Huszar's Basic Dysrhythmias and Acute Coronary

Syndromes: Interpretation & Management

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 Contents
1 ANATOMY AND PHYSIOLOGY OF 14 PACEMAKER AND IMPLANTABLE
THE HEART 1 DEFIBRILLATOR RHYTHMS 226

2 THE ELECTROCARDIOGRAM: BASIC 15 OTHER ASSORTED ECG FINDINGS 236

COMPONENTS AND LEAD MONITORING 17
16 ACUTE CORONARY SYNDROME—
3 COMPONENTS OF THE PATHOPHYSIOLOGY 257
ELECTROCARDIOGRAM 27
17 DIAGNOSTIC ECG CHANGES IN SPECIFIC
4 EIGHT STEPS TO ECG INTERPRETATION MYOCARDIAL INFARCTIONS 283
AND ANALYSIS 53
18 SIGNS, SYMPTOMS, AND DIAGNOSIS OF
5 SINUS NODE DYSRHYTHMIAS 79 ACUTE CORONARY SYNDROMES 307

6 ATRIAL DYSRHYTHMIAS 90 19 MANAGEMENT OF ACUTE CORONARY

SYNDROMES 321
7 JUNCTIONAL DYSRHYTHMIAS 106
Appendix A: Methods of Determining the
8 VENTRICULAR DYSRHYTHMIAS 117 QRS Axis 337

9 ATRIOVENTRICULAR BLOCKS 135 Appendix B: Chapter Review Answer Keys 350

10 CLINICAL SIGNIFICANCE AND Appendix C: Dysrhythmia Interpretation:

TREATMENT OF DYSRHYTHMIAS 148 Self-Assessment 359

11 THE 12-LEAD ELECTROCARDIOGRAM 180 Appendix D: Self-Assessment Answer Keys 427

12 ELECTRICAL AXES AND VECTORS 191 Glossary 445

13 BUNDLE BRANCH AND FASCICULAR Index 447

BLOCKS 207
i
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 Keith Wesley, MD
Medical Director
HealthEast Medical Transportation
St. Paul, Minnesota

Medical Director
United EMS
Wisconsin Rapids, Wisconsin

Medical Director
Chippewa Fire District
Chippewa Falls, Wisconsin
3251 Riverport Lane
St. Louis, Missouri 63043

HUSZAR’S BASIC DYSRHYTHMIAS: INTERPRETATION ISBN: 978-0-323-03974-1

AND MANAGEMENT, FOURTH EDITION
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 Dedication

This book is dedicated to my wife Karen and three sons JT,

Austin, and Camden.

Without your love, confidence, and patience, I could not have

pursued my dream.

I love you.

It is with great gratitude and humility that I continue Dr.

Huszar’s legacy of this wonderful text.

Keith Wesley, MD

v
 About the Author

Keith Wesley is a board-certified emergency medicine physician In 2008, Dr. Wesley moved his practice to Minnesota when
living in Wisconsin. Originally from Tyler, Texas, he graduated he accepted the position as the Minnesota State EMS Medical
from Brigham Young University in 1982 and Baylor College of Director. He currently works for HealthEast Care Systems in
Medicine in Houston, Texas in 1986. He completed an Emerg- St. Paul, where he is the EMS Medical Director for HealthEast
ency Medicine Residency at Methodist Hospital in Indianapo- Medical Transportation.
lis, Indiana, where he gained his first exposure to EMS flying Dr. Wesley is a former chair of the National Council of State
air medical missions. EMS Medical Directors and is active in the National Association
Dr. Wesley has been involved in EMS since 1989, working of EMS Physicians. Dr. Wesley has co-authored four textbooks
with many services in Wisconsin. In 1992, he was selected by and numerous articles and papers and is a frequent speaker at
the Governor as a founding member of the Wisconsin State state and national conferences. He is currently on the editorial
Physician Advisory Committee and served for 12 years, the board for JEMS magazine.
last 4 years as Chair. In 2006, Dr. Wesley was selected as the An active member of the American College of Emergency
Wisconsin State EMS Medical Director and continues to Physicians and the National Association of EMS Physicians,
provide medical oversight to several services throughout Dr. Wesley has been actively involved in the creation of educa-
Wisconsin. tional programs for medical and nursing students, EMTs, and
From 1992 to 2004, Dr. Wesley was a Clinical Assistant physicians.
Professor, University of Wisconsin Family Practice Residency, When not engaged in EMS duties, Dr. Wesley enjoys sailing
Eau Claire, Wisconsin responsible for the training and education on Lake Superior with his wife Karen and spending time with
of family practice residents rotating through the emergency his three sons.
department. During the same period, Dr. Wesley was an ACLS
instructor overseeing the courses throughout south central
Wisconsin.

vi
Acknowledgments

First, I would like to thank the dedicated men and women of

my EMS services who provided me encouragement, criticism,
and reams of rhythms strips and 12 leads. They include
HealthEast Medical Transportation, Chippewa Fire District,
Higgins Ambulance, and the EMT-Basic services of Ashland
and Bayfield Counties.
Next, I must acknowledge the successful foundation upon
which this book is based. Dr. Huszar expertly crafted this text in
three previous editions. To be given the opportunity to carry on
where this great man left off is an honor.
Finally, no author can accomplish anything without an
editor. I have been most fortunate to have not one but two
excellent editors with Laura Bayless and Andrea Campbell.
Thank you both for the encouragement to make this project a
success. Also, I’d like to thank Linda Honeycutt for giving me
this opportunity and her tireless support.

