2 things that must be done before any arrhythmia observed on an EKG is Tx?
1. assess pt hemodynamic response to rhythm: BP and symptoms
2. find cause
What will result from early beats on EKG if the pattern continues?
stimulate various areas of the heart to stimulate arrhythmia & find area acting up
What procedure may be done during EPS?
may Tx Afib by ablation of SA node & putting in pacemaker
AE of EPS?
lethal arrhythmias can occur
How long is Holter monitor worn?
24 - 48 h
- 1. should not remove pads or shower
- 2. keep a diary of s/s that occur to compare to EKG
First action if see sinus brady on monitor?
check on pt- may not be symptomatic - if not symptomatic will try to find cause & monitor
6 causes of bradycardia?
- 1. athletes
- 2. sleeping
- 3. hypothyroidism
- 4. increased ICP
- 5. hypoglycemia
- 6. inferior wall MI
Important consideration with bradycardia & DM?
bradycardia & hypoglycemia have similar s/s - need to monitor pt BG & check BG if pt having s/s: pale, cool skin; diaphoretic; weakness, dizziness, syncope; NV
Action if pt is symptomatic with bradycardia?
atropine 0.5mg & put pads for defib on to externally pace if atropine doesn't work
pt may need PPM
5 s/s of bradycardia?
- 1. low BP
- 2. diaphoretic, pale, cool skin
- 3. dizziness & syncope
- 4. NV (decreased BF to GI)
- 5. angina
How will bradycardia be Tx if atropine is not an option?
externally pacing with debifrillator
If a pt has a HR of 56 & BP of 96/42 but is not symptomatic what will be the priority nursing action?
look for cause & monitor closely
Priority action with a pt who is tachycardic?
Tx the underlying cause
4 causes of tachycardia?
pain, anxiety, fever, shock
3 s/s of tachycardia?
- 1. dizziness
- 2. dyspnea
- 3. hypotension r/t decreased CO
What Tx may be used for tachycardia if pt is clinically stable?
Tx for pt who is tachycardic & symptomatic?
beta blockers to decrease HR & O2 use: PO or IV (breviblock)
Monitoring needed when giving beta blockers (for tachycardia)?
Monitor closely to make sure don't drop HR or BP too much
Tx for SVT?
Tx anything that may be causing it first: pain, anxiety, fever, shock
Then will give adenosine to stop heart
6 causes of PACs?
- 1. caffeine
- 2. stress
- 3. tobacco
- 4. alcohol
- 5. CAD
- 6. COPD
First action if new PAC develops?
Assess pt (VS, chest pain, s/s) & eval for caffeine intake, stress, etc
What is usually done if pt complains of PAC's?
first priority is to ask about caffeine intake & monitor for more serious arrhythmias that can develop - will usually wear holter monitor
Med that may be given for PACs?
IV beta blocker?
Causes of BBB?
anything that could overwork the heart & cause hypertrophy of heart muscle, MI
First action if new BBB occurs on EKG?
ask pt about chest pain - could be MI
assess for other s/s
Tx for BBB if it is ongoing?
assess pt for symptoms of MI & inform MD
atrial tachydysrhythmia with regular or irregular R-R waves
3 causes of atrial flutter?
- 1. CAD
- 2. hypertension
- 3. lung disease
What med will be given to pt with ongoing atrial flutter?
blood thinners r/t pooling in atria
What may happen to the heart with atrial flutter?
HF r/t fast HR & decreased CO
3 primary goals in Tx of atrial flutter?
slow ventricular response with meds that increase AV block: Ca channel blockers, beta blockers, digoxin
Actions if pt is on a cardizem drip & HR is 56?
Assess & get VS: stop med & call MD
3 types of meds that may be given for atrial flutter?
- 1. anticoagulants
- 2. meds that increase AV block
- 3. antiarrhythmia
3 anti-arrhythmic drugs that may be given for atrial flutter?
