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12 lead EKG interpretation part 1

12 lead EKG interpretation part 1

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02/02/2013

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RESPONDING TO THE CALL bell,you find GeorgeSmythe, 67, sittingup in bed and complaining of chestdiscomfort. Mr. Smythe had a laparo-scopic cholecystectomy earlier today.You take his vital signs and perform achest pain assessment, which in-cludes the onset, location, quality,intensity, duration, and any radiationof the discomfort. You ask aboutassociated signs and symptoms andfactors that aggravate or relieve thepain. Following your facility’sproto-col, you administer supplementaloxygen at 2 to 4 liters/minute vianasal cannula and page the physi-cian on call, who orders stat serumcardiac biomarkers, a 12-lead elec-trocardiogram (ECG), and sublin-gual nitroglycerin.Do you know what to look for todetermine if Mr. Smythe’s 12-leadECG is abnormal? Could you rec-ognize signs that he’s having amyocardial infarction (MI)? If youcan independently interpret a 12-lead ECG, you can anticipate andprepare for the emergency careyour patient may need.In this article, I’ll cover thebasics of 12-lead ECG interpreta-tion, focusing on a normal ECG.Next month, I’ll discuss ECGabnormalities.
What’s happening in the heart
The heart’sinternal conduction cir-cuit initiates each heartbeat andcoordinates all parts of the heart tocontract at the proper time. A nor-mal heartbeat is initiated in thesinoatrial (SA) node, a specializedgroup of cells in the right atrium.The SA node depolarizes at a rateof 60 to 100 times/minute, causingthe atria to contract and propelblood into the ventricles.Atrial depolarization producesthe first element on the ECGwaveform: the
Pwave
.The P waveis the first part of the cardiac cycleand appears as a small, semicircu-lar bump (see
Tracing a normalECG waveform
).The wave of depolarization con-tinues through the atria until itencounters the next importantstructure, the
atrioventricular (AV) node
.The AV node receivesthe atrial impulse and (after abriefpause to let the ventricles fill)transmits it to the ventricles via the
bundle of His.
Acollection of car-diac conduction fibers, the bundleof His splits into the right and left
bundle branches
.The bundle branches are high-speed conducting fibers that rundown the intraventricular septumand transmit the cardiac impulse tothe
Purkinje fibers
.These fibersform a complex network that min-gles with ventricular myocardialcells. The function of the Purkinjefibers is to rapidly stimulate ven-tricular muscle fibers, resulting inthe next major event in the cardiaccycle:
ventricular depolarization
.Ventricular depolarization gen-erates the
QRS complex 
,the electri-cal equivalent of ventricular sys-tole. (Remember that electricalactivity precedes mechanical activi-ty,and the ECG shows only electri-cal activity.) If you palpate a carotidor radial pulse while looking at acardiac monitor,you should feel apulse with each QRS complex onthe monitor.The QRS complex normally hasaduration of 0.06 to 0.1 second. Aduration greater than 0.12 second
36
Nursing2006,
Volume 36, Number 11www.nursing2006.com
Find howthe ECG translatesthe heart’s electrical activityinto a waveform and what it tells youabout yourpatient’s condition.
BY GUY GOLDICH, RN, CCRN, MSN
12-leadECG
Understanding the
part I
 
usually indicates prolonged ven-tricular conduction caused by abundle-branch block.The QRScomplex is variable in appearanceand may have a different shape (ormorphology) in different patientsor even look different in variousECG leads in the same patient. TheQRS complex may have one, two,or three wave components,depending on the lead and yourpatient’s condition.The last major wave componentof the ECG is the
T wave,
which islarger than the P wave and round-ed or slightly peaked. Immediatelyfollowing the QRS complex, it rep-resents ventricular repolarizationor a metabolic rest period betweenheartbeats. During repolarization,electrolytes such as potassium,sodium, and calcium cross the cellmembrane (back to their originallocation) to prepare the cardiac cellfor the next depolarization.Besides the three waveforms, thenormal ECG cardiac cycle tracinghas two important
segments,
or flat(isoelectric) parts of the tracingbetween the waveforms: the
PRinterval
and the
ST segment
.The PR interval is the periodfrom the beginning of the P wave tothe beginning of the QRS complex.It consists of the P wave plus theshort isoelectric segment that termi-nates at the start of the QRS com-plex. The normal PR interval lasts0.12 to 0.2 second; this representsthe time from SA node depolariza-tion to ventricular depolarization. If the PR interval is
less
than 0.12 sec-ond, then the cardiac impulse didn’tfollow the normal conduction path-way. If the PR interval is
longer 
than0.2 second, then a disease processmay be affecting the cardiac con-duction pathway, keeping it fromfunctioning properly.The ST segment consists of theisoelectric line between the end of the QRS complex and the begin-ning of the T wave. The ST seg-ment reveals information aboutthe heart’s oxygenation status. Forexample, myocardial ischemia (atemporary, reversible decrease inoxygenation) often results in anST segment below the baseline of the ECG tracing. When myocar-dial cells are injured (reversiblephysical damage from lack of oxy-gen), the ST segment often is ele-vated above the baseline. So ST-segment elevations are a key indi-cator of MI. I’ll discuss this indetail in the next part of thisseries. For tips on how to use theECG to calculate heart rates andmore, see
Paper training.
Catching the wave
If you examine a 12-lead ECG,you’ll notice that some QRS com-
www.nursing2006.com
Nursing2006,
November
37
PR intervalST segmentQRS complexQT intervalPRTQS
2.5
 ANCC/AACNCONTACT HOURS
Tracing a normal ECG waveform
 
