Basic Arrhythmias

Review

1
 Presented by
Rapid Response
Training

2
These slides are for recommendations from the
AHA. All modalities of care should be based on
your facilities Protocal.

3
 These slides are brought to you from Rapid
Response Training, using the American Heart
Associations algorithms as a guideline only.

4
Any duplication of this information if
forbidden, and only for the review use
of the paying student.

5
Basic Arrhythmias
Objectives

6
 Objectives
• Explain Heart Anatomy and Basic
Electrophysiology
• Explain Normal ECG
Measurements
• Recognize and Understand Basic
Arrhythmias

7
 Basic Arrhythmias

Cardiac Anatomy
Understanding Electrophysiology

8
 Lines and Calibration
10
mV

1 millivolt (mV) = 1 mm
?

What is the approximate

PR interval in this rhythm
1 second
strip?
0.04 second

0.20 second

9
 ECG Measurements

• PR interval
0.12  0.20 s or
3-5 boxes
• QRS complex
<0.12 s or
>3 boxes
• QT interval
Corrected for
Heart Rate

10
 Anatomy of the Heart

AO
AO = Aorta

LA
PA
LA = Left Atrium
RA
RA = Right Atrium
LV LV = Left Ventricle

PA = Pulmonary Artery RV

RV = Right Ventricle

11
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Right Bundle
RV
Pathways Branch

Purkinje System
Atrioventricular (AV)
Node

12
 Conduction System Anatomy

Sinus Node
60-100 bpm

LV
RV

13
 Conduction System Anatomy

Sinus Node
Sinus Brady
occurs HERE!

LV
RV

14
15
 Conduction System Anatomy

LV
Internodal Pathway RV

16
 Conduction System Anatomy

LV
Internodal Pathway RV
1AVHB located
here, shows as
P-R greater
than 5 boxes

17
1*AVHB

18
 Conduction System Anatomy

LV
RV

Atrioventricular (AV)
Node 40-60bpm

19
Conduction System Anatomy
Common Bundle of His
Left Bundle Branch
Right Bundle Branch

LV
RV

20
Conduction System Anatomy
Common Bundle of His
Left Bundle Branch
Right Bundle Branch
2AVHB Type I,
Wenckebach P-R is
normal, longer, longer,
drop. A complete
LV block with a
RV
missing QRS

21
2*AVHB Type I

22
Conduction System Anatomy

LV
RV

Purkinje System

23
Conduction System Anatomy

LV
RV

Purkinje System
2AVHB Type II
occurs here.
Multiple P waves to
each QRS
24
2*AVHB Type II

 

25
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Right Bundle
RV
Pathways Branch

Purkinje System
Atrioventricular (AV)
Node
3AVHB is a complete block/failure, P wave shifts up and
down the baseline without correlation to any QRS 26
3*AVHB

27
 Pacemakers of the Heart

Sinus Node His Bundle

60-100 bpm

Purkinje
System
30-40 bpm
AV Node or less
(junctional
cells)
40-60 bpm

Failure of a pacemaker allows a subsidiary

pacemaker to fire. 28
 Anatomy of the ECG
• P wave
• PR interval
• QRS complex
• ST segment
• T wave
• QT interval

29
 Anatomy of the ECG

P wave-Arium fires

30
 Anatomy of the ECG

PR interval <5 boxes

p AVN

PR

31
 Anatomy of the ECG
QRS

QRS complex-Ventrical
fires, repolarize of
atrium

32
 Anatomy of the ECG

ST
Segment

ST segment
>3 boxes

33
 Anatomy of the ECG

T wave-repolarize
of ventricals

34
Standard Monitoring Leads
Lead 1

35
Standard Monitoring Leads
Lead 2

36
Standard Monitoring Leads
Lead 3

37
 12-Lead ECG
The Big Picture

  


 
 

= 38
 Basic Arrhythmias
Rhythm Strip Interpretation

39
 Basic Arrhythmias
Rhythm Strip Interpretation
Normal Sinus Rhythm 60-100 bpm-
treat symptoms.

40
 Basic Arrhythmias
Rhythm Strip Interpretation
Normal Sinus Rhythm 60-100 bpm-
treat symptoms.
Sinus Bradycardia below 60 bpm-
speed it up.

41
 Basic Arrhythmias
Rhythm Strip Interpretation
Normal Sinus Rhythm 60-100 bpm-
treat symptoms.
Sinus Bradycardia below 60 bpm-
speed it up.
Sinus Tachycardia above 100 bpm-
slow it down.
42
Initial Approach—Analysis
4 Questions

43
Initial Approach—Analysis
4 Questions
• Rate?
– Normal
– Bradycardia, Tachycardia

44
Initial Approach—Analysis
4 Questions
• Rate?
– Normal
– Bradycardia, Tachycardia
• Rhythm?
– Regular or Irregular

45
Initial Approach—Analysis
4 Questions
• Rate?
– Normal
– Bradycardia, Tachycardia
• Rhythm?
– Regular or Irregular
• Are there P waves?
– Is each P wave related to a QRS
with 1:1 impulse conduction?

46
Initial Approach—Analysis
4 Questions
• Rate?
– Normal
– Bradycardia, Tachycardia
• Rhythm?
– Regular or Irregular
• Are there P waves?
– Is each P wave related to a QRS
with 1:1 impulse conduction?
• QRS normal or wide?

