ICU EKG Rhythms

Premature atrial contraction (PAC)

Causes:

stimulants (caffeine or tobacco)

myocardial ischemia

electrolyte abnormalities

myocardial hypertrophy

Interventions:

find the root cause

vital sings, SOB, s/s of decreasing CO

replace electrolytes

typically asymptomatic

may precede afib

Atrial flutter

Causes:

lung disease

ischemic heart disease

hyperthyroidism 

hypoxemia

chf

ETOH abuse 

electrolytes

Interventions:
vital signs, s/s of cardiac ischemia and low CO

loss of atrial kick (20%)

DO NO let pt become hypovolemic

BLOOD STASIS→ANTICOAGULANTS

cardioversion (anti before and after)

medications: depends on rate/tolerance (same as afib)

ablation, MAZE

Atrial fibrillation

Causes:

ischemic/valvular heart disease

hyperthyroidism

hypoxemia

chf

electrolytes

Interventions:

vital signs, s/s of cardiac ischemia and low CO

loss of atrial kick (20%)

DO NO let pt become hypovolemic

BLOOD STASIS→ANTICOAGULANTS

cardioversion (anti before and after)

medications: depends on rate/tolerance (same as afib)

ablation, MAZE

Junctional rhythms

Causes:

any disease or condition affecting the sinus node

can be valvular related/post valve or heart surgery

ischemic heart disease

digoxin 

Interventions:

vs, s/s of cardiac ischemia/low CO

typically no tx unless symptomatic (atropine, trans pacing, dopamint)

(dopamine/atropine to restore AV condition)

Paroxysmal supraventricular tachycardia (PSVT)

Causes:

can occur in healthy individuals without heart disease

stimulants, catecholamines

electrolytes

chf

Interventions:
vs, s/s cardiac ischemia/low CO

may be abated using vagal maneuver (if stable)

heart rate >150 and symptomatic→ emergent cardioversion

meds: adenosine (2nd/unstable)→ restart the heart

EP study to find cause

Premature ventricular contraction

three or more is non-sustained vtach

Causes:
hypoxemia

ischemic heart disease

hypokalemia/magnesemia

acid-base imbalance

increased catecholamines

Interventions:
vs, s/s cardiac ischemia/low CO

treat the cause of PVC and correct/eliminate

Ventricular tachycardia

Causes:

hypoxemia

acid-base imbalance

exacerbation of heart failure

ischemic heart disease

cardiomyopathy 

valvular heart disease 

electrolyte imabalance

Interventions:

DETERMINE A PULSE FIRST

pulseless→ emergency resuscitation

pulse: vs, s/s cardiac ischemia/low CO

electrolyte/acid base correction

meds: amiodarone, lidocaine

→both are antiarrythmics

cardioversion in emergency

Torsades

type of VT causes by elongated QT

check for pulse→ tx is mag, amiodarone, or lidocaine

cardioversion

Ventricular fibrillation

Causes:

hypoxemia

acid base imbalance

exacerbation of heart failure

valvular heart disease

electrolyte abnormalities

Interventions:
PULSE FIRST

start emergency resuscitation→ immediate dfib

electrolyte/acid base correction

meds: epi, atropine, amiodarone, sodium bicarb

find and treat the cause

Asystole

no pulse- no CO

cardiac arrest

causes: preceded by another dysrhythmia (VF)

tx: BLS/ACLS

1st degree AV block

“if R is far from P, you have first degree”

Causes:

aging

ischemia valvular related

ischemic heart disease

Interventions:

typically no treatment

trend PR interval and note if it elongates further

2nd degree type 1 AV block (wenckebach)

“longer, longer, longer, DROP, then you have wenckebach

Causes:

drugs

aging

acute inf wall MI

ischemic heart disease

digitalis toxicity

right ventricular infarct

Interventions:

well treated by pts unless drops are frequent

find and treat cause

typically no tx

trend PR interval

may require pacemaker

2nd degree type II AV block

occurs lower in bundle of HIS or branches

can progress→ 3rd degree

Causes:
heart disease

acute inf wall MI

ischemic heart disease

increased vagal tone

right ventricular infarct

Interventions:

vs, s/s cardiac ischemia and low CO

find and treat cause

trend P and QRS

may require pacemaker or trans pacing in symptomatic pts

meds: atropine if symptomatic or slow

3rd degree AV block (COMPLETE)

no atrial impulses through AV node→ a and v beat independently

P and QRS not synced

“if Ps and Qs disagree you have 3rd degree”

Causes:

heart disease

acute MI

ischemic heart disease

conduction system disorder

Interventions:

vs, s/s low CO and cardiac ischemia

find and treat cause

REQUIRES pacemaker or trans pacing

trend P and QRS

Sinus pause/arrest (atrial standstill)

SA node does not generate any signal→ AV is not stimulated

2 or <2 second pauses are normal (sleeping)

>2 seconds is not normal

Causes:

acute infection

SA fibrosis

increased vagal tone

digoxin and salicylates toxicity

beta blocker OD

Ca channel blockers

myocarditis

MI

sick sinus syndrome

Interventions:

vs, s/s cardiac ischemia/low CO

find and treat cause

FALL RISK- syncope

atropine or epi along with pacemaking

trend P and QRS interval