plexes have upward deflectionsand others have downward deflec-tions. Here’s why.Each ECG lead has a positive (orsensing) electrode and a negativeelectrode, which acts as an anchor.The positive electrode lookstoward its negative electrode andsenses whether electrical energy isbeing directed toward or awayfrom the positive electrode. When electrical energy is directed
toward
the positive monitoring elec-trode, the QRS complex has anupward deflection. When the electri-cal energy is directed
away
from thepositive monitoring electrode, theQRS complex has a downwarddeflection. The more directly alignedthe direction of the electrical energywith the positive electrode, the moreupright the complex. If the electricalenergy approaches the positive mon-itoring electrode at a glancing angle,the complex will still be upright, butless upright than if the energy weredirectly aligned with the positiveelectrode.Energy arriving at a perpendicu-lar angle to the positive electroderesults in either a waveform withlittle deflection (isoelectric) orequal amounts of positive and neg-ative deflection.As the energy is directed awayfrom the positive electrode, theQRS complex becomes progres-sively more negative. When ener-gy flow is directed totally awayfrom the positive electrode, theQRS complex is deflected directlydownward.
Going with the flow:A look at vectors
All cardiac cells are electrochemi-cal, meaning they generate electri-cal energy during depolarization.This electrical energy, called a
vec-tor 
, has strength (measured in mil-livolts) and direction (measured indegrees from an arbitrary zero pointcalled the electrical axis). Each car-diac cell generates its ownmicrovector. The mathematicalaverage of these microvectors is the
mean QRS vector 
or
mean vector,
which follows the conduction path-way of the heart—downward andto the left. The mean vector flowsslightly to the left of the ventricularseptum because the left ventriclehas more and larger cardiac cells.Generally, each person has aunique mean vector direction,which remains constant unless hiscardiac status changes. For exam-ple, left ventricular hypertrophysecondary to heart failure pulls themean vector even more sharply tothe left side.
1
A person who has amean vector in an abnormal direc-tion is said to have an
axis devia-tion.
(For details, see
 Axis deviation: As easy as pie (charts).)
Putting it all together 
The mean vector is a representa-tion of the overall electrical proper-ties of the heart. A 12-lead ECG isthe electrical record of the meanvector from 12 different monitor-ing sites (leads) on the surface of the body. As when you look at anyobject, you need to see all theangles to get a complete picture.
Looking at limb leads
The first six leads of the 12-leadECG come from four electrodesplaced on the patient’s arms andlegs; the right lower leg electrode isthe ground electrode. The limbleads record the mean vector in theup-down and left-right directionalong the body’s frontal plane.Because they use separate positiveand negative electrodes, they’recalled bipolar or standard leads.
Lead I
has the positive electrodeon the left arm and looks towardthe negative electrode on the rightarm for electrical energy. Because
38
Nursing2006,
Volume 36, Number 11www.nursing2006.com
Paper training
 You can use the markings on ECG paper to calculate events within the cardiaccycle. The ECG paper is a grid of large and small blocks. On the horizontal axis,a large block is equal to 0.2 second and a small block is equal to 0.04 second. The vertical axis represents voltage or electrical energy, with each vertical mil-limeter (small block) being 0.1 millivolt of electrical energy. However, in prac-tice, deflections are typically described as being in millimeters, not millivolts.By counting the number of small squares and multiplying by 0.04, you cancalculate the duration of any event in the ECG tracing. A QRS complex that’s 2.5small squares wide is 0.1 second. You also can use the ECG paper to calculateheart rates, using one of two methods. In the 6-second method, you start by looking for the markings (usually short vertical lines) at the top of the rhythmstrip or ECG paper. These markings divide the ECG paper into 3-second inter- vals. Count the number of QRS complexes contained in two intervals (6 sec-onds) and multiply by 10. This method works for both regular and irregularheart rhythms.In the division method, count the number of small squares between any twoheartbeats. Make sure you use the same part in both QRS complexes—usually the peak of the complex works the best. Divide 1,500 by the number of smallsquares and you’ll have the heart rate in beats per minute. This method isaccurate only with regular heart rates because irregular heart rhythms have a varying number of small squares between any two QRS complexes.
Amplitudeor voltage
1 mV0.04second3 seconds0.5 mV(5 mm)0.1 mV(1 mm)0.20second

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