -
UNCONSCIOUS: Abdominal thrust Beestings s p a s m ,
For patient lying (uncosnsious): Foods/medication constriction
1. Position: on the back – supine/flat position Dusk smoke B l o o d
2. Kneel astride the patient’s thighs v e s s e l s :
3. Place the heel of one hand against the vasodilation
patient’s abdomen
▪ Site: midline – between septic r / t i n f e c t i o n Maldistribution
umbilicus * xyphoid (sepsis) of the blood
5. Place the second hand on top of the first bacteria/virus -vasodilation
6. Press into the abdomen with a quick upward
thrust

If coughing forcible: do not intervene, do not leave

XD

EPISTAXIS
• S/S
o Nose bleeding r/t: trauma, extreme
temperature, hypertension

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 LECTURE 13: ECG READING & EMERGENCY NURSING

Neurogenic/ r/t spinal cord P N S e f f e c t -

• Fluid replacement: fluid
Spinal shock injury decreased o Prepare 2 large bore IV catheter
blood pressure (g16/18)
Onlyshock with o 1st line: LR – great plasma expander
decreased – increases blood pressure, replaces
heart rate the sodium
N e g a t i v e o 2nd: NSS
reflexes/absent o Never give to cardiogenic shock –
reflexes high risk for congestion and fluid
F l a c c i d overload
paralysis o Effectiveness: increase urine output
HEAT STROKE – too hot environment
• S/S
STAGES o CNS dysfunction
1. EARLY ▪ Delirium
• Altered LOC – decrease LOC (confusion ▪ Confusion
disorientation restlessness) o Increase body temp – 40 c
2. COMPENSATORY o Skin: hot and dry – anhidrosis
• SNS response – to normalize bP o VS: same with shock
• Response: increase HR • MGT
1. Reduce the high temperature asap
3. PROGRESSIVE ▪ Initial: move the pt to a cool
• Fluid loss: >40% area
• V/S ▪ Cold compress – wet towels
• UO: decreased <30ml/hr – end stage ▪ 3F
• Lab: CVP – decrease (+shock) o FLUID If
o Normal 4-10 cmh2o 2-8mmhg conscious
o o fan
o feet elevated
• health teaching
2. monitor fluid loss and weight loss (athletes)
3. avoid direct sun exposure
4. drink water
5. use hat/umbrella outside

POISONING
1. 1st response: call poison control center – to
instruct what to do
2. Mgt:
a. Stabilize - ABC
b. Identify substances – different
management of tablet and corrosive
substances
c. Reverse & eliminate from body
d. Antidote (last)

TABLETS:

• +GASTRIC LAVAGE
• +ACTIVATED CHARCOAL – absorbs
toxins and eliminate from the body;
alternative: burned toast
• +SYRRUP OF IPECAC – induce vomiting;
30 ml (Adult) 15 ml (childrean) 10ml (infant
– given once only)

ALERT!!!
4. REFRACTORY Acetaminophen (Tylenol) overdose
• Organ failure – multiple • 10-12 tablets
• Come – death • Emergency: severe liver toxicity
• Admit to emergency room for evaluation
MANAGEMENT
1. Improve tissue perfusion
Scene Watusi firecrackers– raw egg for
• Position modified trendelenburg
• Cpr
CORROSIVE SUBSTANCES:
ER • Drain cleaner, toilet bowl cleaner, silver
• Assessment: V/S, UO, labs, CVP kerosene and gasoline, muriatic acid
• O2

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 LECTURE 13: ECG READING & EMERGENCY NURSING

