ecg interpretation using the crisp method: a guide for · pdf filecontinuing education ecg...

CONTINUING EDUCATION

ECG Interpretation Using theCRISP Method A Guide forNurses 21 wwwaornorgCE

DENISE ATWOOD JD RN DIANA L WADLUNDMSN RN CRNFA ACNP-BC

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours are

available for this activity Earn the CE contact hours by readingthis article reviewing the purposegoal and objectives andcompleting the online Examination and Learner Evaluation athttpwwwaornorgCE A score of 70 correct on the exami-nation is required for credit Participants receive feedback onincorrect answers Each applicant who successfully completesthis program can immediately print a certificate of completion

Event 15543Session 1001Fee Members $1680 Nonmembers $3360

The contact hours for this article expire October 31 2018Pricing is subject to change

PurposeGoalTo provide the learner with knowledge specific to using theCRISP (Cardiac Rhythm Identification for Simple People)method to interpret electrocardiograms (ECGs)

Objectives1 Describe the electrical conduction system of the heart2 Identify the elements of an ECG3 Discuss important nursing assessments for a patient who

presents with a potential cardiac problem4 Explain the CRISP algorithm

AccreditationAORN is accredited as a provider of continuing nursingeducation by the American Nurses Credentialing CenterrsquosCommission on Accreditation

ApprovalsThis program meets criteria for CNOR and CRNFA recerti-fication as well as other CE requirements

AORN is provider-approved by the California Board ofRegistered Nursing Provider Number CEP 13019 Checkwith your state board of nursing for acceptance of this activityfor relicensure

Conflict-of-Interest DisclosuresDenise Atwood JD RN and Diana L Wadlund MSN RNCRNFA ACNP-BC have no declared affiliations that couldbe perceived as posing potential conflicts of interest in thepublication of this article

The behavioral objectives for this program were created byHelen Starbuck Pashley MA BSN CNOR clinical editorwith consultation from Susan Bakewell MS RN-BC directorPerioperative Education Ms Starbuck Pashley and Ms Bakewellhave no declared affiliations that could be perceived as posingpotential conflicts of interest in the publication of this article

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for thisarticle

DisclaimerAORN recognizes these activities as CE for RNs Thisrecognition does not imply that AORN or the AmericanNurses Credentialing Center approves or endorses productsmentioned in the activity

httpdxdoiorg101016jaorn201508004ordf AORN Inc 2015

396 j AORN Journal wwwaornjournalorg


DENISE ATWOOD JD RN DIANA L WADLUND MSN RN CRNFA ACNP-BC

ABSTRACTNurses often struggle with identifying electrocardiogram (ECG) rhythms but rapidly interpreting theserhythms is an essential skill that every nurse should master especially in the perioperative setting TheCRISP (Cardiac Rhythm Identification for Simple People) method is an algorithm designed to helpnurses rapidly interpret ECGs Key aspects of assisting patients with suspected cardiac issues includethe nursing assessment correct three-lead ECG placement and calculation of the heart rate Then theperioperative nurse can use the steps of the CRISP method to identify nursing actions related tospecific arrhythmias including determining whether QRS complexes are present P waves are presentand QRS complexes are wide or narrow or whether there are more P waves than QRS complexesAORN J 102 (October 2015) 397-405 ordf AORN Inc 2015 httpdxdoiorg101016jaorn201508004

Key words cardiac rhythms arrhythmias advanced cardiac life support ECG interpretation

Editorrsquos note The shaded portion of this article has beenreprinted with permission from Atwood D Using an algorithmto easily interpret basic cardiac rhythms AORN J200582(5)757-766 Copyright ordf 2005 AORN Inc 2170 SParker Road Suite 400 Denver CO 80231 All rights reserved

Every nurse should be able to recognize basicelectrocardiogram (ECG) rhythms such asnormal sinus rhythm sinus tachycardia atrial

fibrillation atrial flutter heart blocks ventricular fibrilla-tion and asystole To interpret basic ECG rhythms nursesmust understand the normal conduction pathways of theheart as well as the basic pathophysiology of abnormalrhythms This article presents an algorithm that isdesigned to help health care providers rapidly interpretprimary ECG rhythms Fred Killingbeck RN EMT-PCEN CCRN the creator of the algorithm describesthis as the CRISP (ie cardiac rhythm identification forsimple people) method of ECG interpretation

