ECG Interpretation Basics
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Questions and Answers

How do you calculate heart rate from an ECG?

Count the number of QRS complexes and multiply by 10.

What are the characteristics of a normal P wave?

  • Its normal duration is 0.06-0.12 seconds. (correct)
  • It should be rounded and upright. (correct)
  • It is the first deviation from the isoelectric line. (correct)
  • It is inverted.

    • Which of the following are common symptoms of sinus bradycardia?

  • Syncope
  • Dizziness
  • Chest pain
  • All of the above (correct)

    • Atrial fibrillation is characterized by a regular heart rhythm.

    <p>False</p> Signup and view all the answers

    What is the treatment for ventricular fibrillation?

    <p>CPR with immediate defibrillation</p> Signup and view all the answers

    What does it indicate if the QRS complex is prolonged?

    <p>It indicates a ventricular conduction delay.</p> Signup and view all the answers

    Match the following ECG waves with their meanings:

    <p>P wave = Atrial depolarization QRS complex = Ventricular depolarization T wave = Ventricular repolarization U wave = Hypokalemia indication</p> Signup and view all the answers

    What can cause artifact in an ECG reading?

    <p>Patient movement, muscle tremors, loose electrodes, or faulty equipment.</p> Signup and view all the answers

    Asystole is characterized by the presence of electrical activity in the heart.

    <p>False</p> Signup and view all the answers

    What is the normal duration of the PR interval?

    <p>0.12-0.20 seconds.</p> Signup and view all the answers

    What is the primary cause of infective endocarditis?

    <p>Infection by bacteria such as staphylococcus aureus or streptococcus viridians.</p> Signup and view all the answers

    How do you calculate the heart rate from an ECG strip?

    <p>Count the number of QRS complexes and multiply by 10 to get BPM.</p> Signup and view all the answers

    What does a regular rhythm on an ECG indicate?

    <p>The interval between QRS (R) waves is regular.</p> Signup and view all the answers

    What does the P wave represent?

    <p>The depolarization of the left and right atria.</p> Signup and view all the answers

    The PR interval is measured from the beginning of the P wave to the beginning of the QRS complex.

    <p>True</p> Signup and view all the answers

    What is a normal QRS complex duration?

    <p>&lt; 0.12 seconds</p> Signup and view all the answers

    What is a common treatment for sinus bradycardia?

    <p>IV atropine.</p> Signup and view all the answers

    Which of the following is a possible cause of atrial fibrillation? (Select all that apply)

    <p>COPD</p> Signup and view all the answers

    What is assessed when ventricular tachycardia occurs?

    <p>The presence of three or more PVCs.</p> Signup and view all the answers

    Ventricular fibrillation is characterized by regular waveforms on an ECG.

    <p>False</p> Signup and view all the answers

    What is a common diagnostic study for infective endocarditis?

    <p>Blood cultures</p> Signup and view all the answers

    The absence of ventricular electrical activity is known as ______.

    <p>asystole</p> Signup and view all the answers

    Infective endocarditis is often associated with IV drug use.

