EKG

SVT
Also known as PAT

Rhythm is regular
Rate 140-250
P-waves: abnormal, usually hidden in preceding T-wave
How to distinguish it:

shortcut: if P hidden in T equals SVT

the rhythm will be too fast it will have an elevated T- wave
it will start off with a sinus tachycardia changing to an SVT (faster and shorter R-R with elevated T-wave
because its as P-waves hidden on the T-wave)
Treatment

if stable
o check BP
o sedate (will fix it in most patients)
o try doing vagal maneuvers
bearing down (forcing yourself like if your were constipated)
carotid massage
squatting
gag reflex
holding breath
o level of consciousness
o alert, no chest pain, or SOB

drug of choice:
o adenosine IV
give 6 mg bolus flush with 10ml of normal saline and raise arm if doesnt work give double the
dose (12mg in 1 to 2 min)
slows conduction on AV node
he will go into asystole for a few seconds and come back to normal with a regular rhythm
o calcium channel blockers
o beta blockers
o check vitals before and after giving meds
o both drop blood pressure, and slows heart rate
cardioversion (if unstable)
o sync it first so that it can capture the rhythm once done, it will then shock on the R-waves
antiarrhythmic
o amiodarone
o procainamide
Atrial Fibrillation

rhythm: grossly irregular

rate: atrial 400 or more (unmeasurable)
rate: ventricular varies with number of impulses conducted through AV node
PR interval unmeasurable
QRS normal
Most common dysrhythmia
 How to distinguish it:

Can be too fast or too slow

The p-wave is varying in shapes and direction, may be small and hard to distinguish
Treatment

If awake has to be sedated

If occurring greater than 48 hours give anticoagulants for 3 weeks , cardioversion then anticoagulants for
additional 4 weeks
If rate greater than 100 give meds to slow it down and treat with anticoagulants
If less than 48 hours cardioversion or any time unstable
Adequate left ventricular function (slow down rate)
o Beta blockers
o Calcium channel blockers
o Digitalis
With CHF
o Digitalis
o Dilitiazem
o Amiodarone
Sudden onset less than 48 hrs (will convert it to normal sinus rhythm)
If not given anticoagulant patient will have a clot and cause a pulmonary emboli, or stroke
If chronic going to try radiofrequency catheter evasion
Atrial flutter

Rhythm regular or irregular

Rate atrial 250-400
Rate ventricle varies with the number of impulses conducted, will be less than atrial
PR not measureable
QRS normal
How to distinguish it:

P-waves is seen as a saw tooth

Treatment

Control the ventricular rate (by giving calcium channel blockers like Dilitiazem, or beta blockers
If occurring greater than 48 hours give anticoagulants for 3 weeks , cardioversion then anticoagulants for
additional 4 weeks
If rate greater than 100 give meds to slow it down and treat with anticoagulants
If less than 48 hours cardioversion or any time unstable
Adequate left ventricular function (slow down rate)
o Beta blockers
o Calcium channel blockers
o Digitalis
With CHF
o Digitalis
o Dilitiazem
o Amiodarone
Sudden onset less than 48 hrs (will convert it to normal sinus rhythm)
If not given anticoagulant patient will have a clot and cause a pulmonary emboli, or stroke
If chronic going to try radiofrequency catheter ablation
Torsades de pointes

How to distinguish it:

o Twisting of the points; a type of VT
o Large bizarre, multiform QRS complexes of varying amplitude and direction
Caused by
o prolonged QT intervals
o a side effect of type 1 A antiarrhythmic
quinidine
procainamide
o hypokalemia
o hypocalcemia
o hypoglycemia
o overdose of tricyclic antidepressants
o check leads may just be placed wrong
treatment
o magnesium IV
o temporary override pacing
Sinus bradycardia

rhythm regular
rate 40-60
p-waves normal
QRS normal
increase in parasympathetic tone
Causes that lead to bradycardia

may be normal in athletic people at rest or during sleep (35bpm or greater)

certain meds:
o beta blockers
o calcium channel blockers
o digoxin
increase in the parasympathetic tone (bearing down, carotid massage)
pain
being frighten
stress
nausea, vomiting
MI patients
Treatment

