Chapter 27 Management of Patients With Dysrhythmias and Conduction Problems

Christie M. Candelaria, MA, RN, CCRN

Learning Outcomes/Objectives:
Identify clinical characteristics and ECG patterns of normal sinus rhythm and common dysrhythmias as follows:
sinus bradycardia sinus tachycardia atrial fibrillation

atrial flutter
ventricular tachycardia ventricular fibrillation

Describe the nursing and collaborative management of patients with common dysrhythmias mentioned above.

Cardiac conduction
SA Node AV node Bundle of HIS Right & Left Bundle Branches Purkinje Fibers

http://www.youtube.com/watch?v=H04 d3rJCLCE&feature=related

Cardiac Cycle
Refers to the a repetitive pumping process that includes all of the events associated with blood flow through the heart Depolarization- electrical stimulation Systoleperiod during which ventricles mechanically contract and blood is being ejected Repolarization electrical relaxation Diastoleperiod of mechanical relaxation in which ventricles are filling

EKG Paper

EKG Paper

Components of EKG Waveform

P WAVE

Indicates atrial depolarization, contraction of the atrium Normal duration is not longer than 0.11 seconds (less than 3 small squares)

Amplitude (height) is no more than 3 mm

Normally no notching or peaking

Components of EKG Waveforms

PR Interval

Indicates AV conduction time

Duration time is 0.12 to 0.20 seconds

Components of EKG Waveform

QRS Complex
Indicates ventricular depolarization, or contraction of the ventricles Shortly after depolarization begins, the ventricles contract Normal duration is 0.08-0.12

QRS complex
Q Wave 1st downward deflection in the depolarization of the ventricle (many times may be absent)

QRS Complex
R Wave 1st upward deflection of the QRS (may follow a Q wave or be present by itself)

QRS complex
ST Segment
terminal portion of QRS, represents the delay time after depolarization and waiting for repolarization Normally not depressed more than 0.5mm

May be elevated slightly in some leads (no more than 1 mm)

(this is EXTREMELY important in diagnosing MI)

Components of EKG Waveform

T Wave (ahhh rest)

Indicates ventricular repolarization

Not more than 5mm in amplitude in standard leads and 10mm in precordial leads Rounded and asymmetrical
Last 1/3 of vulnerable area of timeif a ventricular response is initiated here, such as a PVC, V-Tach can occur Also useful in diagnosing ischemia or MI

Components of EKG Waveform

QT Interval

Indicates repolarization time General Rule: duration is less than half the preceding R-R interval Will lengthen and shorten as the rate changes

U Wave
Represents repolarization of His-Purkinje system
Not present on every strip A prominent U wave may be due to hypercalcemia, hypokalemia, or digoxin toxicity

Putting it all together:

Dysrhythmias
Disorders of formation or conduction (or both) of electrical impulses within heart
Can cause disturbances of Rate

Rhythm
Both rate, rhythm Potentially can alter blood flow, cause hemodynamic changes Diagnosed by analysis of electrographic waveform

Tips for applying electrodes

Make sure skin is thoroughly dry. Clip chest hair. Remove any excess skin oil with alcohol. Apply tincture of benzoin if keeping electrodes is difficult. Connect each lead wire to a disc before applying it to the chest. Make sure the center of the electrode disc is moist.

Avoid applying electrodes over these areas:

Bony areas Scar tissue Muscle mass (significant) skin folds breast tissue heart apex

Assessment of Cardiac Rhythm

Fig. 365
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Assessment of Cardiac Rhythm

Fig. 369 Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Assessment of Cardiac Rhythm

Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Heart Rate Determination

Evaluation of Dysrhythmias
Holter monitoring
Event recorder monitoring Exercise treadmill testing Signal-averaged ECG Electrophysiologic study

Normal Sinus Rhythm

Originates in the sinoatrial node (SA) Rhythm: atrial/ventricular regular Rate: atrial/ventricular rates 60 to 100 bpm P waves: present, consistent configuration One P wave before each QRS PR interval: 0.12 to 0.20 second and constant QRS duration: 0.04 to 0.10 second and constant

Normal Sinus Rhythm

Sinus node fires 60 to 100 bpm
Follows normal conduction pattern

Fig. 368
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Normal Sinus Rhythm

Sinus Bradycardia

Sinus Bradycardia

Clinical associations
Occurs in response to

Carotid sinus massage Hypothermia Increased vagal tone Administration of parasympathomimetic drugs

Sinus Bradycardia
Clinical associations
Occurs in disease states Hypothyroidism Increased intracranial pressure Obstructive jaundice Inferior wall MI

Sinus Bradycardia

Clinical significance
Dependent on symptoms
Hypotension

Pale, cool skin

Weakness Angina

Dizziness or syncope
Confusion or disorientation Shortness of breath

Sinus Bradycardia

Treatment

Atropine

Pacemaker may be required

Pacemakers

Fig. 36-27
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Pacemakers

Fig. 36-25

Fig. 36-26

Pacemakers

Fig. 36-24 A Fig. 36-24 B

Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Pacer spikes

Sinus Tachycardia

Tachycardia
Heart rate greater than 100 bpm Shorten diastolic time = perfusion time Initial CO and B/P Ventricular filling = stroke volume = aortic pressure Eventually = CO and B/P Increases the work of the heart, increasing myocardial O2 demand

Sinus Tachycardia http://ems-ed.net/Video/emsedbasicecg2.html

Discharge rate from the sinus node is increased as a result of vagal inhibition and is >100 bpm

Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Sinus Tachycardia
Clinical associations Associated with physiologic stressors

Exercise
Pain Hypovolemia Myocardial ischemia Heart failure (HF) Fever

Sinus Tachycardia Clinical significance Dizziness and hypotension due to decreased CO Increased myocardial oxygen consumption may lead to angina

Sinus Tachycardia
Treatment
Determined by underlying cause

-Adrenergic blockers to reduce HR and myocardial oxygen consumption Antipyretics to treat fever Analgesics to treat pain

Atrial Flutter

Atrial Flutter
Clinical associations

Usually occurs with

CAD Hypertension Mitral valve disorders Pulmonary embolus Chronic lung disease Cardiomyopathy Hyperthyroidism Drugs: Digoxin, quinidine, epinephrine

Atrial Flutter
Clinical significance High ventricular rates (>100) and loss of the atrial kick can decrease CO and precipitate HF, angina

Risk for stroke due to risk of thrombus formation in the atria

Atrial Flutter
Treatment Primary goal is to slow ventricular response by increasing AV block Drugs to slow HR: Calcium channel blockers, -adrenergic blockers

Electrical cardioversion may be used to convert the atrial flutter to sinus rhythm emergently and electively

Atrial Flutter
Treatment Primary goal is to slow ventricular response by increasing AV block Antidysrhythmia drugs to convert atrial flutter to sinus rhythm or to maintain sinus rhythm (e.g., amiodarone, propafenone) Radiofrequency catheter ablation can be curative therapy for atrial flutter

Atrial Fibrillation

Atrial Fibrillation
Clinical associations

Usually occurs with

Underlying heart disease, such as rheumatic heart disease, CAD Cardiomyopathy

HF
Pericarditis

Atrial Fibrillation
Clinical associations

Often acutely caused by

Thyrotoxicosis

Alcohol intoxication
Caffeine use

Electrolyte disturbance
Cardiac surgery

Atrial Fibrillation
Clinical significance
Can result in decrease in CO due to ineffective atrial contractions (loss of atrial kick) and rapid ventricular response

Thrombi may form in the atria as a result of blood stasis

Embolus may develop and travel to the brain, causing a stroke

Atrial Fibrillation Treatment

Goals

Decrease ventricular response Prevent embolic stroke

Drugs for rate control: digoxin, adrenergic blockers, calcium channel blockers

Long-tern anticoagulation: Coumadin

Atrial Fibrillation
Treatment

For some patients, conversion to sinus rhythm may be considered

Antidysrhythmic drugs used for conversion: Amiodarone, propafenone cardioversion may be used to convert atrial fibrillation to normal sinus rhythm

Atrial Fibrillation
Treatment If patient has been in atrial fibrillation for >48 hours, anticoagulation therapy with warfarin is recommended for 3 to 4 weeks before cardioversion and for 4 to 6 weeks after successful cardioversion

Atrial Fibrillation
Treatment Radiofrequency catheter ablation Maze procedure Modifications to the Maze procedure

Use of cold (cryoablation) Use of heat (highintensity ultrasound)

LETHAL DYSRHYTHMIAS

Ventricular Tachycardia

Ventricular Fibrillation

Asystole

Nursing Process: Care of the Patient with a Dysrhythmia - Assessment

Assess indicators of cardiac output and oxygenation, especially changes in level of consciousness Physical assessment include

Rate, rhythm of apical, peripheral pulses

Heart sounds Blood pressure, pulse pressure

Signs of fluid retention

Nursing Process: Care of the Patient with a Dysrhythmia Assessment (contd)

Health history: include presence of coexisting conditions, indications of previous occurrence Medications

Nursing Process: Care of the Patient with a Dysrhythmia - Diagnoses

Decrease cardiac output Anxiety Deficient knowledge

Collaborative Problems/Potential Complications

Cardiac arrest Heart failure Thromboembolic event, especially with atrial fibrillation

Nursing Process: Care of the Patient with a Dysrhythmia - Planning

Goals Eradicating or decreasing occurrence of dysrhythmia to maintain cardiac output

Minimizing anxiety
Acquiring knowledge about dysrhythmia, its treatment

Decreased Cardiac Output

Monitoring ECG monitoring Assessment of signs, symptoms Administration of medications, assessment of medication effects Adjunct therapy: cardioversion, defibrillation, pacemakers

Other Interventions
Anxiety Use calm, reassuring manner Measures to maximize patient control to make episodes less threatening Communication, teaching Teaching self-care

Include family in teaching

Cardioversion and Defibrillation

Treat tachydysrhythmias by delivering electrical current that depolarizes critical mass of myocardial ceils When cells repolarize, sinus node usually able to recapture role as heart pacemaker In cardioversion, current delivery synchronized with patients ECG In defibrillation, current delivery is unsynchronized

Defibrillation

Fig. 3621
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Defibrillation

Fig. 36-20 A and B

Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Paddle Placement for Defibrillation

Implantable Cardioverter Defibrillator (ICD)

Device that detects, terminates life-threatening episodes of tachycardia or fibrillation NASPE-BPEG code

Antitachycardia pacing

Implantable CardioverterDefibrillator (ICD)

Fig. 36Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 22

Invasive Methods to Diagnose and Treat Recurrent Dysrhythmias

Electrophysiologic studies Cardiac conduction surgery Maze procedure Catheter ablation therapy

hyperkalemia

hypocalcemia

ST elevation or flag

How will I know what to do? you ask

Treat the patient, not the rhythm - is a good place to start Anticipate the problem Know your drugs Know CPR