    <p>True</p> Signup and view all the answers

    Study Notes

    ECG Interpretation

    • Heart Rate: Count the number of QRS complexes and multiply by 10 to get beats per minute.
      • Atrial rate = number of P waves.
      • Ventricular rate = number of QRS complexes x 10.
    • Rhythm:
      • Regular: Equal intervals between QRS complexes (R waves), varying by less than 0.06 seconds or 1.5 boxes.
      • Irregular: Unequal intervals between QRS complexes (R waves), varying by more than 0.06 seconds or 1.5 boxes.
    • P Wave: Represents atrial depolarization.
      • First deviation from the isoelectric line.
      • Should be rounded, upright, and similar in appearance.
    • PR Interval: Measured from the beginning of the P wave to the beginning of the QRS complex.
      • Represents time from atrial contraction onset to ventricular contraction onset.
      • Normal interval: 0.12-0.20 seconds or 3-5 small squares.
    • QRS Complex: Represents ventricular depolarization.
      • Q Wave: First negative deflection after the P wave, short and narrow, not present in all leads.
      • R Wave: First positive deflection in the QRS complex.
      • S Wave: First negative deflection after the R wave.
      • QRS Interval: Measured from the beginning to end of the QRS complex.
        • Normal duration: less than 0.12 seconds.
        • Wide QRS complexes (greater than 0.12 seconds) may indicate bundle branch block or ventricular conduction issues.
        • Narrow QRS complexes (less than 0.06 seconds) can be normal, but may indicate a ventricular conduction problem.
    • QT Interval: Measured from the beginning of the QRS to the end of the T wave.
      • Represents time taken for ventricular depolarization and repolarization.
      • Normal duration: 0.34- 0.43 seconds.
      • Prolonged QT intervals may result from drug therapy, electrolyte imbalances, or heart rate changes.
    • T Wave: Represents ventricular repolarization.
      • Usually the first upward deflection following the QRS complex.
      • Inverted T wave can indicate myocardial damage.
    • U Wave: Usually not visible, but if present, follows the T wave.
      • Smaller than the T wave, rounded, upright, or positive deflection following the QRS complex.
      • May indicate hypokalemia.
    • Artifact: EKG waves from sources outside the heart.
      • Interference seen on the monitor or ECG strip.
      • Causes: patient movement, muscle tremor, loose electrodes, faulty EKG apparatus.

    Normal Sinus Rhythm

    • Regular rhythm set by the sinoatrial (SA) node (natural pacemaker).

    Sinus Bradycardia

    • Regular but unusually slow heartbeat (less than 60 BPM).
      • Rate: < 60 BPM.
      • Rhythm: Regular.
      • P wave present before each QRS, upright and uniform.
      • PR interval: 0.12-0.20 seconds.
      • QRS complex: 0.06-0.10 seconds.
      • Causes: hypoglycemia, hypothermia, hypothyroidism, medications, MI, sick sinus syndrome.

    Sinus Tachycardia

    • Fast heartbeat related to rapid SA node firing.
      • Rate: > 100 BPM.
      • Rhythm: Regular.
      • P wave present before each QRS, upright and uniform.
      • PR interval: 0.12-0.20 seconds.
      • QRS complex: 0.06-0.12 seconds.
      • Causes: heart disease, hypertension, hyperthyroidism, fever, stress, alcohol, caffeine, nicotine, medications, pain, electrolyte imbalances.

    Atrial Fibrillation

    • Uncoordinated electrical signal in the atria causing them to quiver (400+ BPM) without effective contraction.
      • Ventricular rate is irregular and uncontrolled.
      • Decreased cardiac output due to ineffective atrial contractions.
      • Thrombi may form in the atria due to blood stasis.
      • Rate: 300-600 BPM.
      • Rhythm: Irregular.
      • No P wave.
      • QRS complex: < 0.12 seconds.
      • Causes: heart failure, COPD, pericarditis, heart disease, stress, alcohol, caffeine.

    Atrial Flutter

    • Coordinated rapid atria beating identified by recurring, regular, sawtooth-shaped flutter waves.
      • Atria beat faster than ventricles (4:1 ratio).
      • Rate: 200-350 BPM, ventricular rate = to 0.12 seconds
      • Rhythm: Regular.
      • No clear P waves (flutter waves instead).
      • QRS complex: < 0.12 seconds.
      • Causes: heart failure, pulmonary embolism, MI, digoxin toxicity, CAD, valve problems, drugs, hyperthyroidism, cor pulmonale, hypertension.

    Premature Ventricular Contractions (PVCs)

    • A contraction originating from an ectopic focus in the ventricles.
      • Premature (early) occurrence of a QRS complex.
      • Wide and distorted QRS complex compared to normal conduction pathways.
      • Unifocal PVCs: Same shape, arising from the same focus.
      • Multifocal PVCs: Arise from different foci.
      • Ventricular trigeminy: PVC every other beat.
      • Couplet: 2 consecutive PVCs.
      • Causes: stimulants, electrolyte imbalances, heart disease, hypoxia, fever, exercise, emotional stress.
      • Not harmful in patients with normal hearts, but assess for pulse deficit.

