36

Iocus on
Dysrhythm|as

nervous SysLem ConLrol of Lhe PearL
AuLonomlc nervous sysLem conLrols (lnvolunLary)
O lotosympotbetlc oetvoos system Jecteoses
O 5ympotbetlc oetvoos system flqbt ot fllqbt

Dysrhythm|as assessment of the e|ectr|ca| system
rompL assessmenL of dysrhyLhmlas and Lhe paLlenL's response Lo Lhe rhyLhm ls crlLlcal
CPAnCL musL be assessed by us
Lead lacemenL
O lead wlre lCu or L8 crash card Slm lab" monlLor conLlnuous whlLe ls rlghL smoke over
flre"
4 leads ll v1 MCL (Modlfled chesL lead)
O lead LelemeLry color coded conLlnuous
4 8A LA ChesL v1 ChesL v6 8L LL
O 12 lead noL conLlnuous more lnfo glves us a snapshoL placemenL ln lab
4 8 arm L arm (LxLremlLles)
4 8 Leg L leg (LxLremlLles)
4 v 1 rlghL slde of chesL lMC81An1 musL be ln same place
4 v2 4
Lh
lnLercosLal space aL Lhe 8lCP1 sLernal border
4 v 4
Lh
lnLercosLal space aL Lhe LLl1 sLernal border
4 v4 halfway beLween v2 and v4
4 v
Lh
lnLercosLal space [ Lhe lefL mldclavlcular llne (atera| s|de)
4 v6
Lh
lnLercosLal space aL Lhe lefL anLerlor axlllary llne and aL lefL mldaxlllary llne (|atera|
s|de laLeral vessels speclflcally where lschemla)
4 1rlponlns drawn for nexL 24 hours LkC for nexL 72 hours
O know how Lo read own sLrlp
O Pypokalemla splked 1 wave

LvaluaLlon of uysrhyLhmlas
O 1elemetty
4 SomeLlmes on floor
4 CenLrallzed LelemeLry
4 MusL be puL on wlLhln a few hours
4 Jlll noL send paLlenL up from L8 unless a box ls up on a monlLor ready
4 1elemeLry 46 hours of experlence 8n leader 1 person waLches 4 paLlenLs aL a Llme
4 know baslcs rhyLhm per LelemeLry"
4 Call wlLhln 2 mln Lo hook paLlenL back up
O noltet mooltotloq 244 hours ouLpaLlenL we can see whaL Lhey're dolng
4 Crdered ln ouLpaLlenL offlce
4 1he provlder can see whaL ls golng on
4 rlng lL back and Lake lL off and Lurn lL ln and geL Lhe resulLs
4 uo everyLhlng Lhey usually do
4 no shower
4 Mark how you are feellng
O veot tecotJet mooltotloq days conLlnuously monlLor we can see whaL Lhey're dolng
4 Cell phone LhaL you wrlLe ln how you feel and marks LhaL spoL on LkC
4 keep on oLher Lhan shower
4 Jork sexual acLlvlLy eLc
O Lxerclse Lreadmlll LesLlng ouLpaLlenL and see whaL Lhe hearL does aL resL
AssessmenL of Cardlac 8aLe
O 6 second sLrlp
O Marker for every seconds
O 6 second sLrlp counL splkes x1 P8
O CounL splkes 7 bpm okay raLe
O Coal counL splkes or counL lnbeLween ls LhaL raLe ok? Pas LhaL raLe changed from before?
O normal or noL? Compare Lo lasL Llme
O Come back and now we see 14 splkes Lachycardlc now Change address LhaL
O CeL general hearL raLe and know where you sLand!
AssessmenL of Cardlac 8hyLhm
O LlLLle and blg boxes
4 |tt|e boxes 4 sec (grey)
llLLle boxes x 4 2
4 |g boxes 2 sec (black)
O second markers
O Jorrled abouL measurlng 1lML (across on boLLom)
AssessmenL of Cardlac 8hyLhm 8eadlng Lhe waves
O 1 9 wave sLarLs elecLrlcal sysLem
4 2 sec Laklng Loo much Llme Loo long
O 2 9 |nterva| wanL lL Lo be 2 sec small boxes
4 8epresenLs Llme Laken Lo lmpulse Lo spread Lhrough Lhe aLrla Av node undle of Pls bundle
branches urkln[e flbers polot tlqbt befote veottlcolot coottoctloo
O ; |nterva| Splkes up or down presenL hearL beaL
4 uepolarlzaLlon (conLracLlon) of boLh venLrlcles (sysLole)
O @ wave comes up and goes down (venLrlcular repolarlzaLlon uprlghL pos)
4 S1 SegmenL lmporLanL
4 ls lL Lhere?
4 8 measure how long 2 more lnvesLlgaLlon
4 ;8S ls lL Lhere?
4 1 wave ls lL Lhere?
O soe|ectr|c ||ne basellne waves sprouL from Lhere wave and 1 wave eLc

