Pulseless Rhythms

Pulseless Ventricular Tachycardia

The pulseless ventricular tachycardia rhythm is primarily identified by several criteria. First, the rate is usually greater than 180 beats per minute and the rhythm generally has a very wide QRS complex. Second, the patient will be pulseless and third, the rhythm originates in the ventricles. This is in contrast to other types of tachycardias which have origination above the ventricular tissue (in the atria).

Not all ventricular tachycardias are pulseless and therefore, pulselessness must be established prior to beginning an algorithm. This is accomplished simply by checking a carotid or femoral pulse.

Pulselessness with a tachyarrhythmia occurs because the ventricles are not effectively moving blood out of the heart and there is therefore no cardiac output. Many tachyarrhythmias of a rate >150 will deteriorate into pulselessness if timely treatment is not given.

Pulseless Electrical Activity (PEA) Rhythm PEA rhythm occurs when any heart rhythm that is observed on the electrocardiogram (ECG) does not produce a pulse. PEA can come in many different forms. Sinus Rhythm, tachycardia, and bradycardia can all be seen with PEA.

Performing a pulse check after a rhythm/monitor check will ensure that you identify PEA in every situation.

Pulseless electrical activity usually has an underlying treatable cause. The most common cause in emergency situations is hypovolemia. PEA is treated by assessing and correcting the underlying cause. These causes can be summed up in the 6 Hs and 6 Ts of ACLS. Use the link to review the Hs and Ts. When an underlying cause for pulseless electrical activity cannot be determined, PEA should be treated in the same fashion as asystole

Ventricular Fibrillation

Ventricular fibrillation or VF occurs when there are uncoordinated contractions within the ventricles of the heart. The primary cause of VF is hypoxia (lack of oxygen) to the heart muscle which causes hyperirritability in the cardiac muscle tissue. As a result, multiple muscles cells within the ventricles simultaneously fire as pacemakers causing a quivering or fibrillation that is ineffective for adequate cardiac output.

The two images above show what ventricular fibrillation will look like on a EKG rhythm strip. VF can rapidly lead to heart muscle ischemia and there is a high likelihood that it will deteriorate into asystole.

Asystole or flatline

Asystole is not actually a true rhythm but rather is a state of no cardiac electrical activity. The main treatment of choice for asystole is the use of epinephrine and CPR.

Bradyarrhythmias First-Degree Heart Block Also called first-degree AV block is a disease of the electrical conduction system of the heart in which the PR interval is lengthened beyond 0.20 seconds.

This lengthening of the PR interval is caused by a delay in the electrical impulse from the atria to the ventricles through the AV node

Normally and in the case of ACLS, first-degree heart block is of no consequence unless it involves myocardial infarction or an electrolyte imbalance.

Although first-degree heart block is not clinically significant for ACLS, recognition of the major AV blocks is important because treatment decisions are based on the type of block present.

Second-Degree Heart Block (Type 1) Also called Mobitz 1 or Wenckebach is a disease of the electrical conduction system of the heart in which the PR interval has progressive prolongation until finally the atrial impulse is completely blocked and does not produce a QRS electrical impulse. Once the p-wave is blocked and no QRS is generated, the cycle begins again with the prolongation of the PR interval. One of the main identifying characteristics of second degree heart block type 1 is that the atrial rhythm will be regular.

Second-Degree (AV) Heart Block (Type 2) Also called Mobitz II or Hay is a disease of the electrical conduction system of the heart. Second-degree AV block (Type 2) is almost always a disease of the distal conduction system located in the ventricular portion of the myocardium.

This rhythm can be recognized by the following characteristics: 1. non-conducted p-waves (electrical impulse conducts through the AV node but complete conduction through the ventricles is blocked, thus no QRS) 2. P-waves are not preceded by PR prolongation as with second-degree AV block (Type 1) 3. fixed PR interval 4. The QRS complex will likely be wide 1. The QRS on an ECG will most likely be wide because the block occurs in the His bundle or bundle branches and conduction through the ventricles is slowed.

