Region X Cardiac SOP’s EKG Rhythms and Interventions. Condell Medical Center EMS System February 2008 Site Code #10-7200E1208 Prepared by: Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider should be able to:
Condell Medical Center
Site Code #10-7200E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Hydrogen ion - acidosis
Hyper/hypokalemia (high/low potassium levels)
Give fluids (20 ml/kg)
Provide supplemental O2
Ventilate to blow off retained CO2
Difficult to determine in the field; consider in diabetic ketoacidosis & renal dialysis
Check blood glucose on all altered mental status pts6 H’s
Thrombosis, coronary (ACS) or Thrombosis, pulmonary (embolism)
Think “out of the box”
Check for JVD, B/P
Check for JVD, B/P, absent/decreased breath sounds, difficulty bagging
Obtain 12 lead when applicable; good history taking to lead to suspicions (travel, surgery, immobility)
What is history of current status?5 T’s
There is no electrical activity; you observe a straight lineAsystole
There is no pulse, no perfusion, no blood pressure.
Survival from this dysrhythmia is extremely slim. CPR
is initiated in the absence of a State of Illinois DNR form.
No pulse, no breathing, no B/P!
You’ve got a dead patient or a lead popped off
When the underlying rate is under 60 bpm,
Atropine is indicated.
Remember “when they’re done, give them one”
For asystole and slow PEA <60 give 1 mg Atropine IVP/IO
If the patient has no pulse, this is PEA
Knowing the overall rate helps to
determine if atropine is given or not
Atropine not indicated if heart rate on monitor is >60
Regular P to P and regular R to R
Less than 60 bpm
Positive, upright, rounded, look similar to each other
0.12-0.20 seconds and constant
<0.12 secondsSinus Bradycardia
Treatment indicated if the patient is symptomatic
EMS needs to provide a thorough assessment
to make an accurate clinical decision
Atria are regular, ventricular rhythm is irregular
Atrial rate greater than ventricular rate
Normal in shape; not all followed by QRS
PR gets progressively longer until dropped QRS complex
Normally <0.12 secondsSecond Degree Type I - Wenckebach
Note characteristics of irregular rhythm, grouped beating,
lengthening PR intervals, periodically dropped QRS.
The P to P interval is regular and measures out in all blocks!
“Type I drops one” “Wenckebach winks at you”
Atria regular, ventricular rhythm can be regular or not
Atrial rate greater than ventricular rate which is slow
Normal; more P’s than QRS’s
Usually normal, constant for the conducted beats
Usually <0.12 sec; periodically absent after P wavesSecond Degree Type II - Classical
This rhythm can have a variable block or can have a
set pattern (ie: 2:1; 3:1, etc). The slower the heart
rate, the more symptomatic the patient. Treatment with
Atropine versus TCP based on width of QRS.
Think “Type II is 2:1” (but know block can be 3:1,etc)
Atria regular, ventricular rhythm regular but independent of each other
Atrial rate greater than ventricular; ventricular rate determined by origin of escape rhythm (can be slow or normal)
Normal in shape & size
None (no pattern)
Narrow or wide depending on origin of escape pacemaker3rd Degree - Complete
The patient’s symptoms are based on the ventricular
heart rate - the slower the heart rate the more symptomatic
the patient will be. Again, P to P marches right through.
Treatment with TCP versus Atropine based on width of QRS
Transport with no further intervention
Observed is one to one capture.
Consider sedation with Valium to make
the patient more comfortable.
#1 - Is the patient stable or unstable?
#2 - Is the QRS narrow or wide?
Usually very regular
150 - 200 bpm
Not measured; if P waves seen, PR interval often abnormal
Usually <0.12 seconds unless abnormal conductionSupraventricular Tachycardia - Narrow QRS
SVT is a term used to describe a category of rapid rhythms that
cannot be further defined because of indistinguishable P waves.
This SVT is most likely atrial tachycardia
due to shortened PR interval (abnormal PR interval).
The heart rate (180) is too fast for sinus tachycardia.
The QRS is definitely narrow!
Wide QRS tachycardia is ventricular tachycardia
until proven otherwise. Always treat the patient
for the worst case scenario first
Atria regular; ventricular rhythm can be regular or irregular
Atrial rate 250+, ventricular rate variable
No identifiable P waves; saw tooth or picket fence pattern noted
<0.12 seconds unless abnormal conductionAtrial flutter
Note key characteristics of the flutter waves
or the “saw toothed” appearance also called
the “picket fence”
Atrial rate 400-600; ventricular rate variable
No identifiable P waves
0.12 seconds or less unless abnormal conductionAtrial Fibrillation
Rhythm is irregularly irregular.
Check for medication history of blood thinner
(ie: coumadin)and digoxin (strengthens cardiac contractions).
When obtaining pulse, some impulses stronger than others.
(Caution: both meds can cause in B/P)
No discernible wave forms to be identified or measured
Course Vfib stands up taller from the baseline and is thought to be more receptive to defibrillation
Fine Vfib is flatter and less likely to respond to defibrillationVentricular Fibrillation
There is no pulse, no breathing, no B/P.
This patient is dead and needs immediate
CPR and defibrillation
Generally over 100 bpm
Generally absent; occasionally may be visible but have no relationship with the QRS
>0.12 seconds; often difficult to distinguish between the QRS and T waveVentricular Tachycardia with Pulse
Regular rhythm with wide QRS complex.
You can basically stack the complexes one
on top of the other - they will fit like stacking blocks
#1 - Is the patient stable?
#2 - If the patient is stable, then you get to this next question - #2 -Is the QRS narrow or wide?
after the initial bolus
IV, O2, monitor, pulse ox
Consider 12 lead EKG
EKG: 3rd degree/complete heart block
Goal of therapy: increase heart rate
Intervention: Bradycardia SOP
QRS narrow so start with Atropine 0.5 mg IVP
Prepare to attach TCP in case atropine not effectiveWhat’s your impression & intervention?
What action needs to be taken?
Which SOP do you follow?Case #2
The rhythm is PEA
Important to note the rate (determines if Atropine is given or not)
This patient needs CPR, no defibrillation
Consider the causes (6 H’s and 5 T’s) as you are performing your interventions for PEACase #3
Upon 1st contact with your patients, get into the habit of feeling for a pulse while introducing yourself.
Is the pulse slow, normal, or fast?
Is the pulse regular or irregular?
This first pulse can give you an idea of how critical the situation might be and a clue to what you might find once the monitor is hooked upCase #4
The patient is unstable
Responds only to pain, respirations, poor skin parameters, possibly non-palpable radial pulse, B/P <100
Treatment goal is to convert this lethal rhythm and restore perfusion as soon as possibleCase #5
Second degree Type I - Wenckebach
The overall heart rate runs low but patients are generally not symptomatic due to the heart rate
What is important to know during this assessment?
Why did the patient fall?
If the patient tripped (he did), this is a trauma call
This patient has no problem related to his diabetes so a blood sugar level is not indicatedCase #6
You have confirmed the patient is apneic and pulseless.
Begin CPR (witnessed arrest) until defibrillator charged
Call and look “all clear”, defibrillate at 360 j or highest biphasic settingCase #7
After 2 minutes of immediate CPR following the defibrillation, you stop CPR and check the rhythm
Rhythm looks like NSR, now you can check for a pulse - there is a pulse!!!
Stop CPR, reassess vital signs
B/P is rising from 0/0, P - 80, respirations being assisted by BVM (about 4 -6/minute)Case #7
Edition. Brady. 2006.