-

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rrlle: fCG Fact» Mack Inrlembly Quirl!, 1Jt fmrion Copyright ®2006 Lippincott Williams

a Wilkins

> Front of Book > Autho rs

Author
Springhouse

Best man itoring heads

such as lead II with V ~ 0 r MC l,. lead II 0 r the lead that elsa rly shows the P waves and QRS complex may be used fo r and fo r

Most bedside diffe rentiating

monito ring systems allow fo r simultaneous

I I

monito ring of two leads

sinus node arrhythmias

PACs and AV block. The p reco rdial leads V ~ and Vs 0 r the bipola r leads MC l, and MC [~ a re the best leads fo r ~onito ring rhythms with \lJide QRS complexes

VT from SVT with abe r rancy.

This table lists the best leads fo r monito ring challenging ca rdiac arrhythmias.

AT

~,'.'I, ~" IIIJ..I, 110.,

1:, ... I, ....,I'II:.I.!,1Ii'J.

n, U1

II, ... 1 i '1'" MCLI, iIII,

';'~, ';'" 1i\o.-'l.1, 1II:.l.,

'o'!, '0',. lid I, 1IiJ:,

Common abbreviations

Abbrevia.tio.ns
ACLS

ladVMced
ACS

cardiac

life support

acute
AED

coronary

syndromes

lautomated

external

defibrillator

basic

cardiac

life support

coro.nar'y care unit, critical care unit

chronic

obstructive

pulmonary

diseas.e

r=v=r=

ET endotracheal
FlO"

rractiQn

of ins~i'red

Gx'yogen

i mpl enteb le eerdiov e rte (" def bri IIstor

0

MAP
mean MAT "arte"r:ial pressure,

Imultifocal

atrial ta:chycar,dja

PAS

pulmtmarv

arterv

systolic

PAT

Ip~r}oxys'mai

at:ri~1taC:hycardiq

SVT

Is w p r a v eritri cui a r ta C~,YDardi a

Selec ted referenc es

Albe rt, N,M, "Co rdiac ReS\'T1chronization Thmpy Th rough 8iV€nlriculo r Pocing in. Polienls wilh Heorl Foilure and Venlriculo r o)'$S\'T1chrony," Criti cal. Care Nurse 13 () Suppl): 2-1 ), June 200)"

Cummins, R, 0, (Ed,) A CLS Provider Manual., oollos: Arne rican Heart Associolion , 2004,

Ileal, 8, , et 01. P€diatric ECG iIlMpr€tatioll:

All /1IustratiVE: Guide, Elmsford, N, y,: 810ckwell Futuro, 2004,

ECG Cards, 4th ed. Philodelphio:

Lippincott Willioms a Wilkim , 2005,

ECG illterpr€tatioll:

Allillmdibly

Easy Pod!.et Guide, Philodelphio:

ljppincott Willioms a Wilkins, 2006,

ECG illterpr€tatiQIl

Made illmdibly

Easy, )rd ed, Philodelphio:

ljppincott Willioms a Wilkins, 2005,

Hazinski , M, F, , et 01, (Eds,) Halldboo~ of Eme!'Sell

C'j Cardiovas cular

Care for Heal.th care Providers, Oollos: Arne rican Heo rt Associotion , 2004,

Hesselson, A, Simplified illMpr€tatioll

of Pacem~er

ECGs, Elmsford, N, y,: 810ckwell Futuro, 200),

Khon, M, G, Rapid ECG illterpr€tatioll,

2nd ed. ~hilodelphio: W,8, Sounders Co, , 200),

MasterillS ACLS, 2nd ed. Philodelphio:

ljppincott Willioms ,a Wilkins', 2006,

Mo rton, p, G, , et 01, Griti cal. Care Nursillg: A Hob sti r Approach, 3th ed. Philadebhia: Lippjncott Willioms a Wilkins, 2005,

Rokel, R, E, , end Bope , E,T, (Eds,)

COIlIl'S

CUrr€llt Therapy 2005, Philadelphia: W,8, Sounders Co, , 2005,

Tierney, L,M, , el 01. CUrr€llt Medical. Diasllosis alld Tr€atmellt,

441h ed, New York: McGrow-HiII, 2005,

Woods, S, L, , el 01. Cardiac NursillS, 51h ed, Philodelphio: ljppincott Williomsa Wilkins, 2005,

idle: leG Fects Mf1de InclE'mMy QWclJ, tst lmrion Copyright ®l006 lippincott > sack oJ Book >
ECG

V1illiams

a V1ilkins

Fa(ts M:lde lnc redibl.,. Qui(k!

ECG Filets Made Incredibl,y Quick.!

• • • • • •

Anatomy of the hea rt and co rona ry vessels Rhythm st rip rneasu ring methods and patte rns SA node, at rial, junctional, and vent ricula r rhythms, and AV blocks. 12-lead ECG inte rp retation Antia r rhythmic drugs, defib rillation , ca rdiove rsion , pacemake rs , and ICDs Write -on, 'I.If.:Ite roof pages that come dean urith an alcohol \llipe rp

[Jru3 Facts MadE: In mdibly Qui ck Facts MadE: In mdibly Qui ck

.UN • • •

.Maternal. -Neonatal. Facts MadE: In mdibly Qui ck hdiatri r Fads MadE: In mdibly Qui ck Quick

Wound CarE: Facts MadE: Inmdibly

Title: feG Feet» M(Jft Incremhiy Qulcl!, tst fmrion

Copyright ®2006 lippincott William$

a. Wilkin$

> Back of Book > Eel] effects of elect rol~te imbalances

ECG effects of electrolyte im balances

~1I::;:~

1~1i:f:i'"'i

G1f:« iX"~

1ml:Jls

H~J..:.:.w'ol

~W;,;-rN

Q- ....:';':.... 1

• • • • •
• • • • • • •

FroLorJlCd F'Ii: t:':mIIl E'rcIr<" iC'd q,£i Q!f('p..:~ lJi:?'~d - \\Ia'ill"

H~Q:1I'lII

F;ot"r~C'd Q- ~"'\tI

F~1~G/' "''lCr.cd

- W'ii:.

f'f(~NCd:;;:

:i.OJliT~~

H~JlcIru

"".!lJ.,~N-WlI"""

lDw ~"'pi.:I!uD1''Ml~ IrUd ~\1X'IIIJJ.CIL.I4I

W'>±, 11.J;:0:1',;.:1 'fiiJ'';: ~~cOOiJ:i' ~~!l:1rtll F rr~~tl(o ~ ~'>l' I~'" ~l.Cl'I':lJ.1 \'r",±,-C'd ~ ~~ :i'«,-_C'I'cd,Q"" 'I"~c;:'II.I. Ir:roll':'(';u:uilr OJr.o3:.:l~:
EIc\IiL".«I:;- !Qojlrre'! I~
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H~~!J:;r'lil

R:n - \\\1""';

1.1

WIJ'f(!

~~n

• • •

f'o:o.lIl.cd WOO ~~'K'l'!: ~~\'i,1 F f'rcoI:oo~cd ~ Wl'pm ~!.o:'O~ ~PJ!on::lll ~"~([!er.~

rille:

E(~ Facts Mack Inc niliMy Quid!, 1Jt Edition @2006 lippincott Williams

Copyright

a Wilkins

> Table of Contents > Gene ral

General

Where the heart lies

This illust ration shows e~ctly the hea rt extends wDe re the ~ea rt is located. The .hsa rt lies 1JJit.hinthe mediastinum
I

a cavity that contains ·the tissues and

0 rgans

sepa rating the

fwD

pleu ral sacs. In most peopk

to the left of. the body's midline.

P.2

Coronary vessels

left~~~

ll~iwkli'D:t]uq------ ...
~rOi~~ul!li}~,~ltDUt:

"'------le'rt
sLi~~1Iial1l

OIit~'lI'

m'imy

~----4-==

lPI!iI~I~mart
l!lJl1t

~~~""""ti!!ir=-"'.

Gml1![ It:Drdi~C
'ileim

-~"

Cir~u~~c~ Iit,nnch of I ~rn

Am~fiw
m'll1l1elir~1[:ular

Ice~Clldil1~1
~rilJl'!;h

moin ,~~rM~rv

Qi.le:lt

!1m!"f~---

~d

P.3

r... ===~rl!i~MO!1;~g~m'ii~ = ~'f~~J]f

Gr~RJt
iiartlilil~
W~!~,,------:-"Hr-I'f7--~

1_b..................................

~ilI~)iri[ir

1~~gMmrf~~~gf

Mi~~1! COf~~~~~ini========================iiiiiiii!' ~

1~~~Ii:~lldJ~1
:~r~mCII o~ri~hl
~II)J~~~rv t~f!I m

P.4

Cardia.c conduction system

A~~oodle

~~un~I!:lljJi !If~~"-----~~ 1

.... ~~~~.

Ri~hi. Ilmd l(llt

~{!~d~ l!lfil!l~a.~~
Ilntl!rvojj~ri~u.i~1 ge!)torn .-------~

ECG grid
This ECG grid shows the ho rizontal axis and ve rtical axis and thei r respsctive rnsasu rement 'o,falue$.

~~~'il~~
or ~o~~C!1
itlilV

P.5

Einthoven's triangle
The axes of the th ree bipola r limb leads (I, II, and III) fo rrn a shape known as Einthol!€n's triangle. Because the elect rodes fo r these leads a re about equidistant from the hea rt, the triangle is equilate ral The axis of lead I e:::ctends from sboulds r to shoulde r , with the right-a rrn lead being the negative elect rode and the left-a rrn lead being the positive elect rode. The axis of lead II runs from the negative .. . . . right-a rrn lead elect rode to the positive left ·ieg lead elect rode. The axis of lead III extends from the negative left-a rrn lead elect rode to the positive left ·ieg lead elect rode.

P.6

Augmented leads
Leads aVRI aVL I and aVF are called ausmel'lt€d leads. They measure electrical acthrity bet\lJeen one ,limb and a single electrode. Lead aVR pro\lides acti\lity coming from the heartlslateral wall. Lead aV~ shows electrical acti\lity coming from the heart's inferior wall.
1'10

specific \liew of the heart Lead aVL shows electrical

I (

II

P.l
rJ rOSl

't"10mng car di d rae menr lteri onng I.ea. S

fhfe~ leadwke sy5tem ,Le'a~i

Three-[ eadwire '5yEf~em

leaOlI:

.Lead Mel., -"1

le~d [MeL,

L~'a~.

~jC··.l~.-., 1T1~ _~

l~ad !M'CLa

P.8

NormalECG

P.9

Q,Tc: interval

normals

~D

OAI

o.~!

~o

o.~

a.~..!

':0

o.rs

0.~3

·lD

Gl.1l 0.41

ac
~o

0.12 O.]~

0.]"

a.3~

IC'C

o.zz
O.1~

o.J~

12C

O.J~

m.
l~(

0.2J

O.2~

Gl.2l

a.2~

~c;:

0.200.24

Interpreting
In~e rp re~ing a rhythm step method outlined

rhythm
below provides

strips
~h rough p ractice. You can use seve ral methods , as long as you' re consistent. Rhythm s~ rip analy,-:is requi res a sequential and sy,-:~ema~ic app roach .' The eigh~just that.

s~ rip is a skill developed

Ei~h t -sf e pme t h(I cJ

·1. 2. 3. 4. 5. 6·. .7. 8. .De~e rrnine the rhythm. .Dete rrnine the rate. Evaluate the P wave.

Measu re the P R inte rval, Dete rmine the QRS du ration. Examine Measure the T waves . the QT interval. beats and othe r abno rrnalities ,

Check fo r ectopic

P.l0

Methods

of mea.:s:uring rhythm

• • • • •

Place the ECG st rip on a flat su rface , Position the st r aight edge of a piece of pape r along the st rip's baseline. Move the pape r up slightly so the st r aight edge is nea r the peak of the R wave. With a pencil', rna rk the pape r at the R waves of two consecutive QRS complexes, as shown below. This is the R- R inte rval. fo reach R- R inte rval is the same, the vent r icula r rhythm is regula r. If the distance va r ies , the

Move the pape r ac ross the st rip lining up the two rna rks "Withsucceeding rhythm is i r regula r .

R- R inte rvals . If the distance

Use the same method

to measu're the distance

between

P waves (the P - P interval)

and dete rmine whetbe r the at rial rhythm is regula r-

0r

i r regula r ,

• • • • •

With the ECG on a flat surface, Adjust· the calipers' Pivot the first

place one point of the calipers

on the peak of the first

R wave of two consecutive

QRS complexes.

legs so the other

point is on the peak of the next R wave, as shown below. The distance toward the third R wave and note whetber

is the R-R interval.

point of the calipers

it falls on the peak of that wave.

Check succeeding

R- R inte rvals in the same way. If the1 re all the same, the vent r icula r rhythm is regula r. If they va ry, the rhythm is i r regula r , rneasu re the P - R inte rvals to dete rmine whethe r 'the at rial rhythm is regula r
0r

Using the same method,

i r regula r.

P,ll

R.hythm strip pattems

The rno re you look at rhythm st rips , the mo re you'll notice parte rns. ~he $ymbol$ below rep resent some of the parte rns you might see as you study rhythm st rjps.

j.,JO'!II"'m,ii!!lI~11"DII'lIIIII'-I:ar' ('~itl!I 1"'1'IJ,~ I, .j~~,.1 'M'~::J!:JI Q ,.~,~

din'norm1, ,~'-Ia;ln' ~~ ri,.'vih,-) u ... ~,_ ~ ~'. r,.~

t~l)

(-?

~'I,t!!

_.J11~iIU,,','

'61Iow~ ~I!l1I~alrI(aa in, 5~)

('/~I

PiremalitRJlfB (aiEl' lin ~I PVC)

, 'i"'l,

~\

t . ')I I

r'ij' ,',A~J'.
I
,
"

,I

r~ --',
,

"

,..'

Paro¥m eM' VUf'S't (,a:s II~ PAl)

f'rt'l

P_12

Calcul.,a.ting
T ....s i 20 1::3ble C:3n .... lp e sm:311 blocks

hea.rt
r-r-caj-oa .... 1: e

ra.te
sequencing me1: .... d o of de1:et"mining 1: ... .e .... e r-t e .... asar-t s r-as-t e is 75 e-ca-t mot"e sa be:31:s.T pt"ecise_ Af1:et" coun1:ing 1: ... .e numbet" of blocks be1:.._._.-een R .._._,-;a....-es. S:3me rr-oe-c ocr using .... use 1: ...s .i 1::3ble 1:0 find 1:... .e Fo t" ex:ample • if you c cu.rrs-t be1:.._._.-een R .._._,-;a....-es. rrrtrua-ce . To c:3lcul:31:e 1: ... :31:t"i:31 t":31:e. follo..._._.-1:e .e .... P .._._,-;a....-es_

o e- .:q 1:3t"ge blocks

T ....s i memo

t":3pid t"izing

-re

c:3lcul:31:ion sequence

is

:3'lso c aue cr 1: ... .e 1 50. 100. 75

CDun.rao...-....r.• '60. 50 _..

TnE:1hod.

