1. Pacers, ablation, cardioversion, telemetry, Intro to ACLS
By: Diana Blum
MCC
NURS 2140

2. A dysrhythmia is a disturbance of the rhythm of the heart caused by a problem in the conduction system.
Categorized by site of origin: atrial , AV nodal, ventricular
Blocks are interruptions in impulse conduction: 1st, 2nd type 1&2, 3rd or complete heart block

3. To map= to determine if regular or irregular
Each small box measures 0.04
1 big box (5 small boxes) is equal to a HR of 300
2 big boxes is hr of 150
3 big boxes is hr of 100
4 big boxes is hr of 75
5 big boxes is hr of 60
6 big boxes is hr of 50
7 big boxes is hr of 43
8 big boxes is hr of 38

4. Large box estimate of heart rate works with regular rhythms

5. P-wave = atrial electrical activity
QRS= ventricular electrical activity
T wave= resting phase of ventricle

8. P wave
Measures:

9. QRS WAVE
Measures:

10. QT Wave
Measures approx secs

11. NSR: heart rate is 60-100bpm ST: heart rate 101-180 bpm
Heart rates
NSR: heart rate is bpm
ST: heart rate bpm
SB: heart rate <60 bpm

12. Calculating Heart Rate
Quick Estimate: The 6-second Method
- count the # of QRS complexes in a 6 sec.
length of strip & multiply by 10
(the second mark is = to 5 large boxes)
This can be used is rhythm is reg or unreg.

13. Count small boxes between two R waves. Divide into1500 Gives BPM

14. Atrial arrythmias Normal sinus rhythm Sinus tachycardia
Sinus bradycardia
Premature atrial contraction (PAC)
Supraventricular tachycardia
Atrial flutter
Atrial fibrillation

15. Ventricular arrythmias
Junctional rhythm
AV blocks
Premature junctional rhythm
Premature ventricular contraction (PVC)
Ventricular Tachycardia (V-tach)
Ventricular Fibrillation (V-Fib)
Torsade de Pointes (TdP)
Pulseless electrical activity (PEA)
Asystole

16. ARTIFACT

17. NSR

18. PR interval- 0.12-0.20sec QRS-0.06-0.10sec QT segment 0.36-0.44 sec
Sinus rhythm
PR interval sec
QRS sec
QT segment sec
Heart rate

19. Sinus arrhythmia Hr= 60-100 bpm
On strip it looks regular but does not map out
PR interval=

20. Junctional escape rhythm
HR bpm
<60 bpm is accelerated
Rhythm is regular
Pwaves not always present

21. Junctional Rhythm

22. SB

23. Sinus Bradycardia All criteria same except rate < 60bpm
S/S: dizziness, syncope, angina, hypotension, sweating, nausea, dyspnea
Sometimes no S/S
Treat underlying cause
IV atropine, pacemaker