2 reasons they may be used?
cordarone, rhythmol, & betapace
control rate or to convert to SR
What Tx for atrial flutter may be used in emergencies?
Action to take before use of electrical cardioversion for any pt?
sedate with versed or diprovan: pt feels pain but won't remember it
7 causes of Afib?
- 1. CAD
- 2. CHF
- 3. cardiomyopathy
- 4. caffeine
- 5. stress
- 6. cardiac surgery
- 7. thyrotoxicosis
Afib with RVR?
What will be the result?
Afib with rapid ventricular response
will cause decreased CO
What must be done before treating any pt with an arrhythmia?
assess if pt is symptomatic
3 goals of Tx with Afib?
- 1. Keep vent. response to <100
- 2. prevent cerebral embolism
- 3. convert to SR if possible
Meds that Afib pt may be taking?
- all are on anticoagulants (warfarin or aspirin)
- Ca channel blockers, beta blockers, or digoxin to decrease ventricular response to fast atrial contraction
What may occur if a pt taking Ca channel blockers, beta blockers, or digoxin to control ventricular response with Afib stops taking these meds?
can cause arrhythmia to develop
How may Afib be converted to SR?
What action must be taken before Tx is done?
must do TEE t check for clots in atria to prevent embolism during Tx
What antiarrhythmic drugs may be given for Afib?
fdaWhen my Afib be an emergency?
What Tx may be used?
Afib with RVR
may need cardioversion
3 types of arrhythmias commonly caused by caffeine use?
PACs, Afib, & PVCs
How will cardioversion be done for Afib?
sedate with versed or diprovan & use low joules
Ablation therapy for Afib?
same as for flutter: ablate SA node & put in PPM
surgical procedure that interrupts Afib ectopic signals
incisions are made in both atria & cold therapy used to stop formation & conduction of signals & restore SR
7 causes of PVCs?
- 1. stress
- 2. caffeine
- 3. hypoxia
- 4. hypokalemia
- 5. MI
- 6. fever
- 7. exercise
Lab that will be important for all atrial flutter & Afib patients?
platelets if on aspirin
If a pt has PVCs what should be first action?
check on pt: check O2 status & if O2 is on & check electrolytes (esp. K & Mg)
check electrolytes before calling MD!
Meds that may cause PVC's?
K+ wasting meds: diuretics
Can lasix be given to a pt having PVCs?
yes, if K is normal
What pt can go into lethal arrhythmia easily?
pt with low EF: CHF: need perfect K level
Priority actions with a pt having PVC's?
- 1. check O2 & electrolytes
- 2. monitor closely - can develop lethal arrhythmia
Tx that may be used for PVC's?
- 1. K & Mg replacement & O2
- 2. lidocaine
- 3. cordarone
- 4. beta blockers
What type of arrhythmias may be caused by hypokalemia?
PVCs, Vtach, VFib, Torsades
run of 3 or more PVCs
assess pt immediately & check leads: may be artifact
Sustained & nonsustained V tach?
sustained > 30 seconds: compromises CO & increases risk for development of V fib
4 things that may occur r/t sustained V tach?
- 1. hypotension
- 2. pulmonary edema
- 3. decreased cerebral BF
- 4. cardiopulmonary arrest
Stable & nonstable V tach?
stable = has a pulse
Tx of V tach?
must ID & Tx cause
Tx for V tach with a pulse?
lidocaine or cordarone
Major AE of cordarone?
prolonged QT interval
Normal QT interval?
Tx for pulseless V Tach? (same as Tx for V Fib)
difibrillate & CPR
Clinical characteristics of pt with V Fib?
ventricle is quivering with no pulse or CO
will be unresponsive & apneic
3 causes of V Fib?
- 1. MI
- 2. hyper/hypokalemia
- 3. hypoxia
What arrhythmias may be Tx with lidocaine?
Consideration with renal failure & arrhythmias?
What other condition can cause this?
renal failure can cause fast increase in K
DKA - K+ is attracted to acidic environment & goes into blood
Tx for hyperkalemia in emergencies?
