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Chapter 11: Arrhythmias and Cardiac Emergencies: Authors
Chapter 11: Arrhythmias and Cardiac Emergencies: Authors
Chapter 11: Arrhythmias and Cardiac Emergencies: Authors
critical care. The aim of this chapter is to provide a resource for critical care nurses
internationally that will assist with recognition of key characteristics of sinus, atrial,
cardiac emergencies such as myocardial infarction and cardiac arrest. The chapter
will conclude with practice questions and a case study. Helpful websites and further
Approach (see Figure1). However, before you begin to analyze the rhythm strip,
ALWAYS check the patient first and ensure the patient is stable.
considered Normal Sinus Rhythm, the rhythm must have the following
characteristics:
If the rhythm has all of the above characteristics but the ST segment is
Sinus Rhythms
required for sinus bradycardia, sinus tachycardia, sinus arrhythmia and wandering
60 beats per minute. Generally, a person often becomes symptomatic when their
heart rate drops below 50 beats/minute, however slower heart rates can be
observed in fit & athletic individuals, who will often remain asymptomatic. As a
general rule, when a patient’s heart rate is less than 60/minute critical care nurses
should be prepared to immediately assess for signs of decreased cardiac output (i.e.
heart rate climbs above 150/minute. It is best practice for a critical care nurse to
assess for signs and symptoms of decreased cardiac output (i.e. hypotension,
decreased level of consciousness) when the heart rate is greater than 100/minute
since this could result in patients developing cardiac ischemia, angina or even a
myocardial infarction.
The next two arrhythmias, sinus arrhythmia and wandering atrial pacemaker
Atrial Rhythms
In the next section, rhythms originating in the atria will be explored. These
identified along with nursing implications and helpful tips to assist critical care
Junctional Rhythms
typically transient and non-lethal. The rhythms that will be presented in this section
have the common feature of inverted p waves although in some cases the p waves
are not seen since the depolarization of the atria is occurring close to the time that
the ventricles are being depolarized. Junctional rhythms are simply differentiated by
Ventricular Rhythms
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The rhythms that will be explored in this section include those caused by irritability
and ventricular fibrillation. In addition, ventricular rhythms that arise due to failure
Rhythm Regular
Rate 40-100/minute
p waves No p waves
pri No pri
QRS > .12 seconds (wide and bizarre)
Cause Add here
Treatment Typically transient, no treatment required
AV Blocks
electrical conduction through the AV node. Types of AV block include: 1st degree
heart block, 2nd degree heart block (Mobitz type 1 or Wenkebach), 2nd degree heart
block (Mobitz type 2) and 3rd degree heart block (complete heart block). AV blocks
so prompt identification and treatment is vital for the critical care nurse.
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Summary
arrhythmias when caring for your critically ill patient. In the event that the patient is
patient first and provide emergency treatment. For further development in your
possible. In addition, we have provided resources at the end of this chapter that we
hope you find helpful as you develop further competency in this subject area.
Case Study
Mr Mohammed Ahmed is a 59 year male, who has presented to his local hospital
with severe central, crushing chest pain. He has a past medical history of diabetes,
the procedure, the cardiac catheterization lab team notes a cardiac rhythm change:
This rhythm change is treated immediately and the patient returns to normal sinus
rhythm (NSR) at a rate of 90 beats per minute. Following the procedure, Mr Ahmed
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is transferred to the cardiac care unit. He recovers well following his STEMI & PPCI,
however the following day a further rhythm change is noted by the nursing team:
Mr Ahmed becomes symptomatic with this new cardiac rhythm, with profound
hypotension (BP of 68/45mmHg) and a reduced level of consciousness. The
physician attends and requests emergency interventions.
References
Aehlert, B. (2011). ECGs made Easy 4th ed., Mosby, St. Louis, Missouri.
Link, M., Berkow, L., Kudenchuk, P., Halperin, H., Hess, E., … Donnino, M. (2015).
Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care, Part 7: Adult Advanced Cardiac Life Support, Circulation, 132(18), supp.
2 132:S315-S367, doi:10.1161/CIR. 0000000000000259
Walraven, G. (2011). Basic Arrhythmias 7th ed., Pearson Publishers, Toronto, Ontario.