Cardiac dysrhythmia management & pacemakers
LATEST APRIL 2023
Cardiac dysrhythmias
− Students to review slides 4-29 prior to class: this content will not be covered in NUR 4120
− Normal sinus rhythm
• Answers to evaluation of rhythm will always be within normal limits
• Rate: 60-100bpm
Sinus node dysrhythmias
− Sinus bradycardia
• HR < 60 bpm
• Sinus node creates impulse at slower than normal rate
• Characteristics of NSR but a slower rate
− Etiology: sinus bradycardia
• Sleep • Medication
• Athletic training ▪ CCB (decrease HR/BP), amiodarone,
• Hypothyroidism beta-blockers
• Vagal stimulation • Increased intracranial pressure
▪ Vomiting, suctioning, pain • CAD/Acute MI
, • Hypoxemia • Acute decompensated heart failure
• Altered mental status
− Sinus bradycardia: clinical manifestations and management
• Clinical manifestations:
▪ SOB altered LOC
▪ Hypotension
▪ EKG changes (ST segment changes PVC’s)
• Management:
▪ Resolve causative factors
▪ Atropine 0.5 mg IV every 3-5 minutes
⮩ Maximum dose of 3 mg
⮩ Atropine won’t work on a patient with a heart transplant
▪ Emergency transcutaneous pacing
▪ Catecholamines
− Sinus tachycardia
• HR: 100-120
• Sinus node creates impulse at faster than normal rate
• Does not start or stop suddenly
− Etiology: sinus tachycardia
• Physiologic stress
▪ Acute blood loss, anemia
▪ Shock
▪ Hyper/hypovolemia
▪ Heart failure
▪ Pain
▪ Hypermetabolic states
▪ Fever
▪ Exercise
▪ Anxiety
• Medications
▪ Catecholamine
▪ Atropine
▪ Stimulants (caffeine, nicotine)
▪ Illicit drugs (Ecstasy, cocaine)
− Sinus tachycardia: clinical manifestations and management
• Clinical manifestations
▪ Decreased filling time of heart
⮩ Reduces cardiac output
→ Syncope
→ Hypotension
, → Acute pulmonary edema (assess lung sounds, diff. breathing)
• Management
▪ Abolish the cause
▪ Synchronized cardioversion (hemodynamic instability)
▪ Vagal maneuvers → recharges SA node
▪ Adenosine (only for narrow QRS)
▪ Narrow QRS?
⮩ Beta-blockers (rare)
⮩ Calcium-channel blockers (rare)
⮩ Adenosine
▪ Wide QRS?
⮩ sotalol, amiodarone
▪ Increased fluid/sodium (POTS) postural orthostatic tachycardia
Atrial dysrhythmias
− Atrial flutter
• Conduction defect in the atrium, filling time is affected, risk = coagulation
• Creates atrial rate between 250-400 times/minute (ventricular rate 75-150)
• Not all impulses conducted to ventricle: therapeutic block at AV node
• 2:1, 3:1, 4:1
• Regular atrial activity
• P wave = “saw tooth” appearance
• HR > 100 bpm
▪ “uncontrolled”
• HR > 150 bpm
▪ “rapid ventricular rate”
− Etiology: atrial flutter**
• COPD
• Pulmonary HTN
• Valvular disease
• Thyrotoxicosis
• Open heart surgery
− Atrial flutter: clinical manifestations and management
• Clinical manifestations:
▪ Chest pain
▪ Dyspnea
▪ Hypotension
• Management:
▪ Electrical cardioversion for unstable patient
▪ See treatment for atrial fibrillation
▪ Medications to slow the ventricular response:
LATEST APRIL 2023
Cardiac dysrhythmias
− Students to review slides 4-29 prior to class: this content will not be covered in NUR 4120
− Normal sinus rhythm
• Answers to evaluation of rhythm will always be within normal limits
• Rate: 60-100bpm
Sinus node dysrhythmias
− Sinus bradycardia
• HR < 60 bpm
• Sinus node creates impulse at slower than normal rate
• Characteristics of NSR but a slower rate
− Etiology: sinus bradycardia
• Sleep • Medication
• Athletic training ▪ CCB (decrease HR/BP), amiodarone,
• Hypothyroidism beta-blockers
• Vagal stimulation • Increased intracranial pressure
▪ Vomiting, suctioning, pain • CAD/Acute MI
, • Hypoxemia • Acute decompensated heart failure
• Altered mental status
− Sinus bradycardia: clinical manifestations and management
• Clinical manifestations:
▪ SOB altered LOC
▪ Hypotension
▪ EKG changes (ST segment changes PVC’s)
• Management:
▪ Resolve causative factors
▪ Atropine 0.5 mg IV every 3-5 minutes
⮩ Maximum dose of 3 mg
⮩ Atropine won’t work on a patient with a heart transplant
▪ Emergency transcutaneous pacing
▪ Catecholamines
− Sinus tachycardia
• HR: 100-120
• Sinus node creates impulse at faster than normal rate
• Does not start or stop suddenly
− Etiology: sinus tachycardia
• Physiologic stress
▪ Acute blood loss, anemia
▪ Shock
▪ Hyper/hypovolemia
▪ Heart failure
▪ Pain
▪ Hypermetabolic states
▪ Fever
▪ Exercise
▪ Anxiety
• Medications
▪ Catecholamine
▪ Atropine
▪ Stimulants (caffeine, nicotine)
▪ Illicit drugs (Ecstasy, cocaine)
− Sinus tachycardia: clinical manifestations and management
• Clinical manifestations
▪ Decreased filling time of heart
⮩ Reduces cardiac output
→ Syncope
→ Hypotension
, → Acute pulmonary edema (assess lung sounds, diff. breathing)
• Management
▪ Abolish the cause
▪ Synchronized cardioversion (hemodynamic instability)
▪ Vagal maneuvers → recharges SA node
▪ Adenosine (only for narrow QRS)
▪ Narrow QRS?
⮩ Beta-blockers (rare)
⮩ Calcium-channel blockers (rare)
⮩ Adenosine
▪ Wide QRS?
⮩ sotalol, amiodarone
▪ Increased fluid/sodium (POTS) postural orthostatic tachycardia
Atrial dysrhythmias
− Atrial flutter
• Conduction defect in the atrium, filling time is affected, risk = coagulation
• Creates atrial rate between 250-400 times/minute (ventricular rate 75-150)
• Not all impulses conducted to ventricle: therapeutic block at AV node
• 2:1, 3:1, 4:1
• Regular atrial activity
• P wave = “saw tooth” appearance
• HR > 100 bpm
▪ “uncontrolled”
• HR > 150 bpm
▪ “rapid ventricular rate”
− Etiology: atrial flutter**
• COPD
• Pulmonary HTN
• Valvular disease
• Thyrotoxicosis
• Open heart surgery
− Atrial flutter: clinical manifestations and management
• Clinical manifestations:
▪ Chest pain
▪ Dyspnea
▪ Hypotension
• Management:
▪ Electrical cardioversion for unstable patient
▪ See treatment for atrial fibrillation
▪ Medications to slow the ventricular response:
