Basic EKG Review

Purpose: Review basic electrocardiographic clues to rhythm interpretation and identify

appropriate nursing intervention.

Objectives: The participant will

o Identify key components of the cardiac conduction system
o List sequence of electrical cardiac events
o Describe ECG waves, complexes and intervals
o Determine rates and measure intervals and complexes
o Discuss rules and identifying characteristics of sinus rhythms, atrial rhythms,
junctional rhythms, atrio-ventricular blocks, ventricular rhythms, asystole and
paced rhythms
o Identify ectopic “beats” and rhythms
o Accurately interpret a variety of EKG rhythms from 6 second strips
o Demonstrate knowledge of physiologic and pharmacologic effects on EKG

Outline:
o Anatomy and physiology of the heart
o Electrical conduction through the heart
o Measurements and rates
o Types of rhythms
o Physiologic and pharmacologic effects of EKG
o Post evaluation

Necessary Equipment: Calipers

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 Anatomy and Physiology

The heart is made up of four chambers: the right atria, the left atria, the right
ventricle, and the left ventricle. The atria receive the blood. The ventricles pump the
blood.

The heart is a specialized muscular structure made up of myocardial cells. These

cells are grouped closely together forming intercalated disks which allow the groups of
muscle cells to function together as one. This allows the atria and the ventricles to
contract independently of each other.

Cardiac muscle also adapts to the amount of blood that it needs to pump. There is
a direct proportion between the amount of blood returning to the heart and the force of
contraction which empties the ventricle. The greater the amount of blood entering the
heart the stronger the contraction. This is caused by the heart muscle stretching to
accommodate the amount of blood. This ability is called Frank-Starling’s Law of the
Heart.

The heart muscle cells (the myocardium) have a long rest period which is called
the refractory period between contractions. This allows the heart chambers enough time
to fill with blood before the next contraction.

Image from Heart.org.in

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 Cardiac muscle cells have four properties:
1. Cardiac muscle cells provide their own stimulation. They do not have
nerve innervation like skeletal muscle cells do. This is called
automaticity.
2. Cardiac muscle cells are able to respond to an electrical impulse. This is
called excitability.
3. Cardiac muscles also have conductivity, the ability to transmit an
impulse to another cardiac cell.
4. Cardiac muscle cells also have contractility, the ability to contract after
receiving an impulse.

Three ions are necessary for muscle cell contraction:

1. Na+ (Sodium)
2. K+ (Potassium)
3. Ca+ (Calcium)

The sympathetic and parasympathetic nervous systems affect the heart.

The stimulation of the sympathetic nervous system:

1. causes release of epinephrine
2. this causes the heart rate, cadiac output, and blood pressure to increase

The stimulation of the parasympathetic nervous system:

1. causes release of acetylcholine`
2. this slows heart rate and decreases cardiac output and blood pressure

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 Electrical Conduction through the Heart

The conduction system of the heart is made up of specialized cardiac cells that initiate
impulses for contraction. This explains the automaticity property of the heart. The
conduction system consists of the sinoatrial node (S-A node), the atrioventricular node
(A-V node), the atrioventricular bundle (A-V bundle or A-V bundle of HIS), the Purkinje
fibers and the bundle branches.

Image from www.guthrie.org

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 Image from www.daviddarling.inf/encyclopedia/H/heart

The S-A node is located in the posterior wall of the right atrium. It is commonly
known as the pacemaker as it normally starts the rate and rhythm for the entire heart.
The S-A node sends impulses that trigger atrial contraction. If the S-A node doesn’t fire
other sites in the heart will respond. If higher sites don’t respond the lower ones will. The
lower the site, the slower the speed. This will make more sense as you learn the different
rhythms.

The stimulated atrial cells then send the impulse down the internodal pathways
to the A-V node. The A-V node is located near the interatrial septum. The A-V node
slows the impulses allowing the atria to finish contracting before the ventricles start to
contract.

From the A-V node the impulse then travels to the A-V bundle. The A-V bundle
goes from the right side of the intra-atrial septum to the beginning of the interventricular
septum where it branches into the right and left bundle branches. These branches
divide further into Purkinje fibers that cover the inner surface of the ventricles. Impulses
relayed from the Purkinje fibers initiate ventricular contraction.

