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

a Wilkins

> Front of Book > Autho rs


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

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.


~,'.'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.e r=v=r= . critical care unit chronic obstructive pulmonary diseas.nar'y care unit.

Imultifocal atrial ta:chycar.dja PAS pulmtmarv arterv systolic .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.

YDardi a .PAT Ip~r}oxys'mai at:ri~1taC:hycardiq SVT Is w p r a v eritri cui a r ta C~.

200). (Eds. Simplified illMpr€tatioll of Pacem~er ECGs. (Eds." Criti cal.M.Selec ted referenc es Albe rt.th care Providers. Philodelphio: ljppincott Willioms a Wilkins. Mo rton. el 01. 2005. MasterillS ACLS. Philadebhia: Lippjncott Willioms a Wilkins. CUrr€llt Medical.. L. y. ECG illterpr€tatiQIl Made illmdibly Easy. N. R. E. Woods. Care Nurse 13 () Suppl): 2-1 ). . p.T. 4th ed. . June 200)" Cummins. 2005. G. Oollos: Arne rican Heo rt Associotion . N. . 2004. oollos: Arne rican Heart Associolion . . Philodelphio: ljppincott Willioms . 200).: 810ckwell Futuro. .8. Polienls wilh Heorl Foilure and Venlriculo r o)'$S\'T1chrony. 2005. Elmsford.) COIlIl'S CUrr€llt Therapy 2005. Griti cal. Khon. Diasllosis alld Tr€atmellt. 8. Elmsford.: 810ckwell Futuro.M. Hesselson. M. Philodelphio: ljppincott Williomsa Wilkins. . y.et Guide. E. 0. )rd ed. . Philadelphia: W. 2004. 2nd ed. R. New York: McGrow-HiII. Rokel. . F. Sounders Co. Cardiac NursillS. ~hilodelphio: W. end Bope . 3th ed.) Halldboo~ of Eme!'Sell C'j Cardiovas cular Care for Heal. "Co rdiac ReS\'T1chronization Thmpy Th rough 8iV€nlriculo r Pocing in. et 01. Ileal. 2006. Sounders Co. Hazinski . el 01. Philodelphio: Lippincott Willioms a Wilkim . 2005. ECG Cards. N. Tierney.8. A. 51h ed. 2nd ed. 441h ed. Care Nursillg: A Hob sti r Approach. S. 2005. P€diatric ECG iIlMpr€tatioll: All /1IustratiVE: Guide. et 01. ECG illterpr€tatioll: Allillmdibly Easy Pod!. Philodelphio: ljppincott Willioms a Wilkins. 2006.a Wilkins'. 2004. 2005. L. M. Rapid ECG illterpr€tatioll. et 01.) A CLS Provider Manual. . G. (Ed.

and AV blocks.idle: leG Fects Mf1de InclE'mMy QWclJ. and ICDs Write -on.UN • • • . and vent ricula r rhythms. defib rillation . pacemake rs . junctional. 'I. Qui(k! ECG Filets Made Incredibl.Maternal. at rial.y Quick..:Ite roof pages that come dean urith an alcohol \llipe rp • [Jru3 Facts MadE: In mdibly Qui ck Facts MadE: In mdibly Qui ck . 12-lead ECG inte rp retation Antia r rhythmic drugs.! • • • • • • Anatomy of the hea rt and co rona ry vessels Rhythm st rip rneasu ring methods and patte rns SA node. tst lmrion Copyright ®l006 lippincott > sack oJ Book > ECG V1illiams a V1ilkins Fa(ts M:lde lnc redibl..If. -Neonatal. Facts MadE: In mdibly Qui ck hdiatri r Fads MadE: In mdibly Qui ck Quick Wound CarE: Facts MadE: Inmdibly . ca rdiove rsion .

-_C'I'cd..:'II.Title: feG Feet» M(Jft Incremhiy Qulcl!.«I:. tst fmrion Copyright ®2006 lippincott William$ a.: ~~cOOiJ:i' ~~!l:1rtll F rr~~tl(o ~ ~'>l' I~'" ~l..Iblil'~ ~~lm1.cd . 1.:1 'fiiJ''. Wilkin$ > Back of Book > Eel] effects of elect rol~te imbalances ECG effects of electrolyte im balances ~1I::.':..J..±..] I H~~!J:.W'ii:.CIL.:l~: EIc\IiL".w'ol ~W.1 WIJ'f(! ~~n • • • f'o:o.1 \'r".:~ lJi:?'~d .o:'O~ ~PJ!on::lll ~"~([!er.:'..OJliT~~ H~JlcIru "".:0:1'..~N-WlI""" lDw ~"'pi..r'lil R:n .\\\1""'. 1 • • • • • • • • • • • • FroLorJlCd F'Ii: t:':mIIl E'rcIr<" iC'd q. 11....o3:.:I!uD1''Ml~ IrUd ~\1X'IIIJJ...cd WOO ~~'K'l'!: ~~\'i.u:uilr OJr.Cl'I':lJ..-C'd ~ ~~ :i'«.-rN Q.:.I4I W'>±..lIl.1 F f'rcoI:oo~cd ~ Wl'pm ~!. Ir:roll':'('.!lJ.Q"" 'I"~c.!Qojlrre'! I~ ~1!..~"'\tI F~1~G/' "''lCr.:.I.:~ 1~1i:f:i'"'i G1f:« iX"~ 1ml:Jls H~J.: :i.\\Ia'ill" H~Q:1I'lII F.£i Q!f('p.ot"r~C'd Q. f'f(~NCd:.~ .

the body's midline. . The .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. In most peopk to the left of.hinthe mediastinum I a cavity that contains ·the tissues and 0 rgans sepa rating the fwD pleu ral sacs.hsa rt lies 1JJit.

h moin .~~rM~rv Qi.2 Coronary vessels left~~~ ll~iwkli'D:t]uq-----.le:lt !1m!"f~--- ~d .P.nnch of I ~rn Am~fiw m'll1l1elir~1[:ular Ice~Clldil1~1 ~rilJl'!... Gml1![ It:Drdi~C 'ileim -~" Cir~u~~c~ Iit. ~rOi~~ul!li}~.~ltDUt: "'------le'rt sLi~~1Iial1l OIit~'lI' m'imy ~----4-== lPI!iI~I~mart l!lJl1t ~~~""""ti!!ir=-"'..

.3 r......------:-"Hr-I'f7--~ 1_b.................. ===~rl!i~MO!1...... ~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..~g~m'ii~ = ~'f~~J]f Gr~RJt iiartlilil~ W~!~...

Ilmd l(llt ~{!~d~ l!lfil!l~a.i~1 ge!)torn ...c conduction system A~~oodle ~~un~I!:lljJi !If~~"-----~~ 1 .P. ~~~~.~~ Ilntl!rvojj~ri~u. ~~~'il~~ or ~o~~C!1 itlilV .falue$.-------~ ECG grid This ECG grid shows the ho rizontal axis and ve rtical axis and thei r respsctive rnsasu rement 'o. Ri~hi..4 Cardia.

. The axis of lead II runs from the negative . The axis of lead III extends from the negative left-a rrn lead elect rode to the positive left ·ieg lead elect rode. and III) fo rrn a shape known as Einthol!€n's triangle. ..P. .5 Einthoven's triangle The axes of the th ree bipola r limb leads (I. the triangle is equilate ral The axis of lead I e:::ctends from sboulds r to shoulde r . right-a rrn lead elect rode to the positive left ·ieg lead elect rode. Because the elect rodes fo r these leads a re about equidistant from the hea rt. with the right-a rrn lead being the negative elect rode and the left-a rrn lead being the positive elect rode. . II.

1'10 specific \liew of the heart Lead aVL shows electrical I ( I II . Lead aVR pro\lides acti\lity coming from the heartlslateral wall.6 Augmented leads Leads aVRI aVL I and aVF are called ausmel'lt€d leads. They measure electrical acthrity bet\lJeen one .P. Lead aV~ shows electrical acti\lity coming from the heart's inferior wall.limb and a single electrode.

Le'a~i Three-[ eadwire '5yEf~em leaOlI: . ~jC··.. -"1 le~d [MeL.l~..P. S fhfe~ leadwke sy5tem .-.l rJ rOSl 't"10mng car di d rae menr lteri onng I.Lead Mel. 1T1~ _~ l~ad !M'CLa .ea. L~'a~.

P.8 NormalECG .

.2~ Gl.J~ 12C O.24 Interpreting In~e rp re~ing a rhythm step method outlined rhythm below provides strips ~h rough p ractice.~ a. l~( 0.2l a.! ':0 o. as long as you' re consistent.' The eigh~just that. Rhythm s~ rip analy. 2.-:~ema~ic app roach . s~ rip is a skill developed Ei~h t -sf e pme t h(I cJ ·1.1~ o.1l 0. Check fo r ectopic .De~e rrnine the rhythm. 4.~! ~o o.]" a.2J O.Dete rrnine the rate.: 0. .3~ IC'C o.Tc: interval normals ~D OAI o.200. Measu re the P R inte rval. 5. Dete rmine the QRS du ration.~3 ·lD Gl.-:is requi res a sequential and sy. .12 O. Evaluate the P wave.41 ac ~o 0.]~ 0.2~ ~c.rs 0. 8. beats and othe r abno rrnalities .P. .~.J~ m.zz O. the QT interval. You can use seve ral methods .7. 3.9 Q. 6·. Examine Measure the T waves .

the rhythm is i r regula r . R. 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. i r regula r.P. . as shown below.l0 Methods of mea. If the1 re all the same.R inte rval is the same. as shown below.:s:uring rhythm • • • • • Place the ECG st rip on a flat su rface . If they va ry. legs so the other point is on the peak of the next R wave.R inte rval. This is the R.R inte rvals . fo reach R. With a pencil'. the vent r icula r rhythm is regula r. rneasu re the P . point of the calipers it falls on the peak of that wave. the vent r icula r rhythm is regula r. The distance toward the third R wave and note whetber is the R-R interval.R inte rvals to dete rmine whethe r 'the at rial rhythm is regula r 0r Using the same method. If the distance va r ies . Move the pape r up slightly so the st r aight edge is nea r the peak of the R wave. If the distance • Use the same method to measu're the distance between P waves (the P . Position the st r aight edge of a piece of pape r along the st rip's baseline. Check succeeding R. • • • • • With the ECG on a flat surface. the Move the pape r ac ross the st rip lining up the two rna rks "Withsucceeding rhythm is i r regula r .R inte rvals in the same way. rna rk the pape r at the R waves of two consecutive QRS complexes.P interval) and dete rmine whetbe r the at rial rhythm is regula r- 0r i r regula r .

