- •Contents
- •Contributors and consultants
- •Not another boring foreword
- •A look at cardiac anatomy
- •A look at cardiac physiology
- •A look at ECG recordings
- •All about leads
- •Observing the cardiac rhythm
- •Monitor problems
- •A look at an ECG complex
- •8-step method
- •Recognizing normal sinus rhythm
- •A look at sinus node arrhythmias
- •Sinus arrhythmia
- •Sinus bradycardia
- •Sinus tachycardia
- •Sinus arrest
- •Sick sinus syndrome
- •A look at atrial arrhythmias
- •Premature atrial contractions
- •Atrial tachycardia
- •Atrial flutter
- •Atrial fibrillation
- •Wandering pacemaker
- •A look at junctional arrhythmias
- •Premature junctional contraction
- •Junctional escape rhythm
- •Accelerated junctional rhythm
- •Junctional tachycardia
- •A look at ventricular arrhythmias
- •Premature ventricular contraction
- •Idioventricular rhythms
- •Ventricular tachycardia
- •Ventricular fibrillation
- •Asystole
- •A look at AV block
- •First-degree AV block
- •Type I second-degree AV block
- •Type II second-degree AV block
- •Third-degree AV block
- •A look at pacemakers
- •Working with pacemakers
- •Evaluating pacemakers
- •A look at biventricular pacemakers
- •A look at radiofrequency ablation
- •A look at ICDs
- •A look at antiarrhythmics
- •Antiarrhythmics by class
- •Teaching about antiarrhythmics
- •A look at the 12-lead ECG
- •Signal-averaged ECG
- •A look at 12-lead ECG interpretation
- •Disorders affecting a 12-lead ECG
- •Identifying types of MI
- •Appendices and index
- •Practice makes perfect
- •ACLS algorithms
- •Brushing up on interpretation skills
- •Look-alike ECG challenge
- •Quick guide to arrhythmias
- •Glossary
- •Selected references
- •Index
- •Notes
Quick guide to arrhythmias
Sinus arrhythmia |
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Sinus bradycardia |
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Features
•Rhythm irregular; varies with respiratory cycle
•P-P and R-R intervals shorter during inspiration, longer during expiration
•Normal P wave preceding each QRS complex
Treatment
• Typically no treatment necessary; possible correction of underlying cause
Cut along the dotted lines for quick-review
cards.
Features
•Rhythm regular
•Rate < 60 beats/minute
•Normal P wave preceding each QRS complex
•Normal QRS complex
•QT interval may be prolonged
Treatment
•No treatment needed if patient is asymptomatic; if drugs are cause, possibly discontinuation of use
•For low cardiac output, dizziness, weakness, altered level of consciousness, or low blood pressure, consider temporary or permanent pacemaker and atropine, dopamine, or epinephrine
Sinus tachycardia |
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Sinus arrest |
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Features
•Rhythm regular
•Atrial and ventricular rates > 100 beats/minute
•Normal P wave preceding each QRS complex
•Normal QRS complex
•QT interval commonly shortened
Treatment
•No treatment necessary if patient is asymptomatic
•Correction of underlying cause
•Beta-adrenergic blocker or calcium channel blocker administration, if cardiac ischemia occurs
Features
•Rhythm normal, except for missing PQRST complexes
•P wave is periodically absent with entire PQRST complexes missing; when present, normal P wave precedes each QRS complex
Treatment
•No treatment needed if patient is asymptomatic
•For mild symptoms, possible discontinuation of drugs that contribute to arrhythmia
•Atropine administration if patient is symptomatic
•Temporary or permanent pacemaker for repeated episodes
359
QUICK GUIDE TO ARRHYTHMIAS
360
Premature atrial contractions (PACs) |
|
Atrial tachycardia |
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Features
•Premature, abnormal P waves (differ in configuration from normal P waves)
•QRS complexes after P waves, except in blocked PACs
•P wave often buried or identified in preceding T wave
Treatment
•No treatment needed if patient is asymptomatic
•Beta-adrenergic blockers or calcium channel blockers, if PACs occur frequently
•Treatment of underlying cause; avoidance of triggers (caffeine or smoking) and use of stress-reduction measures
Features
•Rhythm regular if block is constant; irregular if not
•Rate 150 to 250 beats/minute
•P waves regular but hidden in preceding T wave; precede QRS complexes
•Usually has sudden onset and termination
Treatment
•Vagal stimulation and adenosine administration
•Calcium channel blocker, beta-adrenergic blocker, amiodarone, procainamide, sotalol, or digoxin administration; cardioversion
•Atrial overdrive pacing
•If other treatment fails, synchronized cardioversion may be considered
Atrial flutter |
Atrial fibrillation |
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Features
•Atrial rhythm regular; ventricular rhythm variable
•Atrial rate 250 to 400 beats/minute; ventricular rate depends on degree of AV block
•Sawtooth P-wave configuration (F waves)
Treatment
•Calcium channel blockers or beta-adrenergic blockers if patient is stable and heart function is normal
•Amiodarone, ibutilide, flecainide, propafenone, or procainamide if arrhythmia is present for less than 48 hours
•Synchronized cardioversion immediately if patient is unstable
•Anticoagulation before cardioversion if rhythm is present for more than 48 hours
Features
•Atrial and ventricular rhythms grossly irregular
•Atrial rate > 400 beats/minute; ventricular rate varies
•No P waves; replaced by fine fibrillatory waves
Treatment
•Calcium channel blockers or beta-adrenergic blockers if patient is stable
