Sinus Bradycardia:


Inherent Rate: less than 60 bpm.

• P wave is upright on lead II, look-alike and before QRS

• T wave is present after QRS.


▪︎ Interventions: (based on AHA 2016 ACLS Guidelines)

- Correct possible causes (Hypothermia, Hypoglycemia, Toxins, Hypokalemia, Hyperkalemia).

- Give Atropine 0.5 mg every 3-5 minutes maximum of 3 mg.

- Get ready or start Transcutaneous Pacer (TCP).

- If Atropine and TCP are ineffective and continues to be hypotensive, give Dopamine 2-20 mcg/kg per minute and titrate to effect.

- If profound bradycardia after Atropine and TCP, give Epinephrine 2-10 mcg/min and titrate to effect.

Sinus Tachycardia:


Inherent Rate: 100-150 beats per minute.


• P wave is visible

• QRS is narrow

• T wave is present

Sinus Tachycardia:


Inherent Rate: 100-150 beats per minute.


• P wave is visible

• QRS is narrow

• T wave is present

❤️Atrial arrythmias :

Atrial Fibrillation:

Atrial Fibrillation occurs when the atrial sites depolarize simultaneously at 400-600 bpm enabling the atrium to contract but only quiver.

The most common terms used with Afib less than 100 bpm is Controlled VR (ventricular respone) or SVR (slow ventricular response).

If the rate is greater than 100 bpm then it is called Uncontrolled VR (ventricular response) or RVR (rapid ventricular response).

If the rate goes over 150 bpm, then t'll be identified as an AVNRT (atrio-ventricular nodal reentry tachycardia) SVT (supraventricular tachycardia). It is the most common SVT diagnosed in patients.

Atrial Tachycardia:


• Rate: 150-250
• P waves: Visible
• QRS: Narrow

Atrial Tachycardia is caused by an irritated site in the Atria. It is regularly-regular with visible P waves (unlike SVT where the P waves are absent).

Interventions are focused on correcting the causes depending on the patient's stability.


Follow AHA 2016 Guidelines ACLS algorithms. Most common cause is possible Digoxin overdose.


▪︎Interventions:

• If Stable:
- Give Digibind, B-blockers, Calcium-Channel blockers, Anti-arrhythmics

- No Adenosine if caused by Digoxin overdose


• If Unstable:
- Synchronized cardioversion 10 J only

Atrial Flutter:


Atrial Flutter with 4:1 Block (4 P waves to 1 QRS)


• P waves are described as "Sharks Teeth," "Sawtooth," or Picket Fences".

• T waves are not visible. Can also have 2:1, 3:1, or variable blocks.


Atrial flutter occurs when an abnormal conduction circuit develops inside the atrium, allowing the atria to beat excessively fast, about 250-300 beats per minute. If rate goes over 150 bpm, it can also be interpreted as SVT (AVNRT).


▪︎ Causes:
- Decreased blood flow to the heart (ischemia) due to coronary heart disease, atherosclerosis, or a blood clot

- High blood pressure (hypertension)

- Disease of the heart muscle (cardiomyopathy)

- Abnormalities of the heart valves (especially the mitral valve)

- An abnormally enlarged chamber of the heart (hypertrophy)

- After open heart surgery

- Drugs (cocaine, methamphetamine, diet pills, etc.)

- Chronic obstructive pulmonary disease
- Alcohol (liquor, wine, beer)


▪︎ Intervention:

• If stable:
- Keep airway patent, support breathing

- Keep O₂Sat 94-99%, PCO₂ 35-40 mm Hg

- Start IV/IO, 12-Lead ECG, draw/send labs

- NO Adenosine!

- May give Sotolol 100 mg (1.5 mg/kg) IV over 5 minutes. Avoid if prolonged QT

- May give Metoprolol 5 mg IV over 2-5 minutes, may repeat every 5 minutes. If no history of heart disease or CHF only.

