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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. Objectives. Upon successful completion of this module, the EMS provider will be able to: identify various rhythm strips
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Rhythm ReviewMarch 2010 CECondell EMS System Prepared by: Steve Holtz, FF,PM Libertyville Fire Department Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
Objectives • Upon successful completion of this module, the EMS provider will be able to: • identify various rhythm strips • state criteria critical to identifying rhythm strips • Identify ST elevation on a 12 lead EKG
Rhythm Review Sinus Rhythm Regular rhythm Rate 60 -100 P waves upright, uniformed PR interval 0.12 – 0.20 seconds QRS complex <0.12 seconds
Rhythm Review Sinus Arrhythmia Rhythm is irregular Common in children Influenced by respirations – rate increases during inhalation and decreases during exhalation
Rhythm Review 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
Rhythm Review Atrial Flutter Rhythm can be regular or irregular P waves form flutter waves P waves also called a picket fence appearance
Rhythm Review Sinus Tachycardia Rate greater than 100/minute Treatment aimed at determining the cause Do not treat this rhythm with medication
Rhythm Review 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
Rhythm Review 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 O2 is helpful
Rhythm Review 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
Rhythm Review 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
Rhythm Review 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
Rhythm Review 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
Rhythm Review 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
Rhythm Review Sinus Arrest Patient usually complains of passing out, not having energy May need permanent pacemaker implanted Support and treat symptoms
Rhythm Review Asystole Patient needs CPR and for you to identify the cause Think 6 H’s and 5 T’s
Rhythm Review 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?
Rhythm Review 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
Rhythm Review 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
Rhythm Review 3rd 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
Rhythm Review There is NO pulse!
Rhythm Review NO pulse! 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)
Rhythm Review NO pulse!
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
Rhythm Review 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)
II, II, aVF (inf wall), V5 Call Medical Control before giving Nitroglycerin; can develop hypotension
V2, V3, V4, V5 Watch for ventricular dysrhythmias (V3, V4 – widow maker) & heart block
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)
