arrhythmias (1)

7/28/2019 Arrhythmias (1)

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ArrhythmiasSherry Vickers, RN, MSN, CCRN

Evaluation of Arrhythmias

Electrophysiology Study (EPS) electrical stimulation to various areas of the atriumand ventriclehttp://www.hrsonline.org/patientinfo/symptomsdiagnosis/hearttests/epstudy/Used to identify different mechanisms of tachy dysrhythmias as well as heartblocks, brady dysrhythmias and cause of syncope

Holter monitor: pt. wears for 24-48 hours and keeps a diary of events

Event monitor: recorder placed over chest during symptoms (use telephone)Only turned on when symptoms occur and then call to report symptoms

Electrical cardioversion:

For emergenciesExample: When the pt is hemodynamically unstableDifferent mode that the defibrillator can do

Sedate the pt because you are shocking them while they are awake.Versed- doesnt get rid of pain, it just makes you not remember the pain.

May mix it with Demerol.Diprivan (given by anesthesiologists)

May do TEE to see if there are any clots in atrium, because you dont want to shocksomeone with a clot because you can throw the clot.)Synchronized with R interval (so it doesnt fire in the QT interval)

HIT SYNC BUTTON

Sinus Bradycardia

Rate less than 60/min

Signs and Symptoms:

Grey

N/V

Hypotension

weakness

Pale, cool skin

Angina

Dizziness/syncope

Confusion/disorientation (hypoxia)

SOB

TreatmentIf pt. symptomatic give Atropine (increases the HR) and may need pacemaker

If Atropine does not work: Pace pt externally

Sinus TachycardiaRate greater than 100/min

Treat underlying cause

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http://www.hrsonline.org/patientinfo/symptomsdiagnosis/hearttests/epstudy/http://www.hrsonline.org/patientinfo/symptomsdiagnosis/hearttests/epstudy/


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Fever, pain, anxiety, shock, hypoxia- bodys way of compensating, trying to

speed up to get blood to tissues

If temp: Tylenol

If Pain: give pain meds

Signs and Symptoms

Dizziness Dyspnea

Hypotension (d/t dec CO)

Angina

TreatmentIf symptomatic can give B-adrenergic blockers (metoprolol, atenolol) to slow the ratedown

Premature Atrial ContractionsEctopic focus that did not originate in the SA node

Aggravation around the SA nodeOriginates in the atrium (L or R)

New onset: need to investigate why the pt is having themFirst thing to ask: DIET

Causes:

Stress

Caffeine

Tobacco

Alcohol

CAD

COPD

Treatment: monitor.

Dont cause a lot of problems; we dont really worry about them.

They are just early beats.

But you do need to count them, along with PVCs for heart rate!

Could give Beta Blockers for treatment

BBBQRS > 0.12 seconds

New onset: need to know whyL or R is determined by 12-lead

Causes:

MI

CHF

Heart disease

Cardiomyopathy

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Treatment:Monitor unless new BBB

Atrial FlutterSawtooth-shaped flutter waves

Causes: CAD

Hypertension

lung disease

Atrial rate 250 to 350/min; ventricle rate varies (usually on the slow side)

Need blood thinner (RISK FOR BLOOD CLOT)Increased risk for thrombus formation in the atria d/t stasis bloodCoumadin to prevent strokes

The high ventricular rates and loss of the atrial kick decreases CO which causesserious consequences such as HF (especially

in pts with underlying heart disease)

Treatment

Rapid ventricular response: need to slowdown

Cardizem: reduces rateControlled A-fib/A-flutter: been slowed bymeds

Drug Therapy: Cardizem, digoxin, B-adrenergic blockers, Cordarone, Rythmol,Betapace

Cardizem or Digoxin: May actuallyconvert pt back to SR (mostly new onset)

Atrial FibrillationTotal disorganization of the atrial electrical activityIntermittent or persistent

Cause:CADCHFCardiomyopathy

caffeine usestresscardiac surgerythyrotoxicosis

Ineffective atrial contractions and/or rapid ventricular response will cause decreasedCO

