Ms.
Azmat Jehan Khan
RN,BScN, MScN
Assistant Professor
AKUSONAM
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Code Management and Review of
Critical Care Drugs
OBJECTIVES
1. Life threatening Dysrhythmias
2. Indications for initiating Cardio Pulmonary Resuscitation
3. Roles of care givers in managing cardiopulmonary arrest
situations.
4. Utilization of crash cart and defibrillator
Part B
1. Medications used in code managements
2. Documentation during a code.
3. Post resuscitation management
4. Psychosocial, legal and ethical issues
5. Involvement of the family during a code
What is Dysrhythmia
• A cardiac dysrhythmia is an abnormal heart beat: the rhythm may
be irregular in its pacing or the heart rate may be low or high.
• Tachy-arrhythmias and Brady-arrhythmias
• Some dysrhythmias are potentially life threatening while other
dysrhythmias (such as sinus arrhythmia) and normal.
• The most common life-threatening arrhythmia is ventricular
fibrillation, which is an erratic, disorganized firing of impulses from
the ventricles (the heart's lower chambers).
American heart Association, 2010
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Why Dysrhythmias occur….
A disturbance between electrical conductivity
& the mechanical response of the myocardium.
A disturbance in impulse formation
-abnormal rate
-ectopic focus
A disturbance in impulse conduction
-delays and blocks
Combination of several mechanisms
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Dysrhythmias
Any deviation from the normal rhythm of the heart
May Cause:
Sudden death
Syncope
Heart failure
Dizziness
Palpitations
No symptoms
Life Threatening Arrhythmias
There are two main types of arrhythmia
1. Bradyarrhythmias:
Failure of impulse generation: Sinus node dysfunction
Failure of impulse propagation: AV conduction abnormality (2nd
and 3rd degree heart block)
2. Tachyarrhythmias:
Supraventricular
– SVT
– Atrial Flutter
– Atrial Fibrillation
Ventricular
– VT
– VF
Dysrhythmia Diagnosis
Electrocardiograms,
Stress tests,
Echocardiograms,
Holter monitors,
Electrophysiology studies,
Cardiac catheterization
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Recognition and Management
Treat the Patient ... not the Monitor
!!!!
Evaluate the patient’s symptoms and clinical signs
• Ventilation
• Oxygenation
• Heart rate
• Blood pressure
• Level of consciousness
• Look for signs of inadequate organ perfusion
(AHA 2010)
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Lets practice some ECGs
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Atrioventricular (AV)
Blocks
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First Degree AV Block
Rhythm: Regular; can be irregular
Rate: Usually 60-100 BPM; Rhythm dep.
P Waves: Upright/Normal
P-R Interval: > 0.20 s (200 ms); Constant
(Q)RS Complex: 0.04-.12 s (40-120 ms)
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Significance
Clinical significance
None
Treatment
None
Note – this can progress to 2º or 3º heart block
Second Degree Heart Block (2º)
Mobitz Type I (Wenkebach)
Mobitz Type II
Second Degree AV Block (Mobitz I/ Wenckebach)
Rhythm: Atrial: Reg.; Ventr.: Regularly irreg.
Rate: Atrial: Normal; Vent.: Norm./Slow
P Waves:
Normal: extra P waves regular
P-R Interval:
Not constant; progressively
Lengthens - drops beat
(Q)RS Complex: Usually .04-.12 s (40-120 ms)
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Second Degree Heart Block (2º)
Mobitz Type I/(Wenkebach)
PR PR PR DROPPED BEAT
2nd Degree AV block Mobitz 1
Significance
Clinical Significance
Slight symptoms eg. Lethargy, Confusion
Treatment
1. None if asymptomatic
2. Atropine if slow ventricular rate
3. Possible temporary pacemaker until rhythm resolves
Note – this can progress to 3º Heart Block
Second Degree AV Block (Type II)
Rhythm: Atrial: Reg.; Ventr.: Regular or irreg.
