ecg interpretation - reach air medical services · the six second ecg, a practical guide to basic...
TRANSCRIPT
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ECG Interpretation
Introduction to Cardiac TelemetryMichael Peters, RN, CCRN, CFRN – CALSTAR Air Medical Services
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Disclosures
• Nothing to disclose
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Objectives
• Describe the electrical conduction pathway in the heart
• Interpret a rhythm strip and identify life threatening
dysrhythmias
• Anticipate common dysrhythmia treatment plans
• Identify presence of a pacemaker and its proper operation
• Apply skills toward the introduction of 12-lead EKG analysis
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Cardiac Anatomy & Physiology
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Cardiac Anatomy & Physiology
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Einthoven’s Triangle
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Precordial Leads
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ECG monitor lead placement
“White on Right”
“Smoke over Fire”
“Snow over Trees”
“Chocolate lies close to
the heart”
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Anatomy of the ECG
P wave
• Precedes QRS
• Usually rounded and
upright
• 2-3mm amplitude
• 0.06 - 0.12 second duration
Abnormalities
• Notched, peaked, enlarged
– atrial hypertrophy
• Inverted – retrograde
( junctional) conduction
• Varying – wandering
pacemaker rhythm
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Anatomy of the ECG
PR Interval
• Measured from the
beginning of the P-wave to
the beginning of the QRS.
• Tracks atrial impulse from
SA node through AV node,
bundle branches.
• 0.12 – 0.20 second duration
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Anatomy of the ECG
QRS Complex
• Depolarization of the
ventricles
• 5 – 30mm amplitude
• 0.06 – 0.10 second duration
• May not see all 3 waves
• + or – deflection
depending on lead
Wide QRS (>0.12 sec) may
signify ventricular conduction
delay or origin.
• Notched R wave – BBB
• Deep Q wave – prior MI
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Anatomy of the ECG
ST Segment
• Beginning of ventricular
repolarization
• S to beginning of T
• Usually isoelectric
ST depression
• >0.5mm below baseline
• Myocardial ischemia,
electrolyte imbalance
ST elevation
• >1mm above baseline
• Myocardial injury (STEMI)
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Anatomy of the ECG
T wave
• Ventricular repolarization
• Follows S wave
• 0.5-10mm amplitude
• Round and smooth
• Upright I, II, V3-V6,
inverted aVR
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Anatomy of the ECG
T wave
Tall, peaked or tented –
myocardial injury or
hyperkalemia
Inverted (I, II, V3-V6) –
myocardial ischemia
Notched or pointed (adult) -
pericarditis
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Anatomy of the ECG
QT interval
• Represents ventricular
polarization/depolarization
• Beginning of QRS to end T
• Varies with age, gender,
heart rate (0.36 – 0.44 sec)
Prolonged QT
• Congenital defect
• Caused by certain
medications
• Risk for torsades de pointes
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QT Prolongation Drugs
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Analyzing a Rhythm Strip
Barill, T. (2012). The Six Second ECG, A Practical Guide to Basic and 12 Lead ECG Interpretation. SkillStat Learning Inc.
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Analyzing a Rhythm Strip
Heart Rate – Methods of calculation
1. Six second count
Barill, T. (2012). The Six Second ECG, A Practical Guide to Basic and 12 Lead ECG Interpretation. SkillStat Learning Inc.
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Analyzing a Rhythm Strip
Heart Rate – Methods of calculation
2. Countdown Method
Barill, T. (2012). The Six Second ECG, A Practical Guide to Basic and 12 Lead ECG Interpretation. SkillStat Learning Inc.
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Analyzing a Rhythm Strip
Heart Rate – Methods of calculation
3. Caliper Method (1,500 Method)
– Use calipers to measure the number of 1mm (small)
boxes between R-R interval. Divide 1500 by this #.
Example:
1500 / 19 QRS complexes per minute
Heart Rate = 79 beats per minute
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Artifact and Wandering
Baseline
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Interpreting a Rhythm Strip
1. Rate – Too fast or slow?
2. Rhythm – Regular or Irregular?
3. QRS wide or narrow?
4. P-wave for every QRS?
5. ST segment/T-wave abnormalities, ectopy,
pacemaker spikes, etc.
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Normal Sinus Rhythm
Rate: 60-100 bpm
Rhythm: Regular
QRS: Narrow (<0.12 sec)
P wave for every QRS
T wave rounded, upright
No ectopic beats (PVC/PAC)
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Sinus Bradycardia
Rate: Less than 60 bpm P wave for every QRS
Rhythm: Regular T wave rounded, upright
QRS: Narrow (<0.12 sec) No Ectopic beats
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Sinus Tachycardia
Rate: Greater than 100bpm P wave for every QRS
Rhythm: Regular T wave rounded, upright
QRS: Narrow (<0.12 sec) No Ectopic beats
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Sinus Arrhythmia
Usually regular sinus rate (60-100) with irregular rhythm that corresponds with respirations. Common in pediatrics.
