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Life-Threatening Arrhythmias: Events

Elizabeth J. Tombs, RN, MSN, IBCLC, RLC, Assistant

Professor,Anita Thigpen Perry School of

Nursing, TTUHSCLubbock, Texas

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Carol A. Strahan, RN, MSN, CCRN, CEN, Assistant Faculty

Retention CounselorAnita Thigpen Perry School of

Nursing, TTUHSCLubbock, Texas

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Objectives

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1. Recognize the electrical process of the heart.

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Objectives

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2. Identify patterns and causes of atrial fibrillation and ventricular tachycardia.

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Objectives

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3. Identify patterns and treatment of asystole and pulseless electrical activity (PEA).

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Heart Rhythms

Heart Rhythms

– paroxysmal atrial tachycardia (PAT) or supraventricular tachycardia (SVT)

– ventricular tachycardia

P wave

P P P P P P P P

PR Interval

PR Interval: variesRegular Rhythm: Regular P to P and Regular R to

RRate: Atrial usually 60-100 Ventricular usually

20-60QRS Interval: normal or wide

Causes

• MI (myocardial infarction)• Medication side effect• Hypoxia• Conduction system lesion

Treatment

• May try pacemaker• Consider atropine or epinephrine• May need dopamine to sustain cardiac output

Rate: >100 – 160 (upper limit)Regular Rhythm: Yes – generally

PR Interval: .12 - .20 secsQRS Interval: >.12 secs

Rate: 100

Causes

• Fever• Hypoxia• Medication side effect (ex. Beta adrenergic)• Pathologic underlying condition (thyroid

storm)

Treatment

• If stable, treat underlying cause (i.e., decrease fever)

• If unstable:– consider medications (ex. beta blocker)– consider starting O2

Regular Rhythm: mostly regular and visually identifiable pattern

Rate: generally >150 for SVT and >160 – 250 for PATPR Interval: no identifiable P waves at such a rapid pace

QRS Interval: narrow complexes

PAT/SVT Symptoms

• Distress• Anxious• Impending doom

Causes

• Likely premature atrial complex (PAC) triggered

• Stimulants (caffeine, medications)• Anxiety• Damage to myocardial tissue

Treatment

• If stable, treat underlying cause– vagal maneuvers– carotid massage– may give adenosine– also consider: calcium channel blocker, digitalis,

beta blocker

• If unstable: – cardioversion

Cardioversion: needs to be synched on the R waves

R

Rhythm: irregularRate: atrial = 350 – 700 (ventricular = >150

uncontrolled A-fib)PR Interval: no P waves

QRS Interval: narrow complexes

Causes

• MI damage• Pulmonary heart disease• Valvular heart disease• Hyperthyroidism

Treatment

• If less than 48 hours:– convert back to sinus rhythm (SR)– consider: digitalis, calcium channel blockers, beta

blockers, amiodarone, or cardioversion• If greater than 48 hours: control heart rate (HR)

and give anticoagulant to prevent blood clots• If unstable: cardioversion

PR Interval: P wave is saw-toothRegular Rhythm: mostly regular and visually

identifiable patternRate: Atrial = 250 – 350 (ventricular rate

depends on the conduction ratio)QRS Interval: narrow complexes

Causes

• Heart disease• Valvular heart disease• Lung disease

Treatment

• If stable, treat underlying cause– consider: calcium channel blocker, digitalis, beta

blocker– may use adenosine for A-flutter

• If unstable: cardioversion

Regular Rhythm: mostly regular and visually identifiable pattern

Rate: >100 (generally >150)PR Interval: no P waves

QRS Interval: wide and bizarre complexes

Causes

• Premature ventricular complexes (PVCs)• PVC causes:

– hypokalemia– hypoxia– heart disease

• Low magnesium• Stimulants •

Treatment

• Treat the patient, not the monitor• Check pulse

– if pulse:• amiodarone• O2 started

– if no pulse: • cardiopulmonary resuscitation (CPR)• defibrillate

Treatment

• Medications: epinephrine, amiodarone, and O2 (follow advanced cardiac life support [ACLS] protocol)

Bizarre and chaotic rhythm; no detectible P or QRS

(looks like static)

Causes

• PVCs• R on T phenomena • Heart disease• Hypokalemia• Hypoxia• Low magnesium• Stimulants

Treatment

• CPR• Immediate defibrillation• ACLS protocol• Medication: epinephrine, amiodarone, O2

Regular Rhythm: no Rate: 0

PR Interval: 0QRS Interval: 0

Asystole:A-none

systole-contractions

Causes• Massive MI• Profound hypoxia• Heart disease• 5 Hs

– hypothermia– hypothermia– hypokalemia– hypoxia– hydrogen ion acidosis– hypovolemia

Causes

• 5 Ts– toxic/tablets– thrombosis (coronary)– thrombosis (pulmonary embolism)– tension pneumothorax– tamponade–

Treatment

• CPR• Medications: epinephrine, may consider

atropine• Consider transcutaneous pacing• ACLS protocol

Any organized electrical rhythm where patient does not have a pulse

Causes

• Inability to cause systole• Either the current is too weak or the muscle is

not able to contract• 5 Hs• 5 Ts

Treatment

• CPR• Identify and reverse cause• Medications: epinephrine• ACLS protocol• Treat the patient not the monitor

After the Event

• Continue to provide supportive measures• Provide education to family and patient:

– cardiac arrhythmia– treatment– prevention

• Provide support to family and patient:– resources– holistic aspects (spiritual, cultural, etc.)

Life-Threatening Arrhythmias: Etiology/Treatment

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Release Date:02/01/2012

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Requirements of successful course completion:

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•Complete the course evaluation.

•Complete the posttest with a score of 80% or greater.

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Conflicts of Interest:

Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN, CCRN, CEN has disclosed that no financial interests, arrangements or affiliations with organization/s that could be perceived as a real or apparent conflict of interest in employment, leadership positions, research funding, paid consultants or member of an advisory board or review panel, speaker’s bureau, major stock or investment holder, or other remuneration.

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Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN, CCRN, CEN has disclosed that no significant relationships with commercial companies whose products or services are discussed in educational presentations. For speakers, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

Off-label Use:

Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN, CCRN, CEN has disclosed that no products with off-label or unapproved uses are discussed within this activity.

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