Approach Lo Assesslng Cardlac 8hyLhms

PlCPLlCP1 1PlS SLluL SPCuLu knCJ
;uesLlons
O ls Lhere a p wave?
O ls Lhere a p wave for every ;8S?
O ALrlal rhyLm 's regular?
O Measure 8 lnLerval ls lL normal?
O venLrlcular rhyLhm ;8S regular?
O venLrlcal raLe



Norma| |nus hythm
O Slnus node flres 6 Lo 1 bpm
O lollows normal conducLlon paLLern




|nus radycard|a
O Slnus node flres 6 bpm
O normal rhyLhm ls aeroblcally Lralned aLhleLes and durlng
sleep
O Cnly Lhlng off ls P8
Assessmeot
O LCC alerL and orlenLed
O LlsLen Lo Lhelr hearL
O ls LelemeLry correcL? ls Lhere a lub dub?
O Are you dlzzy? Pow are you feellng? %chest pa|n synscope)
O JhaL ls Lhere basellne?
O JhaL medlcaLlons have Lhey had?
O SomeLlmes aL nlghL
O usually runnlng 1's monlLor drops Lo 4 JhaL Lo do?
4 Assess paLlenLs how are Lhey dolng how are Lhey feellng? Ask quesLlons? Jhy Lhelr P8 [usL
plummeLed? Are Lhey ln Lhe baLhroom?
cllolcol slqolflcooce
uependenL on sympLoms lOc Jlzzy (belp potleot sofety) pole cool sklo JecteoseJ cotJloc ootpot
coo effect ptofosloo
1teotmeot
trop|ne for exLreme bradycardla
locemoket may be requlred
lnLernal
xterna| lf can'L geL Lhelr P8 up (bedslde LkC on crashcarL) call 8apld 8esponse 1eam
**normal for swlmmer aLhleLe may run ln 4's and 's and LhaL's flne!

|nus @achycard|a
O ulscharge raLe from Lhe slnus node ls lncreased and ls 1 bpm
O wave presenL
O 117 bpm we assess Lhem Lhey're flne Lhey're [usL hanglng ouL
LhaL's ok
O 1 bpm we need Lo brlng Lhem down
O cAu5 ooxlety sttess polo fevet exetclse
O Look aL a basellne Lo see lf we should respond
4 12 and usually are LhaL's flne
4 16 whaL's golng on?
O Assess MedlcaLlons blood pressure changes flnd ouL JP?? (Sudafed caffelne Lplen nlfedlplne)
cllolcol ossoclotloos
AssoclaLed wlLh physlologlc sLressors
cllolcol slqolflcooce
ulzzlness
lncreased myocardlal oxygen consumpLlon may lead Lo ang|na
O P8 up o2 demand up noL geLLlng C2 needs chesL paln
O uitty dyspneo hypotension due to uck45u cO
1teotmeot
O eLa blocker po (metopro|o| opressor) teJoce nk ooJ Jecteose myocotJlol O2 coosomptloo
O eLa blocker lv push
4 JaLch bedslde monlLorlng don'L wanL Lhem Lo drop Loo low
O ulgoxln
O Calclum Channel lockers

