Rhythms

Rhythms

Normal Sinus Rhythm

Name:	Normal sinus rhythm (regular sinus rhythm)
Description:	60-100 beats per minute Each complex is complete: P wave, QRS complex, T wave No untoward, wide, bizarre, ectopic, early, late, or different-looking complexes All intervals within normal limits
Treatment:	Monitor vital signs; check blood pressure.
Questions:	SAMPLER
Next Step	Monitor the patient’s condition.

Sinus Arrhythmia

Name:	Sinus arrhythmia (normal variation)
Description:	60-100 beats per minute Each complex is complete: P wave, QRS complex, T wave No untoward, wide, bizarre, ectopic, early, late, or different-looking complexes All intervals except the R-R interval are within normal limits
Treatment:	Monitor vital signs.
Questions:	SAMPLER
Next Step:	Monitor the patient’s condition; sinus arrhythmia may be a variation caused by normal breathing, or it may be associated with diabetes or advanced age.

Sinus Bradycardia

Name:	Sinus bradycardia (normal slow)
Description:	Below 60 beats per minute Each complex is complete: P wave, QRS complex, T wave No untoward, wide, bizarre, ectopic, early, late, or different-looking complexes All intervals except the rate are within normal limits
Treatment:	Monitor vital signs; check blood pressure; this may be normal in the young and healthy. If the blood pressure is normal, no other treatment is required. If the patient is hypotensive, “shocky,” cool or clammy, or has chest pain or a change in mental status, refer to the current ACLS guidelines at the back of this book.
Questions:	SAMPLER. “Do you take digitalis, propranolol, or quinidine?”
Next Step:	Consider hypoxia, acute myocardial infarction, digitalis toxicity, calcium channel blocker overdose, and electrical conduction system damage. Monitor the blood pressure, check the cardiac monitor for ectopic activity related to a low heart rate, consider vasovagal response, and treat the underlying cause.

Sinus Tachycardia

Name:	Sinus tachycardia (normal fast)
Description:	100-160 beats per minute Each complex is complete: P wave, QRS complex, T wave. Note: P waves may be buried in the previous T wave No untoward, wide, bizarre, ectopic, early, late, or different-looking complexes All intervals except the rate are within normal limits
Treatment:	Monitor vital signs; check blood pressure; treat underlying condition.
Questions:	SAMPLER. “Do you take digoxin?”
Next Step:	Tachycardia can be caused by fear or anxiety, fever, hypoxia, shock, congestive heart failure, medications, pain, methamphetamines, cocaine/crack, and blood loss. At very fast rates, the heart cannot refill fully, leading to reduced cardiac output. In the setting of ischemia, this hard work can further damage the heart muscle.

Premature Atrial Contractions

Name:	Premature atrial contractions (early ectopic atrial activity)
Description:	Usually 60-100 beats per minute but varies depending on the number of extra atrial beats created and conducted and on the rate of the underlying rhythm Premature atrial contractions are ectopic beats that occur in the context of other rhythms. Each complex is complete: P wave, QRS complex, T wave. The early P waves look different from normal P waves. These early P waves may be smaller or peaked. The QRS complex may be normal or conducted differently. P-R intervals may vary (usually shorter), depending on the distance from the ectopic foci to the AV node. The R-R interval varies at the ectopic complex.
Treatment:	Monitor vital signs; watch for change in rhythm. No other treatment is necessary.
Questions:	SAMPLER
Next Step:	Premature atrial contractions may be a normal variation.

Premature Ventricular Contractions

Name:	Premature ventricular contractions (early ectopic ventricular complexes)
Description:	The rate depends on the underlying rhythm. Do not count the premature ventricular contractions. Premature ventricular contractions are ectopic beats that occur in the context of other rhythms. Premature ventricular contractions are not a rhythm themselves. The premature ventricular contraction is an untoward, wide, bizarre, early, and different-looking complex. If there is just one ectopic focus, the premature ventricular contraction is called unifocal, and each one looks the same. If more than one ectopic focus is present, the premature ventricular contractions are called multifocal and vary in appearance.
	Intervals may be irregular owing to the premature complexes and compensatory pauses. No P waves are present before the premature ventricular contraction.
Treatment:	Monitor vital signs, check blood pressure. Occasional premature ventricular contractions with no symptoms require no treatment. Premature ventricular contractions in the presence of acute myocardial infarction/chest pain, frequent multifocal or unifocal premature ventricular contractions (more than 6 per minute), or back-to-back premature ventricular contractions require management with medication.
Questions:	SAMPLER/OPQRST-I
Next Step:	Monitor the patient’s condition. Watch the monitor for runs of premature ventricular contractions or a change in rhythm.

Atrial Flutter

Name:	Atrial flutter (F waves) (very rapid atrial rate; think of atrial fluuuuuuutter)
Description:	Atrial flutter is a fast, constant firing of an ectopic focus. The atrial rate is very fast, 240-360 beats per minute. Instead of P waves, atrial flutter has F waves. The ventricular rate depends on the conduction ratio, 2 : 1, 3 : 1, 4 : 1; it is usually 60-100 beats per minute. The complexes are incomplete. They start with F waves as a baseline: F wave, F wave, QRS complex, F wave (with T wave buried in the F wave), F wave. Baseline consists of constant F waves and intermittently conducted QRS complexes (if you turn the rhythm strip upside down, it resembles a sawtooth pattern).
	Intervals cannot be measured, because there is no P wave. QRS complexes usually are within normal limits. T waves usually cannot be seen.
Treatment:	Hemodynamically stable patients (no signs of shock) require no initial treatment. If the ventricular (QRS) rate is rapid (120-140 beats per minute), monitor vital signs and check blood pressure. Follow ACLS guidelines.
Questions:	SAMPLER/OPQRST-I. “Do you take digitalis?”
Next Step:	Monitor the patient’s condition; perform frequent blood pressure and rhythm checks.

Atrial Fibrillation

Atrial fibrillation (f waves) (uncoordinated, fast atrial activity)

Description:

Atrial rate appears as the baseline, 350-600 beats per minute. Waves may be coarse (and countable) or so fine they are too small to count. There are no P waves; instead atrial fibrillation has f waves, known as fibrillatory waves.

Ventricular rate is 100-160 beats per minute. The R-R interval is always irregular because of chaotic constant stimulation from the atria.

Baseline is all f waves, with QRS complexes usually within normal limits.

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Tags: Flip and See ECG

Aug 21, 2016 | Posted by admin in CARDIOLOGY | Comments Off

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