Anda di halaman 1dari 49

3/27/2015

Dysrhythmias
Chapter36

Copyright2014byMosby,animprintof
ElsevierInc.

PropertiesofCardiacCells

Automaticity
Excitability
Conductivity
Contractility

Copyright 2014 by Mosby an imprint of Elsevier Inc

ConductionSystemoftheHeart

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

NervousSystemControl
ofHeart
Autonomicnervoussystemcontrols
Parasympatheticnervoussystem
DecreasesrateofSAnode
SlowsimpulseconductionofAVnode

Sympatheticnervoussystem
IncreasesrateofSAnode
IncreasesimpulseconductionofAVnode
Increasescardiaccontractility
Copyright 2014 by Mosby an imprint of Elsevier Inc

Dysrhythmias
Disorderofimpulseformation,
conductionofimpulses,orboth
SAnodenormalpacemakerofheart
(60100beats/minute)
Secondarypacemakers
AVnode(4060beats/minute)
HisPurkinjefibers(2040beats/minute)
Copyright 2014 by Mosby an imprint of Elsevier Inc

ElectrocardiogramMonitoring
Graphictracingofelectricalimpulses
producedbyheart
WaveformsofECGrepresentactivity
ofchargedionsacrossmembranesof
myocardialcells

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

ElectrocardiogramMonitoring

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright 2014 by Mosby an imprint of Elsevier Inc

12LeadECG

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

CaseStudy
iStockphoto/Thinkstock

S.D.isa45yearoldwomanwho
comestotheEDcomplainingof
suddenonsetofpalpitationsand
shortnessofbreath.
Standardprotocolrequiresyouto
obtaina12leadECGandattachS.D.to
thecardiacmonitorforcontinuous
monitoring.
Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

Describetheappropriatelocationto
applytheleadsforboththe5lead
cardiacmonitoraswellasthe12 lead
ECG.

Copyright 2014 by Mosby an imprint of Elsevier Inc

LeadPlacement

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

LeadPlacement

Copyright 2014 by Mosby an imprint of Elsevier Inc

ECGTimeandVoltage

Copyright 2014 by Mosby an imprint of Elsevier Inc

CalculatingHR
Count
NumberofQRScomplexesin1minute
RRintervalsin6seconds,andmultiplyby
10
NumberofsmallsquaresbetweenoneRR
interval,anddividethisnumberinto1500
NumberoflargesquaresbetweenoneRR
interval,anddividethisnumberinto300

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

AssessmentofCardiacRhythm

Copyright 2014 by Mosby an imprint of Elsevier Inc

PatientPreparation

Clipexcessivehaironchestwall
Rubskinwithdrygauze
Mayneedtousealcoholforoilyskin
Applyelectrodepad

Copyright 2014 by Mosby an imprint of Elsevier Inc

Artifact

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

TelemetryMonitoring
ObservationofHRandrhythmata
distantsite
Twotypes
Centralizedmonitoringsystem
Advancedalarmsystemalertswhenit
detectsdysrhythmias,ischemia,or
infarction

Copyright 2014 by Mosby an imprint of Elsevier Inc

AssessmentofCardiacRhythm
InterprettherhythmANDevaluatethe
clinicalstatusofthepatient
Isthepatienthemodynamically
stable?
Determinecauseofdysrhythmia
Treatthepatient,notthemonitor!

Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

TheUAPobtainsthe12leadECG
recordingforS.D.whileyouprintouta
rhythmstripfromthecardiacmonitor.
Describethemethodyouwoulduseto
assessS.D.srhythmstrip.

Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

AssessmentofCardiacRhythm
1.
2.
3.
4.
5.
6.
7.
8.

Pwave
Atrialrateandrhythm
PRinterval
Ventricularrateandrhythm
QRScomplex
STsegment
QTinterval
Twave
Copyright 2014 by Mosby an imprint of Elsevier Inc

NormalSinusRhythm
Sinusnodefires60100beats/minute
Followsnormalconductionpattern

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintofElsevierInc.

