microsoft power point - ekg notes

8/3/2019 Microsoft Power Point - EKG Notes

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Basic Dysrhythmias

Adam Glaser, BS, EMT-P

-Electrical Conduction of the Heart-A System of Defining 3-Lead EKGs


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Pieces Parts


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Electrical

Conductionand the ECG

Electrical

Conductionand the ECG


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The Isoelec t r ic L ine


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EKG Waveforms

Cardiac Cycle = P, QRS, and T

Waves

Deflections from/to iso-line Segments

Sections between waveforms (ST)

Intervals From wave to complex (PR-I)


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The Electrocardiograph

Electrical Activity

Not Muscle Records +/ impulses Paper 25mm/s Counting Rates

300-150-100-75-70-60-50 6 s x 10 10 s x 6 The little number on

the monitor


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Lead Considerations $25,000 mVoltmeter

Lead Views:

1 Superior

2 Inferior, Anterior

3 Inferior, Left


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The Components SA Node

Internodal Pathways

AV Junction

AV Node

Bundle of His

L & R Bundle Branch

Purkinje Network Purkinje Fibers


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Ode to a Node Have a heart, and have no fear,

The SA node is over here.Beating at a constant rate,

60 100 is really great.The AV node can make a show,If SA node has gone too slow.

40 60 is not too badIf its all youve got, you will be glad.Should the whole thing drop its speed,

His and bundle branches will take the lead.And that, my friend is the whole and part,

Of the conduction system of your heart. Flip and See ECG, Cohn/Gilroy-Doohan


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Sino AtrialNode

The Natural Pacemaker

Connects directlyto atrial fibers

Fires 60-100 times per

minute

Wavelike AtrialDepolarization

The P-Wave

P-Wave

P-R Interval

Q-Wave

.04 Sec .04 Sec .04 Sec .04 Sec .04 Sec

0.20 Seconds per 5 Boxes


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AV Junction

Receives impulses from

SA Node via the AtrialCells An electrical funnel

Impulses hit at varioustimes

Causes delay PR-I

Susceptible to blockage Path from A to V

Delivers impulse to the AV

Node


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Atrio-Ventricular Node Lies between the Atria

and Ventricles Collects impulses from

above

Stimulates Ventricles If unstimulated

Intrinsic rate 40-60


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Bundle of His /Left and Right Bundle Branches

Distributes Impulses from theNode

The Ventricular Messengers


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Purkinje Network/Fibers

Direct connection with

ventricular tissue

Intrinsic rate 20-40 ifunstimulated

P-Wave

P-R Interval

QRS

Complex

T-Wave


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The Six Step Approach What is the Rate?

Is the Rhythm Regular?

Are there P-Waves?

Is the P-R Interval Normal? Is the QRS Complex Normal?

Is There a P-Wave for Every QRS?


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Step 1 = Rate Is the rate between 60-100 (Sinus)

Between 40-60 (Junctional/Bradycardic)

Above 100 (Tachycardic)

Between 20-40 (Ventricular)


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Step 2 = Regularity At-a-glance: Does it look regular?

Are the P-Waves evenly spaced?

Are the QRS Complexes evenly spaced?


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Step 3 = P-Waves Are P-Waves present?

Are they upright and rounded?

Are they irregular in any way: Notched /

Peaked / Depressed? Are they all the same?


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Step 4 = P-R Interval Is the P-R Interval between 0.12-0.20?

Is it too long / too short? (Block)

Is it the same on every conduction?

Is it absent?


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Step 5 = QRS Complex Is it there?

Is it between 0.04 - 0.12?

Does it have any abnormalities? (Notched

/ Rabbit Eared / Wide / Bizarre)


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Step 6 = P-QRS Married? Is there a P-wave for every QRS?

Are there more P-Waves than QRS?

Are the P-Waves after or within the QRS?


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Describe What Youve Found!!! IN GENERAL (underlying rhythms)!!!

What are the abnormalities?

Does it originate in the Sinus Node?

Does it follow through from the Atria to theventricles? Are there abnormal delays?