NORMAL PHYSIOLOGY OF CARDIACIMPULSE CONDUCTIONCardiac impulses are conducted through the conductionsystem which consists of the sinoatrial (SA) node atrioven-tricular (AV) junction and AV node bundle of His right andleft bundle branches and Purkinje fibers (Figure 1)1 Normalconduction of a cardiac impulse is generated in the SA nodelocated in the upper portion of the right atrium The SAnode is the natural pacemaker of the heart and it producesa heart rate between 60 and 100 beats per minute (bpm)The impulse spreads through the right and left atria via theinternodal pathways1 The impulse then travels to the AVjunction located in the lower portion of the right atriumThe impulse is delayed for 008 to 012 seconds in the AVjunction which gives the atria time to contract (iedepolarize) The AV node is located in the AV junction Ifthe SA node fails to function the AV node is the next inline in the conduction pathway and it takes over as theheartrsquos pacemaker The AV node produces a heart ratebetween 40 and 60 bpm1


wwwaornjournalorg AORN Journal j 397

The impulse spreads from the AV junction to the bundle

of His and down the interventricular septum The bundle

of His divides into the right and left bundle branches in

the ventricles which end in the Purkinje system (ie a

network of fibers that spread throughout both ventricles

and papillary muscles) The cardiac impulse terminates

with a contraction (ie ventricular depolarization) when

these fibers are stimulated by an impulse1

ELEMENTS OF AN ECGAn ECG gives a picture of the electrical activity that causes

the different parts of the heart to beat and relax An ECG

consists of segments or intervals (ie P wave PR interval

QRS complex ST segment T wave QT interval) that

help determine where an impulse was generated and assess

the length of time it takes an impulse to travel through the

heart (Figure 2)2

Atrial depolarization produces the P wave on an ECG The

presence of P waves indicates that impulses are being

generated in the SA node The PR interval represents the

amount of time the impulse takes to travel from the

beginning of atrial depolarization to the beginning of ven-

tricular depolarization The QRS complex correlates with

depolarization (ie contraction) of the ventricles The in-

terval from the end of ventricular depolarization to the

beginning of ventricular repolarization is represented by the

ST segment The T wave corresponds to repolarization of

the ventricles The total time for both ventricular depolar-

ization and repolarization is represented by the QT interval

NURSE ASSESSMENTWhen caring for a patient who is suspected of having a cardiacproblem the perioperative nurse must rapidly assess the pa-tient including checking the patientrsquos level of consciousnessvital signs skin color pain and temperature before beginninganalysis of a suspected ECG abnormality If the patient in-dicates that he or she is having chest pain the nurse must askthe patient to describe the chest pain Pain that is unrelentingand described as being sharp or radiating may indicateischemia (ie lack of blood and oxygen to the heart) and couldbe indicative of a myocardial infarct2 Exertion-induced painthat is relieved by rest is suggestive of angina and not amyocardial infarct2 Chest pain that gets worse when thepatient is supine and is relieved when the patient sits up andleans forward is indicative of pericarditis while chest pain

caused by coughing or deep inspiration is suggestive of chestwall and not cardiac pain2 A patient who reports a suddenonset of tearing or ripping pain may be experiencing adissecting aortic aneurysmda medical emergency2

When assessing a patient for cardiac problems it is importantfor the perioperative nurse to understand that womenrsquos cardiacsymptoms often differ from what men report3 For examplewomen may report vague nontypical symptoms such as

upper back or shoulder pain jaw pain or pain spreading to the jaw pressure or pain in the center of the chest lightheadedness pain that spreads to the arm unusual fatigue for several days sleep disturbances shortness of breath indigestion and anxiety3

Because their symptoms may not be those that are typicallyrecognized by the lay public as being classic heart attacksymptoms women are often reluctant to seek treatment orthey may delay treatment For this reason womenrsquos symptoms

printamp

web4C=FPO

Figure 1 Cardiac conduction pathways Reprinted withpermission from Atwood D Using an algorithm to easilyinterpret basic cardiac rhythms AORN J 200582(5)757-766 Copyrightordf 2005 AORN Inc 2170 S Parker RoadSuite 400 Denver CO 80231 All rights reserved

AtwooddWadlund October 2015 Vol 102 No 4


may have been present for as long as one month before theypresent for evaluation and their outcomes are worse thanmenrsquos One source reported that

Women suffering a heart attack were nearly twice as likely todie in the hospital compared to men with in-hospital deathsreported for 12 percent of women and 6 percent of men in thestudy Women were also less likely to undergo treatment to openclogged arteries which can be lifesaving when performed soonafter the heart attack starts4

CORRECT THREE-LEAD ECGPLACEMENTAfter performing a clinical assessment and to help ensure anaccurate ECG reading correct lead placement is requiredCorrect three-lead ECG placement can be accomplished ac-cording to the color of the lead or letters on the end of the leadThe white (RA) lead should be placed on the right side of thepatientrsquos chest below the clavicle and near the right arm Theblack (LA) lead is placed on the left side of the chest below theclavicle and near the left arm The ground (G) lead is placedmidline to the clavicle at about the fifth or sixth intercostalspace on the left chest If the nurse determines that the patientis stable he or she should rule out nonmedical explanations for

