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Considerations:
Conscious patients may require analgesia for discomfort
While pacing, avoid touching the gelled area of the quick combo redi-pak or patient to prevent electrical shock.
Do not use pads for more than eight hours of continuous pacing
The patient can be paced and defibrillated through the same set of pads
Transvenous Cardiac Pacing
The patient may require transvenous cardiac pacing which is a catheter that is inserted via venous access. The tip of the pacing catheter sits against the inner wall of the right atrium, right ventricle, or both the right atrium and right ventricle. The proximal end of the catheter is attached to the pulse generator. The venous access kit and pacemaker wire kit is located in the bottom drawer of the crash cart. The pacemaker generator is located in ICU/CCU or 2 Center. The settings on the generator are the same as transcutaneous pacing:
mA=output, rate, mode=demand or fixed).
Advantages: Disadvantages: The patient will take longer to tolerate
Better to initiate than transcutaneous pacing
External/Non- Invasive
Transvenous Pacer Supplies:
Central Line Kit: 3rd drawer
Pacer wire: 3rd drawer
Pulse generator (power supply for pacer wire): ICU/CCU or 2C
Recognition and Treatment of Dysrhythmias
Assessing the patient for hemodynamic compromising ECG changes are crucial in determining interventions and affect patient outcomes. In addition to monitoring the ECG rhythm, frequently assess the patients ABC’s by:
Initiate and maintain an adequate airway to ensure adequate breathing or ventilation
Monitor blood pressure, pulse, respiratory rate, pulse oximetry (if pulse is present) and level of consciousness
Monitor fluid and electrolytes (potassium, phosphorous, magnesium and calcium) because electrolyte abnormalities can result in dysrhythmias
Treat the patient not the monitor
Normal Sinus Rhythm
Sinus rhythm is defined as a heart rate between 60 and 100 thus provides an adequate cardiac output and blood pressure
Interventions:
Continue to monitor
Sinus Bradycardia
Assess for signs & symptoms of diminished perfusion with bradycardia (HR <60):
Chest pain, SOB, LOC, weakness, fatigue, dizziness, hypotension, and diaphoresis
Interventions:
Check for pulse and blood pressure
If patient is symptomatic the physician should see the patient immediately. Initiate appropriate emergency interventions.
Determine cause and treat. Causes could include: vagal stimulation, medications causing a negative chronotropic effect, hypoxia and intracranial pressure
Consider the need for atropine (1st drawer)
Consider Transcutaneous Pacing
Sinus Tachycardia
Assess for signs & symptoms of diminished perfusion with tachycardia (HR 100): Hypotension, syncope, blurred vision, chest pain, palpitations, anxiety, crackles, jugular vein distention, and S3
Interventions:
Contact physician or call a code blue
Consider the need for adenosine (1st drawer )
Determine cause and treat
There are numerous conditions that can cause sinus tachycardia and all should be considered during assessment, treatment and during response to treatment.
Conditions that may cause sinus tachycardia include:
Cardiac dysrhythmia Medications/illicit drugs/poison
Respiratory distress/Hypoxia Pain
Metabolic disorder Acidosis
Head injury/ICP Compensatory (early shock)
Emotions (anger, anxiety) Fever
Ventricular Tachycardia
Description: Wide complex, fast and regular rhythm
Assess for signs and symptoms of diminished perfusion with VT: Hypotension, LOC leading to unresponsiveness, and SOB. Ventricular Tachycardia most often precedes cardiac arrest and the patient may be conscious or unconscious.
Interventions:
Assess for pulse
If the patient is stable (has a pulse) and does not have indications of diminished perfusion: administer medications
If the patient is unstable with a pulse: cardiovert
If the patient is unstable (pulseless): defibrillate
Ventricular Fibrillation
Description: Erratic electrical activity. No distinct rhythm
Signs and symptoms associated with ventricular fibrillation: The patient is in full cardiac arrest without a blood pressure or pulse.
Interventions:
Treat for cardiac arrest
Initiate CPR according to AHA guidelines
Defibrillate: 200, 300, 360 joules
Consider administering
epinephrine or vasopressin (1st drawer)
lidocaine or amiodarone (1st drawer)
Asystole
Description: Absence of electrical activity “flat line”
Interventions:
Check lead placement, assess for pulse
Initiate CPR according to AHA guidelines
Consider administering epinephrine and atropine (1st drawer)
Documentation of Code Events
A detailed chronological record of all interventions during the code must be documented on the resuscitation record. Please refer to the Policy in the hospital wide Policy & Procedure manual in the cardiology section for documentation guidelines. Documentation must include:
Time the code was called and time of the physicians arrival
Staff in attendance at code (interns, residents, nurses)
Time CPR was started
Any actions taken
Patient’s response (vital signs, cardiac rhythm)
Time of intubation, tube size and lip line (LL) in centimeters (cm)
Time of defibrillation and the energy used
Time and sites of IV initiations
Types and amounts of fluids administered
Time of medications given
EKG rhythm strips to document events and response to treatment
Disposition: Patient condition following resuscitation or transfer to ICU