What are the exceptions to the underlying

rhythm? (Describe those also)


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E K G I N T E R P R E T A T IO N C H A R T

R H Y T H M R A T E R E G U L A R IT Y P -W A V E ( U /R ) P -R

I N T E R V A L

Q R S P - Q R S

M A R R I

N S R 6 0 -1 0 0 R e g u la r N o r m a l/U p r ig h t /R o u

n d e d

0 .1 2 - 0 .2 0 se c . 0 .0 4 -

0 . 1 2

Y e s

S i n u s

T a c h y c a r d i a

A b o v e

1 0 0

R e g u la r N o r m a l/U p r ig h t /

R o u n d e d

0 .1 2 - 0 .2 0 s e c 0 .0 4 -

0 . 1 2

Y e s

S i n u s

B r a d y c a r d i a

B e lo w 6 0 R e g u la r N o r m a l/U p r ig h t /

R o u n d e d

0 .1 2 - 0 .2 0 s e c 0 .0 4 -

0 . 1 2

Y e s

S i n u s

A r r h y t h m i a

6 0 -1 0 0 I r r e g u la r N o r m a l/U p r ig h t /

R o u n d e d

0 .1 2 - 0 .2 0 s e c 0 .0 4 -

0 . 1 2

Y e s

A t r i a l

Fibr i l lat ion

U s u a l ly

T a c h y

I r r e g u l a r N o t D isc e r n ib le N o t D isc e rn ib le 0 .0 4 -

0 . 1 2

N o t

D i s c e r n i

A tr ia l F lu t t e r M a y b e

N o r m a l / T a c h y

A t r i a - r e g u l a r /

V e n t r i c le s -r e g u l a r o r i r r e g u l a r

S a w t o o t h p a t te r n ,

2 : 1 , 3 : 1 , 4 : 1 r a t i o s

0 . 1 2 - 0 . 2 0 o n t h e

c o n d u c t i ng b e a t

0 . 0 4 -

0 . 1 2

O n t he

c o n d u c t if lu t t e r w

( P ) S V T 1 4 0 -2 2 0 R e g u la r I n Q R S /T c o m p le x

o r n o t p r e s e nt

S h o r t e ne d o r

a b s e n t

0 . 0 4 -

0 . 1 2

N o

1 st D e g r e e

B l o c k

N o r m a l R e g u la r N o r m a l/ U p r ig h t /

R o u n d e d

L o n g e r t ha n

0 . 2 0

0 . 0 4 -

0 . 1 2

Y e s

2 n d D e g r e e

( T y p e 1 )

W e n c k eb a c h

N o r m a l

o r B r a d y

I r r e g u la r N o r m a l/U p r ig h t /R o u

n d e d

L e n g t h e n i n g

un t i l bea t is

d r o p p e d

0 . 0 4 -

0 . 1 2

N o

2 n d D e g r e e

( T y p e 2 )M o b it z I I

B r a d y I r r e g u la r N o r m a l/U p r ig h t /R o u

n d e d 2 : 1 , 3 : 1 , 4 : 1

N o r m a l o r lo n g

o n c o n d u c t edb e a t s

0 . 0 4 -

0 . 1 2

O n t he

c o n d u c t iW a v e

3 rd D e g r e e

C o m p l e t e

H e a r t B l o c k

4 0 -6 0 A t r ia -R e g u la r

V e n t . - R e g u l a r

N o r m a l / U p r i g h t /

R o u n d e d

A t r i a

in d e p e n d e n t o f

V e n t r i c le s

U s u a l ly

g r e a t e r

t h a n

0 . 1 2

N o

J u n c t i o n a l

( a c c e l / t a c h )

4 0 - 6 0

( 6 0 + /

1 0 0 + )

R e g u la r I n v e r t e d /R e t ro g ra d e /

A b s e n t

S h o r t / N o r m a l /

A b s e n t

0 . 0 4 -

0 . 1 2

Y e s - if P

is visible

V e n t r ic u l a r

T a c h y c a r d i a

1 0 0 -2 2 0 U su a lly R e g u la r N o t D isc e rn ib le

(usua l ly )

N o t D isc e rn ib le G r e a te r

t h a n

0 . 1 2

N o

V e n t r ic u l a r

Fibr i l lat ion

R a p i d /

C h a o t i c

I r r e g u la r N o t d is c e rn ib le N o t

D e t e r m i n a b l e

W id e / B i

z a r r e

N o

A sy s t o le 0 N /A N o n e N o n e N o n e N o

A g o n a l

I d i o v e n t r i c u l a r

2 0 -4 0 I r r e g u la r N o n e N o n e W id e N o

- P V C - W id e , B iz a r r e Q R S C o m p l e x , L o o k a t u n d e r ly in g r h y t h m . C a n a p p e a r in c o u p l e t s , t r ip l e t s, o r s h o r t r u n s o f V T

b e m u l t i- f o c a l o r u n i- f o c a l . C a u s e d b y r a n d o m f ir in g w i th i n t h e v e n t r i c le s . N o a t r i a l f ir in g .