Using

1: ... .e

ru.rrr-to e r- of

1:3 t"ge

blocks

to e-r we

em

R -co-a-ooe

s 0 r-

P .._._,-;a....-es :3S

:3 guide.

you

C:3n

t":3pidly

e s t trr-ce-ce -o-err-c t"icul:3 r- 0 r- :31: t"i:31 r e

e s by

1: ... .e

.. 300.

Totl .. ·:

ECG F<ict~ M<idE- Incn.dibly

@2006 lippincott VViliiams

Qpicld, a. vvttkfns

1~t Edition

Copy..-ight

> Table of Conten1:$

> SA Node

SA Node

Norma.l.

sinus

rhythm

• •

At .... al: i Vent

..-egula......

r tcuta r : .... egula

Rate
• 60 to 100 bea1:sl"minu1:e (SA node's no .... mal firing rate)

P Wave
• • • • No ..-m:=.1:s:h:=.pe (r'ound Up .... ight in lead II One for All simila every QRS complex and shape and smooth)

r tn s tze

'Ni~h;I"I

1"10

rrnat

I;m;~s (0. 12

~O

0.20

secol"ld)

Q.R S
•

COnril'p

i ex
(0.06 to 0 _10 second)

Vv'ithin

no t"m;al limits

T "Wave
• • No rrne! Up .... ight shape and .... ounded in lead II

QT intervall
• 'Ni~h;I"I
1"10

rrnat I;m;~s (0. 36 to 0.44

secol"ld)

Other
• • R.o:!pr es emt s no rm:=.1 c;a ..-di::=.c conduction No ectopic
0

:=.:::: the

st;and;a..-d

;ag:=.in:s:t umich

:=.11 othe

r t"hythms

;a

r e comp;a

t"ed

r abe .... an t beats r

P.14

Sinus

arrhythmia.

Rhythm
• • • • I r r.eguta r Co .... esponds · r to the .... espi .... to .... cycle a y .... val sho r ta ....du ..-ing inspi sbo r t es.t P-P r ation ; longe r cfu t'ing 0.12 e>=pi .... ation

P - P inte .... val and Diffe .... ence

R- R inte

bet......-een

long es t and

'irrte .... val eccc eects

second

Rate
• U~u"lIy ....,.;~h;n rrnal ltrrrit s (60 ~o 100 be"~~fm;nu~e) no

• • •

Va rie:::: "Wi1:hre:s:pi ration Inc re;ase:s: du ring inspi ra1:ion Dec rea:s:es du ring e>=piration

• •

No .... mal No .... mal

size configu r ation

• •

M"y

"" ry ~I;gh~ly no .... mal limits

Vv'ithin

QRS cot"nplex
• Preceded by P ""'''''

• •

No .... mal No .... mal

size configu r ation

QT interval
• • M"y "" ry ~I;gh~ly ltrrrit s

U:s:ually "Wi1:hin no rrnal

Other
• Phasic slo wing and quickening

p, 1 5

Sinus

a,rrhythmia

'.

Drugs • • Digoxin Morphine

'. '.

Inferior-wall Inhibition

MI of reflex ""'gal activity (tone)

During inspiration
• Oec-rea::::ed v.agal

t orre

•
•

Inc reased

H R.
.... e1:u .... n

Inc .... ea::::!2!d venous

During expiration
'. .• • Dec reased Oec reased Inc .... eased H R. venous r e tu rn

....-agal tone

What
• • • • • •

to loo~: for
no s'yTTIptoms (commonly rate insignificant) du ring tnsp i ration du ring e:xpi ration ......nenH R. inc reases
i

Possibly

Inc rea::::ed pe riph~ r al pulse

Dec rea sed pe riphe ral pul::::e rate Possible disappea

r'ance of arrhythmia

, such as du ring eX€!rc ise

Signs and s'yTTIptoms of uncle rlying condition Dizziness

0 .... ::::-yncope

if present

(" urith rna rked

sinus

a r .... hythmia)

What
• • •

to do
rt rhythm, in patient taking digoxin
I

Monito rhea

If sinus a r rhythm;::. develop:::: suddenly If induced by drugs (mo rphtne

0

notify

docto r . ......nethe r to continue giving the drug,

r ano the r sedative)

, notify

docto r ........no\Ifill decide

• •

Usually no t'reatmen1: If un related

if patient

asymp1:omatic
I

1:0 .... e:::pi .... t ion ;: r

(abrio .... mal)

1: ....e;:.1:ment

of unde rlying cause

P.16

Sin usb r a.dye ar d ia.

Rhythm
• Regular

Less than 60 beats Iminute

• • •

No rrnal size No rrnal configu ration P ......-ave befo re each QRS complex

PR interval
• • W'ithin no rrnal limits Constant

• •

No rrnal du ration No rrnal configu ration

TWQve
• • No rrnal size No rrnal configu ration

• •

W'ithin no rrnal limits Possibly prolonged

P_17

Sinus

bra,dycardia

Ca t"diomyopa1:hy Condi1:ions: 1:ha1: inc t"eas:e -....-agal s t trr-ualaat+or-r s:uch as: -....-omi1:ing

_ _

An"tiat"t"hy'thmics: Be1:a -cact t"ene Calcium Digoxin Li1:hium t"gic

(esrrrf blocke blocke

octe

r-or-oe , pt"opafenone,

quinidine,

s c t.sstof

t"s: (me1:op t"s: (dil1:iazem,

e-odo l , p t"opanolol) ve t"apamil)

channel

_ _ _

Glaucoma Hype t"kalemia t"mia

Hyp01:he

Hypo1:hyt"oidis:m Inc t"eas:ed Infe IC P

r to t"-.........-all I M r-cf t at -tscf-oerrrte r-cf-i t ts ct+s esas e

Myoca _ _ Myoca SA node

_ _

Puls:e Regula

r-za-t e

f e s s "than

60

to e sa-t ...-minu"te s

t" t"hy'thm b t"adyca t"dia -induced s:-yncope (kno-.......n as: a 5.1u1!:.e:s -Adams a.J-.J-acle:)

Pos:s:ibly

If
_

pat:ie
No

nt: can

COITI pe

nsa.t:e

1'0 r

dec

rease

CO

s:yrnp"toms:

11" pa.t:ie nt: ca.n"t: COITI poensa,t:e

Al1:e t"ed r-r-oe-rraat S:1:a1:us: r
r-i

Blu r- r-e cr -o-i s fo _ _ _ _ Cf-ie s t pain Cool, clammy

s lc-ir-r

Ct"ackles: Dizzines:s: Dys:pnea Hypo1:ens:ion S _] hea S-yncope t"1: s:ound ." indica1:ing hea t"1: failu t"e

Obs:e

t"ve

pa1:ien1:

and
'r

moni1:o

r- hea

t"1: t"hy'thm

fo t" b t"adyca

t"dia

p t"og t"es:s:ion"

E-....-alua"te pa"tien1:'S: _ Pt"epat"e pa"tien"t

ote t"ance

fo t" t"hy'thrn

a1: r e s-c and s:uch

"""'-;1:h ac"ti-....-i"ty_ as: dt"ug sacfr-r-r ir-rts-t r sa-t fo

r-i

f'o r- 'r r-e e+rr-oerrt s , as: needed,

(a"tt"opine,

dopam:ine,

epinepht"ine)

o r- "tempo

t"a t"y o r- pet"manen"t

pacernaket"

+r-s e r t torr .

Ho'YV
No

it:

',S:

t: ere a to e d
if pa1:ien1: as:yrnp1:oma1:ic unde t"lying caus:e , co r-r eoc t to r-r of r-t-t t-u-r-i guidelines:

1:t"ea1:men1:

If s:yrnp"toma1:ic B t"adyca

r-cf-tsa algo

P,18

Br a,dllcardia algorithm
1t~litr,irw;(M~~aJ~lp ~Dmrnad8gdi!19'ror~lmre:~1Clm~lfi~n
B~I~!f(:lfidill

laD iil\o: I~!filu Iml!iittdl !i!SiI.lS'~INj~~rt}\~ii ~lIllm!~¥l~Uiil~il\Of ~;~!lIT ~r~ns:Ol'~hm~~~ d

6$~~ iW,~Ylilll~~ tl~f.~~~ ~au~ by ~fi$~~f

,~I'm,~B!f~r 1r11~~utameCQS, ~t~~ WSE!mh~~I' fill ml~~· l'm ~jl~~

~!igrlll~ ]bioD'l:
'I

~VIM~~~I,

flfllii U~~cliili1~,dG~r,~llloodl~i~'dm~iElEl Dr'

