BEDSIDE ECG INTERPRETATION
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1 BEDSIDE ECG INTERPRETATION Presented by: Ryan Dean, RN, MSN, CCRN, CCNS, CFRN Flight Nurse 2017 Based on presentations originally by Gennifer DePaoli, RN
2 Objectives Hospital policies Electrical conduction pathway How to interpret a rhythm strip Sinus and atrial dysrhythmias Junctional and ventricular dysrhythmias Paced rhythms Medications and treatment Common mistakes Questions???
3 Hospital Policies for Telemetry Patients Record EKG strips every 4 hours Patient is always on a cardiac monitor, even if off the unit All EKG changes need to be: Recorded MD notified For better or for worse!
4 Bedside Telemetry Look at the patient- are they perfusing? Level of consciousness Vital signs Skin signs Look at the rhythm Regular or irregular Are there P waves present Narrow or wide Fast or slow
5 Electrical Conduction Pathway SA node: BPM AV node: BPM Ventricles: BPM
6 Autonomic Nervous System FIGHT OR FLIGHT
7 Willem Einthoven ( ) Dutch doctor and physiologist Invented the first practical electrocardiogram (EKG or ECG) in 1903 Assigned the letters P, Q, R, S and T to the various deflections still used today The term "Einthoven's triangle" is named for him. It refers to the imaginary inverted equilateral triangle
8 Einthoven s Triangle Limb leads: positive and negative electrodes. (bipolar) -Leads I, II, III Augmented leads: only positive electrodes (unipolar) - Leads avr, avl, avf *Heart is the zero reference point or central terminal
9 How to Read a Rhythm Strip The conduction of an electrical impulse for a single heart beat normally contains five major waves: P, Q, R, S, AND T A cardiac cycle is measured from the beginning of one P wave to the beginning of the next P wave
10 Measuring Intervals PRI: 0.12 to 0.20 sec QRS: < 0.12 sec QTI: < ½ of R to R interval
11 Interpreting a Rhythm Strip 1.) P waves- examine each P wave - Are there P waves present? Are they all upright? - Do all P waves look alike? - Is there a P wave before every QRS complex? - Are the P to P intervals equal? 2.) PR intervals- measure each PRI - Are PRI s present? If so, are they equal? - Are all PRI s within the normal range of 0.12 to ) QRS complexes- examine and measure each complex - Are all QRS complexes present? Do they look alike? - Is there a QRS complex after every P wave? - Are the R to R intervals equal? - Are all QRS complexes within the normal range of <0.12 sec?
12 QT/QTc Does QT=QTc? Why do we care? Drugs can change the interval.
13 Interpretation Practice How is the quality of the strip? Is there artifact? Does it look regular? If not sure, use calipers or paper to measure. Are there P waves, PRI s, QRS complexes? Are they WNL?
14 More Practice
15 Normal Sinus Rhythm What is the atrial rate? Ventricular rate?
16 Sinus Bradycardia Less than 60 BPM What is the atrial rate? Ventricular rate? Are there P waves present? Does a QRS complex follow every P wave? Is SB ever a normal finding? What are signs of poor cardiac output? What are some causes of SB?
17 Sinus Tachycardia 101 to 150 BPM What is the atrial rate? Ventricular rate? Are there P waves present? Does a QRS complex follow every P wave? Is ST ever a normal finding?
18 Sinus Arrhythmia Regularly Irregular What is the atrial rate? Ventricular rate? Are there P waves present? Does a QRS complex follow every P wave? Is this a normal finding?
19 Atrial Dysrhythmias Most atrial dysrhythmias are not lethal but some may require intervention. Patient assessment is necessary to determine tolerance of the dysrhythmia.
20 Premature Atrial Contraction (PAC) PAC s originate from any atrial site outside of the SA node NOTE: Although the term contraction is used with PAC, this complex represents electrical activity and may not reflect an actual contraction.
21 Supraventricular Tachycardia (SVT) Greater than 150 BPM Can you identify P waves? Are the intervals WNL? What interventions or treatments might be implemented?
