Pacers, ablation, cardioversion,
telemetry, Intro to ACLS
By: Diana Blum
MCC
NURS 2140
• A dysrhythmia is a disturbance of the rhythm
of the heart caused by a problem in the
conduction system.
• Categorized by site of origin: atrial , AV nodal,
ventricular
• Blocks are interruptions in impulse
conduction: 1st, 2nd type 1&2, 3rd or complete
heart block
2
Each small box measures 0.04
1 big box (5 small boxes) is equal to a HR of 300
2 big boxes is hr of 150
3 big boxes is hr of 100
4 big boxes is hr of 75
5 big boxes is hr of 60
6 big boxes is hr of 50
7 big boxes is hr of 43
8 big boxes is hr of 38
3
Large box estimate of heart rate works with
regular rhythms
• P-wave = atrial electrical activity
• QRS= ventricular electrical activity
• T wave= resting phase of ventricle
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P wave
Measures:
0.12-0.20
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QRS WAVE
Measures:
0.06-0.10
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QT Wave
Measures
approx 0.400.48 secs
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Heart rates
• NSR: heart rate is 60-100bpm
• ST: heart rate 101-180 bpm
• SB: heart rate <60 bpm
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Calculating Heart Rate
• Quick Estimate: The 6-second Method
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- count the # of QRS complexes in a 6 sec.
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length of strip & multiply by 10
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(the second mark is = to 5 large boxes)
• This can be used is rhythm is reg or unreg.
• Count small boxes between two R waves.
Divide into1500 Gives BPM
Atrial arrythmias
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Normal sinus rhythm
Sinus tachycardia
Sinus bradycardia
Premature atrial contraction (PAC)
Supraventricular tachycardia
Atrial flutter
Atrial fibrillation
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Ventricular arrythmias
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Junctional rhythm
AV blocks
Premature junctional rhythm
Premature ventricular contraction (PVC)
Ventricular Tachycardia (V-tach)
Ventricular Fibrillation (V-Fib)
Torsade de Pointes (TdP)
Pulseless electrical activity (PEA)
Asystole
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ARTIFACT
NSR
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Sinus rhythm
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PR interval- 0.12-0.20sec
QRS-0.06-0.10sec
QT segment 0.36-0.44 sec
Heart rate 60-100
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• Hr= 60-100 bpm
• On strip it looks regular but does not map
out
• PR interval= 0.12-0.20
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HR 40-60 bpm
<60 bpm is accelerated
Rhythm is regular
Pwaves not always present
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Junctional Rhythm
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SB
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Sinus Bradycardia
• All criteria same except rate < 60bpm
• S/S: dizziness, syncope, angina, hypotension,
sweating, nausea, dyspnea
• Sometimes no S/S
• Treat underlying cause
• IV atropine, pacemaker
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Sinus Bradycardia:
Your pt is pale, c/o dizziness & fatigue. Pulse 56,
BP 86/60
• ACLS protocol:
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1. airway
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2. oxygen
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3. ECG, BP, oximetry
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4. IV access
• If s/s of poor perfusion: altered mental status, CP,
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hypotension, signs of shock
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a. prepare for transcutaneous placing
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b. atropine 0.5 mg IV while waiting for pacer
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- may repeat for total 3 mg IV
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c. epinephrine or dopamine drip while waiting pacer
or
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if pacing ineffective
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ST
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Sinus Tachycardia
• All criteria same as with NSR except rate >100
• Causes: fever, dehydration, hypovolemia, increased
sympathetic nervous system stimulation, stress,
exercise, AMI
• S/S: Palpations #1, angina and < CO from < V filling
time
• Treatment: correct cause, eliminate caffeine, nicotine,
alcohol. Beta blockers may be ordered
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Sinus Tachycardia
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Heart rate greater than 100 but less 180
Caused by external influences (fever, blood
loss, exercise)
Adenosine used
B-blockers may cause condition to worsen ( if MI
limits vent function the heart will compensate by
increasing rate then CO will fall)
• Remember to identify and treat cause !!!