47
• Rate
• Rhythm
• P waves
• P→
QRS
• Therapy 48
• Rate 60-100/min
• Rhythm
• P waves
• P→
QRS
• Therapy 49
• Rate 60-100/min
• Rhythm Regular
• P waves
• P→
QRS
• Therapy 50
• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P→
QRS
• Therapy 51
• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P→ 1:1 conduction
QRS
• Therapy 52
• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P→ 1:1 conduction
QRS None
• Therapy 53
 Normal Sinus Rhythm

• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P→ 1:1 conduction
QRS None
• Therapy 54
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Right Bundle
RV
Pathways Branch

Purkinje System
Atrioventricular (AV)
Node

55
 Normal Sinus Rhythm

• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P→ 1:1 conduction
QRS None, what if Chest Pain?
• Therapy 56
 Chest Pain
* M-

* O-
* N-

* A-

57
 Chest Pain
* M- Morpine Sulfate, 2-4mgs, titrate to effect,

10mgs max. min B/P of 90systolic

* O-
* N-

* A-
58
 Chest Pain
* M- Morpine Sulfate, 2-4mgs, titrate to effect,

10mgs max. min B/P of 90systolic

* O- Oxygen, 15L NRB
* N-

* A-
59
 Chest Pain
* M- Morpine Sulfate, 2-4mgs, titrate to effect,

10mgs max. min B/P of 90systolic

* O- Oxygen, 15L NRB
* N- NTG 1 tab/spray sl, @ 3-5 min, max 3.
*B/P has to be min 90 systolic, cant have a

greater than 30 pt drop in B/P

NO Cialis, Viagra, Levitra, w/in 24hrs.
* A- 60
 Chest Pain
* M- Morpine Sulfate, 2-4mgs, titrate to effect,

10mgs max. min B/P of 90systolic

* O- Oxygen, 15L NRB
* N- NTG 1 tab/spray sl, @ 3-5 min, max 3.
*B/P has to be min 90 systolic, cant have a

greater than 30 pt drop in B/P

NO Cialis, Viagra, Levitra, w/in 24-48hrs.
* A- Aspirin, 2-4 baby aspirin, 160-324mg, po. 61
•

OR

62
 Chest Pain
* F- Fentanyl, 50-150 mcgs, titrate to effect,

250 mcgs max. min B/P of 90systolic

* O- Oxygen, 15L NRB
* N- NTG 1 tab/spray sl, @ 3-5 min, max 3.
*B/P has to be min 90 systolic, cant have a

greater than 30 pt drop in B/P

NO Cialis, Viagra, Levitra, w/in 24hrs.
* A- Aspirin, 2-4 baby aspirin, 160-324mg, po. 63
• Rate
• Rhythm
• P
waves
• P→
QRS 64
• Rate <60/min
• Rhythm
• P
waves
• P→
QRS 65
• Rate <60/min
• Rhythm Regular
• P
waves
• P→
QRS 66
• Rate <60/min
• Rhythm Regular
• P Present
waves
• P→
QRS 67
• Rate <60/min
• Rhythm Regular
• P Present
waves 1:1 conduction
• P→
QRS 68
• Rate <60/min
• Rhythm Regular
• P Present
waves 1:1 conduction
• P→ Treat underlying cause,
QRS 69
 Sinus Bradycardia

• Rate <60/min
• Rhythm Regular
• P Present
waves 1:1 conduction
• P→ Treat underlying cause,
QRS 70
 Sinus Bradycardia

• Rate <60/min
• Rhythm Regular
• P Present
waves 1:1 conduction
• P→ Treat underlying cause,
QRS Atropine, Pacing, Dopamine71
 Conduction System Anatomy

Sinus Node
Sinus Brady
occurs HERE!

LV
RV

72
 Sinus Brady
• Atropine 0.5mg @ 3-5 min, max dose
3mgs.

73
 Sinus Brady
• Atropine 0.5mg @ 3-5 min, max dose
3mgs.
• Pacing, start @ 70bpm, 40ma, raise ma
up 10ma until CAPTURE! Than back ma
down by 5ma and maintain.

74
 Sinus Brady
• Atropine 0.5mg @ 3-5 min, max dose
3mgs.
• Pacing, start @ 70bpm, 40ma, raise ma
up 10ma until CAPTURE! Than back ma
down by 5ma and maintain.
• Dopamine drip 2-20mcg/kg/min,
WEIGHT based!

75
 Sinus Brady
• Atropine 0.5mg @ 3-5 min, max dose
3mgs.
• Pacing, start @ 70bpm, 40ma, raise ma
up 10ma until CAPTURE! Than back ma
down by 5ma and maintain.
• Dopamine drip 2-20mcg/kg/min,
WEIGHT based!
• Epi drip 2-10mcg/min, TIME based!

76
A little break from Cardiology,
here is some important
information you NEED to
know!!!!!

77
Review material

78
 Review material

Hypothermia is also known as Temperature

Regulated Management

79
 Review material

A pt showing signs of a STROKE needs a

CAT scan!!!!!!

80
 Review material

If you have Hypotension/lowB/P with ROSC

Give a Fluid Bolus!!!!!! 1-2L

81
 Review material

Continue compressions while the defibrillator

is charging!

82
 Review material

NO hypothermia protocal if pt is talking!

Pt MUST be comatose with ROSC.

83
 Review material

Anyone with chest pain, get a 12 lead EKG

84
 Review material

Aspirin dose is:

160-325mg p.o.
Or 2-4 tablets under the tonge

85
 Review material

Amiodarone dose:
V. Tach with a PULSE(alive) 150mg
V. Tach NO PULSE or V Fib(dead) 300mg

86
 Review material

Endtitle CO2, better known as PETCO2

Measures/assess’ quality CPR!

It also confirms endotracheal tube placement.

87
 Review material

Once a shock has been given, start CPR

IMMEDIATELY!

88
 Review material

The leading cause of death in the ADULT is

HEART ATTACK!

When you get a return of spontaneous

circulation/ROSC, bring them to the
APPROPRIATE hospital which allows Coronary
reperfusion!!!!!!!