If cause by DKA?
will give 10u R insulin with D50 (to prevent hypoglycemia OR give bicarb
3 Tx/procedures that can cause V Fib?
cardiac pacing, cath procedures, after coronary reperfusion with fibrinolytics
Tx for V Fib?
immediate initiation of CPR & defibrillation
4 causes of Torsades?
- 1. hypokalemia
- 2. hypomagnesemia
- 3. OD on tricyclic antidepressants: imipramine, amitryptyline, nortriptyline, etc
- 4. antidysrhythmic drugs
Causes of first degree AV block?
MI & ischemia of heart, some drugs
Symptoms of first degree AV block?
will be asymptomatic but may be precursor to more serious rhythms: need to monitor
Most important intervention with existing first degree AV block?
With new development?
existing: monitor for more serious dysrhythmias
new: check pt for s/s of ischemia/MI
Why can MI cause AV blocks?
can cause infarction at AV node
Tx of first degree AV block?
monitor for more serious arrhythmias & stop any meds that may increase the block: Ca channel blockers, beta blockers, digoxin: any med that slows HR can slow conduction
Causes of Wenckebach?
- dig or beta blockers
- Usually r/t: MI or ischemic heart
Priority action if Wenckebach occurs?
Tx for symptomatic & asymptomatic Wenckebach?
symptomatic: atropine 0.5mg &/or temporary pacemaker
asymptomatic: monitor & have TCP nearby
If no cause for Wenckebach other than old age what will Tx probably be?
What often occurs with 2nd degree AVB type II?
progresses to 3rd degree
Results of 2nd degree AVB type II?
decreased HR, BP, CO leads to myocardial ischemia
3 causes of 2nd degree AVB type II?
- 1. MI
- 2. dig toxicity
- 3. rheumatic heart disease
Tx for 2nd degree AVB type II?
will get temporary pacemaker until permanent one can be put in
symptomatic: atropine & temp pacemaker
6 causes of 3rd degree AVB?
- 1. MI
- 2. heart surgery
- 3. dig, beta blockers, Ca channel blockers
- 4. myocarditis
- 5. cardiomyopathy
- 6. CAD
What are the results of 3rd degree heart block?
decreased CO leads to myocardial ischemia, HF, & shock
S/S of 3rd degree heart block?
s/s of decreased CO: decreased HR, BP, dizziness, dyspnea, chest pain, etc
may be asymptomatic rarely
Tx of 3rd degree AVB?
same as for 2nd degree Type II: atropine and temporary pacing until PPM
Priority actions if asystole occurs?
look at 2 lines to make sure & assess pt
2 causes of asystole?
MI & cardiac trauma
Tx of asystole?
CPR, ACLS, intubation, TCP, & Tx cause
Meds used for asystole?
pass electric shock that causes depolarization -purpose is so repolarization will occur & allow SA to resume pacemaker role
When is defibrillation used?
pulseless V tach & V fib
Monophasic defib AE?
causes more burns
Advantage of biphasic?
less post defib EKG abnormalities & less burns
need less joules
Biphasic initial & successive shocks?
How is monophasic used?
initial shock 350 joules then start CPR with chest compressions
Steps for defibrillation?
- 1. do CPR until defib avail
- 2. turn on, & select energy
- 3. make sure synchronizer switch is off
- 4. deliver shock
- 5. place pads: R of sternum just below clavicle & L of apex
- 6. all clear & shock
3 arrhythmias that may require synchronized cardioversion?
- 1. V tach with a pulse
- 2. SVT
- 3. A fib with RVR
What is done before use of synchronized cardioversion?
sedation with versed or diprovan b/c painful
may also give demerol for pain
Procedure for synchronized cardioversion?
same procedure as for defib EXCEPT: make sure synchronization switch is ON - if not can cause it to hit on QT interval & cause lethal arrhythmia
2 priorities when using synchronized cardioversion?
