cardiac electrophysiology
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Basic Arrhythmias Basic Arrhythmias InterpretationInterpretation
Cardiac Cardiac ElectrophysiologyElectrophysiology
Natalie Bermudez, RN, BSN, MSNatalie Bermudez, RN, BSN, MSClinical Educator for TelemetryClinical Educator for Telemetry
Myocardial Cardiac Cell TypesMyocardial Cardiac Cell Types
P Cells • Pacemaker cells
– Responsible for generation of action potentials
– electrical activity
Cardiomyocytes• Myocardial Cells
– Contractile cells that generate force– Mechanical activity
Cardiac Cell ActivityCardiac Cell ActivityElectrical activity ALWAYS precedes mechanical activity
Electrical activity can occur without a mechanical response
(i.e. pulse).
This is known as pulseless electrical activity (PEA).
Primary Characteristics of Cardiac Cells
Automaticity
Excitability
Conductivity
ContractilityECG Workout Textbook: p. 10
Is it GOOD or BAD???ALL ELECTRICAL CARDIAC CELLS ARE
CAPABLE OF AUTOMATICITY!!!
IRRITABILITY!!!
AutomaticityAutomaticity
It is definitelyREALLYGOOD
THING!!
But it can alsobe a
REALLYBAD THING!!
Electrolytes and Cardiac Cells
• Electrolyte solution surrounds cardiac cells
• K+ primary intracellular ion
• Na+ primary extracellular ion
• Ready State: Inside of the cell
more negative
• Cell stimulated; membrane permeability changes
PolarizationPolarization
DepolarizationDepolarization
RepolarizationRepolarization
Electrical Activity at the Cellular LevelElectrical Activity at the Cellular Level
Cardiac Action Potential• As cardiac cells reverse polarity, the electrical
impulse generated during that event creates an energy stimulus that travels across the cell membrane
• High-speed, self-producing current (heart only)
Slow-Response Cells
• SA node & AV node
• Spontaneously depolarize slowly
• Shorter, non-prominent plateau phase with slower repolarization period
Fast-Response Cells
• Purkinje cells and working myocardial cells
• Rapid depolarization
• Then, a period of sustained depolarization – plateau phase
Phases of Action Potential
Phase 0 • Cellular depolarization is initiated as + ions enter the cell
(Na+ and Ca++)• Working cells rapidly depolarize as Na+ enters the cells
through Na+ fast channels (fast response)• SA/AV node depolarize as Ca++ enters the cell through
Ca++ slow channels (slow-response)
Phases of Action Potential
Phase 1 • Small, early, rapid repolarization as K+ exits the
intracellular space
Phase 2• The plateau phase as Ca++ ions enter the intracellular
space
Phases of Action Potential
Phase 3 • Completion of repolarization and return of cell to
resting state
Phase 4• Resting phase before the next depolarization (Na+
out, K+ in)
POLARIZATIONPOLARIZATION
Electrical charges are balanced and ready for discharge.
The discharge of energy that accompanies the transfer of electrical charges across
the membrane.
The process of electrical discharge and flow
of electrical activity.
An electrical event that can be recorded on
an EKG or rhythm strip.
DEPOLARIZATIONDEPOLARIZATION
The return of electrical charges across the cell membrane.
REPOLARIZATIONREPOLARIZATION
Refractory PeriodRefractory Period
Absolute: The brief period during repolarization when the cell CAN’T respond to any stimulus,
no matter how strong.
*Relative: The brief period during repolarization when excitability is depressed. If stimulated, the
cell may respond, but a stronger than usual stimulus is required.
Supernormal: The cells will respond to a weaker than normal stimulus (this period occurs just before the cells have completely repolarized)
What is an EKG?
• Think of it as a map that shows the road traveled by an electrical impulse
• Each waveform indicates the location of the electrical impulse and if has traveled through that location “normally”
Isoelectric Line & WaveformsIsoelectric Line & WaveformsIsoelectric Line:
electrically neutral baseline of an EKG complex.
Waveform: any part of the EKG tracing that moves away from & returns to the isoelectric line (baseline)
DeflectionsDeflectionsDeflection: a waveform
on an EKG strip that denotes electrical activity; may be positive (upright) and/or negative (downward).
