ELECTROCARDIOGRAPHY Graphic display of the electric forces generated by the heart which are recorded as waves or deflections Conduction

system: SA node (60-100bpm) intermodal pathways AV node (40-60bpm) bundle of His RBB and LBB Purkinje system (20-40bpm) ventricles
Note: Bachmanns bundle is the inter-atrial pathway that transmits from the SA node (right atrium) to the left atrium

ECG Standardization

12 Lead ECG: 6 limb leads and 6 chest leads

P wave QRS complex ST segment T wave U wave 3 Standard (Bipolar) Limb Leads Negative Positive Heart View Electrode Electrode Right Arm Left Arm Lateral Right Arm Left Leg Inferior Left Arm Left Leg Inferior

Atrial depolarization Ventricular depolarization End QRS complex (J point) start T Start of ventricular repolarization End of ventricular repolarization after repolarization (Purkinje fibers)

Note: Q and S are the only NEGATIVE waveforms, all the rest are normally positive

I II III

PR interval (0.12-0.20s) PR segment QRS interval (0.06-0.10s) QT interval (0.35s)

Note: Electric potential moves from negative to positive

Start P wave start QRS complex Duration of atrial depolarization and AV node delay End P wave start QRS complex ST segment baseline Start QRS complex J point Duration of ventricular depolarization Start QRS complex end T wave Duration of ventricular depolarization and repolarization

Note: Mechanical contraction occurs in the interval between depolarization and repolarization

Normal Sinus Rhythm

Rate
Regular HR 300 # large boxes 1500 # small boxes Irregular HR # R waves in a 6 sec strip 10

60-100bpm RR interval: ventricular PP interval: atrial Tachycardia: <3 large boxes Bradycardia: >5 large boxes Consistent RR or PP intervals Every P wave is followed by a QRS complex (1:1 ratio) Uniform: same size, shape, and deflection (positive) 0.12-0.20 seconds and constant 0.06-0.10 seconds (narrow)

3 Augmented (Unipolar) Limb Leads Positive Heart View Electrode None (nonaVR Right Arm diagnostic) aVL Left Arm Lateral aVF Left Leg Inferior
Note: Reference point (zero electrical potential) at the center

Regularity P wave

PR interval QRS interval

V1 V2 V3 V4 V5 V6

6 Precordial (Chest) Leads Positive Electrode Heart View 4th ICS right sternum Septum 4th ICS left sternum Between V2 and V4 Anterior 5th ICS left MCL th 5 ICS left AAL Lateral 5th ICS left MAL

Note: Reference point (zero electrical potential) at the center

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Electrical Axis of the Heart Sum total of all electrical currents generated by the ventricular myocardium during depolarization Mean orientation of the QRS vector with reference to the 6 frontal plane leads Normal Axis: -30 to +100 Leads: I and aVF

Premature Ventricular Contraction

Ventricular Fibrillation

Asystole

Irritable ventricular focus Wide, bizarre looking QRS with NO preceding P wave Complete compensatory pause after No cardiac output Chaotic undulations of the ECG baseline No P wave No true QRS complexes Indeterminate rate Electrical activity in the ventricles completely absent (Flat ECG)

Note: Bigeminy is regular alternating normal sinus and premature beat while Couplets is 2 consecutive premature beats

Myocardial Ischemia
Ischemia Injury Infarction Lack of oxygen Arterial occlusion (clot or coronary spasm) Death of tissue ST depression (subendocardial) T wave inversion ST elevation (transmural) Pathological Q wave

Lead I Normal Axis

Lead avF

Causes

Right Axis Deviation

Left Axis Deviation Extreme Axis Deviation

RV hypertrophy Left posterior fascicular block Left lateral MI Dextrocardia Left pneumothorax Pulmonary embolism Congenital LV hypertrophy Left anterior fascicular block Left bundle branch block Inferior MI Obesity Indeterminate No Mans Land

