McGraw-Hill Education CCRN Review, 1st Edition (2021)
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CCRN CCRN REVIEW
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MICHAEL REID, MSN, RN, CCRN CCRN CCRN REVIEW
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Copyright © 2021 by McGraw Hill. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-1-26-046449-8 MHID: 1-26-046449-0 The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-046448-1, MHID: 1-26-046448-2. eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corpo - rate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com. TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WAR - RANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its opera - tion will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/ or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
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Contents Acknowledgments vii About the Author ix Introduction to the CCRN Exam xi CHAPTER 1 Critical Care Overview . . . . . . . . . . . . . . . . 1 CHAPTER 2 Cardiovascular . . . . . . . . . . . . . . . . . . 31 Review Questions 53 CHAPTER 3 Respiratory . . . . . . . . . . . . . . . . . . . . 65 Review Questions 87 CHAPTER 4 Endocrine . . . . . . . . . . . . . . . . . . . . . 99 Review Questions 106 CHAPTER 5 Gastrointestinal . . . . . . . . . . . . . . . . . . 113 Review Questions 128 CHAPTER 6 Renal . . . . . . . . . . . . . . . . . . . . . . . 135 Review Questions 151 CHAPTER 7 Integumentary . . . . . . . . . . . . . . . . . . 157 Review Questions 165 CHAPTER 8 Hematology/Immunology . . . . . . . . . . . . . 171 Review Questions 179 CHAPTER 9 Musculoskeletal . . . . . . . . . . . . . . . . . . 185 Review Questions 190 CHAPTER 10 Neurology . . . . . . . . . . . . . . . . . . . . 197 Review Questions 217 v
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CHAPTER 11 Behavior/Psychosocial . . . . . . . . . . . . . . . 227 Review Questions 238 CHAPTER 12 Multisystem . . . . . . . . . . . . . . . . . . . . 245 Review Questions 266 CHAPTER 13 Professional Caring and Ethical Practice . . . . . . . 275 Review Questions 280 Practice Test 1 . . . . . . . . . . . . . . . . . . . 287 Answer Key 320 Practice Test 2 . . . . . . . . . . . . . . . . . . . 345 Answer Key 375 Practice Test 3 . . . . . . . . . . . . . . . . . . . 399 Answer Key 431 Practice Test 4 . . . . . . . . . . . . . . . . . . . 455 Answer Key 485 vi CONTENTS
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Acknowledgments First and foremost, I would like to commend and thank all of the nurses who worked during the COVID-19 crisis. Most of us had less than ideal situations to perform our jobs, but we nonetheless pushed through it and did what we do best. The majority of this book was written during the crisis as I worked in an ICU. This was an enormous challenge, but I hope you find benefit in this book as you push yourself to the next level of your career. You absolutely deserve it! To my parents, Jane and Don Reid. I could not have done it without your support. To Edson, I love you. vii
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About the Author Michael Reid, MSN, RN, CCRN has been in critical care since entering the field of nursing many years ago. Initially being exposed to a cardiovascular surgical intensive care unit, Michael went on to work in medical, surgical, and trauma specialized intensive care units. He oversees the development of educational products for his company, Nursology/The NCLEX Cure , and as a consultant for companies and corporations. He is currently dividing his time between working in the ICU, teaching NCLEX and CCRN, writing books, and building new and exciting methods for education in nursing. ix