89
Back to the learning!

90
 Basic Arrhythmias
Supraventricular Arrhythmias

91
 Basic Arrhythmias
Supraventricular Arrhythmias

Reentry Tachycardia

92
Supraventricular Tachycardia (SVT)
AV Reentry Tachycardia

What is different
between these
2 examples?
(Look carefully at
the arrow directions)

Connection between Connection between

atria and ventricle atria and ventricle

Is the QRS complex

normal or wide for each?
Why?
93
 Supraventricular Tachycardia (SVT)
The arrows are moving
upward!!! AV Reentry Tachycardia
Impulse from the Ventricles=
V Tach

What is different
between these
2 examples?
(Look carefully at
the arrow directions)

Connection between Connection between

atria and ventricle atria and ventricle

Is the QRS complex

normal or wide for each?
Why?
94
 Supraventricular Tachycardia (SVT)
The arrows are moving
The arrows are moving
downward!
upward!!! AV Reentry Tachycardia Impulse is coming from the
Impulse from the Ventricles=
atria=
V Tach
SVT

What is different
between these
2 examples?
(Look carefully at
the arrow directions)

Connection between Connection between

atria and ventricle atria and ventricle

Is the QRS complex

normal or wide for each?
Why?
95
 
Usually onsets with PAC
QRS
Normal

• Rate
• Rhythm

• P waves
• P → QRS
• Therapy

96
 
Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm

• P waves
• P → QRS
• Therapy

97
 
Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves
• P → QRS
• Therapy

98
 
Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, and aVF
• P → QRS
• Therapy

99
 
Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, and aVF
• P → QRS Conduction regular
• Therapy

100
 
Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, and aVF
• P → QRS Conduction regular
• Therapy Vagal maneuvers, adenosine,
synchronized cardioversion
101
 Reentry (Paroxysmal) SVT

Usually onsets with PAC
QRS
Normal

• Rate Atrial rate 150-250/min

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, and aVF
• P → QRS Conduction regular
• Therapy Vagal maneuvers, adenosine,
synchronized cardioversion
102
Supraventricular Tachycardia (SVT)

Connection between
atria and ventricle

103
 SVT
• Stable- Vagal, IV Lt A/C, Adenosine
6mgs w/10cc NS flush, 12mgs w/10cc
NS flush, 12mgs w/10cc NS flush

104
 SVT
• Stable- Vagal, IV Lt A/C, Adenosine
6mgs w/10cc NS flush, 12mgs w/10cc
NS flush, 12mgs w/10cc NS flush

• Unstable- Pre-medicate w/Versed or

Valium 2-10 mgs, titrate to effect,
Sync Cardiovert @ 50j, 100j, 200j, 300j,
360j

105
 Basic Arrhythmias
Ventricular Arrhythmias

Ventricular Tachycardia
Ventricular Fibrillation

Asystole
Pulseless Electrical Activity (PEA)

106
 
*Sustained—requires intervention for >30 seconds

• Rate
• Rhythm

• P waves
• P → QRS
• Therapy

107
 
*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm

• P waves
• P → QRS
• Therapy

108
 
*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves
• P → QRS
• Therapy

109
 
*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—obscured
• P → QRS
• Therapy

110
 
*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy

111
 
*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Unstable=sync cardiovert starting @100j,
STABLE= Amiodarone 150mg over 10
min. 112
 Ventricular Tachycardia
Monomorphic*


*Sustained—requires intervention for >30 seconds

• Rate Atrial rate normal

• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Unstable=sync cardiovert starting @100j,
STABLE= Amiodarone 150mg over 10
min. 113
 Ventricular Tachycardia
• Stable- O2-15l w/NRB mask, IV,
Amiodarone 150mgs over 10 min.

114
 Ventricular Tachycardia
• Stable- O2-15l w/NRB mask, IV,
Amiodarone 150mgs over 10 min.
• Unstable- O2-15l w/NRB mask, IV, pre-
medicate w/Versed or Valium 2-10mgs,
titrate to effect, Sync Cardiovert @
100j, 200j, 300j, 360j

115
 Ventricular Tachycardia

Remember, if you have V. Tach without a

PULSE. Treat it as Ventricular Fibrillation!

Pulseless V. Tach is V. Fib!

116
• Rate
• Rhythm

• P waves
• P → QRS
• Therapy

117
• Rate Atrial rate normal (obscured)
• Rhythm

• P waves
• P → QRS
• Therapy

118
• Rate Atrial rate normal (obscured)
• Rhythm Onset tachycardia abrupt
Irregular
• P waves
• P → QRS
• Therapy

119
• Rate Atrial rate normal (obscured)
• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present—obscured
• P → QRS
• Therapy

120
• Rate Atrial rate normal (obscured)
• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy

121
• Rate Atrial rate normal (obscured)
• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Unstable=sync cardiovert shock,
STABLE= Mag Sulfate 2GMS over 10
min.
122
 Polymorphic VT*

*Torsades de pointes—QT prolonged

• Rate Atrial rate normal (obscured)

• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present—obscured
• P → QRS Blocked—fusion complexes possible
• Therapy Unstable=sync cardiovert shock,
STABLE= Mag Sulfate 2GMS over 10
min.
123
 Torsades de Pointes
• Common in

124
 Torsades de Pointes
• Common in
- Pregnancy

125
 Torsades de Pointes
• Common in
- Pregnancy
- Alcoholism

126
 Torsades de Pointes
• Common in
- Pregnancy
- Alcoholism
- Renal Dialysis Pts

127
 Torsades de Pointes
• Common in
- Pregnancy
- Alcoholism
- Renal Dialysis Pts
Stable- O2-15l w/NRB mask, IV,
Mag Sulfate 2GMS over 10 mins

