Heart Study

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LOS ANGELES COUNTY +UNIVERSITY OF S)1J;fHERN CENTER

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DEPARTMENT OF EDUCATION
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INTRODUCTION TO
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DYSRHYTHMIA RECOGNITION
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SELF-STUDY MODULE
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Prepared by:
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Gaye Lynn Miller, R.N., MS, CeRN
Senior Nursing Instructor, Critical Care
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Originating Date: 05/94
Reyised: 01/95, 10/97, 05/99, 05/00
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Introduction to Dys
Self-Study Module "
TABLE OF CONTENTS
Purpose . 111
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Anatomy of the Heart . 1-7
Heart Chambers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
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Heart Valves and Circulation . 3
Coronary Arteries . . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Review Section I . 5-7
Electrical Conduction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11

Sinoatrial Node . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9
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. 8-9
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Electrical Waveforms on the ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-14
P Wave '.' . 12
QRS Waves . 13
T Wave ' 14

Measurement of Intervals . 15-25
PR Interval (PR!) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-19
QRS Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-22

Practice Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-25
Calculating the Heart Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-3

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Practice Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29 ~ -.il \.
Determining the Rhythm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-38
Normal Sinus Rhythm . 32-35
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Practice Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36-38
Lead Placement . 39-46
Lead I .
39-40
Lead II .
41-42
Lead III .
42-43
Review Section III .
44-46

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Atrial Ventricular Node
Bundle of His
Right and Left Bundle Branches
Purkinje Fibers
Review Section II
. 8-9
. 8-9
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I Introduction to Dysrhythmia Recognition
Self-Study Module
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Determining the Lethal and Potentially Lethal 47-60
Ventricular Fibrillation 47
Ventricular Tachycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Asystole 49
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Symptomatic Bradycardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Third Degree Heart Block 51
Pulseless Electrical Activity 52
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Premature Ventricular Contraction (PVC) / 53
Practice Strips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-60
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Interpreting ABGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62
ABGs - Definition 62
pH System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 62
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Respiratory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63
Metabolic System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63
Oxygenation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 63
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Treatment 64
How to Interpret ABGs 65
Practice ABGs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. . .. 67
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Answers to Practice ABGs 68
Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 69
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Potassium
Calcium
Magnesium
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Practice Questions
Answers to Practice Questions
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Introduction to Dysrhythmia Recognition
Self-Study Module

