Nuggets of wisdom from NNR

Update 8/29: Read Sean's comment. These nuggets work well for me where I work, but apparently they're not appropriate across the board. I think they're good to have in mind as "what is probably going to happen," but check with your charge nurse, etc., before getting too proactive! I think my cardio lecture went great this morning: I didn't see any texting or Facebooking, and I saw a lot of scribbling. There was a lot of "could you repeat that?" Here are the two lists of things that seemed to be most helpful to students, judging from "hang on...hang on...could you say that again...."

List 1: 5 Deadly Rhythms (Drop Everything and Attend! Rhythms)

  1. V-fib
  2. V-tach
  3. PEA
  4. Extreme bradycardia
  5. Asystole

If your patient really is in one of these, you're going to have to code them most often. Unless you're like me and have a bizarre penchant for getting patients who tolerate V-tach for an hour at a time. For other rhythm changes, see list 2.

List 2: Chores to Complete Before Calling MD on Other Whacky Rhythms

  1. Check your patient (do they feel OK? get a set a vitals. see if they're doing jumping jacks and causing the rhythm to look weird. etc.): are they symptomatic?
  2. We hope you know this from report, but if not, find out if they have a history of this rhythm ("have you ever been told you have atrial fibrillation?" or "an irregular heartbeat?").
  3. Slap a couple of liters of oxygen on them and get a 12-lead.
  4. Ensure you have good IV access and draw a few tubes of blood to send to lab (you'll probably have orders soon).
  5. Scan the med list to see if likely culprits appear (if your patient is on a high-dose dopamine drip and gets tachy, you've got a pretty high index of suspicion...).
  6. Write down these lab values (most recent): Na, K, Mg, and last set of cardiac enzymes, if any. If they're anticoagulated, write down the PT/INR/PTT.

Following this list (to be completed all at the same time) will help you give good information to the doc, quickly. You've got the lab values ready they're most likely to ask for, you can supply a good guess as to the reason for the rhythm change if you've got a med culprit (docs don't have all that stuff in front of them at 2 AM), you have a 12-lead ready to fax if they want it right then, and you've got blood in the lab all ready for any tests they want done right now. And if they give orders for a drip, you've got a nice working IV (and if you have co-workers like mine, they'll anticipate the drip and have a pole in the room with the bag hanging!). It all contributes to treating the patient as quickly and efficiently as possible while giving the physician the fewest headaches. At least this is my list so far.

As usual, I invite readers to add on (especially the docs: what can we have ready for you that streamlines these conversations?)!