Dysrhythmias ✅ Flashcards
(151 cards)
1
Q
what is the main thing to consider when it comes to bradycardia?
A
is it symptomatic or not
think about the pts age and what they are doing
2
Q
List signs of symptomatic bradycardia (9)
A
1) change in mental status (confusion)
2) poor capillary refill
3) pallor
4) warm/clammy skin
5) cold fingers & toes
6) decrease in BP (hypotensive)
7) change in RR
8) orthostasis (dizziness when rising)
9) decrease in urine output
3
Q
why do we see a decrease in urine output in sinus bradycardia?
A
the kidneys want to hold on to the fluid we have
4
Q
list causes of sinus bradycardia (5)
A
1) lower metabolic needs (sleep)
2) vagal stimulation (anything that causes pt to bear down)
3) medications → BBs, CCBs, & Digoxin (add on med)
4) increased ICP
5) myocardial infarction
5
Q
what is used to tx symptomatic bradycardia and what does it do?
A
Atropine → blocks the parasympathetic nervous system
6
Q
Give an example of a time Atropine is used
A
During a code (when pt is having symptomatic bradycardia) → used when pt is really starting to decompensate
7
Q
how is Atropine given?
A
1 mg IV push → given like a bolus
8
Q
Nursing management of sinus bradycardia?
A
1) assess pt for sx
2) may require pacing (pacemaker)
3) meds: atropine; may also require epinephrine or dopamine
9
Q
what is sinus arrhythmia?
A
sinus nose impulse at irregular rhythm
10
Q
what is sinus arrhythmia associated with & how?
A
Associated with the respiratory cycle
- will slow with exhalation
- will increase with inspiration
11
Q
what cause of sinus bradycardia can also cause sinus arrhythmia?
A
Vagal stimulation (good vagal tone)
- increased vagal stimulation will decrease HR
12
Q
does sinus arrhythmia reflect normal or abnormal cardiac function?
A
normal cardiac function
13
Q
who is sinus arrhythmia more commonly seen in?
A
more common among kids & young adults
14
Q
how is sinus arrhythmia depicted on strip?
A
RR interval will vary
There is a P wave for every QRS
15
Q
list causes of sinus tachycardia (3)
A
1) stress → physiologic (fever) or psychological
2) medications that stimulate sympathetic response → stimulants (ADHD meds) or illicit drugs (cocaine, amphetamines)
3) conditions such as thyroid disease & anemia
16
Q
how does sinus tachycardia impact diastolic filling time?
A
it decreases
17
Q
what can sinus tachycardia cause overtime? (2)
A
1) pulmonary edema
2) cardiac ischemia
18
Q
what is the management for sinus tachycardia?
A
tx the cause
19
Q
What is Ectopy?
A
describe heartbeats that originate from an area other than the heart’s natural pacemaker (SA node). Can be benign or can be a problem
20
Q
What is Foci?
A
areas within the heart that are not the normal pacemaker (sinoatrial node) but can initiate electrical impulses
21
Q
What can foci lead to?
A
premature heartbeats or arrhythmias
22
Q
Where can foci be located? (3)
A
in the atria, AV junction , or ventricles
23
Q
List two examples of ectopic beats
A
1) PVC (premature ventricular complex)
2) PAC (premature atrial complex)
24
Q
Foci is more often than not what?
A
scar tissue
25
What occurs in PAC?
premature activation of the atria
- an early heartbeat originating from an ectopic foci in the atria, instead of the sinoatrial (SA) node, disrupting the normal sinus rhythm.
26
what is the clinical significance of PAC?
Usually no significance, typically benign and do not cause any problems
Can occur in anyone
27
List causes of PAC (5)
1) caffeine
2) smoking
3) alcohol
4) myocardial infarction
5) COPD
28
what are the clinical manifestations of PAC?
Can be asymptomatic or feel like a skipped beat
29
how is PAC depicted on strip?
P wave will look different
Shortened PR interval
30
List an example of when a PAC can occur
drinking a coffee and then feeling a skipped beat
31
what is the tx for PACs?
loop monitor that could be placed under the skin ; but usually do not need Tx
32
what is the patho of a-fib?
multiple **ectopic foci**, often originating in the **pulmonary veins**, override the SA node
This causes the atria to depolarize rapidly and erratically (up to 300–600 bpm; not good beating just fibrillating)
Leads to **incomplete atrial contraction.**
33
In a-fib, why do we never see a ventricular rate of 300 bpm?
