Appendix 3

ACLS Rhythms for the ACLS Algorithms

The Basics

1 . Anatomy of the cardiac conduction system: relationship to the ECG cardiac cycle. A, Heart: anatomy of conduction system.
B, P-QRS-T complex: lines to conduction system. C, Normal sinus rhythm. Relative
Refractory
Period
A B
Bachmann’s bundle Absolute
Sinus node Refractory
Period
R
Internodal
pathways AVN
Left bundle
branch
AV node PR
P T
Posterior division
Bundle
of His Anterior division
Q
Ventricular
Purkinje fibers S Repolarization
Right bundle QT Interval
branch
Ventricular
P Depolarization
PR

C Normal sinus rhythm

253
 A p p e n d i x 3

The Cardiac Arrest Rhythms

2. Ventricular Fibrillation/Pulseless Ventricular Tachycardia

Pathophysiology ■ Ventricles consist of areas of normal myocardium alternating with areas of ischemic, injured, or
infarcted myocardium, leading to chaotic pattern of ventricular depolarization

Defining Criteria per ECG ■ Rate/QRS complex: unable to determine; no recognizable P, QRS, or T waves
■ Rhythm: indeterminate; pattern of sharp up (peak) and down (trough) deflections
■ Amplitude: measured from peak-to-trough; often used subjectively to describe VF as fine (peak-to-
trough 2 to <5 mm), medium-moderate (5 to <10 mm), coarse (10 to <15 mm), very coarse (>15 mm)

Clinical Manifestations ■ Pulse disappears with onset of VF

■ Collapse, unconsciousness
■ Agonal breaths ➔ apnea in <5 min
■ Onset of reversible death

Common Etiologies ■ Acute coronary syndromes leading to ischemic areas of myocardium

■ Stable-to-unstable VT, untreated
■ PVCs with R-on-T phenomenon
■ Multiple drug, electrolyte, or acid-base abnormalities that prolong the relative refractory period
■ Primary or secondary QT prolongation
■ Electrocution, hypoxia, many others

Recommended Therapy ■ Early defibrillation is essential

Comprehensive ECC algorithm, ■ Agents given to prolong period of reversible death (oxygen, CPR, intubation, epinephrine,
page 10; VF/pulseless VT algo- vasopressin)
rithm, page 77 ■ Agents given to prevent refibrillation after a shock causes defibrillation (lidocaine, amiodarone,
procainamide, β-blockers)
■ Agents given to adjust metabolic milieu (sodium bicarbonate, magnesium)

Coarse VF

Fine VF

254
 ACLS Rhythms for the ACLS Algorithms

3. PEA (Pulseless Electrical Activity)

Pathophysiology ■ Cardiac conduction impulses occur in organized pattern, but this fails to produce myocardial
contraction (former “electromechanical dissociation”); or insufficient ventricular filling during
diastole; or ineffective contractions

Defining Criteria per ECG ■ Rhythm displays organized electrical activity (not VF/pulseless VT)
■ Seldom as organized as normal sinus rhythm
■ Can be narrow (QRS <0.10 mm) or wide (QRS >0.12 mm); fast (>100 beats/min) or slow
(<60 beats/min)
■ Most frequently: fast and narrow (noncardiac etiology) or slow and wide (cardiac etiology)

Clinical Manifestations ■ Collapse; unconscious

■ Agonal respirations or apnea

■ No pulse detectable by arterial palpation (thus could still be as high as 50-60 mm Hg; in such
cases termed pseudo-PEA)

Common Etiologies Mnemonic of 5 H’s and 5 T’s aids recall:

■ Hypovolemia ■ “Tablets” (drug OD, ingestions)

■ Hypoxia ■ Tamponade, cardiac

■ Hydrogen ion—acidosis ■ Tension pneumothorax

■ Hyperkalemia/Hypokalemia ■ Thrombosis, coronary (ACS)

■ Hypothermia ■ Thrombosis, pulmonary (embolism)

Recommended Therapy ■ Per PEA algorithm

Comprehensive ECC Algorithm, ■ Primary ABCD (basic CPR)

page 10; PEA Algorithm, ■ Secondary AB (advanced airway and ventilation);
page 100 C (IV, epinephrine, atropine if electrical activity <60 complexes per minute);
D (identify and treat reversible causes)
■ Key: identify and treat a reversible cause of the PEA

Any organized rhythm without detectable pulse is “PEA”

255
 A p p e n d i x 3

4. Asystole

Defining Criteria per ECG ■ Rate: no ventricular activity seen or ≤6/min; so-called “P-wave asystole” occurs with only atrial
Classically asystole presents impulses present to form P waves
as a “flat line”; any defining ■ Rhythm: no ventricular activity seen; or ≤6/min
criteria are virtually nonexistent
■ PR: cannot be determined; occasionally P wave seen, but by definition R wave must be absent

■ QRS complex: no deflections seen that are consistent with a QRS complex

Clinical Manifestations ■ Early may see agonal respirations; unconscious; unresponsive

■ No pulse; no blood pressure

■ Cardiac arrest

Common Etiologies ■ End of life (death)

■ Ischemia/hypoxia from many causes

■ Acute respiratory failure (no oxygen; apnea; asphyxiation)

■ Massive electrical shock: electrocution; lightning strike

■ Postdefibrillatory shocks

Recommended Therapy ■ Always check for DNAR status

Comprehensive ECC ■ Primary ABCD survey (basic CPR)

Algorithm, page 10; Asystole ■ Secondary ABCD survey
Algorithm, page 112

Asystole: agonal complexes too slow to make this rhythm “PEA”

256
 ACLS Rhythms for the ACLS Algorithms

5. Sinus Tachycardia

Pathophysiology ■ None—more a physical sign than an arrhythmia or pathologic condition

■ Normal impulse formation and conduction

Defining Criteria and ECG ■ Rate: >100 beats/min

Features
■ Rhythm: sinus

■ PR: ≤0.20 sec

■ QRS complex: normal

Clinical Manifestations ■ None specific for the tachycardia

■ Symptoms may be present due to the cause of the tachycardia (fever, hypovolemia, etc)

Common Etiologies ■ Normal exercise

■ Fever
■ Hypovolemia

■ Adrenergic stimulation; anxiety

■ Hyperthyroidism

Recommended Therapy ■ Never treat the tachycardia per se

No specific treatment for sinus ■ Treat only the causes of the tachycardia
tachycardia
■ Never countershock

Sinus tachycardia

257
 A p p e n d i x 3

Rhythmic Algorithm No. 1: Tachycardias Overview

Evaluate patient
Tachycardia • Is patient stable or unstable?
• Are there serious signs or symptoms?
• Are signs and symptoms due to tachycardia?

