CARDIAC/ECG MODULE
THE HEART
CORONARY ARTERIES
FIBRILLATING HEART
CORONARY ARTERIES HEART
PRACTICE RHYTHMS
PRACTICE RHYTHMS
ELECTRICAL CONDUCTION SA Node (60 100) Primary pacemaker AV Node (40 60) ***Creates a pause*** Secondary pacemaker if SA fails to fire Bundle of His L & R Bundle Branches Bundle of His Perkinje Fibers (20 40) Final pacemaker if SA and AV fail to fire AV Junction
ELECTRICAL CONDUCTION Bundle of His AV Junction
ANIMATION OF HEARTBEAT / PQRST
TERM - DEPOLARIZATION Batteries Discharge Deliver electrical energy Cause electric motor to spin, music to play Cells Depolarize Produce electrical energy Cause muscle to contract
TERM - REPOLARIZATION Batteries Recharge Cells Repolarize
ELECTRICAL COMPLEX P wave = atria depolarize QRS = ventricles depolarize T = ventricles repolarize Each PQRST complex normally causes one heartbeat.
SHAPE OF COMPLEXES What do sinus complexes look like? Presence of a round upright P wave Rate usually between 60-100 What do junctional complexes look like? Missing a round upright P wave Rate usually between 40-60 What do ventricular complexes look like? Wide bizarre looking QRS Rate usually between 20-40
SHAPE OF QRS COMPLEX Height Depends on your view point! Worry about width not the height! GOOD BAD GOOD GOOD
ECG GRAPH PAPER ECG Machine Calibration 1 mv tall (2 boxes) Remember: * Paper speed is 25 mm/sec * 1 little box width is.04 seconds (.04 x 5 =.2 seconds) * 1 big box width is.2 seconds * ECG calibration 1mV tall (2 big boxes)
FINDING THE RATE Count the number of QRS complexes in a 6 second strip and multiply by 10.
FINDING THE RATE Rule of 300- Divide 300 by the number of boxes between each QRS = rate (REGULAR RATES ONLY!) Number of big boxes Rate 1 300 2 150 3 100 4 75 5 60 6 50
RATES Sinus < 60 is called: Sinus 60 100 is called: Sinus > 100 is called: sinus bradycardia normal sinus rhythm sinus tachycardia Junctional 40 60 is called: Junctional 60 100 is called: Junctional >100 is called: junctional rhythm accelerated junctional rhythm junctional tachycardia Ventricular 20 40 is called: Ventricular 40 100 is called: Ventricular > 100 is called: ventricular rhythm (idioventricular IVR) accelerated ventricular rhythm ventricular tachycardia (V-tach)
PRACTICE RHYTHMS
SINUS TACYCARDIA
PRACTICE RHYTHMS
NORMAL SINUS RHYTHM
PRACTICE RHYTHMS
NORMAL SINUS RHYTHM Don t worry about the direction of the QRS.
PRACTICE RHYTHMS
SINUS BRADYCARDIA
PRACTICE RHYTHMS Note: Not a 6 second strip
JUNCTIONAL TACHYCARDIA Note: Not a 6 second strip
PRACTICE RHYTHMS
ACCELERATED JUNCTIONAL RHYTHM
PRACTICE RHYTHMS
SUPRAVENTRICULAR TACHYCARDIA A giant term that simply means it is NOT coming from the ventricles! Might be junctional or might be atrial.
PRACTICE RHYTHMS
IDIOVENTRICULAR RHYTHM (IVR)
PRACTICE RHYTHMS
ACCELERATED VENTRICULAR RHYTHM
PRACTICE RHYTHMS
VENTRICULAR TACHYCARDIA Always shortened to V Tach Example: Patient is in V tach.
PRACTICE RHYTHMS
V TACH INTO V FIB An AED would advise a shock for either of these rhythms!
