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Rev 2016
Atrial Fibrillation
By Definition, PACs are early beats that come from the Atria
PACs make the Ventricular Rhythm Irregular, they can occur
as occasional or frequent individual beats or in patterns
such as Bigeminy, or Trigeminy
PACs can be Unifocal or Multifocal (coming from multiple
areas of the atria, and having multiple P wave morphologies).
PACs
QRS Duration and Morphology: Less than 120ms
(0.12seconds) if conducted through the His-
Purkinje System in a normal fashion. If the QRS
following the P wave of a PAC is wider than the other
QRS Complexes, the impulse has depolarized the
heart in an aberrant fashion. (Those beats are called
PACs with aberrant conduction)
PACs indicate that an area, or areas of the atria are
irritated. PACs are often precursor beats to Atrial
Fibrillation and Atrial Flutter.
Treatment for high-risk groups.
Wandering Atrial Pacer
Fast Rhythms:
First Discern if the Rhythm comes from the ventricle
(wide QRS complex), or from above the ventricle
(Narrow QRS complex).
Then Identify the specific origin of the Rhythm.
Treatment of SVTs
Serious signs and symptoms (hypotension, acutely
altered mental status, signs of shock, ischemic chest
discomfort, acute heart failure): 1. Immediate
Synchronized Cardioversion
2. Consider adenosine (now also first line)
Stable without rate related CV compromise:
1.Attempt to visualize the origin of the SVT by
using vagal maneuvers or adenosine.
2. Slow the ventricular response using Ca channel
blockers or B-adrenergic blockers.
Synchronized Cardioversion
Goal: spontaneous depolarization of a critical
mass of cardiac cells to disrupt the erratic
tachycardia, with hope that the conduction
system will restore normal function.
Synchronized with the patients rhythm to
deliver the electrical current on the R wave to
prevent deterioration to less viable rhythm.
Painful: provide analgesia, and anxiolytics
Vagal Maneuvers
Bearing down
Coughing
Suctioning
Deep Held Breath
Digital Rectal Stimulation
Vomiting
Carotid Sinus Massage (Only advanced, insured
practitioners, after checking for bruits)
Adenosine
Used as a diagnostic tool to help identify
rhythm.
Adenosine
6mg IVP, high and fast
May repeat with 12 mg, q 1-2 min x 2