• CAB plus D ASAP
• C - compressions/circulation
• A- airway
• B - breathing
• D - defibrillate/check rhythm ASAP, i.e. as soon as defibrillator arrives

• Pulse check in <10 sec (central pulse)
• Rate ≥ 100/min
• Deep: at least 2" in adults
• Allow complete chest recoil
• Minimize interruptions (<10 sec)
• switch every 2 min
• Hands off pt during defibrillation
• Pulse rhythm and assesment
• Compression: ventilation ratio 30:2 (BVM ventilation)

• After first 30 compressions (if solo)
• Head-tilt/chin-lift (no LLF!). 
• Don't do if potential c-spine injury
• Jaw thrust
• safe in c-spine injury if head is not tilted back.
• Check for obstruction: look in mouth, finger sweep, suction. Check mouth before first several ventilation cycles as chest compression may dislodge foreign bodies in airway.

• Assessment: no breathing or only gasping when checking responsiveness 
• Bag-valve mask (30:2)
• 2 operators best
• Jaw lift into mask
• 15 L O2
• look for chest rise
• Artificial (oropharyngeal or nasopharyngeal) airways improve ventilation
• When more supplies and personnel arrive, do ET intubation.

• 8-10 breaths per min (one breath every 6-8 seconds)
• Don't stop compressions!
• When rate is too high (>10/min) you can get "breath stacking", resulting in increased intrathoracic pressure, decreased VR to heart, impaired CO. 

• asystole
• ventricular fibrillation
• ventricular tachycardia
• PEA (pulseless electrical activity) 

• Shockable rhythms: ventricular fibrillation and pulseless VT (D takes precedence over rest of CAB once paddles are ready!)
• Not shockable: PEA, asystole
• When shockable, defibrillate at 360 J monphasic or 200 J biphasic

• aka "flatline"
• dismal px
• double check connections to monitor
• confirm in 2 leads
• (often preceded by another abnormal rhythm)

• Continue CPR (30:2)
• Give epinephrine 1 mg IV q3-5 min until code ends
• After 5 cycles of 30:2 CPR (about 2 min) check for rhythm change and pulses
• new rhythm = new algorithm
• still asystole = more epi and CPR
• Consider termination after 3 rounds of drugs if no change

• Intraosseous line is best
• Endotracheal tube administration is okay for certain meds (NAVEL)
• naloxone
• vasopressin
• epi - 2mg diluted in 10 cc saline
• lidocaine

• CPR (30:2) & "run the differential"
• Epinephrine 1 mg IV q3-5 minute until code ends
• After 5 cycles of CPR check rhythm and pulses
• new rhythm or pulses = new algorithm
• still PEA - repead meds and CPR and find the reversible cause!!

• The 6 H's and the 5 T's
• Hypovolemia...tx=IV fluid bolus
• Hypoxia...tx=airway and breathing 
• H+ (acidosis)...bicarb, hyperventilation
• Hyperkalemia...insulin, dextrose, bicarb, sometimes Ca gluconate (if cause is not dig. toxicity)
• Hypoglycemia...IV dextrose
• Hypothermia...warming
• Toxins: digoxin...digibind, TCAs...IV bicarb and ventilation, beta blocker...glucagon
• Tamponade: cardiocentesis
• Tension pneumo...thoracostomy
• Thrombosis (ex PE)...tPA
• Trauma

• Do CPR until paddles are charged. All clear! Shock.
• Do CPR for 5 cycles after shock is delivered. Then check rhythm again. If still VF/VT...
• Do CPR until paddles are charged. All clear! shock.
• Do 5 cycles CPR. During 5 cycle interval of CPR give 1 mg epinephrine IV.
• After 5 cycles, check rhythm. If still VF/VT...
• Do CPR until paddles are charged. All clear! shock.
• Do 5 cycles of CPR. During 5 cycle interval of CPR give amiodarone 300 mg.
• After 5 cycles, check rhythm. If still VF/VT...
• Do CPR until paddles are charged. All clear! shock.
• Do 5 cycles of CPR. Give another dose of epi during 5 cycle interval.
• After 5 cycles, check rhythm. If still VF/VT...
• Do CPR until paddles charged. All clear! shock.
• Do 5 cycles of CPR. During 5 cycle interval give 150 mg amiodarone.