PRACTICE RHYTHMS
V FIB / A FIB Atrial Fibrillation: fibrillation instead of P waves & irregular rhythm
PRACTICE RHYTHMS
VERY COOL STRIP!!! Sinus to V Tach SHOCK - ------------V Fib --------------------SHOCK ---- sinus
PRACTICE RHYTHMS
NORMAL SINUS RHYTHM WITH PVC
PRACTICE RHYTHMS
.28 1 ST DEGREE HEART BLOCK PR interval greater than.20 (1 big box) is a 1 st degree heart block. The delay at the AV node is too long.
2 ND DEGREE HEART BLOCK Some of the impulse can t pass through the AV node and the QRS s get dropped.
COMPLETE HEART BLOCK 3 RD DEGREE None of the atrial impulses get though the AV node. The sinus node fires at its own rate of 60-100 (see the P waves) and the ventricles fire at their own rate of 20 40. Only the ventricles produce a pulse! This is very dangerous and will require a pacemaker to be inserted ASAP.
PACED RHYTHMS Heart with a pacemaker set at 60 is in place. See the pacer spikes? Failure to capture. The pacemaker doesn t always cause a contraction. The patient may feel lightheaded or even faint.
4 LEAD VS 12 LEAD 4 LEAD ECG 12 LEAD ECG Looks for rhythm problems Has 4 limb wires (W, B, R & G) Great for continuous monitoring Looks for heart attacks also Has 4 limb wires (W, B, R & G) Has 6 chest wires (V1 V6) 10 wires (6+4) can give us 12 leads or views of the heart.
4 LIMB LEAD PLACEMENT (BIPOLAR)
6 CHEST OR PRECORDIAL LEAD PLACEMENT (UNIPOLAR) V1 4 th Intercostal space (ICS) right sternal border V2 4 th Intercostal space (ICS) right sternal border V4 5 th ICS Mid clavicular line (MCL) V3 Between V2 and V4 V6 5 th ICS Mid Axillary Line V5 Between V4 and V6
TECHNICAL PROBLEMS 60 Hz AC - Electrical interference ECG cables near electric machinery such as hospital bed motor etc. or poor grounding of equipment. Artifact can be cause by: Somatic Tremor shivering, patient moving, nervousness Touching cables Poorly attached electrode(s) ECG cable movement while recording the strip can cause a wandering baseline
OBTAINING A QUALITY 12 LEAD 1. Skin prep is important Dry wet or oily skin Shave or clip chest hair Gently abrade dead skin 2. Reduce chance for artifact Minimize patient movement Secure cables no big loops Watch electrical interference
LEADS ARE VIEWS OF THE HEART Like cars, no one lead (view) shows it all.
WHAT A 12 LEAD ECG LOOKS LIKE 12 Leads: I AVR V1 V4 II AVL V2 V5 III AVF V3 V6
Called Bipolar because leads look between 2 poles
avr Right Side avl Left Side avf - Foot Remember: - Regular Limb leads (I, II, III ) are Bipolar - Augmented leads are Unipolar - Chest (Precordial )Leads are Unipolar
Remember: - Regular Limb leads (I, II, III ) are Bipolar - Augmented leads are Unipolar - Chest (Precordial )Leads are Unipolar
ST ELEVATION = MI (STEMI) ST ELEVATED MYOCARDIAL INFARCTION Locating the ST elevation helps to find the heart attack!
HEART ATTACK LOCATION CHART MI Location Leads showing Leads showing ST elevation ST depressions
WHERE IS THE HEART ATTACK? Rate: Rhythm: Impression:
WHERE IS THE HEART ATTACK? Rate: Rhythm: Impression:
SCENARIO #1 CHEST PAIN (PART 1) 45 year old male complaining of chest pain for 2 hours. You attach him to the monitor and this is the ECG strip recorded in Lead II. Rate: Rhythm: Do you see anything on the strip to be concerned with? Yes No If Yes, explain:
SCENARIO #1 CHEST PAIN (PART 2) Rate: Rhythm: Impression:
SCENARIO # 2 ROUTINE PHYSICAL Rate: Rhythm: Impression:
SCENARIO # 3 ROUTINE PHYSICAL You record this 12 Lead at a clinic and the M.D. tells you to repeat it. Why? Give possible causes: Give possible solutions: