Dysrhythmias

By:

Jay Aries T. Gianan

EMT-B, RM, RN, LPT, MAN
Objectives:
• What is dysrhythmia?
• What are the types of
dysrhythmia?
• What are the causes of this
dysrhythmias?
• How to manage life threatening
dysrhythmias?
• How to provide CPR?
• How to provide ACLS?
Count the heart rate!
What is dysrhythmia?
Dysrhythmia
• Bad + rhythm

• Arrhythmia

• Heartbeat that has an abnormal

speed or rhythm.
What are the types of dysrhythmia?
Types of dysrhythmia
1. Sinus Node Dysrhythmias
1. Sinus Bradycardia
2. Sinus Tachycardia
3. Sinus Arrhythmia
2. Atrial Dysrhythmias
1. Premature Atrial Complex
2. Atrial Fibrillation
3. Atrial Flutter
3. Junctional Dysrhythmias
1. Premature Junctional Complex
2. Junctional Rhythm
3. Junctional tachycardia
4. Ventricular Dysrhythmias
1. Premature Ventricular Complex
2. Ventricular Tachycardia
3. Ventricular Fibrillation
4. Supraventricular tachycardia
5. Asystole
5. Conduction Abnormalities
1. First-Degree Atrioventricular Block
2. Second-Degree Atrioventricular Block,
Type I (Wenckebach)
3. Second-Degree Atrioventricular Block,
Type II
4. Third-Degree Atrioventricular Block
Goals in managing dysrhythmias
• We only perform an action or initiate
plan of care only if the patient is
showing signs & symptoms of low
oxygen or its life threatening.

• If yes, we manage the S/S

Sinus Node Bradycardia
1. Rate: Less than 60 bpm
2. Rhythm: Regular (R to R)
3. P wave: Normal
4. PR interval: Normal
• Less than 5 mini boxes – 0.20
seconds)
5. QRS width : Normal
Nursing Intervention
• ↓ the dose of medications that are causing
the low heart rates
• w/ Negative chronotropic drugs
• Beta blockers “–lol”
• Calcium channel blockers “-pine”
• Verapamil & diltiazem
• Digoxin
• Atropine
• Anticholinergic drug
• ↑ heart rate

• Pacemaker
Sinus Node Tachycardia
1. Rate: Greater than 100 bpm
2. Rhythm: Regular (R to R)
3. P wave: Normal
4. PR interval: Normal
• Less than 5 mini boxes – 0.20
seconds)
5. QRS width : Normal
Nursing intervention
• Treat causes 1st!
• Fever
• Stress
• Anxiety
• Pain
• Nursing school
• Vagal/Valsalva maneuver
• Carotid massage
• Beta blockers “-lol”
• Calcium channel blockers “-pine”
Sinus Arrhythmia (arrhythmia)
• A sinus arrhythmia is an
irregular heartbeat that's either
too fast or too slow.

• One type of sinus arrhythmia,

called respiratory sinus
arrhythmia, is when the heartbeat
changes pace when you inhale and
exhale.
“Respiratory” Sinus Arrhythmia
1. Rate: 60-100 bpm
2. Rhythm: varies depending on pts.
respiratory status
• Slower during exhalation
• Faster with inhalation
3. P wave: Present, Normal
4. PR interval: Normal
• Less than 5 mini boxes – 0.20 seconds)
5. QRS width: Normal
Nursing intervention
• Sinus arrhythmia does not cause
any significant hemodynamic
effect