Keith Wesley, MD

vii
 Publisher Acknowledgments

The editors wish to acknowledge the reviewers of the fourth Ronald N. Roth, MD, FACEP
edition of this book for their invaluable assistance in developing Professor of Emergency Medicine
and fine-tuning this manuscript. University of Pittsburgh, School of Medicine
Medical Director, City of Pittsburgh
Janet Fitts, RN, BSN, CEN, TNS, EMT-P Department of Public Safety
Owner/Educational Consultant Pittsburgh, Pennsylvania
Prehospital Emergency Medical Education
Pacific, Missouri Lynn Pierzchalski-Goldstein, PharmD
Paramedic/Training Officer Clinical Coordinator
New Haven Ambulance District Penrose St Francis Health System
New Haven, Missouri Colorado Springs, Colorado

Mark Goldstein, RN, MSN, EMT-P I/C David L. Sullivan, PhD, NREMT-P
Emergency Services Operations Manager Program Director
Memorial Health System–Emergency & Trauma Center Emergency Medical Services–Continuing Medical Education
Colorado Springs, Colorado St. Petersburg College–Health Education Center
Pinellas Park, Florida
Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT
Lead Instructor Gilbert N. Taylor FF/NREMT-P,I/C
Wilderness Medical Associates Fire Investigator
Flight Paramedic Bourne Fire and Rescue
Spirit MTS, St. Joseph’s Hospital Bourne, Massachusetts
Marshfield, Wisconsin
Our continued thanks also go out to the previous edition
Robert L. Jackson, Jr., BA, MAPS, MAR, NREMT-P, reviewers, whose hard work continues to contribute to the
CCEMT-P ongoing success of this book: Robert Carter, Robert Cook,
Paramedic Robert Elling, Timothy Frank, Glen A. Hoffman, Kevin B.
University of Missouri Healthcare Kraus, Mikel Rothenburg, Judith Ruple, Ronald D. Taylor, Glen
Columbia, Missouri Treankler, and Andrew W. Stern.

viii
 Preface

This text was written to teach medical, nursing, and EMS pro- Throughout the text, the student will encounter text con-
viders the basic skills in cardiac dysrhythmia interpretation. tained in boxes that provides particularly important informa-
Once this is accomplished, the student discovers advanced tion. They include:
instruction in the clinical signs, symptoms, and management of
patients presenting with cardiac dysrhythmias. Key Point
With the advent of ECG monitoring has come readily acces- These contain a summary of the most important information
sible 12-lead electrocardiography, an essential tool in the detec- presented on the associated text.
tion and management of acute coronary syndromes. It is for that
reason that this edition has added several chapters dedicated Author Notes
to 12-lead ECG interpretation. Following these, the student is These contain information related to how the information is
provided an in-depth review of the pathophysiology, clini- being presented and how it may differ from other text. This
cal signs and symptoms, and management of acute coronary information is provided to ensure that the student clearly
syndromes. understands the conventions used by the author.
The amount of anatomy, physiology, and pathophysiology
has been significantly increased from previous versions to bet- Clinical Notes
ter enable the student to develop a more comprehensive under- These contain information related specifically to the medical
standing of the cause of particular dysrhythmias and coronary diagnosis and management of a particular condition.
syndromes. This knowledge provides the student additional
tools to accurately interpret and manage the presented dys- Key Definition
rhythmias and conditions. These contain an extensive definition of a particular term dis-
Each dysrhythmia is presented in its “classic,” form with cussed in the text. A full glossary is enclosed in the back of the
an associated table listing its unique characteristics. These ta- text; however, these Key Definitions will elaborate on the rele-
bles can be used as a quick reference. The accompanying text vant term
contains a more detailed and extensive discussion of these
characteristics. Chapter summary questions covering the major points are
The majority of rhythm strips are from real patients and will presented and, in combination with the self-assessment ques-
not always include all of the “classic” characteristics described tions in Appendix C, provide the student additional practice in
in the text. This is the challenge of ECG dysrhythmia interpreta- ECG interpretation intended to increase competency. For those
tion, and the student should take this into consideration when particularly interested in ECG axis interpretation, Appendix A
examining any rhythm strip. provides an extensive review of the subject.
The treatment algorithms are based on the latest informa- Each chapter builds on the points and interpretation skills
tion from the American Heart Association and the American previously presented, and by moving sequentially through
College of Cardiology recommendations. However, because the them, each the student will have all the information they need
science continues to evolve and local policy and protocol may to intelligently interpret ECG dysrhythmias and 12-lead ECGs,
vary, the student should remain abreast of new treatments and and develop a clinically sound management plan.
consult local medical experts to ensure that their treatment re- Welcome to this exciting, critical, and sometimes challeng-
mains current. ing subject.

