McGraw-Hill Education CCRN Review, 1st Edition (2021)

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CCRNCCRNREVIEW

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MICHAEL REID, MSN, RN, CCRNCCRNCCRNREVIEW

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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 ofthis publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without theprior written permission of the publisher.ISBN: 978-1-26-046449-8MHID:1-26-046449-0The 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 codeMantraVersion 1.0All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarkedname, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of thetrademark. 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 USEThis is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subjectto these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you maynot 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 yourown noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated ifyou 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 USINGTHE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OROTHERWISE, ANDEXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITEDTO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Educationand 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 anyinaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has noresponsibility 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 orinability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall applyto any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

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ContentsAcknowledgmentsviiAbout the AuthorixIntroduction to the CCRN ExamxiCHAPTER 1Critical Care Overview................1CHAPTER 2Cardiovascular..................31Review Questions53CHAPTER 3Respiratory....................65Review Questions87CHAPTER 4Endocrine.....................99Review Questions106CHAPTER 5Gastrointestinal..................113Review Questions128CHAPTER 6Renal.......................135Review Questions151CHAPTER 7Integumentary..................157Review Questions165CHAPTER 8Hematology/Immunology.............171Review Questions179CHAPTER 9Musculoskeletal..................185Review Questions190CHAPTER 10Neurology....................197Review Questions217v

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CHAPTER 11Behavior/Psychosocial...............227Review Questions238CHAPTER 12Multisystem....................245Review Questions266CHAPTER 13Professional Caring and Ethical Practice.......275Review Questions280Practice Test 1...................287Answer Key320Practice Test 2...................345Answer Key375Practice Test 3...................399Answer Key431Practice Test 4...................455Answer Key485viCONTENTS

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AcknowledgmentsFirst and foremost, I would like to commend and thank all of the nurses whoworked during the COVID-19 crisis. Most of us had less than ideal situations toperform 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. Thiswas an enormous challenge, but I hope you find benefit in this book as you pushyourself 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 yoursupport. To Edson, I love you.vii

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About the AuthorMichael Reid, MSN, RN, CCRNhas been in critical care since entering the fieldof nursing many years ago. Initially being exposed to a cardiovascular surgicalintensive care unit, Michael went on to work in medical, surgical, and traumaspecialized intensive care units. He oversees the development of educationalproducts for his company,Nursology/The NCLEX Cure, and as a consultant forcompanies and corporations. He is currently dividing his time between workingin the ICU, teaching NCLEX and CCRN, writing books, and building new andexciting methods for education in nursing.ix

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Introduction to the CCRN ExamIf you are reading this, you have likely reached a point in your career as a criticalcare nurse where you would like to take it to the next level. The CCRN certificationdoes just that. It tells people around you that you have unique and specializedknowledge about critical care. It brings joy and confidence when working thoselong twelve-hour shifts. Depending on your institution, it may also result in a raiseand potential job opportunities.The American Association of Critical Care Nurses (AACN) creates the CCRNexam. This book is written for the adult critical care nursing certification andprovides review on the entire test blueprint detailed in the following table. Certainareas are more important than others, so pay attention to where you spend yourtime studying. Practice makes perfect in so many things in life; with standardizedtests such as this, I would agree.Included in the BookThe CCRN exam blueprint was recently changed in early 2020. This book reflectsthis new update and includesfourfull-length practice tests, each brand new andmade for the new blueprint. Each chapter has a detailed review of the testable areasand a quiz at the end to gauge retention.Exam StructureKudos to you, critical care nurse! You have reached a point where you can takethe CCRN certification exam. You have completed the requisite hours. Now isthe time to put in the study hours and work to pass the exam itself. By readingthisMcGraw-Hill Education CCRN Review, you are on the right path to nailingthis exam.■Exam questions: 125 graded questions plus an additional 25 questions(not graded)■Passing grade: 87 questions (70%) out of 125 questions required to passxi

