ECG for NPs


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  • Before understanding the dynamics of 12 Lead EKG interpretation, it is important to clearly understand the basic anatomy and physiology of the heart. This includes understanding why different rhythms occur and the consequences of those rhythms. So, let’s start by looking at basic A&P of the heart.
  • Right arm Lead I, Left arm Lead aVF. If right drops, RAD; if left drops, LAD. If both drop, combined L&RAD.
  • ECG for NPs

    1. 1. EKG for the NP
    2. 2. Cardiac A&P <ul><li>Heart is a muscle made up of four chambers. </li></ul><ul><li>The heart is the hardest working muscle in the human body. Located almost in the center of the chest, the heart is a hollow muscular organ – approximately the size of your clenched fist. </li></ul>
    3. 3. Cardiac A&P <ul><li>The heart is made up of 4 hollow chambers- </li></ul><ul><ul><li>Two upper chambers that receive blood returning to the heart are the Atria </li></ul></ul><ul><ul><li>Two lower chambers that pump blood out of the heart are the Ventricles </li></ul></ul>
    4. 4. Cardiac A&P <ul><li>The heart is divided into two pumping systems by the septa- </li></ul><ul><ul><li>The Right heart pumps venous (deoxygenated) blood into the lungs </li></ul></ul><ul><ul><li>The Left heart pumps arterial (oxygenated) blood into the systemic circulation </li></ul></ul>
    5. 5. Cardiac A&P <ul><li>Heart Valves permit blood flow in one direction only through the chambers of the heart </li></ul><ul><ul><li>Mitral and Tricuspid valves separate the atria from the ventricles and are referred to as the atrioventricular (AV) valves. </li></ul></ul><ul><ul><li>Aortic and Pulmonic valves separate the ventricles from the aorta and pulmonary artery . </li></ul></ul>
    6. 6. Flow of Blood through the Heart <ul><li>Blood flow can be traced from the right side to the left side of the heart, although it is important to remember that flow occurs simultaneously on both sides! </li></ul><ul><li>Right Side: </li></ul><ul><ul><li>Right Atrium receives unoxygenated blood from the body </li></ul></ul><ul><ul><li>As the chamber pressure in the right atrium rises above that of the right ventricle, the Tricuspid valve opens allowing blood to flow into the right ventricle </li></ul></ul><ul><ul><li>As the pressure in the Right ventricle rises, the Tricuspid valve closes and the Pulmonic valve opens allowing blood to be pumped from the ventricle into the pulmonary artery and lungs. </li></ul></ul>
    7. 7. <ul><li>Right Side: </li></ul><ul><ul><li>Right Atrium receives unoxygenated blood from the body </li></ul></ul><ul><ul><li>As the chamber pressure in the right atrium rises above that of the right ventricle, the Tricuspid valve opens allowing blood to flow into the right ventricle </li></ul></ul><ul><ul><li>As the pressure in the Right ventricle rises, the Tricuspid valve closes and the Pulmonic valve opens allowing blood to be pumped from the ventricle into the pulmonary artery and lungs. </li></ul></ul><ul><li>Left Side : </li></ul><ul><ul><li>Left Atrium receives oxygenated blood from the lungs. </li></ul></ul><ul><ul><li>As the chamber pressure of the left atrium rises above that of the left ventricle, the Mitral valve opens allowing blood to flow into the left ventricle </li></ul></ul><ul><ul><li>As the pressure rises in the Left ventricle , the Mitral valve closes and the Aortic valve opens allowing blood to be pumped from the right ventricle into the aorta and body ! </li></ul></ul><ul><ul><li>Mnemonic: </li></ul></ul><ul><ul><li>R emember a ll t he v entricular p umps l eave a m inor v olume a mount b ehind! </li></ul></ul><ul><ul><li>Right Atrium Tricuspid Ventricles Pulmonic, Left Atrium Mitral Ventricles Aorta Body </li></ul></ul>
