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Practice review

How to ensure patient observations lead to effective management of tachycardia  

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Tachycardia could indicate serious illness. It is essential that nurses promptly identify and act on this significant sign of patient deterioration

 

Author

Phil Jevon, PGCE, BSc, RN, is resuscitation officer/clinical skills lead, Manor Hospital, Walsall. 

Abstract

Jevon P (2010) How to ensure patient observations lead to prompt and effective management of tachycardia. Nursing Times;106: 3, early online publication.

Tachycardia is a normal physiological response to exercise but in the healthcare setting it is considered to be an adverse sign, indicating possible serious illness such as shock. The condition can also be associated with a life threatening cardiac arrhythmia.  This article aims to help nurses understand how to manage it.

Keywords Tachycardia, Patient observations, Patient deterioration

  • This article has been double-blind peer reviewed

 

Practice points

Competencies

  • Nursing staff (including healthcare assistants) measuring heart rate should be able to identify an abnormal pulse rate, record the result and assign a trigger score.
  • Registered nurses should be able to interpret the heart rate measurement and respond appropriately following local early warning score (EWS) escalation protocols. They should alter the frequency of EWS observations if required and be able to intervene with basic treatment measures.
  • Nurses should be able to use a cardiac monitor and start ECG monitoring if necessary (Department of Health, 2008).

 

 

The term tachycardia is defined as a heart rate >100 beats per minute (Resuscitation Council UK, 2006). It is often one of the first signs that patients are beginning to deteriorate (Jevon, 2009a).

The clinical signs of critical illness are associated with compromised respiratory, cardiovascular and neurological functions (Nolan et al, 2005). Adverse signs are:

  • Tachypnoea;
  • Tachycardia;
  • Hypotension;
  • Altered consciousness level (Resuscitation Council UK, 2006).

 

Related physiology

The heart rate is controlled by the cardiovascular centre in the medulla oblongata through the autonomic nervous system (the parasympathetic and sympathetic nervous systems) (Waugh and Grant, 2006; Green, 1991):

  • Vagus nerve (parasympathetic nerve): acts as a brake on the heart. The greater the vagal activity, the slower the heart rate: if vagal activity diminishes, the heart rate increases (Jevon, 2009b). If the vagal tone is completely blocked, the heart rate increases to around 150 beats per minute (Green, 1991);
  • Sympathetic nerve: sympathetic nerve activity (“fight or flight”) has a positive chronotropic action by increasing heart rate. It is particularly active in periods of emotional excitement, exercise and stress.

 

Sinus tachycardia

Sinus tachycardia can be defined as a sinus rhythm >100 beats/min, but the ECG has the same characteristics as sinus rhythm (Jevon, 2009b). Sinus rhythm and sinus tachycardia are illustrated in Figs 1 and 2.

Sinus tachycardia can be a normal response to a physiological stimulus such as exercise. However, if it persists, it is usually an indication of pathophysiology (Jevon, 2009b) and is a common finding in critically ill patients.

There are many causes of sinus tachycardia including: anxiety; emotional distress; pain; fever; drugs such as salbutamol nebuliser and stimulants such as caffeine and nicotine. Tachycardia is also a common finding in many acute illnesses including:

  • Heart failure; 
  • Pulmonary embolism;
  • Pneumonia;
  • Acute respiratory distress syndrome;
  • Anaphylaxis;
  • Heart failure;
  • Shock; 
  • Thyrotoxicosis (Jevon, 2009b).

 

Indications for measuring heart rate

Nurses are expected to accurately measure and interpret heart rate (Department of Health, 2008) and early warning scores (EWS) should identify patients at risk (unless proven otherwise) when they have or develop tachycardia (NICE, 2007). Measurement of heart rate (pulse) should be undertaken following local protocols and EWS guidelines. It is a fundamental part of patient assessment and a key component of the Resuscitation Council (UK)’s (2006) systematic ABCDE (airway, breathing, circulation, disability, exposure) approach to the assessment of critically ill patients. The assessment of pulse is described in Box 1.

Indications for measuring heart rate include:

  • Critical illness;
  • Recording a baseline rate for comparison;
  • Evaluating response to treatment, for example, following a fluid challenge in suspected circulatory shock;
  • Monitoring for adverse reactions to a blood transfusion;
  • Monitoring the effect of certain medicines such as beta-antagonistic therapy.

 

Box 1. Assessing pulse 

  • Palpate the radial pulse: measure the pulse over one minute. A rate >100 is tachycardia.
  • Identify whether the pulse is regular or irregular: an irregular pulse may indicate atrial fibrillation.
  • Assess the volume of the pulse: a weak, thready pulse suggests a poor cardiac output. A bounding pulse may indicate septic shock.

·      Check the colour and temperature of hands and fingers: signs of cardiovascular compromise include cool and pale peripheries.

  • Measure the capillary refill time (CRT): a prolonged CRT (>2 seconds) could indicate poor peripheral perfusion, although other causes include cool ambient temperature and old age (Resuscitation Council UK, 2006).
  • Measure blood pressure: a systolic BP <90mmHg suggests shock.
  • Establish whether the patient has chest pain: central crushing chest pain is suggestive of an acute coronary syndrome.  

Source: Jevon (2009a).

 

Managing tachycardia

Assess patients following the ABCDE approach to identify signs of critical illness. Ensure appropriate senior help is called if necessary, following EWS escalation protocols:

  • Ensure patients have a clear airway and are breathing adequately;
  • For those who are critically ill, administer oxygen as prescribed - for more information, see part 2 of this series, Jevon (2010).
  • Monitor patients’ vital signs and complete the EWS chart following local protocols. It is important to adjust the frequency of EWS observations as appropriate following local protocols;
  • Try to identify the cause of the tachycardia. For example, observe for signs of pain, anxiety and pyrexia. Check if medication has recently been administered that might cause tachycardia;
  • If necessary, take steps to relieve pain and monitor the effects of interventions such as analgesia and repositioning as appropriate;
  • Lie patients flat if they are hypotensive or feeling lightheaded. Intravenous fluids may be prescribed to increase circulating volume of fluid;
  • Start ECG monitoring if appropriate and record a single lead ECG strip from the monitor. If indicated, record a 12 lead ECG; this will help to establish the correct interpretation of the ECG rhythm (Nolan et al, 2005).

The Resuscitation Council (UK) (2006) provides guidance for the effective and safe management of patients with a tachyarrhythmia (fast atrial fibrillation, narrow complex tachycardia and broad complex tachycardia). The algorithm is available at tinyurl.com/tachycardia-RCUK

Conclusion

Tachycardia could indicate critical illness. Nurses should always assess patients following the ABCDE approach and administer oxygen if needed. They should complete the EWS charts following local systems, ensuring escalation protocols are followed if required.

 

 

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