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Dysrhythmia & Ventricular Disorders
Terms in this set (49)
Symptomatic Bradycardia Tx
- Try and find underlying cause and can give O2
- Atropine 0.5 mg IVP bolus q 3 TO 5 minutes up to 3 mg maximum dosage. (sympathetic Nervous System Stimulant that increase HR, by blocking vagal stimulation; not used in those with heart transplant, inferior MI, or spinal cord surgery)
- IV infusion chronotropic agents (dopamine & epinephrine) is now recommended as an equally effective alternative to external pacing when atropine is ineffective.
- Rarely transcutaneous pacing is implemented
What is an artificial pacemaker and what is it used for?
- A device used to provide artificial electrical stimulus to myocardial tissue to induce myocardial depolarization
- The primary purpose is to maintain an adequate rate if the inherent pacemaker is too slow, or if conduction is blocked.
Types of Pacemakers:
can hook up with pads and shock the heart (usually found on crash carts)
Types of Pacemakers:
goes into subclavian vein into the heart (is not sutured! Guard with nurses life! Don't let it move - don't let pt turn over without help don't let them do much)
Types of Pacemakers:
Implanted inside heart
Types of Pacemakers:
Implanted outside heart
Types of Pacemakers:
Temporary through chest wall
Pacemaker Post Implant interventions
- Continuous EKG monitoring- Watch for bradycardia and failure to capture (spikes only, no P's or QRS's after the spike.
- Immobilize arm on same side ( not over head for 2 weeks) to prevent dislodging electrodes.
- Avoid welding and gas powered chain saws
- Cellphones - Opposite side from pacemaker.
- Avoid prolonged exposure at metal-detecting devices. - May set off alarm, does not harm pacemaker. Airport hand held screeners may interfere with pacemaker. Ask for pat down.
- Replace batteries 6-12 years (whole generator replaced) local anesthetic / overnight stay.
- Make sure it works and captures (contracts)
If its pacing the atrium you want to see a p wave, if its pacing the ventricle you want to see a QRS
- No metal devices like MRI (never can have MRI); can put magnet over pacemaker to stop the pacemaker (since magnets stop the pacemaker from working, avoid all magnet)
- No MRI's (Donut magnet to stop pacemaker)
Inform physician before exposure to electromagnetic energy (radiation, lithotripsy, surgery electrocautery)
- Power generating equipment (high voltage transformers, welding equipment, motor generators, car motors, boat motor)
Sinus Tachycardia Tx
- treat underlying cause if possible
- if tachycardia is persistent and causing hemodynamic instability, synchronized Cardioversion is tx of choice
- Valsalva maneuvers (slows HR down)
- Carotid massage MD only!!
- hypovolemic - replace fluids; CHF - diuretics
- Bed rest if hypotensive or weak
- Digoxin, Beta-blockers, Calcium channel blockers (but rarely used)
- Vagal Stimulation, Ablation
What is ablation?
Catheter ablation is a procedure that uses radiofrequency energy (similar to microwave heat) to destroy a small area of heart tissue that is causing rapid and irregular heartbeats. Destroying this tissue helps restore your heart's regular rhythm. The procedure is also called radiofrequency ablation
What happens if the SA node fails?
If SA node fails, The atrium beats from irritability (atrial rhythms) or the AV node takes over (called escape rhythm) as in a junctional escape rhythm
What does a-fib occur with?
Occurs in CAD, MI, CABG, COPD, HTN, DM, CHF, Cardiomyopathy, Pericarditis, valve disorders, increases with age, holiday heart of moderate to heavy alcohol intake; Atrial fibrillation may occur in the postop period of any major surgery, but especially open heart surgery; commonly caused in Dig toxicity
- Heparin/Lovenox, Coumadin until INR therapeutic 2-3. Watch bleeding.
- TEE (transesophogeal ecocardiogram) - TEE goes through the esophogus to assess for clots
- BB's (olol's,)
- Ca channel blockers (Calan, Cardizem)
- May try meds first then..
What is cardioversion?
- Treat tachycardic dysrhythmias by delivering electrical current that depolarizes critical mass of myocardial cells
- When cells repolarize, sinus node usually able to restart role as heart pacemaker
- In cardioversion, current delivery synchronized with patient's ECG
- Cardioversion will fire when it senses an R waves
Sedate client, begin with lower joules, Synchronize with R wave to prevent R on T resulting in VF or VT. If meds do not work, then cardioversion may be attempted. Because of high risk of embolization of atrial thrombi, cardioversion of atrial fib that has lasted longer than 48 hours should be avoided unless the pt has received warfarin for at least 3 to 4 weeks prior to cardioversion. TEE used to make sure there are no clots before cardioversion; Cardioversion (shocking the heart) can be painful to the pt so they are usually sedated. Because atrial function is impaired for several weeks after cardioversion Warfarin is indicated for at least 4 wks after procedure
What is the difference between cardioversion and defibrillator?