The **AV node** filters many of these impulses, so the ventricles beat more slowly, but still irregularly (often 100–175 bpm).
34
how is a-fib depicted on the strip?
1) Rhythm is irregularly irregular
2) NO P WAVES
3) Rate can be uncontrolled greater than 100 (tachycardia)
4) Rate is considered controlled if under 100
**no organized activity on ECG**
35
why is there no P waves in a-fib?
there is no atrial kick
36
how does a-fib affect cardiac output?
decreases cardiac output since there is not an atrial kick (atrial kick accounts for 30% CO)
37
what happens to blood in a-fib?
- In the **left atrial appendage**, blood pools and becomes stagnant (it does not move)
- We have stasis that can lead to infection or clots
38
List causes of a-fib (5)
1) **HTN**
2) **Hyperthyroidism**
3) Valvular heart disease
4) Heart failure
5) Cardiac surgery
39
In a-fib, the AV node does a good job NOT letting every beat through, but there is what?
a lot of artifact
40
If a patient comes in with A-fib and does not have any risk factors noticeable it may be the precursor to diagnosing what?
hyperthyroidism
41
why can hyperthyroidism cause a-fib?
it increases sympathetic activity
42
what are the tx goals for a-fib?
Treatment is based on three major concepts:
1) **Priority** goal is stroke prevention → anticoags
2) Heart rate control
3) Return to sinus rhythm → cardioversion or medications
43
Why are pts in a-fib put on anti-coagulants?
when blood pools in left atrial appendage, clots form and can rupture and travel (embolus)
can go to the brain & cause strokes
44
what % of strokes are caused by a-fib?
15%
45
In what types of a-fib is anticoagulation essential?
Sustained a-fib
Paroxysmal a-fib
46
what is the difference in sustained a-fib and paroxysmal a-fib?
Sustained a-fib → over 7 days
Paroxysmal a-fib → under 7 days
47
What anticoagulants can be used for pts w a-fib? (7)
1) Warfarin (Coumadin)
2) Dabigatran (Pradaxa)
3) Apixaban (Eliquis)
4) Rivaroxaban (Xarelto)
5) Edoxaban (Savaysa)
6) Heparin
7) Enoxaparin (Lovenox)
48
what is the antidote for warfarin?
vitamin K (antagonist)
49
what levels need to be checked for pts on warfarin? what should they be?
PT/INR should be checked every month
Range should be 2-3
50
what should be avoided when taking warfarin? (2)
leafy green vegetables
alcohol
51
what bridge therapy is done when putting a pt on warfarin?
take heparin and warfarin simultaneously until the warfarin kicks in after 5 days
52
what anticoagulant needs to stay in the brown bottle it comes in and CANNOT go in pill boxes?
Dabigatran (Pradaxa)
53
do the DOACs need blood monitoring?
NO
they do not cause as much bleeding as warfarin
54
half life of DOACs?
short
55
what is the antidote for heparin?
protamine sulfate
56
what labs need to be monitored for heparin?
aPTT
57
what can heparin cause?
diff types of thrombocytopenia
58
what is Enoxaparin (Lovenox) also known as?
low molecular weight heparin
59
how is enoxaparin given?
subq injection
60
enoxaparin does not affect the ______ as much as heparin
platelets
61
what meds are used for rate control in a-fib?
1) Beta Blockers (metoprolol)
2) Calcium Channel Blockers (Diltiazem)
3) Digoxin (not used first line, only as an add on)
62
what is important to note about the type of CCBs used in a-fib?
Dihydropyridines → do NOT affect HR and will NOT help us here (anything that ends in "pine" will not affect HR, like amlodipine & nifedipine)
Non-dihydropyridines → Diltiazem is a CCB that is used for A-fib because it will affect HR
63
what is usually the first tx for a-fib that all pts are usually given the opportunity to receive?
what is the contraindication?
Cardioversion
If the left atrial appendage was NOT checked for a clot, it must be done BEFORE cardioversion!!
64
how is the left atrial appendage checked for a clot?
