Defibrillation, Cardioversion and Pacing

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What is Defibrillation useful for?

Treatment of choice to terminate VF and pulseless VT.

What is critical to a successful patient outcome?

Rapid defibrillation (within two minutes).

What happens during Defibrillation?

DC electric shock through the heart that is sufficient to depolarize the cells of the myocardium, subsequent repolarization of myocardial cells will allow SA node to resume the role of the pacemaker.

What is monophasic defibfrillation?

Deliver energy in one waveform.

What is biphasic defibrillation?

Delivers successful shocks at lower energies with fewer postshock ECG abnormalities than monophasic defibrillators.

What is defibrillation measured in?

Joules or watts.

What are biphasic defibrillators set at?

120 - 220 joules.

What are monophasic defibrillators set at?

360 joules.

After the initial shock in defibrillation, what must be started immediately?

CPR with chest compressions.

What are the guidelines for defibrillation?

CPR should progress until defibrillator is available, turn defibrillator on, select proper energy level, check that the synchronizer is turned off, apply conductive materials, one to the right of the sternum just below the clavicle and the other to the left of the apex.

What is Cardioversion used for?

Tx of choice for the patient with hemodynamically stable VT (with a pulse) or SVT tachydysrhythmias (A fib with a rapid ventricular response).

When does the defibrillator deliver a shock during cardioversion?

Synchronized for the R wave of the QRS complex.

What are nursing considerations for cardioversion?

Patient is sedated before the procedure, strict attention is placed on a patent airway.

What is start energy of cardioversion?

50 - 100 joules.

What do you do if patient becomes pulseless or rhythm deteriorates during cardioversion?

Synchronize switch off and defibrillate.

What are safety precautions with defibrillation?

Check that the synchronizer switch is OFF when defibrillation is planned, turn the synchronizer switch ON when cardioversion is planned, be certain all personnel are ALL CLEAR before the device is discharged.

What is an ICD indicated for?

PT that has survived SCD, have spontaneous sustained VT, have syncope with inducible ventricular tacycardia/fibrillation during EPS, and are at high risk for future life threatening dysrhytmias.

How is an ICD placed?

Consists of a lead system placed via a subclavian vein to the endocardium. Battery powered pulse generator is implanted subcutaneously, over the pectoral muscle on the patients nondominant side.

What does ICD sense?

HR, Rhythm, VT/VF, approximately 25 seconds after sensing lethal dysrythmias, the defibrillating mechanism delivers a 24 joule or less shock to the patients heart.

What is important teaching points for the patient with an ICD?

Report any s/s of infection, keep incision dry for 4 days after insertion, avoid lifting arm on ICD side until approved, avoid driving until cleared, avoid direct blows to the ICD site, avoid large magnets, if ICD fires and you do not feel well call EMS or if it fire smore than once.

What is a Cardiac Pacemaker?

Electronic device used to pace heart when the normal conduction pathway is damaged.

What is a permanent pacemaker?

Implanted totally within the body. Power source is planted subcutaneously, usually over the nondominate pectoral muscle.

What are indications for a permanent pacemaker?

Acquired AV block, second degree AV block, third degree AV block, atrial fibrillation with a slow ventricular response, bundle branch block, cardiomyopathy (dilated or hypertrophic), heart failure, SA node dysfunction, tacydysrhythmias.

What is a temporary pacemaker?

One that has the power source outside the body. Can be transvenous, epicardial, and transcutaneous.

What are indications for a temporary pacemaker?

Maintenance of HR and rhythm during special circumstances such as surgery and postoperative recovery, cardiac catheterization, or coronary angioplasty, as prophylaxis before open heart surgery, acute anterior MI with second degree or third degree AV block, electrophysiologic studies to evaluate patient with bradydysrhythmias and tachydysrhytmias.

What is a Transvenous temporary pacemaker?

Consists of a lead or leads that are threaded transvenously to the right atrium and/or right ventricle and attached to the external power source.

What is a Epicardial Temporary Pacemaker?

Involves attaching an atrial and ventricular pacing lead to the epicardium during heart surgery. The leads are passed through the chest wall and attached to the external power surce.

What is an Transcutaneous Temporary Pacemaker?

Used to provide adquate HR and rhythm in ER situations. Noninvasive, temp procedure used until a transvenous pacemaker is inserted or until more definitive therapy is available.

What is Failure to Sense?

Occurs when the pacemaker fails to recognize spontaneous atrial or ventricular activity, and it fires inappropriately.

What is Failure to Capture?

Occurs when the electrical charge to the myocardial is insufficient to produce atrial or ventricular contraction.

What are complications of (invasive) Pacemakers?

Infection and hematoma formation, pneumothorax, failure to sense/capture, perforation of the atrial or ventricular septum.

What are prevention techniques to complications with pacemakers?

Prophylactic IV antibiotics before and after insertion, postinsertion chest x-ray to check lead placement, and to rule out presence of pneumothorax, careful observation of site, continuous ECG monitoring of the patient rhythm.

What is patient teaching in regards to Pacemakers?

Keep incision dry for 4 days after implantation, avoid lifting arm on pacemaker site above shoulder until approved, avoid direct blows to the pacemaker site, avoid close proximity to high output electric generators or large magnets, avoid standing near antitheft device, monitor pulse.

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