High-Tech/High-Care: ECG interpretation: Know the basics Teddy M.

Mitchell RN, BSN, BA Men in Nursing October 2008 Volume 3 Number 5 P !e" # $ %0 &or ye r", there h " bee' my"ti(ue ""oci ted )ith *+, i'ter-ret tio'. M 'y .eel " thou!h they re'/t e0-erie'ced, tr i'ed, t le'ted, or "m rt e'ou!h to (uic1ly 'd ccur tely i'ter-ret the"e te"t". A" )ith 'y 'e) "1ill, o'e "hould 1'o) the b "ic". 2 3e.orm" -roduced by the he rt/" electric l cti3ity re recorded 'd !r -hed o' *+, - -er by "tylu". A -iece o. *+, - -er i" c lled "tri- or tr ci'!. The hori4o't l 0i" re-re"e't" time 'd the 3ertic l 0i" me "ure" electric l 3olt !e or milli3olt".%53 6See 7*+, !rid.89 O'e "m ll bo0 o' the *+, !r -h me "ure" 0.0: "eco'd, 'd l r!e bo0 com-o"ed o. 5 by 5 "m ll bo0e" me "ure" 0.20 "eco'd. ;i1e)i"e, it t 1e" .i3e l r!e bo0e" to e(u l % "eco'd. 2he' c lcul ti'! - tie't/" he rt r te, #$"eco'd "trico'"i"ti'! o. 30 l r!e bloc1" i" u"u lly u"ed. The *+, ) 3e.orm h " m 'y - rt".: The P ) 3e 6the .ir"t com-o'e't o. 'orm l *+, ) 3e.orm9 re-re"e't" co'ductio' o. ' electric l im-ul"e throu!h the tri . Thi" im-ul"e c u"e" the tri to co'tr ct, -u"hi'! blood i'to the 3e'tricle". Ne0t, the PR i'ter3 l tr c1" the tri l im-ul"e throu!h the AV 'ode o. the he rt, bu'dle o. <=S, 'd the ri!ht 'd le.t bu'dle br 'che". The >RS com-le0 co'"i"ti'! o. three "e- r te ) 3e" .ollo)" thi".3 6See 7Norm l "i'u" rhythm.89 Ve'tricul r de-ol ri4 tio' i" immedi tely .ollo)ed by 3e'tricul r co'tr ctio'. The ST "e!me't re-re"e't" the e'd o. 3e'tricul r co'ductio' 'd the be!i''i'! o. 3e'tricul r reco3ery or re-ol ri4 tio', )hich i" re-re"e'ted by the T ) 3e. Occ "io' lly, ? ) 3e m y .ollo) the T ) 3e. ? ) 3e" re curre'tly u'der i'3e"ti! tio', but "ome "u!!e"t th t the"e re-re"e't the l "t l te -h "e o. 3e'tricul r re-ol ri4 tio'.2,5 The -re"e'ce or b"e'ce o. ? ) 3e" i"'/t cli'ic lly "i!'i.ic 't@ ho)e3er, o'e m y "ee ? ) 3e" i' co'ditio'" "uch " thyroto0ico"i", hy-o1 lemi , 'd hy-erc lcemi .# *lectric l co'ductio' "y"tem The "mooth mu"cle o. the he rt i" u'i(ue, 'd i" "-eci li4ed )ith "e3er l dy' mic -ro-ertie". The he rt mu"cle i" "tro'!, 'd h " the bility to co'tr ct 'd reco3er (uic1ly. &urthermore, "e'"i'! the 'eed" o. the body, the he rt c ' 3 ry the mou't o. blood eAected )ith e ch be t to meet the body/" dem 'd". O'e o. the mo"t im-ort 't -ro-ertie" o. c rdi c "mooth mu"cle i" the bility to i'iti te be t )ithout out"ide "timulu". Thi" bility i" 1'o)' " utom ticity.