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NU 407 Cardiovascular Review Porter

Terms in this set (291)

Arrhythmias
...
When it comes to the conduction pathway of the heart. What is responsible for initiating the electrical impulse?
The SA node
The SA node is nicknamed what?
The Pacemaker of the Heart
The SA node initiates the impulse and send it to...
Both atrium
It is during initiation of the SA node impulse that what occurs?
Atrial Contraction
After atrial contraction, the impulse travels to the...
AV node
Where is the AV node located?
Between the atria and ventricles of the heart
What happens when the impulse reaches the AV node?
It pauses
The AV node is considered the _____________ because it does pause the impulse temporarily. Why is this so important?
Gatekeeper
-because without a pause, both the atria and ventricles would contract at the same time which would result in poor CO
After the impulse reaches the AV node and pauses, it then travels to the...
Bundle of His
Where is the Bundle of His locations?
It is the single nerve that traveling down the spectrum
After traveling through the Bundle of His, the impulse then...
Splits with the Bundle of His and travels down the bundle branches
After going through the bundle branches, the impulse the spread out through the...
Purkinje fibers
What is the purpose of the Purkinje fibers?
To bring the impulse to the cells and allow for Ventricular contraction
The primary pacemaker of the heart is the SA node. When the SA node is working well, what is the HR as paced by the SA node?
60-100 beats/min
If the SA node were to fail, what is the secondary pacemaker of the heart and what will it pace the heart at?
The AV node - 40-60 beats/min
Now If the AV node were to fail, what is the tertiary pacemaker of the heart and what will it pace the heart at?
The Bundle of His - 20-40 beats/min
As far as monitoring the electrical activity of the heart is concerned, what is the primary method of doing so?
An Electrocardiogram (ECG/EKG)
An ECG is used with telemetry leads and electrodes. Do you remember the placement of a 5 Lead telemetry???
-White: Right Upper
-Black: Left Upper
-Green: Right Lower
-Red: Left Lower
-Brown: Middle

*White on Right - Cloud over grass - Smoke over fire - Brown on Ground
What is the name of Rhythm picked up by an ECG when the electrode placement is either not in good contact with the skin or is old and gel underside of the electrode has dried out called?
Artifact
-occurs when there is a disruption or disconnection that causes a distortion of the waves forms
If you pt begins showing artifact, you have to...
Fix the artifact prior to analyzing the wave
What are some ways in which you can correct the artifact?
-Make sure electrodes are well-placed
-Ensure leads are secure
-Muscle tremors?
-Assess equipment

*then assess the wave forms again
What is an ECG?
The graphic tracing of the impulses produced in the heart
-the current radiates through the skin and the electrodes pick up the electricity, translate it and print it on paper
ECG picks up 3 main wave forms. What is the P wave?
Atrial contraction
What is the QRS wave/complex?
Ventricular contraction and atrial relaxation
What is the T wave?
Ventricular relaxation
What are the 9 steps to Rhythm Analysis?
1. Rate
2. Regularity
3. P wave
4. PR interval
5. QRS
6. T wave
7. QT wave
8. ST segment
9. Name it
When it comes to analyzing rhythms, how long is each small box?
0.04 seconds
How long is 1 large block and how many small boxes are in a large box?
5 small boxes = 1 large box = 0.20 seconds
When analyzing a cardiac rhythm strip, we should analyzing at least ___ seconds worth of rhythm which is the same as ____ large boxes.
6 seconds; 30 large boxes
When it comes to calculating rate, how do you calculate the atrial rate?
Count the number of P waves in 6 seconds and multiply by 10
When it comes to calculating rate, how do you calculate the ventricular rate?
Count the number of R waves in a 6 seconds strip and multiple by 10
The atrial and ventricular rate will tell you the patients heart rate and should _______.
Match
What is a normal rate?
60-100 beats/min
It is consider _____________ if less than <60 and _____________ if greater than >100.
Bradycardia; tachycardia
What is step #2?
Assess the Regularity of the rhythm
How can you determine if the rhythm is regular or irregular?
Measure the distance from R-R waves
If each set of R-R waves is the same distance throughout the 6 second strip, this means it rhythm is regular and the impulse is...
Being initiated by the SA node and is normal
-NSR, SB, ST, SVT

*if they are irregular, the SA node is not initiates these impulses and are some type of arrhythmia
What is step #3?
Assess the P aves (atrial depolarization/contraction)
Begin to assess the P wave by...
Labeling the P wave with a 'P'
Ensure that there is a... before every QRS complex in the strip.
P wave
If the P wave is normal, how should it appear?
Rounded and upright
-indicated normal atrial depolarization

*keep in mind you cannot assess for atrial repolarization because it's hidden
If the P wave is abnormal, what are some various terms used to describe it?
-Saw-toothed
-Squiggly/fibrillation
-Absent
What is step #4?
Mark the PR interval
-AV conduction time (the pause of the impulse prior to getting through the AV node)
To mark the PR interval, where do you measure from and to?
Measure the beginning of the P wave to the beginning of the QRS