Rate: Atrial: Normal; Ventricular: Slow
P Waves: Normal; extra P waves
P-R Interval: Constant on conducted beats (2:1, 3:1,
4:1)
(Q)RS Complex: Usually .04-.12 s (40-120 ms)
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Second Degree Heart Block (2º)
Mobitz Type II
PR PR DROPPED BEAT PR
Significance
Clinical significance
1. Asymptomatic if only a few beats dropped
2. As the number of dropped beats increase, patient may
experience palpitations, fatigue, dyspnea, chest pain,
lightheadedness
Treatment
1. Observation if asymptomatic
2. Isoproterenol (Isuprel) instead of Atropine because conduction
problem is in the bundle of His and the purkinje system,
therefore, drugs that work directly on the myocardium work
better than those that increase atrial rate
3. Commonly requires placement of a pacemaker
Note – this can progress to 3º Heart Block
Third-Degree AV Block
Rhythm: Atrial & Ventricular: Regular
Rate: Atrial: Normal; Vent.: 40-60; < 40
P Waves: Normal: extra P waves
P-R Interval: No Atrial/Ventricular Relationship
(Q)RS Complex: <0.12 s (120 ms) Junct.;> 0.12 Ventr.
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Third Degree Heart Block (3º)
(Complete)
P P P P P
QRS QRS
3rd degree AV block
Significance
Clinical significance
Symptoms LOC, Confusion, Dizziness, Low BP
Can lead to VT or VF
Can be life threatening
Treatment
1. Atropine or Isoproterenol,
2. Pacemaker: temporary and/or permanent
AV Block Summary
• Uniformly prolonged PR
1st Degree interval
Block
2nd Degree • Progressive PR interval prolongation
Block Mobitz
I
2nd Degree • Constant PR with Sudden conduction failure
Block Mobitz
II
• No AV conduction
3rd Degree Block
Atrial Arrhythmias
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Premature Atrial Contractions (PACs)
Rhythm: Irregular (PACs);Non-compensatory
Rate: Depends on underlying rhythm
P Waves:
Premature and abnormally shaped with
PACs
P-R Interval: .12-.20 s (120-200 ms)
(Q)RS Complex:
.04-.12 s (40-120 ms)
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Atrial Flutter
Rhythm: Atrial: Regular; Ventr.: Varies (regular if
conduction is regular)
Rate: Atrial: 250-400; Ventr.: Varies
P Waves: Big F-Waves – Saw tooth pattern > P
P-R Interval: Unmeasurable
(Q)RS Complex: < 0.1 ; usually normal
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Atrial Fibrillation (A. Fib)
Rhythm: Irregularly irregular
Rate: Atrial: 350-6000; Ventr.: 160-180
Varies
P Waves: No pattern
P-R Interval: No discernable P waves
(Q)RS Complex: 0.04-.12 s (40-120 ms)
Note:
a) If ventricular rate is >100, called uncontrolled A-fib
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Supraventricular Tachycardia (SVT)
Rhythm: Regular
Rate: > 150-250 BPM
P Waves: Indiscernible
P-R Interval: None seen
(Q)RS Complex:
0.04-0.12 s (40-120 ms)
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Ventricular
Arrhythmias
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Premature Ventricular Contractions (PVCs)
Rhythm: Irregular (PVCs); Compensatory
Rate: Depends on underlying rhythm
P Waves: None on premature beat
P-R Interval: None on PVCs
(Q)RS Complex: > 0.12s (120 ms) on PVC
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Types of PVCs
Unifocal PVCs
Couplets
Runs of PVCs
Multifocal PVCs
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Ventricular Tachycardia (VT)
Rhythm: Usually Regular
Rate: 100-250 BPM
P Waves: If present, not associated
P-R Interval: None
(Q)RS Complex: > 0.12s (120 ms)
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Ventricular Fibrillation (V. Fib)
Rhythm: Chaotic;no set rhythm;fine/coarse
Rate: None
P Waves: Absent
P-R Interval: Absent
(Q)RS Complex: No discernable; medium F-waves
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Asystole
Rhythm: No electrical activity
Rate: No electrical rhythm
P Waves:
Absent
P-R Interval:
Absent
(Q)RS Complex:
Absent
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Pulseless Electrical
Activity (PEA)
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Indications For Initiating Cardio Pulmonary
Resuscitation
3 2 1 0 1 2 3
Pulse < 40 41-50 51-100 101-110 111-130 > 130
Systolic BP
< 70 71-80 81-100 101-199 > 200
mmHg
Respiratory
<8 9 -14 15-20 21-29 > 30
Rate
Temp °C < 35 35.1-36.5 36.6-37.4 > 37.5
CNS A V P 41U
Indications For Initiating Cardio