To assist the participant in the recognition of life-threatening dysrhythmias and to prepare
the first-time participant for the Intermediate Cardiac Life Support Program (ICLS).
IOBJECTIVES I
At the end of this self-learning module, the participant will be able to complete the
following with at least 80% accuracy:
1. Identify the four chambers, the four valves, and the three major coronary arteries
of the heart.
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2. Describe the conduction pathway of the heart.
3. Distinguish the P, QRS, and T waveforms on the ECG tracing.
4. Measure the PR interval and the QRS complex.
5. Calculate the heart rate from the ECG tracing using one of the three methods
discussed.
6. Identify normal sinus rhythm on the ECG tracing.
7. Determine the correct ECG electrode placement on the patient.
8. Select the appropriate lead with which to monitor the patient continuously.
9. Identify the five lethal (life-threatening) dysrhythmias.
10. Define and recognize a premature ventricular contraction (PVC).
11. Identify the normal and abnormal ABG values to include pH, CO
2
, HC0
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and p02'
12. Discuss the interpretation of ABGs including normal ABGs, respiratory acidosis and
metabolic alkalosis. .
13. Identify the three electrolytes that may cause lethal dysrhythmias when abnormal.
14. Describe the appropriate treatment to correct the imbalance of these three
electrolytes.
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Self-Study Module
IREFERENCES I
Davis, D. (1992). Differential diai:nosis of arrhythmias. Philadelphia: Saunders.
Grauer, K. (1998). A Practical Guide to ECG Interpretation. St. Louis: Mosby.
Huszar, R. (1994). Basic dysrhythmias. St. Louis: Mosby.
Lipman, B. & Coscio, T. (1994). ECG assessment and interpretation. Philadelphia:
Davis.
Marriott, H. (1996). Electrocardioi:raphy. Baltimore: Williams and Wilkins.
Norman, A. (1989). Rapid ECG interpretation. a self-teachini: manual. New York:
MacMillan.
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Self-Study Module
I ANATOMY OF THE HEART I
I HEART CHAMBERS I
The heart is a four chamber pump that supplies the body with blood containing oxygen
and nutrients. The top two chambers are called the right atrium and the left atrium,
they are divided by the atrial septal wall. The right atrium receives venous blood
from the body via the superior vena cava (SVC) and inferior vena cava (IVC) . The
left atrium receives oxygenated blood from the pulmonary veins.
ATRIA
AORTA
svc
PULMONARY
VEINS
LEFf
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Self-Study Module
The bottom two chambers are the right ventricle and left ventricle which are divided
by the ventricular septal wall. The ventricular walls are thicker than the atrial walls,
especially the left ventricle. The right ventricle is a volume pump and controls the
amount of blood pumped to the left heart. It pumps blood from the right ventricle into
the pulmonary artery and usually operates under low pressure. The left ventricle is a
pressure pump and it pumps the blood into the aorta distributing it to the rest of the
body. It operates under higher pressure than the right side. .
SEPTUM
VENTRICLES
RIGHT VENTRICLE 7'
PULMONARY
ARTERY
LEFT
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Self-Study Module
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IHEART VALVES AND CIRCULATION I
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Deoxygenated blood flows into the right atrium from the superior and inferior vena
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cava. The blood then flows through the tricuspid valve into the right ventricle.
Next, the blood is pumped through the pulmonic valve into the pulmonary artery.
From here it flows to the lungs where oxygenation occurs.
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The oxygenated blood flows via the pulmonary veins to the left atrium where it is
pumped through the mitral valve to the left ventricle. From the left ventricle the
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blood is pumped out through the aortic valve into the aorta and enters the systemic
HEART VALVES
PULMONIC
VALVE
TRICUSPID
circulation.
VALVE
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II
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Right
Coronary
Artery -.;If
Aorta
Left Main Artery
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ICORONARY ARTERIES I
The heart muscle itself is fed by the coronary arteries These arteries branch from the
aorta just above the aortic valve and lie on the outer surface of the heart. The three
main coronary arteries branch many times and extend through all three layers of the
heart. (Outer - epicardial layer, middle - myocardial layer, and inner - endocardial
layer.) The three large coronary arteries are the Right Coronary Artery, the Left
Coronary Artery which divides into the Left Anterior Descending Coronary Artery
and the Circumflex Coronary Artery. Blockage of these arteries can cause abnormal
rhythms or dysrhythmias.
Circumflex
Artery
Left
Anterior
Descendinc \
Artery
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------ ---------------
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Self-Study Module
REVIEW SECTION I
1. The heart has four chambers, the top two chambers are called the _
and the
2. The bottom two chambers are the and the
3. The right ventricle pumps blood into the and is a
_______ pump.
4. The left ventricle pumps the blood into the and is a
_______ pump.
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Self-Study Module
5. Label the following diagram:
m. _
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------ .1.-..... ~
. _ ~
h . - ~ - - - - - - - - -
c.
--- ..-----. f.
g.
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-----
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Self-Study Module
6. The heart muscle is fed by the _ ~ . The three
branches are the
_______________ , the _
and the
7. Blockage of these arteries can cause
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Self-Study Module
ANSWERS FOR REVIEW SECTION I
1. Right atrium
Left atrium
2. Right ventricle
Left ventricle
3. Pulmonary artery
Volume
4. Aorta
Pressure
5. a. Aorta
b. Pulmonary artery
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c. Left atrium
d. Aortic valve
e. Pulmonary veins
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f. Mitral valve
g. Left ventricle
h. Right ventricle
1. Inferior vena cava
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J. Tricuspid valve
k. Pulmonic valve
1. Superior vena cava
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m. Right atrium
6. Coronary arteries'
Right coronary artery
Left anterior descending coronary artery
Circumflex coronary artery
7. Abnormal rhythms (dysrhythmias)
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Self-Study Module
IELECTRICAL CONDUCTION SYSTEM I
The conduction system of the heart transmits electrical impulses through the heart
causing the muscle to contract.
The conduction pathway includes the following:
A. The Sinoatrial Node (SA node) is located at the SVC and right atrial junction. It
is known as the pacemaker of the heart and normally controls the heart rate and
rhythm. SA node impulses cause the atria to depolarize (contract) generating 60
100 beats per minute. From the SA node the impulses travel down the
conduction pathway to the AV node.
B. The Atrioventricular Node (AV node) is located on the floor of the right atrium
next to the tricuspid valve. It generates 40-60 beats per minute and controls the
number of impulses that enter the ventricles. The AV node delays the impulses
to allow time for the atria to contract and empty blood into the ventricles. These
impulses then travel to the bundle of His. If the SA node is unable to function,
the AV node may take over as the pacemaker.
C. The Bundle of His is located at the beginning of the interventricular septum. It
connects the AV node to the bundle branches and has no intrinsic rate.
D. The Right and Left Bundle Branches are located in the interventricular septum.
The right bundle branch carries impulses to the right ventricle and the left bundle
branch carries impulses to the left ventricle. They have no intrinsic rate.
E. The Purkinje Fibers are a network of fibers at the end of each bundle branch
which are dispersed throughout the ventricular wall (myocardium). As the
heart's electrical impulses travel through these fibers ventricular contraction
(depolarization) occurs. The Purkinje fibers have an intrinsic rate of 20-40 beats
per minute.
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Self-Study Module
AV NODE
RIGHT BUNDLE BRANCH
~ ~ L E F T BUNDLE
BRANCH
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The Conduction System
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REVIEW OF SECTION II
1. The node has an intrinsic rate of to
------ .--:----
beats per minute and is known as the of the heart.
2. The node has an intrinsic rate of to
--,-----=--:
beats per minute. It causes a delay in impulse transmission allowing the atria to
________ and empty blood into the ventricles.
3. The have an intrinsic rate of 20 to 40 beats per
minute. They are dispersed throughout the -
4. Label the following diagram with the appropriate conduction system components:
a. ... ~
b. - ~
~ ~ - - - - e .
~ ~ - - - - - f .
c. ~ ~
d. - - . ; ; I I ~ ~ ~ ~ ~
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Self-Study Module
ANSWER FOR REVIEW SECTION II
~
1. SA
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60-100
Pacemaker
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2. AV
40-60
Contract
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3. Purkinje fibers
Heart muscle or myocardium
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4. a.
b.
SA node
AV node
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c.
d.
e.
Right bundle branch
Purkinje fibers
Bundle of His
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f. Left bundle branch
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[ ELECTRICAL WAVEFORMS ON mE ECG I
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Electrical impulses from the heart are recorded on EeG paper via electrodes and leads
placed on the patient's chest. One normal heart beat contains three waveforms; the
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P, QRS and T waves.
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[PWAVE I
The P wave represents atrial depolarization (contraction). See illustration below.
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Time in 0 0.2 0.4 0.6 0.8
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Self-Study Module
IQRS WAVES I
The QRS complex represents ventricular depolarization (contraction) on the
EeG. See illustration below.
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Time in 0 0.2 0.4 0.6 0.8
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The Q wave is the first negative (below baseline) waveform.
The R wave is the first positive (above baseline) waveform.
The S wave is the second negative waveform moving up to the baseline.
The QRS complex is a bigger waveform than the P wave because the ventricles
have thicker walls than the atrial and therefore, a stronger contraction.
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Self-Study Module
The T wave represents ventricular repolarization (resting time). See illustration
below.
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0.8 0.6 0.4 0.2 Time in 0
seconds
During this phase (resting time) it may be easy to stimulate an early heart
contraction in some patients. This may cause dysrhythmias to occur.
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Self-Study Module
[ MEASUREMENT OF ECG WAVEFORMS
Time is measured horizontally on the EeG paper in the following manner:
One small box represents .04 seconds .
One large box represents .20 seconds
(.04 one small box)
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You will need ECG calipers to measure ECG intervals and complexes.
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Self-Study Module
IPR INTERVAL (PRJ) I
It is important to determine the length of the intervals/complexes to ensure that a
patient's EeG is normal. The following section demonstrates how to measure the PR
interval (PRI) and the QRS complex.
The PRJ begins at the onset of the p wave and ends at the first wave of the
QRS complex
The PRJ represents the time for atrial depolarization
Normal PRI is .12 to .20 seconds
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Self-Study Module
A PRJ of greater than .20 indicates abnormally slow conduction of impulses from
the atrium to the ventricles and is called a heart block.
This PRJ is .20 - read on to learn how to do this!
Place one point of your calipers at the beginning of the P wave and the other .,
point at the beginning of the QRS complex. (The QRS complex begins at the
point where the waveform leaves the baseline. This may be either above or
below the isoelectric line [baseline].) See illustration below.
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Self-Study Module
Hold your calipers in this position and move them to the top of the ECG paper.
Count the number of boxes that fit between each point of the calipers.
Calculate the PRI.
Remember each small box represents .04 seconds.
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Self-Study Module
In the example on page 18 the distance from the beginning of the p wave to
beginning of the QRS complex is 4 small boxes.
the
To calculate the PRJ multiply the,number of boxes by .04 seconds (4 x .04
.16) The PRJ is .16 seconds.
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This is a normal PRJ and represents normal conduction from the atrium to t
ventricle.
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Self-Study Module
IQRS COMPLEX I
The QRS begins at the point where the first wave of the complex leaves the
baseline and ends where the last wave of the complex returns to the baseline.
This represents the time required for ventricular depolarization (contraction).
The normal QRS is .06 to .10 seconds
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Measure the QRS complex using the
method described on pages 17 and 18.

