Cardiac Rhythms

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SINUS RHYTHM (Ecg findings)

Rate: 60 - 100 Rhythm: normal
P-wave present, one before each QRS
PRI 0.12 - 0.20 seconds
QRS complex 0.04 - 0.12 seconds

SINUS BRADYCARDIA (Ecg findings)

Rate: 40-60 EVERYTHING NORMAL EXCEPT RATE!
Rhythm: regular
PRI 0.12 - 0.20
QRS comples 0.04 - 0.12 seconds

What is the treatment for sinus bradycardia?

Monitoring only unless symptomatic.
~If symptomatic: Atropine; if not effective: transcutaneous pacing, dopamine IV, or epinephrine infusion

SINUS TACHYCARDIA (Ecg findings)

Rate: >100 EVERYTHING NORMAL EXCEPT RATE!

What is the treatment for sinus tachycardia?

None, UNLESS sustained high rate ~>150
1. O2
2. Adenosine
3. Verapamil
4. Consider (digoxin, beta blockers, or diltiazem)
5. Synchronized cardioversion with sedation.

What is a PAC? How is it treated?

Premature atrial contraction, its an extra beat/early sinus beat. You will see R-wave regular up to a point, then a beat out of place/an extra beat. NO TX for this

ATRIAL FIBRILATION (Ecg findings)

Atrium not contracting, they're shivering! BLOOD POOLING!
Rate & Rhythm: Irregular
No detectable P-waves
PRI: indeterminable
QRS: 0.04 - 0.12

Define controlled vs uncontrolled A-fib

Controlled: rate <100 and asymptomatic
Uncontrolled: rate >100 AND/OR symptomatic

What is the treatment of (asymptomatic) atrial fibrillation?

!!!All NEW ONSET should be on heparin!!!
1. O2
2. Diltiazem, B-blockers, Verapamil, Digoxin

What is the treatment of (symptomatic) atrial fibrillation?

!!!All NEW ONSET should be on heparin!!!
1. O2
2. Consider cardioversion
3. Diltiazem, B-blockers, Verapamil, Digoxin

ATRIAL FLUTTER (Ecg findings)

Flutter waves, rapid atrial rate, vent rate can change dep on amt of flutter waves present b/w QRS complexes
Rate & Rhythm: Both irregular
NO P WAVES!
PRI: indeterminable QRS: normal (0.04 - 0.12 sec)

What is the treatment of atrial flutter?

Controlled: none - managment
Uncontrolled: MUST take action, tx same as a-fib

What are the rhythms that originate in the junction?

Junctional rhythm
Supra ventricular tachycardia

JUNCTIONAL RHYTHM - (Ecg findings)

Rate: usually 40-60 (can be slower or accelerated)
Rhythm: regular
!!!!Usually inverted or absent P-wave!!!! SA node is not being the pacemaker
PRI: <0.12 QRS: normal (0.4 - 0.12 sec)

What are the 3 types of junctional rhythms and what defines them? What is tx dependent on?

Juctional rhythm: rate 40-60
Accelerated junctional rhythm: rate 60-100
Junctional tachycardia: rate > 100
Tx depends on type of rhythm and if pt is symptomatic

What is the treatment of junctional dysrhythmia

Tx depends on type of rhythm and if pt is symptomatic.
If pt is symptomatic w/junctional escape rhythm, atropine can be used. Determine and treat cause.
If asymptomatic: monitor

What are some possible causes of junctional dysrhythmia?

Digoxin, amphetamines, caffiene, nicotine, CAD, HF, cardiomyopathy, electrolyte imbalance, MI, rheumatic heart disease

SUPRA VENTRICULAR TACHYCARDIA (SVT) (Ecg findings)

Rate: 100 - 300
Rhythm: regular
P-wave questionable, sometimes absent. May see P or flutter waves
PRI: None QRS: normal (0.04 - 0.12 sec)

What is the treatment of SVT?

None unless sustained. May try valsalva maneuver
1. Oxygen
2. Adenosine repeat if necesssary
3. Verapamil
4. Consider digoxin, B-blockers, or diltiazem

What rhythms are ventricular arrhythmias? What will be affected?

