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CONTINUING EDUCATION
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1
www.aorn.org/CE
DENISE ATWOOD, JD, RN; DIANA L. WADLUND, MSN, RN, CRNFA, ACNP-BC
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this article, reviewing the purpose/goal and objectives, and
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Event: #15543
Session: #1001
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Conflict-of-Interest Disclosures
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Pricing is subject to change.
Purpose/Goal
To provide the learner with knowledge specific to using the
CRISP (Cardiac Rhythm Identification for Simple People)
method to interpret electrocardiograms (ECGs).
Objectives
1. Describe the electrical conduction system of the heart.
2. Identify the elements of an ECG.
3. Discuss important nursing assessments for a patient who
presents with a potential cardiac problem.
4. Explain the CRISP algorithm.
Accreditation
AORN is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check
with your state board of nursing for acceptance of this activity
for relicensure.
Denise Atwood, JD, RN, and Diana L. Wadlund, MSN, RN,
CRNFA, ACNP-BC, have no declared affiliations that could
be perceived as posing potential conflicts of interest in the
publication of this article.
The behavioral objectives for this program were created by
Helen Starbuck Pashley, MA, BSN, CNOR, clinical editor,
with consultation from Susan Bakewell, MS, RN-BC, director,
Perioperative Education. Ms Starbuck Pashley and Ms Bakewell
have no declared affiliations that could be perceived as posing
potential conflicts of interest in the publication of this article.
Sponsorship or Commercial Support
No sponsorship or commercial support was received for this
article.
Disclaimer
AORN recognizes these activities as CE for RNs. This
recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products
mentioned in the activity.
http://dx.doi.org/10.1016/j.aorn.2015.08.004
ª AORN, Inc, 2015
396 j AORN Journal
www.aornjournal.org
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1
www.aorn.org/CE
DENISE ATWOOD, JD, RN; DIANA L. WADLUND, MSN, RN, CRNFA, ACNP-BC
ABSTRACT
Nurses often struggle with identifying electrocardiogram (ECG) rhythms, but rapidly interpreting these
rhythms is an essential skill that every nurse should master, especially in the perioperative setting. The
CRISP (Cardiac Rhythm Identification for Simple People) method is an algorithm designed to help
nurses rapidly interpret ECGs. Key aspects of assisting patients with suspected cardiac issues include
the nursing assessment, correct three-lead ECG placement, and calculation of the heart rate. Then the
perioperative nurse can use the steps of the CRISP method to identify nursing actions related to
specific arrhythmias, including determining whether QRS complexes are present, P waves are present,
and QRS complexes are wide or narrow or whether there are more P waves than QRS complexes.
AORN J 102 (October 2015) 397-405. ª AORN, Inc, 2015. http://dx.doi.org/10.1016/j.aorn.2015.08.004
Key words: cardiac rhythms, arrhythmias, advanced cardiac life support, ECG interpretation.
Editor’s note: The shaded portion of this article has been
reprinted with permission from: Atwood D. Using an algorithm
to easily interpret basic cardiac rhythms. AORN J.
2005;82(5):757-766. Copyright ª 2005, AORN, Inc, 2170 S
Parker Road, Suite 400, Denver, CO 80231. All rights reserved.
E
very nurse should be able to recognize basic
electrocardiogram (ECG) rhythms, such as
normal sinus rhythm, sinus tachycardia, atrial
fibrillation, atrial flutter, heart blocks, ventricular fibrillation, and asystole. To interpret basic ECG rhythms, nurses
must understand the normal conduction pathways of the
heart, as well as the basic pathophysiology of abnormal
rhythms. This article presents an algorithm that is
designed to help health care providers rapidly interpret
primary ECG rhythms. Fred Killingbeck, RN, EMT-P,
CEN, CCRN, the creator of the algorithm, describes
this as the CRISP (ie, cardiac rhythm identification for
simple people) method of ECG interpretation.
NORMAL PHYSIOLOGY OF CARDIAC
IMPULSE CONDUCTION
Cardiac impulses are conducted through the conduction
system, which consists of the sinoatrial (SA) node, atrioventricular (AV) junction and AV node, bundle of His, right and
left bundle branches, and Purkinje fibers (Figure 1).1 Normal
conduction of a cardiac impulse is generated in the SA node
located in the upper portion of the right atrium. The SA
node is the natural pacemaker of the heart, and it produces
a heart rate between 60 and 100 beats per minute (bpm).
