Pacers_ ablation_ cardioversion_

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					Pacers, ablation, cardioversion,
   telemetry, Intro to ACLS


                 By: Diana Blum
                      MCC
                   NURS 2140
Review

• Cardiac Output: The amount of blood the
•         heart pumps out to body in 1 min.
•         NORMAL: 5 to 8 L

• CO= HR x SV (so, CO can be changed by altering
•       heart rate, stroke vol. or both)

• Stroke Vol. = the amount of blood that the
•        heart ejects in one beat which
•        depends on activity level, physical
•        condition, prior heart disease
• Telemetry Interpretation/ Dysrhythmias




                                           3
• 1. The white lead is placed on the right side of
  the chest. This is usually called the “right arm
  lead.”
• 2. The black lead is placed on the left side of the
  chest. This is called the “left arm lead.”
• 3. The green lead is placed on the right lower
  abdomen, it is called the “right leg lead.”
• 4. The red lead is placed on the right lower
  abdomen, it is called the “left leg lead.”
• 5. The brown lead is placed slightly to the right of
  the midsternum, it is called the “V lead or chest
  lead.”
•
• A dysrhythmia is a disturbance of the rhythm
  of the heart caused by a problem in the
  conduction system.
• Categorized by site of origin: atrial , AV nodal,
  ventricular
• Blocks are interruptions in impulse
  conduction: 1st, 2nd type 1&2, 3rd or complete
  heart block




                                                  6
Each small box measures 0.04
1 big box (5 small boxes) is equal to a HR of 300
2 big boxes is hr of 150
3 big boxes is hr of 100
4 big boxes is hr of 75
5 big boxes is hr of 60
6 big boxes is hr of 50
7 big boxes is hr of 43                             7
8 big boxes is hr of 38
Large box estimate of heart rate works with
regular rhythms
• P-wave = atrial electrical activity
• QRS= ventricular electrical activity
• T wave= resting phase of ventricle




                                         9
10
P wave




   Measures:
   0.12-0.20


               12
            QRS WAVE




Measures:
0.06-0.10
                       13
QT Wave




    Measures
    approx 0.40-
    0.48 secs      14
Heart rates

• NSR: heart rate is 60-100bpm
• ST: heart rate 101-180 bpm
• SB: heart rate <60 bpm




                                 15
Calculating Heart Rate

• Quick Estimate: The 6-second Method
•    - count the # of QRS complexes in a 6 sec.
•      length of strip & multiply by 10
•      (the second mark is = to 5 large boxes)
• This can be used is rhythm is reg or unreg.
• Count small boxes between two R waves.
  Divide into1500 Gives BPM
Atrial arrythmias

•   Normal sinus rhythm
•   Sinus tachycardia
•   Sinus bradycardia
•   Premature atrial contraction (PAC)
•   Supraventricular tachycardia
•   Atrial flutter
•   Atrial fibrillation



                                         18
Ventricular arrythmias
•   Junctional rhythm
•   AV blocks
•   Premature junctional rhythm
•   Premature ventricular contraction (PVC)
•   Ventricular Tachycardia (V-tach)
•   Ventricular Fibrillation (V-Fib)
•   Torsade de Pointes (TdP)
•   Pulseless electrical activity (PEA)
•   Asystole

                                              19
ARTIFACT
NSR




      21
Sinus rhythm

•   PR interval- 0.12-0.20sec
•   QRS-0.06-0.10sec
•   QT segment 0.36-0.44 sec
•   Heart rate 60-100




                                22
• Hr= 60-100 bpm
• On strip it looks regular but does not map
  out
• PR interval= 0.12-0.20


                                          23
HR 40-60 bpm
<60 bpm is accelerated
Rhythm is regular
Pwaves not always present


                            24
Junctional Rhythm




                    25
SB




     26
Sinus Bradycardia

• All criteria same except rate < 60bpm
• S/S: dizziness, syncope, angina, hypotension,
  sweating, nausea, dyspnea
• Sometimes no S/S
• Treat underlying cause
• IV atropine, pacemaker