- 1. maintain patent airway
- 2. if pt becomes pulseless turn synchronization switch off & defibrillate
Function of implantable cardioverter-defibrillator?
monitors HR & rhythm: shocks with 25 joules if VT or VF occurs
can also Tx brady & tachy rhythms
Pre & post procedure pt management with implantable cardioverter-defibrillator?
similar to PPM placement
Pt education post-cardiovert/defibrillator placment?
- 1. Need follow-up to check device
- 2. normal post surgery instructions
- 3. keep incision dry for 4 days
- 4. avoid lifting arm on ICD side above shoulder
- 5. no driving until cleared
- 6. No direct blows t ICD site
- 7. Avoid lg magnets, MRI, security devices in stores (don't stand in them),
- 8. if ICD fires call MD; if it fires more than once or if s/s are occurring with firing: call EMS
- 9. wear medic alert ID & carry ICD card & current list of meds
- 10. CG should learn CPR
power source placed over pec on nondominant side & pacing wires through R atrium & 1 or both ventricles
Where will PPM be placed?
surgery or cath lab
Pre-op care for PPM?
may do hibiclens etc
Action if hiccups occur after placement of PPM?
need to inform MD: may be r/t pacing wire touching diaphragm
- 1. do not allow pt to sleep or turn on R side for about 1 month
- 2. do not raise arm where PPM placed
- 3. HOB elevated & bedrest X 24h
- 4. no pullover shirts X 1 month
- 5. keep immobilizer on until MD D/C's order
power source outside body & sheath with wires in it placed in jugular or femoral vein
When can pt ambulate after placement of temp pacemaker?
30min to 1h after procedure
Tx for dig toxicity?
digibind & may put in temporary pacemaker until it works
3 types of temporary pacemakers?
transvenous, epicardial, & transcutaneous
Purposes of transvenous pacemaker?
- 1. use until underlying cause is found
- 2. bridge for PPM
- 3. prophylactic in case of brady or tachy dysrhthmias post op
When is TCP used?
Where are pads placed for TCP?
one on anterior & one on posterior of chest
Pt teaching with TCP?
will be painful but is temporary
Monitoring for pt with any type of pacemaker?
will have EKG monitoring
2 types of pacemaker malfunctions & their effects?
failure to sense: doesn't sense underlying rhythm: can cause firing during QT
failure to capture: pacemaker firing doesn't cause contraction: can cause bradycardia or asystole
5 complications of pacemaker placement?
- 1. infection
- 2. hematoma
- 3. pneumothorax
- 4. failure to capture/sense
- 5. perforation of atrial or ventricular septum
4 actions to prevent complications with pacemaker placment?
- 1. prophylactic IV ABX before & after
- 2. postinsertion CXR for lead placement & pneumothorax
- 3. observation of insertion site
- 4. continuous EKG
S/S of pneumothorax?
- 1. chest pain
- 2. tachycardia & tachypnea
- 3. dyspnea
- 4. cough
PPM discharge instructions?
- 1. limit arm & shoulder mvmt & do not: Lift arm above shoulder on PPM side, lift anything heavier than newspaper/fork, do yard work, use rifle, hit,
- 2. report s/s of infection/bleeding
- 3. do not get wet until MD says
- 4. avoid direct blows, close proximity to high-output electric getnerators, MRI, anti-theft devices, metal detectors (tell airport security), lean directly over open hood of running car, have cell phone in breast pocket
- 5. monitor pulse regularly & inform PCP if below expected rate
- 6. carry pacemaker info card & current list of meds & wear medic alert bracelet
- 7. do not remove steri-strips: they will fall off
- 8. do not wear tight clothes
Can person with PPM use a microwave?
internal cardiac difibrillator - senses lethal arrhythmia and fires
cardiac resynchronization therapy?
resynchronizes cardiac cycleby pacing both ventricles
What pt may have cardiac resynchronization therapy?
pt with HF with intraventricular conduction delays
pt with severe vent dysfunction will also have ICD