Advanced ECGs For MLAs

Advanced ECGs for MLAs
Cathie Cousins, RN, BScN, CCN(C)
Objectives
1. To review Basic Concepts for the 12-Lead ECG
To discuss the following on the 12-Lead ECG 2. Bradycardia 3. Tachycardia 4. Ventricular Ectopy 5. ST and T wave changes 6. Pacemakers
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1. Basic Concepts
The heart is a pump with an electrical conduction system 2 basic types of cardiac cells in the heart Myocardial cells or muscle cells Specialized cells of the conduction system or pacemaker cells
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Cathie Cousins,RN BScN CCN(C)
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Electrical Axes and Vectors

Each of the 12 leads on the ECG has a different pattern because each lead views the hearts electrical axis from a different position
Atrial and ventricular depolarization and repolarization generate an electric current known as an electrical axis or vector (different from the axis of a lead)
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Average of all the ventricular vectors points to the left and downward Knowing the electrical axis of the heart enables us to determine the normal pattern of each lead and the cause for altered patterns in each lead
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Rate
Both the atrial and ventricular rates should be measured
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The Grid Method for Rate

Uses the distance between 2 sequential complexes on the ECG Each small square represents 0.04 seconds - 1500 small squares in 1 minute - 300 large squares in 1 minute Count the large squares between P waves for atrial rate and R waves for ventricular rate 300 number of large squares = number of beats/min
Quick Tips
300 5 large squares = 60 bpm 5 or > large squares per minute = Bradycardia 300 3 large squares = 100 bpm 3 or > large squares per minute = Tachycardia
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2. Bradycardia
Bradycardia is a heart rate < 60/min Bradycardia can be due a slow sinus rate, the origin of the rhythm or an AV block: - Sinus Bradycardia - Junctional Rhythm - Idioventricular Rhythm - 2 AV Block Type I - 2 AV Block Type II - 3 AV Block
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Sinus Bradycardia
Sinus node is pacing at a rate < 60/min P wave, QRS normal
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Junctional Rhythm
Sinus node and atria fail to pace the heart. AV junction paces at 40-60/min No P wave or PR interval < 0.12, QRS normal
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Idioventricular Rhythm
Sinus node, atria, and AV junction fail to pace. Ectopic pacemaker in the ventricles paces at 20-40/min No P wave, QRS wide, ST & T waves often abnormal
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AV Blocks
2 Type I and 2Type II AV Blocks, sinus node paces the heart Not ever P wave results in QRS, QRS normal or wide
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3 AV Block, sinus node paces the heart P waves do not result in QRS AV junction paces, QRS normal Ventricles pace, QRS wide
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3. Tachycardia
Tachycardia is a heart rate > 100/min Tachycardia can be due to: - Sinus Tachycardia - Supraventricular Tachycardia - Ventricular Tachycardia
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Sinus Tachycardia
Sinus node is pacing at a rate > 100/min
P wave, QRS normal
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Superventricular Tachycardia
Ectopic focus in atria or AV junction paces the heart or Abnormal conduction thru AV node or Accessory pathway P wave or no P wave, QRS narrow or wide, rate > 150/min
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Ventricular Tachycardia
Ectopic pacemaker in ventricles paces the heart No P wave, QRS wide and bizarre
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4. Premature Ventricular Contractions

QRS Duration QRS duration - depolarization of right and left ventricles, from the endocardium to epicardium
Normal QRS duration - 0.06-0.10 sec

