Lake EMS Basic EKG Review: Atrial Rhythms. The Lake EMS Quality Development Team
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1 Lake EMS Basic EKG Review: Atrial Rhythms The Lake EMS Quality Development Team
2 This program is the Intellectual Property of Lake Emergency Medical Services Use of this program is limited to training and Quality Education only Captain Mike Hilliard, Lake EMS Training Officer 2761 West Old Highway 441, Mount Dora, FL / (w); 352/ (f);
3 The challenge With respect to the many revered instructors and authors who teach electrocardiology rhythm assessment, there are many differences in opinion regarding things such as heart rates for rhythms So we defined our own parameters with the blessings of the Lake County Medical Director, Pushpal R. Banerjee, D.O.
4 Our solution Consequently, our Basic EKG Online review meets the criteria as set forth by our Quality Development Department: John Simpson, Chief Operations Officer Michael R. (Mike) Hilliard, Non-Clinical/Non-Quality Training Officer Jamie A. Lowery, District Chief, Field Training Coordinator Scott Temple, Clinical Training Officer Julie Treadwell, Clinical Quality Officer And our Medical Director: Pushpal R. (Paul) Banerjee, D.O.
5 Basic stuff When electricity stimulates muscle we witness depolarization This is an electrical phenomenon We hope mechanically that the muscle contracts When a muscle relaxes we see repolarization on the monitor If the muscle mass is large enough
6 Normal Impulse Conduction Sinus Node SA Node The heart generates it s own electricity, termed Automaticity This refers to the heart being it s own pacemaker AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
7 Normal Impulse Conduction Sinus Node SA Node Sinoatrial (SA) Node starts 99% of all rhythms; unfortunately, we in EMS often see the remainder during our work schedule AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
8 Normal Impulse Conduction Sinus Node SA Node Normal heart pacemaker; automaticity is the term used to create an impulse AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
9 Normal Impulse Conduction Sinus Node SA Node It fires an electrical impulse AV Node Bundle Of His Left Bundle Branch Right Bundle Branch Purkinje fibers
10 Normal Impulse Conduction Intra-atrial pathways Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
11 Normal Impulse Conduction Sinus Node Intra-atrial pathways Carries impulse throughout both atria AV Node Bundle Of His Left Bundle Branch Right Bundle Branch Purkinje fibers
12 Normal Impulse Conduction Sinus Node Intra-atrial pathways Allows depolarization of atria AV Node Bundle Of His Left Bundle Branch Right Bundle Branch Purkinje fibers
13 Normal Impulse Conduction AV Node Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
14 Normal Impulse Conduction Sinus Node AV Node Atrioventricular (AV) Node delays (holds) electrical impulse AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
15 Normal Impulse Conduction Sinus Node AV Node Allows ventricles (two bottom chambers of the heart) to fill with blood from atria (two top chambers of the heart) AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
16 Normal Impulse Conduction AV Junction Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
17 Normal Impulse Conduction Sinus Node AV Junction Directly below the AV Node is the AV Junction; primarily is just a name of the pathway into the ventricles AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
18 Normal Impulse Conduction Bundle of His Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
19 Normal Impulse Conduction Sinus Node Bundle of His Carries impulse to bundle branches; primarily is just a name of the pathway into the septum AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
20 Normal Impulse Conduction Sinus Node Bundle of His Carries impulse to bundle branches; primarily is just a name of the pathway into the septum AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers Septum is divider of the two bottom chambers, termed the ventricles
21 Normal Impulse Conduction Bundle Branches Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
22 Normal Impulse Conduction Sinus Node Bundle Branches Right branch transmits impulse to right ventricle; left branch transmits impulse to left ventricle, it further breaks into an anterior and posterior hemi-branch AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
23 Normal Impulse Conduction Sinus Node Bundle Branches So yes, the heart does have a hemi AV Node Bundle Of His Left Bundle Branch Right Bundle Branch Purkinje fibers
24 Normal Impulse Conduction Purkinje fibers Sinus Node AV Node Left Bundle Branch Bundle Of His Right Bundle Branch Purkinje fibers
25 Normal Impulse Conduction Sinus Node Purkinje fibers Impulse is now transmitted to ventricular muscle allowing depolarization AV Node Bundle Of His Right Bundle Branch Left Bundle Branch Purkinje fibers
