ekg recognition: when to worry recognition-collins.pdfekg recognition: when to worry roslinde m....
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EKG Recognition: When to Worry
Roslinde M. Collins, MD, D,ABSM, FCCP, FAASM
Medical Director, Center for Sleep Disorders at Rutland Regional Medical Center in Vermont
NEPS Conference
September 14, 2012
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Goals of this lecture
• To gain basic understanding of the electricity of the heart
• To review patterns of arrhythmias
• To know when a rhythm is life threatening or potentially life threatening
• Review special cases such as artificial pacemakers and AICDs
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Case #1: Spike Jonze
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Lessons Learned from Case #1:
• Keep an eye on your monitors
• It is helpful to hear your alarms
• No singing and dancing and fooling around in the trauma (control) room
• Don’t shock asystole
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AASM Cardiac Scoring Rules
• Score sinus tachycardia during sleep for a sustained sinus heart rate of greater than 90 beats per minute (bpm) for adults
• Score wide complex tachycardia for a rhythm lasting a minimum of 3 consecutive beats at a rate of greater than 100 bpm with QRS duration of greater than or equal to 120 msec
• Score narrow complex tachycardia for a rhythm lasting a minimum of 3 consecutive beats at a rate of greater than 100 bpm with QRS duration of less than 120 msec
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AASM Cardiac Scoring Rules (cont.)
• Score bradycardia during sleep for a sustained heart rate of less than 40/minute for ages 6 years through adult
• Score asystole for cardiac pauses greater than 3 seconds for ages 6 years through adult
• Score atrial fibrillation if there is an irregularly irregular ventricular rhythm associated with replacement of consistent P waves by rapid oscillations that vary in size, shape , and timing
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EKG Basics
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EKG=
Electrocardiogram=
ECG
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ECG Intervals and Waves-KH Frank G. Yanowitz, M.D., copyright 1997
The EKG complex
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Cardiac Conduction System Diagram - Marquette-KH Marquette Electronics Copyright 1996
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Depolarization = muscle contraction = Systole
Repolarization = muscle relaxation = Diasystole
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12 lead EKG
• Rate
• Rhythm
• Axis
• Ischemia, hypertrophy, etc.
Frontal and Horizontal Plane Lead Diagram-KH Frank G. Yanowitz, M.D.
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Rhythm Strip
• Rate
• Rhythm?
• Holter monitor (3 channels)
• Channel/lead
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(a) 25 seconds snap shot from sleep study in patient number 2 during wakefulness. White arrows show the beats that were initially reported as non-conducted P-waves. Upper channels (C3-A1) (01-A1): electroencephalogram; third and fourth channel (L-EOG-A1) (R-EOG-A1): oculogram; fifth channel (EMG1) (EMG2): electromyogram; sixth channel (EKG1) (EKG2): electrocardiogram; seventh channel (SaO2): oxygen saturation; eighth channel (LEG1) (LEG2): leg movement; ninth channel: airflow; tenth channel: chest movement; eleventh channel: abdomen movement. (Panel (b)) Amplification of the area under the highlighted rectangle in panel (a). White arrows show the PVCs followed by a post-extrasystolic pause. (Panel (c)) 12-lead ECG shows right bundle branch block. White arrows show PVCs arising probably from the left outflow tract.
Truths and Lies from the Polysomnography ECG Recording: An Electrophysiologist Perspective Case Report Med. 2009 May 4; 2009:675078
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Communication of an abnormal EKG
• There is a ________ (wide or narrow) complex __________ (regular or irregular) rhythm with a heart rate of ___.
• There is a ___ beat run of _________ (wide or narrow) complex _________ (regular or irregular) rhythm with a heart rate of ___.
• There is/are _______ second pause(s).
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EKG Interpretation
• Here’s what you need to determine/describe – Heart rate
– Morphology of QRS complex (narrow v. wide)
– Rhythm: regular or irregular
• Identify – Premature beats
– Tachycardia
– Bradycardia
– Pause/arrest/asystole
– Atrial fibrillation
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EKG Interpretation
1. Heart rate
2. Morphology of QRS complex (narrow v. wide)
3. Rhythm: regular or irregular
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First: Determine Heart Rate (Beats Per Minute)
• Do you believe your PSG software? (it counts QRS complexes)
• Do you believe your pulse oximeter? (it uses plethysmography)
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Determine Heart Rate (Beats Per Minute: there are 60 seconds in a minute!)
