Defibrillation, Synchronized Cardioversion and Automatic Internal Cardiac Defibrillators
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What is Transthoracic resistance?
- creates the energy needed to pass through skin, lungs and tissue
- you will transmit the energy through the chest wall
- Single shocks need higher voltage
- Repeated shocks can use lower voltage
- Myocardial cells rupture (elevated Troponin levels) with each shock and with higher voltage (Newer defibrillators are preset to lower voltage levels by giving multiple discharges/shock)
What is biphasic shock?
- Biphasic energy passes through both directions. This lowers the transthoracic resistance
- require less energy to be used, salvage myocardial cells and convert rhythms at lower doses of joules
When would you want to use the defibrillator?
- Vtac--> defib will depolarize all cells at once and hopefully fastest (SA) node will take over.
- V-Fib. This would be a good one too.
- *Neither one is producing any cardiac output.
What is Synchronized Cardioversion?
- Dispenses shock when cells capable of transmission of current during ventricular repolarization
- Can use lower doses/voltage
- Can be elective or emergent
- Can use for atrial fibrillation/flutter (elective), or stable VT (has pulse and awake)
- *need to have an R wave.
Care for Cardioversion?
- Anticoagulate- may be thrombogenic
- Informed Consent
- IV access/ sedation if awake
- Monitor HR, BP, RR. remove oxygen just prior to cardioversion
- Known K+, Mg+ lab values
Procedure for cardioversion?
- Paddles require at least 25 # of pressure
- Pads must seal to the chest (if not, shock can arch to NC and burn nose), AP (Anterior/Posterior) placement preferred to just anterior pad placement
- Call “Stand Clear” prior to shock
- Repeat assessment and VS after procedure
- Use ACLS trained professionals
When/Why would you use an Automatic internal cardiac defibrillator (AICD)?
- Used for sudden death due to heart attach (as opposed to trauma). (spontaneous ventricular tachycardia)
- Used for pacing
- Used for re-synchronization in Heart failure (4 chamber pacing)
- Can be reprogrammed via phone call. Freaky.
How does an AICD work?
- Senses fast rhythms by...
- Measures QRS width for wide tachycardia
- Monitors for high voltage (VT is usually very tall in amplitude)
- watches for sustained rhythm (not salvos or NSVT)
- charges the defib with low voltage
- Discharges the defib
Voltages for various form of Defibrillation?
- Monophasic Defibrillation: 200, 300, 360
- Biphasic Defibrillation: 120, 200, 240
- Synchronized cardioversion: 50, 120, 150
- AICD: 15 for six attempts then 25
Nursing care for pt with AICD?
- Do not defibrillate over pacer
- Patient will feel shock
- Others may/may not feel shock
- Rhythms can be downloaded and examined
- Frequent shocks require further medical work up and rhythm suppression
- Prevent SVT at rates >150- they may be shocked because sometimes the PM cannot tell the difference.
What safety education do you need to give pt?
- What might you include in discharge instructions?
- Can a patient die with an AICD? Of course. They are not immortal.
- What about airport metal detectors? microwave ovens? Metal detectors will be activated. Microwaves shouldn't be a problem, unless they're in one.
- Will they pass out with an activated AICD? No. The V-tac causes pt to pass out.
- Are the patients electrically sensitive? No.
How does a pacemaker work?
Will stimulate "pace making" (usually in the ventricle) cells of heart in the absence of heart cell conductivity in the vicinity of the pacemaker electrode.
What does a pacemaker look like on an ECG?
- PM is silent on auscultation.
Anatomy of a pacemaker?
- If electrode goes bad, it stays in place and another is simply inserted somewhere else.
What is pacer capture vs sense?
- Capture: heart tissue picks up pacer electrical activity and carries it
- Sense: Pacer Maker detects heart's own rhythm and does not fire.
Read about nursing care for recovering cardiac PM pt.
- Look for capture
- Want it "scarred in."
- ECG complex will never look normal
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