management of different kinds of arrhythmias

1. MANAGEMENT OF PATIENTS WITH
ARRHYTHMIAS
MILKA VAIJAN LONDHE
TEACHING FELLOW
SCHOOL OF HEALTH SCIENCES
SCHOOL OF HEALTH SCIENCES
KUBANG KERIAN
KOTA BHARU

2. OBJECTIVES
Define arrhythmias
Explain the pathophysiology of arrhythmias
Identify the manifestation of arrhythmias
Apply the care plan of patients with arrhythmias

6. • RHYTHM DISTURBANCES RESULT FROM ABNORMALITIES OF
IMPULSE FORMATION, IMPULSE CONDUCTION, OR BOTH. BRADY
ARRHYTHMIAS RESULT FROM DECREASED INTRINSIC PACEMAKER
FUNCTION OR BLOCKS IN CONDUCTION, PRINCIPALLY WITHIN THE
AV NODE OR THE HIS-PURKINJE SYSTEM.

7. TYPES
• SUPREVENTRICULAR ARRHYTHMIAS:
• Atrial fibrillation
• Atrial flutter
• Atrial tachycardia
• Atrioventricular nodal reentrant tachycardia
• Paroxysmal supraventricular tachycardia
• Wolff-Parkinson-white-syndrome

8. VENTRICULAR ARRHYTHMIAS:
• Ventricular fibrillation
• Ventricular tachycardia
• Premature ventricular beats
• Torsades de pointes
INHERITED ARRHYTHMIAS:
• Brugada syndrome
• Catecholaminergic polymorphic ventricular tachycardia
• Long QT syndrome
BRADYCARDIA
• Heart block
• Sick Sinus Syndrome

9. ATRIAL FIBRILLATION
• ATRIAL FIBRILLATION:
• Is known as AF or afib, is an
irregular, rapid heart rate that
may cause symptoms like
heart palpitations, fatigue,
and shortness of breath. AF
occurs when the upper
chambers of the heart (atria)
beat out of rhythm.

10. ATRIAL FLUTTER
• It is a common abnormal heart rhythm that starts in the atrial
chambers of the heart. When it first occurs, it is usually associated
with a fast heart rate and is classified as a type of supraventricular
tachycardia.
• Although people with atrial flutter may not experience symptoms,
the disorder can cause stroke, heart failure and other
complications.

11. ATRIAL TACHYCARDIA
• It is a type of abnormal heart rhythm, or arrhythmia. It occurs
when the electrical signal that controls the heartbeat starts from
an unusual location in the upper chambers (atria) and rapidly
repeats, causing the atria to beat too quickly.

12. ATRIOVENTRICULAR NODAL REENTRANT
TACHYCARDIA
AV NODAL REENTRANT TACHYCARDIA (AVNRT), OR ATRIOVENTRICULAR
NODAL REENTRANT TACHYCARDIA:
• IS A TYPE OF ABNORMAL FAST HEART RHYTHM. IT IS A TYPE OF
SUPRAVENTRICULAR TACHYCARDIA (SVT), MEANING THAT IT ORIGINATES
FROM A LOCATION WITHIN THE HEART ABOVE THE BUNDLE OF HIS.

13. PAROXYSMAL SUPRAVENTRICULAR
TACHYCARDIA
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA (PAROXYSMAL
SVT)
• Is an episodic condition with an abrupt onset and termination. SVT
in general is any tachyarrhythmia that requires atrial and/or
atrioventricular (AV) nodal tissue for its initiation and maintenance

14. WOLFF-PARKINSON-WHITE SYNDROME

15. WOLF-PARKINSON-WHITE SYNDROME
CONTD….
• Wolff-Parkinson -white (WPW) syndrome is a condition in
which there is an extra electrical pathway in the heart. The
condition can lead to periods of rapid heart rate (tachycardia).
• Wpw syndrome is one of the most common causes of fast
heart rate problems in infants and children.

