ECG Session By Medic Praise PDF

2.1 12 LEADS ECG MEDIC PRAISE.I.  AXIOM 2 ALL RHYTHM INTERPERTATION MUST BE CORRELATED WITH SIGNS & SYMPTOMS AND PATIENT CONDITION… “TREAT THE PATIENT, NOT THE MONITOR” MEDIC _ MTN 3 MEDIC _ MTN  Lead “Views” 4...

2.1 12 LEADS ECG MEDIC PRAISE.I.  AXIOM 2 ALL RHYTHM INTERPERTATION MUST BE CORRELATED WITH SIGNS & SYMPTOMS AND PATIENT CONDITION… “TREAT THE PATIENT, NOT THE MONITOR” MEDIC _ MTN 3 MEDIC _ MTN  Lead “Views” 4 MEDIC _ MTN 5 MEDIC _ MTN  Inferior Wall 6 ¨ II, III, aVF Left Leg I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 MEDIC _ MTN  Lateral 7 ¨ I, aVL, V5, V6 Lateral Wall I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 MEDIC _ MTN  Anterior Wall 8 I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 MEDIC _ MTN  Septal Wall 9 ¨ V1, V2 ¨ Along sternal borders I aVR V1 V4 II aVL V2 V5 III aVF V3 V6 MEDIC _ MTN  “R” WAVE PROGRESSION The right ventricle depolarizes faster than the left ventricle because it is smaller. The left ventricle sits to the left and posterior to the right ventricle. As current spreads leftward through the left ventricle, the height of the R wave in the precordial leads progressively increases. Normally, in V1 the R wave is more negative and as it progress to V6 the R wave becomes more positively deflected. “R” wave progression indicates that current is flowing normally through the anterior plane of the heart. 10 MEDIC _ MTN  Q Wave 11 Q wave is 10mm in chest leads and 5mm in limb leads MEDIC _ MTN  S Wave 13 MEDIC _ MTN  J-Point 14 MEDIC _ MTN  ST Segment 15 MEDIC _ MTN  ST Segment 16 ¨ Compare to TP segment ST TP MEDIC _ MTN  The J Point ¨ J point - end of QRS complex & beginning of ST segment 18 ¨ Find J-points and ST segments MEDIC _ MTN  ¨ Find J-points and ST 19 segments MEDIC _ MTN 20 ¨ AMI recognition Two things to know n Whatto look for n Where to look MEDIC _ MTN  What to look for 21 ¨ ST segment elevation One millimetre or more (one small box) in limb leads Two millimetres or more (two small boxes) in chest leads Present in two anatomically contiguous leads MEDIC _ MTN  Contiguous Leads 22 ¨ Limb leads that “look” at the same area of the heart OR ¨ Numerically consecutive chest leads MEDIC _ MTN  Contiguous Leads 23 ¨ Inferior wall: II, III, avF ¨ Lateral wall: I, aVL, V5, V6 ¨ Septum: V1 and V2 ¨ Anterior wall: V3 and V4 ¨ Posterior wall: V7, V8, V9 (leads placed on the patient’s back 5th intercostal space creating a 15 lead EKG) MEDIC _ MTN 24 MEDIC _ MTN ST Segment Elevation  ST Segment Analysis 26 MEDIC _ MTN  Practice 27 MEDIC _ MTN  Where to look 28 ¨ ST segment elevation measurement 0.04 seconds after J point MEDIC _ MTN 29 MEDIC _ MTN  Other ECG changes seen in AMI includes pathologic Q wave inverted T wave hyperacute T wave ST segment depression 30 MEDIC _ MTN  MINUTES HOURS DAYS WEEKS YEARS Pathologic Q wave ST segment elevation ST segment depressio n T wave inversion Hyperacut e T wave 31 MEDIC _ MTN  Inferior Wall 32 ¨ RCA ¨ The most common type of MI ¨ Nausea is common ¨ Frequent re-infarction or extends to lateral wall ¨ SA / AV node ¨ SB, sinus arrest, HB - 1st or 2nd degree AV blocks, PVC’s ¨ Nitrates if BP stable ¨ Medical control may ask crew to hold nitro for inferior wall MI until right sided infarct is ruled out. MEDIC _ MTN  Right Ventricular MI 33 ¨ Rare ¨ RCA ¨ LAD or Left circumflex could also cause ¨ Right sided heart failure ¨ Fluids – JVD with hypotension ¨ Watch for inferior wall MI too! MEDIC _ MTN  Right Ventricular Infarction Usually accompanies inferior MI due to proximal occlusion of the RCA