Keith Wesley, MD

ix
 Foreword

This 2010 edition of Drs. Wesley and Huszar’s Basic Dysrhyth- algorithms are a translational toolkit for emergency medical
mias and Acute Coronary Syndromes: Interpretation and Man- technicians, paramedics, nursing student and nurses, medical
agement marks the 109th year since the technique known as students, and physicians. They provide a means to learn at one’s
electrocardiography was first reported by the eminent Dutch own pace and then deliver care based on a solid understand-
physiologist William Einthoven. With this fundamental discov- ing of the essentials of cardiac pathophysiology, especially in
ery came a new methodology that has forever changed the face the acute care setting. This book is particularly helpful for the
of medicine and guided the care of patients with heart disease, new clinician: it helps take the fear out of treating patients with
especially those with acute cardiac pathology. Given that the life-threatening cardiac abnormalities and empowers them by
correct interpretation of an electrocardiogram provides a non- providing the tools for action.
invasive legend to diagnosing and treating heart rhythm disor- Finally it is important to re-emphasize that, although Basic
ders and acute coronary syndromes, it is critical that all clinicians Dysrhythmias and Acute Coronary Syndromes is encyclopedic
who care for patients with the potential for cardiac disease in size and content, it is organized in a way such that it can
feel comfortable knowing how to understand and use this vital be used on the job in the emergency department, on the
tool. telemetry wards, in an intensive care unit, or on the street in
In the span of a little over a century since the ECG was in- the back of an ambulance. When taking care of a patient with a
troduced, the squiggly lines of print on a piece of paper have dysrhythmia or acute infarction, the clinician can see this text
become a clinical guide and call to action. Knowing how to in- as a blueprint and will not need to look beyond it for complete
terpret this code and what to do with the correct interpretation guidance.
requires knowledge and practice. This new edition provides this As you turn the pages of this book as a reference or use it to
comprehensive information in a concise and straightforward learn the essentials of cardiac care, I hope you enjoy this learning
manner. Each chapter is user-friendly and provides state-of-the process. We are living in an extraordinary age in medicine and
art information. Dr. Wesley is an emergency department physi- the teaching messages in this text reflect the incredible prog-
cian, EMS Medical Director with decades of clinical experience, ress over the past century. From the first ECG tracings reported
and a skilled writer and educator. He has supplemented the at the beginning of the 20th century, we now have the clinical
previous edition with up-to-date information, especially in the tools to transform the information from an ECG into definitive
area of the treatment of acute coronary syndromes and cardiac and life-saving care. That translational process is dynamic: this
arrest. The text is easy to read, the figures are refreshing and easy text provides the key up-to-date pathways to successfully treat
to understand, and each section contains a self-assessment test patients and save lives based on the widespread use of cardiac
to help reinforce the key messages. electrogram. I encourage you to use it as a vital resource.
This book builds on the adage that knowledge is power:
this book provides knowledge that can be life-saving. Rooted Keith Lurie, MD
upon the foundation of vector cardiography and electrophysi- Cardiac electrophysiologist
ology that forms the geometric and physiological underpin- Professor of Emergency and Internal Medicine
nings of ECG analysis and understanding, the chapters on ECG University of Minnesota
interpretation, pacemakers and defibrillators, and treatment Minneapolis, Minnesota

x
Publisher’s Note

The author and publisher have made every attempt to check

dosages and advanced life support content for accuracy. The
care procedures presented here represent accepted practices in
the United States. They are not offered as a standard of care.
Advanced life support–level emergency care is performed under
the authority of a licensed physician. It is the student’s respon-
sibility to know and follow local care protocols as provided by
his or her medical advisors. It is also the student’s responsibility
to stay informed of emergency care procedure changes, includ-
ing the most recent guidelines set forth by the American Heart
Association and printed in their textbooks.

xi
 Contents

1 ANATOMY AND PHYSIOLOGY OF Acquiring a Quality ECG 25

THE HEART 1 Artifacts 25
ANATOMY AND PHYSIOLOGY OF THE HEART 2 QRS Size and Wandering Baseline 25
Anatomy of the Heart 2
Circulation of the Blood Through the Heart 2 3 COMPONENTS OF THE
Atrial and Ventricular Diastole and Systole 3 ELECTROCARDIOGRAM 27
ELECTRICAL CONDUCTION SYSTEM OF THE HEART 4 WAVES 28
Accessory Conduction Pathways 5 P Wave 28
Accessory Atrioventricular Pathways 5 Normal Sinus P Wave 28
Atrio-His Fibers 7 Characteristics 28
Nodoventricular/Fasciculoventricular Fibers 7 Description 28
CARDIAC CELLS 7 Significance 28
ELECTROPHYSIOLOGY OF THE HEART 8 Abnormal Sinus P Wave 28
Resting State of the Cardiac Cell 8 Characteristics 28
Depolarization and Repolarization 8 Description 28
Threshold Potential 9 Significance 31
Cardiac Action Potential 10 Ectopic P Wave “P Prime” or “P ′” 31
Refractory Periods 10 Characteristics 31
Dominant and Escape Pacemakers of the Heart 11 Description 31
Mechanisms of Abnormal Electrical Impulse Significance 33
Formation 12 QRS Complex 33
Enhanced Automaticity 12 Normal QRS Complex 33
Reentry 12 Characteristics 33
Triggered Activity 14 Description 33
AUTONOMIC NERVOUS SYSTEM CONTROL Significance 36
OF THE HEART 14 Abnormal QRS Complex 36
Characteristics 36
2 THE ELECTROCARDIOGRAM: BASIC Description 38
CONCEPTS AND LEAD MONITORING 17 Significance 38
BASIC ECG CONCEPTS 17 T Wave 38
Electrical Basis of the ECG 17 Normal T Wave 39
ECG Paper 17 Characteristics 39
BASIC COMPONENTS OF THE NORMAL ECG 19 Description 39
ECG LEADS 20 Significance 40
The Basics of ECG Leads 20 Abnormal T Wave 40
Bipolar Leads 20 Characteristics 40
Monitoring Lead II 20 Description 40
Monitoring Leads I and III 21 Significance 40
Modified Chest Leads (MCL) 23 U Wave 40
Monitoring Lead MCL1 23 Characteristics 40
Monitoring Lead MCL6 23 Description 40
Unipolar Leads 24 Significance 40