.ii!!lI~11"DII'lIIIII'-I:ar' ('~itl!I 1"'1'IJ.a:s II~ PAl) f'rt'l .~ t~l) (-? ~'I.. 5~) ('/~I PiremalitRJlfB (aiEl' lin ~I PVC) .. j.J11~iIU.' Paro¥m eM' VUf'S't (.A~J'. " ..'.-) u .j~~. I ..ln' ~~ ri..I r~ --'.1 'M'~::J!:JI Q .ll R. the mo re you'll notice parte rns.' '61Iow~ ~I!l1I~alrI(aa in..'vih. 'i"'l. r. .~._ ~ ~'.~ I..'. ~he $ymbol$ below rep resent some of the parte rns you might see as you study rhythm st rjps. ')I I r'ij' .P.~'-Ia.. " I . . ~.hythm strip pattems The rno re you look at rhythm st rips .t!! _. .JO'!II"'m. I ~\ ~ t .~ din'norm1...

s i 20 1::3ble C:3n ...e Fo t" ex:ample • if you c cu...a..... ..:31: t"i:31 r e t e s by 1: .. S:3me rr-oe-c ocr using ._.-.. asar-t s r-as-t e is 75 e-ca-t mot"e sa be:31:s.. use 1: . 50 _...-. .e .._...i 1::3ble 1:0 find 1:._.:q 1:3t"ge blocks T .a. lp e sm:311 blocks hea.... ..of 1:3 t"ge blocks to e-r we em R -co-a-ooe s 0 r- P ....._.... rrrtrua-ce ... .. e r-t e . you C:3n t":3pidly e s t trr-ce-ce -o-err-c t"icul:3 r..e ru.. 1: e ra._.. :31:t"i:31 t":31:e.0 r.rrs-t be1:._...-1:e .........-een R . ...P_12 Calcul.....a.te sequencing me1: .rrr-to e r....-. follo._.e numbet" of blocks be1:._. P ...e 1 50.a.s i memo t":3pid t"izing -re t e c:3lcul:31:ion sequence is :3'lso c aue cr 1: ...-.._. .ting T ._.rt r-r-caj-oa .r. .._.-een R . To c:3lcul:31:e 1: ..• '60.rao..... 300.e ._..a. Using 1: .. TnE:1hod..._.s ._.T pt"ecise_ Af1:et" coun1:ing 1: ...-es... 75 CDun.-es :3S :3 guide.-es_ o e.-. 100.-es. d o of de1:et"mining 1: .e .

vvttkfns 1~t Edition Copy.11 othe r t"hythms .a.a r e comp.al limits T "Wave • • No rrne! Up .-m:=.-di::=.. ounded in lead II QT intervall • 'Ni~h....a .Incn.I"I 1"10 rrnat I.....in:s:t umich :=...:::: the st.a t"ed r abe .I"I 1"10 rrnat I. ight shape and .l. sinus rhythm • • At ..and... egula Rate • 60 to 100 bea1:sl"minu1:e (SA node's no .ag:=.. 36 to 0...06 to 0 _10 second) Vv'ithin no t"m.dibly @2006 lippincott VViliiams Qpicld.c conduction No ectopic 0 :=.1 c.R S • COnril'p i ex (0..pe (r'ound Up .1:s:h:=.o:!pr es emt s no rm:=...m. an t beats r . al: i Vent .Totl ..-egula.-ight > Table of Conten1:$ > SA Node SA Node Norma.. 12 ~O 0...-d . a.. ·: ECG F<ict~ M<idE...~s (0.~s (0.. mal firing rate) P Wave • • • • No .m... r tcuta r : ...20 secol"ld) Q. ight in lead II One for All simila every QRS complex and shape and smooth) r tn s tze • 'Ni~h..44 secol"ld) Other • • R.

P... val eccc eects second Rate • U~u"lIy .~h....t P-P r ation ... Rhythm • • • • I r r... val sho r ta ........ mal size configu r ation • • M"y "" ry ~I.du .... mal No . val and Diffe ....14 Sinus arrhythmia... mal No ..ase:s: du ring inspi ra1:ion Dec rea:s:es du ring e>=piration • • No .eguta r Co .nu~e) no • • • Va rie:::: "Wi1:hre:s:pi ration Inc re.gh~ly no ......gh~ly ltrrrit s U:s:ually "Wi1:hin no rrnal Other • Phasic slo wing and quickening ..12 e>=pi . to .-ing inspi sbo r t es.n rrnal ltrrrit s (60 ~o 100 be"~~fm.. longe r cfu t'ing 0... ation P . mal limits Vv'ithin QRS cot"nplex • Preceded by P ""''''' • • No ..-een long es t and 'irrte .. cycle a y ........P inte . espi ..R inte bet.. esponds · r to the ....... mal size configu r ation QT interval • • M"y "" ry ~I....... ence R.

.... Drugs • • Digoxin Morphine '.rrhythmia '.... r ano the r sedative) ... notify docto r .• • Dec reased Oec reased Inc . e1:u .::..:..... .1:ment of unde rlying cause ... eased H R..nethe r to continue giving the drug. ::::-yncope if present (" urith rna rked sinus a r ... .... hythmia) What • • • to do rt rhythm.. Inferior-wall Inhibition MI of reflex ""'gal activity (tone) During inspiration • Oec-rea::::ed v...p...agal t orre • • Inc reased H R. develop:::: suddenly If induced by drugs (mo rphtne 0 notify docto 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 .. t ion .. n Inc .....no\Ifill decide • • Usually no t'reatmen1: If un related if patient asymp1:omatic I 1:0 .. e:::pi ...e... ea::::!2!d venous During expiration '....-agal tone What • • • • • • to loo~: for no s'yTTIptoms (commonly rate insignificant) du ring tnsp i ration du ring e:xpi ration ... mal) 1: ... in patient taking digoxin I Monito rhea If sinus a r rhythm. 1 5 Sinus a... such as du ring eX€!rc ise Signs and s'yTTIptoms of uncle rlying condition Dizziness 0 .. .nenH R. '... venous r e tu rn .: r (abrio .

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.

dopam:ine..... (a"tt"opine.t:e Al1:e t"ed r-r-oe-rraat S:1:a1:us: r r-i Blu r.n"t: COITI poensa.....-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 .pet"manen"t pacernaket" +r-s e r t torr . quinidine...r-e cr -o-i s fo _ _ _ _ Cf-ie s t pain Cool..1:h ac"ti-.t:e 1'0 r dec rease d CO s:yrnp"toms: 11" pa. e-odo l . as: needed.-minu"te s t" t"hy'thm b t"adyca t"dia -induced s:-yncope (kno-.'r r-e e+rr-oerrt s ....S: t: ere a to e d if pa1:ien1: as:yrnp1:oma1:ic unde t"lying caus:e .J-..." indica1:ing hea t"1: failu t"e Obs:e t"ve pa1:ien1: and 'r moni1:o r. 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"-.sstof ) t"s: (me1:op t"s: (dil1:iazem. pt"opafenone.-agal s t trr-ualaat+or-r s:uch as: -.t:ie nt: ca."tempo t"a t"y o r.. 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 . Ho'YV No it: '.e:s -Adams a.J-acle:) Pos:s:ibly If _ pat:ie No nt: can COITI pe nsa..P_17 Sinus bra...dycardia Ca t"diomyopa1:hy Condi1:ions: 1:ha1: inc t"eas:e -....1u1!:...-i"ty_ as: dt"ug sacfr-r-r ir-rts-t r sa-t fo r-i f'o r.n as: a 5.-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 .hea t"1: t"hy'thm fo t" b t"adyca t"dia p t"og t"es:s:ion" E-.. epinepht"ine) o r.-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 """'-.. clammy s lc-ir-r Ct"ackles: Dizzines:s: Dys:pnea Hypo1:ens:ion S _] hea S-yncope t"1: s:ound .. s c t.

i1~~!!J.P.lS'~INj~~rt}\~ii ~lIllm!~¥l~Uiil~il\Of ~.\"lhl~m~ p~C~f 01 11' p~~I~g U~~tlMti. flfllii U~~cliili1~.~t.~llloodl~i~'dm~iElEl Dr' !irli.ib D1] in ~DC!~ ~lisl~Bir i31[lIl~il1~ I ~~~ili~1' Ilpin~~~nillifl I~rIJWi!!11tl1!1' il~llii~~ d Wqi~.Gf3: rn~~ Ii iIlD~i'el:wVCi.~I'm.iIl 11.dllcardia algorithm 1t~litr. m .(M~~aJ~lp ~Dmrnad8gdi!19'ror~lmre:~1Clm~lfi~n B~I~!f(:lfidill laD iil\o: I~!filu Iml!iittdl !i!SiI.~Ylilll~~ tl~f.~B!f~r 1r11~~utameCQS.·Ii3~~~ r!jM~ [J3~8a~ fI'l-(I't.18 Br a.~!lIT ~r~ns:Ol'~hm~~~ d 6$~~ iW. ~t~~ WSE!mh~~I' fill ml~~· l'm ~jl~~ ~!igrlll~ ]bioD'l: 'I ~VIM~~~I.jJl:lir~ biI d~S'&.irw.dG~r.~~~ ~au~ by ~fi$~~f .

0 no rrnal response .l(O llO J rr~lll' !O !Ie' 10 UO lm 1 ~O 'r' 10 ~'O .( lD !O lc-l 10~ l! 100 100 .lluole b rodyco rdia and lochyco rdia in context. Normal heart rates in children kl· 1o'iIJD ~bN"!mtJ1 I.3mple. when 0 child is c r0ng 0r oths rwise upset.0. b rodyco rdia (less than 90 beols iminule) moy occu r in 0 heollhy infonl du ring sleep.l1o<9 jOOJ1"""'1 E:u!'cl'. becouse HR 1f. e1f.< oc ~""lbNtl'mi:Jl t""":c 100-~!C !C 140 110 h~ 1ltD iCGm '(. tachyca rdia moy be . Keep in mind that.P.19 Bradycardia and ta. For e>:.lries conside robly from ths neonats 10 the odolescenl.chycardia in chitdren In child ren . one dafnition of b rodyco rdia 0r lochyco rdia con'l fit 011 child ren.

