Pacers, ablation, cardioversion, telemetry, Intro to ACLS

1. Pacers, ablation, cardioversion, telemetry, Intro to ACLS By: Diana Blum MCC NURS 2140

2. 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

3. To map= to determine if regular or irregular 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

4. Large box estimate of heart rate works with regular rhythms

6. P-wave = atrial electrical activity • QRS= ventricular electrical activity • T wave= resting phase of ventricle

10. P wave Measures: 0.12-0.20

11. QRS WAVE Measures: 0.06-0.10

12. QT Wave Measures approx 0.40-0.48 secs

13. Heart rates • NSR: heart rate is 60-100bpm • ST: heart rate 101-180 bpm • SB: heart rate <60 bpm

14. Calculating Heart Rate • Quick Estimate: The 6-second Method • - count the # of QRS complexes in a 6 sec. • length of strip & multiply by 10 • (the second mark is = to 5 large boxes) • This can be used is rhythm is reg or unreg.

15. Count small boxes between two R waves. Divide into1500 Gives BPM

16. Atrial arrythmias • Normal sinus rhythm • Sinus tachycardia • Sinus bradycardia • Premature atrial contraction (PAC) • Supraventricular tachycardia • Atrial flutter • Atrial fibrillation

17. Ventricular arrythmias • 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

18. ARTIFACT

19. NSR

20. Sinus rhythm • PR interval- 0.12-0.20sec • QRS-0.06-0.10sec • QT segment 0.36-0.44 sec • Heart rate 60-100

21. Sinus arrhythmia Hr= 60-100 bpm On strip it looks regular but does not map out PR interval= 0.12-0.20

22. Junctional escape rhythm HR 40-60 bpm <60 bpm is accelerated Rhythm is regular Pwaves not always present

23. Junctional Rhythm

24. SB

25. 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

26. Sinus Bradycardia:Your pt is pale, c/o dizziness & fatigue. Pulse 56,BP 86/60 • ACLS protocol: • 1. airway • 2. oxygen • 3. ECG, BP, oximetry • 4. IV access • If s/s of poor perfusion: altered mental status, CP, • hypotension, signs of shock • a. prepare for transcutaneous placing • b. atropine 0.5 mg IV while waiting for pacer • - may repeat for total 3 mg IV • c. epinephrine or dopamine drip while waiting pacer or • if pacing ineffective

27. ST

28. 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

29. Sinus Tachycardia • 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 !!!

30. Supraventricular Tachycardia

31. Supraventricular Tachycardia • 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

32. How to treat SVT • B-blockers ( to decrease conduction thru AV • node: • Calcium channel blockers ( to decrease condux • thru AV node) • Radio frequency ablation

34. SVT converted with Adenosinegiven rapid IV Push stimulates vagal response. S/E: flushing,bronchospasm,AVblock

35. AV Blocks • First degree block • Second degree block Type I (Wenchebach) • Second degree block Type II (Mobitz II) • Third degree block • Bundle branch block

36. First degree heart block Rate is usually WNL Rhythm is regular Pwaves are normal in size and shape The PR interval is prolonged (>0.20 sec) but constant

37. 1st degree block • AV node delays the impulse from the SA node for abnormal length of time • Causes: • CAD, MI, drugs that act on AV node (digitalis) • Characteristics: • PR interval >0.20 seconds • Not serious but may progress to 2nd degree

38. 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

39. Second degree heart block type 1 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

40. 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

41. 2nd degree Type I AV block: • RISK: often a temporary block after MI • May progress to complete(3rd degree) • block • TREATMENT; freq. none needed • slow vent rate: ATROPINE will increase AV conduction • To increase rate of SA node:EPINEPHRINE

42. 2ND degree nursing interventions:Type I • Document • Monitor pt/vitals • If ventricular rate slows enough to produce • symptoms, document , notify physician

43. http://www.youtube.com/watch?v=GVxJJ2DBPiQ&feature=related

44. Second degree heart block type 2 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

45. 2nd degree Type II(Mobitz Type II) • 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

46. 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 • may need temporary pacer

47. 2nd degree Type IINursing 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

48. 3rd degree heart block of complete heart block Ventricular rate is regular but there is no correlation between pwaves and QRS Pwaves are normal in size and shape No true PR interval

49. 3rd degree block: complete heart block:“AV dissociation” • 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

50. Atrial Fibrillation Erratic wavy base Pr is not measurable QRS 0.10 sec or less usually http://www.youtube.com/watch?v=VKxQgjj2yVU&feature=related