Monday, December 26, 2011

NANDA Nursing Diagnoses - Definitions and Classification, 2012-2014 Book Info


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A nursing diagnosis is defined as a clinical judgment about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (NANDA-I, 2009). Accurate and valid nursing diagnoses guide the selection of interventions that are likely to produce the desired treatment effects and determine nurse-sensitive outcomes. Nursing diagnoses are seen as key to the future of evidence-based, professionally-led nursing care and to more effectively meeting the need of patients. In an era of increasing electronic patient health records, standardized nursing terminologies such as NANDA-I, NIC and NOC provide a means of collecting nursing data that are systematically analysed within and across healthcare organizations and provide essential data for cost/benefit analysis and clinical audit. Nursing Diagnoses: Definitions and Classification is the definitive guide to nursing diagnoses, as reviewed and approved by NANDA-I. Each nursing diagnoses undergoes a rigorous assessment process by NANDA-I's Diagnosis Development Committee, with stringent criteria used to indicate the strength of the underlying level of evidence. Each diagnosis comprises a label or name for the diagnosis, a definition, defining characteristics, risk factors and/or related factors. Many diagnoses are further qualified by terms such as risk for, effective, ineffective, impaired, imbalanced, self-care deficit, readiness for, disturbed, decreased, etc. The 2012-2014 edition is arranged by concept according to Taxonomy II domains, i.e. Health promotion, Nutrition, Elimination and exchange, Activity/Rest, Perception/Cognition, Self-perception, Role relationships, Sexuality, Coping/ Stress tolerance, Life principles, Safety/protection, Comfort, and Growth/development. The 2012-2014 edition contains revised chapters on NANDA-I taxonomy, and slotting of diagnoses into NANDA & NNN taxonomies, diagnostic reasoning & conceptual clarity, and submission of new/revised diagnoses. New chapters are provided on the use of nursing diagnoses in education, clinical practice, electronic health records, nursing & health care administration, and research . A companion website hosts related resources. Key features 2012-2014 edition arranged by concepts Core references and level of evidence for each diagnosis 16 new diagnoses 8 revised diagnoses Aimed at students, educators, clinicians, nurse administrators and informaticians Companion website available 

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Tuesday, November 22, 2011

Chinese Nutrition Therapy PDF


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The basic principles of Traditional Chinese Medicine
(TCM) are rooted in the Taoist philosophy of
yin and yang. These two polar opposites organize
and explain the ongoing process of natural change
and transformation in the universe.
According to ancient lore, yang marks the sunny
side and yin the shady side of a hill. In the theory of
yin and yang, all things and phenomena of the
cosmos contain these two complementary
aspects. The traditional Taoist symbol for completeness
and harmony is the merging monad of
yin and yang.
The standard of TCM, the Huang Di Nei Jing, “The
Yellow Emperor’s Classic of Medicine,” dates as far
back as 500–300 BC. This 18-volume classic work
has two parts, Ling Shu and Su We. The Su Wen
explains the theoretical foundations of TCM in the
form of a dialogue between the legendary Yellow
Emperor Huan Di and his personal physician Shi
Po.
The Ling Shu, the practical part of the Nei Jing,
reports on therapies and their uses in TCM: acupuncture,
moxibustion, nutritional therapy, and
the use of medicinal herbs.
TCM is rooted in the Taoist worldview employed
by physicians and philosophers for centuries as a
guide for viewing and interpreting natural phenomena.
Tao means harmony–destination–way, the “all-inone,”
the origin of the world. The teachings of Taoism
are based on the work Tao te King (Tao te
Ching), “The Book of theWay and of Virtue,” by the
famous Chinese scholar Lao Tse (600 BC).
Guided by the Taoist perspective, “natural scientists”
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took the findings of these observations of
nature and applied them to humans. They
regarded the human being as a natural being, a
part of nature, subject to and dependent on
nature’s processes.
The main principle of Tao is represented by the
two polarities yin and yang, which, according to
Taoist belief, mirror all phenomena in the universe.

