Heart Rhythms

Atrial Fibrillation

R-R Interval: Grossly irregular Rate: Ventricular Rate varies, Atrial Rate 350-700 per/min P Wave: Not discernable as the atria do not contract (irregular or wavy baseline) PR Interval: unable to measure QRS Interval: less than 0.12 secs Can cause a loss in Cardiac Output due to the loss of the atrial kick Treatment: If less than 48 hrs: Digoxin, CCB's, Beta-blockers, Amodarone, or Cardioversion If greater than 48 hours: Anticoagulate then treat Oxygen ANTITHROMBOTIC THERAPY IS INDICATED FOR ALL PATIENTS WITH ATRIAL FIBRILLATION

Premature Ventricular Contraction

R-R Interval: Regular Rate: Varies P wave: if present, not associated with PVC PR interval: Not measurable QRS: Wide (greater than 0.16 secs), usually a bizarre shape T Wave: slopes off in opposite direction of QRS Treatment: (if frequent and close to the T wave) Magnesium if low Potassium if low Atropine if rate is low Procainamide, Amiodarone, Lidocaine

Ventricular Standstill or Asystole

R-R Interval - absent, no QRS Rate: 0 P waves: Sinus P waves present PR Interval: Not measurable QRS: Absent Treatment: CANNOT BE CARDIOVERTED BECAUSE THERE IS NO ELECTRICAL ACTIVITY Epinephrine 1.0 mg CPR Dopamine Oxygen

Ventral Fibrillation

R-R Interval: Chaotic Rate: 0 P wave: absent PR Interval: Not measurable QRS: Absent May be coarse (more voltage) or fine (less voltage) - VF gets finer and harder to defibrillate the longer it lasts Treatment: Defibrillation followed by 2 mins of CPR regardless of what the monitor shows Epinephrine, Amiodarone, Procainamide, Lidocaine Oxygen

Normal Sinus Rhythm

- Ventricular and atrial rate: 60 to 100 bpm in the adult - Ventricular and atrial rhythm: Regular - QRS shape and duration: Usually normal, but may be regularly abnormal - P wave: Normal and consistent shape; always in front of the QRS - PR interval: Consistent interval between 0.12 and 0.20 seconds - P:QRS ratio: 1:1

Sinus Arrhythmia

- Ventricular and atrial rate: 60 to 100 bpm in the adult - Ventricular and atrial rhythm: Irregular - QRS shape and duration: Usually normal, but may be regularly Abnormal - P wave: Normal and consistent shape; always in front of the QRS - PR interval: Consistent interval between 0.12 and 0.20 seconds - P:QRS ratio: 1:1 NO TREATMENT NECESSARY

Sinus Tachycardia

- Ventricular and atrial rate: Greater than 100 bpm in the adult, but usually less than 120 bpm - Ventricular and atrial rhythm: Regular QRS shape and duration: Usually normal, but may be regularly abnormal - P wave: Normal and consistent shape; always in front of the QRS, but may be buried in the preceding T wave - PR interval: Consistent interval between 0.12 and 0.20 seconds - P:QRS ratio: 1:1 Treatments: Adenosine to slow the rate CCB's If wide QRS present then procainamide, amiodarone, and sotalol are used.

Ventral Tachycardia

3 or more PVC's in a row R-R Interval: regular or slightly irregular Rate: 140-150 to 250 BPM P Wave: absent PR Interval: Not measurable QRS: Wide and Bizarre (greater than 0.16 secs) May self terminate Treatment: Amiodarone, Procainamide, Lidocaine Cardiovert if pulse present, defibrillate if pulseless Potassium & Magnesium Oxygen

Wandering Baseline

Caused by : patient movement moving of the monitor cables loose electrodes

AC Interference

Caused by alternating current from the wall outlet, can be caused by a poorly grounded ECG monitor Causes 60 rhythms per second

Paroxysmal Atrial Tachycardia

Frequently called SVT (supraventricular tachycardia) R-R interval: Regular Rate: 150-250 beats/min P Wave: all P waves alike in their shape but not like the sinus P, one for each QRS PR Interval : 0.12 - 0.20 secs (if able to see the p wave) QRS interval: less than 0.12 secs This is a sudden burst of 3 ore more PACs in a row Treatment: Adenosine Calcium Channel Blockers, Beta-Blockers, Digoxin, Amiodarone Stop using stimulants like caffeine and tobacco If recurrent, ablation may be used.

Premature Atrial Complex (PAC)

R-R interval: Regular, except for early beat Rate: Varies P wave: May differ from sinus P wave; may be notched, peaked, biphasic, or lost in preceding T wave (usually really close to T wave) PR Interval: usually 0.12 - 0.20 secs QRS Interval: usually less than 0.12 secs Usually does not have a compensatory pause May be conducted (QRS follows or non conducted) Treatment: Usually not necessary but if required stop using stimulants such as caffeine and tobacco Digoxin or Quinidine can be given Oxygen

Sinus Arrest

R-R interval: normal except during arrest Rate: can occur at any rate P wave: upright in lead II, one for each QRS PR Intervial: .12 - .20 secs QRS Interval: less than 0.12 secs Treatment: Atropine or Pacemaker Oxygen

Atrial Flutter

R-R interval: regular if conduction ratio is constant or irregular Rate: Ventricular rate varies but atrial rate 250-350 beats/min - P wave: Saw-toothed shape; these waves are referred to as F waves - PR interval: Unable to Measure. - QRS ratio: Less than 0.12 secs ( P:QRS ratio can be 2:1, 3:1, or 4:1) Cardiac output is not influenced by the atrial rate but by the ventricular rate Treatment: Vagal maneuvers or Adenosine to slow AV conduction rate Beta-blockers, CCB's, & digitalis to slow ventricular response rate Cardioversion if meds ineffective ANTITHROMBOTICS ARE ALWAYS GIVEN TO PREVENT CLOTS IN ATRIA

Idioventricular Rhythm

R-R: Regular Rate: 20-40 BPM; May be accelerated with rate 50-100 BPM P wave: absent PR Interval: Cannot Measture QRS Interval: Wide (greater than 0.12 secs) All the above pacemakers have failed (those in the SA node, and the AV node) Note that T wave slopes off in opposite direction of QRS Considered a terminal rhythm, usually occurs as a result of massive heart damage May or may not have pulse, lack of atrial kick Treatment: Atropine 0.5 mg IVP Epinephrine 1mg IVP Dopamine for decreased BP Oxygen CPR