ARYTHMIAS Common types of tachycardia

-There are five main types of arrhythmias, caused by irregular heart

described by the speed of heart rate they rhythms (arrhythmias) include:
cause and where they begin in the heart.
For adults, a normal resting heart rate  Atrial fibrillation (A-
ranges from 60 to 100 beats per minute. fib). This is the most
Highly trained athletes may have resting common type of
heart rates lower than 60. tachycardia. Chaotic,
1.TACHYCARDIA irregular electrical
Tachycardia (tak-ih-KAHR-dee- signals in the upper
uh) is the medical term for a chambers of the heart
heart rate over 100 beats a (atria) cause a fast
heartbeat. A-fib may
minute. Many types of irregular
be temporary, but
heart rhythms (arrhythmias) can
some episodes won't
cause tachycardia.
end unless treated.

A fast heart rate isn't always a  Atrial flutter. Atrial

concern. For instance, the heart flutter is similar to A-
rate typically rises during fib, but heartbeats are
exercise or as a response to more organized.
Episodes of atrial
stress.
flutter may go away
themselves or may
Tachycardia may not cause any
require treatment.
symptoms or complications. But
People who have atrial
if left untreated, some forms of flutter also often have
tachycardia can lead to serious atrial fibrillation at
health problems, including heart other times.
failure, stroke or sudden cardiac
 Ventricular
death.
tachycardia. This type
of arrhythmia starts in
Treatment for tachycardia may
the lower heart
include specific maneuvers, chambers (ventricles).
medication, cardioversion or The rapid heart rate
surgery to control a rapid doesn't allow the
heartbeat. ventricles to fill and
squeeze (contract) to
Types pump enough blood to
the body. Ventricular
There are many different types tachycardia episodes
of tachycardia. Sinus may be brief and last
tachycardia refers to a typical only a couple of
increase in the heart rate often seconds without
caused by exercise or stress. causing harm. But
episodes lasting more
than a few seconds
Other types of tachycardia are
can be life-threatening.
grouped according to the part of
the heart responsible for the  Supraventricular
fast heart rate and the cause. tachycardia
 (SVT). Supraventricula  Fainting (syncope)
r tachycardia is a
 Lightheadedness
broad term that
includes arrhythmias  Rapid pulse rate
that start above the
 Shortness of breath
ventricles.
Supraventricular When to see a doctor
tachycardia causes
episodes of a pounding A number of things can cause a
heartbeat rapid heart rate (tachycardia). If
(palpitations) that
you feel like your heart is
begin and end
beating too fast, make an
abruptly.
appointment to see a health
 Ventricular care provider.
fibrillation. Rapid,
chaotic electrical Seek immediate medical help if
signals cause the you have shortness of breath,
ventricles to quiver weakness, dizziness,
instead of contracting
lightheadedness, fainting or
in a coordinated way.
near fainting, and chest pain or
This serious problem
discomfort.
can lead to death if the
heart rhythm isn't
restored within A type of tachycardia called
minutes. Most people ventricular fibrillation can cause
who have ventricular blood pressure to drop
fibrillation have an dramatically. Collapse can occur
underlying heart within seconds. Soon the
disease or have affected person's breathing and
experienced serious pulse will stop. If this occurs, do
trauma, such as being the following:
struck by lightning.

Symptoms  Call 911 or the

emergency number in
your area.
When the heart beats too fast, it
may not pump enough blood to  If you or someone
the rest of the body. As a result, nearby is well trained
the organs and tissues may not in CPR, start
get enough oxygen. CPR. CPR can help
maintain blood flow to
In general, tachycardia may lead the organs until an
to the following signs and electrical shock
(defibrillation) can be
symptoms:
given.

