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JOURNAL IN EMERGENCY NURSING ATRIAL FIBRILLATION: AN EMERGENCY NURSES RAPID RESPONSE

JOBEL G. LUMADILLA IV ACN PROF. GLORIA V. CRUZ EMERGENCY NURSING

With rapid changes in technology and nursing care, emergency nurses require accurate, in-depth clinical information. As the official journal of the Emergency Nurses Association, the Journal of Emergency Nursing provides peer-reviewed original articles on the clinical, professional, political, administrative, and educational aspects of emergency nursing. Sections in the Journal include Clinical Articles, Case Reviews, Research, Trauma Notebook, CEN Review, Triage Decisions, Pediatric Update, Law and the Emergency Nurse, Sexual Assault: Clinical Issues, and Drug Update. The Journal of Emergency Nursing is recommended for initial purchase in the 1998 edition of the Brandon-Hill study, Selected List of Nursing Books and Journals. Atrial fibrillation (AF or A-fib) is the most common cardiac arrhythmia (irregular heart beat). It may cause no symptoms, but it is often associated with palpitations, fainting, chest pain, or congestive heart failure. However, in some people atrial fibrillation is caused by otherwise idiopathic or benign conditions. AF increases the risk of stroke; the degree of stroke risk can be up to seven times that of the average population, depending on the presence of additional risk factors (such as high blood pressure). It may be identified clinically when taking a pulse, and the presence of AF can be confirmed with an electrocardiogram (ECG or EKG) which demonstrates the absence of P waves together with an irregular ventricular rate. In AF, the normal regular electrical impulses generated by the sinoatrial node are overwhelmed by disorganized electrical impulses usually originating in the roots of the pulmonary veins, leading to irregular conduction of impulses to the ventricles which generate the heartbeat. AF may occur in episodes lasting from minutes to days ("paroxysmal"), or be permanent in nature. A number of medical conditions increase the risk of AF, particularly mitral stenosis (narrowing of the mitral valve of the heart). Atrial fibrillation may be treated with medications to either slow the heart rate to a normal range ("rate control") or revert the heart rhythm back to normal ("rhythm control"). Synchronized electrical cardioversion can be used to convert AF to a normal heart rhythm. Surgical and catheter-based therapies may be used to prevent recurrence of AF in certain individuals. People with AF often take anticoagulants such as warfarin to protect them from stroke, depending on the calculated risk. The prevalence of AF in a

population increases with age, with 8% of people over 80 having AF. Chronic AF leads to a small increase in the risk of death. A third of all strokes are caused by AF. Atrial fibrillation is usually accompanied by symptoms related to a rapid heart rate. Rapid and irregular heart rates may be perceived as palpitations, exercise intolerance, and occasionally produce angina (if the rate is faster and puts the heart under strain) and congestive symptoms of shortness of breath or edema. Sometimes the arrhythmia will be identified only with the onset of a stroke or a transient ischemic attack (TIA). It is not uncommon for a patient to first become aware of AF from a routine physical examination or ECG, as it may be asymptomatic in many cases. As most cases of atrial fibrillation are secondary to other medical problems, the presence of chest pain or angina, symptoms of hyperthyroidism (an overactive thyroid gland) such as weight loss and diarrhea, and symptoms suggestive of lung disease would indicate an underlying cause. A history of stroke or TIA, as well as hypertension (high blood pressure), diabetes, heart failure and rheumatic fever, may indicate whether someone with AF is at a higher risk of complications. The evaluation of atrial fibrillation involves diagnosis, determination of the etiology of the arrhythmia, and classification of the arrhythmia. The minimal evaluation of atrial fibrillation is a history and physical examination, ECG, transthoracic echocardiogram, and case specific bloodwork. Depending upon given resources, afflicted individuals may benefit from an in-depth evaluation which may include correlation of the heart rate response to exercise, exercise stress testing, chest X-ray, trans-esophageal echocardiography, and other studies. If a patient presents with a sudden onset of severe symptoms other forms of tachyarrhythmia must be ruled-out, as some may be immediately life threatening, such as ventricular tachycardia. While most patients will be placed on continuous cardiorespiratory monitoring, an electrocardiogram is essential for diagnosis. Provoking causes should be sought out. A common cause of any tachycardia is dehydration, as well as other forms of hypovolemia. Acute coronary syndrome should be ruled out. Intercurrent illness such as pneumonia may be present. The main goals of treatment are to prevent circulatory instability and stroke. Rate or rhythm control are used to achieve the former, while anticoagulation is used to decrease the risk of the latter. If cardiovascularly unstable due to uncontrolled tachycardia, immediate cardioversion is indicated.