    8. 8. Flow of Blood through the Heart <ul><ul><li>* Blood fills atria </li></ul></ul><ul><ul><li>* Blood enters ventricles </li></ul></ul><ul><ul><li>* Ventricles eject blood </li></ul></ul>
    9. 9. Cardiac Electrical Activity <ul><li>Blood does not simply flow through the heart by gravity. It is assisted by cardiac contractions that are stimulated by electricity flowing through the myocardium. </li></ul><ul><li>The heart is the only muscle in the body that has automaticity. </li></ul><ul><ul><li>What is automaticity? </li></ul></ul>
    10. 10. Cardiac Electrical Activity <ul><li>Automaticity is the capacity of a cell to initiate an impulse without an external stimulus. </li></ul><ul><li>The electrical impulse for contraction comes from the heart itself, not the brain. This explains why someone can be “braindead” and still have a textbook rhythm. </li></ul>
    11. 11. Cardiac Electrical Activity <ul><li>An EKG represents a picture of the flow of electricity as it travels through the heart. It does NOT represent cardiac contraction! Electricity can be present without the presence of contraction. </li></ul><ul><li>Flow originates in the SA Node, travels to the AV Node, the Bundle of His, Bundle Branches and Purkinje Fibers to create a cardiac cycle. </li></ul>
    12. 12. Cardiac Electrical Activity
    13. 13. <ul><li>SA Node- located at the top of the Right Atrium </li></ul><ul><ul><li>It is responsible for initiating the electrical stimulus and maintaining the pace of that rhythm </li></ul></ul><ul><ul><li>It is often times referred to as the primary pacemaker for the heart </li></ul></ul><ul><ul><li>The electrical stimulus is sent to the AV NODE </li></ul></ul>Sinoatrial (SA) NODE
    14. 14. <ul><li>AV Node- located at the junction between the Atria and Ventricles </li></ul><ul><ul><li>It has two main functions </li></ul></ul><ul><ul><ul><li>To slow and organize the signal coming from the SA Node before allowing it to pass through to the ventricles </li></ul></ul></ul><ul><ul><ul><li>To act as pacemaker in the absence of a signal from the SA Node. </li></ul></ul></ul><ul><ul><li>It is often times referred to as the backup pacemaker for the heart </li></ul></ul>Atrioventricular (AV) NODE
    15. 15. <ul><li>Once the AV Node sends the signal through to the ventricles it travels through the </li></ul><ul><ul><li>Bundle of His </li></ul></ul><ul><ul><li>Right and Left Bundle Branches </li></ul></ul><ul><ul><li>Purkinje Fiber (causing ventricular depolarization) </li></ul></ul>Ventricular Conduction
    16. 16. <ul><li>So how is this converted to the telemetry waveform? </li></ul>Ventricular Conduction
    17. 17. Telemetry Rhythm <ul><li>Each element of the electrical pathway plays a part in the waveform. For example: </li></ul><ul><ul><li>The SA Node creates the P wave- therefore, if there is no P wave, it is not a Sinus rhythm! </li></ul></ul><ul><li>The waveform is a measurement of time plotted on graph paper: </li></ul><ul><ul><li>1 small box = .04 seconds </li></ul></ul><ul><ul><li>1 large box = .20 seconds </li></ul></ul><ul><li>So, let’s breakdown the rhythm… </li></ul>
    18. 18. <ul><ul><li>P - SA Node initiating electrical impulse causing depolarization </li></ul></ul><ul><ul><li>PR - electricity traveling from SA Node to AV Node (note pause at AV node) </li></ul></ul><ul><ul><li>QRS - Flow from AV node to Purkinje Fibers </li></ul></ul><ul><ul><li>ST - represents the end of ventricular depolarization </li></ul></ul><ul><ul><li>T - represents ventricular repolarization (resting phase) </li></ul></ul>Ventricular Conduction