ECG irregularities (eg patient movement integrity of elec-trodes inappropriate placement of electrodes)2 If the nursedetermines that the patient is unstable he or she shouldinitiate advanced cardiac life support (ACLS)5

THE CRISP ALGORITHMTo become more skilled and better able to interpret the pa-tientrsquos ECG in an urgent situation the nurse can use ECGstrips to practice using the CRISP algorithm (Figure 3) tobecome proficient at identifying cardiac rhythms Using thismethod the nurse should calculate the heart rate and thenproceed to step 1 of the CRISP algorithm to beginidentifying the patientrsquos specific heart rhythm

Calculating Heart RateCardiac and ECG evaluation start with calculation of the heartrate Heart rates fit into three rate categories bradycardia (ieslower than 60 bpm) normal rate (ie 60 bpm to 100 bpm) andtachycardia (ie faster than 100 bpm)5 To calculate the heart ratethe nurse should count the number of QRS complexes in a six-second strip and then multiply that number by 10 (Figure 4)Rhythm strips are calibrated so that each small square equals004 second each large square equals 02 second and five largesquares equal one second6

Step 1dAre QRS Complexes PresentAfter the heart rate is calculated the nurse would begin usingthe algorithm at step 1 by asking ldquoAre QRS complexes pre-sentrdquo If the answer is ldquonordquo the rhythm is ventricular fibril-lation or asystole (Figure 5)

Ventricular fibrillation occurs when areas of normal myocar-dium in the ventricle alternate with areas of ischemic injuredor infarcted myocardium5 This causes a chaotic pattern ofventricular depolarization with ventricular fibrillation seenon an ECG as a wavy line

According to ACLS guidelines the pathophysiology of asystoleis ldquothe absence of electrical and mechanical activity in theheartrdquo5(p168) Asystole is characterized by a flat linedthat isno ventricular activity can be seen the PR interval cannotbe determined and no deflections (ie an R wave woulddeflect up and a Q wave would deflect down) consistentwith a QRS complex are seen If the answer to step 1 isldquoyesrdquo the nurse should proceed to step 2

Step 2dAre P Waves PresentIf QRS complexes are present the nurse should then ask ldquoAreP waves presentrdquo Based on the answer the nurse should thenprogress to step 3 of the algorithm

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Figure 2 Electrical activity results in contraction of theheart which appears on an electrocardiogram as thetracing shown in this figure Reprinted with permissionfrom Atwood D Using an algorithm to easily interpretbasic cardiac rhythms AORN J 200582(5)757-766Copyright ordf 2005 AORN Inc 2170 S Parker RoadSuite 400 Denver CO 80231 All rights reserved

October 2015 Vol 102 No 4 CRISP Method of ECG Interpretation


Figure 3 The CRISP (Cardiac Rhythm Identification for Simple People) algorithm



Step 3dNo P Waves Are Present Are theQRS Complexes Wide or NarrowIf the answer to step 2 is ldquonordquo and no P waves are present thenurse should ask ldquoAre the QRS complexes wide or narrowrdquoThe nurse can determine this by counting the average numberof small squares that the QRS complexes occupy on the ECGstrip A normal QRS complex should be less than three smallsquares wide After calculating the width the nurse can followthe algorithm to the appropriate answer (ie wide or narrow)

Wide QRS complexesIf the QRS complexes are equal to or wider than three smallsquares on the ECG strip the QRS complexes are consideredto be wide The nurse should then determine the rate of therhythm One of three rhythms will be present depending onthe heart rate documented in the rhythm strip

idioventriculardslower than 40 bpm accelerated ventriculard40 bpm to 100 bpm or ventricular tachycardiadfaster than 100 bpm (Figure 6)

Narrow QRS complexesIf the QRS complexes are narrow (ie narrower than threesmall squares on the ECG strip) one of three rhythms will bepresent atrial fibrillation atrial flutter or supraventriculartachycardia (Figure 7)5 In atrial fibrillation and atrial flutterthe atrial impulses are faster than the SA node impulses

Atrial fibrillationdimpulses take multiple chaotic randompathways through the atria This results in an irregularrhythm

Figure 4 A six-second rhythm strip is used to calculateheart rates and identify rhythms Reprinted withpermission from Atwood D Using an algorithm toeasily interpret basic cardiac rhythms AORN J200582(5)757-766 Copyright ordf 2005 AORN Inc2170 S Parker Road Suite 400 Denver CO 80231 Allrights reserved

