ECG: Rhythm

Identification and
Application to Practice

Department of Nursing Professioanl Practice

What to Expect on the Exam

55 multiple choice questions

Identification of rhythms and rhythm strips
Assessment findings of arrhythmias
Arrhythmia treatment and interventions
Drug actions and side effects
Library Website – ECG Resources
Test Your Knowledge
Coronary Circulation
Autonomic Innervation

Sympathetic

Releases epinephrine
Increased HR, cardiac output, and BP
Increased firing of the SA node

Parasympathetic
Releases acetylcholine
Decreased HR, cardiac output, and BP
Vagal nerve
Electrophysiology: Types of Cardiac Cells

Electrical Cells

Automaticity
Excitability
Conductivity
Myocardial cells
Contractility
Depolarization & Repolarization
Electrical Conduction System
Generates and conducts impulses via specialized
pathways to the atria & ventricle
Electrical Conduction System
Current Flow

EKG lead view of heart’s

activity between 2 points
Refractory Periods

Absolute

Relative
ECG Graph Paper

Horizontal – time
Vertical – voltage
Waveforms

P wave

PR interval

QRS complex

ST Segment

T wave

QT Interval

U wave
Waveform Practice

1. Strip 3.2
Waveform Practice

2. Strip 3.3
Waveform Practice

3. Strip 3.6
Monitor Problems/Artifact
Steps in Analyzing Rhythm Strips
Step 1: Determine Regularity

Determine the regularity of the R waves

Slight variations are considered regular
Step 2: Calculate Rate

Count the number of QRS complexes in a 6 sec strip x 10

Step 3: Identify the P wave
Analyze the P wave
Precedes the QRS
Should be identical in: size, shape & position
Step 4: Measure the PR interval
Beginning of the P to the beginning of the QRS
Count the # of small boxes x .04 seconds
Normal PR Interval is 0.12 to 0.20 seconds
Step 5: Identify P:QRS Ratio

Determine how many P waves precede each QRS complex

Normal finding is 1:1
Step 6: Measure the QRS duration
Beginning of the QRS to end of QRS, when ST begins
Normal is < 0.12 seconds
Step 7: Measure the QT Interval

Count # of boxes X .04

Beginning of the QRS to
the end of the T wave
Less than ½ the R to R
interval is considered
normal
QT Interval is usually 0.32
to 0.44 (adjusted for heart
rate)
Normal Sinus Rhythm
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Regular 60-100 Normal 0.12 – 0.20 1:1 < 0.12 seconds 0.32 – 0.44
seconds seconds
Sinus Tachycardia
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Regular 101-160 Normal 0.12-0.20 1:1 < 0.12 seconds May be

seconds shortened

Causes: Normal sympathetic tone, fever, exercise, hypotension, PE, MI, stress, anxiety
Treatment: Treat underlying cause (pain, fever, etc.)
Significance: Increased oxygen requirement is a warning sign
Sinus Bradycardia
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Regular < 60 Normal 0.12-0.20 1:1 < 0.12 seconds May be

seconds prolonged

Causes: Increased vagal tone, inferior wall MI, hypothyroidism, drugs (beta blockers, digoxin,
morphine, hypothyroidism) can be a normal finding
Treatment: Only if symptomatic – stop above medications, give epinephrine or atropine
Sinus Arrhythmia
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Irregular 60-100 Normal 0.12-0.20 1:1 < 0.12 seconds May vary
seconds slightly

Causes: Normal variation with respiratory cycle

Treatment: None
 Sinus Block and Sinus Arrest
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Usually 60-100 Normal, 0.12 – 0.20 1:1 < 0.12 seconds Normal,
regular, absent during seconds unmeasurable
irregular pause during pause
during pause

Sinus
Block

Sinus
Arrest

Causes: Increased vagal tone, hypoxemia, hyperkalemia, drugs (digoxin, beta blockers,
Ca channel blockers)
Treatment: None, unless symptomatic
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1. Strip 6.1
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2. Strip 6.2
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3. Strip 6.6
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4. Strip 6.9
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5. Strip 6.18
Dysrhythmias that Originate in the Atria
Test Your Knowledge
Atrial Dysrhythmias

