Sinus

Sinus Rhythms:
Rhythms: Dysrhythmia
Dysrhythmia
Recognition
Recognition &
& Management
Management

Terry
TerryWhite,
White,RN,
RN,EMT-P
EMT-P

Sinus
Sinus Rhythms
Rhythms
Possibilities
Possibilities
Normal
Normal Sinus
Sinus Rhythm
Rhythm
(Sinus
(SinusRhythm)
Rhythm)

Sinus
Sinus Bradycardia
Bradycardia
Sinus
SinusTachycardia
Tachycardia
Sinus
SinusArrhythmia
Arrhythmia
Sinus
SinusArrest
Arrest

Sinus
Sinus Rhythms
Rhythms

Expected
Expected ECG
ECG Rhythm
Rhythm
Most
Most do
do not
not result
result in
in altered
altered physiology
physiology
Sinus
Sinus rhythm
rhythm means
means
Pacemaker
Pacemaker site
site isis in
in the
the Sinoatrial
Sinoatrial (SA)
(SA) node
node

Characteristics
Characteristics of
of all
all sinus
sinus rhythms
rhythms are
are
similar
similar

Normal
Normal Sinus
Sinus Rhythm
Rhythm
Characteristics
Characteristics
Pacemaker
Pacemakersite:
site:SA
SAnode
node
Rate:
Rate:60-100
60-100bpm
bpm
PPwaves:
waves:are
areupright
uprightin
inlead
leadII,
II,all
alllook
lookalike
alike
PR
PRinterval:
interval:generally
generallyconstant;
constant;0.12
0.12--0.20
0.20seconds
seconds
R-R
R-Rinterval:
interval:usually
usuallyregular
regular
QRS
QRScomplexes:
complexes:usually
usuallynormal
normalappearing
appearingand
and<<0.12
0.12
seconds,
seconds,may
maybe
bewide
wide
PPto
toQRS
QRSRelationship:
Relationship:one
onePPwave
waveprecedes
precedeseach
eachQRS
QRS
complex
complex

Analyze
Analyze the
the Rhythm
Rhythm

Normal
Normal Sinus
Sinus Rhythm
Rhythm
Pathophysiology
Pathophysiology
None
None specific
specific to
to the
the ECG
ECG rhythm
rhythmitself
itself
Normal
Normal and
and expected
expected ECG
ECG rhythm
rhythm

Management
Management
Treat
Treat the
the patient!
patient!

Sinus
Sinus Bradycardia
Bradycardia
Characteristics
Characteristics
Same
Same as
as NSR
NSR with
with ONE
ONE exception
exception
Rate:
Rate:<<60
60bpm
bpm

Analyze
Analyze the
the Rhythm
Rhythm

Sinus
Sinus Bradycardia
Bradycardia
Pathophysiology
Pathophysiology
Generally
Generallyaaresult
resultof
ofsome
someother
othercause
cause

Excessive
Excessiveparasympathetic
parasympathetictone
toneon
onSA
SAnode
node
Decrease
Decreaseininsympathetic
sympathetictone
toneon
onSA
SAnode
node(blockade)
(blockade)
Administration
Administrationof
ofcalcium
calciumchannel
channelblockers
blockers
Digitalis
Digitalistoxicity
toxicity
Disease
Diseaseof
ofthe
theSA
SAnode
node(sick
(sicksinus
sinussyndrome)
syndrome)
Acute
Acuteinferior
inferiorMI
MI
Hypothyroidism
Hypothyroidism
Hypothermia
Hypothermia
Hypoxia
Hypoxia(later)
(later)
Physical
Physicalconditioning
conditioning

Sinus
Sinus Bradycardia
Bradycardia
Symptomatic
Symptomatic Presentation
Presentation
Variable
Variable
Severe
Severepresentation
presentationmay
mayresult
resultin
in

Dizziness,
Dizziness,lightheadedness,
lightheadedness,altered
alteredmental
mentalstatus,
status,or
orsyncope
syncope
SOB
SOB
CP
CP
Hypotension/Shock
Hypotension/Shock
Pulmonary
Pulmonarycongestion
congestion
Acute
AcuteMI
MI

Sinus
Sinus Bradycardia
Bradycardia
Management
Management
First
First Steps
Steps after
afterABCDs
ABCDs
Symptomatic
Symptomaticor
orAsymptomatic
Asymptomatic
IfIfsymptomatic,
symptomatic,then
thenStable
Stableor
orUnstable
Unstable
Altered
Alteredmental
mentalstatus
status
Severe
Severerespiratory
respiratorydifficulty
difficulty
Shock/Hypoperfusion
Shock/Hypoperfusion

