lake ems basic ekg review: ventricular rhythms · process of 5-steps that help define the rhythm...
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Lake EMS Basic EKG Review:Ventricular Rhythms
The Lake EMSQuality Development Team
This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]
The challenge With respect to the many revered instructors and
authors who teach electrocardiology rhythm assessment, there are many differences in opinion regarding things such as heart rates for rhythms So we defined our own parameters with the blessings of the
Lake County Medical Director, Pushpal R. Banerjee, D.O.
Our solution Consequently, our Basic EKG Online review meets the
criteria as set forth by our Quality Development Department: John Simpson, Chief Operations Officer Michael R. (Mike) Hilliard, Training Officer Jamie A. Lowery, District Chief, Field Training Coordinator Scott Temple, Clinical Training Officer Julie Treadwell, Clinical Quality Officer
And our Medical Director: Pushpal R. (Paul) Banerjee, D.O.
Basic stuff When electricity stimulates muscle we witness
depolarization This is an electrical phenomenon We hope mechanically that the muscle contracts
When a muscle relaxes we see repolarization on the monitor If the muscle mass is large enough
“Hey, that looks like…” Many of us were taught
how to visually recognize EKGs
We were taught a simple process of 5-steps that help define the rhythm characteristics; however, over time we returned to the visual recognition
Basic wave breakdown Please understand this is an interpretation
review, not a diagnostic patient assessment Always treat the patient and not the monitor
P-wave: Atrial depolarization QRS-complex: Ventricular depolarization T-wave: Ventricular repolarization
1st Axiom of EMS And if you forget to treat the patient and are
considering treating the monitor, remember the first axiom of EMS:
1st Axiom of EMS And if you forget to treat the patient and are
considering treating the monitor, remember the first axiom of EMS: If you’re not sure what to do,
1st Axiom of EMS And if you forget to treat the patient and are
considering treating the monitor, remember the first axiom of EMS: If you’re not sure what to do, ask your EMT what the
other paramedics would do in a similar situation.
5-Part EKG AssessmentYour key to success
1. Rate: QRS in 6-second strip, multiply x 10
2. Rhythm: QRS distances consistent throughout strip
3. P-waves (in the entire strip being assessed): Are P-waves present? Do they look like a small rounded hill? Is there a P for every QRS? Is there a QRS for every P? Does each P looks like all the others? Is each P the same distance from the QRS?
4. P to R Interval (PRI): 0.12 to 0.20 seconds
5. QRS-Complexes: Narrow: <0.12-seconds (3 small boxes) Wide: >0.12-seconds
12
Ventricular Rhythms
Idioventricular A slow rhythm that originates in the ventricles Idioventricular is slow and wide!
Automaticity and Inherent Myocardial Cell Firings Remember the initiated heart rate from the
Ventricles is a back-up system; it is here to keep us alive: SA Node: 60-150 bpm (beats-per-minute) AV Junction: 40-60 bpm Ventricles: 30-40 bpm
These are normal values, other rates can and do occur at times
Idioventricular1. Rate:2. Rhythm:
3. P-waves:4. PRI:5. QRS:
< 60 bpm Usually regular, but can be
irregular None None Wide
Idioventricular
5-Part EKG Assessment1. Rate:
What is the rate?
5-Part EKG Assessment1. Rate:
30-bpm
5-Part EKG Assessment2. Rhythm:
Is the rhythm regular or irregular?
5-Part EKG Assessment2. Rhythm:
Regular
5-Part EKG Assessment3. P-waves:
Are P-waves present? Do they look like a small
rounded hill? Is there a P for every
QRS?
Is there a QRS for every P? Does each P looks like all the
others? Is each P the same distance
from the QRS?
5-Part EKG Assessment3. P-waves:
P-waves? No
5-Part EKG Assessment4. P to R Interval (PRI):
Is the PRI between 3-5 small boxes?
5-Part EKG Assessment4. P to R Interval (PRI):
No P-wave; no PRI
5-Part EKG Assessment5. QRS-Complexes:
Is QRS narrow or wide?
5-Part EKG Assessment5. QRS-Complexes:
Wide, 0.16-seconds
This is Idioventricular 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
30 Regular None None Wide
Ventricular Tachycardia Ventricular Tachycardia (VT) is defined as three
or more beats of ventricular origin in succession at a rate greater than 150 beats per minute
Morphology QRS complexes are wide The T-wave is commonly in the opposite
direction as the QRS
Morphology QRS complexes are wide The T-wave is commonly in the opposite
direction as the QRS Termed contralateral
Ventricular Tachycardia Ventricular tachycardia may be either:
Monomorphic (all QRS-complexes with the same shape), or
Polymorphic (varying QRS shapes) Regardless: VT is fast and wide!