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 The Electrocardiogram

The EKG is a recording of the electrical impulses produced by the heart. Each
cardiac cycle should correlate with a pulse.

The cardiac cycle consists of:

1. P wave - atrial depolarization, normally generated by the S-A node
2. PR interval - includes the P wave and the PR segment. The normal range is
0.12 – 0.20 seconds or 120-200 milliseconds. Changes in the conduction
through the AV node are the most common cause of changes in the PR
interval. The PR interval is important in identifying heart blocks.
3. PR segment - isoelectric line (area of inactivity) between the P wave and the
QRS complex
4. QRS complex – ventricular depolarization. It should be less than .012
seconds. A wide QRS may indicate that the conduction originated from the
ventricle. A delay in conduction through either bundle branch will also widen
the QRS. A wide QRS with no P waves is usually a ventricular rhythm.
5. ST segment – area of electrical inactivity between the QRS and T wave)
6. T wave – ventricular repolarization
7. QT interval – includes QRS and T wave (normal measurement is ½ the
previous R-R interval)

Image from www.circulatory-system.com

7
 How to Measure Strips/Rates
Time is measured across the paper horizontally. The standard rate at which the paper
moves is 25 mm per second. The small boxes represent .04 seconds (or 40 ms). The large boxes
represent 0.20 seconds (or 200 ms). Every 3 seconds there is a vertical mark at the top of the
paper.

Image from www.paramedicine101.blogspot.com

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 Image from www.davita-shop.co.uk/ecg-instruments.html

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Methods for rate calculation

1. Count the number of R waves in 6 seconds and multiply by 10.
2. Count the number of large boxes between the two R waves in a regular
rhythm and divide into 300.
3. Count the number of small boxes between two R waves in a regular rhythm
and divide into 1500.

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 Another quick and easy way to determine the ventricular rate is to examine the R
to R interval and use a standard scale to find the rate. If two consecutive R waves are
separated by only one large box, then the rate is 300 beats per minute. If the R waves are
separated by two large blocks, then the ventricular rate is 150 beats per minute. The scale
continues down to show that if two consecutive R waves are separated by 8 large boxes,
then the rate is 37 beats per minute. The pictoral explanation of this method is below:

Image from learntheheart.com

How to interpret an EKG strip

• 6 questions to ask:
– 1. What is the rate? (60-100 beats per minute is normal)
– 2. Is there a P-wave for every QRS complex and do they look alike?
– 3. What is the P-R interval? (0.12 to 0.20 seconds is normal)
– 4. Is there a normal QRS complex and do they all look alike?
(0.04 to 0.12 second width is normal)
– 5. Is there a pattern to any abnormalities?
– 6. What do I need to do about it?

REGULAR OR IRREGULAR
Check the R-R intervals. Are they regular? Irregular?

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This is regular. Image from ambulancetechnicianstudy.co.uk/rhythms.html

This is irregular. Image from ambulancetechnicianstudy.co.uk/rhytjms.html

RATE
Determine the heart rate. If the heart rate is over 100 beats per minute it is called
tachycardia. If the rate is under 60 beats per minute it is called bradycardia.

P-WAVE
Is there a P-wave before each QRS? Is there a one to one relationship between P waves
and the QRS? Do the P waves look the same? Do they point in the same direction? Is
each P wave the same distance from the QRS?

PR INTERVAL
The PR interval represents the time it takes for the impulse to travel from the atria to the
AV node. It should measure 0.12 to 0.20 seconds. The PR interval is important to
determine if there is a heart block or some other conduction problem.

Image from vetgo/com

QRS

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The QRS represents ventricular depolarization. The first downward deflection is called a
Q wave. It is not always present. The first upward deflection is called an R wave. The
downward wave following is the S wave. The QRS should be no longer than 0.10
seconds.

Look at the QRS. Are they all the same size and shape? Is the QRS wider than 0.12
seconds? Do they all point in the same direction? Are they the same distance from the T
wave?

Image from ambulancetechnicianstudy.co.uk/rhythms.html

This is an example of a strip with different QRS complexes.

Now let’s study different types of rhythm.

