Arrhythmia Treatment Flashcards
Assorted Arrhythmias
Bradycardia
Tachycardia
SVT
Atrial fib
Atrial flutter
Heart Blocks
Junctional Rhythms
Vtach
Vfib
PEA
Asystole
AV node saves lives!
Delays signal – “atrial kick”
Back-up pacemaker
Filters in presence of excessive rate
The “gatekeeper”
What represents the delay in the AV node? What is the significance of that delay?
PR interval. Allows for atrial kick (extra 25 % of blood)
Bradycardia
Rate below 60
Treat if symptomatic (altered mental status, cool/clammy, SHOB, ect.)
Discontinue offending medications (beta blockers, CCB, Digoxen)
Atropine- affects SA node increases rate-ventricular rate
Pacing
Dopamine- vasopressor, increases BP
Tachycardia
Rate over 100
Treat if symptomatic
Underlying cause (wide range of these)
Beta blockers
Treat if symptomatic– treat cause- pain meds for pain, fluids for volume depletion, ect.
Try vagal first!!!! Cough
If they are unstable tachycardia:
synchronized cardioversion!
Umbrella term often used for any tachycardia above the ventricles
How to treat?
SVTSupraventricular tachycardia
Vagal maneuvers -cough, bear down, cool water, gag reflex, ect.
Adenosine- 6mg then 12 mg fast
Ca channel blockers or beta blockers
Cardioversion if hemodynamically unstable and refactory to meds
What does hemodynamically unstable mean?
not adequate BP or HR
_____ Administration for SVT
____ cardiac conduction through the AV node and interrupts reentry pathways
Given by ____ IV bolus
6 mg over 1-3 seconds followed by a 20 mL NS bolus; followed by 12 mg dose
Adenosine
Slows
RAPID
Pharmacological or “chemical” conversion for SVT
What is a common initial side effect after the bolus?
Adenosine
Flat line.
Atrial fibrillation & atrial flutter
Rate control- beta blockers, digioxen, CCB (digoxin)
Anticoagulation- Heparin (PTT), Warfarin (PT INR). To prevent PE of strokes.
Rhythm conversion
-Meds - amniodarone
-Cardioversion- if unstable they will be cardioverted. If not, and greater then 48 hours- they will perform TEE before cardioverting.
-Ablation
What is the difference between paroxysmal, persistent, and permanent a. fib?
paroxysmal AF (PAF: episodes of arrhythmia that terminate spontaneously),
persistent AF (episodes that continue for >7 days and are not self-terminating),
permanent AF (ongoing long-term episodes
Why is time of onset an important consideration for treatment of afib or aflutter? For example, what should happen if the time of onset of a fib is >48 hrs?
What does RVR mean? What does it mean for the patient clinically?
Rapid ventricular rate (above 100). This is the same as Uncontrolled A. Fib.
Rate control- beta blockers, digioxen, CCB (digoxin)
Antiarrhythmics
diltiazem
digoxin
amiodarone
sotalol
metoprolol
atropine
What is the concern of a prolonged QT interval which may occur with sotalol?
Best practice, document QT q shift for meds that potentially prolong the QT.
Remember, QT:
the depolarization and repolarization of ventricles.
Diltiazem-
antiarrhythmic, calcium channel blocker. Vasodilators.
Watch blood pressure.
SVTs, A. fib, A. flutter with RVR.
Main side effect- hypotension, bradycardia. Take blood pressure an pulse before using. Contriindicated for hypotension.
Digoxin-
cardiac glycoside. Increases force of contraction. A. Fib, A. flutter, PAT. Digitalis- N/V, blurred vision, anorexia. Use cautiously with hypokalemia. Apical pulse before giving. Check Digoxin level.
Amiodarone-
Can cause:
antiarrhythmic. Used for A. fib, A. flutter, V. Tach, V. Fib.
Can cause pulmonary toxicity.
May make arrhythmia worse (proarrhythmic)
Sotalol-
Measure QT interval
beta blocker/antiarrhythmic. Suppresses arrythmia. Side effect- bradycardia. Proarrhythmic (measure QT interval). Used for Ventricular arrythmias.
Atropine-
anticholinergic, antiarrhythmic.
Increases HR. Blocks parasympathetic.
Not used for second degree type II or 3rd degree Heart block. Used for Sinus brady and second degree type I.
First degree heart block treatment
No treatment
2nd Degree Type I
Commonly temporary, may resolve on own.
Less severe of the 2nd degrees.
Discontinue _______
Treat symptomatic bradycardia with __________
offending medications.- metoprolol
atropine and/or pacing.
2nd Degree Type II
Serious business » CHB or asystole
Often 2° MI
-
_____ for symptomatic hypotension
_____ ineffective
External pacing
Transvenous pacing
Permanent pacer
Dopamine
Atropine
3rd Degree Heart Block
May lead to _____, especially with wide QRS’s.
_____, permanently if not resolved.
asystole
Pace it
Junctional arrhythmias
Often bradycardic
Treatment?
