12 Lead EKG Interpretation NPAA · 12 EKG INTERPRETATION ROADMAP 03 02 04 05 06 01 HIGH SPEED TO...

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12 Lead EKG Interpretationfor Beginners

Johnny R. Tice, DNP, MA, CRNP, FNP-C, PMHNP-BC

Clinical Assistant Professor

University of Alabama Capstone College of Nursing

Objectives:

• Describe normal conduction of the cardiac cycle.

• Discuss standard leads of the 12 lead EKG.

• Examine systematic process of 12 lead EKG interpretation.

• Recognize common dysrhythmias encountered in clinical practice.

• Demonstrate 12 lead EKG interpretation in terms of rate, rhythm, and waveform/interval analysis.

12 EKG INTERPRETATION ROADMAP

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HIGH SPEED TO ADVANCED SESSION.

PRACTICE

WAVEFORM - INTERVAL ANALYSIS

COMMON DYSRHYTHMIAS

RHYTHM

RATE

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The Electrocardiogram

• The electrocardiogram (EKG) is a graphic recording of the electrical events of the cardiac cycle.

• Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac pathophysiology

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The 12 Lead EKG

• Simple, convenient, and cost effective diagnostic tool

• Used as an adjunct to diagnosis cardiac pathology, electrolyte disturbance, and drug toxicity

• Only as capable as the user

Electrical Conduction in the Heart


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The Cardiac Cycle

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EKG Graph Paper

Waveforms and Intervals of Cardiac Cycle


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EKG Limb Leads: Frontal View

A lead: two electrodes of opposite polarity (bipolar) or one electrode and a reference point (unipolar)

Bipolar Limb Leads

Augmented Unipolar Limb Leads

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Precordial Leads: Horizontal View

Precordial Leads: Horizontal View

Summary of Leads

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12 Lead EKG

12 Lead EKG

12 Lead EKG

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12 Lead EKG

Methods of Rate Determination

Count the number of R waves in a six second strip and multiply by 10


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STEP 1: RATE

• HR of 60-100 per minute is normal

• HR > 100 = tachycardia

• HR < 60 = bradycardia

Rate Determination

60 BPM

75 BPM

80-85 BPM

130 BPM

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STEP 2: RHYTHM

Regular or irregular rhythm?


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PRACTICE


Common Dysrhythmias

RHYTHM

RATE

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STEP 3: WAVEFORM -INTERVAL ANALYSIS

P WAVE• Direction of Deflection:

• Upright in Lead II• Inverted in AVR

• Amplitude: 2.5-3.0 mm

• Width: 0.06 – 0.10 sec


P WAVE

• Biphasic: indicates left atrial enlargement

• Notching: significant if ≥ 0.04 sec between peaks


P WAVE

• Notching also known as P-mitrale

• Shape of P-mitrale can vary in different patients

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P WAVE

• Peaking: tall, peaked P waves: possible right atrial enlargement

• Absence of waveform: Consider junctional rhythm or sinoatrial block


P WAVE

• Peaking: tall, peaked P waves: possible right atrial enlargement

• Absence of waveform: Consider junctional rhythm or sinoatrial block


• NORMAL

• PROLONGED: > 0.20 seconds

• SHORTENED: < .0.12 seconds

P-R INTERVAL

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QRS AMPLITUDE

Too low: ≤ 5mm leads I, II, IIIMinimal norm:5 mm in V1 and V67mm in V2 and V59 mm in V3 and V4Maximal norm:20-25 mm in limb leads25-30 mm in V leads


QRS: Q WAVE

• Should not be wider than 0.03 seconds

• View in context of overall cycle

• Consider depth, width, leads of appearance, and clinical presentation


QRS: Q WAVE• Considered pathologic if:

• Width > 30 ms (≥ 0.04)

• Width ≥ 25% of the height of the R wave

• If present in continuous leads, indicative of myocardial necrosis

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QRS Complex


QRS COMPLEX

R WAVE PROGRESSION IN PRECORDIAL LEADS


QRS COMPLEX

TRANSITION ZONEUSUALLY V3 or V4

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12 Lead EKG

R WAVE PROGRESSION NORMAL OR ABNORMAL?TRANSITION ZONE IN WHICH LEAD?


ST SEGMENT

IsoelectricNormal elevation: ≤ 1mm limb, ≤ 2mm precordialNormal depression: never ≥ 0.05mmNo shape angle or frank horizontal formAbnormal depression or abnormal elevation


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T WAVE

• Slightly rounded and symmetrical• Sharply pointed or grossly notched T

waves should be examined with suspicion


QT INTERVAL• Normal: Interval varies

with rate

• Shortened: drug or electrolyte effect

• Prolonged: drug effect, heart disease, electrolyte

Practice

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PRACTICE


Common Dysrhythmias

RHYTHM

RATE

Common Dysrhythmias

Sinus Arrhythmia

Multifocal Atrial Tachycardia

Common Dysrhythmias

• Paroxysmal Atrial Tachycardia

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Common Dysrhythmias

• Supraventricular Tachycardia

Common Dysrhythmias

Atrial Fibrillation

Atrial Flutter

Common Dysrhythmias

Ventricular Tachycardia

Ventricular Fibrillation

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Premature Ventricular Contractions

Common Dysrhythmias

• Junctional Rhythm

Common Dysrhythmias

• First Degree Block

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Common Dysrhythmias

• Second Degree Block, MobitzType 1

• Second Degree Block, Mobitz type 2

Common Dysrhythmias

• Third Degree Heart Block


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PRACTICE


Common Dysrhythmias

RHYTHM

RATE

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PRACTICE

Normal Sinus Rhythm

PRACTICE

Second Degree AV Block: Type 1

PRACTICE

Hyperkalemia

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PRACTICE

Atrial Fib RVR

PRACTICE

Dig Toxicity

PRACTICE

Atrial Flutter with Variable Block

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PRACTICE

Third Degree Heart Block

PRACTICE

Supraventricular Tachycardia

PRACTICE

Hypokalemia

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PRACTICE

Tricyclic Antidepressant Overdose


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PRACTICE


Common Dysrhythmias

RHYTHM

RATE

12 Lead EKG Interpretation NPAA · 12 EKG INTERPRETATION ROADMAP 03 02 04 05 06 01 HIGH SPEED TO...

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