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ECG Interpretation

Cardiac Dysrhythmias

ECG Basics
How to Analyze a Rhythm
Normal Sinus Rhythm
Dysrhythmias
Treatment
and
Nursing

Management

NORMAL IMPULSE
CONDUCTION
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

Pacemakers of the Heart


SA Node

: Dominant pacemaker with an


intrinsic rate
of 60 - 100 beats/minute.

AV Node : Back-up pacemaker with an

intrinsic rate of
40 - 60 beats/minute.

ECG COMPLEX

The PQRST
P WAVE

Atrial

Depolarization
QRS

Ventricular
Depolarization

T WAVE
Ventricular
Repolarization

The ECG Paper


Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV

RHYTHM ANALYSIS
Step
Step
Step
Step
Step

1:
2:
3:
4:
5:

Assess the P waves.


Determine PR interval.
Calculate rate.
Determine regularity.
Determine QRS duration.

Step 1: Assess the P waves

Are there P waves?


Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?

Interpretation?

Step 2: Determine PR interval

Normal Duration: 0.12 - 0.20 seconds.

(3 - 5 small boxes)

Interpretation?

Step 3: Calculate Rate


3
sec

3
sec

Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.

Interpretation?

R
wave

Option 2
Find a R wave that lands on a bold line.
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Step 4: Determine Regularity


R

Look at the R-R distances (using a caliper

or markings on a pen or paper).


Regular (are they equidistant apart)?
Regularly irregular? Irregularly irregular?
Interpretation?

Step 5: QRS duration

Normal: 0.04 - 0.12 seconds

(1 - 3 small boxes)
Interpretation?

P waves
PR interval
Rate
Regularity
QRS duration

Normal
0.12 s
90 to 94 bpm
Regular
0.06 to 0.08
sec

Interpretation: Normal Sinus Rhythm

DYSRHYTHMIA
RECOGNITION AND
MANAGEMENT

P waves
PR interval
Rate
Regularity
QRS duration

Normal
0.16 s
50 to 52 bpm
Regular
0.04 to 0.06
sec

Interpretation: Sinus Bradycardia

Rules of Interpretation

Sinus Bradycardia
Rate

Less than 60

Rhythm

Regular

Pacemaker
Site

SA node

P Waves

Upright & normal

PRI

Normal

QRS

Normal

SINUS BRADYCARDIA
Occurs as a response to a reduced demand for blood flow
Automaticity in the SA Node diminishes

NURSING INTERVENTION:
1. Maintain patent airway, assist breathing if necessary
2. Provide Oxygen
3. Attached cardiac monitoring
4. Monitor blood pressure and pulse oximetry
5. Assess patient of hypoperfusion
6. Asymptomatic Patient: Continue monitoring
7. Evaluate patients tolerance to rhythm and with activity
8. Review PMHx especially drugs

SINUS BRADYCARDIA
NURSING INTERVENTION:
4. Identify and treat underlying cause
5. Prepare ordered meds: ATROPHINE 0.5 mg
6. If patient not responding to Atropine
Prepare the patient for TRANSCUTANEOUS
PACING
b. Epinephrine or Dopamine 2-10 mcg/kg
a.

Bradycardia Algorithm.

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright American Heart Association, Inc. All rights reserved.

P waves
PR interval
Rate
Regularity
QRS duration

Normal
0.12 s
120 to 136 bpm

Regular
0.04 to 0.06
sec
Interpretation: Sinus Tachycardia

Rules of Interpretation

Sinus Tachycardia
Rate

Greater than 100

Rhythm

Regular

Pacemaker
Site

SA node

P Waves

Upright & normal

PRI

Normal

QRS

Normal

SINUS TACHYCARDIA
Due to SYMPATHETIC STIMULATION

NURSING INTERVENTION:
1. Maintain patent airway, assist breathing in necessary
2. Provide Oxygen
3. Attached cardiac monitoring
4. Monitor blood pressure and pulse oximetry
5. Assess patient of hypoperfusion
6. Check LOC
7. Provide calm environment
8. Assess patient for s/sx of angina
9. If leads to cardiac ischemia, TX includes Ca channel/Beta
Blocker