Stable

Stable patient: no serious signs or symptoms

• Initial assessment identifies 1 of 4 types of tachycardias

Atrial fibrillation

1. Atrial fibrillation 2. Narrow-complex

Atrial flutter tachycardias

Evaluation focus, 4 clinical Attempt to establish a

features: specific diagnosis
1. Patient clinically unstable? • 12-lead ECG
2. Cardiac function impaired? • Clinical information
3. WPW present? • Vagal maneuvers
4. Duration <48 or >48 hours? • Adenosine

Atrial flutter
Treatment focus: clinical
evaluation
1. Treat unstable patients Diagnostic efforts yield
urgently • Ectopic atrial tachycardia
2. Control the rate • Multifocal atrial tachycardia
3. Convert the rhythm • Paroxysmal supraventricular
4. Provide anticoagulation tachycardia (PSVT)

Sinus rhythm with WPW syndrome

Treatment of Treatment of SVT

atrial (See narrow-complex
fibrillation/ tachycardia algorithm)
atrial flutter
(See following
table)

Initial sinus rhythm with paroxysmal onset of supraventricular tachycardia (PSVT)

258
 ACLS Rhythms for the ACLS Algorithms

Unstable Monomorphic ventricular tachycardia

Unstable patient: serious signs or symptoms

• Establish rapid heart rate as cause of signs and symptoms
• Rate-related signs and symptoms occur at many rates,
seldom <150 bpm
• Prepare for immediate cardioversion (see algorithm)

3. Stable wide-complex 4. Stable monomorphic VT

tachycardia: unknown type and/or polymorphic VT

Attempt to establish a
specific diagnosis
• 12-lead ECG
• Esophageal lead
• Clinical information

Polymorphic ventricular tachycardia

Confirmed Wide-complex Confirmed Treatment of

SVT tachycardia of stable VT stable
unknown type monomorphic
and
polymorphic VT
(See stable VT:
Preserved Ejection fraction <40% monomorphic
cardiac function Clinical CHF and polymorphic
algorithm)

DC cardioversion DC cardioversion
or or
Procainamide Amiodarone
or
Amiodarone

259
 A p p e n d i x 3

6. Reentry Tachycardia Mechanism

A — Normal impulse comes down Purkinje fibers to join muscle fibers.

B — One impulse (B1) encounters an area of one-way (unidirectional) block (B2) and stops.
C — Meanwhile, the normally conducted impulse (C1) has moved down the Purkinje fiber, into the muscle fiber (C2); and as a
retrograde impulse, moves through the area of slow conduction (C3).
D — The retrograde impulse (D1) now reenters the Purkinje and muscle fibers (D2); and keeps this reentry cycle repeating itself
multiple times (D3).

A Purkinje Fiber

B1 C1
B2 One-Way Block D1

C3 Slow Conduction

D3
C2 C1
D2

Muscle Fiber

260
 ACLS Rhythms for the ACLS Algorithms

7. Atrial Fibrillation/Atrial Flutter

Pathophysiology ■ Atrial impulses faster than SA node impulses

■ Atrial fibrillation ➔ impulses take multiple, chaotic, random pathways through the atria

■ Atrial flutter ➔ impulses take a circular course around the atria, setting up the flutter waves
■ Mechanism of impulse formation: reentry

Defining Criteria and Atrial Fibrillation Atrial Flutter

ECG Features
(Distinctions here between atrial Rate ■ Wide-ranging ventricular response ■ Atrial rate 220-350 beats/min
fibrillation vs atrial flutter; all other to atrial rate of 300-400 beats/min ■ Ventricular response = a function
characteristics are the same)
Atrial Fibrillation Key: A classic
of AV node block or conduction of
clinical axiom: “Irregularly irregu- atrial impulses
lar rhythm—with variation in both
■ Ventricular response rarely >150-
interval and amplitude from R
wave to R wave—is always atrial 180 beats because of AV node
fibrillation.” This one is depend- conduction limits
able.
Atrial Flutter Key: Flutter waves Rhythm ■ Irregular (classic “irregularly ■ Regular (unlike atrial fibrillation)
seen in classic “sawtooth pattern”
irregular”) ■ Ventricular rhythm often regular

■ Set ratio to atrial rhythm, eg,

2-to-1 or 3-to-1

P waves ■ Chaotic atrial fibrillatory waves ■ No true P waves seen

only ■ Flutter waves in “sawtooth pattern”
■ Creates disturbed baseline is classic

PR ■ Cannot be measured

QRS ■ Remains ≤0.10-0.12 sec unless QRS complex distorted by fibrillation/flutter

waves or by conduction defects through ventricles

Clinical Manifestations ■ Signs and symptoms are function of the rate of ventricular response to atrial fibrillatory waves;
“atrial fibrillation with rapid ventricular response” ➔ DOE, SOB, acute pulmonary edema
■ Loss of “atrial kick” may lead to drop in cardiac output and decreased coronary perfusion
■ Irregular rhythm often perceived as “palpitations”