24. Sinus Bradycardia: Your pt is pale, c/o dizziness & fatigue
Sinus Bradycardia: Your pt is pale, c/o dizziness & fatigue. Pulse 56, BP 86/60
ACLS protocol:
1. airway
2. oxygen
3. ECG, BP, oximetry
4. IV access
If s/s of poor perfusion: altered mental status, CP,
hypotension, signs of shock
a. prepare for transcutaneous placing
b. atropine 0.5 mg IV while waiting for pacer
- may repeat for total 3 mg IV
c. epinephrine or dopamine drip while waiting pacer or
if pacing ineffective
ATROPINE IS AN ANTICHOLINERGIC DRUG AND POTENT BELLADONNA ALKALOID. IT WORKS LOCALLY AND SYSTEMICALLY BUT MOSTLY AFFECTS THE SMOOTH MUSCLES AND GLAND CELLS. IT REVERSES CHOLINERGIC MEDIATED DECREASES IN HR, BP, AND SYSTEMIC VASCULAR RESISTENCE. IT CAN INTERFERE WITH VAGAL STIMULI. IT IS WIDELY DISTRIBUTED IN ALL BODY FLUIDS. IT IS METABOLIZED BY THE LIVER AND EXCRETED IN URINE AND BILE.. IT WILL CROSS THE PLACENTA BARRIER AND IS SECRETED IN BREAST MILK. IT IS INDICATED FOR HIGH DEGREE AV BLOCK WITH PROFOUND BRADYCARDIA, SYMPTOMATIC BRADYCARDIA, AND AS A SECOND LINE OF DEFENSE FOR ASYSTOLE AND P.E.A. (EPINEPHRINE IS FIRST). IT IS CONTRAINDICATED FOR THOSE WITH HYPERSENSITIVITY TO IT, THOSE WITH GLAUCOMA, ASTHMA, HEPATIC DISEASE, UNSTABLE HEART. GIVE 1MG/MIN.
EPINEPHRINE IS A NATURALLY OCCURING HORMONE SECRETED BY THE ADRENAL GLANDS. IT IS A SYMPATHOMIMETIC DRUG. IN THAT IT MIMICS THE ACTIONS OF THE SYMPATHETIC NERVOUS SYSTEM. IT IS STIMULATED BY THE ALPHA AND BETA ADRENERGIC RECEPTORS. IT IS A VASOCONSTRICTOR. IT WILL DELAY THE ACTION OF MANY DRUGS. IT STRENGTHENS THE MYOCARDIAL CONTRACTION AND INCREASES HR. DURING CPR IT INCREASES HEART AND BRAIN FLOW. IT RELAXES SMOOTH MUSCLES ESPECIALLY IN THE LUNGS.. IT INCREASES HR AND SBP AND ALSO DECREASES DBP. IT IS INACTIVATED BY THE LIVER EXCRETED IN THE URINE, CROSSES THE PLACENTA AND IS SECRETED IN BREAST MILK. IT IS USED FOR CPR AS A FIRST LINE DRUG FOR VFIB, PULSELESS VTACH, ASYSTOLE, OR P.E.A. IT IS CONTRAINDICATED FOR HTN, BRAIN DAMAGE, ETC. IF GIVEN AS IV INJECTION 1MG/MIN. IF GIVEN AS INFUSION 1-10MCG/MIN TITRATEDTO DESIRED RESPONSE. IF GIVEN IN CARDIAC ARREST 1 DOSE EVERY 3-5MIN IV

25. ST

26. Sinus Tachycardia All criteria same as with NSR except rate >100
Causes: fever, dehydration, hypovolemia, increased sympathetic nervous system stimulation, stress, exercise, AMI
S/S: Palpations #1, angina and < CO from < V filling time
Treatment: correct cause, eliminate caffeine, nicotine, alcohol. Beta blockers may be ordered

27. Sinus Tachycardia Heart rate greater than 100 but less 180
Caused by external influences (fever, blood
loss, exercise)
Adenosine used
B-blockers may cause condition to worsen ( if MI limits vent function the heart will compensate by increasing rate then CO will fall)
Remember to identify and treat cause !!!

28. Supraventricular Tachycardia

29. Supraventricular Tachycardia
Impulse originates in AV junction or atria
Rhythm regular
A-fib most common cause
Ventricular rate
QRS normal configuration
Symptoms:
palpitations, lightheadedness,
Loss of Conscious, CP, SOB

30. How to treat SVT B-blockers ( to decrease conduction thru AV node:
Calcium channel blockers ( to decrease condux
thru AV node)
Radio frequency ablation

32. SVT converted with Adenosine given rapid IV Push stimulates vagal response. S/E: flushing,bronchospasm,AVblock

33. AV Blocks First degree block Second degree block Type I (Wenchebach)
Second degree block Type II (Mobitz II)
Third degree block
Bundle branch block

34. First degree heart block
Rate is usually WNL
Rhythm is regular
Pwaves are normal in size and shape
The PR interval is prolonged (>0.20 sec) but constant