                                             27
Sinus Bradycardia:
Your pt is pale, c/o dizziness & fatigue. Pulse 56,
BP 86/60
• ACLS protocol:
•    1. airway
•     2. oxygen
•     3. ECG, BP, oximetry
•     4. IV access
• If s/s of poor perfusion: altered mental status, CP,
•    hypotension, signs of shock
•         a. prepare for transcutaneous placing
•         b. atropine 0.5 mg IV while waiting for pacer
•             - may repeat for total 3 mg IV
•         c. epinephrine or dopamine drip while waiting pacer
  or
•            if pacing ineffective
                                                           28
ST




     29
  Sinus Tachycardia




• All criteria same as with NSR except rate >100
• Causes: fever, dehydration, hypovolemia, increased
  sympathetic nervous system stimulation, stress,
  exercise, AMI
• S/S: Palpations #1, angina and < CO from < V filling
  time
• Treatment: correct cause, eliminate caffeine, nicotine,
  alcohol. Beta blockers may be ordered

                                                            30
Sinus Tachycardia

• Heart rate greater than 100 but less 180
• Caused by external influences (fever, blood
•   loss, exercise)
• Adenosine used
• B-blockers may cause condition to worsen ( if MI
  limits vent function the heart will compensate by
  increasing rate then CO will fall)
• Remember to identify and treat cause !!!



                                                  31
Supraventricular Tachycardia




                               32
Supraventricular Tachycardia

•   Impulse originates in AV junction or atria
•   Rhythm regular
•   A-fib most common cause
•   Ventricular rate 150-250
•   QRS normal configuration
•   Symptoms:
•         palpitations, lightheadedness,
•         Loss of Conscious, CP, SOB



                                                 33
How to treat SVT

• B-blockers ( to decrease conduction thru AV
•             node:
• Calcium channel blockers ( to decrease condux
•            thru AV node)
• Radio frequency ablation




                                                  34
35
SVT converted with Adenosine
given rapid IV Push stimulates vagal
response.
S/E: flushing,bronchospasm,AVblock




                                       36
AV Blocks

•   First degree block
•   Second degree block Type I (Wenchebach)
•   Second degree block Type II (Mobitz II)
•   Third degree block
•   Bundle branch block




                                              37
Rate is usually WNL
Rhythm is regular
Pwaves are normal in size and shape
The PR interval is prolonged (>0.20 sec) but constant


                                                        38
1st degree block
• AV node delays the impulse from the SA
  node for abnormal length of time
• Causes:
•    CAD, MI, drugs that act on AV node
  (digitalis)
• Characteristics:
•     PR interval >0.20 seconds
• Not serious but may progress to 2nd degree



                                               39
1st degree block nursing intervention:

• Document the dysrhythmia
• Monitor for progression to slower heart rate or
  worsening block
• If progression noted, monitor pt, notify
  physician




                                               40
Pwaves are normal in size and shape;
Some pwaves are not followed by QRS
PR interval: lengthens with each cycle until it appears without QRS Complex
                  then the cycle starts over
QRS is usually narrow


                                                                         41
2nd degree AV block:Type I:

• AV node delays progression of SA node impulse
  for longer than normal
• Some of the SA impulses never reach ventricles
• P waves regular
• Progressive lengthening of PR interval until one P
  wave is not conducted
• CAUSE: ischemia or injury to AV node




                                                   42
2nd degree Type I AV block:

• RISK: often a temporary block after MI
•        May progress to complete(3rd degree)
•           block
• TREATMENT; freq. none needed
•       slow vent rate: ATROPINE will increase
  AV conduction
•       To increase rate of SA
  node:EPINEPHRINE


                                                 43
2ND degree nursing interventions:
Type I
• Document
• Monitor pt/vitals
• If ventricular rate slows enough to produce
•     symptoms, document , notify physician




                                                44
http://www.youtube.com/watch?v=GVxJJ2
DBPiQ&feature=related
Ventricular rate is usually slow
Rhythm is irregular
Pwaves are normal in size and shape (more pwaves than QRS)
PR interval is within normal limits
QRS is usually wide