*check for a consistent length throughout the strip
If the length is consistent, this indicates a normal PR interval. But what does it indicate if the PR intervals are inconsistent?
A heart block is present
How do you calculate the PR interval?
Count the number of the boxes between this distance and multiply by 0.04
What is considered to be a normal PR interval?
0.12-0.2 seconds
What is step #5?
Mark the QRS Interval
-Ventricular depolarization/Contraction
To determine how long the QRS compelx is, mark beginning at the.. and ending at the...
Mark from the beginning of the QRS to the end of the QRS complex where the S wave comes back to the isoelectric line

*will likely be your narrowest measurement
What is isoelectric line?
The line at which everything comes back to baseline
When assessing the length of the QRS complex throughout the strip, consistent is normal but if it is inconsistent, What questions should you ask?
Is it wide or narrow?
How do you calculate the QRS complex
Count the number of the boxes between this distance and multiply by 0.04
What is considered a normal QRS?
0.04-0.12 seconds
What is step #6?
Assess the T wave
-repolarization of the ventricles
To assess the T wave, begin by...
Labeling it
What are you looking at when assessing the T wave?
It is upright?
-this indicates normal ventricular repolarization

*assess all the T waves throughout the strip
If the T wave is abnormal, what are some various terms used to describe it?
-Inverted/Depressed
-Peaked
-Flat
Do you remember what Peaked T waves are associated with?
A Potassium Imbalance (hyperkalemia)
What is step #7?
Measure the QT Interval
-Ventricular depolarization and repolarization
When determining the distance from Q to T, where do you measure from and to?
Measure from the beginning of the QRS to the end of T wave where it comes back to the isoelectric line
how do you calculate the QT Interval?
Count the boxes between and multiply by 0.04
What is a normal measurement for a QT Interval?
Anything less than <0.44 seconds
If this is abnormal this indicates... which puts them at risk for...
Delayed repolarization; at risk for Torsades de Pointes
Do you remember what Torsades de Pointes is associated with?
Hypomagnesmia
What are some other possible items that can affect/prolong Ventricular depolarization (QT Interval)?
-Anti-psychotics
-Anti-Arrhythmics (some)
What is step #8?
Mark the ST segment
-early ventricular repolarization
After labeling the ST segment, what are assessing about it?
-Assess for consistency within the strip
-Assess if it's staying on the isometric line

*flat ST segments on the isometric line are normal
If the ST segment is abnormal, what are some words used to describe it and what do they indicate?
-Elevated —> MI (STEMI)
-Depressed/Inverted —> Ischemia

*however, if they have a history of an MI, their ST segment may naturally and permanently be slightly depressed
If all the corresponding steps were normal, this means the rhythm is called...
Normal Sinus Rhythm (NSR)
Various Rhythms
...
All the different types of rhythms can be categorized into what 3 categories?
-Sinus
-Atrial
-Ventricular
With NSR, what is rate/rhythm?
60-100 beats/min and regular

*normal P wave, PRI and QRS
With Sinus bradycardia, what is the rate and rhythm?
Heart rate less than <60 and regular

*Normal P wave, PRI and QRS
What are some various causes for sinus bradycardia?
-Athletes
-Valsalva Vagal
-Hypothermia
-Medications (BB, CCB)
-Hypothyroidism
-Increased ICP
-Hypoglycemia
-MI (especially if Inferior MI)
Sinus bradycardia should be treated however, this may be normal for...
Athletes
-d/t the regular and rigorous stress they put on their heart, they can train their heart pump at a slower rate and still perfuse their body adequately

*does not need treated because it's normal thus they'll typically asymptomatic
Typically the S&S associated with sinus bradycardia are indicative of...
Poor perfusion
What are some S&S of bradycardia?
-Pale, cool skin
-Hypotension (d/t lack of circulating blood)
-Weakness
-Dizziness
-Angina/SOB
-Confusion/Disorientation
Often sinus bradycardia is only treated if they are symptomatic.

What are some treatments for bradycardia?
-Atropine (#1 choice)
-Pacing
-Stop/Decrease causative drugs (i.e. BB, CCB)
What type of medication is atropine and what does it do?
An anti-cholinergic:
-Increases the firing of the SA node
-Increases conduction through the AV node
-Opposes the vagus nerve stimulation
If the heart does need paced, pts will typically start on __________________ pacing while waiting to be placed on a ______________.
Transcutaneous (external); pacemaker (internal)
With Sinus tachycardia, what is the rate and rhythm?
Anything greater than >100 and regular

*Normal P wave, PRI and QRS
What are come various causes of Sinus Tachycardia?
-Exercise
-Pain
-Fever
-Hypertension (d/t the attempt to compensate and increase blood flow)
-Medications
-HF
-Hyperthyroidism
What are some of the main 3 medications that can cause Sinus Tach?
-Caffeine
-Epinephrine (naturally or medically given)
-Atropine
The S&S r/t sinus tach are associated with...
Poor CO

*so the same S&S as Low perfusion but causes by the Decreased cardiac output
Do you remember what the S&S of Sinus bradycardia were???