Monophasic or Biphasic
See Overhead slide 1-0
Positive & Negative PolesPositive & Negative Poles
Electrical activity that travels towards a
positive pole appears upright on an EKG
appears and is called a positive deflection.
Electrical activity that travels towards a
negative pole appears inverted
(downward) on an EKG and is called a negative deflection
Positive & Negative PolesPositive & Negative PolesSee Overhead Slide 1-1
Cardiac Monitors
Electrodes, Poles, Wires, Leads, and Electrode Placement
Five-Leadwire System
Electrode Pad PlacementElectrode Pad Placement
Electrode
An electrode pad is the medium through electrical activity is registered/recorded
Proper placement of the electrode pad is the most important step in obtaining a good quality and accurate EKG tracing
An EKG lead provides a view of the heart’s electrical activity between two points or poles (one positive & one negative)
The EKG waveforms are recorded via an electrode/wire system – i.e. five-leadwire system
Poles & Lead IIPoles & Lead II
Lead II consists of the following electrode
placement:
•Right Limb Lead (negative pole): the 2nd intercostal space on the right
•Left Limb Lead (positive pole): the 8th intercostal space on the left
•Grounding Lead: 8th intercostal space to the right
LEAD II
Lead II is used alone quite frequently. Normal rhythms present with a prominent
P wave and a tall QRS.
Irritability versus EscapeIrritability versus Escape
Irritability – a site that speeds up and takes over as the pacemaker.
Escape – when the normal pacemaker slows down or fails and a lower site assumes pace making responsibility.
Either of these may exist as a beat or rhythm!
More EKG Terminology
Focus, Ectopy, Aberrancy, Artifact
Important TerminologyImportant Terminology
Focus - The starting point of an electrical impulse
Ectopic – An impulse that originates from a focus other than the primary pacemaker.
AberrancyAberrancy
Aberrancy – abnormal conduction of an electrical impulse
Aberrant Ventricular Conduction – An impulse that originates from the SA node, atria, or AV junction that is abnormally conducted through the ventricles producing a wider than normal
QRS complex: a.k.a “aberrancy”
ArtifactArtifactElectrical activity displayed on graph
paper that is superimposed on cardiac tracings, interfering with interpretation of the rhythm.
Can be caused by outside electrical soures, muscle tremors, patient movement; also called interference.
Cardiac Electrophysiology
The Electrical Conduction Pathway
Nervous System StimulationNervous System Stimulation
Sympathetic Nervous System: causes an increase in heart rate, increase in AV conduction , and increase in ventricular
contractility
The increase is caused a release of norepinephrine
(catecholamine/neurotransmitter)
Nervous System StimulationNervous System Stimulation
Parasympathetic Nervous System: (from the vagus nerve) causes a slowing of the heart rate, a decrease in AV conduction, and a slight decrease in ventricular contractility
The decrease is caused a release of acetylcholine
(catecholamine/neurotransmitter)
PacemakerPacemakerPacemaker – the SA node is the natural/normal
pacemaker of the heart.
Latent Pacemaker Cells – Cells in the electrical conduction system located below the SA node with the property of automaticity
These cells hold the property of automaticity in reserve in case the SA node fails to function properly or electrical impulses fail to be conducted.
a.k.a. – Subsidiary pacemaker cells
The Electrical Conduction Pathway
SA Node
• ie. Sinoatrial Node or Sinus Node
• Posesses the highest level of automaticity
• SA Node is the primary pacemaker of the heart
• If it fails to fire or slows down less than its inherent firing rate (60 – 100), another pacemaker that is lower in the conduction system will take over
AV Node (The Gatekeeper)
Three main functions:
• Slows conduction to allow time for the atria to contract & empty its contents (atrial kick) before the ventricles contract
• Secondary pacemaker (40 – 59 bpm)
• Blocks some of the impulses from being conducted to the ventricles when atrial rate is rapid
AV Node (The Gatekeeper)
Three Regions:
• Atrial-Nodal (upper region)
Pacemaker cells
• Nodal (middle region)
No pacemaker cells (area responsible
for delay)
• Nodal-His (lower region)
Pacemaker cells
Ventricular Conduction
Impulses moves rapidly through the ventricles:
• Bundle of His• Left & Right Bundle branches (LBB divides
into the anterior fascicle and posterior fascicle)
• Purkinje fibers
Tertiary pacemaker (20 – 39)
EKG COMPLEXEKG COMPLEX
PQRST = One EKG complex = One Cardiac CycleTotal Duration of a Cardiac Cycle = ___________ seconds
P WaveP Wave• Depicts the firing of
the SA node and atrial depolarization (contraction).