xii
 Contents xiii

INTERVALS 42 STEP FIVE: IDENTIFY AND ANALYZE THE QRS

PR Interval 42 COMPLEXES 73
Normal PR Interval 42 STEP SIX: DETERMINE THE SITE OF ORIGIN OF THE
Characteristics 42 DYSRHYTHMIA 73
Description 42 STEP SEVEN: IDENTIFY THE DYSRHYTHMIA 77
Significance 42 STEP EIGHT: EVALUATE THE SIGNIFICANCE OF THE
Abnormal PR Interval 42 DYSRHYTHMIA 77
Characteristics 42
Description 43 5 SINUS NODE DYSRHYTHMIAS 79
Significance 45 NORMAL SINUS RHYTHM 79
QT Interval 45 Diagnostic Characteristics 79
Characteristics 45 Clinical Significance 81
Description 46 SINUS ARRHYTHMIA 81
Significance 46 Diagnostic Characteristics 81
R-R Interval 46 Cause of Dysrhythmia 82
Characteristics 46 Clinical Significance 82
Description 46 SINUS BRADYCARDIA 82
Significance 47 Diagnostic Characteristics 82
SEGMENTS 47 Cause of Dysrhythmia 82
TP Segment 47 Clinical Significance 83
Characteristics 47 SINUS ARREST AND SINOATRIAL EXIT BLOCK 84
Description 47 Diagnostic Characteristics 84
Significance 48 Cause of Dysrhythmia 84
PR Segment 48 Clinical Significance 86
Characteristics 48 SINUS TACHYCARDIA 86
Description 48 Diagnostic Characteristics 86
Significance 48 Cause of Dysrhythmia 86
ST Segment 48 Clinical Significance 86
Normal ST Segment 48
Characteristics 48 6 ATRIAL DYSRHYTHMIAS 90
Description 48 WANDERING ATRIAL PACEMAKER 90
Significance 48 Diagnostic Characteristics 90
Abnormal ST Segment 48 Cause of Dysrhythmia 92
Characteristics 48 Clinical Significance 92
Description 48 PREMATURE ATRIAL COMPLEXES 92
Significance 51 Diagnostic Characteristics 92
Cause of Dysrhythmia 95
4 EIGHT STEPS TO ECG INTERPRETATION Clinical Significance 95
AND ANALYSIS 53 ATRIAL TACHYCARDIA (ECTOPIC AND MULTIFOCAL) 95
SYSTEMATIC APPROACH TO ECG ANALYSIS 54 Diagnostic Characteristics 95
STEP ONE: DETERMINE THE HEART RATE 54 Cause of Dysrhythmia 97
The 6-Second Count Method 55 Clinical Significance 97
The Heart Rate Calculator Ruler Method 55 ATRIAL FLUTTER 98
The R-R Interval Method 55 Diagnostic Characteristics 98
Method 1 55 Cause of Dysrhythmia 101
Method 2 58 Clinical Significance 101
Method 3 58 ATRIAL FIBRILLATION 101
Method 4 58 Diagnostic Characteristics 101
The Rule of 300 59 Cause of Dysrhythmia 104
STEP TWO: DETERMINE REGULARITY 61 Clinical Significance 104
Regular 61
Irregular 61 7 JUNCTIONAL DYSRHYTHMIAS 106
STEP THREE: IDENTIFY AND ANALYZE THE P, PREMATURE JUNCTIONAL COMPLEXES 106
P′, F, OR F WAVES 63 Diagnostic Characteristics 106
STEP FOUR: DETERMINE THE PR OR RP′ INTERVALS Cause of Dysrhythmia 108
AND ATRIOVENTRICULAR CONDUCTION RATIO 68 Clinical Significance 109
xiv Contents

JUNCTIONAL ESCAPE RHYTHM 109 SECOND-DEGREE, TYPE I AV BLOCK (WENCKEBACH) 137

Diagnostic Characteristics 109 Diagnostic Characteristics 137
Cause of Dysrhythmia 109 Cause of Dysrhythmia 139
Clinical Significance 110 Clinical Significance 139
NONPAROXYSMAL JUNCTIONAL TACHYCARDIA SECOND-DEGREE, TYPE II AV BLOCK 139
(ACCELERATED JUNCTIONAL RHYTHM, Diagnostic Characteristics 139
JUNCTIONAL TACHYCARDIA) 110 Cause of Dysrhythmia 139
Diagnostic Characteristics 111 Clinical Significance 141
Cause of Dysrhythmia 111 SECOND-DEGREE 2:1 AND ADVANCED AV BLOCK 141
Clinical Significance 111 Diagnostic Characteristics 141
PAROXYSMAL SUPRAVENTRICULAR Cause of Dysrhythmia 141
TACHYCARDIA 113 Wide (>0.12 second) QRS Complex 142
Diagnostic Characteristics 113 Clinical Significance 142
Cause of Dysrhythmia 113 THIRD-DEGREE AV BLOCK (COMPLETE AV BLOCK) 143
Clinical Significance 113 Diagnostic Characteristics 143
Cause of Dysrhythmia 143
Clinical Significance 145

