EKG

drugs that impact impulse 

• (+)hr ex. epinephrine
• (-) hr ex. digoxin

If the problem is in the P wave the problem is in the atria 

should be less than 0.11

QRS= ventricular depolarization ( stimulation) 

should be less than 0.12 sec

ventricular repolarization ( relax)

the repolarization of Purkinje fibers

• - hypokalemia
• -HTN

time needed for the SA node to be stimulated ( atrial depolarization) and the conduction to AV node before ventricular depolarization 

.12-.20 ( if its longer = heart block) 

really should be called PQ

ventricular repolarization 

2+ blocks above= MI

Normal Sinus Rhythm 

- keep assessing

NSR but 60bpm

Give atropene ( to speed up the hr) 

0.5-1mg q3-5min 3mg total

rate 100-150bpm

might lose a P wave 

• cause: anxiety, fear, bleeding 
• treatment: metoprolol ( beta blocker)

O- MI

oxygen, monitor, IV

• Defib the Vfib and pulseless V-tach 
• - in an emergency ( no pulse)

start at 120J ( biphase)

- Not in sync mode

Sync with QRS

Sinus arrhythmia 

Normal except the PP, and RR intervals are irregular 

if no hemodynamics are effects = dont treat

Premature atrial contractions 

• Rhythm=irregular the P can be early 
• ( atria beats 2x before the ventricle picks up the contraction) 

Need full minute strip 

if its less than 6PAC/min dont treat

Atrial fibrillation

• ALWAYS irregular ( NO PR) 
• -atria is asynchronous with ventricle --> blood pools ( stroke risk) 

Atrial rate 300-600

acute:

• - Ca+ channel blocker diltiazem 
•      - push 10-20mg 
•      -drip 5-10 mg/hr

• - Check TEE is (-) then cardiovert 
• - give digoxin while waiting 

chronic: give warfarin and monitor INR

Atrial Flutter

• P waves: saw tooth
• No PR

• 1) Md do vagal maneuver
• 2) adenosine ( slows AV node) 
•       - will cause asystole 
• give 6mg, 12mg, 12mg then 20ml saline flush

Premature ventricular contraction 

Extra impulse in the ventricle 

cause: dig toxicity(2+), nicotine, caffeine

More than 6PVC/min= get MD, on the T wave side 

• amiodarone
• 150mg/10 min
• 1mg/min 6hr
• 0.5 mg/min 18 hr 

monitor lungs, bp, thyroid

Bigeminy: every other beat is a PVC ---> emergency about to go to v tach 

Trigeminy: every 3rd beat 

- give lidocaine if amiodarone is not available

Couplet + triplet 

• 2PVC in a row = couplet
• 3 PVC in a row = v tach--> triplet 

Emergency give amiodarone

unifocal : PVC 1 area of vent


multifocal PVC 2 area of the ventricle

Junctional Rhythm 

• AV node takes over as the pacemaker 
• - Absent/ inverted P wave 

• Give atropene 
• 0.5-1mg q3-5min 3mg total 

If atropene doesnt work do defib

• Supraventricular Tachycardia 
• Sudden 150-200 bpm 

• Narrow complex 
• - No P wave, PR not measurable 

cause: underlying rhythm afib, aflutter 

Treat:

check hemodynamics if unstable cardiovert 

stable: vagal , adenosine 6,12,12 , betablocker

Vtach 

• wide complex >.12 sec 
• P waves buried 100-200

1) check carotid, femoral 

• Vtach + pulse, hemodynamically stable
• - amiodarone
• load 150 mg over 10 min
• 1mg/min 6hrs
• .5mg/min

• Lidocaine 1-1.5mg/kg IV 2-3min
•                1-2mg/min 

toxicity SAMS ( slurred speech, seizure, muscle twitch) 

• Hemodynamically unstable 
• - cardiovert or defib?--look up
• -Epi q3-5min 1mg IVP
• -amiodarone
• 150mg over 10min 1mg/min 6 hr, .5/min 18hr 

Check for reversible causes

NAVEL

• Narcan
• Atropine
• Vasopressin
• Epinephrine
• Lidocaine

• Hypovolemia
• Hypoxia
• Hydrogen
• Hypothermia
• Hypokalemia
• Hyperkalemia ( 10U insulin, sodium bicarb, D50W)

• Tension pneumothorax- need compress 2nd mid
• Tamponade- pericardiocentesis
• Toxins
• Thrombosis pulmonary/coronary

• V fib
• - pulseless 
• - CO=0 

• Defibrilate q2min
• -Epi q3-5min 1 mg 
• -Amiodarone - load 150mg/10min                                     1mg/min 6hr                                              .5mg/min 18hr 

Look for Hs, Ts

Asystole 

CPR NOT Defib

• Epi: 1mg IVP q3-5min
• Must confirm asystole in 2+ leads= death

Reversible causes H's+T's

PEA 

• Mimics NSR but no pulse ( hearts not pumping but the electrical work is) 
• CPR
• epi 1mg IVP q3-5min 
• NO atropine

H's + T's ( usually hypovolemia)

Torsades de Pointes 

Mg deficiency --< give 1-2g Mg IVP

ROSC

Pulse is back post CPR

• low bp: Ise 1-2L of lactage ringers, or NS
• if it doesnt work start vasopressor

idioventricular or ventricular escape rhythm 

• impulse starts below the AV node 
• vent 20-40 
• 40+ = accelerated junctional rhythm 

Treat

• CPR
• Epi 1mg q3-5min
• NO atropine

Ventricular standstill 

atria is firing but no ventricle response 


CPR  no pulse + Epi

• 1st degree AV Block 
• PR prolonged 

atropene .5-1mg

• 2nd degree AV Block, Wenckebach, Mobitz Type 1 
• irregular
• More P than QRS
• progressive PR it widens until its drops

- atropene

2nd Degree AV block Mobitz type 2 

more P> QRS , QRS=abnormal 

• about to get pacemaker 
• no atropene

3rd degree AV block , complete heart block 


must get pacemaker

fired at the right time

hearts not responding

fired spikes at the wrong time

1) Compensatory : HR goes up, BP norm 

- cool skin 

2) Progressive: Bp goes down, organs suffer 

• 3) Irreversible 
• bp down, hr up MOD= 2+ org fail