Rhythm Master 2 (Powerpoint) - 45 Mins - EMT-p

Description This is the normal heart rhythm. It originates in the SA node and follows the appropriate conduction pathways. The rate is normal, and the rhythm is regular. Every beat has a P wave, and every P wave is followed by a ventricular response. EKG Criteria Rate: 60-100 bpm. Rhythm: Regular. A normal variant called Sinus Arrythmia changes rhythm in response to respiration. This is seen most often in young healthy people. Pacemaker: Each beat originates in the SA node. P wave: look the same, all originate from the same locus (SA node) PRI: 120-200 msec QRS: 80-120 msec, narrow unless effected by underlying anomoly

Description Sinus bradycardia originates in the SA node. It has reduced rate generally from a reduction in sympathetic input, or excessive vagal (parasympathetic) tone. This rhythm may accompany inferior MI's, hypoxia, hypothermia, or drug reactions. At moderately slow rates, the patient may be asymptomatic. At slower rates, they may become hypotensive and present with symptoms consistant with decreased perfusion: dizziness, syncope, shock like signs and symptoms. Treatment is aimed at increasing the heart rate. Therapies include atropine, transcutaneous and transvenous pacing, epinephrine, dopamine, isoproterenol. EKG Criteria Rate: <60 bpm. Rhythm: Regular generally. Pacemaker: SA node P wave: Present, all originating from SA node, all look the same. PRI: <200 msec, and constant. QRS: Normal, 80-120 msec.

Description This arrythmia originates from the SA node. It is defined as a sinus rhythm exceeding 100 bpm. Sinus tach is a normal rhythm which occurs in response to increased oxygen demand. This occurs with exercise, infection, hypovolemia, hypoxia, myocardial infarct, and in response to stimulant drugs, The rate usually has a gradual onset and elimination. Treatment is not usually needed, but is aimed at treating the underlying condition. EKG Criteria Rate: >100 bpm. Rhythm: Regular, generally. Pacemaker: SA node. P wave: Present and normal, may be buried in T waves in rapid tracings. PRI: 120-200 msec., generally closer to 120 msec. QRS: Normal.

Description These complexes originate in the atria. They often originate from ectopic pacemaker sites within the atria which results in an abnormal P wave. The complex occurs before the normal beat is expected, hence the prematurity. It is followed by a pause. There are many causes including: increased sympathetic input, exogenous stimulants, drug interactions, AMI, cardiac ischemia, idiopathic. These complexes can indicate increased automaticity. They may lead to re-entry rhythms. EKG Criteria Rate: Underlying rhythm. Rhythm: Irregular with PACs. Pacemaker: Ectopic atrial pacemaker outside SA node. P wave: Ectopic P wave present, generally different than normal SA P wave. PRI: Generall normal range 120-200 msec, but differ from underlying rhythm. QRS: Same as underlying rhythm.

Description This is the most common sustained cardiac arrhythmia. It is characterized by an undulating baseline replacing P waves and an irregularly irregular ventricular response. This arrhythmia occurs with hypertension, ischemic, mitral, myocardial and pericardi al disease, thyrotoxicosis, aging and sometimes occurs in normals. Treatment includes anticoagulation, drugs to slow ventricular conduction and/or cardioversion EKG Criteria Undulating baseline replaces P waves Rhythm: Irregularly irregular

Description This is the most common sustained cardiac arrhythmia. It is characterized by an undulating baseline replacing P waves and an irregularly irregular ventricular response. This arrhythmia occurs with hypertension, ischemic, mitral, myocardial and pericardi al disease, thyrotoxicosis, aging and sometimes occurs in normals. Treatment includes anticoagulation, drugs to slow ventricular conduction and/or cardioversion EKG Criteria Undulating baseline replaces P waves Rhythm: Irregularly irregular

