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NREMT Rhythms

Terms in this set (29)

Normal Sinus Rhythm
1.Site of origin: SA Node
2. P wave: Before every QRS; Same size and shape
3. PR interval: 0.12 to 0.20 seconds
4.QRS: Same size and shape; Less than 0.12 seconds
5.Rhythm:
a. P to P interval- Regular
b. R to R interval- Regular
6.Rate: 60 to 100

Treatment: No rhythm specific treatment necessary.
Treat chief complaint, monitor, and transport patient.
Sinus Bradycardia
1.Site of origin: SA Node
2. P wave: Before every QRS; Same size and Shape
3. PR interval: 0.12 to 0.20 seconds
4.QRS: Same size and shape; Less than 0.12 seconds
5.Rhythm:
a. P to P interval- Regular
b. R to R interval- Regular
6. Rate: Less than 60

Treatment:
Stable Vs Unstable?
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath;
Hypotension/Heart failure

Stable: Monitor and observe

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Sinus Tachycardia
1. Site of origin: SA Node
2. P wave: Before every QRS; Same size and shape
3. PR interval: 0.12 to 0.20 seconds
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - regular
b. R to R interval - regular
6. Rate: 101 - 150

Treatment
Usually doesn't require treatment. Heart rate below 150 bpm doesn't normally cause
hemodynamic compromise.
Consider treating the cause of the tachycardia. Common causes include:
Fever: Consider Antipyretics
Anxiety: Calm the patient
Pain: Pain medication/relaxation techniques
Hypovolemia: Replace fluids as needed
Sinus Arrhythmia
1. Site of origin: SA Node
2. P wave: Before every QRS; Same size and shape
3. PR interval: 0.12 to 0.20 seconds
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Irregular
b. R to T interval - Irregular - The longest R to R interval will be less than twice the
length of remaining R to R intervals
6. Rate: Overall rate varies with respirations; usually 60 to 100
a. Increases as patient inhales
b. Decreases as patient exhales

Treatment
Usually doesn't require rhythm specific treatment. If the patient is bradycardic and unstable
due to the bradycardia then treat the bradycardia.

Stable: Monitor and observe

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Sinus Exit Block
1. Site of origin: SA node fires, but impulse is blocked to the atria
2. P wave: Before every QRS; same size and shape
3. PR interval: Varies slightly within normal limits of 0.12-0.20 seconds
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Regular except during pause
b. R to R interval - Regular except during pause
6. Rate: Varies according to underlying rhythm
7. Pause: The distance from the last normal beat to the next beat is equal to exactly two or more
previous cardiac cycles; able to divide pause equally.

Treatment
Usually doesn't require rhythm specific treatment. If the patient is bradycardic and unstable
due to the bradycardia then treat the bradycardia.

Stable: Monitor and observe

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Sinus Arrest
1. Site of origin: SA node fails to fire for at least two cardiac cycles
2. P wave: Before every QRS; same size and shape
3. PR interval: Varies slightly within normal limits of 0.12-0.20 seconds
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Regular except during pause
b. R to R interval - Regular except during pause
6. Rate: Varies according to underlying rhythm
7. Pause: Equal to more than two previous cardiac cycles; not able to divide the pause equally

Treatment
Usually doesn't require rhythm specific treatment. If the patient is bradycardic and unstable
due to the bradycardia then treat the bradycardia.

Stable: Monitor and observe

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Normal Sinus rhythm with PAC's
1. Site of origin (PAC): Atria
2. P wave: Before every QRS; May be buried in preceding T wave; May vary in size and shape
3. PR interval: Varies within normal limits of 0.12 to 0.20 seconds
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Varies according to underlying rhythm and number of PACs
b. R to R interval - Varies according to underlying rhythm and number of PACs
6. Rate: Varies according to underlying rhythm and number of PACs
7. Occurs: Premature; Usually followed by a noncompensatory pause