*because same for sinus Tachycardia
-Pale, cool skin
-Hypotension (d/t lack of circulating blood)
-Weakness
-Dizziness
-Angina/SOB
-Confusion/Disorientation
What is the treatment for sinus tach?
-Treat the underlying cause! (Pain, fever, hypotension?)
-Vagal maneuvers
-Medications (BB, CCB)
What are various ways to stimulate the Vegal nerve?
-Hold Breath
-Bear down
-Cold Water submersion on face
-Coughing vigorously
With Atrial Flutter, what is the rate and rhythm?
With Atrial flutter the atrial rate and different from the ventricular rate
-Atrial: 200-350 beats/min and regular
-Ventricular: can be >/< 100 (normalish) and regular

*PRI is immeasurable and QRS is typically normal
Why is the PRI in atrial flutter immeasurable?
Because there are numerous P waves before the QRS
While the Atrial rhythm in atrial flutter is typically organized, it extremely rapid. Why?
Because there are too many impulses in the top chambers of the heart
What is the flutter P wave called?
A saw tooth pattern
Typically atrial flutter is the result of...
An obstruction within the normal condition of the top part of the atrium
What are some causes of atrial flutter?
-CAD
-HTN
-MV
-PE
-Medications (Digoxin, Epinephrine)
The S&S of atrial flutter are r/t ....
Low CO
-because the HR is not in sync
What are some S&S of atrial flutter?
Palpitations
-Fatigue
-Dyspnea
-Pre-syncope
If atrial flutter persists, what are 2 possible complications that can occur?
-HF
-Thrombus

*give anti-coat to prevent stroke
How is atrial flutter treated?
The #1 goal is to slow ventricular response down
-Drugs
-Convert to NSR
What medications are commonly used to treat Atrial Flutter and slow the heart down?
-CCB
-BB

*it needs to slow down because it's pumping to fast to get blood through the heart
What are some various interventions to helps get the pt back to NSR?
-Antiarrhymic Drugs
-Synchronized Cardioversion
-RadioFrequency (RF) Ablation
What are some the various anti-arrhythmic drugs used for getting a pt back to NSR?
-Ibutilide
-Amiodarone
-Flecainide
-Dronedarone
What is Synchronized Cardioversion?
A procedure in which an electrical current is delivered (via defibrillator pads) to the pt to hopefully reset the heart and the SA node

*the pt will flat line for a few minutes
When were are shocking the heart and restoring NSR, this will increase the risk for...
Emboli to travel**
What must be done prior to shocking the heart to ensure it safe for the pt?
TEE to look at the heart for clots

*they cannot have a synchronized cardioversion without verify they are not at risk for clots
Where do clots specifically like to form?
LAA
Do you remember what device is commonly to help occult the LAA and prevent clot formation?
The Watchman device
In some cases, they may put a pt with a clot on ____________ depending on the characteristics of the clot and wait a few days. If the clot had diminished, they may proceed with a carioversion.
Lovenox
In addition to doing a TEE prior to a cardio version, a pt is also made... why?
NPO because this procedure will be done under sedation
Prior to doing a cardioversion, what is needed?

"Cardio, Oh Say It Isn't So"
-Consent form signed
-Oxygen required with sedation (continuous pulse ox monitoring)
-Suction available in case of aspiration
-IV access (for sedation or emergency code)
-Intubation in case of code
-Sedation
When it comes to doing a cardioversion, what specific about the machine needs to be turns on and why?
The "Sync" switch
-because this will sync the shock to the R wave
Typically a cardioversion is done will Lowe energy. How many joules are typical for a cardioversion?
50-200 joules
What are some potential complications that are associated with carioversion?
-Arrhythmias
-PE/Stroke
-Burns (use a gel with pads to help prevent)
-Hypotension
What other treatment choice mentioned was the #1 treatment of choice for restoring NSR?
RF Ablation
What is RF ablation?
The use of radio frequency to cause/stimulate the arrhythmia in order to identify the exact location

Then a high energy current (ablation) is used to burn the correct electrical pathway in hopes the SA node will return to normal

*think a combination of a cardiac cath and EPS
A RF Ablation can take up to...
4-6 hours

*depending on how long it takes to identify the location of the arrhythmia
What are basic pre-op teaching regarding a RF ablation?