Note: Right is REACHING while Left is LEAVING

Heart Wall Anterior MI Lateral MI Inferior MI Posterior MI

ECG Conduction Abnormalities

1st Degree AV Block 2nd Degree AV Block Mobitz Type I (Wenckebach) Mobitz Type II Delayed AV conduction PR interval > 1 large square All P waves followed by QRS Intermittent failure of AV conduction Progressive lengthening of PR interval Intermittent drop beats (no QRS) Fixed PR interval Intermittent dropped beats (no QRS) Complete AV dissociation PP interval differs from RR interval P wave NOT always followed by QRS Atrial contraction comes from SA node but ventricular contraction comes from secondary pacemaker Intraventricular conduction disturbance Late depolarization notched QRS Rabbit ears: notched QRS with RsR wave LV (R) beats ahead of RV (R) Rabbit ears at V1, V2, V3 RV (R) beats ahead of LV (R) Rabbit ears at V4, V5, V6 Single complex occurs earlier than the next expected sinus complex Sinus rhythm resumes after Atrial node conducts impulses to the ventricles at more than 1:1 ratio Sawtooth appearance P waves as flutter waves Rapid, erratic electrical discharge comes from multiple ectopic foci No discernable P waves Irregular RR intervals

Epicardial Artery Occluded LAD LCX (or RCA) RCA (or LCX) RCA

Diagnostic Leads V1, V2, V3, V4 I, aVL, V5, V6 II, III, avF V1, V2 (mirror image)

3rd Degree AV Block

Bundle Branch Block Prolonged QRS interval Incomplete: 0.10 to <0.12 secs Complete: >0.12 secs Right BBB Left BBB

BASIC LIFE SUPPORT Pre-hospital medical care that consist of life-saving techniques focused on ABC Non-invasive assessment and interventions of emergency cardiovascular care o Infant BLS: <1 year o Child BLS: 1 year to puberty Females: breast development Males: axillary hair o Adult BLS: beyond puberty Goal: optimize circulation and oxygenation Sudden cardiac arrest is the leading cause of death!

Premature Atrial Contraction

Atrial Flutter

Atrial Fibrillation

CHAIN OF SURVIVAL 1. Early Access Immediate recognition of cardiac arrest and activation of EMS Signs of cardiac arrest: o Unresponsiveness o Absence of normal breathing Not breathing Only gasping o Infants: HR <60bpm 2. Early CPR CPR is most effective when it starts immediately after the victims collapse Highest priority: CHEST COMPRESSIONS (hands-only CPR)

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4.

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Early Defibrillation Most commonly witnessed rhythm: VENTRICULAR FIBRILLATION Most effective treatment for VF: ELECTRICAL DEFIBRILLATION Powerful predictor of successful resuscitation (earlier defibrillation higher survival rate) Effective ACLS Ventilation IV access Anti-arrhythmic drugs Stabilize for transport Integrated Post-arrest Care Acute coronary interventions Neurological care Goal-directed critical care Therapeutic hypothermia Goals: o Reduce mortality from HEMODYNAMIC INSTABILITY o Reduce morbidity from multi-organ failure and brain injury

1-RESCUER ADULT BLS SEQUENCE POSITION o Supine on firm surface o Head and neck on same plane o Rescuer kneeling beside victims thorax o If victim is lying facedown, roll as one unit to supine COMPRESSIONS o Check CAROTID pulse within 10 seconds (at least 5 seconds) o Site: lower half of sternum Heel of hand at center of chest (other hand on top-interlace fingers) Nipple line Straighten arms with shoulders directly over hands Elbows straight Look toward hands o Push hard and fast (start 5 cycles of 30:2) Increase intrathoracic pressure deliver residual PaO2 to heart and brain o Rate: 100 chest compressions per minute 30 compression in 18 seconds o Depth: 2 inches (5cm) Full chest recoil in between to allow max heart refill Unequal compressions: risk for RIB FRACTURE o Minimize interruptions (<10 seconds) AIRWAY o Head Tilt Chin Lift: align oropharyngeal axis o Jaw Thrust: for suspected cervical spine injury Use head tilt chin lift if jaw thrust does not open airway BREATHING o 2 breaths o Duration: 1 second per breath o Interval: 5-6 seconds o Volume: visible chest rise Reposition head Make better seal Try again o Techniques: Mouth-to-mouth Mouth-to-nose Mouth-to-mask Bag mask-to-mouth (E-C Clamp Technique) o Pinch nostrils closed o Make tight seal o Regular (NOT DEEP) breaths o Open nostrils after giving rescue breaths o Avoid rapid and forceful ventilation to prevent gastric inflation o Regular breaths to prevent rescuer dizziness or lightheadedness RESCUE BREATHING o Breaths WITHOUT compressions o Indication: with pulse but inadequate breathing o Adult: 1 breath every 5-6 secs o Child: 1 breath every 3-5 secs o Check pulse every 2 minutes STOP CPR! o Victim wakes up o Provider is tired o EMS arrives