26 Impulse Conduction & the EKG How does this form an EKG on the monitor? Lets break it down one step at a time
27 Impulse Conduction & the EKG Sinoatrial node PR R P T Q S
28 Impulse Conduction & the EKG Sinoatrial node PR R AV node P Q S T
29 Impulse Conduction & the EKG Sinoatrial node PR R AV node P Q S T Bundle of His Bundle Branches Purkinje fibers
30 The PQRST P PR R T P wave Atrial depolarization Q S
31 The PQRST P PR R T P wave Atrial depolarization Q S
32 The PR Interval Atrial depolarization + delay in AV node P PR Q R S T Delay allows time for the atria to contract before the ventricles contract
33 The PR Interval Atrial depolarization + delay in AV node P PR Q R S T Delay allows time for the atria to contract before the ventricles contract
34 The PQRST P PR R T QRS Ventricular depolarization Q S
35 The PQRST P PR R T QRS Ventricular depolarization Q S
36 The PQRST P PR R T T wave Ventricular repolarization Q S
37 The PQRST P PR R T T wave Ventricular repolarization Q S
38 Automaticity and Inherent Myocardial Cell Firings So, let us start by remembering the average rates of initiated heart rates: SA Node: bpm (beats-per-minute) AV Junction: bpm Ventricles: bpm These are normal values, other rates can and do occur at times
39 Hey, that looks like Many of us were taught how to visually recognize EKGs We were taught a simple process of 5-steps that help define the rhythm characteristics; however, over time we returned to the visual recognition
40 Basic wave breakdown Please understand this is an interpretation review, not a diagnostic patient assessment Always treat the patient and not the monitor P-wave: Atrial depolarization QRS-complex: Ventricular depolarization T-wave: Ventricular repolarization
41 1 st Axiom of EMS And if you forget to treat the patient and are considering treating the monitor, remember the first axiom of EMS:
42 1 st Axiom of EMS And if you forget to treat the patient and are considering treating the monitor, remember the first axiom of EMS: If you re not sure what to do, ask your EMT what the other paramedics would do in a similar situation
43 5-Part EKG Assessment Your key to success 1. Rate: QRS in 6-second strip, multiply x Rhythm: QRS distances consistent throughout strip 3. P-waves (in the entire strip being assessed): Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS? 4. P to R Interval (PRI): 0.12 to 0.20 seconds 5. QRS-Complexes: Narrow: <0.12-seconds (3 small boxes) Wide: >0.12-seconds
44 Part 1: Rate Rate: Count the QRSs present in a 6-second strip, then multiply that total x 10 Now you have the heart rate The EKG paper is formatted so that 1-inch equals 1-second in time 6-inches equates to 6-seconds
45 Sample counting
46 Sample counting: Identify 6-second strip Start here
47 Sample counting: Identify 6-second strip 1
48 Sample counting: Identify 6-second strip 1 2
49 Sample counting: Identify 6-second strip 1 2 3
50 Sample counting: Identify 6-second strip
51 Sample counting: Identify 6-second strip
52 Sample counting: Identify 6-second strip
53 Sample counting: Identify 6-second strip End here
54 Sample counting: Identify 6-second strip Hence, a six (6) second strip
55 Sample counting: Identify QRScomplexes in 6-second strip
56 Sample counting: Identify QRScomplexes in 6-second strip 1
57 Sample counting: Identify QRScomplexes in 6-second strip 1 2
58 Sample counting: Identify QRScomplexes in 6-second strip 1 2 3
59 Sample counting: Identify QRScomplexes in 6-second strip
60 Sample counting: Identify QRScomplexes in 6-second strip
61 Sample counting: Identify QRScomplexes in 6-second strip
62 Sample counting: Identify QRScomplexes in 6-second strip
63 Sample counting: Identify QRScomplexes in 6-second strip
64 Sample counting: Identify QRScomplexes in 6-second strip 8 x 10 = 80-bpm (beats per minute)
65 Part 2: Rhythm Rhythm: Are QRS distances consistent throughout strip Is distance from each QRS to other the same? If consistent, rhythm is regular If inconsistent, rhythm is irregular
66 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip
67 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Start here
68 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
69 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
70 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
71 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
72 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
73 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Are these equal to each other (hint, say yes)
74 Sample rhythm assessment: Identify if QRSs are regular in 6-second strip Then this rhythm is regular
75 Part 3: P-waves P-waves (in the entire strip being assessed): Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P look like all the others? Is each P the same distance from the QRS?