F:.chyca.. and ve difficult to identify As H R inc reases • • Vv'itl)in no rrnal limits Constant Q... 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 .. 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 ...20 Sinus ta.P.. possibly supe rimposed on preceding T .rdia..

Anelllia Ca rdiogenic Drug:s: Alllinophyiline _ _ Alllphe1:allline:s: A1:ropine Dobu1:allline Dopallline Epineph.....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.o rhea doc1:o callll r1: rhy1:hlll. o-t de em-o-tronlllen1: rela:><a1:ion _ No 1:rea1:lIIen1: of if ..i I. Pe riphe Regula r- ral pul:s:e r-ze uee satno o-e 100 bea1::s: .j s se • -f'ee-ooe • :s:1: r re:s::s:• anxie1:y.ol • a1:enol. re:s:pon:s:e rrf c o t trte ) 0 r pain Po:s::s:ibly no rlllal 1:0 e::-::e r-c..rine s+aoc tc Hea r1: failu r rhage re Helllo _ _ Hype r1:hy .Us a.u re de·ve LopS r-t :s:ound r vein di:s:1:en1:ion _ _lugula Moni1:o No1:ify P r.. caffeine.nisn-J:s:"f·ai I. ed r -.calciulII channel toto cjce r:s: (ve rapalllil .z:elll) Co r rec1:ion Fo r ca r-cf taac.rdia.-i:s:ion Che:s:1: pain Hypo1:en:s:ion Ne r-coorrar-oe ss Palpi1:a1:ion:s: Syncope If' hea.ol) 0 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....-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:.c:hyc:a.P_21 Sinus ta.. caffeine. T.. tc+t-ce-r-r o Hypo-.n d C:On-J pe nsa1:0 ry n-Jec: ha.rigger:s: (alcohol... Anxie1:y Blu . i:s:chelllia: Ab:S:1:inence frolll 1:rigge Be1:a -ad r-s (alcohol. tr-u. r. dil1:ia.rt ea r-rr rhy1:hlll If' _ CO f'a.rt: Crackle:s: S.::!hea f'a. .

. adyca • Pe r iocl ic all u absent I urith en t f r e PQRST complexes missing • • Vv'hen p resen'l:. equency of pause may in b .. June+tonal ....P inte r vals escape be.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 ...egul:a t" except du ring ...lly "Within Length 0 no rrnal ltrrrit s (60 1:0 100 be:a1:$ ........I no rrnal size P recede:::: each QRS complex and co rlfigu ration PR interval • • Vv'ithin Constant no rmal wtien limit:=: .g complexes) Rate • • U::::u::. • 'Nithin no rrrial limits a r rest Absen1: du ring Other• • The p..a t"'re::::1: r f ...a r re:::1: (i I:" regula r a:::: r e sult of mi::::::::ir.a multiple of the unde Flying P . dia Fe ..a1:s may occu r at end of pau:s:e ..P_22 Sinus arrest • R.. a P wa ve en a P 'wa ve is present is p r es errt QRS complex • . esult iminute) befo .ause isn'1. • No rmal No rrrial Absent du r...

om .. 'ern ::::-yncopal 0 ...rcrt-iom • ::::uch tas tae-t a -ad r..-ith :tho r-t pau:s:es CO w-i tf-r r.ge 0 r- c or-rch.""t sounds and pul:=:edu ring I of :s:-yrnptom:s: r.... • • • No 1..s • calcium channel blocke r..ed st a rus -o-isriom Dizziness Cool Low I clammy skfn blood p t"e::::::::u....eme r.ffec1:ing SA node ct+sc+ca r...ug::: If :::yrnp1.. rrnerrt ee if pa1.cl'io infection trrre .P.ea:s:ed Absence Absence :a t" r es t .1... e 0 t" Syncope nea r -syncope What to do • • Monito P .. -which may r eautt f .gic totoc ke r. rre a r -s vrrc opcal e o ts ocfes cause ci by p r'olorrg ecl pau::::e. m ih r...ecu r-r- Eo-icferrc e of dec • • • • • • ent 0 r- p r.rart-iom :.olonged pause:s: Alte r ed mental Blu r r..s (diltiazem. a::::yrnp1.. 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 0 r- ca r..om::: • follow A::: needed.. r-t r-f-ry-tf-u-rr pcat terrt f .. tec o rt he:=...:apamil) • • • • P r oc atnern tcte Quinidine Ca rdiomyopathy Hype r-tensiV€! he:=..23 Sinus a. fo$' of he:::.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. r -wal! M I 10 myoca r ci+t-is acrt-i-ooe d r. inju r v .oma1.rrest • • • • • Acute Acute Acute CAD Ca • • • • r. s uch a::::a fall.ien1. r.s • and digoxin ...ic r dia of d algo .otid s iruas s ems i't-i-o-i ty What • • • to look. b r adyca cl is c or'rt iru.

..-i1:h rrt i Fe PQRST e I I complex missing and p recedes each QRS complex no ......= pause QT lntervQ.. ion at • • Vv'i1:hin no rrnal lirrrits Cons rant when a P ...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". mal s ize and configu .24 Sinoatrial exit bh:>ck Rhythfli1l • Regula r except du ring a pause (i r regula r as result......avei:::: present QRS cOiJl"f1piex • • • No rrnal du. dia Pwave • • Pe riodically '1vhen p ..on :Ell pause T vvave • No rrnal s iz e ra1:ion :Ell • • No rrnal configu Ab::::en1: durin.frequency (60 to 100 beats fminute) befo re a pause of pause may result in b radyca ...1 ...serrt e ab::::en1: ..-..ration No rrnal configu Ab:s:en1:during ra1:'.. of a pause) • • Usually urithin no rrnal limits Leng1:h 0 .....P..

.s· it infe r to r -.. .fOT :s:ound:s: :and pulse du r... exit bl..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.-i1::h sho .ing Ab:s:ence Ab::::ence Evidence • • SA eod-t block symptoms .t"ed • • • • Cool.... f r-orr-rinju r P r-ot e c t patient v .ed P t"olonged pauses Alte Blu mental -o-ts f orr :s:tatus r....tFia. pau::::e::: 1: 0 t" of dec rea sed CO .1: ..ock What • • • • causE'.-all I M rnyoca Acu1:e ir... such a:s: a fall I -which may r-esurl't f r-orrr s-yncopal 0 r- ~ea r- -s-yncopal episodes caused by p t"olonged pause....l.25 Sinoa. 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..P.-i1::h r ecnr t" r errt r.s -ad rene rolol I I metop t-oto! • p t"op r amotol ) Calcium Digo::-dn channel (diltiazem ve r..-t t"hythm..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. 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 I c alc urrri channel blocke r-s I and digoxin.

.ng_es and configu ration no rrna! May be absent Usu:=...... arte t"na1:ing .. rhythm size ch:=. tes No rrrial . hythm· limit:=: changes Other • Usually rno .rJrl'piex • • • DW r:3ltion Va ...a • In1:er rup1:ed by long :s:inus pause P • • • • YVQVe V...lIy Va r tes .a des May be . hythm· configu r. hythmia on a 6 -second s t r tp .....ation • • No rrrial stze r::=.....tion No rm:=... than e one a r .... tes urith no rmal .lIy p recE!des E!:8ch QRS complex • • Usu:=.-ithin no rm::=...1 configu • • U:=:ually urithin Va ...P..1 limit:s: changes urith ...26 Sic:k sinus syndrolTle • • • Irregul::..1 limits changes ..r Sinus pauses Ab t"up1: r arte crianges • Fa:::1: slow I I 0 .-itt-.....-ith rhythm QRS cO..-ithin no rm::=....

r. _.1:t"an:s:venou:s:) i...equency abla1:ion ..5-yncope 1:achy-b I I I (51:oke:s: -Adam:s: a1:1:ack:s:) If un de!' Iyi ng Dila"ted and ca.: 1:0 ch r orr+c cff s o r-ete r-tll sa-t-icxr-r digoxin I be1:a -e ct t"ene t"gic blocke t" I r-e ct+o -ft".t _ _ Moni1:o ..Ot" pe t"manen1: pacemake t" An1:icoagulan1: fo t" aa-t -izal fib r ...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.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....-allt"ound a 5A node node _ _ _ Open -f-re e r-t :s:u t"ge t"Y I 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 .!' 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: ..-..a1:ion au1:onomic :s:y:s:1:em t".. _ 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.Ot" s truas at" r-e s t Epi:s:ode:s: of .-.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 .. inne o t"....to do in b e a r-t t"hy1:hm.P.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 I di:s:1:ut"bance:s: I .. T t"auma 1:0 5A aa-t r-izal .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 .-.5:1 t-i ecae-t :s:ound t: h !'OrYIboerYI bo lisrYI Acu1:e cf-re s t pain 0 r..-eakne:s::s:) ~a.

.trial contra.act~ .. Prerna....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 . sh:aded :at'"e:a on s1:t'"ip) M:ay be in p t'"eceding T ..ctions • • _ A1:t'"i:al: It'"t'"egul:at'" Ven1: t'"icul:a r : l r...aveis hidden in T .... Vv"ilkins ::-T:able of Con1:en1:s ::-A1: ri:al Atria.ture a......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..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..IncTe'dibfy Vv"illi:ams QWcld.......-igemin:al r- M:ay occu Tf-rr-ee o e- in c.. ~~t Edirion Copy.....ccuote ts rr-ror-ea PACs in :a t'"o"'_'_" indic:a1:e sal 1::achyc:at'"di:a ..-igh1: ©2006 l ippinC01:1: a.-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 .Title: ECGi F..ade..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 • ~ • • P 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 ...

eet 0 . ...rith acute MI..... olong absolute ... iod I If symptomatic Fo .-.. ocainamide Quinidine imbalance::::. failu t to co r re an elect r ol p-te trntxetance r Iying causes Ratient .hee terrt .. such s as c a f'fe irie . s t r e s s .......... y e Co r orra r y hee r t disease Digo::-dn to::-cicity p .. igge ..... eatment if patient asymptomatic 0 r cont r 01 of t r igge r s at ... ial r ef .: In pcat terrts u. acto r y pe ...-1: failu Fe H-ype rthyroidism Hypoxia • • • Irlfec1:ious disease T rigge r s (alcohol' Valvula rhea I c. pe r iocl of SA node y 0 t"ugs that • • P .. cftse ase t 0 . • Elect roly'te • • • Endogenou:s: catecholamine Fatigue Fever relea:s:e from pain 0 r anxie1:y • • • Hea.. olyte imbalances.... at r tat ~ r e r...... has . failu .h-o-thrn tas ... zrto .. Not-e.....a1:ien1: ha:s: he::. avoid unde t .f .......ctions • • • • • • Enhanced Acute COPD automaticity in at . signs Iy • • Teach Demonst of f-iea ..31-. • • • Usually no t .eduction techniques to lessen anxiety.. PACs may be e a ... failu .. elect ... and mo r e s e ve .-1:disease What • • Monito If pie't to do ...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 -..-atch fo r e-o-terence ..... ate r. ugs PACs: that p r olong such as beta-ad r ene .... IIa.... t e.... 't ischemic 0 ..hen PAC'S......... o ffne a . 0 .....ture a.p.... r h-o-thrn ....... .. f r acto e ....1...ased CO I such as h-ypotension and syncope I if p...29 PrelTlSl...trial cOhtra.aff~ine I nicotine) r t dise.........r. espi .occu r • Evidence of dec re. gic blocke r s and calcium channel blocke rs .. tat tissue (most common cause) ...hee . equent I elimination d ... ..

