Topic 6: Lesson Guide

Care of Critically Ill Clients with Dysrhythmias

Topic Outline:
Review of CArdiac Anatomy and Physiology
A. Electrocardiography
B. Arrhythmias
1. Sinoatrial (SA) Node
2. Atrial
3. Junctional
4. Ventricular
5. Atrioventricular Blocks
6. Serum Electrolytes
C. Adjunctive Modalities and Management Thick myocardium on left ventricle
1. Cardioversion
2. Pacemaker Therapy
3. Defibrillators

Review of Cardiac Anatomy and Physiology

Heart – a hollow, muscular organ situated in the anterior thoracic cavity behind the sternum and above the diaphragm.

Layers of the Heart

● Pericardium – a fluid-field sac that acts as a tough protective covering enveloping the heart Pericarditis
● Epicardial fat – a layer of adipose tissue beneath the myocardium
● Epicardium – the outermost layer consists of squamous epithelial cells overlying connective tissue
● Myocardium – a thick, muscular layer that forms the largest portion of the heart’s wall. In this layer, muscle tissue contracts with each
heartbeat.
● Endocardium – the innermost layer of the heart. It is a thin layer of endothelium and connective tissue lining inside the heart.

Cardiac Chambers
● Atrium - serves as volume reservoir for the blood being transported into the ventricles.
o Right Atrium – receives blood from pulmonary arteries
o Left Atrium – receive blood from vena cava

● Ventricles – serve as the pumping chambers of the heart

o Right Ventricle – receives blood from the right atrium
o Left Ventricle - forms the heart’s apex, has a thicker wall because it works harder in pumping the heart against the higher
pressure of the aorta

Heart Valves – The function of the valves is to keep the blood flowing through the heart in a forward direction, and prevent backflow or

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 Systole- contracts
Dystole- relax
regurgitation from one chamber to another. It is associated with heart sounds
● Atrioventricular valves –
Cardiac dystole- the all chambers relax, while
o Mitral valve (Bicuspid valve)
o Tricuspid valve blood flow o the heart
● Aortic valves
● Pulmonary valves
Amount of blood being
Cardiac cycle delivered in the
● Cardiac output = Heart rate x Stroke Volume (usually 70ml). The normal cardiac output is 4 to 8 L/ min system in each beat/
● Phases of Cardiac Cycle pump of the heart
o Isovolumetric ventricular contraction
o Ventricular ejection Polarized cells
o Isovolumetric relaxation
(-)-(+)result to contraction
o Ventricular filling (depolarzation)
o Atrial systole (+)-(-) muscle relax (repolarization)
● Preload - a stretching exerted by blood on the ventricular muscle fibers at the end of diastole.
● Afterload – the pressure that the ventricles need to generate to overcome higher pressure in the aorta to eject blood into the systemic
circulation.

Depolarization and repolarization Sinoatrial

node- 60-100
bpm (rate)
Atherosclerosis Phase 0 ● Rapid o Cardiac cell receives stimulus
- affects depolarization o Sodium and calcium move rapidly into the cell Atrioventricular
cardiac output o Myocardial contraction occurs node
Phase 1 ● Early o Sodium channel closes Bundle of HIS
repolarization o Transmembrane potential fails slightly -left bundle
branch
Phase 2 ● Plateau phase o Little change occurs in the cell’s transmembrane potential -right bundle
o Calcium continues to flow in branch
o Potassium flows out of the cell Purkinje fibers

Phase 3 ● Rapid o Calcium channel close

repolarization o Potassium flows in rapidly
o The cell returns to its original state

Phase 0 ● Resting phase o Active transport through the sodium-potassium pump begins restoring
potassium to the inside of the cells and sodium to the outside

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 o Cell membrane becomes impermeable sodium
o Potassium may move out of the cell.
o The cell is ready for another stimulus