    19. 19. Interpretation of Rhythms <ul><li>Interpretation can be complicated but there are some simple basics you should remember: </li></ul><ul><ul><li>What is the rate? Is it sufficient for adequate perfusion? </li></ul></ul><ul><ul><li>Is the rhythm problem an atrial problem or ventricular problem? Ventricular problems are more life threatening! </li></ul></ul><ul><ul><li>What is the patients baseline? </li></ul></ul>
    20. 20. Interpretation of Rhythms <ul><li>Rules for interpretation: </li></ul><ul><ul><li>Are there upright p waves for each qrs? This tells you if they have a sinus rhythm </li></ul></ul><ul><ul><li>What is the rate? Multiply the # of contractions in a six second strip by 10 (ie: 8 contractions = 80 bpm) </li></ul></ul><ul><ul><li>Is the Rhythm regular or irregular? Must use calipers to accurately asses! </li></ul></ul><ul><ul><li>How wide is the PR interval? This tells you if the pause at AV node is too long </li></ul></ul><ul><ul><li>How wide is the QRS complex? This tells you how efficiently the ventricles are pumping </li></ul></ul>
    21. 21. Interpretation of Rhythms <ul><li>Sinus Rhythms- </li></ul><ul><ul><li>P waves are present and upright for every QRS </li></ul></ul><ul><ul><ul><li>Rates <60 – Sinus Bradycardia </li></ul></ul></ul><ul><ul><ul><li>Rates 60-100 – Normal Sinus Rhythm </li></ul></ul></ul><ul><ul><ul><li>Rates >100 – Sinus Tachycardia </li></ul></ul></ul><ul><ul><ul><li>Rates >150 – Supraventricular Tacycardia </li></ul></ul></ul>
    22. 22. Interpretation of Rhythms <ul><li>Junctional rhythms occur when the AV nodes acts as primary pacemaker, they have no p wave and have slower rate </li></ul><ul><ul><li>40-60bpm= Junctional </li></ul></ul><ul><ul><li>60-100bpm= Accelerated Junctional </li></ul></ul><ul><ul><li>What is this one? </li></ul></ul>
    23. 23. Interpretation of Rhythms <ul><ul><li>Atrial Flutter occurs when an ectopic signal is being sent from the atria to the AV node at an accelerated rate but the AV node only allows the signal through at a normal rate. </li></ul></ul>
    24. 24. Interpretation of Rhythms <ul><ul><li>Atrial Fibrillation occurs when the atria is quivering and the AV node is attempting to control the rate. It is always irregular and p waves are difficult to identify </li></ul></ul><ul><ul><li>What is important for you to remember about AFib? </li></ul></ul>
    25. 25. Interpretation of Rhythms <ul><ul><li>What is important for you to remember about AFib? </li></ul></ul><ul><ul><li>That all Atrial fibrillation patients MUST be anticoagulated! Clots form in the atria as it is fibrillating (quivering) and eventually get pumped out by the ventricles to vital organs! These patients need Coumadin, monitoring for INR and possibly evaluation for a filter in the Aorta to prevent the ejection of clots. </li></ul></ul>
    26. 26. Interpretation of Rhythms <ul><ul><li>PVC’s- Premature Ventricular Contraction </li></ul></ul><ul><ul><li>A PVC is an beat that comes earlier than expected and originates from somewhere in the ventricles, rather than the atria. These are ectopic beats that are non-perfusing. Why? Because they occur before there has been adequate filling time in the ventricle. </li></ul></ul><ul><ul><li>Why is this important as a primary provider? Because a PVC is a red flag that something is wrong. Electrolyte status and medication levels are the most common causes. </li></ul></ul>
    27. 27. Interpretation of Rhythms <ul><ul><li>Ventricular Rhythms! </li></ul></ul><ul><ul><ul><li>These are life threatening! Since you hopefully won’t see these in primary care, we just quickly identify them. </li></ul></ul></ul><ul><ul><ul><li>Ventricular Tachycardia- 3 or more PVC’s in a row; patient may or may not have a pulse </li></ul></ul></ul><ul><ul><ul><li>Ventricular Fibrillation- Quivering of the Ventricles, patient will NOT have a pulse and is the most common cause of sudden cardiac death! </li></ul></ul></ul><ul><ul><ul><li>Asystole- the absence of cardiac conduction </li></ul></ul></ul>
