I.

SINUS RHYTHMS
A sinus rhythm is any cardiac rhythm in which depolarization of the cardiac muscle begins at the sinus node. It is
characterized by the presence of correctly oriented P waves on the electrocardiogram (ECG). Sinus rhythm is
necessary, but not sufficient, for normal electrical activity within the heart.

The term normal sinus rhythm (NSR) is sometimes used to denote a specific type of sinus rhythm where all other
measurements on the ECG also fall within designated normal limits, giving rise to the characteristic appearance
of the ECG when the electrical conduction system of the heart is functioning normally. However, other sinus
rhythms can be entirely normal in particular patient groups and clinical contexts, so the term is sometimes
considered a misnomer and its use is sometimes discouraged.

Other types of sinus rhythm that can be normal include sinus tachycardia, sinus bradycardia, and sinus
arrhythmia. Sinus rhythms may be present together with various other cardiac arrhythmias on the same ECG.

A. Rhythm
1. For an ECG to be described as showing a sinus rhythm, the shape of the P wave in each of the 12 standard
ECG leads should be consistent with a "typical P vector" of +50° to +80°.[2] This means that the P wave should
be:
 always positive in lead I, lead II, and aVF
 always negative in lead aVR
 any of biphasic (-/+), positive or negative in lead aVL
 positive in all chest leads, except for V1 which may be biphasic (+/-)[2]

If the P waves do not meet these criteria, they must be originating from an abnormal site elsewhere in the atria
and not from the sinus node; the ECG cannot therefore be classed as showing a sinus rhythm.

In general, each P wave in a sinus rhythm is followed by a QRS complex, and the sinus rhythm therefore gives
rise to the whole heart's depolarisation. Exceptions to this include complete heart block and certain ventricular
artificial pacemaker rhythms, where the P waves may be completely normal in shape, but ventricular
depolarisation bears no relation to them; in these cases, the speed of the "sinus rhythm of the atria" and the
speed of the ventricular rhythm must be calculated separately.

Characteristics of normal sinus rhythm

By convention, the term "normal sinus rhythm" is taken to imply that not only are the P waves (reflecting activity
of the sinus node itself) normal in morphology, but that all other ECG measurements are also normal.
Criteria therefore include:
 Normal heart rate (classically 60 to 100 beats per minute for an adult).
 Regular rhythm, with less than 0.16 second variation in the shortest and longest durations between
successive P waves.
 The sinus node should pace the heart – therefore, P waves must be round, all the same shape, and
present before every QRS complex in a ratio of 1:1.

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  Normal P wave axis (0 to +75 degrees)
 Normal PR interval, QRS complex and QT interval.
 QRS complex positive in leads I, II, aVF and V3–V6, and negative in lead aVR.

2. Sinus bradycardia is a sinus rhythm with a rate that is lower than normal. In humans, bradycardia is generally
defined to be a rate of less than 60 beats per minute.

3. Sinus tachycardia (also colloquially known as sinus tach or sinus tachy) is an elevated sinus rhythm
characterized by an increase in the rate of electrical impulses arising from the sinoatrial node. In adults, sinus
tachycardia is defined as a heart rate greater than 100 beats/min (bpm). The normal resting heart rate is 60–100
bpm in an average male adult and 60-90 bpm in an average female adult. Normal heart rate varies with age,
from infants having faster heart rates (110-150 bpm) and the elderly having slower heart rates. Sinus
tachycardia is a normal response to physical exercise, when the heart rate increases to meet the body's higher
demand for energy and oxygen, but sinus tachycardia can also indicate a health problem. Thus, sinus tachycardia
is a medical finding that can be either physiological or pathological

4. Sinus arrhythmia is a commonly encountered variation of normal sinus rhythm. Sinus arrhythmia
characteristically presents with an irregular rate in which the variation in the R-R interval is greater than 0.12
seconds. Additionally, P waves are typically mono-form and in a pattern consistent with atrial activation
originating from the sinus node. During respiration, the intermittent vagus nerve activation occurs, which results
in beat to beat variations in the resting heart rate. When present, sinus arrhythmia typically indicates good
cardiovascular health.