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Normal Sinus Rhythm

Regularity: The R-R intervals are constant, the rhythm is regular.

Rate: The atrial and ventricular rates are equal. The heart rate is between
60 – 100 beats per minute (bpm).
P wave: The P waves are uniform. There is one P wave in front of every QRS
complex.
PRI: The PR interval measures between 0.12 – 0.20 seconds. The PRI
measurement is constant.
QRS: The QRS complex measures less than 0.12 seconds.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Sinus Bradycardia
Regularity: The R – R intervals are constant, the rhythm is regular.
Rate: The atrial & ventricular rates are equal; HR is less than 60 bpm
P wave: There is a uniform P wave in front of every QRS complex
PRI: The PR interval measures between 0.12 and 0.20 seconds, the PRI is
constant across the strip.
QRS: The QRS complex measures less than 0.12 seconds.

Sinus bradycardia may be normal in athletes although more often it is the result of a
conduction abnormality or a drug effect.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

What is the rate of this strip?

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Sinus Tachycardia
Regularity: The R – R intervals are constant; the rhythm is regular.
Rate: The atrial & ventricular rates are equal; the heart rate is greater than
100 bpm (usually between 100 and 160 bpm).
P wave: There is a uniform P wave in front of every QRS complex.
PRI: The PR interval measures between 0.12 and 0.20 seconds; the PRI
measurement is constant across the strip.
QRS: The QRS complex measures less than 0.12 seconds.

If your patient has this arrhythmia, try to identify the cause.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

What is the rate of this strip?

Sinus Arrhythmia
Regularity: The R – R intervals vary; the rate changes with the patient’s respirations.
Rate: The atrial and ventricular rates are equal; heart rate is usually in a normal
range (60 – 100 bpm) but can be lower.
P wave: There is a uniform P wave in front of every QRS complex.
PRI: The PR interval measures between 0.12 and 0.20 seconds; the PRI
measurement is constant.
QRS: The QRS complex measures less than 0.12 seconds.

Image from medicine.mcgill.ca/physio/vlab/cardo/exp.html

Treatment is not usually required unless symptomatic bradycardia is present. Sinus

arrhythmia can be confused with sinus arrest (also called sinus pause).

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Above images from www.bem.fi/book/19/19.html

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Wandering Atrial Pacemaker
Regularity: The R – R intervals vary slightly as the pacemaker site changes; the
rhythm can be slightly irregular.
Rate: The atrial and ventricular rate are equal; heart rate is usually within
a normal range (60 – 100 bpm) but can be slower.
P wave: The morphology of the P wave changes as the pacemaker site changes.
There is one P wave in front of every QRS complex, although some may
be difficult to see, depending on the pacemaker site.
PRI: The PR interval will vary slightly as the pacemaker site changes. All PRI
measurements should be less than 0.20 seconds; some may be less than
0.12 seconds.
QRS: The QRS complex measures less than 0.12 seconds.

image from en.ecgpedia.org/wiki/Wandering_Pacemaker

Premature Atrial Contractions

This indicates the early contraction of the atria. The PAC originates in the atria.

Regularity: Since this is a single premature ectopic beat, it will interrupt the
regularity of the underlying rhythm.
Rate: The overall heart rate will depend on the rate of the underlying rhythm.
P wave: The P wave of the premature beat may have a different appearance than
the P waves of the rest of the strip. The ectopic beat will have a P wave,
but it can be flattened, notched, or otherwise unusual. It may be hidden
within the T wave of the preceding complex.
PRI: The PRI should measure between 0.12 and 0.20 seconds, but can be
prolonged; the PRI of the ectopic beat will probably be different from the
PRI measurements of the other complexes.
QRS: The PRS complex measurement will be less than 0.12 seconds.

