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    Chapter 5: Analyzing A Rhythm Strip

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    Chapter 5: Analyzing A Rhythm Strip

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    79 views7 pages

    Chapter 5: Analyzing A Rhythm Strip

    Uploaded by

    telly

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 7

    Chapter 5: Analyzing a Rhythm Strip

    There are 5 steps to be followed in analyzing a rhythm strip

    Step 1: DETERMINE
    THE REGULARITY
    (RHTHYM) OF THE R
    WAVES

    Measure from R wave to R wave across the strip


    IRREGULAR If rhythm varies by 0.12 seconds (3
    small squares) or more between the shortest and
    longest R wave variation
    REGULAR if rhythm varies by less than 0.12
    seconds or does vary

    Step 2: CALCULATE
    THE HEART RATE

    Measurement will always refer to ventricular rate


    unless atrial and ventricular rates differ, in which case
    both will be given.
    Ventricular rate is usually determined by looking at a
    6- second strip

    Regular Rhythms:
    1. Rapid rate calculation Count the # of R waves in
    a 6 second strip and X 10(HR per minute)
    2. Precise rate calculation Count the number of
    small squares between two consecutive R waves
    and refer to conversion table. If conversion table
    not available (1500 / # small squares)
    NOTE: CAN ONLY BE USED FOR REGULAR
    RHTYMS

    Irregular Rhythms:
    1. Rapid rate calculation only used to calculate
    irregular rhythms. (# R waves in 6 second strips X
    10) OR ( # of R waves in 3 second strip X 20)

    Other Hints:
    When rhythm strips have a premature heartbeat,
    the pre mature heart beat isnt included in the
    calculation rate
    When a rhythm covers less than 3 seconds on a
    rhythm strip -cannot determine if regular or
    irregular (Multiply # of R waves X seconds shown
    on rhythm strips (HR per minute).

    Step 3: IDENTIFY AND


    EXAMINE TH P WAVE

    One P wave should precede each QRS complex


    All P waves should be identical in size, shape, and
    position

    Step 4: MEASURE HE

    Measure from the beginning of the P wave as it leaves

    PR INTERVAL

    Step 5: MEASURE THE


    QRS COMPLEX

    baseline to the beginning of the QRS complex


    Count the # of small squares contained I the interval X
    0.04 second
    Measure from the beginning of the QRS complex as it
    leaves baseline until the end of the QRS complex
    when the ST segment begins
    # small squares in measurement x 0.04 second

    Chapter 7: Atrial Arrhythmias

    Under certain circumstances cardiac cells in any part of the heart may take
    on the role of pacemaker of the heart ectopic pacemaker (a pacemaker
    other than the sinus node)
    o The result being ectopic beats or rhythms and are identified based on the
    location atrial, junctional, or ventricular

    Three basic mechanisms that are responsible for ectopic beats and rhythms
    are:
    1. Altered automaticity
    Normally the automaticity of the sinus node exceeds that of all other
    parts of the conduction system, allowing it to control heart rate and
    rhythm
    Pacemaker cells in the atria, ventricles, and AV junction have the
    property of automaticity, but are slower at these sites, therefore
    suppressed by the sinus node under normal circumstances
    Ectopic pacemaker can take over the role the primary pacemaker
    because it usurps control from the sinus node by accelerating its own
    automaticity or because the sinus node relinquishes its role by
    decreasing its automaticity
    Seen in MI, hypoxia, increase in sympathetic tone, digitalis toxicity,
    hypokalemia, and hypocalcemia
    2. Triggered activity
    Results from abnormal electrical impulses that occur during
    repolarization when the cells are quiet
    Triggered activity may result in atrial, junctional, or ventricular beats
    occurring singly, in pairs, in runs (3 beats or more)
    3. Re-entry
    Normally an impulse spreads through the heart only once. With reentry, an impulse can travel through an area of the myocardium,
    depolarize it and then reenter that same area to depolarize it again
    Involves a circular movement of impulses which continues as long as it
    encounters receptive cells
    may result in atrial, junctional, or ventricular beats occurring singly, in
    pairs, in runs (3 beats or more)