• P waves are upright & rounded (in Lead II).
• Precedes a QRS
• Both atria depolarize simultaneously.
P Wave AbnormalitiesP Wave Abnormalitiesp mitrale = Wide & Notched P wave
______________________________________________________________________
p pulmonale = Tall, peaked P wave
________________________________________________________________________
PR SegmentPR Segment
The PR segment represents delay in the AV node
Flat = Baseline
QRS ComplexQRS Complex
Depicts the electrical impulse traveling through the ventricles and ventricular depolarization
(contraction).
Not all QRS complexes have a Q, R, and S.
QRS ComplexQRS ComplexQ wave is the FIRST negative
deflection
R wave is the FIRST positive deflection
S wave is the negative deflection that follows the R
wave
J Point is the point where the QRS complex endsSee Overhead Slide 1-3
QRS Complex VariationsQRS Complex VariationsOverhead Slide 1-2
ST-SegmentST-Segment
The ST-segment represents ventricular contraction and period before ventricular
repolarization. No electricity is flowing. The ST segment is therefore usually even with the
baseline.
ST-Segment Elevation & ST-Segment Elevation & DepressionDepression
To be considered a significant elevation or depression the ST must deviate at least 1 mm
above or below the baseline (in at least 2 or more correlating leads)
ST-Segment DepressionST-Segment Depression
Most often seen with acute myocardial ischemia
Other Causes:
Left and right ventricular hypertrophyLeft and Right BBB
HypokalemiaDrug Effects (i.e. digitalis)
ST-Segment ElevationST-Segment Elevation
Most often seen with acute myocardial injury or infarction
Other Causes:
Coronary vasospasm (Prinzmetal’s Angina)
Pericarditis
Ventricular Aneurysm
Hyperkalemia
Early repolarization (a normal variant)
T WaveT Wave
Depicts ventricular repolarization
Refractory Period
T WavesT WavesPositive Deflection
(above baseline < 5 mm)
Should appear rounded and symmetrical
Peak is closer to the end of the wave
Elevated T WavesElevated T WavesPositive Deflection
(above baseline > 5 mm)
Tall, peaked (tented)
HYPERKALEMIA
or MYOCARDIAL INJURY
Inverted T WavesInverted T WavesNegative Deflection
(below baseline)
Causes:
Myocardial Ischemia
Myocardial Infarction
Pericarditis
Ventricular Enlargement
Bundle Branch Block
Subarachnoid Hemorrhage
Certain Drugs (quinidine or procainamide)
U WaveU Wave
Depicts last phase of ventricular repolarization or endocardial
repolarization???
U WaveU WaveU Wave < 2 mm
Seen most commonly with BRADYCARDIC rate
Can cause inaccuracies when measuring QT intervals
U WaveU WaveU Wave < 2 mm
Large = hypokalemia, cardiomyopathy, LV enlargement
Some drugs may cause a large U wave
May cause Torsades de Pointes
Atrial Repolarization ???Atrial Repolarization ???
Hidden beneath the QRS complex.