!irli.i1~~!!J.·Ii3~~~ r!jM~ [J3~8a~ fI'l-(I't.iIl 11,jJl:lir~ biI d~S'&.Gf3: rn~~ Ii iIlD~i'el:wVCi,ib D1] in ~DC!~
~lisl~Bir i31[lIl~il1~

~~~ili~1' Ilpin~~~nillifl I~rIJWi!!11tl1!1' il~llii~~ d Wqi~,~t,\"lhl~m~

p~C~f 01 11' p~~I~g U~~tlMti, m

P,19

Bradycardia and ta,chycardia in chitdren

In child ren , e1f.lluole b rodyco rdia and lochyco rdia in context. For e>:;3mple, b rodyco rdia (less than 90 beols iminule) moy occu r in 0 heollhy infonl du ring sleep; tachyca rdia moy be
,

no rrnal response
,

when

child is c r0ng

0r

oths rwise upset. Keep in mind that, becouse HR 1f.lries conside robly from ths neonats

10

the odolescenl,

one dafnition

of b rodyco rdia

0r

lochyco rdia con'l fit

011 child

ren.

Normal heart rates in children

kl· 1o'iIJD ~bN"!mtJ1
I.l1o<9

jOOJ1"""'1

E:u!'cl'.<

oc ~""lbNtl'mi:Jl

t""":c

100-~!C

!C 140

110

h~ 1ltD

iCGm

'(;l(O

llO

J rr~lll'

!O !Ie'

10 UO

lm

1 ~O 'r'

10 ~'O

,0,(
lD !O

lc-l

10~

l! 100

100

P.20

Sinus ta.chyca.rdia.

Rhythm
• Regular

G reate

r than

100 beats

/minute

PWQve
• • • • • No rrnal size No rrnal configu May inc r ease P recedes each ration in amplitude QRS complex , possibly supe rimposed on preceding T ........ and ve difficult to identify

As H R inc reases

• •

Vv'itl)in no rrnal limits Constant

Q.;F:. S camp I ex
• • No rrnal du ration No rrnal conf'igu ration

• •

No rrnal size No rrnal conf'igu ration

QT interval
• • Vv'ithin no rrnal limits Commonly sho rtened

P_21

Sinus

ta.c:hyc:a.rdia.

Anelllia Ca rdiogenic Drug:s: Alllinophyiline _ _ Alllphe1:allline:s: A1:ropine Dobu1:allline Dopallline Epineph.rine s+aoc tc

Hea

r1: failu r rhage

re

Helllo _ _ Hype

r1:hy .... tc+t-ce-r-r o

Hypo-..-olelllia Pe rica Pullllona e-cf

t-t-ts

ry

elllboli:S:1II crts-c re:s::s: _

Re:s:pi r-za-t ry o Sep:s:i:s:. T.rigger:s:

(alcohol,

caffeine. re:s:pon:s:e

rrf c o

trte ) 0 r pain

Po:s::s:ibly no rlllal

1:0 e::-::e r-c.j s se • -f'ee-ooe • :s:1: r re:s::s:• anxie1:y,

Pe riphe Regula r-

ral

pul:s:e

r-ze uee

satno o-e

100

bea1::s: ..... tr-u.rt ea r-rr

rhy1:hlll

If'
_

CO

f'a,Us a.n d C:On-J pe nsa1:0 ry

n-Jec: ha,nisn-J:s:"f·ai I,

Anxie1:y Blu .... ed r -....-i:s:ion

Che:s:1: pain Hypo1:en:s:ion Ne r-coorrar-oe ss

Palpi1:a1:ion:s: Syncope

If'

hea,rt:
Crackle:s: S.::!hea

f'a,i I.u re

de·ve

LopS

r-t :s:ound r vein di:s:1:en1:ion

_lugula

Moni1:o No1:ify P r- o

rhea doc1:o callll

r1: rhy1:hlll. r- p rOlllp1:ly if :s:inu:s: 1:achyea and 1:each rdia a ri:s:e:s: :s:uddenly 1:echnique:s: _ af1:e r MI.

o-t de

em-o-tronlllen1:

rela:><a1:ion

No

1:rea1:lIIen1: of

if .pa1:ien1: unde rl-ying

a:S:)!TTIp1:Ollla1:ic cau:s:e rene rgic blocke r:s: (p rop rrtc o-c'tr-e ) ranol.ol • a1:enol.ol) 0 r- calciulII channel toto cjce r:s: (ve rapalllil , dil1:ia.z:elll)

Co r rec1:ion

Fo r ca r-cf taac; i:s:chelllia: Ab:S:1:inence frolll 1:rigge

Be1:a -ad

r-s (alcohol.

caffeine.

P_22

Sinus arrest

R.egul:a t" except

du ring

;a

r re:::1: (i

I:"

regula

r a:::: r e sult

of

mi::::::::ir.g complexes)

Rate
• • U::::u::.lly "Within Length
0

no rrnal

ltrrrit

s (60

1:0

100 be:a1:$ .... esult

iminute) befo
.... dia

Fe

;a

t"'re::::1:

r f .... equency

of pause

may

in b .... adyca

Pe r iocl ic all u absent

urith

en t f r e PQRST

complexes

missing

•
•

Vv'hen p resen'l:.I no rrnal size

P recede:::: each QRS complex

and co rlfigu ration

PR interval
• • Vv'ithin Constant no rmal wtien limit:=: ........... a P wa ve en a P
'wa ve

is present

is p r es errt

QRS complex
• .. • No rmal No rrrial Absent du r;a1:ion configu r at ton

du t"ing a r r es t

• •
•

No rmal size No rmal configu

Absent

ra1:ion

cfu t"ing a r r es t

.. •

'Nithin

no rrrial

limits a r rest

Absen1: du ring

Other• • The p;ause isn'1; June+tonal

;a

multiple

of the unde Flying P - P inte r vals

escape

be;a1:s may occu r at end of pau:s:e

P.23

Sinus a.rrest

• • • • •

Acute Acute Acute CAD Ca • • • •

r- cl'io

infection trrre .... r -wal! M I 10 myoca r ci+t-is

acrt-i-ooe d

r- ugs

Amioda

r orre blocke r s (bi:=:op 1""0101 • metop we 1""0101 FOp r eriotol ) •P

Beta -aci rene rgic Calcium Digoxin channel

taboclce. r- s (diltiazem.

r- :apamil)

•
• •
•

P r oc atnern tcte
Quinidine

Ca rdiomyopathy
Hype r-tensiV€! he:=. r-t cl'is e as e

• • • •

Inc r-ea:s:ed Salicy1ate Sinu:::: node 555

V':3Igal tone 'tcoctc f t v cf ts eese

r-

ca

r- otid

s iruas

s ems i't-i-o-i

ty

What
• • •

to look. fo$'
of he:::.""t sounds and pul:=:edu ring I of :s:-yrnptom:s:
r- ea:s:ed

Absence Absence

:a

t"

r es t

......-ith :tho r-t pau:s:es CO w-i tf-r

r- ecu r-r-

Eo-icferrc e of dec • • • • • •

ent

r-

p r- olonged

pause:s:

Alte r ed mental Blu r

r- ed

st a rus

-o-isriom

Dizziness Cool Low

I

clammy

skfn

blood

p t"e::::::::u.... e
0 t"

Syncope

nea r -syncope

What to do
• • Monito P .... tec o
rt

he:=. r-t r-f-ry-tf-u-rr pcat terrt f .... om

. inju r

v , s uch

a::::a fall.

-which

may

r eautt

f .... 'ern ::::-yncopal

0 ....

rre a r -s vrrc opcal e o ts ocfes

cause

ci by

p r'olorrg ecl pau::::e.

• • •

No 1;.... rrnerrt ee

if pa1;ien1;

a::::yrnp1;oma1;ic r dia of d algo ....1; m ih

r- ug:::

If :::yrnp1;om::: • follow A::: needed.

b r adyca

cl is c or'rt iru.rart-iom

:;.ffec1:ing

SA node

ct+sc+ca r- ge

r-

c or-rch.rcrt-iom

::::uch tas

tae-t a -ad

r- eme

r- gic

totoc ke

r- s

• calcium

channel

blocke

r- s

• and

digoxin

P.24

Sinoatrial

exit bh:>ck

Rhythfli1l
• Regula r except du ring a pause (i r regula r as result. of a pause)

• •

Usually urithin no rrnal limits Leng1:h 0 ....frequency

(60 to 100 beats fminute)

befo re a pause

of pause

may result in b radyca .... dia

Pwave
• • Pe riodically '1vhen p ....serrt e ab::::en1: ......-i1:h rrt i Fe PQRST e
I I

complex

missing and p recedes each QRS complex

no .... mal s ize

and configu .... ion at

• •

Vv'i1:hin no rrnal lirrrits Cons rant when a P .......-;avei:::: present

QRS cOiJl"f1piex
• • • No rrnal du.ration No rrnal configu Ab:s:en1:during ra1:';on
:Ell

pause

T vvave
• No

rrnal s iz e ra1:ion
:Ell

•
•

No rrnal configu
Ab::::en1: durin;;=

pause

QT lntervQ.i
• Vv"ithin no rmal limit::::
:Ell

Ab:s:en1:during

pause

Other
• The pause is a multiple of the unde rlying P - P inte r",,1

P.25

Sinoa.tFia.l.

exit

bl.ock

What
• •
• •

causE'.s· it
infe r to r -.......-all I M
rnyoca

Acu1:e ir.fec1:ion Acute

Acute

r-cf i't-is

Ca r-cf-io ac t i-o-e d t"ug:s:

• • • •

Amioda Beta

r orre t"gic torocke r s (bisop block€!

r- s

-ad rene

rolol
I

metop

t-oto! • p t"op r amotol )

Calcium Digo::-dn

channel

(diltiazem

ve

r- ap:amil)

•
•

P r ocefnarnfcte
Quinidine

• •

CAD C~ r-diomyop:athy

• • • •

Inc t"ea::::ed vagal Salicylate Sinus: node 555

t one

toxicity cl'is e as e

What
• • •

to look
of hea of
r- 1:

.fOT
:s:ound:s: :and pulse du
r- ing

Ab:s:ence Ab::::ence Evidence •

•

SA eod-t block

symptoms

......-i1::h sho .... pau::::e::: 1:

0 t"

of dec rea sed CO ......-i1::h r ecnr t" r errt

r- ed

P t"olonged

pauses

Alte
Blu

mental
-o-ts f orr

:s:tatus

r- t"ed

• • • •

Cool.

clammy

skin

D'iz zrirre ss low blood p r e sau

0

Fe

S-yncope

r-

nea

r-

-s-yncope

What

to do
t"

• •
• • •

Monito

hea..-t

t"hythm. f r-orr-rinju r

P r-ot e c t patient

v , such

a:s: a fall

-which may

r-esurl't f r-orrr s-yncopal

r-

~ea

r-

-s-yncopal

episodes

caused

by p t"olonged

pause.

No treatment If symptomatic As needed

I

if patient
I

asymptomatic fo
r-

guidelines

symptomatic

b r acf uc a r-cf iza r-esjaorus e SA node cl-iscf-ra t"ge o!""conduction

I

discontinuation

of d t"ugs affecting

such

as beta

-ad

r-eme

t"gic blocke

r-s

c alc

urrri

channel

blocke

r-s

and

digoxin.

P.26

Sic:k sinus

syndrolTle

• • •

Irregul::.r Sinus pauses

Ab t"up1: r arte crianges

Fa:::1: slow
I

0 ....

arte t"na1:ing
;a

In1:er rup1:ed

by

long :s:inus pause

P
• • • •

YVQVe
V;a des May be ......-itt-. rhythm size ch:=.ng_es and configu ration

no rrna!

May be absent Usu:=.lIy p recE!des E!:8ch QRS complex

• •

Usu:=.lIy Va r tes

......-ithin

no rm::=.1 limits changes

......-ith rhythm

QRS cO.rJrl'piex
• • • DW r:3ltion Va .... tes No rrrial ......-ithin no rm::=.1 limit:s: changes

urith

.... hythm·

configu

r- ation

• •

No rrrial

stze r::=.tion

No rm:=.1 configu

• •

U:=:ually urithin Va .... tes urith

no rmal .... hythm·

limit:=: changes

Other
• Usually rno .... than e one a r .... hythmia on a 6 -second s t r tp

P.27

Sick.

sinus

syndrorYIe

Au1:onomic _ Degene Hype

di:s:1:ut"bance:s: r-ca'ti or-r of

1:ha1: affec1:

saurt mo rr-r ic; inne o

t"....-;a1:ion

au1:onomic

:s:y:s:1:em

t"....-;ago"tonia d t"ug:s: blocke blocke t":s: t":s:

Ca r-cf tocac-t t-ooe

Be1:a -e cr t"ene t"gic Calcium Digoxin Condi"tion:s: leading age channel

"to fib

e-o s f s of

5A

node

Ad....-;anced _ _ _ _ _

A1:het"o:s:clet"o1:ic Ca t"diomyopa1:hy Hype r-t sar-i o r-r si of

t-i ecae-t

ct+s e e s e

Inflam-ma1:ion . T t"auma 1:0 5A

aa-t r-izal

........-allt"ound a

5A

node

node

_ _ _

Open

-f-re e r-t

:s:u t"ge t"Y

e:s:pecially

-ocal-ooe

:s:u t"ge t"y

Pe r-i c sa r-cf-i t ts Rheuma1:ic b e a r-t ct+se e s e

_ _ _

Change:s:

in

hea r-t

t"a"te and t"ady

t"hy1:hm :s:-yndt"orne a1:r-i sal flu1:1:e ra1:r-i sal fib t"illa1:ion 5A block ,Ot" s truas at" r-e s t

Epi:s:ode:s: of .5-yncope

1:achy-b

(51:oke:s: -Adam:s:

a1:1:ack:s:)

If

un de!' Iyi ng
Dila"ted and

ca.!' diorYIYo
be-r=t -ooer-s-t

pat: hy
t" apical

p !'ese
impul:s:e

nt:

di:s:placed

t"icula

If
_ _ _

Po:s::s:ible c t"ackle:s: .5:1 t-i ecae-t :s:ound

t: h !'OrYIboerYI bo lisrYI
Acu1:e cf-re s t pain 0 r- 1:achypnea

p !'ese

nt:

Dy:s:-pnea Fa"tigue

Hypo"ten:s:ion Neu t"ologic change:s: (confu:s:ion -o-i s fo

r-i

di:s:1:ut"bance:s:

.......-eakne:s::s:)

~a;t
_ _ Moni1:o

;to

do
in b e a r-t t"hy1:hm.

r- fo t" change:s:

P t"epa t"e pa1:ien1:

fo t" po:s::s:ible 1: r-e e-err-oerr-c in1:e r-o-errt

tor-es .

_ _ _. _. _

No If

1: r-e e-err-oerr-c if

pa1:ien1:

a:S:-yTTlp1:oma1:ic of unde t"1-y-ing cau:s:e

:S:-yTTlp1:oma1:icI co r- r-e cre+or1:empo due

lr-ise r-t f o r-i of If at" t"hy1:hmia

t"a t"y pacemake

t" (1:t"an:s:cu1:aneou:s: 0 r- 1:t"an:s:venou:s:)

i- :

1:0 ch r orr+c cff s o r-ete r-tll sa-t-icxr-r

digoxin

be1:a -e

ct

t"ene t"gic

blocke

t"

r-e ct+o -ft".equency

abla1:ion

,Ot"

pe t"manen1:

pacemake

t"

An1:icoagulan1:

fo t" aa-t -izal fib r

Title:

ECGi F.act~

.....ade- IncTe'dibfy Vv"illi:ams

QWcld,.

~~t Edirion

Copy..-igh1:

©2006 l ippinC01:1:

a.

Vv"ilkins

::-T:able of Con1:en1:s ::-A1: ri:al

Atria,.
Prerna.ture a.trial contra.ctions

• • _

A1:t'"i:al: It'"t'"egul:at'" Ven1: t'"icul:a r : l r- t'"egul:a rUn de t'"lying: Possibly t'"egul:a r-

A1:t'"i:a1 :and -coer-rt

r-icmlzs

r-:

V:at'"y

'w-i'tf-r

undet'"lying

r+ro-ttu-n

• ~ • •

r errie

rrr r e

Abno r-rrual configu If

-oca

t'":a1:ioncomp:a

t'"ed 1:0 :a sinus

P warve

t'"ying configu hidden

t'":a1:ions • mul1:iple

e c t ojo+c s-i-ces . sh:aded :at'"e:a on s1:t'"ip)

M:ay be

in p t'"eceding

T .......ave (see

Usu:ally uri1:hin no r-rrual Hrn+es M:ay be af-rot'"1:ened 0 t'"sligh1:ly p t'"olonged fo

r-

-cf-reeC1:opic

be:a1:

QRS
_ •

cOnril'p$ex
Ou r-za-to r-i :and configu f No QR5 complex r-ca't o r-i usu:ally f follo.........-s: PAC no t'"m:al

Conduc1:ed: Nonconduc1:ed:

_ •

Usu:ally no t'"m:al M:ay be dis1:o t'"1:ed if P .......aveis hidden in T .......ave

Usu:ally uri1:hin no r-rrual l'ir-rri s t

Dither
• _ • • _ M:ay be M:ay be M:ay be M:ay be :a single bigemin:al 1:dgernin:al txesat (eve t'"y o ef-re r- be:a1: p t'"em:a1:ur e ) (eve t'"y 1:hi t'"d be:a1: p t'"em:a1:ur e ) (eve t'"y fou r-tf-r txesat p t'"em:a1:ur e ) (p:ai r s ) aa t
e-f

qu:ad ..-igemin:al
r-

M:ay occu Tf-rr-ee o

e-

in c.ccuote

ts

rr-ror-ea PACs in :a t'"o"'_'_" indic:a1:e

sal 1::achyc:at'"di:a

p.29

PrelTlSl.ture

a.trial

cOhtra.ctions

• • • • • •

Enhanced Acute COPD

automaticity

in at .... tat tissue

(most

common

cause)

.... espi

.... zrto .... failu .... y e

Co r orra r y hee r t disease Digo::-dn to::-cicity p .... olong absolute ... f r acto e .... pe r iocl of SA node y