Conduction System of the Heart

P-waves
SA node – the normal pacemaker of the heart
Bachmann’s bundle Faster rate but
Internodal tract- Posterior (Thorel’s),
it can slow down
Middle ( Wenckebach’s) ,
Anterior on AV node
Atrioventricular node - doesn’t possess pacemaker cells
- It has junctional tissue with pacemaker cells
Bundle of His -conduction occurs leading to a heart rate between 40 to
60/min
Right bundle branch- extends down to the right ventricles
Left bundle branch- impulses travel faster down in this area
to feed the larger, thicker-walled left ventricle
Purkinje fibers – automatic firing rate ranges from 20 to 40/min

Atrial repolarization is
not seen because the
ventricle is overlapping
A. ELECTROCARDIOGRAPHY (ECG/EKG)
- It is one of the most essential diagnostic tools that records the heart’s electrical activity as waveforms
- It helps identify rhythm disturbance, conduction abnormalities, and electrolyte imbalances
- Changes in the rhythm can indicate structural, mechanical, or electrical issues.

Types of ECG recording:

a. 12-lead ECG (most common) - it records information from 12 different views of the heart
1. Frontal plane – Six limb leads such as I, II, III, augmented vector right (aVR), augmented vector left (aVL), augmented vector
foot (aVF)
o Bipolar leads - Lead I, II and III – require positive and negative electrode
o Augmented leads – unipolar. requires positive electrodes
2. Horizontal plane- Six precordial leads – V1, V2, V3, V4, V5 V6 - unipolar
b. Rhythm strip – provides continuous information about the heart’s electrical activity commonly, lead II, V1 and V6
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 N Cardiac rhythm
1. 60-100 bpm
2. SA node- conduction begins
3. Follow the N conducion system
SA-AV-HIS-Purkinje
Electrode Placement 4. N velocity-speed, distance x time
Standard limb leads
Cardiac dysrhythmias-
Electrode Placement Area
RA Right arm
dysfunctional rhythm
LA Left arm -Automatic sending of
LL Left leg impulses of SA node
RL Right leg -Spontaneous
V1 Fourth intercostal space to the right of the sternum.
depolarization
V2 Fourth intercostal space to the left of the sternum.
V3 Directly between leads V2 and V4. Most common
V4 Fifth intercostal space at midclavicular line. Impulse pa balik balik
V5 Level with V4 at left anterior axillary line. sa isa ka area
V6 Level with V5 at the midaxillary line. (Directly under the midpoint of the armpit)

ECG Grid- represents the horizontal axis and vertical axis and their corresponding values.

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Rhythm strip and interpretation

PARAMETER DEFINITION LOCATION AMPLITUDE DURATION CONFIGURATION DISORDER

P wave- The first component Precedes the 2 to 3 mm high 0.06 – 0.12 Usually round and Peak P wave – represents
of a normal ECG. QRS seconds upright atrial hypertrophy or
The P wave occurs enlargement (COPD,
during atrial pulmonary emboli, valvular
depolarization, which disease, heart failure)
causes the atria to Inverted P wave
contract.

PR interval The represents the From the start 0.12 to 0.20 If less than 0.12 sec, it is
amount of time for of P wave to seconds associated with junctional
the impulse to travel the beginning arrhythmias and
from the SA node in of the QRS preexcitation syndromes.
the atria through AV complex
node, bundle of His If more than 0.20 sec, may
and right and left indicate digoxin toxicity or

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 bundle, until it heart block.
reaches the
ventricles

QRS complex Represents Follows the 5 to 30 mm high, 0.08 to 0.12 Consist of Q wave Deep wide Q waves may
ventricular PR interval but may differ in seconds (negative represent myocardial
depolarization – other leads deflection), R infarction. Missing QRS
ventricles contract wave (positive complex may indicate an
deflection), and S atrioventricular block or
wave ( negative ventricular standstill.
deflection)

QT Interval The length of time it 0.36 to 0.44 If elongated, may represent

takes the electrical seconds Torsades or Ventricular
impulse to go from Fibrillation
the beginning
of the ventricles –
until the ventricles
completely repolarize
and are ready for
another
contraction.

