ECG Review & Exam Telemetry clinical Skills
Objective for ECG Review & Exam At the completion of this review the participant will be able to identify and interpret: 1. Basic Anatomy and Physiology 2. Correct Lead Placement I,II,III,aVR,aVL,aVF 3. 5 Step - Systematic approach to ECG interpretation 4. Calculating Heart Rates for any age. 5. 27 Types of Rhythms, AV Blocks, Paced Rhythms and Ectopy 6. Lethal Arrhythmias - Shockable and nonshockable rhythms *Exam: Interpreting cardiac rhythms and concepts using critical thinking skills.
Cardiac Anatomy & Physiology Name the chambers, veins, arteries and valves.
Heart Anatomy Inferior/Superior Vena Cava – blood from body Right Atria – deoxygenated blood Tricuspid Value – right side Right Ventricle – deoxygenated blood Pulmonic Value – right right Pulmonary Artery – to lungs Pulmonary Vein – from lungs Left Atria – oxygenated blood Mitral (bicuspid) Value – left side Left Ventricle – oxygenated blood Aortic Value – blood pumped out through Aorta.
Easy way to remember the Cardiac Values‌T.P.M.A.
Tuality uses several different models of telemetry monitors, leads and electrodes.
Attach leads to electrodes BEFORE attaching electrodes to patients skin.
“Pin the LEADS on the PATIENT”
Monitor Continuous ECG’s in II, III, aVF
Lead I Lateral View LA
RA
C Lead II Sectional
RL Ground
Lead III Sectional
LL
What are the 5 steps to Rhythm Interpretation?
Calculate the Atrial and Ventricular Rates
R-R intervals
Is it regularly regular, regularly irregular, irregular ? Present? Shape? Upright? One P - QRS? Regularly occur? Is it 0.12 – 0.20 seconds? Short? Long? Constant? Is it 0.06 – 0.10? Narrow or Wide? Similar in Appearance?
LARGE BOXES 300 – 150 – 100 – 75 – 60 – 50 – 43 – 37 – 33 – 30
HEART RATES SA Node “ natural pacemaker” Sinus Rhythm = 60 – 100 (normal intrinsic rate) Sinus Bradycardia = < 60 (normal sleep/well conditioned athletes/age) Sinus Tachycardia = > 100 (normal exercise/stress/caffeine/fever) Sinus Arrhythmia = variable (breathing, sick sinus syndrome/> < age) The AV nodal junction & HIS Bundle “back-up pacer” Junctional Escape Rhythm = 40 – 60 Accelerated Junctional Rhythm = 60 – 100 Junctional Tachycardia = > 100
SA Node HIS Bundle
AV Node
LBB
The Purkinje Fibers “protective pacer” Idioventricular Rhythm = 3 or more VEB at 20 – 40bpm (Loss of atrial kick causes decreased cardiac output)
Accelerated Idioventricular Rhythm = VEB at > 40 (typically <50 – >110, benign and transient and frequently occurs after cardiac reperfusion but is self limiting)
RBB
Purkinje
HEART RATES Supraventricular (Atrial Tachycardia) Rates Atrial Fibrillation = Controlled or uncontrolled rates, there’s no P waves, F (Flutter “quiver”) waves are present and it is irregularly irregular. Most common arrhythmia! Increases risk for stroke (4-5 fold) and heart related hospitalizations and death.
Atrial Flutter = Atrial ~ 300bpm, Saw tooth pattern, atrial rate fires rapidly, SA Node but not all QRSs are conducted, usually 2:1. or 4:1 conductions. The AV node is the gate keeper and protector from all flutter waves making it into the ventricles. It occurs most often in people with hypertension, CAD and cardiomyopathy and diabetes, or spontaneous in normal hearts. Not typically a stable rhythm and can degenerate into afib.