• BOWEL LAVAGE – enema, laxatives, o Drug overuse

catharics • 2 types
• ACTIVATED CHARCOAL – absorbs toxin o BLS – basic life support
• Never induce vomiting – avoid ipecac ▪ Manual: hands and mouth
• DILUTE – INCREASED FLUIDS/ MILK. o ACLS – advanced cardiac life
HOSPITAL: IVF support
▪ BLS + equipment
• Ambubag
LEAD POISONING • Mechvent
• Chelating agents – removes toxins (lead) • ET tube
• Succimer (chEMET) • Medication
• British anti-lewisite (BAL) • PRINCIPLES
• Disodium edetate (EDTA) 1. Scene assessment – survey the scene
• Hindi naghuhugas ng kamay o Place on back – supine to stable
• DRUG MGTl • 2. STANDARD PRECAUTION
o Cross allergy: peanuts o PPE: gloves
o Lab: BUN & creatinine • 3. RESPONSE ASSESSMENT
o Increased fluids o If adult and child: tap the shoulders
o If infant: tap the sole of the foot
FRACTURE & SPRAIN o Shout: hey, hey, are you ok?
• FIRST AID • 4 . B R E AT H I N G A N D P U L S E
o REST – immobilize – splint – present ASSESSMENT – 10 secs
position o Check face and chest
o ICE COMPRESS – to decrease o Check pulse
bleeding and control bleeding; 10 ▪ Adult & child: carotid
(5-10M/10-15M ▪ Infant: brachial
o COMPRESSION – apply pressure SCENARIOS
o ELEVATE – the affected extremity If UNRESPONSIVE
(+) breathing, (+) pulse – recovery position
AMPUTATED FINGER/TOES (-) breathing (+) pulse – rescue breathing
1. Cleansed: H2O/NSS (-) breathing (-) pulse - proceed to CPR
2. Wrap in sterile gauze: moistened with NSS
3. Place in a plastic bag or container
4. Place container on ice – to maintain the
viability of the cut cgycgy

SNAKE BITES
MGT
• Assess bite mark to determine if the snake
is poisonous
o Poisonous – 2 fangs
P NP
Bite mark 2fangs Saw teeath
head triangular round
eyes Slit like round
mostlyonthegrnd tree
• Bitten part: immobilize below heart level
o Avoid tourniquet, we allow our body
to fight, important is to
• Cleanse the wound – soap and water
• Dressing – bandage

BEE STING
• MGTl
o FIRST: Remove the stinger: scrape
card or finger nails 5. ACTIVATE EMERGENCY PROTOCOL
o Avoid scratching • Ask another person to
o Wound care: wash soap & h20 o Activate EMS – Emergency
o If (+) swelling: lips & mouth (tongue) Medical Service - 911
▪ Epinephrine (epipen) SQ - o Get AED
CHN
▪ Hosp: IV 6. 30 COMPRESSIONS (CAB)
• Use upper body weight to compress
CPR • Rate: 100-120 – push hard & fast ;-;
• Indications
o Disorders: cardiac arrest, MI, Stroke,
cardiac arrest ADULT CHILD INFANT
o Drowning

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 LECTURE 13: ECG READING & EMERGENCY NURSING

AREA Center of “ Between

the chest the nipple
line
USE T O H e e l o f H e e l o f 2 fingers
COMPRESS b o t h one hand
hands
DEPTH At least 2 At least 2 At least 1
inches inches ½ inches

7. 2 RESCUE BREATHS
• Open airwaay: heal tilt chin lift jaw
thrust
• Use CPR mask
• Creates visible rise of chest
• Rate: 10-12

8. CONTINUE CPR
• 5 Cycles
• Ration
i. Adult, child & infant: 30:2
ii. If infant has 2 rescuers: 15:2
9. IF AED Arrives
• Bares chest
• Placement:
i. 1st pad: 2nd IC, R sternal
border
ii. 2nd pad: 5th ICS, l mcl, mac,
aal
• Voice prompt
iii. ANALYZING – make sure no
one is touching the victim
iv. SHOCK ADVISED – check if
CLEAR
v. PRESS SHOCK BUTTON
10. RESUMPTION OF CPR
• Start with compression

IF UNTRAINED
CONTINUOUS CHEST COMPRESSION
• Don’t:
o Check for pulse
o Clear the airway
o Perform M to M

NURSING ALERT!!!
• Common complication: rib fracture
• Punctured internal organ: liver
When to stop
• Spontaneous return of the vital signs -
recover
• Turned over to the EMS
• Operator become exhausted
• Physician assumes responsibility
• Scene becomes unsafe

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