0 t"ugs that • •

P .... ocainamide Quinidine imbalance::::.

Elect roly'te

• •
•

Endogenou:s: catecholamine Fatigue

Fever

relea:s:e from

pain

r anxie1:y

• •
•

Hea..-1: failu

Fe

H-ype rthyroidism
Hypoxia

• • •

Irlfec1:ious disease T rigge r s (alcohol' Valvula rhea

I

c;aff~ine

nicotine)

r t dise;ase

What
• •

to look jor
and ra~e ~ha~ ref1ec~ unde rlying r al
0

Pul~e rhythm I r regula

rhythm

r pe riphe

r apical

pul:s:e rhy'thm

-......hen PAC'S.occu r

Evidence

of dec re;ased

CO

such as h-ypotension

and syncope

if

p;a1:ien1: ha:s: he::...-1:disease

What
• • Monito If
pie't

to do
....hee terrt .... r h-o-thrn . 't ischemic
0 ....

has

....-;;31-...1, . IIa....hee .... cftse ase t

0 ....

, ......-atch fo r e-o-terence .
0 ....

o ffne a .... failu .... t e,

elect

.... olyte

imbalances,

and

mo r e s e ve .... at r tat ~ r e

r- h-o-thrn tas . Not-e.: In pcat terrts

u.rith acute

MI,

PACs

may

be

e a .... signs Iy • • Teach Demonst

of f-iea .... failu t to co r

re

an elect

r ol p-te trntxetance r Iying causes

Ratient .... ate

r- eet

0 ....

avoid

unde

t .... igge .... such s

as c a f'fe irie .

s t r e s s - r.eduction

techniques

to lessen

anxiety.

• • •

Usually

no t .... eatment

if patient

asymptomatic 0 r cont r 01 of t r igge r s at .... ial r ef .... acto r y pe .... iod

I

If symptomatic Fo ....f .... equent

elimination d .... ugs

PACs:

that

p r olong

such

as beta-ad

r ene .... gic

blocke

r s and

calcium

channel

blocke

rs

P.30

Atrial ta.chycardia

Rhythm
• • A~riai: Usually regular Vent r icula .... Regula ....0 r i r .... : egula r depending on AV conduc1:ion ratio and "type o.f at rial 1:achyca .... dia

Rate
• • A 1: ....tal: Th ..-ee
0

r mo Fe consecu1:i-...-e
I

ec1:opic

a t r ial bea1:$ at 1 50 1:0 250 bea1:$ Iminute; .... io at

.... rely e:=-::ceeds 250 bea1:$ Iminute a

Vent ricula .... Va rie:::: depending :

on AV conduction

De-..riates from

no rrrial appea

ranee

• •

May be hidden 'lf visible,

in p r.eceding

T wave each QRS complex

usually up righ~ and p recedes

May be difficul~

~o rrieasu re if P wave can't

be dis~inguished

from

preceding

T wave

• •

U:s:ually no .... mal du r at icn and configu

....rt ion ;: abno rrnallv th rough vent rides

May be abno .... mal if ~mpul:::e:s: conducted

• • •

Usually visible May be dis~o r~ed by P wave May be inve rted if i:s:chemia is present

• •

Usually "Wi~hinno rrnal ltrrrits May be sho r~e r because of rapid ra~e

Other
• May be. cliff'icult to diffe rentiate at rial tachyca rdia "Wi~hblock from sinus arrhythmia "With U waves

P _ 31

Atrial What
• • • • • •

tachycardia
CQu's'es

jot

Digo:x:in -tcoctc tt p- (rrro s t common) C;a r cf torrrvopca tf-rv COPD Congenital anomalies

Co ...pulmonale Dr-ug:s: • • • Albuter-ol Cocaine Theophylline r ol-o-te imbalances

• • • • • • • • •

Elect

H-ype t"thyt"oidism H-ypo xi a MI Physical Systemic

0

r- psychological
h-ype .... tension caffeine

:=:1:

r es s

T t"igge r s (alcohol.

nicotine)

VahAJla r hea..-t disea:=:e WPW ::::-ynd .... ome

What
• • • Rapid Sudden Signs

to loo~:
HR feeling of dec

JOI"

of palpitations

especially
I

urith pain

PAT
I

.... ees e

cr

CO

(h-ypo1:ension

chest

s-yncope)

What
• • • Monito

to do
r-

hea

r- t

r- hythrl).

A:=::=:e:=::=: patient Keep r esusc+re

fo r digo:x:in t tve equipment

t ooctc

tt-p-;

monito

r digoxin

blood

te-oef . .... a .... used. s e

.... eadily

;a....-ailable if vagal

iTlaneuve

• • • • • • •

T t"e:=.tment Possibly 0 rug the

dependent

on type
0

of

t:3ichyc;a

..-di::=.;and s tnus

::::yrnptom

ee ve rity;

di rected

t owa

rd

elimir.::=.ting

cznrs e ::=.r.d dec

re::=.sir.g

ver.t

ricul::=. r r::=.te

Vals::=.h..-;a's rn an eu ve r rapy (ph::=. r rrrac ologric • possible

r c::=. otid r csa r cttcwe ror.ized

·m::=.ss::=.ge to : acrencs tne

t r ea e PAT , arntccta r orie • bet::=. -aci r erte rgic toto eke r s • caf c'turn cf-ianne! toto eke r s • digoxir.

r s iort)

If p::=.tier.t

ur.st::=.ble

syr.ch

elect

ric::=.1 c::=. diove r

r s tor-,

Atri::=.1 overdrive If a r- r+ro-ttrrrrie Ir. p::=.tier.t urit·h

p::=.cir.g r eta'recr to WPW syr.d or. of rome, possible ce rhe-ce r- atxta+ton

CO PO • co r recti

hypoxi::=.

::=.r.d elect

r ot-o-te imb::=.I::=.r.ces

P.32

Atrial tachycardia

with block

• •

Atrial:

Regula r i rregula r if block is va riable

Vent r icula r: Regula r if block is constant,

• •

Atrial:

1 50 to 250 beats (minute

Vent r icula r: Va r ies ""_';thblock

Slightly abno rmal

• •

Usually constant May vary

fo r conducted

P ......-aves

Qft. S comp jI' e X

• Usually no rmal

Usually indisca

rnible

May be indisce

rnible

Other
• Mo re than one P ......-avefo reach QRS complex

P.33

Mul.tifocal atr ial tachyca.rdia

• •

At rial:

Ir regula r

Vent ricula r: Ir regula r

.• .•

Atrial:

100 to :2 50 beats /rninute

(usually less than

160 beats /rninute)

Vent r icula r: 100 to :2 50 beats /rninuts

• •

[on.figu ration:

Va r ies: P wave shapes must appea r

At least th ree diffe rent

Varies

• •

.Usually no rrnal May become abe r rant if arrhythmia pe rsists

Usually disto rted

May be indisce

rnible

P.34

Paroxysmal atr-ial tac:hycardia.

Rhythm
• • Atrial: Regula r Vent r icula r: Regula r

• •

At rial: 150 to 250 beats Iminute Vent r icula r: 150 to 1: 50 beats Iminute

.• •

May not be «is ible May be difficult to distinguish from preceding T ......-ave

May not" be rneasu rable if P ......-ave an't be distinguished c

from preceding

T ......-ave

QRS compte.x
• Usually no rrnal ; may be abe r rantly conducted

T
•

wave
Usually indistinguishable

.•

May be indistinguishable

Other
• Sudden onset, typically sta rted by PAC; may sta rt and stop ab ruptly

P.35

Nar row-e

m p lex t a c hy, a r d ia. algo r it h m

IP~d'om!lrm~r~'Ii!' i ¥fhrniii~Bd ti!1I11IoiliiIliIM .. ~,&iI'B~I~I~tV, lI~CiC~ :nul:
~iL'E :s;~a~il

Ii

'. IliI!ill1lil\i,aM itll:llt r'B"i'i:llrsl~r!l:1i:~1iJ~~

,~Mll!liIl!i~:r ,m~efl~ry' EC~ "ll'j'ill!'lll.I[)I~tD~ Ilre~Sllr&" (lxi fJie'tfll',

iD

liI~$1l.~~ :!:liIpp~t~:,~eC:5 !: "a;jjtl~d. i[j'il~ 9

(;~!lscimi.iS;iIf:D nai ~i1!ltlV

i!:"!lfiIfI!ifII~r$il;ll'!,

p-13~Eii1ittif!ii

~"""'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''i';Q
.......... __ ...................

Stlble

......

..!!!' ;: 110:

iDIDr~i1[[1m,

;; ~lticllir I~;:p~n IC:IlI'lNlrc1" ~ .' II· pLl1SMlIIi~S f!trU'i di1l!EiI· I~,;,.I (liPS; ~c;e ~!.IK~!::s:J;!mfst

'0
,0

,~lti'~li:!:li I~if.:(j,~'il~[.

IOlpmi1l1l2,la!;l~ EOOfwllIl'Ji.3!'lfllitlH~bll'l!!r Irh!l1~m',wi~.

N!llWw'QRS" fc!{,Ill,U'ilil~' ~ rh,~1h_m ,_tF

11ii\iJ,~~t.i!f ~~miii·CilI!iP1~ji: hcIv,r.c!udill

'Pr1\l~aliill:ilI!niD~ 'tJ~ri D,'IImii 1)1"

~mlt!D' ·flitr~1I111\J1'OO' III 11l!l11if.;;K:1I1,BiIJliIlIIB~lTIyi:errm~ '~~idt'ir

IlX~D'tI !!iQ(l$u1~B!~ ,; CorbUlil r:;;Ji9 ~~iltlilll~m!, a hill

bt!ders:; USli·!Hlhl blG!c~aif9: Ml!h 1~i'llIIioo i~ pliilmliiiii8mt

~IS~!:!~ (If

~!Hn

,NdJ. r!i'l1I1ve~.PfQ~,lJjf
'0

~~nNy.:liiPf"-iil:!liifli~f:,t

IOmSI:l~llIl'or"(j(iUnOi~OO. I. Till!illlll~li!rr,e:lJC" wi(~Eldel'!!l!Si!1i1l

cllliilfill;~"D1~'tmo1 A.'II:
!Il~e!'lt:s,

~_~~f~
nl!idiil blm!!:Limm
'0

ItdJrt~m~.i1

,~n1riCD!lV,£"~ ~W11f ~,} fhi!rm;. ~t.::~i~"IJrl~j':Mmr:~~liJI

'0 1C.L:ii'ii.f1!!11

,~lir~llI!! L!!~dbl1ir~g t:~!.Ise,

tlrOO{~~~iJll(:!TI.Il!:i:~1 b1~ek!i,!"

fH~~

~B'i:~f~B!ijB

1~I:Hi:liil.DI' B~ti~ ljilj.fl$l!Hii'OOll,

P.36

Atria.l. flutter

• •

At .... tel: Regula .... .Vent r icula r : TWically regula r , although cycles may alte rnate (depends on AV conduction patte rn)

Rate
• • • •
•

Atrial:

250 to <100beatsfminute (one -half to one -fou r rh of at rial rate), depending on deg ree· of AV block

Vent r tcula r : Usually 60 to 150 beats fminute Usually e:xp ressed Commonly
Only eve·ry

as a ratio

(2: 1

r <1: , fo r example) 1 150 beat:::: {minute vent r tcula r ; known as 2: 1 b~Q ~

to ven1: r icle s because 1:he A V node u::::ually '\.I.I'On'1; accep1: rrro
Fe

300 beat:::: /mit.u1:e at rial and

second
I

1:hi rd ,or

fou r rh impul::::e is condUC1:ed

than

180 impulse:::: Iminute

Vvhen at rial flutte r is fi r s t recognized

vent ricula r rate

typically

e:x:ceed:s: 100 bea,t:s:Iminute

Pwave
• • Abnormal Sa......-toothed appea ranee known as fiut-fE:.r
~.$

r F~.$

PR interval
• Not measu r able

.QRS compiex
• • Du ration: U:::ually u.;1:hin no .... mal lirrrits if fiutte .... -aves a .... bu ried urithin w e the complex May be uridened

Twave
• Not identifiable

QT interval
• Not me;asu rable because T .........-ave i::::n'1; dentifiable i

Othet:
• • Atrial rhy'thm m;ay vary 1:0 diffe bet........-een a fib rillato ry line and flu1:1:er .........-ave:::: (c:alled
atri~ fib-fi,utfE:.rJ_.

-..vi1:h:ar. irregul:ar

ver.1:ricul:ar

re::::por.::::e

M:ay be difficul1:

rer.1:i:a1:e :a1: i:al flU1:1:er from r

:a1:r ial fib ri1I;;'1:ior.

P.37

Atrial

flutter

• •
•

Ca r criac

su .... ry ......-ithacute ge

M'I and elevate at rial p re::::::::ure::::

Condition:::: that
COPD

enla·rge at rial tissue

• • • •
•

Digoxin ~oxici~y Hype r~hyroidism MI Mit r al

pe rica
0

tricuspid
di::::ea::::e

valve di::::ease

rdial

Sys~emic"

r te r ial hypoxi"

• .• .• •

Po::::::ibly no symptom::: Rapid 'Evidence Evidence

if vent r icula r ratei:::

no rrnal of p"lpi~"~ions)

H R if ven~ r tcula r r,,~e is r ap+d (compl"in~ of redl.,lced of reduced

CO if ven1: r icula r ..-a1:e i:::: r ap icl ven~ r icula r filling t irne and co ron" ry pe.rfusion from r ap id ven~ r icula r r,,~e

• • • • •
What
.• • • '.

Angina Hea rt failu H-ypo1:en::::ion Pulrnona ry edem" Syncope

Fe

to do
at bed:::ide ; be ale r t fo r b radyca
I

Moni~o r he" r t rh~hm. Keep r esusc i+at ive equipment Be al~ r t fo r effect:=: of digoxin Monito ~ pa1:ient rdia because ca ..-diove r sion can dec' .... ea:::e HR.

which dep re::::::::es of low CO ..

SA nod~.

clo::::elyfo r evidence

How it'.s' treated

• • • • • If patient hemod-ynamically un::::table and ......-i1:h rial tlut1:e .... f 48 hou r s at o the r"py
0

r less

immedia1:e

s-ynch ronized rs ion

elec1: r ical ca ..-diove r sion

W'i~h,,~ r'ial flut'te r of mo re rhan '18 hou r s , ant icoagulat'ion Vifith no rrnal hea rt tunct+on: Vifith impai red hea r t function Ablation t·he rapy fo r recu r rent beta -ad rene rgic blocke r s (hea r:t failu re at rial flutte r
0
I

befo r e and "ne r olol lor

I

r c" rdiove channel

such as metop

calcium lor

blocke r s such as diltiazem

r J: F below 40%): diltiazem

digoxin

arrriocla rone

P.38

Atrial

fibrilla.tion

• •

Atrial:

Ir r.egula rly i r regula r

Vent r icula r: Ir regula rly i r regula r

• •

Atrial: Almo$·t indisce mible , usually above

"loa

beats /minute ; fa r e=eed$

vent r icula r rate because

rnosr impulses aren't

conducted

th rough the AV junction

Vent r icula r: U$ually 100 to 150 beats /minute

but can be below 100 beats /rninute

Replaced by baseline fib r illato ry wave$ that rep resent

at rial tetanization

from rapid at rial depola r izat icns

lndisce mible

Duration and configu ration usually no rrnal

lndisce mible

Not rneasu rable

• •

Atrial rhythm may va ry between May be difficult to diffe rerrtiate

fib r illato ry line and flut te r wave$ (called atrial. fib -fl.utte:.{) at rial fib r illat ion from at rial flu+te rand MAT

P.39

Atrial

fibrillation

Acute

MI

•
•

CAD
C;ardi;ac su rge ry

•
•
• • •

COPD
Oigo>::in 1:oxici'i:y
0

rug:::: such a::::aminophylline

catechol:amine relea::::ed du ring exe rci::::e

Endogenou::::

Hype r'ten:::ion

• •
•

Hype r'thyroidi::::m Pe rica rdi1:i::::

Rheum:a'tic he::. r1: di::::ea:::e

•
•

T rigge r s (alcohol.
Valvula rhea

caffeine

nico1:ine)
rn+t ral v:::.lve df:::ea::::e)

r't di:::ea::::e (e::s:pecially

What to look Jor

• • • • I .... regula .... i r .... Iy egula r pulse .... hythm Radial Evidence Possibly pulse r a te that'"s r esase SIOUfe ....than 'uri tb no .... mal apical pulse
0

r abno .... mal H R rate

of dec no

ct CO (light -he actectneas

urith eh r orric

• hypotension)

symptoms

at .... fa! fib r ille t iorr

What to do