■ Can be asymptomatic

Common Etiologies ■ Acute coronary syndromes; CAD; CHF

■ Disease at mitral or tricuspid valve

■ Hypoxia; acute pulmonary embolism

■ Drug-induced: digoxin or quinidine most common

■ Hyperthyroidism

261
 A p p e n d i x 3

7. Atrial Fibrillation/Atrial Flutter (continued)

Recommended Therapy Control Rate

Evaluation Focus: Treatment Focus: Normal Heart Impaired Heart

1. Patient clinically unsta- 1. Treat unstable ■ Diltiazem or another calcium ■ Digoxin or diltiazem or amio-
ble? patients urgently channel blocker or meto- darone
prolol or another β-blocker
2. Cardiac function 2. Control the rate
impaired?
3. Convert the rhythm Convert Rhythm
3. WPW present?
4. Provide anticoagulation
Impaired Heart Normal Heart
4. Duration ≤48 or >48 hr?

■ If ≤48 hours: ■ If ≤48 hours:

— DC cardioversion or — DC Cardioversion or
amiodarone or others amiodarone
■ If >48 hours: ■ If >48 hours:
— Anticoagulate × 3 wk, then — Anticoagulate × 3 wk,
— DC cardioversion, then then
— Anticoagulate × 4 wk — DC cardioversion, then
or — Anticoagulate × 4 more wk

■ IV heparin and TEE to rule

out atrial clot, then
■ DC cardioversion within
24 hours, then
■ Anticoagulation × 4 more wk

TEE indicates transesophageal echocardiogram.

Atrial fibrillation

Atrial flutter

262
 ACLS Rhythms for the ACLS Algorithms

8. WPW (Wolff-Parkinson-White) Syndrome

Pathophysiology ■ The prototypical pre-excitation syndrome: congenital mal-

formation; strands of conducting myocardial tissue between
atria and ventricles
■ When persistent after birth strands can form an accessory
pathway (eg, bundle of Kent)

Defining Criteria and ECG Features ■ Rate: most often 60-100 beats/min as usual rhythm is sinus

Key: QRS complex is classically distorted by delta wave ■ Rhythm: normal sinus except during pre-excitation tachycardia
(upwards deflection of QRS is slurred) ■ PR: shorter since conduction through accessory pathway is
faster than through AV node
■ P waves: normal conformation

■ QRS complex: classically distorted by delta wave (upwards

deflection of QRS is slurred)

Clinical Manifestations ■ A person with WPW may never have symptoms

■ People with WPW have same annual incidence of atrial

fibrillation as age- and gender-matched population
■ Onset of atrial fibrillation for WPW patients, however, poses
risk of rapid ventricular response through the accessory
pathway
■ This rapid ventricular response can lead to all signs and
symptoms of stable and unstable tachycardias

Common Etiology ■ The accessory pathway in WPW is a congenital malformation

263
 A p p e n d i x 3

8. WPW (Wolff-Parkinson-White) Syndrome (continued)

Recommended Therapy Wolff-Parkinson-White: Control Rate

Evaluation Focus Treatment Focus Normal Heart Impaired Heart

1. Patient clinically unstable? 1. Treat unstable patients ■ Cardioversion or ■ Cardioversion

2. Cardiac function impaired? urgently ■ Antiarrhythmic (IIb): or
3. WPW present? 2. Control the rate amiodarone or flecainide ■ Amiodarone
3. Convert the rhythm or procainamide or
4. Duration ≤48 or >48 hr?
propafenone or sotalol
4. Provide anticoagulation

Wolff-Parkinson-White: Convert Rhythm

Class III (can be harmful) in treating atrial fibrillation
with WPW:
Duration ≤48 Hours Duration >48 Hours
■ Adenosine
■ β-Blockers ■ Cardioversion or ■ Anticoagulate × 3 wk
■ Calcium channel blockers ■ Antiarrhythmic (IIb): then
■ Digoxin amiodarone or flecainide ■ DC cardioversion
or procainamide or
then
propafenone or sotalol
■ Anticoagulate × 4 wk
If impaired heart: cardio-
version or amiodarone

Wolff-Parkinson-White syndrome: normal sinus rhythm with delta wave (arrow) notching of positive upstroke of QRS complex

264
 ACLS Rhythms for the ACLS Algorithms

9. Junctional Tachycardia

Pathophysiology ■ Area of automaticity (automatic impulse formation) develops in the AV node (“junction”)

■ Both retrograde and antegrade transmission occurs

Defining Criteria and ■ Rate: 100 -180 beats/min

ECG Features
■ Rhythm: regular atrial and ventricular firing
■ Key: position of the P wave;
may show antegrade or ■ PR: often not measurable unless P wave comes before QRS; then will be short (<0.12 secs)
retrograde propagation ■ P waves: often obscured; may propagate antegrade or retrograde with origin at the junction;
because origin is at the may arise before, after, or with the QRS
junction; may arise before,
after, or with the QRS ■ QRS complex: narrow; ≤0.10 secs in absence of intraventricular conduction defect

Clinical Manifestations ■ Patients may have clinical signs of a reduced ejection fraction because augmented flow from
atrium is lost
■ Symptoms of unstable tachycardia may occur

Common Etiologies ■ Digoxin toxicity

■ Acute sequelae of acute coronary syndromes

Recommended Therapy Preserved heart function:

If specific diagnosis unknown, ■ β-Blocker
attempt therapeutic/diagnostic
maneuver with ■ Calcium channel blocker

■ Amiodarone
■ Vagal stimulation
■ NO DC cardioversion!
■ Adenosine . . . THEN
If impaired heart function:
■ Amiodarone

■ NO DC cardioversion!