8 VENTRICULAR DYSRHYTHMIAS 117 10 CLINICAL SIGNIFICANCE AND

PREMATURE VENTRICULAR COMPLEXES 117 TREATMENT OF DYSRHYTHMIAS 148
Diagnostic Characteristics 117 PART 1 148
Cause of Dysrhythmia 121 ASSESSING THE PATIENT 148
Clinical Significance 121 Stable Versus Unstable 148
VENTRICULAR TACHYCARDIA 121 TREATING THE PATIENT 150
Diagnostic Characteristics 121 Electrical Therapy 150
Differentiating Ventricular Tachycardia from Cardioversion and Defibrillation 150
Supraventricular Tachycardia with Wide Sedation 150
QRS Complex 123 Transcutaneous Pacing 151
Cause of Dysrhythmia 123 Pharmacologic Therapy 151
Clinical Significance 124 Atropine Sulfate 151
VENTRICULAR FIBRILLATION 125 Vasopressors 151
Diagnostic Characteristics 125 Antidysrhythmics 152
Cause of Dysrhythmia 126 Calcium Channel Blockers: Diltiazem and
Clinical Significance 127 Verapamil 153
ACCELERATED IDIOVENTRICULAR RHYTHM Beta-Adrenergic Blockers 154
(ACCELERATED VENTRICULAR RHYTHM, Oxygen 154
IDIOVENTRICULAR TACHYCARDIA, SLOW BRADYCARDIAS 154
VENTRICULAR TACHYCARDIA) 128 Clinical Significance of Bradycardias 154
Diagnostic Characteristics 128 Indications for Treatment of Bradycardias 154
Cause of Dysrhythmia 128 Sinus Bradycardia 155
Clinical Significance 129 Sinus Arrest/SA Exit Block 155
VENTRICULAR ESCAPE RHYTHM First-Degree AV Block 155
(IDIOVENTRICULAR RHYTHM) 131 Second-Degree, Type I AV Block (Wenckebach) 155
Diagnostic Characteristics 131 Second Degree, 2:1 and Advanced AV block with
Cause of Dysrhythmia 131 Narrow QRS Complexes 155
Clinical Significance 131 Third-Degree AV Block with Narrow QRS
ASYSTOLE 131 Complexes 155
Diagnostic Characteristics 133 Second-Degree, Type II AV Block 155
Cause of Dysrhythmia 133 Second-Degree, 2:1 with Advanced AV Block
Clinical Significance 133 with Wide QRS Complexes 155
Third-Degree AV Block with Wide QRS Complexes 155
9 ATRIOVENTRICULAR BLOCKS 135 Junctional Escape Rhythm 155
FIRST-DEGREE AV BLOCK 135 Ventricular Escape Rhythm 155
Diagnostic Characteristics 135 TACHYCARDIAS 155
Cause of Dysrhythmia 137 Clinical Significance of Tachycardias 155
Clinical Significance 137 Indications for Treatment of Tachycardias 156
 Contents xv

Sinus Tachycardia 156 SUMMARY OF DYSRHYTHMIA TREATMENT 166

Atrial Tachycardia with Block 156 Part I 166
Narrow-QRS-Complex Tachycardia of Unknown Part II 167
Origin (With Pulse) 156 Drugs Used to Treat Dysrhythmias 167
Atrial Tachycardia Without Block 157 DYSRHYTHMIA TREATMENT ALGORITHMS 168
Paroxysmal Supraventricular Tachycardia with Part I 168
Narrow QRS Complexes (Without Part II 177
Wolff-Parkinson-White Syndrome or
Ventricular Preexcitation) 157 11 THE 12-LEAD ELECTROCARDIOGRAM 180
Junctional Tachycardia 158 THE 12-LEAD ECG 180
Atrial Flutter/Atrial Fibrillation (Without THE 12-LEAD ECG LEADS 180
Wolff-Parkinson-White Syndrome or Unipolar Leads 181
Ventricular Preexcitation) 158 Lead Axis 181
Atrial Flutter/Atrial Fibrillation (With Frontal and Horizontal Planes 181
Wolff-Parkinson-White Syndrome or Standard (Bipolar) Limb Leads 181
Ventricular Preexcitation) 159 Augmented (Unipolar) Leads 185
Wide-QRS-Complex Tachycardia of Unknown Precordial (Unipolar) Leads 186
Origin (With Pulse) 159 Right-Sided Chest Leads 186
Ventricular Tachycardia, Monomorphic Facing Leads 189
(With Pulse) 159
Ventricular Tachycardia, Polymorphic 12 ELECTRICAL AXES AND VECTORS 191
(With Pulse) 160 ELECTRICAL AXIS AND VECTORS 191
Normal Baseline QT Interval 160 THE ELECTRICAL CURRENT, VECTORS, AND
Ventricular Tachycardia, Polymorphic (With Pulse) 160 THE LEAD AXIS 192
Prolonged Baseline QT Interval Torsades de THE HEXAXIAL REFERENCE FIGURE 193
Pointes (TdP) (With Pulse) 161 THE QRS AXIS 196
PREMATURE ECTOPIC BEATS 162 Determining the QRS Axis 198
Premature Atrial Complexes 162 Emergent Method 198
Clinical Significance 162 Steps in Determining an Accurate QRS Axis 203
Indications for Treatment 162 Step 1 203
Premature Junctional Complexes 162 Step 2 203
Clinical Significance 162 Lead II 203
Indications for Treatment 162 Lead aVF 204
Premature Ventricular Complexes 162 Lead III 204
Clinical Significance 162 Step 3 204
Indications for Treatment 162 Lead II 204
PART II 163 Lead aVF 205
CARDIAC ARREST 163 Lead III 205
Clinical Significance 163 Lead aVR 205
Indications for Treatment 163
Treatment 163 13 BUNDLE BRANCH AND FASCICULAR
AYSTOLE 163 BLOCKS 207
Clinical Significance 163 ANATOMY AND PHYSIOLOGY OF THE ELECTRICAL
Indications for Treatment 163 CONDUCTION SYSTEM 208
Treatment 163 Anatomy of the Electrical Conduction System 208
PULSELESS ELECTRICAL ACTIVITY 164 Blood Supply to the Electrical Conduction
Clinical Significance 164 System 208
Indications for Treatment 164 Physiology of the Electrical Conduction System 209
Treatment 164 PATHOPHYSIOLOGY OF BUNDLE BRANCH AND
POSTRESUSCITATION MANAGEMENT 165 FASCICULAR BLOCKS 211
Airway 165 Causes of Bundle Branch and Fascicular
Circulation 165 Blocks 211
Neurologic 165 Significance of Bundle Branch and Fascicular
Metabolic 165 Blocks 211
Temperature Control 165 Treatment of Bundle Branch and Fascicular
Rate and Rhythm Control 165 Blocks 212
xvi Contents