3/27/2015

SinusBradycardia

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

SinusBradycardia
Normalrhythminaerobicallytrained
athletesandduringsleep
Canoccurinresponseto
parasympatheticnervestimulation
andcertaindrugs
Alsoassociatedwithsomedisease
states
Copyright 2014 by Mosby an imprint of Elsevier Inc

3/27/2015

SinusBradycardia
Manifestations

Hypotension
Pale,coolskin
Weakness
Angina
Dizzinessorsyncope
Confusionordisorientation
Shortnessofbreath
Copyright 2014 by Mosby an imprint of Elsevier Inc

SinusBradycardia
Treatment
Atropine
Pacemaker
Stopoffendingdrugs

Copyright 2014 by Mosby an imprint of Elsevier Inc

AudienceResponseQuestion
Apatientscardiacrhythmissinusbradycardiawith
aheartrateof34beats/minute.Ifthebradycardiais
symptomatic,thenursewouldexpectthepatient
toexhibit
a. Palpitations.
b. Hypertension.
c. Warm,flushedskin.
d. Shortnessofbreath.

Copyright 2014 by Mosby an imprint of Elsevier Inc

10

3/27/2015

SinusTachycardia

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

SinusTachycardia
Causedbyvagalinhibitionor
sympatheticstimulation
Associatedwithphysiologicand
psychologicstressors
Drugscanincreaserate

Copyright 2014 by Mosby an imprint of Elsevier Inc

11

3/27/2015

SinusTachycardia
Manifestations

Dizziness
Dyspnea
Hypotension
Angina inpatientswithCAD

Copyright 2014 by Mosby an imprint of Elsevier Inc

SinusTachycardia
Treatment
Guidedbycause(e.g.,treatpain)
Vagalmaneuver
adrenergicblockers

Copyright 2014 by Mosby an imprint of Elsevier Inc

PrematureAtrialContraction

Copyright 2014 by Mosby an imprint of Elsevier Inc

12

3/27/2015

PrematureAtrialContraction
Contractionoriginatingfromectopic
focusinatriuminlocationotherthan
SAnode
Travelsacrossatriabyabnormal
pathway,creatingdistortedPwave
Maybestopped,delayed,orconducted
normallyattheAVnode
Copyright 2014 by Mosby an imprint of Elsevier Inc

PrematureAtrialContraction
Causes

Stress
Fatigue
Caffeine
Tobacco
Alcohol
Hypoxia
Electrolyteimbalance
Diseasestates

Copyright 2014 by Mosby an imprint of Elsevier Inc

PrematureAtrialContraction
Manifestations
Palpitations
Heartskipsabeat

Treatment
Monitorformoreseriousdysrhythmias
Withholdsourcesofstimulation
adrenergicblockers
Copyright 2014 by Mosby an imprint of Elsevier Inc

13

3/27/2015

ParoxysmalSupraventricular
Tachycardia(PSVT)

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

ParoxysmalSupraventricular
Tachycardia(PSVT)
Reentrantphenomenon:PACtriggersa
runofrepeatedprematurebeats
Paroxysmalreferstoanabruptonset
andtermination
Associatedwithoverexertion,stress,
deepinspiration,stimulants,disease,
digitalistoxicity

Copyright 2014 by Mosby an imprint of Elsevier Inc

14

3/27/2015

ParoxysmalSupraventricular
Tachycardia(PSVT)
Manifestations
HRis150220beats/minute(addfor
clarification)
HR>180leadstodecreasedcardiac
outputandstrokevolume
Hypotension
Dyspnea
Angina
Copyright 2014 by Mosby an imprint of Elsevier Inc

ParoxysmalSupraventricular
Tachycardia(PSVT)
Treatment

Vagalstimulation
IVadenosine
IVadrenergicblockers
Calciumchannelblockers
Amiodarone
DCcardioversion