• Can use as an alternative to epinephrine
• Dose: 40 U IV, once
• no proven benefit over epi

• First: amiodarone 300 mg IVB
• 150 mg amiodarone maybe repeated once
• After 2 doses of amiodarone, then give lidocaine if still attempting resuscitation. 
• lidocaine: 1.5 mg/kg IVB
• then 0.75 mg/kg repeated to a max of 3 mg/kg

• It's a type of polymorphic ventricular tachycardia with progressive changes in the QRS complex.
• Associated with long QT interval on sinus EKG. Can be associated with
• hypo-Mg, hypo-K
• drugs: Procan, TCAs, haldol, e-mycin
• bradyarrhythmias
• congenital
• Often presents as brief, recurrent episodes/bursts
• treat with IV magnesium sulfate, 2 gm over 5 min, then IV drip at 0.5-1 g/hr.
• defibrillation when pt is pulseless or unstable
• rapid pacing if bradycardia related

• Support BP with normal saline bolus.
• allow time for "stunned myocardium" to recover
• IV pressors if needed (DA, dobutamine, NE)
• Give appropriate antiarrhythmic (ex. amiodarone, 150 mg IV over 10 min, repeat).
• Check & correct K and Mg
• 12 lead EKG. If acute MI present → cath lab
• Hypothermic protocol if comatose
• Admit to ICU

• Grid with each large square composed of 5 small squares.
• Duration - x-axis
• small squares 40 millisec
• large squares 200 millisec
• Amplitude - y-axis
• small square - 1mm (.1 mV)
• large sqaure - 5 mm (.5 mV)

• lead I - + at 0 degrees (on horizontal)
• lead II - + at +60 degrees (going clockwise from horizontal)
• aVF - + at +90 degrees

• If direction of depolarization is toward the + pole = + deflection
• If direction of depolarization is perpendicular to the axis = flat (equiphasic) or a + and - deflection
• If direction of depolarization is away from + pole = negative deflection

• Normal QRS axis is -30 degrees to +90 degrees.
• mostly positive or equiphasic (flat) in leads I and II
• Duration < 100 msec (2.5 small boxes)
• If >120 msec = wide QRS - pathologic

• Leftward and downward (from sinus node in atrium); 0 to +75 degrees.
• Upright in lead I and upright (or rarely flat) in AvF
• Duration: 80-110 msec (2 to 2.5 boxes)
• Normal amplitude <2.5 mm (=small boxes)
• Normal interval is 120-200 msec (3-5 boxes)
• long PR in 1st degree AV block
• short PR in WPW

• amplitude: <6 mm (6 small boxes) (taller than Ps)
• Upright in leads I and II.
• Duration: measured as part of QT interval. At normal HR (60-100 bpm), QT interval should be < 1/2 R-R interval.   (if not = long QT)

• uniform shape in a given lead
• normal P wave axis (upright in lead I and upright/flat in AvF)
• Normal and constant PR interval (120-200 msec)
• One p-wave for every QRS complex

• Definition: rate < 60 bpm
• Causes include:
• Physiologic - athlete, person is asleep
• Pathologic - hypothyroidism, hyperkalemia, excess vagal stimulation, sinus node dysfunction (SA node exit block & sinus arrest)
• Pharmacologic - beta blockers, CCBs, amiodarone, sotalol, digoxin, clonidine.

Sinus Nodal Block (exit blockor secondary SA nodal block)

(not on test?)

• SA node is not represented on EKG, but when SA node firing is blocked it results in loss of both P-wave and QRS.
• In SA nodal block, you see pauses (breaks without any Ps or QRSs) that a multiples of 2 of the baseline P-P interval. 

• SA node has impaired automaticity.
• Long pause is not a multiple of baseline P-P interval.
• Last beat (after pause) is a junctional escape beat (no preceding P-wave). 

• AV nodal escape - no P wave, narrow QRS, rate 40-60
• Ventricular escape: wide QRS (>120 msec), rate 20-40

AV nodal blocks: First Degree 

(NEED TO KNOW ALL 4 AV NODAL BLOCKS!)

• delay in transmission through AV node
• PR interval is >200 msec (=1 large box)

• Progressive prolongation of PR interval until there is a dropped QRS. 
• Often produces "grouped beats" of QRS's (between the spaces created by the consistently dropped QRS's)
• Generally benign rhythm that occurs at rest and resolves with extertion (walking). 

• Regular P waves with occasional drop of QRS complex.
• PR interval doesn't change before conducting beats.
• Not benign. May progress to complete heart block.
• Associated with CAD, MI, drug toxicity (digoxin, beta blocker, etc).
• NOTE: when there are 2 P waves for each QRS (2:1 conduction) there is no way to differentiate type I and type II (can't observe progressive lengthing of type I). 