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B. Nursing Management
1. Normal sinus rhythm
 No interventions required. Monitor patient if ordered by physician

2. Sinus Bradycardia
 Assess patient –Are they symptomatic?
 Give oxygen and monitor oxygen saturation
 Monitor blood pressure and heart rate
 Start IV if not already established
 Notify MD

3. Sinus Tachycardia
 Assess patient –Are they symptomatic?
 Are they stable?
 Give oxygen and monitor oxygen saturation
 Monitor blood pressure and heart rate
 Start IV if not already established
 Notify MD
 ACLS Protocol (if needed)

4. Sinus Arrhythmia
 Treatment is usually not required unless patient is symptomatic. If patient is symptomatic, find and
treat the cause
 Assess patient –Are they symptomatic?
 Are they stable?
 Give oxygen and monitor oxygen saturation
 Monitor blood pressure and heart rate
 Start IV if not already established
 Notify MD

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C. Reference
1. Hampton, John R (2013). The ECG Made Easy (8th ed.). Edinburgh: Churchill Livingstone. p. 4. ISBN
9780702046421.
2. Gertsch, Marc (2004). "3. The Normal ECG and its (Normal) Variants". The ECG: A Two-Step Approach to
Diagnosis (1 ed.). Springer-Verlag Berlin Heidelberg. pp. 19–21. doi:10.1007/978-3-662-10315-9. ISBN
978-3-540-00869-9. OCLC 942900796.
3. Conover, Boudreau Conover (2003). Understanding Electrocardiography (8th ed.). St Louis: Mosby. p.
46. ISBN 9780323019057.
4. Geiter, Henry B. (2006). E–Z ECG Rhythm Interpretation (1st ed.). Philadelphia: F.A. Davis. p. 106. ISBN
9780803620353.
5. Acar, RD; Bulut, M; Acar, Ş; Izci, S; Fidan, S; Yesin, M; Efe, SC (2015). "Evaluation of the P Wave Axis in
Patients With Systemic Lupus Erythematosus". Journal of Cardiovascular and Thoracic Research. 7 (4):
154–57. doi:10.15171/jcvtr.2015.33. PMC 4685281. PMID 26702344.

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 II. ATRIAL CELL PROBLEMS
Atrial fibrillation is an irregular and often rapid heart rate that can increase your risk of strokes, heart failure and
other heart-related complications. During atrial fibrillation, the heart's two upper chambers (the atria) beat
chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart.
Atrial fibrillation symptoms often include heart palpitations, shortness of breath and weakness. Episodes of
atrial fibrillation may come and go, or you may develop atrial fibrillation that doesn't go away and may require
treatment. Although atrial fibrillation itself usually isn't life-threatening, it is a serious medical condition that
sometimes requires emergency treatment.

A major concern with atrial fibrillation is the potential to develop blood clots within the upper chambers of the
heart. These blood clots forming in the heart may circulate to other organs and lead to blocked blood flow
(ischemia). Treatments for atrial fibrillation may include medications and other interventions to try to alter the
heart's electrical system.

The 4 most common atrial arrhythmias include:

 Atrial Flutter (rate varies; usually regular; saw-toothed)
 Atrial Fibrillation (rate varies, always irregular)
 SupraventricularTachycardia (>150 bpm)
 Premature Atrial Complexes (PAC’s)

A. Rhythm
1. Atrial flutter is a coordinated rapid beating of the atria. Atrial flutter is the second most common
tachyarrhymia

2. The electrical signal that circles uncoordinated through the muscles of the atria causing them to quiver
(sometimes more than 400 times per minute) without contracting. The ventricles do not receive regular
impulses and contract out of rhythm and the heartbeat becomes uncontrolled and irregular. It is the most
common arrhythmia, and 85 percent of people who experience it are older than 65 years.

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3. Encompasses all fast (tachy) dysrhythmias in which heart rate is greater than 150 beats per minute (bpm).

4. A PAC (Premature Atrial Contraction) is not a rhythm; it is an ectopic beat that originates from the atria.
Normal beat, but just occurs early.