16. VENTRICULAR ARRHYTHMIAS
• VENTRICULAR FIBRILLATION: Ventricular fibrillation is a heart
rhythm problem that occurs when the heart beats with rapid,
erratic electrical impulses. This causes pumping chambers in the
heart (the ventricles) to quiver uselessly, instead of pumping
blood. Sometimes triggered by a heart attack, ventricular
fibrillation causes blood pressure to plummet, cutting off blood
supply to the vital organs.

17. VENTRICULAR TACHYCARDIA
VENTRICULAR TACHYCARDIA:
• Is a very fast heart rhythm that begins in the ventricles. ...
Ventricular tachycardia is a pulse of more than 100 beats per
minute with at least three irregular heartbeats in a row. It is
caused by a malfunction in the heart's electrical system.

18. PREMATURE VENTRICULAR BEATS
PREMATURE VENTRICULAR CONTRACTIONS (PVCS)
• ARE EXTRA HEARTBEATS THAT BEGIN IN ONE OF HEART'S TWO
LOWER PUMPING CHAMBERS (VENTRICLES). THESE EXTRA BEATS
DISRUPT REGULAR HEART RHYTHM, SOMETIMES CAUSING TO FEEL
A FLUTTERING OR A SKIPPED BEAT IN THE CHEST.

19. INHERITED ARRHYTHMIAS
• BRUGADA SYNDROME:
IS A CONDITION THAT CAUSES A DISRUPTION OF THE HEART'S NORMAL
RHYTHM. SPECIFICALLY
• THIS DISORDER CAN LEAD TO IRREGULAR HEARTBEATS IN THE HEART'S
LOWER CHAMBERS (VENTRICLES), WHICH IS AN ABNORMALITY CALLED
VENTRICULAR ARRHYTHMIA.

20. CATECHOLAMINERGIC POLYMORPHIC
VENTRICULAR TACHYCARDIA
CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA (CPVT)
• IS A GENETIC DISORDER THAT CAUSES AN ABNORMALLY FAST AND IRREGULAR
HEART RHYTHM IN RESPONSE TO PHYSICAL ACTIVITY OR EMOTIONAL STRESS.
... WHEN A RYR2 GENE MUTATION IS INVOLVED, THE CONDITION IS PASSED
THROUGH FAMILIES IN AN AUTOSOMAL DOMINANT FASHION.

21. LONG QT SYNDROME
LONG QT SYNDROME (LQTS) IS
• A heart rhythm condition that can potentially cause fast, chaotic heartbeats.
• These rapid heartbeats might trigger a sudden fainting spell or seizure. ...
And can have a genetic mutation that puts the person at risk of being born
with congenital long qt syndrome

22. BRADYCARDIA
HEART BLOCK
is an abnormal heart rhythm where the heart beats too slowly (bradycardia ).
• in this condition, the electrical signals that tell the heart to contract are
partially or totally blocked between the upper chambers (atria) and the lower
chambers (ventricles).

23. SICK SINUS SYNDROME
SICK SINUS SYNDROME ( SSS )
• Is a relatively uncommon heart rhythm disorder. SSS is not a
specific disease, but rather a group of signs or symptoms that
indicate the sinus node, the heart's natural pacemaker, is not
functioning properly.

24. RISK FACTORS
• Coronary artery disease, other heart problems and previous heart surgery.
• High blood pressure.
• Congenital heart disease
• Thyroid problems
• . Drugs and supplements. Certain over-the-counter cough and cold
medicines
• Diabetes.
• Obstructive sleep apnea
• Electrolyte imbalance
• Drinking too much alcohol.
• Caffeine or nicotine use

25. CAUSES
• Many things can lead to, or cause, an arrhythmia,
including:
• A heart attack that's occurring right now
• Scarring of heart tissue from a prior heart attack
• Changes to heart's structure, such as from cardiomyopathy
• Blocked arteries in the heart (coronary artery disease)
• High blood pressure
• Overactive thyroid gland (hyperthyroidism)

