DYSRHYTHMIAS

SINUS BRADYCARDIA 1. Determinants Rhythm: regular Rate: <60 P waves: present; same morphology PR interval: 0.12 to 0.20 seconds QRS:<0.10 second; same morphology 2. Treatment: if the patient is asymptomatic, none. If symptomatic, atropine, pacemaker, epinephrine, dopamine. SINUS TACHYCARDIA 1. Determinants Rhythm: regular Rate: >100 P waves: present; same morphology PR interval: 0.12 to 0.20 seconds QRS: <0.10 second; same morphology 2. Treatment: treat the cause (e.g., stress/anxiety, fever, heart failure, pain, hypoxia, hyperthyroidism) SINUS ARRHYTMIAS 1. Determinants Rhythm: irregular; varies by >0.12 seconds Rate: variable; increases with inspiration, decreases with expiration P waves: present; same morphology PR interval: 0.12 to 0.20 seconds QRS: <0.10 second; same morphology 2. Treatment: none PREMATURE ATRIAL COMPLEX 1. Determinants Rhythm: irregular because of ectopic beats Rate: that of underlying rhythm P waves: present; same morphology except for ectopic beat PR interval: 0.12 to 0.20 seconds (PR interval of the ectopic beat may vary from the other) QRS:<0.10 second; same morphology 2. Treatment: usually none ATRIAL TACHYCARDIA 1. Determinants Rhythm: regular Rate: atrial rate 130-250; ventricular rate may be less than atrial rate as a result of lack of condition through the AV node P waves: present; same morphology PR interval:0.12 to 0.20 seconds QRS:<0.10 second; same morphology

2. Treatment: identify and treat the cause (e.g., if caused by digitalis toxicity, discontinue

Digoxin) ATRIAL FLUTTER 1. Determinants Rhythm: atrial rhythm is regular, ventricular rhythm regular or irregular, depending on the AV conduction pattern Rate: atrial rate 230-350; ventricular rate usually <150 (depends on AV conduction) P waves: absent; replace by flutter wave, which have saw tooth appearance PR interval: none QRS: <0.10 second; same morphology 2. Treatment: if hemodynamically unstable, cardioversion ATRIAL FIBRILATION 1. Determinants Rhythm: irregular Rate: atrial rate <350; ventricular rate is variable P waves: none; fibrillatory waves create a wavy, undulating baseline PR interval: none QRS: <0.10 second; normal morphology 2. Treatment: if hemodynamically unstable, cardioversion PAROXYSMAL VENTRICULAR TACHYCARDIA 1. Determinants Rhythm: regular; repeated episode of tachycardia with an abrupt onset lasting from afew seconds to many hours Rate:150 to 250 P waves: cannot be clearly identified; may distort the preceding T waves PR interval: none measurable QRS: <0.10 second; same morphology 2. Treatment: treat underlying causes; if hemodynamically unstable, cardioversion JUNCTIONAL RHYTHM 1. Determinants Rhythm: regular Rate: escape 40 to 60 Accelerated 62 to 99 Tachycardia 100 to 140 P waves: absent; negative in II, III, aVf; may be dissociated from QRS PR interval: not applicable QRS: <0.10 second; same morphology 2. Treatment: if asymptomatic, none. If symptomatic because of decrease HR, atopine or pace maker may be indicated PREMATURE VENTRICULAR COMPLEX 1. Determinants Rhythm: irregular because of PVC Rate: varies with the underlying rhythm

P waves: no P wave with the PVC PR interval: PVC is wide and bizarre morphology QRS: 2. Treatment: none if benign ACCELERATED IDIOVENTRICULAR RHYTHM 1. Determinants Rhythm: regular Rate: 40 to 100 betas/min P waves: absent PR interval: none QRS: (0.12 second); bizarre appearance with same morphology 2. Treatment: non unless hemodynamically ubstable, the treat as with order bradydysrhythnias (atropine and/or pace maker) VENTRICULAR TACHYCARDIA 1. Determinants Rhythm: regular or slightly irregular Rate: 100 to 250 P waves: usually not seen; if present, will be dissociated from ventricular rhythm PR interval: none measurable QRS: (>0.12 second) and bizarre morphology 2. Treatment: defibrillation, CPR, vasopressor, epinephrine, amiodarone, lidocaine VENTRICULAR FIBRILLATION 1. Determinants Rhythm: irregular, chaotic base line Rate: unable to measure P waves: none PR interval: none QRS: none 2. Treatment: defibrillation, CPR, vasopressor, epinephrine, amiodarone, lidocaine TORSADE de DEPOINTES 1. Determinants Rhythm: regular or slightly irregular Rate: 200 to 250 P waves: usually not seen; if present, will be dissociated from ventricular rhythm PR interval: none measurable QRS: wide(>0.12 second) and bizarre morphology; QRS complexes appear to be constantly changing and twist in a spiral pattern around the baseline 2. Treatment: if hemodynamic unstable, electrical therapy, magnesium or overdrive pacing FIRST-DEGREE ATIOVENTRICULAR BLOCK 1. Determinants Rhythm: regular Rate: 60 to 100 P waves: normal; same morphology PR interval: >0.20 second QRS: <0.10 second; same morphology 2. Treatment: usually none unless associated with symtomic bradycardia

SECOND-DEGREE ATRIOVENTRICULAR BLOCK (TYPE I) 1. Determinants Rhythm: irregular Rate: atrial rate 60 to 100; ventricular rate is lower as a result dropped beats P waves: normal; same morphology PR interval: progressive lengthening with each beat until QRS is dropped; the PR interval is reset to normal with the dropped beat and the cycle of PR lengthening begins again QRS: <0.10 second; same morphology 2. Treatment: usually none SECOND-DEGREE ATRIOVENTRICULAR BLOCK (TYPE II) 1. Determinants Rhythm: irregular Rate: atrial 60 to 100; ventricular rate is slower as a result dropped beats P waves: normal; same morphology PR interval: 0.12 to 0.20 second and fixed; except where beat is dropped QRS: wide; same morphology 2. Treatment: pacemaker; there is a high tendency to progress to complete heart block