SVT = Regular rhythm of 100 – 250bpm, it can be a sudden onset or gradually come on and dissipate. Paroxysmal or PSVT means, comes and goes. Stable treatments include vagal maneuvers or adenosine. Long term medications include beta blockers, calcium-channel blockers or antiarrhythmics, or cardiac ablation. Unstable patients with SVT and a pulse are treated with sync cardioversion (50-100J AHA recommendation)
HIS Bundle
AV Node
RBB
LBB
Purkinje
HEART RATES Ventricular Rates (with and without a pulse) Ventricular Tachycardia = 3 or more PVCs at > 100bpm Sustained = >30 seconds, even if it terminates after 30 sec. Non-sustained = < 30 seconds. Pulseless VT requires Unsync Cardioversion (DEFIBRILLATION)
Ventricular Fibrillation = non measurable â&#x20AC;&#x201C; ventricles quiver. Pulseless VF requires Unsync Cardioversion (DEFIBRILLATION)
Agonal = < 20 bpm & Asystole = 0 bpm Perform high quality CPR
PEA = Pulseless Electrical Activity, the heart is conducting electrical impulses But there is no contraction of heart muscle activity. Consider the 5Hs and 5Ts. Hypovolemia, Hypoxia, Hydrogen ions (acidosis), Hyper/Hypokalemia, Hypothermia, Toxins, Tamponade, Tension Pneumothorax, Thrombosis (MI), Thrombosis (PE).
What are normal heart rates for different ages? • Newborns 0 - 1 month old:
70 - 190 beats per minute
• Infants 1 - 11 months old:
80 - 160 beats per minute
• Toddler 1 - 2 years old:
80 - 130 beats per minute
• Toddler 3 - 4 years old:
80 - 120 beats per minute
• Children 5 - 6 years old:
75 - 115 beats per minute
• Children 7 - 9 years old:
70 - 110 beats per minute
• Adolescent 10 years and older, and adults (including seniors): • Well-trained athletes:
60 - 100 beats per minute
40 - 60 beats per minute
U.S. National Library of Medicine 8600 Rockville Pike, Bethesda, MD 20894 U.S. Department of Health and Human Services National Institutes of Health Page last updated: 03 December 2014
Lets Practice Heart Rates and Regularity
P Wave Questions to ask yourself? “Did you know P waves tell you about ATRIAL ACTIVITY!” ◦Are they present? ◦Do they occur regularly? ◦Is there one P-wave for each QRS complex? ◦Are the P-Waves smooth, rounded, and upright? ◦Do all P-Waves have similar shapes?
Whatâ&#x20AC;&#x2122;s so GREAT about the P WAVE? It is electrically activated by the SA Node. The P wave represents atrial depolarization (contraction) In normal EKGs, the P-wave precedes the QRS complex. It looks like a small bump upwards on the baseline. The shape of a P-wave is usually smooth & rounded.
NO p wave??? Then NO SA node activity! Itâ&#x20AC;&#x2122;s NOT a Sinus Rhythm Ask yourself, who is pacing the hear t now? AV Junction? Purkinje?
P WAVE ABNORMALITIES
PAC
PAC
PR INTERVAL
How do you measure PR? Start at the BEGINNING of the P wave to the BEGINNING of the QRS complex, or when the QRS leaves the baseline or isoelectric line.
The PR Interval indicates AV conduction time or the time it takes for the electrical impulse to travel from the Atria into the ventricles. The AV Junction is the GATEKEEPER! It protects the ventricles from being overstimulated from atrial preexcitation rhythms. For example in atrial fib or flutter, it allows only a few through, not all the f waves are conducted to the ventricles. Ask yourself, are the PR-Intervals constant or vary across the ECG tracing? If the PR intervals vary, there could be something wrong with the gatekeeper, perhaps its blocked or injured ! This interval shortens with increased heart rate.
PR Interval 0.12-0.20 sec. AV Junction = GATEKEEPER
Tips & Tricks: How to remember 2nd Degree Heart Blocks: Type I and Type II
Type I Type II
What is a NORMAL QRS COMPLEX
Normal QRS 0.06 – 0.10 Narrow or Wide?
ECG Rhythms: Interpretation Review Name that Rhythm!
Sinus Rhythm
Name that Rhythm
Sinus Bradycardia
Name that Rhythm
Sinus Tachycardia
Name that Rhythm
Name that Rhythm
Sinus Arrhythmia
SupraVentricular Tachycardia
Name that Rhythm
1st Degree AV Block
Name that Block
nd Degree Block Type I
Name that Block
d Degree Block Type II
Name that Block
rd Degree Hear t Block
Name that Block
Atrial Fibrillation
Name that Arrhythmia
Atrial Flutter
Name that Arrhythmia
PAC (4th beat) SR with PAC
Name that Ectopy
PVC (7th beat) SR with PVC
Name that Ectopy
PVC Bigeminy
Note: two in a rowisa couplet
Name that Ectopy
PVC Trigeminy
Note: 4th = Quadrigeminy >5 iscalled occasional
Name that Ectopy
Name that Ectopy
Multifocal PVCs
Inverted p wave on PJC beat
PJC
Sinus Rhythm with PJC
Name that Rhythm
Name that Pacemaker
100% Atrial Pacing
00% Ventricular Pacing
Name that Pacemaker
Name that Pacemaker
AV Pacing
Failure to Capture
Name that Pacemaker Failure
No pacemaker spikes seen
Failure to Pace
Name that Pacemaker Failure
Narr ow Q
RS a n
d re gula r
Junctional Rhythm
Name that Rhythm
Name that Rhythm
ccelerated Junctional
unctional Tachycardia
Name that Rhythm
Accelerated Idioventricular
Name that Rhythm
dioventricular Rhythm
Name that Rhythm
Symptoms arise from decreased cardiac output, if rate is <40.
