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Transcript
EKG Interpretation Just the beginning King County Introduction Cardiac monitoring has been routinely used in the Fire Service for many years Not without some liability Intent of this course is to provide the basics in cardiac rhythm interpretation Introduction cont. This course is not intended to teach diagnosis of heart disease Lead II is not sufficient for EKG diagnosis Recognition of the cardiac cycle will aid in the understanding of EKG’s In order to remain proficient it is necessary to commit time to ongoing training in EKG interpretation Objectives Understand basic cardiac terminology Describe the anatomy of the heart Identify the electrical conduction system Identify abnormal electrical cardiac activity Objectives Identify common cardiac rhythms Identify and effect appropriate therapy for the patient on a monitor Course Completion Participants are expected to pass a written exam and achieve a 70% score Practical exam will include correct interpretation of static rhythms, 70% passing score Primary Obligation It cannot be overemphasized that the primary obligation for non-cardiac arrest patients is: ABC’s & Attention to the patient’s symptoms Vital Signs, physical exam Any necessary treatment with application of the monitor only when basic life support has been completed Anatomy & Physiology Heart is a muscle Divided into four chambers Receives blood from the body via the inferior and superior vena cavae Chambers separated by valves Coronary arteries supply blood to the myocardium Electrical Conduction System Specialized system of interconnected cells spread throughout the entire heart Provides and conducts the signal to the heart muscle to contract in a coordinated fashion Sinoatrial (SA) Node Collection of electrical tissue that is the normal point of origin of electrical activity Named because it is located in the sinus part of the atria Generates “P” waves Atrioventricular (AV) Node A way station that receives the impulses from the atria Named because it is located between the atria and the ventricles Actually used to slow impulses from the atria to the ventricles Bundle of His Receives impulses from the AV node and passes them through the left and right bundle branches in the ventricular septum Purkinje Fibers Last receiving point of the electrical impulses Fibers located in the ventricular musculature Rapidly conducts impulses causing ventricular contraction Automaticity Any portion of the conduction system or heart muscle may initiate an electrical impulse When the AV Node fails to generate an impulse, another cell/area of the heart will initiate electrical activity Secondary Pacemakers Any portion of the heart may initiate an electrical impulse and becomes a secondary pacemaker Determining the location of a secondary pacemaker will become clearer as we proceed through this curriculum Electrocardiographic paper EKG paper Grid of standard dimensions Simply used as a measurement of time Each small box represents 0.04 seconds Larger bolded boxes are .20 seconds Important to remember these values as they aid in the identification of virtually all EKG strips The Cardiac Cycle P wave- indicates atrial “depolarization” PR interval- the interval from the beginning of the P wave to the beginning of the QRS complex PR interval represents the time from atrial depolarization to the beginning of ventricular repolarization Cardiac Cycle Normal PR interval should not exceed 0.2 seconds or one large bolded square on the EKG paper QRS complex- represents electrical depolarization of the ventricle Normal duration of the QRS complex is from 0.08-0.10 seconds (2 to 3 small boxes on the EKG paper Cardiac Cycle T wave- represents repolarization of the myocardium Normal Sinus Rhythm CharacteristicsP wave for each QRS PR interval normal, <0.20 seconds QRS complex is normal, <0.10 seconds Uniform in shape Rate is regular and is between 60-100 Normal Sinus Rhythm Most common rhythm seen in acute MI Does not indicate that the patient is stable or that there is an absence of heart disease Indicates that the origin of the impulse is from the SA Node Indicates normal function of the electrical system Normal Sinus Rhythm Normal Sinus Rhythm Sinus Tachycardia CharacteristicsP wave for each QRS PR interval is normal, < 0.20 seconds QRS complex is narrow, < 0.10 seconds Uniform in shape Rate is regular, > 100/minute Sinus Tachycardia Accelerated discharge of electrical impulses from the sinus node Treatment is “attention to symptoms” Underlying cause is the concern Causes include; shock, stimulants, acute MI where decrease in cardiac output