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Wednesday, November 9, 2011

Clinical Drug Therapy: Rationales for Nursing Practice PDF


Introduction to Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1 Introduction to Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
A Message to Students 2
Overview 2
Sources of Drugs 3
Drug Classifications and Prototypes 3
Drug Names 3
Drug Marketing 3
Pharmacoeconomics 4
Prescription and Nonprescription Drugs 4
Drug Approval Processes 4
Sources of Drug Information 7
Strategies for Studying Pharmacology 7
2 Basic Concepts and Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Overview 9
Cellular Physiology 9
Drug Transport Through Cell Membranes 10
Pharmacokinetics 10
Pharmacodynamics 15
Variables That Affect Drug Actions 17
Tolerance and Cross-Tolerance 20
Adverse Effects of Drugs 20
3 Administering Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Overview 29
General Principles of Accurate Drug Administration 29
Legal Responsibilities 30
Medication Errors 30
Medication Systems 31
Medication Orders 31
Drug Preparations and Dosage Forms 32
Calculating Drug Dosages 34
Routes of Administration 35
4 Nursing Process in Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Overview 47
Nursing Process in Drug Therapy 48
Integrating Nursing Process, Critical Paths and Drug Therapy 51
General Principles of Drug Therapy 59
xvii
xviii CONTENTS
SECTION 2
Drugs Affecting the Central Nervous System . . . . . . . . . . . 71
SECTION 3
Drugs Affecting the Autonomic Nervous System . . . . . . 260
SECTION 4
Drugs Affecting the Endocrine System . . . . . . . . . . . . . . . . . 320
SECTION 5
Nutrients, Fluids, and Electrolytes . . . . . . . . . . . . . . . . . . . . . . 433
SECTION 6
Drugs Used to Treat Infections . . . . . . . . . . . . . . . . . . . . . . . . . . 493
SECTION 7
Drugs Affecting Hematopoiesis and
the Immune System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627
SECTION 8
Drugs Affecting the Respiratory System . . . . . . . . . . . . . . . 693
SECTION 9
Drugs Affecting the Cardiovascular System . . . . . . . . . . . 738
SECTION 10
Drugs Affecting the Digestive System . . . . . . . . . . . . . . . . . . . 863
SECTION 11
Drugs Used in Special Conditions . . . . . . . . . . . . . . . . . . . . . . . 912 

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Tuesday, November 1, 2011

Holistic Nursing Ebook PDF


Holistic nursing is a medical specialty that takes the entire being of the patient into consideration, rather than just diagnosing specific physical symptoms. Holistic nurses often recommend complementary medical treatments to assist patients in attaining better health. The nurse becomes a partner with patients by forging interpersonal and lasting relationships. Nurses who are trained in holistic healthcare practices often work in hospice settings and long-term care facilities.
Florence Nightingale (1820-1910) is said to be one of the first acknowledged holistic nurses. She was known as “The Lady of the Lamp” because she brought comforting light and a gentle smile to war-wounded soldiers. As a nurse, she was efficient and thorough, but she also treated each patient as an individual whose personal needs mattered -- the definition of a holistic nurse.
Holistic nursing should not be considered an alternative to modern medicine, but rather an adjunct for improved health care. The holistic nurse is a degreed professional registered nurse (RN) or licensed practical nurse (LPN), with an additional education in holistic nursing, usually a certificate or a degree. In addition to assessing the patient’s physical condition, holistic nurses will review the patient’s history and immediate environment. They may inquire about stress levels, family relationships, work history, upbringing, religious affiliation, and any other aspect that might affect the patient’s life.
When used as a complement to traditional medicine, holistic nursing can include several alternative healthcare treatments, depending on the specific malady. The patient is carefully evaluated and the nurse recommends a particular combination of treatments. Holistic healthcare practices include aromatherapy, shiatsu massage, yoga, neuro-linguistic programming (NLP), meditation, hypnotherapy, energy healing, and many other modalities.
Nutrition and body cleansing play an important part in holistic nursing. Macrobiotic diets and food combining may be prescribed, sometimes in combination with hydrotherapy (water therapy). The patient may be encouraged to partake in a nutritious diet to help flush harmful toxins from the body and increase energy levels. Additionally, holistic nurses will sometimes practice colonic hydrotherapy, also known as high colonics, where toxins are flushed from the bowels with injections of water.
Many hospitals and clinics employ holistic nurses. They provide patients with human caring and a respect for their personal dignity that is sometimes lacking elsewhere in the healthcare industry. Holistic nursing can be especially effective with terminally ill and long-term patients. The nurses form a personal bond that also extends to the patient’s family and friends to help ease the stress caused by illness. Holistic nursing offers a welcome alternative view of healthcare along with excellent, traditional nursing care.
source: wisegeek.com
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Wednesday, October 19, 2011

