Hi, welcome to our series on the electrocardiogram.
Now in this one we're going to talk
about the treatment and prevention
of ventricular fibrillation.
Now let's review why this
is ventricular fibrillation.
You know, we always recommend
that you walk through those seven steps.
But because we have this mess of
a rhythm, we can't measure the QRS,
we can't measure the PR,
we can't look at the P waves.
Really what we have is just a squiggly line
across the screen with no discernible waves.
Now, I want you to take a look
at what's going on in the ventricle.
Remember, I recommend first
look at the top half of the heart.
What do you see?
Yeah, silence, there's nothing going on there.
But when you look at the bottom of
the heart, I wish I could say that's a party,
but it's really not.
That is chaos.
And because the ventricles are
fibrillating so much, they are just quivering.
They're not functioning in an efficient way.
They don't have time to fill, and they
don't have time to release a volume
out to the rest of the body.
So this is life threatening.
I want you to think from two perspectives.
We have a patient who is experiencing
an acute episode of ventricular fibrillation,
and that's a life threatening emergency,
and what we would consider a "code blue",
That's when a team comes and
helps to resuscitate the patient.
But we also know that people have a tendency
to go into V fib when they're in the community.
Now if we know they have a history
of that, we can implant a special device
to help treat that immediately.
So let's go back and kind of do a V fib overview.
It is the most frequent cause
of sudden cardiac death.
That's why it's so important
that communities have access
to defibrillators that will
walk you through each step.
So even a community member who's
been trained in basic CPR courses
that cover a defibrillator in the
community can help save a life.
Now look at that, you know
how to look at this picture, right?
You're looking at the bottom, and
it's easy to see that the heart is just
beating with this rapid but erratic impulses.
The ventricles are pretty much useless right there.
They're not effective at all, or maybe even no blood
is making it out in pumping from these ventricles.
Why is that?
Because of the chaos you
see going on in the ventricles.
Now, cardiac output and blood pressure,
they're not even really measurable.
They're so incredibly low, and all
blood supply to the body is cut off.
The patient will collapse within
seconds when they go into V fib.
So this is not going to be someone
who's awake and talking to you.
They're going to be down on the ground
after they experience this type of rhythm.
So I bet you want to know who's at risk
for developing this really scary rhythm?
Well, we don't always know the cause of
ventricular fibrillation is not always known,
but here's some things we do know:
If a heart has been damaged, or it has
some scars from maybe a previous heart attack,
because remember, in a heart
attack, or a myocardial infarction,
blood supply is cut off to
part of the heart tissue, right?
doesn't have good perfusion.
Well, tissue that is not perfused
for long enough, is dead.
And dead tissue is stiff tissue.
So stiff tissue doesn't contract very well,
because it is no longer able to be flexible,
like the live heart tissue is.
So one of the risks for developing V fib is somebody
who's had damage from a previous heart attack,
or scars that are developed
from an older heart attack.
Now, ventricular tachycardia quickly
can become ventricular fibrillation,
which is why everyone gets real excited when
you see ventricular tachycardia on the monitor,
because we know if we can intervene quick,
hopefully we can stop that from progressing
or deevolving into ventricular fibrillation.
So you're thinking about patients
who are most at risk of V fib,
their heart has been damaged,
or they're having V Tac,
and we know that can quickly turn into V fib.
So watch your patient closely.
These are the things that
you go into nursing for, right?
This is why you study in
school and put all that effort in
because you want to know what to
look for to keep your patients safe.
So you're going to watch for
the patient to have a rapid decline.
That means they're going to get sick real quick.
Also consider these signs:
They could be having chest pain, tachycardia.
They might feel like their heart is, they
can tell you 'I feel like my heart is racing'.
Well that may be the V Tach.
They're dizzy and nauseated
because they are not being perfused.
Same reason they would be short of breath.
Now loss of consciousness is an obvious
one that all is not well with your patient
when they lose consciousness, but you
also will not have a palpable pulse with V fib.
Now, when we talked about V Tach, we
said you treat it one way if it's pulseless.
and another way if you have a
pulse and the patient is symptomatic.
