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BASIC ECG N240 – Advanced Med-Surg K. Brooks, RN, MSN Starting with the Basics … ► What are the functions of the heart? ►Electrical: “impulse” ►Mechanical: “pump” “contraction” ► What is the normal blood flow through the heart? ► What is the normal electrical pathway conduction? ►Nodes (SA, AV, Bundle) ►Inherent Rates Electrical Conduction Pathway SA Node – “pacemaker” of the heart (60-100bpm) AV Node – junction of the atria and ventricles (40-60bpm) Bundles – Bundle of His connects the AV node to the bundle branches (20-40bpm) Normal Cardiac Cycle Systole Diastole Electrical Depolarization “activate” Repolarization “recovery” Mechanical Contract “empty” Relax “fill” “EKG” - Electrocardiogram An EKG is a useful tool for diagnosing a variety of cardiac abnormalities. It displays the activity of the heart’s electrical impulse flow through the conduction system. What does it tell us? • the electrical conduction through the heart • areas of ischemia or myocardial damage • LV Hypertrophy • electrolyte disturbances / drug toxicity • ECG PAPER EACH E.C.G PAPER DIVIDED TO SMALL SQ WITH LENGTH 1mm BOTH VERITICALLY AND HORIZONTALLY ,,,,,,,,,,,EVERY 5 SMALL SQ FORM ONE LARGE SQ ALSO HORIZONATLY AND VERTICALLY VERTICAL MEASURMANT VOLTAGE SMALL SQ=0.1MV ,,,,,,,,,,,LARGE SQ =0.5mv ANY ECG MACHINE STANDARDIZED IN SUCH MANNER THAT IMPUSLE OF MILLIVOLT WILL CAUSE A DEFLECTION OF 10 SMALL SQUARE OR 2 LARGE SQ . Or 1 mvolt THIS NORMAL VOLTAGE FOR ALL EVERY ECG WHAT CLINICAL APPLICATION FOR THAT • HORIZONTAL MEASURMENT • 1mm = SMALL SQ = 0.04 SECOND AND 5mm= ONE LARGE SQ = O.20 SECOND THEN 1 SECOND = 5 LARGE SQ OR 25mm and 1 minute = 300 large square • What is benefit for that ??? EKG Tracing ………. • Grid Paper • Each small box = 0.04 seconds • Each large box = 0.20 seconds (5 small boxes across) • One second is 5 large boxes • Three seconds is 15 large boxes • Six seconds is 30 large boxes • Each minute has 300 large boxes • 300\R-R the heart regular • If the heart rate iirugular • Count R falling in 30 L sq XXX 10 • Or count R in 15 LS XXXX20 • Anther method • Every 5mm (L S )= 0.20 sec >>>>>>> 1 second = 25mm=2.5cm every 3second = 7.5cm every 6 second 15cm • By ruller count R in 15 cm XXXXby 10 The Concept of a “Lead” By combining certain limb leads into a central terminal, which serves as the negative electrode, other leads could be formed to "fill in the gaps" in terms of the angles of directional recording. These leads required augmentation of voltage to be read and are thus labeled. What Is In Each Beat? (the cardiac cycle in waves, complexes, and intervals) • P Wave – atrial contraction or depolarization, (usually upright) • QRS Complex – time for ventricular contraction or depolarization (usually upright) (0.04 - 0.12sec) (delays in the bundle branches will widen the QRS) • T Wave – ventricular repolarization “recharging” (usually upright) • PR Interval – time between atrial depolarization to ventricular depolarization (beginning of P wave to beginning of QRS)(0.12 - 0.20sec) (prolonged PR = delays in the AV node conduction) • QT Interval – represents one complete ventricular depolarization and repolarization (beginning of QRS to the end of the T wave) (0.32 – 0.44sec) (disturbances are usually due to electrolyte disturbances or drug effects) Reading a Rhythm Strip What Do I Look For? ► Regularity - What is the R – R Interval? ► Rate - Is the rate normal (60-100), slow, or fast? ***Six-second strip method - (30 big boxes) & multiply times ten ► P Wave – Is there a P wave before every QRS? Is it upright? ► QRS Complex – Is there a normal QRS complex following each P wave? Wide or normal? ► T wave – How does your T wave look? Upright? ► Measure your intervals – PR Interval, QRS, QT “Practice Strip” “Check Your Pulse” Match the Rhythm with the Pt • After assessing the EKG strip in a systematic method, gather the information about your pt’s assessment: med hx, s/sx, labs. • Does the rhythm make sense for the pt? • What is going on with the pt? 2nd level assessment • The following should be considered when interpreting ECG • NEVER GIVE IMPRESSION