Best diagnosed ST elevation in lead V4R An important cause of hypotension in inferior MI recognized by jugular venous distension with clear lung fields Aggressive therapy is indicated including: reperfusion, adequate IV fluids for right heart filling, and pacing to maintain A-V synchrony 34 MEDIC _ MTN  Posterior Wall 35 ¨ RCA ¨ Left Circumflex ¨ Seen with Inferior or lateral wall MEDIC _ MTN  Posterior Infarction Tall, broad (>0.04 sec) R wave and ST depression in V1 and V2 (reciprocal changes) Frequently associated with inferior MI Usually associated with obstruction of RCA and or left circumflex coronary artery 36 MEDIC _ MTN  Reciprocal Changes Region of ST Elevation Region of ST Depression Anterior (leads V1-V4) Inferior (true posterior) Inferior (leads II, III, aVF) Anterior (leads V1-V3 or lateral lead 1. aVL) Lateral ( leads I, aVF, V5, V6) Inferior ( leads II, III, aVF) True Posterior Anterior (leads V1-V3) 37 MEDIC _ MTN 38 MEDIC _ MTN  #1 39 MEDIC _ MTN  Normal 12 Lead / #1 40 MEDIC _ MTN 41 MEDIC _ MTN  Acute Anterior Lateral Infarct/ #2 42 MEDIC _ MTN 43 MEDIC _ MTN #3  Anterolateral Infarct/ #3 44 MEDIC _ MTN 45 MEDIC _ MTN #4  Acute Inferior Wall Infarct / #4 46 MEDIC _ MTN 47 MEDIC _ MTN  Inferior Wall MI / Afib / #5 The E KG reveals an irregularly irregular rhythm suggestive of atrial fibrillation. The rate is variable, with a controlled or slow ventricular response. The axis is physiologic. ST-T changes suggestive of ischemia/ injury are present in leads II, III, and aVF. ST elevation of >1mm in limb leads is indicative of a possible inferior wall myocardial infarction. Reciprocal changes are seen in leads one and aVL. 48 MEDIC _ MTN 49 MEDIC _ MTN #6  Anterio-lateral / #6 50 MEDIC _ MTN  A 55 year old man with 4 hours of “crushing” chest pain. 51 MEDIC _ MTN  A 55 year old man with 4 hours of “crushing” chest pain. Acute inferior myocardial infarction (with reciprocal changes)  ST elevation in the inferior leads II, III and aVF 52 MEDIC _ MTN  reciprocal ST depression in the anterior leads  A 63 Year Old woman with 10 hours of chest pain and sweating Can you guess her diagnosis? 53 MEDIC _ MTN  A 63 Year Old woman with 10 hours of chest pain and sweating Can you guess her diagnosis? Acute anterior-lateral myocardial infarction  ST elevation in the anterior leads V1 - 6, I and aVL 54 MEDIC _ MTN  reciprocal ST depression in the inferior leads 55 MEDIC _ MTN  Inferior/Posterior/RVI 56 MEDIC _ MTN 57 MEDIC _ MTN  Inferior - Posterior 58 MEDIC _ MTN 59 MEDIC _ MTN  Normal 60 MEDIC _ MTN  2.2 SINUS/ATRIAL RHYTHMS By Medic Iduitua Micah Rhythms of the SA Node ¨ Sinus Rhythm ¨ Sinus Bradycardia ¨ Sinus Tachycardia ¨ Sinus Arrhythmia MEDIC _ MTN  Sinus Rhythm 1. Rate: 60 - 100/minute 2. Is the rhythm regular or irregular? Regular 3. Are there P waves? Yes PR Interval: 0.12 -.0.20 seconds 4. Is the QRS wide or narrow? Narrow 5. Is there a relationship between P waves and QRS complexes? Yes 1:1 ratio MEDIC _ MTN  Normal Sinus Rhythm 64 MEDIC _ MTN  Sinus Bradycardia 1. Rate: < 60/minute 2. Is the rhythm regular or irregular? Regular 3. Are there P waves? Yes PR Interval: normal to slightly prolonged 4. Is the QRS wide or narrow? Narrow 5. Is there a relationship between P waves and QRS complexes? Yes 1:1 ratio MEDIC _ MTN ¨ Sinus beat slower then 60/minute ¨ Can be caused by vagal stimulation ¨ Can be caused by medications, such as beta blockers ¨ Normally found in well conditioned athletes ¨ PR Interval may be widened by should not be widened past its upper limits MEDIC _ MTN  Sinus Tachycardia 1. Rate: > 100/minute 