- May give Diltiazem 0.25 mg/kg IV slow over 2 minutes, may repeat every 15 minutes. Max. dose is 0.35 mg/kg.


• If Unstable:
- Consider sedation

- If less than 48 hours onset: administer Synchronized Cardioversion 50-100 J

- May administer B-blockers or Calcium-channel blockers (CCB)

- Administer anticoagulants

- If greater than 48 hours: give B-blockers or CCBs, anti-arrhythmics with anticoagulants only. NO cardioversion!


• Other possible interventions:

- Cardiac ablation

- Anticoagulation

- Rate controllers (B-blockers, CCBs, antiarrhythmics)

- Implanted cardioverter-defibrillator


Based on AHA ACLS 2016 Guidelines

❤️Ventricular arrythmias:

Ventricular Tachycardia:

Rate: greater than 100 bpm

• P waves: None
• QRS: wide greater than 0.12
• ST segment and T wave: have opposite polarity to R wave


Patients can be stable or unstable with this rhythm depending on the ventricular rate. The slower the rate, the more stable the patient is. The faster the rate, the more unstable the patient is.

Such rhythm can become pulses and ACLS algorithm per VF protocols must be initiated immediately.

Most common causes are:
- chronic hypoxemia (COPD)
- hypokalemia
- Myocardial Infarction
- toxins.


▪︎ Intervention:

• If Stable:
- Keep airway patent
- Support breathing
- Keep O₂Sat 94-99%
- PCO₂ 35-40 mm Hg
- Start peripheral IV, 12 -Lead ECG
- Administer Amiodarone 150 mg IV/IO diluted in 50-100 mL of D5W given over 10 minutes (If patient is not hypokalemic)
- Administer Lidocaine 1-1.5 mg/kg IV/IO (if patient is hypokalemic)

• If Unstable:
- Consider sedation prior to cardioversion
- Administer Synchronized Cardioversion 100 J


Based on AHA ACLS 2016 Guidelines

Ventricular Fibrillation:


Coarse Ventricular Fibrillation.

The ventricles are no longer contracting but only fibrillation or quivering. There is no blood flow due to no ventricular contraction.

If CPR and ACLS protocols are not initiated, coarse VF will progress to fine VF, then to Asystole.

Follow AHA ACLS 2016 Guidelines.

- High quality CPR with immediate Defibrillatory shock is recommended.

- Biphasic Defibrillators: 120 - 200 Joules or recommended.

- Monophasic Defibrillators: 360 J (followed by 2 mins. CPR). Other secondary interventions can be started if IV/IO access has been established.

▪︎ Interventions:
- Epinephrine 1mg IVP/IO (1:10,000) every 3-5 mins.

- Amiodarone 300mg IVP/IO for the 1st dose; 150mg IVP/IO for the 2nd dose

- Lidocaine 1-1.5mg/kg IVP/IO 1st dose; 0.5-0.75mg/kg 2nd dose

- Correct possible causes

❤️Heart block :

1st Degree AtrioVentricular Block:

PR Interval is consistently prolonged more than 0.20 seconds.

Underlying rhythms can vary with 1st degree AV block.

No QRS is dropped with consistent P to QRS ratio.

2nd Degree Atrioventricular Block Type II with 3:1 Block:

Also known as Mobitz II, Hay

If R-to-R intervals are regular, then blocks can occur as 2:1, 3:1, or 4:1 (P waves to QRS)

If R-to-R intervals are irregular, then block is variable


▪︎Causes:

  -  Idiopathic fibrosis and sclerosis of the conduction system (about 50% of patients)

  -  Ischemic heart disease (40%)

  -  Drugs (eg, beta-blockers, calcium channel blockers, digoxin, amiodarone)

  - Increased vagal tone

  - Valvulopathy

  - Congenital heart, genetic, or other disorders


▪︎Interventions: (based on AHA 2016 ACLS Guidelines)

- Keep airway patent, support breathing

- Start IV/IO, draw/send labs, 12-Lead ECG

- Correct possible causes

- NO Atropine!