THE CARE OF WOUNDS A GUIDE FOR NURSES PDF





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Ebook Content :
Chapter 1 The Physiology of Wound Healing 1
1.1 Introduction 1
1.2 Definitions associated with wounds 1
1.3 The structure of the skin 2
1.3.1 Dermis 2
1.3.2 Epidermis 2
1.4 Wound healing 3
1.4.1 Inflammation 4
1.4.2 Reconstruction 6
1.4.3 Epithelialisation 8
1.4.4 Maturation 9
1.5 Impaired wound healing 9
1.5.1 Hypertrophic scars 9
1.5.2 Keloids 10
1.5.3 Contractures 10
1.5.4 Acute to chronic wounds 10
1.6 Conclusion 11
Chapter 2 The Management of Patients with Wounds 13
2.1 Introduction 13
2.2 Physical care 13
2.2.1 Nutrition 13
2.2.2 Infection 19
2.2.3 Smoking 23
2.2.4 Diabetes mellitus 25
2.2.5 They physical effects of stress 26
2.2.6 Pain 27
2.2.7 Sleeping 30
2.2.8 Hypothermia 32
2.2.9 Steroids 33
2.2.10 Radiotherapy 34
2.3 Psychological care 35
2.3.1 Anxiety 35
2.3.2 Motivation and education 37
2.3.3 Body image 39
2.3.4 Other psychological problems 41
2.4 Spiritual care 43
Chapter 3 General Principles of Wound Management 56
3.1 Introduction 56
3.2 Wound assessment 56
3.2.1 Wound classification 56
3.2.2 The position of the wound 57
3.2.3 The environment of care 58
3.2.4 M = measure 58
3.2.5 E = exudate 61
3.2.6 A = appearance 62
3.2.7 S = suffering 69
3.2.8 U = undermining 70
3.2.9 R = re-evaluate 70
3.2.10 E = edge 71
3.3 Managing wounds 72
3.3.1 Moist wound healing 72
3.3.2 Wound bed preparation 72
3.3.3 Pain management 76
3.4 Documentation 77
3.5 Evaluating the dressing 78
Chapter 4 Wound Management Products 83
4.1 Introduction 83
4.2 The development of dressings through the ages 83
4.2.1 Early days 83
4.2.2 The Dark Ages and early Middle Ages 85
4.2.3 Late Middle Ages and Renaissance 86
4.2.4 The seventeenth, eighteenth and early nineteenth centuries 87
4.2.5 Mid-nineteenth and early twentieth century developments 88
4.2.6 The British Pharmaceutical Codices 89
4.3 Traditional techniques 90
4.4 The use of lotions 91
4.4.1 Antiseptics 91
4.4.2 Antibiotics 95
4.4.3 Honey 96
4.4.4 Saline 0.9% 97
4.4.5 Tap water 97
4.5 Clinical effectiveness of wound management products 97
4.5.1 Providing an effective environment 97
4.5.2 The handling qualities of an effective wound
management product 98
4.6 Modern wound management products 99
4.7 Advanced technologies 105
4.7.1 Growth factors 105
4.7.2 Protease-modulating wound management products 105
4.7.3 Hyaluronan-based products 106
4.7.4 Hyperbaric oxygen 107
iv The Care of Wounds
4.7.5 Topical negative pressure 108
4.7.6 Tissue culture 110
4.7.7 Tissue engineering 110
4.8 Alternative therapies and wound management 112
Chapter 5 The Management of Patients with Chronic Wounds 121
5.1 Introduction 121
5.2 The prevention and management of pressure ulcers 121
5.2.1 The cost of pressure ulcers 122
5.2.2 The aetiology of pressure ulcers 123
5.2.3 Prevention of pressure ulcers 128
5.2.4 Management of pressure ulcers 138
5.3 The management of leg ulcers 143
5.3.1 The epidemiology of leg ulcers 144
5.3.2 The cost of leg ulcers 144
5.3.3 The causes of leg ulcers 145
5.3.4 Venous ulceration 145
5.3.5 Arterial ulcers 152
5.3.6 Ulcers of mixed aetiology 155
5.3.7 Malignant leg ulcers 156
5.3.8 Leg ulceration in rheumatoid arthritis 157
5.4 Diabetic foot ulcers 158
5.4.1 Aetiology 158
5.4.2 Prevention 159
5.4.3 Management 160
5.5 Fungating wounds 162
5.5.1 Aetiology and incidence 163
5.5.2 Management of fungating wounds 163
5.6 Lymphoedema 165
5.6.1 Lymphoedema management 166
5.7 Conclusion 168
Chapter 6 The Management of Patients with Acute Wounds 179
6.1 Introduction 179
6.2 The care of surgical wounds 179
6.2.1 Management of surgical wounds 179
6.2.2 Managing complications 186
6.3 Traumatic wounds 194
6.3.1 Minor traumatic wounds 194
6.3.2 The management of specific types of traumatic wounds 196
6.4 The burn injury 199
6.4.1 Aetiology 200
6.4.2 Incidence 201
6.4.3 The severity of the injury 201
6.4.4 Burn oedema 203
6.4.5 First aid treatment of burns 203
6.4.6 The management of burn injuries 205
Contents v
6.5 Radiation reactions 209
6.5.1 Aetiology 210
6.5.2 The classification of radiation reactions 210
6.5.3 Preventive skin care 210
6.5.4 Managing radiation reactions 211
6.5.5 Care of the patient 212
Chapter 7 Clinically Effective Wound Care 218
7.1 Introduction 218
7.2 Evidence-based practice and clinical effectiveness 218
7.3 Searching and appraising the literature 218
7.3.1 Appraising the literature on wound care 221
7.4 Developing clinical guidelines 222
7.4.1 Guidelines in wound care 222
7.5 The clinical audit cycle 224
7.5.1 Auditing clinical practice 224
7.5.2 Dissemination of audit findings 225
7.6 Conclusions 225
Chapter 8 The Organisation of Wound Management 228
8.1 Introduction 228
8.1 Managing wounds in the community 228
8.2.1 Nurse prescribing 228
8.2.2 Community leg ulcer clinics 229
8.3 Nurse specialists in wound care 230
8.4 The management of pressure-redistributing equipment 232
8.4.1 Equipment stores 232
8.4.2 Total bed management 232
8.5 Wound-healing centres 233
8.6 Conclusions 234
Index 236