Copyright 2014 by Mosby an imprint of Elsevier Inc

AtrialFlutter

Copyright 2014 by Mosby an imprint of Elsevier Inc

15

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

AtrialFlutter
Typicallyassociatedwithdisease
Symptomsresultfromhighventricular
rateandlossofatrialkick
decreasedCO heartfailure
Increasesriskofstroke

Copyright 2014 by Mosby an imprint of Elsevier Inc

AtrialFlutter
Treatment
Pharmacologicagent
Electricalcardioversion
Radiofrequencyablation

Copyright 2014 by Mosby an imprint of Elsevier Inc

16

3/27/2015

CaseStudy
iStockphoto/Thinkstock

S.D.sECGrevealsatrialfibrillation
witharapidventricularresponse
(HR=168).
DescribewhatS.D.srhythmwould
looklike.
Whatmightbethecauseofthis
dysrhythmiaforS.D.?
Copyright 2014 by Mosby an imprint of Elsevier Inc

AtrialFibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

AtrialFibrillation

Paroxysmalorpersistent
Mostcommondysrhythmia
Prevalenceincreaseswithage
Usuallyoccursinpatientswith
underlyingheartdisease
Canalsooccurwithotherdisease
states
Copyright 2014 by Mosby an imprint of Elsevier Inc

17

3/27/2015

Copyright2014byMosby,animprintofElsevierInc.

CaseStudy
iStockphoto/Thinkstock

S.D.sbloodpressureis94/58withHR
of168.
Whattreatmentmightyouexpectthe
healthcareprovidertoinitiallyorder
forS.D.satrialfibrillation?

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

18

3/27/2015

AtrialFibrillation
Aswithatrialflutter causesa
decreaseinCOandanincreasedriskof
stroke

Copyright 2014 by Mosby an imprint of Elsevier Inc

AtrialFibrillation
Treatment
Drugstocontrolventricularrateand/or
converttosinusrhythm(amiodaroneand
ibutilide mostcommon)
Electricalcardioversion
Anticoagulation
Radiofrequencyablation
Mazeprocedurewithcryoablation

Copyright 2014 by Mosby an imprint of Elsevier Inc

JunctionalDysrhythmias
Dysrhythmiasthatoriginateinareaof
AVnode
SAnodehasfailedtofire,orimpulse
hasbeenblockedattheAVnode
AVnodebecomespacerretrograde
transmissionofimpulsetoatria
AbnormalPwave;normalQRS
Associatedwithdisease,certaindrugs
Copyright 2014 by Mosby an imprint of Elsevier Inc

19

3/27/2015

JunctionalDysrhythmias

Copyright 2014 by Mosby an imprint of Elsevier Inc

JunctionalDysrhythmia
Servesassafetymechanismdonot
suppress
Ifrhythmsarerapid,mayresultin
reductionofCO
Treatifpatientissymptomatic
Atropineforescaperhythm
Correctcause
Drugstoreducerateiftachycardia
Copyright 2014 by Mosby an imprint of Elsevier Inc

FirstDegreeAVBlock

Copyright 2014 by Mosby an imprint of Elsevier Inc

20

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

FirstDegreeAVBlock
Associatedwithdiseasestatesand
certaindrugs
Typicallynotserious
Patientsasymptomatic
Notreatment
Monitorforchangesinheartrhythm

Copyright 2014 by Mosby an imprint of Elsevier Inc

SecondDegreeAVBlock,
Type1(MobitzI,Wenckebach)

Copyright 2014 by Mosby an imprint of Elsevier Inc

21

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

SecondDegreeAVBlock,
Type1(MobitzI,Wenckebach)

MayresultfromdrugsorCAD
Typicallyassociatedwithischemia
Usuallytransientandwelltolerated
Treatifsymptomatic
Atropine
Pacemaker

Ifasymptomatic,monitorclosely
Copyright 2014 by Mosby an imprint of Elsevier Inc

SecondDegreeAVBlock,
Type2(MobitzII)