26. CONTD…..
• Underactive thyroid gland (hypothyroidism)
• Smoking
• Drinking too much alcohol or caffeine
• Drug abuse
• Stress
• Certain medications and supplements, including over-the-counter cold and
allergy drugs and nutritional supplements
• Diabetes
• Sleep apnea
• Genetics

27. CLINICAL MANIFESTATION
• A fluttering in the chest
• A racing heartbeat (tachycardia)
• A slow heartbeat (bradycardia)
• Chest pain
• Shortness of breath
• Dizziness
• Sweating
• Fainting (syncope) or near fainting

28. PREVENTION
• Eating a heart-healthy diet
• Increasing physical activity
• Avoiding smoking
• Keeping a healthy weight
• Limiting or avoiding caffeine and alcohol
• Reducing stress, as intense stress and anger can cause heart
rhythm problems
• Using over-the-counter medications with caution, as some cold
and cough medications contain stimulants that may trigger a
rapid heartbeat

29. DIAGNOSTIC TESTS FOR ARRHYTHMIAS
• Electrocardiogram
• Holter monitor
• Echocardiogram
• Stress test

30. TREATMENT FOR ARRHYTHMIAS
• ANTI-ARRHYTHMIC DRUGS
• DEFIBRILLATION
• PACEMAKER

31. ANTIARRHYTHMIC DRUGS
CLASS I a AGENTS
INTERFERE WITH THE
SODIUM (NA+)
CHANNEL.
QUINIDINE
AJMALINE
PROCAINAMIDE
DISOPYRAMIDE
MECHANISM
CLASS 1 PROLONG
THE ACTION
POTENTIAL AND HAS
INTERMEDIATE
EFFECT ON THE 0
PHASE OF
DEPOLARIZATION
MEDICAL USES
VENTRICULAR
ARRHYTHMIAS
PREVENTION OF
PAROXYSMAL RECURRENT
ATRIAL FIBRILLATION
(TRIGGERED BY VAGAL
OVERACTIVITY)
PROCAINAMIDE IN
WOLFF-PARKINSON-
WHITE SYNDROME
INCREASES QT INTERVAL

32. CLASS 1b AGENT
Na+ channel block
(fast
association/dissoci
ation)
Lidnocaine
Phenytoin
Nexiletine
Tocainide
MECHANISM
Can prolong QRS
complex in
overdose
Class 1b shorten
the action potential
of myocardial cell
and has weak effect
on intiation of
phase 0 of
depolarization
MEDICAL USES
Treatment and
prevention during
and immediately
after myocardial
infarction, though
this practice is now
discouraged given
the increased risk of
asystole
Ventricular

33. CLASS 1 C AGENT
NA+ CHANNEL
BLOCK (SLOW
ASSOCIATION/DISSO
CIATION)
ENCAINIDE
FLECAINIDE
PROPAFENONE
MORICIZINE
MECHANISM
HAS NO EFFECT
ON ACTION
POTENTIAL AND
HAS THE
STRONGEST
EFFECT ON
INITIATION PHASE
0 THE
DEPOLARIZATION
MEDICAL USES
PREVENTS PAROXYSMAL
ATRIAL FIBRILLATION
TREATS RECURRENT
TACHYARRHYTHMIAS OF
ABNORMAL
CONDUCTION SYSTEM
CONTRAINDICATED
IMMEDIATELY AFTER
MYOCARDIAL
INFARCTION

34. CLASS 2
BETABLOCKERS
Carvedilol
Propranlol
Esmolol
Metaprolol
Atenolol
Bisoprolol
Nebivolol
MECHANISM
BETA BLOCKING
PROPRANOLOL ALSO
SHOWS SOME CLASS
I ACTION
MEDICAL USES
DECREASE MYOCARDIAL
INFARCTION MORTALITY
PREVENT RECURRENCE
OF TACHYARRHYTHMIAS
PROPRANOLOL HAS
SODIUM CHANNEL-
BLOCKING EFFECT