Atropine
Dopamine
Pacing
Underlying cause (dig toxicity, hypoxia, inferior MI)
What is the rate difference with:
1. junctional rhythm =
2. accelerated junctional tachycardia =
3. junctional tachycardia =
40-60
60-100
> 100
Ventricular Tachycardia (Stable)
VT=
Amiodarone bolus and drip
Cardioversion
three or more PVCs in a row
Ventricular Tachycardia (Unstable)
unstable with a pulse
Cardiovert
Amiodarone drip
AICD - automated implantable defibrillator
Ablation
Underlying cause
Note the treatment difference between stable and unstable vtach
____ first with unstable
_____ first with stable
Cardiovert
Amiodarone
Polymorphic ventricular tachycardia
Defibrillate (synchronized cdv often not possible)
Underlying cause
Magnesium
Potassium
Torsades de pointes (TdP)
What meds can cause a prolonged QT interval preceding TdP?
Sotalol and amniodarone cause prolonged QT interval.
Ventricular Fibrillation and Pulseless Vtach
You, grab the defibrillator (or AED if out of hospital)”
Defibrillation is the immediate treatment goal.
Most common cause of MI. Most common arrhythmia for going into cardiac arrest.
Ventricular fibrillation and pulseless ventricular tachycardia treatment continued
Follow defib with . .
Epinephrine and chest compressions
300mg amiodarone push
Repeat as necessary
What is the underlying cause?
H’s and T’s
major contributing factors to pulseless arrest including PEA, Asystole, Ventricular Fibrillation, and Ventricular Tachycardia. These H’s and T’s will most commonly be associated with PEA, but they will help direct your search for underlying causes to any of arrhythmias associated with ACLS.
Hypovolemia
Hypoxia
H+ ion (acidosis)
Hypo/hyperkalemia
Hypoglycemia
Hypothermia
Toxins (meds, poison)
Tamponade
Tension pneumo
Thrombosis (heart or lungs)
Trauma
Pulseless Electrical Activity (PEA)
Looks like a decent rhythm but isn’t
Remember for PEA: “you can see me, but you can’t feel me”
Will degrade to _____
How to treat?
asystole
Chest compressions
Epinephrine 1 mg every 3-5 minutes
Repeat
NOTHING TO SHOCK.
Look for underlying causes– MI, Hemorrhage, H’s and T’s
Asystole
Treatment same as PEA: ____
Poor prognosis
Underlying cause
CPR, epi
Abnormal potassium (K+) and EKG changes
Hypokalemia
___ present
Arrhythmias:
Sx:
SEE SLIDE!!!!!!
U waves (best seen in precordial leads)
Arrhythmias:
PVCs, polymorphic VT, VF
Sx: muscle cramps, weakness, leading to paralysis
T wave inversion
ST depression
Prominent U wave
Hyperkalemia
Arrhythmias:
Sx:
See slide!!!
Arrhythmias: bradycardia and blocks
Sx: heart palpitations, SOB, chest pain, or N/V
Peaked T waves
P wave flattening
PR prolongation
Wide QRS complex
Synchronized Cardioversion
Typically start with ___ energy
Sedation
Synchronized*
Goal:
lower
reset the heart to NSR
Defibrillation
_____ energy
High quality ____ and _____ in between shocks
Goal:
Higher
CPR
ACLS meds
Reset the heart to NSR and return of spontaneous circulation (ROSC)
Synchronized cardioversionis a ____ ENERGY SHOCK that uses a sensor to deliver electricity that is synchronized with the ____ of the QRS complex (the highest point of the R-wave).
When the “sync” option is engaged on a defibrillator and the shock button pushed, there will be a delay in the shock. During this delay, the machine reads and synchronizes with the patients ECG rhythm. This occurs so that the shock can be delivered with or just after the _______ in the patients QRS complex.
WHY?
LOW
peak
peak of the R-wave
If not, if could cause patient to go into V. Tach
Which rhythms?
Syncronized cardiovert-
Defib-
A. Fib, A. Flutter, Pulse V. Tach, SVT
Pulseless v. Tach, V. Fib.
Pacing
-
-
– common with temporary pacing
Increase mA to ~10% beyond capture
Set rate (often 80)
_____ with transcutaneous pacing
Transcutaneous
Transvenous
Epicardial
Single chamber
Sedation
Permanent Pacemakers
______ – more common in permanent pacers
What is an important question to ask your patient who comes in with a pacemaker?
dual chamber
What is your pacemaker code?
Common Pacemaker Malfunctions
Failure to capture- complex does not follow pacing spike
Failure to sense
Undersensing—pacing spike occurs at preset interval despite the patient’s intrinsic rhythm
Oversensing—loss of pacing artifact; pacing does not occur at preset interval despite the lack of intrinsic rhythm
Battery failure
Implantable Cardioverter Defibrillator
Detects and terminates life-threatening episodes of:
Complications like those associated with pacemaker insertion:
What are the implications for a patient whose ICD is firing several times in a day?
ventricular tachycardia or ventricular fibrillation
In the initial hours after a temporary or permanent pacemaker is inserted, the most common complication is dislodgment of the pacing electrode. Minimizing patient activity can help prevent this complication. If a temporary electrode is in place, the extremity through which the catheter has been advanced is immobilized. With a permanent pacemaker, the patient is instructed initially to restrict activity on the side of the implantation.
Maybe they need to go off a drug they are prescribed.
Some Postpacer/AICD Teaching
Keep arm below head for two weeks
Avoid large magnets
No TSA wands
Monitor s/s infection
Medical bracelet
