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Advanced cardiac life support
- 1. CARDIAC LIFE SUPPORT: RHYTHM RECOGNITION AND MEGACODE LOO CARMEN SUPERVISOR: EP DR HAFIZAH
- 2. • Rate • Rhythm (regular/irregular) • Cardiac axis • P wave • PR interval • QRS complex (wide/narrow) • ST segment • QT interval Step by step interpretation • P wave • present/absent • size • PR interval = 0.12-0.2 sec (3-5 small boxes) • QRS complex (wide/narrow) = <0.12 sec (3 small boxes) • ST segment • QT interval QT interval should be less than 50% of the preceding cycle length Prolonged QT is associated with risk of VT and Torsades de pointes
- 4. • Rate • Rhythm (regular/irregular) • Cardiac axis • P wave • PR interval • QRS complex (wide/narrow) • ST segment • QT interval Step by step interpretation Rate If RR interval is 1 big box (0.2 secs) then the rate is 60/0.2 = 300 bpm •1 big box = 300 beats/min •2 big boxes = 150 beats/min •3 big boxes = 100 beats/min 10 seconds = 50 large square 6 seconds = 30 large square The standard paper speed is 25mm/sec • 1mm (small square) = 0.04sec • 5mm (large square) = 0.2sec REGULAR RHYTHM IRREGULAR RHYTHM • Rate = 300/number of large square between two consecutives R waves • 10 seconds method Rate = number of R waves x 6 • 6 seconds method Rate = number of R waves x 10
- 5. • Rate • Rhythm (regular/irregular) • Cardiac axis • P wave • PR interval • QRS complex (wide/narrow) • ST segment • QT interval Step by step interpretation Rhythm II • Regular : RR interval constant • Regularly irregular : RR interval variable but with a pattern • Irregularly irregular : RR interval variable with no pattern, totally irregular
- 6. • Rate • Rhythm (regular/irregular) • Cardiac axis • P wave • PR interval • QRS complex (wide/narrow) • ST segment • QT interval Step by step interpretation Axis • Major direction of the overall electrical activity of the heart • Normal is -30 to +90 • Significance Alert to look for right and left ventricular hypertrophy Change of axis to the right may suggest PE Change of axis to the left may suggest conduction defect Normal axis 0⁰ - 90⁰ Left axis deviation PATHOLOGICAL -30⁰ -90⁰ Right axis deviation +90⁰ +180⁰
- 8. Cardiac arrest ( no pulse) Shockable rhythm Non- shockable VF Pulseless VT Asystole PEA Arrhythmias ( with pulse) Tachyarrhythmia Bradyarrhythmia Stable Or Unstable Stable Or Unstable
- 9. TACHYARRHYTHMIA • HR >150 bpm • Stable and unstable Narrow QRS complex (< 0.12s) Wide QRS complex ( >0.12s) Regular Irregular Regular Irregular Sinus tachycardia SVT Atrial flutter Atrial Fibrillation VT VF Polymophic VT or Torsades de Points
- 12. Ventricular tachycardia – polymorphic VT Ventricular tachycardia – monomorphic VT
- 13. BRADYARHYTHMIA HR <60BPM STABLE AND UNSTABLE SINUS BRADYCARDIA HEART BLOCK
- 15. Heart Block
- 16. prolongation of PR interval (>0.2s) progressive lengthening of PR interval with eventual dropped ventricular conduction intermittent dropping of ventricular conduction complete dissociation between atria and ventricular
- 17. First Degree Heart Block
- 18. Second Degree Heart Block (Mobitz Type 1)
- 19. Second Degree Heart Block (Mobitz Type 2)
- 20. Third Degree Heart Block (Complete Heart Block)
- 25. Defibrillation Cardioversion Unsynchronized Synchronized shock High energy shock Low energy shock Used in VF/ Pulseless VT Used in most arrhythmia except VF and pulseless VT
- 26. SYNCHRONIZED CARDIOVERSION Narrow regular 50 to 100 Joule Narrow irregular 120 to 200 Joule (Biphasic) or 200 Joule (Monophasic) Wide regular 100 Joule Wide irregular Defibrillation dose (Not synchronized)
- 27. Reversible Causes of Cardiac Arrest 5H 5T Hypovolemia Tension pneumothorax Hypothermia Tamponade (Cardiac) Hypoxia Toxin Hypo/Hyperkalemia Thrombosis (Coronary) Hypothermia Thrombosis (Pulmonary)
- 30. Management for SVT • 2) Pharmacological • Adenosine, 6mg with 20cc NS via cubital fossa, with 3way connected to the cannula, rapidly deliver the adenosine followed by NS flush through 3 way tap and raise the arm • OR IV Verapamil 2-5 mg given 1mg/min up to 20mg • OR IV Diltiazem 2.5mg/min (max 50mg) • OR IV Amiodarone 300mg in 100 cc D5 and 900mg in 100cc D5 in 23H ( infusion) • 1) Non pharmacological • Vasalva manouvre: Supine position, ask patient to blow into 20ml syringe to push plunger out or blow against closed glottis like straining to have bowel movement/ Maintain for 10 seconds and then resume normal breathing • Carotid massage-make sure to exclude carotid bruits, trandelenburg position, and head turn to one side, put finger to the superior part of the palpable carotid pulse, and apply pressure backward and medially in circular or longitudinal massage for <10s, apply up until 1min
