ECG Interpretation. Introduction to Cardiac Telemetry. Michael Peters, RN, CCRN, CFRN CALSTAR Air Medical Services
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1 ECG Interpretation Introduction to Cardiac Telemetry Michael Peters, RN, CCRN, CFRN CALSTAR Air Medical Services
2 Disclosures Nothing to disclose
3 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
4 Cardiac Anatomy & Physiology
5 Cardiac Anatomy & Physiology
6 Einthoven s Triangle
7 Precordial Leads
8 ECG monitor lead placement White on Right Smoke over Fire Snow over Trees Chocolate lies close to the heart
9 Anatomy of the ECG P wave Precedes QRS Usually rounded and upright 2-3mm amplitude second duration Abnormalities Notched, peaked, enlarged atrial hypertrophy Inverted retrograde ( junctional) conduction Varying wandering pacemaker rhythm
10 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 second duration
11 Anatomy of the ECG QRS Complex Depolarization of the ventricles 5 30mm amplitude 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
12 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)
13 Anatomy of the ECG T wave Ventricular repolarization Follows S wave mm amplitude Round and smooth Upright I, II, V3-V6, inverted avr
14 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
15 Anatomy of the ECG QT interval Represents ventricular polarization/depolarization Beginning of QRS to end T Varies with age, gender, heart rate ( sec) Prolonged QT Congenital defect Caused by certain medications Risk for torsades de pointes
16 QT Prolongation Drugs
17 Analyzing a Rhythm Strip Barill, T. (2012). The Six Second ECG, A Practical Guide to Basic and 12 Lead ECG Interpretation. SkillStat Learning Inc.
18 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.
19 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.
20 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
21 Artifact and Wandering Baseline
22 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.
23 Normal Sinus Rhythm Rate: bpm Rhythm: Regular QRS: Narrow (<0.12 sec) P wave for every QRS T wave rounded, upright No ectopic beats (PVC/PAC)
24 Sinus Bradycardia Rate: Less than 60 bpm Rhythm: Regular QRS: Narrow (<0.12 sec) P wave for every QRS T wave rounded, upright No Ectopic beats
25 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
26 Sinus Arrhythmia Usually regular sinus rate (60-100) with irregular rhythm that corresponds with respirations. Common in pediatrics.
27 Sinus Arrest/Pause SA node fails to discharge and then resumes.
28 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.
29 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.
30 Atrial Arrhythmias Multifocal Atrial Tachycardia (MAT) Irregular rhythm, rate >100, varying P waves
31 Atrial Arrhythmias Wandering Atrial Pacemaker Irregular rhythm resulting from multiple pacemaker sites initiating beats.
32 Atrial Arrhythmias Paroxysmal Atrial Tachycardia (PAT) Brief periods of tachycardia that alternate with periods of normal sinus rhythm
33 SUPRAVENTRICULAR TACHYCARDIA (SVT) Rate: bpm P Waves: Frequently buried in preceding T waves and difficult to see PR Interval: Usually not possible to measure Rhythm: Regular QRS: Normal ( sec)but may be wide if abnormally conducted through ventricles
34 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)
35 Atrial Flutter Atrial rate approx. 300 bpm with characteristic sawtooth pattern (flutter waves). Ventricular rate dependent on conduction ratio. Symptoms dependent on cardiac output.
36 Atrial Flutter Atrial rate approx. 300 bpm with characteristic sawtooth pattern (flutter waves). Ventricular rate dependent on conduction ratio. Symptoms dependent on cardiac output.
37 Junctional Rhythms
38 Junctional Rhythms Originates from AV junction if SA node fails Atria depolarize but impulse is retrograde (reverse) Junctional escape rate 40-60bpm
39 Junctional Rhythms Accelerated Junctional ( bpm) Junctional Tachycardia (>100 bpm)
40 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
41 2 nd 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
42 2 nd 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
43 3 rd 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.
44 3 rd Degree AV Block (Complete)
45 Bundle Branch Block
46 Bundle Branch Blocks QRS > 0.12 Assess V1 for QRS morphology Patients with a prolonged QRS (> 0.15) may require a pacemaker
47 Practice with Heart Blocks
48 More Practice
49 Ventricular Dysrhythmias QRS > 0.12 Wide and Bizarre Hidden P waves BPM
50 Premature Ventricular Contraction (PVC)
51 Premature Ventricular Contraction (PVC) Patient Assessment? Treatment?
52 Ventricular Tachycardia Life-threatening dysrhythmia! Wide and bizarre Rate of impulses/min Pulses vs. pulseless
53 Torsades De Pointes Lethal dysrhythmia! Wide and bizarre Often > 150 impulses/min Pulses vs. pulseless
54 Torsades De Pointes Lethal dysrhythmia! Wide and bizarre Often > 150 impulses/min Pulses vs. pulseless
55 Ventricular Fibrillation Pulseless!!! Lethal dysrhythmia
56
57 Idioventricular/Agonal Dysrhythmia Lethal! Last attempt!
58 Asystole Lethal! Immediate Treatment Required!
59 Pulseless Electrical Activity (PEA)
60 Pulseless Electrical Activity (PEA)
61 Pacemakers Power source generates an impulse, which is transmitted to the heart tissue, causing depolarization.
62 Pacemakers Types of temporary pacing Epicardial wires attached directly to the heart wall during cardiac surgery. (A/V)
63 Pacemakers Types of temporary pacing Transvenous Placed percutaneously and advanced to the ventricle via the IJ or subclavian vein. (V)
64 Pacemakers Types of temporary pacing Transcutaneous Pads placed on the patient s bare skin.
65 Pacemakers
66 Pacemaker Troubleshooting Failure to Capture Check connections, patient position, increase ma.
67 Pacemaker Troubleshooting Failure to Pace Check connections, change battery, change pulse generator Over sensing?? mistakes other impulses or muscle activity for intrinsic activity
68 Pacemaker Troubleshooting Failure to Sense Increase sensitivity Decrease demand rate
69 Recognizing Cardiac Tissue Damage
70 Recognizing Cardiac Tissue Damage More than just ST-elevation Ischemia Interrupted oxygen (blood) supply. Tissue is still viable Repolarization temporarily impaired (inverted T-waves)
71 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)
72 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.
73 Zones of Injury Ischemia: T-wave inversion Injury: ST-elevation Infarction (necrosis): pathological Q-wave Reciprocal Changes (opposite side of heart)
74 A Look at 12-Leads
75 Where is the MI?
76 Where is the MI?
77 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
78 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
79 Location Matters R sided MI: Why not NTG?? Nitro vasodilates, causing further loss of preload (i.e. blood, O2), worsening the problem.
80 R sided MI after NTG
81 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
82 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. Dubin MD, D. (2009, May). Reference Sheets from Rapid Interpretation of EKG s. Retrieved from Slate, M. K. (2017, August). EKG Interpretation. Retrieved from Wolters Kluwer Health. (2011). ECG Interpretation Made Incredibly Easy! (5 th Ed.). Ambler, PA: Lippincott Williams & Wilkins.
83 Practice Strips
84 Practice Strips
85 Practice Strips
86 Practice Strips
87 Practice Strips
88 ECG simulator
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