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
1/25/2017 b) If ventricular rate is < 100, called controlled A-fib 32
 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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