Ventricular Tachycardia1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
> 150 bpm Usually regular None None Wide
Ventricular Tachycardia
5-Part EKG Assessment1. Rate:
What is the rate?
5-Part EKG Assessment1. Rate:
210-bpm
5-Part EKG Assessment2. Rhythm:
Is the rhythm regular or irregular?
5-Part EKG Assessment2. Rhythm:
Regular
5-Part EKG Assessment3. P-waves:
Are P-waves present? Do they look like a small
rounded hill? Is there a P for every
QRS?
Is there a QRS for every P? Does each P looks like all the
others? Is each P the same distance
from the QRS?
5-Part EKG Assessment3. P-waves:
P-waves? No
5-Part EKG Assessment4. P to R Interval (PRI):
Is the PRI between 3-5 small boxes?
5-Part EKG Assessment4. P to R Interval (PRI):
No P-wave; no PRI
5-Part EKG Assessment5. QRS-Complexes:
Is QRS narrow or wide?
5-Part EKG Assessment5. QRS-Complexes:
Wide, 0.16-seconds
This is Ventricular Tachycardia1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
210 Regular None None Wide
Ventricular Tachycardia And what should you immediately do after
seeing VT?
Ventricular Tachycardia 12-Lead?
Ventricular Tachycardia 12-Lead? No
Assess patient If stable, consider medication as per Practice
Parameters
Assess patient If stable, consider medication as per Practice
Parameters If unstable
Tincture of Florida Power
Torsades de Pointes Torsades de Pointes is a form of polymorphic VT
(varying QRS shapes) in which the QRS appears to be constantly changing
VT is fast and wide!
Torsades de Pointes1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
> 150 bpm Usually regular None None Wide and varying QRS shapes
Torsades de Pointes
5-Part EKG Assessment1. Rate:
What is the rate?
5-Part EKG Assessment1. Rate:
200-bpm
5-Part EKG Assessment2. Rhythm:
Is the rhythm regular or irregular?
5-Part EKG Assessment2. Rhythm:
Regular; no matter how you look at it
5-Part EKG Assessment3. P-waves:
Are P-waves present? Do they look like a small
rounded hill? Is there a P for every
QRS?
Is there a QRS for every P? Does each P looks like all the
others? Is each P the same distance
from the QRS?
5-Part EKG Assessment3. P-waves:
P-waves? No
5-Part EKG Assessment4. P to R Interval (PRI):
Is the PRI between 3-5 small boxes?
5-Part EKG Assessment4. P to R Interval (PRI):
No P-wave; no PRI
5-Part EKG Assessment5. QRS-Complexes:
Is QRS narrow or wide?
5-Part EKG Assessment5. QRS-Complexes:
Wide, 0.20-seconds
5-Part EKG Assessment5. QRS-Complexes:
Wide, 0.20-seconds And varying shapes
This is Torsades de Pointes1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
200 Regular None None Wide and varying shapes
Cardiac Arrest Patients in cardiac arrest are classified as
being in 3-categories:1. Ventricular fibrillation2. Pulseless Electrical Activity3. Asystole
Ventricular Fibrillation It is a rhythm in which multiple areas within the
ventricles vary in depolarization and repolarization
There is no cardiac output This is the most common initial rhythm in cardiac
arrest
Ventricular Fibrillation The terms coarse and fine have been used to
describe the amplitude of the waveforms in VF Coarse VF usually indicates the recent onset of
VF, which can be readily corrected by prompt defibrillation
Ventricular Fibrillation1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
None None None None None
Ventricular Fibrillation
Ventricular Fibrillation And what should you immediately do after
seeing VF?
Shock it until you recognize it!
Crew accidently found patient in rhythm and brought them back after a few shocks and subsequent treatments
Great Job!
5-Part EKG Assessment1. Rate:
What is the rate?
5-Part EKG Assessment1. Rate:
None
5-Part EKG Assessment2. Rhythm:
Is the rhythm regular or irregular?
5-Part EKG Assessment2. Rhythm:
None
5-Part EKG Assessment3. P-waves:
5-Part EKG Assessment3. P-waves:
P-waves? None
5-Part EKG Assessment4. P to R Interval (PRI):
Is the PRI between 3-5 small boxes?
5-Part EKG Assessment4. P to R Interval (PRI):
None
5-Part EKG Assessment5. QRS-Complexes:
Is QRS narrow or wide?
5-Part EKG Assessment5. QRS-Complexes:
None
This is Ventricular Fibrillation1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
None, wavy line None None None None
Pulseless Electrical Activity PEA is any rhythm (with a QRS) without a pulse Any rhythm can be categorized as PEA
However, if pulseless VT, treat as VF There is no pulse in PEA!