Treatment
A PAC by itself does not require treatment. If the patient is medically unstable or show signs of
poor cardiac output, treat the underlying rhythm and/or rate.
Supraventricular tachycardia
1. Site of origin: Atria
2. P wave: Before every QRS; May be buried in preceding T wave; Same size and shape
3. PR interval: 0.12 to 0.20 seconds
4. QRS: Same size and shape; less than 0.12 seconds
5. Rhythm:
a. P to P interval - Regular
b. R to R interval - Regular
6. Rate: 151 to 250
7. Onset: Starts suddenly

Treatment
Stable Vs Unstable?
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath;
Hypotension/Heart failure

Stable (medication):
1. Vagal Maneuvers (Try to blow the plunger out of empty 10cc syringe)
2. Adenosine 6 mg rapid IV push followed by 10cc flush
a. Adenosine 12 mg rapid IV push followed by 10cc flush
3. Consider Beta Blocker or Calcium Channel Blocker
a. Diltiazem (0.25 mg/kg then 0.35 mg/kg); Sotalol (1.5 mg/kg over 5 min); Metoprolol (5
mg) etc.
4. Consider expert consultation

Unstable (electricity):
1. Consider sedation (i.e. Versed 5mg IV)
2. Consider Adenosine (If narrow complex)
3. Synchronized Cardioversion (100J; 200J; 300J; 360J)(LIFEPAK)
Atrial Fibrillation (A-Fib)
1. Site of origin: Multiple sites in the atria
2. P wave: No distinctive P wave
3. PR interval: Cannot be measured
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Cannot be measured
b. R to R interval - Irregular
6. Rate:
a. Atrial: 350 to 500 or more
b. Ventricular: Less than 60 (slow ventricular response); 60-100 (controlled a-fib); 101-150
(rapid ventricular response); Greater than 150 (uncontrolled a-fib)

Treatment
Tachycardic vs Bradycardic? Stable vs Unstable? If bradycardic treat according to the
bradycardia algorithm. For tachycardia:
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath;
Hypotension/Heart failure

Stable (medication):
1. Cardizem 0.25 mg/kg IV followed by 0.35 mg/kg IV
Unstable (electricity)

1. Synchronized Cardioversion (200J; 300J; 360J)
2. Consider Diltiazem (if cardioversion is not effective) 0.25 mg/kg IV followed by 0.35 mg/kg IV
Atrial Flutter
1. Site of origin: One atrial site
2. P wave: Not present; T waves may be hidden in flutter waves
3. PR interval: Cannot be measured
4. QRS: Same size and shape; less than 0.12 seconds
5. Rhythm:
a. P to P interval - Not present
b. R to R interval - Regular; Except in varying block/ratio
c. F to F interval - Regular
6. Rate:
a. Atrial: 250-350
b. Ventricular: Usually 60-100 but may vary (greater than 150 is uncontrolled aflutter)
7. Ratio of block:
a. Two F waves to 1 QRS: 2:1 ratio
b. Three F waves to 1 QRS: 3:1 ratio etc

Treatment

Tachycardic vs Bradycardic? Stable vs Unstable? If bradycardic treat according to the
bradycardia algorithm. For tachycardia:
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath;
Hypotension/Heart failure

Stable (medication):
1. Cardizem 0.25 mg/kg IV followed by 0.35 mg/kg IV

Unstable (electricity)
1. Synchronized Cardioversion (200J; 300J; 360J)
2. Consider Diltiazem (if cardioversion is not effective) 0.25 mg/kg IV followed by 0.35
mg/kg IV
Normal Sinus with PJC'S
1. Site of origin: AV Junction
2. P wave: Inverted, Buried, or Retrograde
3. PR interval: Usually less than 0.12 seconds, if inverted P wave is present before QRS
4. QRS: Less than 0.12 seconds
5. Rhythm:
a. P to P interval - Varies according to the underlying rhythm and number of PJCs
b. R to R interval - Varies according to the underlying rhythm and number of PJCs
6. Rate: Varies according to the underlying rhythm and number of PJCs
7. Occurs: Prematurely; Usually followed by compensatory pause

