DYSRHYTHMIAS

TYPE
Sinus Bradycardia

CHARACTERISTIC
Sinus rhythm with a resting heart rate of 60 beats per minutes or less Rate- 40-59 bpm P wave- sinus QRS- normal (.06-.12) Conduction- PR normal or slightly prolonged at slower rates Rhythm- regular or slightly irregular A rhythm with elevated rate of impulses originating from the sinoatrial node, defined as a rate greater that 100 beats per minute in an average adult Rate- 101-160 bpm P wave- sinus QRS- normal (.06-.12) Conduction- normal Rhythm- regular or slightly irregular A normal phenomenon of mild acceleration and slowing of the heart rate that occurs with breathing in and out Rate- 45-100 bpm P wave- sinus QRS- normal (.06-.12) Conduction- normal Rhythm- regular or irregular

DRAWING
Sinus Dysrhythmias

MANAGEMENT
y Medical- Treat the underlying cause, atropine, isuprel, artificial pacing if patient is hemodynamically compromised, anticholinergics y Nursing- Intravenous access, supplemental oxygen, and cardiac monitoring should be initiated in the field; ensuring the stability of the patient s condition; continuous monitoring and intravenous access y Medical- identifying and correcting the underlying cause; beta blockers y Nursing- ensuring the stability of the patient s condition; continuous cardiac monitoring and intravenous access

Sinus Tachycardia

Sinus Arrythmia

y Medical- treatment is not usually required unless symptomatic bradycardia is present y Nursing- ensuring the stability of the patient s condition; continuous cardiac monitoring and intravenous access

Atrial Dysrhythmias Wandering Atrial Pacemaker May occur in normal hearts as a result of fluctuations in vagal tone. It may also be seen in patients with heart disease or COPD Rate- variable depending on the site of the pacemaker; usually 45-110 bpm y Medical- usually no treatment required y Nursing- ensure the stability of the patient s condition; continuous monitoring and intravenous access

Premature Atrial Contractions

P wave- also variable in morphology QRS- normal (.06-.12) Conduction- PR interval varies depending on the site of the pacemaker Rhythm- irregular Normally in a non-diseased heart. However, if they occur frequently they may lead to a more serious atrial dysrhythmias; they can also result from CHF, ischemia and COPD Rate- normal or accelerated P wave- usually have a different morphology than sinus P waves because they originate from an ectopic pacemaker QRS- normal (.06-.12) Conduction- normal, however, the ectopic beats may have a different PR interval (0.170.20) Rhythm- PAC s occur early in the cycle and they usually do not have a complete compensatory pause This may occur in individuals with healthy hearts. It may also occur with increased vagal tone, myocarditis, MI, and digitalis toxicity Rate- normal P wave- those that are present are normal QRS- normal (.06-.12) Conduction- normal Rhythm-the basic rhythm is regular. The length of the pause is not a multiple of the sinus interval A type of heart block which involves an impairment of conduction at the sinoatrial node Rate- normal or bradycardia P wave- those that are present are normal QRS- normal (.06-.12) Conduction- normal

y Medical- treatment includes identification of the underlying cause and correction y Nursing- ensure the stability of the patient s condition; continuous cardiac monitoring and intravenous access

Sinus Arrest

y Medical- if the cause is due to increased vagal tone and the patient is symptomatic, atropine may be indicated y Nursing- ensure the stability of the patient s condition; monitoring and intravenous access; decrease or stop stimuli; stress reduction; decrease or stop alcohol intake; oxygen 2-4 liters per minute as prescribed; heat electrolyte imbalance; monitor cardiac rhythm and vital signs y Medical- identification and correction of the underlying cause y Nursing- ensure the stability of the patient s condition; continuous cardiac monitoring and intravenous access

Sinoatrial Block

Multifocal Atrial Tachycardia

Rhythm- basic rhythm is regular A cardiac arrhythmia, specifically a type of supraventricular tachycardia Rate- 100-250 bpm P wave- two or more ectopic P waves with different morphologies QRS- normal (.06-.12) Conduction- PR intervals vary Rhythm- irregular A rapid rhythm of the heart in which the origin of the electrical signal is either the atria or the AV node Rate- atrial 160-250 bpm: may conduct to ventricles 1:1, or 2:1, 3:1, 4:1 into the presence of a block P wave- morphology usually varies from sinus QRS- normal (.06-.12)(unless associated with aberrant ventricular conduction) Conduction- PR interval depends on the status of AV conduction tissue and atrial rate: maybe normal, abnormal, or not measurable An abnormal heart rhythm that occurs in the atria of the heart Rate- a atrial 250-400 bpm; ventricular conduction depends on the capability of the AV junction (usually rate of 150-175 bpm) P wave- not present; usually a saw tooth pattern is present (unless associated with aberrant ventricular conduction) QRS- normal (.06-.12) Conduction- 2:1 atrial to ventricular most common Rhythm- usually regular, but can be irregular if the AV block varies A cardiac arrhythmia that involves the two upper chambers of the heart. It can often be

y Medical- Treatment depends upon the underlying cause; its rate can be reduced by administering verapamil y Nursing- ensuring the stability of the patient s condition; continuous cardiac monitoring and intravenous access; its rate can be reduced by administering verapamil