# Althou!h 'y cell i' the he rt m y i'iti te be t, the -rim ry - cem 1er .or the he rt i" the "i'o tri l 6SA9 'ode, loc ted i' the ) ll o. the ri!ht trium. The SA 'ode h " ' i'here't r te o. #0 to %00 be t" -er mi'ute.B Thi" im-ul"e i" co'ducted to the trio3e'tricul r 6AV9 'ode throu!h the i'ter'od l - th) y". The AV 'ode h " it" o)' i'here't r te o. :0 to #0 be t" -er mi'ute, -ro3ided th t 'o im-ul"e i" "e'"ed .rom hi!her u- i' the co'ductio' "y"tem. *lectricity tr 3el" do)' the bu'dle o. <=S 'd the ri!ht 'd le.t bu'dle br 'che", termi' ti'! i' the Pur1i'Ae .iber".8 6See 7Norm l electric l co'ductio'.89 The mid3e'tricle h " r te o. 20 to :0 be t" -er mi'ute, .ollo)ed by the 3e'tricul r -e0 th t m y be t bet)ee' 0 'd 20 time" -er mi'ute. The"e .e) .leeti'! be t" re o.te' re.erred to " 3e'tricul r e"c -e be t", " the 3e'tricle de"-er tely trie" to e"c -e de th by be ti'! " be"t " it c ' to m i't i' c rdi c -er.u"io'.% The electric l co'ductio' "y"tem o. the he rt i" de"i!'ed to .u'ctio' i' the b"e'ce o. out"ide i'.lue'ce throu!h utom ticity to m i't i' de(u te mech 'ic l co'tr ctio' )hile -ro3idi'! e'd or! ' -er.u"io'. ='ter-ret tio' 'd ' ly"i" =' order to obt i' the *+,, tt ch the *+, electrode" to the clie't. The electrode" mu"t be --lied i' the correct order .or the *+, to be o. 3 lue. =t/" im-ort 't to te ch the clie't th t thi" i" - i'le"" 'd 'o'i'3 "i3e -rocedure th t c ' -ro3ide im-ort 't di !'o"tic i'.orm tio'.

There re "e3er l ) y" to obt i' ' *+,. The C!old "t 'd rdC i" the %2$le d *+,, )hich loo1" t the he rt 'd i" ble to ide'ti.y "-eci.ic he rt ) ll" u"ed to ide'ti.y re " o. d m !e i' the he rt. <o)e3er, bed"ide mo'itori'! 3i telemetry ty-ic lly u"e" "t 'd rd 3$le d "etu-. The "t 'd rd 3$le d *+, u"e" the ri!ht rm 6)hite9, le.t rm 6bl c19, 'd le.t le! 6red9 limb le d".% ;e d == i" commo'ly u"ed to determi'e c rdi c rhythm due to the )ell de.i'ed 'd "e- r ted ) 3e" 'd com-le0e". Se3er l o-tio'" re 3 il ble to determi'e the 3e'tricul r r te o. the he rt. 6See 7Rule" .or b "ic *+, i'ter-ret tio'.89 The .ir"t o-tio' i'3ol3e" cou'ti'! the 'umber o. >RS com-le0e" occurri'! o' #$"eco'd *+, "tri- 'd multi-lyi'! by %0.D The', cou't the >RS com-le0e" i' the #$"eco'd "tri- 'd multi-ly. Eour '")er "hould be %%0 be t" -er mi'ute. A'other ) y i" to cou't the 'umber o. "m ll bo0e" bet)ee' t)o co'"ecuti3e >RS com-le0e" 'd com- ri'! th t 'umber to the *+, co'3er"io' t ble.2 6See r te 7*+, r te co'3er"io' t ble.89 2hile thi" method i" "li!htly more time co'"umi'! 'd 'ot " ccur te i' determi'i'! r te, e"-eci lly )ith irre!ul r rhythm", it c ' -ro3ide clo"e r '!e. Ne0t, determi'e i. the rhythm i" re!ul r. =" the P5P or the R5R di"t 'ce e(u lF =. the di"t 'ce bet)ee' multi-le com-le0e" i" the " me, )e c ' " y )ith "ome reli bility th t the rhythm i" re!ul r.5 ;oo1i'! t the o3er ll *+,, re there u-ri!ht, rou'ded 'd )ell de.i'ed P ) 3e" -recedi'! e ch >RS com-le0F There mu"t be o'ly o'e P ) 3e ""oci ted )ith e ch >RS to be co'"idered "i'u" i' ' ture.: A.ter loo1i'! t the P ) 3e, 3ie) the PR i'ter3 l. Remember th t the 'orm l PR i'ter3 l me "ure" bet)ee' 0.%2 to 0.20 "eco'd 63 to 5 "m ll "(u re"9. =" the PR i'ter3 l e(u l 'd co'"t 't cro"" the *+,F Goe" the PR i'ter3 l me "ure le"" the' 0.