1. Look at the chest for movement while assessing for a carotid pulse for up to 10 seconds, and assess the patient ’s skin, noting the patient ’s skin temperature, color, and moisture.
OBJ: Discuss a systematic approach to the initial emergency care of an unresponsive patient.
2. Direct a team member to start chest compressions. While CPR continues, instruct a team member to attach combination pads to the patient ’s bare chest in the position recommended by the manufacturer. Turn the power to the monitor/defibrillator on and identify the patient ’s cardiac rhythm.
OBJ: Discuss a systematic approach to the initial emergency care of an unresponsive patient.
124 CHAPTER 4 Cardiac Arrest Rhythms
REFERENCES
Atkins, D. L., Berger, S., Duff, J. P., Gonzales, J. C., Hunt, E. A., Joyner, B. L., et al. (2015, Oct). 2015 American Heart Association guidelines for CPR & ECC. Retrieved Jan 11, 2016, from American Heart Association. In Web-based integrated guidelines for cardiopulmonary resuscitation and emergency cardiovascular care—part
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Attaran, R. R., & Ewy, G. A. (2010). Epinephrine in resuscitation: Curse or cure? Future Cardiol , 6(4), 473 – 482.
3. While CPR continues, perform a focused physical examination, looking for possible clues as to the cause of the arrest. Obtain, or direct a team member to obtain, additional information from the para-medics with regard to the circumstances in which the patient was found.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
4. The monitor shows a sinus tachycardia; however, because the patient has no pulse with this rhythm the clinical situation is PEA.
OBJ: Identify four cardiac rhythms that are associated with cardiac arrest.
5. Activate the trauma team, if not already done, and consider the possible causes of the patient ’s car-diac arrest. On the basis of the information provided, hypovolemia (ie, firm distended abdomen) is one possible cause. Ask the IV team member to establish a second IV line and give a fluid challenge of normal saline. The amount given often varies depending on agency policy/local protocol. For the purposes of this scenario, we will give a 20 mL/kg fluid challenge of normal saline to start with.
Because this patient weighs about 70 kg, our initial fluid challenge will be 1400 mL.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
6. While CPR continues, ask the IV team member to give 1 mg of 1:10,000 epinephrine IV push now and repeat the same dose every 3 to 5 minutes as long as the patient has no pulse.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
7. Check the patient ’s other vital signs and repeat the primary survey.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
8. Ask the airway team member to continue to assist the patient ’s breathing with a BMD connected to 100% oxygen. Continue to monitor the patient ’s vital signs and ECG every 5 minutes as you prepare to transport the patient to the operating room (OR). Weigh the decision to place an advanced airway and giving additional IV fluids now (delaying definitive care) versus transporting the patient to the OR and having these interventions performed by the anesthesiologist. Request a team debriefing after the patient ’s transfer is complete.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for cardiac arrest rhythms, including mechanical, pharmacologic (ie, indications, contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
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Tachycardias
INTRODUCTION
The tachycardia algorithm is a treatment guideline that is used when providing care to patients who have a tachycardia with a pulse. You must be able to recognize if a patient is asymptomatic, symptomatic but stable, symptomatic but unstable, or pulseless. Care of the pulseless patient with a tachycardia is provided using the cardiac arrest algorithm, which was discussed in Chapter 4. Familiarity with the tachycardia algorithm requires patient assessment, rhythm recognition, and knowledge of medications, vagal maneu- vers, and electrical therapy.
The signs and symptoms that are experienced by a patient with a tachycardia depend on the ventric-ular rate, how long the tachycardia lasts, the patient ’s general health, and the presence of underlying heart disease. The faster the heart rate, the more likely the patient is to have signs and symptoms resulting from the rapid rate.
When a patient presents with signs and symptoms related to a tachycardia, ask yourself these questions:
1. Is the patient asymptomatic, symptomatic but stable, symptomatic and unstable, or pulseless?
2. Is the QRS wide or narrow? If it is wide, is it monomorphic or polymorphic?
3. Is the ventricular rhythm regular or irregular?
The answers to these questions will help to guide your treatment decisions. Most tachycardias do not cause serious signs and symptoms until the ventricular rate exceeds 150 beats per minute (beats/min) unless the patient has impaired ventricular function (Link, et al., 2015).
