Beruflich Dokumente
Kultur Dokumente
OBJECTIVES Describe normal conduction system of the heart State criteria for performing an EKG/ECG Identify basic normal EKG/ECG waveforms Identify arrhythmias and blocks Describe treatment options for these basic arrhythmias To recognize an acute myocardial infarction on a 12-lead ECG.
Bundle of His
Bundle Branches Purkinje fibers
ECG MADE EASY
The PQRST
Vertically
One large box - 0.5 mV
3 sec
3 sec
Every 3 seconds (15 large boxes) is marked by a vertical line. This helps when calculating the heart rate. NOTE: the following strips are not marked but all are 6 seconds long.
Rhythm Analysis
Calculate rate. Determine regularity. Assess the P waves. Determine PR interval. Determine QRS duration. Evaluate Twave
ECG MADE EASY
Interpretation? 9 x 10 = 90 bpm
ECG MADE EASY
R wave
Identify an R wave that falls on the marker of a big block Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes - 75, etc. (cont)
ECG MADE EASY
3 1 1 0 5 0 7 6 5 0 0 0 5 0 0
Remember the sequence: 300, 150, 100, 75, 60, 50, 43, 37 Count the number of big blocks to the next R wave
Approx. 1 box less than 100 Interpretation? = 95 bpm
ECG MADE EASY
First, identify two consecutive P waves on the rhythm strip. Next, select identical points in each wave, and count the number of small squares between the points. Then divide 1,500 by the number of small squares counted (because 1,500 small squares equal to 1 minute) to get the rate.
ECG MADE EASY
D. 300 METHOD
First, identify two consecutive P waves on the rhythm strip. Next, select identical points in each wave, and count the number of big squares between the points. Then divide 300 by the number of big squares counted (because 300 big squares equal to 1 minute) to get the rate.
ECG MADE EASY
Look at the R-R distances (using a caliper or markings on a pen or paper). To determine if the ventricular rhythm is regular or irregular, measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-r intervals. For atrial rhythm, measure the distance between 2 consecutive P-P intervals.
Interpretation: Regular
Create great-looking signatures for your e-mail
Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS?
Does the duration of the PR interval fall within limits, 0.12 to 0.20 second ( or 3 to 5 small boxes)? Is the PR interval constant?
Does the duration of the QRS complex fall within normal limits, 0.60 to 0.10 seconds? Are all QRS complexes the same size and shape? Does a QRS complex appear after every P wave?
Step 6: Evaluate T Wave Represent ventricular muscle repolarization (when the cells regain a negative charge; also called the resting state). It follows the QRS complex and is usually the same direction as the QRS complex.
TECHNICAL ASPECT OF ECG RECORDING 3 Areas of Consideration in Taking ECGs The ECG Machine The Patient The ECG Tracing
Know your ECG machine Voltage: 110 or 220? Wheres the on/off switch? Stylus or thermal printer? Settings: manual or automatic? How do you load ECG paper?
Operator Console
o How does it work?
1. Start/stop key 2. 1 mV Standardization key 3. Sensitivity keys/knob 5, 10, or 20 mm/mV 4. Speed setting key 25 mm/s or 50 mm/s 5. Lead key/knob I, II,III AVR, AVL, AVF V1, V2, V3, V4, V5, V6
ECG MADE EASY
Preparing for 12-lead ECG Gather all needed supplies. Explain the procedure to the patient. Answer the patients questions. Ask the patient to lie in a supine position in the center of the bed with his arms at his sides. Ensure privacy. Drape the patient for comfort.
Placing the Leads D. Posterior Lead Placement Used to assess the posterior side of the heart Posterior electrodes V7, V8, an V9 are placed same horizontal level as the V6 lead at the fifth intercostal space. V7 placed at posterior axillary line V8 halfway between leads V7 and V9 V9 paraspinal line
Recording the ECG 1. Plug the cord of the ECG machine. 2. Turn on the machine. 3. Enter the patients identification data. 4. Place all the electrodes on the patient. 5. Make sure all leads are securely attached 6. Make sure that the ECG paper speed selector is set to standard 25 mm per second
Keep in mind these important facts about ECG recordings: Theyre legal documents. They belong in the patients chart. They must be saved for future reference and comparison with baseline strips.
Normal Sinus Rhythm The electrical impulse is formed in the SA node and conducted normally. This is the normal rhythm of the heart; other rhythms that do not conduct via the typical pathway are called arrhythmias.
Sinus bradycardia
Rate less than 60 beats per minute Rhythm regular Impulses originating in the sinus node Usually occurs as the normal response to a reduced demand for blood flow.
ECG MADE EASY
Sinus bradycardia
Causes: Conditions that increases vagal stimulation/ decrease sympathetic stimulation Carotid massage Deep relaxation Sleep Valsalvas manuever Drugs
Sinus Tachycardia
Accelerated SA node firing. Sinus rate above 100 bpm. Normal response to exercise or stimulation of the SNS. Causes: Cardiac conditions Non-cardiac condition Drugs Normal Body response
Rhythm #2
Rhythm #3
ATRIAL ARRHYTHMIAS
- They arise from either a single ectopic focus or from multiple atrial foci that supersede the SA node as pacemaker for one or more beats. Causes: - Enhanced automaticity in atrial tissue - Heart Failure - Acute respiratory failure
ECG MADE EASY
NURSING INTERVENTIONS Usually, no treatment is needed if the patient has no symptoms. If the patient has symptoms, treatment may focus On eliminating or controlling trigger factors.