Paroxysmal Atrial Tachycardia

y Medical- adenosine diltiazem, verapamil or metoprolol sotaloi or amiodarone; cardioversion may be used; AV nodal blocking agents like beta-blockers and verapamil; radio frequency ablation y Nursing- valsalva maneuver; instruct patients the following: holding ones breath for a few seconds, coughing, plunging the face into cold water- via the diving reflex , drinking a glass of ice cold water, and standing on one s head; carotid sinus massage

Atrial Flutter

y Medical- cardioversion, vagal maneuvers and verapamil are used when prompt rate reduction is needed; otherwise, digoxin and other ant arrhythmic drugs can be used; anticoagulation of anti-platelet agent; amiodarone, calcium channel blockers, beta blockers y Nursing- vagal maneuvers, ensuring the stability of the patients condition; assess decrease in heart rate; vagal stimulation; carotid sinus massage; oxygen; know underlying condition; electrical synchronized cardioversion y Medical- digoxin, diltiazem, or other antidysrhythmic medications to control the AV

Atrial Fibrillation

identified by taking a pulse and observing that the heartbeats don t occur at regular intervals, but a conclusive indication of AF is the absence of P waves on an electrocardiogram Rate- atria rate usually between 300-600 bpm P wave- not present; wavy baseline is seen instead QRS- normal (.06-.12) Conduction- variable AV conduction; if untreated the ventricular response is usually rapid Rhythm- irregularly irregular Junction Dysrhythmias Premature Junctional Contractions PJCs may occur in both healthy and diseased hearts. If they are occasional, they are insignificant. If they are frequent, junctional tachycardia may result Rate- normal or accelerated. Present; wavy baseline is seen instead P wave- as with junctional rhythm QRS- normal (.06-.12) Conduction- PR interval <0.12 seconds if P waves are present Rhythm- PJC s occur early in the cycle of the baseline rhythm. A full compensatory pulse may occur The clinical significance of the rhythm depends upon the basic rhythm disturbance. If the ventricular rate is rapid, cardiac output may decrease Rate- faster than 10 bpm P wave- as with junctional rhythm QRS- normal (.06-.12) or widened with aberrant ventricular condition Conduction- PR interval usually <0.12

conduction rate and assist with conversion back to normal sinus rhythm; cardioversion may also be necessary to terminate this rhythm; anticoagulation; electrophysiological studies y Nursing- prevent temporary circulatory instability and to prevent stroke; asses for bleeding; administer anticoagulants as ordered; oxygen; give amiodarone as prescribed

y Medical- not usually required y Nursing- assess for frequency

Junctional Tachycardia

y Medical- finding and correcting the underlying cause; vagal maneuvers; verapamil and cardioversion y Nursing- vagal maneuvers; ensure the stability of the patient s condition

Junctional Escape Beats and Rhythm

seconds if present Rhythm- usually regular The most common cause of this rhythm in healthy individuals is sinus bradycardia. It may also be seen in the presence of a high degree or complete AV block. If the ventricular rate is slow, hemodynamic compromise may occur Rate- 40-60 bpm P wave- inverted in leads where they are normally upright; this happens when the atrial depolarization wave moves towards a negative lead. P waves may occur before, during and after the QRS, depending in where the pacemaker is located in the AV junction QRS- normal (.06-.12) Conduction- PR interval <0.12 seconds if present Rhythm- irregular as a result of the escape beats Blocks

y Medical- atropine or a pacemaker may be used to increase the ventricular rate y Nursing- ensure the stability of the patient s condition

First Degree AV Block or PR prolongation

A disease of the electrical conduction system of the heart in which the PR interval is lengthened beyond 0.20 seconds Rate- variable P wave- normal QRS- normal (.06-.12) Conduction- impulse originates in the SA node but has prolonged conduction in the AV junction; PR interval is >0.20 seconds Rhythm- regular Disease of the electrical conduction system of the heart. It refers to a conduction block between the atria and ventricles Rate- variable P wave- normal morphology with constant PP

y Medical- treating the underlying cause and observing for progression to a more advanced AV block. y Nursing- follow-up check-ups and monitoring of ECG

