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Life-Threatening
Arrhythmias: Foundational
Concepts
80712/32612
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EMS/Nursing
80812/
34812
Life-Threatening
Arrhythmias: Events
EMS/Nursing
80812/
34812
Elizabeth J. Tombs, RN, MSN,
IBCLC, RLC, Assistant
Professor,
Anita Thigpen Perry School of
Nursing, TTUHSC
Lubbock, Texas
EMS/Nursing
80812/
34812
Carol A. Strahan, RN, MSN,
CCRN, CEN, Assistant Faculty
Retention Counselor
Anita Thigpen Perry School of
Nursing, TTUHSC
Lubbock, Texas
EMS/Nursing
80812/
34812
Objectives
1. Recognize the electrical
process of the heart.
EMS/Nursing
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34812
Objectives
2. Identify patterns and
causes of atrial fibrillation
and ventricular
tachycardia.
EMS/Nursing
80812/
34812
Objectives
3. Identify patterns and
treatment of asystole and
pulseless electrical activity
(PEA).
Heart Rhythms
• Always life-threatening
• Can become life-threatening
–
–
–
–
–
sinus bradycardia/tachycardia
Mobitz 1 and 2
complete heart block
atrial fibrillation (A-fib)
atrial flutter (A-flutter)
Heart Rhythms
– paroxysmal atrial tachycardia (PAT) or
supraventricular tachycardia (SVT)
– ventricular tachycardia
P
P P
P
P
P
P P
P wave
Complete Heart Block
PR Interval
Complete Heart Block
PR Interval: varies
Regular Rhythm: Regular P to P and Regular R to R
Rate: Atrial usually 60-100 Ventricular usually
20-60
QRS Interval: normal or wide
Complete Heart Block
Causes
•
•
•
•
MI (myocardial infarction)
Medication side effect
Hypoxia
Conduction system lesion
Treatment
• May try pacemaker
• Consider atropine or epinephrine
• May need dopamine to sustain cardiac output
Rate: >100 – 160 (upper limit)
Regular Rhythm: Yes – generally
PR Interval: .12 - .20 secs
QRS Interval: >.12 secs
Rate: 100
Sinus Tachycardia
Causes
•
•
•
•
Fever
Hypoxia
Medication side effect (ex. Beta adrenergic)
Pathologic underlying condition (thyroid
storm)
Treatment
• If stable, treat underlying cause (i.e., decrease
fever)
• If unstable:
– consider medications (ex. beta blocker)
– consider starting O2
Regular Rhythm: mostly regular and visually identifiable
pattern
Rate: generally >150 for SVT and >160 – 250 for PAT
PR Interval: no identifiable P waves at such a rapid pace
QRS Interval: narrow complexes
PAT/SVT
PAT/SVT Symptoms
• Distress
• Anxious
• Impending doom
Causes
• Likely premature atrial complex (PAC)
triggered
• Stimulants (caffeine, medications)
• Anxiety
• Damage to myocardial tissue
Treatment
• If stable, treat underlying cause
– vagal maneuvers
– carotid massage
– may give adenosine
– also consider: calcium channel blocker, digitalis,
beta blocker
• If unstable:
– cardioversion
R
Cardioversion: needs to be
synched on the R waves
PAT/SVT
Rhythm: irregular
Rate: atrial = 350 – 700 (ventricular = >150
uncontrolled A-fib)
PR Interval: no P waves
QRS Interval: narrow complexes
Atrial Fibrillation
Causes
•
•
•
•
MI damage
Pulmonary heart disease
Valvular heart disease
Hyperthyroidism
Treatment
• If less than 48 hours:
– convert back to sinus rhythm (SR)
– consider: digitalis, calcium channel blockers, beta
blockers, amiodarone, or cardioversion
• If greater than 48 hours: control heart rate (HR) and
give anticoagulant to prevent blood clots
• If unstable: cardioversion
PR Interval: P wave is saw-tooth
Regular Rhythm: mostly regular and visually
identifiable pattern
Rate: Atrial = 250 – 350 (ventricular rate
depends on the conduction ratio)
QRS Interval: narrow complexes
Atrial Flutter
Causes
• Heart disease
• Valvular heart disease
• Lung disease
Treatment
• If stable, treat underlying cause
– consider: calcium channel blocker, digitalis, beta
blocker
– may use adenosine for A-flutter
• If unstable: cardioversion
Regular Rhythm: mostly regular and visually
identifiable pattern
Rate: >100 (generally >150)
PR Interval: no P waves
QRS Interval: wide and bizarre complexes
Ventricular Tachycardia
Causes
• Premature ventricular complexes (PVCs)
• PVC causes:
– hypokalemia
– hypoxia
– heart disease
• Low magnesium