ST segment Known as J point, Extend from Not observed 0.08 to 0.12 Change may indicate
represents the end of the S wave to (isoelectric line) seconds myocardial injury or
ventricular the beginning ischemia
conduction or of the T wave
depolarization and
the beginning of
ventricular recovery
or repolarization

T wave The last wave and its Follows the 0.5mm in leads I, II, 0.16 Round and smooth A tall T wave may indicate
wave’s peak ST segment III and up to 10mm seconds Myocardial injury or
represent ventricular in precordial leads electrolyte imbalances
repolarization such as hyperkalemia.
Hypokalemia leads to a
flattened T wave.

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 U wave It represents the .16 to 0.20 Bradycardia, hypokalemia,
repolarization of the seconds hyperkalemia, Digoxin
Purkinje fibers within toxicity
the
Ventricles.

Ectopic Beats – The beats that originate outside of the SA node.

It represents ischemia or damage.
It may or may not actually cause contraction of the heart.
It causes palpitation or skipped beats
eg. Premature Ventricular Contractions (Bigeminy, trigeminy, quadrigeminy), Premature Atrial Contractions,
Premature Junctional Contractions

Steps in Rhythm Interpretation

1. Determine Regularity
2. Determine Rate
3. P waves and PR interval
4. QRS AND QT Interval
5. ST segment and T wave
6. Ectopic Beats

Common Monitor Problems

● Artifacts – also called as waveform interference
● False high-rate alarm
● Weak signals
● Wandering baseline
● Fuzzy baseline

B. ARRHYTHMIA - The absence of cardiac rhythm

DYSRHYTHMIA - The abnormal cardiac rhythm

1. Normal Sinus Rhythm - occurs when an impulse starts in the SA node to the atria and progresses to the ventricles through a normal
conduction pathway.
Rhythm: regular
Rate: 60- 100beats /min
P wave: Normal, similar in shape and size
PR interval: Normal, 0.12 to 0.20 second
QRS complex: 0.08 to 0.12 second
T wave: Normal, upright and rounded shape in lead II

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 QT interval: Normal, 0.36 to 0.44 sec
Other: no ectopic or aberrant beats

Note: For older adult, ECG changes increased in PR, QRS, and QT interval, decreased amplitude of the QRS complex, and a shift of the QRS axis
to the left.

2. Sinoatrial (SA) Node Arrhythmias- The alteration brought by changes in the automaticity of the sinus node, blood supply, and autonomic nerve
system. The SA node acts as the primary pacemaker. The SA node's blood supply comes from the right coronary artery.

SINUS BRADYCARDIA SINUS TACHYCARDIA

Parameters Rhythm: Regular Rhythm: Regular

Rate: less than 60 beats/min Rate: 100 to 160 beats/min
P wave: Normal P wave: Normal but may increase in amplitude
PR interval: Normal and constant PR interval: Normal
QRS complex: Normal QRS complex: Normal
T wave: Normal T wave: Normal
QT interval: Normal, may be prolonged QT interval: Normal, but commonly shortened
Others: None Other: None

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Nursing ● Asymptomatic - treatment isn't necessary ● Check the level of consciousness to assess cerebral perfusion
Interventions ● Evaluate the rhythm at rest and with activity ● Provide a calm environment
● Review the patient’s medications ● Help reduce fear and anxiety
● If symptomatic, treat the underlying cause. ● Prevent injury of the heart by monitoring the signs of heart failure, and
● May administer drugs, such as atropine, treat with drugs to slow the heart rate. Drug of choice: Beta-adrenergic
epinephrine or dobutamine. blockers (metoprolol and atenolol), and calcium blockers ( verapamil
● Pacemaker and diltiazem)
● If caused by hemorrhage, treatment includes replacing blood and
fluid losses and stopping the bleeding. Monitor intake and output,
along with daily weight.
● Check patient's medical history. Over-the-counter
sympathomimetics (nose drops and cold formulas) may contribute
to sinus tachycardia.
● Avoid caffeinated foods, smoking, and drugs like cocaine and
amphetamines
Note: Tachycardia is initially a sign of pulmonary embolism for patients with
predisposing risk factors for thrombotic emboli.