ON SINGLE ECG PARTICULARLY IF THE RESULT NOT FIT WITH CLINICAL DATA What is Normal? “Normal” Sinus Rhythm The electrical impulse originates in the SA Node 1) Rhythm ► Regular 2) Rate ► Regular (R to R Interval) (60 – 100 beats/minute) 3) P wave ► before every QRS complex 4) QRS complex ► narrow, not wide (0.04-0.10sec) A Slight Deviation from “Normal” “too slow and too fast” Sinus Bradycardia 1st Level Assessment ►Rate? (less than 60bpm) ►Symptoms? (subjective and objective) 2nd Level Assessment ►Reasons? Etiology? Nursing Interventions Pharmacology Sinus Tachycardia 1st Level Assessment ►Rate? (> than 100) ►Symptoms? (subjective and objective) 2nd Level Assessment ►Reasons? Etiology? Nursing Interventions ECG ABNORMALITIES MAY BE SEEN IN NORMAL HEALTHY PERSON IN ABSENCE OF ORGANIC HEART DISEASE 1 – EARLY REPOLARIZATION 2- HIGH LV VOLTAGE 3-JUVENILE T WAVE 4-ATHLETIC T WAVE 5-INSIGNIFICANT Q WAVES IN AVL , 1 V5 AND V6 6-RIGHT AXIS DEVIATION 7-SHORT PR INTERVAL 8-FIRST DEGREE HEART BLOCK 9-RBBB ECG MAY NORMAL OR UNINTERPRETED IN PRESENCE OF ORGANIC HEART DISEASE IN FOLLOWING SITUATION 1-ACUTE MI ESPECIALLY EARLY PRESENTATION OR MASKED BY WPW ,LBBB AND PACE MAKER 2-PATIENT WITH SEVER CORONARY ARTERY DISEASE 3-WITH ACUTE PULMONARY EMBOLISM NORMAL ECG OR NON SPECIFIC 4- IN SOME CASE OF LV OR RV HYPERTROPHY 5-ECG MAY NORMAL IN BETWEEN ATTACK OF a-PAROXYSMAL AF b-PAROXYSMAL SVT SOME MEDICAL DISEASE MAY BE MANIFEST WITH ECG 1-CVA ( INTRACERBRAL Hage ) 2-DRUGS TOXISITY 3-ELECTROLYTE DISORDER 4-ENDOCRINE DISEASE TIFECT & ECG 1-LIMB REVERSAL 2-VOLTAGE CALIBRATION 3-INCORRECT PAPER SPEAD 4-EXTERNAL ELECTRICAL INTERFERENCE 5-PATIENT MOVEMENT ( VULONATARY OR BY DIEASE e.g. PARKINSONS • P –WAVE • ABSENT( AF, SINUS NODE ARREST , HYPERK+) • INVERTED( LEAD MALPLACEMT,DEXTROCARDIA) • TO TALL (…..P PULMONALE ….) • TOO WIDE (…..P MITRALE….) PR INTERVAL SHORT 1-NORMAL VARIENT 2-L.G.L SY NDROME 3-WPW SYNDROME 4-AV- JUNCTION RHTYUM LONG 1- HEART BLOCK 2-DRUGS -VARY 1- SECOND DEGREE HB 4-DEPRESSED PERICARIDITIS ELEVATED ATRIAL INFARCTION QRS 1-ABNORMAL SHAPE BBB & FASCICLUR BLOCK 2-ABNORMAL DURATION AND SHAPE WPW , HYEPK+ ,VENTRICULAR RHYTHUM , PACE MAKE AMPILTUDE LOW IN HYPOTHRYRDISM , CALBIRATION PERICARIDAIL EFFUSION HIGH AMLITUDE CALBIRATION L.V.H AND RVH POST. MI Q- WAVES PHYSIOLOGICAL SMALL IN AVL , I, V5 AND V6 PATHOLOGICAL 25% OF R HIGHT ST DEPRESSION 1- ISHEMIA 2-POST MI 3-DRUGS 4-STRIAN PATTERN 5-RESIPROCAL CHANGES ST- ELEVATION 1-MI 2-PERICARIDITIS 3-ANUERYISM 4-EARLY REP 5-PRINZMATEAL ANGINA 6-METASTASIS MYCARDIUM T WAVES TO TALL HYPERKALMEAI MI TOOSMALL INVERTED …DISTURBANCE REPOLARIZTION ( ISHEMIA , INFLAMATION ,DRUGS ,HYPOXIA TOXINS)) QT INTERVAL LONG 1-DRUGS 2-ISHEMIA 3- MI 4-HCMP 5-HYPOTHERMAI 6-CVA U- WAVES S ?????? What is an Arrythmia anyways? ► Definition: a disorder of impulse formation. An abnormal electrical conduction that changes the heart rate and rhythm. A disturbance in the heart’s rhythm. ► Why? Causes? 1) Classified according to their origin 2) Some are mild, asymptomatic – require no treatment 3) Some are catastrophic – require immediate emergency response 4) They can influence cardiac output and blood pressure “Clinical Significance” • Thousands of people suffer with arrythmias • Dysrhythmias are responsible for over 44,000 deaths each year. • There site of origin can often lead us to the problem area • About 15% of strokes occur in patients with atrial arrythmias • A large majority of sudden cardiac deaths are thought to be caused by ventricular dysrhythmias. What is The Big Deal? Why are we so concerned with Arrythmias? SV x HR = CO ► SV dependent on filling time, adequate volume, and myocardial muscle function ► HR dependent on electrical stimulus, Autonomic NS, Parasympathetic NS ►Too Fast ►Too Slow ►Too Irregular NOT GOOD!!! Some of you might be feeling a bit overwhelmed at this time …. Atrial Arrythmias • Atrial arrythmias occur because there are other pacemakers in the atria competing to be the “commander” • SA Node is not healthy and unable to lead Atrial Fibrillation Results from disorganization of atrial electrical activity without effective atrial