EKG Graph PaperEKG Graph Paper
Waveform Measurements
PR IntervalPR Interval
Measurement:0.12 – 0.20 seconds
Represents the time from SA node firing to the end of AV
node delay
PRI AbnormalitiesPRI Abnormalities
Prolonged or Inconsistent PRI’s may indicate a type of heart
block:
1st degree AVBMobitz 1 or Mobitz 2
Complete AVB
PRI AbnormalitiesPRI AbnormalitiesShortened or
Nonexistent PRI’s may indicate:
Tachycardic Rhythms WPW Syndrome
Junctional RhythmsEctopic Atrial Rhythms
Ventricular Rhythms
PRI AbnormalitiesPRI AbnormalitiesSee Overhead Slide 1-4
PR IntervalPR Interval
PRI=
PRI=
QRS DurationQRS Duration
Measurement:0.04 – 0.10seconds
Represents the travel time of
electrical activity through the ventricles
QRS Complex VariationsQRS Complex Variations
Wide and/or notched QRS complexes:
- BBB’s - Aberrant ventricular conductivity- Rhythms with Ventricular Focus
Aberrant QRS ComplexAberrant QRS Complex
See Overhead Slide 1-5
QRS DurationQRS Duration
QRS=
QRS=
QT IntervalQT IntervalMeasurement:
< ½ the distance of the preceding R-R interval
Represents travel time through ventricles to the
end of ventricular repolarization
Normally varies according to age, sex,
and particularly heart rate
QT Rate CorrectedQT Rate Corrected
HR ↑ = QT interval ↓
HR ↓ = QT interval ↑
QTc = QT + 1.75 (ventricular rate – 60)
QT IntervalQT Interval
QT= QTc=
QT= QTc=
Prolonged QT IntervalsProlonged QT IntervalsRepresents a
prolonged time to repolarization
May lead to R-on-T
Phenomenon and ventricular
dysrhythmias!!!
Basics to Interpreting StripsBasics to Interpreting Strips
Rhythm
Rate
P Wave
PR Interval (PRI)
QRS Duration
RHYTHMRHYTHM
Determine regularity or irregularity
Use calipers for accuracy
Measure distance from R-R wave
Regular Rhythm = R-R distance does not vary (less than 3 small boxes of variation does not count)
Irregular Rhythm = R-R distance varies (3 small small boxes or greater)
HEART RATEHEART RATE
Use 1500-rule and the 6-second rule for all regular rhythms
6-second rule only for irregular rhythms
Calculating Heart RatesCalculating Heart Rates
The 6-Second Rule
The Rule of 300’s
The 1500 Rule
6-Second Strip6-Second Strip
Count number of R waves in a 6-second strip and multiply by 10
A.K.A. Rapid Rate Calculation
HR = # R waves x 10
• Not very accurate• Used only for very quick estimate
Rule of 300’sRule of 300’sCount number of large
squares between 2 consecutive R waves and
divide into 300.
HR = 300 / # large squares
• Very quick• Used only with regular
rhythms• Not very accurate with
fast rates
Rule of 300’sRule of 300’s
Scale of 300Scale of 3001 large square = 300 bpm
2 large squares = 150 bpm
3 large squares = 100 bpm
4 large squares = 75 bpm
5 large squares = 60 bpm
6 large squares = 50 bpm
1500 Rule1500 RuleCount number of small squares between 2
consecutive R waves and divide into 1500
A.K.A. – Precise Rate Calculation
• Most accurate
• Used only with regular rhythms
• Time-consuming
P WavesP Waves
• Upright
• Uniform
• Precedes each QRS complex
• Any extra P waves
PRIPRI
• Measure from beginning of P wave to the end of the PR
segment• 0.12 – 0.20 seconds
• Constant
QRS ComplexQRS Complex
• Measure from beginning to the end of QRS complex (1st deflection from
baseline after the PR segment to the beginning of the ST segment)
• 0.04 – 0.10 seconds
• Notched???, Wide, etc.
QT Interval or QTcQT Interval or QTc
• QT Interval = Count the # of small boxes from beginning QRS complex to the end of the T wave. Should be less than ½ the distance of the preceding
R-R interval
• QTc = QT + 1.75 (ventricular rate – 60)
Extras???Extras???
• P waves without QRS complexes
• ST-segment depression or elevation
ReferencesReferencesChernecky, C., et al. (2002). Real world nursing survival guide: ECG’s & the heart. United States
of America: W. B. Saunders Company.
Garcia, T. B., & Holtz, N. E. (2001). 12-lead ecg: The art of interpretation. Sudbury, MA: Jones and Bartlett Publishers.
Huff, J. (2006). ECG workout: Exercises in arrhythmia interpretation (5th ed.). United States of America: Lippincott, Williams & Wilkins.
Smeltzer, S. C., et al. (2008). Brunner and suddarth’s testbook of medical-surgical nursing, (11th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Walraven, G. (1999). Basic arrhythmias (5th ed.). United States of America: Prentice-Hall, Inc.
Woods, S. L., et al. (2005). Cardiac nursing, (5th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
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