causes heart rate increase Sinus Tachycardia Sinus Tachycardia Supraventricular Tachycardia P waves may not be seen due to accelerated rate QRS complex is narrow, < 0.10 seconds Uniform in shape Rate is regular, > 150/ minute Patient’s heart rate is too fast Supraventricular Tachycardia Supraventricular Tachycardia Sinus Bradycardia CharacteristicsP wave for each QRS PR interval is normal, < 0.20 seconds QRS complex is normal, < 0.10 seconds Uniform in shape Rate is regular, < 60/ minute Sinus Bradycardia Transmission of impulses from the SA node is slowed to < 60/ minute Heart rates less than 50/ minute should never be considered to be normal Beta blockers, digoxin, hypoxia, being athletic or with history of a slow heart rate can be the cause Patient’s heart rate is too slow Sinus Bradycardia Sinus Bradycardia Premature Ventricular Contractions CharacteristicsEarly occurring beats that have a characteristic “compensatory pause” Premature QRS complex that is wide and bizarre, conduction time > 0.10 seconds Same shape except when from different focus in the heart Premature Ventricular Contractions Can occur in a healthy individual Viewed with caution in the patient who presents with cardiac symptoms Significant if: occur in 2’s (couplets), 3’s (triplets),run of 4 is Ventricular Tachycardia Frequent occurring with syncope be cautious Premature Ventricular Contractions Ventricular Tachycardia CharacteristicsP waves are usually present but are obscured by wide, rapidly occurring QRS complex QRS complex is wide > 0.10 and bizarre Uniform in shape typically Rate is regular and > 150/ minute Ventricular Tachycardia Life threatening arrythmia Rapid rate decreases cardiac output Place patient supine, anticipating shock Cause can be electrical and not always acute MI If patient unconscious and pulseless is a a shockable rhythm Ventricular Tachycardia Ventricular Tachycardia Idioventricular Rhythm CharacteristicsP waves typically obscured or follow the QRS complex QRS complex is wide, > 0.10 seconds Sometimes uniform in shape Rate is irregular, most often seen with rate < 40/minute Idioventricular Rhythm Observed after defibrillation & can be endpoint in arrest resuscitation attempt Conduction system above the ventricles fails to generate an electricle impulse Inherent rate of 30-40/minute Will likely be in cardiac arrest If unconscious and B/P <60, initiate CPR Idioventricular Rhythm Ventricular Fibrillation CharacteristicsP waves are absent QRS complex absent Baseline wavy, chaotic and inconsistent Rhythm irregular Rate is not countable Ventricular Fibrillation Sudden death & cardiac arrest immediately follow the onset Immediately defibrillate with 200 joules and proceed with standing orders Remember that we now do CPR for 2 minutes between shocks Asystole CharacteristicsP waves are not present QRS complex is not present Absence of any complexes indicate complete cessation of electrical activity The heart is motionless Asystole Pacemakers CharacteristicsP waves sometimes are visible but are not associated QRS complex of times is wide, > 0.10 seconds Preceded by a small spike with either a negative or positive deflection Pacemakers Presence of a pacemaker indicates that there is an underlying rhythm disturbance, usually heart block Technology makes it harder to see when they are present Failure can occur, look for pacer spikes without complex initiated Pacemakers Look for the presence of Ventricular Fibrillation in the patient who is in cardiac arrest Spikes will appear even in the presence of fibrillatory waves Paced Rhythm Paced Rhythm (AV Sequential) Atrial Pacemaker Pacemaker Failure Sinus Arrhythmia CharacteristicsP waves for each QRS PR interval is < 0.20 seconds QRS complex is narrow, < 0.10 seconds Rate varies, will speed up during inhalation and slow down on expiration Sinus Arrythmia This rhythm is commonly found in healthy children or athletic adults Treat specific complaint or injury Sinus Arrythmia Atrial Flutter CharacteristicsP waves are referred to as flutter waves and are uniform in shape, resembling a sawtooth pattern, mirror effect QRS complex is narrow, < 0.10 seconds Rate is both regular and irregular Can be rapid, often seen at 150/minute Atrial Flutter This rhythm is rarely seen in patients with healthy hearts Can be seen in patients with heart disease, acute MI, lung disease and pulmonary embolism Likes to go fast, needs ALS eval and is never normal for patients Atrial Flutter Atrial Fibrillation CharacteristicsP waves are not clearly visible or uniform for each QRS complex QRS complex is typically narrow, but can be wide Is irregular-irregular, depending on ventricular