Serious signs and symptoms are those that affect vital organ function. Examples of serious signs and symptoms are shown in Box 5.1. If the patient is symptomatic but does not have serious signs and symp-toms because of the rapid rate, the patient is considered to be stable. For example, a patient who has symptoms such as lightheadedness or palpitations with stable vital signs is symptomatic, but he or she is not in imminent danger of cardiac arrest. After their airway, breathing, and circulation (ie, ABCs) have been assessed, stable but symptomatic patients are given oxygen (if indicated), intravenous (IV) access is established, and medication therapy is begun. Frequent patient reassessment is essential. If the tachycardia produces serious signs and symptoms, typically with heart rates of 150 beats/min or more, the patient is considered unstable. Unstable patients who have a pulse and serious signs and symptoms caused by the tachycardia should receive immediate synchronized cardioversion.
The management of patients who present with a tachycardia is often complex. As an advanced cardiac life support provider, it is important for you to recognize when to consult expert advice with regard to rhythm interpretation, medications, or patient-management decisions.
129
D E S I R E D R E S U L T S
G OA L Given a patient situation, and working in a team setting, competently direct the initial emer- gency care (including mechanical, pharmacologic, and electrical therapy where applicable) for a patient experiencing a tachycardia.
L E A R N I N G O B J E C T I V E S
After completing this chapter, you should be able to:
1. Differentiate among narrow-QRS tachycardias, wide-QRS tachycardias, and irregular tachycardias.
2. Given a patient situation, describe the electrocardiogram (ECG) characteristics and initial emergency care for narrow-QRS tachycardias, wide-QRS tachycardias, and irregular tachycardias, including mechanical, pharmacologic, and electrical therapy, where applicable.
3. Identify a patient who is experiencing a tachycardia as asymptomatic, symptomatic but stable, symptomatic but unstable, or pulseless.
4. Explain synchronized cardioversion, describe its indications, and list the steps required to perform this procedure safely.
5. For each of the following rhythms, identify the energy levels that are currently
recommended: monomorphic ventricular tachycardia (VT), narrow-QRS tachycardia, atrial fibrillation (AFib), and atrial flutter.
L E A R N I N G P L A N
• Read this chapter before class. Remember to highlight important concepts as you read.
• Develop and use flashcards, flowcharts, and mnemonics to help enhance your retention of the information presented. Flashcards can be particularly helpful with the recall of
medication dosages and rhythm recognition.
• Master identification of the following rhythms: sinus tachycardia, atrial tachycardia (AT), atrioventricular (AV) nodal reentrant tachycardia (AVNRT), AV reentrant tachycardia (AVRT), monomorphic VT, and polymorphic VT (PMVT).
• Master the following medications: O2, adenosine, amiodarone, beta-blockers, diltiazem, magnesium sulfate, procainamide, sotalol, and verapamil.
• Master the following skills:
• Ensure scene safety and the use of personal protective equipment.
• Assign team member roles or performing as a team member in a simulated patient situation.
• Direct or perform an initial patient assessment.
• Obtain vital signs, establish vascular access, attach a pulse oximeter and blood pressure and cardiac monitor, give supplemental O2 if indicated, and order a 12-lead ECG.
• Quickly identify an ECG rhythm, determining whether the QRS is narrow or wide (and if it is wide, if the QRS is monomorphic or polymorphic), regular or irregular.
• Quickly recognize if a patient is asymptomatic, symptomatic but stable, symptomatic but unstable, or pulseless.
BOX 5.1 Signs and Symptoms of Hemodynamic Compromise
Acute changes in mental status
• Demonstrate familiarity with the tachycardia algorithm.
• Demonstrate an understanding of what vagal maneuvers are and when they are indicated.
• Demonstrate an understanding of the actions, indications, dosages, adverse effects, and contraindications for the medications used in the treatment of a narrow-QRS or wide-QRS tachycardia.
• Deliver the correct type of energy (synchronized cardioversion versus defibrillation) and the correct energy level for the tachycardia if electrical therapy is indicated.
• Demonstrate safe operation of the defibrillator if electrical therapy is indicated.
• Recognize the need to change from synchronized cardioversion to defibrillation if the rhythm changes to pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF).
• Consider the possible reversible causes of a cardiac emergency.
• Verbalize when it is best to seek expert consultation.
• Review your performance as a team leader or team member during a postevent debriefing.
• Complete the chapter quiz and review the quiz answers provided.
• Read the case studies at the end of this chapter and compare your answers with the answers provided.
K E Y T E R M S
Delta wave Slurring of the beginning portion of the QRS complex, caused by preexcitation.
Supraventricular arrhythmias Rhythms that begin in the sinoatrial (SA) node, atrial tissue, or the AV junction.
Synchronized cardioversion The timed delivery of a shock during the QRS complex.