Junctional tachycardia: narrow QRS complexes at 130 bpm; P waves arise with QRS

265
 A p p e n d i x 3

Rhythmic Algorithm No. 2: Narrow-Complex Tachycardias

Supraventricular tachycardia

Junctional tachycardia

Multifocal atrial tachycardia

Sinus rhythm (3 complexes) with paroxysmal onset (arrow) of supraventricular tachycardia (PSVT)

266
 ACLS Rhythms for the ACLS Algorithms

Narrow-Complex Supraventricular
Tachycardia, Stable

Attempt therapeutic diagnostic maneuver

• Vagal stimulation
• Adenosine

Preserved • β-Blocker
heart function • Ca 2+ channel blocker
• Amiodarone
NO DC cardioversion!

Junctional tachycardia
• Amiodarone
EF <40%, CHF NO DC cardioversion!

Preserved
heart function • β-Blocker
• Ca 2+ channel blocker
• Amiodarone
NO DC cardioversion!
Ectopic or multifocal
atrial tachycardia
• Amiodarone
EF <40%, CHF • Diltiazem
NO DC cardioversion!

Priority order:
• AV nodal blockade
— β-Blocker
— Ca 2+ channel blocker
Preserved — Digoxin
heart function • DC cardioversion
• Antiarrhythmics:
consider procainamide,
amiodarone, sotalol
Paroxysmal supraventricular
tachycardia

Priority order:
EF <40%, CHF • DC cardioversion
• Digoxin
• Amiodarone
• Diltiazem

267
 A p p e n d i x 3

10. Multifocal Atrial Tachycardia

Pathophysiology ■ Areas of automaticity (impulse formation) originate irregularly and rapidly at different points
in the atria

Defining Criteria and ECG ■ Rate: >100 beats/min; usually >130 bpm
Features
■ Rhythm: irregular atrial firing
If the rate is <100 beats/min,
■ PR: variable
this rhythm is termed “wan-
dering atrial pacemaker” or ■ P waves: by definition must have 3 or more P waves that differ in polarity (up/down),
“multifocal atrial rhythm” shape, and size since the atrial impulse is generated from multiple foci
Key: By definition must have
■ QRS complex: narrow; ≤0.10 sec in absence of intraventricular conduction defect
3 or more P waves that differ
in polarity (up/down), shape,
and size since the atrial
impulse is generated from
multiple foci.

Clinical Manifestations ■ Patients may have no clinical signs

■ Symptoms of unstable tachycardia may occur

Common Etiologies ■ Most common cause is COPD (cor pulmonale) where pulmonary hypertension places
increased strain on the right ventricle and atrium
■ Impaired and hypertrophied atrium gives rise to automaticity

■ Also digoxin toxicity, rheumatic heart disease, acute coronary syndromes

Recommended Therapy Preserved heart function:

If specific diagnosis unknown, ■ β-blocker
attempt therapeutic/diagnostic
■ Calcium channel blocker
maneuver with
■ Amiodarone
■ Vagal stimulation
■ NO DC cardioversion!
■ Adenosine . . . THEN
If impaired heart function:
■ Amiodarone
■ Diltiazem
■ NO DC cardioversion!

Multifocal atrial tachycardia: narrow-complex tachycardia at 140 to 160 bpm with multiple P-wave morphologies (arrows)

268
 ACLS Rhythms for the ACLS Algorithms

11. PSVT (Paroxysmal Supraventricular Tachycardia)

Pathophysiology ■ Reentry phenomenon (see page 260): impulses arise and recycle repeatedly in the AV
node because of areas of unidirectional block in the Purkinje fibers

Defining Criteria and ■ Rate: exceeds upper limit of sinus tachycardia (>120 beats/min); seldom <150 beats/min;
ECG Features up to 250 beats/min
Key: Regular, narrow-complex ■ Rhythm: regular
tachycardia without P-waves, ■ P waves: seldom seen because rapid rate causes P wave loss in preceding T waves or
and sudden, paroxysmal because the origin is low in the atrium
onset or cessation, or both
■ QRS complex: normal, narrow (≤0.10 sec usually)
Note: To merit the diagnosis
some experts require capture
of the paroxysmal onset or
cessation on a monitor strip

Clinical Manifestations ■ Palpitations felt by patient at the paroxysmal onset; becomes anxious, uncomfortable
■ Exercise tolerance low with very high rates
■ Symptoms of unstable tachycardia may occur

Common Etiologies ■ Accessory conduction pathway in many PSVT patients

■ For such otherwise healthy people many factors can provoke the paroxysm, such as
caffeine, hypoxia, cigarettes, stress, anxiety, sleep deprivation, numerous medications
■ Also increased frequency of PSVT in unhealthy patients with CAD, COPD, CHF

Recommended Therapy Preserved heart function:

If specific diagnosis unknown, ■ AV nodal blockade
attempt therapeutic/diagnos- — β-Blocker
tic maneuver with — Calcium channel blocker
■ Vagal stimulation — Digoxin
■ Adenosine . . . THEN ■ DC cardioversion
■ Parenteral antiarrhythmics:
— Procainamide
— Amiodarone
— Sotalol (not available in the United States)
Impaired heart function:
■ DC cardioversion
■ Digoxin
■ Amiodarone
■ Diltiazem

Sinus rhythm (3 complexes) with paroxysmal onset (arrow) of supraventricular tachycardia (PSVT)

269
 A p p e n d i x 3

Rhythmic Algorithm No. 3: Stable Ventricular Tachycardias

Stable Ventricular Tachycardia

Monomorphic or Polymorphic?

Monomorphic ventricular tachycardia

Monomorphic VT Note!
• Is cardiac function impaired? May go directly to
cardioversion

Preserved
heart function Poor ejection fraction
Monomorphic ventricular tachycardia

Medications: any one

• Procainamide
• Sotalol
Others acceptable
• Amiodarone
• Lidocaine

Cardiac function
impaired

Amiodarone
• 150 mg IV over 10 minutes
or
Lidocaine
• 0.5 to 0.75 mg/kg IV push
Then use
• Synchronized cardioversion

270
 ACLS Rhythms for the ACLS Algorithms

Torsades de pointes

Polymorphic VT
• Is baseline QT interval prolonged?

