1. The general impression findings are abnormal (Appearance: normal; Breathing: abnormal; Circu-lation: abnormal skin color).
OBJ: State three areas to assess when forming a general impression of a patient.
2. An abnormal finding that is observed when assessing any of the general impression areas (ie, appear-ance, work of breathing, circulation) suggests that the patient is sick (ie, unstable); move quickly and proceed immediately to the primary survey.
OBJ: State three areas to assess when forming a general impression of a patient.
3. Ask a team member to attach a pulse oximeter, ECG monitor, and blood pressure monitor and obtain the patient ’s baseline vital signs while you perform a focused physical examination.
OBJ: Differentiate between the purposes and components of the primary and secondary surveys.
4. The monitor shows monomorphic VT.
OBJ: Differentiate among narrow-QRS tachycardias, wide-QRS tachycardias, and irregular tachycardias.
5. Ask the airway team member to administer supplemental O2 by nonrebreather mask for now and to monitor the patient ’s oxygen saturation. Direct the IV team member to start an IV of normal saline.
Order a 12-lead ECG and cardiology consult as soon as possible.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for narrow-QRS tachycardias, wide-QRS tachycardias, and irregular tachycardias, including mechan-ical, pharmacologic, and electrical therapy, where applicable.
6. Because the patient is symptomatic and unstable, ask the defibrillation team member to apply com-bination pads to the patient ’s bare chest and prepare to shock the patient. Ensure that the code cart, including intubation equipment, suction, and resuscitation medications, is within arm’s reach.
While preparing to shock the patient, ask the IV team member to sedate the patient.
OBJ: Given a patient situation, describe the ECG characteristics and initial emergency care for narrow-QRS tachycardias, wide-QRS tachycardias, and irregular tachycardias, including mechan-ical, pharmacologic, and electrical therapy, where applicable.
7. Because the patient has a pulse and the rhythm is a monomorphic VT, ask the defibrillation team member to perform synchronized cardioversion.
OBJ: Explain synchronized cardioversion, describe its indications, and list the steps required to perform this procedure safely.
8. The initial monophasic or biphasic energy dose is typically 100 J for an unstable patient with mono-morphic VT. Use the energy setting recommended by the manufacturer.
OBJ: For each of the following rhythms, identify the energy levels that are currently recom-mended: monomorphic VT, narrow-QRS tachycardia, AFib, and atrial flutter.
9. The monitor shows VF.
OBJ: Identify four cardiac rhythms that are associated with cardiac arrest.
10. It is important to recognize that VF is a shockable cardiac arrest rhythm. Instruct the defibrillation team member to ensure that the “Sync” control is off and to prepare to defibrillate the patient, using the energy levels recommended by the manufacturer. Ensure that all team members are clear of the patient and that oxygen is not flowing over the patient ’s chest before the shock is delivered. Instruct the team to resume chest compressions immediately without pausing for a rhythm or pulse check after the shock is delivered.
OBJ: Differentiate between shockable and nonshockable cardiac arrest rhythms.
11. Instruct the airway team member to remove the nonrebreather mask, insert an oral airway, and begin ventilating the patient with a bag-mask device connected to 100% oxygen. Consider placement of an advanced airway. Direct the IV team member to prepare and administer epinephrine 1 mg (1:10,000 solution) every 3 to 5 minutes as long as the patient is in cardiac arrest. Remember to rotate the compressor every 2 minutes to avoid tiring.
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.
164 CHAPTER 5 Tachycardias
12. During cardiac arrest, ensure that the IV team member follows each drug administered with a 20 mL bolus of IV fluid and brief (ie, about 10 to 20 seconds) elevation of the extremity during and after drug administration to aid delivery of the drug into the central circulation.
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.
13. Direct the defibrillation team member to clear the patient, ensure oxygen is not flowing over the patient ’s chest, and then defibrillate the patient. After the shock has been delivered, instruct the team to immediately resume CPR. Direct the IV team member to prepare and administer amiodarone or lidocaine IV while chest compressions are being performed. Consider reversible causes of the arrest using the Five Hs and Five Ts.
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.
14. Amiodarone is an antiarrhythmic that may be considered for VF or pulseless VT unresponsive to CPR, defibrillation, and vasopressor therapy. The initial dose is 300 mg IV/IO, which can be fol-lowed by one dose of 150 mg IV/IO.
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.
15. SPIKES is an acronym for a six-step protocol that is used for conveying distressing information to patients and families. Following the SPIKES protocol can help ease the distress felt by the patient or family who is receiving the news and the health care professional who is breaking the news.
• S—Setting (Select a location that provides for privacy with all appropriate people present)
• P—Perception of what the family understands about the situation (Find out what the family already knows by asking, “ What have you been told so far?” or “ What is your understanding of what has happened?”)