Treatment
PJCs usually do not require rhythm specific treatment. If necessary, treat the underlying rhythm and/or heartrate according to the patient symptoms.
Normal Sinus with PVC
1. Site of origin: Ventricles
2. P wave: Not present or hidden in PVC
3. PR interval: Not measureable
4. QRS: May vary in size and shape; Wide, bizarre, greater than 0.12 seconds
5. Rhythm:
a. P to P interval - Not measurable in PVC; Varies according to the underlying
rhythm and number of PVCs
b. R to T interval - Varies according to the underlying rhythm and number of PVCs
6. Rate: Varies according to the underlying rhythm and number of PVCs
7. Occurs: Premature; Followed by compensatory pause
8. T wave: Deflected in the opposite direction of the QRS

Treatment
Intermittent PVCs can be benign and not require treatment.
Monitor the patient for poor cardiac output or the following "danger signals".
- More than 6 PVCs in 1 minute
- Bigeminy (PVC every other beat)
- Multifocal PVCs (different appearances - originating in different areas of the ventricles)
- R on T phenomenon
- Run of V Tach
If the patient is bradycardic with PVCs - Follow the bradycardia algorithm
If the patient is tachycardic with PVCs - Follow the tachycardia algorithm
Wandering Atrial Pacemaker (WAP)
1. Site of origin: Combination of three or more sites above the bundle of His
2. P wave: Varies according to site of origin
3. PR interval: Varies, if present
4. QRS: Varies according to site of origin; May be greater than 0.12 seconds
5. Rhythm:
a. P to P interval - irregular
b. R to R interval - irregular
6. Rate: Varies; Usually 60 - 100

Treatment
This dysrhythmia is usually not lethal and normally doesn't require treatment. However, it may
need to be treated because it indicates irritability within the cardiac muscle. Symptoms vary
depending on the rate of the wandering atrial pacemaker dysrhythmia and the patient's
tolerance of the dysrhythia.
If the overall heartrate is bradycardic and the patient is stable then monitor and transport.
If the patient is unstable an artificIal pacemaker may be necessary.
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Junctional Escape Rhythm
1. Site of origin: AV Junction
2. P wave: Inverted, buried, or retrograde; Same size and shape, if present
3. PR interval: Usually less than 0.12 seconds, if inverted P wave is present before the QRS
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - regular if present
b. R to R interval - Regular
6. Rate: 40 to 60
7. **Note: It is also possible to see a rate less than 40 which is known as Junctional
Bradycardia Dysrhythmia

Treatment
Stable: Monitor and observe.

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
Accelerated Junctional Rhythm
1. Site of origin: AV Junction
2. P wave: Inverted, buried, or retrograde; Same size and shape, if present
3. PR interval: Usually less than 0.12 seconds, if inverted P wave is present before the QRS
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - regular if present
b. R to R interval - Regular
6. Rate: 61 to 100

Treatment
Normally doesn't require rhythm specific treatment. If the patient is stable monitor and
observe the patient. Consider treating the cause of the tachycardia (fever, anxiety, pain, hypovolemia).
Junctional Tachycardia
1. Site of origin: AV Junction
2. P wave: Inverted, buried, or retrograde; Same size and shape, if present
3. PR interval: Usually less than 0.12 seconds, if inverted P wave is present before the QRS
4. QRS: Same size and shape; Less than 0.12 seconds
5. Rhythm:
a. P to P interval - regular if present
b. R to R interval - Regular
6. Rate: 101 to 150

Treatment
Normally doesn't require rhythm specific treatment. If the patient is stable monitor and
observe the patient. Consider treating the cause of the tachycardia (fever, anxiety, pain,
hypovolemia).
**Note: If the heart rate is greater than 150 BPM treat as SVT.
Idioventricular Rhythm
1. Site of origin: Usually one ventricular site
2. P wave: Not present
3. PR interval: Not measurable
4. QRS: Wide, bizarre, greater than 0.12 seconds
5. Rhythm:
a. P to P interval - Not present
b. R to R interval - Usually regular
6. Rate: 20 to 40 - life threatening; can progress to a lethal dysrhythmia
7. **NOTE: A HR less than 20 is known as an agonal dysrhythmia. It becomes slower until
it completely stops. This is a lethal dysrhythmia.