%2 "eco'd or more the' 0.20 "eco'dF ;e"" the' 0.%2 "eco'd tr '"l te" i'to r te . "ter th ' %00 be t" -er mi'ute, )hile lo'!er th ' 0.20 "eco'd i" ""oci ted )ith co'ductio' -roblem throu!h the i'ter'od l - th) y".# &i' lly, loo1 t the "i4e, "h -e, 'd mor-holo!y o. the >RS com-le0e". A ' rro) >RS com-le0 6le"" th ' 0.%2 "eco'd, 'orm l 0.0: to 0.%29 mo"t li1ely ori!i' ted bo3e the 3e'tricle. Su-r 3e'tricul r rhythm" re u'i.orm, ' rro), 'd u"u lly h 3e r te i' e0ce"" o. %#0 be t" -er mi'ute. 2he' the >RS i" )ide 'd me "ure" !re ter th ' 0.%2 "eco'd, the com-le0 ori!i' te" i' the 3e'tricle )ithout i'iti tio' .rom hi!her u- the co'ducti3e - th) y. The r te o. -urely 3e'tricul r com-le0e" c ' r '!e .rom le"" th ' 20 to more the' %80 be t" -er mi'ute. ;oo1i'! cro"" the *+,, re the >RS com-le0e" e(u l i' hei!ht, )idth, 'd directio'F =. ll re e(u l, the i'iti ti'! im-ul"e come" .rom "i'!le .ocu", re.erred to " mo'o.oc l or u'i.oc l i' ori!i'. >RS com-le0e" th t 3 ry i' hei!ht, )idth, or directio' h 3e im-ul"e" th t "t rt .rom di..ere't -oi't". 6See 7='tri'"ic c rdi c r te".89 Rule" .or b "ic *+, i'ter-ret tio' %. Getermi'e the 3e'tricul r r te. H #0 to %00 be t" -er mi'ute I 'orm l H JI 5D be t" -er mi'uteI br dyc rdi H KI %00 be t" -er mi'uteI t chyc rdi 2. =" the R5R i'ter3 l e(u lF H Ee" 5 re!ul r H No 5 irre!ul r 3. =" there ' u-ri!ht, rou'ded P ) 3e -recedi'! e ch >RS com-le0F H Ee" 5 "i'u" rhythm H No 5 - cem 1er 'ot SA 'ode :. =" >RS ' rro)F 60.%: "ec9 H Ee" 5 'orm l co'ductio' throu!h AV 'ode H No 5 3e'tricul r i' ori!i' 5. Are there 'y e0tr or u'u"u l be t"F H Ee" 5 irrit bility i' c rdi c mu"cle H No 5 'orm l - cem 1er

Re.ere'ce" %. =!' t 3iciu" GG, 2or1m ' ;M. Medic l Sur!ic l Nur"i'!L +ritic l Thi'1i'! .or +oll bor ti3e + re. S i't ;oui", MOL *l"e3ier S u'der", ='c. Publi"hi'! +om- 'y@ 200#. M+o'te0t ;i'1N 2. <u.. O. *+, 2or1outL *0erci"e" i' Arrhythmi ='ter-ret tio'. 5th ed. Phil del-hi , P L ;i--i'cott, 2illi m" P 2il1i'"@ 200#. M+o'te0t ;i'1N 3. *+, ='ter-ret tio' M de ='credibly * "yQ :th ed. Phil del-hi , P L ;i--i'cott 2illi m" P 2il1i'"@ 200B. M+o'te0t ;i'1N :. Plummer BO. *+, +h lle'!e 5 <o) "tri- " 33y re youF Americ ' Oour' l o. Nur"i'!. 200B@%0B6#9LB2 5B2c. M+o'te0t ;i'1N 5. +o'o3er MB. ?'der"t 'di'! electroc rdio!r -hy. 8th ed. St. ;oui"L Mo"by@ 2003. M+o'te0t ;i'1N #. ,uyto' A+, < ll O*. Te0tboo1 o. Medic l Phy"iolo!y. Phil del-hi , PAL 2.B. S 'der" Publi"hi'! +om- 'y@ 2000. M+o'te0t ;i'1N B. O cob"o' +. *+, +h lle'!e", Atrio3e'tricul r Gi""oci tio'. AA+N Ad3 'ced +ritic l + re. 200B@%8629L22%522:. M+o'te0t ;i'1N 8. Smelt4er S+, B re B,, <i'1le O;, +hee3er R<. Bru''er Sudd rth/" Te0tboo1 o. Medic l$Sur!ic l Nur"i'!. %%th *d. Phil del-hi , P L ;i--i'cott 2illi m" P 2il1i'"@ 200#. M+o'te0t ;i'1N D. <ummel OG, et l., ed". Poc1et !uide .or c rdi c electro-hy"iolo!y. Phil del-hi L 2.B. S u'der"@ 2000. M+o'te0t ;i'1N