ECG interpretations - Centegra Health System | Hospital in ... · PDF file•Review basics...
Transcript of ECG interpretations - Centegra Health System | Hospital in ... · PDF file•Review basics...
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ECG Interpretations
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Course Objectives
• Proper Lead Placements
• Review the ECG print paper
• Review the mechanics of the Myocardium
• Review basics of ECG Rhythms
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How Leads Work
• The ECG Leads we use are Bipolar
• When an electrical impulse moves towards the (+) lead
• Displays as an Upward Deflection
• When an electrical impulse moves
toward the (-) lead
• Displays as a Downward Deflection
Lead II is displayed on the monitor because it shows the most (+) moving activity
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ECG Lead Placement
• “Limb Leads” • If 3 Leads (RA, LA, LL) • If 4 Leads (RA, LA, LL, RL)
• RA is ground for all leads (Including the 12 leads) • If there is excess artifact or difficulty with display
• Replace the RA Lead with a fresh sticker
• Place Leads on muscle, not over bone
• When you can: Place the Leads on the Torso of the Patient
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ECG Lead Placement
Remember: “Clouds over Grass, Smoke over Fire”
RA (White) – Negative (-) LA (Black) – Negative (-) RL (Green) – Positive (+) LL (Red) - Positive (+)
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Breakdown of the Cardiac Rhythm Strip:
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HOW TO READ THE PRINTOUT…….. ECG interpretations
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The ECG Paper
• Horizontally (Time) – One small box - 0.04 sec – One large box - 0.20 sec
• Vertically (Voltage)
– One large box - 0.5 mV
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The ECG Paper (cont.)
• Every 3 seconds (15 large boxes) is marked by a vertical line.
– ECG Interpretations are based on 6 seconds
3 sec 3 sec
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THE MECHANICS OF THE MYOCARDIUM………
ECG interpretations
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Pacemakers of the Heart
• SA Node - Dominant pacemaker with an intrinsic rate of 60 - 100 beats/minute.
• AV Node - Back-up pacemaker with an intrinsic rate of 40 - 60 beats/minute.
• Ventricular cells - Back-up pacemaker with an intrinsic rate of 20 - 45 bpm.
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Impulse Conduction & the ECG
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
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The “PQRST”
• P wave - Atrial depolarization
• QRS - Ventricular depolarization
• T wave - Ventricular repolarization
The Atria repolarizes at the same time that the Ventricles depolarize
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MEASUREMENTS OF ECG INTERPRETATIONS……….
ECG interpretations
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Option 1 Step 1: Calculate Rate
• Count the Number of complete QRS complexes in a 6 second rhythm strip, then multiply by 10. • Reminder: all rhythm strips in the modules are 6
seconds in length.
What is the Rate on this Strip? 9 x 10 = 90 bpm
3 sec 3 sec
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Option 2 Step 1: Calculate Rate
– Find an R wave that lands on a bold line. – Count the number of large boxes to the next R wave. If the
second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes - 75, etc. (cont.)
R wave
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Option 2 Step 1: Calculate Rate
– Memorize the sequence: 300 - 150 - 100 - 75 - 60 - 50
What is the Rate on this Strip?
300
150
100
75
60
50
Approx. 1 box less than 100 = 95 bpm
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Step 2: Determine regularity
• Look at the R-R distances (using a caliper or markings on a pen or paper).
• Regular (are they equal distance apart)? Occasionally irregular? Regularly irregular? Irregularly irregular?
R R
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Step 3: Assess the P waves
• Are P waves present? • Do the P waves all look the same? • Do the P waves occur at a regular rate? • Is there one P wave before each QRS complex?
Normal P waves with 1 P wave for every QRS
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Step 4: Determine PR interval
• Normal: 0.12 - 0.20 seconds. (3 - 5 boxes)
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Step 5: QRS duration
• Normal: 0.04 - 0.12 seconds. (1 - 3 boxes)
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PUTTING IT ALL TOGETHER………. ECG interpretations
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Rhythm Analysis
Step 1: Calculate rate. Step 2: Determine regularity. Step 3: Assess the P waves. Step 4: Determine PR interval. Step 5: Determine QRS duration.