Pulmonary Resuscitation
Respiratory Arrest
1. Cardiac Arrest
2. Pulseless VF/ VT
3. Pulseless Ventricular Fib
Causes: Airway Problems
Obstruction Caused By:
CNS depression
Blood
Vomit
Foreign body
Trauma
Infection
Inflammation
Laryngospasm
Causes: Breathing Problems
Decreased Respiratory Drive Lung Disorders
– CNS Depression – Pneumothorax
– Haemothorax
Decreased Respiratory Effort – Infection
– Muscle Weakness – Acute Exacerbation
– Nerve Damage COPD
– Restrictive Chest Defect – Asthma
– Pain From Fractured Ribs – Pulmonary Embolus
– ARDS
Causes: Circulatory Problems
Primary Secondary
Acute coronary syndromes Hypoxaemia
(60–70%, MI)
Blood loss
Dysrhythmias
Hypothermia
Hypertensive heart disease
Septic shock
Valve disease
Drugs
Electrolyte / acid base
abnormalities
Early Recognition Of The Critically
Ill Patient (Chain of Survival)
Management
Most crucial element is TIME from collapse to care.
Primary goal is to stop the dysrhythmias immediately
and to restore normal sinus rhythm
Early effective CPR (BLS) with Advance cardiac life
support (ACLS).
Defibrillation
Early detection and management of reversible causes
(6 Hs & 5 Ts)
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ACLS
75% survived an arrest
67% survived until discharge
Analyze the Rhythm
Ventricular Fibrillation (VF)
Analyze the Rhythm
Asystole
Asystole & PEA Differentials
(The 6Hs & 5Ts)
1. Hypovolemia 1. Tablets (Drug OD)
2. Hypoxia 2. Tamponade
3. Hydrogen ions 3. Tension Pneumothorax
(Acidosis) 4. Thrombosis, Coronary
4. Hyper/hypo-kalemia 5. Thrombosis, Pulmonary
5. Hypothermia
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Analyze the Rhythm
PEA
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Team Approach to Manage Arrest Patient
1. Team leader (ACLS certified)
2. Primary nurse
3. Second nurse
4. Medication nurse
5. Charge nurse (coordinate
CPR)
6. Anesthesiologist
7. Respiratory therapist
8. Recorder
9. Nursing supervisor
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Equipment used in Resuscitation
Crash Cart
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Defibrillator
This is an electrical device with two paddles that are
placed on patient’s chest (on sternum towards the right &
at apex).
It discharges electricity through your heart when a lethal
rhythm is present.
AHA 2005 estimates that with early defibrillation
(within 5 to 7 minutes) only 30% to 45% of cardiac
arrest patients will survive the event, but without it 95%
will die before reaching the hospital.
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Types of Defibrillator
• The shock is given in only
Monophasic one direction from one
Shock electrode to the other.
• Initially direction of shock is
reversed by changing the
Biphasic Shock polarity of the electrodes in
the latter part of the shock
being delivered.
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Defibrillations
Lifepak 20 with AED &
Pacer
Packard Code master XL
Life Pack 12 AED
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Defibrillation
Used with pulseless Ventricular tach &
Ventricular fib
Electrical shock to stop chaotic asynchronous
electrical activity
Goal to have SA node regain control
Perform CPR until defibrillator ready
Charge to 200j, 300j, 360j
No sedation needed-patient unconscious
Clear all personnel with patient or bed
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Defibrillation Safety
Uses unsynchronized electrical discharge to
convert a dysrhythmia (VF or pulseless VT) to
a more stable rhythm
Prior to delivering shock, check to be sure that
no one is touching the bed
Use 25 pounds of pressure if paddles are used
Verify the EKG tracing in 2 leads
Defibrillator may work on battery
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Cardioversion
The procedure the same as for defibrillation with three important
distinctions:
1. The machine must be set on synchronous mode
2. Sedation should be given for the conscious patient if time allows
3. When the delivery button is pushed, there will be a slight delay
in firing because the machine is sensing the R wave in order to
deliver the energy at the precise moment.
The procedure should be explained to the patient and informed
consent obtained whenever possible.
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