Sinus Tachycardia
Premature Atrial Contraction (PAC)
Atrial Tachycardia/Supraventricular Tachycardia
(SVT)
Atrial Flutter
Atrial Fibrillation
Causes of Atrial Dysrhythmias

Hyperthyroidism MI
CHF/atrial stretching Open heart surgery
Caffeine Mitral valve disease
Smoking Hypoxia
Alcohol Electrolyte Imbalance
Excitement, fatigue DIGOXIN TOXICITY
Fever
Variables Affecting Cardiac Output

Rate of SVT
Duration of SVT
Presence of underlying heart disease
Clinical Signs and Symptoms

Change in mental status Palpitations

Anxiety Pulse deficit with a-fib
Shortness of breath Chest pain
Decreased urine output Lightheadedness/
Fatigue Syncope
Extremities cool to touch Decreased BP
Premature Atrial Contraction (PAC)
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular, except Depends on Premature P 0.12-0.20 1:1 < 0.12 seconds

PAC underlying wave different seconds, PAC
rhythm from other P interval may be
waves, may be different
normal
depending on
location

Causes: Alcohol, caffiene, tobacco, digoxin, hypoxia, electrolyte imbalance, COPD

Treatment: Usually none, observe frequency and treat/eliminate the cause
Atrial Tachycardia/ Supraventricular Tachycardia (SVT)
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular > 160 May be hidden Unable to 1:1 < 0.12 seconds
measure

Causes: Alcohol, caffeine, tobacco, digoxin toxicity, hypoxia, electrolyte imbalance,

COPD, valvular heart disease
Treatment: If unstable, vagal maneuvers, adenosine (diagnostic), cardioversion,
ablation
Adenosine

Action Administration

Slows AV conduction time Initial: 6 mg rapid IVP (1-3 seconds)

followed by rapid 20 mL NS Flush
Interrupts re-entry pathway
Subsequent doses: 12 mg rapid IVP (1-3
Can restore NSR
seconds) followed by rapid 20 mL NS
Flush
Administration at most PROXIMAL port
of IV tubing and elevate arm
Indications
Pediatrics:
Symptomatic SVT
Initial – 0.1 mg/kg (max 6mg) rapid IV
May confirm diagnosis of wide complex
push by LIP followed by >5mL NS
tachycardia
flush
Subsequent doses: 0.2 mg/kg (max of
12 mg) rapid IV push followed by
>5mL NS flush
Adenosine

Nursing Implications Adverse and Toxic Effects

Half-life of drug is 5-10 seconds therefore arrhythmia Usually transient due to short
may recur and require further treatment half life
Record ECG rhythm strip before, continuously during Bradycardia
administration, and until stable
Sinus arrest
LIP must be present at bedside to monitor ECG
Ectopic beats
Emergency equipment must be at bedside
Dyspnea
Ideal setup is to have double stopcock in IV line with 2 Chest Pain
separate syringes
Metallic Taste
Flushing
Hypotension
Re-Entry Pathways 

Click here to view re-entry pathway video 

Atrial Flutter
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular or Atrial Flutter waves, Not measured Variable – 3:1, < 0.12 seconds
irregular 250-400 sawtooth 4:1
Ventricular
varies

Causes: Valvular heart disease, hypertension, cardiomyopathy, hypoxia, pulmonary

disease, post open heart surgery
Treatment: If unstable, cardioversion, drugs that slow down the AV node (digoxin,
beta blockers, calcium channel blockers), consider anticoagulation
Atrial Fibrillation
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Irregular Atrial Fibrillatory Not measurable Not measurable < 0.12 seconds
>400 waves
Ventricular
Varies

Causes: Valvular heart disease, hypertension, cardiomyopathy, hypoxia, pulmonary

disease, post cardiac surgery
Treatment: If unstable, restore sinus rhythm by cardioversion or anti-arrhythmic
drugs; consider anticoagulation
Special Considerations: Loss of atrial contraction (atrial kick) 25% of CO
Digoxin

