Basic

Dysrhythmias

Scott Prewitt, RN, MSN, APRN-BC

Cardiac Conduction
System
• Sinus Node: natural
pacemaker, pacing
rate 60 - 100 bpm
• Internodal pathways
• AV node: pacing
rates 40 - 60 bpm
• Bundle of His
• Bundle Branches
• Purkinje Fibers
Interpretation
• Rate:
o too fast (>100)
o too slow (< 60)
o not at all (asystole)
• Regular or Irregular
• P-Wave?
• PRI= 0.12-0.20
• QRS width
• What rhythm is it?
• What do I do?
1 small square = 0.04
seconds
1 large square = 0.2
seconds
5 large squares = 1
second
• 6 second method: count # QRS (R Waves) in
a 6 second strip and multiply X 10
 QRS Analysis
• Narrow/Normal • Wide Complex
o QRS < 0.12sec
o Depolarizes via the o QRS > 0.12 sec
normal conduction o Depolarizes cell to
system cell across the
o Supra-ventricular: myocardium
may be sinus, (slower
atrial, or junctional conduction)
o Ventricular in origin
until proven
otherwise
 Not Life-threatening or
Lethal
• Rate is more than 60 but less
than 100, with a pulse.
• QRS is narrow/normal:
o Less than 0.12 sec or 3 small
squares
PVC’
s
PAC’
s
 Heart Blocks
Type of Block Characteristics

1st Degree AV Block The PR interval is “long”

2nd degree AVB Type I The PR Interval is

Wenckebach progressively longer until
beat is dropped

2nd degree AVB Type II The PR interval is the same,

Classical but you have more P’s than
QRS’s

3RD degree AVB (Complete Like 2 independent rhythms

Heart Block) overlayed (a/v)
Heart Blocks-1st Degree

Treatment: Monitor for symptoms

Heart Blocks-2nd Degree
Type I - Wenckebach

Treatment:
Asymptomatic- Monitor
Symptomatic- Pace/Atropine
 Heart Blocks-2nd Degree
Type II - Classical

Treatment:
• Asymptomatic- Place Pacing Pads/Monitor
Close (Can rapidly deteriorate to 3rd Degree)
• Symptomatic- Pace/Atropine
 Heart Blocks-3rd Degree
Complete

Treatment:
• Asymptomatic- Place Pacing Pads/Monitor Close
• Symptomatic- Pace
Atrial Fibrillation/Atrial Flutter
Atrial Fibrillation/Atrial Flutter
Treatment:
• Anticoagulate with AFib
• Medically Control Rate (Cardizem)
• Medically Cardiovert (Adenosine)
• Electrical Cardioversion (Synch. Defib)
Life-threatening Rhythms
(URGENT)
• Rate may be less than 60.
• Rate may be greater than 100.
• QRS may be normal or wide
• Patient remains conscious
• B/P may be <90mmHg
• Pt may have dyspnea, pain, or
diaphoresis
• Classification depends on patient
tolerance
 Life-threatening Rhythms
(URGENT)
• CHECK PATIENT!
• Apply oxygen
• Start IV or check current IV patency
• If BP is low
o Trendelenburg
o Start IV fluids unless patient in CHF
• Someone to stay with patient and call
MD
 Bradycardias
• Rate <60
o Sinus, atrial,
junctional or
ventricular
• Causes
o Vagal stimulation, Remember: ALWAYS
drugs, physical
fitness, hypothermia,
Check your patient.
hypothyroidism
• Symptomatic vs.
Asymptomatic
Nurses Role
• Patient
Assessment
o Blood pressure
o Heart rate
o Level of
consciousness
o Meds?, Labs?
o Any symptoms…
 Pain
 Dyspnea
 diaphoresis
 Bradycardia-Treatment
• Asymptomatic
o No treatment, continue to observe,
notify MD
• Symptomatic (Urgent/Emergent)
o 1st drug of choice Atropine
 0.5 mg IV push
 If no response, repeat every 3-5
minutes to maximum dose of 3 mg
o Transcutaneous pacemaker
 Tachycardia
• Heart rate is greater than 100
• Causes
o Meds, fever, anxiety, emotional
extremes, hypotension, hypoxia,
CHF, stimulants (caffeine,nicotine)
• Symptomatic vs. Asymptomatic
• Narrow vs. Wide complex
Tachycardia: HR > 100
Nurses Role
• Patient
assessment:
o BP, HR, LOC,
meds, s/s
related to
decreased
cardiac output
• Urgent vs.
Emergent
Narrow QRS
Tachycardias
 URGENT:
Narrow QRS complex
• Assess patient!!! Reassess frequently if
rhythm continues (to assess for
deterioration)
• Report symptoms, VS, labs to MD for
orders
• DOCUMENT: EKG and VS/tolerance
• Possible medications to treat:
o Cardizem (10-20 mg IV push over 2 min,
then drip)
o Adenosine (6mg, 12mg, 12 mg)
o Amiodarone (150mg/100cc D5W over 10
min then follow with maintenance dose)
 EMERGENT:
Narrow QRS complex
• IF UNSTABLE:
o Prepare for synchronized
cardioversion
 Will need Consent
 Oh Say It Isn’t So – O2 sat,
Suction, IV, Intubation equip.,
Sedation
 Wide QRS Tachycardia