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NCLEX-RN Notes PDF

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NCLEX-RN®

The National Council Licensure Examination for registered nurses
(NCLEX-RN®) measures the knowledge and abilities necessary for entrylevel
nurses.
■ It is administered by Computer Adaptive Testing (CAT), which
individualizes tests to match the unique competencies of each test taker.
■ Each exam adheres to the NCLEX-RN® Test Plan, which describes the
content and scope of RN competencies.
■ Practices basic to nursing (e.g., nursing process, caring, teaching,
learning, communication, documentation) are integrated throughout,
and most questions require application and analysis of information.

NCLEX-RN® Test Plan—Distribution of Content
Safe and Effective Care Environment
■ Management of Care 13%–19%
■ Safety/Infection Control 8%–14%
Health Promotion and Maintenance 6%–12%
Psychosocial Integrity 6%–12%
Physiological Integrity
■ Basic Care/Comfort 6%–12%
■ Pharmacological/Parenteral gfd Therapies 13%–19%
■ Reduction of Risk Potential 13%–19%
■ Physiological Adaptation 11%–17%

Taking the NCLEX-RN® Test on a Computer
■ First: You will receive general information about the exam and the testing
center. Your time spent on this will not count.
■ Second: You will take a tutorial on how to use the computer to answer the
questions on NCLEX-RN®. Your answers will not count toward your score,
but the time you take will be subtracted from the total 6 hours you have
for the exam.
■ Third: You will then be presented with real NCLEX-RN® items; there will
be between 75 and 265 items. The test ends when it is 95% certain your
ability is ↑ or ↓ the passing standard.

