Cardiac Dysrhythmias and Output

• Dysrhythmias refer to abnormalities in the heart's rhythm.

Objectives

• Aim to describe the connection between Cardiac Output, Heart Rate (HR), and Stroke Volume.
• Explain the reasons for decreased cardiac output.
• Describe the signs and symptoms of decreased cardiac output

Activities

• Experiment with a sponge, containers and stopwatch to represent BPM, Normal Sinus Rhythm (NSR), and Tachycardia

Cardiac Output

• Normal cardiac output is 5-6 L/min.
• Cardiac Output (CO) is calculated by Heart Rate (HR) multiplied by Stroke Volume(SV).
• SV depends on the resistance to pump blood where it needs to go and volume
• HR is the number of heart beats per minute

Assessment of Cardiac Rhythm

• Interpret the rhythm and evaluate the patient's clinical status.
• Is the patient hemodynamically stable?
• Determine the cause of the dysrhythmia
• It's crucial to treat the patient, not just the monitor readings.

Signs and symptoms of Decreased Cardiac Output

• Hypotension
• Pale, cool skin
• Syncope, dizziness
• Weakness
• Confusion
• Shortness of breath
• Chest pain
• Tachycardia, Bradycardia or Irregularity may be present.

Bradycardia

• Bradycardia is any rhythm lower than 60 beats per minute where a palpable pulse is present.
• Common causes that need addressing ASAP include hypoxia and medications like opioids, beta-blockers, and sedatives.
• If stable, the patient is monitored.
• If unstable, interventions are needed
• Atropine is the first-line drug, given a maximum of three times
• Transcutaneous pacing, dopamine or epinephrine IV push may be required
• Cardiology consult & possible transvenous pacing may be necessary

Brady Treatment: Pacing

• Temporary pacing includes:
  • Transcutaneous pacing (minutes to hours)
  • Transvenous pacing (hours to days)
  • Epicardial pacing (days to weeks post-op until stable)
• Permanent pacing involves implanted devices:
  • Available in wide variety
  • Single, dual, demand
  • Treat specific conduction issues

Pacemaker Spike

• On ECG indicates electrical stimulation from the pacemaker.

Nursing Implications for Pacemakers

• Recognize the risk for other complications:
  • Infection
  • Hematoma
  • Pneumothorax
  • Perforation (atrial or ventricle septum)
  • Lead misplacement
  • New dysrhythmia

Post Operative Care

• Post-operative care for permanent pacemakers focuses on bleeding or infections located at the site.
• All other post operatively interventions are required for early mobility, oral care and breathing exercises
• Cardiac monitoring for any new dysrhythmias
• Patients should not raise arm above shoulder within 4-6 weeks

Pacemakers: Patient and Caregiver Teaching

• Follow-up appointments for pacemaker function checks
• Incision care
• Arm restrictions
• Avoid direct blows
• Avoid high-output generators
• Caregivers should learn CPR
• Refrain from MRIs unless pacemaker approved
• Microwaves are generally safe
• Walk through anti-theft devices at a normal pace
• Air travel is not restricted
• Monitor pulse regularly
• Carry a pacemaker ID card and wear a Medic Alert ID

Tachycardia

• Tachycardia is any rhythm higher than 100 beats per minute with a palpable pulse.
• Common causes that need addressing ASAP include pain, anxiety, sepsis, and hypovolemia.
• If the patient is stable, assess if the patient has narrow or wide QRS.
• Narrow QRS: Vagal maneuvers, adenosine, beta or calcium channel blockers, and expert consultation are needed
• Wide QRS: Adenosine, antiarrhythmic infusion, and expert consultation are needed.
• If unstable, cardioversion or adenosine, and anti-arrhythmic infusion

Synchronized Cardioversion for Unstable Tachycardia

• Having a provider present, along with pads or paddles
• Sync is turned on
• Select the energy level
• Charge & deliver energy
• Consider sedation unless blood pressure is extremely low
• Sync the electricity delivered on the R wave by the machine during cardioversion.

Pulseless

• Indicating a non-palpable pulse or death
• Pulseless Ventricular Tachycardia (pVT)
• Ventricular Fibrillation (VF)
• Asystole
• Pulseless Electrical Activity
• The priority is to start CPR, defibrillate ASAP if VF/pVT, and give epinephrine ASAP for PEA/Asystole.

Defibrillation

• Defibrillation is required if pulseless VT & VF is confirmed
• Manual Mode requires a trained professional.
• AED can be performed by anyone with basic life support skills.
• Follow prompts issued by the AED.
• Stop compressions while analyzing
• Ensure everyone is clear from the bed
• Maintain CPR following if AED recommends shock

Implanted Cardioverter-Defibrillator (ICD)

• Implanted Cardioverter-Defibrillator (ICD) is similar to implanted pacemaker
• ICD Senses heart rhythm and Provides defibrillation for VT or VF
• ICD Decreases mortality for appropriate patients like those with survived sudden cardiac death
• ICD for spontaneous VT , Electrophysiology studies have diagnosed rhythms
• ICD High risk for VF or VT
• Patients need to know that with the addition if ICD -Call provider if discharges one or more times -Call 911If discharges greater then one or feels sick