Treatment
Treat the patient as unstable. Consider a trial of atropine (ACLS wants atropine considered first
for all bradycardic rhythms).
1. (Consider) Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Accelerated Idioventricular Rhythm
1. Site of origin: Usually one ventricular site
2. P wave: Not present
3. PR interval: Not measurable
4. QRS: Wide, bizarre, greater than 0.12 seconds
5. Rhythm:
a. P to P interval - Not present
b. R to R interval - Usually regular
6. Rate: 41 to 100

Treatment
If bradycardic and stable: Monitor and observe
1. (Consider) Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Ventricular Tachycardia with a pulse
1. Site of origin: One or more ventricular sites
2. P wave: Usually not present
3. PR interval: Not measurable
4. QRS: Usually same size and shape; Wide, bizarre, greater than 0.12 seconds
5. Rhythm:
a. P to P interval - Not measurable
b. R to R interval - Usually regular
6. Rate: 101 to 250
7. Occurs: More than 3 PVCs in a row - Sudden onset
8. Duration: Usually greater than 30 seconds; Life threatening; Can progress to a lethal
dysrhythmia

Treatment
Stable Vs Unstable?
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath; Hypotension/Heart failure
Stable (medication):
1. Consider Adenosine (If regular and monomorphic)
2. Amiodarone 150 mg over 10 min
a. Maintenance infusion - Amiodarone 1 mg/min for 6 hours
3. Consider expert consultation

Unstable (electricity):
1. Consider sedation (i.e. Versed 5mg IV)
2. Synchronized Cardioversion (100J; 200J; 300J; 360J)(LIFEPAK)
Torsades de pointes
1. Site of origin: Unclear if one or more ventricular sites
2. P wave: Usually not present
3. PR interval: Not measurable
4. QRS: Usually same shape; Varies in size, going from low to high and back to low
amplitude
5. Rhythm:
a. P to P interval - Not measurable
b. R to R interval - Usually regular
6. Rate: Usually greater than 150
7. Occurs: Sudden onset; Frequently seen in a rhythm with prolonged QT intervals
8. Duration: Varies; Life threatening; Can progress to lethal dysrhythmia

Treatment
Stable Vs Unstable?
Think "CASH" - Chest pain; Altered mental status; Shock/Shortness of breath; Hypotension/Heart failure
Stable (medication):
1. Magnesium Sulfate 2 grams IV over 1 to 2 minutes
2. Consider expert consultation

Unstable (electricity):
1. Defibrillation (200J, 300J, 360J)(LIFEPAK)
First degree AV block
"If The R Is Far From P - Then You Have A First Degree"
1. Site of origin: Underlying rhythm - Usually atrial
2. Site of delay: Between atria and bundle of His
3. P wave: Before every QRS; Same size and shape
4. PR interval: Greater than 0.20 seconds
5. QRS: Same size and shape; Usually less than 0.12
6. Rhythm:
a. P to P interval - Varies according to underlying rhythm
b. R to R interval - Varies according to underlying rhythm
7. Rate: Varies according to underlying rhythm

Treatment
Normally doesn't require any rhythm specific treatment. If the patient has signs of being
unstable or has poor cardiac output treat the underlying rhythm/rate.
Second degree AV block type 1 Mobitz I/Wenckebach
"Longer, Longer, Longer, Drop! Then You Have A Wenckebach"
1. Site of origin: Atria
2. Site of block: AV junction; Progressive
3. P wave: Atleast one for every QRS; Same size and shape
4. PR interval: Becomes progressively longer, until QRS is dropped
5. QRS: Same size and shape; Less than 0.12 seconds
6. Rhythm:
a. P to P interval - Regular
b. R to R interval - Irregular
7. Rate: Atrial and ventricular rates vary

Treatment
Stable: Monitor and observe.