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Thursday, October 13, 2011

IV Med Notes PDF

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Infusion Assessment

Primary infusion fluid—Fluid that is infusing continuously.
Secondary infusion—Fluid that is infusing intermittently, usually
in a 50-250 ml IV bag infusing over 15 minutes to 2 hours.
Patient-controlled analgesia (PCA) pump—Infuses pain medication
and is usually connected to the primary line. Both the
primary line and PCA pump infuse concurrently.
HOT TIP: When assessing the infusions to check for incompatibilities,
the PCA pump can easily be overlooked!! Verify
the type of medication in the PCA pump, and ensure it is
compatible.
Total parenteral nutrition (TPN)/Lipids—TPN usually infuses
continuously over 24 hours. Lipids usually infuse over 8, 10,
or 12 hours connected to the TPN IV line below the filter.
HOT TIP: Due to the additional components/medications in the
TPN solution, NO medication is to be given in the same line as
the TPN or the lipids.
Blood products—Include whole blood, packed red blood cells,
plasma, platelets, albumin, serum globulins.
HOT TIP: NEVER give any medication in the blood component
IV line. The only compatible solution is 0.9% normal saline

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Jones' Clinical Paediatric Surgery Diagnosis and Management PDF

Introduction, 1
1 Antenatal Diagnosis – Surgical Aspects, 3
2 The Care and Transport of the Newborn, 7
3 The Child in Hospital, 13

Neonatal Emergencies, 17
4 Respiratory Distress in the Newborn, 19
5 Diaphragmatic Hernia, 26
6 Oesophageal Atresia and Tracheo-Oesophageal Fistula, 30
7 Bowel Obstruction, 35
8 Abdominal Wall Defects, 44
9 Spina Bifi da, 49
10 Disorders of Sexual Development, 56
11 Anorectal Anomalies, 61

Head and Neck, 67
12 The Scalp, Skull and Brain, 69
13 The Eye, 79
14 The Ear, Nose and Throat, 91
15 Cleft Lip, Palate and Craniofacial Anomalies, 97
16 Abnormalities of the Neck and Face, 106

Abdomen, 115
17 The Umbilicus, 117
18 Vomiting in the First Months of Life, 121
19 Intussusception, 126
20 Abdominal Pain: Appendicitis?, 130
21 Recurrent Abdominal Pain, 136
22 Constipation, 139
23 Bleeding from the Alimentary Canal, 142
24 Infl ammatory Bowel Disease, 147
25 The Child with an Abdominal Mass, 153
26 Spleen, Pancreas and Biliary Tract, 157
27 Anus, Perineum and Female Genitalia, 162
28 Undescended Testes and Varicocele, 168
29 Inguinal Region and Acute Scrotum, 172
30 The Penis, 179

Urinary Tract, 185
31 Urinary Tract Infection, 187
32 Vesico-Ureteric Refl ux, 193
33 Urinary Tract Dilatation, 198
34 The Child with Wetting, 205
35 The Child with Haematuria, 211

Trauma, 215
36 Trauma in Childhood, 217
37 Head Injuries, 224
38 Abdominal and Thoracic Injuries, 231
39 Foreign Bodies, 236
40 The Ingestion of Corrosives, 241
41 Burns, 243

Orthopaedics, 247
42 Neonatal Orthopaedics, 249
43 Orthopaedics in the Infant and Toddler, 254
44 Orthopaedics in the Child, 259
45 Orthopaedics in the Teenager, 266
46 The Hand, 271

Chest, 275
47 The Breast, 277
48 Chest Wall Deformities, 279
49 Lungs, Pleura and Mediastinum, 283

Skin and Soft Tissues, 291
50 Vascular and Pigmented Naevi, 293
51 Soft Tissue Lumps, 298

Answers to Case Questions, 301
52 Answers to Case Questions, 303

Index, 311

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Users Guides to the Medical Literature A Manual for Evidence-Based Clinical Practice PDF

Completely revised and updated with all new coverage of the basic issues in evidence-based medicine in patient care

Abundant real-world examples drawn from the medical literature are woven throughout, and include important related principles and pitfalls in using clinical research in patient care decisions