2010 BLS GUIDELINES Changes: o Look, Listen, and Feel removed o A-B-C C-A-B Critical elements: chest compressions and early defibrillation HEALTHCARE LAY RESCUERS PROVIDERS No pulse check Check for pulse Hands-only CPR 30 chest compressions No rescue breaths 2 rescue breaths Sequence: 1. Ensure safety 2. Assess responsiveness 3. Activate EMS (call for help) 4. Check pulse 5. Start chest compressions 6. Give 2 breaths 7. Use AED 8. Continue CPR 9. Check rhythm every 2 minutes

PHONE First Sudden witnessed collapse CARDIAC in origin 1. Activate EMS 2. Return to victim 3. Provide CPR CPR First Unresponsive pedia Drowning Asphyxia Cardiac and respiratory 1. Give 5 cycles of CPR 2. Leave Victim 3. Activate EMS

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Differences No pulse rate Amount of air per breath Depth of compressions Chest compressions

CHILD CPR <60bpm 3-5 seconds interval 1/3 chest

ADULT CPR Non-palpable for 10 secs 5-6 seconds interval 2 inches (5cm) 2 hands

1 hand or 2 hands for small children *Retain 30 compressions : 2 breaths Differences Rate Breaths 1-RESCUER 30:2 for both adult and child Give 2 breaths every 30 compressions

2-RESCUER Adult 30:2 Child 15:2 Do NOT pause compressions to provide breaths

*If advanced airway is in place, 1 breath every 6-8 seconds First Rescuer Victims SIDE Remain with the victim to begin CPR immediately Perform chest compressions Counts out loud Second Rescuer Victims HEAD Activate EMS and get AED

Location Role

Actions

Maintain open airway

Gives breaths and watch for chest rise *Switching every 5 cycles of CPR (every 2 minutes) *Less than 5 seconds to switch CPR FOR INFANTS Cardiac arrest in infants usually caused by RESPIRATORY compromise The TONGUE is the most common cause of airway obstruction The OCCIPUT resting on the flat surface causes the neck to flex Palpate BRACHIAL pulse (inside of the upper arm) Begin chest compressions if pulse <60bpm with signs of poor perfusion (pallor, mottling, cyanosis) despite O2 support 1-Rescuer 30:2 2-Rescuer 15:2 Depth: 1/3 to 1/2 of AP chest Rate: 100 compressions per minute Head tilt chin lift (external ear canal level with top of infants shoulder) Mouth-to-mouth AND nose

AUTOMATED EXTERNAL DEFIBRILLATOR CPR AED Manually circulate blood Fix an electric problem and oxygen and restart the heart (defibrillation) SLOWS deterioration 50-74% chance of from 7-10% to 3-4% per SURVIVAL if delivered nimute within 5-10 minutes Advantages: o Portable o Light weight o Durable o Cost effective o Minimal training (can be used by layperson) o Analyze heart rhythm and advise if shock is indicated Indication: o Unresponsive o Not breathing o No pulse (or other signs of circulation) Contraindication: <8 years old CPR FIRST! o Start CPR (2 minutes or 5 cycles) first while preparing the AED o Chest compressions deliver oxygen and energy to the myocardium increasing the likelihood that the shock will eliminate VFib o AED is NOT available 99% of the time 4 Universal Control Steps 1. Power On 2. Attachment Upper right sternal border Cardiac apex 3. Analysis STAND CLEAR! No patient movement No one in contact with victim 4. Shock STAND CLEAR! Dosage: (initial shock) o Monophasic: 360kJ o Biphasic: 200kJ o Pediatric: 2-4J/kg Repeat steps until VFib or VTach is terminated o 1-Shock Protocol: if 1 shock fails to eliminate VFib, the incremental benefit of another shock is low prioritize chest compressions AED Safety: STAND CLEAR! (analysis and shock) o No one should touch the victim o Verbal warning o Visual check o Physical hand gestures Remove victim from standing water Dry chest Place AED pad at least 1 inch away from implanted device Remove transdermal patches

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