contraction. Repetitive, irregular, uncontrolled depolarization. Atrial rate ~ 350-600 bpm, Ventricle - varies ► No P Wave! Very “jiggly” baseline wave ► No PR Interval ► Irregular with a wavy baseline ► Rate - Controlled vs. Uncontrolled ► Loss of “Atrial Kick” ► Emboli Potential Atrial Fibrillation • • • • 1st Level Assessment 2nd Level Assessment Nursing Consideration Pharmacologic Consideration – – – – Digoxin Ca+ Channel Blockers Beta Blockers Coumadin On Your Own …. You are responsible for reviewing pharmacology re: arrhythmias: • Please know the actions, doses, side effects, nursing considerations, monitoring, precautions, therapeutic drug levels, s/sx toxicity for the following drugs: • • • • Digoxin Ca+ Channel Blockers (verapamil, diltiazem) Beta Blockers (atenolol, metoprolol) Anticoagulants (warfarin) Atrial Flutter Results from the atria stimulated to contract 250-350 bpm in a circuit fashion around the atrium ► No true P waves – F waves larger than P waves (flutter waves) ► Sawtooth-shaped waves ► Usually a regular rhythm D/T AV Node filter ► Ventricular Rate – atria to ventricle ratio (2:1 or 4:1) Assessment and treatment the same as Atrial Fib The “Basic Blocks” • First Degree AV Block • Third Degree Block (AKA) Complete Heart Block Etiology, 1st and 2nd Level Assessment, Intervention Check Your Pulse! “From the Bottom of My Heart” Arrythmias stemming from the ventricles. Occurs when a pacemaker in the ventricles initiate a beat or a whole rhythm ►Premature Ventricular Contraction (PVC) “FLB” QRS wide and bizarre ►Ventricular Tachycardia (V Tach) 3 or more ventricular ectopic complexes (PVCs) Rate greater than 140-250bpm QRS complex wide and aberrant 3 or More PVCs = Ventricular Tachycardia “Sustained V Tach” Treatment for PVCs / V Tach • Dependent on patient’s condition • How frequent are the PVCs: unifocal, multifocal, healthy heart? • Pulse? No Pulse? • Labs? Particularly K+ and Mg+ levels? • Sustained ? Non-sustained? ►Ventricular Fibrillation (V Fib) Results from part of the ventricle depolarizing at a rapid and erratic uncontrolled manner. There are no recognizable waves and complexes and segments ► Nursing Considerations: ► 1st Level Assessment ► 2nd Level Assessment ► Nursing Intervention V Fib is the most lethal arrhythmia and will be fatal! Patient assessment is crucial! Early Defibrillation! CPR! Bundle Branch Block “The Road Detour” Interruption of conduction in one of the main branches of the Bundle of His • Normal conduction through the bundles? • Why interruptions? • QRS wide – greater than 0.12 seconds Don’t Just Stand There! ASYSTOLE (please, not on my shift ) AKA “flatline”, “cardiac standstill” ►Etiology ►Nursing Assessment and Intervention ►Pharmacological Considerations And you may feel like all rhythms look alike Look Closely and you will see the differences! ST Segment Depression – “Infarcted” “Check Your Pulse” ? Immediate Nursing Question ? “How does my patient look?” “Do they have any symptoms?” (what are symptoms of low CO?) “Do they have a normal or diseased heart?” This can buy you time!!! (to assess and gather more information about the patient’s condition) Top Nursing Priorities ►Check the patient (LOC?) ►ABC – airway, breathing, circulation ►Oxygen administration ►IV Access / Patency ►Electrode placement ►Associated Symptoms? Chest pain, SOB, dyspnea, vertigo, nausea ►Fluids ►Monitor VS Fast Assessment and Identification of the problem are key Nursing Priorities In the cardiac world, time is oxygen. The longer you delay reaction to arrhythmias, the longer the heart suffers. Don’t let your patient “circle the drain”! Pharmacologic Considerations Above the AV NODE (Atrial) (ABCD) • Too Slow Atropine • Too Fast Beta Blockers Calcium Channel Blockers Digoxin Amiodarone Below the AV NODE (Ventricular) (LAP) • Too Fast Lidocaine Amiodarone Procainamide Too Slow ….. • Treatment for Symptomatic Bradycardia is Atropine (check your patient first) Classification: Antidysrhythmic/Anticholinergic Common dose: 0.5mg – 1.0mg – up to 2mg IVP How to give: given every 3-5 minutes SE: hypotension, angina, tachycardia, PVCs, dry mouth Too Fast … • Uncontrolled