35. CLASS 3
K+ CHANNEL
BLOCKER
AMIODARONE
SOTALOL
IBUTILIDE
DOFETILIDE
DRONEDARONE
E-4031
VERNAKALANT
MECHANISM
SOTALOL IS ALSO A
BETA BLOCKER[4]
AMIODARONE HAS
CLASS III MOSTLY,
BUT ALSO I, II, & IV
ACTIVITY
MEDICAL USES
IN WOLFF-PARKINSON-WHITE
SYNDROME
(SOTALOL:) VENTRICULAR
TACHYCARDIAS AND ATRIAL
FIBRILLATION
(IBUTILIDE:) ATRIAL FLUTTER
AND ATRIAL FIBRILLATION
(AMIODARONE): PREVENTION
OF PAROXYSMAL ATRIAL
FIBRILLATION,[6] AND
HAEMODYNAMICALLY
STABLE VENTRICULAR
TACHYCARDIA

36. CLASS 4 AGENTS
CALCIUM CHANNEL
BLOCKERS
VERAPAMIL
DILTIAZEM
MECHANISM
CALCIUM
CHANNEL
BLOCKER
MEDICAL USES
PREVENT RECURRENCE
OF PAROXYSMAL
SUPRAVENTRICULAR
TACHYCARDIA
REDUCE VENTRICULAR
RATE IN PATIENTS WITH
ATRIAL FIBRILLATION

37. CLASS 5
Adenosine
Digoxin
Magnesium
sulfate
MECHANISM
Work by other or
unknown
mechanisms
(direct nodal
inhibition)
MEDICAL USES
Used in
supraventricular
arrhythmias,
especially in heart
failure with atrial
fibrillation,
contraindicated in
ventricular
arrhythmias. Or in the
case of magnesium

38. DEFIBRILLATION
• DEFIBRILLATION - Is the
treatment for immediately life-
threatening arrhythmias with
which the patient does not have
a pulse, ie ventricular fibrillation
(VF) or pulseless ventricular
tachycardia (VT).
• CARDIOVERSION - Is any
process that aims to convert an
arrhythmia back to sinus

39. • Cardioversion is a medical procedure that restores a normal heart
rhythm in people with certain types of abnormal heartbeats
(arrhythmias).
Why it's done
• Cardioversion can correct a heartbeat that's too fast (tachycardia)
or irregular (fibrillation). Cardioversion is usually used to treat
people who have atrial fibrillation or atrial flutter.

40. DEFIBRILLATION
• DEFIBRILLATION IS DONE
AT THE TIME OF
EMERGENCY
CARDIOVERSION
• CARDIOVERSION IS SAME
AS DEFIBRILLATION , BUT
IT IS PLANNED

41. COMPLICATIONS
• Dislodged blood clots: Some people who have irregular heartbeats have blood
clots in their hearts. Electric Cardioversion can cause these blood clots to
move to other parts of your body. This can cause life-threatening
complications, such as a stroke or a blood clot traveling to your lungs
(pulmonary embolism).
• Abnormal heart rhythm: In rare cases, some people who undergo
Cardioversion end up with other heart rhythm problems during or after their
procedure. This is a rare complication.
• Skin burn: Rarely, some people have minor burns on their skin where their

42. NURSING DIAGNOSIS:
• Knowledge deficit related to cardioversion ( defibrillator)
procedure evidenced by frequently questions
Objective:
• Patient verbalizes the knowledge regarding cardioversion
(defibrillation), pre, during and post care after cardioversion
Interventions:
Followed in the next slides

43. NURSING RESPONSIBILITIES BEFORE THE PROCEDURE
• Do not allow the patient to eat or drink anything for about 8 hours before
your procedure. If medications has to be taken before the procedure, allow
him to sip only enough water to swallow the pills.
• Before cardioversion, the procedure called a transesophageal
echocardiogram (TEE) is done to check for blood clots in the heart, which
can be dislodged by cardioversion, causing life-threatening complications
• In a transesophageal echocardiogram, throat is numbed and a flexible tube
containing a transducer is guided down the throat and into esophagus,
which connects the mouth to the stomach. From there, the transducer can
obtain more-detailed images of the heart so that your doctor can check for
blood clots.