76 Sample P-wave assessment: Identify in 6-second strip Are P-waves present?
77 Sample P-wave assessment: Identify in 6-second strip Are P-waves present? YES!
78 Sample P-wave assessment: Identify in 6-second strip Do they look like a small rounded hill?
79 Sample P-wave assessment: Identify in 6-second strip Do they look like a small rounded hill? YES!
80 Sample P-wave assessment: Identify in 6-second strip Is there a P for every QRS?
81 Sample P-wave assessment: Identify in 6-second strip Is there a P for every QRS? YES!
82 Sample P-wave assessment: Identify in 6-second strip Is there a QRS for every P?
83 Sample P-wave assessment: Identify in 6-second strip Is there a QRS for every P? YES!
84 Sample P-wave assessment: Identify in 6-second strip Does each P look like all the others?
85 Sample P-wave assessment: Identify in 6-second strip Does each P looks like all the others? YES!
86 Sample P-wave assessment: Identify in 6-second strip Is each P the same distance from the QRS?
87 Sample P-wave assessment: Identify in 6-second strip Is each P the same distance from the QRS? YES!
88 Part 4: PRI (not Public Radio International) P to R Interval (PRI): 0.12 to 0.20 seconds (3-5 small boxes) The PRI is a window into the effectiveness of the AV Node AV Node has the duty to delay the atrial impulse to allow for better ventricular filling
89 Sample PRI assessment: Identify in 6-second strip
90 Sample PRI assessment: Identify in 6-second strip
91 Sample PRI assessment: Identify in 6-second strip small boxes = 0.20 seconds
92 Part 5: QRSs QRS-Complexes: Narrow: <0.12-seconds (3 small boxes or less) Wide: >0.12-seconds
93 Sample QRS width assessment: Identify in 6-second strip Start measuring when it leaves the flat baseline
94 Sample QRS width assessment: Identify in 6-second strip
95 Sample QRS width assessment: Identify in 6-second strip
96 Sample QRS width assessment: Identify in 6-second strip Stop measuring when it returns to a baseline (may be higher than where you started but it will either level off or go into T-wave)
97 Sample QRS width assessment: Identify in 6-second strip
98 Sample QRS width assessment: Identify in 6-second strip 1 2
99 Sample QRS width assessment: Identify in 6-second strip small boxes = 0.08 seconds
100 QRS Width 85% of time, if QRS is narrow, impulse starts in atrium 85% of time, if QRS is wide, impulse starts in ventricle
101 5-Part EKG Assessment 1. Rate: QRS in 6-second strip, multiply x Rhythm: QRS distances consistent throughout strip 3. P-waves (in the entire strip being assessed): Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS? 4. P to R Interval (PRI): 0.12 to 0.20 seconds 5. QRS-Complexes: Narrow: <0.12-seconds (3 small boxes) Wide: >0.12-seconds
102 Normal Sinus Rhythm NSR is the normal rhythm produced when the SA node initiates the cardiac electrical impulse It is what we compare most rhythms against
103 Normal Sinus Rhythm 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 60 99, on average Regular Normal Normal Narrow
104 Normal Sinus Rhythm
105 5-Part EKG Assessment 1. Rate: What is the rate?