I|rstDegree I |ock someth|ng b|ock|ng and not
happen|ng ||ke |t shou|d
Av cooJoctloo ls ptolooqeJ
O 8 lnLerval can be longer
O wave whlch sLarLs sysLem
O lrom Lo 8 ls Laklng Loo long (more Lhan
boxes from beglnnlng of Lo sLarL of ;8S) auLomaLlcally glves us #ltst ueqtee Av block

cllolcol ossoclotloos
O AbnormallLles due Lo Pl Ml CAu eLc from prevlous hx
cllolcol slqolflcooce
O usually asympLomaLlc
O May be a precursor Lo hlgher degrees of Av block (2
nd
or
rd
degree) noL waves or ;8S waves
abnormal!!! aLrlum Lalklng and venLrlcle noL llsLenlng PLAuS u!
O keep waLchlng lL assess for change
1teotmeot
O Check medlcaLlons beto blockets could cause Lhls prolonged 8 lnLerval Can be a good slde
effecL b/c Lhelr P8 may need Lo lower monlLor for any new changes ln hearL rhyLhm (eg more
serlous Av block) Mlssed some noLes here
O ConLlnue Lo monlLor noLhlng Lo freak ouL abouL
4 Ad[usLmenL ln meds
4 uoes lL geL worse or does lL geL beLLer?

tr|a| I|br|||at|on
O 1oLal dlsorganlzaLlon of ottlol elecLrlcal acLlvlLy
due Lo mulLlple ecLoplc focl resulLlng ln loss of effecLlve
aLrlal conLracLlon
O SA node ln ALrla -O lJeotlfloble l wove
O MosL common dysrhyLhmla
O revalence lncreases wlLh age
O ALrlas are conLracLlng dolng whaL Lhey're supposed Lo do
O uo oot bove llttle bomps fot lk befote Ok5
O Ok5 oot teqolot
O -O l woves

ALrlal llbrlllaLlon
cllolcol ossoclotloos
O Alcohol
O Caffelne
O LlecLrolyLe dlsLurbances
O 8heumaLlc hearL dlsease coronary hearL dlsease
O PearL fallure
cllolcol slqolflcooce
O Can resulL ln uck45 in cO due Lo lneffecLlve ALrlal conLracLlons (loss of ALrlal klck) and rapld
venLrlcular response
O @hrombi may form ln Lhe ALrla as a resulL of blood sLasls occurs lnbeLween beaLs hlgh rlsk of
sLroke when Lhey develop and pass Lhrough Lhe braln
4 CLC1 ln rlghL slde Lungs L
4 CLC1 ln lefL slde SLroke
O Lmbolus may develop and Lravel Lo Lhe braln causlng a L/sLroke
1teotmeot
Coals
&&uecrease venLrlcular response
*revenL embollc sLroke
urugs for raLe conLrol d|gox|n .adrenerg|c b|ockers ca|c|um channe| b|ockers %d||t|azem)
LongLerm anLlcoagulaLlon Coumad|n (prevenL sLroke and w/ Allb) -k 2J 5ec w/ Alb
May be on heparln lnlLlally
1teotmeot
lor some paLlenLs converslon Lo slnus rhyLhm may be consldered
O AotlJystbytbmlc Jtoqs used for converslon m|odarone %I dr|p 9 + mon|tor)
O cotJlovetsloo may be used Lo converL aLrlal flbrlllaLlon Lo normal slnus rhyLhm
4 Can cause cloLs Lo dlslodge Lherefore need anLlcoagulanL Lherapy before and
afLer
O 8adlofrequency CaLheLer AblaLlon new goes up from groln Lo hearL lgnlLes and Lrles
Lo flghL Lhe parL of hearL LhaL causes ls lL cauLerlze lL and goes back Lo slnus LasL resulL
JorsL parL Lry Loo many spoLs damage golng Lo need a pacemaker
4 oslLlonlng a caLheLer ln Lhe rlghL aLrlum bLw Lhe lnferlor vena cava Lrlcuspld
valve
4 uses hlghvolLage hlgh freq form of elecLrlcal energy Llssue ls ablaLed
(desLroyed) dysrhyLhmla ls LermlnaLed normal slnus rhyLhm resLored
O ??lf converLed w/ Lhlswe know LhaL medlclne works and Lhen Lhey wlll go on po Amlodarone lf lL
doesn'L workLhen Lhey canL Lry cardlo verslon Lo work AnyLhlng we Lry ls noL permanenL??