Edited by over 60 internationally recognized editors and contributors from around the globe

Also look for JAMAevidence.com, a new interactive database for the best practice of evidence based medicine


Includes:

1. How to Use the Medical Literature–and This Book–to Improve Your Patient Care
2. The Philosophy of Evidence-Based Medicine
3. What Is the Question?
4. Finding the Evidence
5. Why Study Results Mislead: Bias and Random Error
6. Therapy (Randomized Trials)
7. Does Treatment Lower Risk? Understanding the Results
8. Confidence Intervals
9. Harm (Observational Studies)
10. The Process of Diagnosis
11. Differential Diagnosis
12. Diagnostic Tests
13. Prognosis
14. Summarizing the Evidence
15. How to Use a Patient Management Recommendation
Glossary

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Wednesday, October 12, 2011

ECG and arrhythmia classification


ECG and arrhythmia classification :

Narrow complex arrhythmias (arise above bifurcation of the bundle of His) – QRS duration <0.1s (2.5 small squares)
Broad complex arrhythmias (arise from ventricles or are conducted abnormally from a site above the ventricles so that a delay occurs (rarer). QRS duration is >0.1s (2.5 small squares).

Narrow complex arrhythmias

·         Sinus arrhythmia
·         Sinus tachycardia
·         Sinus bradycardia
·         Junctional tachycardia
·         Atrial tachycardia, Atrial flutter
·         Atrial fibrillation
·         Atrial ectopics

Broad complex arrhythmias

·         Ventricular ectopics
·         Ventricular tachycardia
·         Supraventricular tachycardia with BBB
·         Ventricular fibrillation

NARROW COMPLEX ARRHYTHMIAS:
Sinus arrhythmia: Irregular spacing of normal complexes associated with respiration. The P-R interval is constant, but there are beat-to-beat changes in R-R interval. Normal, especially in young people.
- Because in inspiration, the negative pressure sucks more blood into the chest, which ­ cardiac output. This is detected by baroreceptors which ­ HR).




Sinus tachycardia: Rate over 100bpm. Normal P-QRS-T complexes are present.
Causes include:
·         Pain
·         Fever/sepsis
·         Hypovolemia
·         Anaemia
·         Heart failure
·         Thyrotoxicosis
·         Drugs – atropine, ether, ketamine, catecholamines

Management – correction of underlying disease.
·         b-blockers if tachycardia causes myocardial ischemia in patient with IHD

Sinus bradycardia: Heart rate of <60bpm. May be normal in athletic people, or with increased vagal tone.
Causes:
·         Drugs - b-blockers, digoxin, anticholinesterase drugs, halothane
·         MI
·         Sick sinus syndrome (fibrosis of AV node)
·         Raised intracranial pressure
·         Hypothyroidism
·         Hypothermia

Management: Often not necessary in a fit young person (unless rate is <45-50bpm) and/or there is haemodynamic compromise. You may consider:
·         Correct underlying cause
·         Atropine

Arrhythmias due to re-entry

·         Where there is anatomical branching and re-joining of a conduction pathway.
·         If one limb is slower than the other, the impulse may pass normally down one limb but be blocked in the other. Where the pathways rejoin, the impulse can then spread backwards up the abnormal pathway. If it arrives at a time when the first pathway is no longer refractory to activation, it can pass right around the circuit repeatedly, activating it and resulting in tachycardia

·         Wolf-Parkinson-White syndrome (anatomical “accessory” pathway between the atria and ventricles) “Macro-reentry circuit” (Other macro re-entry circuits can exist in the atrial/ventricular myocardium and cause paroxysmal atrial flutter, AF, ventricular tachycardia).

·         In Junctional tachycardia, there are “micro re-entry” circuits within the AV node itself

Junctional tachycardia: Micro re-entry circuits in or near the AV node (or, as in W-P-W, from an accessory conduction pathway between the atria and ventricles).