106 5-Part EKG Assessment 1. Rate: 80-bpm
107 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
108 5-Part EKG Assessment 2. Rhythm: Regular
109 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
110 5-Part EKG Assessment 3. P-waves: P-waves? Yes Look like rounded hill? Yes P for every QRS? Yes QRS for every P? Yes P looks like each other? Yes P same distance from the QRS? Yes
111 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
112 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.20-seconds
113 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
114 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.08-seconds
115 This is Normal Sinus Rhythm 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 80 Regular Normal Normal Narrow
116 And now For something completely different
117 Sinus Arrhythmia A slight irregularity in sinus rhythm
118 Sinus Arrhythmia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 60-99, on average* Irregular Normal Normal Narrow By on average we mean over a minute the rate would be between 60-99
119 Sinus Arrhythmia
120 5-Part EKG Assessment 1. Rate: What is the rate?
121 5-Part EKG Assessment 1. Rate: 60-bpm
122 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
123 5-Part EKG Assessment 2. Rhythm: Irregular
124 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
125 5-Part EKG Assessment 3. P-waves: P-waves? Yes Look like rounded hill? Yes P for every QRS? Yes QRS for every P? Yes P looks like each other? Yes P same distance from the QRS? Yes
126 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
127 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.16-seconds
128 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
129 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.08-seconds
130 This is Sinus Arrhythmia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 60 Irregular Normal Normal Narrow
131 Sinus Bradycardia Characterized by a decrease in the rate of atrial depolarization due to slowing of the sinus node
132 Sinus Bradycardia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: Sinus rhythm < 60 bpm Regular Normal Normal Narrow
133 Sinus Bradycardia
134 5-Part EKG Assessment 1. Rate: What is the rate?
135 5-Part EKG Assessment Take your time
136 5-Part EKG Assessment You can do it
137 5-Part EKG Assessment 1. Rate: 40-bpm
138 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
139 5-Part EKG Assessment 2. Rhythm: Regular
140 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
141 5-Part EKG Assessment 3. P-waves: P-waves? Yes Look like rounded hill? Yes P for every QRS? Yes QRS for every P? Yes P looks like each other? Yes P same distance from the QRS? Yes
142 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
143 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.20-seconds
144 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
145 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.06-seconds
146 This is Sinus Bradycardia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 40 Regular Normal Normal Narrow
147 Sinus Tachycardia Sinus tachycardia is characterized by an increase in the rate of discharge of the sinus node Can get to rates as high as 190 bpm
148 Sinus Tachycardia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: Sinus rhythm, bpm Regular Normal Normal Narrow
149 Sinus Tachycardia
150 5-Part EKG Assessment 1. Rate: What is the rate?
151 5-Part EKG Assessment 1. Rate: 120-bpm
152 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
153 5-Part EKG Assessment 2. Rhythm: Regular
154 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
155 5-Part EKG Assessment 3. P-waves: P-waves? Yes Look like rounded hill? Yes P for every QRS? Yes QRS for every P? Yes P looks like each other? Yes P same distance from the QRS? Yes
156 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
157 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.16-seconds
158 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
159 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.06-seconds
160 This is Sinus Tachycardia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 120 Regular Normal Normal Narrow
161 Supraventricular Tachycardia Paroxysmal Supraventricular Tachycardia (PSVT) Supraventricular Tachycardia (SVT) Just a category, many rhythms can be in here as long as rate is over 150-bpm and QRS-complex is narrow SVT is fast and narrow!
162 Supraventricular Tachycardia 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: Atrial rhythm > 150 bpm Regular May be obscured in T wave Normal Narrow
163 Supraventricular Tachycardia
164 5-Part EKG Assessment 1. Rate: What is the rate?