Second Degree AV Block (Mobitz type I, Wenkebach)

y Medical- no specific treatment is needed y Nursing- observe for untoward signs and symptoms

interval QRS- normal (.06-.12) Conduction- The PR interval is progressively longer until one P wave is blocked; the cycle begins again following the blocked P wave Rhythm- irregular Second Degree AV Block (Mobitz type II) Mobitz II heart block is characterized on a surface by intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening. The medical significance of theis type of AV block is that it may progress rapidly to complete heart block, in which no escape rhythm may emerge Rate- variable P wave- normal with constant PP intervals QRS- usually widened because this is usually associated with a bundle branch block Conduction- PR interval maybe normal or prolonged, but it is constant until one P wave is not conducted to the ventricles Rhythm- usually regular when AV conduction ratios are constant Third Degree AV Block or Complete AV Block A defect of the electrical system of the heart, in which the generated in the atria (typically the SA node on top of the right atrium) does not propagate to the ventricles Rate- atrial rate is usually normal; ventricle rate is usually less than 70 bpm. The atrial rate is always faster than the ventricular rate P wave- normal with constant PP intervals, but not married to the QRS complexes QRS- may be normal or widened depending on where the escape pacemaker is located in the conduction system Conduction- atrial and ventricular activities y Medical- extreme pacing and atropine for acute, symptomatic episodes and permanent pacing for chronic complete heart block y Nursing- administration of atropine y Medical- treatment is usually artificial pacing y Nursing- ensuring the stability of the patient s condition

are unrelated due to the complete blocking of the atrial impulses Rhythm- irregular Bundle Branch A defect of the heart s electrical conduction Block system Rate- variable P wave- normal if the underlying rhythm is sinus QRS- wide; >0.12 seconds Conduction- this block occurs in the right or left bundle branches or in both. The ventricle that is supplied by the blocked bundle is depolarized abnormally Rhythm- regular or irregular depending on the underlying rhythm Ventricular Dysrhythmias Premature Ventricular Contraction or Ventricular Premature Beat or Extrasystole Is a form of irregular heartbeat in which the ventricle contracts prematurely. This may be perceived as a skipped beat or as palpitations. The depolarization of cardiac myocytes begins in the ventricle instead of the usual place, the sinoatrial node Rate- variable P wave- usually obscured by the QRS,PST or T wave of the PVC QRS- wide >0.12 seconds; morphology is bizarre with the ST segment and the T wave opposite in polarity. Maybe multifocal and exhibit different morphologies Conduction- the impulse originates below the branching portion of the Bundle of His; full compensatory pause is characteristic Rhythm- irregular. PVC s may occur in singles, couplets or triplets; or in bigeminy, trigeminy, or quadrigeminy A tachycardia, or fast heart rhythm that originates in one of the ventricles of the

y Medical- treatment is artificial pacing for a bifasicular block that is associated with an acute MI y Nursing-

y Medical- no specific treatment; electrolyte; oxygen; eliminate stimulant; administer lidocaine, pronestyl or quinidine, betablockers, and benzodiazepines y Nursing- continuous rehydration and by restoring the balance of magnesium, calcium, and potassium within the body; instruct patient that the most effective treatment is the elimination of triggers (particularly the cessation of the abuse of substances such as caffeine, cocaine, and amphetamines)

Ventricular Tachycardia

y Medical- electrical countershock is the intervention of choice if the patient is

heart. This is a potentially life-threatening arrhythmia because it may lead to ventricular fibrillation and sudden death. Although less common, some forms of this arrhythmia appear benign, especially in young individuals Rate- usually between 100-220 bpm, but can be as rapid as 250 bpm P wave- obscured if present and are unrelated to the QRS complexes QRS- wide and bizarre morphology Conduction- the impulse originates below the branching portion of the Bundle of His; full compensatory pause is characteristic Rhythm- three or more ventricular beats in a row; maybe regular or irregular The French term that literally means twisting of the points . It refers to a specific variety of ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram Rate- usually between 150 to 220 bpm P wave- obscured if present QRS- wide and bizarre morphology Conduction- the impulse originates below the branching portion of the Bundle of His; full compensatory pause is characteristic Rhythm- irregular A condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart, making them tremble rather than contract properly. Ventricular fibrillation is a medical emergency. If the arrhythmia continues for more than a few seconds, blood circulation will cease, and death may occur in a matter of minutes Rate- unattainable P wave- may be present, but obscured by

symptomatic and rapidly deteriorating; some pharmacological interventions include amiodarone and lidocaine y Nursing- cardiac monitoring; oxygen; electrolyte

Torsade de Pointes

y Medical- synchronized cardioversion is indicated when the patient is unstable; IV magnesium; IV potassium to correct an electrolyte imbalance; overdrive pacing y Nursing- administer magnesium sulfate and antiarrhythmic drugs as prescribed

Ventricular Fibrillation

y Medical- immediate defibrillation and ACLS protocols; identification and treatment of the underlying cause is also needed y Nursing- administer antiarrhythmic agents like amiodarone or lidocaine as prescribed

ventricular waves QRS- not apparent Conduction- chaotic Rhythm- chaotic electrical activity