Second-degree AV block (Type 2) is clinically significant for ACLS because this rhythm can rapidly progress to complete heart block

Second-degree AV block (Type 2) should be treated with immediate transcutaneous pacing or transvenous pacing because there is risk that electrical impulses will not be able to reach the ventricles and produce ventricular contraction.

Atropine may be attempted if immediate TCP is not available or time is needed to initiate TCP. Atropine should not be relied upon and in the case of myocardial ischemia it should be avoided.

Complete Heart Block Third-degree AV block or complete heart block is the most clinically significant AV block associated with ACLS. Complete heart block occurs when the electrical impulse generated in the SA node in the atrium is not conducted to the ventricles. When the atrial impulse is blocked, an accessory pacemaker in the ventricles will typically activate a ventricular contraction. This accessory pacemaker impulse is called an escape rhythm.

Because two independent electrical impulses occur (SA node impulse & accessory pacemaker impulse), there is no apparent relationship between the P waves and QRS complexes on an ECG.

Characteristics that can be seen on an ECG include: 1. P waves with a regular P to P interval 2. QRS complexes with a regular R to R interval 3. The PR interval will appear variable because there is no relationship between the P waves and the QRS Complexes

In the image above note that the p-waves are independent of the QRS complexes. Also note the 4th QRS complex (impulse) looks different from the others. This is because it is from a different accessory pacemaker in the ventricle than the other QRS complexes.

Common Causes The most common cause of complete block is coronary ischemia and myocardial infarction. Reduced blood flow or complete loss of blood flow to the myocardium damages the conduction system of the heart, and this results in an inability to conduct impulses from the atrium to the ventricles. Those with third-degree AV block typically experience bradycardia, hypotension, and in some cases hemodynamic instability.

The treatment for unstable third-degree AV block in ACLS is transcutaneous pacing. Tachyarrhythmias Supraventricular Tachycardia (SVT) SVT is a broad term for a number of tachyarrhythmias that originate above the ventricular electrical conduction system (purkinje fibers).

Classic Paroxysmal SVT has a narrow QRS complex & has a very regular rhythm. Inverted P waves are sometimes seen after the QRS complex. These are called retrograde p waves

The heart fills during diastole, and diastole is normally 2/3 the cardiac cycle. A rapid heart rate will significantly reduce the time which the ventricles have to fill. The reduced filling time results in a smaller amount of blood ejected from the heart during systole. The end result is a drop in cardiac output & hypotension. With the drop in cardiac output, a patient may experience the following symptoms. These symptoms occur more frequently with a heart rate >150 beats per minute:

Shortness of air (S) Palpitation feeling in chest (S) Ongoing chest pain (U) Dizziness (S) Rapid breathing (S) Loss of consciousness (U) Numbness of body parts (S)

The pathway of choice for SVT in the tachycardia algorithm is based on whether the patient is stable or unstable. The symptoms listed above that would indicate the patient is unstable are noted with the letter (U). Stable but serious symptoms are indicated with the letter (S).

Unstable patients with SVT and a pulse are always treated with cardioversion Atrial Fibrillation The most common cardiac arrhythmia, atrial fibrillation, occurs when the normal electrical impulses that are generated by the SA node are overwhelmed by disorganized electrical impulses in the atria.

These disorganized impulses cause the muscles of the upper chambers of the heart to quiver (fibrillate) and this leads to the conduction of irregular impulses to the ventricles. For ACLS, atrial fibrillation becomes a problem when the fibrillation produces a rapid heart rate which reduces cardiac output and causes symptoms or an unstable condition.

When atrial fibrillation occurs with a (RVR) rapid ventricular rate (rate > 100 beats/min), this is called a tachyarrhythmia. This tachyarrhythmia may or may not produce symptoms. Significant symptoms that occur are due to a reduction in cardiac output.

The following is a list of the most common symptoms.

palpitations or chest discomfort shortness of air and possibly respiratory distress hypotension, light-headedness and possibly loss of consciousness peripheral edema, jugular vein distention, and possibly pulmonary edema

For the purpose of ACLS, it is important to be able to recognize atrial fibrillation when the patient is symptomatic. On an ECG monitor, there are two major characteristics that will help you identify atrial fibrillation. 1. No p-waves before the QRS on the ECG. This is because there are no coordinated atrial contractions. 2. The heart rate will be irregular. Irregular impulses that the ventricles are receiving cause the irregular heart rate. When the heart rate is extremely rapid, it may be difficult to determine if the rate is irregular, and the absence of p-waves will be the best indicator of atrial fibrillation. ACLS Treatments:

For the purposes of ACLS atrial fibrillation is treated when the arrhythmia/tachyarrhythmia produces hemodynamic instability and serious signs and symptoms.

