5. Sinus tachycardia
• Regular
• Narrow QRS
• Always secondary to some cause (anxiety, pain,
hypovolumia, fever etc.)
• Identify and treat the cause
6. Atrial fibrillation
• Irregularly irregular
• Atrial rate >400, ventricular rate 170-
180/min
• Narrow QRS complex
• No definite P waves
• No isoelectric line
7. Atrial Fibrillation- Treatment
• If acute or patient is unstable do
synchronized cardioversion with 50J
• Control ventricular rate with Diltiazem
0.25mg/kg, Verapamil 5mg, Metaprolol
25mg, Digoxin 0.5mg
• If >2 days (onset not known) do ECHO
to R/O thrombus in atrium
• If no clot Cardioversion with 50J
• If there is a clot anti coagulate for 1-3
weeks
11. Multifocal atrial tachycardia (MAT)
• Wandering pacemaker
• Irregularly irregular
• Each P-wave is different in morphology
• Narrow QRS complex
• Standard anti arrhythmic agents ineffective
• Cardioversion has no effect
• Magnesium sulfate 2gm iv over 1 min, and
infusion at 1-2gm/hr
• Maintain K+ level above 4mEq/lt
• Verapamil 5-10mg to control ventricular rate
16. Monomorphic VT
• More than 3 consecutive PVC
• Regular
• Rate >100/min
• Broad QRS complex (>3 small squares)
• Each QRS similar in shape
17. Monomorphic VT
• If unstable (pulseless) A&E(SRMC)
– Start CPR, defibrillate with 200J
biphasic or 360J monophasic, resume CPR
for 2 min, reassess the rhythm
– Adrenaline 1mg, Amiodarone 300mg or
Lidocaine 50-75mg and re attempt
defibrillation
– Defibrillation can be continued as long as
there is shockable rhythm
18. Monomorphic VT
• Stable VT (with pulse)
– Amiodarone 150mg slow iv over 10min,
followed by infusion at 1mg/min for 6 hours
and 0.5mg/min for next 18 hours
– Alternatively Lidocaine 1-1.5mg/kg bolus and
infusion at 1-4mg/min
– Synchronized Cardioversion with 100J
20. Polymorphic VT
• Irregularly irregular
• QRS wide
• Each QRS different from others
• May progress to VF
• Treatment same as VF
21. Torsades de pointes
• Twisting of points
• Special variant of polymorphic VT
• Magnesium sulfate 2gm in 10ml DNS over
2-3 min, followed by infusion at 1-2gm/hr
• Temporary pacing may abolish TdP
23. Ventricular fibrillation
• Irregularly irregular
• Wide and varying QRS
• Disorganized
• Incompatible with life (cannot produce CO)
• Its important to differentiate fine Vfib from
asystole
24. Ventricular fibrillation
• Start CPR immediately, shock with 200J
biphasic or 360J monophasic
• Resume CPR for 2 min (don’t look at
monitor)
• Adrenaline 1mg, Amiodarone 300mg or
Lidocaine 75mg
• Assess rhythm, if Vfib persists shock and
resume CPR for 2 min (repeat the cycle)
29. AV blocks
• First degree AV block
• Second degree AV block
– Mobitz type 1 (Wenckebach)
– Mobitz type 2
• Third degree AV block (complete heart
block)
30. First degree AV block
• Regular
• Prolonged PR interval (>5 small squares)
• Narrow QRS
• No treatment required
31. Second degree Type 1(wenckebach)
• Regularly Irregular
• Progressively increasing PR interval until 1 QRS
is dropped, and the cycle repeats
• QRS narrow
• Reversible
• No treatment if asymptomatic
• If symptomatic give atropine 0.5mg, repeat
every 3 min (max 3mg)
• Temporary pacing
32. Second degree Type 2
• Irregularly irregularly
• Constant PR interval, narrow/wide QRS
• QRS dropped irregularly
• Irreversible
• May progress to complete block
• Atropine 0.5mg repeated every 3min (max 3mg),
may not be effective
• Permanent pacing
33. Third degree (complete) AV block
• Regular P-P interval and R-R interval
• More P waves than QRS
• QRS usually wide, but may be narrow
• Atropine not effective
• Permanent pacing
