Initiating Monitoring
9%of exam
Administering Tests
9%of exam
Analyzing Normal Rhythms
16%of exam
Analyzing Abnormal Rhythms
60%of exam
Processing Findings
6%of exam
Escalation & SBARAlarm ManagementScope of PracticeDocumentationACLS Basics
Quick Facts
- Exam
- CRAT
- Credential
- Rhythm Analysis Technician
- Body
- CCI
- Questions
- 130 items (110 scored)
- Time
- 2 hours
- Pass
- 650 of 900 scaled
- Fee
- $175 application
- Format
- Computer-based MCQ
- Renewal
- Every 3 years
Leads & Placement
- Lead II
- Default monitor lead
- Einthoven
- Bipolar I, II, III
- Augmented
- aVR, aVL, aVF
- Precordial
- V1 through V6
- V1 position
- 4th ICS right sternum
- 5-lead rule
- White on right
- Brown lead
- V1 chest electrode
5-Step Rhythm Analysis
Rate | Regularity | P | PR | QRS
Rate: how fastRegularity: even spacingP: before every QRSPR: 0.12-0.20 sQRS: under 0.12
Rate Method Picker
- Regular rhythm→300 method(300 by boxes)
- Irregular rhythm→6-second method(count times 10)
- Need exact interval→Count small boxes(times 0.04 s)
- Fast, regular, narrow→Consider SVT
- Fast, wide, regular→Assume VT
ECG Grid & Timing
- Paper speed
- 25 mm per second
- Small box
- 0.04 s wide
- Large box
- 0.20 s, 5 boxes
- Calibration
- 10 mm per mV
- 300 method
- Regular rate shortcut
- 6-second method
- Irregular rate, times 10
Waveforms & Intervals
- P wave
- Atrial depolarization
- QRS complex
- Ventricular depolarization
- T wave
- Ventricular repolarization
- PR interval
- 0.12-0.20 s normal
- QRS width
- Under 0.12 s
- QT interval
- Repolarization time
- ST segment
- Injury indicator
- U wave
- Hypokalemia clue
Intrinsic Escape Rates
SA 60-100 | AV 40-60 | Vent 20-40
SA: 60-100 pacemakerAV: 40-60 backupVent: 20-40 last
Arrest vs Exit Block
Sinus arrest
- SA fails to fire
- Pause not multiple
- Unpredictable
Exit block
- SA fires
- Impulse blocked
- Pause is multiple
No firing vs blocked
Conduction & Rates
- SA node
- Pacemaker, 60-100 bpm60-100
- AV junction
- Backup, 40-60 bpm40-60
- His-Purkinje
- Ventricular, 20-40 bpm20-40
- AV nodal delay
- 0.10 s, atrial kick
- Refractory period
- Blocks re-entry
- Autonomic tone
- Sympathetic up, vagal down
- Overdrive suppression
- Fastest pacemaker wins
Sinus Rhythms
- NSR
- 60-100, upright P
- Sinus brady
- Rate under 60
- Sinus tachy
- Rate over 100
- Sinus arrhythmia
- Varies with breathing
- Sinus arrest
- Pause not multiple
- Sinus exit block
- Pause is P-P multiple
STEMI Localization
Inferior | Anterior | Lateral | Septal
Inferior: II, III, aVFAnterior: V1-V4Lateral: I, aVL, V5, V6Septal: V1-V2
PAC vs PVC
PAC
- Narrow QRS
- Early P wave
- Noncompensatory pause
PVC
- Wide QRS
- No P wave
- Compensatory pause
Narrow vs wide
Rhythm ID Picker
- Regular, upright P, 60-100→NSR(normal)
- Irregular, no P waves→AFib
- Sawtooth F waves→Atrial flutter
- Absent, inverted P, narrow→Junctional
- Wide, no P, >100→VT(escalate)
- Chaotic, no complexes→VF(shock)
- PR lengthens then drops→Mobitz I
- Fixed PR, dropped QRS→Mobitz II
Atrial Rhythms
- PAC
- Early abnormal P
- Atrial flutter
- Sawtooth, 250-350
- Atrial fibrillation
- Irregular, no P
- MAT
- 3+ P shapes, >100
- Wandering pacemaker
- 3+ P shapes, <100
- PSVT
- Sudden narrow tachy
- Flutter 2:1
- Ventricular rate near 150
QT-Prolonging Drugs
Torsades: give Mg, stop QT drugs
Sotalol / dofetilideMethadoneHaloperidolFluoroquinolonesLow K, low Mg
AFib vs Flutter
AFib
- No P waves
- Irregularly irregular
- Fibrillatory baseline
Flutter
- Sawtooth F waves
- Often regular
- Atrial near 300
Chaotic vs organized
Junctional Rhythms
- Junctional escape
- 40-60, inverted P
- Accelerated junctional
- 60-100 bpm
- Junctional tachy
- Over 100 bpm
- Inverted P wave
- Retrograde atrial firing
- PJC
- Early junctional beat
- Digoxin clue
- Junctional plus atrial block
Mobitz I vs II
Mobitz I
- PR lengthens
- Then drops QRS