check:
o if patient is alert
o Blood pressure
Severe if (signs and symptoms of decrease perfusion)
o Patient cannot be woken up
o Sweaty
o Cold
o Blood pressure less than 90
Cough
o If the patient is stable asking them to cough may increase the heart rate and atropine wont be
necessary
 Putting the patient in Trendelenburg may also fix the problem (depends on how symptomatic they are)
Drug of choice
o Atropine 0.5mg (blocks the parasympathetic) and increases the heart rate
o If given too slow will decrease heart rate
o Needs to be given within 3 sec, in intervals of 5 minutes
o Maximum dose is 2-3 mg
Can also have a transcutaneous or transvenous pacing (chronic bradycardia)
Question the meds (some meds will decrease Heart rate)
o Beta blockers (meds ending in olol)
o Calcium channel blockers (encainide, flecainide)
o Digitalis (antidote is digibind)
Question dose
Some dont require treatment unless
o Cold, clammy skin
o Hypotension
o Shortness of breath
o Chest pain
o Changes in mental status
o Decrease in urine output
o Heart failure
AV blocks
1st degree block (incomplete block)

Rhythm regular
Rate underlying rhythm
P-waves sinus (normal)
PR prolong greater than 0.20
QRS normal
Cause prolong PR interval

Digitalis
Beta blockers
Calcium channel blockers
How to distinguish it:

Beats go through but much slower

Treatment

need to be continuously monitored

2nd degree block (incomplete block)

mobitz 1
o rhythm regular atrial rhythm (p-wave) with irregular ventricular rhythm (QRS)
o rate atrial normal (sinus)
o rate ventricular less than atrial
o p wave sinus
How to distinguish
o PR prolongs interval and gets longer and longer until it drops a beat (missing QRS) than patterns start
again
 o Only one p wave for every QRS
o No treatment required
Causes
o Digitalis
o Inferior MI
Monitor
o If unstable because of bradycardia
Give atropine
mobitz 2
o rhythm regular
o rate atrial sinus
o rate ventricular will depend on the number of impulses conducted will be less than the atrial rate
(more p waves than QRS)
o p waves sinus
How to distinguish it
o PR interval normal or prolonged; remains constant (sometimes there are more than two p-waves on
every QRS; mostly two or three)
o P-waves are identical and occur regulary
o PR interval is normal or prolonged and remains consistent
Causes
o Seen in anterior MI
o Acute myocarditis
o Degeneration of the electrical conduction system (elderly)
Treatment

If asymptomatic (ventricular rate is extremely slow, decreased Cardiac output)

o Symptoms
Hypotension
Shortness of breath
Heart failure
Chest pain
o Give dopamine or epinephrine (if they are stable)
while you wait for transcutaneous pacemaker
o give Epinephrine (more potent)
The slower they are
The lower the BP
The more decreased LOC
Require permanent pacemaker
You can treat with atropine (but it usually never works)
Very dangerous need pacemaker fast, if not treated will go into a 3rd degree block
3rd degree block (complete block)

Rhythm regular
Rate atrial sinus
Rate ventricular 40-60 if paced by AV node; 30-40 if paced by ventricles
P-waves sinus
PR interval varies no constant relationship between P and QRS; P waves can be seen marching through QRS
complexes
None of the sinus impulses are conducted
How to distinguish it

The p-waves fire on their own

The ventricles fire on their own
First measure the regularity from P-P interval if a p-wave lands on the QRS its more than likely a 3rd degree
PR intervals varies and there is no relationship are not coordinated
QRS normal if block located at AV node; wide if block located at bundle branch
Treatment

This is very dangerous it is also known as a 100% block (complete block)

Check meds could be from digitalis toxicity
If asymptomatic
o Minor symptoms (more commonly, the ventricular rate is extremely slow, cardiac output is decreased
and symptoms are present)
Hypotension
Dyspnea (SOB)
Weakness
Fatigue
Dizziness
Exercise intolerance
o Give Dopamine or epinephrine
Need a permanent pacemaker
Atropine may work (if not go straight to epi drip)
If not treated can become asystole
Place transcutaneous pacemaker while they prepare an external pacemaker
If anterospetal MI
o epi
PAC

rhythm underlying
rate underlying
p-wave with PAC abnormal
PR normal
QRS normal
How to distinguish it