128
 Torsades de Pointes
• Common in
- Pregnancy
- Alcoholism
- Renal Dialysis Pts
Stable- O2-15l w/NRB mask, IV,
Mag Sulfate 2GMS over 10 mins
Unstable- O2-15l w/NRB mask, IV, pre-
medicate, sync cardiovert @ 100j, 200j,
300j, 360j
129
 

• Rate
• Rhythm

• P waves
• P → QRS
• Therapy

130
 

• Rate Chaotic, uncountable

• Rhythm

• P waves
• P → QRS
• Therapy

131
 

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves
• P → QRS
• Therapy

132
 

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS
• Therapy

133
 

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy

134
 

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate defibrillation@360joules if
witnessed. 2 min of CPR first if NOT
witnessed. 135
 Ventricular Fibrillation

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate defibrillation@360joules if
witnessed. 2 min of CPR first if NOT
witnessed. 136
 Ventricular Fibrillation
Coarse VF

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate defibrillation@360joules if
witnessed. 2 min of CPR first if NOT
witnessed. 137
 Ventricular Fibrillation
Fine VF

• Rate Chaotic, uncountable

• Rhythm Onset abrupt
Irregular
• P waves Absent; no normal QRS complexes
• P → QRS Not applicable
• Therapy Immediate defibrillation@360joules if
witnessed. 2 min CPR first if NOT
witnessed. 138
V. Fib or V. Tach NO Pulse

139
 V. Fib or V. Tach NO Pulse
• Witness arrest:

140
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j

141
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)

142
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j

143
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000

144
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)

145
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j

146
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg

147
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)

148
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j

149
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)

150
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• H’s & T’s

151
 V. Fib or V. Tach NO Pulse
• Witness arrest:
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• H’s & T’s
• Defib @ 360j
152
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:

153
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)

154
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j

155
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)

156
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j

157
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000

158
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)

159
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j

160
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg

161
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)

162
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j

163
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)

164
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• H’s & T’s

165
 V. Fib or V. Tach NO Pulse
• Unwitness arrest:
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• Defib @ 360j
• Epi 1mg 1:10,000
• CPR(2min)
• Defib @ 360j
• Amio 300mg
• CPR(2min)
• Defib @ 360j
• CPR(2min)
• H’s & T’s
• Defib @ 360j

166
 Agonal Complexes

• Rate
• Rhythm
• P waves
• P → QRS
• Therapy

167
 Agonal Complexes

• Rate Absent
• Rhythm
• P waves
• P → QRS
• Therapy

168
 Agonal Complexes

• Rate Absent
• Rhythm None—“flatline”
• P waves
• P → QRS
• Therapy

169
 Agonal Complexes

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS
• Therapy

170
 Agonal Complexes

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS Not applicable
• Therapy

171
 Agonal Complexes

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS Not applicable
• Therapy Always check it in two leads,

172
 Asystole

Agonal Complexes ASYSTOLE

Pulseless Electrical
Activity

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS Not applicable
• Therapy Always check it in two leads,

173
 Asystole

Agonal Complexes ASYSTOLE

Pulseless Electrical
Activity

• Rate Absent
• Rhythm None—“flatline”
• P waves Absent
• P → QRS Not applicable
• Therapy Always check it in two leads, than CPR,
Epi 1 mg, H’s and T’s.

174
Asystole

175
 Asystole
• Always check in two leads

176
 Asystole
• Always check in two leads
• CPR for 2 minutes

177
 Asystole
• Always check in two leads
• CPR for 2 minutes
• Epi 1mg 1:10,000 every 3-5min

178
 Asystole
• Always check in two leads
• CPR for 2 minutes
• Epi 1mg 1:10,000 every 3-5min
• H’s & T’s

179
 ARTERIAL PRESSURE

• Rate
• Rhythm

• Therapy

180
 ARTERIAL PRESSURE

• Rate Variable—depends on baseline rhythm

• Rhythm

• Therapy

181
 ARTERIAL PRESSURE

• Rate Variable—depends on baseline rhythm

• Rhythm PEA is not a single rhythm but any
organized rhythm without a pulse
• Therapy

182
 ARTERIAL PRESSURE

• Rate Variable—depends on baseline rhythm

• Rhythm PEA is not a single rhythm but any
organized rhythm without a pulse
• Therapy Identify and treat underlying cause
CPR, Epi 1mg, H’s and T’s

183
 Pulseless Electrical Activity (PEA)

ARTERIAL PRESSURE

• Rate Variable—depends on baseline rhythm

• Rhythm PEA is not a single rhythm but any
organized rhythm without a pulse
• Therapy Identify and treat underlying cause
CPR, Epi 1mg, H’s and T’s

184
Review material

185
 Review material

The purpose of CPR is blood flowing to the

heart and vital organs

186
 Review material

Pt in respiratory arrest but has a pulse, should

be given
1 breath every 5-6 seconds 10-12/min

187
 Review material

If you get an organized rhythm on the monitor,

check for a pulse

188
 Review material

AGONAL GASPS are the last few gasps of air

of someone who is dead/in cardiac arrest!!!!

189
 Review material

With CPR in progress, ALWAYS IV/IO PUSH

medications!!!!!

190
 Review material
• The purpose of CPR is blood flowing to the heart and vital
organs
• Pt in respiratory arrest but has a pulse, should be given
• 1 breath every 5-6 seconds 10-12/min
• If you get an organized rhythm on the monitor, check for a
pulse
• Too much O2 can lead to O2 toxicity
• With CPR in progress, ALWAYS IV/IO PUSH medications!!!!!
• Synchronized cardioversion is ONLY for UNSTABLE pts

191
 Review material
• The purpose of CPR is blood flowing to the heart and vital
organs
• Pt in respiratory arrest but has a pulse, should be given
• 1 breath every 5-6 seconds 10-12/min
• If you get an organized rhythm on the monitor, check for a
pulse
• Too much O2 can lead to O2 toxicity
• With CPR in progress, ALWAYS IV/IO PUSH medications!!!!!
• Synchronized cardioversion is ONLY for UNSTABLE pts
• MET/RRT teams are for rapidly deteriorating pts!!!!