- 31. Management for AF Unstable Electrical cardioversion -start with 120J Pharmacological cardioversion - Amiodarone 300mg in 1H followed by 900mg in 24H OR Stable Rate control -oral beta blocker – T metoprolol 50mg -calcium channel cblocker - IV verapamil 2.5-5mg -IV digoxin 0.5mg in 100cc NS over 30 min Rhythm control Pharmacological cardioversion – IV amiodarone 300mg in 1H, then 900mg in 23H Electrical cardioversion 120J onwards
- 32. Management for VT • IV amiodarone 300mg over 20-60 min and followed by infusion 900mg/23H • Lidocaine 1-1.5mg/kg over 10 min, repeated once at half dose after 10min ( max 3mg/kg) OR • Procainamide 100mg in 5 min, 20-50mg/min until arrythmia suppressed • Sotalol 100mg or 1.5mg/kg over 5min • Avoid in prolonged QT or HF • If torsades de pointes, given IV Mg So4 2g over 10 min
- 35. Transcutaneous Pacing Indications: • Hemodynamically unstable bradycardia • Symptomatic sinus bradycardia • Mobitz Type 2 second degree heart block • Complete heart block
- 36. Transcutaneous Pacing Steps: Explain to the patient regarding the procedure Inform consent Prepare procedural sedations Attach pads (apex and sternum) Select mode: Fixed or demand Select rate: usually starts from 60bpm Select energy Turn Pacer ON, presence of pacing spikes on ECG are indicating that impulse are delivered Look for electrical capture (pacing spikes followed by broad QRS complex and T waves) Feel for mechanical capture Increase energy by 5mA
- 38. Mechanical capture • Signs of improved cardiac output • palpable pulse, • rise in blood pressure, • improved level of consciousness, • improved skin color and temperature
- 39. • References: • American Heart Association • ECG made easy • Life in the fast lane
Editor's Notes
- An ECG - representation of the electrical activity of the heart muscle Regular or irregular>? R-R interval? Rate Regular: 300/ ( bifg boxes from R-R) Irregular: count R in 30 big boxes x 10 ( 300 big boxes= 1 min) Look at the QRS complex Narrow? Broad 0.07- 0.1s Narrow < 0.12s Borad> 0.12s Supraventricular rhythm: arises from above level of bundle of His, junctional, producing narrow QRS complex, as impulse pass through specialized conduction system to the ventricles Ventricular rhythm produce wide QRS complex as impulses does not pulse through AVN/bundle of His, --pass directly to ventricular myocardium, longer time taken for depolar P wave absend? Present? PR wave: normal,shortend or prolonged ( 120-200ms)- 3-4 boxes P followed by QRS complex– if not in heart block Regular/irregular? Rate QRS( broad/narrow) P? absent or present, PR, normal or prolonged P with QRS relationship The normal ECG It will be clear from above that the first structure to be depolarised during normal sinus rhythm is the right atrium, closely followed by the left atrium. So the first electrical signal on a normal ECG originates from the atria and is known as the P wave. Although there is usually only one P wave in most leads of an ECG, the P wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. There is then a short, physiological delay as the atrioventricular (AV) node slows the electrical depolarisation before it proceeds to the ventricles. This delay is responsible for the PR interval, a short period where no electrical activity is seen on the ECG, represented by a straight horizontal or ‘isoelectric’ line. Depolarisation of the ventricles results in usually the largest part of the ECG signal (because of the greater muscle mass in the ventricles) and this is known as the QRS complex. The Q wave is the first initial downward or ‘negative’ deflection The R wave is then the next upward deflection (provided it crosses the isoelectric line and becomes ‘positive’) The S wave is then the next deflection downwards, provided it crosses the isoelectric line to become briefly negative before returning to the isoelectric baseline. In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. This is shown as the ST segment and the T wave. The ST segment is normally isoelectric, and the T wave in most leads is an upright deflection of variable amplitude and duration (see Figures 5 and 6). Normal intervals The recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to be measured, usually in milliseconds. There is a recognised normal range for such ‘intervals’: PR interval (measured from the beginning of the P wave to the first deflection of the QRS complex). Normal range 120 – 200 ms (3 – 5 small squares on ECG paper). QRS duration (measured from first deflection of QRS complex to end of QRS complex at isoelectric line). Normal range up to 120 ms (3 small squares on ECG paper). QT interval (measured from first deflection of QRS complex to end of T wave at isoelectric line). Normal range up to 440 ms (though varies with heart rate and may be slightly longer in females)
