Normal Sinus Rhythm

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• Rate: 60-100 bpm
• Rhythm: regular in both atria and ventricles
• P waves are present
• P waves are upright and uniform
• Interval length: 0.12-0.20
• QRS look similar
• Length of QRS: <0.12

Sinus Bradycardia

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• Rate: <60bpm
• Rhythm: regular
• P waves are present
• Interval length: 0.12-0.20
• QRS look similar
• QRS length: <0.12
• Interventions: Check to see if the patient is symptomatic. Check the patient for signs of decreased cardiac output. If symptomatic, try to find and treat cause of symptoms. If asymptomatic, continue to monitor. Continued failure of medicinal interventions may lead to pacemaker implantation.
• Medications: Atropine, epinephrine

Sinus Tachycardia

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• Rate: >100bpm
• Rhythm: regular
• P waves are present
• Interval length: 0.12-0.20
• QRS look similar
• QRS length: <0.12
• Common causes: pain and fever
• Treatment: Treat the source if at all possible. Check patient for signs of decreased cardiac output. If there is continued failure of medication treatment, synchronized cardioversion may be used. Lack of proper treatment may lead to heart failure.
• Medications: Digoxin, beta blockers, calcium channel blockers

Sinus Arrest

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• Common causes: vagus nerve stimulation, cardiac disease, myocardial infarction, medications, coronary artery disease, cardiomyopathy
• Treatment: Dependent on the patient's presenting symptoms. If no symptoms, monitor for progression. Monitor patient for signs of decreased cardiac output. Medication failure may result in placement of pacemaker.
• Medications: atropine, epinephrine, dopamine

Premature Atrial Contraction

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• Rate: difficult to determine
• Rhythm: irregular
• P waves are premature
• Almost everything appears normal about the rhythm except a beat occasionally being premature.
• Causes: Early depolarization is usually caused somewhere other than the SA node. AV node is the most common place of early depolarization. Heart disease, hypoxia, electrolyte imbalance, digoxin toxicity, stress, stimulants, pain
• Treatment: Monitor patients for symptoms. Determine how often the beats are premature. Treat/remove the cause if at all possible.
• Medications: digoxin, beta blockers, calcium channel blockers

Paroxysmal Supraventricular Tachycardia (PSVT)

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• Consists of a run of repeated premature beats.
• Starts and stops for no known reason. Usually caused by an abnormal electrical pathway inside the heart. 
• Originates anywhere from above the bundle of His.
• Treatment: Vagal maneuvers, possible synchronized cardioversion if patient remains symptomatic or becomes unstable.
• Medications: adenosine (stops and restarts the heart)

Atrial Flutter

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• Identified by recurring and regular sawtooth patterns.
• Rate: Tachycardic
• Atria are contracting quickly, but not completely.
• Cause: abnormal pathway is formed around the right atrium, cardiac surgery, myocardial infarction, digoxin toxicity, valve disease
• Treatment: Stroke precautions need to be implemented due to stagnating blood in the heart. Watchman procedure may be performed. If the patient is symptomatic, find the cause and treat. Patient may just need time. If rhythm is present less than 48 hours, cardiovert the patient. If rhythm lasts more than 48 hours, use anticoagulant therapy for a few weeks, then cardiovert.
• Medications: Cardizem (cardioversion), calcium channel blockers, beta blockers (control ventricular rate if needed)

Atrial Fibrillation

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• Most common dysrhythmia.
• No rhythmic organization present.
• Atria are not contracting, but fluttering.
• Prevalence increases with age.
• Causes: surgery, myocardial infarction, caffeine, coronary artery disease
• High stroke risk due to stagnating blood
• Treatment: If ventricular rate is controlled, cardiovert if the rhythm has been present for less than 48 hours. Pacemaker may be implemented in the long run. Ablation of the abnormal pathways may also be used.
• Medications: Cardizem

Premature Ventricular Contractions

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(Normal sinus with PVC)

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(Ventricular bigeminy)

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(Ventricular trigeminy)

• Very obvious defect
• Unifocal originates from one souce, and the waves look the same. Multifocal originates from multiple sources, and the waves look different.
• A couplet is 2 PVCs in a row.
• Ventricular tachycardia is 3 or more PVCs in a row.
• R on T may occur where the R wave occurs on top of the T wave.
• Ventricular bigeminy: every other beat is premature
• Ventricular trigeminy: every 3rd beat is premature (2 regular, one irregular)
• Causes: digoxin, electrolyte imbalance, stimulants, fever, heart failure, myocardial infarction, pregnancy
• May be harmless if occurring in a normal heart (pregnancy). A disease heart may result in decreased cardiac output.
• Treatment: Find cause and treat.
• Medications: lidocaine, amiodarone

Ventricular Tachycardia

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(Monomorphic)

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(Polymorphic)

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(Torsade de Pointe)

• A run of 3 or more PVCs
• Monomorphic are from the same source and look the same. Polymorphic are from different places and look different.
• Sustained is longer than 30 seconds and will result in decreased cardiac output. Nonsustained is less than 30 seconds.
• Rhythm is life-threatening without termination.
• Treatment: If there is a pulse present, do not shock. Find the cause and attempt to treat. If there is no pulse, shock.
• Medications (Pulse Present): amiodarone, lidocaine
• Torsade de Pointe: Polymorphic VTACH that looks somewhat like a flutter. It is usually caused by hypomagnesium. Treat by administering magnesium. 

Ventricular Fibrillation

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• Most deadly of all the rhythms
• Severe derangement of heart rhythm with no effective contraction or cardiac output
• Causes: shock, drug use, 5H's, 5T's
• Treatment: 5H's and 5T's are reversible. Treat these sources. This is also a shockable rhythm.

Asystole

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• Total absence of ventricular activity
• Legally dead
• Not a shockable rhythm
• Treatment: CPR
• Medications: epinephrine

Pulseless Electrical Activity

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• Electrical activity is present, but there are no contractions occurring.
• This is possible in a dead person with a pacemaker.
• Very poor prognosis
• Causes: 5T's, 5H's (possibly)

• Ventricular Tachycardia with no pulse
• Ventricular fibrillation

• Hypoxia
• Hydrogen
• Hypo/hyper pulmonary
• Hypothermia
• Hypovolemia

• Tension pneumothorax
• Tamponade
• Toxins
• Thrombosis (pulmonary)
• Thrombosis (coronary)

• Strips are 6 seconds long and marked every 3 seconds.
• Every 3 seconds on the paper contains 15 big squares.
• Each big square on the paper consists of 25 small squares.
• Each big square is 0.2 seconds.
• Each small square is 0.04 seconds.

• P wave -- atrial depolarization (contraction)
• PR interval -- Time it takes for an impulse to travel all the way through the atria (total atrial contraction and relaxation)
• QRS complex -- ventricular depolarization (contraction)
• ST segment -- Time between ventricular depolarization and repolarization, should be flat, elevation indicates infarct
• T wave -- ventricular repolarization, high peak may be caused by high potassium
• QT segment -- the entire time frame of repolarization and depolarization of the ventricles

Artifact

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• 3 lead -- 3 electrodes used that view 3 basic angles of the heart, most simple, used for simple bedside monitoring, positive lead 2 is easiest to read
• 5 lead -- usually used in the ICU
• EASI -- 6 lead
• 12 lead -- most in depth, actually only uses 10 leads but still obtains 12 different angles of the heart