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Supraventricular Tachycardia
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Supraventricular Tachycardia
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Impulse originates in AV junction or atria
Rhythm regular
A-fib most common cause
Ventricular rate 150-250
QRS normal configuration
Symptoms:
palpitations, lightheadedness,
Loss of Conscious, CP, SOB
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How to treat SVT
• B-blockers ( to decrease conduction thru AV
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node:
• Calcium channel blockers ( to decrease condux
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thru AV node)
• Radio frequency ablation
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SVT converted with Adenosine
given rapid IV Push stimulates vagal
response.
S/E: flushing,bronchospasm,AVblock
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AV Blocks
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First degree block
Second degree block Type I (Wenchebach)
Second degree block Type II (Mobitz II)
Third degree block
Bundle branch block
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Rate is usually WNL
Rhythm is regular
Pwaves are normal in size and shape
The PR interval is prolonged (>0.20 sec) but constant
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1st degree block
• AV node delays the impulse from the SA
node for abnormal length of time
• Causes:
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CAD, MI, drugs that act on AV node
(digitalis)
• Characteristics:
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PR interval >0.20 seconds
• Not serious but may progress to 2nd degree
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1st degree block nursing intervention:
• Document the dysrhythmia
• Monitor for progression to slower heart rate or
worsening block
• If progression noted, monitor pt, notify
physician
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Pwaves are normal in size and shape;
Some pwaves are not followed by QRS
PR interval: lengthens with each cycle until it appears without QRS Complex
then the cycle starts over
QRS is usually narrow
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2nd degree AV block:Type I:
• AV node delays progression of SA node impulse
for longer than normal
• Some of the SA impulses never reach ventricles
• P waves regular
• Progressive lengthening of PR interval until one P
wave is not conducted
• CAUSE: ischemia or injury to AV node
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2nd degree Type I AV block:
• RISK: often a temporary block after MI
•
May progress to complete(3rd degree)
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block
• TREATMENT; freq. none needed
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slow vent rate: ATROPINE will increase
AV conduction
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To increase rate of SA
node:EPINEPHRINE
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2ND degree nursing interventions:
Type I
• Document
• Monitor pt/vitals
• If ventricular rate slows enough to produce
•
symptoms, document , notify physician
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http://www.youtube.com/watch?v=GVxJJ2
DBPiQ&feature=related
Ventricular rate is usually slow
Rhythm is irregular
Pwaves are normal in size and shape (more pwaves than QRS)
PR interval is within normal limits
QRS is usually wide
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2nd degree Type II
(Mobitz Type II)
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Atrial rate 60 to 100
More P waves than QRS complexes
Ventricular response 2:1 or 3:1
No change in PR intervals of conducted P waves
CAUSES: disease of AV node, AV junctional
tissue, or His-Purkinje system, inferior MI
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2nd degree Type II:
• RISK: unpredictable & may suddenly
advance to complete hrt block
• Especially common after inferior infarction
• A DANGEROUS WARNING DYSRHYTHMIA
• TREATMENT: if vent rate slow, atropine or
epinephrine
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may need temporary pacer
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2nd degree Type II
Nursing Interventions:
• Determine width of QRS
• WATCH for widening QRS complex
• *width QRS indicates location in the conduction
system of the block
•
- the wider the complex, the lower in the
bundle branch system the block will be.
• IF QRS WIDENS, NOTIFY PHYSICIAN
IMMED.
• Prepare for insertion of pacer
• Assess vitals
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Ventricular rate is regular but there is no correlation between pwaves and
QRS
Pwaves are normal in size and shape
No true PR interval
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3rd degree block: complete heart block:
“AV dissociation”
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More atrial waves than ventricular
No conduction of atrial impulses
Atrial/ventricles beat independently
RISKS: bradycardia which produces
a decrease in CO leading to hypotension
& myocardial ischemia
TREATMENT; pacer
NURSING INTERVENTION; monitor ,
hemodynamics , prepare for pacer
•
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Atrial Fibrillation
Erratic wavy base
Pr is not measurable
QRS 0.10 sec or less usually
http://www.youtube.com/watch?v=VKxQgjj2yVU&fe
ature=related
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A fib continued
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Atrial rate > 400 bpm with a varying Ventricular rate
Overall rhythm irregular
No P waves, unable to measure PR interval
QRS=normal: Twave undeterminable
Causes: Rheumatic fever, mitral valve stenosis, cad.