• Does not require treatment

• Atropine if rate decreases below

40 bpm.
Premature Atrial Complex/Contraction
(PACs)
• Premature junctional
contractions (PJCs), also called
atrioventricular junctional
premature complexes or
junctional extrasystole,
are premature cardiac
electrical impulses originating
from the atrioventricular node of
the heart or "junction".
Premature Atrial Complex/Contraction
(PACs) – atrial sneeze
1. Rate: underlying heart rate may vary
2. Rhythm: regular but interrupted d/t early P
waves
3. P wave: an early & different p wave may be
seen or may even be hidden in the p wave
4. PR interval: the early P wave has a shorter
than normal PR interval, but still b/w 0.12 &
0.20 seconds
5. QRS width: the QRS that follows the early P
wave is usually Normal
Causes
• The 3 S’s • Subjective: I feel like…
• Stimulants • My heart skipped a beat
• Caffeine, cigarettes, alcohol • My heart’s pounding
• Stress • Quickening in chest
• anxiety
• Sepsis • Objective
• Rheumatic fever • Pulse deficit
• Hyperthyroidism • Possible hypotension (low BP)
• Increased metabolism
• Digoxin toxicity
• Over contractility of the heart
• Diseases
• CAD, CHF, myocarditis, COPD,
rheumatic heart disease
• Hypokalemia
Nursing intervention
• Treatments are the same on all Premature
dysrhythmias (PAC, PJC, PVC)
• Treat the cause
• Prevention of 3S’s (stress, sepsis,
stimulants)
• Stop or ↓ Digoxin
• Digoxin is an inotropic drug
• ↑ contractility of the heart
• Correct electrolytes imbalance (↓K+)
• Heart relaxant such as:
• Procainamide, lidocaine or
amiodarone
• Beta Blockers “-lol”
• Calcium Channel blockers “-pine,” “-zem”
Premature Junctional
Complex/Contraction(PJCs)
•
A premature junctional complex
(PJC) is an abnormality seen in
the presence of an underlying
sinus rhythm.
• It is an aberrant impulse that
originates in the atrioventricular
junction (junctional tissue) and
occurs early or prematurely
before the next expected P
wave.
Premature Junctional
Complex/Contraction(PJCs) – junctional sneeze
1. Rate: depends on underlying
rhythm usually 40-60 bpm
2. Rhythm: irregular
3. P wave: absent, inverted,
buried or retrograde
4. PR interval: none, short,
retrograde
5. QRS width: Normal
Causes
• The 3 S’s • Subjective: I feel like…
• Stimulants • My heart skipped a beat
• Caffeine, cigarettes, alcohol • My heart’s pounding
• Stress • Quickening in chest
• anxiety
• Sepsis • Objective
• Rheumatic fever • Pulse deficit
• Hyperthyroidism • Possible hypotension (low BP)
• Increased metabolism
• Digoxin toxicity
• Over contractility of the heart
• Diseases
• CAD, CHF, myocarditis, COPD,
rheumatic heart disease
• Hypokalemia
Nursing intervention
• Treatments are the same on all Premature
dysrhythmias (PAC, PJC, PVC)
• Treat the cause
• Prevention of 3S’s (stress, sepsis,
stimulants)
• Stop or ↓ Digoxin
• Digoxin is an inotropic drug
• ↑ contractility of the heart
• Correct electrolytes imbalance (↓K+)
• Heart relaxant such as:
• Procainamide, lidocaine or
amiodarone
• Beta Blockers “-lol”
• Calcium Channel blockers “-pine,” “-zem”
Premature Ventricular
Complex/Contraction(PVCs)
• Premature ventricular
contractions (PVCs) are extra
heartbeats that begin in one of
your heart's two lower pumping
chambers (ventricles).
Premature Ventricular
Complex/Contraction(PVCs) – ventricular sneeze
1. Rate: depends on underlying
rate, varies
2. Rhythm: regular except where
disrupted by the PVCs
3. P wave: None, buried w/n the
QRS
4. PR interval: none, associated
w/ PVC
5. QRS width: wide &
bizarre(>0.14 sec)
Causes
• The 3 S’s • Subjective: I feel like…
• Stimulants • My heart skipped a beat
• Caffeine, cigarettes, alcohol • My heart’s pounding
• Stress • Quickening in chest
• anxiety
• Sepsis • Objective
• Rheumatic fever • Pulse deficit
• Hyperthyroidism • Possible hypotension (low BP)
• Increased metabolism
• Digoxin toxicity
• Over contractility of the heart
• Diseases
• CAD, CHF, myocarditis, COPD,
rheumatic heart disease
• Hypokalemia
Nursing intervention
• Treatments are the same on all Premature
dysrhythmias (PAC, PJC, PVC)
• Treat the cause
• Prevention of 3S’s (stress, sepsis,
stimulants)
• Stop or ↓ Digoxin
• Digoxin is an inotropic drug
• ↑ contractility of the heart
• Correct electrolytes imbalance (↓K+)
• Heart relaxant such as:
• Procainamide, lidocaine or
amiodarone
• Beta Blockers “-lol”
• Calcium Channel blockers “-pine,” “-zem”
Atrial Fibrillation
• Rapid firing of atriums causing a
pooling and swirling of blood
• An uncoordinated electrical
activity in the atria that causes a
rapid, disorganized and twitching
of the atrial musculature
• Huge risk for clots:
• MI clot in the heart
• PE clot in the lungs
• CVA clot in the brain
• DVT clot in the extremities
 • HEART
PACEMAKERS
Atrial Fibrillation
• MAIN
• BACK UP
• Main pacemaker (SA node) has
lost control as boss pacemaker
• Atria gone wild
• l/t 350-600 erratic unorganized
beats all over the atria

