PR: .12- .

20

QRS: .04 - .10

Ventricular rate measure R-R, Atrial measure P-P SA Node = Atrial (master) AV Node = Ventricular (junction) takes over when AV node not functioning Ventricle fires when AV Node stops working

SINUS- (SA Node) SR: 60-100 SB: <60 ST: 101-150 SA: 60-100, off by 3 boxes in sinus only
AT: 151-250, atrial with Pwave, QRS with each Pwave (sometimes Pwave on Twave, so Twave is pointy) SVT: 151-250, no Pwave (Twave round, no point) Aflutter: 250-350 atrial, shark tooth, reg atrial rhythm (not every Pwave has QRS b/c its too fast) 2:1 = 2 Pwaves per QRS, 3:1 = 3 per QRS AFIB: 350-600 atrial, atrial quivering, totally irregular ryhthm, no real Pwaves- just fibrillatory waves

JUNCTIONAL- (AV Node) QRS normal, Pwave <.12 or = .12 and inverted JER: 40-60, no Pwave or < .12 x3 beats AJR: 61-100, no Pwave or < .12 x3 beats JT: 101-180, no Pwave or < .12 x3 beats VENTRICULAR- no Pwave, QRS > .10

VER: 20-40, no Pwave, QRS > .10 x3 beats, reg ventricular rate AIVR: 41-100, no Pwave, QRS > .12 x 3beats, reg ventricular rate VTACH: QRS > .10 x3 beats, reg ventricular rate (rate >100 = VTACH, if <100 = accelerated VTACH) VFIB: totally irregular, no discernible waves Ventricular Standstill: straight line with Pwaves Asystole: straight line with CPR like waves Agonal: rate < to 20, reg or irreg rhythm, no Pwave, QRS- wide, sloppy, notched HB: SA Node firing but something prevents impulse from getting to AV Node DIVC: QRS > .10 (ventricle) measure Pwave to Pwave for sinus rate in heart block only PAC: sinus beat, just early 1st HB: Pwaves march out, QRS for each Pwave, Pwave > .20 Blocked PAC: no QRS, but early Pwave 2nd HB Type 1: Pwaves march out, come QRS with Pwave but sometimes not, no SA Pause: < 3 seconds (15 big boxes) consecutive blocks, PRI gets longer, then blocks, then returns to normal, SA Arrest: > 3 seconds but still > .20 JEB: late beat, no Pwave or < .12, or = .12 and inverted 2nd HB Type 2: Pwaves march out, PRI always the same, sometimes QRS but PJB: early beat, no Pwave or < .12 sometimes not, can have consecutive blocks VEB: 1 beat with QRS > .10, no Pwave 2nd HB 2:1 Conduction: 2 Pwaves for every QRS, cant measure type 1 or 2 b/c PVC: early beat, QRS > .10, no Pwave theres no 2 QRSs in a row, but Pwaves do march out Multifocal PVC: QRS in opposite direction 3rd HB with JER or VER: Pwaves march out, no other rhyme or reason. If V Couplet: 2 PVCs in a row QRS > .10 = VER, if < .10 = JER Bigeminy: every 2nd Beat Trigeminy: every 3rd beat

ADVANCED ARRHYTHMIAS
SA Block/Sinus Exit Block: all complexes march out perfectly on time, but 1 complex is missing exactly on time where it is supposed to be Wandering Atrial Pacemaker: HR 60-100, QRS march out but Pwaves change size and shape, variations in PR interval Multifocal Atrial Tachycardia: tachycardic version of WAP, HR >100, need 3 or > different shaped Pwaves. Easily confused with Afib, so look closely and you can see Pwaves. Torsades de Pointe: when ventricle depolarizes, goes from to . Occurs as complication of prolonged QT interval. Treat with IV magnesium. AV Dissociation: no synchronization between atrium and ventricles, two types: 1) Complete HB: Pwaves march out and fall where conduction is possible but doesnt occur, no consistent PRI. Atrial rate faster than escape rhythm/ventricular rate. Escape rhythm ( junctional 40-60 or ventricular 20-40) determined by rate and width of WRS, no fusion/capture beats 2) Interference In Underlying Rhythm: ventricular rate faster than atrial, fusion beats common, origin of interfering rhythm determined by rate and width of QRS Afib with Complete HB: wavy like afib but with regular R-R intervals, need to identify the escape rhythm. Common with dig toxicity Capture Beat: occurs in junctional or ventricular rhythm, will have Pwave with a normal QRS, can look premature, no complete HB Interpolated PVC: a PVC that doesnt interrupt an underlying rhythm Fusion Beat: combination beat, can be pacemaker or ventricular. Will see sinus beat then fusion beat, usually normal Pwave with wider, taller QRS Echo Beat: occurs in junctional rhythm with retrograde P, looks like Pwave sandwich between 2 QRSs. Same QRS configuration as 1st junctional beat Atrial Tachycardia with Block: atrial rate 151-250, looks like slow A-flutter, atrial/ventricular rate 2:1 / 3:1

12 LEAD EKG CHANGES WITH ACUTE MI

INFERIOR -- II, III, AVF Twave inversion (flat), ST segment elevation may develop bradycardia, R ventricular infarct (R side EKG early) ANTERIOR -- V-2, V-3, V-4 Twave inversion, ST segment elevation, loss of Rwave may develop CHF, ventricular aneurysm, heart block SEPTAL -- V-1 Twave inversion, ST segment elevation, loss of Rwave LATERAL -- I, AVL, V-5, V-6