HTN, MI, hyperthyroidism, COPD, CHF see pp. 604
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A fib continued
• Concern with A fib is the development of
atrial thrombus and loss of atrial kick from
ineffective atrial function.
• Treatment: Ca channel blockers and antiarrhythmics to convert, beta blockers to <
HR, anticoagulants to prevent embolization.
• Synchronized cardioversion
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Atrial Fibrillation
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- - 5 to 6 times more likely to have stroke
- - atrial rate: 300 to 600 times/minute
--prolonged A-Fib may stretch & weaken
heart muscle
- - symptoms: lightheaded, very tired,
SOB, diaphoretic, chest
pain,
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Afib causes :
• Chocolate large amounts: contains
theobromine, a mild cardiac stimulant.
• - sleep apnea
• - athletes more prone (enlarged heart)
• - tall athletes (esp basketball players)
• - aging heart
• - men more than women
• - sleeping on left side or stomach
• etc.
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A-fib treatment:
• ASA not as effective as Coumadin in
preventing strokes.
• ASA less likely to cause abnorm bleeding
• **since hemorrhagic stroke increases with
age & is also increased by taking Coumadin,
some Drs. may switch older pts from
Coumadin to ASA.
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A Fib electrical cardioversion:
• High risk of forming clots & causing stroke
• Anticoagulants taken before treatment and 34 weeks post treatment
• If life-threatening, may need Heparin IV
before cardioversion
• Best time: recent A fib
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Atrial rate of 250-450 bpm ventricular rate varies
Atrial rhythm is regular ventricular rate is
irregular
No identifiable p waves
P wave is not measurable
Qrs: 0.10 or less usually
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Atrial fib/flutter
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Pacer spike should fall before the P wave unless a dual
Chamber pacemaker; if it does not there could be a problem
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PAC
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PAC: premature atrial contraction
• Premature depolarization of atrial origin
• P wave may be buried in T wave
• A pause follows and SA node will start new cycle
of sinus beats
• Indicates atrial irritability
• No risk if occasional
• If 6 or more per minute, indicates atrial
tachycardia
• Treat: digitalis, calcium channel blockers, beta
blockers
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Extra beat
Types
uniform=go the same direction
multifocal= go in different direction
R on T=when the pvc fall on the preceding twave
couplet= 2 pvcs together
bigeminy= pvc every other beat
trigeminy=pvc every third beat
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PVCs (unifocal)
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PVCs (multifocal)
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PVC: ventricular origin
• Complex is wide followed by compenatory
pause
• An irritable focus in ventricle initiates a
contraction before normally expected beat.
• Acute MI most common cause
• QRS is wide and bizarre
• Risks: increasing myocardial irritability,
leading to increased freq. of PVCs
• Can occur as bigeminy (every other beat)
• or short runs
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Ventricular tachycardia
Monomorphic: beats are same size
and shape
Polymorphic: different size and
shape
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V-tach
• Advanced irritability of ventricles due to
ASHD, CHF, acute MI electrolye imbal.
Hypoxia, acidosis,occas drugs
• RISKS: low to no Cardiac output
• Nursing Interventions: monitor, if pt
unconscious,immed. defib
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This is a polymorphic VT
Usually electrical imbalance in nature r/t NA+ or K+
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Torsade de pointes
• Will see prolonged QT interval when in sinus
rhythm
• Will see prominent U wave
• If lasts >10 seconds pt will progress to
unconsciousness, life threatening with ineffective
cardiac output
• TREATMENT: IV magnesium
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Ventricular Fibrillation
Rate can not be determined
because of no identifiable
waves
Rapid chaotic rhythm with no
pattern
No p waves
No PR interval
No QRS
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Vtach/Vfib
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Both can be life threatening
VT= V HR 100-250 bpm
Causes: AMI, CAD, hypokalemia, dig toxic
S/S: palpitations, dizzy, angina, <LOC
Treatment: assess for pulse, if none, defib
VF=Rate undeterminable Cause: same
Treatment: CPR
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V-fib
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May occur after MI
Extensive ventricular irritability
Very little cardiac output
Death within 4 to 8 minutes
TREATMENT: immediate defibrillation
immed defib at 200 J
if unsuccessful, repeat at 300 J
If unsuccessful, repeat at 360 J
CPR
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Asystole
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Asystole and PEA
• CPR
Oxygen
• Epinephrine 1 mg IV/IO (repeat 3-5 minutes)
• May give Vasopressin 40U IV/IO to replace
•
1st or 2nd dose of epinephrine
• Consider Atropine 1 mg IV/IO Repeat every 3 to 5
min (up to 3 doses)
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What arrthymias are considered PEA?