Image from ambulancetechnicianstudy.co.uk/rhytjms.html

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Atrial Fibrillation
Regularity: The atrial rhythm is not able to be measured; all atrial activity is chaotic.
The ventricular rhythm is grossly irregular having no pattern to
its irregularity.
Rate: The atrial rate cannot be measured because it is so chaotic; research
indicates that it exceeds 350 bpm. The ventricular rate is significantly
slower because the AV node blocks most of the impulses. If the
ventricular rate is below 100 bpm the rhythm is said to be “controlled”.
If it is over 100 bpm it is considered to have a “rapid ventricular response”
P wave: In the arrhythmia the atria are not depolarizing in an effective way.
Instead they are fibrillating thus no P wave is produced. All atrial activity
is depicted as “fibrillatory” waves or grossly chaotic undulations of the
baseline.
PRI: Since no P waves are visible, no PRI can be measured.
QRS: The QRS complex measurement should be less than 0.12 seconds.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Atrial fibrillation may be chronic or acute – acute onset represents pathology.

Atrial Flutter
Regularity: The atrial rhythm is regular. The ventricular rhythm will be regular
if the AV node conducts impulses through in a consistent pattern. There
may be a 2:1, 3:1, 4:1 or variable pattern.
Rate: Atrial rate is between 250 and 350 bpm. Ventricular rate will depend
on the ratio of impulses conducted through to the ventricles.
P wave: When the atria flutter they produce a series of well defined P waves.
When seen together, these “flutter” waves have a saw tooth appearance.
PRI: Because of the unusual configuration of the P wave and the proximity
of the wave to the QRS complex it is often impossible to determine a PRI.
Therefore the PRI is not measured.
QRS: The QRS complex measures less than 0.12 seconds. Measurement can be
Difficult is one or more flutter waves is concealed within the QRS
complex.

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 Image from ambulancetechnicianstudy.co.uk/rhythms.html
Junctional Rhythm – represents retrograde conduction.
Regularity: Regular
Rate: Usually less than 60 bpm. If greater than 60 it is called accelerated
junctional.
P wave: Inverted, buried in QRS or may appear after QRS
PRI: variable dependent on when P wave appears.
QRS: Normal

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Supraventricular Tachycardia (SVT) – defined as an fast arrhythmia which

originates at or above the AV node (above ventricles). This includes atrial fibrillation,
atrial flutter, junctional rhythms with a fast rate. Simply, this is a narrow complex
tachycardia of 140 – 220 bpm.

Regularity: Regular
Rate: Usually 140 – 220 bpm. KEY POINT: accurate determination is essential
for assessment of SVT.
P wave: Usually none visible, rate is too fast.
PRI: not applicable
QRS: Normal

Image from ambulancetechnicianstudy.co.uk/rhythms.html

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HEART BLOCKS
These are atrioventricular blocks. This arrhythmia is a delay or interruption in conduction
between the atria and the ventricles

Type of Block PRI R–R Conduction

st
1 Degree Greater than 0.20 Usually regular One P for every
seconds (depending on the QRS
underlying rhythm)
2nd Degree Type 1 Increasing longer until Irregular More P’s than
(Wenkebach) one P is blocked/dropped QRS’s
2nd Degree Constant on conducted Usually regular More P’s than
Type 2 beats (can be greater than (can be irregular if QRS’s
0.20 seconds conduction varies)
3rd Degree No relation of P’s to Regular More P’s than
Complete Heart QRS’s. Not constant. P’s QRS’s
Block march through

Image from arrhythmiacenter.idsutcliffe.com

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First Degree A – V Block
This is the most common conduction disturbance. It occurs in healthy and
diseased hearts. It can be caused by an inferior MI, Digitalis Toxicity,
myocarditis, and hyperkalemia. Treat the underlying cause and observe for
any progression to a more advanced AV block.
Regularity: Varies
Rate: Varies
P wave: The P waves are upright and uniform. Each P wave will be followed by a
QRS complex
PRI: The PRI will be constant across the entire strip but it will always be
greater than 0.20 seconds
QRS: The QRS complex will be less than 0.12 seconds

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Second Degree A-V Block – Type I (Wenkebach)

Represents ischemia and is reversible.

Regularity: The R – R interval is irregular. It changes as the PRI gets progressively

longer.
Rate: Since some beats are not conducted the ventricular rate is usually slower
than normal (less than 100 bpm).
P wave: The P waves are upright and uniform. Some P waves are not followed
by QRS complexes.
PRI: The PR intervals get progressively longer until one P wave is not followed
by a QRS complex. After the blocked beat the cycle starts again.
QRS: The QRS complex measurement will be less than 0.12 seconds (normal)

Image from cardionetics.com

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Second Degree A-V Block – Type II (Mobitz II)
Represents injury and is NOT reversible. May progress rapidly and without warning to
third degree heart block (complete heart block) or asystole.