You cardiovert someone who is alive:
(SVT, rapid A-Fib)
You defibrillate someone who is (basically) dead: (pulseless V-tach, V-fib.)
cardioversion is synched and defibrillation is immediate.
What is the correct lab value for PT (prothrombin time)?
PT 11 to 12.5 seconds (on anticoagulants is 1.5 to 2 times higher)
What is the correct lab value for aPTT (partial prothromblastin time)?
aPTT 30 to 40 seconds (on anticoagulants is 1.5 to 2 times higher)
What is the correct lab value for INR (international normalized ratio)?
INR 0.7 to 1.8 (Theraupeutic is 2.0 to 3.0)
When does a cardioversion need to shock on the heart rhythm?
Needs to produce a delay counter shock starting from each detected R wave (the very top) up until the ST segment. Do NOT need to shock during the T wave because this is know as the vulnerable period and a shock during this period will cause V-fib and V-tach (VT)
Anywhere from 50 to 360 Joules; start low!
What disorders is a-flutter seen in?
Seen in CAD, MI, COPD, Valve disease, Bypass, Thyrotoxicosis, pulmonary HTN
Atrial flutter Tx
- Same tx as A-fib
- Medical management involves use of vagal maneuvers or administration of adenosine (Adenocard, Adenoscan), which cause sympathetic block and slowing of conduction in the AV node, and may terminate the tachycardia or at least allow visualization of flutter waves
- Adenosine should be rapidly administered IV, followed by a 20-mL saline flush and elevation of the arm with the IV line to promote rapid circulation of the medication. If the tachycardia does not terminate within 2-minutes, then a larger dose of adenosine may be given
- TX: Antiarrhythmics: Dig, Ca channel blocker (Calan, Cardizem), BB - olols (Atenolol, esmolol, metoprolol, sotalol) Anticoagulants
- Cardioversion (synchronized; usually done if 48 hours and medications haven't worked PLUS TEE done first to ensure no clots) and also anticoagulants
- Catheter ablation is long term tx of choice
What is ablation?
A fib or VT. Radiofrequency or cold used to destroys cells causing problems during or after an EPS
What is maze?
Open heart for atrial fib. (with other reason for surgery). Incisions atria cause scar tissue and interrupt pathway of dysrhythmia
What is EPS?
- Electrophysiology studies (EPS) are tests that help doctors understand the nature of abnormal heart rhythms (arrhythmias).
-Electrophysiology studies test the electrical activity of your heart to find where an arrhythmia (abnormal heartbeat) is coming from.
- These results can help you and your doctor decide whether you need medicine, a pacemaker, an implantable cardioverter defibrillator (ICD), cardiac ablation or surgery.
- These studies take place in a special room called an electrophysiology (EP) lab or catheterization (cath) lab while you are mildly sedated.
- IV for fluids, meds, moderate sedation
- Invasive- Groin femoral vein/ Catheters with electrodes inserted into the heart, records electrical activity in heart. May be used to induce a Dysrhythmia. May need defibrillation or cardioversion.
What exactly is Supraventricular Tachycardia
Not a particular rhythm but fast rates:
Atrial fib or flutter
Supraventricular Tachycardia Tx
Adenosine (Adenocard) 6mg rapid (quickly!) and flush with 20ml NS. Repeat with 12 mg
When shooting it fast and flushing you get asystole, it stops the heart and hopefully the heart will pick back up to NSR (normal sinus rhythm). If it doesn't start back up - epinephrine
Third Degree Heart Block (Complete Heart Block) Tx
Lethal if not treated -- tx temp pacemaker then permanent pacemaker
P waves and QRS but not 1:1 fashion. But have more P waves than QRS waves.
Atrium and Ventricles are beating at normal rate but they are doing their own thing and not working together.. Thus not getting any cardiac output
How do you know if a PVC is unifocal or multifocal?
Unifocal: All from same focus , same direction
Multifocal: More than one focus, opposite directions
What does PVC indicate?