- Start Transcutaneous Pacing (TCP).

- May give Dopamine 2-20 mcg/kg per minute and titrate to effect.

- If profound bradycardia after TCP, may give Epinephrine 2-10 mcg/min and titrate to effect.

2nd Degree Atrioventricular Block Type I, Mobitz I, Wenckebach:


• P waves: Regular
• P:QRS: Variable
• PR Interval: Variable; progressively lengthens and drops a QRS
• QRS: Narrow, dropped


▪︎Causes:

  -  Idiopathic fibrosis and sclerosis of the conduction system (about 50% of patients)

  -  Ischemic heart disease (40%)

  -  Drugs (eg, beta-blockers, calcium channel blockers, digoxin, amiodarone)

  - Increased vagal tone

  - Valvulopathy

  - Congenital heart, genetic, or other disorders


▪︎ Intervention: (based on AHA 2016 ACLS Guidelines)

- Keep airway patent, support breathing

- Start IV/IO, draw/send labs, 12-Lead ECG

- Correct possible causes

- Give Atropine 0.5 mg IV/IO followed by 10-20 mL NS/LR flush, repeat every 3-5 minutes, max. dose 3 mg

- Consider Transcutaneous Pacing (TCP) if needed

- May give Dopamine 2-20 mcg/kg per minute and titrate to effect.

- If profound bradycardia after TCP, may give Epinephrine 2-10 mcg/min and titrate to effect.

3rd Degree Atrioventricular Block:


P wave: Regular interval; Reg:
P:QRS: Variable
PRI: Variable
QRS: Blocked/dropped
         Narrow - If Junctional Escape Mechanism (JEM): 40-60 bpm
         Wide - If Ventricular Escape Mechanism (VEM): 20-40 bpm


▪︎Causes:

  -  Idiopathic fibrosis and sclerosis of the conduction system (about 50% of patients)

  -  Ischemic heart disease (40%)

  -  Drugs (eg, beta-blockers, calcium channel blockers, digoxin, amiodarone)

  - Increased vagal tone

  - Valvulopathy

  - Congenital heart, genetic, or other disorders


▪︎Intervention: (based on AHA 2016 ACLS Guidelines)

- Keep airway patent, support breathing

- Start IV/IO, draw/send labs, 12-Lead ECG

- Correct possible causes

- NO Atropine!

- Start Transcutaneous Pacing (TCP).

- May give Dopamine 2-20 mcg/kg per minute and titrate to effect.

- If profound bradycardia after TCP, may give Epinephrine 2-10 mcg/min and titrate to effect.

An ECG displayed irregular rhythm absent P- wave. the most likely diagnosis is:
Atrial ectopic beat
Atrial fibrillation
Atrial flatter
Atrial node block
Supra-ventricular tachycardia

A heavy smoker presented with severe retrosternal compressing pain. He was sweating. ECG showed ST segment elevation in leads II, III, avf. The diagnosis is
Acute inferior myocardial infarction
Acute anterior myocardial infarction
Acute lateral myocardial infarction
Acute pericarditis
Acute endocarditis

55 years old women has severe retrosternal chest pain at rest. It lasted more than 30 minutes. ECG shows no changes in ST segment What is the likely diagnosis
Unstable angina
Acute ST- elevation myocardial infarction (MI)
Acute non ST- elevation MI
Acute lobar pneumonia
Psychogenic syndrome

Cardiogenic shock characterized by all following EXCEPT:
Low blood pressure
Low urine output
Warm extremities
Poor cerebral function
Reduce coronary blood flow

❤️Airway Devices :

Types of Airway Devices
1)
2)

Types of extratracheal Devices
1)
2)
3)

Examples of supraglotic Airway Devices
1)
2)

Types of endotracheal Airways
1)
2)
3)
4)

Oxygen delivary Devices
1)
2)
3)
4)
Which oxygen delivery devices deliver the highest oxygen percentage?
Non-rebreather mask