• complete failure of conduction from atria to ventricles (BAD), i.e. atria and ventricles contract at regularly, but independently of one another.
• artial rate is always faster than ventricular rate
• escape rhythms arise from
• Bundle of His - narrow QRS (unless BBB), rate 40-60
• Ventricle - wide QRS (>120 msec), rate 20-40

• Assess appropriateness for clinical condition
• Urgency is driven by sx of poor perfusion, therefore, first step = assess for s/sx of poor perfusion: altered mental status, ischemic chest pain, hypotension, signs of shock (diaphoresis, pale, clammy), difficulty breathing, CHF, seizure or syncope.

• Prepare of transcutaneous pacing, especially for Type II second degree AV block and third degree AV block.
• apply pacing patches
• Turn "Zoll box" to pacing
• Set rate to 60
• Increase amperage until capture = until pacemaker spike is reliably followed by QRS
• Provide narcotic and sedative for pain relief
• Call cardiology for transvenous pacing.
• Atropine may "bridge" until pacing (may be effective alone in treating symptomatic bradycardia, esp sinus).
• Atropine dose: 0.5 mg q3-5 min up 3 mg total
• May worsen cardiac ischemia if HR ↑
• Often ineffective for type II 2° and 3° AVBs

• transcutaneous pacing
• epinephrine drip 2-10 mcg/min
• dopamine drip 2-10 mcg/kg/min

• Sinus tachycardia is the most common tachycardia and is NOT treated by shocking!
• Causes:
• hypovolemia
• hypoxemia
• severe anemia
• pain and anxiety
• stimulants
• hypothyroidism 
• pheochromocytoma
• fever

• Ventricular tachycardia
• intraventricular conduction delay: RBBB, LBBB, or nonspecific (=QRS>120 msec, pattern doesn't fit other BBBs)
• Conduction down (A→V) the bypass tract (in WPW).

• majority are d/t re-entry involving the edges of previously damaged myocardium (MI, myocarditis,etc)
• May occur in otherwise healthy pts (idiopathic)
• May present as PNB or completely asymptomatic.
• Rate is 100-120
• Wide QRS (>120 msec or 3 little boxes)
• R-R interval regularity
• Up to 30% of EKGs show AV dissociation = diagnostic for VT

• In patients with prior MI, a new wide-QRS tachycardia is VT 98% of the time.
• Assume that a new wide-QRS tachycardia is VT (and treat accordingly) until proven otherwise. 

• Preparation
• O2 monitor and supplementation
• IV line and telemetry
• suction and intubation equipment
• Premedication (if possible)
• midazolam, 1-2 mg IV
• fentanyl 25-50 mcg IV (alternate: propofol)
• Synchronized cardioversion
• press "synchronize" button
• all clear!
• Pads or 25 lb pressure on paddles with gel
• 100-200 J biphasic or monphasic shock
• Reset sync mode after each shock

• Amiodarone 150 mg IV over 10 minutes
• SE = hypotension
• May give 2nd dose after 10 min
• Full IV load involves 24 hr drip (ask cardiology first)
• Correct electrolyte imbalance (K, Mg)
• Cardiac consult

• give adenosine for monomorphic and regular tachycardias
• Give 6 mg IV push, followed by NS bolus
• If first dose is ineffective, then give 12 mg IV push 
• Do NOT use adenosine in an irregular wide-QRS tachycardia: can be lethal in pts with WPW who are in Afib.

• QRS>120 msec
• R-S-R' in V1 or V2
• Wide S wave in I or V6 (lateral leads)
• [S wave = late depolarization of RV spreading slowly from the LV]

• QRS < 120 msec
• Broad monophasic R wave in I and V6 (left side leads)
• Mainly negative complex (QS, rS) in V1

• Mechanism: accessory pathway is a muscle bundle (of Kent) that spans the AV septum and electrically connects the atrium to the ventricle → premature ventricular depolarization
• EKG: antridromic AV re-entrant tachycardia (AAVRT): regular wide complex tachycardia
• Tx: IV bolus adenosine 6 mg IVP, repeat at 12 mg if needed.; also responds to amiodarone 150 IV over 10 min if adenosine is unsuccessful (may repeat with 2nd dose)
• Note: do NOT treat VT or WPW+Afib/flutter with adenosine (or BB, CCB, or digoxin).