Transesophageal Echo (TEE)
- Place the probe down the esophagus to be able to see the left atrial appendage
65
what happens if a clot is seen on TEE?
the pt MUST be put on an anti-coag for at least 3 weeks for the clot to begin to dissolve
66
what type of shock is given during cardioversion vs defibrillation?
cardioversion → synchronized shock
defibrillation → unsynchronized shock
67
what kind of rhythms is cardioversion used for vs defibrillation?
cardioversion → organized but abnormal rhythms
defibrillation → deadly, disorganized rhythms
68
list 4 dysrhythmias cardioversion would be used for
1) a-fib
2) a-flutter
3) SVT
4) ventricular tachycardia **WITH** a pulse
69
list 2 dysrhythmias defibrillation would be used for
1) v-fib
2) ventricular tachycardia **WITHOUT** a pulse
70
cardioversion shock will NOT occur until when?
until it hits an R wave (synchronized with the R wave)
71
what is the timing of shock from defibrillation?
delivered immediately without synchronization
72
what is the pt status when cardioversion is used vs defibrillation?
cardioversion → pt often conscious; requires sedation
defibrillation → pt is unresponsive, pulseless, usually not breathing
73
what med is typically used for sedation for cardioversion?
Propofol → sedates in 40 sec & lasts 6 min
74
what is the goal of cardioversion?
restore a normal sinus rhythm
75
In regards to a-fib pts, what does it mean when we say the goal of cardioversion is to restore a normal sinus rhythm?
we want to get the SA node to kick back in again
76
what is the goal of defibrillation?
to stop chaotic activity so the heart's natural pacemaker can restart
77
what are 2 treatments used to **maintain** sinus rhythm in afib?
1) cardiac radio-frequency ablation
2) anti-arrhythmic medications
78
what does cardiac radio-frequency ablation do?
Eliminate foci that is causing the arrhythmia (hopefully tries to put patient back into sinus rhythm forever)
79
what anti-arrhythmic med is used for a-fib?
**Amiodarone**
- will hopefully keep patient in sinus rhythm
- usually only seen in very symptomatic A-fib patients when benefits outweigh the risks
80
1) what can the watchman be used for?
2) what is it designed to do?
3) what kind of device?
4) how do we confirm the seal?
1) non-valvular a-fib
2) to permanently close the left atrial appendage to prevent the clots from forming that cause 90% of strokes
3) an endothelialized device
4) can confirm seal w TEE
81
why is a-flutter known as a "polite" arrhythmia?
it is very organized, very consistent, and acts the way it is supposed to
82
what is the patho of a-flutter?
Instead of starting in the SA node, the electrical signal gets “stuck” in a loop, usually in the right atrium.
- The impulse comes out okay but instead of coming down to the AV node it gets stuck in a loop (“reentry circuit”) around the **tricuspid valve**
- not all atrial impulses are able to get through the AV node
83
in a-flutter, what does the abnormal impulse cause?
causes the atria to beat fast, often **250 to 350 times per minute** (This is NOT a fibrillation it is a BEAT)
84
what does the AV node do in a-flutter?
The AV node acts like a gatekeeper and blocks some of the signals, so the ventricles don't beat as fast, usually at a regular rate, like 150 bpm (a 2:1, 3:1, 4:1 conduction).
85
explain the ratio of atria vs ventricle beats in a-flutter
for every 2 atria beats there is 1 ventricular beat & so on
86
how is a-flutter depicted on strip?
Rate: atrial rate between 220-359 bpm- ventricular rate 75-150
Rhythm: Usually regular but can be irregular because of AV conduction change
R to R: usually regular
P wave: NO P WAVES; there are Flutter waves “sawtooth” or “F waves”
PR interval: Not measurable (b/c no P wave)
QRS duration: Normal
87
how do we know if the rhythm is regular in a-flutter?
if there is a consistent number of F waves or "sawtooth waves" between each QRS
ex: 4 F waves between each QRS complex consistent throughout strip
88
In a-flutter, do we need the AV node to take over?
No, the SA node has not failed (atria is firing 220-359 bpm)
89
What are the tx options for a-flutter? (3)
Same meds that we use to control the rate are very common here
An ablation can occur to burn away the loop to get the patient back in sinus rhythm
Usually gets treated pretty quickly (determine & treat the cause & then they cardiovert it)
90
what is the patho behind SVT?
