8-12
dark line on which the first R-wave fell.
(c) The order is 300, 150, 100, 75, 60, 50, and so forth. The assigned numbers are a result of
dividing 300 by 1, 2, 3, 4, 5, 6, and so forth.
(d) The number corresponding to the line where the second R-wave falls is the pulse. Normal
rate is considered 60-100 beats/ minute, although some fit individuals will have resting rates
down into the 40s.
b. Step 2: Determine if the rhythm is regular (P-wave and QRS complexes occur at regular intervals).
R-waves fall on top of each other when the EKG paper is folded in half and held it up to the
light. Not regular is abnormal.
c. Step 3: Analyze the P-wave. Determine whether there is a P-wave for every QRS complex, the
P-waves are upright, and they are regular and similar in appearance. Any NO is abnormal.
d. Step 4: Determine if there is any ST segment elevation or depression of 2 small squares or more.
e. Step 5: If any heart abnormalities are discovered, refer to Acute MI or Cardiac Resuscitation
sections and evacuate the patient. Many arrhythmias are not addressed in those sections, but
medics are not trained or equipped in the field to treat them. Tachycardias can be treated by diving
reflex, carotid massage (rule out bruit first). Ventricular tachycardia and fibrillation should be treated
as soon as possible.
What Not To Do:
Never treat an EKG. Always treat the patient. Does the information from the EKG correlate to the patient?
Example: When a rhythm looks like atrial fibrillation, feel the patient’s pulse. If it is regular and full, then the
information from the EKG machine “does not correlate,” and is in error.
Procedure: Pericardiocentesis
COL Warren Whitlock, MC, USAWhat: Mechanism to relieve uid or air inside the sac surrounding the heart.
When: The patient has sustained a penetrating wound in the chest that may have entered the heart covering
(pericardium), and is showing signs of shock - hypotension, tachycardia, and tachypnea with narrowed pulse
pressure, mufed heart sounds, pulsus paradoxicus (heart rate increasing with expiration, decreasing with
inspiration—greater than normally seen). The medic must be aware that this procedure is dangerous and should
not be attempted without prior training, and only as a last resort in life threatening emergencies when vital signs
deteriorate: (narrow pulse pressure) low mean arterial pressure, +/- mufed heart sounds. If the vital signs are
stable, the medic should continue IV uids and monitor the patient only. There are also more rare etiologies for
developing uid (viral pericarditis), as well as air (pneumopericardium in diving) in the pericardial sac. These
conditions can be relieved with the same procedure outlined below to relieve blood in the pericardial sac.
What You Need: 18 gauge spinal needle or Pericardiocentesis kit with Mansfield catheter, a 60cc syringe,
sterile preparation kit (alcohol wipe may be adequate in emergencies), local anesthetic, sterile needles, 3-way
stopcock, alligator clips, EKG with defibrillator/monitor, gauze pads/bandage. Emergency drugs (atropine,
lidocaine, epinephrine, oxygen)
What To Do:
Preparation:
- Have the patient lie supine.
- Administer oxygen (nasal cannula or face mask) and pulse oximeter if available.
- Start an IV – volume loading may help attenuate the effects of cardiac tamponade.
- Set up EKG machine to monitor the cardiac rhythm.
- Clean subxiphoid area with antiseptic
Procedure:
Option A – Emergency Technique to Withdraw Fluid Once
- Connect 18 gauge spinal needle and 60 cc syringe