- P A C - C o n d u c t e d b e a t a p p e a r i n g in a n o t h e r w is e n o r m a l r h y t h m . S t i m u l i o r i g in a t e s w it h in t h e a t r ia , b u t n o t in t h e S A .- I f B u n d l e B r a n c h B l o c k o c c u r s , Q R S w ill u s u a l ly b e w i d e r t h a n 0 . 1 2 .


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Normal Sinus Rhythm Rate: 60 - 100

Regularity: Very

P-Waves: Present and Normal

P-R I: 0.12-0.20 sec

QRS: 0.04-0.12 sec and Normal Married: 1 P: 1 QRS, no extras or shortages


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Sinus Arrhythmia Rate: 60 - 100

Regularity: Irregular


P-R I: 0.12-0.20 sec



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Sinus Tachycardia Rate: Over 100 Regularity: Regular


P-R I: 0.12-0.20 sec



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Sinus Bradycardia Rate: Less than 60

Regularity: Regular


P-R I: 0.12-0.20 sec

QRS: 0.04-0.12 sec and Normal

Married: 1 P: 1 QRS, no extras or shortages


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Atrial Fibrillation Rate: Usually tachy

Regularity: Irregular (Irregularly irregular)

P-Waves: Not Discernible

P-R I: Undeterminable

QRS: 0.04-0.12 sec

Married: Undeterminable


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Atrial Flutter Rate: Usually tachy

Regularity: Atria Regular Ventricles May be Irregular

P-Waves: Sawtooth Pattern 2:1, 3:1, 4:1...

P-R I: 0.12-0.20 sec on conducting beat

QRS: 0.04-0.12 sec

Married: P-waves outnumber QRS

(Picket fence)


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(Paroxysmal) Supra Ventricular

Tach Rate: 140-220 Regularity: Regular

P-Waves: Usually falls within the QRS-Tcomplex (not visible)

P-R I: Shorter than 0.12, or absent

QRS: 0.04-0.12 sec and Normal

Married: Undeterminable


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SVT WPW

Usually based on Hx. Delta wave on Q

Shortened PR-I

No Verapamil Accessory Path useincrease


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1st Degree Heart Block Rate: 60 - 100

Regularity: Very


P-R I: Longer than 0.20 sec



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2nd Degree Heart Block (Type

1) Wenkebach Rate: Can be Normal, or usually brady



P-R I: Lengthens until beat is dropped

QRS: 0.04-0.12 sec and Normal Married: P-wave present on conducting beats,

increased delay causes missed QRS

n egree eart oc ype


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n egree eart oc ype

2)Mobitz II Rate: Less than 60 Regularity: Irregular

P-Waves: Present, 2:1, 3:1, 4:1

P-R I: 0.12-0.20 sec on conducting beat

QRS: 0.04-0.12 sec, may begin to widen

Married: P-wave for every QRS and extras

depending on conduction ratio


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3rd Degree Heart Block (CHB)

Complete Heart Block Rate: Ventricular Rate 40-60

Regularity: Atria-Regular

Vent-Regular P-Waves: Present and Normal

P-R I: Atria independent of Ventricles

QRS: Usually greater than 0.12 sec

Married: P-waves completely unrelated to QRS

Complexes.


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Complete Heart Block


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Junctional Rhythm Rate: 40-60 Regularity: Regular

P-Waves: Inverted, Retrograde or Absent P-R I: Shortened or absent

QRS: 0.04-0.12 sec

Married: P-wave for every QRS, sometimes notvisible


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Junctional


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Junctional Accelerated Rhythm

Rate: 60-100

Regularity: Regular

P-Waves: Inverted, Retrograde or Absent

P-R I: Shortened or absent

QRS: 0.04-0.12 sec

Married: P-wave for every QRS,sometimes not visible


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Junctional Tachycardia

Rate: 100-140

Regularity: Regular

P-Waves: Inverted, Retrograde or Absent

P-R I: Shortened or absent

QRS: 0.04-0.12 sec

Married: P-wave for every QRS,sometimes not visible


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Ventricular Tachycardia Rate: 100-220

Regularity: Regular

P-Waves: None P-R I: None

QRS: Greater than 0.12 sec Married: NO

Well look at Torsades de Pointes in Lab


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Ventricular Tachycardia


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Ventricular Fibrillation Rate: No ventricular rate Regularity: Irregular

P-Waves: No P-R I: No

QRS: No, unorganized ventricular baseline

Married: No


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Ventricular Fibrillation


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Asystole

Rate: 0

Regularity: N/A

P-Waves: None

P-R I: N/A

QRS: None

Married: No (verify a second lead)


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Asystole


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Agonal / Idioventricular

Rate: 20-40


P-Waves: None

P-R I: N/A QRS: Wider than 0.12 sec

Married: NO (a dying heart)


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Idioventricular Less regular than this!


