12/10/2014 3 lead ecg interpretation pfn: somacl12slides.jsomtc.org/somacl12/somacl12.pdfjunctional...
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12/10/2014
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Slide 1JSOMTC, SWMG(A)
3 Lead ECG Interpretation PFN: SOMACL12
Hours:
Instructor:
Slide 2JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of 3 Lead ECG interpretation
Condition: Given a lecture in a classroom environment
Standard: Receive minimum score of 84% on AHA standardized written exam
Slide 3JSOMTC, SWMG(A)
References
Basic Arrhythmias, Seventh Edition, Gail Walraven
Advanced Cardiovascular Life Support, Provider Manual 2010
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Slide 4JSOMTC, SWMG(A)
Reason
At some time, you will likely encounter the need to treat a critical cardiac patient. As the leader or a member of the medical team, a comprehensive understanding of cardiac arrhythmias will improve overall patient management.
Slide 5JSOMTC, SWMG(A)
Agenda
Review ECG waves, measurements, and the 6‐step process of analyzing ECG rhythms
Review sinus rhythms
Review atrial rhythms
Review junctional rhythms
Review heart blocks
Slide 6JSOMTC, SWMG(A)
Agenda
Review ventricular rhythms
Review miscellaneous rhythms
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Slide 7JSOMTC, SWMG(A)
ECG Waves and Measurements
Slide 8JSOMTC, SWMG(A)
Waves and Measurements
PAGE 18
Slide 9JSOMTC, SWMG(A)
Basic Rule of Electrical Flow
If flow of electricity is toward a '+' electrode the pattern is upright
If the electrical flow is toward a ' ‐ ' electrode then the pattern will be downward
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Slide 10JSOMTC, SWMG(A)
Leads
Electrode positions allow a single view of the heart’s electrical pattern
By rearranging the electrodes, different views are possible
This method can triangulate to spots on the heart to assess arrhythmias
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Slide 11JSOMTC, SWMG(A)
Graph Paper
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Slide 12JSOMTC, SWMG(A)
Cardiac Cycle
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Slide 13JSOMTC, SWMG(A)
Cardiac Cycle
Slide 14JSOMTC, SWMG(A)
Waves and Measurements
PAGE 28
Slide 15JSOMTC, SWMG(A)
Artifact/Interference
'Artifact'
Electrical Interference
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Slide 16JSOMTC, SWMG(A)
Refractory Periods
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Slide 17JSOMTC, SWMG(A)
Components of Analyzing ECG Rhythms
Slide 18JSOMTC, SWMG(A)
Analyzing ECG Rhythm Strips
ECG’s are more complex than fingerprints
Everyone's is subtly and uniquely theirs
Inadequate to simply memorize 'snapshots' of common ECG’s
Analysis of every ECG 'strip' using a systematic approach
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Slide 19JSOMTC, SWMG(A)
Arrhythmias
Categories
Sinus
Atrial
Junctional
Ventricular
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Slide 20JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
PAGE 59
Slide 21JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
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Slide 22JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform, saw toothed appearance or irregularly irregular
PAGE 63
Slide 23JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform
PRI: Less than .20, constant
PAGE 64
Slide 24JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, uniform
PRI: Less than .20, constant
QRS: Less than .12
PAGE 64
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Slide 25JSOMTC, SWMG(A)
Analysis FormatRegularity: Regular or irregular?
Rate: 60‐100
P Wave: Up right, rounded, Uniform
PRI: Less than .20, constant
QRS: Less than .12
S‐T segment: Elevated or depressed?