Multiply the number of small boxes by
.04 seconds.

The duration of the QRS complex is
.08 seconds
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Self-Study Module
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The above complex illustrates a normal QRS complex measuring .08 seconds.
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Self-Study Module
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The complex above is two small boxes therefore it is .08 seconds, and represents
normal AV conduction.
The complex above is three small boxes therefore it is .12 seconds, which is .02
seconds greater than normal. This represents abnormal AV conduction.
A QRS complex longer than .10 represents abnormally slow conduction of
impulse through the ventricles and indicates a block in the bundle branches.
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Self-Study Module
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PRACTICE STRIPS
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Complete the following practice strips:
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1.
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PRJ _
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_ QRS
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Normal or abnormal conduction
-----
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2.
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PRJ _
QRS _
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-----
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Self-Study Module
3.

PRJ _
QRS _
------
4.
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PRJ _
QRS _
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Self-Study Module
1. PRJ
QRS
Conduction
2. PRJ
QRS
Conduction
3. PRJ
QRS
Conduction
4. PRJ
QRS
Conduction
ANSWERS TO PRACTICE STRIPS
.12
.08
Normal atrial and ventricular
.16
.06
.20
.06
.14
.16
Abnormal ventricular
Ventricular conduction is slower than normal therefore, a bundle
branch block is present.
Do not be concerned if your PRJ or QRS complex measurements differ slightly from
the above answers. If your answers are within one small box you are correct.
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Self-Study Module
ICALCULATING HEART RATE I
The BeG is also used to calculate heart rate.
There are various methods used. The following are three examples:
Example A
300-150-100-75 method
Find an R wave that falls on or near a heavy black line on the BeG paper.
This is where you start.
Count the heavy black lines until you reach the next R wave. This will be
300.
Each heavy line corresponds with the number listed on the example below.
Start
300
150
100
75
60
I
', ..
, ,
" .
, , I
. ,
" .j
, ,.
" I "
The heart rate is slightly faster than 60 beats per minute.