O Ate we wottleJ oboot someooe w/ v lb??
4 As long as Lhelr P8 ls normaland Lhey don'L have addlLlonal pressure Lo worry abouL
4 1hey sLay on Coumad|n and llve llfe long lf ln Aflb
4 1eocb slqos ooJ symptoms of 5ttoke ooJ l
4 1each abouL Coumadln monlLor LherapeuLlc levels rlsk for bleeds

tr|a| I|utter ALrlal dysrhyLhmla ldenLlfled by recurrlng
regular sawLooLhshaped fluLLer waves
O usually occurs ln a dlsease sLaLe
O lluLLer waves ln beLween
O -O Ok5 fot evety l wove
O lottet l woves (sowtootb potteto) mote flottet woves tboo Ok5 complexes
O kote kbytbm coo be teqolotJepeoJs oo bow mooy flottets lo betweeo
4 coolJ be 2 flottets lo betweeo ot 4 flottetslf # of flottets votles Ok5 wlll -O1 be teqolot
4 Can be 8LCuLA8 or l88LCuLA8
O 8LMLML8 Saw LooLh appearance" or someone Look a blLe ouL of Lhe edges of a sLrlp

cllolcol ossoclotloos
O Bisease states: CAB, BTN, pe, Coi Pulmonale, chionic lung uisease, etc.
cllolcol slqolflcooce
O Plgh aLrlal raLes (1) and loss of Lhe aLrlal klck" can uLC8LASL CC and preclplLaLe Pl ang|na
O 8lsk for sLroke due Lo rlsk of Lhrombus formaLlon ln Lhe aLrla (sLasls of blood here)
1teotmeot COAl 5low veottlcolot tespoose by -ckA5-C Av block (co+ ch 8/ockers 8eto b/ockers)
O Coumad|n prevenL sLroke (lf P8 lrregular)
O CeL Lhem back ln slnus rhyLhm and malnLaln lL wlLh am|odarone |but|||de %Corvert)

Am l A llb dolng 1 or A llb dolng 4 b/c Lhe P8 deLermlnes
ulfferenLlaLe on Lhe sLrlpls Lhls Aflb or A lluLLereveryLhlng else ls Lhe same!

**Cn LxAM 1C 8LCCCnlZL A ll A lLu11L8 ll8S1 uLC8LL PLA81 LCCk

bnorma| @|nd|v|dua| beats Lhese are noL sLrlps lndlvldual beaLs wlLhln a sLrlp!

Premoture 4trio/ controction {P4c) @klckY
O ConLracLlon orlglnaLlng from ecLoplc focus ln aLrlum ln locaLlon oLher Lhan SA node ( wave
premaLure)
O May be sLopped delayed or conducLed normally aL Lhe Av node
O ulsLorLed waves presenL (abnormal shape)
O Slnus Lachycardla P8 14 w/ AC
cllolcol ossoclotloos
Can resulL from
O LmoLlonal sLress
O use of caffelne Lobacco alcohol
O *ypox|a C2 may be needed
O |ectro|yte |mba|ances
O C9D (hypoxla)
O valvular dlsease noL as common
Make sure Lhey keep Lhelr P8 hlgh Co ln and assess Lhem esp lf Lhey have more of Lhem noLhlng Lhey're
golng Lo freak ouL abouL leels llke a palplLaLlon lf felL or hearL sklpped a beaL"
1teotmeot decrease sympLoms wlLhdrawal from sources (caffelne) eLc
Premoture ventricu/or controctions {Pvc)
O ConLracLlon orlglnaLlng ln ecLoplc focus of Lhe venLrlcles
O ltemotote occotteoce of o wlJe ooJ JlstotteJ Ok5 complex
O MulLlfocal unlfocal venLrlcular blgemlny venLrlcular Lrlgemlny couples LrlpleLs 8 on 1 phenomena
O #funky ||tt|e beat"
O -o l wove vlslble
4 ,oltlfocol (appear dlfferenL ln shape from eachoLher vC's)
4 uolfocol (same shape vC'S)
4 lqemloy (every oLher beaL)
4 veottlcolot ttlqemloy (every
rd
beaL vC)
4 cooplet (2 ln a row)
4 1tlplet ( ln a row)

Sllde 1 shows same person same Llme dlfferenL vlews MulLlfocal
vC's and blgemlnal
O waves
O ;8S for every wave
O Slnus bradycardla w/ vC's blgemlnal mulLlfocal