    28. 28. 12 Lead EKG <ul><li>First lets talk a minute about the ECG Leads: </li></ul><ul><ul><li>There are 6 standard limb leads that show cardiac electricity from 6 vertical planes. </li></ul></ul><ul><ul><li>There are 6 standard limb leads that show electricity from 6 horizontal planes. </li></ul></ul><ul><ul><li>These leads are I, II, III, aVR, aVL, aVF, V1-V6. </li></ul></ul>
    29. 29. 12 Lead EKG <ul><li>Standard Leads- I, II, III </li></ul><ul><ul><li>There are three leads which are usually designated as I, II and III. </li></ul></ul><ul><ul><li>They are all bipolar (i.e., they detect a change in electric potential between two points) and detect an electrical potential change in the frontal plane. </li></ul></ul><ul><ul><li>Lead I is b/w the right arm and left arm, the left arm being positive. </li></ul></ul><ul><ul><li>Lead II is b/w the right arm and left leg, the left leg being positive. </li></ul></ul><ul><ul><li>Lead III is b/w the left arm and left leg, the left leg being positive. </li></ul></ul><ul><li>Augmented Leads- aVR, aVL, aVF </li></ul><ul><ul><li>The same three leads that form the standard leads also form the three unipolar leads known as the augmented leads. These three leads are referred to as aVR (right arm), aVL (left arm) and aVF (left leg) and also record a change in electric potential in the frontal plane. </li></ul></ul>
    30. 30. 12 Lead EKG <ul><li>Standard and Augmented leads </li></ul><ul><ul><li>I, II, III, aVR, aVL, aVF </li></ul></ul>
    31. 31. 12 Lead EKG <ul><li>Remember, that this is a waveform tracing electrical activity. The waveform picks up electricity going towards the heart as positive deflection and away from the heart as negative. </li></ul><ul><li>This becomes important in analyzing 12 leads and remembering which direction of flow the leads are looking at. </li></ul>
    32. 32. 12 Lead EKG <ul><li>Precordial Leads- </li></ul><ul><ul><li>V1, V2, V3, V4, V5, V6 </li></ul></ul>
    33. 33. 12 Lead EKG Interpretation <ul><li>The first thing you need to understand is how a 12 lead strip is organized. </li></ul><ul><li>There is a small section of rhythm for all 12 leads that occurred simultaneously. </li></ul>
    34. 34. 12 Lead EKG <ul><li>The next thing is that is a continuous rhythm strip of Lead II across the bottom of the analysis. This gives you a place to determine rate and rhythm. </li></ul>
    35. 35. 12 Lead EKG Interpretation <ul><li>Next you are going to look for Axis, Hypertrophy and Infarct. This is very simple if you follow some basic rules. </li></ul><ul><li>Let’s start with an overview. All of the leads should be positive except aVR, aVL, V1 & V2. Look at how that is represented…think of the 8 outside leads as the cup holding the contents and the four inside leads as if they were poured into the cup. </li></ul>
    36. 36. AXIS Deviations <ul><li>Now we can look at Axis. What is an Axis? It is hypothetical line which joins the poles of a lead measuring electrical force. </li></ul><ul><li>Normal Deviation: </li></ul><ul><ul><li>The QRS deflection is positive (mostly upright) in </li></ul></ul><ul><ul><ul><li>Leads I and either aVF or Lead II </li></ul></ul></ul><ul><ul><li>A normal axis means the QRS axis falls between 30 and 90 degrees in the chest. The heart is lying in an angle between these parameters </li></ul></ul>
    37. 37. AXIS Deviations <ul><li>So, lets go back and look at our normal 12 lead again. </li></ul><ul><li>Is Lead I and aVF mostly upright? Yes, then they are both positive which means the flow of electricity is following the same vector! You can also look at Lead II to help confirm, is it positive? Yes! So, this 12 lead has a Normal Axis. </li></ul>