    IDENTIFYING ECG FEATURES OF ATRIAL ARRHYTHMIAS

    Wandering Atrial Pacemaker

    Occurs when the pacemaker site shifts back and forth between the sinus
    node and ectopic atrial sites
    Usually not clinically significant but treatment include monitoring patient
    and changing medications as needed

    Rhythm

    Regular or Irregular

    Rate

    Usually normal; 60-100 BPM


    May be slow ; > 60 BPM

    P Waves

    Vary across a rhythm strip as the pacemakers wanders between


    multiple sites
    The ectopic P wave may appear as a small, pointed, and upright
    wave form; a small squiggle that is barely visible, or it may be
    inverted of the impulse originates from a site lower than the
    atrium near the AVJ
    Generally, at least 3 different P-wave morphologies should be
    identified

    PR Interval

    Usually normal in duration; 0.12 0.20, but may be abnormal


    depending on changing pacemaker location

    QRS
    complex

    Normal; < 0.10

    PREMATURE ATRIAL CONTRACTION


    An early beat originating from an ectopic site in the atrium, which
    interrupts the regularity of the basic rhythm (usually a sinus rhythm)
    The pause associated with the PAC is usually a non-compensatory /
    incomplete pause (the measurement from the R wave before the premature
    beat to the R wave before the premature beat is less than two R-R intervals

    of the underlying regular rhythm


    Compensatory pause is equal to two R-R intervals, but usually seen with
    PVC
    PACs may occur as a single beat, every other beat (bigeminal), every third
    beat (trigeminal), or in pairs (couplets), or more
    Infrequent PACs require no treatment
    Frequent PACs are treated by correcting the underlying cause: reducing
    stress, eliminating, or reducing the consumption of alcohol, caffeine, or
    tobacco, administering oxygen, correcting electrolyte imbalances
    Occasionally an ectopic atrial beat will occur late instead of early called an
    atrial escape beat

    RHYTHM

    Underlying rhythm usually regular, irregular with PACs

    RATE

    That of underlying rhythm

    P WAVE

    P wave associated with PAC is premature and abnormal in size,


    shape, and direction; may be inverted; can be hidden in preceding
    T waves

    PR INTERVAL

    Usually normal, not measureable if hidden in T wave

    QRS
    COMPLEX

    Premature; normal duration


    WIDE QRS complex is called an abbarency

    NON CONDUCTED PAC

    Results when an ectopic atrial focus occurs so early that it finds the AV
    node refractory and the impulse isnt conduced to the ventricles. This
    results in abnormal P waves that do not accompany a QRS complex, but
    followed by a pause

    RHYTHM

    Underlying rhythm usually regular; irregular with non-conducted


    PACs

    RATE

    That of underlying rhythm

    P WAVE

    P wave associated with the non-conducted PAC is premature, and


    abnormal in size shape, or direction, often found hidden in
    preceding T-waves