Prolonged baseline
Normal baseline QT interval
QT interval (suggests torsades)

PR QT

Normal baseline QT interval Long baseline QT interval

• Treat ischemia • Correct abnormal electrolytes

• Correct electrolytes
Therapies: any one Prolonged baseline QT interval
Medications: any one • Magnesium
• β-Blockers or • Overdrive pacing
• Lidocaine or • Isoproterenol
• Amiodarone or • Phenytoin
• Procainamide or • Lidocaine
• Sotalol

QT

Normal baseline QT interval

271
 A p p e n d i x 3

12. Monomorphic Ventricular Tachycardia (Stable)

Pathophysiology ■ Impulse conduction is slowed around areas of ventricular injury, infarct, or ischemia
■ These areas also serve as source of ectopic impulses (irritable foci)
■ These areas of injury can cause the impulse to take a circular course, leading to the reen-
try phenomenon and rapid repetitive depolarizations

Defining Criteria per ECG ■ Rate: ventricular rate >100 bpm; typically 120 to 250 bpm
Key: The same morphology, ■ Rhythm: no atrial activity seen, only regular ventricular
or shape, is seen in every
■ PR: nonexistent
QRS complex
Notes: ■ P waves: seldom seen but present; VT is a form of AV dissociation (which is a defining
characteristic for wide-complex tachycardias of ventricular origin vs supraventricular tachy-
■ 3 or more consecutive
cardias with aberrant conduction)
PVCs: ventricular
tachycardia ■ QRS complex: wide and bizarre, “PVC-like” complexes >0.12 sec, with large T wave of
■ VT <30 sec duration ➔ opposite polarity from QRS
non-sustained VT
■ VT >30 sec duration ➔
sustained VT

Clinical Manifestations ■ Monomorphic VT can be asymptomatic, despite the widespread erroneous belief that sus-
tained VT always produces symptoms
■ Majority of times, however, symptoms of decreased cardiac output (orthostasis, hypoten-
sion, syncope, exercise limitations, etc) are seen
■ Untreated and sustained will deteriorate to unstable VT, often VF

Common Etiologies ■ An acute ischemic event (see pathophysiology) with areas of “ventricular irritability” leading
to PVCs
■ PVCs that occur during the relative refractory period of the cardiac cycle (“R-on-T phenomenon”)
■ Drug-induced, prolonged QT interval (tricyclic antidepressants, procainamide, digoxin,
some long-acting antihistamines)

Recommended Therapy Normal Heart Impaired Heart

Any one of following parenteral ■ Amiodarone

antiarrhythmics: or
■ Procainamide ■ Lidocaine
■ Sotalol then
■ Amiodarone ■ DC cardioversion if persists
■ Lidocaine

Monomorphic ventricular tachycardia at rate of 150 bpm: wide QRS complexes (arrow A) with opposite polarity T waves (arrow B)

272
 ACLS Rhythms for the ACLS Algorithms

13. Polymorphic Ventricular Tachycardia (Stable)

Pathophysiology ■ Impulse conduction is slowed around multiple areas of ventricular injury, infarct, or
ischemia
■ These areas also serve as the source of ectopic impulses (irritable foci) ; irritable foci occur
in multiple areas of the ventricles, thus “polymorphic”
■ These areas of injury can cause impulses to take a circular course, leading to the reentry
phenomenom and rapid repetitive depolarizations

Defining Criteria per ECG ■ Rate: ventricular rate >100 bpm; typically 120 to 250
Key: Marked variation and ■ Rhythm: only regular ventricular
inconsistency seen in the ■ PR: nonexistent
QRS complexes ■ P waves: seldom seen but present; VT is a form of AV dissociation
■ QRS complexes: marked variation and inconsistency seen in the QRS complexes

Clinical Manifestations ■ Rare: asymptomatic polymorphic VT

■ Majority of times: symptoms of decreased cardiac output (orthostasis, hypotension, syncope,
exercise limitations, etc) are seen
■ Seldom ➔ sustained VT; seldom ➔ “stable” VT
■ Tends toward rapid deterioration to pulseless VT or VF

Common Etiologies ■ An acute ischemic event (see pathophysiology) with areas of “ventricular irritability” leading
to PVCs
■ PVCs that occur during the relative refractory period of the cardiac cycle (“R-on-T phenomenon”)
■ Drug-induced prolonged QT interval (tricyclic antidepressants, procainamide, digoxin,
some long-acting antihistamines)

Recommended Therapy Review most recent 12-lead ECG (baseline)

■ Measure QT interval just prior to onset of the polymorphic tachycardia
■ QT interval prolongation? (if YES go to Torsades de Pointes; if NO see below)
Normal baseline QT interval:
■ Treat ischemia
■ Correct electrolytes if abnormal
Then:

Normal Heart Impaired Heart

Parenteral medications: any one ■ Amiodarone

■ β-Blockers or or
■ Lidocaine or ■ Lidocaine
■ Amiodarone or then
■ Procainamide or ■ DC cardioversion if persists
■ Sotalol

Polymorphic ventricular tachycardia: QRS complexes display multiple morphologies (“polymorphic”)

273
 A p p e n d i x 3

14. Torsades de Pointes (a Unique Subtype of Polymorphic Ventricular Tachycardia)

Pathophysiology Specific pathophysiology for classic torsades:

■ QT interval is abnormally long (see below for etiology of QT prolongation)
■ Leads to increase in the relative refractory period (“vulnerable period”) of the cardiac cycle
■ Increases probability that an irritable focus (PVC) will occur on the T-wave (“vulnerable
period” or “R-on-T phenomenon”)
■ R-on-T phenomenon often induces VT