Regularity: Varies
Rate: The atrial rate is usually normal (60-100 bpm). Many of the atrial
impulses are blocked which usually makes the ventricular rate slow,
often one half, one third, or one fourth of the atrial rate.
P wave: P waves are upright and uniform. There are always more P waves than
QRS complexes.
PRI: The PRI on conducted beats will be consistent although it might be
greater than 0.20 seconds
QRS: The QRS complex will be normal

Image from www.cardionetics.com

Above is an example of a constant Second Degree Heart Block Type II. It is constant
because every other p wave is conducted. Below is an example of a periodic Second
Degree Heart block. There is no pattern or consistency to the dropping of the p wave.
More than one p wave can also be dropped.

Image from www.cardionetics.com

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 Image from www.pediatriccardiology.uchicago.edu

Third Degree Heart Block or Complete Heart Block (CHB)

This can progress rapidly to asystole without warning. Have an external pacemaker
nearby.

Regularity: Both the atrial and the ventricular foci are firing regularly making
the P-P intervals and the R-R intervals regular. The P’s and the QRS’s
do not relate.
Rate: The P and QRS rates are different. The ventricular rate will be slower.
P wave: The P waves are upright and uniform. There are more P waves than QRS.
PRI: The block is at the AV node. None of the atrial impulses are conducted
through to the ventricles. There is no PRI. The P waves have no
relationship to the QRS complexes.
QRS: Wide and bizarre looking.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Premature Ventricular Contractions

Regularity: The PVC interrupts the underlying rhythm.
Rate: The rate is determined by the underlying rhythm. PVC’s are not usually
included in the rate determination because they may not produce a pulse.
P wave: The ectopic is not preceded by a P wave. There may be a coincidental
P wave before it but it is not related.
PRI: Since the ectopic comes from a lower focus there will be no PRI.
QRS: The QRS of the ectopic will appear different. It will be wide and bizarre.
It will measure at least 0.12 seconds. The T wave is frequently in the
opposite direction of the QRS complex. If the ectopics are in different
directions they are multifocal (from different foci).

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 Image from ambulancetechnicianstudy.co.uk/rhythms.html

The strip below is ventricular bigeminy (every other beat is an ectopic beat)

Image from lostonthefloor.wordpress.com/2009/02/

Ventricular Tachycardia
Check your patient!!! This is a lethal rhythm. They may or may not have a pulse.
Regularity: This is usually regular although it can be slightly irregular.
Rate: The rate is over 150 bpm.
P wave: None present.
PRI: Not applicable.
QRS: The QRS complexes will be wide and bizarre measuring at least
0.12 seconds. It is often difficult to differentiate between the QRS
complexes and the T waves.

Image from en.wikipedia.org/wiki/File:lead_II_rhythm.ven

Ventricular Fibrillation – This is a lethal arrhythmia. If this is real and not artifact
your patient has no pulse!!!

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Regularity: This arrhythmia is chaotic. There are no waves or complexes that can
be analyzed.
Rate: The ventricles are quivering. There is no complex to count.
P wave: There are no discernable P waves.
PRI: There is no PRI.
QRS: No complexes, only waves.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Asystole
This indicates no electrical activity. Increase the gain on the monitor, check another lead.
If this is truly asystole there will be no pulse. Start CPR!!!

Regularity: There is no electrical activity; only a straight line.

Rate: None
P wave: None
PRI: None
QRS: None

Image from ambulancetechnicianstudy.co.uk/rhythms.html

Pacemaker Rhythms
The type of pacemaker determines the appearance of the strip. The pacemaker will
generate a spike on the strip. There should be a response from the heart for each spike. If
the pacer lead is in the atria you will see a P wave after the spike. If the pacer lead is in
the ventricle there will be a QRS after the spike. This QRS will be wide because the
impulse is generated in the ventricle. If there is a lead in both the atria and the ventricle
then it is “dual chambered” or A-V paced.