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May need cardioversion- called snyc mode, will see red dots on QRS to makesure it doesnt fire during the resting period, because that can throw theminto a lethal arrythmia)

Thrombi can form in atrium (need blood thinner)TEE can assess for clots

A-fib for longer than 48 hours warrants anti-coagulation therapyCoumadin for 3 wks prior and 4 wks after conversion therapy

Treatment:

Goals of treatment:Dec in ventricular responsePrevention of cerebral embolic eventsConversion to SR

CardizemDigoxinCordaroneBetapace

Ablation therapy: Burn out area around the SA node (sometimes chosen overCoumadin therapy)

Could be completely pacemaker dependent s/p procedure depending on howmuch is burned offMaze Procedure:

A heart surgeon creates multiple cuts into the upper part of your hear in anintricate pattern, or maze.Surgeon then stitches the incisions together to produce scars which do not

carry electrical signals

PVCs

Premature Ventricular ContractionsIn heart disease, PVCs may reduce the CO and precipitate angina and HF dependingon the frequency

Cause:StressCaffeineHypoxiaHypokalemiaMIFeverExercise

Treatment:

Lidocaine (side effect- Lidocaine Crazies, messes with CNS, can become veryconfused)Cordarone

Two PVCs (such as one facing up/one facing down, are called multifocal PVCs andare more alarming b/c heart is irritated in more than one spot)

Two aggravated places in the ventricle, puts pt more at risk for lethaldysrhythmias

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Drug Therapy:

Rate control: Calcium channelblockers, beta blockers, digoxin,Multaq

If drug and cardioversion does notconvert rhythm, Coumadin will be


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New onset: look at pt to see if they are symptomatic, VS, electrolyte values(could be causeHypokalemia is biggest cause)

Ventricular TachycardiaPatient can have a pulse or may not have a pulse

Pt will probably lose the pulse within a matterof timeVentricles take control as pacemakerCauses dec CO and the possibility of developing V-fib

Check patient may be artifact (DO NOT TREAT THE MONITOR)Chest physiology, Parkinsons, brushing teeth can mimic it on the monitor

Treatment:

With a pulse Lidocaine or Cordarone

Without a pulse defibrillate, CPR

Ventricular FibrillationHeart is quivering! NO CONo pulseOccurs in acute MI and myocardial ischemia, and in chronic diseases (HF andcardiomyopathy)

Could occur during cardiac cath (d/t stimulation of the ventricle)Coronary reperfusion s/p fibrinolytic therapy

Unresponsive, pulseless, apneic state

Causes:MI

Hyperkalemiahypoxia

Treatment:

CPR and immediate defibrillation (as soon as possible)The quicker defibrillulated the better the chances of survival

Torsades de PointesLife-threatening dysrhythmias which may result from:

HypokalemiaHypomagnesemia

an overdose of tricyclic antidepressant orantidysrythmic drugs

Alcoholics and QT prolongation are most likelythe pts (pts on cordarone)

Magnesium is the pharmacologic treatment

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First degree AV BlockPR interval > 0.20 seconds (prolonged conduction)No treatment monitor.If new onset need to wonder why.

Causes:MIIschemic heart diseaseSome drugs (beta-blockers, Dig toxicity)

Could be a warning sign, if beta-blocker induced subsequent doses could cause moreblocksUsually asymptomatic

No treatmentMonitor for any new changes in heart rhythm

Second degree AV Block Type I

PR interval gradually prolongs until a QRS is not conducted after a P waveWenckebach

WARNINGMay be a warning sign for more serious AV conduction disturbances

Not always symptomaticCV status, N/VSame s/s as bradycardia (d/t low HR)Bradycardia is more likely to become symptomatic when hypotension, HF, or

shock is presentCauses:Digoxin toxicityB-blockers

MIIschemic cardiac diseaseIf continued without treatment, could

result in Type II block

Usually result of myocardial ischemia or infarctionUsually transient and well tolerated