192
 Review material
• The purpose of CPR is blood flowing to the heart and vital
organs
• Pt in respiratory arrest but has a pulse, should be given
• 1 breath every 5-6 seconds 10-12/min
• If you get an organized rhythm on the monitor, check for a
pulse
• Too much O2 can lead to O2 toxicity
• With CPR in progress, ALWAYS IV/IO PUSH medications!!!!!
• Synchronized cardioversion is ONLY for UNSTABLE pts
• MET/RRT teams are for rapidly deteriorating pts!!!!
• If the AED acts up, continue COMPRESSIONS!!!!!

193
 Review material
• The purpose of CPR is blood flowing to the heart and vital
organs
• Pt in respiratory arrest but has a pulse, should be given
• 1 breath every 5-6 seconds 10-12/min
• If you get an organized rhythm on the monitor, check for a
pulse
• Too much O2 can lead to O2 toxicity
• With CPR in progress, ALWAYS IV/IO PUSH medications!!!!!
• Synchronized cardioversion is ONLY for UNSTABLE pts
• MET/RRT teams are for rapidly deteriorating pts!!!!
• If the AED acts up, continue COMPRESSIONS!!!!!
• Remember, Call 911, You get or someone get an AED, come and
help!!!

194
Back to learning!

195
Basic Arrhythmias
Atrioventricular Blocks

196
Basic Arrhythmias
Atrioventricular Blocks

First-Degree AV Block

197
Basic Arrhythmias
Atrioventricular Blocks

First-Degree AV Block
Second-Degree AV Block

198
Basic Arrhythmias
Atrioventricular Blocks

First-Degree AV Block
Second-Degree AV Block
Third-Degree AV block

199
Atrioventricular Blocks
Classification

200
 Atrioventricular Blocks
Classification

• Incomplete AV Block

201
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block

202
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block

Second-Degree AV Block

203
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

204
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

Type II—Mobitz II

205
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

Type II—Mobitz II

206
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

Type II—Mobitz II

• Complete AV Block

207
 Atrioventricular Blocks
Classification

• Incomplete AV Block
First-Degree AV Block
Type I—Wenckebach
Second-Degree AV Block Mobitz I

Type II—Mobitz II

• Complete AV Block
Third-Degree AV Block

208
 Sinus Node

AV Node
AV Nodal
Tissue
>0.20 seconds

QRS <0.12

His-Purkinje System
209
 Sinus Node

• Underlying sinus rhythm

AV Node
AV Nodal
Tissue
>0.20 seconds

QRS <0.12

His-Purkinje System
210
 Sinus Node

• Underlying sinus rhythm

AV Node
• One P wave AV Nodal
Tissue
>0.20 seconds

QRS <0.12

His-Purkinje System
211
 Sinus Node

• Underlying sinus rhythm

AV Node
• One P wave AV Nodal
Tissue
>0.20 seconds
• PR interval >0.20
QRS <0.12
second

His-Purkinje System
212
 Sinus Node

• Underlying sinus rhythm

AV Node
• One P wave AV Nodal
Tissue
>0.20 seconds
• PR interval >0.20
QRS <0.12
second
• One P wave for each QRS
His-Purkinje System
213
 Sinus Node

• Underlying sinus rhythm

AV Node
• One P wave AV Nodal
Tissue
>0.20 seconds
• PR interval >0.20
QRS <0.12
second
• One P wave for each QRS
• Occurs at the Internodal pathways His-Purkinje System
214
 First-Degree AV Block

Sinus Node

• Underlying sinus rhythm

AV Node
• One P wave AV Nodal
Tissue
>0.20 seconds
• PR interval >0.20
QRS <0.12
second
• One P wave for each QRS
• Occurs at the Internodal pathways His-Purkinje System
215
 Conduction System Anatomy

LV
Internodal Pathway RV
1AVHB located
here, shows as
P-R greater
than 5 boxes

216
First-Degree AV Block

Treatment

217
 First-Degree AV Block
• Atropine 0.5mg @ 3-5min, max dose
3mgs

218
 First-Degree AV Block
• Atropine 0.5mg @ 3-5min, max dose
3mgs
• Pacing: start @ 70bpm, 40ma, raise ma
10ma until capture, than back ma down
by 5ma and maintain

219
 First-Degree AV Block
• Atropine 0.5mg @ 3-5min, max dose
3mgs
• Pacing: start @ 70bpm, 40ma, raise ma
10ma until capture, than back ma down
by 5ma and maintain
• Dopamine drip 2-20mcg/kg/min, weight
based

220
 First-Degree AV Block
• Atropine 0.5mg @ 3-5min, max dose
3mgs
• Pacing: start @ 70bpm, 40ma, raise ma
10ma until capture, than back ma down
by 5ma and maintain
• Dopamine drip 2-20mcg/kg/min, weight
based
• Epi drip 2-10mcg/min, time based

221
222
 Sinus Node
• Underlying sinus rhythm
P

AV Nodal
Tissue

>0.20 seconds
PR interval

X
QRS
His-Purkinje System 223
 Sinus Node
• Underlying sinus rhythm
P
• P wave fails to periodically
conduct
AV Nodal
Tissue

>0.20 seconds
PR interval

X
QRS
His-Purkinje System 224
 Sinus Node
• Underlying sinus rhythm
P
• P wave fails to periodically
conduct
AV Nodal
Tissue
• PR interval prolonged
>0.20 seconds
PR interval

