ECG &

PHARMACOLOGY

This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential.
Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
 Anatomy of the Heart

AO
AO = Aorta

LA
PA
LA = Left Atrium
RA
RA = Right Atrium
LV LV = Left Ventricle

PA = Pulmonary Artery RV

RV = Right Ventricle

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 Anatomy of the Heart

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 Anatomy
of the ECG
• P wave
• PR interval
• QRS complex
• ST segment
• T wave

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 Pacemakers of the heart

Sinus Node His Bundle

60-100 bpm

Purkinje System
30-40 bpm
or less

AV Node (junctional
cells)
40-60 bpm

Failure of a pacemaker allows a subsidiary

pacemaker to fire.
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 Lines and Calibration
What is the approximate
PR Interval in this rhythm strip?

}
}

Filipinos
Deserve
1 small box =
0.04 sec } 5 small boxes =
1 BIG box
0.20 sec

More
 ECG
Measurements

• PR interval
0.12 ® 0.20 s
• QRS complex
<0.12 s

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Deserve
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 Heart Rate Estimation
300 150 100 75 60 50 40 30

1. Pick a complex that falls on a

heavy line
2. Then estimate the rate by
counting heavy boxes
3. Using 300, 150, 100, 75, 60,
50, 40, 30
75 to 100 bpm

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 RHYTHM ANALYSIS

5 Questions
• Rate?
• Normal
• Bradycardia, Tachycardia
• Rhythm?
• Regular or Irregular
• Are there P waves?
• Is each P wave related to a QRS with 1:1
impulse conduction?
• PR Interval?
• Normal
• Prolonged
• QRS normal or wide?
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 • Disturbance in Automaticity
• Pacemaker speeds up
• New pacemaker takes over
• Disturbance in Conduction
• Slowing or block in conduction
of electrical impulse
• Combination of Both
• Reentry arrhythmias

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 Normal Sinus Rhythm
• Rate 60-100/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 Conduction
• PR Interval 0.16 seconds
300 150 100 75
• QRS Complex Normal

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 Sinus Bradycardia
• Rate <60/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 Conduction
• PR Interval 0.16 seconds
300 150 100 75 60 50 40 30
• QRS Complex Normal

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 Sinus Tachycardia
• Rate >100/min
• Rhythm Regular
• P waves Present
• P → QRS 1:1 Conduction
• PR Interval 0.16 seconds
• QRS Complex Normal
300 150 100

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 Premature Atrial Contraction (PAC)
ä • Rate Sinus Rate
• Rhythm Irregular—interrupted by PAC
Incomplete compensatory pause
• P waves Different morphology
• P → QRS 1:1 Conduction
• PR Interval 0.16 seconds
300 150 100 75 • QRS Complex Normal

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Deserve
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 Atrial Fibrillation
• Rate Atrial rate cannot be measured
* • Rhythm Ventricular rate—variable
Irregular (irregularly irregular)
• P waves Absent (fibrillation waves)
• F → QRS Conduction irregular
• PR Interval N/A
• QRS Complex Normal

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Deserve
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 Atrial Flutter
• Rate Atrial rate 250-400/min (often 300)
* • Rhythm Ventricular rate—variable
• P waves Absent (flutter waves)
• F → QRS Conduction regular
• PR Interval N/A
• QRS Complex Normal

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Deserve
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 Reentry (Paroxysmal) SVT
• Rate Atrial rate 150-250/min
• Rhythm Onset tachycardia abrupt
Regular
• P waves Present—inverted in leads 2, 3, & aVF
• P → QRS Conduction regular
• PR Interval Normal
• QRS Complex Narrow

Usually onsets with PAC

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Deserve
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Premature Ventricular Contraction (PVC)
• Rate Sinus Rate
• Rhythm Irregular—interrupted by PVC
Complete compensatory pause
• P waves Different morphology
ä • P → QRS 1:1 Conduction
• PR Interval 0.16 seconds
• QRS Complex Normal

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 Ventricular Tachycardia
Monomorphic*
• Rate Tachycardia
• Rhythm Onset tachycardia abrupt
Regular
• P waves Present - obscured
• P → QRS Blocked - fusion complexes possible
ä
• PR Interval N/A
• QRS Complex Wide

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Polymorphic VT* • Rate Tachycardia
• Rhythm Onset tachycardia abrupt
Irregular
• P waves Present – obscured
• P → QRS Blocked - fusion complexes possible
• PR Interval N/A
• QRS Complex Wide