- An ECG is simply a representation of the electrical activity of the heart muscle as it changes with time, usually printed on paper for easier analysis. Regular or irregular>? R-R interval>? Rate Regular: 300/ ( bifg boxes from R-R) Irregular: count R in 30 big boxes x 10 ( 300 big boxes= 1 min) Look at the QRS complex Narrow? Broad 0.07- 0.1s Narrow < 0.12s Borad> 0.12s Supraventricular rhythm: arises from above level of bundle of His, junctional, producing narrow QRS complex, as impulse pass through specialized conduction system to the ventricles Ventricular rhythm produce wide QRS complex as impulses does not pulse through AVN/bundle of His, --pass directly to ventricular myocardium, longer time taken for depolar P wave absend? Present? PR wave: normal,shortend or prolonged ( 120-200ms)- 3-4 boxes P followed by QRS complex– if not in heart block Regular/irregular? Rate QRS( broad/narrow) P? absent or present, PR, normal or prolonged P with QRS relationship The normal ECG It will be clear from above that the first structure to be depolarised during normal sinus rhythm is the right atrium, closely followed by the left atrium. So the first electrical signal on a normal ECG originates from the atria and is known as the P wave. Although there is usually only one P wave in most leads of an ECG, the P wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. There is then a short, physiological delay as the atrioventricular (AV) node slows the electrical depolarisation before it proceeds to the ventricles. This delay is responsible for the PR interval, a short period where no electrical activity is seen on the ECG, represented by a straight horizontal or ‘isoelectric’ line. Depolarisation of the ventricles results in usually the largest part of the ECG signal (because of the greater muscle mass in the ventricles) and this is known as the QRS complex. The Q wave is the first initial downward or ‘negative’ deflection The R wave is then the next upward deflection (provided it crosses the isoelectric line and becomes ‘positive’) The S wave is then the next deflection downwards, provided it crosses the isoelectric line to become briefly negative before returning to the isoelectric baseline. In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. This is shown as the ST segment and the T wave. The ST segment is normally isoelectric, and the T wave in most leads is an upright deflection of variable amplitude and duration (see Figures 5 and 6). Normal intervals The recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to be measured, usually in milliseconds. There is a recognised normal range for such ‘intervals’: PR interval (measured from the beginning of the P wave to the first deflection of the QRS complex). Normal range 120 – 200 ms (3 – 5 small squares on ECG paper). QRS duration (measured from first deflection of QRS complex to end of QRS complex at isoelectric line). Normal range up to 120 ms (3 small squares on ECG paper). QT interval (measured from first deflection of QRS complex to end of T wave at isoelectric line). Normal range up to 440 ms (though varies with heart rate and may be slightly longer in females)
- An ECG - representation of the electrical activity of the heart muscle Regular or irregular>? R-R interval? Rate Regular: 300/ ( bifg boxes from R-R) Irregular: count R in 30 big boxes x 10 ( 300 big boxes= 1 min) Look at the QRS complex Narrow? Broad 0.07- 0.1s Narrow < 0.12s Borad> 0.12s Supraventricular rhythm: arises from above level of bundle of His, junctional, producing narrow QRS complex, as impulse pass through specialized conduction system to the ventricles Ventricular rhythm produce wide QRS complex as impulses does not pulse through AVN/bundle of His, --pass directly to ventricular myocardium, longer time taken for depolar P wave absend? Present? PR wave: normal,shortend or prolonged ( 120-200ms)- 3-4 boxes P followed by QRS complex– if not in heart block Regular/irregular? Rate QRS( broad/narrow) P? absent or present, PR, normal or prolonged P with QRS relationship The normal ECG It will be clear from above that the first structure to be depolarised during normal sinus rhythm is the right atrium, closely followed by the left atrium. So the first electrical signal on a normal ECG originates from the atria and is known as the P wave. Although there is usually only one P wave in most leads of an ECG, the P wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. There is then a short, physiological delay as the atrioventricular (AV) node slows the electrical depolarisation before it proceeds to the ventricles. This delay is responsible for the PR interval, a short period where no electrical activity is seen on the ECG, represented by a straight horizontal or ‘isoelectric’ line. Depolarisation of