. in p r.. Va rie:::: depending : on AV conduction • De-.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 .....30 Atrial ta..rt ion .. mal du r at icn and configu .chycardia Rhythm • • A~riai: Usually regular Vent r icula ..riates from no rrrial appea ranee • • May be hidden 'lf visible. Regula . io at .0 r i r ....tal: Th .. cliff'icult to diffe rentiate at rial tachyca rdia "Wi~hblock from sinus arrhythmia "With U waves .. ... rely e:=-::ceeds 250 bea1:$ Iminute a Vent ricula ....-ee 0 r mo Fe consecu1:i-...... 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....... : egula r depending on AV conduc1:ion ratio and "type o....f at rial 1:achyca .. dia Rate • • A 1: ...: abno rrnallv th rough vent rides May be abno .P.-e I ec1:opic a t r ial bea1:$ at 1 50 1:0 250 bea1:$ Iminute..

t urit·h p::=...a r cf torrrvopca tf-rv COPD Congenital anomalies Co .-di::=..P _ 31 Atrial What • • • • • • tachycardia CQu's'es jot Digo:x:in -tcoctc tt p. Atri::=..r+ro-ttrrrrie Ir. r s iort) If p::=...sir.r..ting cznrs e ::=..psychological h-ype . ees e cr CO (h-ypo1:ension chest s-yncope) What • • • Monito to do r- hea r. ome What • • • Rapid Sudden Signs to loo~: HR feeling of dec JOI" of palpitations I especially I urith pain PAT I .ized ·m::=. otid r csa r cttcwe ror... of rome.ces .t ur.. ::=...ch elect ric::=.t r.. r r::=..1 overdrive If a r. p::=.tment Possibly 0 rug the dependent on type 0 of t:3ichyc.cir. a ..d dec re::=.d or.ble syr...a..::=.a .atxta+ton CO PO • co r recti hypoxi::=.t ricul::=..-ailable if vagal iTlaneuve • • • • • • • T t"e:=.ss::=. r rrrac ologric • possible r c::=. I nicotine) VahAJla r hea.hythrl).tier.a's rn an eu ve r rapy (ph::=. monito r digoxin blood te-oef . eadily .te Vals::=.-.g ver. A:=::=:e:=::=: patient Keep r esusc+re fo r digo:x:in t tve equipment t ooctc tt-p-.I::=. di rected t owa rd elimir.st::=.and s tnus ::::yrnptom ee ve rity..r. used.h. possible ce rhe-ce r.ge to : acrencs tne t r ea e PAT . s e . diove r r s tor-.g r eta'recr to WPW syr...tier. ..-t disea:=:e WPW ::::-ynd . -aci r erte rgic toto eke r s • caf c'turn cf-ianne! toto eke r s • digoxir.. tension caffeine :=:1: r es s T t"igge r s (alcohol. arntccta r orie • bet::=.1 c::=..(rrro s t common) C.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.r..d elect r ot-o-te imb::=.

. • • Atrial: 1 50 to 250 beats (minute Vent r icula r: Va r ies ""_'.-aves Qft. S comp jI' e X • Usually no rmal • Usually indisca rnible • May be indisce rnible Other • Mo re than one P ..thblock • Slightly abno rmal • • Usually constant May vary fo r conducted P .....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..-avefo reach QRS complex .

P.33 Mul.• .figu ration: Va r ies: P wave shapes must appea r At least th ree diffe rent • Varies • • .tifocal atr ial tachyca.• Atrial: 100 to :2 50 beats /rninute (usually less than 160 beats /rninute) Vent r icula r: 100 to :2 50 beats /rninuts • • [on.rdia • • At rial: Ir regula r Vent ricula r: Ir regula r .Usually no rrnal May become abe r rant if arrhythmia pe rsists • Usually disto rted • May be indisce rnible .

may sta rt and stop ab ruptly .......P.-ave QRS compte.34 Paroxysmal atr-ial tac:hycardia... may be abe r rantly conducted T • wave Usually indistinguishable . typically sta rted by PAC. 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 .-ave • May not" be rneasu rable if P .....• May be indistinguishable Other • Sudden onset.x • Usually no rrnal ..• • May not be «is ible May be difficult to distinguish from preceding T .-ave an't be distinguished c from preceding T ...

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..1:i:a1:e :a1: i:al flU1:1:er from r :a1:r ial fib ri1I..P..I... 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 0 r <1: .. mal lirrrits if fiutte ...-ave i::::n'1..$ PR interval • Not measu r able . fo r example) 1 150 beat:::: {minute vent r tcula r .1:hin no .Vent r icula r : TWically regula r .. dentifiable i Othet: • • Atrial rhy'thm m...1:ricul:ar re::::por.-een a fib rillato ry line and flu1:1:er ...36 Atria.'1:ior...... 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).-ave:::: (c:alled atri~ fib-fi.$ 0 r F~. -.....rJ_.-toothed appea ranee known as fiut-fE:..ay vary 1:0 diffe bet...u1:e at rial and second I 1:hi rd .. irregul:ar ver.I'On'1.......vi1:h:ar....utfE:.. accep1: rrro Fe 300 beat:::: /mit.r ~.QRS compiex • • Du ration: U:::ually u. -aves a . . bu ried urithin w e the complex May be uridened Twave • Not identifiable QT interval • Not me....t:s:Iminute Pwave • • Abnormal Sa.asu rable because T .l.. tel: Regula .::::e M:ay be difficul1: rer.. known as 2: 1 b~Q ~ to ven1: r icle s because 1:he A V node u::::ually '\..or fou r rh impul::::e is condUC1:ed than 180 impulse:::: Iminute • Vvhen at rial flutte r is fi r s t recognized I vent ricula r rate typically e:x:ceed:s: 100 bea. ... flutter • • At .

-diove r sion can dec' .-i1:h rial tlut1:e ... ea:::e HR. 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 . Keep r esusc i+at ive equipment Be al~ r t fo r effect:=: of digoxin Monito ~ pa1:ient rdia because ca ..~e • • • • • What ...~e is r ap+d (compl"in~ of redl.-diove r sion W'i~h. f 48 hou r s at o the r"py 0 r less I immedia1:e s-ynch ronized rs ion elec1: r ical ca . be ale r t fo r b radyca I Moni~o r he" r t rh~hm.• .rfusion from r ap id ven~ r icula r r..• • 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..• • • '.. clo::::elyfo r evidence How it'...37 Atrial flutter • • • Ca r criac su .. ry ..... SA nod~.~ r'ial flut'te r of mo re rhan '18 hou r s . which dep re::::::::es of low CO ......P......-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 r tricuspid di::::ea::::e valve di::::ease rdial • Sys~emic" r te r ial hypoxi" • ..-a1:e i:::: r ap icl ven~ r icula r filling t irne and co ron" ry pe.lced of reduced CO if ven1: r icula r ..s' treated • • • • • If patient hemod-ynamically un::::table and . Angina Hea rt failu H-ypo1:en::::ion Pulrnona ry edem" Syncope Fe to do at bed:::ide .

tion • • Atrial: Ir r.egula rly i r regula r Vent r icula r: Ir regula rly i r regula r • • Atrial: Almo$·t indisce mible .{) at rial fib r illat ion from at rial flu+te rand MAT .38 Atrial fibrilla. usually above "loa beats /minute .utte:. fib -fl. fa r e=eed$ 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.P.

. I:" t"egul.P. 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 . mal apical pulse 0 r abno ...or arntccta rone 'the rapy fo r un responsive syrnp1:oma1:ic ... regula . rnon+to r be .at rial fib r-ijlet iorr .. in pulse and he::.a rdiac .r1: failu Fe... 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.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::...39 Atrial fibrillation • Acute MI • • CAD C.... i r ... fo and signs of hea r1: failu re • such as dy:::pnea and pe riphe ral edema...alert fo r . Valvula rhea caffeine I nico1:ine) rn+t ral v:::. Iy egula r pulse ..ridence of 1:oxici1:y... mal H R rate of dec no ct CO (light -he actectneas urith eh r orric • hypotension) symptoms at .-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 .-a1:ch r e-.a1:ien1:i:s:n''ton c... Tell pa1:ien1: 1:0 repo r1: changes ra1:e. diz:z:iness • fain1:F'less • cheS1: pain. 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.. I is used... hythm Radial Evidence Possibly pulse r a te that'"s r esase SIOUfe ..than 'uri tb no ..ar pul:s:e and diffe rences in radial and apical pulse ra1:es.. If p.. • • • • • • 0 rug 'the r~py 1:0corrt r ol -o'errtr tcuta r response.. r1: di::::ea:::e • • T rigge r s (alcohol...ardi.lve df:::ea::::e) r't di:::ea::::e (e::s:pecially What to look Jor • • • • I .

P ..esent in the unde rlying rhythm • Commonly changes on the p rernatu re beat .'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.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 .

s treated • No inte rvention:::: needed I but may be needed fo r accompanying a r rhythmi::.vi~h leng~h of cycle What to look for • No sign:::: 0 r :s:yrnp'tom:s: What to do • Monito r he::.PAl Ashman's phenomenon • Prolonged refr.acto ry pe riod in ::::Io\l..u~e refr"'c~o ry pe riod "'" r.:::: .e~ -.. r t rhythm_ How it'.l"e'" rhythm • Sho r t cycle followed by long cycle bec".

