dysrhythmias chart

DYSRHYTHMIAS AND EKG INTERPRETATION 1 | P a g e I N T E R P R E T R H Y T H M , A S S E S S / T R E A T M E N T

RHYTHM EKG RATE

(BPM) RHYTHM EKG INTERVENTIONS

NORMAL SINUS RHYTHM (NSR)

60 100

Regular

rhythm:

R to R and P to P interval

constant

P wave: present and

similar

PR interval:

.12 .20 seconds and consistent

QRS segment:

.04 - .10 seconds and consistent

None, normal.

SINUS BRADYCARDIA

Causes:

Noncardiac

Athlete Sleeping Elderly

Cardiac

SA node disease MI

Vagal stimulation CAD

Drug Induced

Beta blockers Antianxiety Digitalis

Signs and symptoms: Pale, cool skin Hypotension

Weakness Angina

Dizziness Syncope

Confusion Disorientation

SOB

Less than

60 Regular

P wave:

present and

similar

PR interval: present and

normal

QRS segment:

present and

normal

Assessment

Decreased cardiac output related to slow heart rate

- Blood pressure

- Are you dizzy? Light

headed?

Treat only if the patient is

symptomatic

Atropine*

Stimulate patient.

SINUS TACHYCARDIA

Causes Noncardiac

Anxiety, fright, stress Exercise

Pain Fever

Alcohol ingestion

Hypovolemia

Cardiac

MI CHF

Drug Induced Aminophylline Amphetamines

Caffeine Atropine*

Dopamine Epinephrine

Nicotine

Signs and Symptoms:

Dizziness Dyspnea

Hypotension Angina

Increased myocardial oxygenation

Decreased cardiac output

greater than

100 Regular

P wave:

present and similar

PR interval:

present and

normal

QRS segment:

present and

normal

Assessment

Decreased cardiac output

related to decreased filling

time

Treatment

Treat the cause*

Pain

Pain management

Hypovolemia

Resolve hypovolemia

Vagal maneuvers*

IV beta blockers*

(Lopressor)


ATRIAL DYSRHYTHMIAS

RHYTHM EKG Rate Rhythm EKG Treatment

PREMATURE ATRIAL

CONTRACTIONS (PACS)

Action: Originates in the atrium

Ectopic foci (irritable cell) in the atria

Not life-threatening

Unifocal versus multifocal

Disoriented P wave

AV node stopped (nonconducted PAC)

delayed (lengthened PR

inter.)

Causes

Emotional stress

Fatigue

Caffeine

Tobacco

Alcohol

COPD

Valvular disease

Hypoxia Electrolyte imbalances

CAD

Signs and Symptoms

Isolated PACs: Not important Palpitations

Frequent PACs: SVT warming *

PAC

Conducted PAC

Nonconducted PAC

Variable Irregular

P wave: Different, down

deflection

notched*

PR Interval Varies but WNL

QRS

Usually normal*

(NORMAL FOR

ALL ATRIAL

ARRHYTHMIAS)

Termed as NSR with PACs

Asymptomatic:

No treatment needed

Treat the cause* because

it can cause more lethal

dysrhythmias.

Withdraw from drug or

caffeine

Oxygen

Electrolyte replacement

Medications*

Digoxin

Quinidine (IA) Pronestyl (IA)

ATRIAL FLUTTER

Action

Recurring, regular sawtooth-shaped

flutter waves

Rapid atrial depolarization

Single Ectopic focus SA node not repolarizing

Causes

Atrial ischemia

Stretched atria such as in fluid overload

or CHF

Signs and Symptoms

Decreased CO: HF with underlying

disease

Increased risk of stroke:

Thrombus formation in atria

Variable Atrial Flutter

Atrial Flutter

Atrial rate: 200-350 per

minute

Ventricular

rate:

< 150

Atrial

Regular*

Ventricular

Irregular*

Flutter waves:

Saw tooth waves

Two or more

before each QRS

PR Interval:

Not measurable

QRS Usually normal*

(NORMAL FOR

ALL ATRIAL

ARRHYTHMIAS)

Assessment: Decreased cardiac output

related to decreased filling

time

ineffective myocardial

contraction

Drugs to control rate

Decrease ventricular

response rate for filling time. Digoxin*

Esmolol (Brevibloc)*

Diltiazem (Cardizem)*

Drugs to control Rhythm

Medications convert back

from atrial flutter to normal

sinus rhythm.

Ibutilide (Corvert) (III) Pronestyl (IA)

Amiodarone (III) to

cardiovert chemically

Cardioversion

Atrial Pacing


ATRIAL DYSRHYTHMIAS

RHYTHM EKG RATE RHYTHM EKG TREATMENT

ATRIAL FIBRILLATION

Total disorganization of atrial

electroactivity

Loss of effective atrial contraction

Most common*

Clinical Associations

CAD

Rheumatic heart disease

Alcohol intoxication Stress

Cardiac surgery

Cardiomyopathy

Hypertensive heart disease

Caffeine use

HF

Pericarditis

Electrolyte Imbalances

Clinical Significance Decreased CO: ineffective atrial

contractions

Thombi in atria emboli brain (stroke)

Complications

Emboli

Cardiac output decreased 20-25%

Controlled A. Fib:

Uncontrolled A. Fib:

Atrial rate:

Too fast to

determine

>350 BPM

Ventricular

Rate:

Varies

Controlled

Less than

100

Uncontrolled

>100

Irregular Chaotic

Faster the

rate, the

more regular

it may

appear. But it

is not regular!