The impulse spreads through the right and left atria via the
internodal pathways.1 The impulse then travels to the AV
junction located in the lower portion of the right atrium.
The impulse is delayed for 0.08 to 0.12 seconds in the AV
junction, which gives the atria time to contract (ie,
depolarize). The AV node is located in the AV junction. If
the SA node fails to function, the AV node is the next in
line in the conduction pathway, and it takes over as the
heart’s pacemaker. The AV node produces a heart rate
between 40 and 60 bpm.1
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ª AORN, Inc, 2015
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The impulse spreads from the AV junction to the bundle
of His and down the interventricular septum. The bundle
of His divides into the right and left bundle branches in
the ventricles, which end in the Purkinje system (ie, a
network of fibers that spread throughout both ventricles
and papillary muscles). The cardiac impulse terminates
with a contraction (ie, ventricular depolarization) when
these fibers are stimulated by an impulse.1
ELEMENTS OF AN ECG
Atrial depolarization produces the P wave on an ECG. The
presence of P waves indicates that impulses are being
generated in the SA node. The PR interval represents the
amount of time the impulse takes to travel from the
beginning of atrial depolarization to the beginning of ventricular depolarization. The QRS complex correlates with
depolarization (ie, contraction) of the ventricles. The interval from the end of ventricular depolarization to the
beginning of ventricular repolarization is represented by the
ST segment. The T wave corresponds to repolarization of
the ventricles. The total time for both ventricular depolarization and repolarization is represented by the QT interval.
NURSE ASSESSMENT
When caring for a patient who is suspected of having a cardiac
problem, the perioperative nurse must rapidly assess the patient, including checking the patient’s level of consciousness,
vital signs, skin color, pain, and temperature, before beginning
analysis of a suspected ECG abnormality. If the patient indicates that he or she is having chest pain, the nurse must ask
the patient to describe the chest pain. Pain that is unrelenting
and described as being sharp or radiating may indicate
ischemia (ie, lack of blood and oxygen to the heart) and could
be indicative of a myocardial infarct.2 Exertion-induced pain
that is relieved by rest is suggestive of angina and not a
myocardial infarct.2 Chest pain that gets worse when the
patient is supine and is relieved when the patient sits up and
leans forward is indicative of pericarditis, while chest pain
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An ECG gives a picture of the electrical activity that causes
the different parts of the heart to beat and relax. An ECG
consists of segments or intervals (ie, P wave, PR interval,
QRS complex, ST segment, T wave, QT interval) that
help determine where an impulse was generated and assess
the length of time it takes an impulse to travel through the
heart (Figure 2).2
Figure 1. Cardiac conduction pathways. Reprinted with
permission from Atwood D. Using an algorithm to easily
interpret basic cardiac rhythms. AORN J. 2005;82(5):757766. Copyright ª 2005, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
caused by coughing or deep inspiration is suggestive of chest
wall, and not cardiac, pain.2 A patient who reports a sudden
onset of tearing or ripping pain may be experiencing a
dissecting aortic aneurysmda medical emergency.2
When assessing a patient for cardiac problems, it is important
for the perioperative nurse to understand that women’s cardiac
symptoms often differ from what men report.3 For example,
women may report vague nontypical symptoms such as
upper back or shoulder pain,
jaw pain or pain spreading to the jaw,
pressure or pain in the center of the chest,
lightheadedness,
pain that spreads to the arm,
unusual fatigue for several days,
sleep disturbances,
shortness of breath,
indigestion, and
anxiety.3
Because their symptoms may not be those that are typically
recognized by the lay public as being classic heart attack
symptoms, women are often reluctant to seek treatment or
they may delay treatment. For this reason, women’s symptoms
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October 2015, Vol. 102, No. 4
CRISP Method of ECG Interpretation
ECG irregularities (eg, patient movement, integrity of electrodes, inappropriate placement of electrodes).2 If the nurse
determines that the patient is unstable, he or she should
initiate advanced cardiac life support (ACLS).5
THE CRISP ALGORITHM
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To become more skilled and better able to interpret the patient’s ECG in an urgent situation, the nurse can use ECG
strips to practice using the CRISP algorithm (Figure 3) to
become proficient at identifying cardiac rhythms. Using this
method, the nurse should calculate the heart rate and then
proceed to step 1 of the CRISP algorithm to begin
identifying the patient’s specific heart rhythm.
Calculating Heart Rate
Figure 2. Electrical activity results in contraction of the
heart, which appears on an electrocardiogram as the
tracing shown in this figure. Reprinted with permission
from Atwood D. Using an algorithm to easily interpret
basic cardiac rhythms. AORN J. 2005;82(5):757-766.