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 Ventricular Fibrillation
• Rate Chaotic, uncountable
• Rhythm Irregular
• P waves Absent
• P → QRS N/A
* • PR Interval N/A
• QRS Complex No normal QRS complexes

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 Asystole
• Rate Absent
• Rhythm None – flat line
• P waves Absent
• P → QRS N/A
• PR Interval N/A
• QRS Complex Absent

Agonal Complexes
Pulseless Electrical
Activity ASYSTOLE

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Deserve
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Pulseless Electrical Activity (PEA)
• Rate Absent
• Rhythm PEA is not a single rhythm but any
organized rhythm without a pulse
• P waves Present
• P → QRS 1:1 Conduction
• PR Interval Usually normal
• QRS Complex Normal

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Normal AV Conduction Sinus Node

•Underlying sinus rhythm

•One P wave AV Node

AV Nodal
Tissue
0.12-0.20 seconds
•PR interval 0.12 to 0.20
seconds QRS <0.12

•One P wave for each QRS

His-Purkinje System

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Normal AV Conduction

•Underlying sinus rhythm

•One P wave
Prolongation
•PR interval 0.12 to 0.20 –PR Interval more than 20 seconds
seconds

•One P wave for each QRS Dropped Beat

P-wave without QRS
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 • Atrioventricular Blocks
• Classification

• Incomplete AV Block
First-Degree AV Block Type I—Wenckebach
Mobitz I
Second-Degree AV Block
Type II—Mobitz II

• Complete AV Block
Third-Degree AV Block

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First-Degree AV Block Sinus Node

P
•Underlying sinus rhythm

•One P wave
AV Nodal
Tissue

•PR interval >0.20 second

>0.20 seconds

•One P wave for each QRS

QRS <0.12

His-Purkinje System

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Deserve
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First-Degree AV Block

PRoL PRoL PRoL

9 boxes 9 boxes 9 boxes

DROPPED BEAT PROLONGATION

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Second-Degree AV Block - Mobitz I
Wenckebach Phenomenon

•Underlying sinus rhythm Sinus Node

•P wave fails to periodically P

conduct
AV Nodal
Tissue

•PR interval prolonged

>0.20 seconds
PR interval

X
•One P wave for each QRS
QRS
until block
His-Purkinje System

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Deserve
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Second-Degree AV Block - Mobitz I

PRoL PRoL PRoL PRoL

8 11 8 11

DROPPED BEAT PROLONGATION

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Second-Degree AV Block -Mobitz II
Sinus Node
• Underlying sinus rhythm
P
• One P wave Block

• PR interval usually normal, Ò

AV Node

no prolongation Often Normal

AV Nodal
Tissue

• One P wave for each QRS Often normal

QRS complex

until sudden block and

dropped QRS
His-Purkinje System
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Deserve
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Second-Degree AV Block -Mobitz II

11

DROPPED BEAT PROLONGATION

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Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS
Sinus Node

P
QRS from
AV-His
Ò escape
ã

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60 AV Node

• PR interval variable QRS <0.12

• P waves unrelated to QRS

• Narrow QRS = block above His
junction
His Purkinje System

Filipinos
Deserve
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Third-Degree AV Block—Junctional Escape
P waves unrelated to QRS
Sinus Node

P
QRS from
AV-His
Ò escape
ã

• Underlying sinus rhythm (usual)

• Escape junctional rate 40-60 AV Node

• PR interval variable QRS <0.12

• P waves unrelated to QRS

• Narrow QRS = block above His
junction
His Purkinje System

Filipinos
Deserve
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Third-Degree AV Block—Ventricular Escape

P waves unrelated to QRS

Sinus Node

AV Node

• Underlying sinus rhythm

(usual)
• Escape ventricular rate 30-40
QRS from
• PR interval variable QRS >0.12
ã His-Purkinje
escape
• P waves unrelated to QRS
• Wide QRS = block below His
junction
His-Purkinje System
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Deserve
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summary
AVB DROPPED BEAT PROLONGATION

First Degree AVB

Mobitz I

Mobitz II

Third Degree AVB ALTERNATES / VARIABLE

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 AV Block - Which Type? DROPPED
BEAT
PROLONGATION AVB

u Variable Third
Degree

v First
Degree

w Mobitz
II

x
Mobitz I

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 Thank you for choosing
FDM Training Center
for your Forward Learning!

