CMS Life threatening dysrhythmias

• Sinus bradycardia

• 3rd degree AV block (complete)

• PVCs

• Ventricular tachycardia and fibrilation

• Asystole and pulselessness electrical activity

• Pacemaker malfunctions (failure to sense/capture)

• Sinus rhythm, tachycardia, and a-fib w/ RVR

What are need to know rhythms?

• Oxygen

• Meds

  • Amiodarone, atropine, epinephrine, dopamine

  • Diltiazem and metoprolol

• Pacing vs. Defibrillation vs. Cardioversion

• CPR

What are need to know tx?

1. SA node (60-100 bpm)

2. AV node (40-60)

3. Bundle of HIS (20-40)

4. Right and left bundle branch

Normal conduction pathway

Abnormal rate or activity altered conduction

• Can be triggered by MI, increased thyroid hormone, beta blockers

What is a dysrhythmia?

DECREASE CO

• Low SBP <90 and Low MAP <65

• Altered mental status

• CP

• Dizziness

• Diaphoresis

What do all cardiac dysrthymias have the ability to do?

The SA node sends slower impulses, but conduction continues normally throughout the heart

• P-P, R-R regular

• PR interval and QRS WNL

• Rate <60 (normal for atheletes and runners)

What is sinus bradycardia?

• Assess ABCs (SOB)

• Determine if sx are present (If new onset, it’s a problem; place on EKG)

• Identify the underlying cause and manage

• Asymptomatic: CONTINUE TO MONITOR ABC’s

• Symptomatic: TREAT

What is the INTERVENTION for sinus bradycardia?

• Symptomatic

  • IF HYPOXEMIC: OXYGEN

  • Possible IV FLUIDS (depends on cause)

  • Give ATROPINE IVP 1; if needed, repeat Q3-5 MIN until a MAX of 3MG (3 doses)

    • Also for PVCs

  • Alternative:

    • Transcutaneous pacing (atropine ineffective)

    • Dopamine

    • Permanent pacemaker

What is the TX for sinus bradycardia?

Transcutaneous pacing (defib pads acts like pacemaker to set a pace on a pt.) with IV SEDATION as needed

What if atropine is ineffective or max reached when treating symptomatic sinus bradycardia?

Dopamine infusion at 5-20 MCG/KG/MIN (best is 5-10 MCG/KG/MIN for BRADYCARDIA, if NO HYPOTENSION is present)

What do you give as an alternative medication if atropine or transcutaneous pacing doesn’t work?

Place PERMANENT pacemaker

What should you do if transcutaneous pacing does not work in sinus bradycardia?

3 doses max

• don’t have to give all three

How many doses of atropine can you give in sinus bradycardia?

INCREASES HR

• Blocks parasympathetic actions on the SA NODE (decrease SA node)

• Also gets rid of PVCS

What does atropine do?

Separate electrical stimuli trigger atria and ventricle; no complete conduction (No communication between atria and ventricle)

• Ventricle is not getting conduction from AV node

• P-P and R-R regular

• QRS WIDE

• More P WAVES (atrial) than QRS complexes (ventricle)

• No relationship between P and QRS

What is complete (3rd degree) heart block?

D

A nurse is reviewing the provider’s orders for a patient with complete (3rd degree) AV heart block. Which order should the nurse question?

A. Administer oxygen at 2 L/min via nasal cannula.
B. Apply transcutaneous pacing pads and keep the pacemaker available at the bedside.
C. Maintain continuous cardiac monitoring and obtain a 12-lead ECG.
D. Administer atropine 0.5 mg IV for a heart rate of 32/min.

1. ASYMPTOMATIC:

   1. Monitor and notify HCP

   2. If HYPOXEMIC: apply oxygen to maintain pulse ox ≥95%

2. SYMPTOMATIC:

   1. Treat with TRANSCUTANEOUS PACING; R/O medication cause

   2. If cause cannot be fixed: PERMANENT PACEMAKER

What is the TX for complete (3rd degree) AV heart block?