Description Atrial flutter is characterized by "sawtooth" atrial activity and a conduction ratio to the ventricles of 2:1 to 8:1. It is caused by a reentrant circuit located in the right atrium. It may occur when the atria are enlar ged in chronic obstructive lung disease, mitral or tricuspid disease, pericarditis or post-operatively. Definitive treatment is direct-current cardioversion, surgical or catheter ablation. EKG Criteria Rate: 250 - 350 bpm (atrium) Rhythm: Atrial rate regular, ventricular conduction 2:1 to 8:1 Pacemaker: Reentrant circuit rhythm located in the right atrium P wave: Saw-tooth or picket fence PRI: Constant onset

Description There are several different types of SVT depending on the site of reentry (accessory pathway, atrioventricular node or atrium). This rapid rhythm starts and stops suddenly. Treatment includes vagal maneuvers, antiarrhythmia medication, radio-frequency ablation or surgical modification of site of reentry. \par }\pard \s15\widctlpar\adjustright {EKG Criteria \par Rate: \par Rhythm: \par Pacemaker: \par PRI: \par \par Atrium - Normal or prolonged (>200 msec) \par QRS: \par }} EKG Criteria Rate: 140 - 220 bpm Rhythm: Regular Pacemaker: Reentry circuit Accessory pathway: Normal or short (if down accessory pathway) A-V nodal reentry: Hidden in or at end of QRS PRI: Depends on location of circuit QRS: Normal if accessory pathway used - prolonged (>120 msec) with delta wave

Description Adenosine, given as a rapid intravenous bolus, can produce a potent vagal effect and convert supraventricular tachycardia in a few seconds. Side effects include flushing, bronchospasm and short-lived high-grade atrioventricular block.

• A.

  SUPRAVENTRICULAR TACHYCARDIA CONVERTED WITH ADENOSINE

• B.

  V-Fib

• C.

  A-Fib

Description These premature complexes originate in the atrioventricular junction. Retrograde conduction through the atria may cause an inverted P wave in Lead 2. Integrate conduction may be normal (<120 msec). Common etiologies include ischemia, hypoxemia, valvular disease, digitalis or normal variant. EKG Criteria Rate: Underlying rhythm Rhythm: Irregular with PJC's Pacemaker: Ectopic junctional pacemaker P wave: If present, negative in Lead 2 PRI: 120 msec or less QRS: 80-120 msec, unless prolonged by aberrant conduction

Description An escape beat serves as a protective mechanism when higher centers in the conducting system fail to fire. Junctional escapes are recognized by their unchanged or only slightly changed QRS complex ending a cardiac cycle longer than the dominant cycle. This rhythm occurs with increased vagal tone to the sinoatrial node, hypoxemia, and digitalis toxicity. EKG Criteria Rate: 40 - 60 bpm Rhythm: Regular Pacemaker: Atrioventricular junction P wave: If present, negative in lead 2 PRI: 120 msec or less QRS: 80 -120 msec, unless prolonged by aberrant conduction

Description Conduction disturbances are characterized as first degree, second degree Mobitz 1, second degree Mobitz II and complete heart block. The normal P-R interval is 120 - 200 msec. First degree AV block is a constant and prolonged PR interval. Possible etiologies include insult to AV node, hypoxemia, myocardial infarction, digitalis toxicity, ischemia of the conduction system and increased vagal tone but is also seen in normals. EKG Criteria Rhythm: Regular PRI: >200 msec

Description Wenkebach is characterized by progressive delay at the AV node until the impulse is completely blocked. Etiologies are the same as cause first degree AV block and is also seen in normals. This conduction abnormality does usually not progress to higher degree heart blocks. EKG Criteria Rhythm: Irregular PRI: Progressive lengthening of PRI until dropped beat. A clue to Wenckebach is that the QRS's appear to occur in groups.