Defining Criteria per ECG ■ Atrial Rate: cannot determine atrial rate
Key: QRS complexes display ■ Ventricular rate: 150-250 complexes/min
“spindle-node” pattern ➔ ■ Rhythm: only irregular ventricular rhythm
VT amplitude increases then ■ PR: nonexistent
decreases in regular pattern
■ P waves: nonexistent
(creates the “spindle”) ➔
initial deflection at start of one ■ QRS complexes: display classic “spindle-node” pattern (see left column: “Key”)
spindle (eg, negative) will
be followed by the opposite
(eg, positive) deflection at
the start of the next spindle
(creates the “node”)

Clinical Manifestations ■ Majority of times patients with torsades have symptoms of decreased cardiac output
(orthostasis, hypotension, syncope, exercise limitations, etc)
■ Asymptomatic torsades, sustained torsades, or “stable” torsades is uncommon
■ Tends toward sudden deterioration to pulseless VT or VF

Common Etiologies Most commonly occurs with prolonged QT interval, from many causes:
■ Drug-induced: tricyclic antidepressants, procainamide, digoxin, some long-acting antihistamines
■ Electrolyte and metabolic alterations (hypomagnesemia is the prototype)
■ Inherited forms of long QT syndrome
■ Acute ischemic events (see pathophysiology)

Recommended Therapy Review most recent 12-lead ECG (baseline):

■ Measure QT interval just before onset of the polymorphic tachycardia
■ QT interval prolongation? (if YES see below; if NO go to the polymorphic VT algorithm)
Long baseline QT interval:
■ Treat ischemia
■ Correct electrolytes if abnormal
Then therapies (any one):
■ Magnesium
■ Overdrive pacing
■ Isoproterenol (pharmacologic overdrive pacing)
■ Phenytoin
■ Lidocaine

Torsades de pointes
(a unique subtype of polymorphic ventricular
C tachycardia)
Arrows: A — Start of a “spindle”; note negative
initial deflection; note increasing
QRS amplitude
A B B — End of “spindle”; start of “node”
C — End of “node”; start of next “spin-
dle”; note positive initial deflection;
increase-decrease in QRS amplitude

274
 ACLS Rhythms for the ACLS Algorithms

15. Normal and Prolonged Baseline QT Interval

QT

Normal baseline QT interval

Rate: 80 bpm
QT interval: 0.36 sec
(within QTc range of 0.32 – 0.39 sec
for a heart rate of 80 bpm)

PR QT

Prolonged baseline QT interval

Due to drug toxicity
PR interval: >0.20 sec
Rate: 80 bpm
QT interval: prolonged, 0.45 sec
(above QTc range of 0.32 – 0.39 sec
for a heart rate of 80 bpm)
QRS complex: widened, >0.12 sec

275
 A p p e n d i x 3

Rhythmic Algorithm No. 4: Bradycardias

Sinus bradycardia with borderline first-degree AV block

Second-degree AV block type I

Second-degree AV block type II

Complete AV block with a ventricular escape pacemaker (wide QRS: 0.12 to 0.14 sec)

Third-degree AV block with a junctional escape pacemaker (narrow QRS: <0.12)

276
 ACLS Rhythms for the ACLS Algorithms

Bradycardias
• Slow (absolute bradycardia = rate <60 bpm)
or
• Relatively slow (rate less than expected
relative to underlying condition or cause)

Primary ABCD Survey

• Assess ABCs
• Secure airway noninvasively
• Ensure monitor/defibrillator is available
Secondary ABCD Survey
• Assess secondary ABCs (invasive airway
management needed?)
• Oxygen–IV access–monitor–fluids
• Vital signs, pulse oximeter, monitor BP
• Obtain and review 12-lead ECG
• Obtain and review portable chest x-ray
• Problem-focused history
• Problem-focused physical examination
• Consider causes (differential diagnoses)

Serious signs or symptoms?

Due to the bradycardia?

No Yes

Type II second-degree AV block Intervention sequence

or • Atropine 0.5 to 1 mg
Third-degree AV block? • Transcutaneous pacing if available
• Dopamine 5 to 20 µg/kg per minute
• Epinephrine 2 to 10 µg/min
• Isoproterenol 2 to 10 µg/min

No Yes

• Prepare for transvenous pacer

Observe • If symptoms develop, use
transcutaneous pacemaker until
transvenous pacer placed

277
 A p p e n d i x 3

16. Sinus Bradycardia

Pathophysiology ■ Impulses originate at SA node at a slow rate

■ Not pathological; not an abnormal arrhythmia

■ More a physical sign

Defining Criteria per ECG ■ Rate: <60 beats/min

Key: Regular P waves fol- ■ Rhythm: regular sinus
lowed by regular QRS com-
■ PR: regular; <0.20 sec
plexes at rate <60 beats/min
Note: Often a physical sign ■ P waves: size and shape normal; every P wave is followed by a QRS complex; every QRS
rather than an abnormal complex is preceded by a P wave
rhythm
■ QRS complex: narrow; ≤0.10 sec in absence of intraventricular conduction defect

Clinical Manifestations ■ At rest, usually asymptomatic

■ With increased activity, persistent slow rate will lead to symptoms of easy fatigue, SOB,
dizziness or lightheadedness, syncope, hypotension

Common Etiologies ■ Normal for well-conditioned people

■ A vasovagal event such as vomiting, valsalva, rectal stimuli, inadvertent pressure on

carotid sinus (“shaver’s syncope”)
■ Acute MIs that affect circulation to SA node (right coronary artery); most often inferior AMIs

■ Adverse drug effects, eg, blocking agents (β or calcium channel), digoxin, quinidine

Recommended Therapy ■ Treatment rarely indicated

■ Treat only if patient has significant signs or symptoms due to the bradycardia

■ Oxygen is always appropriate

Intervention sequence for bradycardia
■ Atropine 0.5 to 1 mg IV if vagal mechanism

■ Transcutaneous pacing if available

If signs and symptoms are severe, consider catecholamine infusions:
■ Dopamine 5 to 20 µg/kg per min