the ventricles results in usually the largest part of the ECG signal (because of the greater muscle mass in the ventricles) and this is known as the QRS complex. The Q wave is the first initial downward or ‘negative’ deflection The R wave is then the next upward deflection (provided it crosses the isoelectric line and becomes ‘positive’) The S wave is then the next deflection downwards, provided it crosses the isoelectric line to become briefly negative before returning to the isoelectric baseline. In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. This is shown as the ST segment and the T wave. The ST segment is normally isoelectric, and the T wave in most leads is an upright deflection of variable amplitude and duration (see Figures 5 and 6). Normal intervals The recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to be measured, usually in milliseconds. There is a recognised normal range for such ‘intervals’: PR interval (measured from the beginning of the P wave to the first deflection of the QRS complex). Normal range 120 – 200 ms (3 – 5 small squares on ECG paper). QRS duration (measured from first deflection of QRS complex to end of QRS complex at isoelectric line). Normal range up to 120 ms (3 small squares on ECG paper). QT interval (measured from first deflection of QRS complex to end of T wave at isoelectric line). Normal range up to 440 ms (though varies with heart rate and may be slightly longer in females)
- An ECG - representation of the electrical activity of the heart muscle Regular or irregular>? R-R interval? Rate Regular: 300/ ( bifg boxes from R-R) Irregular: count R in 30 big boxes x 10 ( 300 big boxes= 1 min) Look at the QRS complex Narrow? Broad 0.07- 0.1s Narrow < 0.12s Borad> 0.12s Supraventricular rhythm: arises from above level of bundle of His, junctional, producing narrow QRS complex, as impulse pass through specialized conduction system to the ventricles Ventricular rhythm produce wide QRS complex as impulses does not pulse through AVN/bundle of His, --pass directly to ventricular myocardium, longer time taken for depolar P wave absend? Present? PR wave: normal,shortend or prolonged ( 120-200ms)- 3-4 boxes P followed by QRS complex– if not in heart block Regular/irregular? Rate QRS( broad/narrow) P? absent or present, PR, normal or prolonged P with QRS relationship The normal ECG It will be clear from above that the first structure to be depolarised during normal sinus rhythm is the right atrium, closely followed by the left atrium. So the first electrical signal on a normal ECG originates from the atria and is known as the P wave. Although there is usually only one P wave in most leads of an ECG, the P wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. There is then a short, physiological delay as the atrioventricular (AV) node slows the electrical depolarisation before it proceeds to the ventricles. This delay is responsible for the PR interval, a short period where no electrical activity is seen on the ECG, represented by a straight horizontal or ‘isoelectric’ line. Depolarisation of the ventricles results in usually the largest part of the ECG signal (because of the greater muscle mass in the ventricles) and this is known as the QRS complex. The Q wave is the first initial downward or ‘negative’ deflection The R wave is then the next upward deflection (provided it crosses the isoelectric line and becomes ‘positive’) The S wave is then the next deflection downwards, provided it crosses the isoelectric line to become briefly negative before returning to the isoelectric baseline. In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. This is shown as the ST segment and the T wave. The ST segment is normally isoelectric, and the T wave in most leads is an upright deflection of variable amplitude and duration (see Figures 5 and 6). Normal intervals The recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to be measured, usually in milliseconds. There is a recognised normal range for such ‘intervals’: PR interval (measured from the beginning of the P wave to the first deflection of the QRS complex). Normal range 120 – 200 ms (3 – 5 small squares on ECG paper). QRS duration (measured from first deflection of QRS complex to end of QRS complex at isoelectric line). Normal range up to 120 ms (3 small squares on ECG paper). QT interval (measured from first deflection of QRS complex to end of T wave at isoelectric line). Normal range up to 440 ms (though varies with heart rate and may be slightly longer in females)
