[mountainnurse]

Hi, I am new to this site and have encountered a question that I can't seem to find a definitive answer to. I am a second year nursing student and have been asked to prioritize care of four patients with abnormal cardiac rhythms. We have not been given any information about the diagnosis, if the pt is symptomatic, or anything additional besides these four criteria.

Ventricular fibrillation (1)
A-fib (2)
sinus brady (?)
sinus tachy (?)

The first two are obvious to me, but with such little information it is difficult for me to make an assessment on which of these two rhythms requires my attention first. Any suggestions would be greatly appreciated.
Thanks!!!

[neneRN]

I don't know how you could prioritize pts on rhythyms alone (except the V fib); many pts are in chronic A-fib with medical management of rate and blood thinners and the Afib is okay for them....a sinus tach of 100 is much less significant than a rate of 140, but even 140 could be caused by something as simple as a fever....a bradycardia of 20 is a top priority pt but a rate of 50 on pt on a beta blocker is normal.....too many what ifs to prioritize without knowing pt presentation and c/o...maybe you were just supposed to pick the one most serious rhythym, the Vfib?

[Sweetooth EMT-P, RN]

Based on the arrythmias alone I would say

v-fib
Bradycardia
Sinus tach
a-fib

But like the other poster said that is hard to do without having more info...

swtooth

[mountainnurse]

I have had the same problem because there is not enough info. Can you tell me why you chose sinus brady over A fib? I thought with the risk of emboli that this would be a priority... I would love to know your reasoning.
We are not suppossed to pick the most serious, we have to chose the order in which we would attend to the patients based on the rhythyms alone. My teacher is notorious for giving us questions that are very subjective...Based on the rhythms alone I have ranked them as 1 V fib, 2 A fib, 3 sinus brady, 4 sinus tachy (there is more treatment for sinus brady than sinus tachy and with the risk of emboli I chose A fib over sinus brady) I know there is room for debate here and I am assuming it is a new onset of A fib and not a controlled, or medically managed, case. Thanks for your help!!!!

[Sweetooth EMT-P, RN]

Sinus brady is more likely than a-fib to cause sympstoms especially if something like hypoxia is causing it, UNLESS it is new onset a-fib and the ventricular rate is uncontrolled. Your main concern in the acute stages with a-fib is not with an emboli, it usually takes at least 24 hours if not more for a paitent in a fib to form them, hence the fact that a new onset fibber can be cardioverted within 24 hours without anticoagulants. The big concern for someone in a-fib will be the ventricular rate and the symptoms they may be experiencing because of it, such as hypotension (pretty rare with this rhythm), unstable angina, and CHF. I am wondering if the whole point to your assignment is to make you realize the importance of treating the patient and not the monitor.

Swtooth

[mountainnurse]

Thank you so much for your thoughts. I think it is something we have to learn as nursing students that every patient will present differently and we can't know what is going on based soley on the monitor. This is why I have so much trouble with this question because there are too many what ifs.... I would at least like to know what the diagnosis of the patient is. The only clear cut answer for me is V fib since you have raised so many good points about sinus brady over a fib. I guess I will just have to hear her out next week on her reasoning, and she may decide the question was too vague. I really appreciate your insight, it always helps to hear a more experienced point of view.

[cardiacRN2006]

Originally Posted by swtooth

Based on the arrythmias alone I would say

v-fib
Bradycardia
Sinus tach
a-fib

But like the other poster said that is hard to do without having more info...

swtooth

I agree with this, unless the afib is new onset. But then again, how many of these are new onset??

In reality, if you have a pt in Vfib, you aren't seeing the other pts anytime soon!

[MARIAN202]

Ventricular fibrillation
A-fib
sinus brady stable seek expert consult
sinus brady IF UN STABLE: CALL A CODE/ PREPARE T0 PACE GIVE .5MG ATROPINE IV/IO
sinus tachy STABLE USE VAGAL MANEUVERS ETC BE PREPARED TO CALL A CODE BECAUSE IT MY TURN INTO VT/VF

VT/VF ARE TREATED THE SAME/CALL A CODE.

SINUS BRADY THE KEY QUESTION IS WHETHER THE BRADYCARDIA IS CAUSING THE PATIENT SYSTOMS OR SOME OTHER ILLNESS CAUSING THE BRADYCARDIA. CONSIDER: HYPOVOLEMIA,HYPOXIA,ACIDOSIS,HYPO/HYPERKLEMIA,HYPOGLYCEMIA,HYPOTHERMIA,TOXINS (DRUG OVER DOSE),CARDIAC TAMPONADE, TENSION PNEUMOTHORAX,THROMBOSIS (CORONARY AND PULMONARY),TRAUMA (HYPOVOLEMIA, INCREASED ICP, ATHLETE.

SINUS TACHYCARDIA: CONSULT EXPERT. MOST STABLE TACHY RHYTHMS REQUIRE MANAGEMENT BY AN EXPERT DUE TO THE CHALLENGE OF ACCURATELY DETERMINING AND SAFELY TREATING TACHYARRHYTHMIAS.

STABLE NARROW IRR TACHY MAY BE ATRIAL FLUTTER CONTROL THE RATE: DILTIAZEM OR BETA BLOCKERS
STABLE NARROW REG TACHY: RECURRENT SVT,AF,JUNCTIONAL OR ECTOPIC ATRIAL TACHY. RATE CONTROL DILTIAZEM OR BETA BLOCKERS


STABLE WIDE IRR TACHY: (AVOID CALCIUM CHANNEL BLOCKERS AND DIGOXIN DUE TO POSSIBLE AF+WPW) CONSIDER AMIODARONE. MAGNESIUM 2g IV OVER 5 MIN FOR TORSADES

STABLE WIDE REG TACHY
IF VT, AMINIODARONE 150MG IV OVER 10 MINS. REPEAT PRN (MAX 2.2g IV/24hr), ELECTIVE SYNCHRONIZED CARDIOVERSION.

IT'S A TRICK QUESTION
LOOK AT THE ALOGRITHMS FOR ACLS

[intra-aortic]

V fib
Sinus brady
Sinus tach
A fib

This question seems to be a bit unfair if no other information is provided. Bradycaria at what rate? Sinus tach at what rate? and A fib with RVR or controlled rate. This seems to be one of those unfair nursing school type of question.

[breatheasy]

Originally Posted by futuremountainnurse

Hi, I am new to this site and have encountered a question that I can't seem to find a definitive answer to. I am a second year nursing student and have been asked to prioritize care of four patients with abnormal cardiac rhythms. We have not been given any information about the diagnosis, if the pt is symptomatic, or anything additional besides these four criteria.

Ventricular fibrillation (1)
A-fib (2)
sinus brady (?)
sinus tachy (?)

The first two are obvious to me, but with such little information it is difficult for me to make an assessment on which of these two rhythms requires my attention first. Any suggestions would be greatly appreciated.
Thanks!!!

ACLS is by far the best place to get this information