Premature ventricular contractions (PVC)
Ventricular tachycardia
Ventricular fibrillation (V-fib)
QRS interval is affected!!!!!!

What is a PVC?

A beat that arises from ventricular in origin, the myocardium itself, or the conduction pathways in the ventricles.
---Beat is usually wide and bizzarre looking
Can be unifocal (all PVC's look the same) or multifocal (different PVC's - indicative of more irritation to heart)

PREMATURE VENTRICULAR CONTRACTION (PVC) (Ecg findings)

Wide QRS complex > 0.12
T wave deflection is OPPOSITE of the QRS complex

What is bigeminy? What is trigeminy?

Bigeminy: every other beat is a PVC
Trigeminy: every 3rd beat is a PVC

What is a couplet? What is a 5 beat run?

Couplet: 2 PVC's together
5 Beat run of PVC's: 5 PVC's together

3+ PVC's together constitute what?

Ventricular tachycardia (V tach)

What is the treatment for 5 beat run of V tach

1. O2
2. Amiodarone bolus followed by a drip OR
3. Lidocaine bolus IV push followed by drip

SUSTAINED V TACH (Ecg findings)

Rate: > 100 LIFE THREATENING!!!!!!!
Rhythm: Regular
NO P-WAVES!!!
PRI: None
QRS: > 0.12

What is the treatment for (asymptomatic) sustained V tach?

1. O2
2. Amiodarone over 10 min
3. Lidocaine slow IV push, may repeat after 5 min
4. Procainamide IV

What is the treatment for (symptomatic) sustained V tach?

Cardiovert

Coarse Ventricular Fibrillation (V-fib) (Ecg findings)

CHAOTIC RHYTHM, NO DISTINCT PATTERN
Rate & rhythm: indeterminable and irregular, NO P, R chaotic
PRI: None
QRS: indeterminable
!!!!!!Life-threatening!!!!!!!!!

What is the treatement for pulse-less V Tach, or V Fib?

1. Attempt defibrillation 120-200 J Biphasic, 360 J Mono.
2. Followed by immediate CPR (chest comp for 2 min before pulse check)
3. Drugs delivered during CPR, after rhythm checks: Epi, Vasopressin, Amiodarone, Lidocaine

Sinus Rhythm w/1st Degree AV block -EEG

Rate & Rhythm: 60-100 & Regular
PRI: >.20 !!!!!!!!!
QRS: 0.04 - 0.12 seconde

2nd degree AV block Wenckebock TYPE 1

Rate: varies
Rhythm: R-R irregular; P-P regular
PRI: varies, PRI increases in size until a QRS complex is dropped (norm-longer-longer-longer-dropped QRS-normal...)
QRS: 0.04-0.12

2nd degree heart block Classic Heart block, TYPE 2

Rate & Rhythm: rate varies, rhythm normal (occ dropping of QRS - random) - similar to Wenckebock but no progression towards QRS drop
PRI & QRS: normal except when QRS is dropped
!!!!!!!!!LIFE THREATENING!!!!!!!! can lead to complete block

3rd degree heart block COMPLETE BLOCK

Rate & Rhythm: Regular
PRI: varies, no relationship with QRS complexes
QRS: normal duration
!!!!!!!LIFE THREATENING, W/O A PACEMAKER, PT WILL DIE!!!!!! p wave & QRS complexes march out independently of eachother

ASYMPTOMATIC treatment of 2nd degree heart blocks (T1& 2) & complete BLOCK (all blocks except 1st degree AV)

Usually not unless HR drops too low
1. O2

SYMPTOMATIC (HR<60) treatment of 2nd degree heart blocks (T1& 2) & complete BLOCK (all blocks except 1st degree AV)

1. O2 & prepare for external pacing
2. Atropine
3. Dopamine & Epinephrine - to keep pressure up

Treatment of asystole

NOT A SHOCKABLE RHYTHM!!!!
1. CPR
2. O2 3. Epi
4.Atropine 4. Vasopressin (may be given instead of 1st or 2nd dose of epi)

What is the treatment of choice for V-Fib & V-Tach?

Defibrillation

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