Figure 5 Ventricular fibrillation (a) and asystole (b)Reprinted with permission from Atwood D Using analgorithm to easily interpret basic cardiac rhythmsAORN J 200582(5)757-766 Copyright ordf 2005AORN Inc 2170 S Parker Road Suite 400 DenverCO 80231 All rights reserved

Figure 6 Idioventricular tachycardia (a) acceleratedventricular tachycardia (b) and ventricular tachycardia (c)Reprinted with permission from Atwood D Using an al-gorithm to easily interpret basic cardiac rhythms AORNJ 200582(5)757-766 Copyright ordf 2005 AORN Inc2170 S Parker Road Suite 400 Denver CO 80231 Allrights reserved

Figure 7 Atrial fibrillation (a) atrial flutter (b) andparoxysmal (ie sudden onset) supraventricular tachy-cardia (c) Reprinted with permission from Atwood DUsing an algorithm to easily interpret basic cardiacrhythms AORN J 200582(5)757-766 Copyright ordf2005 AORN Inc 2170 S Parker Road Suite 400Denver CO 80231 All rights reserved



Atrial flutterdimpulses take a circular course around the atriaThis is characterized by flutter-shaped (ie saw-tooth) waves

Supraventricular (ie atrialdliterally above the ventricles)tachycardiadimpulses from the atria to the ventricles aredisrupted and reentry occurs This results in a rapid (iefaster than 150 bpm) narrow QRS complex rhythm

Step 3dP Waves Are Present Are ThereMore P Waves Than QRS ComplexesIf P waves are present the nurse should ask ldquoAre there more Pwaves than QRS complexesrdquo The nurse then should followthe algorithm to the appropriate answer

NoIf every P wave is followed by a QRS complex sinus rhythm ispresent Sinus rhythms all have normal impulse formation andconduction and the impulses originate at the SA node5 Sinusbradycardia and sinus tachycardia are not abnormal rhythmsbut their impulses are conducted at a slower or faster ratethan normal These rhythms are physical signs (eg minorpalpitations hyperthermia hypovolemia) rather than apathological condition The specific type of sinus rhythmcan be identified by determining the heart rate

sinus bradycardiadslower than 60 bpm normal sinus rhythmd60 bpm to 100 bpm or sinus tachycardiadfaster than 100 bpm (Figure 8)

One type of sinus bradycardia is first-degree AV block inwhich a delay in conduction of the atrial impulse to theventricles occurs resulting in prolongation of the PR intervalto more than 02 second In first-degree AV block a QRScomplex follows each P wave and the PR interval remainsconstant

YesIf more P waves are present than QRS complexes the rhythmis because of a conduction block (ie second-degree AV blocktype I second-degree AV block type II third-degree AV block[Figure 9]) The number of P waves must be compared withthe number of QRS complexes

Second-degree AV block type Idthe pathophysiology ofsecond-degree heart block type I also known as Mobitz typeI or Wenckebach originates in the AV node Impulseconduction is increasingly slowed at the AV node causingthe PR intervals to lengthen progressively until one P wave isnot followed by a QRS complex This rhythm is irregular5

The nurse should think of a type I or Wenckebach as theblock with the lengthening PR interval A simplemnemonic device to help in remembering this is as follows

I frac14 Lengthening PR interval

Figure 8 Sinus bradycardia (a) normal sinus rhythm(b) sinus tachycardia (c) and first-degree atrioventric-ular block (d) Reprinted with permission from AtwoodD Using an algorithm to easily interpret basic cardiacrhythms AORN J 200582(5)757-766 Copyright ordf2005 AORN Inc 2170 S Parker Road Suite 400Denver CO 80231 All rights reserved

Figure 9 Second-degree atrioventricular (AV) blocktype I (a) second-degree AV block type II (b) andthird-degree AV block (c) Reprinted with permissionfrom Atwood D Using an algorithm to easily interpretbasic cardiac rhythms AORN J 200582(5)757-766Copyright ordf 2005 AORN Inc 2170 S Parker RoadSuite 400 Denver CO 80231 All rights reserved



Second-degree AV block type IIdthe pathophysiology of asecond-degree AV heart block type II also known as Mobitztype II or non-Wenckebach is at the site of the block andmost often is below the AV node (ie infranodal) Impulseconduction is normal through the node thus no first-degreeblock and no previous PR prolongation occur on the ECGAs a result the PR interval is constant with conducted beatsbut some P waves will be present without a QRS complexThis rhythm is irregular5 The nurse should think of thetype II block as having equal PR intervals but the QRScomplexes drop (ie the impulse is not conducted to theventricles so they do not contract)