                                                             46
2nd degree Type II
(Mobitz Type II)
•   Atrial rate 60 to 100
•   More P waves than QRS complexes
•   Ventricular response 2:1 or 3:1
•   No change in PR intervals of conducted P waves
•   CAUSES: disease of AV node, AV junctional
    tissue, or His-Purkinje system, inferior MI




                                                     47
2nd degree Type II:

• RISK: unpredictable & may suddenly
  advance to complete hrt block
• Especially common after inferior infarction
• A DANGEROUS WARNING DYSRHYTHMIA
• TREATMENT: if vent rate slow, atropine or
  epinephrine
•     may need temporary pacer




                                            48
2nd degree Type II
Nursing Interventions:
• Determine width of QRS
• WATCH for widening QRS complex
• *width QRS indicates location in the conduction
  system of the block
•      - the wider the complex, the lower in the
  bundle branch system the block will be.
• IF QRS WIDENS, NOTIFY PHYSICIAN
  IMMED.
• Prepare for insertion of pacer
• Assess vitals

                                                    49
Ventricular rate is regular but there is no correlation between pwaves and
QRS
Pwaves are normal in size and shape
No true PR interval

                                                                             50
3rd degree block: complete heart block:
“AV dissociation”
• More atrial waves than ventricular
• No conduction of atrial impulses
• Atrial/ventricles beat independently
• RISKS: bradycardia which produces
•    a decrease in CO leading to hypotension
  & myocardial ischemia
  TREATMENT; pacer
NURSING INTERVENTION; monitor ,
  hemodynamics , prepare for pacer
•


                                               51
      Atrial Fibrillation




Erratic wavy base
Pr is not measurable
QRS 0.10 sec or less usually
http://www.youtube.com/watch?v=VKxQgjj2yVU&fe   52
ature=related
A fib continued

•   Atrial rate > 400 bpm with a varying Ventricular rate
•   Overall rhythm irregular
•   No P waves, unable to measure PR interval
•   QRS=normal: Twave undeterminable
•   Causes: Rheumatic fever, mitral valve stenosis, cad.
    HTN, MI, hyperthyroidism, COPD, CHF see pp. 604




                                                        53
A fib continued




  • Concern with A fib is the development of
    atrial thrombus and loss of atrial kick from
    ineffective atrial function.
  • Treatment: Ca channel blockers and anti-
    arrhythmics to convert, beta blockers to <
    HR, anticoagulants to prevent embolization.
  • Synchronized cardioversion

                                                   54
Atrial Fibrillation

•   - - 5 to 6 times more likely to have stroke
•   - - atrial rate: 300 to 600 times/minute
•   --prolonged A-Fib may stretch & weaken
•      heart muscle
•    - - symptoms: lightheaded, very tired,
•                      SOB, diaphoretic, chest
•                      pain,



                                                  55
Afib causes :

• Chocolate large amounts: contains
  theobromine, a mild cardiac stimulant.
• - sleep apnea
• - athletes more prone (enlarged heart)
• - tall athletes (esp basketball players)
• - aging heart
• - men more than women
• - sleeping on left side or stomach
• etc.


                                             56
A-fib treatment:

• ASA not as effective as Coumadin in
  preventing strokes.
• ASA less likely to cause abnorm bleeding
• **since hemorrhagic stroke increases with
  age & is also increased by taking Coumadin,
  some Drs. may switch older pts from
  Coumadin to ASA.