• See an organized or semi-organized rhythm
BUT NO PULSE:
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This includes:
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- idioventricular rhythms
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- ventricular escape beats
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- postdefibrillation idioventricular
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http://www.campaignfornursing.com/events/WINNERS/pennsylvania/
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ST elevation
12 lead ekg
• The electrocardiogram (EKG) is a device that
receives electric impulses from the body and
changes them into a monitor tracing that can be
analyzed to find problems with electrical
conduction in the heart. The EKG simply picks up
electrical impulses; it does not read mechanical
activity. When a patient has ischemia, injury or
necrosis to the heart muscle, the electrical
impulses change in the area involved. Nurses
can analyze the electrical changes and
determine if they indicate mechanical
dysfunction.
• The EKG is simply a volt meter that picks up
electrical signals. Therefore, anything that
interferes with electrical conduction can
cause changes in the EKG. These variables
can be divided into three main categories:
– 1) physiological variables not specific to the heart
(ie. pulmonary embolism, increased intracranial
pressure)
– 2) electrical interference (ie. poorly placed lead)
– 3) ischemia, injury, or infarction
5 Steps to 12 Lead Interpretation
1. Assess regularity and speed
2. Look for signs of infarction
3. Present in >1 lead, but not all?
4. Assess associated conditions
5. Correlate with clinical condition
Normal EKG
MI
Polymorphic VT
VFIB
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• http://nursebob.com/
• http://www.usfca.edu/fac_staff/ritter/ekg.htm
• http://ems-safety.com/12-lead-ekg.htm
Rhythms for Cardioversion
• A-fib
• A-flutter
• Supraventricular tachycardia
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Electrical cardioversion
• It is the treatment of choice if the patient has a
hemodynamically unstable tachydysrhythmia
• It is used for the treatment of unstable ventricular
tychardia with a pulse
• With cardioversion the potential exists to prevent
this life-threatening dysrhythmias.
• Cardioversion may either be a planned or
emergent procedure.
• Properly done cardioversion will correct the
patient’s dysrhythemia with minimal discomfort
and maximum safety.
Chemical cardioversion
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Indication
A. Considered to be an effective alternative to electrical cardioversion for Rapid
conversion of atrial fibrillation and atrial flutter.
B. Ibutilide is moderately effective in causing prompt conversion to sinus rhythm with
greater efficacy in patients who have atrial flutter.
2. Action.
A. Ibutilide prolongs action potential duration by activating a slow inward current,
largely carried by sodium ions.
B. Blocks the rapidly activating component of the delayed rectifier potassium current.
C. No significant effect on heart rate, PR interval, or QRS interval
D. Potential prolongation by Ibutilide leads to an increase in atrial and ventricular
refractoriness in vivo.
E. No clinically significant effect of Ibutilide to lower blood pressure or worsen
congestive heart failure.
F. Route of elimination: hepatic.
3. Administration.
A. Ibutilide is available in 10 mL vials containing 0.1 mg/mL (1 mg total).
B. For intravenous administration, the recommended dose of Ibutilide is 1mg over a
10 minute period in patients weighing > 60 kg
C. Patients weighing < 60 kg, the recommended dose is 0.01 mg/kg initially, with a
second dose of the same strength 10 minutes later if necessary.
D. Ten minutes after the end of the initial infusion, a second 10 minute infusion of
equal strength can be given if the arrhythmia has not terminated.
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Cautions.
A. Prolong ventricular repolarization
B. Carries a risk of excessive QT prolongation
C. Acquired long-QT syndrome
D. Associated polymorphic ventricular tachycardia (torsade de
pointes)
E. Careful patient selection and clinical monitoring during drug
administration.
5. Contraindications.
A. QTc interval exceeding 440ms
B. Bradycardia
C. Electrolyte disturbances
D. Other QT-prolonging drugs
6. Adverse Effects.
A. Ventricular tachycardia
B. Premature ventricular complexes
C. Hypotension
D. Bundle branch block
E. Atrioventricular
• Post cardioversion care:
• 1. generally the care for a patient tells
cardioversion is the same as for the
fibrillation.