B. Nursing Management
1. Atrial Flutter (rate varies; usually regular; saw-toothed)
 Assess Patient
 O2 if not already given
 Start IV if not already established and hang NS
 Notify MD
 Prepare for cardioversion

2. Atrial Fibrillation (rate varies, always irregular)

 Assess Patient
 O2 if not already given
 Start IV if not already established and hang NS
 Notify MD
 Prepare for cardioversion

3. SupraventricularTachycardia (>150 bpm)

 Assess Patient
 O2 if not already given
 Vagalmaneuvers (cough and valsalva)
 Start IV if not already established and hang NS
 Notify MD
 Prepare for cardioversion

4. Premature Atrial Complexes (PAC’s)

 Most benign –no risk
 May be a sign of underlying heart condition
 Medical Treatment- No treatment necessary if asymptomatic
 Treat the cause; Drug therapy
 Beta Blockers

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  Calcium Channel Blockers
 Assess patient
 Monitor patient

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C. Reference
1. Hampton, John R (2013). The ECG Made Easy (8th ed.). Edinburgh: Churchill Livingstone. p. 4. ISBN
9780702046421.
2. Gertsch, Marc (2004). "3. The Normal ECG and its (Normal) Variants". The ECG: A Two-Step Approach to
Diagnosis (1 ed.). Springer-Verlag Berlin Heidelberg. pp. 19–21. doi:10.1007/978-3-662-10315-9. ISBN
978-3-540-00869-9. OCLC 942900796.
3. Conover, Boudreau Conover (2003). Understanding Electrocardiography (8th ed.). St Louis: Mosby. p.
46. ISBN 9780323019057.
4. Geiter, Henry B. (2006). E–Z ECG Rhythm Interpretation (1st ed.). Philadelphia: F.A. Davis. p. 106. ISBN
9780803620353.
5. Acar, RD; Bulut, M; Acar, Ş; Izci, S; Fidan, S; Yesin, M; Efe, SC (2015). "Evaluation of the P Wave Axis in
Patients With Systemic Lupus Erythematosus". Journal of Cardiovascular and Thoracic Research. 7 (4):
154–57. doi:10.15171/jcvtr.2015.33. PMC 4685281. PMID 26702344.

8|Page
 III. AV JUNCTION PROBLEMS
Atrioventricular block (AV block) is a type of heart block that occurs when the electrical signal traveling from the
atria, or the upper chambers of the heart, to ventricles, or the lower chambers of the heart, is impaired.
Normally, the sinoatrial node (SA node) produces an electrical signal to control the heart rate. The signal travels
from the SA node to the ventricles through the atrioventricular node (AV node). In an AV block, this electrical
signal is either delayed or completely blocked. When the signal is completely blocked, the ventricles produce
their own electrical signal to control the heart rate. The heart rate produced by the ventricles is much slower
than that produced by the SA node

A. Rhythm
1. Bundle Branch Block is a condition in which there's a delay or blockage along the pathway that electrical
impulses travel to make your heart beat. It sometimes makes it harder for your heart to pump blood efficiently
through your body. The delay or blockage can occur on the pathway that sends electrical impulses either to the
left or the right side of the bottom chambers (ventricles) of your heart. Bundle branch block might not need
treatment. When it does, treatment involves managing the health condition, such as heart disease, that caused
bundle branch block.

2. First Degree Heart Block (AV block) is a disease of the electrical conduction system of the heart in which
electrical impulses conduct from the cardiac atria to the ventricles through the atrioventricular node (AV node)
more slowly than normal. First degree AV block not generally cause any symptoms, but may progress to more
severe forms of heart block such as second- and third-degree atrioventricular block.

3. Second Degree Heart Block Type I (AV block) Mobitz type I (Wenckebach) occurs when there is an intermittent
conduction block within the AV node that results in a failure to conduct an impulse from the atria into the
ventricles. The impaired nodal conduction is progressive to the point that there is a total block.

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4. Second Degree Heart Block Type II (AV block) also known as Mobitz II is almost always a disease of the distal
conduction system (His-Purkinje System). Mobitz II heart block is characterized on a surface ECG by
intermittently nonconducted P waves not preceded by PR prolongation and not followed by PR shortening.

5. Third Degree Heart Block (AV block) is a medical condition in which the nerve impulse generated in the
sinoatrial node (SA node) in the atrium of the heart cannot propagate to the ventricles. Because the impulse is
blocked, an accessory pacemaker in the lower chambers will typically activate the ventricles.

B. Nursing Management.
1. Bundle Branch Block
 Often, no treatment is required for bundle branch block.
 But it’s still important to have regular checkups. Your doctor will want to monitor your condition to
make sure that no other changes occur.

2. First Degree Heart Block

 Certain medications can cause first-degree heart block as a side effect:
 Digitalis: This medication is commonly used to slow down the heart rate. If it’s taken in high
dosages or for a long period, digitalis can cause first-degree heart block.
 Beta blockers: These drugs inhibit the part of the nervous system that speeds up the heart. This
can have the side effect of delaying electrical conduction within the heart, which can cause first-
degree heart block.
 Calcium channel blockers: Among their other effects, calcium channel blockers can slow down
the conduction within the heart’s AV node, resulting in first-degree heart block.