Electrical impulse above ventricles – tissue at bundle of his and above (starting at the atria)
- it occurs ABOVE the ventricle (possible reentry); starting at AV node or above
- AV node cannot control it so every beat goes thru (if node is going at 175 bpm than we see a rate of 175 bpm)
- If it is an AV node reentry: the node is no longer in control it is now the loop
- Usually a narrow tachycardia: above the ventricle
91
what is true of atrial and ventricular rates in SVT?
they are > 100 bpm at rest
92
list the clinical manifestations of SVT (6)
1) palpitations
2) chest pain
3) SOB
4) dizziness
5) syncope
6) panic anxiety (not a cause but pt gets panicky bc of the SVT)
93
what are the tx options for SVT? (5)
1) Vagal maneuvers
2) Adenosine
3) Unstable: synchronized cardioversion
4) IV medications (Beta Blockers, CCBs)
5) Oral medications (Beta Blockers, CCBs)
94
why CAN a pt with unstable SVT receive synchronized cardioversion?
they still have a pulse & BP and are still breathing
95
how is Adenosine given? how can we get it to the heart faster?
IV push
to the heart faster we elevate the patient’s appendage (limb) so the med can flow right down and to the heart
96
Aside from SVT, when else can Adenosine be used?
in a-fib and a-flutter (works for arrythmias)
97
what is the onset of Adenosine?
RAPID onset so it works right away to break the problem
98
how is SVT depicted on strip?
Rate: > 100
Rhythm: Regular
P wave: if visible, inverted p waves sometime seen after QRS
PR interval: not measurable
QRS duration: normal
99
in SVT, a-fib & a-flutter, how do we know that the ventricle (conduction system) is totally fine?
they all occur from the AV node up
100
what does abnormal ventricular conduction (BBB) mean?
Right or left bundle branch block
- Delay in conduction of ventricles (impulse is slowing/ having a hard time getting thru)
- Damage to the bundle branches
101
how is abnormal ventricular conduction (BBB) depicted on strip?
QRS prolonged or wide > 0.12 seconds
102
what is the tx for BBB?
tx underlying cause, so CAD or cardiomyopathy
103
how can damage to the bundle branches occur and what does it cause?
could be congenital, heart attack, etc, which slows down the flow through the bundle branches & we will see a prolonged (wide) QRS complex
104
ANYTIME we see the QRS complex get wide, what do we know?
the problem is below the AV node
105
what else might we see on a strip when there is a BBB and what does it tell us?
rabbit ears at the peak of R wave
- tells us its taking some time for the blood to flow (why we have wide QRS)
106
what is the patho in PVC?
Impulse starts in ventricles and carried out the ventricles
107
on strip, why does PVC impulse look abnormal?
bc impulse does not start in atria
108
explain the different types of PVCs
Bigeminy (PVC every 2 beats)
Trigeminy (PVC every 3 beats)
Quadrigeminy (PVC every 4 beats)
109
Clinical manifestations of PVC?
Asymptomatic or “heart skipped a beat”
110
**Three of more successive PVC = ?**
**ventricular tachycardia**
111
management of PVC?
fixing the cause
112
clinical significance of PVC?
can be seen in healthy people, could be from a lot of caffeine or stress, etc; however, we should NOT see a lot of PVC
113
what is the FIRST thing that should be done when PVCs are seen on strip? why?
First thing to do is check potassium
**bc the BIGGEST cause of PVC is HYPOkalemia**
114
What med can cause PVCs?
loop diuretics (furosemide (Lasix) bc it can wash out potassium & sodium with the fluid
115
Two PVCs that look the same are called what?
couplet
116
difference btwn monomorphic PVCs and polymorphic PVCs?
monomorphic: they look the same
polymorhpic: PVC’s that do NOT look alike (this is bad)
117
list the causes of v-tach (9)
1) ACS
2) Myocardial infarction
3) Electrolyte imbalances
4) Cardiomyopathies
5) Structural heart disease
6) Scar tissue
7) Anemia
8) Re-entry
9) Or smt that messes up conduction system
118
untreated v-tach can lead to what?
can lead to ventricular fibrillation and sudden cardiac death
119
how do the QRS complexes differ in sinus tachy and ventricular tachy?
sinus tachy: narrow complexes
ventricular tachy: wide complexes (how we know it’s something to do with the ventricle)
120
list the clinical manifestations of v-tach (4)
1) decreased cardiac output
2) hypotension
3) pulselessness
4) unresponsiveness
121
what are the tx options for v-tach? (4)
1) Epinephrine
2) Amiodarone
3) Cardioversion (with a pulse)
4) Defibrillation (without a pulse)
122
difference between monomorphic v-tach and polymorphic v-tach?