Copyright 2014 by Mosby an imprint of Elsevier Inc

22

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

SecondDegreeAVBlock,
Type2(MobitzII)
Associatedwithheartdiseaseanddrug
toxicity
Oftenprogressiveandresultsin
decreasedCO
Treatwithpacemaker

Copyright 2014 by Mosby an imprint of Elsevier Inc

ThirdDegreeAVHeartBlock
(CompleteHeartBlock)

Copyright 2014 by Mosby an imprint of Elsevier Inc

23

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

ThirdDegreeAVHeartBlock
(CompleteHeartBlock)
Associatedwithsevereheartdisease,
somesystemicdiseases,certaindrugs
UsuallyresultsindecreasedCO
Canleadtosyncope,HF,shock
Treatwithpacemaker
Drugstoincreaseheartrateifneeded
whileawaitingpacing
Copyright 2014 by Mosby an imprint of Elsevier Inc

PrematureVentricularContractions

Copyright 2014 by Mosby an imprint of Elsevier Inc

24

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

Copyright2014byMosby,animprintof
ElsevierInc.

PrematureVentricularContractions
Associatedwithstimulants,electrolyte
imbalances,hypoxia,heartdisease
NotharmfulwithnormalheartbutCO
reduction,angina,andHFindiseased
heart
Assessapicalradialpulsedeficit

Copyright 2014 by Mosby an imprint of Elsevier Inc

25

3/27/2015

PrematureVentricularContractions
Treatment
Correctcause
Antidysrhythmics

Copyright 2014 by Mosby an imprint of Elsevier Inc

AudienceResponseQuestion
Apatienthasadiagnosisofacutemyocardialinfarction,and
hiscardiacrhythmissinusbradycardiawith6to8
prematureventricularcontractions(PVCs)perminute.The
patternthatthenurserecognizesasthemostcharacteristic
ofPVCsis
a.
b.
c.
d.

Anirregularrhythm.
AninvertedTwave.
Awide,distortedQRScomplex.
AnincreasinglylongPRinterval.

Copyright 2014 by Mosby an imprint of Elsevier Inc

VentricularTachycardia

Copyright 2014 by Mosby an imprint of Elsevier Inc

26

3/27/2015

Copyright2014byMosby,animprintof
ElsevierInc.

VentricularTachycardia
Ectopicfocitakeoveraspacemaker
Monomorphic,polymorphic,
sustained,andnonsustained
Consideredlifethreateningbecauseof
decreasedCOandthepossibilityof
deteriorationtoventricularfibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

VentricularTachycardia
TorsadesdePointes

Copyright 2014 by Mosby an imprint of Elsevier Inc

27

3/27/2015

VentricularTachycardia
Associatedwithheartdisease,electrolyte
imbalances,drugs,CNSdisorder
Canbestable(patienthasapulse)or
unstable(pulseless)
SustainedVTcausesseveredecreaseinCO
Hypotension,pulmonaryedema,decreased
cerebralbloodflow,cardiopulmonaryarrest

Copyright 2014 by Mosby an imprint of Elsevier Inc

VentricularTachycardia
Precipitatingcausesmustbeidentified
andtreated(e.g.,hypoxia)
VTwithpulse(stable)treatedwith
antidysrhythmics orcardioversion
PulselessVTtreatedwithCPRand
rapiddefibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

AcceleratedIdioventricularRhythm
(AIVR)
Developswhentheintrinsicpacemaker
rate(SAnodeorAVnode)becomesless
thanthatofventricularectopicpacemaker
Rateisbetween40and100beats/minute
Atropineifpatientsymptomatic
Temporarypacing
Donotsuppressrhythm

Copyright 2014 by Mosby an imprint of Elsevier Inc

28

3/27/2015

VentricularFibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

VentricularFibrillation
AssociatedwithMI,ischemia,disease
states,procedures
Unresponsive,pulseless,andapneic
Ifnottreatedrapidly,deathwillresult
TreatwithimmediateCPRandACLS
Defibrillation
Drugtherapy(epinephrine,vasopressin)
Copyright 2014 by Mosby an imprint of Elsevier Inc

29

3/27/2015

AudienceResponseQuestion
Apatientinthecoronarycareunitdevelopsventricular
fibrillation.Thefirstactionthenurseshouldtakeisto
a.
b.
c.
d.