Indicates ventricular irritability & increasing frequency indicates increasing irritability
What are some causes of PVCs?
ischemia/infarction (MI, CHF,CAD) hypoxia, hypovolemia, K+ imbalances, caffeine, smoking and alcohol
Dangerous if More 6/minute, patterns, couplets, runs, multifocal; May treat underlying cause or no treatment unless symptoms.
Tx: Antiarrhythmics (Amiodarone, Lidocaine, Betapace)
- these cut down on irritability of the heart
Ventricular Tachycardia with a pulse Tx
Antiarrhythmics, sync cardioversion
Ventricular Tachycardia without a pulse Tx
- CPR until Defibrillator arrives, Shock, CPR, Shock, CPR, Shock, CPR Intubate, Epinephrine or Vasopressin (ADH; can repeat 1 time), Amiodarone or Lidocaine.
- CPR 2min intervals, Shock every 2 min. If shock at 200 jules first then Can turn up to 300
- Precordial thump - fist hits heart and jars the heart and starts it back up. Usually not done
Defibrillate/shock! (no pulse - dying/dead)
V-fib you D-FIB! Same treatment as pulseless v tach
V fib = Check pulse, CPR until Defib arrives.
- 1st Shock, CPR, EPI ( Q 3-5 min)/ (Vasopressin x1 instead of epi) Check rhythm
- 2nd Shock, CPR, Check rhythm, (Lidocaine/Amiodarone/ Magnesium)
- 3rd Shock, CPR, Continue meds, check rhythm
What can the rate of V-tach be?
And this is because an irritable focus within the ventricles fires regularly at a rapid rate to override higher sites for control of the heart; no nodes to block conduction
What are some things you will see on a strip in terms of V-tach?
- Considered regular rhythm
- Rate: up to 250
- No p waves
- No PRI
- Wide QRS's
Causes of V-tach
- Heart disease
MI, Cardiomyopathy, HF, Valve disease,
Hypotension, Ventricular aneurysm
- Drug toxicity
- Electrolyte imbalances: hypokalemia and
How do you do rescue breathing?
Pt with a pulse but not breathing, give 1 breath every 5-6 seconds
You do not have to wait until the patient stops breathing to give breaths.
After intubated give 1 breath every 6-8 seconds
What are some general rules when defibrillating someone with v-tach no pulse and v-fib?
- Apply Gel pads
- Unsynchronized (unlike cardioversion)
- 25 pounds pressure with paddles
- Escalating shocks ( 200 J, 300 J, 360 J) CPR in between shocks
- I'm clear, you're clear, all clear- Shock and resume CPR
What dysrhythmias do you use a cardioverter for?
- A Fib
- A flutter
- VT with pulse
What dysrhythmias do you use defibrillator for?
- VT without pulse
- V fib
Which patients would you use an Implantable Cardioverter Defibrillator (ICD) for?
VT or Vfib and it is implanted same as pacemaker into heart
What are the functions of an Implantable Cardioverter Defibrillator (ICD)?
- Overrides fast rhythm with electrical pulses
- Small shocks to cardiovert
- Strong shock to defibrillate
- Paces in bradycardia
What does an Automated External Defibrillator (AED) do?
- Automatically analyzes rhythm
- Provides shock if needed
- Remove from water/ wet areas before using
- All clear
- Malls, airplanes, airports require them usually
What does a Vest Defibrillator do?
- Wearable vest that cardioverts and defibrillates until the AED can be implanted.
- Weighs about a pound
- Worn under clothing.
What are some nursing care interventions for a pacemaker and implantable cardioverter defibrillator (ICD)?
- Monitor heart rate and rhythm with ECG.
- Incision for bleeding, infection, hematoma, edema, tenderness, warmth, drainage, continuous throbbing or pain. Leave open
- CXR (chest x ray) to verify no pneumothorax occurred
- Assess coping (family CPR, may also feel the shock)
- No tight clothing, No tub soaks, creams/powders until heals
- Call 911 if dizziness occurs
How do you verify asystole (aka arrest/standstill)?
- Verify in two leads
- No electrical activity
What are some possible causes of asystole?
Remember your H's and T's!
H's (hypoxia, hydrogen-acidosis, hyper/hypo K+,Glucose, hypovolemia, hyperthermia.)
T's (trauma, toxins, cardiac tamponade, tension pneumothorax, thrombus of heart or lung.
- CPR, Intubation, IV
- Epinephine 1 mg Q 3-5 minutes or one dose of Vasopressin then to Epi. (Atropine NO LONGER USED)
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