II frac14 PR intervals with dropped QRS complexes

Third-degree AV blockdthe primary pathophysiology inthird-degree AV heart block is AV dissociation Injury ordamage to the cardiac conduction system has occurred sothat no impulses pass between the atria and ventricles (iecomplete block) This rhythm is regular5 The nurse shouldthink of a third-degree block as a dysfunction of the heart inwhich the atria and ventricles do not associate with oneanother so they beat independently and do notcommunicate with each other

III frac14 Do not look at or talk to each other

CASE STUDY ONEA 16-year-old girl arrives in the OR to undergo an appen-dectomy She is healthy with no medical history She does nottake any medications on a regular basis but she received 1 mgof hydromorphone by IV in the emergency department lessthan an hour earlier Her ECG strip is presented (Figure 10)To interpret the patientrsquos ECG the nurse asks and answers thefollowing questions

1 Are QRS complexes present Yes2 Are P waves present Yes3 Are there more P waves than QRS complexes No4 What is the heart rate 70 bpm (ie count the number of

QRS complexes in a six-second strip and multiply by 10)5 What is the rhythm Normal sinus rhythm6 What is appropriate treatment for this patient

Normal sinus rhythm and a heart rate of 70 bpm is anormal finding in a 16-year-old girl No treatment isnecessary

CASE STUDY TWOA 36-year-old woman presents to the OR for removal of abenign breast mass The physician injects 25 mL of lidocaine1 with epinephrine 1100000 He then makes a 3-cmincision into her breast and begins to remove the mass Fiveminutes into the surgery the nurse reviews the patientrsquos ECGstrip (Figure 11) To interpret the patientrsquos ECG the nurseasks and answers the following questions

1 Are QRS complexes present Yes2 Are P waves present Yes3 Are there more P waves than QRS complexes No4 What is the heart rate 120 bpm to 124 bpm5 What is the rhythm Sinus tachycardia6 What is appropriate treatment for this patient The

anesthesia professional notes that the patient isadequately sedated The surgeon observes that tachy-cardia could have resulted from the injection ofthe lidocaine with epinephrine The anesthesia profes-sional administers a bolus of 1 mgkg of esmolol over 30seconds Esmolol is an IV beta-blocker medicationeffective in the treatment of sinus tachycardia The sur-geon is able to conclude the procedure without furtherincidents

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Figure 10 Rhythm strip for a 16-year-old girl whopresents with normal sinus rhythm and a heart rate of70 beats per minute Reprinted with permission fromAtwood D Using an algorithm to easily interpret basiccardiac rhythms AORN J 200582(5)757-766 Copy-right ordf 2005 AORN Inc 2170 S Parker Road Suite400 Denver CO 80231 All rights reserved

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Figure 11 Rhythm strip for a 36-year-old woman whopresents for removal of a benign breast mass and ex-hibits tachycardia after an injection of lidocaine withepinephrine Reprinted with permission from Atwood DUsing an algorithm to easily interpret basic cardiacrhythms AORN J 200582(5)757-766 Copyright ordf2005 AORN Inc 2170 S Parker Road Suite 400Denver CO 80231 All rights reserved



CASE STUDY THREEA 70-year-old man has just undergone a repair of anabdominal aortic aneurysm He is transferred to the post-anesthesia care unit in stable condition with a pulse of 110bpm and a blood pressure of 9050 mm Hg As the post-anesthesia care unit RN is talking to him the patient becomesunresponsive and his ECG strip changes (Figure 12) Tointerpret the patientrsquos ECG the nurse asks and answers thefollowing questions

1 Are QRS complexes present Yes2 Are P waves present No3 Are the QRS complexes wide or narrow Wide4 What is the heart rate 27 bpm5 What is the rhythm Idioventriculardbecause the

patient is pulseless he is considered to be in pulselesselectrical activity (PEA) which means that even thougha rhythm is present on the monitor no pulse isdetected

6 What is appropriate treatment for this patient Thenurse starts with the CABs of resuscitation (iecompression airway breathing) by assessing and man-aging the patientrsquos circulation airway and breathingThe nurse notifies the surgeon or anesthesia profes-sional initiates an arrest announcement and startscardiopulmonary resuscitation (CPR) because the pa-tient has no pulse and is unresponsive The nurse alsoadministers a fluid bolus because hypovolemia is acommon cause of PEA The nurse should assess thepatient for other causes of PEA (eg severe prolongedhypoxia or acidosis flow-restricting pulmonaryembolus) if the fluid bolus does not correct the PEA7

In this case the team determines that the patient hashypokalemia and administers IV potassium afterwhich the patientrsquos PEA resolves