    38. 38. AXIS Deviations <ul><li>How do you determine if the axis is deviated? Remember you are only looking at Leads I and aVF, and possibly Lead II. There are basic rules to follow: </li></ul><ul><ul><li>The axis is normal if the QRS deflection is positive in leads I and aVF. </li></ul></ul><ul><ul><li>There is RAD if the QRS deflection is negative in lead I, but positive in aVF. </li></ul></ul><ul><ul><li>There is LAD if the net QRS is positive in lead I, but negative in aVF. </li></ul></ul><ul><ul><li>The axis is indeterminate if net QRS deflection is negative in I and aVF. </li></ul></ul>
    39. 39. AXIS Deviations <ul><li>So, lets look at some EKG’s. </li></ul><ul><li>Is this a right or left axis deviation? </li></ul><ul><li>Is Lead I upright? No! Is aVF upright? Yes! </li></ul>
    40. 40. AXIS Deviations <ul><li>So, lets look at some EKG’s. </li></ul><ul><li>Is this a right or left axis deviation? </li></ul><ul><li>Is Lead I upright? No! Is aVF upright? Yes! Right Axis Deviation! </li></ul>
    41. 41. AXIS Deviations <ul><li>So, lets look at some EKG’s. </li></ul><ul><li>Is this a right or left axis deviation? </li></ul><ul><li>Is Lead I upright? Yes! Is aVF upright? No! </li></ul>
    42. 42. AXIS Deviations <ul><li>So, lets look at some EKG’s. </li></ul><ul><li>Is this a right or left axis deviation? </li></ul><ul><li>Is Lead I upright? Yes! Is aVF upright? No! Left Axis Deviation </li></ul>
    43. 43. Causes of Axis Deviations <ul><li>Right Axis Deviation: </li></ul><ul><li>The QRS is downward or negatively deflected in I and positive in aVF or Lead II. </li></ul><ul><ul><li>The heart is lying in an angle lower the 30 degrees in the chest. Can be normal in young adults or &quot;thin people.&quot; May be abnormal in people who have a block in the posterior division of the left bundle. Can imply delayed activation of the right ventricle ( as seen in RBBB ) or Right Ventricular enlargement. Pathology: Right Ventricular enlargement and hypertrophy. C.O.P.D. Pulmonary Embolism, Congenital heart Disease, Inferior wall MI. </li></ul></ul>
    44. 44. Causes of Axis Deviations <ul><li>Left Axis Deviation: </li></ul><ul><li>The QRS is upright or positively deflection in I and negative in aVF or Lead II. </li></ul><ul><ul><li>The heart is lying in an angle greater than 90 degrees in the chest. Can be normal in the presence of acites, abdominal tumors, pregnancy or obesity. Abnormalities are due to Left Ventricular enlargement or a Left anterior hemiblock. Pathology: Left ventricular enlargement, and hypertrophy, Hypertension, Aortic Stenosis. Ischemic Heart Disease. Inferior wall MI. </li></ul></ul>
    45. 45. Ventricular Hypertrophy <ul><li>Echocardiogram is the Gold Standard for determining chamber size. EKG is not reliable. However, it can provide some insight or prompt you to order an echo. So, look at these basic Simplified Criteria for Diagnosing . </li></ul><ul><li>LVH- </li></ul><ul><ul><li>Deepest S wave in lead V1 or V2, </li></ul></ul><ul><ul><li>plus tallest R wave in lead V5 or V6 > 35 </li></ul></ul><ul><ul><li>Patient > 35 years old. </li></ul></ul><ul><li>RVH- </li></ul><ul><ul><li>RAD or indeterminate axis. </li></ul></ul><ul><ul><li>RAA (p wave >2.5mm in II, II or aVF) </li></ul></ul><ul><ul><li>Incomplete RBBB </li></ul></ul><ul><ul><li>Persistent precordial S waves. </li></ul></ul><ul><ul><li>Tall R wave in lead V1. </li></ul></ul>
