V1- Right SB, 4th ICS

ECG Placement V2- Left SB, 4th ICS

RA-Salt (white) V3- Left MCL, 5th ICS
LA- Pepper (Black) V4- Halfway b/n V2 and V4
RL-Green V5- Left, MAxL, level of V4
LL- Ketchup (red) V6- Left, AAxL, level of V4

Waves and Intervals Heart Activity Normal/Abnormal

De-Contract
Re-Relax
 P Wave (R&L) ATRIAL DEpolarization
 QRS Complex (R&L) VENTRICULAR DEpolarization
 T Wave (R&L) VENTRICULAR REpolarization
 PR Interval (PRI) Time interval from Onset of ATRIAL
Depo (P) to Onset of VENTRICULAR
Depo (QRS)
 QRS Complex Duration of Ventricular Depo (QRS)
Duration
 ST Segment Early ventricular repolarization
 U wave Origin for this wave is not clear - but
probably represents "after
depolarizations" in the ventricles
 QT Interval Duration of ventricular
depolarization and repolarization
 RR Interval Duration of ventricular cardiac cycle
(an indicator of ventricular rate)
(1 small box=0.04sec)
[1 big (5 small)= 0.2sec]
 Abnormal P wave indicates Artrial
Arrythmias
 Abnormal QRS indicates Ventricular
Arrhythmias
 Abnormal T Wave indicates potassium
imbalance.
 Tall is hyperkalemia- K+ is muscle RELaxant
 Flat or depressed is hypokalemia (U-wave
present)
 N= 0.12-0.20 (3-5 small squares)
 >0.20= Heart Blocks
 N= 0.05-0.10
 <0.05sec (NARROW) -SVT, Afib/flutter)
 >0.10 (WIDE) (Vtach, Vfib)
 Slightly Elevated ST segment - ST Elevation
Myocardial Infarction (STEMI)
 Super Elevated ST Segment- ACUTE
Myocardial Infarction
 Slightly Depressed/Inverted ST segment-
NONSTEMI
Not usually observable if it becomes apparent
suspect Hypokalemia.
 N= 0.36 - 0.44 sec.
 < 0.36 sec. indicates hypercalcemia
 > 0.44 sec. indicates hypocalcemia
(Torsades de Pointes)
 Narrow R-R is a tachycardia.
 Wide R-R is a bradycardia

HEART RATE COMPUTATION

A. IRREGULAR Rhythm= 6 second strips
o Count the R’s in a 6 second strips x 10
B. REGULAR Rhythm
o A. Big Box Method
-300/# of Big Box between 2 R’s
o B. Small Box Method- Not recommended (1500/Small box between 2 R’s)
HEARTBLOCKS (BRADYCARDIA)

RHYTHMS DESCRIPTION
ST -CONSISTENT PROLONGED PRI
1 Degree Heart Block

2ND Degree Heart Block -PROGRESSIVE BLOCK

-Progressively Longer PRI then Dropped QRS
-Long (PRI)->Longer (PRI)->DROP
a. WENKEBACH
Phenomenon (MOBITZ I)

-Normal (PRI)-> Normal (PRI)->DROP

b. MOBITZ II

3rd Degree Heart Block -INTERMITTENT BLOCK

-DROPS in QRS
-Pwave and QRS march- No correlation
-SUPER BRADYCARDIA

UNSTABLE BRADY MANAGEMENT (A-T-D-E)

Asess:
-BP- < 90/60
-LOC- Decreased
-Chest pain - (+)
-Signs of shock

 A-Atropine- 0.5mg bolus/3-5mins max: 3mg

 T-Transcutaneous pacing
 D-Dopa- 2-20mcg/kg/min
 E-Epi- 2-10mcg/min
TACHYCARDIA
ATRIAL TACHYCARDIA = HR-100bpm
RHYTHMS DESCRIPTION
1. PREMATURE ATRIAL CONTRACTION -Peaked, Biphasic (by 2) P wave
(PAC) -Narrow QRS
-Cause: Caffeine, stress- Usually No mgmt

2. ATRIAL FLUTTER- SAWTOOTH -More P waves than QRS (P waves are Visible-> SAWTOOTH)
-Cause: CHF, MI and Electrolyte Imbalance
-Mgmt: Cardioversion and Procainamide

3. ATRIAL FIBRILLATION -More P waves than QRS (P waves are Not Visible)
-Irregular Narrow QRS

VENTRICULAR TACHYCARDIA

RHYTHMS DESCRIPTION
1. PREMATURE VENTRICULAR -Wide QRS and inverted T wave
CONTRACTION (PVC) -Cause: CHF, MI and electrolyte imbalance
-Mgmt: Dx->Holter, stress test, Give Betablockers, calcium blockers
Anti arrythmic

UNIFOCAL

MULTIFOCAL

2. SUPRAVENTRICULAR TACHYCARDIA -More than 170 beats/min

(SVT) -No P wave
 -Regular R to R interval
-Management: Carotid massage for 10 sec.
-Mx: Carotid massage 10 sec, Adenosine, Beta blockers, Calcium
blockers
-May progress to serious arrhythmia.

3. VENTICULAR TACHYCARDIA -No P and T waves

-Regular wide QRS
-Non-sustained VT
-Cause: CHF, MI and electrolyte imbalance
-Management: give Adenosine

MONOMORPHIC

-Management: give Mg SO4 and consider defibrillation if unstable.

POLYMORPHIC

4. VENTRICULAR FIBRILLATION

COARSE

FINE

TACHYCARDIA MANAGEMENT

Unstable S/sx
-BP- < 90/60
-LOC- Decreased
-Chest pain - (+)
-Signs of shock

RHYTHMS STABLE UNSTABLE

1. ATRIAL FLUTTER/ATRIAL BCDH SYNCHORNIZE CARDIOVERSION
FIBRILLATION B-Beta Blocker (METOPROLOL) (2.5-
5mg-2min/5min) 120-200J
C- Calcium Channel Blocker
(VERAPAMIL) 5-10mg-2min then
Maintain
D- Digoxin
H- Heparin
2. SUPRAVENTICULAR CABC SYNCHRONIZE CARDIOVERSION
TACHYCARDIA (SVT) C - Carotid Massage
A - Adenosine: 1st dose: 6mg and
2nd dose: 12mg rapid IV push 50-100J
follow with NS flush
B - Beta Blocker
C- Calcium channel blocker
3. VENTRICULAR TACHYCARDIA AA SYNCHRONIZE CARDIOVERSION
MONOMORPHIC A-Adenosine- 1st dose: 6mg and
100J
2nd dose: 12mg rapid IV push follow
with NS flush
A-Anti Arrythmic Infusion or
Amiodarone 150mg over 10mins
4. VENTRICULAR TACHYCARDIA M-Magnesium Sulfate DEFIBRILLATION
POLYMORPHIC
Cardiac Arrest Rhythms

RHYTMS ECG
1. (PVT) Pulseless
Ventricular Tachycardia

2. (VF) Ventricular
Fibrillation

3. Asystole or Flat Line

4. (PEA) Pulseless
Electrical Activity-any
organized rhythm
without a pulse