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Adult CCRN Test BlueprintTOPICNUMBER OF QUESTIONS(EXAM TOTAL: 125)PERCENTAGEOF TESTClinical Judgment102 questions80%CardiovascularRespiratoryMultisystemNeurologyGastrointestinalRenalEndocrinologyBehavioral/PsychosocialIntegumentaryHematology/ImmunologyMusculoskeletal21 questions19 questions17 questions10 questions8 questions8 questions5 questions5 questions3 questions3 questions3 questions17%15%14%8%6%6%4%4%2%2%2%Professional Caring andEthical Practice23 questions20%Advocacy/Moral AgencyCaring PracticesResponse to DiversityFacilitation of LearningCollaborationSystems ThinkingClinical InquiryQuestions roughly equal in weight forthis 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, CCRNxiiINTRODUCTION TO THE CCRN EXAM

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Critical Care OverviewThis chapter includes catheter line access, hemodynamic monitoring, advancedelectrocardiogram (ECG) interpretation, mechanical intubation, and sedation.These sections influence a variety of topic areas in this book and on the CCRNexam. By mastering these areas first, you will have a better idea of how the humanbody compensates or corrects issues visible to us through monitoring. Whether apatient has perforated the bowel, is experiencing a myocardial infarction, or has asevere allergic reaction, the data we assess is likely to show acute changes. Manyquestions on the CCRN exam will proceed assuming you know how to interpret allforms of hemodynamic information.Catheter Line AccessThere 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 requirespecialized training and care. Peripheral lines are covered in more detail inChapter 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 11

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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 CLABSIArterial 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 badconnections)■Underdamped: abnormally high reading (typically faulty set-up ortransducer)■Risks■Vasospasms during insertion➞utilize lidocaine■Limb ischemia due to loss of collateral blood flow; always perform Allen’s testto confirm adequate collateral blood flow.Pulmonary Artery Catheter (PAC)■Catheter locations■Pulmonary artery—the nurse may assist in the placement and be asked toinflate and deflate the balloon as the placement advances (see Figure 1-1)■Commonly called aSwan-Ganzcatheter■Clinical applications■Diagnostic assessmentⓦPulmonary pressureⓦWedge pressures; read from the a-wave (little hill in the valley)■SvO2(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 placement2McGRAW-HILL EDUCATION CCRN REVIEW

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■Catheter migration—it may slip out of position, monitor the waveform forchanges■Thrombosis formation—typically at the catheter tip. Never force flush.■Pulmonary artery rupture (overinflated wedge)➞never remove the balloonsyringe from the portFigure 1-1Placement of PA Catheter: Pressure Analysis3020100Pressure (mmHg)Right AtriumRight VentriclePulmonary ArteryRARVLVLAPAARARVLVLAPAARARVLVLAPAARARVLVLAPAAPulmonary Artery WedgeDialysis LinesDialysis catheters are covered in more detail in Chapter 6, “Renal.”Hemodynamic MonitoringOn the CCRN exam, hemodynamic monitoring is included in questions forcardiovascular, pulmonary, and multisystem sections. It is most likely to arise inthe cardiovascular section given the sheer number of questions in that test area.I have placed hemodynamic monitoring first in this book because of the vastimportance to a number of critical care concepts.CHAPTER 1■CRITICAL CARE OVERVIEW3

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Vital Signs/Hemodynamic NumbersAs a refresher, the following information shows vital signs and the generalbenchmarks. Changes occur to vital signs for a number of reasons. Aside from thedisease process, vital signs may change due to treatments, medications, procedures,and complications. Being able to recognize an acute change from normal isessential. Advanced certification requires advanced reasoning. Luckily for you, theCCRN exam does not require you to memorize formulas for deducing numbers(mean arterial pressure [MAP], systemic vascular resistance [SVR], etc.), but you doneed 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 meanarterial pressure and perfusion■MAP less than 60 often suggests a state of shockⓦAssess urine output➞beginning of Multi-Organ DysfunctionSyndrome (MODS)■Heart rate (HR)■Reflex tachycardia: tachycardia onset when blood pressure is low or a patientis 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 volumeTable 1-1Quick A&P ReviewBLOOD PRESSURE REGULATIONBaroreceptors•Aortic arch and carotid sinus•Artery walls stretch➞vasodilation, decreasein HR (vagus nerve)•Artery walls withdraw➞vasoconstriction,increase in HRChemoreceptors•Aortic arch and carotid sinus•O2and CO2sensitive•Decrease in oxygen➞increase in HR andvasoconstriction (not in heart and brain)•Hydrogen ion (H+) sensitiveRenin–Angiotensin–Aldosterone System(RAAS)•Renal blood flow regulates•Decrease in kidney perfusion➞reninsecretion•Na+and H20 retention•Vasoconstriction4McGRAW-HILL EDUCATION CCRN REVIEW

