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Ventricular dysrhythmias
1. Dysrhythmias Originating
in the Ventricles
Ventricular escape
complexes and
rhythms
Accelerated
idioventricular rhythm
Premature ventricular
contraction
Ventricular tachycardia
Torsades de pointes
Ventricular fibrillation
Asystole
Artificial pacemaker
rhythm
2. Dysrhythmias Originating
in the Ventricles
>0.12 seconds, bizarreQRS
NonePRI
NoneP Waves
Ventricle
Pacemaker
Site
Escape complex, irregular;
escape rhythm, RegularRhythm
15–40Rate
Ventricular Escape Complexes
and Rhythms
Rules of Interpretation
3. Dysrhythmias Originating
in the Ventricles
Ventricular Escape Complexes and Rhythms
Etiology
Safety mechanism to prevent cardiac standstill
Results from failure of other foci or high-degreeAV block
Clinical Significance
Decreased cardiac output, possibly to life-threatening levels
Treatment
For perfusing rhythms, administer atropine and/orTCP
For nonperfusing rhythms, follow pulseless electrical activity
(PEA) protocols
4. Dysrhythmias Originating
in the Ventricles
>0.12 seconds,
bizarre
QRS
NonePRI
NoneP Waves
Ventricle
Pacemaker
Site
Escape complex,
irregular;
escape rhythm, Regular
Rhythm
60-100Rate
Accelerated Idioventricular
Rhythm
Rules of Interpretation
5. Dysrhythmias Originating
in the Ventricles
Accelerated Idioventricular Rhythm
Etiology
A subtype of ventricular escape rhythm that frequently occurs
with MI
Ventricular escape rhythm with a rate of 60–110
Clinical Significance
May cause decreased cardiac output if the rate slows
Treatment
Does not usually require treatment unless the patient becomes
hemodynamically unstable
Primary goal is to treat the underlying MI
6. Dysrhythmias Originating
in the Ventricles
>0.12 seconds, bizarreQRS
NonePRI
NoneP Waves
VentriclePacemaker Site
Interrupts regular
underlying rhythm
Rhythm
Underlying rhythmRate
Premature Ventricular Contractions
Rules of Interpretation
7. Dysrhythmias Originating
in the Ventricles
PrematureVentricular Contractions
Etiology
Single ectopic impulse resulting from an irritable focus in
either ventricle
Myocardial ischemia, increased sympathetic tone, hypoxia,
idiopathic causes, acid-base disturbances, electrolyte
imbalances, or as a normal variation of the ECG
May occur in patterns
Bigeminy, trigeminy, or quadrigeminy
Couplets and triplets
8. Dysrhythmias Originating
in the Ventricles
PrematureVentricular Contractions
Clinical Significance
Malignant PVCs
More than 6/minute, R onT phenomenon, couplets or runs of
ventricular tachycardia, multifocal PVCs, or PVCs associated with
chest pain
Ventricles do not adequately fill, causing decreased cardiac
output
9. Dysrhythmias Originating
in the Ventricles
PrematureVentricular Contractions
Treatment
Nonmalignant PVCs do not usually require treatment in
patients without a cardiac history
Cardiac patient with nonmalignant PVCs
Administer oxygen and establish IV access
Malignant PVCs:
Lidocaine 1.0 –1.5 mg/kg IV bolus
Repeat doses of 0.5-0.75 mg/kg to max dose of 3.0 mg/kg
If PVCs are suppressed, administer lidocaine drip 2–4 mg/min
Reduce the dose in patients with decreased output or decreased
hepatic function and patients >70 years old
10. Dysrhythmias Originating
in the Ventricles
>0.12 seconds,
bizarre
QRS
NonePRI
If present, not
associated with
QRS
P Waves
Ventricle
Pacemaker
Site
Usually regularRhythm
100–250Rate
Ventricular Tachycardia
Rules of Interpretation
11. Dysrhythmias Originating
in the Ventricles
VentricularTachycardia
Etiology
3 or more ventricular complexes in succession at a rate of >100
Causes include myocardial ischemia, increased sympathetic
tone, hypoxia, idiopathic causes, acid-base disturbances, or
electrolyte imbalances
VT may appear monomorphic or polymorphic
Torsade’s De Pointes
Clinical Significance
Decreased cardiac output, possibly to life-threatening levels
May deteriorate into ventricular fibrillation
13. Dysrhythmias Originating
in the Ventricles
Torsades de pointes
Typically occurs in nonsustained bursts
ProlongedQT interval during “breaks”
QRS rates from 166–300
RR interval highly variable
Treatment
Do not treat as standardVT
Administer magnesium sulfate 1–2 g diluted in 100 ml D5W
over 1–2 minutes
Overdrive pacing
14. Dysrhythmias Originating
in the Ventricles
NoneQRS
NonePRI
Usually absentP Waves
Numerous
ventricular foci
Pacemaker
Site
No organized
rhythm
Rhythm
No organized
rhythm
Rate
Ventricular Fibrillation
Rules of Interpretation
15. Dysrhythmias Originating
in the Ventricles
Ventricular Fibrillation
Etiology
Wide variety of causes, often resulting from advanced
coronary artery disease
Clinical Significance
Lethal dysrhythmia with no cardiac output and no organized
electrical pattern
16. Dysrhythmias Originating
in the Ventricles
Ventricular Fibrillation
Treatment
InitiateCPR
Defibrillate with 200, 300 and 360 J (or biphasic equivalent)
Control the airway and establish IV access
Administer epinephrine 1:10,000 every 3–5 minutes
Consider 40 IUVasopressin IV (one time only)
Consider second-line drugs
Amiodarone
Lidocaine
Provide continuous compressions
17. Dysrhythmias Originating
in the Ventricles
AbsentQRS
AbsentPRI
AbsentP Waves
No Electrical
Activity
Pacemaker
Site
No Electrical
Activity
Rhythm
No Electrical
Activity
Rate
Asystole
Rules of Interpretation
18. Dysrhythmias Originating
in the Ventricles
Asystole
Etiology
Primary event in cardiac arrest, resulting from massive
myocardial infarction, ischemia, and necrosis
Final outcome of ventricular fibrillation
Clinical Significance
Asystole results in cardiac arrest
Poor prognosis for resuscitation
19. Dysrhythmias Originating
in the Ventricles
Asystole
Treatment
Administer CPR and manage the airway
Treat for ventricular fibrillation if there is any doubt about the
underlying rhythm
Administer medications:
Epinephrine
20. Dysrhythmias Originating
in the Ventricles
>0.12 seconds,
bizarre
QRS
If present, variesPRI
None produced by
ventricular pacemakers;
pacemaker spike
P Waves
Depends upon
electrode placement
Pacemaker
Site
May be regular or
irregular
Rhythm
Varies with
pacemaker
Rate
Artificial Pacemaker
Rules of Interpretation
21. Dysrhythmias Originating
in the Ventricles
Artificial Pacemaker Rhythm
Etiology
Single vs. dual chamber pacemakers
Fixed-rate vs. demand pacemakers
Clinical Significance
Used in patients with a chronic high-grade heart block, sick
sinus syndrome, or severe symptomatic bradycardia
22. Dysrhythmias Originating
in the Ventricles
Artificial Pacemaker Rhythm
Problems with Pacemakers
Battery failure
“Runaway” pacers
Displaced leads
Management Considerations
Identify patients with pacemakers
Treat the patient
Use of a Magnet