Rapid Interpretation of ECGs Rapid Interpretation of ECGs
The Dale Dubin Method The Dale Dubin Method David Myers, MS,RN,ANP David Myers, MS,RN,ANP- -BC BC Richard J. Nadan, MBA,MS,RN,ACNP Richard J. Nadan, MBA,MS,RN,ACNP- -BC BC With Sections from: With Sections from: Introduction Introduction Why the Dale Dubin method? Why the Dale Dubin method? Classic, most popular, & most referenced Classic, most popular, & most referenced ECG text book ECG text book First published in April, 1970 First published in April, 1970 Printed in 46 languages Printed in 46 languages Uses a systematic & logical approach Uses a systematic & logical approach Quick & easy learning Quick & easy learning Used by all healthcare professionals Used by all healthcare professionals around the world around the world Myth or Fact? Myth or Fact? Who is Dale Dubin, MD? Who is Dale Dubin, MD? Born in 1940 Born in 1940 A famous, millionaire, plastic surgeon & A famous, millionaire, plastic surgeon & medical school professor medical school professor Arrested in Florida in 1986 & charged with Arrested in Florida in 1986 & charged with sending & receiving child pornography by sending & receiving child pornography by US mail US mail Sentenced to 5 years in jail on 22 counts of Sentenced to 5 years in jail on 22 counts of child pornography & cocaine use child pornography & cocaine use He was released in 1989 He was released in 1989 Myth or Fact? Myth or Fact? Although Dr. Dubin lost his medical Although Dr. Dubin lost his medical license he continues to publish high license he continues to publish high quality texts on topics in cardiology & quality texts on topics in cardiology & electrophysiology electrophysiology 2 And now, to the really And now, to the really important stuff important stuff Cardiovascular Anatomy Cardiovascular Anatomy Tissue Layers Tissue Layers Endocardium Endocardium Myocardium Myocardium Pericardium Pericardium Cardiovascular Anatomy Cardiovascular Anatomy Coronary Circulation Coronary Circulation Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy Cardiovascular Anatomy RCA RCA: : SA Node 50% of population, AV Node 90%, Rt SA Node 50% of population, AV Node 90%, Rt atrium, Rt ventricle atrium, Rt ventricle Inferior wall of LV, Posterior wall 90% Inferior wall of LV, Posterior wall 90% LCA LCA: : Left anterior descending Left anterior descending Anterior wall, septum, His bundle, rt bundle, Anterior wall, septum, His bundle, rt bundle, Anterior fascicle of left bundle Anterior fascicle of left bundle Circumflex Circumflex SA node 50%, AV node 10%, Left atrium, Lateral SA node 50%, AV node 10%, Left atrium, Lateral wall of left ventricle, Posterior wall 10%, wall of left ventricle, Posterior wall 10%, Posterior fascicle of left branch Posterior fascicle of left branch 3 Cardiac Physiology Cardiac Physiology The Cardiac Cycle The Cardiac Cycle Diastole Diastole Systole Systole Ejection Fraction Ejection Fraction Stroke Volume Stroke Volume Preload Preload Cardiac Contractility Cardiac Contractility Afterload Afterload Cardiac Physiology Cardiac Physiology Nervous Control of Nervous Control of the Heart the Heart Sympathetic Sympathetic Parasympathetic Parasympathetic Autonomic Autonomic Control of the Control of the Heart Heart Role of Role of Electrolytes Electrolytes Cardiac Physiology Cardiac Physiology Electrophysiology Electrophysiology Cardiac Muscle Cardiac Muscle Atrial Atrial Ventricular Ventricular Excitatory & Excitatory & Conductive Fibers Conductive Fibers Atrioventricular Atrioventricular Bundle Bundle Cardiac Physiology Cardiac Physiology Cardiac Conduction System: Properties Cardiac Conduction System: Properties Excitability Excitability Conductivity Conductivity Automaticity Automaticity Contractility Contractility Cardiac Physiology Cardiac Physiology Components Components Sinoatrial Node Sinoatrial Node Internodal Internodal Atrial Pathways Atrial Pathways Atrioventricular Atrioventricular Node Node Atrioventricular Atrioventricular Junction Junction Bundle of His Bundle of His Left & Right Left & Right Bundle Branches Bundle Branches Purkinje Fibers Purkinje Fibers A Brief History of EKGs A Brief History of EKGs In 1790, Luigi In 1790, Luigi Galvani made a Galvani made a dead frog dead frog s legs s legs dance by electrical dance by electrical stimulation stimulation 4 A Brief History of EKGs A Brief History of EKGs In 1855, Kollicker & In 1855, Kollicker & Mueller found that Mueller found that when a motor nerve when a motor nerve to a frog to a frog s leg was s leg was laid over its isolated laid over its isolated beating heart, the beating heart, the leg kicked with each leg kicked with each heartbeat heartbeat A Brief History of EKGs A Brief History of EKGs This made an association between the This made an association between the rhythmic pumping of the heart & an rhythmic pumping of the heart & an electrical phenomena electrical phenomena Very basic & very important Very basic & very important A Brief History of EKGs A Brief History of EKGs In the mid 1880s In the mid 1880s Ludwig & Waller Ludwig & Waller used a used a capillary capillary electrometer electrometer to to monitor the hearts monitor the hearts electric stimuli from electric stimuli from a person a person s skin s skin A Brief History of EKGs A Brief History of EKGs Dr. Willem Dr. Willem Einthoven placed Einthoven placed skin sensors on a skin sensors on a person & suspended person & suspended a silver wire a silver wire between the poles of between the poles of a magnet. The wire a magnet. The wire twitched with each twitched with each heart beat. heart beat. A Brief History of EKGs A Brief History of EKGs This was a great idea, but Dr. Einthoven This was a great idea, but Dr. Einthoven wanted a timed tracing wanted a timed tracing He drilled two holes in the poles of the He drilled two holes in the poles of the magnet & projected a light beam magnet & projected a light beam though the holes onto photographic though the holes onto photographic paper paper He named the waves P, QRS, & T He named the waves P, QRS, & T He named his 1901 invention the He named his 1901 invention the E Electro lectroK Kardio ardioG Gram ram A Brief History of EKGs A Brief History of EKGs 5 A Brief History of EKGs A Brief History of EKGs Since 1901 the medical profession has Since 1901 the medical profession has used used EKG EKG to represent the to represent the electrocardiogram. Some say that electrocardiogram. Some say that ECG ECG is more correct. Medicine tends is more correct. Medicine tends to honor tradition & has used EKG for to honor tradition & has used EKG for over a century. over a century. Basic Principles Basic Principles The EKG records the electrical activity The EKG records the electrical activity of contraction of the myocardium of contraction of the myocardium The EKG provides a record of cardiac The EKG provides a record of cardiac electrical activity electrical activity The EKG provides information about The EKG provides information about the heart the heart s function & structure s function & structure Basic Principles Basic Principles Basic Principles Basic Principles Myocytes (myocardial cells) are Myocytes (myocardial cells) are polarized (negative) at rest polarized (negative) at rest When depolarized (positive) they When depolarized (positive) they contract contract Technically, however, in the strictest Technically, however, in the strictest sense, a resting polarized cell has a sense, a resting polarized cell has a negatively charged interior & a negatively charged interior & a positively charged outside surface. But positively charged outside surface. But we will keep this simple & only we will keep this simple & only consider the interior. consider the interior. Basic Principles Basic Principles Depolarization can be considered a Depolarization can be considered a wave traveling through the heart wave traveling through the heart The cell The cell- -to to- -cell conduction of cell conduction of depolarization through the depolarization through