Single Focus (mono) vs. Multiple Foci (poly)
**multiple foci is very bad** because it means there are many “ghosts” down there causing problems
123
how is v-tach depicted on strip?
Rate: 100- 250 bpm
Rhythm: regular
P wave: usually not visible
PR interval: none
QRS duration: > 0.12
124
if you are observing the tele screen at the nurses station and see v-tach on a strip what is the first thing you do?
GO ASSESS THE PT!!!
125
Explain what to do when a pt in v-tach HAS a pulse
1) check pulse, breathing, if they are awake, LOC, etc
2) **cardioversion** (this will shock at the bottom)
126
Explain what to do when a pt in v-tach is PULSELESS
- assess for breathing, LOC
- **START CPR!!**
- **Defibrillation** immediately
127
why MUST CPR be started if the pt has no pulse?
there is only 4 minutes before the brain becomes anoxic
128
how can defibrillation vary?
Can be Biphasic or Monophasic
- Biphasic needs less energy (lower joules)
129
what drug therapy can be given during cardiac arrest?
Epinephrine
Amiodarone
Lidocaine
130
how is epinephrine given during cardiac arrest and why?
given 1 mg every 3-5 mins
to ripen the heart bc it is an SNS stimulator
131
when would amiodarone and lidocaine be given during cardiac arrest?
if the shock is NOT working for a pt experiencing ventricular arrhythmias
132
what does lidocaine do?
helps restable the action potential (considered a type II anti-arrythmic)
133
what happens in v-fib?
the impulses are rapid & disorganized
there is NO atrial activity
134
what causes v-fib?
same causes as v-tach
may result from untreated or unsuccessful tx of v-tach
135
list the clinical manifestations of v-fib (3)
1) Absence of audible heartbeat
2) Absence of palpable pulse
3) Absence of respirations
136
how is v-fib depicted on strip?
Rate: often cannot be determined, >220
Rhythm: Irregular
P wave: Not visible
PR interval: Not visible
QRS duration: Not visible
**DISORGANIZED**
137
what is the tx options for v-fib? (4)
1) Immediate defibrillation
2) CPR
3) Vasoactive medications (vasodilators or constrictors)
4) Antiarrhythmics
138
v-fib can cause sudden death, usually from what?
ruptured plaque that knocks down the artery & the pt will die
139
what are the diff types of v-fib that can be seen on strip?
Coarse v-fib: easily visible
Fine v-fib: hard to see (more minimal on strip)
140
ventricular asystole is aka what?
flatline
141
what determines ventricular asystole?
absent QRS complexes, confirmed on two different leads
142
what is absent in ventricular asystole?
cardiac electrical activity
143
how is ventricular asystole depicted on strip?
Rate: not measurable
Rhythm: not measurable
P wave: not visible
PR interval: not measurable
QRS duration: absent
T wave: absent
144
what is done when a pt is in ventricular asystole? (3)
1) CPR
2) rapid assessment to identify possible problems
3) fix the cause
145
what is pulseless electrical activity (PEA)?
Organized electrical rhythm on the monitor but the pt has no pulse, is unresponsive (not awake), and not breathing
146
what is done when a pt is in PEA?
CPR and life support
147
list the causes of PEA (7)
1) Anything that obstructs the filling and contracting of the RV
2) Tension Pneumothorax
3) Cardiac Tamponade
4) Thrombosis (PE or Clot in the Coronary Artery)
5) Hypovolemia (Tx with volume or blood)
6) Acidosis/Potassium
7) Trauma
148
What is tension pneumothorax?
pressure is so great (too much air in pleural space) that it pushes the lung down onto the RV which obstructs the flow of blood into the RV
**Nothing is going to make it over to the left side of the body, thus no blood getting out to rest of body**
149
Tx for tension pneumothorax?
take a needle with catheter attached and when we pull the needle out it takes all the air with it which moves the lung back over to where it is supposed to be
150
what is cardiac tamponade?
there is a pericardial effusion: collection of fluid in pericardium (i.e. could be infection or malignancies) - when this gets so big that it pushes down on the RV, it won’t fill
151
tx for cardiac tamponade?
Basically same type of Tx as tension pneumothorax
- pulling blood out from the pericardium until it comes off the RV so the blood can flow to the left side of the heart to pump out to the rest of the body