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Normal Sinus Rhythm (NSR)
• Rate 60 - 100 bpm • Regularity regular • P waves Before each QRS Complex • PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
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Sinus Rhythms:
• Sinus Tachycardia
• Sinus Bradycardia
• Sinus Arrhythmia
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Sinus Tachycardia
• Rate between 100 and 150 bpm • Regularity regular • P waves before each QRS Complex • PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
Remember: sinus tachycardia can be a response to physical or psychological
stress, not a primary arrhythmia.
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Sinus Bradycardia
• Rate less than 60 bpm • Regularity regular • P waves before each QRS Complex • PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
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Sinus Arrhythmia
• Rate 60 - 100 bpm • Regularity irregular • P waves normal • PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
Can be related to respirations, common in pediatrics
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Atrial Rhythms
• Wandering Atrial Pacemaker • Atrial Tachycardia • Atrial Flutter • Atrial Fibrillation
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Wandering Pacemaker
• Rate 40-60 bpm • Regularity slightly irregular • P waves change from beat to beat, may disappear completely
• PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
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Atrial Tachycardia
• Rate more than 100 bpm • Regularity regular • P waves normal, flat or inverted • PR interval varies • QRS duration 0.04 - 0.12 sec
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Atrial Flutter
• Rate Ventricle Rate - normal Atrial Rate - 250-320 bpm
• Regularity regular • P waves flutter wave – Multiple
per each QRS Complex • PR interval not measurable • QRS duration 0.04 - 0.12 sec
(Turning the strip upside down may make the saw tooth pattern more prominent)
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Atrial Fibrillation
• Rate Atrial Rate – can’t be counted
Ventricular Rate - varies • Regularity irregularly irregular • P waves not distinguishable • PR interval not measurable • QRS duration 0.04 - 0.12 sec
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Junctional Rhythms
• Junctional Escape • Junctional Bradycardia • Accelerated Junctional • SVT
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Junctional Escape
• Rate 40-60 bpm • Regularity regular • P waves inverted or flat • PR interval < 0.12 - if before the QRS Complex
• QRS duration usually <0.12 sec, but can be greater
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Junctional Bradycardia
• Rate <40 bpm • Regularity regular • P waves inverted or flat • PR interval < 0.12 sec • QRS duration usually <0.12 sec, but can be greater
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Accelerated Junctional
• Rate 60 - 100 bpm • Regularity regular • P waves inverted or flat • PR interval < 0.12 - if before the QRS Complex
• QRS duration usually <0.12 sec, but can be greater
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Junctional Tachycardia
• Rate more than 100 bpm • Regularity regular • P waves inverted or flat • PR interval 0.12 - 0.20 sec • QRS duration 0.04 - 0.12 sec
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Supraventricular Tachycardia (SVT)
• Rate greater than 150 bpm • Regularity regular • P waves unable to be read • PR interval buried in previous QRS Complex • QRS duration 0.04 - 0.12 sec
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Blocks
• 10 HB + Underlying Rhythm • 20 Type I - Wenkebach • 20 Type II - Classical • 30 degree HB
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1st Degree AV Block
• Prolonged conduction delay in the AV node or
Bundle of His. • PRI will be greater than 0.20 • There will be one P wave in front of every QRS
Complex • The underlying rhythm is part of the interpretation
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20 HB Mobitz I - Wenckebach
• Rate Atrial Rate – normal Ventricular Rate – Bradycardic
• Regularity regular • P waves normal • PR interval progressively longer until
the QRS is missed – then recaptures
• QRS duration 0.04 - 0.12 sec
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20 HB Block, Type II - Classical
• Rate Atrial Rate – normal Ventricular Rate – Bradycardic • Regularity regular • P waves ratio of 2:1, 3:1 (P waves to QRS) • PR interval normal or prolonged when followed by a
QRS Complex (P-R Interval will always be the same)
• QRS duration 0.04 - 0.12 sec - P wave conduction is blocked in a consistent repeating pattern
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3rd Degree AV Block
• Rate Atrial Rate – normal Ventricular Rate – Bradycardic Rate • Regularity regular from P to P or QRS to QRS • P waves unrelated to QRS Complex • PR interval unrelated to QRS Complex • QRS duration slower than 0.12 seconds
– The P waves are completely blocked in the AV junction; QRS complexes originate independently from below the AV junction.