ECG &
PHARMACOLOGY
This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential.
Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
Filipinos
Deserve
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 ADVANCED
CARDIOVASCULAR
LIFE SUPPORT

This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential.
Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
 PRE-ARREST ARREST POST-ARREST (ROSC)

V
VISUALIZE
CONSCIOUSNESS, BREATHING, COLOR
VITAL SIGNS A RESCUE BREATHING: 1 q 6 sec
ADVANCED AIRWAY:

B
Primary confirmation:
AIRWAY, BREATHING, CIRCULATION 5-pt auscultation
DISABILITY, EXPOSURE Secondary confirmation:
VERBALIZE Qualitative - Yellow
Quantitative - Waveform Capnography

O
SAMPLE
(35-45 mmHg)

C
OXYGENATE if SpO2 95%
Nasal Cannula 2-4 1-2L PNSS/PLRS
Face Mask 6-10 Dopamine 5-10 mcg/kg/min
NRM 11-15
Epinephrine 0.1 – 0.5 mcg/min

M
Parameters of HQCPR:
Norepinephrine 0.1 – 0.5 mcg/kg/min

D
• Push HARD: depth (2-2.4 in = 5-6 cm)
Monitor
• Push FAST: rate (100-120 comp/min) TARGETED TEMPERATURE MANAGEMENT
• Allow chest recoil 30 mL/kg PNSS/PLRS 4oC x 30mins

I
• Minimize interruptions <10 sec Core body temp: 32-36
Establish an IV/IO Access • Avoid excessive ventilation At least 24 hours
Assess CPR quality:

T E
Continuous Waveform Capnography (10mmHg) NGT
CVP 12-LEAD
TEAM DYNAMICS
• Clear Roles and Responsibilities
CXRAY
• Knowing your Limitation
• Constructive Intervention
URINARY CATHETER
• Knowledge Sharing
• Summarizing and Re-evaluation
• Mutual Respect
• Clear Messages STEMI – CATH LAB
Filipinos
Deserve • Close-Loop Communication NSTEMI - ICU
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 MEGACODE PHASES
Phase Status Goal

Pre-Arrest
Patient is alive but may be
experiencing a life-threatening Prevent Cardiac Arrest
problem.

Revive the patient and achieve

Cardiac Arrest Patient has No Pulse, No Breathing
and Unresponsive
Return Of Spontaneous Circulation
(ROSC)

Post Arrest
Patient has achieved Return Of
Stabilize the patient
Spontaneous Circulation

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 PRE ARREST VOM I T
SYSTEMATIC APPROACH

V
Consciousness Ø Is the patient conscious?
Initial Breathing Ø Is the patient breathing?
Impression isualize Ø Pallor / Cyanotic
Color
Airway Ø RR and O2 Saturation

V
Breathing
Primary Ø HR & BP
Circulation Alert
Assessment ital Signs Disability Ø Assess AVPU Voice
Pain
Exposure Ø Trauma & Temperature Unresponsive

Signs & Symptoms Ø How are you feeling?

V
Allergy Ø Do you have allergies with food/ meds?
Secondary
Assessment erbalize Medications Ø Any maintenance meds?
Past Medical Hx Ø Past Hospitalization / Familial Dse
Last Meal Ø What & when was your last meal?
Event Ø What where you doing prior the s/sx?
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 PRE ARREST VOM I T

O
If O2 saturation is >95%, provide supplemental O2.
Nasal Cannula: 2-4 L/min
xygen Face Mask: 6-10 L/min
Non-Rebreather:11-15 L/min
SALT PEPPER

M
Attach 3-lead ECG:
onitor WHITE – Right upper chest below the clavicle
BLACK – Left upper chest below the clavicle
RED – Left lower chest
CHILI

I
Ø Large Bore
ntravenous Peripheral antecubital vein of the non-dominant hand.` Ø Non-Collapsable
Access Ø Medial Malleolus
2 failed attempts: proceed to Intraosseous Access (IO) Ø Proximal Tibia
Ø Humeral Head
Ø Sternum
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 PRE ARREST VOM I T
T reatment Based in the Rhythm and Status of the Patient

Bradycardia Tachycardia
ØSinus Bradycardia
Ø1st Degree AV Block ØSupraventricular Tachycardia
Ø2nd Degree AV Block (Mobitz 1) ØMonomorphic Ventricular
Ø2nd Degree AV Block (Mobitz 2) Tachycardia (+ pulse)
Ø3rd Degree AV Block
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T reatment