Description This is a higher degree of conduction block then Mobitz I and may progress to complete AV block. AV conduction appears normal until suddenly there is no AV conduction following one P wave. This may occur in a pattern (every 2nd, 3rd or 4th complex) or may occur randomly. This is intermittent block at the AV node and may progress to complete heart block. EKG Criteria PRI: Constant on conducted complexes until a sudden block of AV conduction. That is, a P wave is abruptly not followed by a QRS

Description Third degree AV block is total lack of conduction through the AV node. The rate and the interval between the QRS depend upon the origin of the escape mechanism. This conduction defect is dangerous and may progress to ventricular standstill. Treatment is an artificial ventricular pacemaker. EKG Criteria P wave: Independent P waves and QRS's with no relationship with the two (AV dissociation) QRS: The QRS is normal in duration and slow (40-60 msec) with junctional escape rhythm. The QRS is wide (>120 msec) and slower (30-40 bpm) with ventricular escape rhythm.

Description A PVC is a depolarization that arises in either ventricle before the next expected sinus beat. The normal sequence of depolarization is altered because the impulse originates in the ventricle. The two ventricules depolarize sequentially insteat of simultaneously. Conduction moves more slowely than through the specialized conduction pathways, this results in a widened QRS complex (greater than 0.12 sec). PVCs may occur as isolated complexes or may occur in pairs, triplets, or in a repeating sequence with normal QRS complexes. Three or more PVCs in a row is considered a run of Ventricular Tachycardia. If it lasts for more than 30 seconds it is designated sustained VT. Treatment: Rarely treated unless symptomatic. PVCs may indicate acute mycardial ischemia requiring rapid intervention including oxygen, NTG, morphine, thrombolytic. Treating with lidocaine will cease the PVC, but won't address the ischemic cause. EKG Criteria Rhythm: Irregular QRS: Is not normal looking. Broadened, greater than 0.12 seconds. P waves are usually obscured by the QRS, ST segment, or T wave of the OVC. The P wave may sometimes be seen as notching during the ST segment or T wave.

Description PVC's may occur in patterns. When each normal complex is followed by a PVC forming groups of 2, the term "ventricular bigeminy" is used. EKG Criteria QRS: Normal QRS complex followed by premature wide bizarre complex (PVC) in patterns of 2

Description Ventricular Tachycardia (VT) is defined as three or more beats of ventricular origin in succession at a rate greater than 100 beats per minute. There are no normal (narrow) looking QRS complexes. Consequences of VT depend on accompanying myocardial dysfunction. It may be well tolerated or associated with life-threatening hemodynamic compromise. Treatment: If patient is stable, they are initially treated with lidocaine, procainamide, or bretylium tosylate. Hemodynamically unstable VT (with a pulse) is cardioverted at 200J, 300J, 360J as needed. VT without a pulse is treated like VF and defibrillated. EKG Criteria No normal looking QRS complexes, often bizzare with notching. Width of QRS>0.12 sec. ST segment and T wave are opposite polarity to the QRS. Sinus node may be depolarizing normally. There is usually complete AV dissociation. P waves are sometimes seen between QRS complexes. They have no impact on the QRS complexes. Rate: Generally 100 to 220 bpm Rhythm: Generally regular, on occassion can be modestly irregular.

Description Ventricular escape rhythm is a protective escape mechanism when higher centers in the conducting system fail to conduct to the ventricle. Ventricular escapes are recognized by the slow rate, wide QRS, and absence of preceding P waves. A slow ventricular escape rhythm is an ominous sign. Treatment is an artificial ventricular pacemaker. EKG Criteria Rate: 40 bpm Rhythm: Regular P wave: Regular if present PRI: If present, varies (no relationship to QRS complex [AV dissociation]) QRS: QRS interval >120 msec wide and bizarre

Description Ventricular Fibrillation is a rhythm in which multiple areas within the ventricles display marked variation in depolarization and repolarization. There is no organized depolarization, therefore the ventricles do not contract as a unit. The myocardium is quivering when visualized grossly. There is no cardiac output. This is the most common arrythmia seen in cardiac arrest from ischemia or infarction. The rhythm is described as coarse or fine VF. Coarse VF indicates recent onset of VF. Prolonged delay without defibrillation results in fine VF and eventually asysyole. Resuscitation becomes more difficult as VF becomes finer. Treatment is always immediate unsynchronized defibrillation at 200J, 300J, 360J for adult patients. EKG Criteria Rate: Very rapid, too disorganized to count. Rhythm: Irregular, waveform varies in size and shape No normal QRS complexes. Absent ST segments, P waves, T waves.