**Sllde 2 unlfocal vC's nC1L a slngle vC ls labeled lsolaLed
O waves
O ;8S for every wave
O Slnus rhyLhm 's
O *@ segment goes be|ow |soe|ectr|c ||ne
**8LMLML8 AC's follow all Lhe rulesvC's look funky!
**SLL SLluLS


unlfocal
Jould be worry abouL??
noL as worrled b/c we're regular
ls Lhls someLhlng new?
|gem|ny geLLlng llLLle concerned LhaL Lhe venLrlcles have Lo Lake over
every oLher beaL and do Lhelr own Lhlng So sLarL Lo geL worrled
P8 ls 7 would be worrled lf brady or Lachy
lnvLS1lCA1L Lhls Lhey can go lnLo vLach wlLh blgemlny

@r|p|et's present (or beaL vLach ls consldered + vC's LogeLher)
8LAu S18l
Can call lL 6 buL probably less b/c ln a row CC probably
bad due Lo ln a row
Slnus wave and ;8S presenL
mlghL be flrsL degree hearL block ln or more hearL boxes
lf you geL Lhls sLrlp on Lhe LesL
More worrled abouL LrlpleLs compared Lo bradycardla (aL
leasL Lhey have a beaL and ;8S)
More vC's and runnlng Lhem LogeLher worrledesp lf
LrlpleLhearL ls saylng please glve me a slnus beaL" lf Lhey don'L go
ouL of lLconsldered vLach"







Assessmeot
O Px
O ls Lhls new? Cr has he been dolng Lhls before
O CounL vC as conLracLlng buL ouLpuL noL very good
O uo you feel ditty? Po/pitotions?
cllolcol ossoclotloos
O SLlmulanLs Caffelne alcohol nlcoLlne amlnophylllne eplnephrlne lsoproLerenol
O ulgoxln
O LlecLrolyLe lmbalances
O Pypoxla
O lever
O ulsease sLaLes Ml mlLral valve prolapse Pl CAu when sLarLs Lo effecL sLrucLure of hearL
Lakes a Loll on elecLrlcal sysLem
4 Lnlarged rlghL aLrla lnLerpheres w/ SA node A flb or noL sLarLlng correcLly affecLed
's
4 LefL venLrlcular hyperLrophy v flb
cllolcol slqolflcooce
O ln normal hearL usually benlgn
O ln hearL dlsease vCs may decrease CC and preclplLaLe anglna and Pl
1teotmeot
O ased on a cause of vC's
4 C2 Lherapy for hypoxla check C2
4 LlecLrolyLe replacemenL check Lhese
4 urugs Aderenerglc blockers amlodarone
4 1ake home Lhlngy
4 Check paLlenL's hemodynamlc sLaLus Lo assess lf drug Lherapy needed

Ientr|cu|ar @achycard|a
O 8un of Lhree/four or more vCs
O Monomorphlc polymorphlc susLalned (see v Lach on monlLor and doesn'L sLop) and nonsusLalned
(sLarLs and sLops)
O Consldered llfeLhreaLenlng because of decreased CC and Lhe posslblllLy of deLerloraLlon venLrlcular
flbrlllaLlon
cllolcol ossoclotloos
O
O CAB
O lectiolyte imbalances
O Caiuiomyopathy
O ong QT Synuiome
O Biug toxicity
O CNS uisoiueis
cllolcol slqolflcooce
v1 can be sLable (paLlenL has a pulse) or unsLable (paLlenL ls pulseless)
*usta|ned I@ Severe decrease ln CC llfe LhreaLenlng
O PypoLenslon
O ulmonary edema
O uecreased cerebral blood flow
O Cardlopulmonary arresL (lf someLhlng ls noL done)
AssessmenL
O LCC
O alplLaLlons
O ulzzy
O SC
O uecreased cardlac ouLpuL

1 unS1ALL no pulse already ln cardlopulmonary arresL
Check pulse sLarL C8 decompress bed flaL bed no breaLhes
Call CCuL help
SLarL vLS sLay w/ paLlenL
2 S1ALL pulse
8espond Lo you? ?LS! uLSL
1teotmeot
O MedlcaLlons (lf pulse) sota|o| am|odarone ||doca|ne I proca|nam|de
O Cardloverslon (conLrolled v 1ach + pulse) ls used lf drug Lherapy ls lneffecLlve
O I@ w|thout a pu|se |s a ||fethreaten|ng s|tuat|on D I|b %treat at I I|b)

