Strip Rate Rhythm P Waves PRI QRS Discussion Atrial Flutter Varies REG Or IRREG NO--- “F” (Saw Tooth) N/A <0.12 Sec, =’ ~ Patient may alternate between a-flutter and a-fib; may be regular or irregular; typically classified by f-wave distribution; i.e., this strip is 3:1—there are 3 f-waves per QRS complex. --Cardioversion; Digoxin; others…. Ventricular Tachycardia > 100- 200 REG N/A N/A >0.12 Sec, =, ~ “Wide & Bizarre” 2 Types: --With or Without a Pulse (See PVC’s for more discussion) -CPR (No Pulse) -Synchronized Cardioversion -Lidocaine or amiodarone IV -ACLS! Ventricular Fibrillation (Coarse) 0 NONE N/A 0.12- 0.20 sec NONE -CPR -IMMEDIATE DEFIBRILLATION -ACLS -Epinephrine, others Ventricular Fibrillation (Fine) 0 NONE N/A N/A NONE -CPR -IMMEDIATE DEFIBRILLATION -ACLS -Epinephrine, others Asystole 0 NONE NO N/A NONE -Check the Leads & Patient ! -CPR & ACLS -NON-Shockable Rhythm -Source?? -Epinephrine IV -Atropine IV Strip Rate Rhythm P Waves PRI QRS Discussion Pulseless Electrical Activity (PEA) Varies REG Present,
IMPORTANT: THIS RHYTHM MAY LOOK LIKE ANY RHYTHM THAT SHOULD HAVE A PULSE ! The approach in treatment of PEA is to treat the underlying cause. “6Hs and 6Ts”: ions () or or () , Cardiac () () ( from blood loss) Or Variable Variable PATIENT IS UNRESPONSIVE, WITH NO IF RHYTHM ON MONITOR IS ASYSTOLE, VENTRICULAR FIBRILLATION, OR VENTRICULAR TACHYCARDIA, THEN (BY DEFINITION) THEY CANNOT BE PEA, BECAUSE THESE RHYTHMS ARE NOT (USUALLY) ASSOCIATED WITH A PULSE.. Treated as Asystole: Search for Source Epinephrine IV Atropine IV (Possible) Polymorphic Ventricular Tachycardia (Toursades des Pointes) > 100- 200 IRREG N/A N/A >0.12 sec “Twist Around the Point” “Typical medications for Ventricular Tachycardia (Monomorphic V-Tach) will make it --DEFIBRILLATE --Magnesium IV Strip Rate Rhythm P Waves PRI QRS Discussion Junctional Rhythms Varies (AV REG Absent, Inverted, 0 – < < 0.12 AV Node or AV Junctional area has taken over as
Junct Rate= 40-60) Biphasic, or retrograde (after the QRS) 0.12 sec Sec, =, ~ “pacemaker,” so no P wave, or “different p-wave -Junctional Rhythm -Accelerated Junctional Rhythm -Junctional Tachycardia Degree A-V Block Varies REG + ↑ ~ 1:1 QRS > 0.20 Sec = < 0.12 Sec, =, ~ -Can be a normal variant -Can be benign, or a precursor of “bad things to come…” -Check previous EKG’s -Continue to monitor patient Second Degree A-V Block, Mobitz I (Wenkebach) < 60 (usual) + ↑ ~ NOT 1:1 QRS Vary * See Disc. NONE -PRI gradually lengthens until a QRS complex is ‘dropped.’ pattern -athletes; post-valvular surgery, MI, Drug-induced: beta-blockers, CA+ Channel blockers, amiodarone, lidocaine, digoxin Second Degree A-V Block, Mobitz II < 60 (usual) NONE N/A N/A NONE Mobitz II block most commonly is caused by an acute myocardial infarction (anterior or inferior). etiologies can also occur (as above) Third Degree A-V Block 20-40 NONE + ↑ ~ NOT 1:1 N/A NONE -Emergency Pacemaker (Drug induced: as Infection -Hyperkalemia -more Strip Rate Rhythm P Waves PRI QRS Discussion -----------“INDIVIDUAL” ECTOPY / ECTOPIC BEATS--------------- Premature Ventricular Contractions (PVC’s) (Unifocal) Varies Irreg N/A “Wide -PVC’s MAY be benign.
None preceding the PVC & Bizarre” -May be a sign of ventricular irritability due to surgery, injury, Premature Ventricular Contractions (PVC’s) (Bigeminy) Varies Irreg None preceding the PVC N/A “Wide & Bizarre” Such as in an MI; may occur due to electrolyte imbalances; toxins, etc. -Generally speaking, the more PVC’s per minute, the worse it is. Premature Ventricular Contractions (PVC’s) (Multifocal) (Frequent) Varies Irreg None preceding the PVC N/A “Wide & Bizarre” -Greater than 6 PVC’s per minute is frequently used as criteria to treat with antiarrhythmics. -Increasing frequency of PVC’s, particularly if appearing in couplets, triplets, salvos, or “runs of V-Tach” Premature Ventricular Contractions (PVC’s) ( Couplets) Varies Irreg None preceding the PVC N/A “Wide & Bizarre” Lidocaine IVP Lidocaine Infusion Amiodarione IVP Others… Strip Rate Rhythm P Waves PRI QRS Discussion Premature Ventricular Contractions (PVC’s) (Triplets, Salvos) Varies IRREG None preceding the PVC N/A < 0.12 sec Sign of “Increased Ventricular Irritability= greater chance of V-Tach & Cardiac Arrest Lidocaine IVP Lidocaine Infusion Amiodarione IVP Others…
Multi Focal PVC’s Varies IRREG None preceding the PVC N/A < 0.12 sec As above Premature Junctional Contraction / Premature Atrial Contraction (PJC) (PAC) Varies IRREG None preceding the PAC or PJC N/A NONE Typically benign If this is a change, be vigilant for other changes! Paced Rhythms Varies REG Or IRREG May or may not be present N/A NONE Look for the “Pacer Spike” or “Spikes” before the QRS Complex. -100% Paced -Demand Paced -% Paced / % Captured *AICD Artifact N/A IRREG N/A --If continues, Search for source & eliminate; --Wait for it to go away! --60 cycle = machinery “Noise”