Action Administration

Slows heart rate by decreasing conduction First IV Dose must be given by LIP
through the AV node (negative
Total Dose: 1 – 1.5mg IV or PO in divided
chronotropic action)
doses(0.25 – 0.5 mg q4-6h over 24h)
Increases force and velocity of myocardial
Monitor renal function and serum level
contractility (positive inotropic action)
including K+ level
IV Digoxin must be given in monitored
Indications setting (requires continuous telemetry)
CHF Pediatrics:
SVT dosing based on age, weight, and disease
process – see Lexicomp/UpToDate
Atrial Flutter
Atrial fibrillation
Digoxin
Nursing Implications
Toxic effects are common and frequently
associated with serious arrhythmias.
Assume any rhythm is drug induced until
proven otherwise
50-70% of dig IV is excreted in the urine –
frequently assess patient’s renal function
(BUN and creatinine)
Digoxin is not removed by dialysis
Digoxin half life is 1.5 to 2 days in a
patient with normal renal function
Avoid cardioversion – threshold for VFib is
lowered by digoxin
Any electrolyte imbalance may contribute
to digoxin toxicity
Normal serum dig level is 0.65–2.55mg/mL
Adverse and Toxic Effects
Cardiac:
Arrhythmia or heart block
Non-Cardiac:
Mental status change
Visual disturbance, halos, colored vision
Nausea, vomiting, diarrhea
Hyperkalemia
Drug Interactions:
Increased serum dig level and increased risk
for toxicity when administered with
amiodarone, quinidine, verapamil, or
nifedipine
Beta Blockers

Action Selective vs. Non-Selective Blockers

Decreases automaticity Cardioselective blockers

Decreases AV Node conduction Brevibloc
Decreases myocardial contractility Lopressor
Decreases catecholamine release Tenormin
Beta 1 blockade: Non-Selective Blockers
Decreases HR Inderal
Decreases contractility Indications
Beta 2 blockade: Supraventricular and ventricular
dysrhythmias
Bronchoconstriction
Prevents sudden death related to
Hypoglycemia
catecholamine surge post MI
Administration
See specific drug for dosing information
Beta Blockers

Contraindications Adverse Effects

Bronchospastic disease Severe bradycardia

Hypotension
Use with caution in patients with ↓ LVF
and in ↓ BP
Bradycardia
2nd and 3rd degree heart block
Use cautiously in patients receiving
calcium channel blockers
Propanolol is contraindicated in cocaine
induced ACS
SBP <100
Severe LV failure
Hypoperfusion
2nd/3rd degree heart block
Nursing Implications
Monitor for hypotension during IV admin
Concurrent use with calcium channel
blocker can cause severe hypotension
Monitor cardiac and pulmonary status
during administration
May cause myocardial depression
Calcium Channel Blockers (Cardizem)

Action Administration

Inhibits calcium influx to myocardial cells Bolus dose – 0.25mg/kg over 2 min given
by MD
Decreases SA automaticity
Continuous infusion – 5-15mg/hr in D5W,
Decreases AV conductivity
titrated to HR
Decreases contractility
Closely monitor BP, HR, and PR interval
Causes vasodilation
Use cautiously in patients receiving IV
Indications beta blockers
Paroxysmal SVT (PSVT) Pediatrics:
A-fib/A-flutter Minimal information is available. Refer to
adult dosing for use in adolescent patients
Re-entry arrhythmias
Hypertension
Angina
Calcium Channel Blockers (Cardizem)

Nursing Implications Adverse Effects

Cardizem vials are refrigerated Bradycardia

Hold if systolic BP <90 or diastolic <60 or
per MD parameters
Determine baseline PR interval and
continue to monitor q1h x 4 and with any
dose changes
IV calcium may restore BP in toxic cases
Less negative inotropic effect than
verapamil. Better tolerated by patients Contraindications
with LV dysfunction
Heart block/prolonged PR interval
Hypotension
CHF
Headache
Hyperglycemia
Pts with sick sinus syndrome or advanced
heart blocks who do not have a
functioning pacemaker
WPW or other wide complex tachycardia
Concurrent administration with beta
blockers can cause severe hypotension and
decreased LV function
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1. Strip 7.2
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2. Strip 7.3
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3. Strip 7.8
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4. Strip 7.10
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5. Strip 7.35
Dysrhythmias that Originate in the Ventricle
Ventricular Arrhythmias