Remember normal heart rate is 60-100 beats per minute.
27
I
Self-Study Module
I
Example B 6-second strip
I
Each 3-second interval is marked by a vertical line at the top of the ECG
paper.
I
Two of these 3-second intervals equal 6 seconds.
I
Count the number of QRS complexes in a 6-second strip and multiply this x
10.
I
See example below.
I
I
I
I
f
I
" cl"
L
d
6 SUOW'l Mt.mo
.J
!
t
28
Self-Study Module
Example C
Small box method
In one minute, 1500 small boxes go through the ECG machine.
Count the number of small boxes from one R to the next R wave.
Divide 1500 by that number and this will give you the heart rate.
See example below.
~ ' = 1 0 0
15
Total number of small boxes in this strip is 15.
Divide 1500 by 15 and this will give you 100 beats per minute.
This method is useful when you do not have a 6-second strip.
Not accurate when rhythm is irregular.
29
I
Self-Study Module
I
PRACTICE STRIPS
I
Complete the following practice strips:
I
1.
I
I
I
I
_
I
2.
I
I
I
I
_
3.
)',',
Rate
Rate
Rate _
30
I.'J'
\
Self-Study Module
I
4.
I
:1
:1
,I
_ Rate
II
5. Use 300-150-100 method
il
II
il
I
_ I
I
I
I
I
I
6. Use the small box method
_
Rate
Rate
II
31
I
Self-Study Module
1. Rate 80 beats/minute
2. Rate 110 beats/minute (tachycardia)
4. Rate 50 beats/minute (bradycardia)
6. Rate 125 beats/minute (tachycardia)
( 1500
= 125)
12
III
II)
II
"
I
,
, ~
,
32
"iiiiiili"".::
Self-Study Module
IDETERMINING TIIE RHYTIIM I
INORMAL SINUS RHYTIIM I
A. Criteria for sinus rhythm.
P waves all have the same configuration.
QRS complexes all have the same configuration.
The P to P interval (distance from one P wave to the next P wave) is the
same and does not vary.
The R to R interval (distance from one R wave to the next R wave) is the
same and does not vary.
All the above occurs throughout the entire ECG strip.
,......
~ : ' . .;+;
. .
. ....~ ......~
- ~ . , '
. . .
_......_+0-..... ~ .. .. , "'" ... ;. ;........ ,,"., .. . i
.-' ~ r-., ..- f ~ ,.. ~ . ~ , .. .,
.......
-.
. -
_
...
,"
The distance from P to P is regular--therefore the atrial rhythm is regular.
33
Self-Study Module
B. (Cont'd)

P wave for each QRS

P to P is regular

R to R is regular

PRI is .18

QRS is .08

Rate is 90

Interpretation: NSR
c. If regular sinus rhythm is less than 60 beats per minute, the rhythm is called
sinus bradycardia.
P wave for each QRS
P to P is regular
R to R is regular
PRI is .14
QRS is .08
Rate is 50
Interpretation: Sinus bradycardia
35
j"
_" '-'---' .""":J .-"
- -.I ~ " J .......... " ' ' - ' ' ' ' ' ' ' ' U ~ l U U U l l
Self-Study Module
~

I
I
D. If regular sinus rhythm is greater than 100 beats per minute, the rhythm is called
sinus tachycardia.
P wave for each QRS
I
P to P is regular
R to R is regular
I
PRIis.14
QRS is .08
Rate is 110
I
Interpretation: Sinus tachycardia
I
E. If regular sinus rhythm is 60 to 100 beats per minute but the P to P and R to R
are slightly irregular, the rhythm is called sinus arrhythmia.
,
I
t
,
, ..,..
co.
P wave for each QRS
P to P is irregular
R to R is irregular
PRIis .12
QRS is .08
Rate is 80
Interpretation: Sinus arrhythmia
36
~ i i l l i i ' i ' "
I
Self-Study Module
PRACTICE STRIPS
1.
P wave per QRS: _
P to P: _
R to R: _
PRI: _
QRS:
Rate: ----------
Interpretation:
2.
P wave per QRS: _
P to P: _
R to R: _
PRI: _
QRS:
Rate: ----------
Interpretation:
37

Self-Study Module
3.
P wave per QRS: _
P to P:
Rto R:---------
PRI: _
QRS:
Rate: ----------
Interpretation:
4.
P wave per QRS: _
P to P: _
R to R: _
PRI: _
QRS:
Rate: ----------
Interpretation:
38
-----------
Self-Study Module
ANSWER TO PRACTICE STRIPS
1. P wave present for each QRS
'Ii,.
:.
,I
il
I
I
I
I
I
I
I
1
,
P to P: Regular
R to R: Regular
PRJ: .12
QRS: .08
Rate: 70
Interpretation: Normal sinus rhythm
P to P: Regular
R to R: Regular
PRI: .14
QRS: .06
Rate: 130
Interpretation: Sinus tachycardia
P to P: Regular
R to R: Regular
PRI: .16
QRS: .08
Rate: 50
Interpretation: Sinus bradycardia
P to P: Irregular
R to R: Irregular
PRJ: .12
QRS: .08
Rate: 60
Interpretation: Sinus arrhythmia
39
,
Self-Study Module
I ECG ELECTRODE and LEAD PLACEMENT I
The ECG electrodes and leads must be correctly placed on the patient's chest in order
to interpret the ECG rhythm accurately.
Each lead reviewed provides a different picture of the electrical activity in the heart.
The ECG configuration will be different depending on which lead is used to interpret
the rhythm.
The three electrodes are placed in the positions noted on the diagram below. Right of
the sternum, placed below the right clavicle, left of the sternum, placed below the left
clavicle and the third electrode is placed on the left at approximately the seventh rib.
The white color-coded lead hooks up to the right electrode, the black color-coded lead
hooks up to the left upper electrode and the red or green lead hooks up to the left
lower electrode.
o Electrode
L - ~
(cable with colored
coded end)
The lead (cable) snaps/
hooks onto the electrode
If the BCG monitor is turned on to the Lead I, the R electrode becomes negative and
the L upper electrode is positive. The left lower electrode is the ground.
40
Self-Study Module
The electrical impulses travel from the negative lead toward the positive lead.
Therefore the EeG waves are upright in lead 1.
41
Self-Study Module
The right-sided electrode is negative.
The left-lower electrode is positive.
The left-upper electrode is the ground.
When the ECG monitor is viewing
lead II the electrical impulses
travel from the negative lead
toward the positive lead.
-R
+L
Therefore the ECG waves are
upright in lead II.
II
42
--
Self-Study Module

The right-sided electrode is the ground.