SINUS ARRHYTHMIA

Rhythm: Irregular
Rate: 60 to 100 beats/min
P wave: Normal

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 PR interval: Normal
QRS complex: Normal
T wave: Normal
QT interval: Normal
Other: Phasic slowing and quickening
Sinus Arrhythmia results from an inhibition of reflex vagal activity, or tone. The cyclic irregular rhythm varies with the respiratory
cycle

Nursing ● If sinus arrhythmia is unrelated to respiration it may require treatment

Interventions ● Monitor heart rhythm during respiration
● If sinus arrhythmia is induced by drugs, the practitioner may decide to continue it because the condition may be
worsened if discontinued.
● If taking digoxin, notify the physician immediately. It may be experiencing digoxin toxicity.

3. Atrial arrhythmias - also called supraventricular arrhythmia, begins in the upper chambers of the heart.

PREMATURE ATRIAL CONTRACTIONS (PAC) ATRIAL TACHYCARDIA

Parameters Rhythm: Irregular Rhythm: Regular

Rate: 60- 100 beats/min Rate: 150 to 250 beats/min
P wave: Abnormal, may be hidden in the preceeding T wave P wave: Almost hidden
PR interval: Normal PR interval: Not measurable
QRS complex: Normal QRS complex: Normal
T wave: Normal or distorted T wave: abnormal, with some embedded P waves
QT interval: Normal QT interval: Normal or shortened

The presence of three or more PAC is called atrial tachycardia

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Nursing ● Avoid caffeinated drinks and alcohol ● Monitor serum digoxin level.
Interventions ● Stress reduction activities ● Valsalva maneuver or carotid sinus massage may
● Ask patient factors that could trigger ectopic beats be applied for paroxysmal atrial tachycardia (PAT)
● Monitor signs of heart failure ● Monitor the cardiac rhythm and chest pain
● Drug of choice: Beta-adrenergic blockers and calcium ● Monitor patient for signs of heart failure and MI
channel blockers ● Drug therapy (amiodarone, digoxin, beta-blockers,
calcium channel blockers
● If the patient is unstable, synchronized
cardioversion may be used.
● Pacemaker, atrial overdrive pacing,
radiofrequency ablation

ATRIAL FLUTTER ATRIAL FIBRILLATION

Parameter Rhythm: Atrial – regular, Ventricular - varies Rhythm: Irregularly irregular

Rate: Atrial – 250 to 350 beats/min, Ventricular - 60 to 100 Rate: Atrial – Indiscernible, Ventricular – 100 to 150
beats/min but may accelerate up to 150 beats/min beats/min
P wave: classic sawtooth appearance P wave: Absent, replaced by fibrillatory waves
PR interval: Unmeasurable PR interval: Indiscernible
QRS complex: Normal QRS complex: Normal
T wave: Unidentified T wave: Indiscernible
QT interval: Unmeasurable QT interval: Unmeasurable
Other: None

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 Nursing ● Control the rate and convert rhythm
Interventions ● If cardioversion is indicated, administer sedative and resuscitation equipment at the bedside.
● Evaluate for bradycardia because cardioversion reduces heart rate
● Monitor symptoms of decreased cardiac output (syncope, dizziness, chest pain) and heart failure (dyspnea and
peripheral edema)
● Drug therapy (anticoagulants, beta-adrenergic blockers, calcium channel blockers)

4. Junctional Arrhythmias – if the SA node fails to function properly, the specialized junctional pacemaker cells in the AV junction take over as the
heart’s pacemaker and have an inherent firing rate of 40 to 60 beats/min.