165 5-Part EKG Assessment 1. Rate: 270-bpm
166 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
167 5-Part EKG Assessment 2. Rhythm: Regular
168 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
169 5-Part EKG Assessment 3. P-waves: P-waves? Yes Look like rounded hill? Hard to tell, blurred into T-wave P for every QRS? Yes QRS for every P? Yes P looks like each other? Yes P same distance from the QRS? Yes
170 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
171 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.08-seconds
172 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
173 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.05-seconds
174 This is SVT 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 270 Regular Normal Normal Narrow
175 ST/SVT: What Came First? ST secondary to: Medications (illicit, prescribed, or OTC drugs) Fever Fear Anxiety Hypovolemia Pain Other(s) SVT secondary to: Abrupt Paroxysmal
176 Atrial Flutter This arrhythmia is the result of a reentry circuit within the atria It is often described as resembling a saw tooth or picket fence Atrial waves are called flutter waves (F-waves)
177 Atrial Flutter 1. Rate: 2. Rhythm: 3. F-waves: 4. PRI: 5. QRS: , on average May be regular or irregular Resemble a saw tooth Normal Narrow
178 Atrial Flutter
179 5-Part EKG Assessment 1. Rate: What is the rate?
180 5-Part EKG Assessment 1. Rate: 70-bpm
181 Just curious, how fast are the atriums firing?
182 Wicked fast Rate: 290-bpm The atria do not rest even when the ventricles contract
183 Wicked fast 5 Rate: 290-bpm The atria do not even rest when the ventricles contract
184 Wicked fast Rate: 290-bpm The atria do not even rest when the ventricles contract 5 10
185 Wicked fast Rate: 290-bpm The atria do not even rest when the ventricles contract
186 Wicked fast Rate: 290-bpm The atria do not even rest when the ventricles contract
187 Wicked fast Rate: 290-bpm The atria do not even rest when the ventricles contract
188 Wicked fast Rate: 290-bpm The atria do not even rest when the ventricles contract
189 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
190 5-Part EKG Assessment 2. Rhythm: Regular
191 5-Part EKG Assessment 3. P-waves: P-waves? Look like rounded hill? P for every QRS? QRS for every P? P looks like each other? P same distance from the QRS?
192 5-Part EKG Assessment 3. P-waves: P-waves? NO F-wave (ski jump) P-wave (rounded hill)
193 5-Part EKG Assessment Flutter (F)-waves: Do not start in SA Node; impulse starts somewhere else within atria Subsequently it does not follow regular pathways and makes a unique wave More pointed, like a ski jump, saw tooth, or picket fence appearance
194 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
195 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.20-seconds Ok, you might say there is no P-wave, but don t worry. It s not significant compared to the appearance of the F-wave
196 PRI The PRI is a window into the effectiveness of the AV Node AV Node has the duty to delay the atrial impulse to allow for better ventricular filling In the case of Atrial Flutter, the AV Node still holds the impulse
197 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
198 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.08-seconds
199 This is Atrial Flutter 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 70 Regular No, F-waves Normal Narrow
200 Atrial Fibrillation (A-Fib) Atrial fibrillation may result from multiple areas of reentry within the atria or from multiple ectopic foci The atrial electrical activity is very rapid, but each electrical impulse results in the depolarization of only a small islet of atrial myocardium rather than the whole atrium
201 Atrial Fibrillation (A-Fib) Irregularly irregular: Implies that there is no repeating pattern, ever! If you looked at an entire minute of A-Fib, the pattern would never repeat
202 Time is length How long is 60-seconds?
203 Time is length How long is 60-seconds? 60-inches 5-feet
204 Atrial Fibrillation (A-Fib) 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 40 to 180 beats per minute Irregularly irregular No P-waves None Narrow
205 Atrial Fibrillation (A-Fib)
206 5-Part EKG Assessment 1. Rate: What is the rate?
207 5-Part EKG Assessment 1. Rate: 90-bpm
208 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
209 5-Part EKG Assessment 2. Rhythm: Irregular
210 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
211 5-Part EKG Assessment 3. P-waves: P-waves? No
212 5-Part EKG Assessment 3. P-waves: Could you argue that some waves look like P-waves?