In V fib, there will be no pulse, which is why
we, when we think we see V fib on a monitor,
we're always going to check for a pulse to
make sure that it's not a monitor problem,
that it's really a patient problem
who's actually experiencing V fib.
You know, monitors are fantastic,
and they're really important
but nothing replaces a thoughtful
human nurse at the bedside
who can look at all the information,
and particularly put hands on the patient
to assess them and make sure you have an
accurate and clear picture of what's going on.
Now, there's some other risk factors, like if
they have gone into ventricular fibrillation before.
They have what we call a
history of ventricular fibrillation.
So if they've had a heart
attack, they've had V fib before,
they might have a heart defect that
they were born with, or cardiomyopathy.
So that's a list.
I'm not a big fan of list because my
working memory can't keep track of all that.
And most people's can't keep a track of all that.
So the best strategy, when you're
looking at lists of things is to do what?
Remember the word chunk?
Yes, we want you to chunk the information together.
So take a look at that list.
My brain sees two chunks, right?
One is, 'oh there, the
history of doing this before'.
The second one is any damage to the heart.
Now I'll be able to remember like damage to
a heart because that could be a heart attack,
that could be a congenital heart
defect, or that could be cardiomyopathy.
I know those are all direct damage to the heart.
So instead of memorizing four
things, I'm just going to keep track of,
'Hey, some other risk factors are they've
done it before, and their heart has been damaged'.
All right, now we've got this list, but look.
Injuries that cause damage to the
heart muscle, such as electrocution,
well, that falls into my same category.
If I saw that on a test question, I would
recognize if someone was electrocuted,
that's like them being
defibrillated without any controls.
Now, here's the last two categories.
So what we've talked about so far is:
they have a history, they've done it
before, direct damage to the heart muscle.
Now there's two more, so that
will meet my process of four.
So they've done it before, direct
damage to the heart muscle,
which could be any one of
the examples we talked about:
stimulant drugs, such as
cocaine, or methamphetamine.
This is an extreme risk factor for
people who are using street drugs.
It's not controlled, it's not prescribed.
So they're not making wise choices with how
much they're taking and which drugs they're missing.
And this is the worst case scenario for someone taking
a stimulant drug like cocaine or methamphetamine,
it's going to be cardiac sudden death.
So here's a tip, if you see a test question, we have
someone who's come in on cocaine or methamphetamine,
which patient complaints
Would you follow up on first?
Any indication that that person,
patient is having cardiac issues?
Chest pain, feel like their heart is racing,
all those things are going to absolutely
put me on high alert to watch for this.
So one other strategy I'm using,
do you hear that I'm using repetition?
That's because no one can just take in
constant streams of information and remember it.
So I keep backing up in giving you
an outline, or what I call a scaffold,
so it's easier for you to remember.
So we know we have what was the first one?
Cool, history, they've done V fib before.
What's the second piece of our scaffold?
Right, direct damage to the heart.
Third piece? street drugs.
Street drugs that are stimulant drugs, that's
going to put them at risk for V fib and death.
And last, electrolytes that are significantly
off particularly potassium or magnesium.
So that's when you need to know your lab work.
Be familiar with,
'Hey, do I have a risk for this patient to
have some crazy electrolyte issues going on?'
That's easily identifiable on
just reviewing the lab work.
This is a common lab that's drawn
on all admissions to the patients
just coming to the hospital just about.
So watch your electrolyte levels if
they're way off, this patient is at extreme risk
and further assessment and treatment needs
to be done to prevent ventricular fibrillation.
So let's talk about if you
see V fib in the community.
Well, first of all, you're going to
call 911 if you're in the community.
If you're in the hospital, hospitals
usually call this a "code blue".
That means you push a button and a whole team of
experts are alerted, to rush to that patient's aid.
Now you'll see in the middle we've got
there a AED, automatic external defibrillator.
That would be if this happened in the community.
Lots of communities have put these in their
basketball gyms, at their sports complexes,
shopping malls, churches, any place where
large groups of people meet or congregate.