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Introduction to the CCRN Exam If you are reading this, you have likely reached a point in your career as a critical care nurse where you would like to take it to the next level. The CCRN certification does just that. It tells people around you that you have unique and specialized knowledge about critical care. It brings joy and confidence when working those long twelve-hour shifts. Depending on your institution, it may also result in a raise and potential job opportunities. The American Association of Critical Care Nurses (AACN) creates the CCRN exam. This book is written for the adult critical care nursing certification and provides review on the entire test blueprint detailed in the following table. Certain areas are more important than others, so pay attention to where you spend your time studying. Practice makes perfect in so many things in life; with standardized tests such as this, I would agree. Included in the Book The CCRN exam blueprint was recently changed in early 2020. This book reflects this new update and includes four full-length practice tests, each brand new and made for the new blueprint. Each chapter has a detailed review of the testable areas and a quiz at the end to gauge retention. Exam Structure Kudos to you, critical care nurse! You have reached a point where you can take the CCRN certification exam. You have completed the requisite hours. Now is the time to put in the study hours and work to pass the exam itself. By reading this McGraw-Hill Education CCRN Review , you are on the right path to nailing this exam. ■ Exam questions: 125 graded questions plus an additional 25 questions (not graded) ■ Passing grade: 87 questions (70%) out of 125 questions required to pass xi
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Adult CCRN Test Blueprint TOPIC NUMBER OF QUESTIONS (EXAM TOTAL: 125) PERCENTAGE OF TEST Clinical Judgment 102 questions 80% Cardiovascular Respiratory Multisystem Neurology Gastrointestinal Renal Endocrinology Behavioral/Psychosocial Integumentary Hematology/Immunology Musculoskeletal 21 questions 19 questions 17 questions 10 questions 8 questions 8 questions 5 questions 5 questions 3 questions 3 questions 3 questions 17% 15% 14% 8% 6% 6% 4% 4% 2% 2% 2% Professional Caring and Ethical Practice 23 questions 20% Advocacy/Moral Agency Caring Practices Response to Diversity Facilitation of Learning Collaboration Systems Thinking Clinical Inquiry Questions roughly equal in weight for this section (~3% each) If you have any questions regarding exam eligibility or the application itself, visit www.aacn.org. Good Luck! Michael Reid, MSN, RN, CCRN xii INTRODUCTION TO THE CCRN EXAM
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Critical Care Overview This chapter includes catheter line access, hemodynamic monitoring, advanced electrocardiogram (ECG) interpretation, mechanical intubation, and sedation. These sections influence a variety of topic areas in this book and on the CCRN exam. By mastering these areas first, you will have a better idea of how the human body compensates or corrects issues visible to us through monitoring. Whether a patient has perforated the bowel, is experiencing a myocardial infarction, or has a severe allergic reaction, the data we assess is likely to show acute changes. Many questions on the CCRN exam will proceed assuming you know how to interpret all forms of hemodynamic information. Catheter Line Access There are two main forms of line access critical care nurses use on a daily basis, central lines and peripheral lines. There are many types of central lines; all require specialized training and care. Peripheral lines are covered in more detail in Chapter 7, “Integumentary,” where infiltration is also covered. Central Venous Catheter/Line (CAC) ■ Catheter locations ■ Internal jugular (IJ-neck), subclavian (chest), and femoral (groin) lines ■ PICC lines and Midlines (arm) ■ Port-a-cath/Vas Cath/Perm-a-cath (chest) ■ Clinical applications ■ Central venous pressure (CVP) monitoring ■ Medication (vasopressors, caustic meds) ■ Fluid administration ■ Total parenteral nutrition (TPN) administration ■ Long-term antibiotic needs ■ Dialysis (Shiley, Quinton) ■ Chemotherapy ■ Risks ■ Pneumothorax, vascular damage, arrhythmias, or bleeding during placement ■ Infection (central line–associated bloodstream infection [CLABSI]) C H A P T E R 1 1