CASE STUDY FOURA 23-year-old man is brought emergently to the OR followinga gunshot wound to the left chest His blood pressure onarrival is 400 mm Hg and a rapid infuser device administers afourth unit of packed red blood cells The trauma surgeonmakes a thoracotomy incision and suctions 2000 mL of bloodfrom the left chest The surgeon discovers that a 25-cm holehas occurred in the patientrsquos left ventricle As the surgeon issewing the hole in the left ventricle the ECG changes(Figure 13) To interpret the patientrsquos ECG the nurse asksand answers the following questions

1 Are QRS complexes present No2 Does the rhythm appear wavy or flat Flat3 What is the rhythm Asystole4 What is appropriate treatment for this patient The

nurse calls for additional help and requests that additionaltype O-negative blood be brought to the room while sheretrieves the crash cart The surgeon provides internalcardiac massage while awaiting arrival of the crash cartThe anesthesia professional begins to administer blood assoon as it is brought to the room The RN circulatorassigns a nurse to document activities and assigns anothernurse to run the defibrillator The surgeon follows ACLSguidelines for asystole ordering atropine to be adminis-tered followed by epinephrine Resuscitative efforts areunsuccessful and 35 minutes after resuscitation beganthe surgeon pronounces the patient dead

CONCLUSIONPerioperative nurses may not perform ECG interpretation on adaily basis however the ability to identify ECG rhythms andunderstand how they relate to the electrical function of theheart and the implications for patients are valuable skills for allnurses8 The techniques described in this article allow

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Figure 12 Rhythm strip for a 70-year-old man whounderwent repair of an abdominal aortic aneurysm andexhibits idioventricular rhythm Reprinted withpermission from Atwood D Using an algorithm toeasily interpret basic cardiac rhythms AORN J200582(5)757-766 Copyright ordf 2005 AORN Inc2170 S Parker Road Suite 400 Denver CO 80231 Allrights reserved

printampweb4C=FPO

Figure 13 Rhythm strip for a 23-year-old man who hada gunshot wound and exhibits asystole Reprinted withpermission from Atwood D Using an algorithm toeasily interpret basic cardiac rhythms AORN J200582(5)757-766 Copyright ordf 2005 AORN Inc2170 S Parker Road Suite 400 Denver CO 80231 Allrights reserved



perioperative nurses to begin recognizing basic cardiac rhythmsbut perioperative nurses should access books on this topic tounderstand this complex process and make it moremanageable for the novice ECG interpreter Countless coursesalso are available that can be taken in person or online (seeResources) to help perioperative nurses become more familiarand comfortable with the skill of ECG interpretationPerioperative managers are responsible for ensuring thatnurses are competent to interpret ECGs and to respondappropriately to the identified arrhythmias Providingsimulation exercises is an excellent way for perioperativemanagers to both educate their perioperative nurses and tovalidate competency in ECG interpretation The mostimportant learning tool is constant practice Perioperativenurses should print ECG strips and use the CRISP algorithmto guide them in interpreting the rhythm Nurses also shouldtap into the expertise of seasoned nurses to obtain feedbackon any suspected arrhythmia and its treatment options Witheducation and practice basic ECG interpretation can becomesecond nature to perioperative nurses Acknowledgment The authors thank Fred Killingbeck RNEMT-P CEN CCRN Wittmann Arizona for providing thecardiac rhythm algorithm andGWare EMT and L Rider EMTfirefighters with the Glendale Fire Departmentrsquos MEDIC 155Glendale Arizona for providing ECG strips used in this article

References1 Mirvis DM Goldberger AL Electrocardiography In Mann DL

Zipes DP Libby P Bonow RO Braunwald E eds Braunwaldrsquos HeartDisease A Textbook of Cardiovascular Medicine 10th ed Phila-delphia PA Elsevier Saunders 2015114-152

2 Nettina SM Cardiovascular function and therapy In LippincottManual of Nursing Practice 10th ed Philadelphia PA WoltersKluwer HealthLippincott Williams amp Wilkins 2014324-379

3 What are the symptoms of a heart attack The Cleveland Clinichttpmyclevelandclinicorgservicesheartdisorderscoronary-artery-diseasehic_Heart_Attackmi_symptoms Accessed July 1 2015

4 Women donrsquot get to hospital fast enough during heart attack Studyfinds pre-hospital delays linked to more deaths among women

American College of Cardiology httpwwwaccorgabout-accpress-releases201503051633women-dont-get-to-hospital-fast-enough-during-heart-attack Published March 5 2015 AccessedAugust 31 2015