• • • Monito r fo r evidence If drug 1:herapy of dec rea:s:ed ca t"diac output rnorrtto r se rum d rug levels; in pulse and he::.r1: failu Fe. If p;a1:ien1:i:s:n''ton c;a rdiac .......-a1:ch r e-..ridence of 1:oxici1:y. fo and signs of hea r1: failu re • such as dy:::pnea and pe riphe ral edema. rnon+to r be ;alert fo r ; I:" t"egul;ar pul:s:e and diffe rences in radial and apical pulse ra1:es.

is used.

Tell pa1:ien1: 1:0 repo r1: changes

ra1:e. diz:z:iness • fain1:F'less • cheS1: pain.

• • • • • •

0 rug 'the r~py 1:0corrt r ol -o'errtr tcuta r response. If p a't terrt hemod-ynamically

0 r etec t r-ic al c a r cl-io-oe s ton uri1:h d n..-g 'the rapy r s-ynch r orriz ecl c a r cl-io-oe s ton (rnos t succ e ss tul if done uri1:hin 43 hou r s e f't e r a t rial fib r illetiorr onse t ) r

uns tetote • trnrnecifa'te

v-ti1:ha t rial fib r-illet-iorr of 'rno r e 1:han 43 hou r s : arrt tco'agiuta't ton befo r-e and af=te r ca rdiove r siorr v-ti1:hotf-rer wtse no rrrial hee r-r func rtorr: txera -e ci rene rgic jatocjce r s • such as rne toca r otol , 0 r calcium v-ti1:himpai red hee r t f'unc t ton (he a r t failu r e 0 rEF below 40%): ctttt taz ern Radio -frequency
atxta+ton
I

channel

bto cke r s such as cfil'tjaz errr

digoxin

,or

arntccta rone

'the rapy

fo r un responsive

syrnp1:oma1:ic .at rial fib r-ijlet iorr

P .'10

Ashman's phenomenon

Rhythm
• • Atrial: Ir regula r Vent ricula r: Irregula r

Reflects the unde rlying rhythm

PWQve
• • • May be visible Abno rmal conf'igu ration Unchanged i·f p r.esent in the unde rlying rhythm

Commonly changes on the p rernatu re beat ..if rneasu rable at all

QRS complex
• Alte red configu ration urith RBBB patte rn

Deflection opposite

that of QRS complex in most leads because

of RBBB

Usually changed because

of RBBB

Other
• • No compensate ry pause afte r an abe r rant beat by a long cycle Abe·r rancy may continue fo r seve ral beats and typically ends a sho r t cycle p receded

PAl

Ashman's

phenomenon

Prolonged

refr;acto

ry pe riod

in ::::Io\l..l"e'" rhythm

Sho r t cycle followed by long cycle bec",u~e refr"'c~o ry pe riod "'" r;e~ -..vi~h leng~h of cycle

What to look for

• No sign::::
0

r :s:yrnp'tom:s:

What to do
• Monito r he::. r t rhythm_

How it',s treated

• No inte rvention:::: needed
I

but may be needed

fo r accompanying

a r rhythmi::.::::

P.42

Wandering

pacemaker

• •

Atrial:

Va r ies slightly, "Withan i r regula r P - P inte rval

Vent r icula r: Va r ies slightly, "Withan i r regula r R- R inte rval

Va r ies , but usually "Within no rrnal limits

r less than 60 beats /minute

• •

Alte red size and configu ration from changing pacemake May be absent
0r

r site "Withat least th ree diffe rent P -"oJJave shapes visible if impulse
0 r iginates

inve rted

0r

occu r afte r QRS complex

in the AV junction

Va r ies from beat to beat as pacemake

r site changes

Less than O. 12 second if the impulse

0 r ig inates

in the Av junction

Du ration and configura+ion

usually no rrnal because

vent r icula r depola r izat ion is no rrnal

No rrnal size and configu ration

Usually urithjn no rrnal limits

May be difficult

to diffe rentiate

"oJJande ring pacemai<:e r from

PACs

P.43

Wandering

pa.cem.aker

COPD

• • • •

Digoxin toxicity lnc re;:.::::ed pa r asympathetic lnflarnrnat ion of at rial t issue Valvula ....hea .... disea::::e 1: (\l'dg::.l) influence:::: on SA node
0

r AV junction

What
• •
•

fo

look for
is una........-ae of a r ..-hy1:hmia) r 60 beat:::: Iminute no rrnal
0

'Usually Pulse

no ::::yrnp1:om:::: (pa1:ient rate

0

r les::::than

Rhythm

regula r

r sl;ghtly

; r regula r

At lea.:::1:three

di:::tinct

P ......-aveconf'igur

at ions

(distingui:::h

urande..-ing

pacemake

....from

PAC;;.)

What to do
• Mon;to r he" r t rhythm.

\IVa'tch fo r e-..ridence

of hemodyn;amic

in:s:'t:abili'ty

such as h"ypo'ten:s:ion and

chanse::::

in mental

statu::::.

• •

:Usually no 't reatment If symptomatic

I

if pat';ent

a:s:ymptomatic ..-egimen; investigation and ·t reatment of unde rlying cause of arrhythmia

review of medi~ation

Totle:

ECG F",ct~ M",.t.e-Incntd>hly

$2006 lippincott vvtttf arns

Quid,!, a. vvttkfns

1~t Ed>ri.. n

~opy .... ight

> Table

of Con1:en1:s

> June

June

Premature

junctional

cOhtra.ctions

At';",I:

Irregul",r

du';ng

PJCs

•
•

Ven1: r icula r : Ir regul:a r du ring

Unde ..-Iying .... hythm possibly

P JCs

r eg'ula ....

• •

At..-ial:

Reflects

unde

.... lying

rf-ncthrn rhythm

Ven1: r icula r : Reflec1:s unde Flying

P v.vave
• • • Usually tn ce .... ted May May (leads II, III, and aVF) du .... ing
0

(see shaded

a r ea on st..-ip) depending on initial di .... ection of depola .... taa

t ton

occu r tae fo r e be hidden

r afte

r QRS complex

in QRS complex

PR interval
• • 5ho rtened Not measu (less rhan r able if no O. 12 ·second)

if P "",ve

precedes

QPS complex

P wa ve p .... ctes QRS complexece

QRS cOil'i'nplex
• Usually no .... mal configu .... ation and du r ation because vent .... fetes usually depola r iz.e no t"mally-

U::::ually no

r- mal

c.onfigu

r- a-cton

U::::ually "Wi1:hin no rrrial

ltrrrit s

Other
• Commonly accompanied by a compen::::a1:O ry pau::::e reilec1:ing re1: rog rade a1:rial condUC1:ion

PAS

Prema,ture

junctional

contr acttons

• •

CAD COPD

• • • • • • • •

Digoxin toxicity Elect rolyte imbalances Hea r t failu re Hype rthyroidi$m Infe rio r -\1.0'<111 MI lnflarnrnato ry changes in the AV junc'tion afte rhea r t $Urge ry Myoca rdial ischernia Perica rditis

• •

T rigge r s (alcohol, caffeine, Valwla rhea rt di$ease

nicotine)

• •

POS$ible feeling of palp itatjcns Hypotension

0r

skipped enough

beat$

if P JCs are fr.equent

What fa do
• • Monito r ca rciiac rhythm fo r frequent Monitor patient for hemodynamic P JCs ; may indicate junctional irritability and can lead to mo re se rious arrhythmia such as junctional tachvca r dia , instab ilitv.

• • • •

U$ually no treatment If $ymptomatic

if patient

a$ymptomatic

, treatment

of unde rlying cause of drug of caffeine, decrease in

0r

If digoxin toxicity, If ectopic beats

discontinuation because

frequent

elimination

of caffeine

intake

P.46

Junctiona.l rhythm

A ~ r ial:

R.egul:. r

Ven~ r icula r : R.egul:. r

• •

A~r ial: 40 to 60 beats

/minu~e

Ven~ r icula r : 40 to 60 be:.~s /minu~e

Pwave

• • •
• •

Usu:.lly inver~ed

(Ie:.ds

II, III, and :.VF)

0

M:.y occu r befo re , du ring, M:.y be hidden

r :.f~e r QRS complex

in QRS complex

5ho r tene d (less than O. 12 second)

if ~ W<lve precedes QRS complex

QRS complex

No~ rne asu r'able if no .p W<lve precedes

• •

Dur:.~ion:

Usu:.lly .....,;~hin no rrnal hmtts Usuallv no rrnal

C.onfigu rarton:

T
•

WaVE'
Configu r at ion: Usuallv no rrnal

Usuallv urithjn no rrnal lirntts

Ot.her
• Impo r~:.n~ to diffe ren~i:.~e junc+ional rh~hm from idioven~ r'icula r rh~hm (:. life -th re:.~ening a r rh~hmi:.)

P.47

Junctional

rhythm

• • •

Ca r d'iornyopathv Conditions Drugs • • • Beta -ad rene rgic blocke rs Calcium channel blocke r s Digoxin that dtstu rb no rrnal SA node function
0r

impulse conduction

• • • • • • •

Elect rolyte imbalances Hea r t failu re HyPoxia Inc rea sed pa rasympathetic Myoca r djt is SA node ischemia SSS (vagal) tone

What to look jor

What to do
• • • Monito rhea r t rhythm. Monito r digoxin and elect rolyte leve'ls: of dec rea sed CO.

\!\latch fo r evidence

How it ',S' treated

• • • Identification Atropine; Junctional and co r rection
0r

of unda rlying cause pacemake r should neve r be supp ressed

tempo r a ry rhythm

pe rrnanent

can prevent

vent r icula r standstill;

P.48

Ac: c e leor at e d j u net ion al r hyt h m

• •

At rial:

Regula r

Vent ricula r : Regula r

Rate
• • At rial: 60 to 100 beats fminute zrntnute

Vent ricula r : 60 to 100 beats

• • •
• •

If present,

in....-erted

in leads
0

11,111, r afte.

and

aV.

May occu r befo re , du ring, May be hidden

QRS complex

in QRS complex

Sho rtened

(less than

O. 12 second)

if P w.;,....-e precedes QRS complex

QRS c.omplex

Not measu rable

if no P w.;,....-e precedes

QRS complex
• • Du ration: Configu Usually """;thin no rrnal limits ration: Usually no rmal.

Usually """;thin no rmal limits

Usually """;thin no rmal limits

Other
• Need to diffe rentiate accele rated junctional rhythm from accele rated idio....-ent ricula r rhythm (a possibly life -th reatening arrhythmia)

P.49

Accel.era.ted junctional

rhythm

• • • • • • • • •

Digoxin toxicity Ca rchac su r ge ry

(common cause)

Elect rolyte d istu rbances Hea rt failu re Infe rio r -urall MI Myoca rditis Poste rio r -urall MI Rheumatic hea rt disease Valvula rhea r t disease

• • •

Norrnal pulse rate and regula r rhythm Possibly no symptoms Possibly symptoms of dec reased CO (from loss of at rial kick ) , such as hypotension, cl1anges in mental status, weak pe riphe r al pulses

• • •

Monito rhea r t rhythm. \!\latch for evidence of decreased CO and hemodynamic instability.

Monito r se rum digoxin and elect rolyte levels.

• •

Identification Discontinuation

and co r recti on of unde rlying cause of digoxin

p" 50

J u n c: t ion al t a.c: hyc ar di a

Rhythm
• • Anial: Usually regular but may be difficult to determine if P wave is hidden in QRS complex or preceding T wave

Vent r icula r: Usually regula r

• •

Atrial:

Exceeds

100 beatsfminute

(usually 100 to 200 beatsfminute)

but may be difficult

to determine

if P wave isn't visible

Vent ricula r: "Exceeds 100 beats fminute

(CIsually 100 to 200 beats fminute)

• • •
• •

Usually inverted May occu ....befo May be hidden

in leads
Fe

u , Iii, and aV~

;af1:e....QRS complex

du .... ing lor

in QRS complex

Sho rtened

(less than 0" 12 second)

if P wave precedes QRS complex

QRS complex

Not rne asu r abte if no P wave precedes

• •

Ou .... iori: Vv'ithin no .... at mal lirrrits Configu ration: U:s:ually no rrrial

• • •

Configu ration:

Usually no rrnal in T wave

May be abno rrnal if P wave is hidden May be indisce .... nible

becau::::e of f::.::::1: ....a"l:e

Usually urithin no rrrial limits

Other
• May have gradual (nonpa roxysmal)
0

r sudden

(pa roxysmal)

onset

P.51

J u n c t ion 311 t a.c hyc ar d i a.

• • • • • • • • • •

Digoxin

toxicity

(most

common)

Elect rolyte

imbalances

Hea r t failu re Hypokalemia Inferior-,-,-",II (may MI rdial ischemia aHe rhea r t su rge ry agg ra""te condition)

lnfe rio r -,-,-",IImyoca Inflammation

of AV junction

Poste rio r -,-,-",IIM I Poste rio r -,-,-",II yoca m Val-...ula rhea r t disease rdial ischemia

What
• • Pulse Effects

to lool<: JOI'
rate abo-...e 100 beats /minute with regula r rhythm and hemodynamic instability (hypotension) because of rapid HR of dec reased CO (loss of at rial kick)

• •

Monito 'll'atch

rhea

r t rhythm. of digoxin. toxicity; rnontto r digoxin blood le-...el.

fo r e"';dence

How "it ',~ treated

• • • • Identification If due and treatment toxicity, of unde rlying discontinuation tachvca rdia onset cause of digoxin; ablation in some cases·, possibly digoxin-bindi.ng d rug to reduce rinse r+ion se rum digoxin le-...el

to digoxin

Fo r recu r rent If symptomatic • • • vagal with with

junctional with

, possibly

the rapy rdia:

follo.....-ed by pe rrnanent

pacemake

pa roxysmal and

of junctional

tachyca

maneuve

r<

d rugs such as adenosine beta

to slow H R -ad rene rgic

0

o the r urise no rrnal hea r t function: impai red hea r t function

blocke

rs , calcium r orre

channel

blocke

r s ,or

arnioda

rona

(hea r t failu re

rEF

below

40%): amioda

i .. I@:

ECG

FJ6Jct:§.MJ6Jde IncTembly Lippinco't't Vifilliam::::

Qu:;clcl'"

~:§.t Emrion

Copyrigh't

®200';

a.

Vifilkin::::

> Table of c crrt en-ts > ..... rrt e

Vent

Premature

ventricubil.r

c:ontra.ctions

• • •

A'trial:

Irregular

during
r-

P\IC:::: du ri.ng P\IC::::

r-

Ven't ricula r : I r- regula Urrcfe rlying rhy'thm

may be regula

• •

A't rial:

Re fbact s rrrrcferlying

rhy'thm rhy'th~

Ven't ricula r : Re fbec t s rrrrcf rlying e

• • •

U::::uallyab::::en'tin ec t ocrtc taea t May appea

r-

zaf't r- QRS complex e

w-i tf-r

r-e-t rog r-zsle c orrch.rcrt c iom 'to zs ria t rhy'thm

U::::uallyno rmal if p r eserrt in un de rlying

PR interval
• No t rFIea::::u rable e:x:c:ep'tin rrrrcf rlying e rhy'thm