X
QRS
His-Purkinje System 225
 Sinus Node
• Underlying sinus rhythm
P
• P wave fails to periodically
conduct
AV Nodal
Tissue
• PR interval prolonged
• One P wave for each QRS PR interval
>0.20 seconds

until block
X
QRS
His-Purkinje System 226
 Sinus Node
• Underlying sinus rhythm
P
• P wave fails to periodically
conduct
AV Nodal
Tissue
• PR interval prolonged
• One P wave for each QRS PR interval
>0.20 seconds

until block
X
• This occurs in the Bundle
QRS
of His=PACING!
His-Purkinje System 227
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

Sinus Node
• Underlying sinus rhythm
P
• P wave fails to periodically
conduct
AV Nodal
Tissue
• PR interval prolonged
• One P wave for each QRS PR interval
>0.20 seconds

until block
X
• This occurs in the Bundle
QRS
of His=PACING!
His-Purkinje System 228
Conduction System Anatomy
Common Bundle of His
Left Bundle Branch
Right Bundle Branch
2AVHB Type I,
Wenckebach P-R is
normal, longer, longer,
drop. A complete
LV block with a
RV
missing QRS

229
Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

TREATMENT

230
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

231
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

• IV

232
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

• IV
• Premedicate with Versed or Valium, 2-
4mgs, titrate to effect

233
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

• IV
• Premedicate with Versed or Valium, 2-
4mgs, titrate to effect
• Pacing starting at 70 bpm, and 40 ma,
you raise ma by 10 points, until you
achieve capture.

234
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

• IV
• Premedicate with Versed or Valium, 2-
4mgs, titrate to effect
• Pacing starting at 70 bpm, and 40 ma,
you raise ma by 10 points, until you
achieve capture.
• Capture is a Pacer spike that produces
a QRS AND a pulse!

235
 Second-Degree AV Block—Mobitz I
Wenckebach Phenomenon

• O2, 15L NRB mask

• IV
• Premedicate with Versed or Valium, 2-
4mgs, titrate to effect
• Pacing starting at 70 bpm, and 40 ma,
you raise ma by 10 points, until you
achieve capture.
• Capture is a Pacer spike that produces
a QRS AND a pulse!
• Once you achieve Capture, back the ma
down by 5 points and maintain as long
as you still have a QRS and a pulse. 236
 

237
   Sinus Node

P
• Underlying sinus rhythm Block


AV Node

Often Normal
AV Nodal
Tissue

Often normal
QRS complex

His-Purkinje System
238
   Sinus Node

P
• Underlying sinus rhythm Block

• One P wave 
AV Node

Often Normal
AV Nodal
Tissue

Often normal
QRS complex

His-Purkinje System
239
 PR intervals unchanged
  Sinus Node

P
• Underlying sinus rhythm Block

• One P wave 
AV Node
• PR interval usually normal, no
Often Normal
prolongation AV Nodal
Tissue

Often normal
QRS complex

His-Purkinje System
240
 PR intervals unchanged
  Sinus Node

P
• Underlying sinus rhythm Block

• One P wave 
AV Node
• PR interval usually normal, no
Often Normal
prolongation AV Nodal
Tissue

• One P wave for each QRS until Often normal

QRS complex
sudden block and dropped
QRS
His-Purkinje System
241
 Second-Degree AV Block—
Mobitz II
PR intervals unchanged
  Sinus Node

P
• Underlying sinus rhythm Block

• One P wave 
AV Node
• PR interval usually normal, no
Often Normal
prolongation AV Nodal
Tissue

• One P wave for each QRS until Often normal

QRS complex
sudden block and dropped
QRS
His-Purkinje System
242
 Second-Degree AV Block—
Mobitz II
PR intervals unchanged
  Sinus Node

P
• Underlying sinus rhythm Block

• One P wave 
AV Node
• PR interval usually normal, no
Often Normal
prolongation AV Nodal
Tissue

• One P wave for each QRS until Often normal

QRS complex
sudden block and dropped
QRS
• Occurs in the Purkinje His-Purkinje System

fibers=PACING! 243
Conduction System Anatomy

LV
RV

Purkinje System
2AVHB Type II
occurs here.
Multiple P waves to
each QRS
244
Second-Degree AV Block—
Mobitz II
TREATMENT

245
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask

246
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask
• IV

247
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect

248
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.

249
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.
• Capture is a Pacer spike that produces a QRS AND
a pulse!

250
 Second-Degree AV Block—
Mobitz II
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.
• Capture is a Pacer spike that produces a QRS AND
a pulse!
• Once you achieve capture, back the ma down by 5
points and maintain as long as you still have a QRS
and a pulse.
251
252
• Underlying sinus rhythm (usual)

Sinus Node

P
QRS from
AV-His
 escape
AV Node

QRS <0.12

His Purkinje System

253
• Underlying sinus rhythm (usual)
• Escape junctional rate 40-60
Sinus Node

P
QRS from
AV-His
 escape
AV Node

QRS <0.12

His Purkinje System

254
• Underlying sinus rhythm (usual)
• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
QRS from
AV-His
 escape
AV Node

QRS <0.12

His Purkinje System

255
 P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
 escape
AV Node

QRS <0.12

His Purkinje System

256
 P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
• Narrow QRS = block above His  escape
junction AV Node

QRS <0.12

His Purkinje System

257
 P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
• Narrow QRS = block above His  escape
junction AV Node

• Complete failure/blockage of QRS <0.12

electrical system

His Purkinje System

258
 Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
• Narrow QRS = block above His  escape
junction AV Node

• Complete failure/blockage of QRS <0.12

electrical system

His Purkinje System

259
 Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
• Narrow QRS = block above His  escape
junction AV Node

• Complete failure/blockage of QRS <0.12

electrical system=PACING!

