Arrythmias & code management

What is the treatment for cardiac tamponade?

IV fluids, Pericardiocentesis, pericardial window (OR procedure)

How do you treat ventricular tachycardia?

If a pulse is present- give Amiodarone/lidocaine, or do cardioversion. If there is no pulse present- Defibrillation & CPR

How does looking at ETCO2 help in monitoring ROSC in a patient with VF or pulseless VT?

If it's equal to 7.5, then that usually means there will be imminent ROSC. If it's greater- check BP and pulse

How do you treat PEA?

If there is no pulse, do CPR, endotracheal intubation, IV access, epinephrine IVP, treat underlying cause

How do you treat a patient with systole?

If there is no pulse, do CPR, endotracheal intubation, IV access, epinephrine IVP, treat underlying cause

In what case are PVCs a grave concern?

If they're multifocal (more than one shape), equal to or greater than 6 PVCs per min, if the R is on the T, and if they're in pairs/triplets

Atrial Fibrillation

Irregular rhythm, rate varies, No true P wave, PRI not measurable, QRS is usually normal

Premature Ventricular Contractions

Irregular underlying rhythm, rate varies, no P wave or PRI. QRS is less than or equal to 0.12

What is Beck's triad and in which condition might you see it?

JVD distention, muffled heart tones, narrowed PP. See it with cardiac tamponade.

What are some meds you can give for hypotension?

Levophed or Dopamine

Ventricular Fibrillation

-No rhythm -Rate is 300+ -No P wave, PR interval, or QRS

Before using a defibrillator to terminate ventricular fibrillation, the nurse should ensure the synchronizer switch is OFF. Why is this so important? 1. The defibrillator won't deliver a shock if the synchronizer switch is turned off 2. The defibrillator won't deliver a shock if the synchronizer switch is turned on 3. The delivered shock must be synchronized with the QRS complex 4. The shock must be synchronized with the T wave

2

How do you calculate CPP Cerebral perfusion pressure?

MAP-CVP (normal is 70-90)

What's the path behind atrial fibrillation?

Many sites within the atria are generating their own electrical impulses leading to irregular conduction of impulses to the ventricles. Can be caused from MI, Obstructive sleep apnea, left ventricular hypertrophy.

When do you use Cardioversion?

Maybe VT with a pulse

How should you manage shivering?

Meperidine (Demerol) will decrease shivering threshold. Sedatives may sedate to decrease shivering but will not decrease shivering threshold.

The monitor tech on a telemetry unit asks the charge nurse why every patient whose monitor shows atrial fibrillation is receiving Coumadin (warfarin). Which response by the charge nurse is best? 1.Coumadin controls the heart rate in clients with atrial fibrillation. 2.Coumadin prevents atrial fibrillation from progressing to a lethal arrhythmia. 3. Coumadin prevents clot formation in the atria of clients with atrial fibrillation. 4. This is just a coincidence.

3

The nurse on the telemetry unit is faced with various situations. Which situation takes priority? 1. A client asks for assistance to the bathroom 2. A client's rhythm reveals NSR with occasional PVC's 3. A client's rhythm suddenly changes from NSR to uncontrolled atrial fibrillation 4. A client's rhythm suddenly changes from uncontrolled atrial fibrillation to NSR 5. The cardiologist asks the nurse to round on his clients with him

3

How may boxes are in a normal interval?

3-5

What is the target temperature for cooling?

33 degrees celsius for 24 hours

Takostubo cariomyopathy

A weakening of the left ventricle, the heart's main pumping chamber. Usually, it's the result of severe emotional or physical stress.

What are your priorities in a code?

ABCs, compressions & pulse checks, clustered care, rhythm recognition/shock/treatment, closed feedback

What is happening during ventricular tachycardia?

Abnormal tissues in the ventricle generate a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing cardiac arrest.

What kind of medications can you give for SVT?

Adenosine IVP then BB, CCB, amiodarone

For the concerning PVC rhythms, what is the treatment?

Amiodarone IVP/infusion

How do you know when a code should be terminated?