Slide 26JSOMTC, SWMG(A)
Sinus Rhythms
Slide 27JSOMTC, SWMG(A)
Sinus Rhythms
Normal Sinus Rhythm (NSR)
Sinus Bradycardia
Sinus Tachycardia
Sinus Arrhythmia
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Slide 28JSOMTC, SWMG(A)
Normal Sinus Rhythm (NSR)Rhythm: Regular
Rate: 60‐100
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 80
Slide 29JSOMTC, SWMG(A)
Sinus BradycardiaRhythm: Regular
Rate: Less than 60
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 82
Slide 30JSOMTC, SWMG(A)
Sinus TachycardiaRhythm: Regular
Rate: Greater than 100 , <150
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 84
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Slide 31JSOMTC, SWMG(A)
Sinus ArrhythmiaRhythm: Irregular
Rate: Normal 60‐100
P wave: Present, up right rounded
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 85
Slide 32JSOMTC, SWMG(A)
Atrial Rhythms
Slide 33JSOMTC, SWMG(A)
Atrial Rhythms
Wandering Pacemaker
Atrial Tachycardia/Supraventricular Tachycardia (SVT)
Premature Atrial Complexes (PAC)
Atrial Flutter
Atrial Fibrillation
PAGE 110
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Slide 34JSOMTC, SWMG(A)
Wandering PacemakerRhythm: Regular, 1 complex out of place
Rate: Normal 60‐100
P wave: Present, morphing
PRI: Constant, less than .20
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 110
Slide 35JSOMTC, SWMG(A)
Premature Atrial Complex (PAC)
Rhythm: Regular
Rate: Normal 60‐100
P wave: Present, morphing
PRI: Constant, less than .20
QRS: Less than .12, but came early;
led a P wave
ST segment: Back to isoelectric line
PAGE 112
Slide 36JSOMTC, SWMG(A)
Supraventricular Tachycardia (SVT)
Rhythm: Regular
Rate: 150‐250
P wave: May or may not be visible
PRI: Often difficult to measure
QRS: Less than .12
ST segment: Back to isoelectric line
PAGE 114
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Slide 37JSOMTC, SWMG(A)
Atrial FlutterRhythm: Regular
Rate: Atrial rate is 250‐300; ventricular rate slightly tachycardic
P wave: Often present as "saw teeth"; more P waves than QRS
PRI: Difficult to determine
QRS: Less than .12
ST segment Back to isoelectric line
PAGE 114
Slide 38JSOMTC, SWMG(A)
Atrial Fibrillation
Rhythm: Grossly irregular
Rate: Atrial: >350 , ventricular WNL
P wave: Not discernible
PRI: Unable to measure
QRS: Less than .12
ST segment: Back to isoelectric line; T waves often not seen
PAGE 119
Slide 39JSOMTC, SWMG(A)
Junctional Rhythms
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Slide 40JSOMTC, SWMG(A)
Junctional Rhythms
Junctional Pacemaker
Premature Junctional Complex (PJC)
Junctional Escape Rhythm
Accelerated Junctional Rhythm
Junctional Tachycardia
PAGE 158
Slide 41JSOMTC, SWMG(A)
Junctional PacemakerRhythm: Regular
Rate: 40‐60
P wave: Inverted or absent
PRI: Normal if present
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 158
Slide 42JSOMTC, SWMG(A)
Premature Junctional Complex (PJC)Rhythm: Regular with 1 irregular beat
Rate: Depends on underlying rhythm
P wave: Normal; except the premature complex(s)
PRI: Usually normal if present
QRS: Less than .12 (underlying rhythm?)
ST segment: Back to isoelectric
PAGE 161
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Slide 43JSOMTC, SWMG(A)
Junctional Escape RhythmRhythm: Regular
Rate: 40‐60
P wave: Inverted or absent
PRI: Normal if P waves present
QRS: Less than .12
ST segment: Back to isoelectric (if normal)
PAGE 164
Slide 44JSOMTC, SWMG(A)
Accelerated Junctional RhythmRhythm: Regular
Rate: 60‐100 BPM
P wave: Inverted or absent
PRI: Normal if present
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 166
Slide 45JSOMTC, SWMG(A)
Junctional TachycardiaRhythm: Regular
Rate: 100‐180 (usually)
P wave: Inverted or absent
PRI: Normal if P wave present
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 168
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Slide 46JSOMTC, SWMG(A)
Heart Blocks
Slide 47JSOMTC, SWMG(A)
Heart Blocks
First Degree
