Why It Matters:

• Failure to Rescue: Up to 60% of cardiac arrests in hospitals are preventable if early signs are caught.

• Nurses are the frontline in spotting subtle changes in condition (especially vital signs and behavior).

• Outcomes: ICU stays often lead to ICU-acquired weakness, cognitive dysfunction, PTSD, and reduced quality of life.

Why It’s Hard for New Nurses:

• Lack of pattern recognition = too many irrelevant details, missed warning signs.

• Inexperience leads to “doing everything” rather than “doing the right thing fast.”

Contributing Factors:

• Lack of access to care, structural racism, historical trauma, and medical mistrust all increase the likelihood that chronic illness will become complex.

• Complex patients often don’t recover—EOL conversations happen during active treatment.

• High ICU mortality + aggressive treatment often lead to undignified death.

End-of-Life Decision-Making:

• Most decisions are made by surrogates (family), often in emotional distress.

• Be aware of: cultural values, grief stages, health literacy, and mistrust.

• Nurses are key to educating and supporting families through this vulnerable process.

The Dying Process:

1. Early Stage: More sleep, less appetite.

2. Middle Stage: Mental status changes, irregular vitals.

3. Late Stage: Surge of energy, “death rattle,” cool/mottled skin.

Comfort Care:

• Morphine for pain and air hunger.

• Scopolamine for secretions.

• Benzos for anxiety.

• Mouth care, spiritual and emotional support.

Post-Mortem Care:

• Follow state and hospital protocols.

• Offer family viewing and support.

• Contact organ donation teams if applicable

Perfusion = how well oxygenated blood is reaching tissues.

Key Indicators:

• LOC (Level of Consciousness): Confusion = early sign of low perfusion.

• Pulses: Weak = low cardiac output.

• Skin: Pale or cool = potential poor circulation.

• Capillary Refill: Delayed = inadequate perfusion.

• Urine Output: <30 mL/hr = low kidney perfusion (kidneys get 25% of CO!).

❤️ 2. Hemodynamics: Understanding the Pump

Cardiac Output (CO) = Heart Rate x Stroke Volume

Stroke Volume is made of:

• Preload: Volume of blood at end of diastole (measured with CVP or PAOP).

• Afterload: Resistance the heart pumps against (SVR/PVR).

• Contractility: Strength of the heart’s squeeze.

• Ejection Fraction: % of blood pumped out with each beat (not the same as SV!).

Monitoring Tools:

• Central Venous Line (CVP): Measures right heart preload.

• Pulmonary Artery Catheter (PA line):

  • Measures left heart preload (PAOP)

  • Cardiac output

  • Mixed venous oxygen (SvO2)

  • Has 4 ports: proximal, distal, thermistor, balloon

🌬️ 3. Oxygen Evaluation: Is the Body Getting Enough O2?

O2 Delivery Depends On:

• Cardiac Output

• Hemoglobin

• Oxygen saturation (SaO2)

• PaO2 (dissolved O2 in plasma)

Venous O2 Saturation = Oxygen leftover after tissue use

• ScvO2 (central) → from upper body (CVP line)

• SvO2 (mixed) → from whole body (PA line)

Normal Range: ~60–75%

• Low SvO2: Low supply or high tissue demand

• High SvO2: Low demand or excessive supply (e.g. early sepsis)

• ECG (electrocardiogram) = electrical activity of the heart

• Different from echocardiogram, which shows heart structure and movement

What ECG shows:

• How the heart's electrical system fires

• Clues about rate, rhythm, and possible issues like ischemia, blocks, or arrhythmias

• PR interval: 0.12–0.20 sec

• QRS duration: <0.10 sec

• QT interval: ≤0.44 sec

  • QTc > 0.50 sec = DANGEROUS (risk of torsades or lethal arrhythmia)

📏 4. How to Analyze a Rhythm Strip

Use these steps every time:

1. Rate – Count QRS in 6 sec strip × 10

2. Regularity – Are R-R and P-P intervals equal?

3. Are there P waves?

4. Is there 1 P for each QRS, and 1 QRS for each P?

5. Any extra findings? (e.g., U waves, odd shapes)

Purpose: Help manage bradycardia, heart blocks, or electrical dysfunction.

Types:

• Transcutaneous (pads, emergency)

• Transvenous (ICU, catheter-based)

• Epicardial (post-op)

• Implanted/Internal (long-term)

1. Failure to fire: No pacer spikes when needed

2. Failure to capture: Pacer fires but no response from heart

3. Under-sensing: Pacer doesn’t detect intrinsic heart rhythm, fires inappropriately

🔹 Sinus Rhythms

• Sinus Bradycardia (<60 bpm): Can be normal (athletes) or symptomatic (treat w/ atropine if unstable)

• Sinus Tachycardia (>100 bpm): Often compensatory (fever, anemia, hypovolemia), treat underlying cause

🔹 Junctional Rhythms

• Originate near the AV node

• P waves: absent, inverted, or buried

• Rate varies; accelerated junctional rhythm = 60–100 bpm

🔹 Atrial Arrhythmias

• Atrial Fibrillation (AFib): Irregular, no distinct P waves; risk for clots → anticoagulate

• Atrial Flutter: Regular "sawtooth" pattern (F-waves), similar management to AFib

• SVT (Supraventricular Tachycardia): Rapid, narrow QRS, regular; treat w/ vagal maneuvers, adenosine, cardioversion if unstable

💥 Lethal Ventricular Rhythms

⚠️ Ventricular Tachycardia (VTach)

• Wide QRS, fast rhythm

• With a pulse: Treat w/ amiodarone, cardioversion

• No pulse: Immediate CPR + defibrillation

⚠️ Torsades de Pointes

• Twisting ribbon-like rhythm

• Give magnesium ASAP

⚠️ Ventricular Fibrillation (VFib)

• Chaotic, no pulse

• Immediate CPR + defibrillation

⚠️ Pulseless Electrical Activity (PEA)

• Normal rhythm but no pulse

• CPR + epinephrine; identify & treat 5 H’s and T’s:

  • H’s: Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia

  • T’s: Tamponade, Tension pneumothorax, Toxins, Thrombosis (MI, PE)

⚠️ Asystole

• Flatline = dead

• Confirm leads → CPR + epi if full code

⚡ Cardioversion vs Defibrillation

• Cardioversion: Synchronized (R wave), used in unstable AFib/flutter/SVT

• Defibrillation: Unsynchronized, used in VFib or pulseless VTach

💊 Key Meds

• Epinephrine: 1 mg Q4 min during CPR

• Amiodarone: Antiarrhythmic for VTach, VFib

• Atropine: For symptomatic bradycardia

• Adenosine: For SVT (6 mg → 12 mg); crash cart required!