Description Ventricular Fibrillation is a rhythm in which multiple areas within the ventricles display marked variation in depolarization and repolarization. There is no organized depolarization, therefore the ventricles do not contract as a unit. The myocardium is quivering when visualized grossly. There is no cardiac output. This is the most common arrythmia seen in cardiac arrest from ischemia or infarction. The rhythm is described as coarse or fine VF. Coarse VF indicates recent onset of VF. Prolonged delay without defibrillation results in fine VF and eventually asysyole. Resuscitation becomes more difficult as VF becomes finer. Treatment is always immediate unsynchronized defibrillation at 200J, 300J, 360J for adult patients. EKG Criteria Rate: Very rapid, too disorganized to count. Rhythm: Irregular, waveform varies in size and shape No normal QRS complexes. Absent ST segments, P waves, T waves.

Description Asystole represents the total absence of ventricular electrical activity. Since depolarization does not occur, there is no ventricular contraction. This may occur as a primary event in cardiac arrest, or it may follow VF or pulseless electrical activity (PEA). Ventricular asystole can occur also in patients with complete heart block in whom there is no excape pacemaker. VF may masquerade as asystole; it is best always to check two leads perpendicular to each other to make sure that asystole is not VF. Treatment for each arrythmia is very different. Fine VF which may mimic asystole should be treated with defibrillation. But defibrillating asystole is potentially harmful. Treatment: Epinephrine and Atropine are administered. Consider causes: pulmonary embolism, acidosis, tension pneumothorax, cardiac tamponade, hyperkalemia, hypokalemia, hypoxia, hypothermia, overdose, myocardial infarction. (Pneumonic: PATCH(4)-O-MIne. EKG Criteria Complete absence of ventricular electrical activity. Occasional P waves or erratic ventricular beats may be seen. These patients will be pulseless. Treatment must be immediate if the patient is to have any chance at resusctiation. Rate: None Rhythm: None

Description Indications for artificial ventricular pacemakers include symptomatic unreliability or failure of the patient's own conduction system. A ventricular pacemaker is typically placed in the right ventricle and can sense and (or pace with) the ventricle. An atrioventricular (A-V) synchronous pacemaker has an additional wire is were placed in the right atrium which can sense and/or pace the atrium. EKG Criteria Spike precedes wide bizarre QRS when ventricular pacing. Spike precedes P wave when atrial pacing. With dual chamber (AV synchronous) pacemaker, a spike may be seen only before the A wave, only before the QRS or before both.

Description Indications for artificial ventricular pacemakers include symptomatic unreliability or failure of the patient's own conduction system. A ventricular pacemaker is typically placed in the right ventricle and can sense and (or pace with) the ventricle. An atrioventricular (A-V) synchronous pacemaker has an additional wire is were placed in the right atrium which can sense and/or pace the atrium. EKG Criteria Spike precedes wide bizarre QRS when ventricular pacing. Spike precedes P wave when atrial pacing. With dual chamber (AV synchronous) pacemaker, a spike may be seen only before the A wave, only before the QRS or before both.

Description Pathologic Q waves indicate myocardial death. Infarction locations are determined by the presence of Q wave; Anterior: Q waves in leads V1, V4, I and AVL. Inferior: Q waves in leads II, III, AVF, Lateral: Q waves in leads V5-V6, I and AVL. Posterior: Tall R waves in leads V1-V2. ST segment elevation may be present in an acute MI but also with Prinzmetal's angina, LV aneurysm, pericarditis or a normal variant. With MI, ST segment elevation resolves within days but pathologic Q waves may remain. EKG Criteria Pathologic Q waves are >30 msec wide or 1/3 length of the QRS complex. ST segment elevation is >1mm above the isoelectric line. Leads involved will localize the area of the myocardium involved.