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Cardiac Output (CO)/IndexThe amount of blood being pumped out of the heart will directly influence anumber of processes. This is why CO is enormously important. Many factorsinfluence CO, but the simplest way to understand CO is through the followingequation: CO = HR × stroke volume (SV). Stroke volume equals the amount ofblood 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 bodysurface area (BSA): CI = CO/BSAStroke VolumeChanges to stroke volume affect a multitude of critical care areas—most noticeably,the cardiovascular system. What is the causative factor for a changing strokevolume? 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 worseningright-sided compliance■Pulmonary artery occlusion pressure (PAOP) is sometimes used when“wedging” the balloon on a PA catheter. It may show overall pressure from theleft side of the heart➞left-sided heart failure.■Increasing preload may lead to ventricular failure and cardiomyopathyContractility■The squeeze (contraction) of the heart■Often manipulated via medications (inotropes)Afterload■The force with which the left ventricle must overcome to open valves andeject blood■Systemic vascular resistance (SVR) affects left ventricle afterload■Pulmonary vascular resistance (PVR) affects right ventricle afterloadTreatments for HemodynamicsTo be able to treat an abnormal hemodynamic value, you must first understandwhat normal is. Below are a series of treatment modalities for commonly seenabnormal hemodynamics.Low Preload■Patient may be hypovolemic (dehydrated)■Often the first intervention to correct low BP issuesCHAPTER 1■CRITICAL CARE OVERVIEW5

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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 ofbumetanide may be used to prevent rapid changes in fluid volume■In severely unstable patients who cannot tolerate even slight changes tovolume status, continuous renal replacement therapy (CRRT) or continuousveno-venous hemofiltration (CVVH) may be usedLow 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 oroverly effective treatment. It is possible the primary treatment simply needs tobe 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) ormetabolic issues (hyperthyroidism)■Not typically dangerous unless sustained for long periods of time6McGRAW-HILL EDUCATION CCRN REVIEW

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■Administer■Beta blockers■Calcium-channel blockers■Fix the underlying problem (nervous system, metabolic pathways)Hemodynamic ValuesLearning all the key hemodynamic areas can certainly be tricky. Even more difficultis understanding what each direction may mean when one goes up or down. Beginwith learning the normal hemodynamic ranges. To reiterate, Table 1-2 shows themost important hemodynamic numbers. The individual chapters of this book willexplain why a certain hemodynamic change may happen due to a disease or disorder.Table 1-2Hemodynamic ValuesHEMODYNAMIC/OXYGENATION VALUENORMAL PARAMETERMean arterial pressure (MAP)70–110 mmHg•<60 mmHg considered shock (check urineoutput)Cardiac output (CO)4–8 L/minCardiac index (CI)2.5–4.0 L/min/m2Stroke volume (SV)50–100 mL/beatStroke index25–45 mL/beat/m2Central venous pressure (CVP)Right atrial pressure (RAP)2–6 mmHgPulmonary artery pressure15–30 mmHg (systolic)2–8 mmHg (diastolic)Pulmonary artery wedge pressure (PAWP)Pulmonary artery occlusion pressure (PAOP)6–12 mmHgSystemic vascular resistance (SVR)800–1200 dynes/s/cm–5Pulmonary vascular resistance (PVR)50–250 dynes/s/cm–5Mixed venous oxygen saturation (SvO2)60–75%Central venous oxygen saturation (ScvO2)Greater than 70%Arterial oxygen saturation (SaO2)95–99% (room air)•Do not confuse with PaO2on arterial bloodgasesOxygenation MonitoringBy monitoring oxygenation throughout the body, the nurse may evaluate currentlevels, delivery, and consumption necessary for metabolic function. Changes inpatient condition or evaluation of treatments may be assessed through monitoringoxygenation levels. These concepts are applied more specifically in the pulmonarychapter.CHAPTER 1■CRITICAL CARE OVERVIEW7