                                                57
A Fib electrical cardioversion:

• High risk of forming clots & causing stroke
• Anticoagulants taken before treatment and 3-
  4 weeks post treatment
• If life-threatening, may need Heparin IV
  before cardioversion

• Best time: recent A fib




                                             58
Atrial rate of 250-450 bpm ventricular rate varies
Atrial rhythm is regular ventricular rate is
irregular
No identifiable p waves
P wave is not measurable
Qrs: 0.10 or less usually                            59
Atrial fib/flutter




                     60
61
Pacer spike should fall before the P wave unless a dual
Chamber pacemaker; if it does not there could be a problem




                                                             62
PAC




      63
PAC: premature atrial contraction
• Premature depolarization of atrial origin
• P wave may be buried in T wave
• A pause follows and SA node will start new cycle
  of sinus beats
• Indicates atrial irritability
• No risk if occasional
• If 6 or more per minute, indicates atrial
  tachycardia
• Treat: digitalis, calcium channel blockers, beta
  blockers

                                                 64
Extra beat
Types
        uniform=go the same direction
        multifocal= go in different direction
        R on T=when the pvc fall on the preceding twave
        couplet= 2 pvcs together
        bigeminy= pvc every other beat
        trigeminy=pvc every third beat

                                                          65
PVCs (unifocal)




                  66
PVCs (multifocal)




                    67
PVC: ventricular origin

• Complex is wide followed by compenatory
  pause
• An irritable focus in ventricle initiates a
  contraction before normally expected beat.
• Acute MI most common cause
• QRS is wide and bizarre
• Risks: increasing myocardial irritability,
  leading to increased freq. of PVCs
• Can occur as bigeminy (every other beat)
• or short runs

                                                68
Ventricular tachycardia




  Monomorphic: beats are same size
  and shape
  Polymorphic: different size and
  shape
                                     69
V-tach

• Advanced irritability of ventricles due to
  ASHD, CHF, acute MI electrolye imbal.
  Hypoxia, acidosis,occas drugs
• RISKS: low to no Cardiac output
• Nursing Interventions: monitor, if pt
  unconscious,immed. defib




                                               70
This is a polymorphic VT
Usually electrical imbalance in nature r/t NA+ or K+




                                                       71
72
Torsade de pointes

• Will see prolonged QT interval when in sinus
  rhythm
• Will see prominent U wave
• If lasts >10 seconds pt will progress to
  unconsciousness, life threatening with ineffective
  cardiac output
• TREATMENT: IV magnesium




                                                       73
Ventricular Fibrillation




            Rate can not be determined
            because of no identifiable
            waves
            Rapid chaotic rhythm with no
            pattern
            No p waves
            No PR interval                 74
            No QRS
Vtach/Vfib

•   Both can be life threatening
•   VT= V HR 100-250 bpm
•   Causes: AMI, CAD, hypokalemia, dig toxic
•   S/S: palpitations, dizzy, angina, <LOC
•   Treatment: assess for pulse, if none, defib
•   VF=Rate undeterminable Cause: same
•   Treatment: CPR




                                                  75
V-fib

•   May occur after MI
•   Extensive ventricular irritability
•   Very little cardiac output
•   Death within 4 to 8 minutes
•   TREATMENT: immediate defibrillation
•      immed defib at 200 J
•      if unsuccessful, repeat at 300 J
•      If unsuccessful, repeat at 360 J
•   CPR

                                          76
Asystole




           77
Asystole and PEA

• CPR
  Oxygen
• Epinephrine 1 mg IV/IO (repeat 3-5 minutes)
• May give Vasopressin 40U IV/IO to replace
•   1st or 2nd dose of epinephrine
• Consider Atropine 1 mg IV/IO Repeat every 3 to 5
  min (up to 3 doses)




                                                78
79
What arrthymias are considered PEA?

• See an organized or semi-organized rhythm
  BUT NO PULSE:
•     This includes:
•             - idioventricular rhythms
•            - ventricular escape beats
•            - postdefibrillation idioventricular
•