Will have an elevated T because the p wave contracted early (non-compensated)

or will have a p waves very close to the t-waves
very slow rate
Causes

caffeine
beer
stress
alcohol
heart failure
epinephrine
norepinephrine
electrolyte imbalance
Treatment
 infrequent PAC require no treatment
frequent PAC
o eliminating or reducing
alcohol intake
stress
tobacco (administer oxygen)
correcting electrolyte imbalance
also treated with
o beta blockers
o Calcium channel blockers
o Antianxiety drugs
Pacemaker
monitor
cardioversion (if condition unstable)
o low blood pressure
o cool clammy skin
o chest pain
o SOB
**after cardioversion may use beta and calcium blockers to control rhythm

Sedation
o Use vagal maneuvers
If fails use adenosine 6mg bolus with rapid 10 ml saline
Asystole

Flat line (standstill)

Occurs after VT, VF, PEA
Caused by extensive myocardial damage
o Hypoxia
o Hyperkalemia
o Hypokalemia
o Hypothermia
o Drug overdose
Treatment

Check pulse
o If patient is conscious it is not ventricular standstill
Check monitor lead system
o Loose electrode pad or lead wire
Check rhythm in two leads
o Fine VF may look like a straight line
Start CPR, establish IV line, ventilate patient, give epinephrine 1mg IV push and repeat every 3-5min, or
vasopressin 40 units IV push may be given
VT

rhythm regular
rate 140-250
QRS wide greater than 0.12 (wide and bizarre)
Check pulse if no pulse treat as V-fib
How to distinguish it:
 QRS wide and bizarre
Its a precursor to death
Goes into V-tach, V-fib, and asystole
Treatment

Shock them as fast as you can

If stable
o Check pulse
o Check blood pressure
Normal blood pressure
No chest pain
No shortness of breath
No signs of decreased perfusion
No pulse
o Antiarrhythmic medication
Amiodarone (Drug of choice)
Lidocaine
procainamide
sotalol (po)
o if unresponsive to drug therapy
sedate
cardiovert
place a pacemaker and an implanted cardioverter defibrillator (ICD)
if unstable
o sedate
o symptoms
hypotension
chest pain
shortness of breath
sings of decreased perfusion
cool
clammy skin
peripheral cyanosis
decreased lever of consciousness
decreased urine output
o cardiovert
o antiarrhythmic medication
o implantable cardioverter defibrillator
o ablation
PVCs

rhythm regular and irregular PVC

Rate underlying rhythm
P-waves none associated with PVC
PVC occurring I the preceding T is a great concern
How to distinguish it:

Will have a normal sinus rhythm and a QRS coming in faster than its supposed to
Treatment

Isolated (one) PVC in to whole strip requires no treatment

 Multiple or consecutive managed with antiarrhythmic agents
o IV amiodarone (drug of choice)
o Procainamide
o Lidocaine
First check pulse oximeter most of the time only need oxygen
Check electrolytes
Check potassium levels
If they have more than 6 PVC in a minute its significant
If one unifocal PVC may just be an acid-base
Trigemini
o Every third R interval (QRS) will have a PVC
Bigeminy
o Every second R interval will have a PVC
VF

Terminal rhythm
Sudden cardiac death
Theres no contraction
No pulse
No perfusion (after 4 min will be brain damaged)
Causes

Acute MI
Electrolyte imbalance
o Hypokalemia
o Hypomagnesemia
Digitalis toxicity
Excessive does of antiarrhythmetics
Cardiac trauma
VF may preceded by significant PVCs or VT
Anesthesia
Pacemaker implantation
Placement of pulmonary artery catheter
As methods as V-tach
Treatment
Once V-fib occurs
o no cardiac output
o no peripheral pulses
o no blood pressure
o patient becomes unconscious
o cyanosis and seizures
course VF
o Check pulse
o Rapidly assess patient
o If patient is conscious V-fib isnt problem
Check ECG may be loose lead or dry electrodes
Patient movement
Muscle tremors
 o If there is no pulse
Patient is unconscious
Defibrillate at 200 joules
If no crash cart do CPR for 5 cycles (2 min) before initial shock
Fine VF
o Early onset defibrillation will reverse it to normal
Treatment
Check pulse if no pulse

Rapid defibrillation (200 joules then increase to 360)

CPR
Establish IV line
Ventilate patient
Administer either epinephrine or vasopressin
Vasopressin works better if not you can then use epinephrine after 10-20 min
Then CPR again
Consider one antiarrhythmetics
o Amiodarone (300 IV push diluted in 20ml of D5W)
o Lidocaine
o Procainamide
Shock, drug, CPR, amiodarone, CPR, shock