• 2. If it is a elective procedure, digoxin is
usually withheld for 48 hours prior to
cardioversion to prevent dysrhythmias after
the procedure.
• 3. Airway patency should be maintained and
the patient state of consciousness should be
evaluated.
Indications for pacemaker
• Temporary:
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-symptomatic bradycardia (not controlled
by meds)
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- ant MI
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- drug overdose (dig, beta blocker)
• Permanent:
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- 2nd degree Mobitz Type II
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- 3rd degree Block
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- symptomatic bradycardia, arrhythmias
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- suppress tachyarrythmias
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Modes of Pacing
• Synchronous (demand )Mode
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- sensitivity is set to patient beats
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- pacer will fir when pt rate goes below
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that what is set
• Asynchronous pacing:
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- for asystole, or profound bradycardia
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- does not sense any pt beats
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- fires at set rate no matter what pt rate is
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Position of the letter
Designation
1st letter
Chamber being paced (A=atrium, V=ventricle, 0=none)
2nd letter
Chamber being sensed (A=atrium, V=ventricle, 0=none)
3rd letter
Pacing Mode (O=none, I=inhibited, T=triggered, D=dual)
4th letter
Rate Response (R=rate response is on)
Chambers that can be paced:
Atrium
Ventricle
Dual (both atrium and ventricle)
ICD (Implantable Cardioverter Defibrillator)
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Dual Paced
• Atrial Pace, Ventricular Pace (AP/VP)
AV
AP
VP
V-A
AV
AP
VP
V-A
Implant Cardioverter Defibrillator
ICD
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ICD
• - prevents sudden cardiac death due to
• V-tach or V-fib.
• Pt can feel the shock
•
-defib felt like “kick in the chest”
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that lasts 1 second
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- cardiovert feels like “thump in chest
•
- pt doesn’t feel pacing
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Problems with pacers
• Failure to fire
• Failure to capture
• Undersensing (low battery, poor lead
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position)
• Oversensing (turn down output, magnetic
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interference)
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Operative failures with pacers:
• Pneumothorax
• Pericarditis
• Infection
• Hematoma
• Lead dislodgement (seen on X-ray)
• Venous thrombosis (rare but would see
•
unilateral edema to arm on same side
•
as pacer)
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Pt Education:
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1. carry ID card (Xray code seen in standard chest Xray)
2. not allowed to drive for 1 month
3. no metal detectors or no longer than nec.
4. MRI interrupts pacing-can’t get one for some time if new
5. No power generators (welding)
6. microwave questionable
7. radiotherapy (may damage circuits) The
pacer may need to be surgically moved if in
path of radiation field.
8. TENS (transcutaneous electrical stimulation) interferes
may need reprogramming
9. Cell phone use in opposite ear of pacer and store away
from side of pacer
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EP with Ablation
An electrophysiology study is simply a study
of the electrical function of your heart.
•
•
A (IV) catheter may be placed and be used to continuously administer
fluids. The purpose of this IV is to provide the nurses and doctors with a
quick means of administering medications, should your heart rhythm
abnormality occur.
An EP team doctor will explain why the procedure is necessary and
what risks are involved for you.
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–
•
The degree of risk varies with each person and is related to your specific condition.
After discussing this information,
a consent form needs to be signed prior to
Prior to the EP study, your skin will be washed with a special soap and
the hair shaved from potential catheter insertion sites. The most
common site used is the groin, or the area at the crease of the leg
about midway between the center of your body and your hip.
Occasionally the forearm, neck or collarbone areas are used. The
purpose of this washing is to provide a clean insertion site and reduce
the chance of infection
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NPO after midnight the night before the test. If your test is not
scheduled until later in the day, may have a clear liquid breakfast, after
which you must not eat or drink. You may take your morning pills with a
sip of water. All your medicines will be reviewed, and some may be
withdrawn prior to the test.
You will not receive anything to put you to sleep before this test. It is
important for you to describe sensations you have during the test to the
staff in the EP laboratory.
If you have dentures and they are tight-fitting, you may wear them
during the study. You may also wear your glasses and watch if you
wish.
An initial EP study takes an average of two and a half hours; however,
they may range from one to six hours.
