Cardiac Rhythm

Front 1

Back 1

Normal Sinus Rhythm
"Rhythm - Regular
Rate - (60-100 bpm)
QRS Duration - Normal
P Wave - Visible before each QRS complex
P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree block)
Indicates that the electrical signal is generated by the sinus node and travelling in a normal fashion in the heart.
Treatment:
PT Stable - no Cardiac treatment
PT unstable - Possible PEA - Fix underlining causes"

Front 2

Back 2

Sinus Bradycardia
"A heart rate less than 60 beats per minute (BPM).
Rhythm - Regular
Rate - less than 60 beats per minute
QRS Duration - Normal
P Wave - Visible before each QRS complex
P-R Interval - Normal
TREATMENT
Usually benign and often caused by patients on beta blockers
PT Stable - (Could be normal for runners / physically fit person)
PT unstable
- Possible cause of Brain injury (contra indication of D50 due to increased intracranial Pressure
- Possible Over dose on Beta Blockers - Glucagon Dose - 1 to 2 mg
- Possible low glucose -consider D50 25 mg (or 12.5 half dose)
- Possible Pacing required
- Speed up rate with Atropine .5 mg Rapid push"

Front 3

Back 3

Sinus Tachycardia
"An excessive heart rate above 100 beats per minute (BPM) which originates from the SA node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger then medications may be required to suppress the rhythm
- Regular
Rate - More than 100 beats per minute
QRS Duration - Normal
P Wave - Visible before each QRS complex
P-R Interval - Normal
The impulse generating the heart beats are normal, but they are occurring at a faster pace than normal. Seen during exercise
TREATMENT
PT Stable - Could be normal - if caused from a known stress, freight, illness or exercise - no treatment
PT unstable - possible cardio vert with "

Front 4

Back 4

Supraventricular Tachycardia (SVT) Abnormal
"A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not under direct control from the SA node. SVT can occur in all age groups
Rhythm - Regular
Rate - 140-220 beats per minute
QRS Duration - Usually normal
P Wave - Often buried in preceding T wave
P-R Interval - Depends on site of supraventricular pacemaker Impulses stimulating the heart are not being generated by the sinus node, but instead are coming from a collection of tissue around and involving the atrioventricular (AV) node
Treatment:
PT Stable -
PT unstable -

Front 5

Back 5

Atrial Fibrillation
"Many sites within the atria are generating their own electrical impulses, leading to irregular conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm can be felt when palpating a pulse
Rhythm - Irregularly irregular
Rate - usually 100-160 beats per minute but slower if on medication
QRS Duration - Usually normal
P Wave - Not distinguishable as the atria are firing off all over
P-R Interval - Not measurable The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm
Treatment:
PT Stable -
PT unstable - "

Front 6

Back 6

Atrial Flutter
"Rhythm - Regular
Rate - Around 110 beats per minute
QRS Duration - Usually normal
P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but sometimes 3:1
P Wave rate - 300 beats per minuteP-R Interval - Not measurable As with SVT the abnormal tissue generating the rapid heart rate is also in the atria, however, the atrioventricular node is not involved in this case.
Treatment:
PT Stable -
PT unstable - High Flow O2, IV, Cardisem (deltisem) 15 to 20 mg, 20 to 25mg "

Front 7

Back 7

1st Degree AV Block
"1st Degree AV block is caused by a conduction delay through the AV node but all electrical signals reach the ventricles. This rarely causes any problems by itself and often trained athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in length, or 3-5 small squares on the ECG.
Rhythm - Regular
Rate - 60 to 100
QRS Duration - Normal
P Wave - Ratio 1:1
P Wave rate - Normal
P-R Interval - Prolonged (>5 small squares)
Treatment:
PT Stable -
PT unstable -

Front 8

Back 8

2nd Degree Block Type 1 (Wenckebach) (Mobitz I)
"Another condition whereby a conduction block of some, but not all atrial beats getting through to the ventricles. There is progressive lengthening of the PR interval and then failure of conduction of an atrial beat, this is seen by a dropped QRS complex.
Rhythm - Regularly irregular
Rate - Normal or Slow
QRS Duration - Normal
P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
P Wave rate - Normal but faster than QRS rate
P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped
Treatment:
PT Stable -
PT unstable - "

Front 9

Back 9

2nd Degree Block Type 2 (Mobitz II)
"When electrical excitation sometimes fails to pass through the A-V node or bundle of His, this intermittent occurrence is said to be called second degree heart block. Electrical conduction usually has a constant P-R interval, in the case of type 2 block atrial contractions are not regularly followed by ventricular contraction
Rhythm - Regular
Rate - Normal or Slow
QRS Duration - Prolonged
P Wave - Ratio 2:1, 3:1
P Wave rate - Normal but faster than QRS rate
P-R Interval - Normal or prolonged but constant
Treatment:
PT Stable -
PT unstable - "

Front 10

Back 10

3rd Degree Block
"3rd degree block or complete heart block occurs when atrial contractions are 'normal' but no electrical conduction is conveyed to the ventricles. The ventricles then generate their own signal through an 'escape mechanism' from a focus somewhere within the ventricle. The ventricular escape beats are usually 'slow'
Rhythm - Regular
Rate - Slow
QRS Duration - Prolonged
P Wave - Unrelated
P Wave rate - Normal but faster than QRS rate
P-R Interval - Variation
Complete AV block. No atrial impulses pass through the atrioventricular node and the ventricles generate their own rhythm
Treatment:
PT Stable -
PT unstable - "

Front 11

Back 11

Bundle Branch Block – (Extra)
"Bundle Branch Block – (Extra) Abnormal conduction through the bundle branches will cause a depolarization delay through the ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle Branch Block (RBBB) indicates problems in the right side of the heart. Whereas Left Bundle Branch Block (LBBB) is an indication of heart disease. If LBBB is present then further interpretation of the ECG cannot be carried out.
Rhythm - Regular
Rate - Normal
QRS Duration - Prolonged
P Wave - Ratio 1:1P Wave rate - Normal and same as QRS rate
P-R Interval - Normal
Treatment:
PT Stable -
PT unstable - "

Front 12

Back 12

Premature Ventricular Complexes (PVC)
"Due to a part of the heart depolarizing earlier than it should
Rhythm - Regular
Rate - Normal
QRS Duration - Normal
P Wave - Ratio 1:1
P Wave rate - Normal and same as QRS rate
Treatment:
PT Stable -
PT unstable -

Front 13

Back 13

Junctional Rhythms
"
Rhythm - Regular
Rate - 40-60 Beats per minute
QRS Duration - Normal
P Wave - Ratio 1:1 if visible. Inverted in lead IIP Wave rate - Same as QRS rate
P-R Interval - Variable
Treatment:
PT Stable -
PT unstable - "

Front 14

Back 14

Ventricular Tachycardia (VT) Abnormal
"Rhythm - Regular
Rate - 180-190 Beats per minute
QRS Duration - Prolonged
P Wave - Not seen Results from abnormal tissues in the ventricles generating a rapid and irregular heart rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go into cardiac arrest.
Shock this rhythm if the patient is unconscious and without a pulse
Treatment:
PT Stable -
PT unstable - "

Front 15

Back 15

Ventricular Fibrillation (VF) Abnormal
"Disorganized electrical signals cause the ventricles to quiver instead of contract in a rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain. Immediate treatment by defibrillation is indicated. This condition may occur during or after a myocardial infarct.
Rhythm - Irregular
Rate - 300+, disorganized
QRS Duration - Not recognizable
P Wave - Not seen This patient needs to be defibrillated!! QUICKLY
Treatment:
PT Stable -
PT unstable -
CPR, Pads on and Shock ASAP, CPR, Bag valve Mask + High Flow O2, Shock every 2 min if necessary, IV, EPI, 1mg 1:10,000, amiodarone 300 mg, EPI 1mg 1:10,000, amiodarone 150 mg, find and fix any H's and T's, maybe some D50, fluid boils, Narcan. then maybe call Medical Control and possibly call the code. "

Front 16

Back 16

Asystole - Abnormal
"Rhythm - Flat Rate - 0 Beats per minute
QRS Duration - None
P Wave - None Carry out CPR!!
Treatment:
PT Stable -
PT unstable -

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Back 17

Myocardial Infarct (MI)
"Rhythm - Regular
Rate - 80 Beats per minute
QRS Duration - Normal
P Wave - Normal
S-T Element does not go isoelectric which indicates infarction. However this is not diagnostic unless associated with a 12 lead ECG
Treatment:
PT Stable -
PT unstable - "