 Sensation of a racing,  If you're not trained in

pounding heartbeat or CPR or worried about
flopping in the chest giving rescue breaths,
(palpitations) then provide hands-
only CPR. Push hard
 Chest pain
 and fast on the center beats a minute is quite common
of the chest at a rate during sleep and in some people,
of 100 to 120 particularly healthy young adults
compressions a minute and trained athletes.
until paramedics
arrive. You don't need
If bradycardia is severe, an
to do rescue breathing.
implanted pacemaker may be
 If an automated needed to help the heart
external defibrillator maintain an appropriate rate.
(AED) is available
nearby, have someone Symptoms
get the device for you,
and then follow the A slower than typical heartbeat
instructions. (bradycardia) can prevent the
An AED is a portable
brain and other organs from
defibrillation device
getting enough oxygen, possibly
that can deliver a
causing these signs and
shock to reset the
symptoms:
heart rhythm. No
training is required to
use the device.  Chest pain
The AED will tell you  Confusion or memory
what to do. It's problems
programmed to give a
shock only when  Dizziness or
appropriate. lightheadedness

 Easily tiring during

2.BRADYCARDIA
physical activity
Bradycardia (brad-e-KAHR-dee-
 Fatigue
uh) is a slow heart rate. The
hearts of adults at rest usually  Fainting (syncope) or
beat between 60 and 100 times near-fainting
a minute. If you have  Shortness of breath
bradycardia, your heart beats
When to see a doctor
fewer than 60 times a minute.

Many things can cause signs

Bradycardia can be a serious
and symptoms of bradycardia.
problem if the heart rate is very
It's important to get a prompt,
slow and the heart can't pump
accurate diagnosis and
enough oxygen-rich blood to the
appropriate care. See your
body. If this happens, you may
health care provider if you are
feel dizzy, very tired or weak,
concerned about a slow heart
and short of breath. Sometimes
rate.
bradycardia doesn't cause
symptoms or complications.
If you faint, have difficulty
breathing or have chest pain
A slow heart rate isn't always a
lasting more than a few minutes,
concern. For example, a resting
heart rate between 40 and 60
call 911 or emergency medical  Inflammatory disease,
services. such as rheumatic
fever or lupus
Causes
 Certain medications,
including sedatives,
opioids, and drugs
used to treat heart
rhythm disorders, high
blood pressure and
certain mental health
disorders

To better understand the causes

of bradycardia, it may be helpful
to know how the heart typically
beats.

Typical heartbeat Enlarge image The typical heart has four

Bradycardia can be caused by: chambers — two upper
chambers (atria) and two lower
 Heart tissue damage chambers (ventricles). Within
related to aging the upper right chamber of the
heart (right atrium) is a group of
 Damage to heart
cells called the sinus node. The
tissues from heart
sinus node is the heart's natural
disease or heart
pacemaker. It produces the
attack
signal that starts each
 A heart condition heartbeat.
present at birth
(congenital heart Bradycardia occurs when these
defect)
signals slow down or are
 Inflammation of heart blocked.
tissue (myocarditis)
Sinus node problems
 A complication of
heart surgery

 An underactive thyroid
gland (hypothyroidism)

 Imbalance of
chemicals in the blood,
such as potassium or
calcium

 Repeated pauses in
breathing during sleep
(obstructive sleep
BradycardiaEnlarge image
apnea)
Bradycardia often starts in the
area of the heart called the
sinus node. In some people,
sinus node problems cause
alternating slow and fast heart
rates (bradycardia-tachycardia
syndrome).
Heart block (atrioventricular
block)
Bradycardia can also occur if
the heart's electrical signals
don't move correctly from the
upper chambers (atria) to the
lower chambers (ventricles). If
this occurs, the condition is
called heart block, or
atrioventricular block.
ventricles will usually
beat on their own but
at a very slow rate.
Risk factors
Bradycardia is often associated
with damage to heart tissue
from some type of heart disease.
Anything that increases the risk
of heart problems can increase
the risk of bradycardia. Risk
factors for heart disease
include:
 Older age
 High blood pressure