His Purkinje System

260
 Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60
Sinus Node
• PR interval variable
P
• P waves unrelated to QRS QRS from
AV-His
• Narrow QRS = block above His  escape
junction AV Node

• Complete failure/blockage of QRS <0.12

electrical system=PACING!
• If no pacing available, Epi Drip 2-
10mcg/min. His Purkinje System
261
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Right Bundle
RV
Pathways Branch

Purkinje System
Atrioventricular (AV)
Node
3AVHB is a complete block/failure, P wave shifts up and
down the baseline without correlation to any QRS 262
Third-Degree AV Block—
Junctional Escape
TREATMENT

263
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask

264
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask
• IV

265
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect

266
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.

267
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.
• Capture is a Pacer spike that produces a QRS AND
a pulse!

268
 Third-Degree AV Block—
Junctional Escape
• O2, 15L NRB mask
• IV
• Pre-medicate with Versed or Valium, 2-4mgs, titrate
to effect
• Pacing starting at 70 bpm, and 40 ma, you raise ma
by 10 points, until you achieve capture.
• Capture is a Pacer spike that produces a QRS AND
a pulse!
• Once you achieve capture, back the ma down by 5
points and maintain as long as you still have a QRS
and a pulse.
269
270
 Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)

QRS from
QRS >0.12
 His-Purkinje
escape

271
His-Purkinje System
 Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)
• Escape ventricular (wide QRS)
rate 30-40
QRS from
QRS >0.12
 His-Purkinje
escape

272
His-Purkinje System
 Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)
• Escape ventricular (wide QRS)
rate 30-40
• PR interval variable QRS from
QRS >0.12
 His-Purkinje
escape

273
His-Purkinje System
 P waves unrelated to QRS

Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)
• Escape ventricular (wide QRS)
rate 30-40
• PR interval variable QRS from
QRS >0.12
• P waves slide up and down  His-Purkinje
escape
baseline, unrelated to QRS

274
His-Purkinje System
 P waves unrelated to QRS

Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)
• Escape ventricular (wide QRS)
rate 30-40
• PR interval variable QRS from
QRS >0.12
• P waves slide up and down  His-Purkinje
escape
baseline, unrelated to QRS
• Wide QRS = block below
Bundle of His junction
275
His-Purkinje System
Third-Degree AV Block—
Ventricular Escape
P waves unrelated to QRS

Sinus Node

P
• Underlying sinus rhythm
AV Node
(usual)
• Escape ventricular (wide QRS)
rate 30-40
• PR interval variable QRS from
QRS >0.12
• P waves slide up and down  His-Purkinje
escape
baseline, unrelated to QRS
• Wide QRS = block below
Bundle of His junction
276
His-Purkinje System
 Conduction System Anatomy
Common Bundle
Sinus Node of His

Left Bundle
Branch
Internodal LV
Right Bundle
RV
Pathways Branch

Purkinje System
Atrioventricular (AV)
Node
3AVHB is a complete block/failure, P wave shifts up and
down the baseline without correlation to any QRS 277
Review materials

278
 Review materials

At the beginning of shift work, all members

should have a delegated task in case of a code.

If you can NOT perform a “task”, ask for a new

task or role!

279
 Review materials

To minimize interruptions in CPR,

ALWAYS continue compressions while the
defibrilator is charging

280
 Review materials

Hyperventilation causes VASOCONSTRICTION

which lowers output.

281
 Review materials

Afib energy dose is 120-200j

282
 Review materials

If a pt has Vtach on monitor, check for a pulse!

283
Basic Arrhythmias
Pacing

284
 Basic Arrhythmias
Pacing
Transcutaneous—Transvenous
Ventricular,
Atrial, and Dual Chamber

285
Pacemakers –

286
Pacemakers –

• Transcutaneous

287
Pacemakers –

• Transcutaneous
• Transvenous

288
Pacemakers –

• Transcutaneous
• Transvenous
− Ventricular

289
Pacemakers –

• Transcutaneous
• Transvenous
− Ventricular
− Atrial

290
Pacemakers –

• Transcutaneous
• Transvenous
− Ventricular
− Atrial
− Dual Chamber

291
 Pacemakers

–
• Transcutaneous


292
 Pacemakers

• Transvenous

293
 Pacemakers
• Transvenous
— Ventricular, notice the
wide QRS
—When each pacer spike
produces an QRS
complex that IS
capture!!!

294
Pacemaker Malfunction
Sinus Node

295
 Cardioversion
Energy Recommendations
Biphasic Waveform Starting Doses
–
• Atrial Fibrillation (120-200)150 J Initial
• Atrial Flutter & SVT 50 J Initial 

• Monomorphic VT 100 J Initial

• Increase the energy dose in a stepwise
fashion for any subsequent
cardioversion attempts, ie: 50j, 100j,
200j, 300, 360j
• Use manufacturer-recommended doses

296
 Cardioversion
Energy Recommendations
Monophasic Waveform
• Atrial Fibrillation 200 J
• Atrial Flutter & SVT 200 J –

• Monomorphic, Unstable 
With Pulse 100 J

• Polymorphic or Pulseless VT—Treat as

VF with high-energy unsynchronized
defibrillation doses

(Do not use low energy—high likelihood of causing

VF in unsynchronized mode) 297
 Self-Assessment
What is this rhythm?

298
 Self-Assessment
What is this rhythm?

If there is no pulse, what is this rhythm?

