12/10/2014 3 lead ecg interpretation pfn: somacl12slides.jsomtc.org/somacl12/somacl12.pdfjunctional...
TRANSCRIPT
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Slide 1JSOMTC, SWMG(A)
3 Lead ECG Interpretation PFN: SOMACL12
Hours:
Instructor:
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of 3 Lead ECG interpretation
Condition: Given a lecture in a classroom environment
Standard: Receive minimum score of 84% on AHA standardized written exam
Slide 3JSOMTC, SWMG(A)
References
Basic Arrhythmias, Seventh Edition, Gail Walraven
Advanced Cardiovascular Life Support, Provider Manual 2010
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Slide 4JSOMTC, SWMG(A)
Reason
At some time, you will likely encounter the need to treat a critical cardiac patient. As the leader or a member of the medical team, a comprehensive understanding of cardiac arrhythmias will improve overall patient management.
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Agenda
Review ECG waves, measurements, and the 6‐step process of analyzing ECG rhythms
Review sinus rhythms
Review atrial rhythms
Review junctional rhythms
Review heart blocks
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Agenda
Review ventricular rhythms
Review miscellaneous rhythms
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ECG Waves and Measurements
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Waves and Measurements
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Basic Rule of Electrical Flow
If flow of electricity is toward a '+' electrode the pattern is upright
If the electrical flow is toward a ' ‐ ' electrode then the pattern will be downward
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Leads
Electrode positions allow a single view of the heart’s electrical pattern
By rearranging the electrodes, different views are possible
This method can triangulate to spots on the heart to assess arrhythmias
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Graph Paper
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Cardiac Cycle
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Cardiac Cycle
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Waves and Measurements
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Artifact/Interference
'Artifact'
Electrical Interference
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Refractory Periods
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Components of Analyzing ECG Rhythms
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Analyzing ECG Rhythm Strips
ECG’s are more complex than fingerprints
Everyone's is subtly and uniquely theirs
Inadequate to simply memorize 'snapshots' of common ECG’s
Analysis of every ECG 'strip' using a systematic approach
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Arrhythmias
Categories
Sinus
Atrial
Junctional
Ventricular
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Analysis FormatRegularity: Regular or irregular?
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Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
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Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform, saw toothed appearance or irregularly irregular
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Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform
PRI: Less than .20, constant
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Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform
PRI: Less than .20, constant
QRS: Less than .12
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Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, Uniform
PRI: Less than .20, constant
QRS: Less than .12
S‐T segment: Elevated or depressed?
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Sinus Rhythms
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Sinus Rhythms
Normal Sinus Rhythm (NSR)
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
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Normal Sinus Rhythm (NSR)Rhythm: Regular
Rate: 60‐100
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
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Sinus BradycardiaRhythm: Regular
Rate: Less than 60
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
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Sinus TachycardiaRhythm: Regular
Rate: Greater than 100 , <150
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
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Sinus ArrhythmiaRhythm: Irregular
Rate: Normal 60‐100
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
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Atrial Rhythms
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Atrial Rhythms
Wandering Pacemaker
Atrial Tachycardia/Supraventricular Tachycardia (SVT)
Premature Atrial Complexes (PAC)
Atrial Flutter
Atrial Fibrillation
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Wandering PacemakerRhythm: Regular, 1 complex out of place
Rate: Normal 60‐100
P wave: Present, morphing
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
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Premature Atrial Complex (PAC)
Rhythm: Regular
Rate: Normal 60‐100
P wave: Present, morphing
PRI: Constant, less than .20
QRS: Less than .12, but came early;
led a P wave
ST segment: Back to isoelectric line
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Supraventricular Tachycardia (SVT)
Rhythm: Regular
Rate: 150‐250
P wave: May or may not be visible
PRI: Often difficult to measure
QRS: Less than .12
ST segment: Back to isoelectric line
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Atrial FlutterRhythm: Regular
Rate: Atrial rate is 250‐300; ventricular rate slightly tachycardic
P wave: Often present as "saw teeth"; more P waves than QRS
PRI: Difficult to determine
QRS: Less than .12
ST segment Back to isoelectric line
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Atrial Fibrillation
Rhythm: Grossly irregular
Rate: Atrial: >350 , ventricular WNL
P wave: Not discernible
PRI: Unable to measure
QRS: Less than .12
ST segment: Back to isoelectric line; T waves often not seen
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Junctional Rhythms
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Junctional Rhythms
Junctional Pacemaker
Premature Junctional Complex (PJC)
Junctional Escape Rhythm
Accelerated Junctional Rhythm
Junctional Tachycardia
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Junctional PacemakerRhythm: Regular
Rate: 40‐60
P wave: Inverted or absent
PRI: Normal if present
QRS: Less than .12
ST segment: Back to isoelectric
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Premature Junctional Complex (PJC)Rhythm: Regular with 1 irregular beat
Rate: Depends on underlying rhythm
P wave: Normal; except the premature complex(s)
PRI: Usually normal if present
QRS: Less than .12 (underlying rhythm?)