Ectopic foci (beat) in the ventricles discharge and initiate the ventricular contraction; cluster of cells get irritated

• NO P WAVE

What are premature ventricular contractions (PVCs)?

• Hypoxia, acidosis

• MI

• Electrolyte imbalance

• Anxiety, stress

• Dehydration

• Stimulant/irritants:

  • Caffiene

  • Alcohol

  • Drugs; cocaine

What are the causes of PVCs?

• Multifocal: 2 or more areas of agitation

• Run of V-tach: fast, abnormal heartbeat; 3 or more consecutive heartbeats. Something is irritating ventricles

What are the types of PVCs?

1. ANY PATIENT:

   1. CORRECT UNDERLYING CAUSE (ex. stress, MI, electrolytes)

2. ASYMPTOMATIC (WITH NO CARDIAC DISEASE)

   1. MONITOR ONLY

3. SYMPTOMATIC

   1. If hypoxemic: oxygen to maintain pulse ox ≥95%

   2. ATROPINE WHEN HR <60

   3. BETA BLOCKER (PROPANOLOL) WHEN HR >60

   4. Cardiologist consult

What is the TX for PVCs?

B

A patient with a history of coronary artery disease is on continuous telemetry. The nurse observes frequent PVCs occurring in a pattern of bigeminy. The patient reports palpitations and mild dizziness. Vital signs are: BP 104/66 mm Hg, HR 96/min, RR 18/min, SpO₂ 96%. Laboratory results show a potassium level of 3.1 mEq/L. Which intervention should the nurse anticipate?

A. Administer the prescribed IV magnesium sulfate and reassess the cardiac rhythm.

B. Administer the prescribed beta blocker to decrease ventricular ectopy.

C. Administer atropine IV to suppress the premature ventricular contractions.

D. Prepare the patient for synchronized cardioversion because frequent PVCs indicate an unstable rhythm.

An ectopic foci in the ventricles becomes the pacemaker of the heart; repetitive firing of an irritated ventricle

• Intermittent or SUSTAINED (on the test)

What is ventricular tachycardia?

140-180 bpm

What is the bpm of ventricular tachycardia?

• WITH PULSE and STABLE

• WITH PULSE and UNSTABLE

• PULSELESS

What are the types of ventricular tachycardia? (test)

• Ischemic heart disease

• MI

• Cardiomyopathy

• Low K and low Mg

• Valvular disease

• Advanced HF

• Drug toxicity

• Hypotension

• Ventricular aneurysm

(don’t memorize)

What are the causes of ventricular tachycardia?

• Refractory v tach

• V fib

• Torsades de Pointes (type of v tach); alive, usually pt. with Mg issue

• Known electrolyte imbalance

When is MAGNESIUM used in v tach?

1-2 G in 10ML D5W IV over 5-20 MIN

How do you give Magnesium?

1. Apply O2 (if deteriorating quickly)

   1. In some cases, pulse ox may be ≥95%, and oxygen is not needed

2. Confirm rhythm with 12-lead ECG

3. AMIODARONE 150MG IV INFUSION OVER 10 MIN THEN DRIP

4. LIDOCAINE 1.0-1.5 MG/KG IV BOLUS AND/OR MAGNESIUM IV

What is the TX for v tach WITH PULSE and STABLE?

Conscious, oxygenates well, BP good

What is a stable patient?

• V tach (stable/unstable)

• V fib

• Atrial tachydysrhythmias

When is AMIODARONE used?

INHIBITS ADRENERGIC stimulation (antiarrhythmic)

• Slows cardiac conduction through sinus node

• PROLONGS REFRACTORY (recovery) periods

• Helps SA NODE to regain/maintain appropriate rhythm

What does amiodarone do?

Low CO = low BP and HR

What is a SIDE EFFECT of amiodarone (NOT ADVERSE EFFECT)? (test)

• PULMONARY FIBROSIS

• THYROID ISSUES

• LIVER DISEASE

What are the ADVERSE EFFECTS of amiodarone? (test)

142 days; stays in the system for a long time

How long is the half life of amiodarone and what does that mean?

