Basic ECG Interpretation

Electrocardiography (ECG) is a graphic recording representing the electrical activities or forces produced by the heart. To interpret dysrhythmias, everything that we are going to discuss on EKG is on LEAD II which is the most common lead used when monitoring the EKG. Why Lead II? - It shows UPRIGHT WAVEFORMS that can easily identified. - It shows clearer movement of electrical impulse as it travels toward the positive electrodes. As an entry level RN in the USA, one of the expected responsibilities when working in any monitored areas (ICU, Telemetry or even regular M/S floor is not only to identify or detect, but more so, to treat CARDIAC DYSRHYTHMIAS independently.

Structure

Function and Location

Dominant pacemaker of the heart located in upper portion of right atrium. Intrinsic rate 60-100 bpm. Direct electrical impulses between SA and AV nodes. Part of AV junctional tissue. Slows conduction creating a slight delay before impulses reach ventricles. Intrinsic rate 40-60 bpm. Transmits impulses to bundle branches. Located below AV node. Conducts impulses that lead to left ventricle. Conduct impulses that lead to right ventricle. Spreads impulses rapidly throughout ventricular walls. Located at terminals of bundle branches. Intrinsic rate 20-40 bpm.

SinoAtrial (SA) node Internodal pathways AtrioVentricular (AV) node Bundle of His Left Bundle Branch Right Bundle Branch Purkinje System
PATHOPHYSIOLOGY

SA NODE (60-100BPM) INTERNODAL ATRIAL PATHWAYS

---SLOWS CONDUCTION- SLIGHT DELAY IMPLUSE---

(ATRIAL MUSCLES) AV NODE (40-60BPM) BUNDLE OF HIS LEFT AND RIGHT BUNDLE BRANCHES PURKINJE FIBERS (20-40BPM)

DEPOLARIZATION AND REPOLARIZATION

Hearts Electrical Activity is governed by the movement of ions and electrolytes (Na+ K+ and Ca++) across a permeable membrane. When hearts muscle cells are in RESTING PHASE, there are MORE POSITIVE IONS OUTSIDE THE CELLS than the inside cells. During CONTRACTION PHASE, the Na+ IONS RUSH INSIDE THE CELL making it more ++++. DEPOLARIZATION- movement of ions from NEGATIVE TO POSITIVE. CONTRACTION PHASE!

REPOLARIZATION- movement of ions from POSITIVE TO NEGATIVE. RESTING PHASE!

ECG MONITORING LEADS Standard Limb Leads (3) Augmented Leads (3) Chest Leads (3)
A complete cardiac cycle is consists of one heart beat which is equivalent to the formation of P wave, QRS wave and T wave. Electrical Components Deflection

P wave

PR interval QRS interval

ST segment T wave QT interval U wave

Description First wave seen. Small rounded, upright (positive) wave indicating ATRIAL DEPOLARIZATION (and contraction) Distance between beginning of P wave and beginning of QRS complex. Measures time during which a depolarization wave travels from the ATRIA TO VENTRICLES. Three deflections following P wave. Indicates VENTRICULAR DEPOLARIZATION (and contraction) Q Wave: FIRST NEGATIVE DEFLECTION R Wave: FIRST POSITIVE DEFLECTION S Wave: FIRST NEGATIVE DEFLECTION after R wave Distance between S wave and beginning of T wave. Measures time between VENTRICULAR DEPOLARIZATION AND BEGINNING OF REPOLARIZATION. Rounded upright (positive) wave following QRS. Represents VENTRICULAR REPOLARIZATION. Measured from beginning of QRS to end of T wave. Represents total VENTRICULAR ACTIVITY. Small rounded, upright wave following T wave. Most easily seen with a slow HR. Represents REPOLARIZATION OF PURKINJE FIBERS.

Hearts original electrical impulse (normal pacemaker) originates from the SA node spreading through the ATRIAL MUSCLES called ATRIAL DEPOLARIZATION. ------Round, Upright, Small The electrical impulse spreads through the VENTRICLES (BUNDLE OF HIS) VENTRICULAR DEPOLARIZATION. The Primary and dominant pacemaker of the heart is the SA node (60-100bpm), the fastest and most dominant pacemaker. If the SA node fails to respond another pacemaker will take over.

ECG CALCULATION
The EKG/ECG Strip: -Heated Stylus -ECG Machine

Characteristics: Heat-sensitive Standardized 25 millimeters (mm) per second

VERTICAL AXIS- represents VOLTAGE in mm or mv

HORIZONTAL AXIS- represents TIME in seconds 1 small box= 1mm= 0.04sec 1 large box= 5 small boxes= 5mm= 0.20sec 5 large boxes= 25 small boxes= 1sec 30 large boxes= 6 secs

DETERMINING THE RATE

- The Six-Second Strip- IRREGULAR - The Division Method or 1500 Method- REGULAR - Box Method or Sequence Method- REGULAR 100 75 = 25 25 5 = 5 5 x 3 = 15 100 15 = 85

THE SIX SECOND STRIP

FORMULA: # of R waves x 10 = RATE Why multiply by 10? 6 x 10 = 60 seconds (1 minute) So, # of R waves or Six Second Strip x 10 = HEART RATE (beats per minute)

THE DIVISION METHOD or 1500 METHOD

FORMULA: 1500 divided by # of small boxes between two R waves = HEART RATE

THE BOX METHOD or SEQUENCE METHOD 2 Conditions to satisfy: 1. Rhythm should be REGULAR. 2. Start on R wave that falls on heavy dark line. FORMULA: The large box starting from the first R wave that falls on heavy dark line has total of 300. 300-150-100then count the remaining small boxes starting from the 2nd R wave to the end of large box. And subtract it to the total of large box.