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Exceptions / Disruptions Premature Ventricular Contractions

Premature Atrial Contractions Bundle Branch Blocks

Pacer Considerations (Atrial, Ventricular orBoth)

Premature Ventricular


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Premature Ventricular

Contractions Wide, Bizarre QRS Complex

Always identify the underlying rhythm first Can appear in couplets, triplets, short runs

of V-Tach, bigeminy and trigeminy

Can be uni-focal or multi-focal

Caused by random firing within the

ventricles Not accompanied by a P-wave


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PVCs


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PACs P-QRS Complex

appearing in an

unexpected location

Caused by a stimulusfrom within the Atria,

but not from the SANode


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PJC


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Bundle Branch Block Any rhythm having a BBB will have a

widened twin peaked R-Wave


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Paced Rhythms Patients may have various types of

pacemakers Atrial

Ventricular

Both

Vertical spike on monitor is an indicator


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Paced Rhythms Various


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Artifact 60 Cycle Interference

Loose Leads/Moving Ambulance


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Rhythm Interpretation andPatient Assessment

A 68 year-old female complains of shortness of


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breath for the last day. She is feverish and has aproductive cough. Her BP is 164/78, HR

matches with the ECG below, and RR of 20.She speaks in 6 word-sentences. She has

rhonchi in her right lung. Her past medicalhistory includes an MI 4 years ago and mild

hypertension.

A 61 year-old male collapses at a localb i CPR t t d b hi


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business. CPR was started by his co-workers. The patient has a history of highcholesterol, hypertension and was recently

diagnosed with angina. Your quick-lookreveals the following rhythm.

A 65 year-old male calls for weakness. The patientstates that he has been feeling this way over the


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states that he has been feeling this way over the

last 2 days and becomes more short of breath withactivity. He also becomes dizzy when he standsup. The patient has a history of COPD and is on

home oxygen at 2 liters/minute. His BP is 128/84,RR 22 with some pursed-lip breathing. He states

that he has a history of skipped heart beats. Lung

sounds reveal wheezes in the mid-lobes and bases.He takes Alupent, prednisone, Altace and Cozaar.

A 78 year-old male is found unconscious in his


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bed. He was last seen the night before by hisfamily. As you move him to the floor, you seethat a bottle of nitroglycerin falls out of the bedand onto the floor. The patient is warm but his

back reveals mottling. He is pulseless andapneic.

You respond to a 58 year-old male in cardiac


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arrest. The patients daughter tells you that hedidnt feel well for the last few days.

She also states that he is a chronic alcoholic.The patient is lying in his bed, pale-gray in color

and apneic. He is also pulselessness. Hisabdomen is distended and he has large blood

stains on his pillow.

A 58 year-old male complains of dizziness andnausea The symptoms started 45 minutes ago


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nausea. The symptoms started 45 minutes ago

when he was getting dressed for work. Thesymptoms did not change when he lied down onthe couch. He denies chest pain or jaw pain. He

had a similar episode 4 months ago but thesymptoms resolved. His BP is 100/50, HR below,and RR of 16. His CBG is 80. Lung sounds are

clear.6-sec ond st r ip

A 70 year-old male experienced a syncopal


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A 70 year old male experienced a syncopal

episode. He is found on his bed, pale anddiaphoretic. He has had problems with dizzinesswhen standing up for the last few days. He had

dark tarry stools for the last week. His BP is88/40, RR of 28 and HR below. He is pale.

A 52 year-old female complains of epigastric pain.


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5 yea o d e a e co p a s o ep gast c pa

Onset was 30 minutes ago. She also complainsof nausea and mild shortness of breath. Her

history includes CHF, Type II diabetes and high

cholesterol. BP is 134/88, HR matches the ECGbelow, and RR is 12. Her medications includefurosemide, K-Dur, digitalis, and metoprolol.


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And Now For the Summary The ECG should confirm what you know about

the patient V-fib for dead folks

Tachycardia for dehydration

PVCs for chronic heart conditions AV blocks chronic or acute conditions

Treat the rhythm in perspective

Underlying cause drug overdose, hypovolemia

Sources In order of


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preference Many of the pictures and info from:

Flip and See ECG, 2nd Edition Cohn/Gilroy-Doohan

A great resource

Paramedic Paramedic Textbook, Revised 2nd Edition Mick J. Sanders, Mosby

ECGs Made Easy, 2nd Edition Barbara Aehlert, RN, Mosby

Basic Dysrhythmias, Interpretation and Management,

3rd

Edition Robert J. Huszar, Mosby

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