3. Second Degree Heart Block Type I and Second Degree Heart Block Type II
 Mobitz Type 1: Commonly referred to as Wenckebach block , Mobitz Type 1 may not cause noticeable
symptoms. Still, it can be a forerunner for the more serious type of second-degree heart block, Mobitz
Type 2. For this reason, Mobitz Type 1 should be monitored carefully by your doctor. Daily pulse checks
on your own may also be advised.
 Mobitz Type 2: In this type of second-degree heart block, the heart doesn’t beat effectively. It impacts
the heart’s ability to pump blood throughout the body. Often, a pacemaker is necessary to ensure that
the heart will continue to beat regularly and efficiently.

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4. Third Degree Heart Block
 People with third-degree heart block require immediate medical attention. Their irregular and unreliable
heartbeats heighten the risk of cardiac arrest.
 A temporary or permanent pacemaker is used to treat third-degree heart block, providing a carefully
timed electrical impulse to the heart muscle.

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C. Reference
1. Conduction disorders. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Conduction
Disorders_UCM_302046_Article.jsp. Accessed Feb. 11, 2018.
2. Sauer WH. Left bundle branch block. https://www.uptodate.com/contents/search. Accessed Feb. 11,
2018.
3. Sauer WH. Right bundle branch block. https://www.uptodate.com/contents/search. Accessed Feb. 11,
2018.
4. Bundle branch block and fascicular block. Merck Manual Professional Version.
https://www.merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-
disorders/bundle-branch-block-and-fascicular-block. Accessed Feb. 11, 2018.
5. Cardiac resynchronization therapy. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/HeartFailure/Cardiac-Resynchronization-
Therapy_UCM_452920_Article.jsp. Accessed Feb. 11, 2018.
6. Lopez-Jimenez F (expert opinion). Mayo Clinic, Rochester, Minn. Accessed March 4, 2018.

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 IV. VENTRICULAR CELL PROBLEMS
Abnormal rapid heart rhythms (arrhythmias) that originate in the lower chambers of the heart (the ventricles).
Ventricular arrhythmias include ventricular tachycardia and ventricular fibrillation. Both are life threatening
arrhythmias most commonly associated with heart attacks or scarring of the heart muscle from previous heart
attack.

A. Rhythm
1. Premature ventricular contractions (PVC’s) are extra heartbeats that begin in one of your heart's two lower
pumping chambers (ventricles). These extra beats disrupt your regular heart rhythm, sometimes causing you to
feel a fluttering or a skipped beat in your chest.

Premature Ventricular Complex

Premature Ventricular Complex Bigeminy

Premature Ventricular Complex Quadrigeminy

Premature Ventricular Complex Trigeminy

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2. Idioventricular rhythm (ventricular escape rhythm; rate usually >20 –<40 bpm) is very similar to ventricular
tachycardia except the ventricular rate is less than 60 beats per minute. All other characteristics of VT apply; this
includes the presence of atrioventricular dissociation, as seen in the ECG and strip below, and the Brugada
Criteria. An idioventricular rhythm is frequently referred to as a “slow ventricular tachycardia” for this reason.
When the ventricular rate is between 60 and 100 bpm, it is referred to as an accelerated idioventricular rhythm.
This is a hemodynamically stable rhythm that occurs commonly after myocardial infarction and no treatment is
needed.

3. Accelerated Idioventricular rhythm (>40 bpm) is a ventricular rhythm with a rate of between 40 and 120 beats
per minute. Idioventricular means “relating to or affecting the cardiac ventricle alone” and refers to any ectopic
ventricular arrhythmia

4. Agonal rhythm (20 or less bpm) is when the Idioventricular rhythm is 20 beats or less per minute. Frequently
is seen as the last-ordered semblance of a heart rhythm when resuscitation efforts are unsuccessful

5. Ventricular tachycardia (>150 bpm) is a heart rhythm problem that occurs when the heart beats with rapid,
erratic electrical impulses. This causes pumping chambers in your heart (the ventricles) to quiver uselessly,
instead of pumping blood. Sometimes triggered by a heart attack, ventricular fibrillation causes your blood
pressure to plummet, cutting off blood supply to your vital organs.