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■ Embolisms (thrombus formation, air embolism) ■ Nursing considerations ■ Confirmation (x-ray) necessary before use ■ Never force flush clogged lumen (request alteplase) ■ Monitor coagulopathy ■ Always culture before antibiotics ■ Catheter tip sent to lab if pulled for CLABSI Arterial Lines (A-line) ■ Catheter locations ■ Radial or femoral (radial preferred; femoral carries larger infection risk) ■ Clinical applications ■ Real-time blood pressure analysis ■ Arterial blood gas (ABG) draws ■ Troubleshooting ■ Square Wave Test (zeroing of transducer) ■ Assess the patient first, then move toward technology ■ Overdamped: abnormally low reading (typically clots, kinks, or bad connections) ■ Underdamped: abnormally high reading (typically faulty set-up or transducer) ■ Risks ■ Vasospasms during insertion ➞ utilize lidocaine ■ Limb ischemia due to loss of collateral blood flow; always perform Allen’s test to confirm adequate collateral blood flow. Pulmonary Artery Catheter (PAC) ■ Catheter locations ■ Pulmonary artery—the nurse may assist in the placement and be asked to inflate and deflate the balloon as the placement advances (see Figure 1-1) ■ Commonly called a Swan-Ganz catheter ■ Clinical applications ■ Diagnostic assessment ⓦ Pulmonary pressure ⓦ Wedge pressures; read from the a-wave (little hill in the valley) ■ SvO 2 (mixed venous) blood draws/assessment ■ Monitor drug effects (pressors, inotropes, nitric oxide) ■ Treatment evaluations (balloon pumps, ventricular assistive devices) ■ Troubleshooting ■ Square Wave Test ■ Overdamped (same as A-line) ■ Underdamped (same as A-line) ■ Risks ■ Dysrhythmias during placement ➞ monitor ECG for acute changes ■ Pneumothorax may occur during placement 2 McGRAW-HILL EDUCATION CCRN REVIEW
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■ Catheter migration—it may slip out of position, monitor the waveform for changes ■ Thrombosis formation—typically at the catheter tip. Never force flush. ■ Pulmonary artery rupture (overinflated wedge) ➞ never remove the balloon syringe from the port Figure 1-1 Placement of PA Catheter: Pressure Analysis 30 20 10 0 Pressure (mmHg) Right Atrium Right Ventricle Pulmonary Artery RA RV LV LA PA A RA RV LV LA PA A RA RV LV LA PA A RA RV LV LA PA A Pulmonary Artery Wedge Dialysis Lines Dialysis catheters are covered in more detail in Chapter 6, “Renal.” Hemodynamic Monitoring On the CCRN exam, hemodynamic monitoring is included in questions for cardiovascular, pulmonary, and multisystem sections. It is most likely to arise in the cardiovascular section given the sheer number of questions in that test area. I have placed hemodynamic monitoring first in this book because of the vast importance to a number of critical care concepts. CHAPTER 1 ■ CRITICAL CARE OVERVIEW 3
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Vital Signs/Hemodynamic Numbers As a refresher, the following information shows vital signs and the general benchmarks. Changes occur to vital signs for a number of reasons. Aside from the disease process, vital signs may change due to treatments, medications, procedures, and complications. Being able to recognize an acute change from normal is essential. Advanced certification requires advanced reasoning. Luckily for you, the CCRN exam does not require you to memorize formulas for deducing numbers (mean arterial pressure [MAP], systemic vascular resistance [SVR], etc.), but you do need to know how to apply the concepts. ■ Blood pressure (BP)—invasive or noninvasive (see Table 1-1) ■ 89 mmHg or lower is indicative of shock ■ 180 mmHg or higher is indicative of hypertensive crisis ■ Be cautious of an abnormally low diastolic pressure, it may influence mean arterial pressure and perfusion ■ MAP less than 60 often suggests a state of shock ⓦ Assess urine output ➞ beginning of Multi-Organ Dysfunction Syndrome (MODS) ■ Heart rate (HR) ■ Reflex tachycardia: tachycardia onset when blood pressure is low or a patient is hypoxic. Be aware that certain medications mask this reflex tachycardia (beta blockers). ■ A tachyarrhythmia may influence cardiac output and blood pressure ■ A bradyarrhythmia may lead to a similar decrease in blood pressure ■ Central venous pressure (CVP) ■ Normal: 2 to 6 mmHg ■ Sensor at the tip of a central line catheter ■ Aids in assessment of preload (pressure in right side of heart) ■ Elevated may suggest heart failure ■ Decreased may suggest low fluid volume Table 1-1 Quick A&P Review BLOOD PRESSURE REGULATION Baroreceptors • Aortic arch and carotid sinus • Artery walls stretch ➞ vasodilation, decrease in HR (vagus nerve) • Artery walls withdraw ➞ vasoconstriction, increase in HR Chemoreceptors • Aortic arch and carotid sinus • O 2 and CO 2 sensitive • Decrease in oxygen ➞ increase in HR and vasoconstriction (not in heart and brain) • Hydrogen ion (H + ) sensitive Renin–Angiotensin–Aldosterone System (RAAS) • Renal blood flow regulates • Decrease in kidney perfusion ➞ renin secretion • Na + and H 2 0 retention • Vasoconstriction 4 McGRAW-HILL EDUCATION CCRN REVIEW
