CARDIAC RHYTHMS AND THE EMT. What We Need to Know: V-Fib V-Fib V-Tach V-Tach Asystole Asystole.

CARDIAC RHYTHMS AND CARDIAC RHYTHMS AND THE EMTTHE EMT

What We Need to Know:What We Need to Know:

V-FibV-Fib

V-TachV-Tach

AsystoleAsystole

What We Want to Know:What We Want to Know:

How come it does that How come it does that

What it isn’tWhat it isn’t

What it’s going to beWhat it’s going to be

EMT DEFIBRILLATION 10 EMT DEFIBRILLATION 10 COMMANDMENTSCOMMANDMENTS

I. Thou shalt save a life.I. Thou shalt save a life. II. Thou shalt act professionally.II. Thou shalt act professionally. III. Thou shalt never ignore the patient.III. Thou shalt never ignore the patient. IV. Thou shalt follow standing orders.IV. Thou shalt follow standing orders. V. Thou shalt know ventricular fibrillation V. Thou shalt know ventricular fibrillation

with all your heart.with all your heart.

VI. Thou shalt act fast.VI. Thou shalt act fast. VII. Thou shalt act cautiously.VII. Thou shalt act cautiously. VIII. Thou shalt document the care you VIII. Thou shalt document the care you

give.give. IX. Thou shalt maintain the equipment.IX. Thou shalt maintain the equipment. X. Thou shalt never screw up.X. Thou shalt never screw up.

Cardiac Cycles Make Us Cardiac Cycles Make Us SmileSmile

Normal Sinus Rhythms Normal Sinus Rhythms Make Us Very, Very Make Us Very, Very HappyHappy

Hook ‘em Up: 3-leadHook ‘em Up: 3-lead

Hook “em Up: 5-LeadHook “em Up: 5-Lead

We Should See:We Should See:

Itty bitty boxes, itty boxes, & big boxesItty bitty boxes, itty boxes, & big boxes

Itty bitty boxes=.05 secondsItty bitty boxes=.05 seconds Itty boxes=.20 secondsItty boxes=.20 seconds Big boxes=1 secondBig boxes=1 second

Normal Sinus RhythmNormal Sinus Rhythm 60-100 beats per minute60-100 beats per minute Each complex is complete: P wave, QRS Each complex is complete: P wave, QRS

complex, T wavecomplex, T wave No untoward, wide, bizarre, ectopic, early, No untoward, wide, bizarre, ectopic, early,

late, or different looking complexeslate, or different looking complexes All intervals within normal limitsAll intervals within normal limits

Sinus ArrhythmiaSinus Arrhythmia 60-100 beats per minute60-100 beats per minute 100-160 beats per minute100-160 beats per minute Each complex is complete: P wave, QRS Each complex is complete: P wave, QRS

complex, T wavecomplex, T wave No untoward, wide, bizarre, ectopic, early, No untoward, wide, bizarre, ectopic, early,

late, or different looking complexeslate, or different looking complexes All intervals except the R-R are within All intervals except the R-R are within

normal limitsnormal limits

Sinus TachycardiaSinus Tachycardia 100-160 beats per minute100-160 beats per minute Each complex is complete: P wave, QRS Each complex is complete: P wave, QRS

complex, T wavecomplex, T wave No untoward, wide, bizarre, ectopic, early, No untoward, wide, bizarre, ectopic, early,

late, or different looking complexeslate, or different looking complexes All intervals within normal limitsAll intervals within normal limits

Sinus BradycardiaSinus Bradycardia Rate less than 60 beats per minuteRate less than 60 beats per minute 100-160 beats per minute100-160 beats per minute Each complex is complete: P wave, QRS Each complex is complete: P wave, QRS

complex, T wavecomplex, T wave No untoward, wide, bizarre, ectopic, early, No untoward, wide, bizarre, ectopic, early,

late, or different looking complexeslate, or different looking complexes All intervals within normal limitsAll intervals within normal limits

Junctional RhythmJunctional Rhythm 40-60 beats per minute40-60 beats per minute No preceding P wave or..No preceding P wave or.. Occasionally the P waves have a retrograde Occasionally the P waves have a retrograde

conduction either before or after the QRS conduction either before or after the QRS complexcomplex

QRS and the T wave are usually normalQRS and the T wave are usually normal

Atrial FibrillationAtrial Fibrillation Irregularly irregular rhythmIrregularly irregular rhythm Ventricular rate will varyVentricular rate will vary No P wavesNo P waves Undulating base lineUndulating base line

Atrial FlutterAtrial Flutter P waves take on a saw-toothed appearance, P waves take on a saw-toothed appearance,

become flutter ‘f’ wavesbecome flutter ‘f’ waves R waves may appear regularR waves may appear regular Atrial rate is 250-350/ minuteAtrial rate is 250-350/ minute Several flutter waves for each R waveSeveral flutter waves for each R wave