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6. Ventricular fibrillation is a heart rhythm problem that occurs when the heart beats with rapid, erratic
electrical impulses. This causes pumping chambers in your heart (the ventricles) to quiver uselessly, instead of
pumping blood. Sometimes triggered by a heart attack, ventricular fibrillation causes your blood pressure to
plummet, cutting off blood supply to your vital organs.

Coarse type

Fine type

7. Torsades de Pointes is a specific type of abnormal heart rhythm that can lead to sudden cardiac death. It is a
polymorphic ventricular tachycardia that exhibits distinct characteristics on the electrocardiogram (ECG)

8. Pulseless Electrical Activity (PEA) Electricity is working, but the mechanics and plumbing are not. I n PEA, there
is electrical activity, but the heart either does not contract or there are other reasons these results in an
insufficient cardiac output to generate a pulse and supply blood to the organs. The absence of a palpable pulse
and absence of myocardial muscle activity with presence of organized electrical activity on the cardiac monitor.
The patient is clinically dead despite some type of organized rhythm on monitor.

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B. Nursing Management
1. Premature ventricular contractions (PVC’s)
 Assess patient
 O2 at 2 liters; Oxygen may abate the PVC’s
 Start IV if not already established and hang NS
 Monitor for frequent PVC’s and deterioration to more serious rhythms

2. Idioventricular rhythm (ventricular escape rhythm; rate usually >20 –<40 bpm)
 Assess your patient: patient will most likely be symptomatic with a weak, thready pulse
 Run continuous monitor strips/record
 Begin CPR
 Call Code Blue
 Notify MD
 Start IV if not already established and hang NS

3. Accelerated Idioventricular rhythm (>40 bpm)

 Assess your patient: patient will most likely be symptomatic with a weak, threadypulse
 Run continuous monitor strips/record
 Begin CPR
 Call Code Blue
 Notify MD
 Start IV if not already established and hang NS

4. Agonal rhythm (20 or less bpm)

 Make sure there is no any loose leads or leads that have come off the patient
 Call a Code Blue
 Start CPR
 Notify MD
 If death is the expected outcome:
 Monitor vital signs
 Record rhythm progression
 Support family and friends

5. Ventricular tachycardia (>150 bpm)

 Assess your patient
 If symptomatic, treatment must be aggressive and immediate
 Pulse present
 Oxygen
 Patent IV (preferably x2)
 Monitor patient very closely
 Pulseless
 Call Code Blue
 Begin CPR
 Defibrillate ASAP
 Start IV if not already established and hang NS
 Notify MD

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6. Ventricular fibrillation
 Assess your patient
 Many things can mimic v-fib on a monitor strip such as electric razoror shivering
 You must check your patient!
 Treatment must be aggressive and immediate
 Start CPR/ACLS
 Call a Code Blue
 Defibrillate ASAP
 Start IV if not already established and hang NS
 Notify MD

7. Torsades de Pointes
 Assess your patient
 Make sure there is no any loose leads or leads that have come off the patient
 Start CPR
 Call a Code Blue
 Start IV if not already established and hang NS
 Notify MD
 Must treat the cause –usually giving Magnesium

8. Pulseless Electrical Activity (PEA)

 Assess your patient
 Treatment must be aggressive and immediate
 Call a Code Blue
 Start CPR/ACLS
 Run continuous monitor strips/Record
 Start IV if not already established and hang NS
 Notify MD

