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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)

CharacteristicsHR >150, P waves often hidden
SymptomsPalpitations, racing heart, weakness, fatigue, SOB, diaphoretic
TreatmentsVagal 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

Characteristicspulseless VT, can be monomorphic (all examples above) or polymorphic (torsades)
SymptomsDizziness, SOB, Chest pain, potential cardiac arrest
Treatments1. 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

Characteristicspulseless VF, rapid/irregular electrical signals cause the ventricles to quiver uselessly instead of pumping blood
SymptomsUnresponsive no pulse or breathing
Treatments1. 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
SymptomsNo symptoms at times, SOB, chest pain, weakness/dizzy
Treatments1. 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

CharacteristicsSecond-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)
SymptomsNo symptoms at times, SOB, chest pain, weakness/dizzy
Treatments1. 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)

CharacteristicsSecond-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
SymptomsWill have symptoms-SOB, chest pain, weakness/dizzy
Treatments1. 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)

CharacteristicsSecond-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
SymptomsHigh 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
Treatments1. 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

CharacteristicsUpper 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
SymptomsNo symptoms or can cause palpitations, SOB, weakness
Treatments1. 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

CharacteristicsPEA patient is unresponsive and has NO palpable pulse in the presence of organized cardiac electrical activity
SymptomsCardiac arrest no pulse, no breathing
TreatmentsStart 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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