42 Wandering pacemaker • • Atrial: Va r ies slightly.P. "Withan i r regula r R.R inte rval • Va r ies . 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 . but usually "Within no rrnal limits 0 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.P inte rval Vent r icula r: Va r ies slightly. "Withan i r regula r P .

-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.aker • COPD • • • • Digoxin toxicity lnc re... investigation and ·t reatment of unde rlying cause of arrhythmia review of medi~ation ....ent a:s:ymptomatic .::::ed pa r asympathetic lnflarnrnat ion of at rial t issue Valvula .to r he" r t rhythm...hea ....) What to do • Mon..:.P. disea::::e 1: (\l'dg::. • \IVa'tch fo r e-...-egimen.l) influence:::: on SA node 0 r AV junction What • • • fo look for is una....cem..ridence of hemodyn..-ae of a r ...... r regula r • At lea.from PAC.:::1:three di:::tinct P .. • • :Usually no 't reatment If symptomatic I if pat'.amic in:s:'t:abili'ty I such as h"ypo'ten:s:ion and chanse:::: in mental statu::::..43 Wandering pa...ghtly .-aveconf'igur at ions (distingui:::h urande.-ing pacemake .

.-ip) depending on initial di ..!... ation and du r ation because vent . ing 0 (see shaded a r ea on st.. ctes QRS complexece QRS cOil'i'nplex • Usually no . 12 ·second) if P ""."..vave • • • Usually tn ce .onfigu r....... • • At... vvttkfns 1~t Ed>ri.-Iying . mal configu . ted May May (leads II.t.I: Irregul".... ection of depola . n ~opy .ctions • At'. ight > Table of Con1:en1:s > June June Premature junctional cOhtra....-ial: Reflects unde .ng PJCs • • Ven1: r icula r : Ir regul:a r du ring Unde ... and aVF) du .. III.. taa t ton occu r tae fo r e be hidden I I r afte r QRS complex I in QRS complex PR interval • • 5ho rtened Not measu (less rhan r able if no O.ct~ M"....e-Incntd>hly $2006 lippincott vvtttf arns Quid....... hythm possibly P JCs r eg'ula ...ve precedes QPS complex P wa ve p .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 .Totle: ECG F".. a.. lying rf-ncthrn rhythm Ven1: r icula r : Reflec1:s unde Flying P v...r du'.mal c.e no t"mally- • U::::ually no r... fetes usually depola r iz.

Valwla rhea rt di$ease nicotine) • • POS$ible feeling of palp itatjcns Hypotension 0r skipped enough beat$ if P JCs are fr. • • • • U$ually no treatment If $ymptomatic if patient a$ymptomatic . If ectopic beats discontinuation because frequent elimination of caffeine intake .PAS Prema. treatment of unde rlying cause of drug of caffeine.equent What fa do • • Monito r ca rciiac rhythm fo r frequent Monitor patient for hemodynamic P JCs . decrease in 0r If digoxin toxicity.ture junctional contr acttons • • CAD COPD • • • • • • • • Digoxin toxicity Elect rolyte imbalances Hea r t failu re Hype rthyroidi$m Infe rio r -\1. caffeine.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. may indicate junctional irritability and can lead to mo re se rious arrhythmia such as junctional tachvca r dia . instab ilitv.

p W<lve precedes • • Dur:..egul:..~hin no rrnal hmtts Usuallv no rrnal C. r • Ven~ r icula r : R.~ening a r rh~hmi:.~e junc+ional rh~hm from idioven~ r'icula r rh~hm (:.onfigu rarton: T • WaVE' Configu r at ion: Usuallv no rrnal • Usuallv urithjn no rrnal lirntts Ot. III.lly . M:.n~ to diffe ren~i:.P.ds II.her • Impo r~:.~ion: Usu:.46 Junctiona.) .l rhythm • A ~ r ial: R. r • • A~r ial: 40 to 60 beats /minu~e Ven~ r icula r : 40 to 60 be:. du ring. life -th re:.. and :.y occu r befo re .VF) 0 M:.egul:..~s /minu~e Pwave • • • • • Usu:..y be hidden r :.. 12 second) if ~ W<lve precedes QRS complex QRS complex No~ rne asu r'able if no .f~e r QRS complex in QRS complex 5ho r tene d (less than O.lly inver~ed (Ie:.

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.S' treated • • • Identification Atropine.P. . 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. Monito r digoxin and elect rolyte leve'ls: of dec rea sed CO. \!\latch fo r evidence How it '.

.. 12 second) if P w. r afte....omplex Not measu rable if no P w...P..thin no rmal limits Other • Need to diffe rentiate accele rated junctional rhythm from accele rated idio.thin no rrnal limits ration: Usually no rmal..-e precedes QRS complex QRS c. du ring..-erted in leads 0 11...111.-e precedes QRS complex • • Du ration: Configu Usually """.. May occu r befo re . in.. May be hidden QRS complex in QRS complex Sho rtened (less than O.thin no rmal limits • Usually """.-ent ricula r rhythm (a possibly life -th reatening arrhythmia) ...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. and aV. • Usually """...

49 Accel.era.P. such as hypotension. weak pe riphe r al pulses • • • Monito rhea r t rhythm. • • Identification Discontinuation and co r recti on of unde rlying cause of digoxin . Monito r se rum digoxin and elect rolyte levels. cl1anges in mental status. \!\latch for evidence of decreased CO and hemodynamic instability.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 ) .

befo May be hidden in leads Fe u .. Iii..a"l:e • Usually urithin no rrrial limits Other • May have gradual (nonpa roxysmal) 0 r sudden (pa roxysmal) onset ... 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 . 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 .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 ...af1:e. nible becau::::e of f::.QRS complex I du ...::::1: ....... and aV~ .p" 50 J u n c: t ion al t a....

el to digoxin Fo r recu r rent If symptomatic • • • vagal with with junctional with .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. rnontto r digoxin blood le-...-.IIM I Poste rio r -.. fo r e"'.-".P.c hyc ar d i a.-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 .-". possibly digoxin-bindi.-.el...or arnioda rona (hea r t failu re rEF below 40%): amioda .II yoca m Val-.-. calcium r orre channel blocke r s ..51 J u n c t ion 311 t a.. ablation in some cases·.. of digoxin.-".II (may MI rdial ischemia aHe rhea r t su rge ry agg ra""te condition) lnfe rio r -. of unde rlying discontinuation tachvca rdia onset cause of digoxin. possibly the rapy rdia: follo. • • • • • • • • • • Digoxin toxicity (most common) Elect rolyte imbalances Hea r t failu re Hypokalemia Inferior-.dence How "it '..~ treated • • • • Identification If due and treatment toxicity..-"..ng d rug to reduce rinse r+ion se rum digoxin le-..IImyoca Inflammation of AV junction Poste rio r -.-. toxicity.

-i'th e rpola'ted 'irrt .clcl'" ~:§.vave • • Oppo::::i'te di r-e t f orr 'to QRS complex c May 'trigger more se r tous rhy'thm di::::'turbance:::: . Vifilkin:::: > Table of c crrt en-ts > .-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.ctions • • • A'trial: Irregular during r- P\IC:::: du ri...t Emrion Copyrigh't ®200'..figu ra'tion: T y.......ng P\IC:::: r- Ven't ricula r : I r.....i .. I@: ECG FJ6Jct:§.-ide bu't u::::uallyno rmal in ·unde rlying rhy'thm (see ::::haded a r esason st rip) Con... a. 12 s ec ortci Biza r r e and .r c:ontra..QRS complex e w-i tf-r r-e-t rog r-zsle c orrch...-een 't-wo no rmally Full ccrnp ens aeo ry pau::::eab::::en't...-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....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.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.MJ6Jde IncTembly Lippinco't't Vifilliam:::: Qu:.. rrt e Vent Premature ventricubil....

egula r pul::::e rhy1:hm each PVC on auscul1:ation -... ..on..-a1:e . What to do • • .e r"".. 0 Ob...... gement r imbalances (hype rkalemia rs • hypocalcemia I hypO'magne:s:emia I hypokalemia) of vent r icula r chambe • I r rit:able focu:::: • • • • Irritation Metabolic MI of vent ricles by pacemake acidosi:::: r elect rode::: 0 r PA cathete r 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 .s..c t ion s What cau.-i1:h recen1:ly developed Moni1:o rhea r't P\fCs I 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.men P\fC occu r s Abno rmally urith • • Palpitation:::: Evidence if PVCs a Fe frequent $-yncope) of dec rea$ed CO (hwoten$. antiarrhy1:hmic drugs after di::::charge" how to activate EMS and perform CPR if the patient urill be taking • • • • No treatment if patient asymptomatic and has no e-o-iclence of hee r t disease I If ::::ymp1:oma1:iclor dange r ous.. • P romp1:ly ass ess p a t ierrts .es thet'n • Enhanced .. clo$ely fo r de""..ar c: 0 n t r a..lopment Teach family members r mo re dange rOU$ PVC patte r'ris.....au't..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 I lidocaine I p rocainamide 0 rigin: 1: eatment r .oma1:ici'ty (u:::u:al c:2lu:s:e) • • Elect rolyte Enl::.-ithmomenta ea rly he..: sound 1 Fily i r .P.53 Pre m at u r e ve n t ric: u l..

...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 .. can produce \iT because the second corrt rac~ion usually mee~s r ef r ac'to ry t issue . r digoxin ~oxici~y.54 Patterns of potentially Som ..P.. th r .. s .. Mul~iform PVCs may indica~e s . r s ...n~ially dang . a r t diseas . ve r . H . PVCs a r . mo r .. Paired PVc's Two PVCs in a row.. a r . dang . r .. . r ous than dang. J~ultijorm PVC. r . sorn ...erous PVCs o th . A bu r s t .. p o t .... d a run of \iT . h .or salvo. 0 call e d paired PVCs 0 r a V€rdri cul= caupIe! (see shaded a r eas on s t rip above) . rous on .... PVCs in a row is consid . of r mo r .


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



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.


Id iave n t ric u lar r hyt h m

• •


Usually can't

be de~ermined regula r

Vent ricula r: Usually

• •


Usually can't

be determined zrntnure

Vent ricula r: 20 to 40 beats

Usually absent

No~ rne asu rable


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

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

Usually prolonged

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


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

CO (hypotension, of B P



of faintne«

, syncope,


r palpation

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



patient readily

until hemodynamic a"if.3ilable. and patient


has been

r es to red.




until effective about

HR has been


is stable. and requi red

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

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

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 . Co: eo at e did i GIve n t r ic u lar r hoyt h m I.P.58 Ac.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.

