The document discusses cardiac rhythms and monitoring. It provides information on: 1) Electrode placements for cardiac monitoring and which leads are best for viewing different waveforms like P waves and QRS complexes. 2) How to interpret a rhythm strip by examining features like heart rate, rhythm regularity, presence of atrial activity, and relationship between atrial and ventricular rhythms. 3) Causes and characteristics of different cardiac rhythms like bradycardias, tachycardias, conduction abnormalities, and rhythms associated with cardiac arrest.

1. Cardiac monitoring and Rhythm recognition Rhythm in lead II ( most prominent P wave with sufficient amplitude to trigger the rate meter.

2. Electrode positions for cardiac monitor +ve Left shoulder, -ve right shoulder: lead I : Good QRS -ve right clavicle, +ve left lower chest : lead II good P and QRS enough for triggering rate meter -ve left clavicle and +ve left lower chest:Lead III Good P waves

3. Monitoring after Cardiac Arrests Rhythm monitores Watch for arching if jell and not jelpads are used Rhythm interpreted by rhythm strip Diagnosis by 12 lead ECG

4. How to read a rhythm strip ? Ventricular rate Rhythm QRS regular or irregular Is Atrial activity present Relationship Atrium vs Ventricle QRS width normal or prolonged

5. Ventricular rate < 60/min Bradychardia > 100/min Tachycardia 1second = 5 large squares Number of large squares between beats . Divide into 300

6. Regular or Irregular rhythm Atrial Fibrillation irregular check R-R intervals on strip ( paper and mark ) Ectopics Before next beat : premature ectopic late : escape beats 3 Ectopics consecutive is tachycardia If in self terminating runs : paroxysmal escape beats are narrow then ventricular Broad anywhere in the heart

7. Is Atrial Activity present lead V1 will record the best recording of Atrial activity Slow rate : vagal stimulus or Adenosine Atrial flutter rate 300/min Irregularity of Atrial Fibrillation Shape of the P wave P upright II and AVF : sinoatrial node P wave inverted in II and AVF then retrograde conduction

8. Relationship Atrial and Ventricular rhythm 1st degree block : PR > 0.21 seconds 2nd Degree Block AV Wenckebach ( Mobits I ): progressive prolonging PR until P dropped Mobitz II : blocked P wave without PR prolonging (*permanent pacing) Fixed 2:1 unlickely to progress 3rd Degree : Atrioventricular dissociation : Atrial Fibrillation

9. Conduction Ventricles RBBB: Broad QRS; R wave in V1 and secondary ST/T changes LBBB: Broad QRS; R in I and absence septal q inV6 ( R wave ) Hemiblock : LAHB:Absence of other causes of left axis deviation with LAD LPHB: RAD

10. Causes Left Axis Deviation inferior MI Wolff-Parkinson-White syndrome Ostium primum ASD Hyperkalaemia

11. Causes Right Axis Deviation Right ventricular Hypertrophy Pulmonary Embolism Cor Pulmonale W-P-W syndrome Ostium secundum Anterolateral MI

12. Rhythms Associated with cardiac arrest VF Asystole EMD / PEA Cardiac output loss severe bradycardias ventricular tachycardia

13. Ventricular Fibrillation ventricular myocardium depolarises at random. All coordination lost Confused polymorphic ventricular tachycardia ( torsades de pointes ) AF in the presence of AV nodal bypass

14. Polymorphic Ventricular Tachcardia tachycardia rate varies from beat to beat complexes have pointed appearances arise from background Long QT syndrome or abnormal T repolarisation Treatment : B blockers, magnesium and pacing can initiate VF

15. Atrial Fibrillation with pre-excitation rapid, broad achycardias variable QRS complexes W-P-W syndrome : QRS show delayed start More organised and lacks chaotic activity of variable amplitude

16. Ventricular Tachycardia broad complex tachycardia with rate 120 - 270/min QRS configuration constant

17. Asystole if suspected the gain controll should be turned up check not fine VF

18. Bradycardias 3rd Degree: Complete heart block : P =90/min or AF ; QRS=20 - 50/min

19. Agonal rhythm slow, wide irregular ventricle complexes of varying morphology becomes broader before all electrical activity is lost