                                                    80
http://www.campaignfornursing.com/events/WINNERS/pennsylvania/




                                                                 81
ST elevation
12 lead ekg

• The electrocardiogram (EKG) is a device that
  receives electric impulses from the body and
  changes them into a monitor tracing that can be
  analyzed to find problems with electrical
  conduction in the heart. The EKG simply picks up
  electrical impulses; it does not read mechanical
  activity. When a patient has ischemia, injury or
  necrosis to the heart muscle, the electrical
  impulses change in the area involved. Nurses
  can analyze the electrical changes and
  determine if they indicate mechanical
  dysfunction.
• The EKG is simply a volt meter that picks up
  electrical signals. Therefore, anything that
  interferes with electrical conduction can
  cause changes in the EKG. These variables
  can be divided into three main categories:
  – 1) physiological variables not specific to the heart
    (ie. pulmonary embolism, increased intracranial
    pressure)
  – 2) electrical interference (ie. poorly placed lead)
  – 3) ischemia, injury, or infarction
5 Steps to 12 Lead Interpretation
1. Assess regularity and speed
2. Look for signs of infarction
3. Present in >1 lead, but not all?
4. Assess associated conditions
5. Correlate with clinical condition
• V1 &V2 look at right ventricle
• V3 & V4 look at septum and lateral left
•          ventricle
• V5 & V6 look at anterior/lateral left vent.




                                                86
89
90
91
92
• http://nursebob.com/




• http://www.usfca.edu/fac_staff/ritter/ekg.htm




• http://ems-safety.com/12-lead-ekg.htm
Rhythms for Cardioversion
• A-fib
• A-flutter
• Supraventricular tachycardia




                                 94
Electrical cardioversion
• The difference between defibrillation and cardioversion is that
  the countershock is synchronized to the QRS complex which
  allows the electric current to be delivered after the R wave and
  before the the period associated with the T wave. It is the
  treatment of choice if the patient has a hemodynamically
  unstable tachydysrhythmia. It is the primary treatment for most
  tachydysrhythmias. It is used for the treatment of unstable
  ventricular tychardia with a pulse, since this often leads to
  ventricular fibrillation, atrial flutter, atrial fibrillation, and most
  tachycardias. With cardioversion the potential exists to prevent
  this life-threatening dysrhythmias.
• Cardioversion may either be a planned or emergent procedure.
  If done as an elective procedure, the patient should be sedated
  before cardioversion begans. Of course, the institutions policies
  and procedures for conscious sedation should be followed.
• Properly done cardioversion will correct the patient’s
  dysrhythemia with minimal discomfort and maximum safety.
    Chemical cardioversion

•    Indication
             A. Considered to be an effective alternative to electrical cardioversion for Rapid
     conversion of atrial fibrillation and atrial flutter.
             B. Ibutilide is moderately effective in causing prompt conversion to sinus rhythm with
     greater efficacy in patients who have atrial flutter.
•    2. Action.
             A. Ibutilide prolongs action potential duration by activating a slow inward current,
     largely carried by sodium ions.
             B. Blocks the rapidly activating component of the delayed rectifier potassium current.
             C. No significant effect on heart rate, PR interval, or QRS interval
             D. Potential prolongation by Ibutilide leads to an increase in atrial and ventricular
     refractoriness in vivo.
             E. No clinically significant effect of Ibutilide to lower blood pressure or worsen
     congestive heart failure.
             F. Route of elimination: hepatic.
•    3. Administration.
             A. Ibutilide is available in 10 mL vials containing 0.1 mg/mL (1 mg total).
             B. For intravenous administration, the recommended dose of Ibutilide is 1mg over a
     10 minute period in patients weighing > 60 kg
             C. Patients weighing < 60 kg, the recommended dose is 0.01 mg/kg initially, with a
     second dose of the same strength 10 minutes later if necessary.
             D. Ten minutes after the end of the initial infusion, a second 10 minute infusion of
     equal strength can be given if the arrhythmia has not terminated.
•   Cautions.
          A. Prolong ventricular repolarization
          B. Carries a risk of excessive QT prolongation
          C. Acquired long-QT syndrome
          D. Associated polymorphic ventricular tachycardia (torsade de
    pointes)
          E. Careful patient selection and clinical monitoring during drug
    administration.
•   5. Contraindications.
          A. QTc interval exceeding 440ms
          B. Bradycardia
          C. Electrolyte disturbances
          D. Other QT-prolonging drugs
•   6. Adverse Effects.
          A. Ventricular tachycardia
          B. Premature ventricular complexes
          C. Hypotension
          D. Bundle branch block
          E. Atrioventricular
• Post cardioversion care:
• 1. generally the care for a patient tells
  cardioversion is the same as for the
  fibrillation.
• 2. If it is a elective procedure, digoxin is
  usually withheld for 48 hours prior to
  cardioversion to prevent dysrhythmias after
  the procedure.
• 3. Airway patency should be maintained and
  the patient state of consciousness should be
  evaluated.
Indications for pacemaker