ST segment: Back to isoelectric
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Junctional Escape RhythmRhythm: Regular
Rate: 40‐60
P wave: Inverted or absent
PRI: Normal if P waves present
QRS: Less than .12
ST segment: Back to isoelectric (if normal)
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Accelerated Junctional RhythmRhythm: Regular
Rate: 60‐100 BPM
P wave: Inverted or absent
PRI: Normal if present
QRS: Less than .12
ST segment: Back to isoelectric
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Junctional TachycardiaRhythm: Regular
Rate: 100‐180 (usually)
P wave: Inverted or absent
PRI: Normal if P wave present
QRS: Less than .12
ST segment: Back to isoelectric
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Heart Blocks
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Heart Blocks
First Degree
Second Degree Type 1
Second Degree Type 2
Third Degree
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First DegreeRhythm: Regular
Rate: 60‐100, sometimes bradycardic
P wave: Present normal
PRI: Greater than .20
QRS: Less than .12
ST segment: Back to isoelectric
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Second Degree Type 1'Wenckebach'/Mobitz 1
Rhythm: Irregular
Rate: 60‐100, possibly bradycardic
P wave: Present, normal
PRI: Grows longer until QRS 'drops'
QRS: Less than .12
ST segment: Back to isoelectric
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Second Degree (Mobitz 2)Rhythm: Irregular
Rate: 60‐100, sometimes bradycardic
P wave: Present, WNL; more P’s than QRS’s
PRI: Normal until it 'drops' a QRS
QRS: Less than .12
ST segment: Back to isoelectric
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Third Degree (Complete Heart Block)Rhythm: Regular
Rate: Atrial 60‐100
Ventricular 20‐60
P wave: Present, normal ‐more P’s than QRS’s
PRI: No relationship between P‐QRS
QRS: Less than .12; possibly > .20
ST segment: Back to isoelectric
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Ventricular Rhythms
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Ventricular Rhythms
Premature Ventricular Complex (PVC)
Ventricular Tachycardia
Ventricular Fibrillation
Idioventricular Rhythm
Asystole
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Premature Ventricular Complex (PVC)Rhythm: What is the underlying rhythm?
Rate: Underlying rhythm?
P wave: Underlying rhythm?
PRI: Underlying rhythm?
QRS: Wider than QRS, comes early,
No preceding P‐Wave
ST segment: Underlying rhythm
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Premature Ventricular Complex (PVC)Bigeminy (PVC)
Trigeminy (PVC)
Quadgeminy (PVC)
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Premature Ventricular Complex (PVC)Couplet (PVC)
Triplet (PVC)
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Ventricular Tachycardia (VT)Rhythm: Regular
Rate: 150‐250
P wave: Absent
PRI: Normal; likely indiscernible
QRS: Wider than .12
ST segment: Difficult to discern
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Ventricular FibrillationRhythm: Irregular
Rate: Incalculable
P wave: None discernible
PRI: None
QRS: Bizarre ventricular conduction
ST segment: Incalculable
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IdioventricularRhythm: Regular
Rate: 20‐40 BPM
P wave: Absent
PRI: There is no PRI
QRS: Wide and bizarre, > .12
ST segment: May appear to be above/below isoelectric line
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AsystoleRhythm: None
Rate: Zero
P wave: None
PRI: None
QRS: None
ST segment: None
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Miscellaneous Rhythms
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Miscellaneous RhythmsFIL is the electrically filtered actual rhythm going on during CPR
CPR is the artifact caused by compressions
RAW is what comes across the screen when both are going on
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Questions?
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Slide 64JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of 3 Lead ECG interpretation
Condition: Given a lecture in a classroom environment
Standard: Receive minimum score of 84% on AHA standardized written exam
Slide 65JSOMTC, SWMG(A)
Agenda
Interpret ECG waves and measurements
Identify the components of analyzing ECG rhythms
Identify sinus rhythms
Identify atrial rhythms
Identify junctional rhythms
Identify heart blocks
Slide 66JSOMTC, SWMG(A)
Agenda
Identify ventricular rhythms
Identify miscellaneous rhythms
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Slide 67JSOMTC, SWMG(A)
Reason
At some time, you will likely encounter the need to treat a critical cardiac patient. As the leader or a member of the medical team, a comprehensive understanding of cardiac arrhythmias will improve overall patient management.