QRS complex
• • • Occu r-s ea r-He 'than e::-:pec'ted rDu r-art-iom: Eccc e'e

cls O. 12 s ec ortci
Biza r r e and ......-ide bu't u::::uallyno rmal in ·unde rlying rhy'thm (see ::::haded a r esason st rip)

Con,figu ra'tion:

T y,vave
• • Oppo::::i'te di r-e t f orr 'to QRS complex c May 'trigger more se r tous rhy'thm di::::'turbance:::: ........-hen P\IC occna s on 'the ctowrrstcjoe r of 'the preceding normal T we ve (R-on-T phenomenon)

QT interval
• No t u::::uallymea::::u red e:x:c:ep'tin rrrrcf rlying e rhy'thm

Other
• • • P\IC may be follo......-ed by full lr-i-t rpola'ted e P\IC:
0

r ~ncomple'te

ccrnp ens aeo ry pau::::e c orrch.rcrt e'cl QRS c orrrcilecoas'w-i tf-rourt g r ee t di::::'tu r:bance 'to rrrrcf rlying e P\IC:::: rhy'thm

Occu r-s be't......-een 't-wo no rmally

Full ccrnp ens aeo ry pau::::eab::::en't......-i'th e rpola'ted 'irrt

P.53

Pre m at u r e ve n t ric: u l.ar c: 0 n t r a.c t ion s

What cau,s;es thet'n

• Enhanced ;au't,oma1:ici'ty (u:::u:al c:2lu:s:e)

• •

Elect rolyte Enl::. gement r

imbalances

(hype rkalemia rs

• hypocalcemia

hypO'magne:s:emia

hypokalemia)

of vent r icula r chambe

I r rit:able

focu::::

• •
• •

Irritation Metabolic
MI

of vent ricles by pacemake acidosi::::

r elect rode:::

r PA cathete

Mi1: r al valve

p t"olapse

• • •

Myoca rditis Sympathomimetic T rigge r s (alcohol

I

d rug:=:such as epineph caffeine

I

rine

nicotine)

What to 100:1<:: for

•
• •

Possibly
No rrnal

no symp1:om:::
pulse ..-a1:e ......-ithmomenta ea rly he;;. ...: sound 1 Fily i r .... egula r pul::::e rhy1:hm each PVC on auscul1:ation -....men P\fC occu r s

Abno rmally

urith

• •

Palpitation:::: Evidence

if PVCs a

Fe

frequent $-yncope)

of dec rea$ed

CO (hwoten$;on,

What to do
• • .. • P romp1:ly ass ess p a t ierrts ......-i1:h recen1:ly developed Moni1:o rhea
r't

P\fCs

especially

those

-wi1:hunde rlying hea r t disease

0 r complex

medical

problems"

rhy1:hm of patient:::: -wi1:hP\fC::::and se r ious symp1:om::::" of mo re frequen~ PVC.

0

Ob.e r"", clo$ely fo r de"",lopment Teach family members

r mo re dange rOU$ PVC patte

r'ris. antiarrhy1:hmic drugs after di::::charge"

how to activate

EMS and perform

CPR if the patient

urill be taking

• • • •

No treatment

if patient

asymptomatic

and has no e-o-iclence of hee r t disease

I

If ::::ymp1:oma1:iclor

dange r ous- fo rm of p\fC occu r s 0 rigin:

1: e atrnent r

dependen1:

on cause
I

Fo r P\fCs of pu rely ca rdiac Fo r P\fCs of nonca rdiac

drug:::: 1:0 supp r es s ven1: ricula r i r ri1:abili1:y of cause

such as amioda

rone

lidocaine

p rocainamide

0 rigin:

1: eatment r

P.54

Patterns of potentially
Som .. PVCs a r .. mo r .. dang .. r ous than

dang.erous PVCs
o th .. r s , H .. r .. a r .. sorn .. p o t ..n~ially dang .. rous on .. s .

Paired

PVc's

Two PVCs in a row, th r ....

0

call e d paired

PVCs

r a V€rdri cul=

caupIe! (see shaded

a r eas on s t rip above)

, can produce

\iT because

the second

corrt rac~ion

usually mee~s

r ef r ac'to ry t issue , A bu r s t ,or

salvo, of

r mo r .. PVCs in a row is consid .. r .. d a run of \iT .

J~ultijorm

PVC.S

Mul~iform

PVCs look d+ffe rerrt from

0

one ano the r (see shaded

areas

on st r ip above)

and arise

ei~her

from

d iffe r ent si~es or from

the same

si~e via abnormal

concluc+ion

. Mul~iform

PVCs may indica~e

s .. ve r .. h .. a r t diseas ..

r digoxin

~oxici~y.

p,55

PVC that. occur every other beat (bigeminy) or every third beat (trigeminy) can result in \iT or VF. The shaded areas on the strip shown above illustrate ventricular

bigeminy.

R-Ol1-

T phenomenon

In R-on-T phenomenon, a PVC occu rs so ea rly that it falls on the T \!lave of the p receding beat (see shaded a rea on st rip above). Bec·ause the cells haven't fully rapola rized , \iT

r VF can result.

P.56

Id iave n t ric u lar r hyt h m

• •

A~rial:

Usually can't

be de~ermined regula r

Vent ricula r: Usually

• •

A~rial:

Usually can't

be determined zrntnure

Vent ricula r: 20 to 40 beats

Usually absent

No~ rne asu rable

because

of ab serit

P wave

QRS complex
• • Du r at ion: boceeds O. 12 second because of abno rmal ven~ ricula r depola r iz.at ion Configu rat ion: INide and b iz a r re

Twave
• • Abnormal Usually deflec~s in oppostre di recrton from QRS complex

Usually prolonged

Other
• • Commonly If any occu rs ""';~h ~hi rd -deg ree AV block p r eserrt , not associated ""';~h QRS complex P waves

P.57

Id i ove n t ric u lar r hyt h m

• •

Digoxin ·toxicity Drugs • • • Beta -ad rene rgic blocke r s Calcium Tricyclic channel antidep blocke rs ressants rs vent ricles because of block in conduction system

• •

Failu re of all of hea r t's highe r pacemake Failu re of sup r averit r icula r impulses Metabolic MI Myoca rdial Pacemake 555 Thi rd -deg ree AV block ischemia r failu re imbalance

to reach

• • • • • •
• •

Evidence Difficult

of sha rply dec reased auscultation

0

CO (hypotension, of B P

dizziness,

feeling

of faintne«

, syncope,

light-headedness)

r palpation

What toO de
• • • • • Monito r ECG continually; Keep at .... opine Erifo rce bed Tell patient If patient
ariel

periodically

assess

patient readily

until hemodynamic a"if.3ilable. and patient

stability

has been

r es to red.

pacemake

....equipment

rest

until effective about

HR has been

maintained

is stable. and requi red

t

and family needs

the se r ious natu re of this arrhythmia pacemake

re atrnerrr. problems, when to contact. dono r , and how pacemake r function urill be rnorrito red.

a pe rrnanent

r , e><plain how it wo rks , how to recognize

How it's treated

• • • • • 5upp re«ion Possible of arrhythmia not goal of treatment; a r rhythm;a acts as safety mechanism against vent r icula r standstill

at ropine
I

to inc r.ease H.R

In erne rgency Pe rrnanerrt

transcutaneous pacem:ake r until t ransvenous pacemake r car. be inse rted r (such as arniocla rone , lidocaine) corrt r aincfica'teci fo r idiovent r icula r rhythm because of possible supp r ession of escape beats

pacemake d rugs

Antia r rhythmic

P.58

Ac; Co: eo at e did i GIve n t r ic u lar r hoyt h m I.er

Rhythm
• • Atrial: Can't be dete rmined Vent r icula r : U$ually regula r

• •

At rial: U$ually can't be dete rmined Vent r icula r : 40 to 100 beats /minute

PWilve

Not rneasu rable

• •

Duration:

hreed$

o. 12 $econd.

Configu ration:

INide and biza r re

TWQve
• • Abnormal U$ually deflects in oppos ite di recti on from QRS complex

U$ually p rolonged

Other

P.59

Accelerated

idioventricular

rhythm

• •

Digoxin Drugs • • •

~oxici~y

Be~a -ad rene rg ic blocke r s Calcium . Tricyclic channel antidep blocke rs ressants

• •

Failu re of all of hea r t's highe r pacemakers Failu r e of sup r averit r icula r impulses Metabolic MI Myoca rdial Pacemake SSS Thi rd -deg ree AV block ischemia r failu Fe imbalance to reach verrt r icles because of block in conciuc+ion sys~em

• • • • • •
• •

What ta look far

Eoidence Difficul~ of sha rply dec reased CO (hypo~ension, d izz iness , ligh t -haadadness , syncope)

auscutratton

r p alp.at ion of B P

What to do
• • • • • Monito r ECG continually; Keep at ropine Enfo rce bed Tell pa~ien~ If pa~ien~ pe riodically

assess p'at ierrt urrt il hemodynamic

readily available.

stabili~y

has been

r esto red.

and pacemake

r equipmen~

res·~ unt il effec~ive

and family about

H R has been

mairrta inecl and pa~ien~

is s~able. requi red ~rea~men~ problems, .. when to contact physician, and how pacemake r func+ion """;11 e rnorrito red. b

~he se rious pacemake

natu re of th is a r rh~hmia

and

needs

pe rrnanerrt

r , e"Plain

how i~ wo rks , how to recogni"e

• • • • •

Supp r.ession of arrhythmia Possible a~ ropine

I

not goal of t r.eatment HR

; a r rh~hmia

acts

as safety

mechanism

against

vent r icula r standstill

to inc rease

In erne rgenc:y transcutaneous Pe rrnanerrt pacemake d rugs r

pacem:ake r urrt il t r:ansvenous p:acemake r can be inse rted

An~ia r rh~hmic

(such as arniorfa rone , lidocaine)

corrt raindicated

fo r accele rated

idiovent

r icula r rh~hm

because

of possible

supp ression

of escape

beats

P.60

Ve n t ric u lar t .<!!I.C hyc ar d i a

Rhythm
• • A~rial: Can'~ be de~ermined regula r but may be sligh~ly· i r regula r

Ven~ ricula r: Usually

IRate
• • A~rial: Can'~ be de~e rmined rapid (100 to 250 beats (minute)

Vent r icula r: Usually

Pwave
• • Usually absen~ If P resen~ , not a«ocia~ed .....,.;~h QRS complex

Not rrieasu rable

QRS complex
• • • • Du ration: Configu E=eeds ra~ion: O. 12 second arnplrtude Usually b iz a r re , urith inc reased rphic shape \IT in polymo rphic \IT

Unifo rm in monomo Cons tarrtly changes

If \risible,

occu rs opposite

the

QRS complex

No~ rrieasu rable

Ven~ r icula r flu+te r: A va r iat ion of \IT

P.61

Ventric:ula.r

t3!.chycardia

Usually inc reas:ed myoca ..-dial i r r itability.

_' enhanced aU'i:oma1:ici1:y clo

which may be t rigge red by:

.: •.
.• CAD

PVC:::: du ring

wns t r olce of p ..-eceding system

T ......-ave

reent ry in Pu rkinje

.• • •
'_

Ca rdiomyopathy D .... to:=<ici1:y (cocaine ug Elect rolyt~ imbalances

He::. r1: failu
Fe
I

p roc

atnarn+de

lor

quinidine)

such as: h-ypokalemia

.• • •
'.

Mi Myoca rdtal ischemia Re........-a t"ming du Fing h-ypo1:he rmia

Val-...ula rhea r t di::::ease

What
•
• Usually

toO look Jar

irlitially
......-eak 0 r ab:::ent pulses-

Pos::::ibly only m:ino r symptom::::

•
•

H-ypotension

and dec rea sed leve-I of consctousne

I

ss • quickly

leading

to un responsivene:s::s
pe·..-fu::::ion

if unt t"eated

Po::::::::ible angina

hea

1"""1:

failu

re

and

sutxs

t arrt tal dec Fea:::e in 0 rgan

'. .• • •

Dete rrrrine urtretf-re.... atient p Monito rhea rt rhythm;

is conscious

and has spontaneous p rog re~~ to VF.

.... espi r a+ions and palpable

ca .... otid pulse_

rhythm

may rapidly

Teach family membe .... how to activate s Teach patient and family about

EMS and pe .... .... CPR if patient fo m

urill have an ICD 0 ....be on long-te .... antia r r hy.thmic the r apy afte r discha .... m ge_

the se r ious natu r e of a ........ hythmia

and need fo .... rornp t t r eatment_ p

Ho"'Nit's treated
• • • • • • • Fo.... ulseless p Fo.... nstable u
\JT •

immediate

defib r illation immediate

0

patient

urith pulse.

s-ynch .... onized guided

ca r diove .... sion by adequacy

(E F

If no definitive Fo.... table s For stable Co r r ection ICO

diagno~i~ of 5VT

r VT
0

treatment

above

40%)

of ca rdiac

function • s o t alol , amioda .... one • 0 .... idocaine l

patient patient

urith monomo .... phic urith rrronorno r phic

r polyrno r phic \JT and no .... mal ca r diac furrc t ion ; p .... ocainamide r phic \fT but poo r EF: amioda r one
0

0 .... polyrno

r li~ocaine

1_ _ follo-......-ed ca r diove r sion V by

of elect r olyte imbalances

P.62

Torsa.de:s: de po intes

• •

Atrial:

Can't" be dete rmined

0

Vent r icula r: May be regula r

r i r regula r

• •

Atrial:

Can't be date rmined.

Vent r icula r: 1-50to 300 beats /rninute

Not identifiable

Not rneasu rable

QRS complex
• • Usually \llide Usually a phasic ....-a r iat'ion in elect r ical pola rity, \llith complexes that point downwa rd fo r several beats and then upwa rd fo r $eve ral beats

Not disce rnible

Prolonged

Other
• May be pa ro X"l'$ma , sta rting and stopping I suddenly

P .63

Ter sades

de po irrte s

• • • • • • • •

AVblock 0 rug toxicity (soralol , p rocainarrride (hypocalcemia, synd rome , quinidine) hypokalemia, hypomagnesemia)

Elect rolyte imbalances

He red ita ry QT prolongation Myoca rdial ischemia P r inzrnetal's angina

Psychot ropic drugs SA node disease

(pheno thiazines,

tricyclic

ant idep ressants )

resulting

in seve re b radvca rdia

• • •

i'alpitations Hypotension

, dizziness,

chest pain, and sho rtness o.f breath level of consciousness

if patient

is conscious

and dec reased

loss of consciousness,

pulse, and respi rations

• •

Monito rhea rt rhythm and obse rve fo r QT prolongation Oete rrnine "oJJtJethe patient r is conscious

in patients

receiving

d rugs that may cause to rsades ca rotid pulse ..

de pointes.