JUNCTIONAL ESCAPE RHYTHM JUNCTIONAL TACHYCARDIA

Parameter Rhythm: Regular Rhythm: Regular

Rate: 40 to 60 beats/min Rate: 100 to 200 beats/min
P wave: Inverted, or absent P wave: Inverted or hidden
PR interval: Shortened PR interval: Shortened or unmeasurable
QRS complex: Normal QRS complex: 0.08 sec
T wave: Normal T wave: Normal
QT interval: Normal QT interval: Normal
Other: None Other: None
*Three or more PJCs occur in a row

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Nursing ● Identify and correct underlying causes
Interventions ● Monitor cardiac rhythm,
● Monitor digoxin and electrolyte level
● Give atropine and keep emergency equipment ready
● Watch for signs of decreased cardiac output such as hypotension, syncope, blurred vision, change in mental status
and weak peripheral pulses
o Use of Vagal maneuvers and drugs such as adenosine
o May administer potassium supplement
o Pacemaker

5. Ventricular Arrhythmias - a more serious arrhythmia that begins in the lower chambers of the heart.

PREMATURE VENTRICULAR CONTRACTIONS ASYSTOLE ( VENTRICULAR STANDSTILL)

Parameter: Rhythm: Irregular Rhythm: Atrial - indiscernible

Rate: Varies Rate: Atrial - indiscernible
P wave: Absent, but present with other QRS complexes P wave: May be present
PR interval: Unmeasurable except in underlying rhythm PR interval: Unmeasurable
QRS complex: Early with bizarre and wide configuration QRS complex: Absent, occurs during stimulus
T wave: Normal; opposite direction T wave: Absent
QT interval: Usually unmeasurable QT interval: unmeasurable
Other: Underlying rhythm sinus tachycardia Other: nearly flat line

Note: Asystole must be confirmed in more than one ECG

lead.

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 Nursing ● If infrequent and asymptomatic, treatment is not
Interventions required
● Monitor if with underlying heart diseases
● If cardiac in origin, may give drugs that suppress
ventricular irritability such as procainamide,
amiodarone or lidocaine
● Educate family how to contact Emergency response
team and how to perform CPR
● Cardiopulmonary resuscitation (CPR)
● Oxygen therapy
● IV or intraosseous epinephrine, vasopressin and
atropine
● Treat reversible cause such as hypovolemia,
cardiac tamponade, and tension pneumothorax

VENTRICULAR TACHYCARDIA TORSADES DE PONTES VENTRICULAR FIBRILLATION

(V-TACH) (V-FIB)

Parameter: Rhythm: Atrial- unmeasurable,
ventricular – regular or slightly irregular
Rate: Atrial- Unmeasurable,
ventricular - regular 100 to 250
beats/min
P wave: absent
PR interval: unmeasurable
QRS complex: greater than 0.12
seconds, wide and bizarre
T wave: Opposite direction of QRS
complex
QT interval: Unmeasurable
Other: Variations include ventricular
Rhythm: Paroxysmal, starting and
stopping suddenly
Rate: Atrial- unmeasurable,
ventricular - regular 150 to 250
beats/min
P wave: absent
PR interval: Unmeasurable
QRS complex: wide with changing
amplitude
T wave: Opposite direction of QRS
complex
QT interval: Unmeasurable
Other known as twisting about the
Rhythm: Chaotic, no recognizable
pattern
Rate: Indiscernible
P wave: Absent
PR interval: Unmeasurable
QRS complex: Indiscernible
T wave: Indiscernible
Other: Waveform is a wavy line
Note: It is the most common cause of
sudden cardiac death in people outside
the health care facility

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 flutter and torsades de pointes points

Nursing ● Continuous ECG monitoring, ensure patent venous access ● Start defibrillation and CPR
Interventions ● Monitor the level of consciousness, respiration rate, and pulse rate ● Drug of choice: Epinephrine and
● May require a defibrillator and CPR, or synchronized cardioversion vasopressin, amiodarone, lidocaine,
● Teach the family about the nature of the disease and how to call magnesium sulfate
emergency medical care and perform CPR when at home ● Educate family on how to call
● Administer magnesium sulfate emergency medical care perform
● Electric cardioversion CPR and use an automated external
defibrillator when at home

6. Atrioventricular Heart Blocks – This refers to an interruption or delay in the conduction of electrical impulses between the atria and the
ventricles. The block can occur at the AV node, bundle of His, or the bundle branches.