 Smoking
Heart blocks fall into three main
 Heavy alcohol use
groups.
 Illegal drug use
 First-degree heart
 Stress and anxiety
block. In the mildest
form, all electrical Healthy-lifestyle changes or
signals from the atria medical treatment may help
reach the ventricles,
lower the risk of heart disease.
but the signal is
slowed. First-degree
Complications
heart block rarely
causes symptoms and
Possible complications of
usually needs no
bradycardia can include:
treatment if there's no
other problem in
electrical signaling.  Frequent fainting

 Second-degree heart  Inability of the heart to

block. Not all pump enough blood
electrical signals (heart failure)
reach the ventricles.  Sudden cardiac arrest
Some beats are or sudden death
dropped, resulting in a
slower and sometimes Prevention
irregular heart rhythm.
Bradycardia can be caused by
 Third-degree
certain medications, particularly
(complete) heart
if they are taken at high doses,
block. None of the
so it's important to take all
electrical signals from
medications as directed.
the atria reaches the
ventricles. When this Although bradycardia is not
happens, the typically preventable, health
care providers recommend up to two drinks a day
strategies to reduce the risk of for men. If you can't
developing heart disease. Take control your alcohol
the following heart-healthy use, talk to a health
care provider about a
steps:
program to quit
drinking and manage
 Get regular
other behaviors
exercise. Your health
related to alcohol
care provider may give
abuse.
you recommendations
about how much and  Manage
what type of exercise stress. Intense
is best for you. emotions may affect
heart rate. Some ways
 Eat a healthy
to relieve stress are
diet. Choose a
getting regular
healthy, low-fat, low-
exercise, joining a
salt, low-sugar diet
support group and
that's rich in fruits,
trying relaxation
vegetables and whole
techniques, such as
grains.
yoga.
 Maintain a healthy
 Go to scheduled
weight. Being
checkups. Have
overweight increases
regular physical exams
the risk of developing
and report signs or
heart disease.
symptoms to your
 Keep blood pressure health care provider.
and cholesterol under
Monitor and treat existing heart
control. Make lifestyle
disease
changes and take
medications as
If you already have heart
prescribed to manage
high blood pressure, disease, there are steps you can
diabetes and high take to lower your risk of
cholesterol. developing bradycardia or
another heart rhythm disorder:
 Don't smoke. If you
need help quitting, talk
 Follow the plan. Be
to your health care
sure you understand
provider about
your treatment plan.
strategies or programs
Take all medications
to help.
as prescribed.
 If you drink, do so in
 Report changes
moderation. If you
immediately. If your
choose to drink
symptoms change or
alcohol, do so in
worsen or you develop
moderation. For
new symptoms, tell
healthy adults, that
your health care
means up to one drink
provider immediately.
a day for women and
3. Premature ventricular contractions
(PVCs)
Premature ventricular
contractions (PVCs) are extra
heartbeats that begin in one of
the heart's two lower pumping
chambers (ventricles). These
extra beats disrupt the regular
heart rhythm, sometimes
causing a sensation of a
fluttering or a skipped beat in
the chest.
Premature ventricular
contractions are a common type
of irregular heartbeat
(arrhythmia). PVCs are also
called:
 Premature ventricular
complexes
 Ventricular premature
beats
 Ventricular
extrasystoles
Occasional premature
ventricular contractions in
people without heart disease
usually aren't a concern and
likely don't need treatment. You
might need treatment if the
premature ventricular
contractions are very frequent
or bothersome, or if you have an
underlying heart condition.
Symptoms
Premature ventricular
contractions often cause few or
no symptoms. But the extra
beats can cause unusual
sensations in the chest, such as:
 Fluttering
 Pounding or jumping
 Skipped beats or
missed beats
 Increased awareness
of the heartbeat
When to see a doctor
If you feel fluttering, pounding or
a sensation of skipped
heartbeats in your chest, talk to
your health care provider. A
health care provider can
determine if the sensations are
due to a heart condition or other
health concern. Similar signs