■ Epinephrine 2 to 10 µg/min

■ Isoproterenol 2 to 10 µg/min

Sinus bradycardia: rate of 45 bpm; with borderline first-degree AV block (PR ≈ 0.20 sec)

278
 ACLS Rhythms for the ACLS Algorithms

17. First-Degree Heart Block

Pathophysiology ■ Impulse conduction is slowed (partial block) at the AV node by a fixed amount

■ Closer to being a physical sign than an abnormal arrhythmia

Defining Criteria per ECG ■ Rate: First-degree heart block can be seen with both sinus bradycardia and sinus
Key: PR interval >0.20 sec tachycardia
■ Rhythm: sinus, regular, both atria and ventricles

■ PR: prolonged, >0.20 sec, but does not vary (fixed)

■ P waves: size and shape normal; every P wave is followed by a QRS complex; every QRS
complex is preceded by a P wave
■ QRS complex: narrow; ≤0.10 sec in absence of intraventricular conduction defect

Clinical Manifestations ■ Usually asymptomatic at rest

■ Rarely, if bradycardia worsens, person may become symptomatic from the slow rate

Common Etiologies ■ Large majority of first-degree heart blocks are due to drugs, usually the AV nodal blockers:
β-blockers, calcium channel blockers, and digoxin
■ Any condition that stimulates the parasympathetic nervous system (eg, vasovagal reflex)

■ Acute MIs that affect circulation to AV node (right coronary artery); most often inferior AMIs

Recommended Therapy ■ Treat only when patient has significant signs or symptoms that are due to the bradycardia

■ Be alert to block deteriorating to second-degree, type I or type II block

■ Oxygen is always appropriate

Intervention sequence for symptomatic bradycardia
■ Atropine 0.5 to 1 mg IV if vagal mechanism

■ Transcutaneous pacing if available

If signs and symptoms are severe, consider catecholamine infusions:
■ Dopamine 5 to 20 µg/kg per min

■ Epinephrine 2 to 10 µg/min

■ Isoproterenol 2 to 10 µg/min

First-degree AV block at rate of 37 bpm; PR interval 0.28 sec

279
 A p p e n d i x 3

18. Second-Degree Heart Block Type I (Mobitz I–Wenkebach)

Pathophysiology ■ Site of pathology: AV node

■ AV node blood supply comes from branches of the right coronary artery

■ Impulse conduction is increasingly slowed at the AV node (causing increasing PR interval)

■ Until one sinus impulse is completely blocked and a QRS complex fails to follow

Defining Criteria per ECG ■ Rate: atrial rate just slightly faster than ventricular (because of dropped beats); usually normal
Key: There is progressive range
lengthening of the PR interval ■ Rhythm: regular for atrial beats; irregular for ventricular (because of dropped beats); can
until one P wave is not followed
show regular P waves marching through irregular QRS
by a QRS complex (the
dropped beat) ■ PR: progressive lengthening of the PR interval occurs from cycle to cycle; then one P wave
is not followed by a QRS complex (the “dropped beat”)
■ P waves: size and shape remain normal; occasional P wave not followed by a QRS com-
plex (the “dropped beat”)
■ QRS complex: ≤0.10 sec most often, but a QRS “drops out” periodically

Clinical Manifestations— Due to bradycardia:

Rate-Related
■ Symptoms: chest pain, shortness of breath, decreased level of consciousness

■ Signs: hypotension, shock, pulmonary congestion, CHF, angina

Common Etiologies ■ AV nodal blocking agents: β-blockers, calcium channel blockers, digoxin

■ Conditions that stimulate the parasympathetic system

■ An acute coronary syndrome that involves the right coronary artery

Recommended Therapy Intervention sequence for symptomatic bradycardia:

Key: Treat only when patient ■ Atropine 0.5 to 1 mg IV if vagal mechanism
has significant signs or symp-
■ Transcutaneous pacing if available
toms that are due to the
bradycardia If signs and symptoms are severe, consider catecholamine infusions:
■ Dopamine 5 to 20 µg/kg per min

■ Epinephrine 2 to 10 µg/min

■ Isoproterenol 2 to 10 µg/min

Second-degree heart block type I. Note progressive lengthening of PR interval

until one P wave (arrow) is not followed by a QRS.

280
 ACLS Rhythms for the ACLS Algorithms

19. Second-Degree Heart Block Type II (Infranodal) (Mobitz II–Non-Wenkebach)

Pathophysiology ■ The pathology, ie, the site of the block, is most often below the AV node (infranodal); at the
bundle of His (infrequent) or at the bundle branches
■ Impulse conduction is normal through the node, thus no first-degree block and no prior PR
prolongation

Defining Criteria per ECG ■ Atrial Rate: usually 60-100 beats/min

■ Ventricular rate: by definition (due to the blocked impulses) slower than atrial rate

■ Rhythm: atrial = regular; ventricular = irregular (because of blocked impulses)

■ PR: constant and set; no progressive prolongation as with type I—a distinguishing charac-
teristic.
■ P waves: typical in size and shape; by definition some P waves will not be followed by a
QRS complex
■ QRS complex: narrow (≤0.10 sec) implies high block relative to the AV node; wide
(>0.12 sec) implies low block relative to the AV node

Clinical Manifestations— Due to bradycardia:

Rate-Related
■ Symptoms: chest pain, shortness of breath, decreased level of consciousness

■ Signs: hypotension, shock, pulmonary congestions, CHF, acute MI

Common Etiologies ■ An acute coronary syndrome that involves branches of the left coronary artery