response can be rapid Atrial Fibrillation Cells within the atria fire chaotically Will be observed to have a rapid ventricular response with new onset Digoxin, beta blockers, calcium channel blockers can be used to control rate Also coumadin prescribed to reduce the incidence of clots in the heart chambers Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Atrial Fibrillation Nodal Rhythm CharacteristicsP waves are absent QRS complex is narrow, < 0.10 seconds Uniform in shape Rate is regular, typically > 40/minute but may be in excess of 100/minute Nodal Rhythm Nodal rhythm occurs when the SA node fails to function Expect to see narrow QRS complex, <0.10 seconds Can be caused by Digitalis Toxicity, acute MI, hypoxia, diseased sinus node In some patients this may be their normal rhythm Nodal Rhythm Nodal Rhythm Accelerated Nodal Rhythm First Degree Heart Block CharacteristicsP wave for each QRS PR interval is >0.20 seconds Rate is regular QRS complex is narrow, < 0.10 seconds Uniform in shape First Degree Heart Block Occurs when there is delayed conduction of an impulse through the AV node Patients presentation dictates need for intervention Some patients may have first degree heart block as their primary rhythm First Degree Block First Degree Heart Block First Degree Heart Block First Degree Heart Block Second Degree Heart Block Wenckebach, Mobitz Type 1 CharacteristicsP waves are present P wave occurs at a regular rate QRS complex is uniform in shape and narrow, <0.10 seconds PR interval progressively lengthens until QRS complex is dropped Wenckebach, Mobitz Type 1 Sinus impulse is progressively delayed through the AV node until no conduction occurs Causes include ischemic heart disease, acute MI, digitalis toxicity Patient’s presentation determines intervention, if ventricular rate is slow the patient may not have symptoms Wenckebach, Mobitz Type 1 Wenckebach, Mobitz Type 1 Wenckbach, Mobitz Type 1 Second Degree Heart Block Mobitz Type II CharacteristicsP waves are present P waves occur at a regular rate PR interval is fixed , may be prolonged On occasion there will be more than one P wave for each QRS complex Mobitz Type II QRS complex may be narrow, < 0.10 or may be wide, > 0.10 Series of non conducted P waves may be seen (atrial depolarization only) Ratio at which the QRS complex is conducted varies and is noted as a ratio, 2:1, 3:1, etc. (#P’s for each QRS complex) Mobitz Type II Most often seen in the setting of acute MI Frequently have syncope associated due to the slow rate Commonly progresses to complete heart block ALS evaluation paramount, since patient will often times be in shock Mobitz Type II Mobitz Type II Mobitz Type II Third or Complete Heart Block CharacteristicsP waves occur at a regular interval, typically at a rate of 60-100 beats/min. P waves do not have a fixed, or constant relationship to the QRS complex PR interval abnormally prolonged, > 0.20 and changing Complete Heart Block QRS complex may be narrow, < 0.10 or wide, > 0.10 depending on where in the heart the impulse originates QRS rate is usually constant, typically between 20-40 beats/min. Indicates that there is no transmission of impulses between the atria and the ventricles Complete Heart Block Often occurs in the setting of acute MI Can occur with Digitalis toxicity, elderly with conduction system problems May present with syncope This type of heart block may be transient ALS evaluation paramount, since patient will often times be in shock Complete Heart Block Complete Heart Block Complete Heart Block P.E.A. Pulseless Electrical Activity CharacteristicsP waves may be present PR interval may be normal, < 0.20 sec. QRS complex may be narrow, < 0.10 or wide, > 0.10 Rate can be regular or irregular Can be normal rhythm P.E.A Pulseless Electrical Activity is indicated by the absence of a detectable pulse and the presence of some type of electrical activity Seen during cardiac arrest secondary to acute MI, pulmonary embolus, cardiac tamponade, tension pneumothorax or a hypovolemic state P.E.A. (sinus tachycardia) Treatment Protocols Do not attempt to treat any patient from what is seen on the monitor alone, unless V. Tach with unconsciousness or V. Fib. Patient presentation will direct intervention Request ALS evaluation when possible lethal arrythmias are identified Ongoing Education It is recommended that EMT’s receive regular ongoing education to remain proficient at EKG recognition Quarterly review/refresher by a paramedic or equivalent Attach EKG strips to your MIRF forms for department reviewer for feedback and identification confirmation EKG Interpretation Questions? The end or just the beginning?