and symptoms can be caused by
many other conditions such as
anxiety, low red blood cell count
(anemia), overactive thyroid
(hyperthyroidism) and
infections.
Causes
To understand the cause of
premature ventricular
contractions (PVCs), it might
help to learn more about how
the heart typically beats.
The heart is made of four
chambers — two upper
chambers (atria) and two lower
chambers (ventricles).
The heart's rhythm is controlled
by a natural pacemaker (the
sinus node) in the right upper
chamber (atrium). The sinus
node sends electrical signals
that typically start each
heartbeat. These electrical
signals move across the atria,
causing the heart muscles to
squeeze (contract) and pump
blood into the ventricles.
Next, the signals arrive at a
cluster of cells called
the AV node, where they slow
down. This slight delay allows
the ventricles to fill with blood.
When the electrical signals
reach the ventricles, the
chambers contract and pump
blood to the lungs or to the rest
of the body.
In a typical heart, this heart
signaling process usually goes
smoothly, resulting in a resting
heart rate of 60 to 100 beats a
minute.
PVCs are irregular contractions
that start in the ventricles
instead of the atria. The
contractions usually beat sooner
than the next expected
heartbeat.
The cause of premature
ventricular contractions isn't
always clear. Certain things
including heart diseases or
changes in the body can make
cells in the lower heart
chambers electrically unstable.
Heart disease or scarring may
cause the heart's signals to be
misrouted.
Premature ventricular
contractions may be caused by:
 Certain medications,
including
decongestants and
antihistamines
 Alcohol or drug misuse
 Stimulants such as
caffeine or tobacco
 Increased levels of
adrenaline in the body
due to exercise or
anxiety
 Injury to the heart
muscle due to disease
Risk factors
Certain lifestyle choices and
health conditions may make a
person more likely to develop
premature ventricular
contractions (PVCs).
Risk factors for PVCs include:
 Caffeine
 Tobacco
 Alcohol
 Stimulants such as
cocaine or
methamphetamines
 Exercise — if you have
certain types of PVCs
 Anxiety
 Heart attack
 Heart disease,
including congenital
heart disease,
coronary artery
disease, heart failure
and a weakened heart
muscle
(cardiomyopathy)
Complications
Having frequent premature
ventricular contractions (PVCs)
or certain patterns of them
might increase the risk of
developing irregular heart
rhythms (arrhythmias) or
weakening of the heart muscle
(cardiomyopathy).
Rarely, when accompanied by
heart disease, frequent
premature contractions can lead
to chaotic, dangerous heart
rhythms and possibly sudden
cardiac death.
5. Ventricular tachycardia
entricular tachycardia is a heart
rhythm problem (arrhythmia)
caused by irregular electrical
signals in the lower chambers of
the heart (ventricles). This
condition may also be called V-
tach or VT.
A healthy heart typically beats
about 60 to 100 times a minute
at rest. In ventricular
tachycardia, the heart beats
faster, usually 100 or more
beats a minute.
Sometimes the rapid heartbeat
prevents the heart chambers
from properly filling with blood.
As a result, the heart may not be
able to pump enough blood to
the body. If this happens, you
may feel short of breath or
lightheaded, or you may lose
consciousness.
Ventricular tachycardia
episodes may be brief and last
only a couple of seconds
without causing harm. But
episodes lasting more than a
few seconds (sustained V-tach)
can be life-threatening.
Sometimes ventricular
tachycardia can cause the heart
to stop (sudden cardiac arrest).
Treatment for ventricular
tachycardia may include
medication, a shock to the heart
(cardioversion), catheter
procedures or surgery to slow
the fast heart rate and reset the
heart rhythm.
What is ventricular tachycardia?
Mayo Clinic cardiologist Suraj
Kapa, M.D., discusses common
misconceptions about
ventricular tachycardia.
Symptoms
When the heart beats too fast, it
may not pump enough blood to
the rest of the body. So the
organs and tissues may not get
enough oxygen. Signs and
symptoms that occur during an
episode of ventricular
tachycardia are due to a lack of
oxygen and may include:
 Chest pain (angina)
 Dizziness
 Pounding heartbeat
(palpitations)