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 . e"Plain how i~ wo rks .at ion of B P What to do • • • • • Monito r ECG continually. and pacemake r equipmen~ res·~ unt il effec~ive and family about H R has been mairrta inecl and pa~ien~ is s~able.P. . ligh t -haadadness . d izz iness . how to recogni"e • • • • • Supp r. stabili~y has been r esto red.59 Accelerated idioventricular rhythm • • Digoxin Drugs • • • ~oxici~y Be~a -ad rene rg ic blocke r s Calcium . and how pacemake r func+ion """. Keep at ropine Enfo rce bed Tell pa~ien~ If pa~ien~ pe riodically assess p'at ierrt urrt il hemodynamic readily available. syncope) auscutratton 0 r p alp. lidocaine) corrt raindicated fo r accele rated idiovent r icula r rh~hm because of possible supp ression of escape beats .. requi red ~rea~men~ problems. when to contact physician.eatment HR . 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.ession of arrhythmia Possible a~ ropine I not goal of t r. b ~he se rious pacemake natu re of th is a r rh~hmia and needs pe rrnanerrt r .11 e rnorrito red.

urith inc reased rphic shape \IT in polymo rphic \IT Unifo rm in monomo Cons tarrtly changes • If \risible.60 Ve n t ric u lar t ..P. 12 second arnplrtude Usually b iz a r re .<!!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~ .~h QRS complex • Not rrieasu rable QRS complex • • • • Du ration: Configu E=eeds ra~ion: O. not a«ocia~ed .. occu rs opposite the QRS complex • No~ rrieasu rable • Ven~ r icula r flu+te r: A va r iat ion of \IT ..

. mal ca r diac furrc t ion ... sion by adequacy (E F If no definitive Fo... onized guided ca r diove ... CPR if patient fo m urill have an ICD 0 ....• CAD PVC:::: du ring wns t r olce of p ..... s-ynch . ...: •. r1: failu Fe I p roc atnarn+de lor quinidine) such as: h-ypokalemia ..... otid pulse_ rhythm may rapidly Teach family membe . ulseless p Fo..... Mi Myoca rdtal ischemia Re..... idocaine l patient patient urith monomo .. polyrno r li~ocaine 1_ _ follo-.-fu::::ion if unt t"eated Po::::::::ible angina hea 1"""1: failu re I and sutxs t arrt tal dec Fea:::e in 0 rgan '.......• • • '_ Ca rdiomyopathy D ........ to:=<ici1:y (cocaine ug Elect rolyt~ imbalances He::...be on long-te . antia r r hy... hythmia and need fo ........-eceding system T ......thmic the r apy afte r discha . . atient p Monito rhea rt rhythm. amioda .... _' enhanced aU'i:oma1:ici1:y clo which may be t rigge red by: ... is conscious and has spontaneous p rog re~~ to VF..P. how to activate s Teach patient and family about EMS and pe .......r t3!. m ge_ the se r ious natu r e of a ...-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·.... ocainamide r phic \fT but poo r EF: amioda r one 0 0 .......• • • '...ula rhea r t di::::ease What • • Usually toO look Jar irlitially . ...-ave reent ry in Pu rkinje . espi r a+ions and palpable ca . 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 ... p .-dial i r r itability.-ed ca r diove r sion V by of elect r olyte imbalances .. rornp t t r eatment_ p Ho"'Nit's treated • • • • • • • Fo.... one • 0 ..... .-a t"ming du Fing h-ypo1:he rmia Val-.....chycardia • Usually inc reas:ed myoca . nstable u \JT • immediate defib r illation immediate 0 patient urith pulse.61 Ventric:ula..• • • Dete rrrrine urtretf-re. phic urith rrronorno r phic r polyrno r phic \JT and no .

.62 Torsa.-a r iat'ion in elect r ical pola rity.P..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. \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 .. Vent r icula r: 1-50to 300 beats /rninute • Not identifiable • Not rneasu rable QRS complex • • Usually \llide Usually a phasic .

immediate synch roniz ed ca rdiove rsion .63 Ter sades de po irrte s • • • • • • • • AVblock 0 rug toxicity (soralol . p rocainarrride (hypocalcemia. 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.. quinidine) hypokalemia. 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 . chest pain. pulse. de pointes. of offending drug Co r·rection of elect rolyte imbalances For unstable ICO patient "Withpulse. V. and has spontaneous respi rations and palpable • • • • • • • Oefib r illat ion Ove rd rive pacing Magnesium sulfate O·iscontinuation I. synd rome . and sho rtness o. dizziness.P .f breath level of consciousness if patient is conscious and dec reased loss of consciousness. tricyclic ant idep ressants ) resulting in seve re b radvca rdia • • • i'alpitations Hypotension .

..aves ...... 111::.r Coarse f'ibriUa. able Other • Elec1: r ical defib r illat ion mo re successful urith coa ... Anial: Can't be determined rn 0 Vent r icula r : No patte r regula rity.an''t be dete rmined QT interval '_ No1: rne asu .-::::e fib .-.-y wave:::: than "With fine .tion Fine • '..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.P.1:0.64 Ventricula.... just fib r illa+o ry wave:=: Rate • • Atrial: C.

6~ Ventricula. 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)". r illatfon: 200 to 300 joules epineph . the rapy the patient "Willbe taking afte r cfischa rge. 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)". hypokalemia) (digoxin i p rocainamide . • • • S~an CPR. 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.3te EMS and pe rfo rrn CPR.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 .P. and family about r ant ia r rh~hmic • • • trnrnedtate defib rfttatton up to ~h reetimes "Wi~h 200 joules.3S0P r esstn .a.r fibrill.

!!\lBf!j' R 'tfl15.66 Pulselsss arrest algorithm I)iiElry.r:~!tW1iiltl !i:b~r~i'im dm~~rilliJIJli'i.J~ 'Of51~I PEA r\l!~.C~ '~j) . :11 Ill!!!' plj_~e.Qr SCiOO.~ 11m.P.~ iGi'S'Iltooili d~m D~I!IpiMgi~iil1l:J. 'g'hro !IlOO~illt!i!I!J~ if. ei~~8. ~e~e~ t!i1~ iii u.rjj~I'IlC(l.0.1m'1~\ I~pl!. 'IE!. ~~pe:lliYIIt~ 1 ' ~.V. O!):[Is[d!llr 3llJ>lI!l)lm~1 m~ ILV. dme Q~ e~ll'ie~mrir!!J: i iii II Di!!~~i(:iIll Ii1.rmi.!l. . LO. Gjve..hU~etlJ[t1pr':ii:!iien~ Wtl~ijili I~im5~5.1J.~~Ni~. or 1.. !iJwel iih!l~k Ibi~h\'!~i~ . lif:'J~.[pJe.\ mil:!"l!:! .mi~jl. ~I • Imriliildiill81~ f8~mjj.8. .!l~njJfeS-tml" be~tf11 ~[fa~S~ii[iJii~ .C'.OfL.t . min lif' IIi 3 do~5. . 01' II.k iji' Imgh~_f'd~~B~ ImOt'iillpl~1IJ5[t::wil1 I' ~ I~[j]~sl. Ii l!iSlj'c!!ole" Oil! iIIi!' ~~. rili' '~~BiI~It:.I~") min @~ milM 1 ~g~ !Jf 'i'1!I~1il~!'Ii!!i~~ 40 1fI1ilIi 1. .~15'l1im UAg~'i'1l:1 dlMiiloIYilS1:i' llJfe~1~4C' !. ~I rul~r ~ilj iildi'l'iifiClilili DltWl1~ is jllileCl:i!. !I:~tI!1:k ~Lt'!sEi..'Dr' II.'rut' ~ I I ~. 6'~lnl(!~~lIifJ:(}rim I'.V.EI~'iP1i~hrin:e II.ij!m~ !!ttliql' i!lbmt.~oo.itW C~R- m~~----""'Ii' .~!l~~! i~r~: V"or ~ ~I Imi'fl1l~~DilIly ri)~ufi}O QP~fIn 5t~tI~'\S> . t~' ~.3.

jj~IIt1mlur Ii aOMl: m~rn~liliii'$i~. Iir~dm~: d~m'. lill~1iai I ~totU~lp~~~i~: ~s i~~iil~. Imm~~ia~ulV CPR! M'5time I~C~~~~~l ~ntj~rmv~ics.P. ~ig~le~}.~i~G d~rirmCf-R~ I~ I~ IDtlm~~BJmi~~B5ill[Jj.P .~~ laPIA: It-~r{jjrrm~e~~lilleOOf. :~fst~~~~t.~rOto 00x i . ~IUl~5CV~i)S ~IC'R!!.~ICoqtil1~~ Iffll.




Vent r icula r: Not present

• •


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

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

QRS complex occu r s in response



• • • • • • • • • •

Ca rdiac


0 rug ove rdo:!:e Hypothe


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


• • •

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

Un responsive

Lack of spontaneous No CO 0 r pe rfuston

disce mible




• • •

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



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


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



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

• • 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

• • At rial: Reflects underlving rhythm eventually dec reases

Vent r icula r: Reflects unde rlying rhythm;

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

Same as unde rlying rhythm;

eventually disappaa

r s as P wave disappaa


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

• • • 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



a.systole "Withinseve r al minutes

10 rg:.. rrria Hypok:. • • Epin . ct rol~ ... I. nt iffca+ion • • • • • • ~o AC LS guid .. Pac e mak e r th e r:.... s (such Hyp ... sis fo r ca r dtac volum . di:..py (r:. ss l.x n ... acco rding Id ..... n loss of consc iousn . :.~ ropin . mo r rh:.. co r r . atrn . r th r ornbolyt ic th e r:. M:.r~ CPR imm .g . a and sudd .«ive M:..l .py 0 fo r mass ive pulrnona ry .rit:. rrria from ..tion su rg e ry 0 fo r hypoxemi:. rrrria Hypovol ... rfusion of >...nd ~r .Y1 Pulseless electrical activity What causes it • • • • Acidosis C:. 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 ..~ . ssants ) 0 rug ove r dos .. nt of caus . z :. rrria Hypoxi:.f . trnbalanc ventil:.. r e ly e ff e ctive) . rk:.n~id . rrria Hypoth ...c rarnponad .. r-di:..ack of B P ancl puis .. mbolism r:. M I • • • • • • • pulrnona ry .. s h . p .. mbolism T e ns ion pn e urno tho r ax • • • Apn . r ioa rdioc .. infusion fo r hypovol . ly... ct ton o. No CO 0 r p ... lin ...P.nd :.«ive acut .. nt . as ~ ricyclic :.. including: rarnponad . ph r in .ns • S~:..l ... p r .

as ven1: . in AV node s ... 'oNilkil"l~ of Con1:en1:::: ::..... mal limits ...a on ::::'1: rip) • Cons1:an1: QRS complex • • VVithin no .A-V elock A-V Block First-degree AV block Rhythm • Regula .ade IncTemhly ®2006 Lippil"lcott 'oNilli"'m~ Qu>cl<!.. tcutar • • • No rrrial No rrrial Each size configu . mal limits (0 OS second) conduction if conduction delay may delay be occu ...... · Rote • • V!fi1:hin A1:. ial no .12 second. in His-Pu • • • No rmal size No rmal co rlfigu ration M".aCt5 JII. ation by a QRS complex followed • • Prolol"lged Mo re rhan 0....... kinje system If rrro r e than 0...y be abrio rrnal if QRS complex i~ p rolol"lged • VVithin no .... mal 1:he same ltrn+rs .Table ECG F..Illle: Copydght ::. "5t Emrion a.20 :::econd (see shaded a re..