• Temporary:
•    -symptomatic bradycardia (not controlled
  by meds)
•    - ant MI
•    - drug overdose (dig, beta blocker)
• Permanent:
•    - 2nd degree Mobitz Type II
•    - 3rd degree Block
•    - symptomatic bradycardia, arrhythmias
•    - suppress tachyarrythmias

                                                99
Modes of Pacing
• Synchronous (demand )Mode
•    - sensitivity is set to patient beats
•    - pacer will fir when pt rate goes below
•        that what is set
• Asynchronous pacing:
•      - for asystole, or profound bradycardia
•      - does not sense any pt beats
•      - fires at set rate no matter what pt rate is



                                                       100
Position of the letter
Designation
1st letter
Chamber being paced (A=atrium, V=ventricle, 0=none)



2nd letter
Chamber being sensed (A=atrium, V=ventricle, 0=none)



3rd letter
Pacing Mode (O=none, I=inhibited, T=triggered, D=dual)



4th letter
Rate Response (R=rate response is on)
Chambers that can be paced:

Atrium
Ventricle
Dual (both atrium and ventricle)
ICD (Implantable Cardioverter Defibrillator)




                                               102
Dual Paced
     • Atrial Pace, Ventricular Pace (AP/VP)



          AV    V-A         AV   V-A




     AP                AP
           VP               VP
Implant Cardioverter Defibrillator
ICD




                                 104
ICD

• - prevents sudden cardiac death due to
• V-tach or V-fib.
• Pt can feel the shock
•       -defib felt like “kick in the chest”
•               that lasts 1 second
•       - cardiovert feels like “thump in chest
•       - pt doesn’t feel pacing



                                                  105
Problems with pacers

• Failure to fire
• Failure to capture
• Undersensing (low battery, poor lead
•                  position)
• Oversensing (turn down output, magnetic
•                 interference)




                                            106
Operative failures with pacers:
• Pneumothorax
• Pericarditis
• Infection
• Hematoma
• Lead dislodgement (seen on X-ray)
• Venous thrombosis (rare but would see
•     unilateral edema to arm on same side
•     as pacer)



                                             107
Pt Education:
•   1. carry ID card (Xray code seen in standard chest Xray)
•   2. not allowed to drive for 1 month
•   3. no metal detectors or no longer than nec.
•   4. MRI interrupts pacing-can’t get one for some time if new
•   5. No power generators (welding)
•   6. microwave questionable
•   7. radiotherapy (may damage circuits) The
•       pacer may need to be surgically moved if in
•      path of radiation field.
•   8. TENS (transcutaneous electrical stimulation) interferes
•       may need reprogramming
•   9. Cell phone use in opposite ear of pacer and store away
•      from side of pacer