Count the QRS complexes in your EKG: – # QRS complexes in 60 seconds = BPM – # QRS complexes in 30 seconds X2 = BPM – # QRS complexes in 20 seconds X3 = BPM – # QRS complexes in 15 seconds X4 = BPM – # QRS complexes in 10 seconds X6 = BPM – # QRS complexes in 6 seconds X10 = BPM – # QRS complexes in 5 seconds X12 = BPM – # QRS complexes in 4 seconds X15 = BPM – # QRS complexes in 3 seconds X20 = BPM – # QRS complexes in 2 seconds X30 = BPM – # QRS complexes in 1 seconds X60 = BPM
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Determine Heart Rate: “Eyeballing It”
One second
One compex per second = 60 BPM (1X60) More than one complex per second is >60 BPM Less than one complex per second is <60 BPM
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Practice heart rate
(5 seconds)
(one second)
Heart rate of the whole strip: 6 complexes x 12 = 72
Heart rate of the triplet: 3 complexes x 60 = 180
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EKG Interpretation
1. Heart rate
2. Morphology of QRS complex (narrow v. wide)
3. Rhythm: regular or irregular
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QRS Morphology
Narrow = Normal
Wide = Abnormal
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Narrow (QRS) Complex vs. Wide (QRS) Complex
Narrow complex
• QRS interval is < 0.12 sec
• Originating from above or at the AV node
Wide complex
• QRS interval is > 0.12 sec
• Intraventricular conduction delay
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Wide QRS Complexes Are Abnormal
• Represent – Abnormal conduction through the ventricles
• LBBB, RBBB, fascicular blocks
• “Intraventricular conduction delay”
– Primary (pacemaker) of ventricular origin • Premature Ventricular Contraction (PVC)
• Idioventricular rhythm
• Ventricular tachycardia (VT)
• Ventricular fibrillation (VF)
• Artificial pacemaker (ventricular)
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Example of wide complex QRS
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How can I tell? Narrow Complex
• EEG spike
Wide Complex
• EEG K complex
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EKG Interpretation
1. Heart rate
2. Morphology of QRS complex (narrow v. wide)
3. Rhythm: regular or irregular
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Regular rhythm: R-R interval is constant (measure distance or time)
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Irregular rhythm (includes premature beats)
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Regular v. Irregular Rhythm
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Sinus Rhythm or Not? Look for the P waves!
Regular v. Irregular Rhythm
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Identify
–Premature beats
–Tachycardia
–Bradycardia
–Pause/arrest/asystole
–Atrial fibrillation
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Premature Beats: occur earlier than your next predicted
QRS complex
Premature Atrial Contractions (PACs)
• Narrow (usually)
• Look like EEG spikes
Premature Ventricular Contractions (PVCs)
• Wide complex
• Look like K complexes
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Premature Atrial Contractions (PACs)
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Premature Ventricular Contractions (PVCs)
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PVC patterns are important to recognize: abnormal PVC rhythms increase the risk of having deadly
ventricular rhythms such as Venticular Tachycardia (VT) and Ventricular
Fibrillation (VF)
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Bigeminy (every other beat is a PVC)
Trigeminy (every third beat is a PVC)
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Couplet
More than 3 PVCs = Ventricular tachycardia (VT)
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Identify
–Premature beats
–Tachycardia (heart rate greater than 100)
–Bradycardia
–Pause/arrest/asystole
–Atrial fibrillation
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Sustained Ventricular Tachycardia (VT)
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Non-Sustained Ventricular Tachycardia (NSVT)
• Heart rate of whole strip: 120 (12 x 10)
• Heart rate of burst of NSVT: 160 (8 x 20)
6 second strip
3 seconds
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Ventricular Fibrillation (VF or Vfib) (often looks like sawtooth waves!)
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VF: Torsades de Pointe (think of CSR)
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Holter monitor recording showing ventricular tachycardia degenerating to ventricular fibrillation. HR, heart rate. Cleveland Clinic
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Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF)
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Vfib Shocked
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AICD: Automatic Implantable Cardioverter Defibrillator
• Indicated in patients with previous VT, VF, sudden cardiac death or increased risk of ventricular arrhythmias
• Often has pacemaker ability
• Safe for health care providers to perform CPR, etc.