Performdefibrillation.
Initiatecardiopulmonaryresuscitation.
Prepareforsynchronizedcardioversion.
AdministerIVantidysrhythmicdrugsperprotocol.

Copyright 2014 by Mosby an imprint of Elsevier Inc

Asystole
Representstotalabsenceofventricular
electricalactivity
Noventricularcontraction
Patientunresponsive,pulseless,
apneic
Mustassessinmorethanonelead

Copyright 2014 by Mosby an imprint of Elsevier Inc

Copyright2014byMosby,animprintof
ElsevierInc.

30

3/27/2015

Asystole
Usuallyresultofadvancedcardiac
disease,severeconduction
disturbance,orendstageHF
TreatwithimmediateCPRandACLS
measures
Epinephrine and/orvasopressin
Intubation

Poorprognosis
Copyright 2014 by Mosby an imprint of Elsevier Inc

PulselessElectricalActivity
Electricalactivitycanbeobservedon
theECG,butnomechanicalactivityof
theventriclesisevident,andthe
patienthasnopulse
Prognosisispoorunlessunderlying
causequicklyidentifiedandtreated

Copyright 2014 by Mosby an imprint of Elsevier Inc

PulselessElectricalActivity
HsandTsPneumonic
Hypovolemia
Hypoxia
Hydrogenion
(acidosis)
Hyper/hypokalemia
Hypoglycemia
Hypothermia

Toxins
Tamponade(cardiac)
Thrombosis(MIand
pulmonary)
Tension
pneumothorax
Trauma

Copyright 2014 by Mosby an imprint of Elsevier Inc

31

3/27/2015

PulselessElectricalActivity
Treatment
CPRfollowedbyintubationandIV
epinephrine
Treatmentisdirectedtowardcorrection
oftheunderlyingcause

Copyright 2014 by Mosby an imprint of Elsevier Inc

SuddenCardiacDeath(SCD)
Deathfromacardiaccause
MajorityofSCDsresultfrom
ventriculardysrhythmias
Ventriculartachycardia
Ventricularfibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

Prodysrhythmia
Lifethreateningdysrhythmiascaused
byantidysrhythmiadrugs
SevereLVdysfunctionincreasesrisk
DigoxinandclassIA,IC,andIII
antidysrhythmiadrugs
Mostsusceptiblefirstfewdaysofdrug
therapy
Copyright 2014 by Mosby an imprint of Elsevier Inc

32

3/27/2015

Defibrillation
TreatmentofchoiceforVFandpulseless
VT
Mosteffectivewhencompletedwithin2
minutesofdysrhythmiaonset
PassageofDCelectricalshockthroughthe
hearttodepolarizecellsofmyocardium
AllowsSAnodetoresumepacemakerrole

Copyright 2014 by Mosby an imprint of Elsevier Inc

Defibrillation
Monophasicdefibrillatorsdeliver
energyinonedirection
Biphasicdefibrillatorsdeliverenergyin
twodirections
Uselowerenergies
FewerpostshockECGabnormalities

Copyright 2014 by Mosby an imprint of Elsevier Inc

Defibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

33

3/27/2015

Defibrillation
Outputismeasuredinjoulesorwatts
persecond
Recommendedenergyforinitial
shocksindefibrillation
Biphasic:120to200joules
Monophasic:360joules

ImmediateCPRafterfirstshock
Copyright 2014 by Mosby an imprint of Elsevier Inc

Defibrillation

Copyright 2014 by Mosby an imprint of Elsevier Inc

Defibrillation
1. StartCPRwhileobtainingandsetting
updefibrillator
2. Turnonandselectenergy
3. Makesuresyncbuttonisturnedoff
4. Applygelpads
5. Charge
6. Positionpaddlesfirmlyonchest
7. EnsureAllclear!!!!!
8. Delivercharge
Copyright 2014 by Mosby an imprint of Elsevier Inc

34

3/27/2015

CaseStudy
iStockphoto/Thinkstock

S.D.wasadmittedtothetelemetry
unitandanIVamiodaronedripwas
started.
Thepurposeofthedrugwastoconvert
heratrialfibrillationtonormalsinus
rhythm.

Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

Althoughherheartratehasdecreased
to108beats/minute,sheremainsin
atrialfibrillation24hourslater.
Acardiologistwasconsultedand
electricalcardioversionisplanned.

Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

WhatwouldyouteachS.D.aboutthe
scheduledprocedure?
Whatarethreedifferencesbetween
defibrillationandcardioversion?

Copyright 2014 by Mosby an imprint of Elsevier Inc

35

3/27/2015

SynchronizedCardioversion
Choiceoftherapyforventricular(VT
withapulse)orsupraventricular
tachydysrhythmias
Synchronizedcircuitdeliversa
countershockontheRwaveofthe
QRScomplexoftheECG

Copyright 2014 by Mosby an imprint of Elsevier Inc

SynchronizedCardioversion
Proceduresimilartodefibrillation
exceptsyncbuttonturnedON
Ifpatientstable,sedateprior
Initialenergylower
7075joules(biphasic)
100joules(monophasic)

Ifpatientbecomespulseless,turnsync
buttonoffanddefibrillate
Copyright 2014 by Mosby an imprint of Elsevier Inc

ImplantableCardioverter
Defibrillator(ICD)
Appropriateforpatientswho
HavesurvivedSCD
HavespontaneoussustainedVT
Havesyncopewithinducibleventricular
tachycardia/fibrillationduringEPS
Areathighriskforfuturelifethreatening
dysrhythmias

Decreasesmortality
Copyright 2014 by Mosby an imprint of Elsevier Inc

36

3/27/2015

ImplantableCardioverter
Defibrillator(ICD)
Consistsofaleadsystemplacedvia
subclavianveintotheendocardium
Batterypoweredpulsegeneratoris
implantedsubcutaneously
SensingsystemmonitorsHRand
rhythm delivering25joulesorlessto
heartwhendetectslethaldysrhythmia
Copyright 2014 by Mosby an imprint of Elsevier Inc

ImplantableCardioverter
Defibrillator(ICD)

Copyright 2014 by Mosby an imprint of Elsevier Inc

ImplantableCardioverter
Defibrillator(ICD)
Includesantitachycardiaand
antibradycardiapacemakers
Overdrivepacingfortachycardias
Backuppacingforbradycardias

Preprocedureandpostprocedurecare
sameaspacemaker

Copyright 2014 by Mosby an imprint of Elsevier Inc

37

3/27/2015

ImplantableCardioverter
Defibrillator(ICD)
Varietyofemotionsarepossible

Fearofbodyimagechange
Fearofrecurrentdysrhythmias
ExpectationofpainwithICDdischarge
Anxietyaboutgoinghome

ParticipationinanICDsupportgroup
shouldbeencouraged
Copyright 2014 by Mosby an imprint of Elsevier Inc

ImplantableCardioverter
Defibrillator(ICD)
PatientandCaregiverTeaching
1.
2.
3.
4.
5.
6.
7.

Followupappointments
Incisioncare
Armrestrictions
Sexualactivity
Driving
Avoiddirectblows
Avoidlargemagnets,MRI
Copyright 2014 by Mosby an imprint of Elsevier Inc

ImplantableCardioverter
Defibrillator(ICD)
PatientandCaregiverTeaching
8.
9.
10.
11.
12.
13.