No consistent perfusion for 30 minutes, length of time between arrest and BLS/ACLS taken into account as well as age/comorbidities

Asystole

No rhythm, rate, P wave, PRI, or QRS

What's the path behind the 3rd degree heart block? (Complete heart block)

Atrial contractions are normal, but no electrical condition is conveyed to the ventricles. The ventricles generate their own signals through an escape rhythm.

Stage 3 Late stage of cerebral injury after cardiac arrest

BBB breaks down. There in an increase in cerebral edema. Seizures and neuronal death can happen.

For VF and pulseless VT, treatment is the same for both.

CPR, electricity, drugs, maintain oxygenation

What is CCR?

Cardio-cerebral resuscitation

How should you assess for cardiomyopathies?

Check for dyspnea, SOB, peripheral edema, crackles/rales, murmurs, S3 or S4, antiarrythmias, weak peripheral pulses, fatigue weakness

When do you defibrillate?

Only pulseless VT or VF

How do you treat ventricular fibrillation?

This disorganization of electrical signals causes the ventricles to quiver instead of contracting normally. If there is no pulse present, you may have to do CPR, defibrillation, endotracheal intubation, IV access, Epinephrine IVP, Amiodarone IVP

What is the treatment for cardiomyopathies?

Oxygenation, BB/ACEI/ARB, diuretics, inotropic agents, nitrates, pacemaker/AICD, transplantation, hospice

benign

PVCs may be ___ and need no treatment

What are some meds you can give for hypertension?

Tridil (NTG) or Cardene (nicardipine)

What's the path behind sinus bradycardia?

Usually benign caused by patients on beta blockers, may be caused by obstructive sleep apnea; may be normal for conditioned athletes

For Cardiac tamponade PC post CT/Pacer Wire removal what precautions should you take?

VS every 15 min for an hour, then 30 min for one hour. Auscultate heart tones every hour, monitor for arrhythmias, hypotension

What kind of stimulation can you do as far as collaborative care for SVT?

Valsalva, Hold breath and carotid sinus massage

What does the QRS complex indicate?

Ventricular depolarization, atrial repolarization

What does the T wave indicate?

Ventricular repolarization

Stress Cardiomyopathy (Broken Heart Syndrome)

Rapid and severe heart muscle weakness (cardiomyopathy) caused by intense emotional or physical stress. May occur with grief, fear, extreme anger, and surprise. Symptoms include SOB, chest pain, etc. Caused by excessive norepinephrine load and symptoms are usually temporary and reversible.

Normal Sinus rhythm

Regular rhythm, PRI interval is 0.12-0.2 sec, QRS is less than 0.12-0.20 sec, QT interval is usually 0.36 to 0.44 sec. Rate is 60-100.

Ventricular Tachycardia

Regular rhythm, rate is 150-250. No P wave, PRI not measurable, QRS is wide

3rd degree heart block (complete heart block)

Rhythm is irregular. Rate is slow. P wave is unrelated to QRS. PRI is variable and QRS is prolonged.

Supraventricular Tachycardia

Rhythm is regular, rate is 160-220. P wave may not be seen. PRI is indeterminate. QRS is less 0.12

Sinus tachycardia

Rhythm is regular. Rat his over 100. P wave is 1:1 before each QRS. PRI is normal. QRS complex duration is normal.

Sinus bradycardia

Rhythm is regular. Rate is less than 60. P wave is 1:1 before each QRS, PRI is normal. QRS complex duration is normal

2nd degree Heart Block (Mobitz 2)

Rhythm is regular. Rate varies. P wave ratio is 2:1 or 3:1. PRI is the same for each conducted beat. QRS is usually normal.

PEA Pulseless electrical activity

Rhythm, rate, P wave, PRI, QRS all varies

Benign PVCs can be part of the following rhythms

SR with rare PVCs, SR with occasional PVCs, or a fib with occasional PVCs

Shivering

Sympathetic response counteracts hypothermia: first through vasoconstriction, and then by heat production through shivering

What other collaborative treatments besides vagus nerve stimulation or medications can you do for SVT?

Synchronized cardioversion (then BB,CCB, amiodarone). You can also do ablation for long term.