First-degree atrioventricular block Type I second-degree atrioventricular block

Parameter: Rhythm: Regular Rhythm: Atrial-Regular; ventricular - irregular

Rate: Normal Rate: Normal
P wave: Normal P wave: Normal
PR interval: Prolonged PR interval: Progressively prolonged
QRS complex: Normal QRS complex: Normal
T wave: Normal, may be prolonged T wave: Normal
QT interval: Normal QT interval: Normal
Other: None Other: Wenckebach pattern of grouped beats

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Nursing ● Identify and correct underlying causes
Interventions ● Check patient’s medication regimen
● Monitor signs of myocardial ischemia
● Monitor cardiac rhythm
● Asymptomatic – treatment rarely required
● Patent venous line
● For slow HR, to give atropine
● Pacemaker if indicated

Type II second-degree atrioventricular block Third-degree atrioventricular block

Parameter: Rhythm: Atrial-Regular; ventricular - irregular Rhythm: -Regular

Rate: normal Rate: Atrial- 60 to 100 beats/minute; ventricular – 40 to 60
P wave: Normal beats/minute
PR interval: Normal or prolonged P wave: Normal
QRS complex: Normal or widened PR interval: Variable
T wave: Normal QRS complex: normal; or widened
QT interval: Normal T wave: Normal
Other: None QT interval: appears normal
Other: None

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Nursing ● Maintain ECG monitoring
Interventions ● Patent venous line
● Complete bed rest
● Oxygen therapy
● Teach family about the use of pacemaker
● Drug of choice dopamine, epinephrine or atropine to increase cardiac output
● Pacemaker

Note: Use atropine cautiously for it could worsen the ischemia during MI and may induce ventricular tachycardia or
fibrillation.

7. Pulseless Electrical Activity (PEA)

There are electrical impulses throughout the heart but the heart is not responding to that impulse, meaning the heart is not beating. These
patients present the same as asystole and given time without intervention will progress to asystole

8. Serum Electrolytes Imbalances- shows distinctive rhythm changes on the ECGs. Ions such as potassium and calcium play a major role in
the heart’s electrical activity.

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 HYPERKALEMIA HYPOKALEMIA

Parameter: Rhythm: Regular Rhythm: Regular

Rate: Normal Rate: Normal
P wave: Normal P wave: Normal; may become peak
PR interval: Normal or prolonged PR interval: May be prolonged
QRS complex: Widened QRS complex: Normal or widened, prolonged (severe)
T wave: Tall, peaked-classic T wave: Tall, peaked-classic
QT interval: Shortened QT interval: Indiscernible
Other: Intraventricular conduction disturbances ST segment: Depressed
Other: Amplitude of U wave is increased and fusing with the
T wave

Nursing ● Identify and correct underlying cause ● Identify and correct the underlying cause
Interventions ● Maintain continuous ECG monitoring ● Maintain continuous ECG monitoring
● Patent venous line ● Patent venous line
● Start drug therapy (calcium gluconate, insulin and ● Monitor potassium level
glucose, and sodium bicarbonate), sodium ● Encourage adequate intake of foods and fluids rich
polystyrene sulfonate (cation exchange resins in potassium
● Dialysis for patients with renal failure ● Give potassium supplement
● Monitor potassium level
● Adequate hydration before, during and after the
administration of the chemotherapy
● Complete bed rest
● Oxygen therapy
● Teach the family about the use of pacemaker
● Drug of choice dopamine, epinephrine or atropine
to increase cardiac output
● Pacemaker