the myocardium is carried by fast myocardium is carried by fast- -moving moving Na Na + + ions ions Basic Principles Basic Principles 6 Basic Principles Basic Principles Cardiac Depolarization Cardiac Depolarization Basic Principles Basic Principles Repolarization is an electrical phenomenon Repolarization is an electrical phenomenon that begins immediately after depolarization. that begins immediately after depolarization. The broad hump that we see on an EKG wave The broad hump that we see on an EKG wave is the most active phase of repolarization is the most active phase of repolarization Basic Principles Basic Principles Sensors called Sensors called electrodes are put on electrodes are put on the skin the skin As the positive wave of As the positive wave of depolarization within depolarization within the myocytes flows the myocytes flows towards a positive towards a positive electrode, there is an electrode, there is an upward deflection on upward deflection on the EKG the EKG Basic Principles Basic Principles The heart The heart s dominant pacemaker is the s dominant pacemaker is the SA Node (sinoatrial node) SA Node (sinoatrial node) Its pacing activity is known as Sinus Its pacing activity is known as Sinus Rhythm Rhythm Generation of pacemaking stimuli is Generation of pacemaking stimuli is automaticity automaticity Other focal areas of the heart that have Other focal areas of the heart that have automaticity are called automaticity are called automaticity automaticity foci foci Basic Principles Basic Principles The SA Node is located in the upper The SA Node is located in the upper- - posterior wall of the right atrium posterior wall of the right atrium The depolarization wave flows away The depolarization wave flows away from the SA Node in all directions from the SA Node in all directions Imagine the atria as a pool of water, a Imagine the atria as a pool of water, a pebble dropped in at the SA Node pebble dropped in at the SA Node produces an enlarging, circular wave produces an enlarging, circular wave (depolarization) that spreads outward. (depolarization) that spreads outward. Basic Principles Basic Principles 7 Basic Principles Basic Principles Each depolarization wave emitted by the SA Node Each depolarization wave emitted by the SA Node spreads through both atria producing a spreads through both atria producing a P wave P wave on on the EKG the EKG Note the positive wave of atrial depolarization Note the positive wave of atrial depolarization advancing toward a positive electrode producing an advancing toward a positive electrode producing an upward P wave upward P wave Basic Principles Basic Principles The P wave The P wave represents the represents the depolarization of depolarization of both atria & the both atria & the virtually virtually simultaneous simultaneous contraction of the contraction of the atria. atria. Basic Principles Basic Principles Atrio Atrio- -Ventricular (AV) valves prevent Ventricular (AV) valves prevent ventricle ventricle- -to to- -atrium blood backflow atrium blood backflow AV valves electrically insulate the AV valves electrically insulate the ventricles from the atria ventricles from the atria EXCEPT for EXCEPT for the the AV Node AV Node, the only conducting path , the only conducting path between the atria & ventricles between the atria & ventricles Basic Principles Basic Principles The AV Node is just above, but The AV Node is just above, but continuous with, a specialized continuous with, a specialized conduction system that distributes conduction system that distributes depolarization to the ventricles very depolarization to the ventricles very efficiently. efficiently. Basic Principles Basic Principles Basic Principles Basic Principles Blood flow Blood flow O O 2 2 depleted blood enters the RA via the depleted blood enters the RA via the IVC, SVC, & coronary sinus IVC, SVC, & coronary sinus Atrial contraction forces blood through the Atrial contraction forces blood through the tricuspid valve into the RV tricuspid valve into the RV Ventricular contraction will force blood Ventricular contraction will force blood through the pulmonic valve into the through the pulmonic valve into the pulmonary artery pulmonary artery 8 Basic Principles Basic Principles Remember Remember T Tri ricuspid valve is on the cuspid valve is on the ri right ght Both atria contract simultaneously, both Both atria contract simultaneously, both ventricles contract simultaneously ventricles contract simultaneously Right & left sides of the heart have very Right & left sides of the heart have very different responsibilities different responsibilities Basic Principles Basic Principles Basic Principles Basic Principles Blood flow Blood flow Blood enters the LA through the Blood enters the LA through the pulmonary veins pulmonary veins The LA contracts & forces blood through The LA contracts & forces blood through the mitral valve into the LV the mitral valve into the LV The LV contracts & forces blood through The LV contracts & forces blood through the aortic valve in to the Ao (aorta) into the aortic valve in to the Ao (aorta) into systemic circulation systemic circulation Remember Remember Mitra Mitral l valve in on the valve in on the l left eft Basic Principles Basic Principles Basic Principles Basic Principles Back to the AV Node Back to the AV Node When the wave of atrial depolarization When the wave of atrial depolarization enters the AV Node, depolarization slows enters the AV Node, depolarization slows down, producing a brief pause down, producing a brief pause This allows time for blood in the atria to This allows time for blood in the atria to enter the ventricles enter the ventricles Slow conduction through the AV Node is Slow conduction through the AV Node is carried by Ca carried by Ca ++ ++ ions ions Basic Principles Basic Principles Remember Remember The AV Node is the only electrical The AV Node is the only electrical conduction pathway between the atria & conduction pathway between the atria & ventricles ventricles We are correlating electrical activity with We are correlating electrical activity with mechanical physiology mechanical physiology Atria contract forcing blood through the Atria contract forcing blood through the AV valves AV valves It takes time for blood to flow though the It takes time for blood to flow though the valves into the ventricles valves into the ventricles 9 Basic Principles Basic Principles Time for blood flow means a necessary pause Time for blood flow means a necessary pause It takes time for blood to flow though the It takes time for blood to flow though the valves into the ventricles valves into the ventricles A necessary pause that produces a short flat A necessary pause that produces a short flat baseline after each P wave on the EKG baseline after each P wave on the EKG Remember this pause!!! You will need it later Remember this pause!!! You will need it later Basic Principles Basic Principles Note the pause Note the pause Basic Principles Basic Principles Just a thought Just a thought So far we have talked about Na So far we have talked about Na + + & Ca & Ca ++ ++ What medications do you know about that What medications do you know about that might affect these channels? might affect these channels? Basic Principles Basic Principles Depolarization conducts slowly Depolarization conducts slowly through the AV Node through the AV Node Upon reaching the ventricular Upon reaching the ventricular conduction system, depolarization conduction system, depolarization rapidly shoots through the rapidly shoots through the His Bundle His Bundle & the & the Left Left & & Right Bundle Branches Right Bundle Branches Basic Principles Basic Principles The ventricular conduction system originates The ventricular conduction system originates at the His Bundle, which penetrates the AV at the His Bundle, which penetrates the AV valves, then immediately bifurcates in the valves, then immediately bifurcates in the interventricular septum into the Right & Left interventricular