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■Mixed venous oxygen saturation (SvO2)■The amount of oxygen on hemoglobin returning to the lungs■Normal: 60% to 75%ⓦLow: body using more oxygen (infection, low cardiac output, low SaO2,anemia)ⓦHigh: body using less oxygen (late septic shock, hypothermia)■Central venous oxygen saturation (ScvO2)■The amount of oxygen on hemoglobin returning to central access (IJ orsubclavian line)■Normal: greater than 70%■Low or high for same reasons as SvO2■End-tidal carbon dioxide (EtCO2)■The amount of partial pressure carbon dioxide at the end of exhalation■Capnography■Normal: 35 to 45 mmHg■Elevation of EtCO2displays retention and hypoventilation■Confirmation of endotracheal tube placement (colorimeter)■Assessment of CPR effectiveness■Oxygen consumption (VO2)■Normal: 250 to 350 mL/min■Consumption is low in septic shock■Oxygen delivery (DO2)■Normal: 900 to 1100 mL/min■Delivery is low in poor cardiac functionAdvanced ECG InterpretationOne of the most difficult skills to master is the ability to read an ECG quickly, if atall. Many people struggle with being able to distinguish certain rhythms, especiallysince many of these rhythms may look similar. Supraventricular tachycardia maylook a lot like atrial fibrillation with rapid ventricular response. The CCRN examdoes not always have an ECG strip to analyze, so understand interventions for therhythms and the full clinical picture. Certain things do pop up more often on theexam, such as pacing, QT prolongation, torsades, and implantable cardioverter-defibrillators (ICDs). Note that the exam assumes you understand advancedcardiovascular life support (ACLS) protocol and the basics of a code blue.Applying LeadsBefore 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 wherea reverse (right-sided) ECG may be requested by the physician. This is typicallyduring a right-sided myocardial infarction. Remember the basic landmarks utilizedwhen placing leads: the midclavicular line, mid-axillary line, and the ability tocount intercostal spaces effectively.8McGRAW-HILL EDUCATION CCRN REVIEW

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■3-lead ECG requires three bipolar leads: right arm, left arm, and left leg. Itprovides one angle of view on the heart.■5-lead ECG requires all four bipolar leads on the limbs. It also includes oneprecordial (unipolar) lead. The precordial lead is typically placed at the V1position, 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 leadsare placed in the same V1through V6position, but mirrored or reversed:■V1: fourth intercostal, right sternal border■V2: fourth intercostal, left sternal border■V3: halfway between V2and V4■V4: fifth intercostal, left midclavicular line■V5: fifth intercostal, left anterior axillary line■V6: fifth intercostal, left mid-axillary lineECG InterpretationIdentifying a rhythm and how to react in each scenario is detailed next. A commonstrategy 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” waveswith the corresponding skinny “QRS” complex and “T” wave.CHAPTER 1■CRITICAL CARE OVERVIEW9

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Sinus TachycardiaCCRNFigure# 01.02Dragonfly Media Group10/05/20Interpretation■100 BPM or moreCauses■Reflex tachycardia (hypovolemia, hypoxia)■Stimulants (caffeine, drugs or medications, etc.)■Pain or fear■Hypoglycemia■HyperthyroidismSigns 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 blockerSinus BradycardiaInterpretation■59 BPM or less10McGRAW-HILL EDUCATION CCRN REVIEW

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Causes■Hypothyroidism■Depressant medications■Alcohol■Benzodiazepines■Opioids■Professional athletesSigns 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 BPMCauses■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 OVERVIEW11

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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 conditionwarrants 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 moreCauses■Same as atrial fibrillation without RVRSigns 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 conditionwarrants and nothing else has worked■Catheter ablation (maze procedure)12McGRAW-HILL EDUCATION CCRN REVIEW