 Lightheadedness
 Shortness of breath
Ventricular tachycardia may go
away on its own within 30
seconds (nonsustained V-tach)
or last more than 30 seconds
(sustained V-tach or VT). Brief
episodes may not cause any
symptoms. But
sustained VT can cause
serious problems, including:
 Fainting
 Loss of consciousness
 Cardiac arrest (sudden
death)
When to see a doctor
Many different things can cause
ventricular tachycardia. It's
important to get a prompt,
accurate diagnosis and
appropriate care. See your
health care provider if you or
your child has any problems
with the heartbeat. In some
cases, urgent or emergency
care is needed.
Call 911 or your local emergency
number if anyone has these
symptoms:
 Chest pain that lasts
more than a few
minutes
 Difficulty breathing
 Fainting
Causes
Ventricular tachycardia is
caused by faulty heart signaling
that triggers a fast heart rate in
the lower heart chambers
(ventricles). The fast heart rate
doesn't allow the ventricles to
fill and squeeze (contract) to
pump enough blood to the body.
Many things can cause or
contribute to problems with
heart signaling and lead to
ventricular tachycardia. These
include:
 Prior heart attack or
other heart condition
that caused scarring of
heart tissue (structural
heart disease)
 Poor blood flow to the
heart muscle due to
coronary artery
disease
 Congenital heart
diseases, including
long QT syndrome
 Imbalance of
substances in the
blood called
electrolytes — such as
potassium, sodium,
calcium and
magnesium
 Medication side
effects
 Use of stimulants such
as cocaine or
methamphetamine
Sometimes, the exact cause of
ventricular tachycardia can't be
determined (idiopathic
ventricular tachycardia).
How does the heart beat?
To better understand the cause
of ventricular tachycardia, it
may be helpful to know how the
heart typically works.
The heart is made of four
chambers — two upper
chambers (atria) and two lower
chambers (ventricles).
The heart's rhythm is controlled
by a natural pacemaker (the
sinus node) in the right upper
chamber (atrium). The sinus
node sends electrical signals
that typically start each
heartbeat. These electrical
signals move across the atria,
causing the heart muscles to
squeeze (contract) and pump
blood into the ventricles.
Next, the signals arrive at a
cluster of cells called
the AV node, where they slow
down. This slight delay allows
the ventricles to fill with blood.
When the electrical signals
reach the ventricles, the
chambers contract and pump
blood to the lungs or to the rest
of the body.
In a typical heart, this heart
signaling process usually goes
smoothly, resulting in a resting
heart rate of 60 to 100 beats a
minute.
In ventricular tachycardia, faulty
electrical signaling in the
heart's lower chambers causes
the heart rate to increase to 100
or more beats a minute.
Risk factors
Any condition that puts a strain
on the heart or damages heart
tissue can increase the risk of
ventricular tachycardia.
Lifestyle changes or proper
medical treatment for the
following conditions and events
may lower the risk:
 Heart disease
 Medication side
effects
 Severe electrolyte
imbalances
 Use of stimulant drugs
such as cocaine or
methamphetamine
A family history of tachycardia
or other heart rhythm disorders
makes a person more likely to
develop ventricular tachycardia.
Complications
Complications of ventricular
tachycardia depend on:
 How fast the heart is
beating
 How long the rapid
heart rate lasts
 Whether there are
other heart conditions
Possible complications of
ventricular tachycardia include:
 Frequent fainting
spells or
unconsciousness
 Heart failure
 Sudden death caused
by cardiac arrest
Ventricular fibrillation
A dangerous condition related to
ventricular tachycardia is
ventricular fibrillation (V-fib).
In V-fib, the lower heart
chambers contract in a very
rapid and uncoordinated
manner.
This irregular rhythm happens
most often in people with heart
disease or a prior heart attack.
It may also occur in those with
electrolyte imbalances (such as
high or low potassium levels).
Ventricular fibrillation may
cause sudden cardiac arrest and
lead to death if not treated
immediately.
Prevention
The best ways to prevent
tachycardia are to maintain a
healthy heart and prevent heart
disease. If you already have
heart disease, monitor it and