·         Narrow complex tachycardia with rate of 150-200bpm
·         SHORT P-R
·         Slurred upstroke on the R wave (Delta wave in V4 in WPW)
·         Inverted T waves in V2-5 are characteristic

Management: This arrhythmia may be associated with severe circulatory disturbance
·         If they are haemodynamically compromised -cardioversion
·         Carotid sinus massage (rarely converts to sinus rhythm, but slows the rate and will reveal the underlying rhythm if in doubt) (helps differentiate from atrial flutter/AF)
o    The carotid sinus is a small dilatation of the proximal part of the internal carotid artery at the level of the superior border of the thyroid cartilage. It is vagally innervated and is involved in the control mechanism for causing a fall in HR and CO in response to rise in arterial pressure. Gentle pressure here may result in slowing of the heart and occasionally, termination of re-entry SVT. Never do on both sides or it can cause asystole and occlusion of the main arterial blood supply to the brain.
·         Adenosine (slows AV conduction so is useful for terminating re-entry SVTs of the WPW type)
·         Verapamil, b-blockers, amiodarone, flecainide may control the rate of convert to sinus rhythm

Atrial tachycardia and Atrial flutter: Due to an ectopic focus depolarising from anywhere within the atria. They contract faster than 150bmp and P waves can be seen superimposed on T waves of the preceding beats.
·         AV node conducts at a maximum of 200bpm, so if the atrial rate is faster, AV block will occur (Typically see ventricular rate as 150bpm with atrial flutter)
·         If the atrial rate is >250bpm, there is no flat baseline between P waves and you get “sawtooth” pattern
·         Can occur with any type of block (2:1, 3:1, 4:1)
·         Atrial tachycardia is typically a paroxysmal arrhythmia with intermittent tachycardia and palpitations (may be precipitated by many factors – stress, alcohol, caffeine)
o    With 2:1 block = characteristic of digitalis toxicity

Management: Very sensitive to direct current cardioversion (almost 100% success rate), so should be used first line if there is haemodynamic compromise
·         Carotid sinus massage and adenosine ® slow AV conduction and reveal underlying rhythm and block if there is doubt
·         Other drug treatment as for AF

Atrial fibrillation: Very common. It is a chaotic and uncoordinated atrial depolarisation (absence of P waves), with an irregular baseline and completely irregular ventricular rate. The ventricular response rate will normally be rapid – about 120-200 bpm.
Common causes:
·         Ischaemia
·         Myocardial disease/pericardial disease
·         Mitral valve disease
·         Sepsis
·         Electrolyte disturbance (esp. Hypokalaemia or hypomagnesaemia)
·         Thyrotoxicosis
·         Thoracic surgery

Since contraction of the atria contributes 30% to ventricular filling, the onset of AF may result in significant ¯ in CO. Fast AF may precipitate cardiac failure, pulmonary oedema and myocardial ischaemia and systemic thromboembolism may occur if blood clots in the fibrillating atria form.

Management: Treatment is aimed at restoration of sinus rhythm if possible and if not, maintaining the rate to <100bpm and prevention of embolic complications. Management depends on how long it has been present.
Acute:
·         Correct precipitating factors where possible
·         DC cardioversion (for recent onset)
·         Digoxin – to slow ventricular rate
·         Amiodarone – to restore sinus rhythm
·         Verapamil – control ventricular rate
·         b-blockers – sometimes used to control ventricular rate
Chronic:
·         Aim to control ventricular rate to <100bpm – allows time for adequate ventricle filling and maintains CO
·         Digitalisation
·         b-blockers of verapamil
·         Amiodarone

When AF has been present for more than a few hours, anticoagulation is necessary before cardioversion to prevent the risk of embolisation. (Usually warfarin for 3 weeks prior to elective DCC)

Atrial ectopic beats: An abnormal P wave is followed by a normal QRS. The P wave is not always easily visible
·         “Ectopic” indicates that depolarisation originated in an abnormal place – get an abnormally shaped P wave
·         If the focus depolarises EARLY, the beat produced is an extrasystole (premature) and may be followed by a compensatory pause
·         If the underlying SA node is slow, sometimes an atrial focus takes over – escape beat as it occurs after a SMALL DELAY
Causes:
·         Any heart disease
·         Ischaemia, hypoxia
·         Light anaesthesia
·         Sepsis
·         Shock
·         Anaesthetic drugs

Management: Correction of underlying cause and treatment is not necessary unless runs of atrial tachycardia occur.