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Cardiac Output (CO)/Index The amount of blood being pumped out of the heart will directly influence a number of processes. This is why CO is enormously important. Many factors influence CO, but the simplest way to understand CO is through the following equation: CO = HR × stroke volume (SV). Stroke volume equals the amount of blood ejected from the heart with every heartbeat. ■ CO = HR × SV ■ Cardiac output can change one of two ways: ■ Increase or decrease of heart rate ■ Changes to stroke volume (described below) ■ Cardiac index (CI) is calculated by taking the CO and dividing it by body surface area (BSA): CI = CO/BSA Stroke Volume Changes to stroke volume affect a multitude of critical care areas—most noticeably, the cardiovascular system. What is the causative factor for a changing stroke volume? What signs and symptoms might be seen with changes in stroke volume? The following three terms are important; understand them well. Preload ■ Blood returning to the right side of the heart ■ Central venous pressure (CVP): may show overall volume status and worsening right-sided compliance ■ Pulmonary artery occlusion pressure (PAOP) is sometimes used when “wedging” the balloon on a PA catheter. It may show overall pressure from the left side of the heart ➞ left-sided heart failure. ■ Increasing preload may lead to ventricular failure and cardiomyopathy Contractility ■ The squeeze (contraction) of the heart ■ Often manipulated via medications (inotropes) Afterload ■ The force with which the left ventricle must overcome to open valves and eject blood ■ Systemic vascular resistance (SVR) affects left ventricle afterload ■ Pulmonary vascular resistance (PVR) affects right ventricle afterload Treatments for Hemodynamics To be able to treat an abnormal hemodynamic value, you must first understand what normal is. Below are a series of treatment modalities for commonly seen abnormal hemodynamics. Low Preload ■ Patient may be hypovolemic (dehydrated) ■ Often the first intervention to correct low BP issues CHAPTER 1 ■ CRITICAL CARE OVERVIEW 5
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■ Common saying to “fill up the tank” ■ Administer ■ Crystalloids (normal saline and lactated Ringer’s most common) ■ Colloids (albumin, blood products) High Preload ■ Patient may be fluid overloaded (edema) ■ Administer ■ Diuretics (furosemide is common) ■ If the patient is too unstable for forced diuresis, an intravenous drip of bumetanide may be used to prevent rapid changes in fluid volume ■ In severely unstable patients who cannot tolerate even slight changes to volume status, continuous renal replacement therapy (CRRT) or continuous veno-venous hemofiltration (CVVH) may be used Low Afterload ■ Patient is likely vasodilated ■ Often the sign of effective treatment such as intra-aortic balloon pump usage ■ Expected finding in certain types of shock (septic, anaphylactic, neurogenic) ■ Administer (if needed) ■ Norepinephrine (Levophed) ■ Remember, if an afterload is abnormally low, it may be due to an overshoot or overly effective treatment. It is possible the primary treatment simply needs to be decreased. High Afterload ■ Patient is likely vasoconstricted (clamped down) ■ Prolonged periods of high afterload may lead to heart failure ■ Administer ■ Nitrates (nitroglycerin, nitroprusside) (SVR reduction) ■ Hydralazine and clonidine (SVR reduction) ■ Sildenafil or nitric oxide (PVR reduction) Low Contractility ■ Patient may have heart failure ■ Administer ■ Inotropic agents ⓦ Digoxin ⓦ Dobutamine ⓦ Epinephrine ⓦ Dopamine (high dose) ⓦ Milrinone (right-sided heart failure) High Contractility ■ Patient may have heightened sympathetic nervous response (fight or flight) or metabolic issues (hyperthyroidism) ■ Not typically dangerous unless sustained for long periods of time 6 McGRAW-HILL EDUCATION CCRN REVIEW