Copyright ª 2005, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
may have been present for as long as one month before they
present for evaluation, and their outcomes are worse than
men’s. One source reported that
Women suffering a heart attack were nearly twice as likely to
die in the hospital compared to men, with in-hospital deaths
reported for 12 percent of women and 6 percent of men in the
study. Women were also less likely to undergo treatment to open
clogged arteries, which can be lifesaving when performed soon
after the heart attack starts.4
CORRECT THREE-LEAD ECG
PLACEMENT
After performing a clinical assessment and to help ensure an
accurate ECG reading, correct lead placement is required.
Correct three-lead ECG placement can be accomplished according to the color of the lead or letters on the end of the lead.
The white (RA) lead should be placed on the right side of the
patient’s chest below the clavicle and near the right arm. The
black (LA) lead is placed on the left side of the chest below the
clavicle and near the left arm. The ground (G) lead is placed
midline to the clavicle at about the fifth or sixth intercostal
space on the left chest. If the nurse determines that the patient
is stable, he or she should rule out nonmedical explanations for
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Cardiac and ECG evaluation start with calculation of the heart
rate. Heart rates fit into three rate categories: bradycardia (ie,
slower than 60 bpm), normal rate (ie, 60 bpm to 100 bpm), and
tachycardia (ie, faster than 100 bpm).5 To calculate the heart rate,
the nurse should count the number of QRS complexes in a sixsecond strip and then multiply that number by 10 (Figure 4).
Rhythm strips are calibrated so that each small square equals
0.04 second, each large square equals 0.2 second, and five large
squares equal one second.6
Step 1dAre QRS Complexes Present?
After the heart rate is calculated, the nurse would begin using
the algorithm at step 1 by asking, “Are QRS complexes present?” If the answer is “no,” the rhythm is ventricular fibrillation or asystole (Figure 5).
Ventricular fibrillation occurs when areas of normal myocardium in the ventricle alternate with areas of ischemic, injured,
or infarcted myocardium.5 This causes a chaotic pattern of
ventricular depolarization, with ventricular fibrillation seen
on an ECG as a wavy line.
According to ACLS guidelines, the pathophysiology of asystole
is “the absence of electrical and mechanical activity in the
heart.”5(p168) Asystole is characterized by a flat linedthat is,
no ventricular activity can be seen, the PR interval cannot
be determined, and no deflections (ie, an R wave would
deflect up and a Q wave would deflect down) consistent
with a QRS complex are seen. If the answer to step 1 is
“yes,” the nurse should proceed to step 2.
Step 2dAre P Waves Present?
If QRS complexes are present, the nurse should then ask, “Are
P waves present?” Based on the answer, the nurse should then
progress to step 3 of the algorithm.
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Figure 3. The CRISP (Cardiac Rhythm Identification for Simple People) algorithm.
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October 2015, Vol. 102, No. 4
Figure 4. A six-second rhythm strip is used to calculate
heart rates and identify rhythms. Reprinted with
permission from Atwood D. Using an algorithm to
easily interpret basic cardiac rhythms. AORN J.
2005;82(5):757-766. Copyright ª 2005, AORN, Inc,
2170 S. Parker Road, Suite 400, Denver, CO 80231. All
rights reserved.
Step 3dNo P Waves Are Present. Are the
QRS Complexes Wide or Narrow?
If the answer to step 2 is “no” and no P waves are present, the
nurse should ask, “Are the QRS complexes wide or narrow?”
The nurse can determine this by counting the average number
of small squares that the QRS complexes occupy on the ECG
strip. A normal QRS complex should be less than three small
squares wide. After calculating the width, the nurse can follow
the algorithm to the appropriate answer (ie, wide or narrow).
Wide QRS complexes
If the QRS complexes are equal to or wider than three small
squares on the ECG strip, the QRS complexes are considered
to be wide. The nurse should then determine the rate of the
rhythm. One of three rhythms will be present depending on
the heart rate documented in the rhythm strip:
CRISP Method of ECG Interpretation
Figure 6. Idioventricular tachycardia (a), accelerated
ventricular tachycardia (b), and ventricular tachycardia (c).
Reprinted with permission from Atwood D. Using an algorithm to easily interpret basic cardiac rhythms. AORN
J. 2005;82(5):757-766. Copyright ª 2005, AORN, Inc,
2170 S. Parker Road, Suite 400, Denver, CO 80231. All
rights reserved.