213 5-Part EKG Assessment 3. P-waves: Could you argue that some waves look like P-waves? You could; however, they do not look like other waves that are preceding the QRS-complex
214 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
215 5-Part EKG Assessment 4. P to R Interval (PRI): No; no P-waves, no PRI
216 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
217 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.06-seconds
218 This is Atrial Fibrillation 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 90 Irregular None None Narrow
219 Junctional Rhythm If the AV node is not depolarized by the arrival of a sinus impulse within approximately 1.0 to 1.5 seconds, AV Junction will initiate an impulse It occurs because of failure of the sinus node to initiate an appropriately timed impulse or because of a conduction problem between the sinus node and the AV junction
220 Junctional Rhythm Normally a rate of 40 to 60 bpm, can be > 100 bpm P waves may precede, coincide with, or follow the QRS If P waves seen, they will be negative (upside down)
221 Junctional Rhythm 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: bpm, can be > 100 Usually regular Upside down, if seen Shortened Narrow
222 Junctional Rhythm, before
223 Junctional Rhythm, during
224 Junctional Rhythm, and after
225 The good, bad, and the ugly Which Junctional rhythm produces the poorest cardiac output? Which one is the besterer? Junctional Rhythm, P-wave before QRS Junctional Rhythm, P-wave during QRS Junctional Rhythm, P-wave after QRS
226 Which produces which output? 1. Good 2. Bad 3. Ugly A. Junctional Rhythm, before B. Junctional Rhythm, during C. Junctional Rhythm, after Which is which?
227 Good: Junctional Rhythm, after Although it may go against common sense, this is the best Because of the extended time for ventricular filling
228 Bad: Junctional Rhythm, before Poor cardiac output as AV node is bypassed resulting in very little ventricular filling time
229 Ugly: Junctional Rhythm, and during Worst cardiac output Identical to a compression in CPR as both chambers compressed at same time
230 5-Part EKG Assessment 1. Rate: What is the rate?
231 5-Part EKG Assessment 1. Rate: 50-bpm
232 Automaticity and Inherent Myocardial Cell Firings Remember the initiated heart rate from the AV Junction is a back-up system; it is here to keep us alive: SA Node: bpm (Not working) AV Junction: bpm Ventricles: bpm These are normal values, other rates can and do occur at times
233 5-Part EKG Assessment 2. Rhythm: Is the rhythm regular or irregular?
234 5-Part EKG Assessment 2. Rhythm: Regular
235 5-Part EKG Assessment 3. P-waves: Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
236 5-Part EKG Assessment 3. P-waves: Look like rounded hill? Uh, NO Looks like a U
237 No, not ewe too
238 5-Part EKG Assessment 4. P to R Interval (PRI): Is the PRI between 3-5 small boxes?
239 5-Part EKG Assessment 4. P to R Interval (PRI): Yes, 0.12-seconds But a little shortened
240 5-Part EKG Assessment 5. QRS-Complexes: Is QRS narrow or wide?
241 5-Part EKG Assessment 5. QRS-Complexes: Narrow, 0.06-seconds
242 This is Junctional Rhythm 1. Rate: 2. Rhythm: 3. P-waves: 4. PRI: 5. QRS: 50 Regular Inverted Slightly narrow Narrow
243 This is the end Stay tuned for the next installment of Basic EKG Review: Coming up later: Dreaded Heart Blocks Ventricular Rhythms
244 This program is the Intellectual Property of Lake Emergency Medical Services Use of this program is limited to training and Quality Education only Captain Mike Hilliard, Lake EMS Training Officer 2761 West Old Highway 441, Mount Dora, FL / (w); 352/ (f);
245 Lake EMS Basic EKG Review: Atrial Rhythms The Lake EMS Quality Development Team
Lake EMS Basic EKG Review: Dreaded Heart Blocks. The Lake EMS Quality Development Team
Lake EMS Basic EKG Review: Dreaded Heart Blocks The Lake EMS Quality Development Team This program is the Intellectual Property of Lake Emergency Medical Services Use of this program is limited to training
Basic EKG Interpretation. Nirja Parikh, PT, DPT
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