• Potentially life threatening side effects

• Use cautiously in patient with THYROID disease and SEVERE PULMONARY or LIVER disease (test)

• Monitor BP, HR, s/s PULMONARY COMPROMISE

What are the PRECAUTIONS the nurse should consider with administering amiodarone?

In-line filter (central line) for infusions

• Because it easily infiltrates

How is amiodarone administered?

• SYNCHRONIZED CARDIOVERSION IS PRIORITY

  • Typically LOWER JOULES than defib

  • Patient MUST have a pulse

• Apply OXYGEN

• May give IV AMIODARONE 150MG, Magnesium, or Lidocane

• Oral antidysrhythmics when STABLE again (AMIODARONE and DILTIAZEM)

What is the TX for v tach WITH PULSE and UNSTABLE?

• Low BP

• Chest pain

• SOB

• Diaphoresis

What is an unstable patient?

Electrical shock given on the R (of the QRS) to stop tachydysrhythmia

• MUST SYNC, do NOT just shock → can cause VFIB

What is synchronized cardioversion?

Amount of joules

What is the difference between pacing and cardioversion?

1. Patient MUST have a pulse

2. MODERATE SEDATION (propofol) AND OXYGEN

3. Place electrode pads to chest

4. Press SYNCHRONIZED MODE (R wave)

5. Start with LOW JOULES (50-100)

What is the cardioversion process?

SA node to take back control of rhythm

What is the goal of cardioversion?

• V-fib: The patient is in CARDIAC ARREST because the VENTRICALS are quivering rather than contracting effectively. Since the ventricles are the heart’s main pumping chambers, they cannot generate an effective CO, resulting in NO pulse and NO systemic perfusion.

• A-fib: The patient is generally ALIVE with a PULSE and ongoing perfusion because the ventricles can still contract and pump blood. However, the patient is at risk for CLOTS

What is the difference between vfib and afib?

Normal electrical conduction is replaced by chaotic ventricular activity WITHOUT contractions (not pumping); they are dead

What is ventricular fibrillation?

Minutes

How fast do you need to fix vfib?

• Low Mg and K

• Hemorrhage

• MI

• Shock

What types of patients are at risk for vfib?

COMPRESSIONS and DEFIBRILLATION (shock)

• MAX JOULES, no synchronization, no sedation

• Think: What caused this?

• Goal: SA NODE regain control

What is the TX for v tach PULSELESS AND vfib? (test)

Electrical shock TO STOP chaotic asynchronous electrical activity

What does defibrillation do? (test)

• Upper right chest

• Lower left size

• Adult pads can be used for children

Placement for defibrillation

• Usually work on battery so keep them CHARGING when not in use

• PRIOR TO DELIVERING SHOCK, CHECK TO BE SURE THAT NO ONE IS TOUCHING THE BED

  • CLEAR (test)

What is defibrillation safety?

1. PT UNRESPONSIVE

2. CALL FOR HELP (FLOOR STAFF FIRST)

3. ASSESS ABCs, PATIENT PULSELESS (CALL CODE)

4. PERFORM CPR (COMPRESSIONS THEN VENTILATION) UNTIL DEFIBRILLATOR IS READY

5. DEFIBRILLATE, THEN RESUME CPR

6. CHECK RHYTHM Q2MIN

7. EPINEPHRINE 1MG IVP Q3-5 MIN (NO MAX, same dose as atropine)

   1. CONSIDER AMIODARONE 300MG IVP (double dose) OR LIDOCAINE IV/IO

   2. CONSIDER MAGNESIUM

What are the STEPS of TX for v tach pulseless or vfib?

ONLY for v tach pulseless and vfib

When do you use amiodarone 300mg IVP?

Anyone

• V tach

• Vfib

• Asystole/PEA

Who can you give epinephrine to in cardiac arrest?

• IV/IO dose

• 1 MG (10 ML of 1:10,000 solution) Q3-5 MIN

• Then fast flush 200 mL so whole amount gets to pt.

How do you administer epinephrine?

• Increase VASOCONSTRICTION throughout

• Stimulates cardiac cells

• Increases vigor of vfib

What does epinephrine do?

B

A nurse enters a patient's room and finds the patient unresponsive and pulseless. The cardiac monitor displays a flat line in two leads, and the nurse confirms that the electrodes are properly attached. Which action should the nurse take first?

A. Prepare the defibrillator and deliver an unsynchronized shock.

B. Begin high-quality CPR and administer epinephrine as prescribed.

C. Perform synchronized cardioversion at 200 joules.

D. Administer amiodarone IV and prepare for defibrillation.

NO (NO DEFIB NO CARDIOVERSION)

Is asystole and PEA shockable?

• No instrinsic pacemaker is firing

• No electrical actvity or mechanical pump

• Cardiopulmonary arrest

What is asystole?

Lack of palpable pulse in the presence of organized electrical activity (heart is not beating actually beat, it just shows up on monitor and can be any rhythm)

What is pulseless electrical actvity (PEA)?

• Arterial line goes flat (no waveform)

• Check pulses hourly

How do you confirm someone had PEA when you are not in the room?

1. PT UNRESPONSIVE

2. CALL FOR HELP (FLOOR STAFF FIRST)

3. ASSESS ABCs, PT. PULSELESS (CALL CODE)

4. BEGIN CPR (COMPRESSIONS THEN VENTILATION)

5. GIVE EPI ASAP!! (test)

6. START AN IV IF NONE PRESENT

7. GIVE EPI 1MG IVP Q3-5 MIN (NO MAX DOSE)

8. RECHECK RHYTHM Q2MIN

9. REVIEW AND TX CAUSES (H’S AND T’S)

What is the STEPS for TX of asystole and PEA?

• Hypoxia

• Hyper/hypokalemia

• Hydrogen ion acidosis

• Hypovolemia

• Hypothermia

What are the 5 H’s for reversible causes of asystole and PEA?

• Emergent situation

• Unconscious patient

  • No RR

  • No pulse

What is cardiac arrest?

• High quality and effective

• Look for chest recoil

• 100-120 bpm

• 2in then up

How do you preform CPR?

WHEN PT IS DEAD NOT RRT

When do you call a code? (test)

• A nurse and respiratory therapist trained in critical care (usually from the ICU)

• PRIMARY NURSE STAYS IN THE ROOM AND GIVES REPORT TO RR TEAM (test)

What does the RRT include?

Prevent deterioration and/or treat patient beginning to deteriorate

What is the goal of RRT?

• Very low BG

• Change in rhythm or new LOW CO S/S

• New onset AMS change

• New onset SX and can’t ID cause

• O2 SAT <90 (esp. if not responding to O2)

When do you call RRT?

• RN’s, RT, MD (or more)

• Charge nurse and other unit staff may assist

• Primary care nurse STAYS IN ROOM/GIVES REPORT

What is the code team?

• Team leader

• Code cart/defibrillator

• Documenter

• Med administration

• IV access

• Ventilations

• Compressions

What are the individual roles during a code?

PRIMARY SURVEY

• Pt unresponsive

• Call for HELP (floor staff first)

• Assess further

• If no pulse, call CODE

• Preform CAB

• Defibrillate, if appropriate

SECONDARY SURVEY

• IV access and ACLS (other drugs)

• Advanced airway (ET tube, changes CPR amt)

• Differential diagnosis (H’s and T’s)

What are the primary and secondary steps for cardiopulmonary arrest?

• O2 all the way, 15L

• Mask seal

• Enough for chest rise

How do you use an AMBU bag?

Suspected hypoxia

• Prompt tx of hypoxemia may prevent cardiac arrest

• Apply 100% O2

• Monitor pt. airway and breathing

When do you give O2 in cardiopulmonary arrest?

NO, it is unreliable and should use ABGs instead

Can you use a pulse ox during cardiopulmonary arrest?

• LARGE BORE IVS PREFERRED (16, 18)

• Biggest veins: antecubital access

  • May require central line

What types of IV’s are preferred for cardiopulmonary arrest?