The left-upper electrode is negative.

The left-lower electrode is positive.

43
LI,'
'1IIi.ili",......
Self-Study Module
I
,
III
1
When the EeG monitor is viewing lead III the electrical impulses travel from the t
negative lead toward the positive lead.
- L upper I
~
+ L lower I
Because of this positioning the EeG complex may be biphasic (some portion of
wave is positive and some portion is negative) or it may be upright. I
I
* When using a three-lead system, the preferred lead to monitor your patient would be
lead II.
I
I
I
I
I
44
I
'-------' '----
L E A D I ~
/' \ I
/-
2.
BeG Complex:
~
45
\
\
'--
'-.---/
,-
3.
~
REVIEW SECTION III
Label the following diagrams.
For each lead indicate the location of the positive, negative and ground electrode.
State whether the complex in that lead is normally positive, negative, or biphasic.
Label the color of each lead.
Indicate the direction the electrical impulses normally travel.
Self-Study Module
toduction to Dysrhythmia Recognition
i-Study Module
ANSWERS TO REVIEW SECTION
1.
ECG waveform is upright
2.
LE%,
<2)
@
~ \ - . . \ \ t 2>'(1(.1<
~ \ '---- ECG waveform is upright
46
@
Reel.
'-----4)0
~ \ o . c . "
'-----" "'----'
.
1111
Self-Study Module
3.
@
Ret}
'\
.....---

w\.l\t..
"-----"
e
~ \ a . ( . "
47

BeG waveform is upright
or biphasic
I
I
l ~ l
Jl j
.;
+! I
.
1
1
,
I .....
I
I
I
I
I
I
I
F 77f7W:-"-'-""""''''' '" $'''''''11

etion to Dysrhythmia Recognition
dy Module
I DETERMINING THE LETHAL DYSRHYTHMIAS I
..e following dysrhythmias will be discussed:
) Ventricular Fibrillation Symptomatic Bradycardia/Third Degree Heart Block
Ventricular Tachycardia Pulseless Electrical Activity (PEA)
Asystole Premature Ventricular Contraction (PVC)
FIBRILLATION
*'i
efinition: Total disorganization of the heart's electrical activity associated with signs
d symptoms of no pulse, no blood pressure.
Chaotic rhythm
No identifiable BeG waveforms
Ventricular contractions are absent, the heart is fibrillating (looks like a bag
of wiggly worms).
It can appear large and coarse or small and fine. (See illustrations below.)

i
II ii 1'1
:II
Coarse Ventricular Fibrillation
Fine Ventricular Fibrillation
48
1.J1;;1l-..>LUUy IV.lUUUIC
IVENTRICULAR TACHYCARDIA I
Definition: a rapid ventricular rate associated with signs and symptoms of
cardiovascular collapse, e. g., low BP, high HR.
Heart rate is 150 beats/minute or greater.
P wave difficult to see (may appear sporadically).
QRS complexes are wide and bizarre (usually> .12) and look alike.
Usually regular rhythm, i.e., R to R is regular.
f t ... --<- ...
, 11;1
r
lv.
I
49
...." . . , . ' ' " ' , . . ' ' ' ' ' ' ' ~ " ' ' , ' ' ' ' , . " . ~ .,.'_'" "0
Self-Study Module
IASYSTOLE I
Definition: Electrical activity is absent.

A straight line is usually present on the EeG.

Always check two different leads On the monitor to verify this rhythm.
50
Self-Study Module
ISYMPTOMATIC BRADYCARDIA I
Definition: Same as sinus bradycardia except the patient has a low blood pressure and
is restless or lethargic
Therapy or treatment is the same as Third Degree Heart Block.
rt:-:- '_._ .. ' .._._-=.,. .....:. ~ .
-.........,.. : _ : { ~ :
51
~ ~ ~ _ = , ...." ' c ~ & _
Self-Study Module
ITHIRD DEGREE HEART BLOCK I
Definition: This rhythm represents complete absence of conduction between the atria
and the ventricles. It may also be called complete heart block.

The AV node is not functioning.

Atrial impulses from SA node are not getting through to the ventricles so
the Purkinje fibers must become the pacemaker for the ventricles.

P waves are present but do not correlate with ventricular activity.
Therefore, there is no relationship between the p wave and qrs complex.

P to P and R to R intervals are usually .. constant but share no relationship
with each other.