Premature Ventricular Contraction (PVC)

Ventricular Tachycardia
Ventricular Tachycardia: Torsades de Pointes
Ventricular Fibrillation
Etiology of Ventricular Dysrhythmias

Cardiac disease
Acute MI
Medications (B-stimulants, anesthetics)
Catecholamine stimulation
Hypoxia
Hypercarbia
Acid/base imbalance
Electrolyte imbalance
Mechanical (CVL, PA catheter, cardiac cath)
Premature Ventricular Contraction (PVC)
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Underlying Underlying Absent or Absent Underlying Widened or

rhythm, except rhythm disassociated Rhythm bizarre
for PVC from ectopic beat

Causes: Anxiety, caffeine, digoxin, epinephrine, aminophylline, hypoxia, acidosis,

CHF, MI, elevated BP, electrolyte imbalance (↓Mg, ↑K or ↓K)
Treatment: If significant, Amiodarone or Lidocaine
Significance of PVC’s
When to Treat a PVC:
Frequent (6/min)
Multifocal
Sustained runs
R on T
Bigeminy
Trigeminy

When not to treat a PVC:

Escape beats (because it’s not a PVC!)
 Premature Ventricular Contraction (PVC)

Bigeminy

Trigeminy

Paired
PVCs
Premature Ventricular Contraction (PVC)

Multifocal
PVCs

Unifocal
PVCs

Torsades
Ventricular Tachycardia
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular > 100 Obscured Absent N/A > 0.12 seconds

Causes: Post MI, ischemia, cardiomyopathy, mitral valve prolapse, CHF, digoxin,
electrolyte imbalance (↓K, ↓Mg)
Treatment:
Stable – Drugs (amiodarone, lidocaine, procainamide)
Unstable – cardioversion
Pulseless – defibrillation
Sustained Ventricular Tachycardia With a Pulse

Assess patient for level of consciousness (LOC)

Call Rapid Response Team
Get emergency cart
Administer O2
Establish IV access
If stable, treat pharmacologically
If unstable, prepare for cardioversion
Amiodarone

Action Administration

Prolongs refractory period of myocardial Rapid infusion:

cells Pulse – 150 mg IV over 10 min
Has calcium channel, alpha, and beta Pulseless – 300 mg for pulseless
blocking properties
Slow infusion: 360 mg IV over 6h
Dilates coronary and peripheral vessels
Maintenance infusion: 540 mg IV over 18h
Indications
Pediatrics:
Atrial and ventricular dysrhythmias
Pediatric dose 5mg/kg IV over 20-60min
For shock-refractory VF/pulseless VT
Supplies and Monitoring
For stable VT with decreased LVF
0.22 micron filter, D5W only
Used as adjunct to cardioversion in SVT
Monitor for hypotension & prolonged QT
To control rate of A fib/flutter when other
therapies are ineffective Monitor adverse/toxic effects
Drug half life is 20-47 days
Ventricular Tachycardia: Torsades de Pointes
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Irregular and Ventricular Obscured Absent N/A ≥ 0.12 seconds

Chaotic 250-350

Causes: Drugs – quinidine, procainamide, tricyclic antidepressants, ↓ Mg

Treatment: Magnesium, overdrive pacing, defibrillate
Ventricular Fibrillation
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Chaotic 0 None None None None None

Causes: Sudden cardiac death, CAD, Acute MI

Treatment: Assess patient, start CPR, defibrillate
Pulseless V-Tach/V-Fib

Assess patient for level of consciousness (LOC)

