EMS NOTES

"What You Need to Know"

Forrest Munden, Paramedic Tutor

26th Edition

emsnotes.com

THE BIG QUESTION: STABLE OR UNSTABLE?

Before treating ANY rhythm, ask: Is this patient stable or unstable?

UNSTABLE = Any of these signs:

Hypotension (BP < 90 systolic)
Altered mental status
Chest pain
Shortness of breath / pulmonary edema
Signs of shock (pale, cool, sweaty)

THE SIMPLE RULE

If Patient Is...	And Rhythm Is...	Then Do...
UNSTABLE	Too fast	Synchronized cardioversion
UNSTABLE	Too slow	Pacing (+ Atropine)
STABLE	Any rhythm	Medications / monitor
PULSELESS	VF or VT	Defibrillate!
PULSELESS	Asystole / PEA	CPR + Epinephrine

NORMAL SINUS RHYTHM

Normal Sinus Rhythm (NSR)

Rate:	60-100 bpm
Rhythm:	Regular
P Waves:	Present, upright, one before each QRS
QRS:	Narrow (<0.12 sec)

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FAST RHYTHMS (TACHYCARDIAS)

Sinus Tachycardia

Rate:	>100 bpm
Rhythm:	Regular
P Waves:	Normal (may be hard to see at fast rates)

Treatment: NONE for the rhythm itself! Find and treat the CAUSE.

SVT (Supraventricular Tachycardia)

Rate:	150-250 bpm (very fast!)
Rhythm:	Regular
P Waves:	Hidden or absent
QRS:	Narrow

STABLE SVT:

Vagal maneuvers
Adenosine 6mg rapid IV
If no luck: 12mg

UNSTABLE SVT:

Synchronized cardioversion
50-100 Joules

Ventricular Tachycardia (V-Tach)

Rate:	100-250 bpm
Rhythm:	Regular
QRS:	WIDE (>0.12 sec) — bizarre looking

WIDE + FAST = V-TACH UNTIL PROVEN OTHERWISE!

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ATRIAL RHYTHMS

Atrial Fibrillation (A-Fib)

Rate:	Variable (can be slow, normal, or fast)
Rhythm:	Irregularly irregular (totally random)
P Waves:	NONE — just a wavy baseline

How to spot A-Fib: The R-R intervals are all different. No two beats are the same distance apart.

Atrial Flutter

Rate:	Atrial: ~300 \| Ventricular: usually 150
Rhythm:	Usually regular
P Waves:	Sawtooth pattern (flutter waves)

Rate of exactly 150? Think A-Flutter with 2:1 block!

PVCs

Premature Ventricular Contraction (PVC)

Look:	Wide, bizarre beat that comes early
Pause:	Followed by a compensatory pause
Treatment:	Usually none — unless frequent or symptomatic

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SLOW RHYTHMS (BRADYCARDIAS)

Sinus Bradycardia

Rate:	<60 bpm
Rhythm:	Regular
P Waves:	Normal

Symptomatic Bradycardia: Atropine 1mg IV → Pacing if needed

HEART BLOCKS

1st Degree AV Block

PR Interval:	>0.20 sec (more than 5 small boxes)
Treatment:	NONE — just monitor

2nd Degree Type I (Wenckebach)

Pattern:	PR gets longer, longer... then DROPS a beat
Treatment:	Usually benign — Atropine if symptomatic

2nd Degree Type II (Mobitz II) ⚠️

Pattern:	PR stays the same, then SUDDENLY drops beats
Danger:	Can progress to complete block!

Type II = DANGEROUS! Get pacing pads on immediately.

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3rd Degree (Complete) Heart Block ⚠️

Pattern:	P waves and QRS have NO relationship
P Rate:	Normal (~60-100)
QRS Rate:	Slow (20-40)

Complete block = PACE IMMEDIATELY if symptomatic!

CARDIAC ARREST RHYTHMS

Ventricular Fibrillation (V-Fib)

Look:	Chaotic squiggly line — no organized pattern
Pulse:	NONE

V-FIB = SHOCK IMMEDIATELY!
Defibrillate 200J → CPR → Epi → Shock → Amiodarone

Asystole (Flatline)

Look:	Flat line (confirm in 2 leads!)
Pulse:	NONE

ASYSTOLE = DO NOT SHOCK!
CPR + Epinephrine 1mg every 3-5 min

SHOCKABLE vs NON-SHOCKABLE

SHOCK ⚡	DON'T SHOCK 🚫
V-Fib	Asystole
Pulseless V-Tach	PEA

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MEDICATION QUICK REFERENCE

Drug	Dose	Use
Epinephrine	1mg IV/IO q3-5min	All cardiac arrest
Amiodarone	300mg, then 150mg	V-Fib / V-Tach
Atropine	1mg IV q3-5min (max 3mg)	Bradycardia
Adenosine	6mg → 12mg → 12mg	SVT
Diltiazem	0.25 mg/kg IV	A-Fib rate control
Magnesium	2g IV	Torsades de Pointes

CARDIOVERSION vs DEFIBRILLATION

	Cardioversion	Defibrillation
Sync?	YES	NO
Patient	Has a pulse	PULSELESS
Energy	Start low (50-100J)	Max (200J biphasic)

THE H's AND T's

H's

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo/Hyperkalemia
Hypothermia
Hypoglycemia

T's

Tension pneumothorax
Tamponade (cardiac)
Toxins / Tablets
Thrombosis (PE)
Thrombosis (MI)

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