*just like a cardiac cath
-Informed Consent
-NPO for 6-8 hours
-Make sure you have a pt baseline (PA, VS, LOC)
-Pre-Assess allergies (shellfish or iodine)
-Kidney disease or DM
-IV access present
What are some basic Post-Op teaching regarding a RF Ablation?
-Assess pt and compare to baseline
-Monitor VS, pain and site every 15 minutes for an hour
-Assess neurovascular functions well
-Bed rest with HOB flat
The next type of atrial dysrhymia is a atrial fibrillation. What is the atrial and ventricular rate/Rhythm for A-Fib?
Atrial: 350-600 beats/min and irregular
Ventricular: >/< 100 beats/min and irregular

*PRI is not measurable but QRS complex is normal
Atrial fibrillation is a rhythm in which there is...
Rapid electrical activity in the atrium, so much so that it overwhelms the AV node and causes an irregular ventricular rate too
What are some possible causes contributing to A-Fib?
-CAD
-Rheumatic Heart Disease
-Cardiomyopathy
-HTN
-HF
-Pericarditis
-Alcohol
-Caffeine OD
-Stress
-Electrolyte Imbalances

*most of them tend to r/t to heart disease/conditions
The S&S of A-Fib are r/t...
Decreased CO
What are the S&S of A-Fib?
-Angina
-Dizziness
-Fatigue
-SOB
-Palpitations
-S&S of am embolus/thrombi
It is important to monitor and embolus as well because 17% of all strokes are causes by A-Fib. This being said, pts with A-Fib should have an order for what medication?
An Anti-coagulant
How is A-Fib treated?
-Reduce the Ventricular rate
-Prevent Embolism (CVA)
-Convert to NSR
What medication are commonly used to help reduce the ventricular rate?
-CCB
-BB
-Anti-Arrhythmics
What is the most common medication used to help prevent emboli?
Anticoagulants (Coumadin/Warfarin)
What are some ways that may be used to convert a pt to NSR?
-Amiodarone (IV drip or push)
-Synchornized Cardioversion
-Ablation (Maze Procedure)
With amiodarone, pts often will remain... in order to help monitor and maintain an appropriate rhythm.
NPO
What is a Maze procedure?
An open-heart surgery to expose the problematic vessel so that ablation can be used to create a "maze" of scar tissue and prevent the abnormal current from being conducted
When it comes to ventricular arrhythmias, these are the more serious because...
The ventricles are responsible for expelling the blood to the body (CO)

*this is impaired, the pt is NOT getting any blood or perfusion
What is Ventricular Tachycardia?
A run of 3+ PVC (Premature Ventricular Contraction)
What is the Rate/Rhythm for V-Tach?
Ventricular rate of 150-250 and regular
-P waves are not visible
-PRI is not measurable
-QRS is wide (0.12) and bizarre
What are some various causes of V-Tach?
-MI (heart damage and not conducting electrical current like it should)
-CAD
-Electrolyte Imbalances
-Cardiomyopathy
-Drug toxicity (causing prolonged QT intervals)
If there is prolonged QT interval, this increases the risk for developing what type of V-Tach?
Torsade De Pointes
V-Tach can be further divided by type.

What is the difference between monomorphic and polymorphic V-Tach?
Monomorphic: 1 abnormal area in the heart causing the V-Tach
-Consistent QRS complex appearance

Polymorphic: multiple abnormal areas in the heart causing V-Tach
-Random QRS complex appearance
Another way to differentiate V-Tach is by sustained vs non-sustained.

What is the difference?
Sustained: V-Tach lasting longer than 30 seconds

Non-Sustained: V-Tach lasting less than 30 seconds
With the S&S of V-Tach that are all r/t...
Low CO
The S&S of V-tach will vary based on...
Whether V-Tach is stable or unstable
What is the difference be stable and unstable V-Tach?
Stable: PT is on the monitor and has a pulse

Unstable: PT has NO pulse - dead
What are some S&S of Stable V-Tach?
-Dizziness
-Shortness of breath
-Lightheadedness
-Feeling as if your heart is racing (palpitations)
-Chest pain (angina)
-Seizures
-Hypotension
With unstable V-Tach the pt has gone into...
Cardiopulmonary arrest
How is stable V-Tach treated?
-ID and treat the cause
-Anti-Arrhythmics (Amiodarone)
-Cardioversion
-IV Magnesium if Torsades
How is unstable V-Tach treated?
-CPR
-Defibrillate (as soon as available)
-Epinephrine (to stimulate the heart again)
-Intubation
Another type of Ventricular arrhythmia is Ventricular Fibrillation. This means the heart is...
Quivering
What is the rate/Rhythm with V-Fib?
-Rate is immeasurable and irregular
-Absent P waves
-PRI immeasurable
-QRS is not measurable either
What are some possible causes of V-Fib?
-MI (d/t damaged heart muscle not conducting)
-HF
-Cardiomyopathy
-Electrolyte Imbalances
-Drug toxicities
-Cardiac Cath
Which electrolyte imbalances are critical and can cause V-Fib?
-Hyperkalemia
-Hypocalcemia
-Acidosis
The S&S of V-Fib are r/t...
NO cardiac output
What are the S&S associated with V-Fib?
-Unresponsive
-Pulseless
-Apneic (no breathing)
How is V-Fib treated?
-Initiate CPR immediately
-Defibrillate
-Epinephrine
-Intubation
When it comes to defibrillating a pt in the instance of either Unstable V-Tach or V-Fib, what is required before hand?
Nothing - it is an emergency***
-No consent needed
-No Sedation associated with it
When getting the crash cart, know the difference between the Peds vs Adult crash carts and make sure do you what prior to rolling it down the hall?
UNPLUG it
-defibrillators are plugged to keep them charged and ready at all times but needs to be unplugged to move
When giving meds during CPR and defibrillating, it is important you...
Always remember to flush the med and make sure CPR is active
-CPR is the only this that will circulate the medication
The goal of defibrillating is to...
Move electrical current through the heart
There are 2 types of defibrillators. What are they?
Monophasic: delivers 360 joules of electrical current through the heart moving in 1 direction