Narrow QRS complexes
If the QRS complexes are narrow (ie, narrower than three
small squares on the ECG strip), one of three rhythms will be
present: atrial fibrillation, atrial flutter, or supraventricular
tachycardia (Figure 7).5 In atrial fibrillation and atrial flutter,
the atrial impulses are faster than the SA node impulses.
Atrial fibrillationdimpulses take multiple, chaotic, random
pathways through the atria. This results in an irregular
rhythm.
idioventriculardslower than 40 bpm,
accelerated ventriculard40 bpm to 100 bpm, or
ventricular tachycardiadfaster than 100 bpm (Figure 6).
Figure 5. Ventricular fibrillation (a) and asystole (b).
Reprinted with permission from Atwood D. Using an
algorithm to easily interpret basic cardiac rhythms.
AORN J. 2005;82(5):757-766. Copyright ª 2005,
AORN, Inc, 2170 S. Parker Road, Suite 400, Denver,
CO 80231. All rights reserved.
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Figure 7. Atrial fibrillation (a), atrial flutter (b), and
paroxysmal (ie, sudden onset) supraventricular tachycardia (c). Reprinted with permission from Atwood D.
Using an algorithm to easily interpret basic cardiac
rhythms. AORN J. 2005;82(5):757-766. Copyright ª
2005, AORN, Inc, 2170 S. Parker Road, Suite 400,
Denver, CO 80231. All rights reserved.
AORN Journal j 401
AtwooddWadlund
Figure 8. Sinus bradycardia (a), normal sinus rhythm
(b), sinus tachycardia (c), and first-degree atrioventricular block (d). Reprinted with permission from Atwood
D. Using an algorithm to easily interpret basic cardiac
rhythms. AORN J. 2005;82(5):757-766. Copyright ª
2005, AORN, Inc, 2170 S. Parker Road, Suite 400,
Denver, CO 80231. All rights reserved.
Atrial flutterdimpulses take a circular course around the atria.
This is characterized by flutter-shaped (ie, saw-tooth) waves.
Supraventricular (ie, atrialdliterally above the ventricles)
tachycardiadimpulses from the atria to the ventricles are
disrupted and reentry occurs. This results in a rapid (ie,
faster than 150 bpm) narrow QRS complex rhythm.
October 2015, Vol. 102, No. 4
Figure 9. Second-degree atrioventricular (AV) block
type I (a), second-degree AV block type II (b), and
third-degree AV block (c). Reprinted with permission
from Atwood D. Using an algorithm to easily interpret
basic cardiac rhythms. AORN J. 2005;82(5):757-766.
Copyright ª 2005, AORN, Inc, 2170 S. Parker Road,
Suite 400, Denver, CO 80231. All rights reserved.
sinus bradycardiadslower than 60 bpm,
normal sinus rhythmd60 bpm to 100 bpm, or
sinus tachycardiadfaster than 100 bpm (Figure 8).
One type of sinus bradycardia is first-degree AV block, in
which a delay in conduction of the atrial impulse to the
ventricles occurs, resulting in prolongation of the PR interval
to more than 0.2 second. In first-degree AV block, a QRS
complex follows each P wave, and the PR interval remains
constant.
Yes
Step 3dP Waves Are Present. Are There
More P Waves Than QRS Complexes?
If P waves are present, the nurse should ask, “Are there more P
waves than QRS complexes?” The nurse then should follow
the algorithm to the appropriate answer.
No
If every P wave is followed by a QRS complex, sinus rhythm is
present. Sinus rhythms all have normal impulse formation and
conduction, and the impulses originate at the SA node.5 Sinus
bradycardia and sinus tachycardia are not abnormal rhythms,
but their impulses are conducted at a slower or faster rate
than normal. These rhythms are physical signs (eg, minor
palpitations, hyperthermia, hypovolemia) rather than a
pathological condition. The specific type of sinus rhythm
can be identified by determining the heart rate:
402 j AORN Journal
If more P waves are present than QRS complexes, the rhythm
is because of a conduction block (ie, second-degree AV block
type I, second-degree AV block type II, third-degree AV block
[Figure 9]). The number of P waves must be compared with
the number of QRS complexes.
Second-degree AV block type Idthe pathophysiology of
second-degree heart block type I, also known as Mobitz type
I or Wenckebach, originates in the AV node. Impulse
conduction is increasingly slowed at the AV node, causing
the PR intervals to lengthen progressively until one P wave is
not followed by a QRS complex. This rhythm is irregular.5
The nurse should think of a type I or Wenckebach as the
block with the lengthening PR interval. A simple
mnemonic device to help in remembering this is as follows.