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Sinus Arrest/Pause
SA node fails to discharge and then resumes.
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Atrial Arrhythmias
• Premature Atrial Contraction (PAC)
– Conducted (QRS complex following) or non-conducted.
– P-P interval shorter than prior beats.
– P wave may be hidden in prior T wave.
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Atrial Arrhythmias
• Premature Atrial Contraction (PAC)
– Conducted (QRS complex following) or non-conducted.
– P-P interval shorter than prior beats.
– P wave may be hidden in prior T wave.
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Atrial Arrhythmias
• Multifocal Atrial Tachycardia (MAT)
– Irregular rhythm, rate >100, varying P waves
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Atrial Arrhythmias
• Wandering Atrial Pacemaker
– Irregular rhythm resulting from multiple pacemaker sites initiating beats.
http://www.ekgstripsearch.com/WAP.htm
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Atrial Arrhythmias
• Paroxysmal Atrial Tachycardia (PAT)
– Brief periods of tachycardia that alternate with periods of normal sinus rhythm
https://aneskey.com/atrial-arrhythmias/
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SUPRAVENTRICULAR
TACHYCARDIA (SVT)
Rate: 150–250 bpm
P Waves: Frequently buried in
preceding T waves and difficult to
see
PR Interval: Usually not possible to
measure
Rhythm: Regular
QRS: Normal (0.06–0.10
sec)but may be wide if abnormally
conducted through ventricles
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Atrial Fibrillation
Chaotic, asynchronous, electrical activity in atrial tissue.
• Leads to loss of atrial kick (30% of cardiac output)
• Absence of P waves and irregular ventricular response (Irregularly irregular)
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Atrial Flutter
• Atrial rate approx. 300 bpm with characteristic “sawtooth” pattern (flutter waves).
• Ventricular rate dependent on conduction ratio.
• Symptoms dependent on cardiac output.
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Atrial Flutter
• Atrial rate approx. 300 bpm with characteristic “sawtooth” pattern (flutter waves).
• Ventricular rate dependent on conduction ratio.
• Symptoms dependent on cardiac output.
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Junctional Rhythms
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Junctional Rhythms
• Originates from AV junction if SA node fails
• Atria depolarize but impulse is retrograde (reverse)
• Junctional escape rate 40-60bpm
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Junctional Rhythms
Accelerated Junctional (60-100 bpm)
Junctional Tachycardia (>100 bpm)
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First Degree AV Block
*Characterized by PR interval > 0.2 sec*
Rate: Normal (not affected) P wave for every QRS
Rhythm: Regular Narrow QRS, normal T
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2nd Degree AV Block Type I
*AKA Wenckebach or Mobitz I*
Rate: Normal (A>V) P wave for every QRS but
Rhythm: Atrial – regular QRS drops
Ventricular – Irregular Gradual PR increase
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2nd Degree AV Block Type II
*AKA Mobitz II*
Rate: Normal (A>V) P wave for every QRS but
Rhythm: Atrial – regular QRS drops SUDDENLY
Ventricular – Irregular PR remains constant
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3rd Degree AV Block
(Complete)
*Potential LIFE THREATENING Rhythm*
Rate: Slow (20-60) QRS: normal or wide
Rhythm: Atrial – regular; Ventricular – regular
Atria and ventricles operating independently, no relation between P and QRS.
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3rd Degree AV Block (Complete)
https://www.unm.edu/~lkravitz/EKG/avblocks.html
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Bundle Branch Block
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Bundle Branch Blocks
• QRS > 0.12
• Assess V1 for QRS morphology
• Patients with a prolonged QRS
(> 0.15) may require a
pacemaker
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Practice with Heart Blocks
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More Practice…
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Ventricular Dysrhythmias
• QRS > 0.12
• Wide and Bizarre
• Hidden P waves
• 20-40 BPM
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Premature Ventricular
Contraction (PVC)
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Premature Ventricular
Contraction (PVC)
• Patient Assessment?
• Treatment?
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Ventricular Tachycardia
• Life-threatening dysrhythmia!
• Wide and bizarre
• Rate of 101-250 impulses/min
• Pulses vs. pulseless
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Torsades De Pointes
• Lethal dysrhythmia!