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Differentiating The Heart Blocks
Heart Block R to R PR interval
20 Type I – Wenckebach
Irregular - Dropped QRS
Irregular – longer, longer, longer
20 Type II - Classical
Regular if consistent degree of block
Regular for PR interval; just more P’s than QRS
3rd degree - complete Regular Irregular – no pattern
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• Look at the R to R intervals – Are they regular or not
• Look at the PR intervals – Are they consistent? If not, is there a pattern
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Differentiating The Heart Blocks
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Differentiating The Heart Blocks
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Comparing Heart Blocks
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Ectopic Beats
• Premature Atrial Contraction (PAC)
• Premature Junctional Contraction (PJC)
• Premature Ventricular Contraction (PVC)
– Uni-focal – Multi-focal
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Premature Atrial Contractions (PAC)
• Etiology: Excitation of an atrial cell forms an
impulse that is then conducted normally through the AV node and ventricles.
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Premature Junctional Contractions (PJC)
• Etiology: Excitation of cells in the AV Node. A pause is dependent on if the SA Node is depolarized when the impulse occurs.
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Premature Ventricular Contraction (PVC)
– Ectopic beats originate in the ventricles resulting in wide and bizarre QRS complexes.
– Compare multiple premature beats:
• When multiple PVCs look alike, they are called “uniform”
• When multiple PVCs look different, they are called “multifocal”
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Unifocal PVC
Multifocal PVC
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PVC Patterns
• Bigeminy: – Every other beat is a PVC
• Trigeminy: – Every third beat is a PVC
• Quadgeminy – Every fourth beat is a PVC
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Run of PVCs
If 3 or more PVCs occur in a row: This is a Run of V-Tach (Ventricular Tachycardia)
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Ventricular Rhythms
• Wolf Parkinson White (WPW) • Ventricular Tachycardia (V-Tach) • Torsade de pointes • Ventricular Fibrillation (V-Fib) • Asystole
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Wolf Parkinson White (WPW)
– Congenital defect in conduction system – Presence of abnormal electrical pathway that can cause
tachycardia – Episodes often begin occurring in teens and early 20’s
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Normal Conduction WPW Conduction
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Wolf Parkinson White (WPW)
• The pacemaker impulse bypasses the AV Node • Rate: 60-100 bpm • Rhythm: regular • P wave: less than 0.12 sec • QRS: > .12 seconds (wide and bizarre)
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Only Rhythm with Delta Wave
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Ventricular Tachycardia (monomorphic)
• Ventricular cells fire continuously due to a looping re-entrant circuit • Rate usually regular, 100 - 250 bpm • P wave: absent • QRS: complexes bizarre, > .12 • Rhythm: usually regular
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Ventricular Tachycardia (polymorphic)
• Ventricular cells fire continuously due to a looping re-entrant circuit from multiple foci
• Rate usually regular, 100 - 250 bpm • P wave: may be absent, inverted or retrograde • QRS: complexes bizarre, > .12 • Rhythm: usually regular
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Torsade de Pointes A Multifocal V-Tach
• Escape rhythm (safety mechanism) to prevent ventricular standstill • Bundle of HIS/Purkinje Fiber pacemaker take over • Rhythm: varies from beat to beat • P wave: absent • QRS: > .12 seconds (wide and bizarre)
*Can be caused by mixture of antiarrhythmic drugs and non-sedating antihistamines,
anti fungal meds and certain antibiotics * Can be seen in alcoholic, anorexia and/or bulimic patients
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Ventricular Fibrillation
• Rhythm: irregular (coarse or fine), wave form varies in size and shape • Fires continuously from multiple foci • No organized electrical activity • No cardiac output
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Asystole
• Ventricular standstill, no electrical activity, no cardiac output – no pulse! • Remember! No defibrillation with Asystole • Rate: absent due to absence of ventricular activity.