    Accelerated Idioventricular Rhythm

    • Ventricles try to prevent cardiac standstill when SA and AV nodes fail.
      • Rate: 40-100 BPM.
      • Rhythm: Regular.
      • No P wave.
      • Wide and distorted QRS.
      • Causes: drugs, MI, metabolic imbalances, hyperkalemia, cardiomyopathy.

    Ventricular Tachycardia (VT)

    • 3 or more consecutive PVCs.
      • Ventricle takes control as pacemaker.
      • Life-threatening dysrhythmia due to decreased cardiac output and potential for ventricular fibrillation.
      • Monomorphic VT: QRS complexes have the same shape, size, and direction.
      • Polymorphic VT: QRS complexes gradually change shape, size, and direction.
      • Torsades de Pointes (TdP): Polymorphic VT associated with prolonged QT interval.
        • Hallmark finding: QRS complexes deflect upwards and downwards around the baseline.
      • Rate: 150-250 BPM.
      • Rhythm: Regular or irregular.
      • No P wave.
      • Wide and distorted QRS.
      • Causes: underlying heart disease, MI, medications that prolong QT interval, electrolyte imbalance, digitalis toxicity, CHF.

    Ventricular Fibrillation (VF)

    • Severe heart rhythm derangement with irregular waveforms of varying shapes and amplitudes.
      • Multiple ectopic foci in the ventricle.
      • Ventricle quivers with no effective contraction, resulting in no cardiac output.
      • Lethal dysrhythmia requiring defibrillation.
      • Rate: Not measurable.
      • Rhythm: Irregular.
      • No P wave or measurable QRS.
      • Causes: AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, drug toxicity, trauma.

    Asystole

    • Absence of ventricular electrical activity.
      • Occasionally P waves may be seen.
      • No ventricular contraction due to lack of depolarization.
      • Lethal dysrhythmia requiring immediate treatment.
      • Causes: advanced heart disease, severe cardiac conduction system problem, end-stage HF.

    Pulseless Electrical Activity (PEA)

    • Organized electrical activity on ECG, but no mechanical heart activity or pulse.
      • Most common dysrhythmia after defibrillation.
      • Prognosis is poor unless the underlying cause is quickly identified and addressed.
      • Causes: hypovolemia, hypoxia, metabolic acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, trauma.

    ECG Rhythm Strip Interpretation

    • Heart Rate:
      • Count QRS complexes and multiply by 10 for beats per minute (BPM).
      • Atrial rate = number of P waves.
      • Ventricular rate = total QRS x 10.
    • Rhythm:
      • Assess for regularity of intervals between QRS (or R) waves.
        • Regular: Intervals vary less than 0.06 seconds (1.5 boxes).
        • Irregular: Intervals vary more than 0.06 seconds (1.5 boxes).
    • P Wave:
      • First deviation from the isoelectric line, representing atrial depolarization.
      • Should be rounded, upright, and occur at regular intervals.
      • Normal duration: 0.06-0.12 seconds.
      • Variations point to potential atrial conduction issues.
    • PR Interval:
      • Measured from the P wave onset to QRS onset.
      • Reflects the time from atrial contraction to ventricular contraction onset.
      • Normal interval: 0.12-0.20 seconds (3-5 small squares).
      • Variations suggest possible conduction issues in the AV node, bundle of His, or bundle branches.

    QRS Complex

    • Q Wave:
      • First negative deflection after the P wave.
      • Short and narrow, often absent in several leads.
      • Wide, deep Q waves can signify a myocardial infarction (MI).
    • R Wave:
      • First positive deflection within the QRS.
    • S Wave:
      • First negative deflection after the R wave.
    • QRS Interval:
      • Duration from the beginning to end of the QRS complex.
      • Represents ventricular depolarization (contraction).
      • Normal duration: less than 0.12 seconds.
      • Variations may indicate conduction problems in the bundle branches or ventricles.
    • QT Interval:
      • Measured from the beginning of the QRS to the end of the T wave.
      • Represents the time for both ventricular depolarization and repolarization.
      • Normal duration: 0.34-0.43 seconds.
      • Variations can be caused by issues affecting repolarization, such as drugs, electrolyte imbalances, and changes in heart rate.