Pulseless Electrical Activity
PEA usually looks like this
Asystole (Cardiac Standstill) Asystole represents the total absence of
electrical activity Since depolarization does not occur, there is no
ventricular contraction
Asystole (Cardiac Standstill) 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
None None None None None
Asystole
5-Part EKG Assessment1. Rate:
What is the rate?
5-Part EKG Assessment1. Rate:
None
5-Part EKG Assessment2. Rhythm:
Is the rhythm regular or irregular?
5-Part EKG Assessment2. Rhythm:
None
5-Part EKG Assessment3. P-waves:
5-Part EKG Assessment3. P-waves:
P-waves? None
5-Part EKG Assessment4. P to R Interval (PRI):
Is the PRI between 3-5 small boxes?
5-Part EKG Assessment4. P to R Interval (PRI):
None
5-Part EKG Assessment5. QRS-Complexes:
Is QRS narrow or wide?
5-Part EKG Assessment5. QRS-Complexes:
None
This is Asystole 1. Rate:2. Rhythm:3. P-waves:4. PRI:5. QRS:
None None None None None
Pacer Rhythms Pacers provide a low energy burst of electricity
that can be identified on the EKG by a pacer spike
Pacer Rhythms
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Look for the pacer spikes
Pacer Rhythms Or the friendly reminders to look for pacer
spikes
Ectopi A beat originating from a source of cardiac
stimulus other than the SA node
Ectopi A beat originating from a source of cardiac
stimulus other than the SA node, usually caused by some irritation of the myocardium
Premature VentricularContraction (PVC) A PVC is a depolarization that arises in either
ventricle before the next expected beat This results in a bizarre-appearing QRS
The sequence of repolarization is also altered, usually resulting in a ST segment and T wave in a direction opposite to the QRS complex
PVCs PVCs have 3 primary hallmarks:
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Wide
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide
3. Compensatory Pause: Yes
PVCs PVCs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Wide Because the beat is generated in the ventricles, it is wide
3. Compensatory Pause: Yes Let me explain
PVCs Regularity:
PVCs Regularity: Irregular
≠
PVCs Regularity: Irregular QRS Complex:
PVCs Regularity: Irregular QRS Complex: Wide
PVCs Regularity: Irregular QRS Complex: Wide Compensatory Pause:
PVCs Regularity: Irregular QRS Complex: Wide Compensatory Pause: Yes
Compensatory/Non-Compensatory Pause Measure the distance between 3 normal/regular
QRSs Compare the distance between the normal QRS
before and after the beat in question If the distance is the same there is a compensatory
pause If the distance is not the same, there is no
compensatory pause
PVCs Measure distance between 3 normal QRS-
waves
PVCs Measure distance between 3 normal QRS-
waves
PVCs This distance is our standard measurement
PVCs This distance is our standard measurement It can only be measured with regular complexes
PVCs This distance is our standard
If a funny looking beat does not disturb this rhythm tempo then it is said to have a compensatory pause
PVCs Good, now identify the normal QRS-waves
before and after the funny looking beat
PVCs Now measure the distance and compare to the
original measurement
PVCs The distance is the same
PVCs So we have a compensatory pause
Compensatory pause
PVCs So we have a compensatory pause So this is a PVC because it is wide and has the
compensatory pause
Compensatory pause
Significance of compensatory pause When an electrical discharge occurs within the
ventricles, it depolarizes all of the other cells in both ventricles
Significance of compensatory pause When an electrical discharge occurs within the
ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems
Significance of compensatory pause When an electrical discharge occurs within the
ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them
Significance of compensatory pause When an electrical discharge occurs within the
ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them So the timing is unchanged
Significance of compensatory pause When an electrical discharge occurs within the
ventricles, it depolarizes all of the other cells in both ventricles Basically it reboots their systems It cannot travel into the atriums to reset them So the timing is unchanged And that is why we have a compensatory pause as
the timing is undisturbed
PVCs How about if there are different shaped ectopic
beats?
PVCs Measure distance between 3 normal QRS-
waves Just like before as the process is still the same
PVCs Now measure the distance and compare to the
original measurement
PVCs First funny looking beat is the same distance
Compensatory pause
PVCs They are the same
Compensatory pause
PVCs Even for different looking PVCs
Compensatory pause
PVCs Even for different looking PVCs
Also known as multifocal
Compensatory pause Compensatory pause
PVCs What about back-to-back PVCs?