RIGHT BUNDLE BRANCH BLOCK 212 14 PACEMAKER AND IMPLANTABLE

Pathophysiology of Right Bundle Branch Block 212 DEFIBRILLATOR RHYTHMS 226
Causes of Right Bundle Branch Block 214 PACEMAKERS 226
Significance of Right Bundle Branch Block 214 TYPES OF PACEMAKERS 227
Treatment of Right Bundle Branch Block 214 Fixed-Rate or Demand 227
ECG Characteristics in Right Bundle Branch Block 214 Single-Chamber and Dual-Chambered 227
QRS Complexes 214 Single-Chamber Pacemakers 228
Duration 214 Dual-Chambered Pacemakers 229
QRS Axis 214 PACEMAKER RHYTHM 230
Ventricular Activation Time 214 Diagnostic Features 230
ST Segments 215 Clinical Significance 231
T Waves 215 PACEMAKER MALFUNCTION 231
QRS Pattern in Right Bundle Branch Block with IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR
Anteroseptal Myocardial Infarction 216 THERAPY 232
LEFT BUNDLE BRANCH BLOCK 216 ICD Malfunction 233
Pathophysiology of Left Bundle Branch Block 216
Causes of Left Bundle Branch Block 218
ECG Characteristics of Left Bundle Branch Block 218 15 OTHER ASSORTED ECG FINDINGS 236
QRS complexes 218 CHAMBER ENLARGEMENT 237
Duration 218 Pathophysiology 237
QRS Axis 218 Dilatation 237
Ventricular Activation Time 218 Hypertrophy 237
QRS Pattern in Left Bundle Branch Block 218 RIGHT ATRIAL ENLARGEMENT 237
ST Segments 218 Pathophysiology 237
T Waves 218 ECG Characteristics 237
QRS Pattern in Left Bundle Branch Block with P Waves 237
Anteroseptal Myocardial Infarction 219 LEFT ATRIAL ENLARGEMENT 238
HEMIBLOCKS 219 Pathophysiology 238
LEFT ANTERIOR FASCICULAR BLOCK (LEFT ECG Characteristics 238
ANTERIOR HEMIBLOCK) 219 P Waves 238
Pathophysiology of Left Anterior Fascicular RIGHT VENTRICULAR HYPERTROPHY 238
Block 219 Pathophysiology 238
Causes of Left Anterior Fascicular Block 220 ECG Characteristics 239
ECG Characteristics in Left Anterior Fascicular P Waves 239
Block 220 QRS Complexes 239
QRS Complexes 220 ST Segments 239
Duration 220 T Waves 239
QRS Axis 220 LEFT VENTRICULAR HYPERTROPHY 239
QRS Pattern 220 Pathophysiology 239
ST Segments 220 ECG Characteristics 239
T Waves 221 P Waves 239
LEFT POSTERIOR FASCICULAR BLOCK QRS Complexes 239
(LEFT POSTERIOR HEMIBLOCK) 221 ST Segments 242
Pathophysiology of Left Posterior Fascicular T Waves 242
Block 221 Diagnosis of Left Ventricular Hypertrophy 242
Causes of Left Posterior Fascicular Block 221 PERICARDITIS 243
ECG Characteristics in Left Posterior Fascicular Pathophysiology 243
Block 222 ECG Characteristics 244
QRS Complexes 222 PR Intervals 244
Duration 222 QRS Complexes 244
QRS Axis 222 ST Segments 244
QRS Pattern 222 T Waves 244
ST Segments 222 ELECTROLYTE IMBALANCE 245
T Waves 222 Hyperkalemia 245
BIFASCICULAR BLOCKS 222 Pathophysiology 245
INTRAVENTRICULAR CONDUCTION DELAY 222 ECG Characteristics 245
 Contents xvii