I ¼ Lengthening PR interval:
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October 2015, Vol. 102, No. 4
Figure 10. Rhythm strip for a 16-year-old girl who
presents with normal sinus rhythm and a heart rate of
70 beats per minute. Reprinted with permission from
Atwood D. Using an algorithm to easily interpret basic
cardiac rhythms. AORN J. 2005;82(5):757-766. Copyright ª 2005, AORN, Inc, 2170 S. Parker Road, Suite
400, Denver, CO 80231. All rights reserved.
Figure 11. Rhythm strip for a 36-year-old woman who
presents for removal of a benign breast mass and exhibits tachycardia after an injection of lidocaine with
epinephrine. Reprinted with permission from Atwood D.
Using an algorithm to easily interpret basic cardiac
rhythms. AORN J. 2005;82(5):757-766. Copyright ª
2005, AORN, Inc, 2170 S. Parker Road, Suite 400,
Denver, CO 80231. All rights reserved.
Second-degree AV block type IIdthe pathophysiology of a
second-degree AV heart block type II, also known as Mobitz
type II or non-Wenckebach, is at the site of the block and
most often is below the AV node (ie, infranodal). Impulse
conduction is normal through the node; thus, no first-degree
block and no previous PR prolongation occur on the ECG.
As a result, the PR interval is constant with conducted beats,
but some P waves will be present without a QRS complex.
This rhythm is irregular.5 The nurse should think of the
type II block as having equal PR intervals, but the QRS
complexes drop (ie, the impulse is not conducted to the
ventricles, so they do not contract).
1.
2.
3.
4.
II ¼ PR intervals with dropped QRS complexes:
Third-degree AV blockdthe primary pathophysiology in
third-degree AV heart block is AV dissociation. Injury or
damage to the cardiac conduction system has occurred so
that no impulses pass between the atria and ventricles (ie,
complete block). This rhythm is regular.5 The nurse should
think of a third-degree block as a dysfunction of the heart in
which the atria and ventricles do not associate with one
another so they beat independently and do not
communicate with each other.
III ¼ Do not look at or talk to each other:
CASE STUDY ONE
A 16-year-old girl arrives in the OR to undergo an appendectomy. She is healthy with no medical history. She does not
take any medications on a regular basis, but she received 1 mg
of hydromorphone by IV in the emergency department less
than an hour earlier. Her ECG strip is presented (Figure 10).
To interpret the patient’s ECG, the nurse asks and answers the
following questions:
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5.
6.
Are QRS complexes present? Yes
Are P waves present? Yes
Are there more P waves than QRS complexes? No
What is the heart rate? 70 bpm (ie, count the number of
QRS complexes in a six-second strip and multiply by 10)
What is the rhythm? Normal sinus rhythm
What is appropriate treatment for this patient?
Normal sinus rhythm and a heart rate of 70 bpm is a
normal finding in a 16-year-old girl. No treatment is
necessary.
CASE STUDY TWO
A 36-year-old woman presents to the OR for removal of a
benign breast mass. The physician injects 25 mL of lidocaine
1% with epinephrine 1:100,000. He then makes a 3-cm
incision into her breast and begins to remove the mass. Five
minutes into the surgery, the nurse reviews the patient’s ECG
strip (Figure 11). To interpret the patient’s ECG, the nurse
asks and answers the following questions:
1.
2.
3.
4.
5.
6.
Are QRS complexes present? Yes
Are P waves present? Yes
Are there more P waves than QRS complexes? No
What is the heart rate? 120 bpm to 124 bpm
What is the rhythm? Sinus tachycardia
What is appropriate treatment for this patient? The
anesthesia professional notes that the patient is
adequately sedated. The surgeon observes that tachycardia could have resulted from the injection of
the lidocaine with epinephrine. The anesthesia professional administers a bolus of 1 mg/kg of esmolol over 30
seconds. Esmolol is an IV beta-blocker medication
effective in the treatment of sinus tachycardia. The surgeon is able to conclude the procedure without further
incidents.
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AtwooddWadlund
Figure 12. Rhythm strip for a 70-year-old man who
underwent repair of an abdominal aortic aneurysm and
exhibits idioventricular rhythm. Reprinted with
permission from Atwood D. Using an algorithm to
easily interpret basic cardiac rhythms. AORN J.