44. NURSES RESPONSIBILITY DURING THE PROCEDURE
• A nurse will place several large patches called electrodes on the chest. The
electrodes will be connected to a cardioversion machine (defibrillator) using
wires.
• The defibrillator will record the heart rhythm throughout the procedure and
will deliver shocks to the heart to restore a normal heart rhythm. This
machine can also correct the heart's rhythm if it beats too slowly after
cardioversion
• Before the shocks are delivered, a nurse will insert an intravenous (IV) line in
the arm. The IV line is used to give the medications that will make patient to
sleep during the procedure so that patient won't feel any pain from the
shocks. the IV line can be used to give additional medications that can help
restore the heart rhythm.

45. NURSING RESPONSIBILITY AFTER THE
PROCEDURE
• Electric cardioversion is done on an outpatient basis, meaning
patient can go home on the same day procedure is done. Patient
will spend an hour or so in a recovery room being closely
monitored for complications.
•IN CASE OF DEFIBRILLATION ( EMERGENCY )
PATIENT WILL REMAIN IN THE HOSPITAL TILL HE
GETS RECOVERED COMPLETELY….

46. NURSES RESPONSIBILITIES ( EDUCATION TO THE
PATIENT AFTER THE PROCEDURE)
• Avoid or limit caffeine and alcohol.
• Use less salt (sodium), which can help lower blood pressure.
• Increase physical activity.
• Quit smoking.
• Eat heart-healthy foods and maintain a healthy weight.
• Try to limit or manage stress and anger.

47. PACEMAKER
• A device for stimulating the
heart muscle and regulating
its contractions.
• A pacemaker is a small
device with two parts — a
generator and wires (leads,
or electrodes) — that's
placed under the skin in the
chest to help control the
heartbeat

48. WHO NEEDS PACEMAKER
•Cardiac arrhythmias
•Aging-where heart muscle damage
•Some medications- like medicines of cough and
cold
•Genetic condition which causes the abnormal heart

49. WHY ITS DONE
• Pacemakers are implanted to help control the heartbeat. They
can be implanted temporarily to treat a slow heartbeat after a
heart attack, surgery or overdose of medication.
• Pacemakers can also be implanted permanently to correct a slow
heartbeat (bradycardia) or, in some cases, to help treat heart
failure.
• Device can be implanted directly into the heart, where it emits an
electrical impulse to control the heartbeat.

50. WHAT A PACEMAKER DOES
• An implanted electronic pacemaker mimics the action of natural
pacemaker. An implanted pacemaker consists of two parts:
• The pulse generator: This small metal container houses a battery
and the electrical circuitry that regulates the rate of electrical
pulses sent to heart.
• Leads (electrodes). One to three flexible, insulated wires are each
placed in a chamber, or chambers, of the heart and deliver the
electrical pulses to adjust the heart rate.

51. • Pacemakers monitor the heartbeat and, if it's too slow, the
pacemaker will speed up your heart rate by sending electrical
signals to the heart. In addition, most pacemakers have sensors
that detect body motion or breathing rate, which signals the
pacemaker to increase the heart rate during exercise to meet
body's increased need for blood and oxygen.

52. • NURSING DIAGNOSIS:
• Knowledge deficit regarding pacemaker evidenced by frequently
asked questions
• OBJECTIVE:
• Patient verbalizes the knowledge regarding the procedure,
complications
• INTERVENTIONS:
• Followed in the next slides

53. COMPLICATIONS
• Infection where the pacemaker was implanted
• Allergic reaction to the dye or anesthesia used during your
procedure
• Swelling, bruising or bleeding at the generator site
• Damage to the blood vessels or nerves near the pacemaker
• Collapsed lung