    PR
    INTERVAL
    QRS

    Absent with non-conducted PAC


    Absent with non-conducted PAC

    PAROXYMAL ATRIAL TACHYCARDIA

    Trial tachycardia is often precipitated by a PAC and commonly starts and


    stops abruptly, occurring in bursts or paroxysmal. By definition, three or
    more consecutive PACs (at a rate of 140 - 250 BPM) is considered to be
    atrial tachycardia
    Rhythm ay be due to enhanced automaticity of atrial pace maker cells
    resulting in rapid firing of an ectopic atrial focus, or to an atrial re-entry
    circuit in which an impulse travels rapidly and repeatedly around a circular
    pathway in the atria
    Causes: anxiety (pt can feel palpitations of a rapid HR)
    Priorities of treatment:
    o Cardioversion in patients whose conditions are unstable (cool,
    clammy, skin, low B, C/O chest pain, low CO, SOB)
    o Sedation of patients are stable
    o Vagal Maneuvers bearing down, coughing, breath holding, squatting
    helps to slow HR through increasing parasympathetic tone
    o Adenosine 6 mg bolus over 1-2 seconds, followed by a rapid 10 ml NS
    flush. If initial dose does not work after 2 minutes, administer a 12 mg
    bolus of adenosine IV rapidly over 1-2 seconds, followed by rapid 10 mL
    NS flush. Then repeat if ineffective ONLY 3 ATTEMPTS.
    o If pt does not respond to VM or administration of 3 doses adenosine,
    attempt rate control using a calcium channel blocker or a beta blocker

    RHYTHM

    Regular

    RATE

    140 250 BPM

    P WAVE

    Abnormal (commonly pointed); usually hidden in preceding T


    waves, making T Wave and P wave as one wave deflection; one P
    wave to each QRS complex unless AV block present

    PR
    INTERVAL
    QRS

    Usually not measureable


    Normal

    ATRIAL FLUTTER

    Originates in an ectopic pacemaker site in the atria typically depolarizing a


    rate between 250 and 400 BPM the atrial muscles respond to this rapid
    stimulation by producing wave forms that resemble teeth of a saw / flutter
    Found in patients with mitral or tricuspid valve disease and common after
    cardiac surgery, PE
    Treatment: control ventricular rate (calcium channel or beta blockers),
    assessing anticoagulant needs, and restoring sinus rhythm
    While the atria can tolerate the extremely high heart rate reasonably well,
    the ventricles cannot. Fortunately the AVE node is present to slow down

    and diminish he number of impulses that pass through to the ventricles


    various ratios
    Atrial flutter and PAT can be difficult to differentiate due to high BPM. Can
    be differentiated by closely examining the baseline
    o Atrial Flutter isoelectric line is absent
    o Atrial tachycardia isoelectric line is present

    RHYTHM

    Regular or irregular (depends of AV conduction ratios)


    o If the conductio ratio is regular (2:1 throughout), the rhythm
    is describes as atrial flutter with 2:1 AV conduction
    o If the conduction ratio varies (from 4:1 to 2:1 to 6:1) the
    rhythm is describes as atrial flutter with variable AV
    conduction

    RATE

    Atrial Rate: 250 400 BPM


    Ventricular Rate: varies with number of impulses conducted
    through AV node ( will be less than atrial rate)

    P WAVE

    Sawtooth deflections called flutter waves affecting entire baseline

    PR
    INTERVAL
    QRS

    Not measureable
    Normal

    ATRIAL FIBRILLATION

    A rapid and highly irregular heart rhythm caused by chaotic electrical


    impulses that arise from an ectopic site in the atria, depolarizing at a rate
    greater than 400 BPM
    Impulses are so rapid causing the atria to quiver instead of contract,
    producing irregular, wavy deflections
    Can be seen I n healthy individuals and is usually temporary and ay be
    associated with emotional stress or excessive alcohol consumption can
    spontaneously revert back to sinus rhythm
    Clinical consequence of Atrial Fibrillation are similar to those of atrial flutter

    RHYTHM

    Grossly irregular )unless ventricular rate is very rapid, in which


    case he rhythm becomes more regular)

    RATE

    Atrial Rate: 400 BPM or more, not measureable on surface ECG


    Ventricular Rate: Varies with number of impulses conducted
    through AV node ( will be less than atrial rate)
    o When ventricular rate is < 100 BPM, the rhythm is called
    Controlled Atrial Fibrillation
    o When ventricular rate is > 100 BPM, the rhythm is called

    Uncontrolled Atrial Fibrillation


    P WAVE

    Irregular wave deflections called fibrillatory waves affecting entire


    baseline

    PR
    INTERVAL
    QRS

    Not measurable
    Normal

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