septum into the Right & Left Bundle Branches Bundle Branches The His bundle & both Bundle Branches are The His bundle & both Bundle Branches are bundles bundles of rapidly conducting of rapidly conducting Purkinje Purkinje Fibers Fibers Basic Principles Basic Principles Like the Like the myocardium, myocardium, Purkinje Fibers use Purkinje Fibers use fast fast- -moving Na moving Na + + ions for the ions for the conduction of conduction of depolarization depolarization 10 Basic Principles Basic Principles The ventricular conduction system is The ventricular conduction system is composed of bundles of rapidly composed of bundles of rapidly- - conducting Purkinje Fibers that carry conducting Purkinje Fibers that carry depolarization away from the AV Node depolarization away from the AV Node at high speed at high speed Basic Principles Basic Principles The Purkinje Fibers terminate in tiny The Purkinje Fibers terminate in tiny filaments that directly depolarize the filaments that directly depolarize the ventricular myocytes ventricular myocytes The rapid passage of depolarization The rapid passage of depolarization down the ventricular conduction down the ventricular conduction system is too weak to record on the system is too weak to record on the EKG EKG Basic Principles Basic Principles Depolarization of the ventricular Depolarization of the ventricular myocardium records as a QRS complex myocardium records as a QRS complex Basic Principles Basic Principles The terminal The terminal filaments of the filaments of the Purkinje Fibers Purkinje Fibers Producing a QRS Producing a QRS complex complex Basic Principles Basic Principles The terminal filaments of the Purkinje The terminal filaments of the Purkinje Fibers spread out just beneath the Fibers spread out just beneath the endocardium that lines both ventricular endocardium that lines both ventricular cavities cavities Ventricular depolarization begins at he Ventricular depolarization begins at he lining & proceeds outward to the lining & proceeds outward to the outside surface (epicardium) of the outside surface (epicardium) of the ventricles ventricles Basic Principles Basic Principles Purkinje Fibers branch & subdivide just Purkinje Fibers branch & subdivide just beneath the endocardial lining, but do beneath the endocardial lining, but do not penetrate the myocardium. not penetrate the myocardium. 11 Basic Principles Basic Principles The QRS complex actually represents the The QRS complex actually represents the beginning of ventricular contraction beginning of ventricular contraction The physical event of ventricular contraction The physical event of ventricular contraction actually last longer than the QRS complex actually last longer than the QRS complex Basic Principles Basic Principles The Q wave is the first downward wave The Q wave is the first downward wave of the QRS complex. It is followed by an of the QRS complex. It is followed by an upward R wave. The Q wave is often upward R wave. The Q wave is often absent on the EKG absent on the EKG Basic Principles Basic Principles The Q wave, when The Q wave, when present ALWAYS present ALWAYS occurs at the occurs at the beginning of the beginning of the QRS complex & is QRS complex & is the first downward the first downward deflection of the deflection of the complex complex Basic Principles Basic Principles If there is an If there is an up upward deflection in a QRS ward deflection in a QRS complex that appears before a Q wave, it is complex that appears before a Q wave, it is NOT a Q wave. NOT a Q wave. When present, the Q wave is ALWAYS the When present, the Q wave is ALWAYS the first wave in the complex first wave in the complex It is now popular to use small letter to It is now popular to use small letter to designate small waves in the QRS complex; a designate small waves in the QRS complex; a q q wave is a small wave, a wave is a small wave, a Q Q wave is a big wave is a big wave wave Basic Principles Basic Principles The first upward wave of the QRS is the The first upward wave of the QRS is the R wave R wave Any downward wave PRECEDED by Any downward wave PRECEDED by an upward wave is an S wave an upward wave is an S wave Basic Principles Basic Principles 12 Basic Principles Basic Principles An upward wave is always called an R An upward wave is always called an R wave wave Distinguishing between the downward Distinguishing between the downward Q & downward S waves really depends Q & downward S waves really depends on whether the downward wave occurs on whether the downward wave occurs before or after the R wave before or after the R wave The Q is before the R, & the S is after The Q is before the R, & the S is after the R the R Just remember the alphabet! Just remember the alphabet! Lets Play Name That Wave Lets Play Name That Wave 1: 1: Q wave Q wave 2: 2: R wave R wave 3: 3: S wave S wave 4: 4: QS wave QS wave Name That Wave Name That Wave Yes, # 4 is a little unfair. There is no upward wave, Yes, # 4 is a little unfair. There is no upward wave, hence we cannot determine whether it is a Q wave or hence we cannot determine whether it is a Q wave or an S wave. Therefore it is called a QS wave, & is an S wave. Therefore it is called a QS wave, & is considered to be a Q wave when we look for Qs considered to be a Q wave when we look for Qs Basic Principles Basic Principles Following the QRS complex, there is a Following the QRS complex, there is a segment of horizontal baseline known as the segment of horizontal baseline known as the ST segment, & then a broad T wave appears ST segment, & then a broad T wave appears Basic Principles Basic Principles The St segment is a The St segment is a horizontal, flat, & most horizontal, flat, & most importantly, it is importantly, it is normally level with normally level with other areas of the other areas of the baseline baseline If it is elevated or If it is elevated or depressed beyond the depressed beyond the normal baseline level, it normal baseline level, it is usually a serious is usually a serious pathology pathology Basic Principles Basic Principles The ST segment represents the plateau The ST segment represents the plateau (initial) phase of ventricular (initial) phase of ventricular repolarization. repolarization. Ventricular repolarization is rather Ventricular repolarization is rather minimal during the ST segment minimal during the ST segment 13 Basic Principles Basic Principles The T wave The T wave represents the final, represents the final, rapid rapid phase of phase of ventricular ventricular repolarization repolarization Basic Principles Basic Principles Both phases of Both phases of repolarization is repolarization is accomplished by K accomplished by K + + ions leaving the ions leaving the myocytes myocytes Ventricular systole Ventricular systole begins with the QRS begins with the QRS & persists until the & persists until the end of the T wave end of the T wave Basic Principles Basic Principles Ventricular contraction (systole) spans Ventricular contraction (systole) spans depolarization & repolarization of the depolarization & repolarization of the ventricles ventricles This a major & convenient physiological This a major & convenient physiological marker marker Basic Principles Basic Principles Since ventricular systole lasts from the Since ventricular systole lasts from the beginning of the QRS until the end of beginning of the QRS until the end of the T wave, the the T wave, the QT interval QT interval has clinical has clinical significance significance Basic Principles Basic Principles Basic Principles Basic Principles The QT interval is a good indicator of The QT interval is a good indicator of repolarization, since repolarization repolarization, since repolarization comprises most of the QT interval comprises most of the QT interval Patients with Long QT interval (LQT) Patients with Long QT interval (LQT) syndromes are vulnerable to deadly syndromes are vulnerable to deadly rapid ventricular rhythms rapid ventricular rhythms 14 Basic Principles