Biphasic: delivers 120-200 joules of electrical current through the heart in both directions
With biphasic, because the eclectically current is moving in 2 directions you typically start with how much energy?
120 and increase with each delivery of shock until 200 reached
-will continue shocking at 200 joules until pt is revived or code has ended
What type of ventricular arrhythmia is classified by a complete absence of ventricular activity?
Asytole
What is typically the cause of asytole?
End Stage HF
-severe conduction Damage and heart fails
What are some S&S of asytole?
-Unresponsive
-Pulseless
-Apenic
How is asytole treated?
-CPR
-Epinephrine
-Intubation

*defibrillation is not used and will not be helpful in the case asytole
What Ventricular arrhythmia is classified as an organized electrical activity without any mechanical activity of the ventricles?
Pulseless Electrical Activity (PEA)
-this means the pt is attached but is not longer reasoning to an electrical stimulus
What are some causes associated with PEA?

*H's and T's
-Hypovolemia
-Hypoxia
-Metabolic Acidosis
-Hypercalemia
-Hypokalemia
-Hypoglycemia
-Hypothermia
-Tamponade
-Thrombus
-Tension Pneumothorax
How is PEA treated?
-ID and treat the case
-CPR
-Epinephrine
-Intubation

*Defibrillation will not help with PEAs either and should not be done
With Cardiac Arrest rhythms, you can shock with.... but you cannot shock with..
YES SHOCK:
-Pulseless V-Tach
-V-Fib

NO, DO NOT SHOCK:
-Asystole
-PEA
Other Sinus Problems:
...
What are some other sinus problems that are abnormal but still associated with a sinus rhythm?
Premature Beats:
-Premature Atrial Contractions (PAC)
-Premature Ventricular Contractions (PVC)

Heart Blocks:
-1st Degree
-2nd Degree Type 1
-2nd Degree Type 2
-3rd Degree
What does a PAC does?
Excitation of an atrial cell from an impulse that forms sooner than expected but that is conducted normally through the AV node and ventricles
What is the rate/rhythm of PACs?
Typically 60-100 beats/min but irregular
-P wave is abnormal when prior to PAC
-Normal PRI
-Normal QRS
What are some various causes of PAC?
-Stress
-Fatigue
-Caffeine
-Tobacco
-Alcohol
-Hyperthyroidism
-COPD
-CAD
-Valvular Disease
What are some S&S of PAC?
-Palpitations (may feel the extra beat)
Generally a few PACs are not problematic, however, if there are multiple PACs coupled with heart disease, this puts a pt at risk for...
Supraventricular Tachycardia (SVT)
PAC are diagnosed by...
Identifying NSR and PACs on an ECG strip
How are PACs treated?
ID and treat the cause
-lifestyle medications and minimize risk factors
What are PVCs?
When electrical impulses comes early to the ventricle cells because it was originated in the ventricles —> causing early contraction of the ventricles
What is the rate/rhythm of PVCs?
Typically 60-100 beats/min and irregular
-P waves hidden in QRS
-PRI immeasurable
-Wide and Bizarre QRS (>0.12 sec)
What are some various causes of PVCs?
-Stimulants (caffeine/alcohol/nicotine/epi)
-Electrolytes imbalances
-Hypoxia
-Stress/Emotions
-Fever
-Exercise
S&S of PVC are typically only harmful with....
Increased frequency
What are some S&S of PVCs?
-Palpitations
-Decreased CO —> Angina
-Pulse Deficit (pulses not palpable)
How are PVCs treated?
-ID and treat the case
-BB
-Amiodarone
PVCs can come in various patterns. Identify the following PVC pattern:

Same foci and shape because the same area of the ventricles is initiating the impulse
NSR with Unifocal PVCs
Idenity the following PVC pattern:

Different foci and shapes of each PVC
NSR with Multifocal PVCs
Identify the following PVC pattern:

PVCs with every other beat
NSR with Bigeminy

*the more PVC's the worst the scenario
Identify the following PVC pattern:

PVCs with every third beat
NSR with Trigeminy
Identify the following PVC pattern:

Two PVCs in the row without a normal beat
NSR with Couplets
Identify the following PVC pattern:

3 PVCs in a row without a normal beat
NSR with Triplets OR V-Tach

*after 2 beats of PVCs, count the run and name accordingly
I.e. 15 beat run of V-Tach
Heart Blocks
...
Heart blocks are associated with a blockage of what part of the anatomy?
The AV node
So if a pt has a heart block, always state the.... first followed by the type of AV block.
Underlying rhythm

*i.e. NSR with 1st degree AV block
With a heart blockage of the AV node, where is the conduction problem?
The AV node
-because the current is not getting through the node properly
If the px is with the AV node, what area of the ECH will be affected?
The PRI (and sometimes the QRS)
-because the AV slows down or potentially blocks the impulse altogether
What is the rate and rhythm of a 1st degree AV block?
Normal (60-100 bpm) and regular
What does the PRI of a 1st degree AV block look like?
>0.2 seconds (prolonged but consistent)

"If R is far from P, then you have a 1sr degree"
What are some various causes of 1st Degree AV Block?
-MI
-CAD
-Rheumatic Fever
-Hyperthyroidism
-Electrolyte Imbalances (Hypokalemia)
-Vagal Stimulation
-Meds: Dig, BB< CCB, Flecainide
What are the S&S associated with 1st Degree AV Block?
Typically asymptomatic because no affecting CO or perfusion yet
-BUT monitor for progression to 2nd/3rd degree blocks
Because there are not really any S&S, what is the treatment?
No treatment
-you may be able to improve rhythm by removing or reducing causative factors
What are some other name for a 2nd Degree AV Block?
Mobitz I or Wenckebach
What is A rate for Wenckebach?
Normal (60-100 bpm) and regular
The P wave for Wenckebach is ___________ but the PRI is....
Normal; progressively lengthening with each beat and repeats
What is the V rate for Wenckebach?
Slower than the atrial rate and irregular
With Wenckebach, describe the QRS.
The QRS is normal with a blocked pattern
-the PRI progressively lengthens till it drops a QRS and then repeats consistently

"Longer, Longer, Longer DROP, then you have a Wenckebach"
What are some various causes of Wenckebach?
-Inferior MI (#1 cause)
-CAD
-Digoxin
-BB

*same type of causes a 1st degree AV blocks
What are the S&S like for Wenckebach?
Typically still asymptomatic but progressing in severity

Transient bradycardia b/c V rate is slowing may cause:
-Decreased CO
-Lightheadedness
-Dizziness
-Hypotension
If they are still asymptomatic, what is the treatment?
No treatment
-may look at causative factors to help improve
If they are beginning to show signs of decreased CO, what is the treatment?
-Atropine
-Temporary Pacemaker to override the electrical activity with the correct rhythm
How does atropine work to help with Wenckebach?
It stimulates the SA node to increase the chances of getting more impulses through the AV
-hope is less dropped QRS complexes
What is another name for a 2nd Degree AV Block?
Mobitz II
What is the A rate and PRI like for Mobitz II?
A rate is normal and regular and PRI is either normal or prolonged

*Yet the PRI is the STILL remaining consistent even when it's abnormal
What is the V rate and QRS like for Mobitz II?
V rate is slower and irregular and QRS is typically wide and blocked pattern but consistent

*with Mobitz II, there may be multiple blocked QRS complexes compared to Mobitz I but regardless how many dropped, the pattern is consistent

"If some P's don't through then you have a Mobitz II"
What are some possible causes of Mobitz II?
-Rheumatic Heart Disease
-CAD
-Anterior MI
-Drug Toxicities (i.e. overdose)
What are some S&S r/t Mobitz II?
We are beginning to see more decreased CO resulting in symptoms depending on how many QRS are dropped:
-Hypotension
-Ischemia
-Chest pain/angina
What is primary Compilation associated with a Mobitz II?
If a pt has Mobitz II, it can easily and often quickly progress to 3rd Degree AV Block
How is Mobitz II treated?
With a permanent pacemaker
What is another term for 3rd Degree AV block?
Complete
What had happened with a Complete AV Block?
There is a complete blockage of the AV node meaning there is NO communication between the atria and ventricles

BUT the ventricles will still beat d/t automaticity of cardiac cells
Why does it become extremely problematic if both chambers are beating but without communication?
Because it is very likely that the atria and ventricles could beat at the same time which results in NO cardiac output
What is A rate and PRI like for a Complete AV Block?
-A Rate is normal and regular
-P wave was normal but could be buried/hidden BUT it is still regular even if it's hidden
-PRI is inconsistent because no connection the QRS
What is he V rate like for Complete AV Block
-V rate is 20-60 bpm and regular
-QRS may be normal or wide
-QRS has no relation to P wave

