CARDIAC RHYTHMS AND THE EMT

What We Need to Know: V-Fib V-Tach Asystole

What We Want to Know: How come it does that What it isn’t What it’s going to be

EMT DEFIBRILLATION 10 COMMANDMENTS I. Thou shalt save a life. II. Thou shalt act professionally. III. Thou shalt never ignore the patient. IV. Thou shalt follow standing orders. V. Thou shalt know ventricular fibrillation with all your heart.

VI. Thou shalt act fast. VII. Thou shalt act cautiously. VIII. Thou shalt document the care you give. IX. Thou shalt maintain the equipment. X. Thou shalt never screw up.

Cardiac Cycles Make Us Smile

Normal Sinus Rhythms Make Us Very, Very Happy

Hook ‘em Up: 3-lead

Hook “em Up: 5-Lead

We Should See: Itty bitty boxes, itty boxes, & big boxes Itty bitty boxes=.05 seconds Itty boxes=.20 seconds Big boxes=1 second

Normal Sinus Rhythm 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

Sinus Arrhythmia 60-100 beats per minute 100-160 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 are within normal limits

Sinus Tachycardia 100-160 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

Sinus Bradycardia Rate less than 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 within normal limits

Junctional Rhythm 40-60 beats per minute No preceding P wave or.. Occasionally the P waves have a retrograde conduction either before or after the QRS complex QRS and the T wave are usually normal

Atrial Fibrillation Irregularly irregular rhythm Ventricular rate will vary No P waves Undulating base line

Atrial Flutter P waves take on a saw-toothed appearance, become flutter ‘f’ waves R waves may appear regular Atrial rate is 250-350/ minute Several flutter waves for each R wave

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

Ventricular Fibrillation Uncoordinated firing of ventricles like a ‘bag of worms’ Does not generate a pulse Completely incoordinated electrical activity without any discernible complexes All waves are f waves

Asystole No pulse Less than 5 beats per minute Occasional agonal beats No complexes

Pulseless Electrical Activity Electrical impulse is generated, but cardiac muscle does not respond Rhythm can be anything Treatment is CPR PALPATE PULSES

Premature Ventricular Contractions (PVCs) Rate depends on the underlying rhythm. Do not count the PVCs Wide, bizarre, early and different-looking complex. No P waves are present before the PVC

Let’s Get Worried Paired PVCs Multiform PVCs

More Worries Bigeminy R-on-T

What do you think? Torsades De Pointes Regular or irregular Rate 150-250 beats per minute P wave hidden QRS complex usually wide, twisting above and below baseline May start and stop suddenly

And as long as we’re worrying….. ST Elevation May signify injury

Artifact: Loose electrodes Dried gel Muscle tremor or patient movement Broken cable tips or wires 60-cycle interference

Artifact 60-cycle interference Tremors Patient movement Tapping

Artifact Patient brushing teeth Patient swinging telemetry Respirations

And finally…. If the monitor looks like this: And the patient looks like this: Check your leads

Cause to Worry?

What’s this?

What’s this?

What’s this?

What are we going to do about it?? SHOCK EM!!

Defibrillation Procedure Determine need Assess patient Witnessed/non-witnessed arrest—shock as soon as equipment is ready Follow with 2 minutes of CPR

Shockable Rhythms Pulseless V-Tach V-Fib

Non-Shockable Rhythms: Asystole PEA—Pulseless Electrical Activity Can show as ANY rhythm on the monitor

Defibrillation Procedure Attach monitor Properly place pads Set Defib power CLEAR THE PATIENT Place paddles on chest with aprox. 25# of pressure

Defibrillation Procedure Deliver shock Immediately provide 2 minutes of CPR Re-assess patient Repeat shock as needed

Cautionaries: Do not dump load through open-air discharge or paddle-to-paddle Keep paddles clean Keep your hands and patient’s chest as dry as possible

Document: By voice recording By maintaining rhythm strips By trip report

Trouble-shooting Loose cables/electrodes Patient movement Defib power not turned on Low battery

Maintenance: Schedule routine maintenance checks Check battery Check defib operation Check monitor paper Check wires for wear Document maintenance checks

Questions??