Second Degree Type 1
Second Degree Type 2
Third Degree
PAGE 199
Slide 48JSOMTC, SWMG(A)
First DegreeRhythm: Regular
Rate: 60‐100, sometimes bradycardic
P wave: Present normal
PRI: Greater than .20
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 200
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Slide 49JSOMTC, SWMG(A)
Second Degree Type 1'Wenckebach'/Mobitz 1
Rhythm: Irregular
Rate: 60‐100, possibly bradycardic
P wave: Present, normal
PRI: Grows longer until QRS 'drops'
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 206
Slide 50JSOMTC, SWMG(A)
Second Degree (Mobitz 2)Rhythm: Irregular
Rate: 60‐100, sometimes bradycardic
P wave: Present, WNL; more P’s than QRS’s
PRI: Normal until it 'drops' a QRS
QRS: Less than .12
ST segment: Back to isoelectric
PAGE 208‐209
Slide 51JSOMTC, SWMG(A)
Third Degree (Complete Heart Block)Rhythm: Regular
Rate: Atrial 60‐100
Ventricular 20‐60
P wave: Present, normal ‐more P’s than QRS’s
PRI: No relationship between P‐QRS
QRS: Less than .12; possibly > .20
ST segment: Back to isoelectric
PAGE 209‐211
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Slide 52JSOMTC, SWMG(A)
Ventricular Rhythms
Slide 53JSOMTC, SWMG(A)
Ventricular Rhythms
Premature Ventricular Complex (PVC)
Ventricular Tachycardia
Ventricular Fibrillation
Idioventricular Rhythm
Asystole
PAGE 241
Slide 54JSOMTC, SWMG(A)
Premature Ventricular Complex (PVC)Rhythm: What is the underlying rhythm?
Rate: Underlying rhythm?
P wave: Underlying rhythm?
PRI: Underlying rhythm?
QRS: Wider than QRS, comes early,
No preceding P‐Wave
ST segment: Underlying rhythm
PAGE 242
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Slide 55JSOMTC, SWMG(A)
Premature Ventricular Complex (PVC)Bigeminy (PVC)
Trigeminy (PVC)
Quadgeminy (PVC)
PAGE 249
Slide 56JSOMTC, SWMG(A)
Premature Ventricular Complex (PVC)Couplet (PVC)
Triplet (PVC)
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Slide 57JSOMTC, SWMG(A)
Ventricular Tachycardia (VT)Rhythm: Regular
Rate: 150‐250
P wave: Absent
PRI: Normal; likely indiscernible
QRS: Wider than .12
ST segment: Difficult to discern
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Slide 58JSOMTC, SWMG(A)
Ventricular FibrillationRhythm: Irregular
Rate: Incalculable
P wave: None discernible
PRI: None
QRS: Bizarre ventricular conduction
ST segment: Incalculable
PAGE 253
Slide 59JSOMTC, SWMG(A)
IdioventricularRhythm: Regular
Rate: 20‐40 BPM
P wave: Absent
PRI: There is no PRI
QRS: Wide and bizarre, > .12
ST segment: May appear to be above/below isoelectric line
PAGE 255‐257
Slide 60JSOMTC, SWMG(A)
AsystoleRhythm: None
Rate: Zero
P wave: None
PRI: None
QRS: None
ST segment: None
PAGE 258
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Slide 61JSOMTC, SWMG(A)
Miscellaneous Rhythms
Slide 62JSOMTC, SWMG(A)
Miscellaneous RhythmsFIL is the electrically filtered actual rhythm going on during CPR
CPR is the artifact caused by compressions
RAW is what comes across the screen when both are going on
Slide 63JSOMTC, SWMG(A)
Questions?
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Slide 64JSOMTC, SWMG(A)
Terminal Learning Objective
Action: Communicate knowledge of 3 Lead ECG interpretation
Condition: Given a lecture in a classroom environment
Standard: Receive minimum score of 84% on AHA standardized written exam
Slide 65JSOMTC, SWMG(A)
Agenda
Interpret ECG waves and measurements
Identify the components of analyzing ECG rhythms
Identify sinus rhythms
Identify atrial rhythms
Identify junctional rhythms
Identify heart blocks
Slide 66JSOMTC, SWMG(A)
Agenda
Identify ventricular rhythms
Identify miscellaneous rhythms
12/10/2014
23
Slide 67JSOMTC, SWMG(A)
Reason
At some time, you will likely encounter the need to treat a critical cardiac patient. As the leader or a member of the medical team, a comprehensive understanding of cardiac arrhythmias will improve overall patient management.
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