    T Wave and U Wave

    • T Wave:
      • Represents ventricular repolarization.
      • Usually the first positive deflection following the QRS complex.
      • Normal duration: 0.16 seconds.
      • Variations may be caused by fluid or electrolyte imbalances, ischemia, or infarction.
    • U Wave:
      • Not always visible on EKG strips.
      • Smaller than the T wave, rounded, and upright.
      • Can indicate hypokalemia (low potassium levels).

    Normal Sinus Rhythm (NSR)

    • Regular rhythm set by the sinoatrial node (SA node).
    • All components of the EKG are normal.

    Sinus Bradycardia

    • Regular rhythm but slow heart rate (less than 60 BPM).
    • May be normal for athletes, during sleep, or in response to a vagal maneuver.
    • Causes: Hypoglycemia, hypothermia, hypothyroidism, medications, MI, sick sinus syndrome.
    • Symptoms: Syncope (passing out), dizziness, shortness of breath (SOB), cool, clammy skin.
    • Treatment: May involve stopping medications, holding or reducing dosages, or administration of IV atropine (anticholinergic).

    Sinus Tachycardia

    • Heart rate faster than 100 BPM due to rapid SA node firing.
    • Requires further investigation to determine if normal for the individual.
    • High heart rate correlates with high respiratory rate.
    • May present with palpitations.
    • Causes: Heart disease, hypertension, hyperthyroidism, fever, stress, alcohol, caffeine, nicotine, drugs, medication side effects, pain, electrolyte imbalances (potassium).
    • Symptoms: Dizziness, SOB, lightheadedness, palpitations, chest pain, syncope.
    • Treatment: Vagal maneuvers initially, followed by IV beta blockers (metoprolol), adenosine, or calcium channel blockers (diltiazem).

    Atrial Arrhythmias

    • Occur when the SA node fails to generate an impulse, resulting in other atrial tissue or internodal pathways initiating an impulse.
    • Four most common types: atrial flutter, atrial fibrillation, supraventricular tachycardia, and premature atrial complexes.

    Atrial Fibrillation (A-Fib)

    • Uncoordinated electrical signal circles through the atria, causing quivering (400+ BPM) without effective contraction.
    • Ventricles receive irregular impulses, resulting in an uncontrolled and irregular heartbeat (tachycardia).
    • Decreased cardiac output (CO) due to ineffective atrial contractions ("loss of atrial kick") and/or a rapid ventricular response.
    • Blood stasis can lead to thrombi forming in the atria.
    • Embolized clots can travel to the brain, causing stroke.
    • Patients are usually on blood thinners.
    • Causes: Heart failure, COPD, pericarditis, heart disease, stress, high alcohol or caffeine consumption.
    • Symptoms: Palpitations, irregular pulse, dizziness, fainting, fatigue, confusion, trouble breathing (especially while lying down), chest tightness.
    • Treatment: Rate control to lower the ventricular rate to 80-100 BPM. Options include Digoxin, beta blockers, calcium channel blockers (verapamil IV for rapid rate control), antithrombotic therapy, chemical or electrical cardioversion.

    Atrial Flutter (A-Flutter)

    • Coordinated, but rapid beating of the atria.
    • Identified by recurring, regular, sawtooth-shaped "flutter waves."
    • Atria beat faster than the ventricles (often a 4:1 ratio of flutter waves to QRS complexes).
    • Atrial rate can reach 350-600 BPM.
    • Causes: Heart failure, pulmonary embolism, MI, digoxin toxicity, coronary artery disease (CAD), valve problems, drugs, hyperthyroidism, cor pulmonale, hypertension.
    • Symptoms: Palpitations, SOB, anxiety, weakness, angina, syncope.
    • Treatment: Cardioversion, antiarrhythmics (procainamide, diltiazem, verapamil, digitalis, or beta blockers) to slow the ventricular rate, heparin to reduce thrombus formation.

