ECG

sinus rhythm

sinus bradycardia

• SA node fires at less than 60 bpm

• Stable tx

  • Oxygen

  • Meds/monitor pt

  • Consider pacing later 

• Unstable tx

  • Oxygen

  • Meds

  • Prepare for temporary pacing (pads)

• Meds: atropine 1 mg q 3-5 min (3 mg max)

  • You only tx if symptomatic (dizzy, lightheaded, blurry vision, syncope, hotn, pallor, cold clammy skin)

sinus tachycardia

• SA nodes fire at greater than 100 bpm

• Tx

  • ID cause

  • May use beta blockers

• Unstable

  • Immediate synchronized cardioversion

supraventricular tachycardia (SVT)

• Abruptly starts and stops

• Abnormal or hidden P wave (too fast to see)

• Meds and perform diagnostic measures

• Vagal stimulation

• Adenosine (acts on receptors in the cardiac AV node, so push fast)

• Synchronized cardioversion

atrial fibrillation

• Atria fire rapidly from multiple foci (total disorganization)

• Irregularly irregular appearance of P waves (no sinus rhythm)

• Symptomatic symptoms: palpitations, hotn, weakness, dizziness, SOB, angina

• Tx

  • Rate control

    • Goal is <100 bpm

    • CCB, B blockers, dig

    • Cardioversion

  • Prevent embolic events

    • Anticoagulation

  • Conversion to sinus rhythm

atrial flutter

• No sinus rhythm

• “Saw tooth” pattern to P waves

• Tx (almost the same as a-fib)

  • Rate control

    • Goal is <100 bpm

    • Amiodarone

    • Cardioversion

  • Prevent embolic events

    • Anticoagulation

  • Conversion to sinus rhythm

junctional rhythm

• Failure of SA node (no sinus rhythm)

• Ventricle (AV) node takes over as primary pacemaker

• Intrinsic rate of 40-60 bpm

• P wave is abnormal, inverted, or hidden

• Tx

  • Determine cause

  • Avoid electricity

idioventricular rhythm (ventricular escape)

• Happens after junctional rhythm

• Failure of SA and node

• Intrinsic rate of 20-40 bpm

• Absent P waves

• Wide QRS

• Tx

  • Determine cause

  • No electricity 

  • Pacemaker placement

first degree block

• Normal sinus rhythm

• Result PR >0.20

• Asymptomatic, so no tx

second degree type I block

• AV node is getting tired, holds the impulse for longer and longer until there is no AV conduction

• Longer, longer, longer, drop

• Lengthening PR interval until QRS dropped

• If symptomatic: atropine, pacer, dopamine (same tx as bradycardia)

second degree type II block

• Rhythm appears normal until there is a P wave with no QRS

• PR is fixed (may be normal or long)

• Symptomatic: atropine, pacer, dopamine (same as type I)

third degree block

• Atria and ventricles are working independently

• SA node fires at a constant rate (60-100)

• Ventricles don't receive impulse so AV junction takes over and fires impulses (15-60)

• P-P is regular and QRS-QRS is regular, no correlation

• Tx if symptomatic: pacer, dopamine

  • Atropine does not work because the SA node does not talk to the AV node

premature ventricular complexes

• Single irritable focus within the ventricles that fires prematurely to initiate an ectopic beat

• Regular rhythm with one early beat

• P waves present except for the early beat

• Normal QRS except an early beat will be >0.12 seconds

• Consider lidocaine or procainamide

• R on T phenomenon

  • PVC lands directly on the T wave during the hearts vulnerable phase

• Tx is amiodarone or lidocaine bolus then drip

ventricular fibrillation

• Chaotic firing within the ventricles (electrical problem)

• No QRS, P waves, or rate

• No cardiac output, pulse, CO

• Tx

  • Begin CPR, defibrillate as soon as possible

  • Epinephrine 1 mg 1 3-5 min

pulseless ventricular tachycardia

• Ectopic ventricular site takes over as pacer

• Fires at a rapid rate >100 bpm

• QRS >0.12 sec

• Can have a pulse or be pulseless

• Tx

  • Check pulse

  • If pulse present, prepare for sedation and cardioversion

  • If no pulse present

    • CPR and immediate defibrillation

    • Epinephrine 1 mg q 3-5 min

    • Additional shocks prn immediately followed by CPR

  • Lidocaine, amiodarone 

pulseless electrical activity (PEA)

• Electrical activity on the monitor

• No palpable pulse

• Electricity is working, but the heart is not pumping

• Tx

  • CPR

  • Identify and tx cause

  • DO NOT defibrillate

asystole

• Total absence of ventricular electrical activity

• Pumping problem

• Pt is unresponsive, apneic, and pulseless

• Tx

  • Immediate CPR 

  • Identify cause

  • DO NOT defibrillate

  • Epi