35. 1st degree block
AV node delays the impulse from the SA node for abnormal length of time
Causes:
CAD, MI, drugs that act on AV node (digitalis)
Characteristics:
PR interval >0.20 seconds
Not serious but may progress to 2nd degree

36. 1st degree block nursing intervention:
Document the dysrhythmia
Monitor for progression to slower heart rate or worsening block
If progression noted, monitor pt, notify physician

37. Second degree heart block type 1
Pwaves are normal in size and shape;
Some pwaves are not followed by QRS
PR interval: lengthens with each cycle until it appears without QRS Complex
then the cycle starts over
QRS is usually narrow

38. 2nd degree AV block:Type I:
AV node delays progression of SA node impulse for longer than normal
Some of the SA impulses never reach ventricles
P waves regular
Progressive lengthening of PR interval until one P wave is not conducted
CAUSE: ischemia or injury to AV node

39. 2nd degree Type I AV block:
RISK: often a temporary block after MI
May progress to complete(3rd degree)
block
TREATMENT; freq. none needed
slow vent rate: ATROPINE will increase AV conduction
To increase rate of SA node:EPINEPHRINE

40. 2ND degree nursing interventions: Type I
Document
Monitor pt/vitals
If ventricular rate slows enough to produce
symptoms, document , notify physician

42. Second degree heart block type 2
Ventricular rate is usually slow
Rhythm is irregular
Pwaves are normal in size and shape (more pwaves than QRS)
PR interval is within normal limits
QRS is usually wide

43. 2nd degree Type II (Mobitz Type II)
Atrial rate 60 to 100
More P waves than QRS complexes
Ventricular response 2:1 or 3:1
No change in PR intervals of conducted P waves
CAUSES: disease of AV node, AV junctional tissue, or His-Purkinje system, inferior MI

44. 2nd degree Type II:
RISK: unpredictable & may suddenly advance to complete hrt block
Especially common after inferior infarction
A DANGEROUS WARNING DYSRHYTHMIA
TREATMENT: if vent rate slow, atropine or epinephrine
may need temporary pacer

45. 2nd degree Type II Nursing Interventions:
Determine width of QRS
WATCH for widening QRS complex
*width QRS indicates location in the conduction system of the block
- the wider the complex, the lower in the bundle branch system the block will be.
IF QRS WIDENS, NOTIFY PHYSICIAN IMMED.
Prepare for insertion of pacer
Assess vitals

46. 3rd degree heart block of complete heart block
Ventricular rate is regular but there is no correlation between pwaves and QRS
Pwaves are normal in size and shape
No true PR interval

47. 3rd degree block: complete heart block: “AV dissociation”
More atrial waves than ventricular
No conduction of atrial impulses
Atrial/ventricles beat independently
RISKS: bradycardia which produces
a decrease in CO leading to hypotension & myocardial ischemia
TREATMENT; pacer
NURSING INTERVENTION; monitor , hemodynamics , prepare for pacer

48. Atrial Fibrillation Erratic wavy base Pr is not measurable
QRS 0.10 sec or less usually

49. A fib continued
Atrial rate > 400 bpm with a varying Ventricular rate
Overall rhythm irregular
No P waves, unable to measure PR interval
QRS=normal: Twave undeterminable
Causes: Rheumatic fever, mitral valve stenosis, cad. HTN, MI, hyperthyroidism, COPD, CHF see pp. 604

50. A fib continued
Concern with A fib is the development of atrial thrombus and loss of atrial kick from ineffective atrial function.
Treatment: Ca channel blockers and anti- arrhythmics to convert, beta blockers to < HR, anticoagulants to prevent embolization.
Synchronized cardioversion

51. Atrial Fibrillation
- - 5 to 6 times more likely to have stroke
- - atrial rate: 300 to 600 times/minute
--prolonged A-Fib may stretch & weaken
heart muscle
- - symptoms: lightheaded, very tired,
SOB, diaphoretic, chest
pain,

52. Afib causes :
Chocolate large amounts: contains theobromine, a mild cardiac stimulant.
- sleep apnea
- athletes more prone (enlarged heart)
- tall athletes (esp basketball players)
- aging heart
- men more than women
- sleeping on left side or stomach
etc.

53. A-fib treatment:
ASA not as effective as Coumadin in preventing strokes.
ASA less likely to cause abnorm bleeding
**since hemorrhagic stroke increases with age & is also increased by taking Coumadin, some Drs. may switch older pts from Coumadin to ASA.

54. A Fib electrical cardioversion:
High risk of forming clots & causing stroke
Anticoagulants taken before treatment and 3-4 weeks post treatment
If life-threatening, may need Heparin IV before cardioversion
Best time: recent A fib

55. Atrial flutter Atrial rate of 250-450 bpm ventricular rate varies
Atrial rhythm is regular ventricular rate is irregular
No identifiable p waves
P wave is not measurable
Qrs: 0.10 or less usually

56. Atrial fib/flutter

58. Paced beat Pacer spike should fall before the P wave unless a dual
Chamber pacemaker; if it does not there could be a problem

59. PAC

60. PAC: premature atrial contraction
Premature depolarization of atrial origin
P wave may be buried in T wave
A pause follows and SA node will start new cycle of sinus beats
Indicates atrial irritability
No risk if occasional
If 6 or more per minute, indicates atrial tachycardia
Treat: digitalis, calcium channel blockers, beta blockers

61. Premature ventricular conduction (PVC)
Extra beat
Types
uniform=go the same direction
multifocal= go in different direction
R on T=when the pvc fall on the preceding twave
couplet= 2 pvcs together
bigeminy= pvc every other beat
trigeminy=pvc every third beat

62. PVCs (unifocal)

63. PVCs (multifocal)

64. PVC: ventricular origin
Complex is wide followed by compenatory pause
An irritable focus in ventricle initiates a contraction before normally expected beat.
Acute MI most common cause
QRS is wide and bizarre
Risks: increasing myocardial irritability, leading to increased freq. of PVCs
Can occur as bigeminy (every other beat)
or short runs

65. Ventricular tachycardia
Monomorphic: beats are same size and shape
Polymorphic: different size and shape

66. V-tach
Advanced irritability of ventricles due to ASHD, CHF, acute MI electrolye imbal. Hypoxia, acidosis,occas drugs
RISKS: low to no Cardiac output
Nursing Interventions: monitor, if pt unconscious,immed. defib

67. Torsades de pointe This is a polymorphic VT
Usually electrical imbalance in nature r/t NA+ or K+

69. Torsade de pointes Will see prolonged QT interval when in sinus rhythm
Will see prominent U wave
If lasts >10 seconds pt will progress to unconsciousness, life threatening with ineffective cardiac output
TREATMENT: IV magnesium

70. Ventricular Fibrillation
Rate can not be determined because of no identifiable waves
Rapid chaotic rhythm with no pattern
No p waves
No PR interval
No QRS

71. Vtach/Vfib Both can be life threatening VT= V HR 100-250 bpm
Causes: AMI, CAD, hypokalemia, dig toxic
S/S: palpitations, dizzy, angina, <LOC
Treatment: assess for pulse, if none, defib
VF=Rate undeterminable Cause: same
Treatment: CPR

72. V-fib May occur after MI Extensive ventricular irritability
Very little cardiac output
Death within 4 to 8 minutes
TREATMENT: immediate defibrillation
immed defib at 200 J
if unsuccessful, repeat at 300 J
If unsuccessful, repeat at 360 J
CPR

73. Asystole

74. Asystole and PEA CPR Oxygen
Epinephrine 1 mg IV/IO (repeat 3-5 minutes)
May give Vasopressin 40U IV/IO to replace
1st or 2nd dose of epinephrine
Consider Atropine 1 mg IV/IO Repeat every 3 to 5 min (up to 3 doses)

76. What arrthymias are considered PEA?
See an organized or semi-organized rhythm BUT NO PULSE:
This includes:
- idioventricular rhythms
- ventricular escape beats
- postdefibrillation idioventricular

78. ST elevation

79. 12 lead ekg
The electrocardiogram (EKG) is a device that receives electric impulses from the body and changes them into a monitor tracing that can be analyzed to find problems with electrical conduction in the heart. The EKG simply picks up electrical impulses; it does not read mechanical activity. When a patient has ischemia, injury or necrosis to the heart muscle, the electrical impulses change in the area involved. Nurses can analyze the electrical changes and determine if they indicate mechanical dysfunction.