2. Is the rhythm regular or irregular? Regular 3. Are there P waves? Yes PR Interval: normal to slightly shortened 4. Is the QRS wide or narrow? Narrow 5. Is there a relationship between P waves and QRS complexes? Yes 1:1 ratio MEDIC _ MTN ¨ Sinus tachycardia evolves in response to a primary precipitating mechanism. These are many and varied but include: pain, fever, anxiety, hypoxemia, and hypovolemia. ¨ Maximum sinus rate is 220- age in years (+/- 10) MEDIC _ MTN  Sinus Arrhythmia 1. Rate: 60 - 100/minute 2. Is the rhythm regular or irregular? Irregular 3. Are there P waves? Yes PR Interval: Normal 4. Is the QRS wide or narrow? Narrow 5. Is there a relationship between P waves and QRS complexes? Yes 1:1 MEDIC _ MTN ¨ Normal response to respiratory variation. ¨ Exhalation = slower ¨ Inhalation = faster, because inhalation increases venous return by lowering intrathroacic pressure ¨ This rhythm is most commonly seen with breathing due to fluctuations in parasympathetic vagal tone. During inspiration stretch receptors in the lungs stimulate the cardioinhibitory centers in the medulla via fibers in the vagus nerve. ¨ Seen more in children then adults. ¨ All rhythms will have a some sinus arryythmia, as our rate does not stay at a absolute constant. MEDIC _ MTN WANDERING ATRIAL PACEMAKER ¨ Changing P wave with change of ectopic foci ¨ Rate- 100 ¨ Rhythm- irregularly irregular ¨ P wave- at least 3 morphologies ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- variable MEDIC _ MTN MEDIC _ MTN MEDIC _ MTN  Atrial Flutter ETIOLOGY: n Occurs /w heart disease n Cad n Valve disorders CLINICAL SIGNS n “Saw tooth” p-waves, called f-waves n Atrial rate = 250 – 400/ min n Av node blocks some impulses n Incomplete emptying of atria cause risk for thrombus GIVE ANTICOAGULANTS MEDIC _ MTN Atrial Flutter MEDIC _ MTN MEDIC _ MTN MEDIC _ MTN Atrial Fibrillation ¨ CHAOTIC ELECTRICAL ACTIVITY IN ATRIA ¨ ATRIA QUIVER (>500 beats/minute) INSTEAD OF CONTRACTING AS A UNIT ¨ ETIOLOGY: ADVANCED AGE VALVE DISORDERS CARDIOMYOPATHY MEDIC _ MTN Atrial Fibrillation “F” FIBRILLATORY WAVES ø P-WAVES, ø P-R INTERVAL QRS normal VENTRICULAR RATE IS IRREGULAR RAPID VENTRICULAR RESPONSE à PULSE DEFICIT MEDIC _ MTN Atrial Rhythms MEDIC _ MTN PREMATURE ATRIAL CONTRACTION *PAC* ¨ Rate- depends on the underlying rhythm ¨ Rhythm- depends on the underlying rhythm but irregular with PAC ¨ P wave- different morphology from sinus P ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- variable with PAC but normal in underlying sinus rhythm MEDIC _ MTN MEDIC _ MTN MEDIC _ MTN 2.3 JUNCTIONAL RHYTHMS By MEDIC PRAISE.I.  JUNCTIONAL RHYTHMS 87 ¨ Premature junctional contraction ¨ Junctional escape rhythm ¨ Accelerated junctional rhythm ¨ Junctional tachycardia MEDIC _ MTN PREMATURE JUNCTIONAL CONTRACTION PJC 88 ¨ Rate- depends on underlying rhythm ¨ Rhythm- depends on the underlying rhythm but irregular with PJC ¨ P wave- none, antegrade, retrograde ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- variable with PJC MEDIC _ MTN 89 ¨ PJC results in a compensatory pause MEDIC _ MTN  Junctional escape rhythm 90 ¨ Rate- 40-60 ¨ Rhythm- regular ¨ P wave- none, antegrade, retrograde ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- none, short, retrograde MEDIC _ MTN 91 MEDIC _ MTN  Accelerated junctional rhythm 92 ¨ Rate- 60-100 ¨ Rhythm- regular ¨ P wave- none, antegrade, retrograde ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- none, short, retrograde MEDIC _ MTN  Junctional tachycardia 93 ¨ Rate- 100 ¨ Rhythm- regular ¨ P wave- none, antegrade, retrograde ¨ P- QRS – 1-1 ¨ QRS- normal ¨ PRI- none, short, retrograde MEDIC _ MTN 94 MEDIC _ MTN  pre-exitation syndrome 95 wolf parkinson white syndrome ¨ presence of an accessory pathway- bundle of kent ¨ impulse reaches the ventricle through the accessory pathway before the purkinje fibres MEDIC _ MTN 96 MEDIC _ MTN 97 MEDIC _ MTN 98 MEDIC _ MTN 99 ¨ short PRI ¨ sluring of the QRS (delta wave ) MEDIC _ MTN 2.4 VENTRICULAR RHYTHMS By MEDIC PRAISE.I.  