Front 18

Back 18

Paced Rhythm
"Rhythm - Irregular
Rate - 60 Beats per minute
QRS Duration - Normal
P Wave - Normal
S-T Element does not go isoelectric which indicates infarction. However this is not diagnostic unless associated with a 12 lead ECG
Treatment:
PT Stable -
PT unstable -

Front 19

Back 19

NSR with unifocal PVC
"Rhythm - irregular
Rate – (60-100 bpm)
QRS Duration – normal when present
P Wave – visible before each QRS complex
PVC in one direction
Treatment:
PT Stable - High Flow O2, SAMPLE History, IV, Fluid
PT unstable -
(Chest Pain) - High Flow O2, SAMPLE History, IV, Fluid boils, Aspirin, .4 nitro up to three times, Morphine 2mg"

Front 20

Back 20

Normal Sinus with multifocal Couplet PVC
"Rhythm - irregular
Rate – (60-100 bpm)
QRS Duration – normal when present
P Wave – visible before each QRS complex
PVC in both directions
Treatment:
PT Stable - High Flow O2, SAMPLE History, IV, Fluid
PT unstable -
Chest Pain - High Flow O2, SAMPLE History, IV, Fluid boils, Aspirin, .4 nitro up to three times, Morphine 2mg"

Front 21

Back 21

Junctional Brady
"
Rhythm: Regular
Rate: 40-60bpm
P waves: Inverted or absent
PR interval: Short or Absent
QRS width: Normal
Interventions: If hemodynamically stable = No tx-If not stable, tx like sinus Brady = Atropine
Treatment:
PT Stable -
PT unstable - Atropine .5 mg rapid push"

Front 22

Back 22

Slow V-Tach
"Wide complex regular rhythm with rate 40-120 Runs may last few minutes
Treatment:*** Observe only!
rhythm is self-terminating, NOT destabilizing If hypertensive, consider atrial pacing***
Danger: if you treat this with lidocaine or amiodarone or procainamide, rhythm will go to asystole, patient will die.
Treatment:
PT Stable -
PT unstable - "

Front 23

Back 23

Fine Ventricular Fibrillation
"Rhythm - chaotic
Rate – 0 bpm
QRS Duration – none present
P Wave –absent or chaotic varying in size and shape.
Treatment:
PT Stable -
PT unstable -

Front 24

Back 24

Torsades de pointes
"Rhythm – irregular
Rate – 60-100 bpm or 150-300 depending on where pace is coming from.
Torsades de pointes is a polymorphic ventricular tachycardia that differs from general ventricular tachycardia in both appearance and cause. The phrase “torsades de pointes” means “twisting on a point” which explains the action of the QRS complex and how it varies from beat to beat. Each QRS complex is wide and changes in size with each beat. The QT interval is increased to 600 milliseconds or more. Torsades can occur as both a perfusing or non-perfusing rhythm. It is a shockable rhythm.
Treatment:
PT Stable -
PT unstable - "

Front 25

Back 25

Pulseless Electrical Activity (PEA)
"Any rhythm shown on monitor when the patient does NOT have a pulse.
Interventions: CPR, intubation, ACLS drugs -Tx cause
Treatment:
PT Stable -
PT unstable - "

Front 26

Back 26

Agonal rhythm
"Rhythm: Slightly irregular to totally irregular
Rate:20-40 bpm pattern of slowing in later stages
P wave: usually not present
AV conduction.
PR interval is not present and not measured
Ventricular conduction ARS complexes are extremely wide and may exceed .60 seconds.
Treatment:
PT Stable -
PT unstable - "

Front 27

Back 27

Idioventricular rhythm
"Rhythm: regular
Rate: 30-45 bpm
QRS duration: complexes are wide (> 0.12 sec, often > 0.16 sec)ventricular signal is transmitted by cell-to-cell conduction between cardiomyocytes and not by the conduction system.
Treatment:
PT Stable -
PT unstable - "

Front 28

Back 28

Multifocal Atrial Tachycardia
"Rhythm: Irregular
Rate: 100-250 bpm
P wave: two or more ectopic P waves with different morphologies
QRS duration: Normal
Treatment:
PT Stable - High Flow O2, IV, Monitor, Fluid Bolus
PT unstable - "