Rhythm
Bradycardia
Stable Unstable
Atropine
Sinus Bradycardia
A 1 mg bolus every 3-5 minutes
Maximum dose: 3 mg
First Degree
AV BLOCK T Transcutaneous Pacing
(TCP)
MONITOR
2ND DEGREE TYPE 1 & D Dopamine
5-20 mcg/kg/min
(MOBITZ TYPE 1)
OBSERVE E Epinephrine
2-10 mcg/min
2ND DEGREE TYPE 2

TDE only
(MOBITZ TYPE 2)
3RD DEGREE AV
BLOCK
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T reatment

RHYTHM
Tachycardia
STABLE UNSTABLE
Physiologic: Sedate:
VAGAL MANEUVERS
Propofol ; Etomidate ; Diazepam ;
SVT 1. CSM for 5-10 seconds (No to 60y/o)

S
Midazolam

P
Supraventricu 2. Cough forcefully 3x
lar
Tachycardia Pharmacologic:
ADENOSINE Synchronized Cardioversion
6mg, 12mg, 12mg 50J
1-2 mins interval

Monomorphic Physician Sedate

Ventricular
Tachycardia
(+) Pulse P Pharmacologic:
AMIODARONE
150mg infusion
S Synchronized Cardioversion
100J
over 10 minutes

Filipinos
Deserve
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 CARDIAC BLS SURVEY
ARREST 1 RESCUER
• Check scene safety “Scene is safe”
• Check for responsiveness “Hey are you okay?”
• Shout for help “Help! Someone Help!
• Check for pulse & breathing for at least 5 no more than 10 sec.

*No pulse, No Breathing

CODE BLUE Crash Cart
• “Activate emergency response and get and AED.”
• Start High Quality CPR.
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 Team Roles
Team Leader

Compressor

Airway

Monitor

Medication

Recorder

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 Delegating Team Roles
Compressor “Push hard at a depth of 5-6 cm or 2-2.4 inches.”

“Push fast at a rate of 100-120 compressions per minute.”

”Allow full chest recoil.”

“Minimize interruptions to less than 10 seconds.”

“Switch with the monitor every 2 minutes / you feel tired.”

Airway “Give 2 breaths every 30 compressions.”

“Make sure there is chest rise.”

“Avoid excessive ventilation , give 1 breath over 1 second.”

Monitor “Secure the pads and give shock as I order.”

Medication “Secure the IV/IO and give meds as I order.”

Recorder “Record the events of the code.”

“Prompt me every 2 minutes.”

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 HIGH PERFORMANCE TEAM(METRICS)
15 seconds before 2 mins:
• Pulse check with compressions: note if positive or negative pulse
• Pre-charge the defibrillator

2 mins:
• Hands hover over the chest
• Pulse check without compressions
• Analyze the rhythm CHEST
• Deliver shock for shockable rhythm
Ø Pads on the chest, shocking shock delivered
• Switch Compressions every 2 mins or if tired
Real time feedback device (metronome)
Continue compressions during intubation (Non-COVID)
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 Cardiac Arrest Rhythms
SHOCKABLE NON-SHOCKABLE
Ventricular Fibrillation Asystole
Pulseless Ventricular
Tachycardia Pulseless Electrical
1.Monomorphic Activity
2.Polymorphic

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 Cardiac Arrest Management
CLASS I High Quality CPR
Shock : 360 Joules Vfib Asystole
CLASS IIA
Vtach PEA
CLASS IIB Medication

Epinephrine Amiodarone Lidocaine

ØPriority Medication Ø1st dose: 300 mg IV bolus Ø1st dose: 1 – 1.5 mg/kg

Ø1 mg, 1: 10,000 Dilution Ø2 dose: 150 mg IV bolus Ø2nd dose: 0.5 – 0.75 mg/kg
nd

ØInterval of 3-5mins
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 TEAM DYNAMICS
ROLES
ü Clear Roles &
Responsibilities
ü Knowing your limitation
ü Constructive intervention

WHAT TO COMMUNICATE
ü Knowledge Sharing üMutual Respect
üClear Messages
ü Summarizing & Re-evaluating üClose-loop Communication

HOW TO COMMUNICATE
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 Post Arrest Management
ADVANCED AIRWAY:
Initial Stabilization