- AV node
Mobitz II
- PR fixed
- Sudden dropped QRS
- His-Purkinje
Progressive vs fixed
Ventricular Rhythms
- PVC
- Wide, no P
- R-on-T
- PVC on T wave
- Bigeminy
- Every other beat PVC
- VT
- Wide, over 100
- Torsades
- Twisting, long QT
- VF
- Chaotic, no complexes
- Idioventricular
- 20-40 escape
- AIVR
- 40-100, reperfusion
- Asystole
- Flat line, confirm
VT vs SVT
VT
- Wide QRS
- AV dissociation
- Assume if unsure
SVT
- Narrow QRS
- Regular and fast
- Adenosine responsive
Wide vs narrow
AV Blocks
- First degree
- PR over 0.20 s
- Mobitz I
- PR lengthens, drops
- Wenckebach
- Type I, AV node
- Mobitz II
- Fixed PR, drops
- Third degree
- P and QRS independent
- Complete block
- Often needs pacing
MAT vs WAP
MAT
- Rate over 100
- 3+ P shapes
- COPD, hypoxia
WAP
- Rate under 100
- 3+ P shapes
- Often benign
Fast vs slow
Pacemakers & ICDs
- Atrial paced
- Spike before P
- Ventricular paced
- Spike, wide QRS
- AV sequential
- Two spikes, DDD
- Biventricular CRT
- Resynchronizes heart failure
- Failure to capture
- Spike, no response
- Failure to sense
- Fires despite intrinsic
- ICD
- Detects, shocks VT
Capture vs Sense
Failure to capture
- Spike present
- No depolarization
- Lead or battery
Failure to sense
- Ignores intrinsic
- Fires anyway
- R-on-T risk
No response vs blind
Ischemia & MI
- ST elevation
- Acute injury current
- Inferior MI
- II, III, aVF
- Anterior MI
- V1 through V4
- Lateral MI
- I, aVL, V5, V6
- Posterior MI
- V1-V3 tall R
- Reciprocal change
- Mirror ST depression
- Limb STEMI
- 1 mm, 2 contiguous
- Precordial STEMI
- 2 mm V2-V3 men
Pharmacology
- Atropine
- Speeds bradycardia
- Adenosine
- Stops SVT
- Amiodarone
- VT, AFib control
- Beta-blockers
- Slow rate, AV
- Calcium blockers
- Slow AV node
- Digoxin
- Toxicity, junctional ectopy
- Magnesium
- Torsades first-line
- QT drugs
- Sotalol, haloperidol, methadone
Shockable Rhythms
Shock VF and pulseless VT only
VF: shockPulseless VT: shockAsystole: no shockPEA: no shock
Escalation Urgency
- VF or pulseless VT→Call code, defib(seconds)
- Asystole or PEA→Call code, CPR
- New STEMI pattern→Activate cath lab
- Sustained VT, has pulse→Notify RN stat
- Symptomatic high block→Prep pacing
- R-on-T PVCs→Notify RN
- New AFib RVR→Notify RN
Emergency & ACLS
- Shockable
- VF, pulseless VT
- Non-shockable
- Asystole, PEA
- Defibrillation
- Unsynchronized shock
- Cardioversion
- Synchronized shock
- CPR
- No pulse, compress
- Code activation
- Unresponsive, summon team
- Confirm asystole
- Check two leads
Alarms & Scope
- Alarm fatigue
- Desensitized to alerts
- Customize alarms
- Set to baseline
- SBAR
- Structured handoff format
- Scope of practice
- Recognize, not treat
- HIPAA
- Protect strip data
- False alarm
- Verify patient first
- Artifact
- Motion mimics rhythm
Common Traps
PAC vs PVC pause
PAC noncompensatory pause ≠ PVC compensatory pause
Flutter vs Fib
Flutter sawtooth, regular ≠ Fib chaotic, irregular
Mobitz I vs II
I lengthens then drops ≠ II drops without warning
VT vs artifact
VT real, patient sick ≠ Artifact motion, stable patient
Escape vs primary
Escape protects, backup ≠ Do not suppress escape
Recognize vs treat
CRAT recognizes and reports ≠ CRAT never treats
Regular vs irregular rate
Regular uses 300 method ≠ Irregular uses 6-second
Last Minute
- 1.Small box is 0.04 s
- 2.Large box is 0.20 s
- 3.Calibration 10 mm per mV
- 4.Normal PR 0.12 to 0.20 s
- 5.Normal QRS under 0.12 s
- 6.SA node fires 60-100 bpm
- 7.Regular rate: 300 box method
- 8.Irregular rate: 6-second strip
- 9.AFib is irregular, no P
- 10.Flutter shows sawtooth waves
- 11.Mobitz II drops without warning
- 12.Shock VF and pulseless VT
- 13.Asystole and PEA not shockable
- 14.Confirm lethal rhythm second lead
- 15.CRAT recognizes, never treats
- 16.Pass is 650 of 900
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