Basic Principles With rapid heart rates both depolarization & With rapid heart rates both depolarization & repolarization occur faster for greater repolarization occur faster for greater efficiency, therefore the QT interval varies efficiency, therefore the QT interval varies with heart rate with heart rate Precise QT interval measurements are Precise QT interval measurements are corrected for rate, we call this the QTc corrected for rate, we call this the QTc In general, the QT interval is normal if it is In general, the QT interval is normal if it is less than half the R less than half the R- -to to- -R interval at normal R interval at normal rates rates Basic Principles Basic Principles Physiologically, a cardiac cycle Physiologically, a cardiac cycle represents atrial systole followed by represents atrial systole followed by ventricular systole, & the resting stage ventricular systole, & the resting stage that follows until another cardiac cycle that follows until another cardiac cycle begins begins Basic Principles Basic Principles Basic Principles Basic Principles So far you have seen the P, QRS, & T So far you have seen the P, QRS, & T waves waves There is one other wave that you may There is one other wave that you may see on occasion see on occasion The U wave The U wave Basic Principles Basic Principles The U wave The U wave A small deflection that may occasionally follow A small deflection that may occasionally follow the T wave the T wave Neither presence nor absence is abnormal Neither presence nor absence is abnormal Part of ventricular repolarization Part of ventricular repolarization Generally small, rounded ( < 2 mm), same Generally small, rounded ( < 2 mm), same direction as T wave direction as T wave Larger with at slow heart rate, smaller at fast heart Larger with at slow heart rate, smaller at fast heart rate rate Basic Principles Basic Principles U wave U wave 15 Basic Principles Basic Principles Basic Principles Basic Principles The movement of three types of ions determines The movement of three types of ions determines all aspects of cardiac conduction, contractions, & all aspects of cardiac conduction, contractions, & repolarization repolarization Basic Principles Basic Principles - - Review Review Relationship of the Relationship of the ECG to electrical events ECG to electrical events in the heart in the heart ECG components ECG components P wave P wave QRS complex QRS complex T wave T wave Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review 16 Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review Basic Principles Basic Principles - - Review Review Recording the EKG Recording the EKG EKG paper is graph paper EKG paper is graph paper The smallest divisions are 1 mm The smallest divisions are 1 mm squares squares 1 mm high x 1 mm long 1 mm high x 1 mm long Time axis (x) is horizontal & moves left Time axis (x) is horizontal & moves left to right, like we read to right, like we read Amplitude axis (y) is vertical Amplitude axis (y) is vertical Recording the EKG Recording the EKG Between heavy black lines there are 5 small squares Between heavy black lines there are 5 small squares Each large square is formed by heavy black lines on Each large square is formed by heavy black lines on each side & is 5 mm long x 5 mm high each side & is 5 mm long x 5 mm high 17 Recording the EKG Recording the EKG Deflection is the direction of a wave Deflection is the direction of a wave Upward or downward Upward or downward Amplitude is the magnitude of voltage of electrical activity Amplitude is the magnitude of voltage of electrical activity Amplitude is measured from the baseline (isoelectric line) Amplitude is measured from the baseline (isoelectric line) Recording the EKG Recording the EKG When a wave of depolarization When a wave of depolarization advances toward a positive skin advances toward a positive skin electrode it produces a positive electrode it produces a positive deflection deflection Be positive. This will make more sense in a Be positive. This will make more sense in a little while. little while. Recording the EKG Recording the EKG Upward deflections Upward deflections are called positive are called positive deflections deflections Downward Downward deflections are deflections are called negative called negative deflections deflections Recording the EKG Recording the EKG As we said earlier, the horizontal axis is time As we said earlier, the horizontal axis is time Each small box is 0.04 of a second Each small box is 0.04 of a second Each big box (or 5 small boxes) is 0.2 of a Each big box (or 5 small boxes) is 0.2 of a second second Recording the EKG Recording the EKG With this information it is now possible to With this information it is now possible to determine the time of any part of the cardiac determine the time of any part of the cardiac cycle cycle Recording the EKG Recording the EKG EKG paper passes out of the EKG machine at EKG paper passes out of the EKG machine at a set & constant speed a set & constant speed In 0.12 second, 3 small squares In 0.12 second, 3 small squares In general, the paper travels at 25 mm / second In general, the paper travels at 25 mm / second 18 Recording the EKG Recording the EKG A standard EKG is composed of 12 A standard EKG is composed of 12 separate leads separate leads 6 limb leads 6 limb leads 6 chest leads (also called precordial leads 6 chest leads (also called precordial leads or vector leads) or vector leads) Recording the EKG Recording the EKG Recording the EKG Recording the EKG Limb leads are placed on the right & Limb leads are placed on the right & left arms & left leg left arms & left leg Two electrodes are used to record a Two electrodes are used to record a lead lead A different pair for each lead A different pair for each lead Recording the EKG Recording the EKG Recording the EKG Recording the EKG Remember the positive & negative Remember the positive & negative deflections that an EKG tracing can deflections that an EKG tracing can make? This is where it all comes make? This is where it all comes together together Recording the EKG Recording the EKG Bipolar limb leads Bipolar limb leads are recorded using 2 are recorded using 2 electrodes electrodes Selecting different Selecting different electrodes will yield electrodes will yield different leads different leads One electrode is One electrode is positive & one is positive & one is negative negative 19 Recording the EKG Recording the EKG Bipolar simply means one pole is Bipolar simply means one pole is positive & one pole is negative positive & one pole is negative The poles are the electrodes The poles are the electrodes Recording the EKG Recording the EKG Lead I is horizontal Lead I is horizontal Left arm positive, right arm negative Left arm positive, right arm negative Lead II is diagonal Lead II is diagonal Left foot is positive, right arm is negative Left foot is positive, right arm is negative Lead III is vertical Lead III is vertical Left foot is positive, but now the left arm is Left foot is positive, but now the left arm is negative negative Recording the EKG Recording the EKG The EKG machine will switch the The EKG machine will switch the polarity of the electrodes automatically polarity of the electrodes automatically i.e.: the left arm switched from positive to i.e.: the left arm switched from positive to negative depending which lead we were negative depending which lead we were looking at looking at This bipolar limb configuration is call This bipolar limb configuration is call Einthoven Einthoven s Triangle (remember him?) s Triangle (remember him?) Recording the EKG Recording the EKG With your pen draw With your pen draw Negative sign ( Negative sign (- -) on ) on your right hand your right hand Positive sign (+) on Positive sign (+) on your left leg your left leg Both signs (+/ Both signs (+/- -) on ) on your left hand your left hand Lets play Twister!!! Lets play Twister!!! Recording the EKG Recording the EKG Creating three intersecting lines produces a Creating