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Atrial FlutterCCRNFigure# 01.07Dragonfly Media Group10/05/20Atrial flutter has similar causes, signs and symptoms, and interventions to atrialfibrillation. It is typically spoken about in reference to the AV conduction. Theabove 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 aroundthe atria at a fast rate. One of the easiest ways to differentiate between a sinustachycardia and an SVT is by simply identifying the rate. Anything above 150 isfairly indicative of an SVT. This cannot be confirmed, however, without an ECG.Interpretation■150 BPM or higher■Skinny “QRS” complexesCauses■Often paroxysmal■Atrial fibrillation or atrial flutter■Wolff-Parkinson-White syndromeSigns and Symptoms■Palpitations■Fatigue and shortness of breath■Loss of blood pressure➞unconsciousCCRN TipWolf-Parkinson-White syndrome is anelectrical conductiondisorder. It typicallyleads to abnormallyhigh heart rates with orwithout symptoms andmay be diagnosed viashort PR intervals andcharacteristic “delta”waves. If the conditionis serious enough,radiofrequencyablation may berequired.CHAPTER 1■CRITICAL CARE OVERVIEW13

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Interventions■Valsalva maneuver■Adenosine (crash cart needed nearby)■Cardioversion■AblationPreventricular Contractions (PVCs)Interpretation■Wide “QRS” complexesCauses■Myocardial damage (MI)■Electrolyte imbalances (potassium, magnesium, calcium)■Stress and stimulantsSigns and Symptoms■Oftentimes none■Feeling of skipped heartbeatInterventions■Telemetry monitoring■Treat underlying problem■Review chemistry panel■Medications (amiodarone IV, lidocaine IV)Intrinsic AutomaticityThe underlyingconduction system is fairlystraightforward. Rhythmswith a BPM above theintrinsic rate are typicallycalled “accelerated.” Ifthey are signifi cantlyhigher, the rhythm is called“tachycardia.”• SA node: 60 to 100 BPM• AV node: 40 to 60 BPM• Purkinje fibers: 20 to40 BPM14McGRAW-HILL EDUCATION CCRN REVIEW

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Idioventricular RhythmCCRNFigure# 01.10Dragonfly Media Group10/05/20Interpretation■Wide “QRS” complexesCauses■Diseases (infection, anemia)■Drug toxicity■Electrolyte imbalances■Post reperfusion: this rhythm may be noticed transiently in ICU (acceleratedidiopathic ventricular rhythm [AIVR])Signs and Symptoms■Often none (asymptomatic)■Hypotension causing dizziness (symptomatic)Interventions■Treat the underlying problem■Atropine■Amiodarone or lidocaine■PacingVentricular Tachycardia (VT aka V-Tach)Interpretation■Wide “QRS” complexes■Typically 170 BPM or moreCHAPTER 1■CRITICAL CARE OVERVIEW15

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Causes■Myocardial damage (MI)■Hypotension/hypovolemia■H’s and T’sSigns 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 PEATorsades de PointeInterpretation■Drastic variety of “QRS” complexesCauses■Hypomagnesemia■QT prolongationSigns and Symptoms■Same as ventricular tachycardiaInterventions■ACLS protocol■Magnesium sulfate■Treat the underlying problemCCRN TipQT prolongationoften occurs due tomedications such ashaloperidol or otherantipsychotics. Someantibiotics and digitalistoxicity may also leadto QT prolongation.Less common causesare electrolyteimbalances.16McGRAW-HILL EDUCATION CCRN REVIEW

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Ventricular Fibrillation (VF aka V-Fib)CCRNFigure# 01.13Dragonfly Media Group10/05/20Interpretation■Quivering or fibrillating wavesCauses■H’s and T’sSigns and Symptoms■Pulseless■Loss of blood pressure■UnconsciousInterventions■Code blue■ACLS protocolAsystoleInterpretation■Flat lineCauses■H’s and T’sSigns and Symptoms■Pulseless■Loss of blood pressure■UnconsciousCCRN TipAny loss of perfusion tothe brain longer than5 minutesmay lead tobrain damage.CHAPTER 1■CRITICAL CARE OVERVIEW17

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