1. - Unstable pt= pt presenting w/ any S/S of CNS, CVS, or respiratory system (eg chest pain, shortness of breath, hypotension, or confusion) . -1st step in ALL palpable ventricular arrythmia is Synchronized Defibrillation - Epinephrin(IV) in 1:10,000 is for Rx. of heart rate and blood pressure. - Epinephrin(SC) in 1:1000 of inhaled is used to Rx. Anaphylaxis respiratory distress.
  2. Tachycardia>100
    1. "QRS" complex is wide=MORE than 0.12 sec.= VENTRIVCULAR pathology
      1. No palpable Pulse, No breathing=Dead Pt.!
        1. flat line EKG
          1. Hx. of lightning or electrical injury
          2. Dx. Asystole
          3. Rx. I.Epinephrine, II.Atropine, III.transcutaneous pacing
        2. normal EKG
          1. Dx. Pulseless Electrical activity
        3. Ventricular fibrilation
          1. Rx. 1st: unsynchronized defibrillation(x3)
          2. 2nd: II.Epinephrine OR vasopressin , III.Defibrilate. IV.intubate, V.Defibrilate, VI.Amioderone or lidocain, VII. Procainamide
          3. IF after Echo-cardiology the Ejection fraction less then 35% OR positive arrhythmia induction on electro-physiology study
          4. Rx. Automated Implantable Cardiac Defibrillator
        4. Dx. Ventricular tachycardia
          1. S/S: can present dead or Alive with a palpable pulse= HR is 120 or more & 3 ventricular beats or more
          2. Dead Pt.
          3. Alive w/ palpable pulse
          4. UNStable
          5. Rx. 1st: Synchronized defibrillation
          6. stable
          7. Rx. I. Amioderon, II.Lidocain, III.Procainamide
          8. Long term Rx. for V.Tach is I. Beta-Blocker,II.AICD
      2. Palpable pulse = pt. is alive and breathing
        1. Hx. Heart Block, lithium, TCA, Porcainamide, a/w sudden audiatory of visual sti(eg : phone ringing)
          1. Torsade de Pontes=EKG with elevation of "QT"
          2. Stable
          3. Rx.MgSo4
          4. Unstable
          5. Rx.Unsynchronized defibrillation
        2. Hx. Atrial Arrhythmia (Epstein anomaly), trans-position of the great vessels, S/S: loud S1
          1. EKG= sluffed upstroke "QRS" deflection aka "Delta"-waves & short "PR' less than 0.12 sec.
          2. Dx. WPW= Wolff-Parkenson White Synd.
          3. Rx.Short term: Procainamide; Long term: Ablation
    2. any "QRS" complex is narrow = LESS than 0.12 sec. is a/w ATRIAL pathology
      1. IRREGULAR PULSE
        1. Hx. Respiratory Disease
          1. EKG= QRS narrow +"PR' & "RR" are variable + 'P" has 3 different shapes
          2. Dx. Multi-focal Atrial Tachycardia
          3. Inv. Pulse Oxy & BMP
          4. Rx.: I Rx. the Respiratory disease will Rx. the arrhythmia II.Atenolol(IV), if contraindicated, Verapamil(IV)
        2. EKG= 350 to 500 ATRIAL beats, May have some "QRS" that are more than 0.12s, NO "P" wave
          1. Dx. Atrial Fibrilation
          2. both atrial Fibrillation & Flutter have the same Rx.
          3. Chronic is atrial arrhythmia for 2 or more days
          4. less than 60 y. of age
          5. Rx. Asprin
          6. more than 60 y of age
          7. Rx. Warfarin
          8. Acute
          9. Unstable
          10. Rx. Synchronized shock
          11. Stable
          12. Hx. Migraine, or CVS, or thyroid disease,
          13. Rx. Beta-Blocker= Propanolol (PO)
          14. Hx. depression, COPD, or asthma
          15. Rx. Ca-Channel Blocker ( eg Cardiazem(IV) , once controlled start (PO), and d/c (IV) )
          16. Hx. low or boarder line blood pressure, or CHF
          17. Rx. Digoxin
          18. LONG term Rx is Cardiac Ablation
      2. REGULAR PULSE
        1. EKG=240 to 300 Atrial beat, "P" wave is saw tooth- shaped, 2:1 Atrio-Ventricular block , sawtooth "P" wave
          1. Dx. Atrial Flutter
        2. EKG= 130 to 220 that SUDDENLY starts & Stops
          1. Dx. Supraventricular Tachycardia
          2. Rx.
          3. Chronic
          4. Acute
          5. I. Vagal Stimulation maneuvers II. Adenosin x 3 III. Same as the Rx. of an Acute stable pt with atrial fibrillation or flutter.
  3. Bradycardia<60
    1. EKG=constant "R-R" w/ SUDDEN dropped "QRS"
      1. Dx. Mobitz II
    2. S/S Canon "a" wave on JVP
      1. Dx. 3ed Degree Heat block
        1. Rx. 1st: Atropin(IV) OR Pacemaker(External) is for acute Rx. 2nd: Pacemaker(IV) is the long term Rx.
    3. ANY type of bradycardia S/S on P/E (eg palpable bradycardia with SOB or pain) = Must be treated
    4. R/O HYPO-thermia
      1. Rx. Rewarming normalizes Heart beats