• AV nodes blocks most of the

these erratic beats & protects
the ventricles
Atrial Fibrillation

1. Rate: will vary, usually over 100 BPM

2. Rhythm: irregularly irregular
3. P wave: none because the atria are
not contracting (flat line) or uneven
fibrillatory baseline
4. PR interval: none because the atria
are not contracting
5. QRS width: normal & upright but
not evenly spaced out, usually
narrow
Causes

• Open heart surgery

• Pulmonary hypertension
• Alcohol can induce holiday heart
syndrome
• Hyperthyroidism (↑
metabolism)
Signs and Symptoms
• Chest pain
• Oxygen – SpO2 lower
• Low BP + tachycardia (HR ↑100)
• Lethargy
• Anxiety
• Palpitations (gallops in the heart)
• Shortness of breath
• Elevated ventricle rate or HR
• Dizziness or syncope fainting
Nursing intervention
• Main goal:
• Slow HR & restore normal
electrical conduction at the SA
node
• Effective/organize pump in the
atria
• Prevent clots
 Nursing intervention (ABCDE)
• Anticoagulants – prevent clots
• Warfarin (anticoagulant)
• Watch out for INR 2.5 – 3.5 (therapeutic thinning range) • Cardioversion (50-200 joules) is
• Advised pt. not to ↑ or ↓ of intake of green leafy vegetables
• Green leafy veggies has vit K+ that blocks warfarin
not:
effectiveness, same amount
• Beta blockers – slow heart rate
• Cardiac ablation – burn erratic cells
• Digoxin – deeper contraction
• Defibrillation – supersized shock
• ↑ contractility known as inotropic drug (200-360 joules of electricity)
• Helps atrium get a deeper contraction &slows HR known as negative
chronotropic drug
• Indicated for deadly rhythms
• Never give on HR ↓ than 60 BPM • V-fib or pulseless V-tach
• Listen for apical pulse for 1 full minute on the 5th intercostal space
• Watch out for digoxin toxicity (↑ 2.0 )
• Green halos
• Low K+ = ↑ risk for toxicity
• Electro cardioversion (50 – 200 joules)
• To reset SA node (main pacemaker of the heart)
• Usually done after TTE (transthoracic echocardiography)
• to rule out blood clots in the atria
• Last resort is to shock the pt. & spread possible clots all over the
body.
Atrial Flutter
• Similar to A-fib but the heart’s
electrical signals spread through
the atria in a fast but regular
rhythm instead of irregular
found in A-fib
 • HEART
PACEMAKERS
Atrial Flutter
• MAIN
• BACK UP
• I saw the birds fluttering
• Birds in the ATRIA, that are
flapping & FLUTTERING their
wings in SEQUENCE, all together
in UNISON
• Main pacemaker (SA node) has
lost control as boss pacemaker
• Atria gone wild
• Impulses are more unison & look
like a flock of birds fluttering
their wings together
Atrial Flutter
1. Rate: 75 to 150 BPM BPM
2. Rhythm: usually regular – not like
A-fib “irregular/unorganized”
3. P wave: No P wave, looks like a
teeth on a saw (saw tooth)
4. PR interval: none, d/t atria not
contracting
5. QRS width: usually normal
Junctional Rhythm
• AV node has taken over as the
main pacemaker instead of SA
node
• Junctional because it takes over
at the AV node basically the
midway or junction b/w the
atrium & ventricles.
Junctional Rhythm
1. Rate: 40 – 60 bpm
2. Rhythm: regular
3. P wave: inverted, absent or
retrograde or buried
4. PR interval: none, short or
retrograde
5. QRS width: normal
Types of Junctional Rhythm
1. Junctional
• HR 40 – 60 bpm
2. Accelerated junctional
• HR 60 – 100 bpm
3. Junctional tachycardia
• HR above 100 bpm
Causes
• Low oxygen
• Myocardial ischemia
• Drugs that slow the HR
• Beta blockers
Cal
Digoxin
• Inflammation of the heart
• Myocarditis, cardiac surgery,
Sepsis (Lyme disease or rheumatic
fever)
Signs and symptoms
• Because atria are not squeezing l/t low
cardiac output and low oxygen
• Chest pain
• Oxygen – SpO2 lower
• Low BP + tachycardia (HR ↑100)
• Lethargy
• Anxiety
• Palpitations (gallops in the heart)
• Shortness of breath
• Elevated ventricle rate or HR
• Dizziness or syncope fainting
Nursing intervention
• Stop drugs or decrease
• Beta blockers
• Calcium channel blockers
• Digoxin
• If it doesn’t work.
• Atropine to ↑ HR
• Only if the QRS is not wide
• Not given for junctional tachycardia
• If that doesn’t work
• Pacemaker
• Permanently fix the problem
1 Degree Atrioventricular Block - PR
st

