2.  Automaticity
 Excitability
 Conductivity
 Contractility
 Refractoriness

5.  SA node
› 80–100 bpm
 Atrial foci
› 60–80 bpm
 Junctional foci
› 40–60 bpm
 Ventricular foci
› 20–40 bpm

8.  PR interval
 0.12 to 0.20 s (3 -
5 small squares)
 QRS complex
 < 0.12 s duration
(3 small squares)
 QT interval
 varies based on
rate
 QTc=Normal =
0.42 s.
 ST segment
 no elevation or
depression

9.  Count R waves in 6 sec strip
 Multiply by 6!
 What is this heart rate?

11.  Palpitations
 Dizziness
 Syncope
 Chest pain
 Nausea/vomiting
 Poor perfusion
› delayed cap refill,
cool/clammy
extremities, pallor
 Hypotension
 AMS- altered mental
status
 Cardiac arrest
 Weakness
 Fatigue

12.  Is patient symptomatic?
 Stable versus unstable
 Level of consciousness?
 Support ABCs
 Oxygen
 Monitor ECG, SpO2, blood pressure
 Identify and treat
 Determine cause, if possible
Code
versus
Rapid Response

15.  Sinus Rhythm is normal!
 Sinus Bradycardia
› Symptoms: loss of consciousness, pallor,
dizziness, chest pain, confusion, AMS,
hypotension, SOB, orthostatic blood pressure
changes
› Atropine
› Pacing
 external, transvenous, permanent
 Sinus Tachycardia
› Symptoms: loss of consciousness, pallor, dizziness,
chest pain, confusion, AMS, hypotension, SOB
› Normal in some circumstances
› Treat the cause
› Beta blockers, adenosine (SVT), Ca channel
blockers

16.  Premature Ventricular contractions (PVC)
 Treatment:
 Symptomatic versus asymptomatic
 Bigeminy, trigeminy
 Determine cause (stimulants, dehydration, etc)
 Beta blockers, ablation

18.  RIGHT BBB  LEFT BBB

19. •Rhythm - Irregularly irregular
•Rate - usually 100-160 beats per minute
but slower if on medication
•QRS Duration - Usually normal
•P Wave - Not distinguishable as the atria
are firing off all over
•P-R Interval - Not measurable
•The atria fire irregular electrical impulses
causing irregular heart rhythm

20. •Rhythm – Regular (usually)
•Rate - Around 110 beats per minute
•QRS Duration - Usually normal
•P Wave - Replaced with multiple F (flutter)
waves, usually at a ratio of 2:1 (2F -
1QRS) but sometimes 3:1
•P Wave rate - 300 beats per minute
•P-R Interval - Not measurable
Abnormal tissue generating the rapid heart
rate is in the atria

21.  Symptoms:
 AMS, chest pain, syncope, SOB,
hypotension
 Long term risk of stroke
 Treatment:
 Rate versus rhythm control
(Atrial Kick!)
 Beta blockers, Ca channel
blockers, synchronized
cardioversion , ablation, AV node
ablation+pacemaker

22.  PR interval > 0.20 seconds
 Rarely any symptoms or treatment
 Can be caused by medications (beta blockers)
or be a contradiction to medications
 Delayed conduction through the AV node

23. •Rhythm - Regularly irregular (P waves, QRS may be irregular)
•Rate - Normal or Slow
•QRS Duration - Normal
•P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.
•P Wave rate - Normal but faster than QRS rate
•P-R Interval - Progressive lengthening of P-R interval until a QRS
complex is dropped
•Increasing delayed conduction through the AV node, eventually
resulting in non conducted beat

25. •Rhythm – Regular (P
Waves, QRS will be
irregular)
•Rate - Normal or Slow
•QRS Duration – may be
prolonged
•P Wave - occur regularly
(“march out”)
•P-R Interval - Normal or
prolonged but constant
•Random lack of
conduction through the
AV node

28. •Rhythm - Regular
•Rate - Slow
•QRS Duration – Prolonged
•P Wave – Unrelated (but “march out”)
•P Wave rate - Normal but faster than QRS rate
•P-R Interval - Variable
• No atrial impulses pass through the atrioventricular node and
the ventricles generate their own rhythm
•A/V dissociation

30.  Symptoms:
› similar to bradycardia- SOB, dizziness, LOC, chest pain,
pallor, confusion, AMS, hypotension, orthostatic blood pressure
changes
 Causes:
› Damage to the AV node – MI, scar tissue
 Second Degree type 2 may lead to complete heart block
 Complete heart block is rarely stable
 Treatment:
 Atropine is not effective (stimulates the SA node which is
usually working, it’s the AV node that’s slowing
conduction or not conducting at all)
 Pacing- external in emergent situations, transcutaneous or
external with sedation if patient is conscious, permanent
implanted pacer for long term management

31. •Rhythm - Regular
•Rate - 180-190 Beats per minute
•QRS Duration - Prolonged
•P Wave - Not seen
•Poor cardiac output causes the pt to go into
cardiac arrest.
•Shock this rhythm if the patient is
unconscious and without a pulse

33. •Rhythm - Irregular
•Rate - 300+, disorganized
•QRS Duration - Not recognizable
•P Wave - Not seen
•NO PULSE
•Life Threatening Arrhythmia
•CPR, DEFIBRILLATE

34.  Causes:
 Ischemia, infarction, drugs, hypoxia, electrolytes
(Hypo/Hyper)
 Treatment:
› If unstable, defibrillate
› For VT, may synchronize cardiovert
› Drugs (ACLS)
› Torsades: Magnesium
 Determine cause and correct
 Long term treatment:
AICD

41.  Is the rhythm regular? Irregular? Fast? Slow? Is
there a P, QRS, T? Easily identifiable?
 Is there a P wave for every QRS? What is the
PR interval? Does it vary or is it the same? Is
the P wave rhythm regular?(do they “march
out”?)What is the atrial rate?
 What does the ventricular rhythm look like?
What is the rate? Fast? Slow?

42.  PR=.20 QRS= .08 Rate: 50’s
 PR=.16 QRS= .06 Rate: 70’s

43.  PR= ? QRS= .06 Rate: 100’s
 PR= .18 QRS= .08 Rate: 80’s

44.  PR= .18 QRS= .06 Rate: 120’s
 PR= ? QRS= .40 Rate: 180’s

45.  PR= .18 QRS= .12 Rate: 80’s Rhythm- multifocal
PVC’s
 PR= .18 -? QRS= .08 Rate: 180’s Rhythm- SR-PSVT

46.  PR= Varies QRS= .12 Rate: 60’s
 PR= ? QRS= .? Rate: ? Rhythm- V- Fib

47.  PR= ? QRS= .10 Rate: 80’s
 PR= -? QRS= .20 Rate: 40’s

48.  PR= varies -? QRS= .40 Rate: 40’s
 PR= ? QRS= .28 Rate: 40’s

49.  PR= .38 QRS= .08 Rate: 60’s