2005;82(5):757-766. Copyright ª 2005, AORN, Inc,
2170 S. Parker Road, Suite 400, Denver, CO 80231. All
rights reserved.
Figure 13. Rhythm strip for a 23-year-old man who had
a gunshot wound and exhibits asystole. Reprinted with
permission from Atwood D. Using an algorithm to
easily interpret basic cardiac rhythms. AORN J.
2005;82(5):757-766. Copyright ª 2005, AORN, Inc,
2170 S. Parker Road, Suite 400, Denver, CO 80231. All
rights reserved.
CASE STUDY THREE
CASE STUDY FOUR
A 70-year-old man has just undergone a repair of an
abdominal aortic aneurysm. He is transferred to the postanesthesia care unit in stable condition with a pulse of 110
bpm and a blood pressure of 90/50 mm Hg. As the postanesthesia care unit RN is talking to him, the patient becomes
unresponsive and his ECG strip changes (Figure 12). To
interpret the patient’s ECG, the nurse asks and answers the
following questions:
A 23-year-old man is brought emergently to the OR following
a gunshot wound to the left chest. His blood pressure on
arrival is 40/0 mm Hg, and a rapid infuser device administers a
fourth unit of packed red blood cells. The trauma surgeon
makes a thoracotomy incision and suctions 2,000 mL of blood
from the left chest. The surgeon discovers that a 2.5-cm hole
has occurred in the patient’s left ventricle. As the surgeon is
sewing the hole in the left ventricle, the ECG changes
(Figure 13). To interpret the patient’s ECG, the nurse asks
and answers the following questions:
1.
2.
3.
4.
5.
6.
Are QRS complexes present? Yes
Are P waves present? No
Are the QRS complexes wide or narrow? Wide
What is the heart rate? 27 bpm
What is the rhythm? Idioventriculardbecause the
patient is pulseless, he is considered to be in pulseless
electrical activity (PEA), which means that even though
a rhythm is present on the monitor, no pulse is
detected.
What is appropriate treatment for this patient? The
nurse starts with the CABs of resuscitation (ie,
compression, airway, breathing) by assessing and managing the patient’s circulation, airway, and breathing.
The nurse notifies the surgeon or anesthesia professional, initiates an arrest announcement, and starts
cardiopulmonary resuscitation (CPR) because the patient has no pulse and is unresponsive. The nurse also
administers a fluid bolus because hypovolemia is a
common cause of PEA. The nurse should assess the
patient for other causes of PEA (eg, severe prolonged
hypoxia or acidosis, flow-restricting pulmonary
embolus) if the fluid bolus does not correct the PEA.7
In this case, the team determines that the patient has
hypokalemia and administers IV potassium, after
which the patient’s PEA resolves.
404 j AORN Journal
1.
2.
3.
4.
Are QRS complexes present? No
Does the rhythm appear wavy or flat? Flat
What is the rhythm? Asystole
What is appropriate treatment for this patient? The
nurse calls for additional help and requests that additional
type O-negative blood be brought to the room while she
retrieves the crash cart. The surgeon provides internal
cardiac massage while awaiting arrival of the crash cart.
The anesthesia professional begins to administer blood as
soon as it is brought to the room. The RN circulator
assigns a nurse to document activities and assigns another
nurse to run the defibrillator. The surgeon follows ACLS
guidelines for asystole, ordering atropine to be administered followed by epinephrine. Resuscitative efforts are
unsuccessful and 35 minutes after resuscitation began,
the surgeon pronounces the patient dead.
CONCLUSION
Perioperative nurses may not perform ECG interpretation on a
daily basis; however, the ability to identify ECG rhythms and
understand how they relate to the electrical function of the
heart and the implications for patients are valuable skills for all
nurses.8 The techniques described in this article allow
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October 2015, Vol. 102, No. 4
CRISP Method of ECG Interpretation
perioperative nurses to begin recognizing basic cardiac rhythms,
but perioperative nurses should access books on this topic to
understand this complex process and make it more
manageable for the novice ECG interpreter. Countless courses
also are available that can be taken in person or online (see
Resources) to help perioperative nurses become more familiar
and comfortable with the skill of ECG interpretation.
Perioperative managers are responsible for ensuring that
nurses are competent to interpret ECGs and to respond
appropriately to the identified arrhythmias. Providing
simulation exercises is an excellent way for perioperative
managers to both educate their perioperative nurses and to
validate competency in ECG interpretation. The most
important learning tool is constant practice. Perioperative
nurses should print ECG strips and use the CRISP algorithm
to guide them in interpreting the rhythm. Nurses also should
tap into the expertise of seasoned nurses to obtain feedback
on any suspected arrhythmia and its treatment options. With
education and practice, basic ECG interpretation can become
second nature to perioperative nurses.
