1. Rhythm Review March 2010 CE Condell EMS System Prepared by: Steve Holtz, FF,PM Libertyville Fire Department Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: Upon successful completion of this module, the EMS provider will be able to: identify various rhythm strips identify various rhythm strips state criteria critical to identifying rhythm strips state criteria critical to identifying rhythm strips Identify ST elevation on a 12 lead EKG Identify ST elevation on a 12 lead EKG

3. Rhythm Review Rhythm Review

4. Sinus Rhythm Regular rhythm Rate 60 -100 P waves upright, uniformed PR interval 0.12 – 0.20 seconds QRS complex <0.12 seconds

5. Rhythm Review Rhythm Review

6. Rhythm Review Sinus Arrhythmia Rhythm is irregular Common in children Influenced by respirations – rate increases during inhalation and decreases during exhalation

7. Rhythm Review

8. Sinus w/PAC Underlying rhythm is sinus Abnormal complexes are early P wave unusual to the underlying normal P wave The PR interval different from the underlying normal

9. Rhythm Review

10. Atrial Flutter Rhythm can be regular or irregular P waves form flutter waves P waves also called a picket fence appearance

11. Rhythm Review

12. Sinus Tachycardia Rate greater than 100/minute Treatment aimed at determining the cause Do not treat this rhythm with medication

13. Rhythm Review

14. Atrial Fibrillation Rhythm grossly irregular No discernable P waves Pulses irregular in strength when palpated Auscultated heart rate will hear some tones louder than others Patient is at risk of a stroke from throwing a clot from the fibrillating atria

15. Rhythm Review

16. Sinus w/PVC (Multifocal) Underlying rhythm regular Abnormal beats come early, are wide and bizarre To determine overall heart rate, count all complexes in 6 seconds and multiply by 10 Often administration of O 2 is helpful

17. Rhythm Review

18. SVT Rate over 150-160 P waves usually not seen or if present will be abnormal (appearance, shorter PR interval). Patient usually symptomatic with pounding in chest, paleness, diaphoresis If patient relatively stable, treat with Adenosine

19. Rhythm Review

20. V-Tach 3 or more PVC’s in a row If patient is relatively stable, treat with antidysrhythmic (Amiodarone 150 mg slow IVPB over 10 minutes or Lidocaine 0.75 mg/kg) Do not mix anitdysrhtymics – makes heart irritable

21. Rhythm Review

22. Junctional Rhythm Inherent rate 40-60 per minute P waves changed – may be absent, inverted, or after the QRS Symptoms generally determined by overall rate If symptomatic bradycardia, treat with Atropine 0.5 mg and consider need to apply TCP if not responsive to Atropine

23. Rhythm Review

24. V- Fib Patient apneic, no pulse Immediate CPR for 2 minutes if unwitnessed If witnessed, CPR only until defibrillator charged and ready to defibrillate Resume CPR immediately after each defibrillation, start with compressions

25. Rhythm Review

26. Sinus Bradycardia Overall rate <60 If patient asymptomatic, observe If patient symptomatic, prepare Atropine 0.5 mg rapid IVP May repeat every 3-5 minutes (max 3 mg) Consider application of TCP if no response to Atropine

27. Rhythm Review

28. Sinus Arrest Patient usually complains of passing out, not having energy May need permanent pacemaker implanted Support and treat symptoms

29. Rhythm Review

30. Asystole Patient needs CPR and for you to identify the cause Think 6 H’s and 5 T’s

31. Rhythm Review

32. Paced Rhythm Looking for spike in front of a widened QRS Determine perfusion status of patient Check blood pressure Does he have a pulse that matches the monitor?

33. Rhythm Review

34. Second degree Type II – classical Rate is slow – makes patient symptomatic More P waves than QRS complexes PR interval will be consistent A more lethal block – be aggressive – start with TCP Check for presence of acute MI

35. Rhythm Review

36. Second degree Type I – Wenchebach Irregular rhythm PR intervals get longer and longer A QRS is periodically dropped Think Type I drops one Patient rarely symptomatic - observe

37. Rhythm Review

38. 3 rd degree – complete heart block Rhythm regular, almost always slow P to P marches out (not a problem at the SA node) QRS are regular No correspondence between P waves and QRS If symptomatic treat with TCP (lethal rhythm) Check for presence of acute MI

39. Rhythm Review There is NO pulse!

40. Rhythm Review PEA – rate slow (50) CPR, search for causes (6 H’s, 5 T’s) First drug is Epinephrine 1 mg (repeated every 3-5 minutes) If rate is <60, alternate with Atropine 1 mg (max 3 mg) NO pulse!

41. Rhythm Review NO pulse!

42. Rhythm Review PEA – rate >60 CPR, search for causes (6 H’s, 5 T’s) Epinephrine 1 mg every 3- 5 minutes NO atropine – rate >60!!! NO defibrillation – electrical activity is okay

43. Rhythm Review

44. Sinus rhythm with wide QRS Patient will not be symptomatic for EMS intervention due to wide QRS Wide QRS indicates ventricular conduction defect – more time taken to conduct through ventricles so QRS time longer (ie: wide QRS)

45. Where is the ST elevation?

46. II, II, aVF (inf wall), V5 Call Medical Control before giving Nitroglycerin; can develop hypotension

47. Where is the ST elevation?

48. V2, V3, V4, V5 Watch for ventricular dysrhythmias (V3, V4 – widow maker) & heart block

49. Where is the ST elevation?

50. II, III, aVF – Inf Wall Call Medical Control after aspirin given and before Nitroglycerin; give report including vital signs Notice reciprocal changes (ST depression I, aVL, V1, V2)

51. Where is the ST elevation?

52. V2, V3 – Septal MI Watch for heart block – treat second degree Type II and 3 rd degree with TCP