John F. Briggs

The Cardiac Arrhythmias

Cardiac arrhythmias are disturbances in the rhythm of the heart, manifested by irregularity or by abnormally fast rates (tachycardias) or abnormally slow rates (bradycardias). Patients who perceive these abnormalities most frequently observe palpitations,which somedescribe as the sensation of ‘my heart turning over in my chest’, or awareness that their hearts are beating rapidly or slowly. Other symptoms include weakness, shortness of breath, lightheadedness, dizziness, fainting (syncope) and, occasionally, chest pain. The symptoms tend to be more severe when the rate is faster, the ventricular function is worse, or the arrhythmia is associated with abnormalities of autonomic tone. However, many patients with arrhythmias report no symptoms, and the condition may first be discovered during a routine examination. A tachyarrhythmia that is rapid enoughand lasts long enough canproduce cardiomyopathy and congestive heart failure. In these cases, treatment of the arrhythmia can often return normal function to the ventricles. Although certain physical signs present during arrhythmias can help the physician make a correct diagnosis, electrocardiography is the standard method used for recognizing cardiac arrhythmias. A prolonged electrocardiographic recording, often called a ‘Holtermonitor’, or an event recorder that the patient activates when sensing an abnormality, may assist in confirming the diagnosis when the arrhythmia occurs sporadically, as is often the case.

THE USE OF TRACHEOTOMY IN THE CRITICALLY ILL PATIENT

In early 1949 the routine use of tracheotomy for acute chest injuries was instituted at the Ancker Hospital, St. Paul, Minnesota (1) . This procedure was introduced in order to obviate the necessity for repeated bronchoscopic aspirations when bronchial secretions are profuse. Patients in a state of coma or in a greatly weakened condition are unable to bring up these secretions and subsequently may die of bronchopenumonia. We have used tracheotomy since 1949 in patients with various conditions other than thoracic injuries (2). Creech, Woodhall and Ochsner (3) have reported on the importance of tracheotomy in the treatment of pulmonary complications associated with tetanus. We do not take the view that bronchial secretions should be tolerated in critically ill or unconscious patients and that patients should come to autopsy with “terminal pneumonia.” For too long tracheotomy has been considered a procedure to be used only for an acutely obstructed airway. It should have a place in the equipment of the surgeon and internist for the purpose of combatting the complications which often hasten death. Recent textbooks and even articles describe the ease with which a nurse can pam a nasal catheter into the larynx and obtain adequate suction in the tracheal and bronchial passages of an unconscious patient. This undoubtedly is true of the experienced nurse, trained in the fine art of postoperative care; however, the usual general duty nurse is either reluctant to insert the catheter into the larynx, or has not had the experience necessary to know when the trachea has been cleansed properly. In the case of the unconscious or critically ill patient, we have found it necessary to rely on a bronchoscopist in order to gain adequate suction by this procedure, which should be carried out as often as every thirty minutes for adequate cleansing of the respiratory tract. However, as is well known, repeated bronchoscopic aspirations are attended with much laryngeal trauma and bleeding. Tracheotomy would therefore offer a more efficient route and would bypass an organ which should be carefully guarded. When a catheter is inserted through a tracheotomy tube, the cough reflex is maintained, even in the most profound stupor. The additional help of the suction catheter in removing the sputum when it is raised saves the patient considerable strength, since it is only with great effort that he can expel this sputum through the larynx. The larynx is an efficient block to both air and sputum in an unconscious patient. In addition to acting as a passageway for a suction catheter, tracheotomy reduces the volume of tracheal dead space and removes the resistance of the