12 Lead ECG Interpretation: The Basics and Beyond
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1 12 Lead ECG Interpretation: The Basics and Beyond Cindy Weston, DNP, RN, CCRN, CNS-CC, FNP-BC Assistant Professor Texas A&M University College of Nursing Objectives Review the basics of 12 lead electrocardiogram Review the physiology of ECG Review when to order and mechanisms for coding and billing a 12 lead ECG Identify12 common arrhythmias and the evidence-based treatment Identify acute myocardial infarction and discuss current treatment guidelines Disclosures No Conflicts I struggled with everything cardiac in nursing school. 1
2 My Tips Understand Anatomy Take a Systematic Approach Ask yourself Is this clinically significant? Know common arrhythmias Know what to do about them Conduction System Willem Einthoven 2
3 Action Potential Intrinsic Rates SA Node beats/min AV Node beats/min Bundle of HIS beats/min Purkinje Fibers beats/min Basic Rhythm Depolarization 3
4 Waves & Intervals P wave Atrial depolarization (right then left) Usually upright (positive) PR interval seconds Measures start of atrial depolarization to start of ventricular depolarization Waves & intervals QRS wave/interval Q not always present, R first positive, S negative after R Ventricular depolarization < T wave Ventricular repolarization Usually upright May vary based on perfusion, electrolytes, meds Waves and Intervals QT interval < 0.40 seconds Corrected QTc ( ) Men <0.47; women < 0.48 > 0.50 DANGER!!! 4
5 Waves and Intervals U wave Repolarization of Purkinje fibers Electrolyte imbalance: hypokalemia, hypercalcemia, digoxin toxicity, use of some antiarrhythmics, congenital long QTc ST segment horizontal Sm box 0.04 sec Lg box 0.20 sec vertical Lg box 0.5mV Sm box 0.1mV ECG Graph paper 5
6 My Systematic Approach Rate Regularity Waves: p,q,r,s,t,u Intervals: PR, QRS, QTc ST segments R wave progression Axis: lead I & AVF RATE # QRS 6 second strip x 10 Memorize: 300, 150, 100, 75, 60, 50 rule 1500 / #small boxes between R-R waves Regularity 6
7 PQRST(U) waves Intervals: PR, QRS, QTc ST Segments 7
8 12 LEAD ECG 12 snapshots of the electrical conduction in the heart Inferior Latera l 12 Views Limb leads give 6 views I,II,III (Bipolar) AVR, AVL, AVF (unipolar, augmented vector) Precordial leads give 6 views V1, V2, V3, V4, V5, V6 Einthoven s Triangle 8
9 Precordial chest leads v leads 12 Lead ECG 3 limb leads (I, II, III) 3 Augmented Vector leads (AVR, AVL, AVF) 6 Precordial leads (V1-V6) 9
10 R wave progression AXIS Direction of electrical vector during ventricular depolarization AXIS- NORMAL Left- Wedding Ring Lead I Right- Aggie Ring Lead AVF 10
11 AXIS- LEFT Deviation Left- Wedding Ring Lead I Right- NO Aggie Ring Lead AVF AXIS- RIGHT Deviation Left- NO Wedding Ring Lead I Right- Aggie Ring Lead AVF AXIS- Extreme Right no man s land Left- NO Wedding Ring Lead I Right- NO Aggie Ring Lead AVF 11
12 12
13 Hypertrophy: LVH Left Axis Deviation R wave in AVL exceeds 13 mm R wave in V5 or V6 PLUS S wave in V1 or V2 exceeds 35 mm eye ball test QRS touch RVH 13
14 RVH BBB: Left 14
15 BBB: Right 15
16 16
17 BREAK TIME!!! 12 Common Issues Acute Coronary Syndrome STEMI NSTEMI/Unstable angina Contiguous Leads 17
18 STEMI Brown, H. (2014). Synopsis and review of the American College of Cardiology Foundation/American Heart Association 2013 ST-elevation myocardial infarction guideline. AACN Advanced Critical Care, 25(2), Contiguous leads 18
19 19
20 Contiguous Leads 20
21 STEMI Brown, H. (2014). Synopsis and review of the American College of Cardiology Foundation/American Heart Association 2013 ST-elevation myocardial infarction guideline. AACN Advanced Critical Care, 25(2),
22 STEMI Brown, H. (2014). Synopsis and review of the American College of Cardiology Foundation/American Heart Association 2013 ST-elevation myocardial infarction guideline. AACN Advanced Critical Care, 25(2), STEMI Brown, H. (2014). Synopsis and review of the American College of Cardiology Foundation/American Heart Association 2013 ST-elevation myocardial infarction guideline. AACN Advanced Critical Care, 25(2),
23 ST depression 23
24 24
25 T-wave inversion Q-waves 25
26 NPs treating suspected Acute Coronary Syndrome Give ASA 325 mg x1 STEMI If outpatient EMS transport to ED with notification If inpatient- prepare for reperfusion (STEMI protocol) ST depression/t-wave inversion/cp Serial cardiac enzymes Serial ECGs 12 Abnormal Rhythms Premature Beats 26
27 When to order a 12 lead Chest pain (duh!) Possibly indigestion, jaw pain, arm pain, anxiety, sense of doom. Palpitations Transient loss of consciousness New diagnosis HTN DX: HTN, Diabetes, Smoking, Hyperlipidemia Routine $8.00 Diagnostic with interpretation $16 What about Routine Screen? IPPE: Initial Preventative Physical Examination (no deductible or Co-payment!) G0403: Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report G0404: Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination G0405: Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination 27
28 12 Abnormal Rhythms Atrial Fibrillation Atrial Fibrillation Treatment Guidelines Antiarrhythmic Rate Control Rhythm Control 28
29 Anti-arrhythmics Top 12 Abnormal Rhythms Atrial Flutter 29
30 12 Abnormal Rhythms Supraventricular Tachycardia SVT 30
31 Treatment Vagal Adenosine Calcium channel blockers Digoxin Beta blockers Cardioversion 12 Abnormal Rhythms WPW 31
32 12 Abnormal Rhythms Sinus Tachycardia 32
33 12 Abnormal Rhythms Sinus Bradycardia Junctional Rhythm 12 Abnormal Rhythms 1 degree AV Block 33
34 12 Abnormal Rhythms 2 nd Degree AV Block Type 1 12 Abnormal Rhythms 2 nd Degree AV Block Type 2 12 Abnormal Rhythms Complete Heart Block 34
35 QUESTIONS? References Ecgpedia.org Thaler, M. (2015). The only EKG book you ll ever need. 8 th Ed. Lippincott Williams & Wilkins. Garcia, T. (2015). 12 Lead ECG: The art of interpretation. Burlington, MA: Jones & Bartlett Learning. Green, J. & Chiaramida, A. (2015). 12-Lead EKG Confidence: A step by step guide. New York: Springer Publishing Co. Dr. Smiths ECH Blog: EMS 12 Lead: Skillstat: 35
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