*look at the V rate to help determine what part of the heart is pacing it

"If the P's and Q's do not agree, then you have a 3rd degree"
What are some various causes associated with Complete AV Block?
-CAD
-MI
-Myocarditis
-Cardiomyopathy
-Meds: Digoxin, BB, CCB
With Complete AV Block you will see S&S r/t...
Decreased CO
What are some S&S associated with Complete AV Block?
-Ischemia —> chest pain/angina
-HF
-Shock d/t little to no blood flow
-Syncope from lack of blood flow
What are primary rhythm complications seen with Complete AV Block?
-Severe bradycardia
-Asystole
How is Complete AV Block treated?
-Pacemaker ASAP
What are some temporary medications given for Complete AV Block while waiting on a pacemaker?
-Dopamine
-Epinephrine

*to help get heart started and increased HR
It is important to note that electricity is determine by....and Muscle activity is determined by what?
Waveform on ECG; Pulse, BP, Urine Output and Alertness
Note: AV Heart blocks
A common treatment for several dysrhytmias was a pacemaker. What is that?
An electronic device that stimulates the cardiac muscle to contract on a rhythm
A pacemaker is typically used when...
The normal conduction pathways are damaged by override a slow or abnormal rhytm
What are some potential indications for a pt receiving a pacemaker?
-Symptomatic Bradycardia
-Symptomatic 2nd or 3rd Degree AV Block
-Sick Sinus Syndrome (SSS)
What is SSS?
When there is a problem with the SA node that can result in a variety of problematic rhythms but it comes and goes
-often see a rhythm either too long/short followed but pauses
There are temporary and permanent pacemakers. A temporary pacemaker is only done for...
Emergency use or procedural use
-i.e. in case of a drug toxicity cause a dysthymia till it gets out of the body

*often while waiting for a permanent pacemaker if their rhythm is too unstable too
A temporary pacemakers means the power source is...
On the outside of the body - Transcutaneous
Temporary pacemakers are noninvasive but because of this they do have to...
Deliver a shock through the skin
The goal of a Temporary pacemakers is to deliver a shock of the lowest possible __________ while still maintaining the appropriate ________.
Voltage; rate/CO
Because temporary pacing is typically uncomfortable, what are some nursing interventions?
-Provide pain management
-Educate pt that is temporary
What are the 2 different types of temporary pacemakers?
Transvenous and Epicardial
What is a TransVenous pacemaker?
A pacemaker in which leads are thread through the veins to the heart and attached to an external power source
What is used to verify the placement of Transvenous leads?
CXR
A transvenous pacemaker is used to provide a bridge to a...
Permanent pacemaker
-or until the px has resolved
What is an epicardial pacemaker?
A pacemaker in which the wires are either externally placed or internally attached to the heart muscle
An epicardial pacemaker is most commonly seen after...
S/P Thoracotomy or CABG d/t the high of arrhythmias
When caring for pts with epicardial pacemakers, what are some things to remember?
-Always Provide a Safe electrical environment
-Wear rub gloves when handling
-Make sure the tips of each wire do not touch each other
-Protect the exposed parts of the electrodes with rubber (should be covered and taped to the pt skin)
With pt on a epicardial pacemaker, d/t the nature of placement, they are at an increased risk for.... when removing the wires.
Cardiac tamponade
-d/t damage the myocardium and causing bleeding
Regarding of the type of temporary pacemaker, what are pt at risk for?
Pain and burns

*skin is sensitive
What are permanent pacemakers used for?
Non-emergent cases to help electrically pace the heart
-typically takes a few hours to implant and pt needs to be stable first
The power source for permanent pacemakers is found...
Under the skin typically on the non-dominate side
When it comes to placing a permanent pacemaker, this done with... and the leads are placed...
Under anesthesia and under fluoroscopy to help ensure placement

Leads are placed into the epicardium
What is used to verify the placement of leads?
CXR
Keep in mind that if you defibrillating a pt with a permanent pacemaker, do not place the pads where?
Over the generator
How long do the leads of permanent pacemaker lasts?
Axp ~10 years
Now, the lead placement for permanent pacemakers can very depending on the need and type of dysthymia.