Ventricular rate is usually less than 40.
mil
"
52
{" .q/\i
Introduction to Dysrhythmia Recognition;::;-;, (" I
Self-Study Module \ '

'\
IPULSELESS ELECTRICAL ACTIVITY (PEA)
DefInition: A normal ECG rhythm is present on the monitor indicating electrical
activity but mechanical activity is absent (no contractions).
Blood is not being pumped out of the heart, therefore the patient will have
no pulse.
Even though the ECG shows NSR the patient has no pulse.
__ 1.', F: --
.,. - =--= .. __ __ If1:- ;;-- li=!:..:"::.+-'- ..1-. -..=J:=.:=:_='.="--'--'-J
+' ,. -- , - -r--- --- I --I:::.T -j .- --.-,-- --I-f--- -=1===1='- I-e...: --I--- - .' .-, 1--"- ,'-1--- -4 -- ,
r--:i -f- f - ---l - I - r--- -, -- - l, I 1 r
:c::j iCc:' :._:. = -_:/-=..:. - f:-+=i'-:-='E .--=-- I=:.-=r-'=::-- '-=:=::::
-:'. .
.. I: ..'. :::1= .:==:jc.--: == i1'==1=, "'::=:- =t I [==*=t==.:: :1 :=,d I-:=r=-::s-- ..-..:-l
"'" ,--::=+'=1...=' =.=F---.'" -: I!-::-+--:-t,;;: --/:.-----!::::A:, ,-,--f::::c:h,-.:' ..
. -v r-r---'o.. - ,r . . .. , .-l=r- ... .r-:'- - .. ..
-'T .. '"
53
";
oduction to Dysrhythmia Recognition
,..If.Studv Module
~ R E M A T U R E VENTRICULAR CONTRACTION (pVC) I
Definition: An irritable focus in the ventricles causing early or premature
depolarization (contraction).
The PVC will cause the ECG rhythm to be irregular.
PVCs may also increase the heart rate.
The QRS is bizarre looking and wider than .12.
Frequent PVCs (greater than 6 per minute) are often treated with
Lidocaine.
PVCs that are multifocal (do not look alike) are more serious than unifocal
PVCs (look the same).
W:U:lt
I
I
I
I \
Unifocal
54
Self-Study Module
PRACTICE STRIPS
Identify the dysrhythmia
1.
2.
t
3.
55
,troduction to Dysrhythmia Recognition
"elf-Study Module
4.
I
5. The patient has no pulse.
6.
56
..
...
'6
'L
alnpow
0l
..
'ZI
'11
'01

01

r .
1

tmUUlAU1SArT 01 UOl1:'lnnOnTn
09

01 uop;,npOlluI
I
-
Self-Study Module
I
II
I
I
11
I
I
I
I
I
I
I
I
I
I
I
1. Ventricular tachycardia (V-tach)
2. Asystole
3. Ventricular fibrillation (V-fib)
4. Complete heart block/bradycardia (3 AVB)
5. Pulseless electrical activity (PEA)
6. V-fib
7. V-tach
8. Asystole
9. Sinus rhythm with a pair of PVCs
10. Complete heart block
11. Sinus rhythm with one PVC
12. V-fib
13. V-tach
14. Sinus rhythm with multifocal PVCs
1
15. V-tach
16. PEA
61
Self-Study Module
IINTERPRETING ABGs I
IABGs - DEFINITION 'I
Blood sample taken from an artery to determine:
Acid-base status (PH)
Oxygenation
Ventilation
Normal values
pH
pC0
2
HC0
3
p02
O
2
Sat
= 7.35-7.45
= 35-45 mmHg
= 23-25 mEq/L
= 80-100 mmHg
= 95-100%
!PHSYSTEM I
Reflects the acidity or alkalinity of a solution
Reflects alteration in respiratory and metabolic processes
Respiratory - controls CO
2
(acid)
t CO
2
= ~ pH acidotic
~ CO
2
= t pH alkalosis
Metabolic - kidney controls HC0
3
(base)
t HC0
3
= t pH alkalosis
~ HC0
3
= ~ pH acidotic
62
Self-Study Module
ITREATMENT
1. Respiratory
a. Respiratory acidosis caused by hypoventilation

pC0
2
> 45 mmHg
Treat the cause - e.g., decreased respiratory rate
Hyperventilate with bag-va1ve-mask (ambu bag)
b. Respiratory alkalosis caused by hyperventilation.
pC0
2
< 35 mmHg
Treat the cause - e.g., increased respiratory rate caused by pain or anxiety
Breathe into "brown" bag
Relieve pain or anxiety
2. Metabolic system
a. Metabolic acidosis caused by a loss of bicarbonate (HC0
3
) or retention of
metabolic acids
HC03 < 22
Treat underlying cause, i.e., diabetes, diarrhea
Give bicarb replacement only if pH < 7.10 and HC0
3
< 10
b. Metabolic alkalosis caused by an increase in the intake of HC0
3
or from
I
increased loss of metabolic acids
HC03 > 26
I
Treat underlying cause, i.e., vomiting, chloride depletion
I
Give chloride, replace electrolytes
I
I
64
I
l
,I(:
';Introduction to Dysrhythmia Recognition
,:Self-Study Module
3. Oxygenation
I
a. Decreased oxygenation
P02 < 80
O
2
Sat < 92
Treat with:
Oxygen administration
Increase FP2
Intubate/ventilate
[ HOW TO INTERPRET ABGs I
1. Look at pH - increased, decreased or normal.
2. Look at pC0
2
- increased, decreased or normal.
3. Look at HC0
3
- - increased, decreased or normal.
4. Look at oxygenation P0
2
, O
2
sat.
Examples
1. pH 7.39
pCO
z
38
HC0
3
-
23
pOz 100
Oz Sat 98%
2. pH 7.52
pC0
2
,.30
HC0
3
-
24
pOz 88
Oz Sat 96%
3. pH "/\7.49
pCO
z
35
HC0
3
- 1128
pOz 85
Oz Sat 97%
Normal
Normal
Normal
Normal
Normal
Increased (alkalotic)
Decreased (alkalotic)
Normal
Normal
Normal
Normal
Normal
Normal
Interpretation: NOnrull ABGs
Treatment: None
Interpretation: Respiratory Alkalosis
Treatment: "Brown "bag treatment
if awake
Interpretation: Metabolic Alkalosis
Treatment: Treat the cause
65
IntroductIOn to Dysrhythmia Recognition
Self-Study Module
4. pH
pC0
2
HC0
3
p
0
2
O
2
Sat
7.20
56
23
72
86%
'
Decreased
Increased
Normal
Decreased
Decreased
(acidotic)
(acidotic)
(hypoxemia)
Interpretation: Respiratory Acidosis
with hypoxemia
Treatment:
Hyperventilate with
ambu bag and ensure
patient is receiving
100% O
2
(or as close
as possible)
5. pH
pC0
2
HCO
3
p
0
2
O
2
Sat
7 . 0 5 < ~
39
5 JI
98
95%
Decreased
Normal
Decreased
Normal
Normal
(acidotic)
(acidotic)
Interpretation: Metabolic Acidosis
Treatment:
Treat the cause
66