22 Atrial Flutter Saw-toothed waves Flutter waves have a typical saw-toothed appearance Ventricular rate is typically BPM Atrial rate usually ranges from impulses per minute Loss of atrial kick
23 Atrial Fibrillation No identifiable P waves or PRI s The atrial heart rate is typically Loss of atrial kick- no forceful contraction of atria Irregularly Irregular
24 40 to 60 impulses/minute Characteristic P wave changes Junctional Dysrhythmias
25 Junctional Dysrhythmias P wave Characteristics: inverted, buried, and retrograde
26 Junctional Bradycardia and Accelerated Junctional
27 Practice
28 Heart Blocks
29 First-Degree Heart Block PR interval > 0.20 seconds * Not a true block, but a delay in the electrical conduction
30 Second-Degree Heart Blocks Two types of 2 nd degree heart blocks: type I and type II Interruption in the conduction of an electrical impulse through AV Junction
31 Second-Degree Heart Block, Type I
32 Second-Degree Heart Block, Type II Intermittent interruption Not a progressive block PRI s are constant
33 Third-Degree Heart Block Lethal dysrhythmia!!! Complete dissociation, atria and ventricles function independently Atrial rate is usually between , ventricular rate is Treatment???
34 Bundle Branch Block
35 QRS > 0.12 Assess V1 for QRS morphology Patients with a prolonged QRS (> 0.15) may require a pacemaker Bundle Branch Blocks
36 Practice with Heart Blocks
37 More Practice
38 Ventricular Dysrhythmias QRS > 0.12 Wide and Bizarre Hidden P waves BPM
39 Premature Ventricular Contraction (PVC)
40 Premature Ventricular Contraction (PVC) Patient Assessment? Treatment?
41 Ventricular Tachycardia Life-threatening dysrhythmia! Wide and bizarre Rate of impulses/min Pulses vs. pulseless
42 Lethal dysrhythmia! Wide and bizarre Often > 150 impulses/min Pulses vs. pulseless Torsades De Pointes
43 Ventricular Fibrillation Pulseless!!! Lethal dysrhythmia
44 Idioventricular/Agonal Dysrhythmia Lethal! Last attempt!
45 Asystole Lethal! Immediate Treatment Required!
46 Name this rhythm
47 Pulseless electrical activity Can be ANY electrical rhythm PEA
48 Pacemakers!
49 Pacemaker Terminology Fixed- set to generate impulses at a constant rate, usually 60-80/ min Demand- set to generate electrical impulses only when the patient s heart rate falls below a predetermined rate, usually <70 BPM Capture- the cardiac cell s ability to depolarize in response to the electrical impulse generated by a mechanical pacemaker Sensing- the ability of the pacemaker to detect an intrinsic depolarization
50 Sensing Factors That May Affect Sensing Are: Lead polarity (unipolar vs. bipolar) Lead integrity Insulation break Wire fracture EMI Electromagnetic Interference MRI machines
51 Under-sensing... Pacemaker does not see the intrinsic beat, and therefore does not respond appropriately Intrinsic beat not sensed Scheduled pace delivered
52 Over-sensing An electrical signal other than the intended P or R wave is detected Marker channel shows intrinsic activity......though no activity is present
53 Interpretation
54 More Interpretation What s happening in this strip?
55 More Rhythms
56 Ventricular Rhythm Practice
57 More Practice
58 And Even More Practice
59 Looks Like ST vs A-flutter (2:1) LBBB vs STEMI SVT vs A-fib Pericarditis vs STEMI V-fib vs broken wire Junctional vs a-fib (slow)
60 Dysrhythmia Interpretation Practice Practice, Practice, and More Practice Evaluate P waves Measure PR intervals Evaluate the QRS complexes, including shape and size Identify any abnormalities in the ST segments, T waves, and QT intervals Count both the atrial and ventricular rates Look for unusual markings, such as pacer spikes
61 Common Causes: H s and T s The H s include: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyper-/hypokalemia (check K and Mg levels, Hypothermia The T s include: Toxins, Tamponade (cardiac),tension pneumothorax, Thrombosis (coronary and pulmonary), Trauma
62 Putting It All Together Always assess your patient first! Determine the situation Investigate the cause Intervene/Treatment Reassess
63 Questions???
64 Bonus Slides
65 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
66 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
67 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
68 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
69 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
70 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
71 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
72 Rhythm Interpretation MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION: MEASURE: PR interval Rhythm QRS complex Heart rate INTERPRETATION:
73 Sgarbossa Criteria Discordance: Opposite deflections of the QRS and ST segment Concordant STE > 1mm in any lead Discordant STE > 5mm Concordant STD > 1mm in V1, V2, or V3
74 Sgarbossa Criteria 64 yo female, difficulty breathing Pulmonary edema was present upon exam and this is the initial 12-Lead. What do you see?
75 Pericarditis Acute vs. Chronic
76 Pericarditis 12-Lead ECG
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