Unstable:
1. Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Second Degree AV Block Type 2 Mobitz II
"If Some P's Don't Get Through - Then You Have A Mobitz II"
1. Site of origin: Atria
2. Site of block: AV junction; Intermittent Block
3. P wave: At least one for every QRS; Same size and shape
4. PR interval: Equal throughout; May be normal or prolonged
5. QRS: Same size and shape; Usually less than 0.12 seconds
6. Rhythm:
a. P to P interval - Varies according to underlying rhythm
b. R to R interval - Irregular
7. Rate: Atrial and ventricular rates vary - Can be life threatening
8. Ratio of block:
a. 2 P waves to 1 QRS = 2:1 block/ratio
b. 3 P waves to 1 QRS = 3:1 block/ratio
c. 4 P waves to 1 QRS = 4:1 block/ratio
d. Varying number of P waves to 1 QRS = Varying block/ratio

Treatment
If stable monitor and observe.
If unstable:
1. (Consider while preparing TCP) Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Third Degree AV Block
Complete Heart Block/Complete AV Dissociation
"If P's And Q's Don't Agree - Then You Have A Third Degree"
1. Site of origin: Atria and ventricles
2. Site of block: Between atria and ventricles
3. P wave: No relationship to QRS; Same size and shape
4. PR interval: Appears to vary; No true PR interval
5. QRS: Same size and shape; Usually wide, bizarre, and greater than 0.12 seconds
6. Rhythm:
a. P to P interval - Regular
b. R to R interval - Regular
7. Rate:
a. Atria: Usually 60-100
b. Ventricular: Usually 20-40
c. Life threatening; Can progress to lethal dysrhythmia

Treatment
Treat the patient if unstable. Consider a trial of atropine (ACLS wants atropine considered first
for all bradycardic rhythms). Do not delay transcutaneous pacing when necessary!
1. (Consider while preparing TCP) Atropine - 1 mg q 3-5 min; Max 3 mg
2. If atropine not effective
a. Transcutaneous pacing OR
b. Dopamine IV infusion - 5-20 mcg/kg/min titrated to response OR
c. Epinephrine - 2-10 mcg/min titrated to response
d. Obtain expert consultation
Ventricular fibrillation (V-fib)
1. Pulse: NO PULSE
2. Site of origin: Many ventricular sites
3. P wave: Not present
4. PR interval: Not Measureable
5. QRS: Not present; Only a chaotic, wavy line
6. Rhythm:
a. P to P interval - Not present
b. R to R interval - Not present
7. Rate: Not measurable; Patient doesn't have a pulse; This is a lethal dysrhythmia
8. Wave Amplitude: Coarse or fine

Treatment
CPR - 2 minutes - 30 and 2 with BVM ventilations and high flow oxygen until advanced airway
Every 2 minutes - Pulse/Rhythm check - alternating compressors
Attach monitor/defibrillation pads
At every pulse check - if no change in rhythm - Defibrillate at 200J increasing subsequent doses to 300J
then 360J or according to manufacturer recommendations and continue CPR
Obtain IV/IO access - initiate fluid bolus
After second shock - Administer Epinephrine 1 mg 1:10,000 every 3-5 minutes
Consider advanced airway and capnography
After third shock - Amiodarone 300 mg followed by 150 mg 5 minutes later
Continue CPR/Defibrillation/med administration monitoring for changes
Treat reversible causes - Hypoxia; hypovolemia; hydrogen ion acidosis; hyper/okalemia; hypothermia;
toxins; tension pneumothorax; tamponade; thrombosis cardiac; thrombosis pulmonary
Pulseless ventricular tachycardia
1. Pulse: NO PULSE
2. Site of origin: One or more ventricular sites
3. P wave: Usually not present
4. PR interval: Not measurable
5. QRS: Usually same size and shape; Wide, bizarre, greater than 0.12 seconds
6. Rhythm:
a. P to P interval - Not measurable
b. R to R interval - Usually regular
7. Rate: 101 to 250
8. Occurs: More than 3 PVCs in a row - Sudden onset
9. Duration: Usually greater than 30 seconds; Life threatening; Can progress to a lethal
dysrhythmia

