EKG Interpretation NURS 6413 Fall 2024.pdf

Oh… my Heart! Dr. Jasmine Bonder Dr. Alison Peterson  Structure Physiology Contents Clinical significance ECGS Actions post ECGS  Normal Steps: 1. Heart rate 2. Intervals 3. Axis...

Oh… my Heart! Dr. Jasmine Bonder Dr. Alison Peterson  Structure Physiology Contents Clinical significance ECGS Actions post ECGS  Normal Steps: 1. Heart rate 2. Intervals 3. Axis 4. Rhythm- regular vs irregular 5. Conduction Blocks 6. Pre-excitation 7. Enlargement and Hypertrophy 8. CAD/ACS 9. Other conditions  Each intervals Duration 0.06 – 0.10 seconds Amplitude 0.5 – 2.5 mm  Heart Rate #1 It’s the first step in determining the heart’s rhythm 3 step method (300 or 1500 method) 1. Find an R wave that falls on, or nearly one, one the heavy lines 2. Count the # of large squares until the next R wave 3. Determine the rate in beats per minute as follows: If there is one large square between successive R waves, then each R wave is separated by 0.2 seconds. Over course of 1 second, there are 5 cycles of cardiac activity (1 second/0.2 seconds) and over 1 minute, 300 cycles. HR=300 bpm 3 large squares = 100 beats per minute 4 large squares = 75 beats per minutes 5 large squares= 60 beats per minute 6 large squares = 50 beats per minutes Or divide 300 by the # of large squares between R waves- regular rhythms Count the total # of small squares between R waves and /1500- tachy rhythms Axis  Right Axis Deviation Normal RVH Conduction disturbances MI Valvular Disease Pulmonary HTN Congenital Pulmonary disease  Left Axis Deviation Left Axis deviation Normal LVH Conduction disturbances MI Valvular Disease Systemic HTN Congenital Other  Abnormal vs. Normal Heart rate 60–100 per minute 100 per minute Heart rhythm Regular Irregular P wave Sinus P wave Non-sinus P wave PR interval period 0.12–0.20 seconds 0.20 seconds QRS wave Normal Abnormal voltage QRS wave Abnormal electric axis QRS duration augmentation Pathological Q wave ST segment Normal ST segment Elevation and depression of ST segment T wave Normal T wave Tip, flat, or inverted T wave Other issues U wave Abnormal electrolyte-related ECG Drug-related ECG  4 questions: Ask the 4 questions? Are there normal p waves present? Are the QRS complexes wide or narrow? What is the relationship between the p waves and QRS complexes? Is the rhythm regular or irregular?  Rhythms Clinical Cause and Treatment STEMI Management significance Code Management  Sinus rhythms Sinus Bradycardia Sinus Tachycardia Sinus Rhythm Sinus Rhythm  Sinus Brady Rate: Less than 60 BPM Rhythm: Regular P waves: Upright/consistent PR- 0.12- 0.20 QRS -> Less than 0.12  Sinus Bradycardia Causes: Medication, electrolytes, ICP, Cardiac Ischemia (CAD) Eating disorders, Hypothyroid Well trained athelete Treatment Are they symptomatic?? Pacemaker, Medication (atropine), Athlete, Monitor Pace (initially)  Sinus Tachycardia Rate: greater than 100bpm Rhythm: Regular P wave- upright  Sinus Tachycardia Causes: Thyroid, fever, Illness, medication, anxiety, dehydration, energy drinks, pain, blood loss, sympathetic nerve stimulation Criteria: Greater than 100 bpm- 150bpm Treatment: Fix concern Hydration  Irregular Ventricular Rhythms SVT PVC V-tach (pulse and pulseless) Ventricular fibrillation SVT  SVT Causes: Idiopathic, Medication, Electrolyte Treatment: Vagal response, carotid massage, adenosine (6,12,12), electric cardioversion PVC  PVC Causes: Electrolyte imbalance, medication Treatment: Generally benign and are not a cause for concern unless underlying cardiopathy Monitor, fix electrolyte Holter