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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 Continuing Education Contact Hours Approvals indicates that continuing education (CE) contact hours are available for this activity. Earn the CE contact hours by reading this article, reviewing the purpose/goal and objectives, and completing the online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program can immediately print a certificate of completion. This program meets criteria for CNOR and CRNFA recertification, as well as other CE requirements. Event: #15543 Session: #1001 Fee: Members $16.80, Nonmembers $33.60 Conflict-of-Interest Disclosures The contact hours for this article expire October 31, 2018. 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 http://dx.doi.org/10.1016/j.aorn.2015.08.004 ª AORN, Inc, 2015 www.aornjournal.org AORN Journal j 397 AtwooddWadlund October 2015, Vol. 102, No. 4 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 398 j AORN Journal print & web 4C=FPO 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 www.aornjournal.org 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 print & web 4C=FPO 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 www.aornjournal.org 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. AORN Journal j 399 AtwooddWadlund October 2015, Vol. 102, No. 4 Figure 3. The CRISP (Cardiac Rhythm Identification for Simple People) algorithm. 400 j AORN Journal www.aornjournal.org 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. www.aornjournal.org 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: www.aornjournal.org CRISP Method of ECG Interpretation print & web 4C=FPO print & web 4C=FPO 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: www.aornjournal.org 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. AORN Journal j 403 print & web 4C=FPO October 2015, Vol. 102, No. 4 print & web 4C=FPO 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 www.aornjournal.org 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