P Waves 245 QRS Axis 250

PR Intervals 245 ST Segments/T Waves 250
QRS Complexes 245 CHRONIC COR PULMONALE 250
ST Segments 245 Pathophysiology 250
T Waves 245 ECG Characteristics 252
QT Interval 245 P Waves 252
Hypokalemia 245 QRS Complexes 252
Pathophysiology 245 QRS Axis 252
ECG Characteristics 246 ST Segments/T Waves 252
P Waves 246 EARLY REPOLARIZATION 252
QRS Complexes 246 Pathophysiology 252
ST Segments 246 ECG Characteristics 252
T Waves 246 QRS Complexes 252
U Waves 246 ST Segments 252
QT Intervals 246 T Waves 252
Hyper Calcemia 246 HYPOTHERMIA 252
Pathophysiology 246 Pathophysiology 252
ECG Characteristics 246 ECG Characteristics 253
QT Intervals 246 PR Intervals 253
Hypocalcemia 248 QRS Complexes 253
Pathophysiology 248 QT Interval 253
ECG Characteristics 248 Osborn Wave 253
ST Segments 248 PREEXCITATION SYNDROMES 253
QT Intervals 248 Pathophysiology 253
DRUG EFFECTS 248 ECG Characteristics 254
Digitalis 248 Ventricular Preexcitation (Accessory AV
Pathophysiology 248 Pathways) 254
ECG Characteristics 248 PR Intervals 254
PR Intervals 248 QRS Complexes 254
ST Segments 248 Atrio-His Preexcitation (Atrio-His Fibers) 254
T Waves 248 PR Intervals 254
QT Intervals 248 QRS Complexes 254
Procainamide 249 Nodoventricular/Fasciculoventricular
Pathophysiology 249 Preexcitation (Nodoventricular/
ECG Characteristics 249 Fasciculoventricular Fibers) 254
QRS Complexes 249 PR Intervals 254
T Waves 249 QRS Complexes 254
PR Intervals 249 Clinical Significance 254
ST Segments 249 BRUGADA SYNDROME 254
QT Intervals 249 Pathophysiology 254
Quinidine 249 ECG Characteristics 254
Pathophysiology 249 QRS Complexes 254
ECG Characteristics 249 ST Segments 254
P Waves 249
QRS Complexes 249
T Waves 249 16 ACUTE CORONARY SYNDROME—
PR Intervals 249 PATHOPHYSIOLOGY 257
ST Segments 249 CORONARY CIRCULATION 259
QT Intervals 249 Left Coronary Artery 259
ACUTE PULMONARY EMBOLISM 250 Right Coronary Artery 260
Pathophysiology 250 Summary 260
Symptoms 250 CORONARY HEART DISEASE 261
Signs 250 Pathophysiology of Coronary Atherosclerosis and
ECG Characteristics 250 Thrombosis 261
P Waves 250 Stable, Vulnerable, and Unstable Plaques 261
QRS Complexes 250 Plaque Erosion and Rupture 262
xviii Contents

THROMBUS FORMATION AND LYSIS 263 ANTERIOR MYOCARDIAL INFARCTION 286

Blood Components 263 Coronary Arteries Involved and Site of Occlusion 286
Platelets 263 Location of Infarct 286
Prothrombin 263 ECG Changes 286
Fibrinogen 264 ANTEROSEPTAL MYOCARDIAL INFARCTION 288
Plasminogen 264 Coronary Arteries Involved and Site of Occlusion 288
Tissue Components 264 Location of Infarct 288
von Willebrand Factor 264 ECG Changes 288
Collagen Fibers 264 LATERAL MYOCARDIAL INFARCTION 290
Tissue Factor 264 Coronary Arteries Involved and Site of Occlusion 290
Tissue Plasminogen Activator 264 Location of Infarct 290
Phases of Thrombus Formation 264 ECG Changes 290
Phase 1: Subendothelial Exposure 264 ANTEROLATERAL MYOCARDIAL INFARCTION 292
Phase 2: Platelet Adhesion 264 Coronary Arteries Involved and Site of Occlusion 292
Phase 3: Platelet Activation 265 Location of Infarct 292
Phase 4: Platelet Aggregation 265 ECG Changes 292
Phase 5: Thrombus Formation 265 EXTENSIVE ANTERIOR MYOCARDIAL INFARCTION 294
Phases of Thrombolysis 265 Coronary Arteries Involved and Site of Occlusion 294
Phase 1: Activation of Intrinsic and Extrinsic Location of Infarct 294
Pathways 265 ECG Changes 294
Phase 2: Plasmin Formation 265 INFERIOR MYOCARDIAL INFARCTION 296
Phase 3: Fibrinolysis 265 Coronary Arteries Involved and Site of Occlusion 296
MYOCARDIAL ISCHEMIA, INJURY, AND INFARCTION 266 Location of Infarct 296
Myocardial Ischemia 266 ECG Changes 296
Myocardial Injury 266 POSTERIOR MYOCARDIAL INFARCTION 298
Myocardial Infarction 267 Coronary Arteries Involved and Site of Occlusion 298
ACUTE CORONARY SYNDROMES 267 Location of Infarct 298
Angina 267 ECG Changes 298
Stable Angina 267 RIGHT VENTRICULAR MYOCARDIAL INFARCTION 300
Unstable Angina 268 Coronary Arteries Involved and Site of Occlusion 300
Acute Myocardial Infarction 268 Location of Infarct 300
ACUTE MYOCARDIAL INFARCTION 268 ECG Changes 300
Anatomic Locations of Myocardial Infarctions 269
The Four Phases of a Transmural Myocardial 18 SIGNS, SYMPTOMS, AND DIAGNOSIS OF
Infarction 269 ACUTE CORONARY SYNDROMES 307
Phase 1 269 INTRODUCTION 308
Phase 2 271 HISTORY TAKING IN SUSPECTED ACUTE CORONARY
Phase 3 271 SYNDROMES 309
Phase 4 272 Chief Complaint 309
ECG Changes in Acute Myocardial Infarction 272 SIGNS AND SYMPTOMS OF ACUTE CORONARY
Ischemic T Waves 273 SYNDROMES 310
ST Segments Changes 275 Symptoms of Acute Coronary Syndromes 310
ST-Segment Elevation 275 General and Neurologic Symptoms 310
ST-Segment Depression 277 Cardiovascular Symptoms 311
Pathologic Q Waves 277 Pain 311
Physiologic Q Waves 277 Palpitations 312
Pathologic Q Waves 278 Respiratory Symptoms 312
Determining the site of a Myocardial Infarction 279 Dyspnea 312
Complications of Acute Myocardial Infarction 279 Cough 313
Wheezing 313
17 DIAGNOSTIC ECG CHANGES IN SPECIFIC Gastrointestinal Symptoms 313
MYOCARDIAL INFARCTIONS 283 Signs of Acute Coronary Syndromes 313
INTRODUCTION 284 General Appearance and Neurologic Signs 313
SEPTAL MYOCARDIAL INFARCTION 284 Vital Signs 313
Coronary Arteries Involved and Site of Occlusion 284 Pulse 313
Location of Infarct 284 Respirations 314
ECG Changes 284 Blood Pressure 314
 Contents xix