5 Categories of arrhythmias Texas Heart Institute httpwwwtexasheartorgHICTopicsCondarrhycatcfm Accessed September4 2015

6 Understanding EKGs Geeky Medics httpgeekymedicscom20110305understanding-an-ecg Accessed July 8 2015

7 Pulseless electrical activity etiology Medscape httpemedicinemedscapecomarticle161080-overviewa5 Accessed July 172015

8 Landrum MA Fast Facts About EKGs for Nurses The Rules ofIdentifying EKGs in a Nutshell New York NY Springer PublishingCompany LLC 2014

ResourcesAehlert BJ ECGs Made Easy 5th ed Philadelphia PA Elsevier HealthSciences 2015

Ashley EA Niebauer J Conquering the ECG In Cardiology ExplainedLondon England Remedica 2004

ECG Mastery Program MedMasterycom httpwwwmedmasterycomcourseecggclidfrac14CMXOmPjo4MYCFchffgodsHkOVw

Kusumoto FM ECG Interpretation From Pathophysiology to ClinicalApplication New York NY Springer Science amp Business Media2009

Learn to read electrocardiograms ECG Academycom httpwwwecgacademycomgclidfrac14CJOb2-Ho4MYCFc5lfgodjbkIGA

Denise Atwood JD RN is a vice president of hos-pital operations at Maricopa Integrated Health SystemPhoenix AZ Ms Atwood has no declared affiliation thatcould be perceived as posing a potential conflict of in-terest in the publication of this article

Diana L Wadlund MSN RN CRNFA ACNP-BC isan acute care nurse practitioner with the general surgeryand trauma services at Paoli Hospital Paoli PAMs Wadlund has no declared affiliation that could beperceived as posing a potential conflict of interest in thepublication of this article



EXAMINATION

Continuing EducationECG Interpretation Using theCRISP Method A Guide forNurses 21 wwwaornorgCE

PURPOSEGOALTo provide the learner with knowledge specific to using the CRISP (Cardiac Rhythm Identification forSimple People) method to interpret electrocardiograms (ECGs)

OBJECTIVES1 Describe the electrical conduction system of the heart2 Identify the elements of an ECG3 Discuss important nursing assessments for a patient who presents with a potential cardiac problem4 Explain the CRISP algorithm

The Examination and Learner Evaluation are printed here for your convenience To receivecontinuing education credit you must complete the online Examination and Learner Evaluationat httpwwwaornorgCE

QUESTIONS1 The cardiac conduction system consists of the

1 sinoatrial (SA) node2 atrioventricular (AV) junction3 bundle of His4 right and left bundle branches5 Purkinje fibers6 AV node

a 1 3 and 5 b 2 4 and 6c 2 3 5 and 6 d 1 2 3 4 5 and 6

2 The SA node is the natural pacemaker of the heart and itproduces a heart rate between 60 and 100 beats perminute (bpm)a true b false

3 The cardiac impulse terminates with1 a contraction2 relaxation3 ventricular repolarization

4 ventricular depolarizationa 1 and 4 b 2 and 4c 1 2 and 4 d 1 2 3 and 4

4 The segments or intervals on an ECG help determine1 level of consciousness2 where an impulse was generated3 where the impulse goes when the cycle is complete4 the time it takes an impulse to travel through the

hearta 1 and 3 b 2 and 4c 1 2 and 4 d 1 2 3 and 4

5 The presence of _____ indicates that impulses are beinggenerated in the SA node and the _____ represents theamount of time the impulse takes to travel from thebeginning of atrial depolarization to the beginning ofventricular depolarizationa T wavesST segment b P wavesQRS complexc P wavesPR interval d QRS complexesT wave


6 If a patient is having chest pain that is unrelenting and isdescribed as sharp or radiating this could be indicative ofa a dissecting aortic aneurysm b a myocardial infarctionc angina d pericarditis

7 Chest pain that gets worse when the patient is supine andis relieved when the patient sits up and leans forward isindicative ofa chest wall pain b a myocardial infarctionc angina d pericarditis

8 In comparison with men women may report vaguenontypical symptoms such as1 back shoulder or jaw pain2 lightheadedness3 unusual fatigue for several days4 sleep disturbances5 shortness of breath

6 anxietya 1 3 and 5 b 2 4 and 6c 2 3 5 and 6 d 1 2 3 4 5 and 6

9 Cardiac and ECG evaluation starts with the calculation ofa the QRS complex b the heart ratec the respiratory rate d the QT interval

