Ecg

Electrocardiography for Health Care Professionals
Chapter 5: ECG Interpretation and Clinical Significance Part B
Copyright The McGraw-Hill company, Inc. Permission required for reproduction or display.
Learning Outcomes

Summarize the process of evaluating ECG tracings and determining the presence of dysrhythmias. Identify criteria used for classification of dysrhythmias. Describe various rhythms and dysrhythmias. Identify the dysrhythmias using the criteria for classification.
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Learning Outcomes (Contd)

Explain how dysrhythmias may affect the patient. Discuss basic patient care and treatment for dysrhythmias. Describe an electronic pacemaker, its function, and the normal pacemaker rhythm characteristics. Identify the steps in evaluating electronic pacemaker function on an ECG tracing.
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Presentation Topics Part B

Heart Block Rhythms Bundle Branch Block Dysrhythmias Rhythms Originating from the Ventricles Electronic Pacemaker Rhythms
Chapter 5
Heart Block Rhythms

Occur when electrical activity has difficulty traveling along normal conduction pathway Ventricular depolarization is delayed or absent Three levels of heart blocks

1st degree heart block 2nd degree AV block, Mobitz I (Wenckebach) 2nd degree AV block, Mobitz II 3rd degree block
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First Degree AV Block

Delay in electrical conduction around the AV node Electrical stimulus is prevented from traveling to ventricular conduction system
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First Degree AV Block Criteria

Rhythm regularity between P-P interval and R-R interval is constant. Rate normal, 60-100 beats per minute P wave configuration

Same configuration and shape P wave occurs before each QRS complex
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First Degree AV Block Criteria (Contd)

PR interval greater than 0.20 second QRS duration normal 0.06-0.10 second
Chapter 5
First Degree AV Block What You Should Know

Patient will maintain normal cardiac output

No change in the patient will occur with this rhythm
Monitor and report further degeneration and development of other heart blocks
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Second Degree AV Block, Mobitz I (Wenckebach)

Some electrical impulses are blocked/non-conducted at AV junction region AV node conducts electrical impulse to ventricular conduction pathway until it fails, then resets in a repetitious pattern The ventricular rhythm is irregular
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Second Degree AV Block, Mobitz I (Wenckebach)
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Second Degree AV Block, Mobitz I Criteria

Rhythm

P-P interval regular R-R interval irregular due to blocked impulses Atrial rate within normal limits Ventricular rate slower than atrial rate
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Rate

Second Degree AV Block, Mobitz I Criteria (Contd)

P wave configuration

Normal size, upright One P wave for every QRS, with additional P waves
PR interval varies, starts short, gets progressively longer until QRS wave is dropped, then cycle is restarted QRS duration normal 0.06-0.10 second
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Second Degree AV Block, Mobitz I What You Should Know

Patient may not exhibit signs of low cardiac output until rate decreases to 40 beats per minute or lower Condition usually results from inflammation around AV node and is often temporary
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Second Degree AV Block, Mobitz I What You Should Know (Contd)

If patient exhibits signs of low cardiac output, notify licensed practitioner If no low cardiac output signs are exhibited, monitor patient for progression to third degree heart block
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Second Degree AV Block, Mobitz II

Referred to as the classical heart block AV node selects which electrical impulses to block No pattern or reason for dropping QRS complex exists Frequently progresses to third degree AV block
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Second Degree AV Block, Mobitz II
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Second Degree AV Block, Mobitz II Criteria

Rhythm

P-P interval is regular R-R interval is irregular Atrial rate is within normal limits Ventricular rate is slower than atrial rate
Rate

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Second Degree AV Block, Mobitz II Criteria (Contd)


Normal size Upright One P wave for every QRS complex, but additional P waves

PR interval constant, even after QRS drop occurs QRS duration normal, 0.06-0.10 second
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Troubleshooting