.:.I between What to do.-.AV ble ck • • Degene Fati. Monito F patient's Gi..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$..ation arid co r . Iying cause . ection of unde ...P. and p FOgFession to rno Fe se r ious hea r t block...-e (age .:: Fate jor • • • • • • • No rrnal pulse Regula F Fhythm Usually no symptoms Usually no significant Inc Feased effect on CO S. calcium channel blocke beta-adFeneFgic • Identifi~.-edigoxin.. and S~ hea r d on ca r ciiac auscultation if P R inte " «a I is ext Femely long inte n.73 First-degree . bfocke rs cautiously.... ca rcliac Fhythm to detect rs ..

.....a QRS complex e s "Iong longe r • dropped to cycle the va r ta+ton in delay r the non conducted f ..74 Type I second-degree AV block Rhythll"n • • Atrial: Vent Regular t"icul:::.1 limit:::: • No rrrial size • • No rrrial configu Each follo.a1:e exceed:::: ventricular r a'te s u::::u:=. ribed sh...lIy . r : It" regul:=. cycle 'ern beat..ep ea ts .....-ithin r.-..R tn-ce until a P wa ve appea r s ur+ttrou t a QRS complex.al ..-.P..-ithin no rrna! limits Other • • Wenckebach P R trrte r-ca! p. 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 ... s ho r t e r than inte t"..-ed ra1:ion by a QRS complex ecccep t blocked P wave • • • • P rog re::::::::ively longe r (see Commonly Slight Afte cle sc.ave appe:a r s "Wi1:hou1: .au::::e of nor-conducted be.aded I ..... r ' Rate • • Atrial Both r.a rea:::: on :::1: rip) II "Wi1:h each cycle urit il .a1:e bec....a P .....a1:::: no rm:=..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. 1.a get:::: 1.. cycle then .

about temporary pacemaker..." :it • • CAD Drugs • • • • Be1:a -.. atr.opine can -wor:::en ischemia) T ranscutanaous until the 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 -.P..-e::::olve::: .7S Type I second-degree AV block Wh a e cause... opine (use cautiously pacing I if patient if needed an MI. · 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...11 I M Rheum..:rtic feve . • • • Obse rve fo r signs and symptoms Eva luate Teach patient fo r p oss ibte causes.... if indicated.. rhythmia ... patient How • • • it's treated and treatment of unde rlying cause i::: having I Identification At ..

...... conduction en r a't-io is: constant ::::uch sas 2: 1 3: 1 • • Atrial Both eccce ecfs ven'tricula may be r ........- if block occu r..-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..egula r-espond to d r-·opped is inte beat 0 -..s at bundle b of His: 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.-:31 r-i:able r- Regula .-hen lock b r.....mal Vv'ithin no Vv'idened limits: 0 r- na r-r- 0-..-izal: Regula r- Vent r icula r : I r ro::gula t" co rr- Pauses Ir r...a!s b ranch and no r-rrual R.-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 ...rni"ttent r- conduction I r-atio 0 i:s:.P_76 Type II sec:ond-degree AV block • • • • • At r.to BBB if block absent occu r s at bundle Pe r iodically • No r-rrual size 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:" .... 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 I :=:0no u.anche:::: and ::::imila r..-arning o ccnar-s R........ation • No r-rrual configu Q_T intervai • Vv'i1::hin no ..

. ..ridence of decre.- is placed .- (fo..:l'tierl't fo r t r..an:s:venou5 pacemake patient and family about p acernake rs I • Teach if indicated... V......it '. • • • Adminis1:e r oxygen......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-.ake r attached 1:0 pa1:ient 0 r in room. • Fatigue • • • H\lPotension Slow pulse Regula r 0 r i . pacem...A'II bl..311MI .T! Type What • • • • Ante II sec.-anscutaneous pacing initia:l:ed quickly .I.ond-degree causes' it r io . fo r co r rect.~ treated • • T . MoYil' .-"I.-ug:::: A t .able cause:::: (:s:uch a:s:i:s:chemia). p repa re p..-ine I 0"- combination of the::::e d .alua1:e pa1:ient :s:eve re block..on1:0 rno Fe Obse rve c....-an::::cutaneou::::pacemake. dopamine infusion I epineph .a rdiac Ev. t i oe changes e he a r t disease in conduction .se r ious ::::ignsand ::::ymptoms) until a pe rrnanerrt pacemake..-egula r rf-ru-thrrr What • • to do rhythm fo r p rog re:s:::::.I". 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 t ranscu1:aneous rinse rtion.-hen indicated and I.ain Dyspne .ased • • Che:s:1: p..P.

... igin bundle of vent of His .. 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 ....ave:::occu .. mal stze No ..-.. bu r ieci in QRS complex T wave PR i~terval • No1: mea:s:u r... mal May be confi~u .. o ..78 Third-degree AV block Rhythn....- r+cuta r : Regula ..a vent e::::cape rhy1:hm) rhy1:hm) IminU1:e in irlfranodal r tcula r e::::cape • • • No ...and be:a'l: independen1:ly of each other" .. • • At.. tcute r depola .. tze t ton no rrna! if the Vv'idened tf-te level of the bundle s T ....'tricre:s: .. · 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 (.......-ial: Vent Regula.. a+ton 0 ...a1:ion M'ay be abno rmal' if QRS cornptex 0 rigin..able • • • Configu Appea .ave • No rrnal ::::iz:e • • Norm::...a1:es in vent ride QT interval • Vv'ithin no rrrial limits Other • • A'trta P ..are depol:ariz:ed r "Wi1:hou't QRS complexes from differen1: p:acemaker ::::i1:e:s: .a junctional (.and ver.P.1 configur..

-icrt pa1:ien1: bed r • Fo r. dopamine pacing infusion (mOS1: e epineph r re c e+oe ) combina1:ion (fo r.... _ Ec-ct sarus t-ooe an:te rio level. t.....-all i • Toxic e f=fe t s of drug:::: (digoxin..... • Re s t ...e'tic MI 'tone . V.co ...ate pe 'WhQt" _ eo do I V. line.escape bea1:s Pe r-manen1: .or-..... • _ • Adrniniste r- oxygen...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.. fo r. c propranolol) At: inf'ranodal.t"a::::yrnpa'tt-. dial ischemia)_ roe t terrt'.s 1:0 oe s level.. En:s:u e pa1:en1: ..sf-ro r-t -1:e r-m use in erne r-gencies) I r-ime .Or- • • A1:r-opine c or'rt r-za-irrcftca't e cl pacemake r- I especially "When accompanied by uride-complex -coarrtr-ic rrlta r.evel of AV • _ node AV node Inc rea::::ed Infe damage pa.. c t efote e e c t+o+t c.P.au:s:es: of a ...patient 'w-i'tf-r 58 r-iours signs and :S:-yTTlp1:oms I -irru-rte cfizrt e 1:r ee rrrrerrt I including: _ 1:r-anscu1:aneous I. hythmia (d r.'" Third-degree AV bloc:k At: I.ugs: I As::s:es$ pa1:ien1: Minimize rnyoca . r......

. e ."'th "'the lef"'t :a .a.. ode pl:ace-:nen"'t_ fo ..igh"'t leg...igh"'t :a t.m.e: ..... ~"'tic:al -rc»..x d limb le:ads:.c e ..-..-.pole) -"""'-......-.rT)..e: pole). ..... RA....e: :a minus: indic:a"'tes: :a neg:a"'ti. S:j. I_e:ad I pl:ac~m~n"'t p I. :and ...._.. ding pole..-._.....pole) -"""'-. RL I r....e: pole) -"""'-..e:ach .-.ope ... oL:lnd.... .-. b P le a d lef"'t leg _A r. eco .....-. :a-... Connec"'ts: "'the r......._....ngs:s:ho-....:a."'th "'the ..e: pole).. rplus: s:ign (-+-) indic:a"'tes: :accu .Ief"'t leg (pos:i"'ti.m (neg:a"'ti.igh.-."m (neg:a"'ti.Le:ad Vifilli:ams: a..-:able 12-Lead L. 1 Z. :Lea. :a"'te . 1: is: c.. m (neg:a"'ti. of c:a ......d Connec"'ts: 111 "'the lef"'t :a .."'t :a r.h-y-.e: indic:a"'tes: :a 9 ...... Belo--.....:hms: (-) _ Thes:e d r.Copy ._.. Vifilkins: > . ec"'t G elec"'t . di:ac s:ign r.-co pole..-.. LA le:ad I lef"'t _ :a r.. igh"'t of ®:LOO6con"'ten"'ts: L ippinco"'t"'t >..ng is: :a s::ample r- "'th:a"'t Connec"'ts: "'the r..... "'th":. m (pos:i"'ti. :and LL :a pos:i"'ti..."'th "'the lef"'t leg (pos:i"'ti:v-e: pole) _ . :'"'t:ands: EC G fo s:"'t ip igh"'t fo :a r....e: ..-.