This strip is an example of A-V pacing, ventricular pacing, and a PVC. The first two are
A-V paced. The next is ventricular paced followed by a PCV.

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 Image from lifeinthefastlane.com…pacemaker

The strip below is ventricular pacing.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

The strip below is an example of dual chamber pacing. The atrial lead is not firing each
time. Can you tell which complexes are dual paced?

Image from tveatch.org/ekgs/ekg104

This is also A-V pacing. Don’t let the spikes in opposite directions confuse you.

Image from lostonthefloor.wordpress.com/2009/03/

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Sometimes you may see the pacemaker is firing at a regular rate but the spikes have no
effect on the QRS complex. This is called “failure to sense”. In other words the
pacemaker is unable to tell if the heart is even contracting but it has been programmed to
maintain a certain rate. So it fires at this rate. If there is a spike without corresponding
cardiac electrical activity then the heart was unable to react to the pacer’s impulse.

This is an example of failure to sense. The spikes are not related to the QRS complexes.

Image from lostonthefloor.wordpress.com/2009

Below is an example of failure to capture. Usually the spikes are followed by some
electrical activity like a QRS complex. But not all the spikes generated a response. The
first and fifth spike in the strip below are not captured. This could be caused by a lead
being fractured or becoming displaced.

Image from amrshams.blogspot.com

You need to call the physician if you find either failure to capture or failure to
sense. The pacemaker will either need reprogrammed or the leads/generator will need
replaced.

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ST Segment Elevation – This means there has been myocardial injury. This is
usually a reliable sign that a true infarction has occurred.

ST Elevation

Image from ambulancetechnicianstudy.co.uk/rhythms.html

ST Segment Depression – This could be caused by angina or a non-Q wave

infarction. With angina the ST segment will return to baseline shortly after the pain is
relieved. With a non-Q wave infarction the ST segment remain down for at least 48
hours. The only EKG changes seen with non-Q wave infarctions are T wave inversion
and ST segment depression.

Image from ambulancetechnicianstudy.co.uk/rhythms.html

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If you patient is having chest pain you should obtain a 12 lead EKG. Elevation in
different leads tells you the injury is occurring.

Lead Changes Type of MI Culprit Artery Reciprocal Changes

II, III aVF Inferior wall Right Coronary I, aVL
V3, V4 Anterior wall Left Anterior V2, aVF
I, aVL, V5, V6 Lateral wall Circumflex V1
V1, V2 Septal wall Left Anterior V3, aVF
ST depression V1, V2 Posterior wall Circumflex or
Right Coronary

The diagram below shows you how to place leads for a 12 lead EKG.

Image from www.statmedicaleducation.com/education.html

Electrode Placement and Lead Selection – Proper electrode placement is

essential to the acquisition of accurate EKG strips. Choose the lead that gives the best
picture. Getting a good signal is more important than precise electrode positioning for
monitoring. First the skin must be prepped. Any hair should be removed and the site
cleaned with an alcohol wipe and dried. When you are placing the electrodes remember
that bone is not as good a conductor as muscle but it is less likely to produce artifact.
Remember that increasing the gain on the monitor also increases any artifact. The further
you place the electrodes from the heart the smaller the complexes will be.

There are three lead and five lead systems for telemetry monitoring. Each lead is a
different color and is marked where it should be placed.

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 White – Right Arm
Black – Left Arm
Brown – Chest
Green – Right Leg
Red – Left Leg

You program the monitor to choose which lead to look at.

Lead 1 looks at the lateral view of the heart (left ventricle, left atrium)
Lead II is the most common lead but not the optimal lead. It looks at an inferior view of
the heart (the bottom of the heart - the left and right ventricles).
Lead III also looks at an inferior view of the heart (right and left ventricle).
The MCL1 view was designed for a three lead system to view ventricular activity. With a
5 lead system use V1. This lead can differentiate between right and left bundle branch
blocks. Use this lead with Lead II to differentiate between SVT and ventricular
tachycardias.

Image from www.sci.utah.edu/

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Cardiac Drugs - We’ll break this down into simple categories.