three intersecting lines produces a point of reference point of reference Recording the EKG Recording the EKG So far we have discussed 3 of the 6 limb So far we have discussed 3 of the 6 limb leads leads Lead I Lead I Lead II Lead II Lead II Lead II Now for the other 3 Now for the other 3 AVR AVR AVL AVL AVF AVF 20 Recording the EKG Recording the EKG Another standard lead is the AVF lead Another standard lead is the AVF lead AVF uses the left foot as positive & both AVF uses the left foot as positive & both arms as a common negative ground arms as a common negative ground The The A A in AVF means in AVF means augmented augmented Recording the EKG Recording the EKG Dr. Emanuel Goldberg designed the Dr. Emanuel Goldberg designed the augmented limb leads augmented limb leads He discovered that he had to amplify He discovered that he had to amplify (augment) the voltage in the EKG (augment) the voltage in the EKG machine to match the magnitude of machine to match the magnitude of Leads I, II, & III Leads I, II, & III He named it A (augmented) V (voltage) He named it A (augmented) V (voltage) F (Foot) F (Foot) Recording the EKG Recording the EKG AVF is a combination of Leads II & III AVF is a combination of Leads II & III Recording the EKG Recording the EKG AVR & AVL are obtained in the same manner AVR & AVL are obtained in the same manner Augmented limb leads are unipolar because Augmented limb leads are unipolar because they stress the importance of the positive they stress the importance of the positive electrode electrode Recording the EKG Recording the EKG Remember Remember AV AVR R R Right arm positive ight arm positive AV AVL L L Left arm positive eft arm positive AV AVF F Left Left f foot positive oot positive Recording the EKG Recording the EKG The augmented (unipolar) limb leads, The augmented (unipolar) limb leads, AVR, AVL, & AVF intersect at different AVR, AVL, & AVF intersect at different angles than the bipolar limb leads, I, II, angles than the bipolar limb leads, I, II, & III & III They produce three other intersecting They produce three other intersecting lines of reference lines of reference 21 Recording the EKG Recording the EKG Recording the EKG Recording the EKG The 6 limb leads combined The 6 limb leads combined Recording the EKG Recording the EKG Deep breath Deep breath Don Don t panic by the t panic by the kaleidoscope of limb leads. It will make kaleidoscope of limb leads. It will make more sense in a little while. more sense in a little while. Recording the EKG Recording the EKG Think of each lead Think of each lead as a camera looking as a camera looking at the heart from a at the heart from a different angle different angle In the ICU or In the ICU or telemetry floor, telemetry floor, think of the camera think of the camera as a video camera as a video camera Recording the EKG Recording the EKG Points to remember Points to remember The heart The heart s electrical activity remain s electrical activity remain constant constant The positive electrode position changes The positive electrode position changes from lead to lead from lead to lead The tracing will look slightly different in The tracing will look slightly different in each lead each lead Recording the EKG Recording the EKG Points to remember Points to remember The angle from which we record the The angle from which we record the electrical activity changes with each lead electrical activity changes with each lead A wave of depolarization is a progressive A wave of depolarization is a progressive wave of POSITIVE charges passing wave of POSITIVE charges passing through myocardial cells through myocardial cells 22 Recording the EKG Recording the EKG Points to remember Points to remember When a depolarization wave moves When a depolarization wave moves toward a POSITIVE electrode, a POSITIVE toward a POSITIVE electrode, a POSITIVE deflection is produced deflection is produced When a POSITIVE current moves toward a When a POSITIVE current moves toward a POSTIVE electrode it produces a POSITVE POSTIVE electrode it produces a POSITVE deflection deflection Repetitious, but vitally important!!! Repetitious, but vitally important!!! Recording the EKG Recording the EKG Lets go car shopping Lets go car shopping Based only on the photo below, would you buy Based only on the photo below, would you buy this car? this car? Recording the EKG Recording the EKG Now would you buy this car? Now would you buy this car? Recording the EKG Recording the EKG A bit of trivia A bit of trivia In 2001, Jeffrey Seiden, a third In 2001, Jeffrey Seiden, a third- -year year medical student at Yale University, was studying medical student at Yale University, was studying his electrocardiography textbook when he his electrocardiography textbook when he happened upon the following message tucked away happened upon the following message tucked away in the book's copyright notice: in the book's copyright notice: Congratulations for Congratulations for your perseverance. You may win the car on page 46 by your perseverance. You may win the car on page 46 by writing down your name & address & submitting it to writing down your name & address & submitting it to the publisher. the publisher. Trivia Continued Trivia Continued Dr. Dale Dubin had inserted the note into his 50th Dr. Dale Dubin had inserted the note into his 50th printing of his "Rapid Interpretation of EKGs," printing of his "Rapid Interpretation of EKGs," putting his classic Thunderbird up for grabs. Of the putting his classic Thunderbird up for grabs. Of the 60,000 who bought the book containing the offer, 60,000 who bought the book containing the offer, only five spotted the hidden message & contacted the only five spotted the hidden message & contacted the publisher with news of their find. The five names publisher with news of their find. The five names were placed in a hat, & Jeffrey Seiden's was chosen at were placed in a hat, & Jeffrey Seiden's was chosen at random. The 1965 Thunderbird convertible was random. The 1965 Thunderbird convertible was delivered to him on 4 December 2001 by Dubin's delivered to him on 4 December 2001 by Dubin's daughter, who drove it to Seiden's school. daughter, who drove it to Seiden's school. Recording the EKG Recording the EKG The point of the car is that observation The point of the car is that observation from six angles is clearly better than one from six angles is clearly better than one 23 Recording the EKG Recording the EKG A positive left arm electrode is used to record A positive left arm electrode is used to record LATERAL leads (I & AVL) LATERAL leads (I & AVL) A positive left foot electrode is used to record A positive left foot electrode is used to record INFERIOR leads (II, III, & AVF) INFERIOR leads (II, III, & AVF) Recording the EKG Recording the EKG Lateral & inferior will play a role later Lateral & inferior will play a role later when referring to myocardial ischemia, when referring to myocardial ischemia, injury, or infarction injury, or infarction Recording the EKG Recording the EKG Now for the six chest leads (also called Now for the six chest leads (also called precordial leads or vector leads) precordial leads or vector leads) Recording the EKG Recording the EKG The chest leads are V The chest leads are V 1 1 , V , V 2 2 , V , V 3 3 , V , V 4 4 , V , V 5 5 , & , & V V 6 6 The chest lead is always positive The chest lead is always positive The leads are positioned on the chest The leads are positioned on the chest from right to left covering the heart in from right to left covering the heart in its normal anatomical position its normal anatomical position Again, the lead is positive, the patient Again, the lead is positive, the patient s s back is negative back is negative Recording the EKG Recording the EKG Recording the EKG Recording the EKG Each of the vector Each of the vector leads is oriented leads is oriented through the AV through the AV Node & projects Node & projects through the through the patient patient s back which s back which is negative is