*they also

have atrial

flutter. When

they see

flutter they

think it is a P

wave. But it

is not a

frigken P wave! All P

waves must

look the

same.

Random

flutter wave

not P Wave.

P wave Not identifiable

Chaotic

PR interval

Not measurable

QRS

Usually normal*

(NORMAL FOR ALL ATRIAL

ARRHYTHMIAS,

initiated above

the ventricles. )

Cardiac output

likely to be lower (20-25%):

normally, atria

will squeeze to

increase and rid

of blood and put

it in ventricle

(atrial kick).

Drugs to control rate

Diltiazem (CCB) (IV)

Decreases ventricular response

Brevibloc

Ibutilide

Digoxin

Dugs to control Rhythm

Pronestyl (IA)

Amiodarone (III)

Anticoagulation***

Warfarin for a fib longer than

48 hours

TEE to rule out presence of

clot in atria, stasis of blood,

emboli

Long term anticoagulation

Cardioversion

Atrial Pacing

Ablation (unresponsive to

cardioversion)

MAZE: stops A fib by

interrupting electrical signals

SUPRAVENTRICULAR

TACHYCARDIA

(AKA SVT / PAT / PSVT)

An irritable foci above the ventricles

Overrides the SA node

Causes

Common in children and young adults

Fever Sepsis Caffeine Tobacco Alcohol Stress

COPD Cor Pulmonale CAD

CHF Post CABG Anesthesia

Hypoxia

Cardiac anomalies

Sypathomimetic drugs

Signs and Symptoms

Prolonged HR

Decreased CO r/t decreased CV

Hypotension

Dyspnea

Angina

PAT / PSVT

NSR PAC PAT

150-200 /

minute

Regular or

Slightly

Irregular

P wave: Often not

identifiable

Absent

PR Interval:

Shortened /

normal

QRS:

Usually normal,

initiated above

the ventricles.

Treatment

Vagal stimulation through

Valsava maneuver

Slows heart rate down

Coughing

Carotid massage:

dont do it! Can have person stroke. Do

not massage both sides at

the same time.

Cardioversion AV ablation

Surgical cardiac cath EPS

study

Medications

Digoxin

Pronestyl (IA)

Inderal (II)

IV Adenosine*


HEART BLOCKS


FIRST DEGREE HEART BLOCK

Impulse is slowed through the AV node

Clinical Conditions Associated

MI CAD Rheumatic Fever

Vagal stimulation Hyperthyroidism

Drug use of: digoxin, b-blockers, CCB,

flecainimide Prolonged PR interval. Looks like NSR but PR interval is LONGER.

Varies but

normal Regular

PR Interval: Greater than .20

seconds,

prolonged*

QRS: Normal

Usually asymptomatic

No treatment needed.

Monitor and drugs.

Adjust drug therapy

Atropine: if symptomatic

and bradycardic

Monitored for progression

into more advanced degree of

block

SECOND DEGREE HEART BLOCK

TYPE I MOBITZ I * / WENKEBACH

Gradual lengthening of PR interval

Occurs in the AV node


Digoxin Use Beta blocker use

CAD

Clinical Significance

MI or infarction

Warning signs of *more serious AV

conduction

Disturbance

Dropped QRS. PR interval progressively becoming prolonging. The

PR interval, longer, longer, longer, then it DROPS a QRS complex.

Poor conduction through the AV node.

Normal

Atrial

Rhythm:

Normal

Ventricular

Rhythm:

Slow blocked QRS

Pattern of

grouped beats

PR progressively

lengthens until a

QRS complex is

dropped*

Symptomatic:

Atropine* to increase HR

Temporary pacemaker

Asymptomatic:

Closely observe rhythm

SECOND DEGREE HEART BLOCK

TYPE II AKA MOBITZ II*


Rheumatic Heart Disease

CAD

Anterior MI Drug toxicity


Progressive to type III heart block

Poor prognosis

Conduction through AV node variable.

Same constant PR interval.