    46. 46. Bundle Branch Block <ul><li>In Bundle Branch Block, the firing of the Ventricles does not occur simultaneously as it should. Conduction reaches a block in one of the branches (in the cardiac septum) and refers it to the opposing branch to be conducted completely. It is then when conduction jumps the Intra-Ventricular Septum to ultimately conduct to the remaining blocked Bundle Branch. It is because of this that you see two different distinctly separate QRS complexes over-lapping one another. Hence, the &quot;Rabbit Ear“ </li></ul><ul><li>The last 0.04 seconds of deflection on the QRS complex is used to determine the direction of the block. </li></ul>
    47. 47. Bundle Branch Block <ul><li>In V1 and V6- if the QRS duration is greater that 0.12 seconds and … </li></ul><ul><li>the last 0.04 second segment of the complex is pointing down (negative deflection), the block is LEFT. </li></ul><ul><li>If the last 0.04 seconds of the QRS complex is pointing up and is positively deflected, the block is RIGHT. </li></ul>
    48. 48. Infarct <ul><li>Infarct is more complicated to diagnose but can be broken down into some basic steps. </li></ul><ul><ul><li>AMI diagnosis criteria: 1mm. or more of ST elevation in 2 or more contiguous leads. Anterior wall requires 2mm. or more of ST elevation (V1-V4) Caution: LBBB </li></ul></ul><ul><ul><li>Assure that aVR is primarily negative. </li></ul></ul><ul><ul><li>Rule out a left Bundle Branch Block (LBBB) in V1 and or V2. </li></ul></ul><ul><ul><li>Check all leads for patterns of ischemia, injury, infarction and reciprocal changes. </li></ul></ul><ul><ul><li>ST depression indicates angina </li></ul></ul>
    49. 49. Infarct <ul><li>ST segment elevation with an upward concavity (i.e., &quot; smiley &quot; configuration) is usually benign, especially when seen in an otherwise healthy, asymptomatic individual.  This is known as early repolarization . </li></ul><ul><li>In contrast, ST segment elevation with coving or a downward convexity (&quot; frowny &quot; configuration) is much more likely to be due to acute injury (from acute infarction). </li></ul>
    50. 50. Infarct <ul><li>ST Elevation: </li></ul><ul><ul><li>V1, V2, V3, and V4 -- 0.2mV or more in leads- Anterior–Septal MI </li></ul></ul><ul><ul><li>V1, and V2 -- 0.2mV or more in leads- Posterior MI </li></ul></ul><ul><ul><li>II, III, and aVF -- 0.1mV or more in 2 leads - Inferior MI </li></ul></ul>
    51. 51. Anterior-Septal Infarct <ul><li>V1, V2, V3, and V4 -- 0.2mV or more in leads- </li></ul>
    52. 52. Anterior-Septal Infarct <ul><li>V1, V2, V3, and V4 -- 0.2mV or more in leads- </li></ul>
    53. 53. Posterior Infarct <ul><li>The &quot;true&quot; posterior MI is recognized by pathological R waves in leads V1-2. </li></ul>
    54. 54. Inferior Infarct <ul><li>Significant pathological Q waves are seen in leads II, III and aVF along with resolving ST segment elevation and symmetrical T wave inversion. This is a classic inferior MI. </li></ul>
    55. 55. Ischemia <ul><li>ST Depression: </li></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>&quot;Strain&quot; </li></ul></ul><ul><ul><li>Digitalis effect </li></ul></ul><ul><ul><li>Hypokalemia/Hypomagnesemia </li></ul></ul><ul><ul><li>Rate-related changes </li></ul></ul><ul><ul><li>Any combination of the above </li></ul></ul>
    56. 56. Summary <ul><li>Remember, it isn’t as important to know every rhythm and every possible complication. What is important, is to know what is life threatening, what needs intervention in the primary care setting and what patient education can make a difference. Obviously, lifestyle modifications is very important in preventing or reversing many of these complications. </li></ul>
    57. 57. References <ul><li>Ferry, D.R. (2001). Basic Electrocardiography in Ten Days. McGraw-Hill; New York. </li></ul><ul><li>Huff, J.(2002). ECG Workout: Exercises in arrhythmia interpretation. Lippencott, Philadelphia. </li></ul><ul><li>Grauer, K (2008). 12 Lead ECG’s: a webbrain for easy interpretation. Retreived from . </li></ul>