Ientr|cu|ar I|br|||at|on
O Severe derangemenL of Lhe hearL rhyLhm lrregular and of varylng conLour and ampllLude
O no effecLlve conLracLlon or CC occurs
O shaklng hearL"
cllolcol ossoclotloos
O , ischemia
O Chionic uiseases: BF anu caiuiomyopathy
cllolcol slqolflcooce
O unresponslve pulseless and apnelc sLaLe CCuL Sl1uA1lCn*
O lf noL LreaLed rapldly deaLh wlll resulL
1teotmeot
O Assess apnelc pulseless call CCuL
O C8
O ALu nexL Lhlng ln room save llfe shocks Lhem"
O Crash CarL
O 1elemeLry auLomaLlcally calls CCuL Lo floor assess Lake care of pL
systo|e
O 8epresenLs LoLal absence of venLrlcular elecLrlcal acLlvlLy
O no venLrlcular conLracLlon (CC) occurs because depolarlzaLlon does noL occur
cllolcol ossoclotloos severe Pl or advanced cardlac dlsease
cllolcol slqolflcooce
4 unresponslve pulseless and apnelc sLaLe
4 rognosls for asysLole ls exLremely poor (aL leasL w/ A llb elecLrlcal sysLem ls shaken movlng"
4 no cardlac ouLpuL (CC)
1teotmeot
1 8un ln and assess
2 Call CCuL
SLarL C8
4 ALu conLlnue compresslons
Crash carL

9u|se|ess |ectr|ca| ct|v|ty %9)
O LlecLrlcal acLlvlLy can be observed on Lhe LCC buL Lhere ls no mechanlcal acLlvlLy of Lhe venLrlcles and
Lhe paLlenL has no pulse
O waves
O ;8S for every
O Slnus bradycardla accordlng Lo sLrlp
4 1o know Assess paLlenL know whaL lL was beforehand (was lL 's beforehand and now
4's?)
4 CC ln and assess LA potleot ootespooslve oo polse ooJ opoelc bot bove beootlfol sloos
tbytbm/sloos btoJy tote
4 Cnly way Lo know LA ls lf we go ln and assess Lhem!

cllolcol ossoclotloos
O Pypovolemla
O Pypoxla
O MeLabollc acldosls
O Pyperkalemla or hypokalemla
O PypoLhermla
O urug overdose
O Cardlac Lamponade sLlck needle ln and geL fluld ouL of hearL
O Ml
O 1enslon pneumoLhorax
O L
we Joot koow bow looq tbls potleot bos beeo lo lA b/c tbls potleot looks llke tbey bove o ootmol tbytbm
1teotmeot
O C8 (chesL compresslons) followed by lnLubaLlon and lv eplnephrlne
O ALroplne ls used lf Lhe venLrlcular raLe ls slow
O 1reaLmenL ls dlrecLed Loward cottectloo of tbe ooJetlyloq coose
O noL a good scenarloCCuLS can go on for hours LlecLrlclLy ls LherebuL no C2
uegree of severlLy
uepends on sympLoms
uL baslcally
O Slnus rhyLhms bradys Lachs
O AC's vC's funky llLLle beaLs could be bad or noL
O rady/1achy
O ALrlal lssues A flb or A fluLLer
O llrsL degree worrled abouL hlgher level hearL blocks
O Second degree 1ype l do noL Lalk abouL P8 brady no ;8S waves for 's LreaL
brady
O Second degree 1ype ll do noL Lalk abouL P8 brady no ;8S waves for 's LreaL
brady
O 1hrld degree
O venLrlcal lssues do noL wanL Lo have Lhls (v 1ach and v llb)

9acemakers
O used Lo pace Lhe hearL when Lhe normal conducLlon paLhway ls damaged or dlseased
O MCS1 CCMMCn 8LASCn radycard|a sympLoms ln P8
O lnlLlally lndlcaLed for symptomotlc btoJyJystbytbmlos
O AotltocbycotJlo ooJ ovetJtlve pocloq
O acemaker splke on LkC
O Lvery paLlenL's ls dlfferenL dependlng on where Lhe need ls acemaker helps Lhe hearL Lry Lo beaL"
and causes a ;8S ased on 1lML Sends elecLroacLlvlLy and Lells when need Lo beaL Also has
overdrlve paclng llke lf P8 ls 1 bpm and Lhen Lhe pacemaker Lakes over and beaLs 1 bpm
acemaker Lakes conLrol of elecLrlcal lmpulse of hearL and goes wlLh lL ased on each separaLe beaL lf
Lhe beaLs geL Loo close LogeLher lL recognlzes lL