    Ventricular Arrhythmias

    • Occur when the ventricles take over as the pacemaker, often due to an ectopic focus.
    • Can cause sudden and severe rhythm disturbances with a high risk of death if not quickly addressed.
    • Examples: Ventricular tachycardia (VT), Ventricular fibrillation (VF), Torsades de Pointes.
    • All require prompt and aggressive medical intervention.

    Premature Ventricular Contractions (PVCs)

    • Contraction originating from an ectopic focus in the ventricles.
    • Results in a premature (early) QRS complex, appearing wide and distorted.
    • Possible types:
      • Unifocal PVC: Same shape, originating from a single focus.
      • Multifocal PVC: Arise from different foci, resulting in varying shapes.
      • Ventricular Trigeminy: Every other beat is a PVC.
      • Couplet: Two consecutive PVCs.
    • Causes: Stimulants (caffeine, alcohol, nicotine, epinephrine, isoproterenol), electrolyte imbalances, heart disease, hypoxia (low oxygen), fever, exercise, emotional stress.
    • Treatment: Assess the patient's hemodynamic status to determine if drug therapy is necessary. Options include beta blockers, lidocaine, or amiodarone

    Accelerated Idioventricular Rhythm (AIVR)

    • Ventricles attempt to maintain rhythm after SA and AV node failure.
    • No P waves.
    • Rate: 40-100 beats per minute.
    • Cardiac output is often compromised.
    • Amiodarone should not be used.
    • Causes: Drugs, MI, metabolic imbalances, hyperkalemia, cardiomyopathy.
    • Symptoms: Pale, cool skin, weakness, dizziness, hypotension, mental status changes.
    • Treatment: Often tolerated well without specific treatment. If symptomatic (hypotension, chest pain), atropine is an option. Temporary pacing may be required.

    Ventricular Tachycardia (VT)

    • Run of 3 or more PVCs.
    • Ventricles take control as the pacemaker due to repeated firing from an ectopic focus.
    • Life-threatening due to decreased CO and potential progression to VF, which is lethal.
    • Types:
      • Monomorphic VT: QRS complexes have the same shape, size, and direction.
      • Polymorphic VT: QRS complexes gradually change shape, size, and direction with each beat.
      • Torsades de Pointes (TdP): Polymorphic VT with a prolonged QT interval, associated with sudden upward and downward deflections of QRS complexes.
    • Causes: Underlying heart disease, MI, medications (QT prolonging drugs), electrolyte imbalances, digitalis toxicity, CHF.
    • Symptoms: Angina, syncope, lightheadedness/dizziness, palpitations, SOB, absent or rapid pulse, loss of consciousness, hypotension
    • Treatment: If no pulse, initiate CPR. If pulse is present and patient is unstable, cardiovert and start drug therapy (amiodarone, lidocaine, antiarrhythmics). Ablation and long-term Implantable Cardioverter-Defibrillator (ICD) may be necessary.

    Ventricular Fibrillation (VF)

    • Severe heart rhythm disturbance.
    • Characterized by irregular waves of varying shape and amplitude on EKG.
    • Multiple ectopic foci fire in the ventricle, causing quivering with no effective contraction.
    • No cardiac output occurs.
    • Lethal dysrhythmia requiring immediate intervention.
    • Causes: AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, drug toxicity, trauma.
    • Symptoms: Loss of consciousness, absent pulse.
    • Treatment: CPR with immediate defibrillation.

    Asystole

    • Absence of ventricular electrical activity.
    • P waves may be seen occasionally.
    • No ventricular contraction occurs (no depolarization).
    • Lethal dysrhythmia requiring immediate treatment.
    • Symptoms: Unresponsiveness, pulseless, apneic.
    • Assessment: Always assess rhythm in multiple leads.
    • Causes: End-stage heart disease, severe conduction system problem, end-stage heart failure.
    • Treatment: CPR, epinephrine, and intubation. Correction of the underlying cause is crucial.