-igh"t a t"rTi (posi"tive pole) 'w-i-tf-r "the hea...-"t (nega"tive pole). .-"the lef"t leg (posi"tive pole) 'w-i t l-r "the hea.d aV.. Lea. C'oru-rec t s "the lef"t Lead Connec"ts aV·..P..a. "the ....-"t (nega"tive pole)..81 Lead Connects aV·.-"t(nega"tive pole).-m (posi"tive pole) uri"th "the f-re e.

r ight $~e rnal bo rde r v. To reco rd a 12 -lead ECG'. place elec~ rodes V 1. and III) and '~he th ree augmented leads (a V R' using these elect rodes...82 Precordiall.. left $~e rnal bo rde r V~ and V~.. Fifth ICS. II... a rrns and leg$ (\iJi~h '~he g round lead on the patient's to reco rd the p reco rdial chest leads . Fifth ICS ....P... left rnidclavicula V5....Ieft ants rio r axilla ry line V...Ief~ mid axilla ry line V'· ·1 ...ead a V ~ . The th ree standa as follows: rd limb leads (I. r line v~: Mid .~.. y V>fi..) are reco rded placement on the patient's Then.... between . and aV... Fifth ICS ... Fou rth ICS. Fou rth ICS. place elect rodes right leg)..

~.. lead V~ at the paraspinal bet..... Fifth v~.. right ste rnal bo r de r v.. v~. make sura the poste r io r electrode~ line . Posterior I... Place lead V1 at the poste r io r line.d el. left ~te mal bo rde r Fou rth ICS... Fifth ICS.. and V9 are placed at the same level ho r izontally as tha V~ lead at the fifth intercostal space...P.l:il!<ll'll' lill~ . . right ante rio r axilla ry line ICS...nriiQrior :iI..ea..-een leads V.. and lead V~ halfway V1" V~. and V~. place the elect rodes as follows: To reco rd the r ight p reco rdial chest V 1~"" Fou rth ICS.. right rnidclavicula r line ICS. Fifth v.33 Right precordial Lead placement leads .ectrode placement To ensure axillary an accurate ECG reading. right rnidaxilla ry line M'l!lcilOOl!t:IJ!~' linc Mid!~il:iIIO'!l'lillc II..

f(gme.~8/~.! N.84 EI.niJ~d·lJmb leads: rutJipatil~~' .. -Il-. .eiV'!.ectrica.P.aI'" ~~$~.A~tar"@r wal~ij ILateral wa'lll V.ql't Limb te'ad5 {b. Vlews 1f8fle~ted 0111 1. V~ .-lead ECG Each of the leads on a 12-lead ECG vie\IJS the hea rt from a diffe rent angle. 5. These illust rations show the di rection of elect rical activity (depola rization) rnonito red by each lead and the 12 vie\IJS of the hea rt.{po$arj I ut~u~li III w~ III '"~ .2·Jei9111IECO iI Leard View' of this! he".Il! I w~11 An'it!t!n@f wal~11 V~ V. . IU A. . ·S~fJl:.~w f1f~r. VI ie'(ld$.~ " '116 'If.1 activity and the 12. :2 l~Uer31wa II V3 . tJjmp'Otlfj~! ·S~ wa!~1 p'hll v~ V~.g ~~~ciHc:: vi.

Both mves point do'WTI .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.loil'1 .. devlat.. leads I and "V F' lead I indicates whethe r impulses" re rnoving to the right • • • • 0r !eft.P. d~vi~!tJiO" Ria ht· a. lead I is upright and lead "VF points do'WTI.d Blif'atim1 I .-9ir-' '~trem. Then check the cha rt to dete rmine whethe r the patient's "xis is no rrnal .~erft~IXi!.1 0 r ext reme right deviation. 0~ has a left 1 right. Norrnsl "xis: QRS -complex deflection is positive Left "xis deviation: Right "xis deviation: r up right in both leads.1 and lead "VF indicates whethe r they re mo\ling up 0 0~ do'WTI.~ liG~t 3)(i:1. E>::t reme right "xis deviation: . lead i points do'WTIand lead "VF is up right.ie. Obse rve the deflections of the QRS complexes in.

'.t1ich in the right 101JJe'rquad rant at +30 deg rees on the he >:....t1ethe the deflection r negative is positive 0 r negative.. So the elect r ical axis here is no rrnal at +30 deg rees. the rd pole of a V R' .. .86 EI..p... the QRS complex fo r this lead is negative. In this example . It also allows 0 r negative in leads I and a V~. -100"1 I -. system..Identify the limb lead with the smallest QRS complex 0 r the equiphasic QRS complex... not just by quad rant.3i a I diag ram.If' 11 ...ectrical axis determination: The deg r. \ 7903!r +1 .. a mo re p racise rnsasu rernent of the elect rical axis...:..ee method provides Degree method a patient's elect rical axis by deg ress on the hexaxial take ·these steps.. it's lead III... HI(!" '-18ft step :3 E>:. As you can see... . is x .t1ich the axis fo r lead a V R' is -'!lI:l" -~lrZf ~-~ . To use this method... indicating that the cu r rent is moving to .:NJO' I +1W t~'/l\"~ .3minethe QRS complex in lead a V R r noting .. Step 2 Locate the axis fo r lead Ilion the he >:.3i al diag ram.. Then find the axis pe rpendicula x r to it . It allows you to identify you to dete rmine the axis even if the QRS complex isn't clea rly positive Step 1 .

~ -~ ~' n T l- I I F i. r-~ j I :e. 1 I- ~ ~ ~~ I- - - -l~ J -I~ 'ioi.ng the T wve and ST $egmen~ that you may $ee 1JJhen rnonito ring <I patient with <lngin~...P._.I W .87 ECG c:ha.J. . ~~ 1: ).1 .j t '" .nges in angina.e J-~~~ t- - . I. . These <I re some classic ECG changes invoh'. 1\ f I I . J.. !I' I .

~~ ] ~111~I~~ t~Hi ~1 '" '" It .. T \!..lavesare usually of normal ~ize and configuration.~~ II'f ~ ~jt!:' .. " 11 .'" '~~ .lij .."'. 11m lm f Ql~ qn: ~"J I .: ~~ j ~ I: II 'ij I~~ . ~ .... It ~j j J I~~j 1 . +!'H" '~~f m ~~~~ tt~ f T I .hanges in .. ...nllmm-= =-' I~ II I mil Illmmm . • ~~i . The ele~tion occurs during chest pain and resolves ~en pain subsides.I. I....ul~ 1 .' jf ~ L • 11: j!il' ..88 .... ~. . J II . !l!f I.i ~ angina this illustration sho\IJSa 12-lead ~(G of' a patient with P rnzrnetal's angina.P..ii:i . . 'tt ~f ~m~ ~ f . ~ U ~UI ~m ~tl 1jUI• . .Prinzmeta." r ~I . lmf "-'- urr 1~l . IIltrl'l ' I~ ~j ..l. - ~ ~ntl . I . d .. L r r .... 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. . . Irf' :ilij :1i"" 1 u.ECG c.

i ~ .... aV~...:. ill.._- .... . II.:it'ion nd accompanying T-wave inversion resolves in most' leads.89 Pericarditis ECG changes in acute pe rica rditis evolve th rough two stages: • Stage t-Diffuss ST-segrnent ele'l.'. : - ..'~ 'J ~ ~. a I HI~ ~n 1 ~~ .. - ..l'.P. JU ~ J '" _. : ... and V2 through V. Upright T waves appear in most leads. aVF....wJ ~. The ST-segrnent and T-wave ~hanges are typically seen in leads I.l'..u. . 'the ST-segrnent ele'l.- .'.__ .' • Stage 2-As pericarditis resolves.:itionsof 1 to 2 mm in most limb leads and most precordial leads reflect the intlammatory process..:..~ ...J.

.oca rdina~ i. lnfa ret is the thi rd stage and occu rs "Withactual death In the ea rliest The pathologic stage of an M I ..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. EC G changes usually reveal ST -segment ele. ST·I!J'!)!ilfE)SSiQJI MY'oca rdii!~~ il!l1J1!.'!!O!~e' irnrer.. Sca r tissue eventually replaces the dead tissue.IlI'1Mlli"on .P. It can be resolved by imp ro"'.'! My. EC G changes indicate ST -segrnant T wave changes.:Jfl!ioo M~ . {e<lrrlleSI m·lJel . Vv'ithin hou rs .~s.u-y . The second stage. inju ry.-ation (usually in two 0r mo re contiguous leads).'.if! 25% f!Oo--5r·· 'SlegrrlilllU o'l!II'II.. HWll!ra!!lm~1 w. elevation occu rs in toe leads facing toe a rea of damage .ooa rdillall is... the T waves become EC G e"'.rllt~n: . 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.ng flow 0r reducing oxygen needs.lIriI1:ltll I jY"~ It . P!i!Ih~~'Oll"r.90 '5tage~ of'myocardial ischemia..Qlnlfl.. hype racute 0 of rnvoca rdial cells.~l!!IIi"III!iM '(j~a\i'lIlicr! Mil - .rIl\!(J'invc..Q W:3're5 -I~OO% 01 sr... My. occu r s when the ischemia is prolonged enough to damage the a r-ea of toe hea r t . ST"S8gIll. sr·-:5lEl'I:Jmeml .3"'1II' imrer:S~r! .E!t~!.~b~Ol1i1 . and the damage inve-rted caused is i r reve rs ible .Ur!U:F.. r ve-ry tall T waves may be seen on the EC G. -T""I1!. T'!..ilHcn '" T-v..>rfJt.

..]~I L.:f'...I.' H.ilT " . w. Il"Ij'C"r".. cha racte r istic lead changes column and the ar~ery in an acute involved M I .or:."' ..D n. ~'i.I. w. II.' Y...."""""f" " . m.J!:ll"" 'i.'i'j N'~ II..-.'iil... . .. Ma~ch the lead changes lead changes. the a reas of damage. iI'i..J~ .3ves)in the second column wi~h the affected 'o)J'. ~. .:.::Ij::l'~'l&-d LoN"'" "". (5T eieva~ion ...J ' L. 1"=-""'_ 1l. to iden~ify ....P.. 'ii../•.~ro.I. ..iI t.311 the first in in the third column.~~-..91 Locating myocardial damage AHe r you've noted ..1 " a""..i.!II .y. I il'i• . y '. '11.a'i. . ... use this table .)/... abno rrnal Q 'o)J'.. The fourth column shows reciprocal W-.i1-:~rDI....' .

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