• Wide and bizarre
• Often > 150 impulses/min
• Pulses vs. pulseless
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Torsades De Pointes
• Lethal dysrhythmia!
• Wide and bizarre
• Often > 150 impulses/min
• Pulses vs. pulseless
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Ventricular Fibrillation
Pulseless!!! Lethal dysrhythmia
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Idioventricular/Agonal Dysrhythmia
• Lethal! Last attempt!
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Asystole
Lethal!
Immediate Treatment Required!
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Pulseless Electrical Activity (PEA)
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Pulseless Electrical Activity (PEA)
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Pacemakers
• Power source generates an impulse, which is
transmitted to the heart tissue, causing
depolarization.
http://www.bostonscientific.com/en-US/patients/about-your-device/pacemakers/how-pacemakers-work.html
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Pacemakers
Types of temporary pacing
• Epicardial – wires attached directly to the heart wall during cardiac surgery. (A/V)
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Pacemakers
Types of temporary pacing
• Transvenous – Placed percutaneously and advanced to the ventricle via the IJ or subclavian vein. (V)
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Pacemakers
Types of temporary pacing
• Transcutaneous – Pads placed on the patient’s bare skin.
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Pacemakers
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Pacemaker Troubleshooting
Failure to Capture
• Check connections, patient position, increase
mA.
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Pacemaker Troubleshooting
Failure to Pace
• Check connections, change battery, change pulse
generator
• Over sensing?? – mistakes other impulses or
muscle activity for intrinsic activity
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Pacemaker Troubleshooting
Failure to Sense
• Increase sensitivity
• Decrease demand rate
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Recognizing Cardiac Tissue Damage
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Recognizing Cardiac Tissue Damage
More than just ST-elevation
Ischemia
– Interrupted oxygen (blood)
supply.
– Tissue is still viable
– Repolarization temporarily
impaired (inverted T-waves)
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Recognizing Cardiac Tissue Damage
More than just ST-elevation
Injury
– Prolonged lack of oxygen
(blood) supply.
– Tissue is still viable (for now)
– Cells do not fully repolarize
because of deficient blood
supply (ST elevation)
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Recognizing Cardiac Tissue Damage
More than just ST-elevation
Infarction
– Areas of necrosis (dead
tissue).
– Cells do not depolarize,
causing new pathological Q-
waves to appear.
– Tissue is eventually replaced
by scar tissue.
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Zones of Injury
Ischemia: T-wave
inversion
Injury: ST-elevation
Infarction (necrosis):
pathological Q-wave
Reciprocal Changes
(opposite side of heart)
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A Look at 12-Leads
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Where is the MI?
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Where is the MI?
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Location Matters
Anterior, Septal, Lateral – Involve Left Anterior
Descending and Circumflex
• Left sided Heart Failure (Pump problem)– Dyspnea (w/wo exertion)
– Pulomanry Edema (rales, crackles)
– Orthopnea
– Cool extremities, weak pulses, cyanosis
– Lethargy, fatigue, confusion
– Restlessness
• Treatment – ASA, O2, analgesia, NTG, inotrope
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Location Matters
Inferior, RV, Posterior – Right Coronary Artery
(possibly L Circumflex)
• RV failure (Preload problem)– JVD, Edema, Swelling
– Anorexia, Nausea, Ascites
– Confusion, Lethargy
– Hypotension
– Heart Block (be prepared to PACE!)
• Treatment – ASA, O2, analgesia, VOLUME
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Location Matters
• R sided MI: Why not NTG??
– Nitro vasodilates, causing further loss of preload (i.e.
blood, O2), worsening the problem.
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R sided MI after NTG
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Putting It All Together
• Always assess your patient first!
– Treat the patient not the monitor!
• Determine the situation
• Investigate the cause
• Intervene/Treatment
• Reassess
• Get to definitive care
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Questions??
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References
Barill, T. P. (2012). The Six Second ECG: A Practical Guide to Basic and 12 Lead ECG Interpretation. Palm Springs, CA: SkillStat Learning Inc.
http://www.skillstat.com
Dubin MD, D. (2009, May). Reference Sheets from Rapid Interpretation of EKG’s. Retrieved from http://www.cardiacmonitors.com/personal_reference.php
Slate, M. K. (2017, August). EKG Interpretation. Retrieved from
http://www.rn.org/courses/coursematerial-187.pdf
Wolters Kluwer Health. (2011). ECG Interpretation Made Incredibly Easy! (5th
Ed.). Ambler, PA: Lippincott Williams & Wilkins.
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Practice Strips
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Practice Strips
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Practice Strips
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Practice Strips
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Practice Strips