80. The EKG is simply a volt meter that picks up electrical signals
The EKG is simply a volt meter that picks up electrical signals. Therefore, anything that interferes with electrical conduction can cause changes in the EKG. These variables can be divided into three main categories:
1) physiological variables not specific to the heart (ie. pulmonary embolism, increased intracranial pressure)
2) electrical interference (ie. poorly placed lead)
3) ischemia, injury, or infarction

81. 5 Steps to 12 Lead Interpretation 1. Assess regularity and speed 2
5 Steps to 12 Lead Interpretation 1. Assess regularity and speed 2. Look for signs of infarction 3. Present in >1 lead, but not all? 4. Assess associated conditions 5. Correlate with clinical condition

82. Normal EKG

83. MI

84. Polymorphic VT

85. VFIB

93. Rhythms for Cardioversion
A-fib
A-flutter
Supraventricular tachycardia

94. Electrical cardioversion
It is the treatment of choice if the patient has a hemodynamically unstable tachydysrhythmia
It is used for the treatment of unstable ventricular tychardia with a pulse
With cardioversion the potential exists to prevent this life-threatening dysrhythmias.
Cardioversion may either be a planned or emergent procedure.
Properly done cardioversion will correct the patient’s dysrhythemia with minimal discomfort and maximum safety.

95. Chemical cardioversion
Indication A. Considered to be an effective alternative to electrical cardioversion for Rapid conversion of atrial fibrillation and atrial flutter. B. Ibutilide is moderately effective in causing prompt conversion to sinus rhythm with greater efficacy in patients who have atrial flutter.
2. Action. A. Ibutilide prolongs action potential duration by activating a slow inward current, largely carried by sodium ions. B. Blocks the rapidly activating component of the delayed rectifier potassium current. C. No significant effect on heart rate, PR interval, or QRS interval D. Potential prolongation by Ibutilide leads to an increase in atrial and ventricular refractoriness in vivo. E. No clinically significant effect of Ibutilide to lower blood pressure or worsen congestive heart failure. F. Route of elimination: hepatic.
3. Administration. A. Ibutilide is available in 10 mL vials containing 0.1 mg/mL (1 mg total). B. For intravenous administration, the recommended dose of Ibutilide is 1mg over a 10 minute period in patients weighing > 60 kg C. Patients weighing < 60 kg, the recommended dose is 0.01 mg/kg initially, with a second dose of the same strength 10 minutes later if necessary. D. Ten minutes after the end of the initial infusion, a second 10 minute infusion of equal strength can be given if the arrhythmia has not terminated.

96. Cautions. A. Prolong ventricular repolarization. B
Cautions. A. Prolong ventricular repolarization B. Carries a risk of excessive QT prolongation C. Acquired long-QT syndrome D. Associated polymorphic ventricular tachycardia (torsade de pointes) E. Careful patient selection and clinical monitoring during drug administration.
5. Contraindications. A. QTc interval exceeding 440ms B. Bradycardia C. Electrolyte disturbances D. Other QT-prolonging drugs
6. Adverse Effects. A. Ventricular tachycardia B. Premature ventricular complexes C. Hypotension D. Bundle branch block E. Atrioventricular

97. Post cardioversion care:
1. generally the care for a patient tells cardioversion is the same as for the fibrillation.
2. If it is a elective procedure, digoxin is usually withheld for 48 hours prior to cardioversion to prevent dysrhythmias after the procedure.
3. Airway patency should be maintained and the patient state of consciousness should be evaluated.