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 Hypercalcemia Hypocalcemia

Parameter: Rhythm: Regular Rhythm: Regular

Rate: Normal, bradycardia may occur Rate: Normal
P wave: Normal P wave: Normal
PR interval: May be prolonged PR interval: Normal
QRS complex: Normal, but may be prolonged QRS complex: Normal
T wave: normal, but may be depressed T wave: normal, but maybe flat or inverted
QT interval: Shortened QT interval: Prolonged
ST segment: Shortened ST segment: Prolonged
Other: None Other: None

Nursing ● Identify and correct the underlying cause
Interventions ● Monitor patient for cardiac arrhythmias
● Prepare to give oral phosphate to patients with
normal renal function
● Large volumes of normal saline administration
● Dialysis
● Identify and correct the underlying cause
● Monitor patient for cardiac arrhythmias
● Monitor serum calcium level, start oral calcium
replacement
● Prepare to give emergency IV calcium gluconate in
severe hypocalcemia

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Medications

Usage Usage

Adenosine Effective in treating reentry Amiodarone Wide- and narrow-complex tachycardia,

tachycardias that involve the AV node polymorphic VT, shock-refractory VF or pulseless VT, SVT,
PSVT

Atropine Treats symptom-producing bradycardia Beta-blockers MI, unstable angina, PSVT, A-fib, A-flutter, HTN
and heart blocks

Digoxin Used to treat heart failure, paroxysmal Diltiazem A-fib, A-flutter, PSVT refractory to adenosine with narrow
supraventricular tachycardia, atrial (Calcium channel QRS complex and adequate BP
fibrillation, and atrial flutter blockers)

Epinephrine To restore cardiac rhythm and to treat Dopamine Symptomatic bradycardia and hypotension,
symptom-producing bradycardia cardiogenic shock

Lidocaine VF or pulseless VT, stable VT, Isoproterenol Symptomatic bradycardia, refractory torsade de
wide-complex, tachycardia of uncertain pointes unresponsive to magnesium, bradycardia in heart
origin, wide-complex PSVT. transplant patients, beta blocker poisoning.

Procainamide Recurrent VT or VF, PSVT refractory to Vasopressin Vasodilatory (septic) shock, an alternative to
adenosine epinephrine in shock-refractory VF and pulseless VT.
and vagal stimulation, rapid A-fib,
maintenance after conversion

C. Adjunctive Modalities and Management

1. Cardioversion - A cardioversion procedure helps to correct arrhythmias. It is a procedure that utilizes an electrical current to bring your
heart rhythm back to normal. It is usually used to treat atrial fibrillation and atrial flutter.

2. Pacemaker – a nonpharmacologic treatment used for arrhythmias using an artificial device that electrically stimulates the myocardium to
depolarize, initiating mechanical contractions
a. Permanent pacemaker
b. Temporary pacemaker
i. Transvenous
ii. Transcutaneous
iii. Epicardia
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 Pacemaker malfunction can lead to arrhythmias, hypotension, syncope and other signs and symptoms of decreased cardiac output.
Common problems includes failure to capture, failure to pace, undersensing, and oversensing

3. Defibrillators

a. Manual Defibrillator The voltage and timing for the electrical shock are manually determined after a healthcare
provider assesses the heart rhythm. The majority of these units may be found in hospitals and on
select ambulances.

b. Automated external A type of defibrillator designed for use by untrained persons. It can analyse cardiac rhythms. As a
defibrillator (AED) result, determining whether or not a rhythm is shockable does not necessitate the use of a
qualified health expert.

c. Cardioverter-Defibrillators known as implantable cardioverter-defibrillator (ICD)

It is a pacemaker-like implant. According to the device's programming, they continuously monitor
the patient's heart rhythm and automatically administer shocks for life-threatening arrhythmias. It
is a device programmed to deliver an unsynchronized shock right away.

References:

Burns, S. (2014). AACN Essentials of Critical Care Nursing. New York: McGraw Hill Education.
Perrin, K., & MacLeod, C. (2018). Understanding the Essentials of Critical Care Nursing. New York: Pearson Education Inc.

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