• Are they symptomatic?
• Vitals, EKG, prior EKG
• Always see the patient!
• Unstable = chest pain, respiratory distress, new confusion, new hypotension
• → ACT, ACLS algorithm; set up for EKG, defibrillation/cardioversion

Pulseless

• CPR - minimize interruptions
• Shockable rhythms -  VT, Vfib
• 
• 
• Meds
• Epi 1 mg q3
• Amio 300 mg for refractory VT/Vfib
• Reversible causes
• H = hypovolemia, hypothermia, hypoglycemia, [H+] acidosis, hypo/hyperK
• T = tension pneumo, tamponade, toxins, thrombosis (PE/MI)

Sinus

• Tachy/brady
• Treat underlying causes - pain, hypoxemia, sepsis, HF, PE, thyroid, meds
• BB tox = IV glucagon
• CCB tox = IV calcium
• Sinus arrhythmia = normal; nothing to do
• Sinus pause = may be blocked PAC; look for P wave buried in the preceding T wave (T wave will have diff morphology). AV node is refractory so following complex is not conducted. Tx with BB

Atrial arrhythmia

• Atrial fibrillation/flutter
• Rate = 150 may be A flutter 2:1
• Wandering atrial pacemaker = benign, nothing to do
• Multifocal atrial tachycardia
• Often in setting of lung disease; treat underlying issues (no need to anticoagulate)
• Verapamil or metoprolol

AV junction arrhythmia

• ???

Supraventricular tachycardia

• AVNRT - retrograde P wave?
• Vagal maneuvers
• Adenosine - start with 6 mg, then 12 mg if needed - warn pt feels like kick in chest/heart stopping for few seconds
• Push and flush rapidly (very short half-life)
• Continuous rhythm strip while trying therapy
• Avoid AV nodal blocking meds (BB, CCB, adenosine, digoxin, amiodarone) if afib with pre-excitation (WPW) (FBI = fast, broad, irregular)
• Give procainamide instead
• Unstable = cardiovert
• AVRT
• Junctional tachycardia

AV block

• If bradycardic + symptomatic, likely Type II 2nd degree or complete AVB
• Pacemaker (transcutaneous -> transvenous); sedate before if possible

1st degree Prolonged PR > 200 ms
2nd degree Mobitz type I (Wenckebach) = progressively longer PR before QRS drop Mobitz type II = sudden dropped QRS; may progress to 3rd degree AVB (due to disease below AV node)
3rd degree Complete block; dissociation of P and QRS Atrial and ventricular rates are independent

Ventricular arrhythmias

• Accelerated idioventricular rhythm - look for acute MI. Not VT bc rate < 100

Wide complex ventricular tachycardia

• HR > 100, QRS > 120 ms
• Regular ~ VT, chaotic ~ Vfib
• Check for hemodynamic stability - hypotension, chest pain, mental status
• Unstable = cardiovert; have pads on if uncertain
• Stable = amio bolus; elective synchronized cardioversion
• If pt has known heart disease, treat as VT
• Check K, Mg (want K > 4, Mg > 2)

• Narrow complex