EKG Interpretation Pt 2: Effective Management of A-Fib

Whether you’re working in a hospital or currently doing your clinical, there will be instances that you will encounter clients who will have atrial fibrillation. To manage atrial fibrillation effectively, you must first get acquainted with what it is and what mainly causes it.  

Causes of Atrial Fibrillation

Before treating atrial fibrillation, you should first know what caused the condition. What are some of these causes?

  1. Ischemia

Ischemia is decreased oxygenation to the heart. Ischemia usually happens with myocardial infarction which is mainly caused by decreased oxygen levels of the heart; this then can lead to necrosis.

Lung disease is another viable reason for ischemia; this is because of the decreased oxygen going inside the lungs that can deliberately affect how the heart receives oxygen. Remember, very little, or no oxygen at all will lead to organ failure and eventually, death.

  1. Valve disease

Diseases concerning the heart valves primarily result in the chambers’ inability to open and close at a certain period. When this happens, it can adversely affect the heart because if there are not enough succinct pumps going to the heart, it will result in the decreased cardiac output.

We’ve discussed cardiac output in our previous lectures. To jog your memory, cardiac output is the amount of blood pumped by the heart in a whole minute. If the heart is not contracting efficiently, it is not filled adequately, and the contractions will fail as well.

Without a normal cardiac output, the body will not receive a satisfactory amount of blood and oxygen that are mainly required for proper functioning.

  1. Atrium Problems

When there are issues concerning the atriums of the heart, blood will not be pushed down all the way to the ventricles because the atriums are not contracting properly. There will be minor contractions, but they are not enough to sustain the needs of the heart.

The Atrial Kick

What is an atrial kick? How does one interpret an atrial kick once it’s encountered?

You can think of an atrial kick as someone slamming the door and pushing blood forcefully into the ventricles, slamming the valve shut.

An atrial kick is also similar to packing suitcases wherein you have to try to fill it in with items, then kick the overflowing clothes inside the bag so that you can zip them all in. In atrial fibrillation, this zip-kick motion is almost non-existent.

Formation of Clots

If the chamber is full of blood, it starts pooling in the atriums. Pooling will cause the blood to eventually dry up and start forming fibrinogen and fibrin which is also known as a clot. Clot formation will block the atriums entirely or will be sent out to the system as tiny clots which are the main causes of cerebrovascular accident (CVA), myocardial infarction (MI), or deep vein thrombosis (DVT).

Clots are deadly enough to shut down the lungs in a condition known as pulmonary embolism (PE).

Managing Atrial Fibrillation

How does one combat clot and other issues that cause atrial fibrillation?

  1. Warfarin (Coumadin) treatment is given to thin out blood over long periods of time which leads to de-coagulation. Plavix, an anti-platelet congregator is also given.
  2. A positive inotrope to make the atriums contract better is also used. Inotropes are concerned with the contractility force, and one popular example is Digoxin. Digoxin is a cardiac glycoside that helps with the heart’s atrial kick.
  3. Amiodarone is a used to slow down dysrhythmia, helping the heart contract succinctly and eliminating sporadic contractions.
  4. Calcium channel blockers help the blood vessels and the muscles of the heart to relax. By blocking calcium, excitability is reduced. Increased excitement due to calcium deposits in the heart can lead to its stiffening. The goal is to achieve a soft, supple heart that contracts normally and is relaxed.
  5. Oxygen is given for obvious reasons.
  6. Electrical cardioversion is also given to restart the SA node.

Remember, the main goal when managing a client with atrial fibrillation is to make the atrium contract efficiently and prevent clot formation from happening.

In our following lecture, we will discuss what atrial flutter is. For other nursing-related lectures, just drop by SimpleNursing.com.

15-Second EKG Interpretation: Atrial Fibrillation Pt 1 of 2

We will be talking about atrial rhythms and how to appropriately interpret them. We will determine if what you see on your monitor is atrial fibrillation or something entirely different.

Atrial Fibrillation

What happens when your client’s atrium runs wild or isn’t acting the way it’s supposed to be? Well, the most common rhythm that you’ll see in a clinical setting is something that’s called A-Fib or atrial fibrillation. Atrial fibrillation is the rapid firing of impulses in the right atrium with about 350 to 650 beats or impulses per minute.

Impulses are regulated by the atrioventricular (AV) node which mainly controls the number of impulses that passes along the ventricles. Without the presence of the AV node, and if the ventricles are beating at 650 a minute, there’s not enough amount of time to repolarize and get blood inside the ventricles, resulting to almost a full contraction.

This scenario is similar to the administration of potassium directly to your heart which would cause full contraction; meaning, the heart will contract and no longer open. If that happens, the heart will no longer receive and circulate blood with oxygen.

So, the main thing that you have to remember is that your heart’s primary function is to distribute oxygenated blood throughout the body and the AV node is there to regulate the number of impulses that are coming through inside the heart.  

Five Steps of Rhythm Interpretation

Step 1: Look for a P-wave

With your atrial fibrillation, the first sign to look for when interpreting heart rhythms is if there is the presence of a P-wave. If there’s NO P-wave in a rhythm, that’s a possibility for atrial fibrillation. The P-wave will not be present during atrial fibrillation because there is increased action or fibrillation happening around the node.

Step 2: Look for a PR wave

Since there is NO P-wave in your A-fib, a PR wave will also be absent. So you can easily count that out and move on to the next step.

Step 3: Look for a QRS wave

Typically, a QRS complex wave is between one to three boxes and is around 0.12 seconds. If this is a bit confusing for you, all you need to remember is that the QRS wave must be less than three boxes on your ECG or EKG paper and should be less than 0.12 seconds for an interpretation of atrial fibrillation.

Step 4 – Know the Rate

If the SA node inside the atriums is shooting out 350 to 650 beats per minute and the AV node will not allow that many to go through, the result is tachycardia. Your client will become tachycardic most of the time with atrial fibrillation. The rate will definitely increase, usually more than 100 beats per minute.

Step 5:  Know the Regularity

With atrial fibrillation, you will not have a regular rhythm – the EKG strip will show atypical rhythms popping all over the place; like a DJ throwing beats at parties. The rhythms will be irregular, sporadic, and will not be perfused, unlike the normal ones. This is due to the increased contractions happening within a minute and the AV node not allowing them to go through.

A Summary

As a quick review, the five criteria to take note of when identifying atrial fibrillation rhythms on your EKG strip are the following:

  1. No P-wave
  2. No PR wave
  3. QRS wave is less than three boxes and is below 0.12
  4. Tachycardia – more than 100 beats per minute
  5. Regularity – all over the place or sporadic

If all of these are present on your EKG strip, you can be 99% sure that it’s atrial fibrillation.  

On our next discussion, we will focus on the therapeutic modalities that nurses should do with their clients that have atrial fibrillation. For more useful nursing information, visit us at SimpleNursing.com.