Ventricular TachycardiaVentricular Tachycardia 100-250 beats per minute100-250 beats per minute Only wide, tall, bizarre-looking complexesOnly wide, tall, bizarre-looking complexes QRS greater than 0.12 second (3 itty bitty QRS greater than 0.12 second (3 itty bitty

boxes, wide, weird-lookingboxes, wide, weird-looking

Ventricular FibrillationVentricular Fibrillation Uncoordinated firing of ventricles like a ‘bag Uncoordinated firing of ventricles like a ‘bag

of worms’of worms’ Does not generate a pulseDoes not generate a pulse Completely incoordinated electrical activity Completely incoordinated electrical activity

without any discernible complexeswithout any discernible complexes All waves are All waves are f wavesf waves

AsystoleAsystole No pulseNo pulse Less than 5 beats per minuteLess than 5 beats per minute Occasional agonal beatsOccasional agonal beats No complexesNo complexes

Pulseless Electrical Pulseless Electrical ActivityActivity

Electrical impulse is generated, but Electrical impulse is generated, but cardiac muscle does not respondcardiac muscle does not respond

Rhythm can be anythingRhythm can be anything Treatment is CPRTreatment is CPR

PALPATE PULSESPALPATE PULSES

Premature Ventricular Contractions Premature Ventricular Contractions (PVCs)(PVCs) Rate depends on the underlying rhythm. Do Rate depends on the underlying rhythm. Do

not count the PVCsnot count the PVCs Wide, bizarre, early and different-looking Wide, bizarre, early and different-looking

complex. complex. No P waves are present before the PVCNo P waves are present before the PVC

Let’s Get WorriedLet’s Get Worried

Paired PVCsPaired PVCs

Multiform PVCsMultiform PVCs

More WorriesMore Worries

BigeminyBigeminy

R-on-TR-on-T

What do you think?What do you think?

Torsades De PointesTorsades De Pointes Regular or irregularRegular or irregular Rate 150-250 beats per minuteRate 150-250 beats per minute P wave hiddenP wave hidden QRS complex usually wide, twisting above QRS complex usually wide, twisting above

and below baselineand below baseline May start and stop suddenly May start and stop suddenly

And as long as we’re And as long as we’re worrying…..worrying…..

ST ElevationST Elevation May signify injuryMay signify injury

Artifact:Artifact:

Loose electrodesLoose electrodes Dried gelDried gel Muscle tremor or patient movementMuscle tremor or patient movement Broken cable tips or wiresBroken cable tips or wires 60-cycle interference60-cycle interference

ArtifactArtifact 60-cycle interference60-cycle interference

TremorsTremors

Patient movementPatient movement

TappingTapping

ArtifactArtifact

Patient brushing teethPatient brushing teeth

Patient swinging telemetryPatient swinging telemetry

RespirationsRespirations

And finally….And finally….

If the monitor looks like this:If the monitor looks like this:

And the patient looks like this:And the patient looks like this:

Check your leadsCheck your leads

Cause to Worry?Cause to Worry?

What’s this?What’s this?

What’s this?What’s this?

What’s this?What’s this?

What are we going to do What are we going to do about it??about it??

Defibrillation ProcedureDefibrillation Procedure

Determine needDetermine need Assess patientAssess patient

Witnessed/non-witnessed arrest—shock Witnessed/non-witnessed arrest—shock as soon as equipment is readyas soon as equipment is ready

Follow with 2 minutes of CPRFollow with 2 minutes of CPR

Shockable RhythmsShockable Rhythms

Pulseless V-TachPulseless V-Tach

V-FibV-Fib

Non-Shockable Rhythms:Non-Shockable Rhythms:

AsystoleAsystole

PEAPEA—Pulseless Electrical Activity—Pulseless Electrical Activity Can show as ANY rhythm on the monitorCan show as ANY rhythm on the monitor

Defibrillation ProcedureDefibrillation Procedure

Attach monitorAttach monitor Properly place padsProperly place pads Set Defib powerSet Defib power CLEAR THE PATIENTCLEAR THE PATIENT Place paddles on chest with aprox. 25# Place paddles on chest with aprox. 25#

of pressureof pressure

Defibrillation ProcedureDefibrillation Procedure

Deliver shockDeliver shock Immediately provide 2 minutes of CPRImmediately provide 2 minutes of CPR Re-assess patientRe-assess patient Repeat shock as neededRepeat shock as needed

Cautionaries:Cautionaries:

Do not dump load through open-air Do not dump load through open-air discharge or paddle-to-paddledischarge or paddle-to-paddle

Keep paddles cleanKeep paddles clean Keep your hands and patient’s chest as Keep your hands and patient’s chest as

dry as possibledry as possible

Document:Document:

By voice recordingBy voice recording By maintaining rhythm stripsBy maintaining rhythm strips By trip reportBy trip report

Trouble-shootingTrouble-shooting

Loose cables/electrodesLoose cables/electrodes Patient movementPatient movement Defib power not turned onDefib power not turned on Low batteryLow battery

Maintenance:Maintenance:

Schedule routine maintenance checksSchedule routine maintenance checks Check batteryCheck battery Check defib operationCheck defib operation Check monitor paperCheck monitor paper Check wires for wearCheck wires for wear Document maintenance checksDocument maintenance checks

Questions??Questions??