• Send the patient to the ED if the device discharges
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Sinus Tachycardia v. SVT (Supraventricular Tachycardia)
(10 second strip)
Heart rate is 25 x 6 = 150
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Burst of SVT: often seen in association with arousals following respiratory events
10 second strip
3 seconds
Heart rate of whole strip: 78 (13 x 6) Heart rate of SVT: 200 (10 x 20)
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Identify
–Premature beats
–Tachycardia
–Bradycardia (heart rate less than 60)
–Pause/arrest/asystole
–Atrial fibrillation
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Bradycardia: wide or narrow? P waves or not?
(6 second strip)
4 QRS complexes X 10 = 40 BPM
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Identify
–Premature beats
–Tachycardia
–Bradycardia
–Pause/arrest/asystole
–Atrial fibrillation
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Greater than 3 second pause is considered asystole
PAUSE/ARREST/ASYSTOLE
(3.5 seconds)
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Sick Sinus Syndrome Narrow complex irregular rhythm with frequent long pauses and escape beats.
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Artificial Pacemakers
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Atrial Pacemaker: spike instead of P wave
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Electronic Ventricular Pacemaker Rhythm - Marquette-KH
Marquette Electronics Copyright 1996
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AV Sequential Pacemaker - Marquette-KH Marquette Electronics Copyright 1996
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Identify
–Premature beats
–Tachycardia
–Bradycardia
–Pause/arrest/asystole
–Atrial fibrillation
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Atrial Fibrillation With Moderate Ventricular Response - Marquette-KH Marquette Electronics Copyright 1996
Atrial Fibrillation (Afib)
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Atrial Fibrillation with Rapid Ventricular Response (RVR) is a type of
Supraventricular Tachycardia (SVT)
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Abnormal EKG? Make sure that it’s real!
• Artifact can look like arrhythmias and even asystole
• Lead on the patient?
• Look in another channel/lead
• Asystole artifact: look for your pleth wave tracing or be happy that you have EKG artifact in your EEG
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When to Worry: The Threatening Threes
• Heart rate in the triple digits (> 100)
• Tachycardia of more than 3 beats in a row
• Heart rate in the 30s (or less!)
• Pause of greater than 3 seconds
• More than 6 PVCs per minute (or more than 3 PVCs per 30 second epoch)
• (Irregularly irregular heart rhythm)
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What do I do now?
• Confirm that the arrhythmia is real
• Check on the patient (ABCs)
• Call a code (or 911) if unstable
• If stable and unsymptomatic, call physician coverage if unsure about severity or transfer to ED
• Know your emergency policies and procedures
• Document well and sign out your findings
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Communication of an abnormal EKG
• There is a ________ (wide or narrow) complex __________ (regular or irregular) rhythm with a heart rate of ___.
• There is a ___ beat run of _________ (wide or narrow) complex _________ (regular or irregular) rhythm with a heart rate of ___.
• There is/are ________ second pause(s).
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(Free!) References
• http://library.med.utah.edu/kw/ecg/index.html “The Alan E. Lindsay ECG Learning Center in Cyberspace”
• http://en.ecgpedia.org/wiki/Main_Page “ECGPedia”
• http://learntheheart.com/ “LearnTheHeart.com”
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• Narrow or wide complex?
• Regular or irregular?
• Heart rate?
• What is it?
• Narrow
• Irregular
• 80
• NSR with pauses
(6 seconds)
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• Narrow or wide complex?
• Regular or irregular?
• Heart rate?
• What is it?
• Wide complex
• Regular
• 140
• VT until proven otherwise
(6 seconds)
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• Narrow or wide complex?
• Regular or irregular?
• Heart rate?
• What is it?
• Narrow
• Irregular
• 50
• Atrial fibrillation (Afib)
(6 seconds)
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(6 second strip)
• Narrow or wide complex?
• Regular or irregular?
• Heart rate?
• What is it?
• Wide
• Regular
• 50
• Wide complex bradycardia without P waves (likely idioventricular)
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(6 second strip)
• Narrow or wide complex?
• Regular or irregular?
• Heart rate?
• What is it?
• Narrow
• Irregular
• 110
• Sinus tachycardia with two unifocal PVCs