QRS duration > 0.10 sec, a conduction delay exists in the bundle branches, Purkinjie network or ventricular myocardium, or ventricular ectopic conduction exists
PVCs, premature ventricular complexes: the premature beat originates in an ectopic focus in one ventricle, it depolarizes that ventricle, then the other
No P wave, QRS wide & bizarre, ST often abnormal, T wave often opposite the rhythm Multifocal PVCs come from more than one ectopic focus, each foci has a different shape
1 PVC 2 PVCs 3 PVCs 4 PVCs
= = = =
a PVC couplet triplet ventricular tachycardia
Every 2nd PVC = bigeminy Every 3rd PVC = trigeminy Bigeminy or trigeminy can refer to any ectopic beat so clarify eg. bigeminal PVCs or bigeminal PACs, etc.
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5a. ST Segments
ST segment = end of ventricular repolarization + early part of ventricular repolarization ST segment normally isoelectric Ischemic + injured myocardial cells altered membrane potentials, this allows a current to flow as seen in ST elevation + depression
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Measuring ST Segments
ST measurement = vertical difference between the isoelectric line + end of QRS complex, the J point
ST Segment Elevation
ST segment elevation = >1 mm (>0.1 mV) above baseline after the J point ST segment elevation due to severe injury temporary until ischemia resolved or injured heart tissue heals or dies ST segments elevate in leads facing the injury ST segments depress in leads opposite (reciprocal ) leads
Types of ST Elevation in AMI
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Other Common Causes of ST Segment Elevation

Coronary artery vasospasm Acute pericarditis Ventricular aneursym Hyperkalemia Non-specific ST-T wave changes
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ST Segment Depression
ST segment depression = > 1 mm below baseline after the J point ST segment depression due to severe ischemia temporary until ischemia resolved or heart tissue heals ST segments depress in leads facing the ischemia ST segments elevate in opposite (reciprocal) leads
Types of ST Depression in AMI

Different types of ST depression in AMI: - downsloping - horizontal - upsloping
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Other Common Causes of ST Segment Depression
Left and right ventricular hypertrophy Left and right bundle branch block Digitalis in therapeutic and toxic doses
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Acute MI
Anterior Septal Anterior Lateral Inferior
Facing Leads Opposite Leads
V1-V2 V3-V4 I, aVL, & V5 or V6 II, III, & aVF
None None II, III, & aVF I & aVL
Posterior V7,V8, V9 on 18 lead V1-V4 Right Ventricle V4R, V5R, V6R on 18 lead None
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5b. T waves
A T wave represents ventricular depolarization T waves normally upright, rounded, and slightly asymmetrical. Normally negative in aVR. Normally 1/8 to 2/3 the height of the QRS complex
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Abnormal T Waves in AMI

Normal Heart positive T wave
Subendocardial Ischemia symmetrically positive tall, peaked T wave

Subepicardial Ischemia symmetrically negative deep T wave
Late phases in AMI deeply inverted T waves with abnormal Q waves

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6. Pacemakers
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The 3 Functions of Pacing

1. Sensing the ability of the pacemaker to recognize the patients intrinsic heartbeat 2. Pacing the pacemaker produces a stimulus either when the sensing circuit does not detect an intrinsic heartbeat or at a predetermined time interval
3. Capturing the depolarization of the myocardium in response to pacing

Pacemaker Codes
I II III IV V Chamber(s) paced Chamber(s) sensed Response to sensing Programmable function(s) Antitachyarrhythmia function(s)
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Pacing Leads Sites - Permanent
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Pacing Leads Sites - Temporary
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Pacemaker Sites - Temporary

Transcutaneous External Pacing
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Pacemaker Strip 1
1. Sensing 2. Pacing 3. Capturing

Pacemaker Strip 2
1. Sensing 2. Pacing 3. Capturing

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Thank You
Remember: It is the team that assists the patient in achieving wellness. Thank you and enjoy the exciting world of 12 Lead ECGs.
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Advanced ECGs For MLAs

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Advanced ECGs For MLAs

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Advanced ECGs for MLAs

Cathie Cousins, RN, BScN, CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

Electrical Axes and Vectors

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

The Grid Method for Rate

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

P wave, QRS normal

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

May 13, 2006

Cathie Cousins,RN BScN CCN(C)

4. Premature Ventricular Contractions

Normal QRS duration - 0.06-0.10 sec

1 PVC 2 PVCs 3 PVCs 4 PVCs