•Amiodarone, ibutilide, flecainide, propafenone, or procainamide if arrhythmia is present for less than 48 hours
•Synchronized cardioversion immediately if patient is unstable
•Anticoagulation before cardioversion if rhythm is present for more than 48 hours
Wandering pacemaker
QUICK GUIDE TO ARRHYTHMIAS |
361 |
|
Premature junctional contractions
Features
•Rhythm irregular
•PR interval varies
•P waves change in configuration, indicating origin in sinoatrial node, atria, or AV junction (Hallmark: At least three different P wave configurations)
Treatment
•No treatment if patient is asymptomatic
•Treatment of underlying cause if patient is symptomatic
Features
•Rhythm irregular
•P waves before, hidden in, or after QRS complexes; inverted if visible
•PR interval < 0.12 second, if P wave precedes QRS complex
•QRS configuration and duration normal
Treatment
•No treatment if patient is asymptomatic
•Correction of underlying cause
•Discontinuation of digoxin, if appropriate
•Possible elimination of caffeine
Junctional tachycardia |
|
Junctional escape rhythm |
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Features
•Rhythm regular
•Rate 100 to 200 beats/minute
•P waves before, hidden in, or after QRS complexes; inverted if visible
Treatment
•Correction of underlying cause
•Discontinuation of digoxin, if appropriate
•Vagal maneuvers, adenosine, amiodarone, beta-adrenergic blockers, or calcium channel blockers to slow rate
•Possible pacemaker insertion
•Ablation therapy, if recurrent
Features
•Rhythm regular
•Rate 40 to 60 beats/minute
•P waves before, hidden in, or after QRS complexes; inverted if visible
•PR interval < 0.12 second (measurable only if P wave appears before QRS complex)
Treatment
•Treatment of underlying cause
•Atropine administration for symptomatic slow rate
•Pacemaker insertion if refractory to drugs
•Discontinuation of digoxin, if appropriate
QUICK GUIDE TO ARRHYTHMIAS
362
First-degree AV block
Type I second-degree AV block (Mobitz I, Wenckebach)
Features
•Rhythm regular
•PR interval > 0.20 second
•P wave preceding each QRS complex; QRS complex normal
Treatment
•Cautious use of digoxin, calcium channel blockers, and beta-adrenergic blockers
•Correction of underlying cause
Features
•Atrial rhythm regular
•Ventricular rhythm irregular
•Atrial rate exceeds ventricular rate
•PR interval progressively, but only slightly, longer with each cycle until a P wave appears without a QRS complex (dropped beat)
Treatment
•Treatment of underlying cause
•Atropine administration or temporary pacemaker, for symptomatic bradycardia
•Discontinuation of digoxin, if appropriate
Type II second-degree AV block (Mobitz Type II)
Third-degree AV block (complete heart block)
Features
•Atrial rhythm regular
•Ventricular rhythm possibly irregular, varying with degree of block
•QRS complexes periodically absent
Treatment
•Treatment of underlying cause
•Atropine, dopamine, or epinephrine administration, for symptomatic bradycardia (Atropine may worsen ischemia with MI.)
•Temporary or permanent pacemaker
•Discontinuation of digoxin, if appropriate
Features
•Atrial and ventricular rhythms regular
•Ventricular rate is 40 to 60 beats/minute (AV node origin); < 40 beats/minute (Purkinje system origin)
•No relationship between P waves and QRS complexes
•QRS complex normal (originating in AV node) or wide and bizarre (originating in Purkinje system)
Treatment
•Treatment of underlying cause
•Atropine, dopamine, or epinephrine for symptomatic bradycardia (Don’t use atropine with wide QRS complexes.)
•Temporary or permanent pacemaker
Premature ventricular contractions (PVCs)
QUICK GUIDE TO ARRHYTHMIAS |
363 |
|
Ventricular tachycardia
Features
•Underlying rhythm regular; P wave absent with PVCs
•Ventricular rhythm irregular during PVC
•QRS premature, usually followed by compensatory pause
•QRS complex wide and bizarre, duration > 0.12 second
•Premature QRS complexes occurring singly, in pairs, or in threes; possibly unifocal or multifocal
•Most ominous when clustered, multifocal, and with R wave on T pattern
Treatment
•If warranted, procainamide, lidocaine, or amiodarone administration
•Treatment of underlying cause
•Potassium chloride I.V. if induced by hypokalemia
Features
•Ventricular rate 100 to 250 beats/minute
•QRS complexes wide and bizarre; duration > 0.12 second
•P waves indiscernible
Treatment
• Monomorphic VT with pulse: Give amiodarone,
using Advanced Cardiac Life Support (ACLS) protocol; if unsuccessful, synchronized cardioversion
•Polymorphic VT with normal QT interval: Amiodarone or sotalol using ACLS protocol; if unsuccessful, synchronized cardioversion
•Polymorphic ventricular tachycardia with prolonged QT interval: Stop drugs that may prolong QT interval and treat electrolyte imbalances
•Pulselessness: Initiate cardiopulmonary resuscitation (CPR) and follow treatment for ventricular fibrillation
Ventricular fibrillation |
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Features
•Ventricular rhythm rapid and chaotic
•QRS wide and irregular; no visible P waves
Treatment
•Defibrillation and CPR
•Epinephrine or vasopressin, amiodarone or lidocaine; if ineffective, magnesium sulfate or procainamide
•Endotracheal intubation
•Implanted cardioverter-defibrillator if at risk for recurrent ventricular fibrillation
Features
•No atrial or ventricular rate or rhythm
•No discernible P waves, QRS complexes, or T waves
Treatment
•CPR, following ACLS protocol
•Endotracheal intubation
•Transcutaneous pacemaker
•Treatment of underlying cause
•Repeated doses of epinephrine and atropine, as ordered