CHART 3810

Dysrhythmia Premature ventricular contraction (PVC)

Ventricular Dysrhythmias: Etiology, Physical Assessment, and Treatment

Etiology Organic heart disease Coronary artery disease Myocardial ischemia/irritability and infarction Cardiac valve disease Mitral valve prolapse Heart failure Primary electrical instability Fever Fluid volume deficit Electrolyte imbalance, e.g., hypokalemia, hypercalcemia, hypomagnesemia Acid/base imbalance Drug excess: e.g. Tricyclic antidepressants; digitalis, sympathomimetic amines, and antiarrhythmic agents Moderate to excessive alcohol intake Increase in catecholamine release and sympathetic tone as in emotional stress Sarcoidosis Change in posture Exercise Emotional excitement Vagal stimulation Normal variation that increases with age Precipitated by the same conditions as premature ventricular contractions (see above) Physical Assessment Pulse: May be irregular due to asynchronous firing of the ventricles. The corresponding QRS complex may be detected on the monitor while contractions are felt as a peripheral pulse. BP: Normal or lower than usual due to decreased cardiac output leading to decreased perfusion. Thumping sensation in chest/throat Palpitations If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Altered mental state may be present. Treatment PVCs may be isolated when there is no underlying heart condition. Usually, then, they have no significance and require no treatment. Treatment depends on the cause and clinical manifestations. It is essential to identify and treat the underlying cause. When provoked by fast or slow heart rate, correcting the rate can abolish PVCs. Treatment usually is not required. Treatment is directed at uncovering the etiology and providing adequate oxygenation, pain relief, and rapid identification of causes. Antidysrhythmic drugs such as amiodarone and lidocaine should be administered as ordered per frequency of occurrence.

Ventricular tachycardia (VT)

Pulse: Rapid and weak BP: Hypotensive Cardiac output is decreased therefore the following clinical manifestations occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Changes in mental status, starting with confusion and restlessness, leading to unconsciousness. Conscious sensation of ineffective cardiac activity often accompanied by anxiety. Presence and severity of the signs and symptoms depends on rhythm duration.

Initial treatment is based on the presence or absence of a palpable pulse. If hemodynamically stable, with a pulse, drug intervention is appropriate e.g., procainamide, amiodarone, lidocaine. If hemodynamically unstable (pulseless) defibrillation and cardiopulmonary resuscitation (CPR) is indicated. After initial stabilization other treatments which may be considered include: Implantable cardioverter defibrillator Electrophysiology Studies (EPS): ventricles are stimulated to produce VT: then antiarrhythmic drugs are administered, followed by a second attempt to produce the VT. If unable to reproduce the dysrhythmia, the drug is considered effective and continuous therapy is instituted. Drugs used include: procainamide, amiodarone, and lidocaiane. Radio-frequency ablation, burning the area or focus in the ventricle where the VT is coming from may also be considered. Chapter 39 has a complete description of EPS and ablation.

CHART 3810
Dysrhythmia Torsade de pointes (TdP)

Ventricular Dysrhythmias: Etiology, Physical Assessment, and TreatmentContinued

Etiology Prolonged QT interval, which may be congenital or acquired Severe bradycardia Electrolyte imbalance, e.g., hypokalemia, hypomagnesemia Central nervous system lesions Tricyclic antidepressants Antidysrhythmic drugs, e.g., quinidine, procainamide, amiodarone Antihistamines, e.g., seldane Antibiotics, e.g., erythromycin Diuretics Liquid protein diets Starvation Or any combination of the above Physical Assessment Pulse: Rapid, palpitations felt, often the first symptom BP: Low due to decreased cardiac output If cardiac output is decreased the following clinical manifestations may occur: Angina Syncope Generalized weakness Dizziness Shortness of breath Changes in mental status, starting with confusion and restlessness, leading to unconsciousness. Seizures may be present with a prolonged rhythm. Clinical manifestations are related to the decreased cardiac output caused by the dysrhythmia. Pulse: None palpable and heart sounds usually absent BP: None Unconscious Seizures Apnea Death, if untreated Treatment Assessment of QT interval for prolongation. Magnesium is the treatment of choice to shorten the QT interval. If unsuccessful, overdrive ventricular pacing to keep the heart rate up and the QT interval within normal limits. Stress testing and Valsalva will prolong QT interval and can be used to diagnose congenital prolonged QT interval. All agents that cause torsade de pointe are immediately discontinued. Administer potassium intravenously if QT interval is abnormal. Cardioversion and overdrive pacing are used to terminate torsades, but only may be temporary. Drugs are modified or discontinued if QT interval is prolonged. Initiate CPR and defibrillation per ACLS guidelines.

Ventricular fibrillation (VF)

Pulseless electrical activity

Severe myocardial ischemia Coronary heart disease Myocardial infarction Advanced heart block Abnormal repolarization Vagal stimulation Drug toxicity, e.g., psychotropics, digoxin Metabolic abnormalities, e.g., hypokalemia, hypomagnesemia Hypoxia Trauma Terminal event in many disease states Electrical shock Profound hypovolemia Massive myocardial damage Excessive vagal tone due to loss of sympathetic tone Obstruction of blood flow to or from the heart, e.g., severe pulmonary embolism Pericardial tamponade Myocardial rupture Massive cardiac trauma resulting in cardiac tamponade and/or tension pneumothorax Severe acidosis Hyperkalemia Hypothermia Drug overdose, e.g., tricyclics, betablockers, calcium channel blockers, digoxin Cardiac standstill from massive cardiac muscle damage

Pulse: None palpable BP: None Unconscious Seizures may occur Death, if untreated

Assess for pulse and blood pressure; initiate CPR protocol per ACLS guidelines. Find cause and treat.

Asystole

Pulse: None palpable BP: None Unconscious Death, if untreated

Check the rhythm in two leads in order to rule out the possibility of fine ventricular fibrillation. Also, check the lead placement to make sure it has not fallen off. Initiate CPR and ACLS protocols. Administer drugs per ACLS guidelines, agency protocol or health care providers orders.