Initiate CPR
Call Cardiopulmonary Arrest Team
Defibrillate
Lidocaine

Action Administration

Decreases myocardial excitability IV/IO Bolus

Decreases automaticity by increasing 1-1.5 mg/kg for cardiac arrest
electrical threshold
0.5-0.75mg/kg for perfusing arrhythmia
Suppresses cough and gag reflex
Drip (1-4 mg/min) - ↓ in impaired liver or
Indications LV function
Ventricular dysrhythmias Tracheal dose 2-3 mg/kg
Cardiac arrest Therapeutic serum level: 3.5-5.0 mcg/mL
Toxicity Pediatrics:
Confusion (earliest) Loading Dose:
Drowsiness 1mg/kg IV/IO
Twitching, tremors, seizures 2 to 3 mg/kg ET
Hypotension, dizziness Maintenance drip: 20-50
Cardiac arrest microgram/kg/min IV/IO
Pronestyl (Procainamide)

Action Administration

Slows conduction in the atria, Bundle of Loading Dose: Give 15-18 mg/kg IV
His and ventricles (50mg/min IV for pulseless VT/VF) until:
Decreases automaticity and excitability by Dysrhythmia suppressed
increasing electrical threshold Hypotension occurs
Indications QRS > 50%
Atrial and ventricular dysrhythmias total of 17 mg/kg is given
Rapid AF in WPW Continuous drip 1-4 mg/minute
Monitor For: Pediatrics:
↑ PR/QRS/QT Loading Dose – 10-15mg/kg IV/IO over 30
heart blocks to 60 minutes (For VT with a pulse)

Hypotension Continuous drip - 20-80mcg/kg/min to max

dose 2 Gm per day
Procan and NAPA levels (metabolite)
Special considerations: elderly, renal or
Side Effects: hepatic dysfunction
Nausea, vomiting, Lupus-like syndrome
Asystole
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Absent 0 None None None None None

Causes: Terminal event following Ventricular tachycardia or ventricular fibrillation

Treatment: Check pulse, start CPR, Epinephrine, transcutaneous pacing (TCP)
Pulseless Electrical Activity
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS QT Interval
Duration

Regular 60-100 Normal 0.12 – 0.20 1:1 < 0.12 seconds 0.32 – 0.44
seconds seconds

Reversible Causes Hs
Hypovolemia Hypoxia Hydrogen Ions-
Acidosis Hypo-Hyperkalemia
Hypothermia
Ts
Tension Pneumothorax Tamponade-
Cardiac Toxins Thrombosis-Pulmonary
Thrombosis- Cardiac
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1. Strip 9.1
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2. Strip 9.3
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3. Strip 9.5
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4. Strip 9.6
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5. Strip 9.8
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6. Strip 9.9
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7. Strip 9.32
Rhythm Dance
Junctional Rhythms
Junctional Rhythm
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular 40-60 Inverted in Lead Short or not 1:1, if P wave is < 0.12 seconds
II or hidden, can measureable visible
be before or after
the QRS

Causes: Digoxin toxicity, Beta blockers, Ca Channel Blockers, inferior wall MI,
hypoxia, electrolyte imbalance, valvular disease, myocarditis, cardiomyopathy
Treatment: Treat the cause, atropine, or transcutaneous pacing
Accelerated Junctional Rhythm
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular 60-100 Inverted in Lead Short or not 1:1, if P wave is < 0.12 seconds
II or hidden, can measureable visible
be before or after
the QRS

Causes: Dig toxicity, inf. Wall MI, CHF, post cardiac surgery
Treatment: Treat the underlying cause
Junctional Tachycardia
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular 100-160 Inverted in Lead Short or not 1:1, if P wave is < 0.12 seconds
II or hidden, can measureable visible
be before or after
the QRS

Causes: Dig toxicity, inf. Wall MI, CHF, post cardiac surgery. May be paroxysmal
Treatment:
If stable – vagal maneuvers, adenosine
If unstable – cardioversion
Practice Strips

1. Strip 8.9
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2. Strip 8.19
Electrical Treatment
Electrical Treatment

Defibrillation
Random, unsynchronized shock
Deliver 1 shock immediately followed by 2 minutes of CPR
Adult
Biphasic 120-150-200 J
Monophasic 360 J
AED: device specific
Pediatric
Pediatrics manually defibrillates in-house (changes the joules)
Pediatric dosage: 2 J/kg, subsequent 4 J/kg
Electrical Treatment