prolongation
1. Rate: HR maybe normal, slow,
or fast
2. Rhythm: regular
3. P wave: present & upright
4. PR interval: P-R interval is
greater than 0.20 sec. P-R
interval is constant
5. QRS width: usually narrow
(<.12 second)
2nd Degree Atrioventricular Block, Type I
(Wenckebach) – Mobitz 1
1. Rate: variable
2. Rhythm: irregular & spaced out
3. P wave: present but late
4. PR interval: cycles, PR gradually
gets longer until P wave is
blocked & drops
5. QRS width: Normal when
present

Longer, longer, longer, drop

2nd Degree Atrioventricular Block, Type II –
Mobitz II
1. Rate: slow
2. Rhythm: irregular
3. P wave: too many! More P
waves than QRS (3:1 or 2:1
ratio)
4. PR interval: normal or
prolonged
5. QRS width: wide
3rd Degree Atrioventricular Block
• Occurs when impulses from the
atria are completely blocked at the
AV node & can’t be conducted to
the ventricles

• Atria & ventricles contract

independently

• Complete heart block – most deadly

heart blocks l/t cardiac and death
3rd Degree Atrioventricular Block
• Rate: slow less than 45 bpm
• Rhythm: constant P – P and
constant Q – Q intervals
• P wave: present & completely
disassociated from the QRS
complexes
• PR interval: varies
• QRS width: normal or usually
wide
Supraventricular tachycardia

1. Rate: 140-250 bpm

2. Rhythm: regular
3. P wave: usually not clearly
discernible
4. PR interval: not applicable if P
waves are not discernible
5. QRS width: usually narrow
Recognize the ECG
Recognize the ECG
Recognize the ECG
Recognize the ECG
How to manage life threatening
dysrhythmias?
Ventricular Tachycardia
• 2nd most deadly rhythm
• 2nd of the 2 rhythms that we
shock (defibrillate)
• V FIB
Ventricular Tachycardia
• A very fast heart rhythm that
begins in the ventricles when both
the SA node and AV node fail to
generate an impulse. The ventricles
will assume the role of pacing the
heart.
• More stable than V FIB