10 When interpreting an ECG the CRISP method requiresanswers to questions including1 Are QRS complexes present2 Are P waves present3 Are there more P waves than QRS complexes4 What is the heart rate5 What is the rhythm6 What type of pain is the patient experiencing

a 1 3 and 5 b 2 4 and 6c 1 2 3 4 and 5 d 1 2 3 4 5 and 6



LEARNER EVALUATION


This evaluation is used to determine the extent towhich this continuing education programmet yourlearning needs The evaluation is printed here for

your convenience To receive continuing education credit youmust complete the online Examination and Learner Evaluationat httpwwwaornorgCE Rate the items as described below

OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved1 Describe the electrical conduction system of the heart

Low 1 2 3 4 5 High

2 Identify the elements of an ECGLow 1 2 3 4 5 High

3 Discuss important nursing assessments for a patient whopresents with a potential cardiac problemLow 1 2 3 4 5 High

4 Explain the CRISP algorithmLow 1 2 3 4 5 High

CONTENT5 To what extent did this article increase your knowledge of

the subject matterLow 1 2 3 4 5 High

6 To what extent were your individual objectives metLow 1 2 3 4 5 High

7 Will you be able to use the information from this article inyour work setting1 Yes 2 No

8 Will you change your practice as a result of reading thisarticle (If yes answer question 8A If no answerquestion 8B)

8A How will you change your practice (Select all thatapply)1 I will provide education to my team regarding why

change is needed2 I will work with management to changeimplement

a policy and procedure3 I will plan an informational meeting with physicians

to seek their input and acceptance of the need forchange

4 I will implement change and evaluate the effect ofthe change at regular intervals until the change isincorporated as best practice

5 Other __________________________________

8B If you will not change your practice as a result ofreading this article why (Select all that apply)1 The content of the article is not relevant to my

practice2 I do not have enough time to teach others about the

purpose of the needed change3 I do not have management support to make a

change4 Other __________________________________

9 Our accrediting body requires that we verify the timeyou needed to complete the 21 continuing educationcontact hour (126-minute) program ______________



DENISE ATWOOD JD RN DIANA L WADLUND MSN RN CRNFA ACNP-BC

ABSTRACTNurses often struggle with identifying electrocardiogram (ECG) rhythms but rapidly interpreting theserhythms is an essential skill that every nurse should master especially in the perioperative setting TheCRISP (Cardiac Rhythm Identification for Simple People) method is an algorithm designed to helpnurses rapidly interpret ECGs Key aspects of assisting patients with suspected cardiac issues includethe nursing assessment correct three-lead ECG placement and calculation of the heart rate Then theperioperative nurse can use the steps of the CRISP method to identify nursing actions related tospecific arrhythmias including determining whether QRS complexes are present P waves are presentand QRS complexes are wide or narrow or whether there are more P waves than QRS complexesAORN J 102 (October 2015) 397-405 ordf AORN Inc 2015 httpdxdoiorg101016jaorn201508004

Key words cardiac rhythms arrhythmias advanced cardiac life support ECG interpretation

Editorrsquos note The shaded portion of this article has beenreprinted with permission from Atwood D Using an algorithmto easily interpret basic cardiac rhythms AORN J200582(5)757-766 Copyright ordf 2005 AORN Inc 2170 SParker Road Suite 400 Denver CO 80231 All rights reserved

Every nurse should be able to recognize basicelectrocardiogram (ECG) rhythms such asnormal sinus rhythm sinus tachycardia atrial

fibrillation atrial flutter heart blocks ventricular fibrilla-tion and asystole To interpret basic ECG rhythms nursesmust understand the normal conduction pathways of theheart as well as the basic pathophysiology of abnormalrhythms This article presents an algorithm that isdesigned to help health care providers rapidly interpretprimary ECG rhythms Fred Killingbeck RN EMT-PCEN CCRN the creator of the algorithm describesthis as the CRISP (ie cardiac rhythm identification forsimple people) method of ECG interpretation

NORMAL PHYSIOLOGY OF CARDIACIMPULSE CONDUCTIONCardiac impulses are conducted through the conductionsystem which consists of the sinoatrial (SA) node atrioven-tricular (AV) junction and AV node bundle of His right andleft bundle branches and Purkinje fibers (Figure 1)1 Normalconduction of a cardiac impulse is generated in the SA nodelocated in the upper portion of the right atrium The SAnode is the natural pacemaker of the heart and it producesa heart rate between 60 and 100 beats per minute (bpm)The impulse spreads through the right and left atria via theinternodal pathways1 The impulse then travels to the AVjunction located in the lower portion of the right atriumThe impulse is delayed for 008 to 012 seconds in the AVjunction which gives the atria time to contract (iedepolarize) The AV node is located in the AV junction Ifthe SA node fails to function the AV node is the next inline in the conduction pathway and it takes over as theheartrsquos pacemaker The AV node produces a heart ratebetween 40 and 60 bpm1

















heart (Figure 2)2


















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