CAUTION PACER! However, accelerated idioventricular rhythms may be temporary, harmless and asymptomatic
< 20bpm
Name that LETHAL Arrhythmia â&#x20AC;&#x153;Dying Heartâ&#x20AC;? Sometimes its irregular or intermittent and the patient may not have a palpable pulse - PEA
A gonal Rhythm
CALL A CODE BLUE!
CHECK PATIENT, CHECK LEADS, IF PULSELESS…Begin CPR / ACLS
none none
none none
Name that LETHAL Arrhythmia
Asystole Rhythm
CALL A CODE BLUE! CHECK PATIENT, CHECK LEADS, IF PULSELESS… Begin CPR
Name that RUN! 3 or more pvc in a row Rate > 100bpm Lasts less than 30 seconds
Run of V-Tach
Non-sustained Runs â&#x20AC;&#x201C; Irritable Heart
Notify the Physician CHECK PATIENT, CHECK LEADS, Take their vital signs, 12 Lead, Labs Monitor closely.
Monomorphic entricular Tachycardia
Name that Arrhythmia With or without a Pulse dictates your intervention.
CALL A CODE BLUE!
IF PULSELESS… Begin CPR and Defibrillate
Polymorphic entricular tachycardia
Name that LETHAL Arrhythmia
CALL A CODE BLUE!
IF PULSELESS… Begin CPR and Defibrillate
Torsades de pointes
Name that LETHAL Arrhythmia
CALL A CODE BLUE! IF PULSELESS… Begin CPR and Defibrillate – Consider Magnesium bolus.
Ventricular Fibrillation
Name that LETHAL Arrhythmia
CALL A CODE BLUE!
Begin CPR and Defibrillate
Shockable Rhythms VT & VF
VT Polymorphic – Pulseless
SHOCKABLE! VT Monomorphic – Pulseless
Ventricular Fibrillation - Pulseless
Torsade De Pointes – Pulseless
When you defibrillate a patient, you are STOPPING the heart momentarily so that it can RESET itself to an organized rhythm or convert it out of a lethal arrhythmia.
Defibrillation does not bring back a DEAD FLATLINE or put energy back into the heart and it can not reverse the causes of PEA, the 5Hs or 5Ts.
Non Shockable Rhythm Asystole & PEA
PULSELESS NON – SHOCKABLE RHYTHMS *Check the leads on the patient to make sure they are intact and have conductivity with the patients skin. Ventricular standstill (P wave asystole) – No Pulse
Asystole – No Pulse
Pulseless Electrical Activity – No Pulse
Asystole & PEA are NON-SHOCKABLE HIGH QUALITY CPR AND ACLS MEDICATIONS (EPI)
The End of the ECG Review…
What Questions do you have? What Rhythms are easy & quick? Normal and Lethals are quick! What Rhythms are dif ficult And take more time? Blocks and AV
ECG Exam Instructions ▪ The ECG exam is 1 hour long with 30 additional minutes for review of the questions you missed. ▪ The ECG exam is 45 randomly generated questions, multiple choice, multiple select, and matching. ▪ Keep in mind, the same rhythms may appear more than 1 time. ▪ It is open book and you may use additional references and notes and your ECG workbook. ▪ You must score an 80% or better to pass. ▪ If you score < 80%, don’t worry, you get a second chance. ▪ This exam has a 90% passing rate, 1 in 10 people have to retest and 100% passing rate the 2nd time. ▪ To access your exam, sign into HealthStream and start exam. ▪ Your score will be calculated after you click “submit” and presented on screen. ▪ When your score is presented, raise your hand obtain your certificate or to schedule a retest date. ▪ Good luck!
Reference Materials ECG Strips:
http:// floatnurse-mike.blogspot.com/search?updated-min=2014-01-01T00:00:00-05:00&updated-max=2015-01-01T00:00:00