follow your treatment plan. Be
sure you understand your
treatment plan, and take all
medications as prescribed.
Take the following steps to keep
the heart healthy:
 Limit alcohol. If you
 Eat a balanced,
nutritious diet. A diet
low in saturated and
trans fats and rich in
fruits, vegetables and
whole grains helps
keep the heart healthy.
 Exercise and maintain
a healthy
weight. Being
overweight increases
the risk of developing
heart disease. As a
general goal, aim for at
least 30 minutes of  Limit caffeine. If you
moderate exercise
every day.
 Control blood pressure
and cholesterol
levels. Make lifestyle
changes and take  Stop smoking. If you
medications as
prescribed to manage
high blood pressure
(hypertension) or high
cholesterol.
 Control stress. Avoid
unnecessary stress
and learn strategies to  Use over-the-counter
manage and reduce
stress.
 Don't use illegal
drugs. Don't use
stimulants, such as
cocaine. If you need
help stopping drug use
or misuse, talk to your
health care provider
about an appropriate
program for you.
 Go to scheduled health
checkups. Have
regular physical exams
and report any new
signs or symptoms to
your health care
provider.
choose to drink
alcohol, do so in
moderation. For
healthy adults, that
means up to one drink
a day for women and
up to two drinks a day
for men. Some people
may need to avoid
alcohol entirely. Ask
your health care
provider how much
alcohol, if any, is safe
for you.
drink caffeinated
beverages, do so in
moderation (no more
than 1 to 2 beverages
daily).
smoke and can't quit
on your own, talk to
your health care
provider about
strategies or programs
to help you break a
smoking habit.
medications with
caution. Some cold
and cough medications
contain stimulants
that may increase the
heart rate. Always tell
your health care
provider about the
medications you take,
including those bought
without a prescription.
 ADJUNCT MODALITIES AND
MANAGEMENTS
CARDIOVERSION AND DEFIBRILLATION
Cardioversion and defibrillation are
treatments for tachydysrhythmias. They are
used to deliver an electrical current to
depolarize a critical mass of myocardial
cells. When the cells repolarize, the sinus
node is usually able to recapture its role as
the heart’s pacemaker. One major
difference between cardioversion and
defibrillation has to do with the timing of
the delivery of electrical current.Another
major difference concerns the
circumstance: defibrillation is usually
performed as an emergency treatment,
whereas cardioversion is usually, but not
always, a planned procedure.
Electrical current may be delivered through
paddles or conductor pads. Both paddles
may be placed on the front of the chest (Fig.
27-29), which is the standard paddle
placement, or one paddle may be placed on
the front of the chest and the other
connected to an adapter with a long handle
and placed under the patient’s back, which
is called an anteroposterior placement (Fig.
27-30).
Instead of paddles, defibrillator
multifunction conductor pads may be used
(Fig. 27-31). The pads, which contain a
conductive medium, are placed in the same
position as the paddles. They are connected
to the defibrillator and allow for hands-off
defibrilla-tion. This method reduces the
risks of touching the patient dur-ing the
procedure and increases electrical safety.
AEDs use this type of delivery for the
electrical current.
Whether using pads or paddles, the nurse
must observe two safety measures. First,
maintain good contact between the pads or
paddles (with a conductive medium) and
the patient’s skin to prevent electrical
current from leaking into the air (arcing)
when the defibrillator is discharged.
Second, ensure that no one is in contact
with the patient or with anything that is
touching the pa-tient when the defibrillator
is discharged, to minimize the chance that
electrical current will be conducted to
anyone other than the patient.
When performing defibrillation or
cardioversion, the nurse should remember
these key points:
· Use multifunction conductor pads
or paddles with a con-ducting agent
between the paddles and the skin
(the con-ducting agent is available as
a sheet, gel, or paste).
· Place paddles or pads so that they
do not touch the patient’s clothing
or bed linen and are not near
medication patches or direct oxygen