monitor Vtach  Vtach (pulseless) Causes: MI, electrolyte imbalance, cardiomyopathy, dissection Treatment: CODE MANAGEMENT (CPR, Epi, Chest compression) Electrical Cardioversion Fix Electrolytes  V-tach with a Pulse Causes: MI, electrolytes, cardiomyopathy, dissection Treatment: Electrical Cardioversion Fix Electrolytes CODE MANAGEMENT (Epi, Chest compression)  Torsades Causes: QT prolongation (Medication, electrolyte imbalance) Treatment: 2gm of Mag Sulfate “Ballerina”, “turning on a point”  Irregular Atrial Rhythm Atrial fibrillation Atrial Flutter Premature Atrial Contractions Junctional rhythm (appears to be Atrial but is not) Atrial flutter  Atrial flutter Causes: Underlying arrythmia, electrolyte imbalance Treatment: Rate control Anticoagulation Electric or pharmacological cardioversion Fix electrolytes  Premature Atrial Contraction Causes: An normal variant Treatment: Generally benign Refer to cardiology is there is significant underlying cardiomyopathy (ie EF of REMEMBER P wave greater than normal Whats normal? Causes: Treatment: Monitor  2nd Degree Block Type 1 -> Mobitz 1 Causes: inferior MI, myocarditis, cardiac surgery Type 2 -> Mobitz 2 Causes: Hyperkalemia, Anterior MI, autoimmune, Treatment: treat underlying condition  3rd Degree Block No correlation between AV Atrial rate is independent from Ventricular rate Causes: cardiac ischemia, electrolyte imbalance, medication toxicity Treatment: Fix underlying  Bundle branch block Left and right 1. QRS duration can be measured from any of the 12 leads 2. All that matters is whether the QRS is normal or wide 3. Judge QRS prolongation from the lead where the QRS appears longest 4. If the QRS is: < 0.12 seconds than the QRS is normal > 0.12 seconds than the QRS is wide (greater than half a large box) LBBB  LBBB management: Causes: LVH, ventricular tachycardia, athletes Treatment: treat underlying disorders RBBB  RBBB management Causes: hypertrophic abnormalities, WPW syndrome, RVH Treatment: treat underlying disorders  Atrial Enlargement vs. Hypertrophy Hypertrophy: Condition in which muscular wall of the ventricle(s) becomes thicker than normal Associated with ventricles, pressure overload QRS complex changes used to identify ventricular hypertrophy Enlargement: Occurs as result of volume overload where chamber dilates to accommodate increased blood volume Associated with atria P wave changes used to identify atrial enlargement  Atrial Enlargement RAE Pulmonary HTN Pulmonary emboli COPD Tricuspid/Pulmonary valve disease Some congenital heart disease LAE Systemic HTN Aortic and Mitral disease Left ventricular failure What type of enlargement is this?  Hypertrophies Right Left (Precordial) Left (limb) LVH RVH R axis dev. >100 degrees R wave in V5 or V6 plus S wave in V1 or V2> R wave in aVL > 11mm; R wave in aVF> 20mm; R wave 35mm in I> 13mm Ratio of R wave amplitude to S wave R wave in V5>26mm; V6>18mm; R wave R wave in I plus the S wave in III > 25mm amplitude> than 1 in V1 & V5 LVH  LVH Causes HTN, cardiomyopathy, aortic valve stenosis Treatment: Blood pressure control, heart valve surgery RVH  RVH Causes: Chronic lung disease, pulmonary HTN, heart failure Treatment: treat underlying condition  Breakdown the terminology Ischemia lack of oxygenation ST segment depression or T wave inversion Angina is the classic symptom Need to determine if stable or unstable Unstable can result in ACS or MI Injury prolonged ischemia ST segment elevation Infarct death of tissue may or may not show a Q wave Different Myocardial Infarctions Examples: Calcium Pacemaker Tracings