98. Indications for pacemaker
Temporary:
-symptomatic bradycardia (not controlled by meds)
- ant MI
- drug overdose (dig, beta blocker)
Permanent:
- 2nd degree Mobitz Type II
- 3rd degree Block
- symptomatic bradycardia, arrhythmias
- suppress tachyarrythmias

99. Modes of Pacing Synchronous (demand )Mode
- sensitivity is set to patient beats
- pacer will fir when pt rate goes below
that what is set
Asynchronous pacing:
- for asystole, or profound bradycardia
- does not sense any pt beats
- fires at set rate no matter what pt rate is

100. Position of the letter
Designation
1st letter
Chamber being paced (A=atrium, V=ventricle, 0=none)
2nd letter
Chamber being sensed (A=atrium, V=ventricle, 0=none)
3rd letter
Pacing Mode (O=none, I=inhibited, T=triggered, D=dual)
4th letter
Rate Response (R=rate response is on)

101. Chambers that can be paced:
Atrium Ventricle Dual (both atrium and ventricle) ICD (Implantable Cardioverter Defibrillator)

102. Dual Paced Atrial Pace, Ventricular Pace (AP/VP) AP VP AV V-A AV V-A
Knowing the basic A-V and V-A intervals will help in understanding the four modes or “faces” of dual chamber pacing. In the first example, the pacemaker is pacing in both the atrium and the ventricle–most likely a patient with sinus node dysfunction and AV block. AP VP

103. Implant Cardioverter Defibrillator ICD

104. ICD - prevents sudden cardiac death due to V-tach or V-fib.
Pt can feel the shock
-defib felt like “kick in the chest”
that lasts 1 second
- cardiovert feels like “thump in chest
- pt doesn’t feel pacing

105. Problems with pacers Failure to fire Failure to capture
Undersensing (low battery, poor lead
position)
Oversensing (turn down output, magnetic
interference)

106. Operative failures with pacers:
Pneumothorax
Pericarditis
Infection
Hematoma
Lead dislodgement (seen on X-ray)
Venous thrombosis (rare but would see
unilateral edema to arm on same side
as pacer)

107. Pt Education: 1. carry ID card (Xray code seen in standard chest Xray)
2. not allowed to drive for 1 month
3. no metal detectors or no longer than nec.
4. MRI interrupts pacing-can’t get one for some time if new
5. No power generators (welding)
6. microwave questionable
7. radiotherapy (may damage circuits) The
pacer may need to be surgically moved if in
path of radiation field.
8. TENS (transcutaneous electrical stimulation) interferes
may need reprogramming
9. Cell phone use in opposite ear of pacer and store away
from side of pacer

108. EP with Ablation
An electrophysiology study is simply a study of the electrical function of your heart.

109. A (IV) catheter may be placed and be used to continuously administer fluids. The purpose of this IV is to provide the nurses and doctors with a quick means of administering medications, should your heart rhythm abnormality occur.
An EP team doctor will explain why the procedure is necessary and what risks are involved for you.
The degree of risk varies with each person and is related to your specific condition. After discussing this information,
a consent form needs to be signed prior to
Prior to the EP study, your skin will be washed with a special soap and the hair shaved from potential catheter insertion sites. The most common site used is the groin, or the area at the crease of the leg about midway between the center of your body and your hip. Occasionally the forearm, neck or collarbone areas are used. The purpose of this washing is to provide a clean insertion site and reduce the chance of infection

110. NPO after midnight the night before the test
NPO after midnight the night before the test. If your test is not scheduled until later in the day, may have a clear liquid breakfast, after which you must not eat or drink. You may take your morning pills with a sip of water. All your medicines will be reviewed, and some may be withdrawn prior to the test.
You will not receive anything to put you to sleep before this test. It is important for you to describe sensations you have during the test to the staff in the EP laboratory.
If you have dentures and they are tight-fitting, you may wear them during the study. You may also wear your glasses and watch if you wish.
An initial EP study takes an average of two and a half hours; however, they may range from one to six hours.