negative Dr. Frank Wilson Dr. Frank Wilson introduced the V introduced the V leads leads 24 Recording the EKG Recording the EKG One more time One more time A positive depolarization wave moving A positive depolarization wave moving towards a positive electrode produces a towards a positive electrode produces a positive deflection positive deflection Get it? Get it? Got it. Got it. Good! Good! Recording the EKG Recording the EKG When observing the chest leads from V When observing the chest leads from V 1 1 to V to V 6 6 you should note gradual changes you should note gradual changes in all the waves as the position of the in all the waves as the position of the positive electrode changes for each positive electrode changes for each successive lead successive lead Recording the EKG Recording the EKG Recording the EKG Recording the EKG Leads V Leads V 1 1 & V & V 2 2 are oriented over the are oriented over the right side of the heart while V right side of the heart while V 5 5 & V & V 6 6 are are oriented over the left side of the heart. oriented over the left side of the heart. Therefore they are often called the right Therefore they are often called the right & left chest leads & left chest leads Recording the EKG Recording the EKG Recording the EKG Recording the EKG Leads V Leads V 3 3 & V & V 4 4 are oriented over the are oriented over the interventricular septum with V interventricular septum with V 3 3 being being closer to the right ventricle & V closer to the right ventricle & V 4 4 closer closer to the left ventricle to the left ventricle The right & left bundle branches course The right & left bundle branches course through the interventricular septum through the interventricular septum 25 Recording the EKG Recording the EKG Quick review Quick review The six limb leads all lie in the frontal The six limb leads all lie in the frontal plane plane The six precordial leads lie in the The six precordial leads lie in the horizontal plane horizontal plane 6 + 6 = 12, therefore a 12 6 + 6 = 12, therefore a 12- -Lead EKG Lead EKG Recording the EKG Recording the EKG Recording the EKG Recording the EKG We rarely place the We rarely place the electrodes on a electrodes on a patient patient s wrists or s wrists or ankles, so we have ankles, so we have modified the modified the locations locations Recording the EKG Recording the EKG - - Review Review ECG Leads ECG Leads Bipolar (Limb) Bipolar (Limb) Einthoven Einthoven s s Triangle Triangle Leads I, II, III Leads I, II, III Precordial (unipolar) Precordial (unipolar) V V 1 1 V V 6 6 Recording the EKG Recording the EKG - - Review Review Lead I Lead I Left arm + Left arm + Right arm Right arm Shoulder to Shoulder to shoulder shoulder Always upright Always upright Recording the EKG Recording the EKG - - Review Review Lead II Lead II Left leg + Left leg + Right arm Right arm Right shoulder to Right shoulder to apex apex Always upright Always upright 26 Recording the EKG Recording the EKG - - Review Review Lead III Lead III Left leg + Left leg + Left arm Left arm Left Shoulder to Left Shoulder to apex apex Upright Upright Recording the EKG Recording the EKG - - Review Review Leads I, II, III Leads I, II, III Recording the EKG Recording the EKG - - Review Review Enlargement of Enlargement of waveform waveform aVR, aVL, aVF aVR, aVL, aVF Recording the EKG Recording the EKG - - Review Review aVR aVR Unipolar Unipolar Right arm + Right arm + Neutral reference Neutral reference Orphan lead Orphan lead Negative deflection Negative deflection If positive, 98% of If positive, 98% of the time it the time it s VT s VT Recording the EKG Recording the EKG - - Review Review aVL aVL Unipolar Unipolar Left arm + Left arm + Neutral reference Neutral reference Upright deflection Upright deflection Recording the EKG Recording the EKG - - Review Review aVF aVF Unipolar Unipolar Foot + Foot + Neutral reference Neutral reference Positive Positive 27 Recording the EKG Recording the EKG - - Review Review Vector leads Vector leads Unipolar Unipolar Encircle the Encircle the pericardium pericardium V1: Right ventricle V1: Right ventricle V V 2 2 & V & V 3 3 : : intraventricular intraventricular septum septum V V 4: 4: cardiac apex cardiac apex V V 5 5 & V & V 6 6 : Left lateral : Left lateral wall wall Recording the EKG Recording the EKG - - Review Review V V 1 1 : 4 : 4 th th ICS @ right ICS @ right sternal border sternal border V V 2 2 : 4 : 4 th th ICS @ left ICS @ left sternal border sternal border V V 4 4 : 5 : 5 th th ICS @ MCL ICS @ MCL V V 3 3 : 5 : 5 th th ICS between V ICS between V 2 2 & V & V 4 4 V V 6 6 : 5 : 5 th th ICS @ MAL ICS @ MAL V V 5 5 : 5 : 5 th th ICS between V ICS between V 4 4 & V & V 6 6 Recording the EKG Recording the EKG - - Review Review Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Regulates all vital Regulates all vital functions by reflex functions by reflex & CNS control & CNS control Not conscious Not conscious control control Parasympathetic Parasympathetic Inhibits Inhibits Sympathetic Sympathetic Stimulates Stimulates Autonomic Nervous System Autonomic Nervous System Both the sympathetic Both the sympathetic & parasympathetic & parasympathetic systems secrete their systems secrete their own neurotransmitter own neurotransmitter Parasympathetic Parasympathetic Acetyl Acetylcholine choline (Ach) (Ach) ( (choline cholinergic) rgic) Sympathetic Sympathetic Norepinephrine (N Norepinephrine (N- - epi or NE) epi or NE) ( (adren adrenaline aline- -like = like = adren adrenergic) ergic) 28 Autonomic Nervous System Autonomic Nervous System Sympathetic Sympathetic Norepinephrine Norepinephrine Activates cardiac Activates cardiac 1 1 adrenergic receptors adrenergic receptors Rate of SA Node pacing Rate of SA Node pacing Rate of conduction Rate of conduction Force of contraction Force of contraction Irritability of foci Irritability of foci Autonomic Nervous System Autonomic Nervous System Norepinephrine is a close relative of Norepinephrine is a close relative of epinephrine ( epinephrine ( adrenaline adrenaline ) ) Epinephrine is more potent Epinephrine is more potent Both are emergency drugs as well as Both are emergency drugs as well as naturally occurring chemicals naturally occurring chemicals Norepinephrine is also called Levophed Norepinephrine is also called Levophed Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Quick review Quick review We We ve discussed norepinephrine, ve discussed norepinephrine, epinephrine, & epinephrine, & receptors receptors We We ve discussed Na ve discussed Na + + , K , K + + , Ca , Ca ++ ++ Continue to think about all the different Continue to think about all the different cardiac & emergency medications we can cardiac & emergency medications we can give our patients. Which ones might affect give our patients. Which ones might affect all the receptors & electrolytes we all the receptors & electrolytes we ve ve discussed discussed Autonomic Nervous System Autonomic Nervous System Parasympathetic Parasympathetic Inhibitory Inhibitory Rate of SA Node pacing Rate of SA Node pacing Rate of conduction Rate of conduction Force of contraction Force of contraction Irritability of atrial & junctional foci Irritability of atrial & junctional foci Autonomic Nervous System Autonomic Nervous System The vagus nerves are the body The vagus nerves are the body s main s main parasympathetic pathway parasympathetic pathway Vagal stimulation = inhibits Vagal stimulation = inhibits Vagal stimulation also greatly affects Vagal stimulation also greatly affects the gastrointestinal system the gastrointestinal system Recalling the agony of a sever episode of Recalling the agony of a sever episode of vomiting or painful, crampy diarrhea will vomiting or painful, crampy diarrhea will help you to remember the parasympathetic help you to remember the parasympathetic system system 29 Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Controls blood flow & pressure Controls blood flow & pressure Constriction Constriction Dilation Dilation Alpha adrenergic = constricts