PROBLEMS IN THE ATRIA THAT


CAUSES DYSRHYTHMIAS
ATRIAL

FIBRILLATION
ATRIAL
FLUTTER
SUPRAVENTRICULAR
TACHYCARDIA

ATRIAL FIBRILLATION

Rules of Interpretation
Atrial Fibrillation
Rate
Rhythm
Pacemaker
Site

P Waves
PRI
QRS

Atrial rate 350600


Ventricular rate
varies:100 to 150
BPM

Irregularly
irregular

Atrial (outside SA
Node)

None discernible
None
Normal

ATRIAL FIBRILLATION
CAUSES:
1. DRUGS
2. RHD, Valvular Heart Disease, Hyperthyroidism,

Pericarditis, CAD, MI, Cardiomyopathy, COPD


3. Nicotine, caffeine or alcohol

ATRIAL FLUTTER

Rules of Interpretation

Atrial Flutter
Rate
Rhythm

Atrial rate 250350


Ventricular rate
varies

Usually regular

Pacemaker
Site

Atrial (outside SA
node)

P Waves

Sawtooth waves
are present

PRI

Usually normal

QRS

Usually normal

ATRIAL FLUTTER
CAUSES:
1. DRUG:DIGOXIN
2. Mitral and Tricuspid Valvular Disease
3. Hyperthyroidism
4. COPD
5. Cardiac Surgery
6. MI

ATRIAL FIBRILLATION/ATRIAL
FLUTTER
NURSING INTERVENTION:
1. Maintain patent airway, assist breathing in
2.
3.
4.
5.

necessary
Provide Oxygen
Attached cardiac monitoring
Monitor rhythm, HR blood pressure and pulse
oximetry
Assess patient of hypoperfusion

ATRIAL FIBRILLATION/ATRIAL
FLUTTER
NURSING INTERVENTION:
STABLE PATIENTS: Control, Convert, Administer
Assess for symptoms of decreased CO and HF
Drug of Choice: Beta Blockers/Ca Channel Blockers
If pt with reduced left ventricular function: DIGOXIN
Monitor serum drug levels and observe for toxicity
Obtain baseline serum coagulation studies

UNSTABLE PATIENTS:
Prepare patient for SYNCHRONIZED CARIOVERSION

SUPRAVENTRICULAR
TACHYCARDA

Rules of Interpretation
Paroxysmal
Supraventricular
Tachycardia
Rate
Rhythm
Pacemaker
Site

P Waves

150250
Regular
Atrial (outside SA
Node)

Often buried in
preceding T wave

PRI

Usually normal

QRS

Usually normal

SUPRAVENTRICULAR TACHYCARDIA
CAUSES:
1. Occurs in a pt with normal heart:
2. MI
3. Cardiomyopathy
4. Hyperthyroidism
5. Systemic Hypertension
6. Digoxin Toxicity

SUPRAVENTRICULAR TACHYCARDIA
NURSING INTERVENTION
1. Maintain patent airway, assist breathing

2.
3.
4.
5.
6.

in necessary
Provide Oxygen
Attached cardiac monitoring
Monitor rhythm, HR blood pressure and
pulse oximetry
Assess patient of hypoperfusion
Treat the underlying cause

SUPRAVENTRICULAR TACHYCARDIA
NURSING INTERVENTION

STABLE PATIENTS:
1. Perform VALSALVA MANEUVER:
2. If Valsava Maneuver not effective,
PHARMACOLOGIC THERAPY advised:
ADENOSINE
Ca Channel Blocker/Beta Blocker
Digoxin
Amiodarone

SUPRAVENTRICULAR TACHYCARDIA
NURSING INTERVENTION
UNSTABLE PATIENTS:
1. SYNCHRONIZED CARDIOVERSION is
highly advised

STABLE TACHYCARDIA WITH PULSE


NARROW IRREGULAR QRS
Assess and support ABCs as needed
Give Oxygen, Pulse Oximetry
Monitor ECG (Identify the rhythm)
Establish IV Access
Assess BP
Identify and treat reversible causes

STABLE
IV ACCESS if not established
Obtain 12-Lead ECG
NARROW IRREGULAR QRS

ATRIAL FIBRILLATION
BETA BLOCKER/CACHANNEL
BLOCKER
Verapamil:
Diltiazem:
Atenolol:

STABLE TACHYCARDIA WITH PULSE


NARROW REGULAR QRS
Assess and support ABCs as needed
Give Oxygen, Pulse Oximetry
Monitor ECG (Identify the rhythm)
Establish IV Access
Assess BP
Identify and treat reversible causes

STABLE
IV ACCESS if not established
Obtain 12-Lead ECG
NARROW REGULAR QRS

SVT
VAGAL MANEUVERS
Carotid Sinus Massage
Valsalva Maneuver
No Effect

ADENOSINE 6 mg
No Effect

ADENOSINE 12 mg
No Effect

ADENOSINE 12 mg
No Effect

BETA BLOCKER
Ca CHANNEL BLOCKER
No Effect

AMIODARONE 150 mg

ATRIAL
FLUTTER

BETA BLOCKER/CACHANNEL
BLOCKER
Verapamil:
Diltiazem:
Atenolol:

CARDIAC ARREST
(Pulseless Arrest)
I.

Ventricular Tachyarrhythmias :
a. Ventricular fibrillation
b. Sustained Ventricular Tachycardia

II. Asystole
III. Pulseless Electrical Activity (PEA)

PROBLEMS IN THE VENTRICLES


THAT CAUSE DYSRHYTHMIAS
VENTRICULA

R
FIBRILLATION
VENTRICULA
R
TACHYCARDI
A

VENTRICULAR FIBRILLATION

Rules of Interpretation

Rate

Ventricular
No organized
Fibrillation

Rhythm

rhythm
No organized
rhythm

Pacemaker
Site

Numerous
ventricular foci

P Waves

Usually absent

PRI

None

QRS

None

VENTRICULAR TACHYCARDIA

Rules of Interpretation

Rate

Ventricular
Tachycardia100250

Rhythm
Pacemaker
Site
P Waves
PRI
QRS

Usually regular
Ventricle
If present, not
associated with
QRS
None
>0.12 seconds,
bizarre

V FIB/VTACH
CAUSES:
1. CARDIAC CONDITION: CAD, MI
Cardiomyopathy
2. Drug: DIGOXIN
3. Electrolyte Imbalance

V FIB/V TACH
NURSING INTERVENTION
1. DEFIBRILLATE
2. CPR
3. PHARMACOLOGIC TREATMENT:
EPINEPHRINE or VASOPRESSION
AMIODRONE

ACLS Cardiac Arrest Algorithm.

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright American Heart Association, Inc. All rights reserved.

CARDIAC ARREST
(Pulseless Arrest)
NON SHOCKABLE RHYTHM

I.

ASYSTOLE

II. PEA

Rules of Interpretation

Asystole
Rate

No Electrical
Activity

Rhythm

No Electrical
Activity

Pacemaker
Site

No Electrical
Activity

P Waves

Absent

PRI

Absent

QRS

Absent

PEA

ACLS Cardiac Arrest Algorithm.

Robert W. Neumar et al. Circulation. 2010;122:S729-S767

Copyright American Heart Association, Inc. All rights reserved.

Rules of Interpretation

First-Degree AV
Depends on
Block
Rate
underlying
rhythm
Rhythm
Pacemaker
Site
P Waves

Usually regular
SA node or atrial
Normal

PRI

> 0.20 Seconds

QRS

Usually < 0.12


seconds

Rules of Interpretation
Type I Second-Degree AV
Block
Rate

Rhythm
Pacemaker
Site

P Waves
PRI
QRS

Atrial, normal;
ventricular, normal
to slow

Atrial, regular;
ventricular,
irregular
SA node or arial
Normal, some P
waves not followed
by QRS
Increases until QRS
is dropped, then
repeats
Usually < 0.12
seconds

Rules of Interpretation
Type II Second-Degree AV
Block
Rate
Rhythm
Pacemaker
Site

Atrial, normal;
ventricular, slow
May be regular
or irregular
SA node or atrial

P Waves

Normal, some P
waves not followed
by QRS

PRI

Constant for conducted


beats, may be > 0.20
seconds

QRS

Normal or > 0.12


seconds

Rules of Interpretation

Third-Degree AV Block
Rate
Rhythm
Pacemaker
Site
P Waves
PRI
QRS

Atrial, normal;
ventricular, 40
60
Both atrial and
ventricular are
regular

SA node and AV
junction or
ventricle
Normal,with no
correlation to
QRS

No relationship to
QRS

0.12 seconds or
greater

Thank you

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