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C. Reference
1. Ventricular fibrillation. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/AboutArrhythmia/Ventricular-
Fibrillation_UCM_324063_Article.jsp. Accessed Aug. 13, 2017.
2. Podrid PJ, et al. Clinical features and treatment of ventricular arrhythmias during acute myocardial
infarction. https://www.uptodate.com/contents/search. Accessed Aug. 13, 2017.
3. Prevention & treatment of arrhythmia. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/Arrhythmia/PreventionTreatmentofArrhythmia/Preventio
n-Treatment-of-Arrhythmia_UCM_002026_Article.jsp#.WYsvf4TyvIU. Accessed Aug. 13, 2017.
4. What is the heart? National Heart, Lung, and Blood Institute.
http://www.nhlbi.nih.gov/health/dci/Diseases/hhw/hhw_all.html. Accessed Aug. 13, 2017.
5. Goldman L, et al., eds. Ventricular arrhythmias. In: Goldman-Cecil Medicine. 25th ed. Philadelphia, Pa.:
Saunders Elsevier; 2016. https://www.clinicalkey.com.
6. Ganz LI. Approach to the diagnosis of wide QRS complex tachycardias.
https://www.uptodate.com/contents/search. Accessed Aug. 13, 2017.
7. Ferri FF. Ventricular fibrillation. In: Ferri's Clinical Advisor 2018. Philadelphia, Pa.: Elsevier; 2018.
https://www.clinicalkey.com. Accessed Aug. 13, 2017.
8. What is a stent? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-
topics/topics/stents#. Accessed Aug. 13, 2017.
9. What is an automated external defibrillator. American Heart Association.
https://www.heart.org/idc/groups/heart-
public/@wcm/@hcm/documents/downloadable/ucm_300340.pdf. Accessed Aug. 13, 2017.
10. 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and
Emergency Cardiovascular Care (ECC). Dallax, Tx: American Heart Association.
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/. Accessed Aug. 13, 2017.
11. Arrhythmia. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/health-
topics/topics/arr. Accessed Aug. 13, 2017.
12. Goldberger AL, et al. Sudden cardiac arrest and sudden cardiac death syndromes. In: Goldberger's
Clinical Electrocardiography. 9th ed. Philadelphia, Pa.: Elsevier; 2018. https://www.clinicalkey.com.
Accessed Aug. 13, 2017.
13. Deciding to quit smoking and making a plan. American Cancer Society.
https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/deciding-to-quit-
smoking-and-making-a-plan.html. Accessed Aug. 13, 2017.
14. How does smoking affect the heart and blood vessels? National Heart, Lung, and Blood Institute.
https://www.nhlbi.nih.gov/health/health-topics/topics/smo. Accessed Aug. 13, 2017.
15. Obesity information. American Heart Association.
http://www.heart.org/HEARTORG/HealthyLiving/WeightManagement/Obesity/Obesity-
Information_UCM_307908_Article.jsp#.WZCoxITyvIU. Accessed Aug. 13, 2017.
16. Current physical activity guidelines. Centers for Disease Control and Prevention.
https://www.cdc.gov/cancer/dcpc/prevention/policies_practices/physical_activity/guidelines.htm.
Accessed Aug. 13, 2017.
17. Fact sheets — Moderate drinking. Centers for Disease Control and Prevention.
https://www.cdc.gov/alcohol/fact-sheets/moderate-drinking.htm. Accessed Aug. 13, 2017.
18. Cardiac genetic testing expands possibilities, raises questions. American College of Cardiology.
http://www.acc.org/latest-in-cardiology/articles/2016/03/28/16/18/interview-cardiac-genetic-testing-
expands-possibilities-raises-questions. Accessed Aug. 13, 2017.

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 V. ASYSTOLE
Asystole is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an
induced asystole on a cooled patient on a heart-lung machine and general anesthesia during surgery
necessitating stopping the heart). Asystole is the most serious form of cardiac arrest and is usually irreversible. A
cardiac flatline is the state of total cessation of electrical activity from the heart, which means no tissue
contraction from the heart muscle and therefore no blood flow to the rest of the body.

A. Rhythm
1. Asystole is also known as flatline. It is a state of cardiac standstill with no cardiac output and no ventricular
depolarization, as shown in the image below; it eventually occurs in all dying patients.

B. Nursing Management
1. Asystole
 Assess your patient
 Make sure there is no any loose leads or leads that have come off the patient
 Treatment must be aggressive and immediate
 Call a Code Blue
 Start CPR/ACLS

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C. Reference
1. Baldzizhar, Aksana; Manuylova, Ekaterina; Marchenko, Roman; Kryvalap, Yury; Carey, Mary G.
(September 2016). "Ventricular Tachycardias". Critical Care Nursing Clinics of North America. 28 (3):
317–329. doi:10.1016/j.cnc.2016.04.004. PMID 27484660.
2. Kutsogiannis, Demetrios J.; Bagshaw, Sean M.; Laing, Bryce; Brindley, Peter G. (4 October 2011).
"Predictors of survival after cardiac or respiratory arrest in critical care units". CMAJ : Canadian Medical
Association Journal. 183 (14): 1589–1595. doi:10.1503/cmaj.100034. PMC 3185075. PMID 21844108.
3. https://utmc.utoledo.edu/depts/nursing/pdfs/Basic%20EKG%20Refresher.pdf

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