5.
6.
7.
8.
American College of Cardiology. http://www.acc.org/about-acc/
press-releases/2015/03/05/16/33/women-dont-get-to-hospital-fast
-enough-during-heart-attack. Published March 5, 2015. Accessed
August 31, 2015.
Categories of arrhythmias. Texas Heart Institute. http://www
.texasheart.org/HIC/Topics/Cond/arrhycat.cfm. Accessed September
4, 2015.
Understanding EKGs. Geeky Medics. http://geekymedics.com/
2011/03/05/understanding-an-ecg/. Accessed July 8, 2015.
Pulseless electrical activity: etiology. Medscape. http://emedicine
.medscape.com/article/161080-overview#a5. Accessed July 17,
2015.
Landrum MA. Fast Facts About EKGs for Nurses: The Rules of
Identifying EKGs in a Nutshell. New York, NY: Springer Publishing
Company, LLC; 2014.
Resources
Acknowledgment: The authors thank Fred Killingbeck, RN,
EMT-P, CEN, CCRN, Wittmann, Arizona, for providing the
cardiac rhythm algorithm, and G. Ware, EMT, and L. Rider, EMT,
firefighters with the Glendale Fire Department’s MEDIC 155,
Glendale, Arizona, for providing ECG strips used in this article.
Aehlert BJ. ECGs Made Easy. 5th ed. Philadelphia, PA: Elsevier Health
Sciences; 2015.
Ashley EA, Niebauer J. Conquering the ECG. In: Cardiology Explained.
London, England: Remedica; 2004.
ECG Mastery Program. MedMastery.com. http://www.medmastery
.com/course/ecg?gclid¼CMXOmPjo4MYCFchffgodsHkOVw.
Kusumoto FM. ECG Interpretation: From Pathophysiology to Clinical
Application. New York, NY: Springer Science & Business Media;
2009.
Learn to read electrocardiograms. ECG Academy.com. http://www.ecga
cademy.com/?gclid¼CJOb2-Ho4MYCFc5lfgodjbkIGA.
References
Denise Atwood, JD, RN, is a vice president of hos-
1. Mirvis DM, Goldberger AL. Electrocardiography. In: Mann DL,
Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald’s Heart
Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: Elsevier Saunders; 2015:114-152.
2. Nettina SM. Cardiovascular function and therapy. In: Lippincott
Manual of Nursing Practice. 10th ed. Philadelphia, PA: Wolters
Kluwer Health/Lippincott Williams & Wilkins; 2014:324-379.
3. What are the symptoms of a heart attack? The Cleveland Clinic.
http://my.clevelandclinic.org/services/heart/disorders/coronary-artery
-disease/hic_Heart_Attack/mi_symptoms. Accessed July 1, 2015.
4. Women don’t get to hospital fast enough during heart attack: Study
finds pre-hospital delays linked to more deaths among women.
www.aornjournal.org
pital operations at Maricopa Integrated Health System,
Phoenix, AZ. Ms Atwood has no declared affiliation that
could be perceived as posing a potential conflict of interest in the publication of this article.
Diana L. Wadlund, MSN, RN, CRNFA, ACNP-BC, is
an acute care nurse practitioner with the general surgery
and trauma services at Paoli Hospital, Paoli, PA.
Ms Wadlund has no declared affiliation that could be
perceived as posing a potential conflict of interest in the
publication of this article.
AORN Journal j 405
EXAMINATION
Continuing Education:
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1
www.aorn.org/CE
PURPOSE/GOAL
To provide the learner with knowledge specific to using the CRISP (Cardiac Rhythm Identification for
Simple People) method to interpret electrocardiograms (ECGs).
OBJECTIVES
1.
2.
3.
4.
Describe the electrical conduction system of the heart.
Identify the elements of an ECG.
Discuss important nursing assessments for a patient who presents with a potential cardiac problem.
Explain the CRISP algorithm.
The Examination and Learner Evaluation are printed here for your convenience. To receive
continuing education credit, you must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE.
QUESTIONS
1. The cardiac conduction system consists of the
1. sinoatrial (SA) node.
2. atrioventricular (AV) junction.
3. bundle of His.
4. right and left bundle branches.