• I—Invitation from the family to give information (Ask the family how they prefer to receive the information that you have to share and how much they want to know; keep in mind that ethnic and cultural values play a significant role in the need for information)
• K —Knowledge (Begin with a warning statement that unfavorable news is coming and then pause; “I am sorry to tell you that …”)
• E—Emotions (Give the family time to respond; be sensitive and respectful of cultural differences)
• S—Summarize (Offer to contact the patient ’s physician and to be available if there are further questions, arrange for follow-up support, allow the family the opportunity to see their relative if they wish to do so)
OBJ: Discuss the use of the SPIKES protocol when conveying bad news.
REFERENCES
Anderson, J. L., Halperin, J. L., Albert, N. M., Bozkurt, B., Brindis, R. G., Curtis, L. H.,et al. (2013). Manage-ment of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS guideline recommendations): A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol , 61(18), 1935 – 1944.
Appelboam, A., Reuben, A., Mann, C., Gagg, J., Ewings, P., Barton, A.,et al. (2015). Postural modifica tion to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A random-ised controlled trial. Lancet , 386(10005), 1747 – 1753.
Bontempo, L. J., & Goralnick, E. (2011). Atrial fibrillation. Emerg Med Clin North Am, 29(4), 747 – 758.
Ellenbogen, K. A., & Stambler, B. S. (2014). Atrial tachycardia. In D. P. Zipes, & J. Jalife (Eds.), Cardiac electrophysiology: From cell to bedside (6th ed., pp. 699 – 722). Philadelphia: Saunders.
Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A.,et al. (2011). 2011 ACCF/
AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. J Am Coll Cardiol , 57 (11), 1330 – 1337.
Gahart, B. L.,Nazareno, A. R., & Ortega,M. Q. (2016a). Ibutilide fumarate. In 2016 intravenous medications (32nd ed., pp. 679-680). St. Louis: Mosby.
Gahart, B. L., Nazareno, A. R., & Ortega, M. Q. (2016b). Procainamide hydrochloride. In 2016 intravenous med-ications (32nd ed., pp. 1043 – 1046). St. Louis: Mosby.
Goel, R., Srivathsan, K., & Mookadam, M. (2013). Supraventricular and ventricular arrhythmias. Prim Care , 40 (1), 43 – 71.
Hamdan, M. H. (2010). Cardiac arrhythmias. In T. E. Andreoli, I. J. Benjamin, R. C. Griggs, & E. J. Wing (Eds.), Andreoli and Carpenter ’ s Cecil essentials of medicine (8th ed., pp. 118 – 144). Philadelphia: Saunders.
January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C.,et al. (2014). 2014 AHA/
ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association TaskForce on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol , 64 (21), e1 – e76.
Link, M. S., Berkow, L. C., Kudenchuk, P. J., Halperin, H. R., Hess, E. P., Moitra, V. K.,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 7: Adult advanced cardiovascular life support: Eccguidelines.heart.org .
Mark, D. G.,Brady, W. J., & Pines, J. M. (2009). Preexcitation syndromes: Diagnostic consideration in the ED. Am J Emerg Med , 27 (7), 878 – 888.
Martin, D., & Wharton, J. M. (2001). Sustained monomorphic ventricular tachycardia. In P. J. Podrid, & P.
R. Kowey (Eds.), Cardiac arrhythmia: Mechanisms, diagnosis, and management (2nd ed., pp. 573 – 601).
Philadelphia: Lippincott Williams & Wilkins.
Miller,J. M., & Zipes, D.P. (2012). Therapy forcardiacarrhythmias. In R. W. Bonow, D. L. Mann,D. P. Zipes, &
P. Libby (Eds.), Braunwald ’ s heart disease — a textbook of cardiovascular medicine (9th ed., pp. 710 – 744).
Philadelphia: Saunders.
Mottram, A. R., & Svenson, J. E. (2011). Rhythm disturbances. Emerg Med Clin North Am, 29(4), 729 – 746.
Olgin, J. E. (2008). Approach to the patient with suspected arrhythmia. In L. Goldman, & D. Ausiello (Eds.), Cecil medicine (23rd ed., pp. 394 – 400). Philadelphia: Saunders.
Olgin, J., & Zipes, D. P. (2012). Specific arrhythmias: Diagnosis and treatment. In R. O. Bonow, D. L. Mann, D.
P. Zipes, & P. Libby (Eds.), Braunwald ’ s heart disease — a textbook of cardiovascular medicine (9th ed., pp. 771 – 824). Philadelphia: Saunders.
Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J.,et al. (2016).2015ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. Circulation, 133(14), e506 – e574.
Pandya, A., & Lang, E. (2015). Valsalva maneuver for termination of supraventricular tachycardia. Ann Emerg Med , 65 (1), 27 – 29.
Walker, S., & Cutting, P. (2010). Impact of a modified Valsalva manoeuvre in the termination of paroxysmal sup-raventricular tachycardia. Emerg Med J , 27 (4), 287 – 291.