PVCs Also known as Salvos
PVCs Salvo PVCs
Compensatory pause
Compensatory pause Indicates that the ectopic beat did not interrupt
the atrial firing Subsequently, it occurred south of the AV Node
Premature AtrialContraction (PAC) A beat originating from a source of cardiac
stimulus within the atrium, other than the SA node, usually caused by some irritation of the myocardium Can easily be confused with Sinus Arrhythmia
PACs PACs have 3 primary hallmarks:
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Narrow
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the
normal pathways to enter the ventricles
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the
normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the
normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response
3. Compensatory Pause: No
PACs PACs have 3 primary hallmarks:
1. Regularity: Irregular All ectopic beats cause the underlying rhythm to become
irregular
2. QRS Complex: Narrow Because the beat is generated in the atrium, it follows the
normal pathways to enter the ventricles So it doesn’t disturb the ventricle's response
3. Compensatory Pause: No Termed non-compensatory pause
PACs Hint Easy way to identify if PAC is hidden:
The P-wave does not look like normal P-waves in this complex
PACs Regularity:
PACs Regularity:
PACs Regularity:
≠
PACs Regularity: Irregular
≠
PACs Regularity: Irregular QRS Complex:
PACs Regularity: Irregular QRS Complex: Narrow
PACs Regularity: Irregular QRS Complex: Narrow Compensatory Pause:
PACs Regularity: Irregular QRS Complex: Narrow Compensatory Pause: No
PACs P-wave does not look like normal P-waves in
either complexes
PACs Measure the distance between 3 normal QRS-
waves Assessment process does not change
PACs Now measure the distance from the normal beat
before and after the questionable beat
PACs They are not the same
NO compensatory pause
Non-compensatory pause Indicates that the ectopic beat did interrupt the
normal SA Node firing
Non-compensatory pause Indicates that the ectopic beat did interrupt the
normal SA Node firing Subsequently, it occurred inside the atria
Non-compensatory pause Indicates that the ectopic beat did interrupt the
normal SA Node firing Subsequently, it occurred inside the atria
Hence, it “reset or rebooted” the atrium and SA Node
Non-compensatory pause Indicates that the ectopic beat did interrupt the
normal SA Node firing Subsequently, it occurred inside the atria
Hence, it “reset or rebooted” the atrium and SA Node And thereby changed the timing
Sinus arrhythmia The difference between a rhythm with a PAC
and Sinus Arrhythmia is in Sinus Arrhythmia:
Sinus arrhythmia The difference between a rhythm with a PAC
and Sinus Arrhythmia is in Sinus Arrhythmia: All P-waves look the same to each other
Premature JunctionalContraction (PJC) A premature junctional complex is an electrical
impulse that originates in the AV junction and occurs before the next expected sinus impulse
A retrograde P wave may precede, coincide with, or follow the QRS
PJCs Conduction from the junction to the ventricles
usually occurs along normal pathways Thus the QRS complex is usually narrow The pause following a PJC may be
compensatory or non-compensatory
PJCs Regularity: Irregular QRS Complex: Narrow Compensatory Pause: Can have either
What? Can have either a compensatory or non-
compensatory pause; however…
PJC Hint No visible P-wave
Special Notes on Ectopi Unifocal
Multifocal
All PVCs have same morphology (shape)
When the QRS morphologies (shape) vary, the PVCs may be arising from different areas within the ventricles
Special Notes on Ectopi Quadrigeminy
Trigeminy
Bigeminy
Every fourth beat is a PVC (3 normal beats, 1 PVC)
Every third beat is a PVC (2 normal beats, 1 PVC)
Every other beat is a PVC (1 normal beat, 1 PVC)
Special Notes on Ectopi Salvos PVCs that occur
repetitively in pairs, also called coupling. Even though they are paired, they still retain the expected full compensatory pause seen from ectopi starting from the ventricles
Special Notes on Ectopi VT
R on T phenomenon
When three or more PVCs occur in a row, VT is present
PVCs that fall on the T wave (during the so-called vulnerable period of ventricular repolarization) may precipitate VT or VF
When three or more PVCsoccur in a row, VT is present
R on T phenomenon A PVC can land in the early relative refractory
period of a T-wave and immediately set VT into motion
R on T phenomenon This would be bad
R on T phenomenon
EKG Training
EKG Training So easy,
EKG Training So easy, Well, you get
the picture
As a Department, the Lake EMS Quality Development Team is here to serve youin your educational needs
This program is the Intellectual Property ofLake Emergency Medical ServicesUse of this program is limited to training and Quality Education only
Captain Mike Hilliard, Lake EMS Training Officer2761 West Old Highway 441, Mount Dora, FL 32757-3500
352/383-4554 (w); 352/735-4475 (f); [email protected]
Lake EMS Basic EKG Review:Ventricular Rhythms
The Lake EMSQuality Development Team