flow.
· If cardioverting, ensure that the
monitor leads are attached to the
patient and that the defibrillator is in
sync mode. If defibrillating, ensure
that the defibrillator is not in sync
mode (most machines default to the
“not-sync” mode).
· Do not charge the device until
ready to shock; then keep thumbs
and fingers off the discharge buttons
until paddles or pads are on the
chest and ready to deliver the
electrical charge.
 · Exert 20 to 25 pounds of pressure
on the paddles to ensure good skin
contact.
· Before pressing the discharge
button, call “Clear!” three times: As
“Clear” is called the first time,
ensure that you are not touching the
patient, bed or equipment; as
“Clear” is called the second time,
ensure that no one is touching the
bed, the patient, or equipment,
including the endotracheal tube or
adjuncts; and as “Clear” is called the
third time, per-form a final visual
check to ensure you and everyone
else are clear of the patient and
anything touching the patient.
· Record the delivered energy and
the results (cardiac rhythm, pulse).
· After the event is complete, inspect
the skin under the pads or paddles
for burns; if any are detected,
consult with the physician or a
wound care nurse about treatment.
Cardioversion
Cardioversion involves the delivery of a
“timed” electrical cur-rent to terminate a
tachydysrhythmia. In cardioversion, the de-
fibrillator is set to synchronize with the ECG
on a cardiac monitor so that the electrical
impulse discharges during ventricular depo-
larization (QRS complex). Because there
may be a short delay until recognition of the
QRS, the discharge buttons must be held
down until the shock has been delivered.
The synchronization prevents the discharge
from occurring during the vulnerable pe-
riod of repolarization (T wave), which could
result in VT or ven-tricular fibrillation. When
the synchronizer is on, no electrical current
will be delivered if the defibrillator does not
discern a QRS complex. Sometimes the lead
and the electrodes must be changed for the
monitor to recognize the patient’s QRS
complex.
If the cardioversion is elective,
anticoagulation for a few weeks before
cardioversion may be indicated. Digoxin is
usually with-held for 48 hours before
cardioversion to ensure the resumption of
sinus rhythm with normal conduction. The
patient is in-structed not to eat or drink for
at least 8 hours before the proce-dure. Gel-
covered paddles or conductor pads are
positioned front and back
(anteroposteriorly) for cardioversion.
Before cardioversion, the patient receives
intravenous sedation as well as an analgesic
medication or anesthesia. Respiration is
then supported with supplemental oxygen
delivered by a bag-mask-valve device with
suction equipment readily available.
Although patients rarely require intubation,
equipment is nearby if it is needed. The
amount of voltage used varies from 25 to
360 joules, depending on the defibrillator’s
technology and the type of dysrhythmia. If
ventricular fibrillation occurs after
cardioversion, the defibrillator is used to
defibrillate the patient (sync mode
is not used).
Indications of a successful response are
conversion to sinus rhythm, adequate
peripheral pulses, and adequate blood
pressure. Because of the sedation, airway
patency must be maintained and the
patient’s state of consciousness assessed.
Vital signs and oxy-gen saturation are
monitored and recorded until the patient is
stable and recovered from sedation and the
effects of analgesic medications or
anesthesia. ECG monitoring is required
during and after cardioversion.
Defibrillation
Defibrillation is used in emergency
situations as the treatmentof choice for
ventricular fibrillation and pulseless VT.
Defibrilla-tion depolarizes a critical mass of
myocardial cells at once; when they
repolarize, the sinus node usually
recaptures its role as the pacemaker. The
electrical voltage required to defibrillate the
heart is usually greater than that required
for cardioversion. If three de-fibrillations of
increasing voltage have been unsuccessful,
cardio-pulmonary resuscitation is initiated
and advanced life support treatments are
begun.
The use of epinephrine or vasopressin may
make it easier to convert the dysrhythmia
to a normal rhythm with defibrillation.