- An ECG - representation of the electrical activity of the heart muscle Regular or irregular>? R-R interval? Rate Regular: 300/ ( bifg boxes from R-R) Irregular: count R in 30 big boxes x 10 ( 300 big boxes= 1 min) Look at the QRS complex Narrow? Broad 0.07- 0.1s Narrow < 0.12s Borad> 0.12s Supraventricular rhythm: arises from above level of bundle of His, junctional, producing narrow QRS complex, as impulse pass through specialized conduction system to the ventricles Ventricular rhythm produce wide QRS complex as impulses does not pulse through AVN/bundle of His, --pass directly to ventricular myocardium, longer time taken for depolar P wave absend? Present? PR wave: normal,shortend or prolonged ( 120-200ms)- 3-4 boxes P followed by QRS complex– if not in heart block Regular/irregular? Rate QRS( broad/narrow) P? absent or present, PR, normal or prolonged P with QRS relationship The normal ECG It will be clear from above that the first structure to be depolarised during normal sinus rhythm is the right atrium, closely followed by the left atrium. So the first electrical signal on a normal ECG originates from the atria and is known as the P wave. Although there is usually only one P wave in most leads of an ECG, the P wave is in fact the sum of the electrical signals from the two atria, which are usually superimposed. There is then a short, physiological delay as the atrioventricular (AV) node slows the electrical depolarisation before it proceeds to the ventricles. This delay is responsible for the PR interval, a short period where no electrical activity is seen on the ECG, represented by a straight horizontal or ‘isoelectric’ line. Depolarisation of the ventricles results in usually the largest part of the ECG signal (because of the greater muscle mass in the ventricles) and this is known as the QRS complex. The Q wave is the first initial downward or ‘negative’ deflection The R wave is then the next upward deflection (provided it crosses the isoelectric line and becomes ‘positive’) The S wave is then the next deflection downwards, provided it crosses the isoelectric line to become briefly negative before returning to the isoelectric baseline. In the case of the ventricles, there is also an electrical signal reflecting repolarisation of the myocardium. This is shown as the ST segment and the T wave. The ST segment is normally isoelectric, and the T wave in most leads is an upright deflection of variable amplitude and duration (see Figures 5 and 6). Normal intervals The recording of an ECG on standard paper allows the time taken for the various phases of electrical depolarisation to be measured, usually in milliseconds. There is a recognised normal range for such ‘intervals’: PR interval (measured from the beginning of the P wave to the first deflection of the QRS complex). Normal range 120 – 200 ms (3 – 5 small squares on ECG paper). QRS duration (measured from first deflection of QRS complex to end of QRS complex at isoelectric line). Normal range up to 120 ms (3 small squares on ECG paper). QT interval (measured from first deflection of QRS complex to end of T wave at isoelectric line). Normal range up to 440 ms (though varies with heart rate and may be slightly longer in females)
- Normal heart rate ( 60-100) Above HR>100, called tachycardia Below < 60, called bradycardia Clinical- stable/unstable ECG- narrow/wide, regular vs irregular Origin- supraventricular vs ventricular
- Narrow QRS complex P waves not seen Rate> 150bpm Regular rhythm P waves buried in T wave
- Normal heart rate ( 60-100) Above HR>100, called tachycardia Below < 60, called bradycardia Clinical- stable/unstable ECG- narrow/wide, regular vs irregular Origin- supraventricular vs ventricular
- Sinus rhythm A resting heart beat < 60bpm Normal QRS complex
- First degree heart block PR interval > 200ms ( five small squares) Sinus rhythm Normal P wave followed by normal QRS complex ‘Marked’ first degree block if PR interval >300ms
- Progressive prolongation of the PR interval culminating in a non conducted P wave The PR interval is the longest immediately before the dropped beat The PR interval is the shortest immediately after the dropped beat
- Intermittent non conducted P waves without progressive prolongation of the PR interval ( compare to Mobitzz II) The PR interval in the conducted beates remain constant The P waves ‘ march through’ at constant rate The RR interval surrounding the dropped beat is an exact multiple of the preceding RR interval
- In complete HB, there is complete absence of AV conduction- none of the supraventricular impulses are conducted to the ventricles Atrial and ventricular rate regular but independently dissociated P waves normal
- Less damage to myocardium in cardioversion
- Fixed: will deliver a fixed number of beats regardless pt heart beat Demand: only deliver beats when pt heart beat less than the rate
- Fixed: will deliver a fixed number of beats regardless pt heart beat Demand: only deliver beats when pt heart beat less than the rate