Myocardial Damage 1. Ischemia - tissue repolarizes abnormally, cells functional,

increased irritability, Twave inversion, narrow, symmetrical 2. Injury - cell membrane damaged, ST elevated off baseline, increased Twaves, tissue injured but still salvageable 3. Necrosis - tissue dies, no electricity conduction, diagnostic Qwave on EKG ( deflection first)

Twave inversion, ST segment elevation, loss of Rwave in V-5 and V-6, - Qwave POSTERIOR -- V-2, V-3, V-4 Tall Twaves, ST segment depression, tall Rwaves (everything opposite of anterior)

BUNDLE BRANCH BLOCK - look in V-1 and V-6 only

RBBB: QRS > .12, Twave opposite QRS (deep), RSR pattern Causes: acute MI damaging R ventricle, change in rate not allowing repolarization of right bundle branch, ischemic or fibrotic changes in conduction system LBBB: QRS > .12, Twave opposite of QRS, elevated ST segment, pinched R wave, mainly negative QRS complex in V1 Causes: acute MI, CAD, cardiomyopathy, endocarditis with scarring, conduction system damage with fibrosis Abberancy: the leading into of a temporary bundle branch block. Must have a cause, like PAC, sudden increase in HR Abberant PAC: one beat with an early abnormal Pwave , wider than normal QRS, identifiable L or R BBB in V-1

AXIS DEVIATION - indicates direction of current depolarizing ventricle has changed, used with BBB
Use thumb rule and look at QRS in lead I and AVF only Both up = normal Left up = left deviation Right up = right deviation Both down = axis indeterminate

DUAL CHAMBER PACEMAKERS

I Pace O none Atrium Ventricle Dual II Sense O A V D III Response O Triggered Inhibited D (T & I) IV Functions O P simple programming Multi-programmable Communicating Rate Modulation

Intrinsic: naturally occurring atrial and/or ventricular event Inhibited: when pacer sees the complex its looking for and shuts off Triggered: series of a response to events. Ex) Pwave triggers pacer to look for QRS, if there isnt one it will create one AICD: implanted and set to defib at set upper limit rate or to fire when a lethal rhythm is reached (VT/VF) some have pacing function

VVI: Doesnt sense Pwave. Set rate for firing if no intrinsic beat, called VEI (ventricular escape interval/ rate). To find VEI- first measure paced beats . . . . . . . . if sensing properly you can measure from intrinsic beat to paced beat and the rate will be the same VVIR: Like VVI but recognizes need for increased HR by measuring muscle activity and/or RR, programmed upper and lower rate AAI: Firing inhibited by a sensed Pwave. Measure from P to P, not QRS to QRS DVI: Pacing is inhibited when sensing a ventricular complex. Intrinsic Pwave not sensed, can have 1 or 2 spikes. 1 spike = atrial only and ventricular is inhibited, 2 strikes = AV sequential pacing, no spikes = pacer is inhibited VDD: Triggers a ventricular response at the end of AV interval or is inhibited by intrinsic ventricular activity during AV interval. Paces ventricle at intrinsic atrial rate, has upper and lower limits. Need to measure AVI (same as PRI) and make sure all are the same. If same = atrial sensing is good. When atrial sensing is gone, AVI increases or decreases- can have Weinkebach 2:1. If rate gets too low pacer will pace ventricle at lower tracking rate as VVI, or if too high will pace at upper tracking rate to prevent pacing at rapid rates. DDD: Provides AV synchrony at all times at all rates unless upper escape rate is reached. DDDR: Provides AV synchrony. Like DDD, but has extra sensors (RR, body temp) to allow for changes in rate due to metabolic needs. May be programmed to shorten the AV interval with sensor driven faster rates Safety Pacing: Prevents ventricular pacing as a result of faulty sensed or perceived events during AV delay. Waits 110 milliseconds/.11 seconds before spiking. Its okay to spike in QRS Pacemaker Mediated Tachycardia: Caused by retrograde conduction of ventricular depolarization in pacemaker patients

EMERGENCY IV PUSH MEDS:

MD ONLY: Cardizem (Diltiazem), Verapamil (Calan) - Calcium Channel Blockers- treat SVT, Afib, Aflutter. Cause: low BP, low HR Metoprolol (Lopressor), Propranolol (Inderal) - Beta Blockers I and II- treat SVT, Afib, Aflutter. Cause more severe low BP, low HR Adenosine (Adenocard) - treat SVT. May cause 6-10 sec asystole, slow HR RN: Atropine - For bradycardia per MD order- up to 1mg max dose administered rapidly May give up to 0.5mg for symptomatic bradycardia (HR <60, SBP <90) w/o MD order. Up to 6doses/8hr, max 3mg. Wait 5min between doses Must be on tele, EKG and VS obtained prior to and 5min after administration Lidocaine - For conscious patient in VT with a pulse per MD order- 1mg/kg dose given at 25-50mg/min. Not to exceed 150mg. If no weight, give 75mg. May use up to 2 times in 8hr, at least 30min apart If symptomatic VT with pulse ( dec. LOC, chest pain, SOB, low BP) lasting greater than 30seconds- may administer without MD order Must be on tele, EKG and VS obtained prior to and 5min after administration Digoxin - For Afib/Aflutter per MD order- up to 0.5mg max given over 2min Must be on tele and obtain rhythm strip with PRI and rate documented, and obtain VS prior to administration

EMERGENCY PROTOCOLS:

Steps for resuscitation of patient with pulseless VT/Vfib . . . . . . . Steps for resuscitation of a patient with asystole or PEA (pulseless electrical activity) . . . . . Criteria for treatment of a patient in VT with a pulse . . . . . . . . . . . . . . Treatment for the patient with symptomatic bradycardia . . . . . . . . . . . . .

Precordial Thump, CPR, Defib CPR and call cart Lidocaine Atropine