What is an Atria lead placement?
Wire placed in the atrium at the SA node
What is a ventricular lead placement?
Wire placed in the ventricles for ventricular pacing px
What is a dual changer lead placement?
1 lead placed in the atrium and one in the ventricle
What is Bi-Ventricular lead placement?
1 lead placed in the R and L ventricles to ensure ventricles are contracting at the same time
What type of placement do we typically see more commonly with End-Stage HF?
Bi-Ventricular lead placement
-d/t the dyssynchrony between ventricles
Another type of implanted device is known as a AICD. What does this stand for and what is it?
Automatic Implanted Cardioverter Defibrillator
-an implanted defibrillator into the skin to help restore abnormal rhythm if they revert to VT or VF
How does a AICD defibrillate them?
By delivering 10-25 joules within 20 seconds of determining VF/VT
What are some indication for a pt receiving a AICD?
Recurring VT/VF or High risk for developing VT/VF
-Severe End Stage HF with EF <30
-Hx of cardiac arrest
-Severe Cardiomyopathy
If a pt is not stable enough for the placement of an AICD or cannot afford one, what is the name of wearable cardioverter defibrillator they can use?
A Life Vest
A Life Vest will detect abnormal rhythm just like a AICD but will do what just prior to delivering a shock?
Deliver a warning signal
-that way you can disable the button if it registered falsely
A Life Vest does have to deliver a higher voltage of shock compared to a AICD because it is _____________.
External
Overall, all pacemakers are programmed by the...
MD
Pacemakers have 3 difference ares in which that can be programmed. What are they?
-Rate: Fixed or Demand
-Output: electrical impulse
-Sensitivity: senses activity
What is the difference between a fixed rate vs a demand rate?
Fixed: a continuous firing of electrical impulse to make the HR consistently set a one rate
Demand: a sensing of the heart's activity and delivers electrical impulse as needed only when the HER is out of set parameters
Which type of setting is more common for pacemakers? Fixed or Demand?
Demand
The output of a pacemaker that delivers the electrical impulse can be measured in...
Milliamps (mA)
The sensitivity of pacemakers that sense the heart's activity can be measured in.... and adjusted.
Millivolts (mV)
How can you evaluate a pacemakers status?
Via an ECG
You can evaluate whether or not it is pacing by looking for what on the ECG?
A spike either right in front of each P wave (atrium placement) or right in front of each QRS (ventricle placement)
If the spike is right before the P wave, this means that have what type of pacemaker?
Single Chamber Atrial Pacing (A-Paced)
If the spike is right before the QRS wave, this means that have what type of pacemaker?
Single Chamber Ventricular Pacing (V-Paced)
If the spike is right before the P wave and right before the QRS complex, this means that have what type of pacemaker?
Dual Chamber A+V Paced
You can evaluate whether or not it is sensing in an ECG by looking for...
The correct correlation of spikes in relation to the waveforms
And you can evaluate whether or not it is capturing on an ECG by looking for...
Contraction of the heart
-a spike followed by a mechanical contraction (palpable pulse)
It is important to understand how a pacemaker looks on an ECG when its working properly so you can identify when it is malfunctioning.

If you see a failure to pace, this shows up as..
An Absent spike
-you may see some spikes and then go several beats without one

*this is dangerous! Means no Ventricular response or cardiac output and flat line
If you see a failure to sense, this shows up on an ECG as...
Spikes appearing randomly at the wrong time

*dangerous! Can cause VT or VF because it is not synced to the R wave
If you see a failure to capture, this shows up on an ECG as...
Pacer spikes firing but without a following contraction

*Dangerous! Can cause bradycardia or asystole
What are some potential causes for failure to capture?
-Lead damage
-Lead Dislodgment
-Battery Failure
Keep in mind that you can have a QRS without a.... but you cannot have a pacer spike without a .... following it!
Pacer spike; QRS
What are some Complications associated pacemakers and AICDs?
-Infection
-Hematoma
-Pneumothorax
-Perforation of heart chamber
-Failure to Function (pace/sense/capture) causing arrhythmias
-Poor Implantation
How can help monitor for S&S of a hematoma?
Hematoma will with a swollen areas around the site that is hard and firm
Pt Teaching for Pacemakers/AICDs:

Pt should educate will schedule routine follow up visits with their _____.
PCP

*either in office or may be done via telephone
Pt Teaching for Pacemakers/AICDs:

Report any signs of infections such as..
-Fever
-Drainage
Pt Teaching for Pacemakers/AICDs:

Keep in the incision dry...
4 days
-no showering or bathing
Pt Teaching for Pacemakers/AICDs:

Avoid lifting arm above ___________ on affected side till approved.
Shoulder
-include brushing teeth, combing hair
Pt Teaching for Pacemakers/AICDs:

Avoid driving for... until cleared for risk of...
For 2-5 weeks typically

To avoid risk of a MVC damaging newly placed pacemaker and surgical site if hitting the steering-wheel

*want to avoid direct blows to this area till well healed
Pt Teaching for Pacemakers/AICDs:

Avoid large magnets and strong electromagnetic fields such as...
MRI machine or large card-sized magnets

*microwaves and airport scanners will not affect pacemakers but you do need to notify security if you have one
Pt Teaching for Pacemakers/AICDs:

Avoid standing near....
Anti-theft devices - just walk through them at a normal pace
Pt Teaching for Pacemakers/AICDs:

Teach pts that they should call their HCP immediately if..
If their AICD fired
Pt Teaching for Pacemakers/AICDs:

Pts should call 911 if...
They feel sick or if their device fires more the 1x (even if they feel fine)
-we need to figure out why it's firing
Pt Teaching for Pacemakers/AICDs:

Pts with devices should wear what at all times?
Medical alert bracelet and ID card
Pt Teaching for Pacemakers/AICDs:

Pts should also encourage their caregivers to other in their home to learn...
CPR
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