– Occasional P wave may be identified – Not productive
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Other Rhythms
• Idioventricular • Accelerated Idioventricular • Paced • PEA
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Idioventricular Rhythm
• Escape rhythm (safety mechanism) to prevent ventricular standstill • HIS/Purkinje system takes over as the heart’s pacemaker • Rhythm: regular • Rate: 20-40 bpm • P wave: absent • QRS: > .12 seconds (wide and bizarre)
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Accelerated Idioventricular Rhythm
• Escape rhythm (safety mechanism) to prevent ventricular standstill • Bundle of HIS/Purkinje Fiber system takes over as the heart’s pacemaker • Rhythm: regular • Rate: 60-100 bpm • P wave: absent • QRS: > .12 seconds (wide and bizarre)
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Paced Rhythm
• Man made mechanical pacing device • Rhythm: regular if continuous firing Irregular if pacing on demand • Rate: Based on what is programmed • P wave: dependent on where pacer is originating from • QRS: > .12 seconds (wide and bizarre) The only thing to identify is that it is a “Paced Rhythm”
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Pulseless Electrical Activity (PEA)
• Pick any rhythm that we have discussed and remove the pulse
• This is only electrical activity with no mechanical function
• That is why we treat the patient, not the monitor.
• Consider the H’s and T’s to improve the patient’s out come: - Hypoxia - Hypovolemia - Tension Pneumothorax - Hypothermia - Hypo/Hyperkalemia - Tamponade – Cardiac - Hydrogen Ion (Acidosis) - Thrombosis – Pulmonary - Thrombosis - Cardiac
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NO PULSE
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INTERPRETATIONS……… ECG interpretations
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Normal Sinus Rhythm
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Atrial Fibrillation
Is the patient stable or unstable? Patients can walk around in this rhythm with no problems Watch for medication hx to include: Coumadin, Prodaxa, Eliquis, Xarelto or Lovenox
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Sinus Rhythm w/ Run of V-Tach
Is the patient stable or unstable? Are there multiple occurrences? Interventions: ASA (ACS SOP) and Amiodarone
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20 HB – Mobitz II (Classical)
Is the patient stable or unstable Interventions: Dopamine, TCP
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Sinus Rhythm w/10 Heart Block
Not Normal Sinus Rhythm w/10 Heart Block
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Monomorphic V-Tach
Is the patient stable or unstable? Intervention: Amiodarone 150mg in 50 ml 0.9 NS drip Be ready for Synchronized Cardioversion
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Torsades de Pointes
Is the patient stable or unstable? Intervention: Magnesium 2 Gm w/16 ml 0.9 NS over 5 min or you may get the 2 Gm in 40 ml bag. Be ready for Defibrillation
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Junctional Escape
Is the patient stable or unstable? Interventions: Atropine, Dopamine, TCP
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Artificial Paced Rhythm
Is the patient stable or unstable?
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Pulseless Electrical Activity (PEA)
NO PULSE
Start CPR Consider H’s and T’s Interventions: Epinephrine, Possibly Sodium Bicarbonate
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REVIEW……………..
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Review…………
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For every strip we look at: Rate Regularity Determine P waves Measure PR interval
Determine QRS duration
Pacemaker Rates: SA Node – Dominant pacemaker: 60 – 100 bpm
AV Node – Back-up pacemaker: 40 - 60 bpm
Ventricular cells - Back-up pacemaker: 20 - 45 bpm
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Review………..
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Each small square is 0.04 seconds and a large box is 0.20 seconds
P wave - Atrial depolarization QRS – Ventricular depolarization T wave - Ventricular repolarization
* The Atria repolarizes at the same time that the Ventricles depolarize
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Questions?
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