                                                                  108
EP with Ablation

• The word "electrophysiology" is made up of
  two words. The first part of the word,
  "electro", means electrical, and the second
  part of the word, "physiology", means
  function. Therefore, an electrophysiology
  study is simply a study of the electrical
  function of your heart. This study will provide
  specific information about your arrhythmia.
  Once the doctor has this information, it is
  easier to select the appropriate treatment for
  you
•   A small intravenous (IV) catheter may be placed in a vein in your hand
    or arm. This may be used to continuously administer fluids, or it may be
    covered with a cap for intermittent use. The purpose of this IV is to
    provide the nurses and doctors with a quick means of administering
    medications, should your heart rhythm abnormality occur.
•   An EP team doctor will explain why the procedure is necessary and
    what risks are involved for you. The degree of risk varies with each
    person and is related to your specific condition. After discussing this
    information, you will be asked to sign a consent form to indicate your
    permission for the study
•   Prior to the EP study, your skin will be washed with a special soap and
    the hair shaved from potential catheter insertion sites. The most
    common site used is the groin, or the area at the crease of the leg
    about midway between the center of your body and your hip.
    Occasionally the forearm, neck or collarbone areas are used. The
    purpose of this washing is to provide a clean insertion site and reduce
    the chance of infection
•   You will be asked not to eat or drink anything after midnight the night before your test.
    If your test is not scheduled until later in the day, you may have a clear liquid
    breakfast, after which you must not eat or drink. You may take your morning pills with
    a sip of water. All your medicines will be reviewed, and some may be withdrawn prior
    to the test.
•   You will not receive anything to put you to sleep before this test. It is important for you
    to describe sensations you have during the test to the staff in the EP laboratory.
    Medicines that sedate people may interfere with the ability to find the abnormal heart
    rhythm, but each patient is treated individually and you may discuss this issue with
    the EP team physicians and nurses.
•   If you have dentures and they are tight-fitting, you may wear them during the study.
    You may also wear your glasses and watch if you wish. You should wear a hospital
    gown without bottoms, but may wear your socks if you wish. You should use the
    bathroom just before going to the lab because it may be several hours before you
    return to your room. A bedpan or urinal will be made available to you, should you
    need it during the study. It is sometimes necessary to insert a catheter into the
    bladder for continuous drainage during longer procedures. If this is planned, it will be
    inserted early in the procedure. An initial EP study takes an average of two and a half
    hours; however, they may range from one to six hours. Your family members can wait
    in your room or in one of several lounges, and will be notified when your study is
    finished.
•   Catheters are flexible hollow plastic tubes, much like the intravenous catheter in your
    arm or hand, only larger to be placed in larger central veins. These are placed most
    commonly in veins, but occasionally in arteries, depending upon the type of study you
    are undergoing. Usually, two catheters are used, but, depending on the type of study
    to be performed, as many as five can be used. The purposes of these catheters are
    both to provide access to the vein or artery, for placement of pacing wires into the
    heart, and for administration of medications or fluids.
•   Long, thin, flexible wires, referred to as pacing wires, or intra-cardiac catheters, are
    advanced through the IV catheter and up into the heart chambers under the guidance
    of an x-ray camera (see diagram). These pacing wires are used to both record the
    electrical patterns from inside the heart and to "pace" the heart. Pacing the heart is
    delivery of very small amounts of electricity to the heart muscle through the tip of the
    catheter. This causes a heart beat, and allows the electrophysiologist to compare
    your heart's response to paced beats to already known normal responses.
    Approximately half of the patients undergoing this procedure are aware of each heart
    beat, and therefore, feel their heart speed up, slow down, or "skip a beat". Many other
    people are completely unaware of the pacing procedure.
•   If an arrhythmia is provoked by the pacing, you may feel some of the same symptoms
    that caused you to seek medical attention. Please tell the EP staff what you feel. Let
    them know if you have shortness of breath, dizziness, light-headedness, or chest
    discomfort. A member of the team will be by your side and talking with you at all
    times.
•   After the test, the catheters will be removed. Firm pressure will be applied
    over the puncture site for approximately 15 minutes. This is necessary to
    prevent any bleeding from the insertion site. You will then be taken to your
    hospital room, or the EP recovery area.
•   Flat bed rest is necessary for two to eight hours after the study. During this
    time, it is important to keep the leg or arm used in the procedure straight to
    prevent bleeding from the insertion site. After the specified amount of rest,
    you will be able to resume your previous activity level.
•   Your nurse will be in the room frequently during the first hour after the study
    to take your blood pressure, heart rate, and check your insertion site for
    signs of bleeding. The pulses and temperature of your feet will also be
    checked.
•   You will be instructed to apply pressure firmly to the insertion site if you
    cough or sneeze and while using the bedpan or urinal. If you should notice
    any bleeding at the site, notify your nurse immediately. If your back
    becomes uncomfortable, do not hesitate to ask the nurses for pain
    medications.
•   You will be able to resume your previous diet and your nurse or family
    members can help you eat while you are reclining in bed.
Bundle Branch Blocks: Diagnosed with
12 lead EKG: most common cause: acute
MI
• Right bundle branch block:
• - impulse travels through left ventricle first,
  then activates right ventricle (gives am “M”
  shaped complex
• Left bundle branch block:
•     --impulse first depolarizes right side of
  heart then the left ventricle (gives deep, wide
  “V” shaped complex