111. Long, thin, flexible wires, referred to as pacing wires, or intra-cardiac catheters, are advanced through the IV catheter and up into the heart chambers under the guidance of an x-ray camera (see diagram). These pacing wires are used to both record the electrical patterns from inside the heart and to "pace" the heart. Pacing the heart is delivery of very small amounts of electricity to the heart muscle through the tip of the catheter. This causes a heart beat, and allows the electrophysiologist to compare your heart's response to paced beats to already known normal responses. Approximately half of the patients undergoing this procedure are aware of each heart beat, and therefore, feel their heart speed up, slow down, or "skip a beat". Many other people are completely unaware of the pacing procedure.
If an arrhythmia is provoked by the pacing, you may feel some of the same symptoms that caused you to seek medical attention. Please tell the EP staff what you feel. Let them know if you have shortness of breath, dizziness, light-headedness, or chest discomfort. A member of the team will be by your side and talking with you at all times.

112. After the test, the catheters will be removed
After the test, the catheters will be removed. Firm pressure will be applied over the puncture site for approximately 15 minutes. This is necessary to prevent any bleeding from the insertion site. You will then be taken to your hospital room, or the EP recovery area.
Flat bed rest is necessary for two to eight hours after the study. During this time, it is important to keep the leg or arm used in the procedure straight to prevent bleeding from the insertion site. After the specified amount of rest, you will be able to resume your previous activity level.
Your nurse will be in the room frequently during the first hour after the study to take your blood pressure, heart rate, and check your insertion site for signs of bleeding. The pulses and temperature of your feet will also be checked.
You will be instructed to apply pressure firmly to the insertion site if you cough or sneeze and while using the bedpan or urinal. If you should notice any bleeding at the site, notify your nurse immediately. If your back becomes uncomfortable, do not hesitate to ask the nurses for pain medications.
You will be able to resume your previous diet and your nurse or family members can help you eat while you are reclining in bed.

113. Bundle Branch Blocks: Diagnosed with 12 lead EKG: most common cause: acute MI
Right bundle branch block:
- impulse travels through left ventricle first, then activates right ventricle (gives am “M” shaped complex
Left bundle branch block:
--impulse first depolarizes right side of heart then the left ventricle (gives deep, wide “V” shaped complex

114. Bundle Branch Blocks: Risks: can deteriorate to 3rd degree block
then treat with atropine or pacemaker
Pt can be asymptomatic until progresses

116. Hyperkalcemia

117. hypokalcemia

118. Intro to ACLS

119. Primary Survey
Airway: Open airway, look, listen, and feel for breathing
Breathing: If not breathing slowly give 2 rescue breaths. If breaths go in continue to next step.
Circulation: Check the carotid artery (Adult) for a pulse. If no pulse begin CPR.
Defibrillation: Search for and Shock V-Fib/Pulseless V-Tach

120. Adult ACLS Secondary Survey ABCDs (abbreviated)
Airway: Intubate if not breathing. Assess bilateral breath sounds for proper tube placement.
Breathing: Provide positive pressure ventilations with 100% O2.
Circulation: If no pulse continue CPR, obtain IV access, give proper medications.
Differential Diagnosis: Attempt to identify treatable causes for the problem. .

121. AED
An AED is a device used in cardiac arrest, or sudden cardiac death, when the heart’s electrical activity is disorganized and there is no effective pumping of blood. The AED is capable of recognizing the heart's electrical activity, and determining if an electric shock is required. If the shock is needed, a voice prompt in the AED is activated, telling the rescuer to push a button to deliver the shock

124. stress Common responses can include:
Feeling a sense of loss, sadness, frustration, helplessness, or emotional numbness
Experiencing troubling memories from that day
Having nightmares or difficulty falling or staying asleep 
Having no desire for food or a loss of appetite
Having difficulty concentrating 
Feeling nervous or on edge

125. Teaching to cope Reach out and talk. Express yourself.
Watch and listen.
Stay active.
Stay in touch with family.   
Take care of yourself.

126. ANY QUESTIONS???