Alpha adrenergic = constricts Remember Remember constricts ( see the next constricts ( see the next photo) photo) Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Blood flow is very dependent on heart Blood flow is very dependent on heart rate rate Sympathetic stimulation increases the SA Sympathetic stimulation increases the SA Node pacing rate Node pacing rate Parasympathetic decreases it Parasympathetic decreases it Autonomic Nervous System Autonomic Nervous System Sever pain, seeing one Sever pain, seeing one s own blood, s own blood, severe loss of blood may induce a severe loss of blood may induce a parasympathetic reflex causing syncope parasympathetic reflex causing syncope This is known as This is known as merciful syncope merciful syncope but but better known in health care as better known in health care as vaso vaso- -vagal vagal syncope syncope Be compassionate to the patient that Be compassionate to the patient that passes passes- -out when you draw their blood. out when you draw their blood. They cannot help it! They cannot help it! Autonomic Nervous System Autonomic Nervous System 30 Autonomic Nervous System Autonomic Nervous System Vagal maneuvers Vagal maneuvers Can be induced Can be induced Gagging Gagging Coughing Coughing Carotid sinus Carotid sinus massage (DON massage (DON T DO T DO THIS UNLESS YOU THIS UNLESS YOU REALLY KNOW REALLY KNOW WHAT YOU ARE WHAT YOU ARE DOING!!!) DOING!!!) Autonomic Nervous System Autonomic Nervous System Pressure receptors Pressure receptors Baroreceptors Baroreceptors Especially sensitive when standing Especially sensitive when standing Normally sympathetic reflexes constrict Normally sympathetic reflexes constrict peripheral arteries & increase heart rate peripheral arteries & increase heart rate slightly slightly Orthostatic hypotension (postural hypotension) Orthostatic hypotension (postural hypotension) Near syncopal or syncopal when standing Near syncopal or syncopal when standing Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Autonomic Nervous System Neuro Neuro- -cardiogenic syncope cardiogenic syncope Pooling of blood in lower extremities from Pooling of blood in lower extremities from prolonged standing prolonged standing Sinus pacing accelerates, but peripheral Sinus pacing accelerates, but peripheral vasoconstriction is inadequate vasoconstriction is inadequate Partially filled ventricles contract rigorously Partially filled ventricles contract rigorously which stimulates parasympathetic which stimulates parasympathetic mechanoreseptors in the LV mechanoreseptors in the LV Parasympathetic reflex slows the SA Node Parasympathetic reflex slows the SA Node BP falls BP falls Patient becomes syncopal Patient becomes syncopal Autonomic Nervous System Autonomic Nervous System Rate Rate 31 Rate Rate Remember Remember Rate Rate When examining an EKG you should When examining an EKG you should determine the regularity first determine the regularity first Regular Regular Irregular Irregular Regularly irregular (has a pattern) Regularly irregular (has a pattern) Irregularly irregular (no pattern) Irregularly irregular (no pattern) Then examine the rate Then examine the rate Rate is read as cycles (beats) per minute Rate is read as cycles (beats) per minute (bpm) (bpm) Rate Rate The SA Node (Sinus Node) is The SA Node (Sinus Node) is the heart the heart s dominant center s dominant center of automaticity of automaticity It is the heart It is the heart s pacemaker s pacemaker under normal circumstances under normal circumstances It paces the heart in the It paces the heart in the normal normal range of 60 range of 60 99 99 (100) bpm (100) bpm The regular rhythm it The regular rhythm it generates is called sinus generates is called sinus rhythm (SR) rhythm (SR) Rate Rate If the SA nodes If the SA nodes paces at a rate less paces at a rate less than 60 bpm it is than 60 bpm it is called sinus called sinus bradycardia (SB) bradycardia (SB) Brady = slow; cardia Brady = slow; cardia = heart = heart Rate Rate SB most often results from SB most often results from parasympathetic excess, as in a parasympathetic excess, as in a conditioned athletes at rest conditioned athletes at rest SB can be a side SB can be a side- -effect of medication effect of medication Rate Rate If the SA Node paces faster than 100 (99) it is called If the SA Node paces faster than 100 (99) it is called sinus tachycardia (ST) sinus tachycardia (ST) Tachy = fast Tachy = fast Exercise produces sympathetic stimulation, a Exercise produces sympathetic stimulation, a common cause of ST common cause of ST 32 Rate Rate There are focal areas of automaticity in the heart There are focal areas of automaticity in the heart known as automaticity foci (ectopic foci) known as automaticity foci (ectopic foci) They are potential pacemakers They are potential pacemakers Under normal circumstances they are electrically Under normal circumstances they are electrically silent, hence potential silent, hence potential Rate Rate The proximal end of the AV Node has The proximal end of the AV Node has no automaticity foci no automaticity foci The middle & distil regions do, this is The middle & distil regions do, this is called the AV junction called the AV junction Junctional automaticity foci Junctional automaticity foci The the AV junction paces at a rate of 40 The the AV junction paces at a rate of 40 - - 60 60 Rate Rate Not the SA Node Rate Rate SA Node overdrive suppresses all other foci SA Node overdrive suppresses all other foci All automaticity centers will overdrive All automaticity centers will overdrive suppress all others that have a slower suppress all others that have a slower pacemaker rate pacemaker rate Rate Rate Overdrive suppression also provides an emergency Overdrive suppression also provides an emergency backup backup Rate Rate Don Don t let the 80 vs. 100 confuse you t let the 80 vs. 100 confuse you SA node is inherently 60 SA node is inherently 60 99 (100) 99 (100) Atrial automaticity foci is 60 Atrial automaticity foci is 60 80 !!! 80 !!! Rate Rate So, without SA Node pacing & atrial So, without SA Node pacing & atrial automaticity foci can take over, if that automaticity foci can take over, if that fails, the AV junction can take over, if fails, the AV junction can take over, if that fails, the ventricular automaticity that fails, the ventricular automaticity center takes over center takes over 33 Rate Rate The AV junction has automaticity foci The AV junction has automaticity foci Its inherent rate is 40 Its inherent rate is 40 60 bpm 60 bpm The proximal end of the AV Node has no foci The proximal end of the AV Node has no foci The middle & distil end of the AV Node does The middle & distil end of the AV Node does have foci have foci If the junctional foci is the active pacemaker it If the junctional foci is the active pacemaker it produces a junctional rhythm produces a junctional rhythm Rate Rate Rate Rate Remember that the AV Node is the only Remember that the AV Node is the only conduction link between the atria & conduction link between the atria & ventricular conduction system ventricular conduction system If there is a complete conduction block If there is a complete conduction block in the AV Node then the AV junction in the AV Node then the AV junction will not receive stimulus from above & will not receive stimulus from above & will take over pacing will take over pacing Rate Rate Rate Rate Ventricular automaticity Ventricular automaticity Inherent rate 20 Inherent rate 20 - -40 bpm 40 bpm Specialized Purkinje fibers Specialized Purkinje fibers Produces an idioventricular rhythm Produces an idioventricular rhythm Idio = Greek, meaning Idio = Greek, meaning one one s own s own Rate Rate 34 Rate Rate A note one ventricular automacticty A note one ventricular automacticty In a physiological or pathological In a physiological or pathological emergency, an irritable automaticity focus emergency, an irritable automaticity focus may suddenly discharge at a rapid rate. may suddenly discharge at a rapid