Airway No spontaneous Primary confirmation- 5-pt auscultation

Secondary confirmation:
breathing Qualitative - yellow
Phase

Breathing Quantitative – 35 to 40 mmHg PETCO2

• 1-2L PNSS/PLRS

Circulation Unstable BP • Dopamine 5-10 mcg/kg/min

• Epinephrine 0.1 – 0.5 mcg/kg/min
• Norepinephrine 0.1 – 0.5 mcg/kg/min
TARGETED TEMPERATURE MANAGEMENT
Disability
Continued Care

• 30 mL/kg PNSS/PLRS 4oC

Comatose • Core body temp: 32oC-36oC
• At least 24 hours
NGT

Endorsement Attach CVP 12-LEAD

Contraptions CXRAY

URINARY CATHETER

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Filipinos
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AIRWAY & BREATHING
Perform
Check if the patient can breath on his own Rescue
Positive pulse but NO breathing Breathing

ADULT INFANT
1 breath every 2-3
1 breath every 6 seconds
seconds
10 breaths per minute 20-30 breaths per minute

Note: Re-assess pulse every 2 minutes. If Note: If No chest rise,

NOT present,
pulse is NOT present proceed with CPR.
CPR proceed with MRSOPA

Filipinos
Deserve
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AIRWAY & BREATHING
M ask adjustment
R eposition the head and neck
S uction secretions
O pen the mouth
P ressure increase
A irway adjuncts:
NPA Ø Tip of the nose to
the earlobe

OPA Ø Corner of the lips to the

angle of mandible
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AIRWAY & BREATHING Consider Advanced Airway
Assessment of Endotracheal Tube placement
Qualitative
Ø 5 point Auscultation
Ø Colorimetric Device
Change from White to Yellow or
from Purple to Yellow

Quantitative
Ø Continuous Waveform Capnography
• Most Reliable
• This measures the PETCO2
• Alive patient: 35 to 45 mmHg If you do not achieve 10 mmHg, it means your
• Dead patient during CPR: 10 mmHg CPR is ineffective and needs to be improved.
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Deserve
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CIRCULATION

Blood Pressure: at least 90/60 mmHg

NOT CONGESTED CONGESTED

Fluid Replacement :
1-2 L or 30 mL/ kg NO FLUID
of PNSS/PLR
Medication
• Dopamine: 5 – 10 mcg/kg/min
• Epinephrine: 0.1 – 0.5 mcg/kg/min
• Norepinephrine: 0.1 – 0.5 mcg/kg/min

Filipinos
Deserve
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 DISABILITY Check for AVPU
Start
If patient has GCS of 3/15 Targeted Temperature
Management
Target 32 – 36º Celsius for 24 hours
Ø Esophageal thermometer
Evaluate
Ø Bladder thermometer

NOT CONGESTED CONGESTED

Fluid Replacement at 4º Celsius :
1-2 L or 30 mL/ kg NO FLUID
of PNSS/PLR
External Measures:
Cooling blankets, ice packs, lower room temperature
Filipinos
Deserve
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 Other Critical Care Management

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Endorsement Attach Contraptions

Nasogastric Tube Gastric Decompression

Indwelling Foley
Output Monitoring
Catheter

12 L ECG Rule out STEMI & continuous cardiac monitoring

Portable X-ray Check for rib fractures

Central Venous
Line Monitor Central Venous Presuure

Endorse to ICU; to the INTENSIVIST

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Filipinos
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 ACUTE CORONARY SYNDROMES
Initial Management
•O – Oxygen
•A – Aspirin 160 - 325 mg
•N – Nitroglycerin 0.3 -0.4 mg
•M – Morphine 2 – 4 mg
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 1st 90 Minutes or less
• Percutaneous Coronary Intervention (PCI)
- Preferred treatment
- First Medical Contact to Balloon inflation time
• Sites:
- Brachial
- Radial
- Femoral

To perform PCI, a hospital should be equipped

with a catheterization lab.
Filipinos
Deserve
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8DS STROKE CARE
1 Detection
2 Dispatch Best practice for
3 suspected stroke is to
Delivery
bypass the emergency
4 Door department and go
5 Data straight to the brain
6 Decision imaging suite per
protocol.
7 Drug
8 Disposition
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8D STROKE CARE

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 Thank you for choosing
FDM Training Center
for your Forward Learning!

ADVANCED
CARDIOVASCULAR
LIFE SUPPORT
This document is a property of FDM Training Center for Allied Health Professionals Inc., and the contents are treated confidential.
Therefore, unauthorized reproduction is strictly prohibited unless otherwise permitted by the Management.
Filipinos
Deserve
More