Attempt
Attempt to
to Identify
Identify the
the Cause
Cause
Implement
ImplementCause-Specific
Cause-Specifictreatments,
treatments,ififapplicable
applicable

Asymptomatic
Asymptomatic Bradycardia
Bradycardia

Primary
PrimaryABCD
ABCD --Assess
Assess &
&Treat
Treat Initially
Initially
Secondary
SecondaryABCD
ABCD -- Reassess
Reassess &
& Further
FurtherTreatmt
Treatmt
IV/O
IV/O22/ECG
/ECGMonitor/12
Monitor/12lead
leadECG
ECG
Differential
DifferentialDiagnosis
Diagnosis
Treat
Treatthe
thecause
cause

IF
IF 2
2 or
or 33 AVB,
AVB, then
then
Place
PlaceTCP
TCPin
instandby
standbymode
mode

Symptomatic
Symptomatic Bradycardia
Bradycardia

Primary
PrimaryABCD
ABCD --Assess
Assess &
&Treat
Treat Initially
Initially
Secondary
SecondaryABCD
ABCD -- Reassess
Reassess &
&Further
FurtherTreatmt
Treatmt
IV/O
IV/O22/ECG
/ECGMonitor/12
Monitor/12lead
leadECG
ECG
Differential
DifferentialDiagnosis
Diagnosis

Cause
Causespecific
specifictreatment,
treatment,ififapplicable
applicable

Atropine
Atropine0.5
0.5mg
mgIV
IVqq3-5
3-5min,
min,max
max0.04
0.04mg/kg
mg/kg
TCP
TCP
Dopamine
Dopamine5520
20mcg/kg/min
mcg/kg/min
Epinephrine
Epinephrine2-10
2-10mcg/min
mcg/min
Isoproterenol
Isoproterenol2-10
2-10mcg/min
mcg/min

Sinus
Sinus Bradycardia
Bradycardia
What
What cause-specific
cause-specific treatments
treatments can
can you
you think
think of
of
when
when Sinus
Sinus Brady
Brady isis caused
caused by:
by:
Excessive
Excessiveparasympathetic
parasympathetictone
toneon
onSA
SAnode?
node?
Decrease
Decreasein
insympathetic
sympathetictone
toneon
onSA
SAnode?
node?
Administration
Administrationof
ofcalcium
calciumchannel
channelblockers?
blockers?
Digitalis
Digitalistoxicity?
toxicity?
Disease
Diseaseof
ofthe
theSA
SAnode?
node?
Acute
Acuteinferior
inferiorMI?
MI?
Hypothyroidism?
Hypothyroidism?Hypothermia?
Hypothermia? Hypoxia?
Hypoxia?

Bradycardia
Bradycardia
What
What isis the
the difference
difference between
between absolute
absolute
and
and relative
relative bradycardia?
bradycardia?

Sinus
Sinus Tachycardia
Tachycardia
Characteristics
Characteristics
Essentially
Essentially same
same as
as for
for NSR
NSR with
with ONE
ONE
exception
exception
HR
HR>>100
100bpm
bpm<150
<150

At
At very
very fast
fast rates,
rates,difficult
difficult to
to see
seePPwaves
waves
In
In adults,
adults, ST
STisis generally
generally limited
limited to
to aa rate
rate of
of
<150
<150 bpm
bpm

Analyze
Analyze the
the Rhythm
Rhythm

Sinus
Sinus Tachycardia
Tachycardia
Pathophysiology
Pathophysiology
Generally
Generallyaaresult
resultof
ofsome
someother
othercause
cause

Intake
Intakeof
ofstimulants
stimulants
Increase
Increasecirculating
circulatingcatecholamines
catecholamines&&sympathetic
sympathetictone
tone
Anticholinergic
Anticholinergicor
orsympathomimetic
sympathomimeticdrug
drug
Hypoxia
Hypoxia(CHF,
(CHF,PE,
PE,etc)
etc)
Myocardial
Myocardialischemia
ischemia
Fever
Fever
Thyrotoxicosis
Thyrotoxicosis
Anemia/Hypovolemia/Hypotension/Shock
Anemia/Hypovolemia/Hypotension/Shock

Sinus
Sinus Tachycardia
Tachycardia
Symptomatic
Symptomatic Presentation
Presentation
Variable
Variable
May
Mayresult
resultin
in

Worsening
Worseninghemodynamic
hemodynamicinstability
instability
Dysrhythmias
Dysrhythmias
Worsening
Worseningmyocardial
myocardialischemia
ischemia

Sinus
Sinus Tachycardia
Tachycardia
Management
Management
First
First Steps
Steps after
afterABCDs
ABCDs
Attempt
Attempt to
to Identify
Identify the
the Cause
Cause
Treat
Treatthe
theUnderlying
UnderlyingCause!!!
Cause!!!