5. Purkinje fibers.
6. AV node.
a. 1, 3, and 5
b. 2, 4, and 6
c. 2, 3, 5, and 6
d. 1, 2, 3, 4, 5, and 6
2. The SA node is the natural pacemaker of the heart, and it
produces a heart rate between 60 and 100 beats per
minute (bpm).
a. true
b. false
3. The cardiac impulse terminates with
1. a contraction.
2. relaxation.
3. ventricular repolarization.
406 j AORN Journal
4. ventricular depolarization.
a. 1 and 4
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
4. The segments or intervals on an ECG help determine
1. level of consciousness.
2. where an impulse was generated.
3. where the impulse goes when the cycle is complete.
4. the time it takes an impulse to travel through the
heart.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
5. The presence of _____ indicates that impulses are being
generated in the SA node, and the _____ represents the
amount of time the impulse takes to travel from the
beginning of atrial depolarization to the beginning of
ventricular depolarization.
a. T waves/ST segment b. P waves/QRS complex
c. P waves/PR interval d. QRS complexes/T wave
www.aornjournal.org
October 2015, Vol. 102, No. 4
6. If a patient is having chest pain that is unrelenting and is
described as sharp or radiating, this could be indicative of
a. a dissecting aortic aneurysm. b. a myocardial infarction.
c. angina.
d. pericarditis.
7. Chest pain that gets worse when the patient is supine and
is relieved when the patient sits up and leans forward is
indicative of
a. chest wall pain.
b. a myocardial infarction.
c. angina.
d. pericarditis.
8. In comparison with men, women may report vague,
nontypical symptoms such as
1. back, shoulder, or jaw pain.
2. lightheadedness.
3. unusual fatigue for several days.
4. sleep disturbances.
5. shortness of breath.
www.aornjournal.org
CRISP Method of ECG Interpretation
6. anxiety.
a. 1, 3, and 5
c. 2, 3, 5, and 6
b. 2, 4, and 6
d. 1, 2, 3, 4, 5, and 6
9. Cardiac and ECG evaluation starts with the calculation of
a. the QRS complex.
b. the heart rate.
c. the respiratory rate. d. the QT interval.
10. When interpreting an ECG, the CRISP method requires
answers to questions including
1. Are QRS complexes present?
2. Are P waves present?
3. Are there more P waves than QRS complexes?
4. What is the heart rate?
5. What is the rhythm?
6. What type of pain is the patient experiencing?
a. 1, 3, and 5
b. 2, 4, and 6
c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
AORN Journal j 407
LEARNER EVALUATION
Continuing Education:
ECG Interpretation Using the
CRISP Method: A Guide for
Nurses 2.1
www.aorn.org/CE
T
his evaluation is used to determine the extent to
which this continuing education program met your
learning needs. The evaluation is printed here for
your convenience. To receive continuing education credit, you
must complete the online Examination and Learner Evaluation
at http://www.aorn.org/CE. Rate the items as described below.
8.
Will you change your practice as a result of reading this
article? (If yes, answer question #8A. If no, answer
question #8B.)
8A.
How will you change your practice? (Select all that
apply)
1. I will provide education to my team regarding why
change is needed.
2. I will work with management to change/implement
a policy and procedure.
3. I will plan an informational meeting with physicians
to seek their input and acceptance of the need for
change.
4. I will implement change and evaluate the effect of
the change at regular intervals until the change is
incorporated as best practice.
5. Other: __________________________________
8B.
If you will not change your practice as a result of
reading this article, why? (Select all that apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others about the
purpose of the needed change.
3. I do not have management support to make a
change.
4. Other: __________________________________
9.
Our accrediting body requires that we verify the time
you needed to complete the 2.1 continuing education
contact hour (126-minute) program: ______________
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Describe the electrical conduction system of the heart.
Low
1.
2.
3.
4.
5.
High
2.
Identify the elements of an ECG.
Low
1.
2.
3.
4.
5.
High
3.
Discuss important nursing assessments for a patient who
presents with a potential cardiac problem.
Low
1.
2.
3.
4.
5.
High
4.
Explain the CRISP algorithm.
Low
1.
2.
3.
4.
5.
High
CONTENT
5. To what extent did this article increase your knowledge of
the subject matter?
Low
1.
2.
3.
4.
5.
High
6. To what extent were your individual objectives met?
Low
1.
2.
3.
4.
5.
High
7. Will you be able to use the information from this article in
your work setting?
1.
Yes
2.
No
408 j AORN Journal
www.aornjournal.org