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CARDIAC RHYTHMS AND THE EMT
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What We Need to Know: V-Fib V-Tach Asystole
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What We Want to Know: How come it does that What it isn’t
What it’s going to be
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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.
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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.
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Cardiac Cycles Make Us Smile
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Normal Sinus Rhythms Make Us Very, Very Happy
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Hook ‘em Up: 3-lead
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Hook “em Up: 5-Lead
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We Should See: Itty bitty boxes, itty boxes, & big boxes
Itty bitty boxes=.05 seconds Itty boxes=.20 seconds Big boxes=1 second
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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
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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
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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
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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
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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
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Atrial Fibrillation Irregularly irregular rhythm
Ventricular rate will vary No P waves Undulating base line
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Atrial Flutter P waves take on a saw-toothed appearance, become flutter ‘f’ waves R waves may appear regular Atrial rate is / minute Several flutter waves for each R wave
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Ventricular Tachycardia
beats per minute Only wide, tall, bizarre-looking complexes QRS greater than 0.12 second (3 itty bitty boxes, wide, weird-looking
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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
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Asystole No pulse Less than 5 beats per minute Occasional agonal beats
No complexes
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Pulseless Electrical Activity
Electrical impulse is generated, but cardiac muscle does not respond Rhythm can be anything Treatment is CPR PALPATE PULSES
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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
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Let’s Get Worried Paired PVCs Multiform PVCs
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More Worries Bigeminy R-on-T
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What do you think? Torsades De Pointes Regular or irregular
Rate beats per minute P wave hidden QRS complex usually wide, twisting above and below baseline May start and stop suddenly
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And as long as we’re worrying…..
ST Elevation May signify injury
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Artifact: Loose electrodes Dried gel Muscle tremor or patient movement
Broken cable tips or wires 60-cycle interference
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Artifact 60-cycle interference Tremors Patient movement Tapping
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Artifact Patient brushing teeth Patient swinging telemetry
Respirations
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And finally…. If the monitor looks like this:
And the patient looks like this: Check your leads
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Cause to Worry?
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What’s this?
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What’s this?
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What’s this?
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What are we going to do about it??
SHOCK EM!!
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Defibrillation Procedure
Determine need Assess patient Witnessed/non-witnessed arrest—shock as soon as equipment is ready Follow with 2 minutes of CPR
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Shockable Rhythms Pulseless V-Tach V-Fib
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Non-Shockable Rhythms:
Asystole PEA—Pulseless Electrical Activity Can show as ANY rhythm on the monitor
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Defibrillation Procedure
Attach monitor Properly place pads Set Defib power CLEAR THE PATIENT Place paddles on chest with aprox. 25# of pressure
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Defibrillation Procedure
Deliver shock Immediately provide 2 minutes of CPR Re-assess patient Repeat shock as needed
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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
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Document: By voice recording By maintaining rhythm strips
By trip report
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Trouble-shooting Loose cables/electrodes Patient movement
Defib power not turned on Low battery
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Maintenance: Schedule routine maintenance checks Check battery
Check defib operation Check monitor paper Check wires for wear Document maintenance checks
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Questions??
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