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
.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
.The bundle branches are high-speed conducting fibers that rundown the intraventricular septumand transmit the cardiac impulse tothe
.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 gen-erates the
,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
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