Image from Microsoft Office – Clip Art

Drugs to increase blood pressure – Epinephrine, Dopamine, Levophed

Epinephrine – This drug is often used in cardiac arrest. During CPR epinephrine can help
increase blood flow to the heart and brain. It increases peripheral vasoconstriction,
increases heart rate, and makes ventricular arrhythmias more responsive to electrical
shock. Epinephrine is used for cardiac arrest, symptomatic bradycardia, severe
hypotension, and severe allergic reactions.

Dopamine – Increases heart rate and the force of contraction plus causes
vasoconstriction. It is not as forceful as epinephrine. In higher doses it also increases
oxygen demand and decreases perfusion. Dopamine is used for hemodynamically
significant hypotension and brdaycardia not responsive to atropine.

Levophed (Norepinephrine) – This drug is similar to epinephrine. It is a potent

vasoconstrictor. This increases vascular resistance which increases myocardial oxygen
demand and may exacerbate myocardial ischemia (chest pain). It is used for severe
hypotention. Levophed is considered a drug of last resort for the management of
cardiogenic shock.

Neosynephrine – This drug increases blood pressure and is used often after cardiac arrest.
It increases blood pressure without increasing heart rate.

Image from Microsoft Office – clip art

Drugs to decrease blood pressure – Nitroglycerine, Nipride

Nitroglycerine – Causes vasodilation in arterial and peripheral blood vessels including

coronary arteries. It decreases myocardial oxygen consumption. Increases oxygen
delivery. Nitroglycerine has a short half life. It is used for chest pain and ischemia. It can
lower blood pressure. Nitroglycerine is used for angina pectoris, acute pulmonary edema,
congestive heart failure, and acute myocardial infarction (AMI).

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Nipride (Nitroprusside) – This drug is a rapid acting vasodilator affecting venous and
arterial smooth muscle. Onset of action is immediate with the effects stopping minutes
after stopping infusion. It is used in patients with severe heart failure and hypertensive
emergencies and acute pulmonary edema

Drugs to Stop Arrhythmias Image from Microsoft Office

Amiodarone
This drug decreases electrical conduction and the force of contraction. Amiodarone is ACLS’s
favorite drug for controlling any rapid rate/rhythm. It can cause hypotension which will cause
decreased perfusion and less oxygen delivery. Amiodarone is used for ventricular fibrillation,
pulseless VT, atrial fibrillation, atrial flutter, stable narrow-complex tachycardias, cardiac arrest,
and stable monomorphic VT.

Lidocaine – Lidocaine is not as effective as amiodarone. It suppresses ventricular arrhythmias,

contractility, and can help prevent ventricular fibrillation. It is used for Ventricular fibrillation,
pulseless VT, wide-complex tachycardias, cardiac arrest, and stable VT.

Drugs to help the heart rate

Beta Blockers – works by decreasing heart rate and the force of contraction. Beta
Blockers increase the survival rate after a heart attack (30%). Beta blockers slow the
heart rate, reduce myocardial oxygen consumption, and lower the blood pressure. They
are used for acute coronary syndrome and tachyarrhythmias (atrial fibrillation/flutter).
This class of drugs ends in “lol”. Examples are Metoprolol, Atenolol, and Labetalol.

Calcium Channel Blockers – decrease sinoatrial node automaticity and slow AV node
conduction. They are used to control the ventricular response in patients with rapid atrial
fibrillation/flutter and narrow complex tachycardias. Examples are Verapamil and
Cardiazem.

Atropine – enhances sinus node automaticity and AV conduction. Used to treat

symptomatic bradycardia.

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 References:

Thaler, M., The Only EKG Book You’ll Ever Need, 6th Edition, Lippincott, Williams &
Wilkins, 2009

Walraven, G., Basic Arrhythmias, 6th Edition, 2006. Pearson Education, Inc. Upper
Saddle River, NJ.

Dubin, D., Rapid Interpretation of EKG’s, Edition V, Cover Publishing, Inc, 2000

www.medceu.com/index/courses/telemetry.htm, Telemetry Certification, retrieved

September 2007

www.rnceus.com/ekg/ekgfdav.html, retrieved September 2007

www.mikecowley.co.uk/leads.htm, retrieved September 2007

ACLS: Principles and Practice, American Heart Association, 2007

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