Appearance of the Skin 314 MANAGEMENT OF NON–ST-ELEVATION

Appearance of the Veins 314 MYOCARDIAL INFARCTION 327
Cardiovascular Signs 314 ACUTE CORONARY SYNDROME MANAGEMENT
Heart Sounds 314 STRATEGIES 327
Respiratory Signs 315 A. Initial Assessment and Management of
Breath Sounds 315 Patient with Chest Pain Prehospital/
Rales, Rhonchi, and Wheezes 315 Emergency Department 327
Consolidation and Pleural Effusion 316 B. Management of Suspected Acute Coronary
Appearance of Body Tissues 316 Syndrome 327
Edema 316 C. Reperfusion Therapy: STEMI Protocol 328
RISK STRATIFICATION 316 Primary PCI 328
THE 12-LEAD ECG 316 Emergency Department 328
ECG Changes 316 Fibrinolytics 329
ST-Segment Elevation MI 317 Emergency Department 329
Non–ST-Segment Elevation MI 317 D. Management of Congestive Heart Failure 329
CARDIAC MARKERS 317 Prehospital/Emergency Department 329
MAKING THE DIAGNOSIS 318 E. Management of Cardiogenic Shock 330
Prehospital/Emergency Department 330
19 MANAGEMENT OF ACUTE CORONARY Emergency Department 330
SYNDROMES 321 ACUTE CORONARY SYNDROME MANAGEMENT
GOALS IN THE MANAGEMENT OF ACUTE ALGORITHMS 331
CORONARY SYNDROMES 322
Medical Systems: EMS Transport 322 Appendix A: Methods of Determining the
Role of EMS to Meet Goal 322 QRS Axis 337
Prehospital ECG 322
Prehospital Fibrinolytic Administration 323 Appendix B: Chapter Review Questions
STEMI System Design 323 Answer Key 350
Role of Emergency Department to Meet Goal 323
Triage 323 Appendix C: Rhythm Interpretation:
ECG Interpretation 324 Self-Assessment 359
Determination of Appropriate Therapy 324
GOALS IN THE MANAGEMENT OF ST-ELEVATION Appendix D: Self-Assessment Answer Keys 427
MYOCARDIAL INFARCTION 324
REPERFUSION THERAPY: PCI VERSUS Glossary 445
FIBRINOLYTICS 325
MANAGEMENT OF ACUTE ST-ELEVATION Index 477
MYOCARDIAL INFARCTION 326
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1 Anatomy and
Physiology of the Heart

OUTLINE Anatomy and Physiology of the Accessory Atrioventricular Cardiac Action Potential
Heart Pathways Refractory Periods
Anatomy of the Heart Atrio-His Fibers Dominant and Escape
Circulation of the Blood Through Nodoventricular/ Pacemakers of the Heart
the Heart Fasciculoventricular Fibers Mechanisms of Abnormal
Atrial and Ventricular Diastole and Cardiac Cells Electrical Impulse Formation
Systole Electrophysiology of the Heart Autonomic Nervous System
Electrical Conduction System of Resting State of the Cardiac Cell Control of the Heart
the Heart Depolarization and Repolarization
Accessory Conduction Pathways Threshold Potential

OBJECTIVES Upon completion of this chapter, you should be able to:

1. Name and identify the following anatomical features of the heart:
• The right atria, right ventricle, left atria, and left ventricle of the heart
• The three layers of the ventricular walls
• The base and apex of the heart
• The layers of the pericardium and its associated spaces
2. Define the right heart and left heart and the primary function of each with respect to the pulmonary and systemic
circulations.
3. Name and locate on an anatomical drawing the following major structures of the circulatory system:
• The aorta
• The pulmonary artery
• The superior and inferior vena cavae
• The coronary sinus
• The pulmonary veins
• The four heart valves
4. Define the following:
• Atrial systole and diastole
• Ventricular systole and diastole
5. Name and identify the components of the electrical conduction system of the heart.
6. Name the two basic types of cardiac cells and describe their function.
7. List and define the three major types of accessory conduction pathways, including their location, conduction
capabilities, and potential for disrupting normal cardiac function.
8. Name and define the four properties of cardiac cells.
9. Describe the difference between a resting, a polarized, and a depolarized cardiac cell.
10. Define the following:
• Depolarization process
• Repolarization process
• Threshold potential
11. Name and locate on a schematic of a cardiac action potential the five phases of a cardiac potential.