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■ Administer ■ Beta blockers ■ Calcium-channel blockers ■ Fix the underlying problem (nervous system, metabolic pathways) Hemodynamic Values Learning all the key hemodynamic areas can certainly be tricky. Even more difficult is understanding what each direction may mean when one goes up or down. Begin with learning the normal hemodynamic ranges. To reiterate, Table 1-2 shows the most important hemodynamic numbers. The individual chapters of this book will explain why a certain hemodynamic change may happen due to a disease or disorder. Table 1-2 Hemodynamic Values HEMODYNAMIC/OXYGENATION VALUE NORMAL PARAMETER Mean arterial pressure (MAP) 70–110 mmHg • <60 mmHg considered shock (check urine output) Cardiac output (CO) 4–8 L/min Cardiac index (CI) 2.5–4.0 L/min/m 2 Stroke volume (SV) 50–100 mL/beat Stroke index 25–45 mL/beat/m 2 Central venous pressure (CVP) Right atrial pressure (RAP) 2–6 mmHg Pulmonary artery pressure 15–30 mmHg (systolic) 2–8 mmHg (diastolic) Pulmonary artery wedge pressure (PAWP) Pulmonary artery occlusion pressure (PAOP) 6–12 mmHg Systemic vascular resistance (SVR) 800–1200 dynes/s/cm –5 Pulmonary vascular resistance (PVR) 50–250 dynes/s/cm –5 Mixed venous oxygen saturation (SvO 2 ) 60–75% Central venous oxygen saturation (ScvO 2 ) Greater than 70% Arterial oxygen saturation (SaO 2 ) 95–99% (room air) • Do not confuse with PaO 2 on arterial blood gases Oxygenation Monitoring By monitoring oxygenation throughout the body, the nurse may evaluate current levels, delivery, and consumption necessary for metabolic function. Changes in patient condition or evaluation of treatments may be assessed through monitoring oxygenation levels. These concepts are applied more specifically in the pulmonary chapter. CHAPTER 1 ■ CRITICAL CARE OVERVIEW 7
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■ Mixed venous oxygen saturation (SvO 2 ) ■ The amount of oxygen on hemoglobin returning to the lungs ■ Normal: 60% to 75% ⓦ Low: body using more oxygen (infection, low cardiac output, low SaO 2 , anemia) ⓦ High: body using less oxygen (late septic shock, hypothermia) ■ Central venous oxygen saturation (ScvO 2 ) ■ The amount of oxygen on hemoglobin returning to central access (IJ or subclavian line) ■ Normal: greater than 70% ■ Low or high for same reasons as SvO 2 ■ End-tidal carbon dioxide (EtCO 2 ) ■ The amount of partial pressure carbon dioxide at the end of exhalation ■ Capnography ■ Normal: 35 to 45 mmHg ■ Elevation of EtCO 2 displays retention and hypoventilation ■ Confirmation of endotracheal tube placement (colorimeter) ■ Assessment of CPR effectiveness ■ Oxygen consumption (VO 2 ) ■ Normal: 250 to 350 mL/min ■ Consumption is low in septic shock ■ Oxygen delivery (DO 2 ) ■ Normal: 900 to 1100 mL/min ■ Delivery is low in poor cardiac function Advanced ECG Interpretation One of the most difficult skills to master is the ability to read an ECG quickly, if at all. Many people struggle with being able to distinguish certain rhythms, especially since many of these rhythms may look similar. Supraventricular tachycardia may look a lot like atrial fibrillation with rapid ventricular response. The CCRN exam does not always have an ECG strip to analyze, so understand interventions for the rhythms and the full clinical picture. Certain things do pop up more often on the exam, such as pacing, QT prolongation, torsades, and implantable cardioverter- defibrillators (ICDs). Note that the exam assumes you understand advanced cardiovascular life support (ACLS) protocol and the basics of a code blue. Applying Leads Before placing leads, the nurse must know what kind of ECG is required. Understand a 3-lead, 5-lead, and 12-lead ECG. There are also circumstances where a reverse (right-sided) ECG may be requested by the physician. This is typically during a right-sided myocardial infarction. Remember the basic landmarks utilized when placing leads: the midclavicular line, mid-axillary line, and the ability to count intercostal spaces effectively. 8 McGRAW-HILL EDUCATION CCRN REVIEW
