Cardiac Arrhythmias and Treatments

Basic EKG

Normal ranges:
P-R interval = 0.12 – 0.20 sec (3 – 5 small squares)
QRS width = 0.08 – 0.12 sec (2 – 3 small squares)
Q-T interval 0.35 – 0.43 sec

Measure Regularity

Measure the distance between the peaks of 2 consecutive QRS complexes if they are equal it is a regular rhythm

Normal Sinus Rhythm

There must always be a p wave.
The P wave should be a rounded shape
Each P wave should be the same shape
Each P wave should be followed by a QRS
The P-R interval should be 3-5 small squares and constant
The rhythm should be regular.

Sinus Bradycardia

Sinus bradycardia occurs on an ECG when there is a normal upright P wave in lead II ― sinus P wave ― preceding every QRS complex with a ventricular rate of less than 60 beats per minute.

Supraventricular Tachycardia (SVT)

Characteristics	HR >150, P waves often hidden
Symptoms	Palpitations, racing heart, weakness, fatigue, SOB, diaphoretic
Treatments	Vagal maneuvers, Adenosine 6 mg IVP (1st dose) 12 mg IVP (2nd dose), Synchronized Cardioversion (low energy shock sync with R wave, not the same as AED mode/Defibrillation which is unsynchronized. Beta-blocker/Calcium Channel Blocker can be used as treatment and expert consultation

Ventricular Tachycardia

Characteristics	pulseless VT, can be monomorphic (all examples above) or polymorphic (torsades)
Symptoms	Dizziness, SOB, Chest pain, potential cardiac arrest
Treatments	1. Administer defibrillation shock 2. Continue CPR for 2 minutes 3. Defibrillation Shock again 4. Continue CPR for 2 more minutes 5. Administer Epinephrine 1 mg every 3-5 mins/consider advanced airway 6. Administer 3rd shock 7. Continue CPR for 2 more minutes 8. Administer Amiodarone 300 mg IVP 1st dose, 150 mg 2nd dose (alternative to Amiodarone is Lidocaine 1mg/kg 1st dose 0.5-0.75 mg/kg 2nd dose. You cannot give both Amiodarone and Lidocaine, choose one or the other)

Ventricular Fibrillation

Characteristics	pulseless VF, rapid/irregular electrical signals cause the ventricles to quiver uselessly instead of pumping blood
Symptoms	Unresponsive no pulse or breathing
Treatments	1. Administer defibrillation shock 2. Continue CPR for 2 minutes 3. Defibrillation shock higher energy level again 4. Continue CPR for 2 more minutes 5. Administer Epinephrine 1 mg every 3-5 mins/consider advanced airway 6. Administer 3rd shock higher energy level 7. Continue CPR for 2 more minutes 8. Administer Amiodarone 300 mg IVP 1st dose, 150 mg 2nd dose (alternative to Amiodarone is Lidocaine 1mg/kg 1st dose 0.5-0.75 mg/kg 2nd dose. You cannot give both Amiodarone and Lidocaine, choose one or the other)

Heart Blocks (1st degree)

Characteristics	First-degree heart block is a condition in which the wiring of the heart is slow to send electrical signals but all of the signals are able to pass successfully. There is no electrical block but rather a slowing or delay of the signal Prolonged PR interval
Symptoms	No symptoms at times, SOB, chest pain, weakness/dizzy
Treatments	1. Oxygen administration 2. Cardiac monitors 3. 12 Lead ECG 4. IV access 5. If symptomatic consider administration of Atropine 1 mg IV every 3-5 minutes with a max of 3 doses total (3 mg total) Other treatments -Dopamine 5-20 mcg/kg/min infusion -Epinephrine 2-10 mcg/min infusion -Transcutaneous Pacing 60-80 beats per min -Expert consultation

Heart Blocks (2 degree Type 1/Mobitz 1/Wenckebach

Characteristics	Second-degree Type 1 heart block is a condition in which transmission of impulse through the AV node is progressively delayed until there is a dropped ventricular beat QRS is staying out longer and longer until it is dropped Causes: Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone Increased vagal tone (e.g. athletes) Inferior MI Myocarditis Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)
Symptoms	No symptoms at times, SOB, chest pain, weakness/dizzy
Treatments	1. Oxygen administration 2. Cardiac monitors 3. 12 Lead ECG 4. IV access 5. If symptomatic consider administration of Atropine 1 mg IV every 3-5 minutes with a max of 3 doses total (3 mg total) Other treatments -Dopamine 5-20 mcg/kg/min infusion -Epinephrine 2-10 mcg/min infusion -Transcutaneous Pacing 60-80 beats per min -Expert consultation

Heart Blocks (2 degree Type 2/Mobitz 2)

Characteristics	Second-degree Type 2 heart block is a condition in which is related to structural damage (ischemia) causing a failure of the conduction system at or below the Bundle of His • Narrow QRS = block is within the Bundle of His (approx. 25%) • Wide QRS = block is distal to the Bundle of His
Symptoms	Will have symptoms-SOB, chest pain, weakness/dizzy
Treatments	1. Oxygen administration 2. Cardiac monitors 3. 12 Lead ECG 4. IV access Do not rely on Atropine to fix issue! Transcutaneous pacing first line of treatment or Beta Adrenergic medications (epi/dopamine gtt) Other treatments -Dopamine 5-20 mcg/kg/min infusion -Epinephrine 2-10 mcg/min infusion -Transcutaneous Pacing 60-80 beats per min -Expert consultation

Heart Blocks (3rd Degree)

Characteristics	Second-degree Type 2 heart block is a condition in which there is a complete absence of AV conduction, with none of the supraventricular impulses conducted to the ventricles
Symptoms	High risk of ventricular standstill and sudden cardiac death They require urgent admission for cardiac monitoring, backup temporary pacing and usually insertion of a permanent pacemaker
Treatments	1. Oxygen administration 2. Cardiac monitors 3. 12 Lead ECG 4. IV access Do not rely on Atropine to fix issue! Transcutaneous pacing first line of treatment or Beta Adrenergic medications (epi/dopamine gtt) Other treatments -Dopamine 5-20 mcg/kg/min infusion -Epinephrine 2-10 mcg/min infusion -Transcutaneous Pacing 60-80 beats per min -Expert consultation

Atrial Fibrillation

Characteristics	Upper chambers (the atria) beat chaotically and irregularly — out of sync with the lower chambers (the ventricles) of the heart. Blood is more likely to clot can result in stroke or PE
Symptoms	No symptoms or can cause palpitations, SOB, weakness
Treatments	1. Oxygen administration 2. Cardiac monitors 3. 12 Lead ECG 4. IV access Medications: Rate control (beta blockers, calcium channel blockers, digoxin) Antiarrhythmic drugs (procainamide, amiodarone) Anticoagulants (Coumadin) Synchronized cardioversion

Pulseless Electrical Activity (PEA)/Asystole

Characteristics	PEA patient is unresponsive and has NO palpable pulse in the presence of organized cardiac electrical activity
Symptoms	Cardiac arrest no pulse, no breathing
Treatments	Start CPR immediatley! No pulse so we must adminster Epinepherine 1 mg IV push every 3-5 minutes This is not a shockable rhythm! Our only treatments are CPR + Epi Reversible causes H’s and T’s Hydrogen Ions (Acidosis) Hypothermia Hypovolemia Hypoxia Hypoglycemia Hyperkalemia/Hypokalemia Tamponade Tension Pneumothorax Toxins Thrombosis Pulmonary Thrombosis Cardiac

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