These drugs may also increase cerebral and
coronary artery blood flow. After the
medication is administered and 1 minute of
cardio-pulmonary resuscitation is
performed, defibrillation is again
administered. Antiarrhythmic medications
such as amiodarone (Cordarone, Pacerone),
lidocaine (Xylocaine), magnesium, or pro-
cainamide (Pronestyl) are given if
ventricular dysrhythmia persists (see Table
27-1). This treatment continues until a
stable rhythm resumes or until it is
determined that the patient cannot be
revived.
IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR
The implantable cardioverter defibrillator
(ICD) is a device that detects and terminates
life-threatening episodes of VT or
ventricular fibrillation in high-risk patients.
Patients at high risk are those who have
survived sudden cardiac death syndrome,
usu-ally caused by ventricular fibrillation, or
have experienced symp-tomatic VT
(syncope secondary to VT). In addition, an
ICD may be indicated for patients who have
survived an MI but are at high risk for
cardiac arrest.
An ICD consists of a generator and at least
one lead that can sense intrinsic electrical
activity and deliver an electrical impulse.
The device is usually implanted much like a
pacemaker (Fig. 27-32). ICDs are designed
to respond to two criteria: a rate that
exceeds a predetermined level, and a
change in the isoelectric line seg-ments.
When a dysrhythmia occurs, rate sensors
take 5 to 10 sec-onds to sense the
dysrhythmia. Then the device takes several
seconds to charge and deliver the
programmed charge through the lead to the
heart. Battery life is about 5 years but varies
de-pending on use of the ICD over time. The
battery is checked dur-ing follow-up visits.
Antiarrhythmic medication usually is
administered with this technology to
minimize the occurrence of the
tachydysrhythmia and to reduce the
frequency of ICD discharge.
The first defibrillator, which was implanted
in 1980 at Johns Hopkins University, simply
defibrillated the heart. Today, how-ever,
several devices are available, and many are
programmed for multiple treatments (Atlee (Chart 27-4). The nurse can also assist the
& Bernstein, 2001). Each device of-fers a patient and family in making lifestyle
different delivery sequence, but all are changes necessitated by the dysrhythmia
capable of delivering high-energy (high- and resulting ICD implantation (Dougherty,
intensity) defibrillation to treat a Benoliel, & Bellin, 2000).
tachycardia (atrial or ventricular). The
device may deliver up to six shocks if
necessary. Some ICDs can respond with
antitachycardia pacing, in which the device
delivers electrical impulses at a fast rate in
an attempt to disrupt the tachycardia, by
low-energy (low-intensity) cardioversion, by
defibrillation, or all three (Atlee &
Bernstein, 2001). Some also have
pacemaker capability if the patient devel-
ops bradycardia, which sometimes occurs
after treatment of the tachycardia. Usually
the mode is VVI (V, paces the ventricle; V,
senses ventricular activity; I, paces only if
the ventricles do not de-polarize) (Atlee &
Bernstein, 2001). Some ICDs also deliver
low-energy cardioversion, and some also
treat atrial fibrillation (Bubien & Sanchez,
2001; Daoud et al., 2000). Which device is
used and how it is programmed depends on
the patient’s dysrhythmia.

Complications are similar to those

associated with pacemaker insertion. The
primary complication associated with the
ICD is surgery-related infection. There are a
few complications associ-ated with the
technical aspects of the equipment, such as
prema-ture battery depletion and dislodged
or fractured leads. Despite the possible
complications, the consensus among
clinicians is that the benefits of ICD therapy
exceed the risks.

Nursing interventions for the patient with

an ICD are pro-vided throughout the
preoperative, perioperative, and postoper-
ative phases. In addition to providing the
patient and family with explanations
regarding implantation of the ICD in the
preoper-ative phase, the nurse may need to
manage acute episodes of life-threatening
dysrhythmias. In the perioperative and
postoperative phases, the nurse carefully
observes the patient’s responses to the ICD
and provides the patient and family with
further teaching as needed (White, 2000)