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■ 3-lead ECG requires three bipolar leads: right arm, left arm, and left leg. It provides one angle of view on the heart. ■ 5-lead ECG requires all four bipolar leads on the limbs. It also includes one precordial (unipolar) lead. The precordial lead is typically placed at the V 1 position, but it may be moved. It provides three angles of view on the heart. ■ 12-lead ECG requires all four bipolar leads and six precordial leads. ■ Right-sided ECG requires normal bipolar lead placement. The precordial leads are placed in the same V 1 through V 6 position, but mirrored or reversed: ■ V 1 : fourth intercostal, right sternal border ■ V 2 : fourth intercostal, left sternal border ■ V 3 : halfway between V 2 and V 4 ■ V 4 : fift h intercostal, left midclavicular line ■ V 5 : fift h intercostal, left anterior axillary line ■ V 6 : fift h intercostal, left mid-axillary line ECG Interpretation Identifying a rhythm and how to react in each scenario is detailed next. A common strategy is to think about interventions from a “least invasive to most” mentality. This is how healthcare professionals commonly react in a hospital setting. Hopefully, a lot of this is review. Normal Sinus Rhythm (NSR) It is hard to understand what abnormal is without an understanding of normal. Here is a strip of NSR as a reference point. Note the consistency of the “p” waves with the corresponding skinny “QRS” complex and “T” wave. CHAPTER 1 ■ CRITICAL CARE OVERVIEW 9
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Sinus Tachycardia CCRN Figure# 01.02 Dragonfly Media Group 10/05/20 Interpretation ■ 100 BPM or more Causes ■ Reflex tachycardia (hypovolemia, hypoxia) ■ Stimulants (caffeine, drugs or medications, etc.) ■ Pain or fear ■ Hypoglycemia ■ Hyperthyroidism Signs and Symptoms ■ Heart pounds or pacing (palpitations) ■ Diaphoresis (sweating) ■ Blood pressure typically stable ■ Dizziness: may be hypotensive (symptomatic) Interventions ■ Asymptomatic ■ Typically nothing; treat underlying problem ■ Continue to monitor ■ Symptomatic ■ Treat underlying problem ■ Beta blocker Sinus Bradycardia Interpretation ■ 59 BPM or less 10 McGRAW-HILL EDUCATION CCRN REVIEW
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Causes ■ Hypothyroidism ■ Depressant medications ■ Alcohol ■ Benzodiazepines ■ Opioids ■ Professional athletes Signs and Symptoms ■ Fatigue ■ Hypotension causing dizziness (symptomatic) Interventions ■ Asymptomatic ■ Treat underlying problem ■ Continue to monitor ■ Symptomatic ■ Treat underlying problem ■ Atropine if symptomatic ■ Pacing if nothing else works and patient condition warrants (unconscious, dangerously low BP) Atrial Fibrillation without Rapid Ventricular Response (RVR) Interpretation ■ Multiple atrial depolarizations with inconsistent “QRS” complexes ■ 60–100 BPM Causes ■ Cardiovascular disease ■ Heart failure ■ Heart defect ■ Heart surgery (especially when close to the SA node) ■ Old age (chronic) Signs and Symptoms ■ Typically asymptomatic ■ Severe if leading to embolism events (MI, PE, CVA) CHAPTER 1 ■ CRITICAL CARE OVERVIEW 11
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Interventions ■ Anticoagulant (heparin, warfarin, apixaban) ■ If attempting to revert back to NSR ■ Cardizem (diltiazem) ■ Cardioversion may be used by physician request if the patient condition warrants and nothing else has worked ■ Catheter ablation (maze procedure) Atrial Fibrillation with Rapid Ventricular Response (RVR) Interpretation ■ Multiple atrial depolarizations with inconsistent “QRS” complexes ■ 100 BPM or more Causes ■ Same as atrial fibrillation without RVR Signs and Symptoms ■ Same as atrial fibrillation without RVR ■ Symptomatic (dizziness due to low BP) Interventions ■ Anticoagulation (heparin, warfarin, apixaban) ■ Beta blocker ■ Cardizem (diltiazem) ■ Cardioversion may be used by physician request if the patient condition warrants and nothing else has worked ■ Catheter ablation (maze procedure) 12 McGRAW-HILL EDUCATION CCRN REVIEW