54. HOW TO PREPARE THE PATIENT
• Electrocardiogram
• Holter monitoring.
• Echocardiogram.
• Stress test

55. NURSES RESPONSIBILITY BEFORE THE
PROCEDURE
•START IV LINE
•LOCAL ANESTHESIA
•ARRANGEMENT OF SPECIAL EQUIPMENT

56. NURSES RESPONSIBILITY DURING THE
PROCEDURE
• MONITOR VITAL SIGNS

57. NURSES RESPONSIBILITY AFTER THE
PROCEDURE
•Monitor heart rate, rhythm
•Pain medication

58. SPECIAL INSTRUCTIONS TO THE PATIENT
Cellphones: it's safe to talk on a cellphone, but avoid placing the cellphone
directly over the pacemaker implantation site when the phone is turned on.
Although unlikely, pacemaker could misinterpret the cellphone signal as a
heartbeat and withhold pacing, producing symptoms, such as sudden
fatigue.
Security systems. Passing through an airport metal detector won't interfere
with pacemaker, although the metal in it may sound the alarm. But avoid
lingering near or leaning against a metal-detection system.

59. Medical equipment:
• if a doctor is considering any medical procedure that involves intensive
exposure to electromagnetic energy, tell him or her that you have a
pacemaker. Such procedures include magnetic resonance imaging, therapeutic
radiation for cancer treatment and shock wave lithotripsy, which uses shock
waves to break up large kidney stones or gallstones.
POWER GENERATING EQUIPMENT:
• Stand at least 2 feet (60 centimeters) from welding equipment, high-voltage
transformers or motor-generator systems. If the patient work around such
equipment, doctor can arrange a test in the workplace to determine whether it
affects the pacemaker.

60. NURSING INTERVENTION FOR DYSRHYTHMIAS (
ARRHYTHMIAS)
Nursing diagnosis:
• Chest discomfort/chest pain secondary to cardiac dysrhythmias
associated with altered myocardial automaticity, conductivity or
contractibility
Objective:
Reduce chest discomfort/pain
Interventions:
Assess for signs of ineffective perfusion by system
Renal: oliguria, anuria
Gastrointestinal: nausea, hypoactive or absent bowel sounds

61. • Peripheral: Odema, altered skin colour, temperature, sensation or
integrity, weak or absent pulse
• Cerebral: dizziness, altered mental status, confusion, anxiety,
syncope, altered pupillary response, speech abnormality
• Cardiopulmonary: Hypotension, abnormal respiratory rate, capillary
refill more than 3 seconds, chest pain, dyspnea, crackles and
wheezes, jugular vein distention
• Intervention:
• Assess for and report signs/symptoms of cardiac dysrhythmias
(e.g. irregular apical pulse, adult pulse rate below 60 or above 100
beats/minute, apical-radial pulse deficit, syncope, palpitations).

62. Reduce cardiac workload
• Position patient to minimizes discomfort and facilitate respiration.
• Minimize anxiety with calm reassurance and education.
• Communicate rationale for monitoring and treatments.
• Discuss the benefits calm with the patient and family.
Initiate EKG monitor and pulse oximetry per policy.
IV access, O2, medication and 12 lead-EKG as ordered, monitor vital signs.
• Positive inotropic agents (e.g. dobutamine, dopamine) to increase myocardial
contractility
• Vasodilators (e.g. nitroglycerin) to decrease cardiac workload
• ACE inhibitors (e.g. captopril, ramipril) to decrease cardiac workload
• Diuretics for elevated capillary wedge pressure
• Morphine sulfate to reduce pain, preload and anxiety.

63. Anticipate the need to initiate cardiopulmonary resuscitation.
Assess for contributing factors: pain, fluid and electrolyte
imbalance, drug toxicity (especially digoxin), medication non-
adherence.
Provide psychosocial support for patient and family members.
• If the dysrhythmia is a life-threatening type, encourage the family
unit to calmly formulate a plan of action.
• Reassure the patient will receive the best care in keeping with his
written directives or medical power of attorney.
• Communicate the availability and value of social services as