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•
Long, thin, flexible wires, referred to as pacing wires, or intra-cardiac
catheters, are advanced through the IV catheter and up into the heart
chambers under the guidance of an x-ray camera (see diagram). These
pacing wires are used to both record the electrical patterns from inside
the heart and to "pace" the heart. Pacing the heart is delivery of very
small amounts of electricity to the heart muscle through the tip of the
catheter. This causes a heart beat, and allows the electrophysiologist to
compare your heart's response to paced beats to already known
normal responses. Approximately half of the patients undergoing this
procedure are aware of each heart beat, and therefore, feel their heart
speed up, slow down, or "skip a beat". Many other people are
completely unaware of the pacing procedure.
If an arrhythmia is provoked by the pacing, you may feel some of the
same symptoms that caused you to seek medical attention. Please tell
the EP staff what you feel. Let them know if you have shortness of
breath, dizziness, light-headedness, or chest discomfort. A member of
the team will be by your side and talking with you at all times.
•
•
•
•
•
After the test, the catheters will be removed. Firm pressure will be applied
over the puncture site for approximately 15 minutes. This is necessary to
prevent any bleeding from the insertion site. You will then be taken to your
hospital room, or the EP recovery area.
Flat bed rest is necessary for two to eight hours after the study. During this
time, it is important to keep the leg or arm used in the procedure straight to
prevent bleeding from the insertion site. After the specified amount of rest,
you will be able to resume your previous activity level.
Your nurse will be in the room frequently during the first hour after the study
to take your blood pressure, heart rate, and check your insertion site for
signs of bleeding. The pulses and temperature of your feet will also be
checked.
You will be instructed to apply pressure firmly to the insertion site if you
cough or sneeze and while using the bedpan or urinal. If you should notice
any bleeding at the site, notify your nurse immediately. If your back
becomes uncomfortable, do not hesitate to ask the nurses for pain
medications.
You will be able to resume your previous diet and your nurse or family
members can help you eat while you are reclining in bed.
Bundle Branch Blocks: Diagnosed with
12 lead EKG: most common cause: acute
MI
• Right bundle branch block:
• - impulse travels through left ventricle first,
then activates right ventricle (gives am “M”
shaped complex
• Left bundle branch block:
•
--impulse first depolarizes right side of
heart then the left ventricle (gives deep, wide
“V” shaped complex
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Bundle Branch Blocks:
• Risks: can deteriorate to 3rd degree block
• then treat with atropine or pacemaker
• Pt can be asymptomatic until progresses
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Hyperkalcemia
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Intro to ACLS
Primary Survey
• Airway: Open airway, look, listen, and feel for
breathing
• Breathing: If not breathing slowly give 2
rescue breaths. If breaths go in continue to
next step.
• Circulation: Check the carotid artery (Adult)
for a pulse. If no pulse begin CPR.
• Defibrillation: Search for and Shock VFib/Pulseless V-Tach
Adult ACLS Secondary Survey ABCDs
(abbreviated)
• Airway: Intubate if not breathing. Assess
bilateral breath sounds for proper tube
.
placement.
• Breathing: Provide positive pressure
ventilations with 100% O2.
• Circulation: If no pulse continue CPR, obtain
IV access, give proper medications.
• Differential Diagnosis: Attempt to identify
treatable causes for the problem.
AED
• An AED is a device used in cardiac arrest, or
sudden cardiac death, when the heart’s
electrical activity is disorganized and there is
no effective pumping of blood. The AED is
capable of recognizing the heart's electrical
activity, and determining if an electric shock is
required. If the shock is needed, a voice
prompt in the AED is activated, telling the
rescuer to push a button to deliver the shock
• http://acls.net/quiz/mi_stroke_1.htm
stress
• Common responses can include:
– Feeling a sense of loss, sadness, frustration,
helplessness, or emotional numbness
– Experiencing troubling memories from that day
– Having nightmares or difficulty falling or staying
asleep
– Having no desire for food or a loss of appetite
– Having difficulty concentrating
– Feeling nervous or on edge
Teaching to cope
•
•
•
•
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Reach out and talk.
Express yourself.
Watch and listen.
Stay active.
Stay in touch with family.
Take care of yourself.
ANY QUESTIONS???