rate. Frequently this rate is around 150 Frequently this rate is around 150 200 200 bpm bpm This is a life threatening emergency called This is a life threatening emergency called ventricular tachycardia (VT) ventricular tachycardia (VT) More about this later More about this later Rate Rate Easy rate determination Easy rate determination In an emergency you will not have time In an emergency you will not have time to find or use a calculator, or the to find or use a calculator, or the presence of mind to spend a long time presence of mind to spend a long time analyzing an EKG strip. analyzing an EKG strip. So here is a real quick & simple So here is a real quick & simple method method Rate Rate Memorize Memorize Rate Rate First find an R wave that peaks on a heavy First find an R wave that peaks on a heavy black line, this is START black line, this is START Rate Rate Now, count off: 300, 150, 100 Now, count off: 300, 150, 100 The line the R wave peaks on is START, then the The line the R wave peaks on is START, then the heavy black lines that follow get counted heavy black lines that follow get counted Rate Rate One more time One more time START, 300, 150, 100, 75, 60, 50, START, 300, 150, 100, 75, 60, 50, 35 Rate Rate What you are doing is called the triplet What you are doing is called the triplet method method It works best for regular rhythms It works best for regular rhythms Rate Rate What is the rate? What is the rate? Rate Rate Practice Practice Rate Rate What is the rate? What is the rate? Rate Rate A = 100 A = 100 B = about 150 B = about 150 C = 60 C = 60 D = 75 D = 75 Rate Rate Triplet method Triplet method Why does it make sense? Why does it make sense? 36 Rate Rate Rate Rate The small lines have values as well The small lines have values as well In the back of your Jane Huff workbook In the back of your Jane Huff workbook there is a card for there is a card for counting the boxes counting the boxes This is the triplet method This is the triplet method Rate Rate Rate Rate Stop counting!!! Your patient is dead!!! Rate Rate Another method for rate determination Another method for rate determination On the top of all EKG strips are 3 On the top of all EKG strips are 3- -second second interval hash marks interval hash marks They could be noted as dots, lines, They could be noted as dots, lines, triangles, circles, etc triangles, circles, etc Rate Rate 37 Rate Rate We like to use a 6 We like to use a 6- -second strip to determine second strip to determine rate rate Rate Rate Count the number of R to R cycles in a 6 Count the number of R to R cycles in a 6- - second strip second strip Rate Rate Rate Rate Rate Rate 1 = 20 1 = 20 2 = about 45 2 = about 45 3 = 50 3 = 50 Rhythm Interpretation Rhythm Interpretation Now that you have all the basics lets get Now that you have all the basics lets get ready to identify rhythms ready to identify rhythms 38 Rhythm Interpretation Rhythm Interpretation At this point we will only be looking at 1 lead at At this point we will only be looking at 1 lead at a time a time It is important to remember that using only 1 It is important to remember that using only 1 lead cannot lead cannot Identify/locate an infarct Identify/locate an infarct Identify axis deviation or chamber enlargement Identify axis deviation or chamber enlargement Identify right Identify right- -to to- -left differences in conduction left differences in conduction Provide feedback about the quality or presence of Provide feedback about the quality or presence of pumping action pumping action Rhythm Interpretation Rhythm Interpretation Time Intervals Time Intervals P P R Interval: R Interval: 0.12 0.12 0.20 0.20 sec sec QRS Interval: QRS Interval: 0.08 0.08 0.12 sec 0.12 sec S S T T Segment: Segment: 0.33 0.33 0.42 sec 0.42 sec Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Absolute refractory period Absolute refractory period Onset of the QRS to the peak of the T Onset of the QRS to the peak of the T Cardiac cells are depolarized & are in the Cardiac cells are depolarized & are in the process of repolarizing process of repolarizing At this time the cells cannot be stimulated, At this time the cells cannot be stimulated, conduct, or contract conduct, or contract Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Rhythm Interpretation Relative refractory period Relative refractory period Peak of the T to end of the T Peak of the T to end of the T Cells are repolarized Cells are repolarized This is a vulnerable period This is a vulnerable period A strong stimulus can potentially take over A strong stimulus can potentially take over the primary pacemaker of the heart the primary pacemaker of the heart This is called This is called R on T phenomena R on T phenomena Potential for sudden cardiac death Potential for sudden cardiac death 39 Rhythm Interpretation Rhythm Interpretation Arrhythmia literally means without Arrhythmia literally means without rhythm rhythm Dysrhythmia means bad rhythm & is Dysrhythmia means bad rhythm & is the correct terminology the correct terminology Rhythm Interpretation Rhythm Interpretation Always be consistent & analytical Always be consistent & analytical Always use the 5 Always use the 5- -step method step method Learn the rules for each dysrhythmia Learn the rules for each dysrhythmia Analyze a given rhythm strip according to Analyze a given rhythm strip according to a specific format a specific format Compare your analysis to the rules for each Compare your analysis to the rules for each dysrhythmia dysrhythmia Identify the dysrhythmia by its similarity Identify the dysrhythmia by its similarity to established rules to established rules Rhythm Interpretation Rhythm Interpretation The 5 step method The 5 step method Determine the regularity (rhythm) of the R Determine the regularity (rhythm) of the R waves waves Calculate the heart rate Calculate the heart rate Identify & examine the P waves Identify & examine the P waves Measure the PRI (P Measure the PRI (P- -R interval) R interval) Measure the QRS complex Measure the QRS complex Rhythm Interpretation Rhythm Interpretation Step 1: Determine the regularity Step 1: Determine the regularity Regular Regular Irregular Irregular Regularly Irregular Regularly Irregular Irregularly Irregular Irregularly Irregular Rhythm Interpretation Rhythm Interpretation Step 2: Calculate the rate Step 2: Calculate the rate 6 6- -second strip second strip Triplet method Triplet method Heart rate calculator (counting the boxes) Heart rate calculator (counting the boxes) Rhythm Interpretation Rhythm Interpretation Step 3: Identify & examine the P waves Step 3: Identify & examine the P waves Are P waves present? Are P waves present? Are the P waves upright or inverted? Are the P waves upright or inverted? Do all the P waves look alike? Do all the P waves look alike? Are the P waves regular (P Are the P waves regular (P- -P interval)? P interval)? 40 Rhythm Interpretation Rhythm Interpretation Step 4: The PRI Step 4: The PRI Is there one P wave for each QRS complex? Is there one P wave for each QRS complex? Analyzing the P Analyzing the P R Interval R Interval Within normal limits Within normal limits Long Long Short Short Changing Changing Rhythm Interpretation Rhythm Interpretation Step 5: Step 5: The QRS complex The QRS complex Do all the QRS complexes look alike? Do all the QRS complexes look alike? What is the QRS duration? What is the QRS duration? R to R interval R to R interval Rhythm Interpretation Rhythm Interpretation In addition you can also look at In addition you can also look at T wave configuration T wave configuration Check to see if there is a P wave hidden Check to see if there is a P wave hidden Review of SA Node & Atrial Review of SA Node & Atrial Rhythms Rhythms Review of SA Node & Atrial Review of SA Node & Atrial Rhythms Rhythms Review of SA Node & Atrial Review of SA Node & Atrial Rhythms Rhythms 41 Review of SA Node & Atrial Review of SA Node & Atrial Rhythms Rhythms Review of SA Node & Atrial Review of SA Node & Atrial Rhythms Rhythms