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Rhythm & 12 Lead EKG Review

Rhythm & 12 Lead EKG Review. Electrical Cardiac Cells. Automaticity – the ability to spontaneously generate and discharge an electrical impulse Excitability – the ability of the cell to respond to an electrical impulse

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Rhythm & 12 Lead EKG Review

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  1. Rhythm & 12 Lead EKG Review

  2. Electrical Cardiac Cells • Automaticity – the ability to spontaneously generate and discharge an electrical impulse • Excitability – the ability of the cell to respond to an electrical impulse • Conductivity – the ability to transmit an electrical impulse from one cell to the next

  3. Myocardial Cells • Contractility – the ability of the cell to shorten and lengthen its fibers • Extensibility – the ability of the cell to stretch

  4. ECG Paper • What do the boxes represent? • How do you measure time & amplitude?

  5. Components of the Rhythm Strip • ECG Paper • Wave forms • Wave complexes • Wave segments • Wave intervals

  6. Wave Forms, Complexes, Segments & Intervals • P wave – atrial depolarization • QRS – Ventricular depolarization • T wave – Ventricular repolarization

  7. Intervals and Complexes PR interval – atrial and nodal activity Includes atrial depolarization & delay in the AV node (PR segment) QRS complex Corresponds to the patient’s palpated pulse Large in size due to reflection of ventricular activity

  8. AV Node Bundle of HIS Left Bundle Branch The Electrical Conduction System • SA Node • Right Bundle Branch • Purkinje Fibers

  9. Correlation of ECG Wave Forms

  10. Sinus Rhythms • Originate in the SA node • Normal sinus rhythm (NSR) • Sinus bradycardia (SB) • Sinus tachycardia (ST) • Sinus arrhythmia • Inherent rate of 60 – 100 • Base all other rhythms on deviations from sinus rhythm

  11. Sinus Rhythm

  12. Sinus Bradycardia

  13. Sinus Tachycardia

  14. Sinus Arrhythmia

  15. Atrial Rhythms Originate in the atria Atrial fibrillation (A Fib) Atrial flutter Wandering pacemaker Multifocal atrial tachycardia (MAT) Supraventricular tachycardia (SVT) PAC’s Wolff–Parkinson–White syndrome (WPW)

  16. A - Fib

  17. A - Flutter

  18. Multifocal Atrial Tachycardia (MAT)(Rapid Wandering Pacemaker) • MAT rate is >100 • Usually due to pulmonary issue • COPD • Hypoxia, acidotic, intoxicated, etc. • Often referred to as SVT by EMS • Recognize it is a tachycardia and QRS is narrow

  19. SVT

  20. PAC’s

  21. Wolff–Parkinson–White - WPW • Caused by an abnormal accessory pathway (bridge) in the conductive tissue • Mainly non-symptomatic with normal heart rates • If rate becomes tachycardic (200-300) can be lethal • May be brought on by stress and/or exertion

  22. Wolff–Parkinson–White(AKA - Preexcitation Syndrome)

  23. AV/Junctional Rhythms • Originate in the AV node • Junctional rhythm rate 40-60 • Accelerated junctional rhythm rate 60-100 • Junctional tachycardia rate over 100 • PJC’s • Inherent rate of 40 - 60

  24. Junctional Rhythm

  25. Accelerated Junctional

  26. Ventricular Rhythms • Originate in the ventricles / purkinje fibers • Ventricular escape rhythm (idioventricular) rate 20-40 • Accelerated idioventricular rate 42 - 100 • Ventricular tachycardia (VT) rate over 102 • Monomorphic – regular, similar shaped wide QRS complexes • Polymorphic (i.e. Torsades de Pointes) – life threatening if sustained for more than a few seconds due to poor cardiac output from the tachycardia) • Ventricular fibrillation (VF) • Fine & coarse • PVC’s

  27. VT (Monomorphic)

  28. VT (Polymorphic) Note the “twisting of the points” This rhythm pattern looks like ribbon in it’s fluctuations

  29. VF

  30. PVC’s

  31. AV Heart Blocks • 1st degree • A condition of a rhythm, not a true rhythm • Need to always state underlying rhythm • 2nd degree • Type I - Wenckebach • Type II – Classic – dangerous to the patient • Can be variable (periodic) or have a set conduction ratio (ex. 2:1) • 3rd degree (Complete) – dangerous to the patient

  32. Delay or interruption in impulse conduction in AV node, bundle of His, or His/Purkinje system Classified according to degree of block and site of block PR interval is key in determining type of AV block Width of QRS determines site of block Atrioventricular (AV) Blocks

  33. Clinical significance dependent on: Degree or severity of the block Rate of the escape pacemaker site Ventricular pacemaker site will be a slower heart rate than a junctional site Patient’s response to that ventricular rate Evaluate level of consciousness / responsiveness & blood pressure Assumea patient presenting in Mobitz II or 3rd degree heart block to have an AMI until proven otherwise AV Blocks cont.

  34. 1st Degree Block

  35. 2nd Degree Type I

  36. 2nd Degree Type II (constant) P Wave PR Interval QRS Characteristics Uniform .12 - .20 Narrow & Uniform Missing QRS after every other P wave (2:1 conduction) Note: Ratio can be 3:1, 4:1, etc. The higher the ratio, the “sicker” the heart. (Ratio is P:QRS)

  37. 2nd Degree Type II (periodic) P Wave PR Interval QRS Characteristics Uniform .12 - .20 Narrow & Uniform Missing QRS after some P waves

  38. 3rd Degree (Complete)

  39. How Can I Tell What Block It Is?

  40. Second degree Type I Think Type “I” drops “one” Wenckebach “winks” when it drops one Second degree Type II Think 2:1 (knowing it can have variable block like 3:1, etc.) Third degree - complete Think completely no relationship between atria and ventricles Helpful Tips for AV Blocks

  41. Implanted Pacemaker • Most set on demand • When the heart rate falls below a preset rate, the heart “demands” the pacemaker to take over 41

  42. Paced Rhythm - 100% Capture

  43. Where do those chest stickers go? • Make sure to “feel” for intercostal space – don’t just use your eyes!

  44. Not all nipple lines are created equal Measure intercostal spaces to be accurate in electrode placement All 12 leads measured from same electrode placement ……and the FEMALES

  45. Avoid placing electrodes on top of breast tissue Use the back of the hand to displace breast tissue out of the way to place electrode Avoids perception of “groping” Can ask the patient to move left breast out of way. Lead Placement in the Female

  46. Myocardial Insult Ischemia lack of oxygenation ST depression or T wave inversion permanent damage avoidable Injury prolonged ischemia ST elevation permanent damage avoidable Infarct death of myocardial tissue; damage permanent; may have Q wave

  47. Evolution of AMI A - pre-infarct (normal) B - Tall T wave (first few minutes of infarct) C - Tall T wave and ST elevation (injury) D - Elevated ST (injury), inverted T wave (ischemia), Q wave (tissue death) E - Inverted T wave (ischemia), Q wave (tissue death) F - Q wave (permanent marking)

  48. Sinus w/ 1st degree Block No symptoms are due to the first degree heart block; symptoms would be related to the underlying rhythm

  49. 2nd Degree Type 1 – Wenckebach PR getting longer and finally 1 QRS drops; patient generally asymptomatic; can be normal rhythm for some patients

  50. 2nd Degree Type II (2:1 conduction) Should be preparing the TCP for this patient

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