Treatment:If symptomatic atropine or pacemaker

Especially if history of MI

Second degree AV Block Type IIPR interval constant, impulse not conducted after a P wave

Impulse doesnt make it to the ventricles

Often progresses to third degree blockPoor prognosis

Decreased HR frequently results in dec CO with subsequent hypotension andmyocardial ischemia

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Cause:Rheumatic heart diseaseMIDigoxin toxicity

Treatment:

If symptomatic:pacemakeratropine

Third degreeNo impulses from the atria are conducted to the ventricles DIVORCE

The ventricles are not communicating with eachotherAtria are stimulated and contract independently from the ventricles

Results in dec CO with subsequent ischemia, HF, and shockSyncope could result from severe bradycardia or even periods of asystole

Causes:

CADMyocarditisCardiomyopathyheart surgeryMISick sinus syndrome

Treatment:

Drug therapy:Inc HR and support BP

until pacing is establishedIf due to Calcium

channel blocker toxicity treatwith Calcium chloride

if symptomatic:atropinepacemaker

Dont keep giving a med that might be causing this

AsystoleNo electrical activity

Total absence of ventricular electrical activityMake sure none of the leads have come off

Should be assessed in more than one leadV-fib may masquerade as asystole

Causes:MIcardiac traumaAdvanced cardiac diseaseProlonged arrest without resuscitation

5 Hs and 5 Ts

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HypokalemiaHyperkalemiaCardiac Tamponade

Treatment:CPRACLS

IntubationEpinephrineatropine

Not recommended to shock anymore, shows that it does not improve mortality rates.

Pacemakers

External- use defibrillator pads; pt will need sedation (transcutaneous pacing)

Epicardial: Heart surgeryPts who have had CABGs

Temporary- sheath placed into internal jugular vein or femoral vein by MD

Permanent- placed in surgery or cath lab

Permanent Pacemaker CareDo not allow patient to sleep or turn on right side- can pull leads in heart off, andthen the leads will fire off randomly wherever they are in the heart

Regardless of where the pacemaker was placed

Will have an immobilizer that will hold the arm in place

Dependent on side (R side, R arm will be immobilized)

Do not raise affected arm (side pacemaker is placed)

a month to six weeksKeep HOB elevated for first 24 hours

THEY CANNOT LAY FLATStay in bed until bed rest is up (usually first 24 hours)Do not wear pull over shirts for first month (got to raise arms)Keep immobilizer on until MD DCs order- keeps affected arm immobilized

Wires in the heart can come loose very easilyCould take months for the skin to grow around the wires to anchor them

Prophylactic antibiotic treatment as well as post-opChest x-ray to check lead placement and rule out pneumothoraxMonitor insertion site (bleeding or infection)

EKG monitoring

PPM DC Home Instructions

Do not lift anything heavier than a fork or newspaper- month or so

Do not do yard work, use a push mower, tractor, or hedge clippers

Do not remove steri-strips (let them fall off)

Do not wear tight clothes

Do not get wet until MD says O.K.

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Do not allow child to hit or use rifle on that side

No MRIs- ever, have CT instead

Can use microwaves

Do not have cell phone in breast pocket over PPM

Do not lean directly over open hood of running car (produces an electrical

field)- forever

Will set off metal detectors (keep card on person) Know lowest rate set for PPM if pulse falls below call MD (need to check

pulse regularly)

Carry ID card with you at all times

Pacemakers and leads get recalled all the time

DefibrillationMonophasic Defibrillators- 360 JoulesBiphasic Defibrillators- 150-200 Joules

Dont have to use as much energy, b/c the current is given in two differentways

Automatic external defibrillators (AED)

Implantable Cardioverter-Defibrillator (ICD)

Synchronized Cardioversion-may be used for emergency or nonemergencymust have sync button on when in use

TX of v-fib or v-tach

***** T WAVEMay see a peaked T with hyperkalemiaInverted T wave may suggest myocardial ischemia

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