In hypokalemia, how does the EKG look like?

T wave inverts, prolonged U wave

What are other collaborative care interventions for atrial fibrillation?

TEE first- If no clots are present, do synchronized cardioversion. IF clots are present, anticoagulation next and then synchronized cardioversion. EPS with ablation/possible permanent pacemaker placement

In Hyperkalemia, how does the EKG look like?

Tall, tented T wave, prolonged PR interval, Widened QRS interval

Cardiac Tamponade

The compression of the heart through infiltration fluid in the pericardial sac. This increases the intracardiac pressure and so the heart can't contract effectively.

How do you determine the cardiac rhythm shown?

Count the number of R waves/QRS complexes in the six second strip and multiply by 10

Stage 2 Intermediate stage (1-12 hours) of cerebral injury after cardiac arrest

Cytotoxic cascades are activated. this causes vasoconstriction, which leads to vasospasm, leading to massive uncompensated vasodilation

What is repercussion injury?

Damage observed after restoration of blood flow to ischemic tissues

What are some serious signs or symptoms that you might see with 2nd degree or 3rd degree heart block?

Decreased LOC, confusion, hypotension, chest pain, SOB, dyspnea, crackles, rales

Signs and symptoms of cardiac tamponade

Decreased chest tube drainage, shock, SOB, pulmonary edema, decreased QRS voltage on 12 lead EKG.

What's the path behind the 2nd degree heart block (Mobitz 2)?

Disease of the AV node resulting in intermittently non-conducted QRS complex not proceeded by PR prolongation or PR interval shortening

Why does cardiac arrest happen?

Due to abrupt electrical cessation in the heart from ventricular dysfunction

Stage 1 of cerebral injury after cardiac arrest

Early stage. Supply is less than demand. Cardiac arrest leads to cerebral blood flow decrease which leads to metabolic demand increase

How do you confirm Cardiac tamponade?

Echo

What are most common side effects to therapeutic hypothermia?

Electrolyte disordes, metabolic changes, volume changes, impaired neutrophil & macrophage function, bradycardia, etc.

How do you treat atrial fibrillation?

For IV rate control, you can give Metoprolol, Cardizem, Amiodarone. For PO rate maintenance, you can give BB,CCB, Amiodarone, Digoxin, Tikosyn. For Chronic anticoagulation you can give Coumadin (warfarin) or Pradaxa.

How do we improve neurological outcomes?

Good CPR and cooling

What's the path behind sinus tachycardia?

Gradual onset with discernible cause and variable rate. Can be caused by exercise, exertion, infection, anxiety, dehydration.

What are some things you need to remember for atrial fibrillation?

You want to know if it's an acute episode/new onset, put them on telemetry, give oxygen, put them on fall precautions, if hypotensive give IVF, educate the patient on new meds and anticoagnulations like heparin or lovenox

For patient maintenance, what's important to do?

analgesia, sedation, paralytic, apply arctic sun

Amiodarone is a good _____ to use

anti-arrhythmic

What does the P wave indicate?

atrial depolarization

What are some negatives of cooling after cardiac arrest?

bradycardia, arrythmias, increased urine output/rate of bleeding/rates of sepsis

PVCs can also be of ____ in certain cases

concern

Cardiomyopathies can be

dilated, hypertrophic, ischemic, restrictive

Hypothermia treatment should eb started ____ once ROSC has occurred (within 60 minutes of cardiac arrest)

imediately

QTI varies, but the longer it is, the more likely ventricular irritability will cause

lethal arrhythmias

Epinephrine are given to patients without a

pulse

How can cooling help after cardiac arrest?

reduces metabolic demand of the brain, decreased cellular damage secondary to reperfusion

You want to make sure you rewarm the patient ___ after cooling

slowly

Patients who receive _________ are usually post cardiac arrest, have had a stroke, and GCS of 8 or less and no purposeful movement to pain. Are at least 16 and intubated.

therapeutic hypothermia

End-Stage cardiac disease calls for

transplantation, palliative care, hospice care

____ can actually be harmful if given when patient has ROSC

vasopressors

What does the QT interval show?

ventricular depolarization and repolarization