1emporary pacemaker lnLervenLlons for sympLomaLlc bradycardlc paLlenLs locaLed on crash carL
1hls ls an exLernal pace and uses [ewels Lo elecLrlcally pace paLlenL 1hls ls for hours Lo geL
everyLhlng ready for an lnLernal pacemaker surgery 1he paLlenL may have burns Call Lhe rapld
response or AC1 Leam

lotleot Jocotloo
JhaL ls nC1 ok Lo do?
no M8l
JhaL ls lL ok Lo do?
9acemaker
O ALrla wlre measures wave and beaL
O venLrlcular wlre measures ;8S makes ;8S Lo work
O uuel lead aLrla and venLrlcular leads
O osL op can'L ralse Lhelr arm over Lhelr head (24 weeks) unLll Lhey see PC uo lower arm
exerclses 1o make sure leads are ln place
O uevlce checks baLLery usages properly worklng come ln 1 monLh monLh 6 monLhs and
Lhen once a year MusL have LhaL card and number on Lhe card Lo be able Lo call

mp|antab|e Card|overter Def|br|||ator %CD) has a pacemaker lnslde of lL + shock!
O Apptoptlote fot potleots wbo?
4 Coded before
4 8lsk for v flb or v Lach lu and send ouL preLLy sLrong shock
4 LlLLle blgger Lhan pacemaker
O vla subclavlan veln Lo Lhe endocardlum
O lCu senslng sysLem monlLors Lhe P8 and rhyLhm and ldenLlfles v1 or vl
O lCus are equlpped wlLh anLlLachycardla and anLlbradycardla pacemakers

Jocotloo ls exttemely lmpottoot
O Same as pacemaker
O lf lCu flres needs Lo call and have flres seen
O Allowed Lo drlve
O uescrlbed as klck ln Lhe chesL"
O 1each Lhem whaL Lo do when shocked
O SupporL group
4 AnxleLy relaLed Lo anLlclpaLlon Lo paln
O arLlclpaLlon ln an lCu supporL group should be encouraged

Catheter b|at|on @herapy
LlecLrodeLlpped ablaLlon caLheLer burns" accessory paLhways or ecLoplc slLes ln Lhe aLrla Av node and
venLrlcles
4 nonpharmacologlc LreaLmenL for
Av nodal reenLranL Lachycardla
8eenLranL Lachycardla relaLed Lo accessory bypass LracLs
ConLrol of venLrlcular response of cerLaln LachydysrhyLhmlas
Def|br|||at|on
4 MosL effecLlve meLhod of LermlnaLlng vl and pulseless v1
4 assage of elecLrlcal shock Lhrough Lhe hearL Lo depolarlze Lhe cells of Lhe myocardlum Lo allow Lhe SA
node Lo resume Lhe role of pacemaker
4 uellver energy uslng a monophaslc or blphaslc waveform
O Monophaslc deflbrlllaLors dellver energy ln one dlrecLlon
O lphaslc deflbrlllaLors dellver energy ln Lwo dlrecLlons

knCJ 1PL ulllL8LnCL L1JLLn
O acemaker
O lCu acemaker + debrlllaLor
O Cardloverslon
O ueflbrlllaLlon

CG Changes ssoc|ated w|th cute Coronary yndrome %C)
ueflnlLlve LCC changes occur ln response Lo lschemla ln[ury or lnfarcLlon of myocardlal cells
Changes seen ln Lhe leads LhaL face Lhe area of lnvolvemenL
aLLern of LCC changes wlll provlde lnformaLlon on Lhe coronary arLery lnvolved ln ACS
Coulu be cuiient heait attack (cbanges in ST segment)
Coionaiy aiteiy - uue to uamage theie
se leau Cu
CG Changes ssoc|ated w|th cute Coronary yndrome %C)
lschemla changes
4 ST segment uepiession
4 soelectiic line
&&-ote ooy Jlffeteoces/cbooqes lo blstoty
O ln[ury/lnfarcLlon changes
4 ST segment elevation
4 Physiologic Q wave
CG Changes ssoc|ated w|th cute Coronary yndrome %C)
51 elevotloo (lojoty/lofotctloo)
ook at iunning stiip ( leau), seconus
eau , , = fiom telemetiy
P wave, QRS foi eveiy P, BR iegulai, uon't see any ST changes.
4 oulu you be aleiteu if you saw this on a monitoi.
4 Tioponins woulu come back positive with this..