Treatment
CPR - 2 minutes - 30 and 2 with BVM ventilations and high flow oxygen until advanced airway
Every 2 minutes - Pulse/Rhythm check - alternating compressors
Attach monitor/defibrillation pads
At every pulse check - if no change in rhythm - Defibrillate at 200J increasing subsequent doses to 300J
then 360J or according to manufacturer recommendations and continue CPR
Obtain IV/IO access - initiate fluid bolus
After second shock - Administer Epinephrine 1 mg 1:10,000 every 3-5 minutes
Consider advanced airway and capnography
After third shock - Amiodarone 300 mg followed by 150 mg 5 minutes later
Continue CPR/Defibrillation/med administration monitoring for changes
Treat reversible causes - Hypoxia; hypovolemia; hydrogen ion acidosis; hyper/okalemia; hypothermia;
toxins; tension pneumothorax; tamponade; thrombosis cardiac; thrombosis pulmonary
Pulseless Torsades de Pointes
1. Pulse: NO PULSE
2. Site of origin: One or more ventricular sites
3. P wave: Usually not present
4. PR interval: Not measurable
5. QRS: Usually same size and shape; Wide, bizarre, greater than 0.12 seconds
6. Rhythm:
a. P to P interval - Not measurable
b. R to R interval - Usually regular
7. Rate: 101 to 250
8. Occurs: More than 3 PVCs in a row - Sudden onset
9. Duration: Usually greater than 30 seconds; Life threatening; Can progress to a lethal
dysrhythmia

Treatment
CPR - 2 minutes - 30 and 2 with BVM ventilations and high flow oxygen until advanced airway
Every 2 minutes - Pulse/Rhythm check - alternating compressors
Attach monitor/defibrillation pads
At every pulse check - if no change in rhythm - Defibrillate at 200J increasing subsequent doses to 300J
then 360J or according to manufacturer recommendations and continue CPR
Obtain IV/IO access - initiate fluid bolus
After second shock - Administer Epinephrine 1 mg 1:10,000 every 3-5 minutes
Consider advanced airway and capnography
After third shock - Amiodarone 300 mg followed by 150 mg 5 minutes later
Continue CPR/Defibrillation/med administration monitoring for changes
Treat reversible causes - Hypoxia; hypovolemia; hydrogen ion acidosis; hyper/okalemia; hypothermia;
toxins; tension pneumothorax; tamponade; thrombosis cardiac; thrombosis pulmonary
Asystole
1. Site of origin: No electrical activity in heart muscle
2. P wave: Not present
3. PR interval: Not present
4. QRS: Not present; Only a straight or slightly wavy line
5. Rhythm:
a. P to P interval - Not present
b. R to R interval - Not present
6. Rate: Atrial and ventricular heart rates are 0; A lethal dysrhythmia

Treatment
CPR - 2 minutes - 30 and 2 with BVM ventilations and high flow oxygen until advanced airway
Every 2 minutes - Pulse/rhythm check - switch compressors
Attach monitor/defibrillator pads
After each rhythm check - if no change - resume CPR
Obtain IV/IO access - initiate fluid bolus
Administer Epinephrine - 1 mg 1:10,00 - every 3-5 minutes
Consider advanced airway - Capnography
Continue CPR/Med administration monitoring for changes
Treat reversible causes - Hypoxia; hypovolemia; hydrogen ion acidosis; hyper/okalemia; hypothermia;
toxins; tension pneumothorax; tamponade; thrombosis cardiac; thrombosis pulmonary
Pulseless Electrical Activity (PEA)
1. Site of origin: Mimics any rhythm with a pulse
2. P wave: Mimics any rhythm
3. PR interval: Mimics any rhythm
4. QRS: Mimics any rhythm
5. Rhythm:
a. P to P interval - mimics any rhythm
b. R to R interval - mimics any rhythm
6. Rate: Mimics any rhythm; Patient does not have a pulse; This is a lethal dysrhythmia

Treatment
CPR - 2 minutes - 30 and 2 with BVM ventilations and high flow oxygen until advanced airway
Every 2 minutes - Pulse/rhythm check - switch compressors
Attach monitor/defibrillator pads
After each rhythm check - if no change - resume CPR
Obtain IV/IO access - initiate fluid bolus
Administer Epinephrine - 1 mg 1:10,000 - every 3-5 minutes
Consider advanced airway - Capnography
Continue CPR/Med administration monitoring for changes
Treat reversible causes - Hypoxia; hypovolemia; hydrogen ion acidosis; hyper/okalemia; hypothermia;
toxins; tension pneumothorax; tamponade; thrombosis cardiac; thrombosis pulmonary
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