Wann, L. S., Curtis, A. B., January, C. T., Ellenbogen, K. A., Lowe, J. E., Estes, N.,et al. (2011). 2011 ACCF/
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166 CHAPTER 5 Tachycardias
6
Bradycardias
INTRODUCTION
[Objectives 1, 2]
The bradycardia algorithm is a treatment guideline that is used when providing care to patients who are symptomatic with a bradycardia. You must be able to recognize if a patient is asymptomatic, symptom-atic but stable, symptomsymptom-atic but unstable, or pulseless. Familiarity with the bradycardia algorithm requires patient assessment, rhythm recognition, knowledge of medications, and transcutaneous pacing (TCP).
Cardiac output ¼Stroke volumeHeart rate. Therefore a decrease in either stroke volume or heart rate may result in a decrease in cardiac output. An absolute bradycardia is a heart rate of less than 60 beats per minute (beats/min). When a patient has a relative bradycardia, his or her heart rate may be more than 60 beats/min. This may occur when a hypotensive patient needs a tachycardia (as in hypovolemia) but is unable to increase his or her heart rate because of sinoatrial (SA) node disease, beta-blockers, or other medications. A patient with an unusually slow heart rate may complain of weak-ness, or dizziness and fainting (ie, syncope) can occur. Decreasing cardiac output will eventually produce hemodynamic compromise.
If a patient presents with a bradycardia, assess how the patient is tolerating the rhythm. If the patient has no symptoms, no treatment is necessary but he or she should be observed closely. Many patients tolerate a heart rate of 50 to 60 beats/min but become symptomatic when the rate drops below 50 beats/min. The term symptomatic bradycardia is used to describe a patient who experiences signs and symptoms of hemodynamic compromise related to a slow heart rate. Examples of common signs and symptoms associated with symptomatic bradycardia are shown in Box 6.1.
Treatment of a symptomatic bradycardia should include assessment of the patient ’s oxygen saturation level and determining whether signs of increased work of breathing are present (eg, retractions, tachyp-nea, paradoxical abdominal breathing). Give supplemental oxygen if oxygenation is inadequate, and assist breathing if ventilation is inadequate. Establish intravenous (IV) access and obtain a 12-lead elec-trocardiogram (ECG). Atropine, administered IV, is the drug of choice for symptomatic bradycardia (Link, et al., 2015). Reassess the patient ’s response and continue monitoring the patient. Other inter- ventions that may be used in the treatment of symptomatic bradycardia include epinephrine, dopamine,
or isoproterenol IV infusions, or TCP (discussed later in this chapter).
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 bradycardia.
167
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. Given a patient situation, describe the ECG characteristics and initial emergency care for symptomatic bradycardia, including mechanical, pharmacologic (ie, indications,
contraindications, doses, and route of administration of applicable medications), and electrical therapy, where applicable.
2. Identify a patient who is experiencing a bradycardia as asymptomatic, symptomatic but stable, symptomatic but unstable, or pulseless.
3. Discuss the procedure for TCP, as well as its indications and possible complications.
L E A R N I N G P L A N
• Read this chapter before class.
• Master identification of the following rhythms: sinus bradycardia, junctional rhythm, ventricular escape rhythm, and atrioventricular (AV) blocks: first-degree, second-degree type I, second-degree type II, 2:1 AV block, and third-degree AV block.
• Master the following medications: O2, atropine, dopamine, epinephrine, and isoproterenol.
• Master the following skills: primary and secondary surveys, supplemental O2 delivery devices, attachment and use of ECG monitoring leads, IV access, IV medication administration, and operation of a transcutaneous pacemaker.
• Master the following skills:
• Assign team member roles or perform 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 recognize if a patient is asymptomatic, symptomatic but stable, symptomatic but unstable, or pulseless.
• Demonstrate familiarity with the bradycardia algorithm.
• Demonstrate an understanding of the actions, indications, dosages, adverse effects, and contraindications for the medications used in the treatment of a symptomatic bradycardia.
• Administer medications and perform TCP when indicated.
• Consider reperfusion therapy if the patient’s signs and symptoms are consistent with an acute coronary syndrome (ACS) and there are no contraindications.
• 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.
BOX 6.1 Symptomatic Bradycardia
—
Common Signs and Symptoms• Acute altered mental status
• Diaphoresis
• Ongoing ischemic chest discomfort
• Pulmonary congestion
K E Y T E R M S
Absolute bradycardia A heart rate of less than 60 beats/min.
Relative bradycardia A term that refers to a situation in which a patient’s heart rate may be more than 60 beats/min but, physiologically, the patient needs a tachycardia (as in hypovolemia) and is unable to increase his or her heart rate because of SA node disease, beta-blockers, or other medications.
Symptomatic bradycardia A term used to describe a patient who experiences signs and symptoms of hemodynamic compromise related to a slow heart rate.