AEDs are a good thing to have in case this happens.
So in the community, I'm going to call 911.
I'm going to see if we have
access to an AED, because I know
that patient will die literally in minutes if
they're not treated immediately with defibrillation.
We've got to restore that heart rhythm.
So community, you call 911, you're going
to get the AED and you're going to make sure
you get defibrillation to this
patient as quickly as possible
Hospital, we're going to call a code blue.
We absolutely have defibrillators in the hospital.
And our goal, whether it's community
or in the hospital, is to make sure
we defibrillate as quickly as possible
to try to restore a normal heart rhythm.
Now we're going to take a look at
the prevention of ventricular fibrillation.
This will be for a patient who has a history of
having runs or periods of ventricular fibrillation.
So we use what's called an ICD,
that's an implantable cardiac defibrillator.
Now, it's really small, and it's a power
device that goes underneath the patient's skin,
usually below the left collarbone.
This is something that my mom had
put in, in combination with a pacemaker,
and it radically changed her life,
she had so much more energy.
Now the leads are really flexible, if you look at
our picture there, you have the box that's implanted
underneath the left collarbone, and those wires
run from the ICD through the veins of the heart.
And it constantly monitors the
heart for abnormal heart rhythms
and it responds with a shock as needed.
My mom sleeps by a monitor, so at least
she has contact with it six hours a night,
and that is always sending back
information and data to her cardiologist.
Let's look a little closer at what
this amazing little marvel can do.
So you can program, well, the
physician will program the ICD
one of two ways, or both,
depending on what the patient needs.
There's low energy pacing,
and there's higher energy shock.
So let's look at lower energy pacing
first, that's kind of a kinder, gentler.
The patient may not even know this is going
on, or at most, they'll feel like a painless little
fluttering in their chest, when the ICD responds
to some mild disruptions in their heartbeat.
My mom, it's clear when you look at her strips,
this is going on for her on a fairly regular basis,
and she doesn't even feel it.
Now let's talk about the higher energy shock.
This one is for the more
serious heart rhythm problems.
This is is when the ICD will deliver a much higher
energy shock than it does for low energy pacing.
Remember, low energy pacing - it's kinder, gentler,
the patient may not even know it's happening.
Higher energy shock? Oh, they know.
In fact, I have had patients describe it to me like,
'I felt like I was kicked in the chest by a horse'.
Now the pain usually only lasts a second, and
there shouldn't be a lot of discomfort afterwards
but they will absolutely know that
higher energy shock has been discharged.
Remember that's just for the serious heart
rhythm problems like ventricular fibrillation.
So this remote monitoring, my
mom sleeps by, she does it at night
because she has to be by the
monitor for about six to eight hours.
So it has automatic follow up.
Look what it does.
So when she's sleeping by it at night, it's
constantly communicating with that remote monitor,
or if she's feeling off or she doesn't feel
well, she can also put the monitor up to herself
so that she can tell them,
'hey, I don't feel right'.
She can choose to do
patient-initiated follow up meaning,
'I need you to take a look at my
heart rhythm I'm not feeling well'.
Now all the information is stored in a very secure
data bank, and the physician will review the data.
This is amazing.
You don't have to have tasks
don't have to go to the hospital.
You can do it right from the patient's home.
As things change in our world, think of
the possibilities for remote monitoring,
In countries with limited access
and people who are in very rural areas
that can't get to a hospital
easily, this is brilliant.
So let's wrap up this video series on the treatment
and prevention of ventricular fibrillation.
Because V fib is a life-threatening
emergency that will result in death,
if we can't treat it and restore
a normal heart rhythm quickly,
sustained V Tach can progress to V fib.
So that's another one that is an urgent
and life threatening dysrhythmia.
Now defibrillation is required for sustained V fib,
And patients can have implantable defibrillators
that monitor the heart's rhythm and can
deliver electrical impulses to pace the heart
and defibrillate the heart.
Remember when you're doing your
admission assessments on your patients,
you do want to always ask them
about any pacemakers or ICDs
to help provide the most accurate and safe care.
Thanks for watching this part of our video series.