• Stimulants
•
Treatment
• Treat the patient, not the monitor
• Check pulse
– if pulse:
• amiodarone
• O2 started
– if no pulse:
• cardiopulmonary resuscitation (CPR)
• defibrillate
Treatment
• Medications: epinephrine, amiodarone, and
O2 (follow advanced cardiac life support
[ACLS] protocol)
Bizarre and chaotic rhythm; no detectible P or
QRS
(looks like static)
Ventricular Fibrillation
Causes
•
•
•
•
•
•
•
PVCs
R on T phenomena
Heart disease
Hypokalemia
Hypoxia
Low magnesium
Stimulants
Treatment
•
•
•
•
CPR
Immediate defibrillation
ACLS protocol
Medication: epinephrine, amiodarone, O2
Regular Rhythm: no
Rate: 0
PR Interval: 0
QRS Interval: 0
Asystole:
A-none
systole-contractions
Asystole
Causes
•
•
•
•
Massive MI
Profound hypoxia
Heart disease
5 Hs
–
–
–
–
–
–
hypothermia
hypothermia
hypokalemia
hypoxia
hydrogen ion acidosis
hypovolemia
Causes
• 5 Ts
– toxic/tablets
– thrombosis (coronary)
– thrombosis (pulmonary embolism)
– tension pneumothorax
– tamponade
–
Treatment
• CPR
• Medications: epinephrine, may consider
atropine
• Consider transcutaneous pacing
• ACLS protocol
Any organized electrical rhythm where patient
does not have a pulse
Pulseless Electrical
Activity (PEA)
Causes
• Inability to cause systole
• Either the current is too weak or the muscle is
not able to contract
• 5 Hs
• 5 Ts
Treatment
•
•
•
•
•
CPR
Identify and reverse cause
Medications: epinephrine
ACLS protocol
Treat the patient not the monitor
After the Event
• Continue to provide supportive measures
• Provide education to family and patient:
– cardiac arrhythmia
– treatment
– prevention
• Provide support to family and patient:
– resources
– holistic aspects (spiritual, cultural, etc.)
EMS/Nursing
80812/
34812
Life-Threatening Arrhythmias:
Etiology/Treatment
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Release Date:
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Requirements of successful course completion:
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•Complete the course evaluation.
•Complete the posttest with a score of 80% or greater.
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Conflicts of Interest:
Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN,
CCRN, CEN has disclosed that no financial interests, arrangements or
affiliations with organization/s that could be perceived as a real or apparent
conflict of interest in employment, leadership positions, research funding,
paid consultants or member of an advisory board or review panel, speaker’s
bureau, major stock or investment holder, or other remuneration.
Commercial Support:
There is no commercial support and/or relevant financial relationships
related to this educational activity. Commercial support is defined as financial
(or in-kind) contributions given by a commercial interest, which is used to pay
all or part of the costs of a CNE activity. Relevant financial relationships are
defined as financial relationships of any amount, occurring within the past 12
months, including financial relationships of a spouse or life partner that could
create a conflict of interest.
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Non-endorsement of Products:
Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN,
CCRN, CEN has disclosed that no significant relationships with commercial
companies whose products or services are discussed in educational
presentations. For speakers, significant relationships include receiving from a
commercial company research grants, consultancies, honoraria and travel, or
other benefits or having a self-managed equity interest in a company.
Disclosure of a relationship is not intended to suggest or condone bias in any
presentation, but is made to provide participants with information that might
be of potential importance to their evaluation of a presentation.
Off-label Use:
Elizabeth J. Tombs, RN, MSN, IBCLC, RLC and Carol A. Strahan, RN, MSN,
CCRN, CEN has disclosed that no products with off-label or unapproved uses
are discussed within this activity.
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