For the patient with unstable tachycardia due to a tachyarrhythmia, immediate cardioversion is recommended. Drugs are not used to manage unstable tachycardia. Cardioversion of stable atrial fibrillation should be performed with caution if the arrhythmia is more than 48 hours old and no anticoagulant therapy has been initiated due to the risk of emboli that can cause MI and stroke. Atrial Flutter This abnormal heart rhythm technically falls under the category of supra-ventricular tachycardias. Atrial flutter is typically not a stable rhythm and will frequently degenerate into atrial fibrillation.

Atrial Flutter will usually present with atrial rates between 240-350 beats per minute. These rapid atrial rates are caused by electrical activity that moves in a self-perpetuating loop within the atria. The impact and symptoms of atrial flutter depend upon the ventricular rate of the patient (i.e. cardiac output). Usually, with atrial flutter, not all of the atrial impulses will be conducted to the ventricles, and the more atrial impulses that are conducted, the greater the negative effect. Symptoms Symptoms of atrial flutter are similar to those of atrial fibrillation and may include the following:

palpitations, chest pain or discomfort shortness of air lightheadedness or dizziness nausea nervousness and feelings of impending doom symptoms of heart failure such as activity intolerance and swelling of the legs occur with prolonged fast flutter)

Complications As with its symptoms, atrial flutter shares the same complications as atrial fibrillation. These complications are usually due to ineffective atrial contractions and rapid ventricular rates. Ineffective atrial contractions can lead to thrombus formation in the atria and rapid ventricular rates can cause decompensation and heart failure.

Prevent complications from atrial flutter with early cardioversion. Treatment For the purposes of ACLS, atrial flutter is treated the same as atrial fibrillation. When atrial flutter produces hemodynamic instability and serious signs and symptoms, it is treated using ACLS protocol. For the patient with unstable tachycardia due to this tachyarrhythmia (atrial flutter), immediate cardioversion is recommended. Drugs are not used to manage unstable tachycardia.

Cardioversion Atrial flutter is considerably more sensitive to electrical direct-current cardioversion than atrial fibrillation, and usually requires a lower energy shock. 20-50J is commonly enough to revert to sinus rhythm. Other Tachycardia Rhythms There are several other tachycardia rhythms that can be seen with both stable and unstable tachycardia. These rhythms include monomorphic of which ventricular are tachycardia and polymorphic wide-complex ventricular tachycardias. tachycardiaboth

Wide complex tachycardias are defined as a QRS of 0.12 second. Expert consultation should be considered with these rhythms. These wide-complex tachycardias are the most common forms of tachycardia that will deteriorate to ventricular fibrillation. Monomorphic Ventricular Tachycardia

With monomorphic VT all of the QRS waves will be symmetrical. Each ventricular impulse is being generated from the same place in the ventricles thus all of the QRS waves look the same. Treatment of monomorphic VT is dependent upon whether the patient is stable or unstable. Expert consultation is always advised, and if unstable, the ACLS tachycardia algorithm should be followed.

Polymorphic Ventricular Tachycardia

With polymorphic ventricular tachycardia, the QRS waves will not be symmetrical. This is because each ventricular impulse can be generated from a different location. On the rhythm strip, the QRS might be somewhat taller or wider.

One commonly seen type of polymorphic ventricular tachycardia is torsades de pointes. Torsades and other polymorphic VT are advanced rhythms which require additional expertise and expert consultation is advised. If polymorphic VT is stable the ACLS tachycardia algorithm should be used to treat the patient. Unstable polymorphic ventricular tachycardia is treated with unsynchronized shocks (defibrillation). Defibrillation is used because synchronization is not possible.

These wide complex tachycardias tend to originate in the ventricles rather than like a normal rhythm which originates in the atria.