and has spontaneous

respi rations

and palpable

• • • • • • •

Oefib r illat ion Ove rd rive pacing Magnesium sulfate O·iscontinuation

I. V.

of offending

drug

Co r·rection of elect rolyte imbalances For unstable ICO patient "Withpulse, immediate synch roniz ed ca rdiove rsion

P.64

Ventricula.r
Coarse

f'ibriUa.tion

Fine

• '.

Anial:

Can't be determined rn
0

Vent r icula r : No patte

r regula rity.

just

fib r illa+o ry wave:=:

Rate
• • Atrial: C;an''t be determined

Vent r icula r: Can't be dete rmined

Can't be dete rmined

PR interval
• Can't be dete rmined

Can't be dete rmined

T wave
• C;an''t be dete rmined

QT interval
'_ No1: rne asu .... able

Other
• Elec1: r ical defib r illat ion mo re successful urith coa ..-::::e fib .... 111::.1:0..-y wave:::: than "With fine ......-;aves

P.6~

Ventricula.r

fibrill.a.tion

• • • • • • • • • •

Acid -b ase imbalance CAD 0 rug ~oxici~y Elec~ ric shock Elec~ rol~e MI Myoca rdial ischemia rrnia such as dila~ed ca rdiomyopa~hy imbalances (hype rcalcarnia , hype rkalerrria , hypokalemia) (digoxin
i

p rocainamide

, quinidine)

Seve re hypo~he Unde rlying Llnt rea~ed

hea r t disease \IT

• •

Full ca rdtac Un responsive

a r resr: parienr "Wi~hno detectable B P 0 r cent ral pulses

Assess

partent

to de~e rrnine

if rhvthrn

is VF.

•
• •

S~an CPR.
Teach Teach patient's patient family about the se r ious natu re of this the ICD if applicable
0

a r rh~hmia

and

how to acti"0)";3te EMS and pe rfo rrn CPR. the rapy the patient "Willbe taking afte r cfischa rge.

and family

about

r ant ia r rh~hmic

• • •

trnrnedtate

defib

rfttatton

up to ~h reetimes

"Wi~h 200 joules, r illatfon:

200 to 300 joules epineph

, then

360 joules

Failu re to co r rect Follo"Wing VF and

VF af~e r ~h ree at ternp ts at defib pulse less \IT algo rithm guidelines

r ine 0 r "o)";3S0P r esstn

P.66

Pulselsss arrest algorithm

I)iiElry;3.~15'l1im UAg~'i'1l:1 dlMiiloIYilS1:i' llJfe~1~4C' !.mi~jl; LO. t~' ~,~!l~~! i~r~: V"or ~
~I

Imi'fl1l~~DilIly ri)~ufi}O QP~fIn 5t~tI~'\S> ., Gjve.EI~'iP1i~hrin:e II.V.OfL;, ~e~e~ t!i1~

iii

u.~oo.J~ 'Of51~I PEA r\l!~. ei~~8;t ,!!\lBf!j' R 'tfl15, min lif' IIi 3 do~5,~

iGi'S'Iltooili d~m D~I!IpiMgi~iil1l:J. O!):[Is[d!llr 3llJ>lI!l)lm~1 m~ ILV.'Dr' II.C','rut'

I
I

~,rmi.!l.8,r:~!tW1iiltl !i:b~r~i'im dm~~rilliJIJli'i. !iJwel iih!l~k Ibi~h\'!~i~ ,ij!m~ !!ttliql' i!lbmt;k iji' Imgh~_f'd~~B~ ImOt'iillpl~1IJ5[t::wil1
I'
~

I~[j]~sl,
~I

• Imriliildiill81~ f8~mjj;

6'~lnl(!~~lIifJ:(}rim I'.V. or 1.0, ~~pe:lliYIIt~ 1 ' ~,I~") min @~ milM 1 ~g~ !Jf 'i'1!I~1il~!'Ii!!i~~ 40 1fI1ilIi 1,1J. 01' II,C~ '~j) ,rjj~I'IlC(l, lif:'J~,Qr SCiOO,itW

C~R-

m~~----""'Ii'
., Ii l!iSlj'c!!ole" Oil! iIIi!' ~~.~ 11m.

'IE!;
. .

dme Q~ e~ll'ie~mrir!!J:

iii

II Di!!~~i(:iIll Ii1;~~Ni~, !I:~tI!1:k

~Lt'!sEi, :11 Ill!!!' plj_~e;\ mil:!"l!:!

;1m'1~\

I~pl!.!l~njJfeS-tml" be~tf11 ~[fa~S~ii[iJii~ ,[pJe,

~I

rul~r ~ilj iildi'l'iifiClilili DltWl1~ is jllileCl:i!. 'g'hro !IlOO~illt!i!I!J~ if,hU~etlJ[t1pr':ii:!iien~

Wtl~ijili I~im5~5; rili' '~~BiI~It:.

P.P

.~ICoqtil1~~ Iffll.~~ laPIA: It-~r{jjrrm~e~~lilleOOf, lill~1iai I ~totU~lp~~~i~: ~s i~~iil~. :~fst~~~~t, jj~IIt1mlur

Ii

aOMl: m~rn~liliii'$i~; ~ig~le~}. Imm~~ia~ulV CPR! M'5time I~C~~~~~l ~ntj~rmv~ics;~i~G d~rirmCf-R~

I~
I~

IDtlm~~BJmi~~B5ill[Jj, Iir~dm~: d~m';

~IUl~5CV~i)S ~IC'R!!,~rOto 00x i

P.68

.A~ystol,e

•.

Vent r icula r: Not present

• •

Atrial:

Usually indisce rnible

Vent r icula r: Not present

May be present

Not rneasu rable

•.

Not rneasu rable

• •

looks like a nea.rly flat line on a rhythm st rip except If the patient has a pacemake

du ri.ng chest comp ress ions "WithCP R

0r

r , pace r spikes may show on the st rip, but no P wave

QRS complex occu r s in response

P.69

Asystol,e

• • • • • • • • • •

Ca rdiac

tamponade

0 rug ove rdo:!:e Hypothe

rrrria

Hypovolemia Hypoxia Massive MI Seve re elect rolyte dtstu rbances acid -base rax , especially distu rbances hype rkalernia , especially and hypokalemia acidosis pulrnona ry embolism

Seve re , unco r rected Tension pneurnotho

metabolic

What
• • •

to look 101'
pariant resp i rations, of vital
0 rgans

Un responsive

Lack of spontaneous No CO 0 r pe rfuston

disce mible

pulse,

and

BP

W~at
• • •

to do
0 rde

Ve rify lack of do -not - resuscitate Ve rify asystole S~a r t CPR, by checking

r. one ECG lead. ai rway com rol ....,.;~h~racheal intubattcn.

mo re than

supplemental

oxygen,

and advanced

How 'it',s tl'ea.tea

• • • • Identification and rapid treatment of potentially reve rsible causes; othe r""";se , asystole possibly i r reve rsible

Ea rly transcutaneous I.V. epinephrine Fo r pe r s is terrt and

pacing

at-rcpfne
despi~e app rop ria~e managemen~: possible end of re susc i+at'ion

asys~ole

P.70

P u ls eo ss e I.ec t ric al a.c t ivi ty I.e

Rhythm
• • At rial: Same as unde rlying rhythm; becomes i r regula r as rate slows i r regula r as rate slows Vent r icula r: Same as unde rlying rhythm; becomes

RatE"
• • At rial: Reflects underlving rhythm eventually dec reases

Vent r icula r: Reflects unde rlying rhythm;

P WaVE"
• Same as unde rlying rhythm: gradually flattens and then disappaa rs

Same as unde rlying rhythm;

eventually disappaa

r s as P wave disappaa

rs

QPl:S complE"x
• Same as unde rlying rhythm; becomes p rog.ressively "Wider

T Wi.1VE"
• Same as unde rlying rhythm; eventually becomes indisce mible

Same as unde rlying rhythm;

eventually becomes

indisce mible

Other
• • • Also kno\IJTIas PEA Cha racte rized by some elect r ical activity Usually becomes a flat line indicating (may be any rhythm) but no mechanical activity
0r

detectable

pulse

a.systole "Withinseve r al minutes

P.Y1

Pulseless electrical

activity

What causes it
• • • • Acidosis C:. r-di:.c rarnponad .. as ~ ricyclic :.n~id .. p r .. ssants )

0 rug ove r dos .. s (such Hyp .. rk:.l .. rrria Hypok:.l .. rrria Hypoth .. rrrria Hypovol .. rrria Hypoxi:. M:.«ive M:.«ive acut .. M I

•
• • •
• •

pulrnona ry .. mbolism

T e ns ion pn e urno tho r ax

• • •

Apn .. a and sudd .. n loss of consc iousn .. ss l.ack of B P ancl puis .. No CO

0

r p .. rfusion

of >.rit:.10 rg:.ns

S~:.r~ CPR imm .. di:.~ .. ly.

• •

Epin .. ph r in .. :.nd :.~ ropin .. acco rding Id .. nt iffca+ion • • • • • •

~o AC LS guid .. lin .. z

:.nd ~r .. atrn .. nt of caus .. including: rarnponad ..

p .. r ioa rdioc .. nt .. sis fo r ca r dtac volum .. infusion

fo r hypovol .. rrria from .. s

h .. mo r rh:.g ..

co r r .. ct ton o.f .. I.. ct rol~ .. trnbalanc ventil:.tion su rg e ry

0

fo r hypoxemi:. r th r ornbolyt ic th e r:.py

0

fo r mass ive pulrnona

ry .. mbolism r:.x

n .... dl e d e comp r e ss ion

r ch e s t tub e ins e r t ion fo r ~e ns ion pn e umotho

..

Pac e mak e r th e r:.py

(r:. r e ly e ff e ctive)

Illle:
Copydght ::- Table

ECG F.aCt5 JII.ade IncTemhly

®2006 Lippil"lcott 'oNilli"'m~

Qu>cl<!, "5t Emrion

a. 'oNilkil"l~

of Con1:en1:::: ::- A-V elock

A-V Block

First-degree

AV block

Rhythm
• Regula .... ·

Rote
• • V!fi1:hin A1:.... ial no .... mal 1:he same ltrn+rs . as ven1: .... tcutar

• • •

No rrrial No rrrial Each

size configu .... ation by a QRS complex

followed

• •

Prolol"lged Mo re rhan 0.20 :::econd (see shaded a re;a on

::::'1:

rip)

Cons1:an1:

QRS complex
• • VVithin no .... mal limits (0 OS second) conduction if conduction delay may delay be occu .... in AV node s .... kinje system

If rrro r e than

0.12

second.

in His-Pu

• •
•

No rmal size No rmal co rlfigu ration

M",y be abrio rrnal if QRS complex i~ p rolol"lged

VVithin

no .... mal

limits

P.73

First-degree

,AV ble ck

• •

Degene Fati....-e (age - Felated) DFugs • • • Beta-adFeneFgic Calcium Digoxin channel

changes

in hea r t

bfocke rs blocke
FS

• • •

MI Myoca Fdial ischemia Myoca Fditis

What to

loo$;::
Fate

jor

• • • • •
• •

No rrnal pulse

Regula F Fhythm Usually no symptoms Usually no significant Inc Feased effect on CO S, and S~ hea r d on ca r ciiac auscultation if P R inte " «a I is ext Femely long

inte n.-;:.I between

What to do.
Monito F patient's Gi....-edigoxin, ca rcliac Fhythm to detect rs , and p FOgFession to rno Fe se r ious hea r t block. bfocke rs cautiously.

calcium

channel

blocke

beta-adFeneFgic

Identifi~;ation

arid co r .... ection

of unde .... Iying cause

P.74

Type

I second-degree

AV block

Rhythll"n
•
•

Atrial:
Vent

Regular
t"icul:::. r : It" regul:=. r '

Rate
• • Atrial Both r;a1:e exceed:::: ventricular r a'te s u::::u:=.lIy ......-ithin r;a1:e bec;au::::e of nor-conducted be;a1::::

no rm:=.1 limit::::

No rrrial

size

•
•

No rrrial configu
Each follo......-ed

ra1:ion
by a QRS complex ecccep
t

blocked

P wave

• • • •

P rog re::::::::ively longe r (see Commonly Slight Afte cle sc; ribed

sh;aded
I

;a

rea:::: on

:::1:

rip)
II

"Wi1:h each

cycle

urit il

;a

P ......-;ave appe:a

r s "Wi1:hou1: ;a QRS complex

e s "Iong

longe r • dropped to cycle the

va r ta+ton in delay
r the non conducted

f .... cycle 'ern beat.

s ho r t e r than

inte

t"....-;al .... p eceding

it

• •

Vv'ithin

no rrrial

limits

Pe r iocl ic all u absent

• • •

No rmal No rrrial Deflection

size configu may ration be opposi1:e tha1: of 'the QRS complex

Usually

......-ithin no rrna!

limits

Other
• • Wenckebach P R trrte r-ca! p;a get::::
1;

1;e rn p rog

of

grouped

bea't:::: rand

(foo'tp

rin't::::

of r-e-al

Wenckebach) sho r
t ens

r es s i uefu longe

R- R tn-ce

until

P wa ve

appea

r s ur+ttrou

QRS

complex;

cycle

then

....ep

ea

ts

P.7S

Type I second-degree

AV block

Wh a e cause.:;" :it
• • CAD Drugs • • •
•

Be1:a -;ad rene rg ic blocke Calcium Digoxin

pa ra::::yrnpa1:he1:ic

rs

channel

blocke r s

Inc rea sed

"tone

• •

Infe rio r -.......,11 I M Rheum;:rtic feve .... ·

What
• • •

to fook for
of dec rea sed CO (hypotension, ::::igns and symptom:::: if vent light -headedne«) r icula ~ rate is slo ur

Usually no symptoms Evidence Pronounced

What to do
•
•

Monito r ca rdiac
A::::se::::::::

rhythm

fo r p FOg ression

of deg Fee of block_

patient's

tole ranee of rhythm. of dec reased CO.

• • •

Obse rve fo r signs and symptoms Eva luate Teach patient

fo r p oss ibte causes. about temporary pacemaker, if indicated.

patient

How
• • •

it's

treated
and treatment of unde rlying cause i::: having
I

Identification At .... opine

(use cautiously pacing

I

if patient if needed

an MI; atr.opine

can -wor:::en ischemia)

T ranscutanaous

until the a .... rhythmia

..-e::::olve:::

P_76

Type II sec:ond-degree AV block

• • • • •

At

r- -izal:

Regula

r-

Vent

r icula r : I r ro::gula t" co

rr-

Pauses Ir
r- egula

r-espond

to d r-·opped is inte

beat
0

-.......-hen lock b

r- rni"ttent

r-

conduction
I

r-atio
0

i:s:....-:31 r-i:able
r-

Regula ............... conduction en

r a't-io is: constant

::::uch sas 2: 1

3: 1

• •

Atrial Both

eccce ecfs ven'tricula may be

......-ithin no r-rrual limit:s:

No r rrual size

• •

No r mal Some

configu

ration

not follo-wed by a QRS complex

• • •

U::s:ually ......-ithin no r-rrual limits: Constant fo

r-

but

may

be

p t"olonged

conducted

taea t s bea1:

May be s+rcr "tened af1:e r a nonconduc1:ed

Q_RS
• • •

cOl'npiex
r- mal

Vv'ithin no Vv'idened

limits:

r-

na

r-r-

0-.......-

if block

occu

r- s

at

bundle b

of His:
r- anche::::

and

::::imila r- to BBB if block absent

occu r s at

bundle

Pe r iodically

No r-rrual

size r- ation

No r-rrual configu

Q_T intervai
• Vv'i1::hin no .... mal ttrn+t s

Other
• • • PR and R-R interval::: don't vary before a dropped beat (se e :=:haded area
't-wo

on s t r+o )
r-waf

:=:0no u.-arning

o ccnar-s

R- R -irrte r-e-al that Mu:=:t be a complete

c or'rt a'irts non conducted block in one bundle

P 'warooeecqu.a!s b ranch and

no r-rrual R- R -irrte
r-

s in conduction in the othe

r-

'irrt e r rr'ri't t ej-rt -irrte

ruption

bundle

fo

r-

a d t:"opped

beat

to occu t:"

P.T!

Type
What
• • • • Ante

II sec.ond-degree
causes' it
r io ....-"I.I.,I";311MI .... t i oe changes e he a r t disease in conduction

.A'II bl.ock

Oegene 0 r ganic

system

Se-ce r e CAD

What
• •

to 1001< fo$"
as long a::::co is adequa1:e CO ('as dropped beat:::: increa:s:e)