Atrial Fibrillation - Beta Blockers (Lopressor, Labetolol) - Calcium Channel Blockers (Cardizem, Verapamil) - Glycosides/Inotropes (Digoxin) • Ventricular Arrhythmias - Antiarrythmics (Lidocaine, Procainamide, Amiodarone) Practice on your Own … Antiarrhythmic IV Drips • Lidocaine bolus of 50-100mg (1mg/kg) over 2-3 minutes • IV Drip: (1gm/250ccs) or (2Gm/500ccs) to run at 1-4mg/min How to figure that in ml/hr for a pump ….. Know nursing considerations / monitoring and s/sx of toxicity Non – Pharmacologic Treatment • Electroshock – Cardioversion Unstable “tachy” rhythms • Ablation • Defibrillation (and internals) Nursing Consideration and Care *** Look at Patient Teaching in Table 35-9 Pacemakers I. External Pacing – noninvasive temporary with patches on chest wall II. Internal Pacing – invasive temporary internal through the femoral arteries III. Permanent Pacemaker – inserted through the chest wall – open heart IV. Modes: Demand or Override *** Review Pt Teaching with a pacemaker Case Study Example Mrs. Taylor has become more forgetful lately. She has trouble managing her medications. She is supposed to take (1) Digoxin in the morning, but sometimes she takes one at night. As a result, her Digoxin level has reached toxic levels. She comes to the ER with nausea, vomiting, fatigue, vision changes. You put her on the EKG monitor and she is in 3rd degree heart block with a HR of 32. Her blood pressure is 70/40. The ER doctor orders for you to put her on an external pacemaker. She will remain on this pacemaker to maintain an adequate HR and CO until her Dig toxicity resolves. We are done for the day! Additional References http://medlineplus.gov http://www.nurse411.com click on: educational links click on: basic EKG tutorial, put in your name, and push play Adams, M., Josephsen, D., Holland, L. (2005). Pharmacology for Nurses: A pathophysiologic approach. New Jersey: Prentice Hall. Further Study on Your Own Taking it a step further ….. Challenge yourself The Health of the Heart Walls The heart is composed of four walls and each of the walls is fed oxygen through direct and indirect blood flow. This blood flow is delivered by coronary arteries and through collateral circulation. Heart Walls • Anterior Wall Includes most of the left ventricle, the intraventricular septum • Inferior Wall Includes most of the right ventricle and some of the left ventricle, extends down to the apex • Lateral Wall Located on the left side of the heart (no right heart involvement) • Posterior Wall Lies along the back of the heart Coronary Artery Supply Right Coronary Artery Left Main Coronary Artery Left Circumflex Coronary Artery Left Anterior Descending Right Coronary Artery feeds the right atrium and ventricle inferior wall posterior wall SA Node and AV Node (in most people) Left Anterior Descending anterior wall and intraventricular septum apex of the heart papillary muscles bundle branches Circumflex lateral and posterior wall of L Ventricle How Does This Tie To The EKG? When one looks at an EKG and notices disturbances or problems in certain areas of the heart, it is useful to understand which coronary artery supplies that area. This can help you identify the vessel where blood supply is possibly compromised (arteriosclerotic changes) Example A patient that came into the hospital with Sick Sinus Syndrome (SA Node is not feeling well) and was in Symptomatic Sinus Bradycardia may go for a Coronary Angiogram. During this procedure, the MD may find that they have atherosclerotic changes and blocks in their Right Coronary Artery that feeds blood supply (and O2) to that node. Without proper blood supply, that area is unable to perform normal electrical conduction and begins to show disturbances (arrhythmias). This patient may need to have an angioplasty or stent placement or CABG to open up that area to better blood supply. Additional References http://medlineplus.gov http://www.nurse411.com click on: educational links click on: basic EKG tutorial, put in your name, and push play Adams, M., Josephsen, D., Holland, L. (2005). Pharmacology for Nurses: A pathophysiologic approach. New Jersey: Prentice Hall.