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Atrial Flutter CCRN Figure# 01.07 Dragonfly Media Group 10/05/20 Atrial flutter has similar causes, signs and symptoms, and interventions to atrial fibrillation. It is typically spoken about in reference to the AV conduction. The above rhythm has a 4:1 conduction ratio. The sawtooth waves between “QRS” complexes are called “f” (flutter) waves. Supraventricular Tachycardia (SVT) SVT is a type of reentry rhythm caused by an electrical loop moving around the atria at a fast rate. One of the easiest ways to differentiate between a sinus tachycardia and an SVT is by simply identifying the rate. Anything above 150 is fairly indicative of an SVT. This cannot be confirmed, however, without an ECG. Interpretation ■ 150 BPM or higher ■ Skinny “QRS” complexes Causes ■ Often paroxysmal ■ Atrial fibrillation or atrial flutter ■ Wolff-Parkinson-White syndrome Signs and Symptoms ■ Palpitations ■ Fatigue and shortness of breath ■ Loss of blood pressure ➞ unconscious CCRN Tip Wolf-Parkinson- White syndrome is an electrical conduction disorder. It typically leads to abnormally high heart rates with or without symptoms and may be diagnosed via short PR intervals and characteristic “delta” waves. If the condition is serious enough, radiofrequency ablation may be required. CHAPTER 1 ■ CRITICAL CARE OVERVIEW 13
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Interventions ■ Valsalva maneuver ■ Adenosine (crash cart needed nearby) ■ Cardioversion ■ Ablation Preventricular Contractions (PVCs) Interpretation ■ Wide “QRS” complexes Causes ■ Myocardial damage (MI) ■ Electrolyte imbalances (potassium, magnesium, calcium) ■ Stress and stimulants Signs and Symptoms ■ Oftentimes none ■ Feeling of skipped heartbeat Interventions ■ Telemetry monitoring ■ Treat underlying problem ■ Review chemistry panel ■ Medications (amiodarone IV, lidocaine IV) Intrinsic Automaticity The underlying conduction system is fairly straightforward. Rhythms with a BPM above the intrinsic rate are typically called “accelerated.” If they are signifi cantly higher, the rhythm is called “tachycardia.” • SA node: 60 to 100 BPM • AV node: 40 to 60 BPM • Purkinje fibers: 20 to 40 BPM 14 McGRAW-HILL EDUCATION CCRN REVIEW
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Idioventricular Rhythm CCRN Figure# 01.10 Dragonfly Media Group 10/05/20 Interpretation ■ Wide “QRS” complexes Causes ■ Diseases (infection, anemia) ■ Drug toxicity ■ Electrolyte imbalances ■ Post reperfusion: this rhythm may be noticed transiently in ICU (accelerated idiopathic ventricular rhythm [AIVR]) Signs and Symptoms ■ Often none (asymptomatic) ■ Hypotension causing dizziness (symptomatic) Interventions ■ Treat the underlying problem ■ Atropine ■ Amiodarone or lidocaine ■ Pacing Ventricular Tachycardia (VT aka V-Tach) Interpretation ■ Wide “QRS” complexes ■ Typically 170 BPM or more CHAPTER 1 ■ CRITICAL CARE OVERVIEW 15
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Causes ■ Myocardial damage (MI) ■ Hypotension/hypovolemia ■ H’s and T’s Signs and Symptoms ■ Pulsed versus pulseless ■ Conscious versus unconscious ■ Diaphoretic and dizzy (symptomatic) Interventions ■ Pulseless electrical activity (PEA) ■ CPR, defibrillate, medications ■ Treat the underlying problem ■ Asymptomatic ■ Treat the underlying problem ■ Monitor for progression to PEA Torsades de Pointe Interpretation ■ Drastic variety of “QRS” complexes Causes ■ Hypomagnesemia ■ QT prolongation Signs and Symptoms ■ Same as ventricular tachycardia Interventions ■ ACLS protocol ■ Magnesium sulfate ■ Treat the underlying problem CCRN Tip QT prolongation often occurs due to medications such as haloperidol or other antipsychotics. Some antibiotics and digitalis toxicity may also lead to QT prolongation. Less common causes are electrolyte imbalances. 16 McGRAW-HILL EDUCATION CCRN REVIEW
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Ventricular Fibrillation (VF aka V-Fib) CCRN Figure# 01.13 Dragonfly Media Group 10/05/20 Interpretation ■ Quivering or fibrillating waves Causes ■ H’s and T’s Signs and Symptoms ■ Pulseless ■ Loss of blood pressure ■ Unconscious Interventions ■ Code blue ■ ACLS protocol Asystole Interpretation ■ Flat line Causes ■ H’s and T’s Signs and Symptoms ■ Pulseless ■ Loss of blood pressure ■ Unconscious CCRN Tip Any loss of perfusion to the brain longer than 5 minutes may lead to brain damage. CHAPTER 1 ■ CRITICAL CARE OVERVIEW 17
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