Recommended Therapy Intervention sequence for bradycardia due to type II second-degree or third-degree
Pearl: New onset type II heart block:
second-degree heart block in ■ Prepare for transvenous pacer
clinical context of acute coro-
■ Atropine is seldom effective for infranodal block
nary syndrome is indication
for transvenous pacemaker ■ Use transcutaneous pacing if available as a bridge to transvenous pacing (verify patient
insertion tolerance and mechanical capture. Use sedation and analgesia as needed.)
If signs/symptoms are severe and unresponsive to TCP, and transvenous pacing is
delayed, consider catecholamine infusions:
■ Dopamine 5 to 20 µg/kg per min
■ Epinephrine 2 to 10 µg/min
■ Isoproterenol 2 to 10 µg/min

Type II (high block): regular PR-QRS intervals until 2 dropped beats occur; borderline normal QRS complexes indicate high nodal or nodal block

Type II (low block): regular PR-QRS intervals until dropped beats; wide QRS complexes indicate infranodal block

281
 A p p e n d i x 3

20. Third-Degree Heart Block and AV Dissociation

Pathophysiology Injury or damage to the cardiac conduction system so that no impulses (complete block) pass
Pearl: AV dissociation is the between atria and ventricles (neither antegrade nor retrograde)
defining class; third-degree or
complete heart block is one type This complete block can occur at several different anatomic areas:
of AV dissociation. By conven- ■ AV node (“high” or “supra” or “junctional” nodal block)
tion (outdated): if ventricular
■ Bundle of His
escape depolarization is faster
than atrial rate = “AV dissocia- ■ Bundle branches (“low-nodal” or “infranodal” block)
tion”; if slower = “third-degree
heart block”

Defining Criteria per ECG ■ Atrial rate: usually 60-100 beats/min; impulses completely independent (“dissociated”)
Key: The third-degree block from ventricular rate
(see pathophysiology) causes ■ Ventricular rate: depends on rate of the ventricular escape beats that arise:
the atria and ventricles to — Ventricular escape beat rate slower than atrial rate = third-degree heart block (20-40
depolarize independently, beats/min)
with no relationship between — Ventricular escape beat rate faster than atrial rate = AV dissociation (40-55 beats/min)
the two (AV dissociation)
■ Rhythm: both atrial rhythm and ventricular rhythm are regular but independent (“dissoci-
ated”)
■ PR: by definition there is no relationship between P wave and R wave
■ P waves: typical in size and shape
■ QRS complex: narrow (≤0.10 sec) implies high block relative to the AV node; wide
(>0.12 sec) implies low block relative to the AV node

Clinical Manifestations— Due to bradycardia:

Rate-Related ■ Symptoms: chest pain, shortness of breath, decreased level of consciousness
■ Signs: hypotension, shock, pulmonary congestions, CHF, acute MI

Common Etiologies ■ An acute coronary syndrome that involves branches of the left coronary artery
■ In particular, the LAD (left anterior descending) and branches to the interventricular septum
(supply bundle branches)

Recommended Therapy Intervention sequence for bradycardia due to type II second-degree or third-degree
Pearl: New onset third-degree heart block:
heart block in clinical context ■ Prepare for transvenous pacer
of acute coronary syndrome ■ Use transcutaneous pacing if available as a bridge to transvenous pacing (verify patient
is indication for transvenous tolerance and mechanical capture; use sedation and analgesia as needed)
pacemaker insertion If signs/symptoms are severe and unresponsive to TCP, and transvenous pacing is
Pearl: Never treat third-degree delayed, consider catecholamine infusions:
heart block plus ventricular ■ Dopamine 5 to 20 µg/kg per min
escape beats with lidocaine
■ Epinephrine 2 to 10 µg/min
■ Isoproterenol 2 to 10 µg/min

Third-degree heart block: regular P waves at 50 to 55 bpm; regular ventricular “escape beats” at 35 to 40 bpm;
no relationship between P waves and escape beats

282
 ACLS Rhythms for the ACLS Algorithms

21. Transcutaneous Pacing

A. Bradycardia: no pacing
B. Pacing stimulus below threshold: no capture
C. Pacing stimulus above threshold: capture occurs

Rhythm Strip Comments

A. Bradycardia (third-degree ■ QRS rate = 41 beats/min

heart block): no pacing
■ P waves seen = 125 beats/min
(Note: Rates and intervals
slightly altered due to ■ QRS = very wide, 0.24 sec; ventricular escape beats
monitor compensation for ■ QRS and T wave polarity = both positive
pacing stimulus)
■ Patient: SOB at rest; severe SOB with walking; near syncope

B. Transcutaneous pacing ■ With TCP, monitor electrodes are attached in modified lead II position
initiated at low current
■ As current (in milliamperes) is gradually increased, the monitor leads detect the pacing
(35 mA) and slow rate
(50 beats/min). stimuli as a squared off, negative marker
Below the threshold ■ TC pacemakers incorporate standard ECG monitoring circuitry but incorporate filters to
current needed to stimu- dampen the pacing stimuli
late the myocardium
■ A monitor without these filters records “border-to-border” tracings (off the edge of the
screen or paper at the top and bottom borders) that cannot be interpreted

C. Pacing current turned ■ TCP stimulus does not work through the normal cardiac conduction system but by a direct
up above threshold electrical stimulus of the myocardium
(60 mA at 71 beats/min)
and “captures” the ■ Therefore, a “capture,” where TCP stimulus results in a myocardial contraction, will resem-
myocardium ble a PVC
■ Electrical capture is characterized by a wide QRS complex, with the initial deflection and
the terminal deflection always in opposite directions
■ A “mechanically captured beat” will produce effective myocardial contraction with produc-
tion of some blood flow (usually assessed by a palpable carotid pulse)

283
 A p p e n d i x 3

Lead I Size 1.0 HR=41

Bradycardia: prepacing attempt

Lead I Size 1.0 HR=43 35 mA

Pacing attempted: note pacing stimulus indicator (arrow) which is below threshold; no capture

Lead I Size 1.0 HR=71 60 mA

Pacing above threshold (60 mA): with capture (QRS complex broad and ventricular; T wave opposite QRS)

284