Occasionally
Occasionally requires
requires treatment
treatment
Beta
Betablockers
blockers
Calcium
Calciumchannel
channelblockers
blockers

Sinus
Sinus Arrhythmia
Arrhythmia
Characteristics
Characteristics
Same
Sameas
asNSR
NSRexcept
exceptfor:
for:

Rate:
Rate:60-100
60-100bpm,
bpm,may
maybe
beslightly
slightlyfaster
fasteror
orslower
slower
R-R
R-Rinterval:
interval:irregular
irregular

Analyze
Analyze the
the Rhythm
Rhythm

Sinus
Sinus Arrhythmia
Arrhythmia
Pathophysiology
Pathophysiology
Most
Mostoften
oftenrelated
relatedto
toventilations
ventilations

decreased
decreasedvagal
vagaltone
toneduring
duringinspiration
inspirationcausing
causingHR
HRtotoincrease
increase
increased
increasedvagal
vagaltone
toneduring
duringexpiration
expirationcausing
causingHR
HRtotodecrease
decrease

Most
Mostcommon
commonin
inchildren,
children,young
youngadults
adultsand
andphysically
physically
conditioned
conditioned
May
Maybe
beother
othercauses
causes
heart
heartdisease
disease
drug
drugrelated
related

Sinus
Sinus Arrhythmia
Arrhythmia
Presentation
Presentation
Usually
Usually no
no clinical
clinical significance
significance
Does
Does not
not require
require treatment
treatment
Symptoms
Symptoms may
may occur
occur ifif sinus
sinus arrhythmia
arrhythmia
results
results in
in bradycardia
bradycardia
Management
Management
Treat
Treat the
the patient!
patient!

Sinus
Sinus Arrest
Arrest
Characteristics
Characteristics
May
Maysimply
simplybe
bean
anaddition
additionto
toan
anunderlying
underlyingrhythm
rhythm
e.g.
e.g.NSR
NSRwith
withepisodes
episodesof
ofsinus
sinusarrest
arrest

Same
Sameas
asNSR
NSRwith
withthese
theseexceptions:
exceptions:

Rate:
Rate: Usually
Usually60-100
60-100bpm
bpmbut
butmay
maybe
beless
lessthan
than60
60bpm
bpm
Rhythm:
Rhythm:irregular
irregular
R-R
R-Rinterval:
interval:not
notall
allequal
equalwhen
whensinus
sinusarrest
arrestoccurs
occurs

Appears
Appearsas
asaasinus
sinusrhythm
rhythmwith
withunexpected
unexpectedepisodes
episodesof
of
no
noconduction
conduction
No
NoPPwave;
wave;QRS
QRSmay
mayonly
onlyresult
resultfrom
fromectopic
ectopiccomplex
complex

Analyze
Analyze the
the Rhythm
Rhythm

Sinus
Sinus Arrest
Arrest
Pathophysiology
Pathophysiology
Depression
Depressionin
inthe
theautomaticity
automaticityof
ofthe
theSA
SAnode,
node,or
or
Block
Blockin
inthe
theconduction
conductionpathways
pathwaysfrom
fromSA
SAnode
nodeinto
into
atria
atria
Often
Oftenprecipitated
precipitatedby:
by:
Increase
Increaseininvagal
vagaltone
tone
Hypoxia
Hypoxia
Hyperkalemia
Hyperkalemia
Excessive
Excessivedrugs:
drugs:digitalis,
digitalis,beta
betablockers,
blockers,quinidine
quinidine
SA
SANode
Nodeischemia
ischemiaor
orSick
SickSinus
SinusSyndrome
Syndrome

Sinus
Sinus Arrest
Arrest
Presentation
Presentation
Transient
Transientepisodes
episodesmay
mayno
noclinical
clinicalmanifestation
manifestationor
or
significance
significance
Alternative
Alternativepacemaker
pacemakersite
siteshould
shouldtake
takeover
overto
toprevent
prevent
extreme
extremebradycardia
bradycardia
Symptoms
Symptomsmost
mostlikely
likelyififepisodes
episodesprogress
progressto
to
prolonged
prolongedsinus
sinusarrest
arrestresulting
resultingin
inbradycardia
bradycardia

Sinus
Sinus Arrest
Arrest
Management
Management
Treat
Treatlike
likeBradycardia
Bradycardia