Airtravel
Avoidantitheftdevices
WhattodoifICDfires
MedicAlertID
ICDidentificationcard
CaregiverstolearnCPR

Copyright 2014 by Mosby an imprint of Elsevier Inc

38

3/27/2015

Pacemakers
Usedtopacetheheartwhenthe
normalconductionpathwayis
damaged
Pacingcircuitconsistsof
Programmablepulsegenerator(power
source)
Oneormoreconducting(pacing)leadsto
myocardium

Copyright 2014 by Mosby an imprint of Elsevier Inc

PacemakerSpike

Copyright 2014 by Mosby an imprint of Elsevier Inc

Pacemakers
Paceatriumand/oroneorbothof
ventricles
Mostpaceondemand, firingonlywhen
HRdropsbelowpresetrate
Sensingdeviceinhibitspacemakerwhen
HRadequate
PacingdevicetriggerswhennoQRS
complexeswithinsettimeframe

Copyright 2014 by Mosby an imprint of Elsevier Inc

39

3/27/2015

Pacemakers
Antitachycardiapacing:deliveryofa
stimulustotheventricletoterminate
tachydysrhythmias
Overdrivepacing:pacingtheatriumat
ratesof200500impulses/minuteto
terminateatrialtachycardias

Copyright 2014 by Mosby an imprint of Elsevier Inc

Pacemaker

Copyright 2014 by Mosby an imprint of Elsevier Inc

Pacemakers
Cardiacresynchronizationtherapy
(CRT)
Resynchronizesthecardiaccycleby
pacingbothventricles
Biventricularpacing
Usedtotreatpatientswithheartfailure
CanbecombinedwithICDformaximum
therapy
Copyright 2014 by Mosby an imprint of Elsevier Inc

40

3/27/2015

TemporaryPacemakers
Powersourceoutsidethebody
Transvenous
Epicardial
Transcutaneous

Copyright 2014 by Mosby an imprint of Elsevier Inc

TemporaryTransvenousPacemaker

Copyright 2014 by Mosby an imprint of Elsevier Inc

EpicardialPacing
Leadsplacedonepicardiumduring
heartsurgery
Passedthroughchestwalland
attachedtoexternalpowersourceas
needed

Copyright 2014 by Mosby an imprint of Elsevier Inc

41

3/27/2015

TranscutaneousPacing
Foremergentpacingneeds
Noninvasive
Bridgeuntiltransvenouspacercanbe
inserted
Uselowestcurrentthatwillcapture
Patientmayneedanalgesia/sedation

Copyright 2014 by Mosby an imprint of Elsevier Inc

TranscutaneousPacing

Fig109.Anterioposteriorplacementofadhesiveelectrodepadsfordefibrillationortranscutaneouspacing.
From:Soleetal.IntroductiontoCriticalCareNursing,5thEdition.W.B.Saunders

Copyright 2014 by Mosby an imprint of Elsevier Inc

TemporaryPacemaker

Copyright 2014 by Mosby an imprint of Elsevier Inc

42

3/27/2015

Pacemakers
ECGmonitoringformalfunction
Failuretosense
Causesinappropriatefiring

Failuretocapture
Lackofpacingwhenneededleadsto
bradycardiaorasystole

Copyright 2014 by Mosby an imprint of Elsevier Inc

Pacemakers
Monitorforothercomplications

Infection
Hematomaformation
Pneumothorax
Atrialorventricularseptumperforation
Leadmisplacement

Copyright 2014 by Mosby an imprint of Elsevier Inc

Pacemakers
Postprocedurecare
OOBoncestable
Limitarmandshoulderactivity
Monitorinsertionsiteforbleedingand
infection
Patientteachingimportant

Copyright 2014 by Mosby an imprint of Elsevier Inc

43

3/27/2015

Pacemakers
PatientandCaregiverTeaching
Followupappointments
forpacemakerfunction
checks
Incisioncare
Armrestrictions
Avoiddirectblows
Avoidhighoutput
generator

NoMRIsunlesspacer
approved
MicrowavesOK
Avoidantitheftdevices
Airtravel
Monitorpulse
PacemakerIDcard
MedicAlertID

Copyright 2014 by Mosby an imprint of Elsevier Inc

RadiofrequencyCatheter
AblationTherapy
Electrodetippedablationcatheter
burnsaccessorypathwaysorectopic
sitesintheatria,AVnode,and
ventricles
Nonpharmacologictreatmentof
choiceforseveralatrialdysrhythmias
Postcaresimilartocardiac
catheterization
Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

S.D.selectricalcardioversionwas
successful.
S.D.ssinusrhythmhasremained
stablefor24hoursandsheisreadyto
gohome.