    Pulseless Electrical Activity (PEA)

    • Organized electrical activity present on the EKG, but no mechanical heart activity or pulse.
    • Common dysrhythmia seen after defibrillation.
    • Poor prognosis unless underlying cause is quickly identified and treated.
    • Causes: Hypovolemia (low blood volume), hypoxia (low oxygen), metabolic acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, trauma.
    • Treatment: CPR, epinephrine, intubation. Correction of the underlying cause is critical.

    Infective Endocarditis (IE)

    • Infection of the endocardium (innermost heart layer) and heart valves.
    • Associated with poor prognosis and reduced life expectancy.
    • Increasing prevalence linked to increased IV drug use.
    • Subacute form: Affects those with preexisting valvular disease.
    • Acute form: Affects those with healthy valves.
    • Most common causes: Staphylococcus aureus and Streptococcus viridans.
    • Risk Factors: History of valve or heart problems (rheumatic heart disease, congenital heart disease, Marfan's syndrome), open wounds, abscesses, procedures, infected needles, prosthetic valves, prior history.
    • Stages:
      • Bacteremia: Bacteria enters the bloodstream.
      • Adhesion: Bacteria adheres to the valve endothelium.
      • Vegetation: Masses of bacteria, fibrin, and platelets form on heart valves or endocardium, prone to embolization.
    • Left-sided vegetation: Emboli can travel to the brain, kidneys, spleen, and extremities.
    • Right-sided vegetation: Emboli can travel to the lungs (pulmonary embolism - PE).
    • Complications: Heart failure, dysrhythmias, kidney problems, night sweats, SOB.

    Clinical Manifestations of IE

    • Chills
    • Roth spots (on the eye)
    • Malaise
    • Fatigue
    • Anorexia
    • Splinter hemorrhages (under fingernails)
    • Petechiae
    • Osler's nodes (tender purple/pink nodules on fingers and/or toes)
    • Janeway's lesions (painless, small, flat hemorrhages on the palms or soles)
    • Fever

    Diagnostic Studies for IE

    • 2-3 blood cultures within 1 hour, collected from different sites.
    • ESR, C-reactive protein, CBC
    • Echocardiogram (echo) to visualize vegetation

    Diagnosis of IE

    • Requires either:
      • Two major criteria and one minor criterion.
      • One major criterion and three minor criteria.
      • Five minor criteria.
    • Major Criteria:
      • Positive blood culture.
      • New valvular vegetation.
    • Minor Criteria:
      • Predisposing heart condition (rheumatic heart disease) or IV drug use.

    Treatment for IE

    • IV antibiotics for 4-8 weeks (inpatient) after identifying the causative organism and selecting the appropriate antibiotic (usually vancomycin or penicillin).
    • Repeat blood cultures every 24-48 hours until infection clears.
    • Echo and inflammatory markers (blood work) at 1, 3, 6, and 12 months after antibiotic completion.
    • Valve replacement may be required.

    Patient Teaching for IE

    • Avoid contact with people who have infections.
    • Avoid stress and fatigue, plan rest periods.
    • Regular dental visits.
    • Importance of completing antibiotic regimen.
    • Drug rehabilitation (if necessary)

    Monitoring Instructions for Patients with IE

    • Monitor body temperature (alternate Tylenol and ibuprofen for fever).
    • Be aware of potential complications.
    • Understand the nature of the disease and how to prevent reinfection.
    • Stress follow-up care, good nutrition, and prompt treatment of common infections.
    • Assess home setting and coping strategies.
    • Assess IV lines (patient should not leave with an IV).
    • Encourage compression stockings.
    • Instruct on deep breathing and coughing every 2 hours.

    EKG Components and Significance

    • P Wave: Atrial depolarization (contraction). Problems with the P wave indicate swelling of the atria.
    • QRS Complex: Depolarization of ventricles and atrial repolarization. Prolonged QRS interval suggests ventricular conduction delay.
    • T Wave: Ventricular repolarization. Inverted T waves often occur after myocardial damage.

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    Description

    Test your knowledge on the fundamentals of ECG interpretation, including heart rate calculations, rhythm analysis, and wave identification. This quiz covers key components such as P waves, PR intervals, and QRS complexes essential for understanding cardiac function.

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