Atrial Flutter
A supraventricluar tachycardia No P waves. Instead flutter waves (note sawtooth pattern) are formed at a rate of 250 - 350 bpm. Originates in a single atrial focus Results from a reentry circuit and possibly increased automaticity.
NURSING INTERVENTION (Atrial Flutter) If the patient is hemodynamically unstable, prepare for immediate synchronized cardioversion. Administer a beta-adrenergic blocker ( metoprolol), or calcium channel Blocker (diltiazem) to control the ventricular rate if the patient has normal heart function. In patients with impaired heart function, use digoxin or amiodarone. Monitor the patient closely for evidence of low cardiac output
Atrial Fibrillation
Chaotic, asynchronous, electrical activity in atrial tissue Results from firing of multiple impulses from numerous ectopic pacemakers in the atria. Absence of P wave Irregularly irregular ventricular response.
ECG MADE EASY
Atrial Fibrillation
Origin: Right or left atrium Rate: 400 BPM Characteristic: Random, chaotic rhtym; atria quiver, associated with irregular rhythm P wave: absent QRS: Normal morphology Irregular irregular RR interval
Atrial Fibrillation
Causes: nicotine, caffeine, or alcohol Drugs, such as aminophylline and digoxin Certain diseases Endogenous catecholamine released during exercise NURSING INTERVENTIONS Intervention aim to control the ventricular rate, establish anticoagulation,a nd restore and maintian
NURSING INTERVENTIONS
Intervention aim to control the ventricular rate, establish anticoagulation, and restore and maintain a sinus rhythm. Treatment typically includes drug therapy to control the ventricular response or a combination of electrical cardioversion. Monitor carefully patients rhythm, heart rate, and blood pressure. In stable patients, beta-adrenergic blockers and calcium channel blockers are given. Patients with reduced ventricular function typically received digoxin.
ECG MADE EASY
Usually, no treatment is needed for asymptomatic patients. If the patient is symptomatic, however, his medications should be reviewed and the underlying cause investigated and treated. Monitor the patients heart rhythm and assess for signs of hemodynamic instability, such as hypotension and changes in mental status.
Junctional Rhythm
Junctional rhythm occurs when the AV node, instead of the sinus node, becomes the pacemaker of the heart. When the sinus node slows (eg, from increased vagal tone) or when the impulse cannot be conducted through the AV node (eg, because of complete heart block).
ECG MADE EASY
Rhythm #4
QRS duration?
70 bpm occasionally irreg. 2/7 different contour 0.14 s (except 2/7) 0.08 s
Rhythm #5 Rhythm #5
QRS duration?
Rhythm #6 Rhythm #6
0.06 s
Ventricular Arrhythmias
60 bpm occasionally irreg. none for 7th QRS 0.14 s 0.08 s (7th wide)
Ectopic beats that originate in the ventricles and occur earlier than expected. May occur singly, in pairs (couplets), or in clusters. May also appear in patterns, such as bigeminy or trigeminy. May be uniform in appearance or multiform.
ECG MADE EASY
When an impulse originates in a ventricle, conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.
Ventricular Conduction
Normal
Signal moves rapidly through the ventricles
Abnormal
Signal moves slowly through the ventricles
If the patient are infrequent and the patient has normal heart function and is asymptomatic, just observe the patient. Patient with PVCs accompanied by serious problem should have continuous ECG monitoring and emergency equipment readily available. Make sure the patient has a patent venous access. Prepare to give drugs that suppress ventricular irritability - Lidocaine - Procainamide - Amiodarone
ECG MADE EASY
Ventricular Tachycardia
Three or more PVCs in a row with a ventricular rate above 100 bpm. May be monomorphic or polymorphic. It occurs when an ectopic focus or foci fire repetitively and the ventricle takes control as the pacemaker. Monomorphic VT
Ventricular Tachycardia
no normal looking QRS complexes Rate: > 100 beats per minute and usually not faster than 220 beats per minute Rhythm: usually regular but may be irregular P waves: in rapid VT the p waves are usually not recognizable. At slower ventricular rates, p waves may be recognized and may represent normal atrial depolarization from sinus node at a rate slower than VT, but electrical activities do not affect one another QRS, ST segment, Twave: The width of the QRS is 0.12 second or greater The QRS morphology is often bizarre, with notching
ECG MADE EASY
The blue line shows the characteristic "twist" around the isoelectric baseline Torsades de Pointes
Ventricular Fibrillation
This life-threatening arrhythmia is marked by rapid, disorganized depolarizations of the ventricles and a disruption in the normal flow of electrical impulses through the cardiac conduction system. The ventricles quiver rather than contract. As a result, they fail to pump blood, and cardiac output falls to zero. If fibrillation continues, it eventually leads to ventricular asystole( or standstill), and death quickly follows. On the ECG strip, ventricular activity appears as fibrillatory waves with no recognizable pattern.
ECG MADE EASY
Ventricular Fibrillation
No normal looking QRS Rate: VF rate is very rapid and usually too organized to count. Rhythm: irregular. Electrical waveforms vary in size and shape. There are no QRS complexes. ST segments, P waves, and T waves are absent as well.
ECG MADE EASY
Asystole Asystole is ventricular standstill. The patient is completely unresponsive, with no electrical activity in the heart and no cardiac output. This arrhythmia results most often from a prolonged period of cardiac arrest without effective resuscitation.
Asystole
Rhythm # 7
Rhythm # 8