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ECG Rhythms for ACLS

ECG Rhythms for ACLS

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Published by: reza_faramarzi on Nov 02, 2011
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01/12/2014

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 ACLS Rhythms for the ACLS Algorithms
A p p e n d i x
3
253
Posterior divisionAnterior divisionPurkinje fibersSinus nodeBachmann’s bundleAVnodeBundleof HisRight bundlebranchLeft bundlebranchInternodalpathways
1 .
Anatomy of the cardiac conduction system:relationship to the ECG cardiac cycle.
A,
Heart:anatomy of conduction system.
B,
P-QRS-T complex:lines to conduction system.
C,
Normal sinus rhythm.
A
The Basics
B
AVN
PQSR
AbsoluteRefractoryPeriodRelativeRefractoryPeriodVentricularRepolarization
PRPR
 
QT Interval
T
VentricularDepolarization
PPR
C
Normal sinus rhythm
 
2.Ventricular Fibrillation/Pulseless Ventricular Tachycardia
Defining Criteria per ECG
Clinical Manifestations
s
Pulse disappears with onset of VF
s
Collapse, unconsciousness
s
Agonal breaths
apnea in <5 min
s
Onset of
reversible death 
Common Etiologies
s
Acute coronary syndromes leading to ischemic areas of myocardium
s
Stable-to-unstable VT, untreated
s
PVCs with R-on-T phenomenon
s
Multiple drug, electrolyte, or acid-base abnormalities that prolong the relative refractory period
s
Primary or secondary QT prolongation
s
Electrocution, hypoxia, many others
Recommended Therapy
Comprehensive ECCalgorithm,page 10;VF/pulseless VT algo- rithm, page 77 
s
Early defibrillation is essential
s
Agents given to prolong period of reversible death (
oxygen,
CPR, intubation,
epinephrine 
,
vasopressin 
)
s
Agents given to prevent refibrillation after a shock causes defibrillation
(lidocaine, amiodarone,procainamide,
β 
-blockers)
s
Agents given to adjust metabolic milieu
(sodium bicarbonate, magnesium)
254
A p p e n d i x
3
Coarse VFFine VF
The Cardiac Arrest Rhythms
Pathophysiology
s
Ventricles consist of areas of normal myocardium alternating with areas of ischemic, injured, orinfarcted myocardium, leading to chaotic pattern of ventricular depolarization
s
Rate/QRS complex:
unable to determine;no recognizable P, QRS, or T waves
s
Rhythm:
indeterminate;pattern of sharp up (peak) and down (trough) deflections
s
Amplitude:
measured from peak-to-trough;often used subjectively to describe VF as
fine 
(peak-to-trough 2 to <5 mm),
medium-moderate 
(5 to <10 mm), coarse (10 to <15 mm),
very coarse 
(>15 mm)
 
Any 
organized rhythm without detectable pulse is “PEA”
 ACLS Rhythms for the ACLS Algorithms
255
3.PEA (Pulseless Electrical Activity)
Defining Criteria per ECG
s
Rhythm displays organized electrical activity (not VF/pulseless VT)
s
Seldom as organized as normal sinus rhythm
s
Can be narrow (QRS <0.10 mm) or wide (QRS >0.12 mm);fast (>100 beats/min) or slow(<60 beats/min)
s
Most frequently:fast and narrow (noncardiac etiology) or slow and wide (cardiac etiology)
Clinical Manifestations
s
Collapse;unconscious
s
Agonal respirations or apnea
s
No pulse detectable by arterial palpation (thus could still be as high as 50-60 mm Hg;in suchcases termed
pseudo-PEA
)
Common Etiologies
Mnemonic of 5 H’s and 5 T’s aids recall: 
s
Hypovolemia
s
Tablets
(drug OD, ingestions)
s
Hypoxia
s
Tamponade, cardiac
s
Hydrogen ion
 —
acidosis
s
Tension pneumothorax
s
Hyperkalemia/Hypokalemia
s
Thrombosis, coronary (ACS)
s
Hypothermia
s
Thrombosis, pulmonary (embolism)
Recommended Therapy
Comprehensive ECCAlgorithm,page 10;PEA Algorithm,page 100 
s
Per PEA algorithm
s
Primary ABCD (basic CPR)
s
Secondary
AB
(advanced airway and ventilation);
C
(IV,
epinephrine, atropine 
if electrical activity<60 complexes per minute);
D
(identify and treat reversible causes)
s
Key:
identify and treat a reversible cause of the PEA
Pathophysiology
s
Cardiac conduction impulses occur in organized pattern, but this fails to produce myocardialcontraction (former
electromechanical dissociation
);or insufficient ventricular filling duringdiastole;or ineffective contractions

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