299
H’s & T’s (underlying causes)

300
 H’s & T’s (underlying causes)
• Hypovolemia
• Hypoxia
• Hypo/Hyperkalemia
• Acidosis(Hydrogen Ion)
• Hypothermia
• Hypoglycemia
• Tension Pneumothorax
• Toxins
• Tamponade
• Thrombosis-Cardiac-Pulmonary-Stroke
• Trauma
301
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.

302
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.

303
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).

304
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.

305
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.

306
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.

307
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression

308
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.

309
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.
• Tamponade-Pericardiocentesis, needle into the sac that holds the
heart, draw out the blood.

310
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.
• Tamponade-Pericardiocentesis, needle into the sac that holds the
heart, draw out the blood.
• Thrombosis Cardiac-heart attack, STEMI

311
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.
• Tamponade-Pericardiocentesis, needle into the sac that holds the
heart, draw out the blood.
• Thrombosis Cardiac-heart attack, STEMI

• Thrombosis Pulmonary-bad outcome

312
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.
• Tamponade-Pericardiocentesis, needle into the sac that holds the
heart, draw out the blood.
• Thrombosis Cardiac-heart attack, STEMI

• Thrombosis Pulmonary-bad outcome

• Thrombosis Stroke-stroke center within 90 min for reperfusion.

313
• The H’s and T’s Hypovolemia–fluid bolus (200ml), check lung sounds,
repeat as necessary based on B/P.
• Hypoxia-high flow O2 assist with bag valve mask (BVM) w/ 100% O2.
• Hypo/Hyperkalemia-Mag Sulfate 2 GMS IVP (fast).
• Acidosis (Hydrogen Ion)-Sodium Bicarb, 1 mEq/kg, normal ph is 7.35-
7.45.
• Hypothermia-Warm them up, no drugs if temp is below 95F, just CPR.
• Hypoglycemia-Dextrose 25GMS, IVP, normal 80-120.
• Tension Pneumo-Needle Decompression
• Toxins-Heroin-Narcan 2mgs, repeat as necessary, Tricyclics-Sodium
Bicarb 1mEq/kg.
• Tamponade-Pericardiocentesis, needle into the sac that holds the
heart, draw out the blood.
• Thrombosis Cardiac-heart attack, STEMI

• Thrombosis Pulmonary-bad outcome

• Thrombosis Stroke-stroke center within 90 min for reperfusion.

• Trauma-Trauma hospital

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Review material

315
 Review material

When given an order by a Doctor, you MUST

repeat the order back to make sure that it is
correct. This is called closed loop
communication.

316
 Review material
Rapid Response Team (RRT)
Medical Emergency Team (MET)

These are the names of the team that responds to patients

that are rapidly deteriorating in order to improve patient
outcomes.

317
 Review material

Target temperature Management or Hypothermia

Recommended range is 32*-36* for at least 24 hours

318
 Review material

Stable blood pressure has to be above 90 Systolic

319
 Review material

If pt is unconscious and NO pulse,

start COMPRESSIONS immediately!!!!!!

320
 Review material

NEVER stop compressions longer than 10 seconds!!

Pulse check always less than 10 second

321
 Review material

Compression rate in CPR 100-120/min

322
 Review material

Always switch out compressors every 2 minutes of CPR

323
 Review material

Petco2 above 10mm Hg is a sign of effective CPR!

324
 Review material

Proper ventilation for a pt with an advanced airway is 10-12

breaths per minute or 1 breath @ 5-6 sec

325
Algorithm
SINUS BRADY
(HR below 60bpm)

Atropine
Pacing
Dopamine drip
Epi drip

326
Algorithm
Chest Pain
(MONA)

Oxygen
Aspirin
Nitroglycerin
Morphine Sulfate

327
 Algorithm
SVT
Stable
Vagal
IV Lt A/C
Adenosine 6mgs w/10cc NS flush,
Adenosine 12mgs w/10cc NS flush,
Adenosine 12mgs w/10cc NS flush
Cardiology consult

328
 Algorithm
SVT
Unstable
IV Lt A/C
Pre-medicate w/Versed or Valium, titrate to effect
Sync Cardiovert @ 50J, 100J,
200j, 300j, 360j

329
 Algorithm
Monomorphic Ventricular Tachycardia
STABLE

IV
Amiodarone 150mg,
drip over 10 minutes

330
 Algorithm
Monomorphic Ventricular Tachycardia
UNSTABLE
IV
Pre-medicate w/Versed or Valium,
titrate to effect
Sync Cardiovert @ 100j, 200j, 300j, 360j

331
 Algorithm

Polymorphic Ventricular Tachycardia

Torsades
STABLE
IV
Magnesium Sulfate 2GMS over 10-20 min

332
 Algorithm

Polymorphic Ventricular Tachycardia

Torsades
UNSTABLE
IV
Pre-medicate w/Versed or Valium,
Titrate to effect
Sync Cardiovert @ 100j, 200j, 300j, 360j

333
 Algorithm
Ventricular Fibrillation or
Ventricular Tach w/o Pulses
WITNESSED
Defib @ 360j
CPR 2 min
Defib @ 360J
Epi 1mg
CPR 2 min
Defib @ 360J
Amiodarone 300mg
CPR 2 min
Defib @ 360j
CPR 2 min
H’s & T’s

334
 Algorithm
Ventricular Fibrillation or
Ventricular Tach w/o Pulses
UNWITNESSED
CPR 2 min
Defib @ 360J
CPR 2 min
Defib @ 360j
Epi 1mg
CPR 2 min
Defib @ 360J
Amiodarone 300mg
CPR 2 min
Defib @ 360j
CPR 2 min
H’s & T’s
335
Algorithm
Asystole

CPR
Epi
H’s & T’s

336
 Algorithm
PEA
(Pulseless Electrical Activity)

CPR
Epi
H’s & T’s

337
 Basic
Arrhythmias

QUESTIONS?

338