NS

• Manual regulation (no pump)

• Flush between meds

What fluids are given in cardiopulmonary arrest?

Intraosseous access (IO); drill into bone

What should you do if there is no IV access on the patient during a cardiopulmonary arrest?

• Primary and secondary survey

• Ongoing assessment

  • Chest rise

  • Pulse checks (vitals)

  • ABGs, labs

• Crowd control

• Family communication (nurse for doc and family)

• Transfer for ICU

What is the logical flow of code events for cardiopulmonary arrest?

TARGETED TEMPERATURE MANAGEMENT (TTM)

What happens if the interventions for cardiopulmonary arrest if a pulse or spontaneous circulation (ROSC) returns to the patient?

• Post code, after the patient has return of spontaneous circulation (ROSC) yet remains unresponsive to verbal commands

• Temperature control (my be hypo or normothermic)

What is TTM?

32-37.5 C (89.6-99.5 F) for 36 HOURS then slowly return

What is the temperature for TTM?

After ROSC the brain is inflammed and tries to work hard while is it injured which can kill brain cells, so cooling helps slow down brain damage

Why TTM after cardiac arrest?

60 MINS of resuscitation and maintained for 36 HOURS

When does TTM start?

If cooling, the nurse may administer SEDATION WITH OR WITHOUT PARALYTIC AGENT TO PREVENT SEIZURES AND SHIVERING (keep their body from trying to warm up)

What can the nurse do during TTM?

• TRANSCUTANEOUS

• TRANSVENOUS

• PERMANENT

What are the types of pacemakers?

To improve conduction coordination between the right and left ventricles and/or atria (improves HR and/or rhythm)

What is the GOAL of pacing?

• SYMPTOMATIC BRADYCARDIA OR SICK SINUS SYNDROME (SA node dysfunction)

• HEART BLOCK (2 OR 3 DEGREE) OR BUNDLE BRANCH BLOCK

• AFIB OR FLUTTER WITH RVR

What are the INDICATIONS for pacing?

• TRANSCUTANEOUS (NON-INVASIVE)

• TRANSVENOUS (INVASIVE)

What are the TEMPORARY PACERS? (test)

1. Clip/wax hair if needed or clean off sweat

2. Set rate and CHECK PULSE (should match)

3. Reassess BP, sedation

What are the steps of transcutaneous pacing?

External pads

• Uncomfortable due to the muscle involvement, skin irritation and diaphoresis → SEDATE

What are TRANSCUTANEOUS (NON-INVASIVE) pacers?

• Wire inserted via jugular of subclavian vein

• Pacing occurs in the RIGHT VENTRICLE

• Sometimes used if waiting for permanent pacer

What are TRANSVENOUS (INVASIVE) pacers?

• mA (milliamp); electricity

• Rate (how fast)

• mV (millivolts)

What are the settings on a pace maker?

Palpate RADIAL and CAROTID and take BP to make sure it matches

What should you do when you set the rate on a pacer?

1. Single chamber

2. Dual chamber

3. Biventricular

   1. Right atrium

   2. Right ventricle

   3. Left ventricle

What are the types of permanent pacemaker?

CXR

What is used to confirm pacemaker?

Pulse generator

• Houses the battery and a tiny computer

• Send electrical pulse down lead

• Senses underlying rhythm

• Powered by lithium battery (5-10 years)

• Combined wtih defib; shock just in case

One before QRS (ventricles), ventricular pace

How many pacer spikes does a single pacemaker create?

1. Pneumothorax (accidentally punctures lung)

2. Lead moves or breaks

3. Failure to capture

4. Failure to sense

What are the potential complications of pacemakers?

Rhythm ‘sensed’ correctly, impulse sent on time (not strong enough), but no contraction

IMMEDIATELY NOTIFY HCP

What is failure to capture? (test)

• Inadequate stimulus

• Lead dislodgement

• Lead fracture

• Myocardial ischemia

What are the causes of failure to capture? (test)