Cardioversion (Synchronized) Nursing Implications

Electrical shock delivered via defibrillator Pre-medicate whenever possible

Must be on the “Sync” mode Reactivation of sync mode is required
after each attempted cardioversion
Sync mode delivers energy just after the
“R” wave Equipment defaults to
unsynchronized/defibrillation mode
Look for “Sync” markers on the “R” wave
“All clear” must be announced prior to
All tachycardias with serious S & S
shocking the patient
Adult Dosing
Ensure that no one is touching the patient,
SVT and Atrial flutter - start with 50 the bedside or anything connected to the
joules and then increase patient
Atrial fibrillation and V-tach with a pulse -
start with 100 joules and ↑ as needed
Pediatric Dosing
Pediatric dose: 0.5-1 J/kg
R on T Phenomenon
Catheter Ablation for Atrial Fibrillation

Initial trigger tends to come from PV and can act as irritable foci setting off A-Fib
Burning (ablating) tissues around vein turns them into scars
Scars don’t conduct electricity, therefore, electrical firing can’t exit from burnt area
Mapping catheters - Map out arrhythmic electrical activity
Ablation catheters
Burn and isolate PV
Catheter Ablation for V-tach

V-Tach is induced
Mapping catheter – Maps out arrhythmic electrical activity
Ablation catheter – Burns and isolates irritable foci
HEART BLOCKS
Test Your Knowledge
The Heart Block Poem

If the R is far from P then you have a FIRST DEGREE

Longer, longer, longer, drop! Then you have a WENKEBACH (2nd DEGREE TYPE
I)

If some P’s don’t get through, then you have a 2nd DEGREE TYPE II

If P’s and Q’s don’t agree, then you have a THIRD DEGREE
Heart Blocks

1st Degree Heart Block

2nd Degree Heart Block:

Type I (Wenckebach)
Type II (Advanced)
3rd Degree: Complete Heart Block
1st Degree Heart Block
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular Underlying Normal > 0.20 seconds 1:1 < 0.12 seconds
rhythm

Causes: May be normal, digoxin toxicity, Beta blockers, Ca Channel blockers,

pericarditis, acute rheumatic fever, AV node ischemia from CAD, Inferior wall /RCA
MI, ↑K, increased vagal tone
Treatment: None, continue to monitor
PR interval 0.21-0.25 seconds & no symptoms – no treatment, continue to monitor
PR interval > 0.26 seconds – withhold meds causing > PR (eg, digoxin)
If symtompatic, consider atropine (rarely used)
First Degree Danger: In the presence
of acute MI, 1st degree heart block may
progress to 2nd or 3rd degree heart block
2nd Degree Heart Block (Type I)
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Atrial Underlying Normal Progressively Variable, more < 0.12 seconds

Regular rhythm lengthens P’s than QRS’s
Ventricular
Irregular

Causes: Inferior wall MI, Digoxin toxicity, Beta blockers, Ca Channel Blockers, acute
infection, rheumatic fever, myocarditis, electrolyte imbalance, CAD, post cardiac
surgery
Symptoms – Irregular pulse, symptoms related to ventricular rate
Usually transient and reversible (72-96 hours)
Atropine
Action
Reduces vagus nerve stimulation
Enhances rate of the sinus node
Facilitates AV conduction
Indications
Symptomatic sinus bradycardia
May be beneficial in presence of AV
block at the nodal level (narrow QRS)
Administration
0.5-1mg IV/IO every 3-5 minutes (max
dose 0.04mg/kg)
Tracheal 1-2 mg diluted in 10mL NS
Pediatrics:
0.02 mg/kg IV/IO bolus every 5 min (max
dose 0.5mg bolus/total dose 1mg for
infants and children, min dose 0.1mg)
Max dose 1mg bolus/total dose 2 mg for
adolescents
Tracheal 0.03mg/kg (absorption may be
unreliable)
2nd Degree Heart Block (Type II)
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Atrial regular Underlying Normal Constant, may be Variable, more Normal if block
Ventricular rhythm normal or P’s than QRS’s is at bundle of
regular/ prolonged HIS, wide if
irregular block is at bundle
branches