S1 depresslon (SLluL)
Show on leau.will be shown on telemetiy on bottom one
yncope
rlef lapse ln consclousness (pass ouL) accompanled by a loss ln posLural Lone (falnLlng) Jorrled abouL
. Beait
. Biain
Aumitteu to caiuiac flooi, caiuiac woik up(to monitoi bloou status, to monitoi bloou to
biain)
cotJlovoscolot cooses
vosocoosttlctloo
Bypotension
. Fib
Bioppeu caiuiac output (BR X S) if one of these uioppeu
-oocotJlovoscolot cooses
Behyuiateu
Bypovolemia
Bypoglycemia
Tiauma
Anxiety (cholineigic iesponse - ex: look at bloou)

uCnL wlLh LecLure!

MaLerlal below ls for you lf you wanL more lnformaLlon
Ln[oy!
Seconduegree Av lock
1ype 1 (MoblLz l Jenckebach)
Cradual lengLhenlng of Lhe 8 lnLerval due Lo prolonged Av conducLlon Llme
ALrlal lmpulse ls nonconducLed and a ;8S complex ls blocked (mlsslng)
Seconduegree Av lock
1ype 1 (MoblLz l Jenckebach)
Cllnlcal assoclaLlons
urugs dlgoxln .adrenerglc blockers
May be assoclaLed wlLh CAu and oLher dlseases LhaL can slow Av conducLlon
Seconduegree Av lock
1ype 1 (MoblLz l Jenckebach)
1reaLmenL
lf sympLomaLlc aLroplne or a Lemporary pacemaker
lf asympLomaLlc monlLor wlLh a LranscuLaneous pacemaker on sLandby
SympLomaLlc bradycardla ls more llkely wlLh one or more of Lhe followlng hypoLenslon Pl shock
Seconduegree Av lock
1ype 2 (MoblLz ll)
wave ls nonconducLed wlLhouL progresslve anLecedenL 8 lengLhenlng
Seconduegree Av lock
1ype 2 (MoblLz ll)
Cllnlcal assoclaLlons
8heumaLlc hearL dlsease
CAu
AnLerlor Ml
ulglLalls LoxlclLy
Seconduegree Av lock
1ype 2 (MoblLz ll)
Cllnlcal slgnlflcance
CfLen progresses Lo Lhlrddegree Av block and ls assoclaLed wlLh a poor prognosls
8educed P8 ofLen resulLs ln decreased CC wlLh subsequenL hypoLenslon and myocardlal lschemla
Seconduegree Av lock
1ype 2 (MoblLz ll)
1reaLmenL
lf sympLomaLlc (eg hypoLenslon anglna) before permanenL pacemaker can be lnserLed Lemporary
Lransvenous or LranscuLaneous pacemaker
ermanenL pacemaker
1hlrduegree Av PearL lock
(CompleLe PearL lock)
lorm of Av dlssoclaLlon ln whlch no lmpulses from Lhe aLrla are conducLed Lo Lhe venLrlcles
ALrla are sLlmulaLed and conLracL lndependenLly of Lhe venLrlcles
venLrlcular rhyLhm ls an escape rhyLhm
1hlrduegree Av PearL lock
(CompleLe PearL lock)


1hlrduegree Av PearL lock
(CompleLe PearL lock)
Cllnlcal assoclaLlons
Severe hearL dlsease CAu Ml myocardlLls cardlomyopaLhy
urugs ulgoxln .adrenerglc blockers calclum channel blockers
1hlrduegree Av PearL lock
(CompleLe PearL lock)
Cllnlcal slgnlflcance
uecreased CC wlLh subsequenL lschemla Pl and shock
Syncope may resulL from severe bradycardla or even perlods of asysLole
1hlrduegree Av PearL lock
(CompleLe PearL lock)
1reaLmenL
lf sympLomaLlc LranscuLaneous pacemaker unLll a Lemporary Lransvenous pacemaker can be lnserLed
urugs (eg aLroplne eplnephrlne) 1emporary measure Lo lncrease P8 and supporL unLll
Lemporary paclng ls lnlLlaLed
ermanenL pacemaker as soon as posslble