• Is it hemodynamically stable?
o Regular rate > 120 at rest
o Uniform (looks alike) QRS > 0.12 sec (3 sm
squares)
o No signs of impaired consciousness or tissue
perfusion

• It is hemodynamically unstable?
 URGENT:
Wide QRS Tachy
• Assess patient!!!!!
• Stable ??? (BP >90, no symptoms)
o Apply oxygen and start IV
o Have someone stay with patient and
call MD
o Reassess frequently
o Report symptoms, VS to MD for
orders!
 URGENT:
Wide QRS Tachy
• Possible medications:
 Amiodarone 150mg/100 cc D5W
over 10 min followed by
maintenance dose.
 Lidocaine 1mg/kg IV push
 Procainamide 20 mg/min (max
dose of 17 mg/kg)
 EMERGENT:
Wide QRS Tachy
• Assess patient!!!
• UNSTABLE??? Report
symptoms & VS to MD for orders
• Initiate appropriate procedures
o Call Code Blue
o Immediate unsynchronized
defibrillation
o Followed by immediate CPR
Nurses Role

• ALWAYS
assess the
patient
• Start IV
• Apply oxygen
• Stay with
patient
• Report
symptoms
and/or
changes to MD
 Lethal Rhythms
• Pulseless Ventricular tachycardia
(Vtach)
• Ventricular fibrillation (Vfib)
• Asystole
• Pulseless Electrical Activity (PEA)
 Lethal Rhythms
• Start CPR
• Call Code Blue
• Attach Defibrillator
• Intubate
• Start IV if needed
• ACLS Meds per Algorithms
• Notify Attending MD
 Pulseless Ventricular
Tachycardia

• Treatment:
o Defibrillate 200J (Biphasic)/360J
(Monophasic)
• Drugs:
o Epinephrine 1 mg IV push every 3-5
minutes
OR
Vasopressin 40 units IV push (single dose)
 Ventricular Fibrillation

• No definite QRS, chaotic electrical activity

• Treatment:
o Defibrillate 200J (Biphasic)/360J
(Monophasic)
• Drugs:
o Epinephrine 1 mg IV push every 3-5
minutes
OR
Vasopressin 40 units IV push (single
dose)
Ventricular Fibrillation

Coarse VF

Fine VF
Name That Rhythm…

Vfib (Torsade de Pointe)

Magnesium Sulfate
 Asystole

• Treatment:
o CPR
o Epinephrine 1 mg every 3-5 minutes
o Atropine 1 mg every 3-5 minutes to
max 3 mg
Pulseless Electrical Activity
• Can be any rhythm except VT, VF, or
asystole that Patient has NO PULSE.
• CANNOT determine PEA via ECG.
• Only patient assessment reveals no
pulse.
Pulseless Electrical Activity

• Treatment:
P Pulseless Pump (CPR)
E Electrical Epinephrine
A Activity Atropine
 TEST

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