Ventricular Rhythms 101 ¨ Idioventricular rhythm ¨ Accelerated idioventricular rhythm ¨ Premature ventricular complex (ventricular ectopic) ¨ Ventricular tachycardia ¨ Ventricular Fibrillation MEDIC _ MTN  Idioventricular Rhythm 102 1. Rate: 20 - 40/minute 2. Is the rhythm regular or irregular? regular 3. Are there P waves? No PR Interval:None 4. Is the QRS wide or narrow? Wide 5. Is there a relationship between P waves and QRS complexes? No P Waves MEDIC _ MTN  Accelerated Idioventricular Rhythm 103 1. Rate: 40 - 100/minute 2. Is the rhythm regular or irregular? regular 3. Are there P waves? No PR Interval: none 4. Is the QRS wide or narrow? Wide 5. Is there a relationship between P waves and QRS complexes? No P waves MEDIC _ MTN 104 MEDIC _ MTN 105 MEDIC _ MTN  Premature Ventricular Complex (PVC) 106 1. Rate: depends on underlying rhythm 2. Is the rhythm regular or irregular? Irregular 3. Are there P waves? None in the PVC PR Interval: None 4. Is the QRS wide or narrow? Wide; bizarre appearance 5. Is there a relationship between P waves and QRS complexes? None in PVC MEDIC _ MTN 107 ¨ An impulse originating in the ventricle, it is wide and unusual. It is not preceded by a P wave. There is a pause following the premature beat. ¨ They also identify an ectopic pacing site within the ventricle. This is worrisome clinically as a pacing site that is irritable in the ventricle could take over the basic rhythm and lead to ventricular tachycardia or promote a more serious event. ¨ Because of their areas of origin, PVCs have a distinct appearance and stand out from the MEDIC _ MTN 108 ¨ if the patient has multiple PVCs, but they all look the same, they are described as unifocal. ¨ When a PVC is unifocal, it is thought to consistently come from the same ectopic pacing site in the ventricle. ¨ Sometimes the patient will have PVCs with more than one morphology. In this scenario they are termed multifocal. MEDIC _ MTN PREMATURE VENTRICULAR CONTRACTION 109(PVC) ¨ CLINICAL SIGNS: DEPEND ON FREQUENCY PVC à SHORT DIASTOLIC FILLING TIME C.O. FREQUENT PVC – SENSATION OF PALPATIONS, SKIPPED BEATS BIGEMINY – PVC EVERY OTHER BEAT TRIGEMINY – PVC EVERY 3RD BEAT MEDIC _ MTN  bigeminy 110 MEDIC _ MTN 111 ¨ Couplet- two PVC in a row ¨ 3 or more PVC in a row is run of salvos or VT ¨ Watch out for PVC landing on a T wave- R on T MEDIC _ MTN  Ventricular Tachycardia 112 1. Rate: 100 - 250/minute 2. Is the rhythm regular or irregular? regular 3. Are there P waves? None or dissociated PR Interval: None 4. Is the QRS wide or narrow? Wide; bizarre appearance 5. Is there a relationship between P waves and QRS complexes? No MEDIC _ MTN 113 MEDIC _ MTN  Ventricular Tachycardia 114 MEDIC _ MTN  Polymorphic VT 115 MEDIC _ MTN  Ventricular Fibrillation 116 1. Rate: Indeterminate 2. Is the rhythm regular or irregular? Chaotic 3. Are there P waves? None PR Interval: None 4. Is the QRS wide or narrow? None 5. Is there a relationship between P waves and QRS complexes? No P waves, no QRS complexes MEDIC _ MTN  Ventricular Fibrillation 117 MEDIC _ MTN  Ventricular Fibrillation 118 MEDIC _ MTN 119 QUESTIONS MEDIC _ MTN