In second degree type I, the PR interval in front of the dropped QRS complex is longer than the PR interval behind the dropped QRS complex In second degree type II, the interval is constant Both rhythms should be reported
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Second Degree Mobitz II What You Should Know

Observe patient for signs of low cardiac output Condition can progress quickly to third degree AV block or complete heart block
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Third Degree AV Block

Also known as complete heart block (CHB) All electrical impulses originating above the ventricles are blocked No correlation exists between atrial and ventricular depolarization
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Third Degree AV Block
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Third Degree AV Block Criteria

Rhythm

P-P interval is regular R-R interval is regular, but different from P-P interval Atrial rate is 60 to 100 beats per minute Ventricular is 20 to 40 beats per minute
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Rate

Third Degree AV Block Criteria (Contd)


Normal size and shape, but may be buried in QRS complex Number of P waves does not correlate to number of QRS complexes P waves outnumber QRS complexes
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Third Degree AV Block Criteria (Contd)

PR interval

Intervals will vary A long PR interval followed by a short PR interval indicates complete heart block Constant May be within normal limits or wider depending on the location of the block
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QRS duration

Third Degree AV Block What You Should Know

Patient will show signs of low cardiac output and may be unconscious Initiate Code Blue when patient shows first signs of low cardiac output Immediate medical intervention may be required temporary pacemaker Rhythm strips should be mounted and identified in patients record
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Apply Your Knowledge

Identify this type of AV block:
ANSWER: Second degree AV block type I

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Identify this type of AV block:
ANSWER: First degree AV block

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Bundle Branch Block (BBB) Dysrhythmias

Occur when one or both ventricular pathways are damaged Ventricle with damaged pathway receives current one cell at a time Longer contraction time reflected in wider QRS complex
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Bundle Branch Block Dysrhythmias (Contd)

Right bundle branch block (RBBB)

Right side of the conduction pathway is blocked after the His bundle Conduction travels to left ventricle first, then moves to the right side Chapter 5
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Bundle Branch Block Dysrhythmias (Contd)

Left Bundle Branch Block (LBBB)

Left conduction pathway is blocked Conduction travels to right ventricle first, then moves to the left side
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Branch Bundle Block Dysrhythmias Criteria

Specific characteristics of left or right BBB identifiable in leads V1 to V6 Rhythm

May be regular or irregular Depends on underlying rhythm
Rate atria and ventricles depend on basic rhythm

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Branch Bundle Block Dysrhythmias Criteria (Contd)

P wave configuration shape, configuration, deflection, and coordination with QRS complex depend on basic rhythm PR interval normal, 0.12-0.20 second QRS duration 0.12 second or greater
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Bundle Branch Blocks What You Should Know

Patient exhibits normal effects of basic rhythm Widening of QRS complex must be reported to a licensed practitioner immediately Condition may require pacemaker or Code Blue
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Will the QRS complex be of normal duration or widened in a bundle branch block?
ANSWER: Widened; 0.12 second or greater

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Rhythms Originating from the Ventricles

Rate of automaticity is 20-40 beats per minute Current initiated in Purkinje fibers QRS duration and configuration will be 0.12 second or greater, suggesting cell-by-cell stimulation
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Rhythms Originating from the Ventricles (Contd)

Premature ventricular contractions (PVC) Idioventricular rhythm Accelerated idioventricular rhythm Ventricular tachycardia (V tach) Agonal rhythm Ventricular fibrillation (V fib) Asystole
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Premature Ventricular Complex (PVC)

Caused by an ectopic beat that occurs early in the cycle and originates from the ventricles
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Premature Ventricular Complex Criteria

Rhythm

P-P and R-R intervals are regular with early QRS complexes Early complex has full compensatory pause Atrial and ventricular rates are the same for the underlying rhythm Early complexes make ventricular rhythm faster than normal rhythm
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Rate

Premature Ventricular Complex Criteria (Contd)

P wave configurations

Shape is that of the underlying rhythm P waves not identified on early ventricular complex Follows underlying rhythm P wave not present in early complex
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PR interval

Premature Ventricular Complex Criteria (Contd)

QRS duration

Follows underlying rhythm Duration of early complex greater than 0.12 second QRS shape is bizarre, with T wave in opposite direction from QRS wave
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Types of Premature Ventricular Complexes

Unifocal early beat (has similar shape, suggesting only one irritable focus present) Multifocal varied shapes and forms of the PVCs Interpolated PVC occurs during the normal R-R interval without interrupting the normal cycle. Occasional more than one to four PVCs per minute Frequent more than five to seven PVCs per minute
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Types of Premature Ventricular Complexes (Contd)

Bigeminy every other beat is a PVC Trigeminy every third beat is a PVC Quadrigeminy every fourth beat is a PVC R on T PVCs PVC occurs on the T wave or the vulnerable period of the ventricular refractory period Coupling two PVCs occur back to back
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Premature Ventricular Complexes What You Should Know

Significance depends on their frequency Can occur in normal hearts May feel dizziness or other symptoms of low cardiac output R on T PVCs and coupling increase risk of a more serious dysrhythmia Notify practitioner if symptoms of low cardiac output develop
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Idioventricular Rhythm

Impulse created by the ventricular pacemaker Presents with the classic wide QRS complex, slow ventricular rate and absent P waves
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Idioventricular Rhythm Criteria

Rhythm

R-R interval is regular, P-P interval cannot be determined Ventricular rate is 20-40 beats per minute

Rate

P wave is absent PR interval cannot be measured QRS duration and configuration

0.12 seconds or greater with a wide, bizarre appearance

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Idioventricular Rhythm What You Should Know

Profound loss of cardiac output The patient will likely be unconscious Notify health care practitioner immediately Likely to require medication and/or pacing
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Accelerated Idioventricular Rhythm

Impulse created by the ventricular pacemaker The heart rate is faster than an idioventricular rhythm QRS complex is wide and bizarre and P waves are absent
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Accelerated Idioventricular Rhythm Criteria

Rhythm

R-R interval is regular. P-P interval cannot be determined Ventricular rate is 40-100 beats per minute

Rate

P wave is absent PR interval cannot be identified QRS duration

Wide, bizarre appearance and 0.12 second or greater

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Accelerated Idioventricular Rhythm What You Should Know

Decrease in cardiac output due to slow ventricular rate Patient may be unconscious Notify health care practitioner May require medication and/or pacing
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Ventricular Tachycardia (V tach)

Three or more PVCs occur in a row Ventricles are in continuous state of contraction-relaxation
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Ventricular Tachycardia Criteria

Rhythm

P-P interval usually not identifiable R-R interval usually regular, can be slightly irregular at times Atrial rate cannot be determined Ventricular rate 100-200 beats per minute
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Rate

Ventricular Tachycardia Criteria (Contd)

P wave configurations usually absent PR interval cannot be determined QRS duration

Greater than 0.12 second T wave in opposite direction (usually down) from QRS complex
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Ventricular Tachycardia What You Should Know

Lost atrial kick and decreased ventricular filling time results in decreased cardiac output Approximately 50% of patients become unconscious immediately Notify licensed practitioner
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Ventricular Tachycardia What You Should Know (Contd)

If patient is unresponsive, issue Code Blue, begin CPR, use emergency equipment Mount rhythm strips in patients medical record If patient is responsive, licensed practitioner may initiate treatment plan
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Troubleshooting

Heart rates less than 60 beats per minute can cause escape beats Often PVCs occur in response to bradycardia
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Agonal Rhythm

Occurs when all of the pacemakers in the heart have failed Ventricular rate is less than 20 beats per minute
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Agonal Rhythm Criteria

Rhythm

R-R interval may or may not be regular
Rate is less than 20 beats per minute P wave is absent PR interval cannot be determined QRS duration and configuration

0.12 second or greater with a wide, bizarre appearance

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Agonal Rhythm What You Should Know

Profound loss of cardiac output Patient will be unconscious Notify health care practitioner immediately This is a medical emergency; BLS and ACLS interventions will be initiated
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Safety

Follow facilitys guidelines on stocking of crash cart for Code Blue emergencies
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Ventricular Fibrillation (V fib)

Chaotic asynchronous electrical activity within ventricular tissue results in no cardiac output
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Ventricular Fibrillation Criteria

Rhythm

R-R interval, if able to determine, will be irregular Ventricular rate, if identifiable, will be greater than 300 beats per minute
Rate

P wave configurations not identifiable PR interval not identifiable QRS duration cannot be determined
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Ventricular Fibrillation What You Should Know

If patient is conscious and talking, leads are loose or detached Patient will be unresponsive Code Blue situation is present Begin CPR and emergency measures immediately Advanced cardiac life support (ACLS) should begin immediately
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Asystole

Often called straight line or flat line No electrical activity is present in the myocardium
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Asystole Criteria

Rhythm no waveforms are present Rate no atrial or ventricular rates are present P wave configurations no P waves are present PR interval none, since no waveforms are present QRS duration not measurable, no waveforms are present
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Asystole What You Should Know

Situation is life-threatening Patient is in cardiac arrest; initiate emergency procedures
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Patient Education and Communication for Emergency

If family/friends are present, explain that there is an emergency and escort them out of immediate area
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How is an accelerated idioventricular rhythm differ from an idioventricular rhythm? ANSWER: Rate. Accelerated idioventricular rhythm occurs at a rate of 40 to100 beats per minute while an idioventricular rhythm occurs at a rate of 20 to 40 beats per minute.
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Identify this rhythm.
ANSWER: Ventricular tachycardia

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What is the ventricular rate in a patient suffering from an agonal rhythm?
ANSWER: Less than 20 beats per minute
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Electronic Pacemaker Rhythms

Also known as artificial pacemakers Deliver electrical impulse to myocardium, causing cells to depolarize Can pace the atria, ventricles, or both Usually implanted under the skin
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Electronic Pacemaker Rhythms (Contd)

Performing ECG on patient with pacemaker may require additional training Each pacemaker is individually set for the desired heart rate and electrical current Atrial pacing is used alone when the AV node and ventricular conduction are performing correctly
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Electronic Pacemaker Rhythms (Contd)
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Pacemaker Safety

Electrical current from pacemaker cannot be transmitted to those who encounter the patient
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Evaluating Pacemaker Function

Pacing spike

Thin spike on ECG tracing indicating electrical current from pacemaker After spike, either a P wave or QRS complex will appear
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Evaluating Pacemaker Function (Contd)

AV delay

Similar to PR interval on normal rhythm tracing Measured from atrial spike to ventricular spike Normally 0.12-0.20 second If patient has normal P wave and pacerinduced ventricular complex, measure from beginning of P wave to ventricular spike
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Seven Steps To Evaluating Pacemaker ECG Tracing

Step 1 What are the rate and regularity of the paced rhythm? Step 2 What are the rate and regularity of the intrinsic rhythm? Step 3 Is the atrial lead sensing appropriate? Step 4 Is atrial capture present?
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Seven Steps To Evaluating Pacemaker ECG Tracing (Contd)

Step 5 Is AV delay appropriate? Step 6 Is ventricular sensing appropriate? Step 7 Is ventricular capture present? Note: If patient does not have an AV sequential pacemaker, steps 3 through 5 can be eliminated.
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Complications of Pacemaker in Relationship to ECG Tracing

Weak battery complications

Slow firing rates Less effective sensing capabilities Less than predetermined electrical current Sensing capability too low for pacemaker to see normal contractions
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Program complication

Complications Visible on ECG Tracings

Malfunctioning failure to pace Malsensing failure to sense Loss of capture failure to depolarize Oversensing perceiving sources other than the heart
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Your Responsibility

To recognize normal pacemaker rhythms and possible complications!
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A pacemaker can provide stimulation to which regions of the heart?
ANSWER: Atria, ventricles, or both
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Chapter 5 Summary

Evaluating an ECG requires basic knowledge of the components of the rhythm The process of evaluating an ECG tracing includes determining the rhythm, rate, P wave configuration, PR interval, and QRS duration and configuration Sinus rhythm is a normally functioning rhythm Dysrhythmias are abnormal rhythms
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Chapter 5 Summary (Contd)

Many dysrhythmias can result in low cardiac output Each of the dysrhythmias may affect the patient with varying degrees of severity Pacemakers can pace the atria, ventricles or both and are seen as a spike on the ECG Evaluating a pacemaker involves seven steps, similar to a non-paced rhythm
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END OF CHAPTER FIVE

ECG Interpretation and Clinical Significance

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Electrocardiography for Health Care Professionals

Chapter 5: ECG Interpretation and Clinical Significance Part B

Learning Outcomes (Contd)

Presentation Topics Part B

Heart Block Rhythms

First Degree AV Block

First Degree AV Block Criteria

First Degree AV Block Criteria (Contd)

First Degree AV Block What You Should Know

Patient will maintain normal cardiac output

No change in the patient will occur with this rhythm

Second Degree AV Block, Mobitz I (Wenckebach)

Second Degree AV Block, Mobitz I (Wenckebach)

Second Degree AV Block, Mobitz I Criteria

Second Degree AV Block, Mobitz I Criteria (Contd)

Second Degree AV Block, Mobitz I What You Should Know

Second Degree AV Block, Mobitz I What You Should Know (Contd)

Second Degree AV Block, Mobitz II

Second Degree AV Block, Mobitz II

Second Degree AV Block, Mobitz II Criteria

Second Degree AV Block, Mobitz II Criteria (Contd)

Second Degree Mobitz II What You Should Know

Third Degree AV Block

Third Degree AV Block

Third Degree AV Block Criteria

Third Degree AV Block Criteria (Contd)

Third Degree AV Block Criteria (Contd)

Third Degree AV Block What You Should Know

Apply Your Knowledge

ANSWER: Second degree AV block type I

Apply Your Knowledge

ANSWER: First degree AV block

Bundle Branch Block (BBB) Dysrhythmias

Bundle Branch Block Dysrhythmias (Contd)

Right bundle branch block (RBBB)

Bundle Branch Block Dysrhythmias (Contd)

Left Bundle Branch Block (LBBB)

Branch Bundle Block Dysrhythmias Criteria

Specific characteristics of left or right BBB identifiable in leads V1 to V6 Rhythm

May be regular or irregular Depends on underlying rhythm

Rate atria and ventricles depend on basic rhythm

Branch Bundle Block Dysrhythmias Criteria (Contd)

Bundle Branch Blocks What You Should Know

Apply Your Knowledge

ANSWER: Widened; 0.12 second or greater

Rhythms Originating from the Ventricles

Rhythms Originating from the Ventricles (Contd)

Premature Ventricular Complex (PVC)

Premature Ventricular Complex Criteria

Premature Ventricular Complex Criteria (Contd)

Premature Ventricular Complex Criteria (Contd)

Types of Premature Ventricular Complexes

Types of Premature Ventricular Complexes (Contd)

Premature Ventricular Complexes What You Should Know

Idioventricular Rhythm Criteria

P wave is absent PR interval cannot be measured QRS duration and configuration

0.12 seconds or greater with a wide, bizarre appearance

Idioventricular Rhythm What You Should Know

Accelerated Idioventricular Rhythm

Accelerated Idioventricular Rhythm Criteria

P wave is absent PR interval cannot be identified QRS duration

Wide, bizarre appearance and 0.12 second or greater