Usually no :s:ymptoms E-..ridence of decre;ased •

•

Che:s:1: p;ain
Dyspne ..

Fatigue

• • •

H\lPotension Slow pulse Regula r

0

r i .... ..-egula r rf-ru-thrrr

What
•
•

to do
rhythm fo r p rog re:s:::::;on1:0 rno
Fe

Obse rve c;a rdiac

Ev.alua1:e pa1:ient

:s:eve re block.

fo r co r rect;able

cause:::: (:s:uch a:s:i:s:chemia).

• • •

Adminis1:e r oxygen. Res1:rict pa1:ient to bed re:s:t: :s:ymptoms:

I

If pa1:ient ha:s: no se riou:s: :s:igns and • • monito r patient cont muoustv

keeping

ranscu1:aneous rinse rtion.

pacem;ake

r attached

1:0

pa1:ient

r in room.

p repa re p;:l'tierl't fo r t r;an:s:venou5 pacemake patient and family about p acernake rs

I

Teach

if indicated.

MoYil' ;it ',~ treated

• • T ..-anscutaneous pacing initia:l:ed quickly ......-hen indicated and I. V. dopamine infusion
I

epineph

..-ine

0"-

combination

of the::::e d ..-ug::::

A t ..-an::::cutaneou::::pacemake..-

(fo..- se r ious ::::ignsand ::::ymptoms) until a pe rrnanerrt

pacemake..-

is placed

P.78

Third-degree

AV block

Rhythn;,
• • At..-ial: Vent Regula..-

r+cuta r : Regula .... ·

Rate
• • Ven1: r icula r : U::::ually 40 to 60 bea1::::iminU1:e Ven1: ricula r : U::::ually Ie:::::::: than 40 beat:::: in an int ranodal block block (;a junctional (;a vent e::::cape rhy1:hm) rhy1:hm)

IminU1:e in irlfranodal

r tcula r e::::cape

• • •

No .... mal stze No .... mal May be confi~u .... a+ton

0 ....

bu r ieci in QRS complex

T wave

PR i~terval
• No1: mea:s:u r;able

• • •

Configu Appea

.... ation
1""5

depends if the block

on location block is at is at

of escape the level

mechanism of the AV node b .... ancbe

and
0 ....

o .... igin bundle

of vent of His

.... tcute r depola

.... tze t ton

no rrna! if the

Vv'idened

tf-te level

of the

bundle

T ,",ave
• No rrnal ::::iz:e

•
•

Norm::.1 configur;a1:ion
M'ay

be abno rmal' if QRS

cornptex

rigin;a1:es in vent ride

QT interval
• Vv'ithin no rrrial limits

Other
•
•

A'trta
P

;and ver.'tricre:s: ;are depol:ariz:ed r "Wi1:hou't QRS complexes

from

differen1:

p:acemaker

::::i1:e:s: ;and be:a'l: independen1:ly

of each

other"

......-;ave:::occu

P.'"

Third-degree

AV bloc:k

At: I.evel of AV
• _

node

AV node
Inc rea::::ed Infe

damage
pa,t"a::::yrnpa'tt-.e'tic MI 'tone

....or-.......-all i

Toxic

e f=fe t s of drug:::: (digoxin. c

propranolol)

At: inf'ranodal,
_ Ec-ct sarus t-ooe an:te rio

level,
r- M I

• _

Possibly Dec

no

:S:-yTTlptorns: e>::eept CO from to s s of

exe

reis€!

in1:ole and

ranee

and

unexplained to s s of aa-trial

fatigue kick

r-esas e

ct

AV

synch

t"ony

r-e:s:ul1:ing

•
_

Changes
Che:s:1:

in level

of con::::ciousness

and

mental

statu::::

pain

_
• _

Dyspnea
Hyp01:en::::ion l igh1: -b e acte ctrre s s

_ •

Seve 510Uf

re

fa1:igue Fiphe r-zal pulse r- ate

pe

'WhQt"
_

eo

do
I V. line.

En:s:u e pa1:en1: ....

•
_ •

Adrniniste

r-

oxygen.
fo r- co ........ c t efote e e c t+o+t c;au:s:es: of a ........ hythmia (d r- ugs:
I

As::s:es$ pa1:ien1: Minimize

rnyoca .... dial

ischemia)_

roe t terrt'.s 1:0

oe s

level. t.

Re

t ....
-icrt

pa1:ien1:

bed

Fo r- patient

'w-i'tf-r

58

r-iours signs

and

:S:-yTTlp1:oms I -irru-rte cfizrt e 1:r ee rrrrerrt

including:

1:r-anscu1:aneous I. V. dopamine

pacing infusion

(mOS1: e epineph

r re

c e+oe ) combina1:ion (fo r- sf-ro r-t -1:e r-m use in erne r-gencies)

r-ime ,Or-

• •

A1:r-opine

c or'rt r-za-irrcftca't e cl pacemake r-

especially

"When

accompanied

by

uride-complex

-coarrtr-ic rrlta r- escape

bea1:s

Pe r-manen1:

Copy

.... igh"'t of

®:LOO6con"'ten"'ts:

L ippinco"'t"'t >. 1 Z- Le:ad

Vifilli:ams:

a..

Vifilkins:

>

.-:able

12-Lead
L; ... b
P

le a d
lef"'t leg _A

r- ope

.... I_e:ad
I

pl:ac~m~n"'t

p I.a.c e ... e .... 1: is: c; .... ~"'tic:al -rc». rplus: s:ign (-+-) indic:a"'tes:

:accu

.... :a"'te

.... eco

.... ding pole.

of

c:a

.... di:ac s:ign

r- h-y-.:hms:
(-)

_ Thes:e

r- :a,-.......-;ngs:s:ho-._._.-co
pole. :and

........ ec"'t G

elec"'t

.... ode

pl:ace-:nen"'t_

fo

.... "'th":,

S:j.x d

limb

le:ads:.

RA.

:'"'t:ands: EC G

fo s:"'t ip

igh"'t fo

:a

r- rT);

LA le:ad

lef"'t _

:a

r- m;

RL

r- igh"'t

leg;

:and

LL

:a pos:i"'ti.....-.e:

:a minus:

indic:a"'tes:

:a neg:a"'ti.....-.e:

indic:a"'tes:

:a 9 .... oL:lnd.

Belo--._._.- e:ach

.... :a-.......-;ng is:

:a s::ample

r-

"'th:a"'t

Connec"'ts:

"'the

r- igh."'t

:a

r- m

(neg:a"'ti.....-.e:

.pole)

-"""'-;"'th "'the

lef"'t

:a .... m

(pos:i"'ti.....-.e:

pole).

Connec"'ts:

"'the

r- igh"'t

:a t."m

(neg:a"'ti.....-.e:

.pole)

-"""'-;"'th "'the

.Ief"'t

leg

(pos:i"'ti.....-.e:

pole).

:Lea.d
Connec"'ts:

111
"'the lef"'t :a .... m (neg:a"'ti.....-.e: pole) -"""'-;"'th "'the lef"'t leg (pos:i"'ti:v-e: pole) _

P.81

Lead
Connects

aV·...
"the ..-igh"t a
t"rTi

(posi"tive

pole)

'w-i-tf-r

"the hea..-"t (nega"tive

pole).

Lea.d

aV,a..-m (posi"tive pole) uri"th "the f-re e...-"t(nega"tive pole).

C'oru-rec t s "the lef"t

Lead
Connec"ts

aV·..-"the lef"t leg (posi"tive pole) 'w-i t l-r "the hea..-"t (nega"tive pole).

P.82

Precordiall.ead
a V ~ , and aV.) are reco rded

placement
on the patient's Then, a rrns and leg$ (\iJi~h '~he g round lead on the patient's to reco rd the p reco rdial chest leads , place elect rodes right leg). The th ree standa as follows: rd limb leads (I, II, and III) and '~he th ree augmented leads (a V R' using these elect rodes.

To reco rd a 12 -lead ECG', place elec~ rodes

V 1.... Fou rth ICS, r ight $~e rnal bo rde r

v.......

Fou rth ICS, left $~e rnal bo rde r V~ and V~, r line

v~: Mid ......... between ... y

V>fi.... Fifth ICS, left rnidclavicula V5.... Fifth ICS .Ieft

ants rio r axilla ry line

V,~.... Fifth ICS ,Ief~ mid axilla ry line

V'· ·1

P,33

Right precordial

Lead placement
leads , place the elect rodes as follows:

To reco rd the r ight p reco rdial chest V 1~""

Fou rth ICS, left ~te mal bo rde r Fou rth ICS, right ste rnal bo r de r

v;.;,....

v~.... Fifth v.~.... Fifth v~.... Fifth

ICS, right rnidclavicula

r line

ICS, right ante rio r axilla ry line ICS, right rnidaxilla ry line

M'l!lcilOOl!t:IJ!~' linc Mid!~il:iIIO'!l'lillc

II,nriiQrior :iI;l:il!<ll'll' lill~

Posterior I,ea.d el,ectrode placement

To ensure axillary an accurate ECG reading, make sura the poste r io r electrode~ line , and lead V~ halfway V1" V~, and V9 are placed at the same level ho r izontally as tha V~ lead at the fifth intercostal space, Place lead V1 at the poste r io r line, lead V~ at the paraspinal bet......-een leads V, and V~.

P.84

EI.ectrica.1 activity and the 12,-lead ECG

Each of the leads on a 12-lead ECG vie\IJS the hea rt from a diffe rent angle. These illust rations show the di rection of elect rical activity (depola rization) rnonito red by each lead and the 12 vie\IJS of the

hea rt.

Vlews 1f8fle~ted 0111

1,2·Jei9111IECO

iI

Leard

View' of this!
he",ql't

Limb te'ad5 {b,{po$arj I ut~u~li III w~ III

'"~

.. -Il-.

IU
A.f(gme,niJ~d·lJmb leads: rutJipatil~~' ,eiV'!,! N,g ~~~ciHc:: vi,~w

f1f~r;~8/~, ,aI'"

~~$~.

VI

ie'(ld$, tJjmp'Otlfj~! ·S~ wa!~1 p'hll

v~
V~. ,
.

·S~fJl:;Il! I w~11
An'it!t!n@f wal~11

V~ V. 5,

V~

,A~tar"@r wal~ij
ILateral wa'lll

V,~
"

'116
'If.
:2

l~Uer31wa II

V3

P.85

Electrical axis determination: Quadrant method

This cha rt will help you quic~ly dete rmine the di rection of a patient's elect rical "xis. Obse rve the deflections of the QRS complexes in. leads I and "V F' lead I indicates whethe r impulses" re rnoving to the right • • • •
0r

!eft.1 and lead "VF indicates whethe r they re mo\ling up

0

0~

do'WTI. Then check the cha rt to dete rmine whethe r the patient's "xis is no rrnal .

0~

has a left 1 right.1 0 r ext reme right deviation.

Norrnsl "xis: QRS -complex deflection is positive Left "xis deviation: Right "xis deviation:

r up right in both leads.

lead I is upright and lead "VF points do'WTI. lead i points do'WTIand lead "VF is up right. Both mves point do'WTI .

E>::t reme right "xis deviation:

.-9ir-'

'~trem,~ liG~t
3)(i:1;d Blif'atim1

.~erft~IXi!; d~vi~!tJiO"

Ria ht· a,,;ie; devlat.loil'1

p,86

EI.ectrical axis determination:

The deg r.ee method provides

Degree method
a patient's elect rical axis by deg ress on the hexaxial take ·these steps. system, not just by quad rant. It also allows 0 r negative in leads I and a V~. To use this method,

a mo re p racise rnsasu rernent of the elect rical axis. It allows you to identify

you to dete rmine the axis even if the QRS complex isn't clea rly positive

Step 1
.Identify the limb lead with the smallest QRS complex 0 r the equiphasic QRS complex. In this example , it's lead III..

Step 2
Locate the axis fo r lead Ilion the he >:;3i a I diag ram. Then find the axis pe rpendicula x r to it , ......t1ich the axis fo r lead a V R' is

-'!lI:l"
-~lrZf ~-~ .
,

-100"1
I

-.If' 11

;;:;:NJO'

+1W

t~'/l\"~ . \ 7903!r
+1

,.'.,

HI(!"

'-18ft

step :3
E>:;3minethe QRS complex in lead a V R r noting ......t1ethe the deflection r negative is positive 0 r negative, As you can see, the QRS complex fo r this lead is negative, indicating that the cu r rent is moving to ........ the rd pole of a V R' ......t1ich in the right 101JJe'rquad rant at +30 deg rees on the he >:;3i al diag ram, So the elect r ical axis here is no rrnal at +30 deg rees. is x

P.87

ECG c:ha.nges in angina,

These
<I re

some classic ECG changes invoh';ng the T wve and ST $egmen~ that you may $ee 1JJhen rnonito ring

<I

patient with <lngin~.

I.
~~ 1:
). J; !I'

1\

f
I

I
.J,
,_;

I-

~ ~ ~~
I-

-l~ J

-I~
'ioi..

r-~

:e, ,j t '"

,I
W

..,1

.~
-~

~'

n
T

l-

I
F

i.e J-~~~
t-

P.88

.ECG c;hanges in .Prinzmeta.l.i ~ angina

this illustration sho\IJSa 12-lead ~(G of' a patient with P rnzrnetal's angina. Marked 5T·segment ele~tions sppea r in leads that are mcnitc ring the hea rt a rea ~e re the co rona ry a rtery spasm occu rs. The ele~tion occurs during chest pain and resolves ~en pain subsides. T \!.lavesare usually of normal ~ize and configuration.
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P.89

Pericarditis
ECG changes in acute pe rica rditis evolve th rough two stages: • Stage t-Diffuss ST-segrnent ele'l,l';:itionsof 1 to 2 mm in most limb leads and most precordial leads reflect the intlammatory process. Upright T waves appear in most leads. The ST-segrnent and T-wave ~hanges are typically seen in leads I, II, ill, aV~, aVF, and V2 through V..' • Stage 2-As pericarditis resolves, 'the ST-segrnent ele'l,l';:it'ion nd accompanying T-wave inversion resolves in most' leads. a

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P.90

'5tage~ of'myocardial

ischemia,

injury~ and infarct

I-schemia is the fi rs t stage and indicates dep ression

0r

that blood flow and oxygen demand

a reoout of balance.

It can be resolved

by imp ro"';ng flow

0r

reducing

oxygen needs.

EC G changes

indicate

ST -segrnant

T wave changes.

The second stage,

inju ry, occu r s when the ischemia

is prolonged

enough to damage

the a r-ea of toe hea r t , EC G changes usually reveal ST -segment

ele....-ation (usually in two

0r

mo re contiguous

leads).

lnfa ret is the thi rd stage and occu rs "Withactual death In the ea rliest The pathologic stage of an M I , hype racute
0

of rnvoca rdial cells. Sca r tissue eventually

replaces

the dead tissue,

and the damage inve-rted

caused

is i r reve rs ible , elevation occu rs in toe leads facing toe a rea of damage ..

r ve-ry tall T waves may be seen on the EC G. Vv'ithin hou rs , the T waves become
EC G e"';dence

and ST -segrnent

Q wave is the last change to occu r in the evolution of an M I and is toe only pe rrnanent

of rnvoca rdial nec rosis.

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P,91

Locating myocardial damage

AHe r you've noted
..

cha racte r istic lead changes column and the ar~ery

in an acute involved

M I , use this table

.

to iden~ify
.

the a reas of damage.

Ma~ch the lead changes lead changes.

(5T eieva~ion , abno rrnal Q 'o)J';3ves)in the second

column wi~h the

affected

'o)J';311 the first in

in the third

column.

The fourth

column shows reciprocal

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