Self-Study Module
1. pH 7.25
pC0
2
55
HC0
3
23
p0 2
54
O
2
Sat 80%
2. pH 7.50
pC0
2
39
HCO
3
28
p0 2 80
02 Sat 95%
PRACTICE ABGs .
Interpretation: _
Treatment: _
Interpretation: _
Treatment: _...,....;.. _
"
3. pH 7.43
mrerynmtioo: _
pC0
2
37
HCO-
3
25
Treatment: _
pO;:! 88
02 Sat 97%
67
1. pH 7.25 Decreased
pCO
2
55 Increased
HC0
3
-
23 Normal
p02 54 Decreased
O
2
Sat 80% Decreased
2. pH 7.50 Increased
pC0
2
39 Normal
HC0
3
-
28 Increased
p02 80 Normal
O
2
Sat 95% Normal
3. pH 7.43 Normal
pC0
2
37 Normal
HC0
3
-
25 Normal
88 Normal
O
2
Sat 97% Normal
III
p02
III
III
III
II
II
II
II
,:
_I
Self-Study Module
ANSWERS TO PRACTICE ABGs
(acidotic)
(acidotic)
(hypoxemia)
Interpretation:
Treatment:
(alkalosis)
(alkalosis)
Interpretation:
Treatment:
Interpretation:
Treatment:
Respiratory Acidosis
with hypoxemia
Hyperventilate with
ambu bag and ensure
patient is receiving
I()()% O
2
Metabolic Alkalosis
Treat the cause
Normal ABGs
None
68
Self-Study Module
ELECTROLYTES
This chapter includes a brief discussion of three electrolytes which, when they become
abnormal or imbalanced may prevent resolution of a lethal dysrhythmia.
IELECTROLYTES
1. Potassium (K+) 3.6-5.2 mEq/L
Promotes transmission of impulses through the heart's conduction system
Aids in the regulation of acid-base balance
Promotes contractility of h ~ heart muscles
a. Hyperkalemia (K+ > 5.2 mEq/L)
Causes:
Renal disease
Excessive administration of KCI
Signs and Symptoms:
~ u s c l e weaklless
ECG changes ~ peaked T waves
Slowing of conduction and decrease in excitability therefore a
decrease in contractility
Treatment:
Treat underlying causes
Check K+ level
Severe K+ > 6.5 mEq/L
Give CaCl
2
or calcium gluconate, LV. insulin, NaCH0
3
,
Kayexlate, or dialysis (depends on patient diagnoses and situation
69
Self-Study Module
b. Hypokalemia (K+ < 3.6 mEq/L)
Causes:
Loss of K+ through:
GJ diarrhea, vomiting
Skin, extreme sweating
Stress - Release of epinephrine promotes entry of K+ into
cells from extracellular space
Signs and Symptoms:
I
Fatigue, leg cramps
~ reflexes, muscle tone'
Disrupts cellular integrity in heart - damages muscle
Dysrhythmias occur due to irritable muscle, usually ventricular
dysrhythmias (PVCs, V-tach, V-fib)
, Treatment:
L
,
Check K+ level
Administer K+ (20 mEq KCl/hr per LV.)
Monitor ECG
Watch for respiratory arrest
I
2. Calcium (Ca++) 8.8 - 10.3 mg/dL
I
Maintains hardness of bones and teeth
Promotes muscle contractions - skeletal and cardiac
I
Works directly on contractile force of cardiac muscles
, a. HypercaIcemia(> 10.3 mg/dL)
Occurs when rate of Ca++ entry into serum exceeds kidney excretion
I
Causes:
Hyperparathyroidism and malignancy
I
t GJ absorption - Vit D overdose and t Ca++ supplements
I
I
70
I
Self-Study Module
Signs and Symptoms:
neuromuscular irritability
Weakness, fatigue
GI - Nausea, vomiting, t gastric secretion
Renal failure
cardiac action potential causing short repolarization period,
V-fib can occur here
Asystole at Ca++ levels L 18.0 mg/dL
Treatment:
Usually for Ca++ levels> 12.0 mg/dL
Normal saline and loop diuretics
Maintain urine output 200-300 cc/hr
Lasix q 2-4h
Phosphate administration (Phosphate binds Ca++)
b. Hypocalcemia 8.8 mg/dL)
Causes:

intestinal absorption
Ca++ deficient diet
Impaired Vit D metabolism
Chronic diarrhea
Small bowel disease
Excessive Ca++ loss
Massive infections or bums
Alkalosis
Administration large amount citrated blood (Bank Blood)
ETOH
71
. Self-Study Module
Signs and Symptoms:
Neuro
Muscle cramping
Seizures
Personality changes - depression
t
irritable confusion
Finger numbness/tingling
Respiratory
Stridor
Spasm (brQ!!.<1hial smooth muscle)
. Respiratory arrest
Cardiovascular (CV)
+contractility of cardiac muscles
Prolonged QT
Hypotension
Treatment:
Check Ca++ levels
Ca++ replacement
Calcium gluconate or CaCI (they are not interchangeable) PO/IV
Phosphate binders
t
give antacids so Ca++ does not bind with
phosphate
Ca++ supplements
Mg++ replacement may also be necessary
In code situation
Use CaCI prefilled syringe
10 ml = 13.6 mEq Ca++
I. V. dose 2-4 mg/kg
Repeat in 10 minute intervals
72
.l.uuuuu\,.UUU ~ U Uy:SlllyLnnua Kecognltlon
Self-Study Module
3. Magnesium(Mg++) 1.7 - 2.3 mg/dL
Promotes contraction of cardiac muscles
Activates enzymes for cellular metabolism
a. Hypermagnesemia (> 2.3 mg/dL)
Causes:
Renal failure
Laxatives, antacids
Signs and Symptoms:
Cardiovascular (CV)
Bradycardia
SA, AV nodal blocks
Complete heart block
, Hypotension
Vasodilation
Flushing
Sweating
CNS
Drowiness
Coma at Mg++ levels 2.. 12-15 mg/dL
Respiratory
Respiratory center depression
Gl
Nausea, vomiting
Sensation of thirst
Renal
Renal failure
73

Self-Study Module
Treatment:
Check Mg++ level
Eliminate cause
Loop diuretics, normal saline infusion
Calcium gluconate to antagonize symptoms
Dialysis if due to renal failure
b. Hypomagnesemia 1.7 mg/dL)
Causes:
Diuretic therapy
Digitalis
Malnutrition
Chronic alcoholism
Colitis
Signs and Symptoms:
Neuro
Mood changes, confusion
Peripheral nerve irritability
Tremors, convulsions, tetany
Cardiovascular (CV)
Dysrhythmias
PVCs
SVT
V-fib, V-tach, or Torsade de pointes
III
GI
Anorexia, nausea, vomiting
Sensation abdominal distention
,
,
I
,
74
Self-Study Module
Treatment:
Check Mg ++ level
Monitor levels daily on patients at risk
Mg++ replacement
Dietary - mild symptoms
1. V. for symptomatic patient
~ <
Monitor other electrolytes as well
If K+, Mg++ - correct Mg++ first
Code situation
For V-tach:
Give 1-2 gm Mg++ diluted in 10 ml DsW
Administer over 1-2 minutes
For V-Fib
Give 1-2 gm Mg++ IVP
75

Self-Study Module
PRACTICE QUESTIONS
1. K+ < 3.2 mEq/L is dangerous because it can cause:
a. Ventricular dysrhythmias
b. Teeth to fall out
c. Seizures
d. Depression
2. Treatment of low K+ would be to administer:
a. Phosphate
b. PO fluids
c. LV. KCI
d. Antacids
3. Hypocalcemia especially levels < 8.8 mg/dL can cause:
,
III ,.\.'
II
.
I
,
,"
II
-
a-
li
II
a. Increase in Vitamin D
b. Decreased contractility of a r d i a ~ muscle
c. Renal failure
d. Mood changes, relaxed, calm
4. Treatment of low Ca++ would be to administer:
a. Phosphate
b. Normal saline
c. Vitamin C supplements
d. Calcium gluconate PO or I. V.
5. Hypomagnesemia especially levels < 1.7 mg/dL are dangerous because it can
cause:
a. Weak deep knee reflexes
b. Respiratory depression
c. Torsade de pointes .
d. Sensation of thirst
6. Treatment of low Mg++ in a code situation would be to administer:
a. Mg 1-2 gm IVP over 1-2 min
b. Lasix 80 mg IVP
c. Normal saline 500 cc bolus
d. CaCI to increase hypotension
76
- -- - -- ....... ..- J ..I..I..I..l.a .I.""",,,",V!)l11LIUll
Self-Study Module
7. Mr. C. is admitted complaining of nausea and vomiting., He is confused and his
BeG shows Torsade de pointes. His medical history shows that he has been on
digitalis for several years. The cause of these symptoms most likely would be:
a. Hypomagnesemia
b. Hypercalcemia
c. Hypophosphatemia
d. Hypokalemia
8. Mrs. J. is admitted with a history of renal disease. She has been complaining of
muscle weakness and lightheadedness. Her BCG shows peaked T waves. These
symptoms most likely would be caused by:
a. Hypokalemia
b. Hypomagnesemia
c. Hyperkalemia
d. Hypercalcemia
l
_11-'
77
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Self-Study Module
ANSWERS TO PRACTICE QUESTIONS
1. a
2. c
3. b
4. d
5. c
6. a
7. a
8. c
78

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LOS ANGELES COUNTY +UNIVERSITY OF S)1J;fHERN CENTER

Electrical Conduction System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-11

QRS Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20-22

Calculating the Heart Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-3

F 77f7W:-"-'-""""''''' '" $'''''''11

Introduction to Dysrhythmia Recognition

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