                                                114
Bundle Branch Blocks:

• Risks: can deteriorate to 3rd degree block
• then treat with atropine or pacemaker
• Pt can be asymptomatic until progresses




                                               115
116
Hyperkalcemia




                117
• Practice
Slide 1




          120
Slide 2




          121
Slide 3




          122
Slide 5




          123
Intro to ACLS
Primary Survey

• Airway: Open airway, look, listen, and feel for
  breathing
• Breathing: If not breathing slowly give 2
  rescue breaths. If breaths go in continue to
  next step.
• Circulation: Check the carotid artery (Adult)
  for a pulse. If no pulse begin CPR.
• Defibrillation: Search for and Shock V-
  Fib/Pulseless V-Tach
Adult ACLS Secondary Survey ABCDs
(abbreviated)
• Airway: Intubate if not breathing. Assess
  bilateral breath sounds for proper tube
  placement.
       .

• Breathing: Provide positive pressure
  ventilations with 100% O2.
• Circulation: If no pulse continue CPR, obtain
  IV access, give proper medications.
• Differential Diagnosis: Attempt to identify
  treatable causes for the problem.
AED

• An AED is a device used in cardiac arrest, or
  sudden cardiac death, when the heart’s
  electrical activity is disorganized and there is
  no effective pumping of blood. The AED is
  capable of recognizing the heart's electrical
  activity, and determining if an electric shock is
  required. If the shock is needed, a voice
  prompt in the AED is activated, telling the
  rescuer to push a button to deliver the shock
• http://acls.net/quiz/mi_stroke_1.htm
stress

• Common responses can include:
  – Feeling a sense of loss, sadness, frustration,
    helplessness, or emotional numbness
  – Experiencing troubling memories from that day
  – Having nightmares or difficulty falling or staying
    asleep
  – Having no desire for food or a loss of appetite
  – Having difficulty concentrating
  – Feeling nervous or on edge
Teaching to cope
•   Reach out and talk. Create opportunities to talk, but do not force them. Try asking
    questions like, what do you think about these events, or how do you think these
    things happen? After a traumatic event, it is important for the patient/family to feel like
    they can share their feelings and to know that their fears and anxieties are
    understandable.
•   Express yourself. Your patient may be feeling different emotions at different times.
    Sadness. Anger. Fear. Confusion. These feelings are normal reactions to this
    situation. Don't be afraid to allow your client to express how he or she feels and share
    your feelings with them.
•   Watch and listen. Be alert for any change in behavior. Is the patient sleeping more,
    or less? Are they withdrawing from friends or family? Are they behaving in any way
    out of the ordinary? This may show that they are having trouble coming to terms with
    this event. Recognizing even small changes in behavior can give you an early
    warning that something is troubling them
•   Stay active. Go for a walk, volunteer with a community group, write a poem, play a
    musical instrument. Trying any of these can be a positive way to handle your
    emotions.
•   Stay in touch with family. If possible, stay in touch with trusted family, friends, and
    neighbors to talk things out and help deal with any stress or worry.
•   Take care of yourself. Losing sleep, not eating, and worrying too much can make
    you sick. As much as possible, try to get enough sleep, eat right, exercise, and keep
    a normal routine. It may be hard to do, but it can keep you healthy and better able to
    handle a tough time.
ANY QUESTIONS???

				
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