Causes: Anterior/septal MI, CAD, cardiomyopathy, rheumatic heart disease

Treatment: Consider pacemaker or atropine
3rd Degree Heart Block
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Atrial regular Atrial Normal, may be Varies, no Varies Normal or wide,

Ventricular 60-100 hidden relationship depending on
regular Ventricular 20- between P and level of the block
60 QRS

Causes: Anterior/inferior wall MI, digoxin, Beta Blockers, Ca Channel Blockers, ↑

vagal tone, myocarditis, endocarditis, post cardiac surgery
Treatment: Pacemaker
Serious Signs and Symptoms

Chest pain
Dyspnea
Change in level of consciousness (LOC)
Crackles/CHF
Acute MI
Hypotension
Wide QRS
Heart Block Interventions/Algorithm
Assess Cardiac Output
Provide oxygen
If symptomatic:
Atropine (at the level of the AV node)
Transcutaneous pacing with sedative as needed
Dopamine
Epinephrine
Determine cause and eliminate
What do you do if your patient with 3rd degree heart block develops PVCs?

PVC’s in 3rd degree heart block are ventricular escape

beats
These are functional and necessary to provide some
cardiac output
Do not use Lidocaine
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1. Strip 8.2
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2. Strip 8.8
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3. Strip 8.9
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4. Strip 8.20
Pacemakers
Test Your Knowledge
What is a Pacemaker?

A pacemaker is a battery powered device that delivers an electrical stimulus

to the myocardium resulting in contraction.

Temporary or Permanent

Single chamber – Atria or Ventricle

Dual chamber – AV Sequential Pacemaker

Fixed or Non-Fixed
AICD Placement

Automated Implantable Cardioverter Defibrillator

May include one or all of the following functions:
Anti-tachycardia pacing
Cardioversion
Defibrillation
Bradycardia pacing
3 Types:
Single Chamber ICD – RV
Dual Chamber ICD – RA and RV
Biventricular ICD – RA, RV & LV
Atrial Pacemaker
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular if 1:1 Varies with Paced beats Varies Normal if < 0.12 seconds
pacing underlying similar in size normal AV
rhythm and shape, conduction
pacing artifact
before P wave
Ventricular Pacemaker
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular, if 1:1 Varies with May be present Varies Varies with Paced beats will
pacing underlying underlying be similar in size
rhythm rhythm and shape,
pacing artifact
before QRS
AV Sequential Pacemaker
Rhythm Rate P Wave PR Interval P:QRS Ratio QRS Duration

Regular, if 1:1 Varies with P waves should Varies Should be 1:1 for QRS complex
pacing underlying follow atrial paced beats should follow
rhythm pacing spike ventricular
pacing spike
Pacemaker Terms

Firing/pacing - pacemaker has delivered a stimulus and

pacing artifact (spike) is seen on ECG
Capturing – the heart has responded to the stimulus
Electrical capture – pacing spike is followed by a P or QRS
wave
Mechanical capture = cardiac depolarization is followed by
contraction/pulse
Sensing – ability of pacemaker to recognize the patient’s
intrinsic beats
Pacemaker Malfunctions

Failure to capture/loss of capture – pacing stimulus fails to induce a cardiac depolarization

Failure to Sense – pacemaker fails to sense patient’s intrinsic beats

Pacemaker Classifications

1st Letter – Chamber paced

2nd Letter – Chamber where intrinsic activity is sensed
3rd Letter – Pacemaker response to chamber sensed
Most common classifications:
AOO (Atrial fixed)
VVI (Ventricular demand)
DDD (AV sequential)
DVI (AV sequential)
DOO (AV sequential fixed)
Practice Strips

1. Strip 10.1
Practice Strips

2. Strip 10.2
Practice Strips

3. Strip 10.4
Practice Strips

4. Strip 10.20
ECG - Evaluation
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