• flutter waves at ~300/min (250-350)
• narrow QRS
• Undulating baseline  seen in inferior leads (II, III, F) & V1
• Almost always presents with a block [often 2:1 i.e. 2 p-waves for each QRS.]
• "sawtooth" pattern
• Mechanism: macro-reentry involving right atrium. 
• Adenosine briefly increases block 

• Slow the rate by increasing the block
• IV diltiazem bolus 0.25 mg/kg then drip at 5-15 mg/hr. May give 2nd bolus of 0.35 mg/kg in 10 min.
• IV metoprolol 5 mg q5 min x1-4 doses
• (IV esmolol bolus (500 mcg/kg) and drip)

• Definition: nonspecific term that refers to a tachycardia originating above the bundle of His. Includes several specific rhythms.
• EKG: Regular, narrow QRS, fast rhythm without P waves or flutter.

• Vagal maneuvers
• valsalva
• carotid sinus massage (make sure atropine rescue is available)
• Adenosine
• produces brief (3 sec) block at AV node
• antecubital, large bore IV needed
• push 6 mg adenosine followed by NS 10 cc bolus
• Repeat with 12 mg if not effect
• 2nd line if adenosine doesn't work: IV diltiazem, esmolol, or metoprolol
• Cardioversion

• irregularly, irregular QRS's
• No organized P-waves
• Rate 100-180
• Note: A. flutter and A. tachycardia are irregular if there's a variable block, i.e. 2:1 changes to 3:1.
• Treat like A flutter: IV diltiazem or beta blocker to slow

• Is patient stable or unstable?
• Unstable - do synchronized cardioversion
• Stable - further identify as:
• unknown stable regular monomorphic wide-QRS
• stable VT
• stable regular, narrow QRS
• stable irregular, narrow QRS or atral flutter
• AF+WPW

1. First: IV adenosine 6 mg then 12 mg PRN
2. Second: IV amiodarone 150 mg/10 min, repeat PRN
3. Synchronized cardioversion 100 J

• IV amiodarone or synchronized cardioversion @ 100 J

• First IV adenosine (+/- vagal maneuvers)
• Second, IV diltiazem or beta blocker
• Synchronized cardioversion @ 50-100 J

• IV diltiazem or beta blocker
• Synchronized cardioversion
• atrial fibrillation: 120-200 J
• atrial flutter: 50-100 J

• Continuous cardiac monitoring/12 lead ECG
• Provide supplemental O2, monitor pulse ox
• Obtain IV access
• Bedside CXR (r/o Ao dissection)
• Administer cardiac meds (aspirin, nitro,morphine, heparin, beta blockers)
• Rapidly assess reperfusion ability: PTCA vs thrombolytics

• Hear wheezing
• Bronchiolitis is common cause, esp 3-6 mo (up to 2 yo). (CXR is not recommended for dx)
• key: head positioning and suctioning
• may give albuterol
• Asthma
• albuterol

• stridor (inspiratory, high-pitched)
• Causes
• Croup - give epi 
• Anaphylaxis 
• Foreign body (CXR)
• Tx: epinephrine, nebulizer racemic mixture

• ABC's
• Categorize: respiratory failure vs. respiratory distress? compensated vs. decompensated shock?
• Decide next steps
• Act (ex. airway repositioning, nasal suction, supplemental O2)

• Distress: increased rate, effort, and noise of breathing, requires much energy
• give supplemental O2 (ex. mask)
• Failure: slow or absent RR, weak or no effort, quiet
• assisted airway

• compensated: systolic BP is okay, but perfusion is poor. Central and peripheral pulses are unequal. Skin is cool and pale. Capillary refill prolonged (>2 sec)
• decompensated: systolic hypotension with poor or absent pulses, poor color, etc.

• secondary assessment: H&P
• tertiary assessment: labs, XR

• shock = inadequate delivery of metabolic substrates to meet needs of tissues
• shock ≠ low bp
• can be normal bp (compensated) or low bp (decompensated)
• hypotension = late sign of shock (esp in kids)

• Infant: 30-60
• Toddler 24-40
• Preschooler: 22-34
• School-age: 18-30
• OR:
• normal 40-30-20; too high 60, 50, 40
• 1st 6 mo: 40s, too high: 60
• 6-12 mo: 30s, too high: 50
• 1 yr: 20s, to high: 40

• < 3 mo: 80-205
• 3 mo - 2 yo: 75-190
• 2 - 10 yo: 60 - 140
• 10+: 50-100
• Normal temp: 98.6 or 37C

• infant: > 60s-70s 
• 1 to 10: > 70 + (2 x age in years)