Copyright 2014 by Mosby an imprint of Elsevier Inc

44

3/27/2015

CaseStudy
iStockphoto/Thinkstock

Asyouenterherroomtoprovide
dischargeteaching,shetellsyousheis
experiencingsomechestheaviness
andtightnessrightunderherbreast
bone.

Copyright 2014 by Mosby an imprint of Elsevier Inc

CaseStudy
iStockphoto/Thinkstock

YouasktheUAPtoobtaina12lead
ECGwhileyounotifyS.D.shealthcare
provider.
WhatspecificECGchangewillyoube
lookingfortodetermineifS.D.schest
painisrelatedtocardiacischemia?
Injury?Infarction?

Copyright 2014 by Mosby an imprint of Elsevier Inc

ECGChangesAssociatedWithAcute
CoronarySyndrome(ACS)

Copyright 2014 by Mosby an imprint of Elsevier Inc

45

3/27/2015

ECGChangesAssociatedWithAcute
CoronarySyndrome(ACS)
Ischemia
STsegmentdepressionand/orTwave
inversion
STsegmentdepressionissignificantifit
isatleast1mm(onesmallbox)belowthe
isoelectricline
Changesreversewhenadequateblood
flowisrestoredtomyocardium
Copyright 2014 by Mosby an imprint of Elsevier Inc

ChangesAssociatedWith
MyocardialIschemia

Copyright 2014 by Mosby an imprint of Elsevier Inc

ECGChangesAssociatedWithAcute
CoronarySyndrome(ACS)
Injury
STsegmentelevationoccurs
Significantif>1mmabovetheisoelectric
line

Iftreatmentispromptandeffective,may
avoidorlimitinfarction
Absenceofserumcardiacmarkersconfirms
noinfarction

Copyright 2014 by Mosby an imprint of Elsevier Inc

46

3/27/2015

ChangesAssociatedWithInjury

Copyright 2014 by Mosby an imprint of Elsevier Inc

ECGChangesAssociatedWithAcute
CoronarySyndrome(ACS)
Infarction
PhysiologicQwaveisthefirstnegative
deflectionfollowingthePwave
Smallandnarrow(<0.04secondinduration)

PathologicQwaveisdeepand>0.03
secondinduration

Copyright 2014 by Mosby an imprint of Elsevier Inc

ChangesAssociatedWithInfarction

Copyright 2014 by Mosby an imprint of Elsevier Inc

47

3/27/2015

ECGFindingWith
AnterolateralWallMI

Copyright 2014 by Mosby an imprint of Elsevier Inc

Syncope
Brieflapseinconsciousnessaccompanied
byalossinposturaltone(fainting)
Noncardiovascularcauses

Stress
Hypoglycemia
Dehydration
Stroke
Seizure
Copyright 2014 by Mosby an imprint of Elsevier Inc

Syncope
Cardiovascularcauses
Cardioneurogenicorvasovagalsyncope
Carotidsinussensitivity

Dysrhythmias(tachycardias,
bradycardias)
Prostheticvalvemalfunction
Pulmonaryemboli
HF

Copyright 2014 by Mosby an imprint of Elsevier Inc

48

3/27/2015

Syncope
Diagnosticstudies

Echocardiography
Stresstest
EPS
Headup,tilttest
Toassessforcardioneurogenicsyncope
Abnormalresponsetopositionchange
causesparadoxicvasodilationand
bradycardia(vasovagalresponse)
Copyright 2014 by Mosby an imprint of Elsevier Inc

49