Atrial

Rate:

Normal

Ventricular

Rate

Slow

Atrial

Rhythm:

Normal

Ventricular

Rhythm:

Irregular

Sudden

dropped complex*

P wave:

Normal

PR Interval:

Constant

CONSISTENT*

QRS: Suddenly dropped

complex

Often WIDE

Discontinue causative

medications

Drugs Used

Atropine*

Epinephrine*

Temporary pacemaker

Permanent pacemaker

needed*

Increases sinus rate

Monitor for progression into

third degree heart block


HEART BLOCKS


THIRD DEGREE HEART BLOCK

AKA COMPLETE HEART BLOCK

AV dissociation Independent atrial and ventricular

activity

No impulses from atria and ventricles


Severe heart disease CAD MI

Myocarditis Cardiomyopathy

Amyloidosis Sclerosis

Medications: digoxin B-blockers CCB


Asymptomatic or Life threatening

Decreased CO with subsequent

ischemia, HF, and stroke

Syncope: severe bradycardia / asystole

More than 1 P wave for every QRS. Totally miscommunication. P

to P. No dropped beat.

Atrial faster than

ventricular

Atria and ventricular

independently

regular

P wave:

Normal

PR Interval:

varies

QRS interval: Normal or wide

Normal: above

bundle

Widened: Below

of His

Atropine*

Increases HR and BP

For bradycardia

More effective with Mobitz I,

does not work well with

Mobitz II

Calcium Chloride

For CCB toxicity

Pacemaker:

Temporary, and if no

improvement permanent

Transthoracic pacemaker

VENTRICULAR DYSRHYTHMIAS


PREMATURE VENTRICULAR

CONTRACTIONS (PVCS)

Ectopic focus or foci in the ventricle,

emitting impulses which are early in the

cycle and override the SA node impulse

Each focus creates an impulse which

looks the same each time

Potentially lethal* and lead to V. tach

1. Unifocal: same shaped PVCs 2. Multifocal: PVCs appearing

different

3. V. trigeminy: every 3rd beat as

PVC

4. V. Bigeminy: every 2nd beat as

PVC

5. Couplet: two consecutive PVCs

Causes

cardiac disease

electrolyte imbalance

K and Mg

hypoxemia

stimulants (caffeine)

Signs and Symptoms Reduced CO: angina and acute MI

Pulse deficit

Unifocal PVC

Multifocal PVCs

Runs of PVCs

"

Depends on

underlying

rhythm and the # of

PVCs

Similar to

atrial.

Because

they are

occurring early, QRS

complex

gets wide.

Irregular

P wave:

No P wave

preceding PVC

PR Interval:

Immeasurable

QRS of PVC:

>0.12 seconds

Premature

occurrence of the

QRS wide and distorted

T wave:

Large and

opposite direction

CRITERIA FOR

TREATMENT: More than 6 per minute

Multiform

Runs of PVCs: indicates ventricular tachycardia*

R on T

CORRECT CAUSE:

Correct hypoxia with oxygen

therapy

Check pulse ox

Correct electrolyte

imbalance with electrolyte

replacement

Especially Mg and K

Before administering

medications, consider the underlying rhythm/rate

MEDICATIONS:

Lidocaine* if underlying rate

normal or tachycardic (IB) to

erase PVC and what is

causing it. If land on T wave,

can put them into code.

Atropine* if underlying rate

is bradycardic



VENTRICULAR TACHYCARDIA

Three or more PVCs Foci fire repetitively: ventricle takes

control as pacemaker

1. Monomorphic: QRS complexes

same

2. Polymorphic: QRS complexes

change back and forth

Torsades de Pointes:

Polymorphic VT associated with

prolonged QT

Life-threatening dysrhythmia*

Causes

MI Hypokalemia

Hypomagnesimia Hypoxia

Signs and Symptoms

Stable (with a pulse)

Unstable (Pulseless)

Sustained: Less than 30 seconds

Decreased CO leading to:

Hypotension

Pulmonary Edema

Decreased cerebral blood flow

Cardiopulmonary arrest

Torsades De Pointes* TREATMENT MUST BE MAGNESIUM, OR YOU WILL NOT GET THEM BACK.

Ventricular Tachycardia

150 200 per minute

Regular

P wave:

Usually not

identifiable

PR Interval:

Not applicable

QRS Complex:

>0.12 seconds

If conscious and stable:

Lidocaine bolus and drip (IB)

Cough CPR

Cardioversion

If unconscious and

pulseless

CPR - full code

Defibrillation Vasopressors Epinephrine

Antidysrhythmics

Aminodarone

Treat cause

electrolytes

drug toxicities

AICD

Torsades de Pointe:

Magnesium first!

VENTRICULAR FIBRILLATION

Asynchronous, chaotic, impulses

emitted from multiple foci in the

ventricle.

Quivering of the heart

No cardiac output

Cardiac arrest


Acute MI Myocardial ischemia

Cardiac pacing Catheterization

Chronic HF Cardiomyopathy

Coronary Perfusion Accidental electrical shock

Hyperkalemia

Hypoxemia

Acidosis

Drug toxicity

Clinical significance

Unresponsive

Pulseness Apneic

Death

Defibrillation

Not

measurable

Irregular and

chaotic

P wave

Not visible

PR Interval and QRS:

Not measurable

Defibrillation

CPR

Medications

Amiodorone (III)

Lidocaine (IB)

This is the most common

terminal event in sudden

cardiac death syndrome*

AED

dysrhythmias chart

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