• No effective ventricular contraction

• No cardia output
• No oxygen to the body
Ventricular Tachycardia
• Rate: 100 – 250 bpm
• Rhythm: regularly spaced & even
like tombstones
• Wave: none
• PR interval: none
• QRS: wide & even
Ventricular Fibrillation
• Most deadly rhythm
• 2 of the rhythm being
defibrillate
Ventricular Fibrillation
• A chaotic pattern of electrical
activity in the ventricles in which
electrical impulses arise from
many different foci.

• No effective ventricular
contraction
• No cardia output
• No oxygen to the body
Ventricular Fibrillation
• Rate: unknown or
indistinguishable
• Rhythm: chaotic waveform and
rhythm
• P wave: none because the atria
are non contracting
• PR interval: none because the
atria are not contracting
• QRS: none because the ventricles
are not fully contracting
Pulseless electrical activity (PEA)
• Clinically dead but there is
electrical activity in the heart

• The patient is in cardiac arrest

but the monitor shows a heart
rhythm that should produce a
pulse, but does not
Pulseless electrical activity (PEA)
• Rate: bradycardia, normal or
tachycardia
• Rhythm: regular
• P wave: present
• PR interval: normal
• QRS: present, wide or narrow
Looks like a normal rhythm but

NO PULSE!
Asystole
• A cardiac arrest rhythm with no
electrical activity in the heart. As
a result, the heart stops beating
and there is a total standstill on
the EKG monitor
Asystole
• NO electrical activity in the heart
• NO pumping
• NO cardiac output

•NO LIFE!
Asystole
• Rate: N/A
• Rhythm: N/A
• P wave: N/A
• PR interval: N/A
• QRS: N/A

• NOTHING!
How to provide Cardiopulmonary
resuscitation (CPR)?
Cardiopulmonary Resuscitation
• CPR
– or Cardiopulmonary Resuscitati
on
– is an emergency lifesaving
procedure performed when the
heart stops beating. Immediate
CPR can double or triple chances
of survival after cardiac arrest.
Automated External Defibrillator (AED)
• An automated external
defibrillator (AED) is a portable
electronic device that automatically
diagnoses the life-
threatening cardiac arrhythmias of v
entricular fibrillation (VF)
and pulseless ventricular
tachycardia, and is able to treat
them through defibrillation, the
application of electricity which stops
the arrhythmia, allowing the heart
to re-establish an effective rhythm.
How to provide Advanced Cardiac Life
Support (ACLS)?
 BEGIN CPR
- oxygen/ventilation
- Attached monitor & Defibrillator Asytole/PEA
No
VFIB/pVT Yes Shockable Rhythm CPR (2 mins)
IV/IO Access
͞Shock͟
Epinephrine 1 mg IVP q
(120-200J)
3-5 mins
- Advanced Airway
CPR (2 mins) - Capnography
IV/IO Access

Yes Rhythm Shockable?

Rhythm Shockable? No
No
Yes
Signs of ROSC Asytole/PEA
͞Shock͟- ј
joules
No
CPR (2 mins)
Epinephrine 1 mg IVP q Post Cardiac Arrest Algorithm
CPR (2 mins)
3-5 mins
Treat reversible causes
- Advanced Airway
- Capnography

Rhythm Shockable?

Yes
CPR (2 mins)
- Amiodarone 300 mg
then 150 mg
- Lidocaine 1-1.5 mg/kg
then 0.5-0.75 mg/kg
- Treat Reversible
damage
 Activity
• You are working as an
occupational health nurse in a
building that employs several
people with significant cardiac
risk factors. The organization’s
safety officer has asked you about
purchasing and installing an AED.
• What other information would you
need before you reply?
• Discuss the evidence that supports
your answer.