BROAD COMPLEX ARRHYTHMIAS


Ventricular ectopic beats: Depolarisation spreads from a focus in the ventricles by an abnormal (\slow) pathway, so the QRS is wide and abnormal. (T wave is also abnormal in shape).
·         Usually benign if there is no structural heart disease
·         May be associated with abnormalities – Hypokalaemia, light anaesthesia (with halothane), raised CO2, intracranial pressure

The onset of runs of VT should be taken seriously where:
·         There is a bigeminal rhythm (one ectopic beat with every normal beat)
·         If they occur in runs of 2 or more (or more than 5/minute)
·         Where they are multifocal (arising from different foci – hence having different shapes)
·         Where the R wave is superimposed on the T wave

Management:
·         Small dose of b-blocker
·         If underlying sinus rhythm is slow, increase the rate with IV atropine (as ventricular ectopics could be a form of escape beat)
·         Lignocaine is the drug of choice
·         Alternatives – amiodarone

Ventricular tachycardia: A focus in the ventricular muscle depolarises at high frequency. Excitation spreads through the ventricles by an abnormal pathway. There are no P waves, wide QRS which may be slightly irregular/vary in shape.
Can be triggered by:
·         Hypoxia
·         Hypotension
·         Fluid overload
·         Electrolyte imbalance (low K, Mg)
·         Myocardial ischaemia
·         Adrenaline injection

Management:
·         Synchronised direct current cardioversion if the patient is haemodynamically unstable
·         If they relapse back into VT – lignocaine, amiodarone can sustain sinus rhythm
·         NOT verapamil

Supraventricular tachycardia with bundle branch block: Where there is abnormal conduction from the atria to the ventricles, a SVT may be broad complex if there is a BBB. Sometimes it can be due to ischaemia.

BUT – all tachycardias should be treated as VT if there is any doubt.
·         RBBB : V1 looks more at the right side of the heart, so if the right ventricle is the last to depolarise due to a block, you see  the last deflection in V6 will be negative (going away from the left of the heart) and the last deflection in V1 will be positive (going towards the right of the heart)
·         LBBB (much more common): V6 looks at the left heart, so if the left ventricle is the last depolarising due to a block, you see last deflection in V6 will be positive and the last deflection in V1 will be negative (going away from the right of the heart)
Ventricular fibrillation: This results in cardiac arrest. There is chaotic and disorganised contraction of ventricular muscle and no QRS complexes can be identified on the ECG.

Management: Immediate DCC


DISTURBANCES OF CONDUCTION


First degree block: PR interval is >0.2s (delayed). Usually benign, but can progress to 2nd degree block.

Second degree block – Mobitz type I (Wendebach): Progressive lengthening of the PR interval and then failure of conduction of an atrial beat. This is followed by a conducted beat with a short PR interval. The cycle then repeats
·         Common with inferior MI, tends to be self-limiting and doesn’t tend to require treatment

Secondary degree block – Mobitz type II: When excitation intermittently fails to pass through to the ventricles. Most beats are conducted normally, but occasionally, there is atrial contraction without a subsequent ventricular contraction
·         Often progresses to complete heart block

Second degree block – 2:1 type: Where there is alternate conducted and non-conducted beats resulting in 2 P waves for every QRS. A 3:1 or 4:1 block may also exist.
·         May herald complete heart block

Third degree (complete) heart block: Complete failure of conduction from the atria to the ventricles, so the ventricles are excited by an escape mechanism (slow) from a focus in the ventricles. There is no relationship between the P waves and the QRS complexes and the QRS complexes are abnormally shaped.
·         May be transient due to vagal stimulation (responds to IV atropine)
·         Acute inferior MI (due to AV nodal ischaemia)
·         Anterior MI – indicates more extensive damage, including the His-Purkinje system


Bundle branch block: If the impulse from the SA and AV nodes reaches the IV septum normally, the PR interval will be normal, but if there is a subsequent delay in depolarisation of the L/R bundle branches, there will be a delay in depolarisation of part of the ventricular muscle and the QRS complex will be wide and abnormal
·         RBBB – often found in normal, may indicate right heart problems
·         LBBB – often indicates heart disease