ECG Interpretation Basics

Robert Catlow RN, BSN, CNOR Jeanette Hester MSN, RN January 2009

Objectives
Define cardiac output Identify anatomy of the heart & its conduction system Understand common ECG terminology Relate ECG waveforms to mechanical function of the heart Demonstrate correct lead placement for telemetry Demonstrate ECG Interpretation Skills
Atrial arrhythmias Junctional arrhythmias Ventricular arrhythmias Conduction block arrhythmias

Review/interpret rhythm strips

Cardiac Output
Cardiac Output (CO) = Heart Rate (HR) X Stroke Volume (SV) HR = measurement of ventricular impulses, per min. Normal HR = 60-100bpm SV = amount of blood pumped by each ventricular contraction, in ml. Normal SV = 60-80 ml CO = amount of blood pumped by each ventricle, in liters/minute Normal CO = 4-8 l/min

Electrophysiology of the Heart

Electrophysiology: Automaticity: ability to start an impulse Conductivity: ability to transmit impulse Contractility: contract or squeeze (muscle) Rhythmicity: keep impulse/cycle regular All the above are dependent upon electrolyte balance (K, Na, Mg, etc.), nutrients, oxygen supply, and health of the hearts conductive system

Mechanical Physiology of the Heart

Four chambers, Right Atria, Right Ventricle, Left Atria, Left Ventricle Four valves = tricuspid (R), pulmonic, mitral (L), aortic Pump = three tissue layers; epicardium, myocaridum, and endocardium rhythmically moving blood in single direction Blood = necessary purpose for the pump

Conduction System
1 = SA Node 2 = AV Node 3 = Bundle of HIS 4 = Left and Right Bundle Branches 5 = Purkinje Fibers

Conduction System & Pacemaker Sites

SA Node: Normal pacemaker with normal adult rate 60-100 impulses/minute AV Node: Secondary pacemaker with inherent rate (adult) 40-60 impulses/minute Ventricular conduction components (Left & Right Bundle Branches and the Purkinje Fibers) tertiary pacemaker with inherent rate of 20-40 impulses/minute

Normal Conduction
SA Node initiates impulse Intra-atrial pathways carry the impulse to AV Node, slows conduction allowing complete atrial contraction Bundle of HIS passes the impulse to the ventricular components of Left & Right Bundle Branches which divide into the Purkinje Fibers

Terminology
Baseline isoelectric horizontal line Waves deflections from the baseline with defined beginning and end points Spike deflection from the baseline (straight vertical line) Biphasic waveform both above and below the baseline Segment portion of the baseline between two waves (may be elevated or depressed) Interval defined by start and end points, includes all portions of the interval waves and segments Depolarization impulse formation, conduction & contraction Repolarization relaxation & recovery

What makes an ECG waveform?

When electrical energy travels toward a positive electrode a positive (upward) deflection appears on the ECG When electrical energy travels toward a negative electrode a negative (downward) deflection appears on the ECG When electrical energy travels across the axis of the positive to negative electrode a biphasic deflection appears on the ECG

Cardiac Conduction & Waveforms

P Wave/PR Interval: depolarization (contraction) of the atria. PR interval measured from start of P to the start of QRS complex QRS Complex: depolarization (contraction) of the ventricles T Wave/ST Segment: repolarization (relaxation) of the ventricles. ST segment is measured from end of S wave to start of the T wave

Electrical and mechanical activity are linked. The P wave represents atrial contraction, the QRS complex ventricular contraction (pulse), and the T wave ventricular recovery.

Lead Placement
Smoke over fire/snow falls on grass White is right Chocolate is close to your heart
Black over red and white over green, brown in the middle. Set up for these leads are:
White on right (RA) right arm/shoulder/chest Black = (LA) left arm/shoulder/chest Green = (RL) right leg/flank Red = (LL) left leg/flank Brown = grounding lead, must be either anterior axillary line, 5th intercostal space, or lower sternum

Telemetry VS 12-Lead ECG

Telemetry usually views one of the 12 standard ECG leads 12-Lead ECG provides 12 views of the hearts electrical activity
Limb Leads reveal a vertical view (most commonly used in telemetry monitoring) V-Leads reveal a horizontal view

Measuring an ECG Strip

Each small box equals 0.04 sec Each large box equals 0.20 sec Intervals are measured from start of the wave (leaves baseline) to beginning of next waveform (at baseline)

Time is measured on the horizontal axis (width) of the graph paper, electrical energy is measured on the vertical axis (height).

Normal Rhythm Intervals

Normal Intervals - Adult PR Interval - 0.12 sec 0.20 sec PR < 0.12 sec (short) = origin closer than normal to Bundle of HIS PR > 0.20 sec (long) = AV delay (AV Block) QRS Interval - 0.06 sec 0.12 sec QRS 0.10-0.11 may represent an intraventricular delay QRS > 0.12 sec may signify a ventricular dysrhythmia QT Interval 0.30 sec 0.45 sec** RR Interval indicates heart rate 1.00 sec - 0.60 sec or a heart rate of 60 100 RR > 1.00 sec = Bradycardia RR < 0.60 sec = Tachycardia QT Interval and corrected QT Interval measured for advanced interpretation, QTc = QT/ RR (notify <.30 or >.49

** QT generally should not exceed RR interval at normal rates

Measuring Rate The Six Second Rule

Most popular method ECG paper is marked in 3 second intervals Count # of R waves in 6 seconds and multiply by 10 = HR

Measuring RateThe Block/300 Rule

Select an R wave on a dark line Divide 300 by number of large boxes counted, count back # big boxes 300, 150, 100, 75, 60, 50 to next R wave Not desirable for counting irregular rhythms

Normal Sinus Rhythm (NSR/SR)

Most common ECG rhythm NSR/SR rate = 60-100 bpm Rhythm is regular Cardiac cycle has one/normal P wave, QRS complex, and T wave Called sinus because it originates from the sinoatrial node (SA Node) ECG diagnosis/rate must always be clinically confirmed with the presence of a pulse (r/o PEA)

EctopyTerminology
Cardiac irritability = increased automatism results in extra heart beats which may have a negative effect on CO Ectopy = an impulse formation located somewhere other than the SA Node
Extra (premature) contractions are identified by the location they come from - the focus (atrium, ventricle, junction)

Premature contractions = impulses & conduction that occur early in the cardiac cycle Bigeminy every other complex is ectopic Trigeminy every third complex is ectopic

Premature Beats
There are three types of premature contractions (PACs, PJCs, PVCs) Ectopy can be identified by evaluating the premature beat for the presence of a p wave or not and the width of the ventricular contraction

Premature Atrial Contractions (PACs)

Premature atrial beat

normal-sized QRS complex P wave precedes the premature complex normal looking beats fall early Rhythm is irregular due to the early complex

Premature Junctional Contraction (PJC)

PJCs originate in the junction

normal sized QRS complex p wave is absent or inverted rhythm is irregular due to premature complex(es)

Premature Ventricular Contractions (PVCs)

premature ventricular beat
originate in the ventricle wide-bizarre QRS complex (QRS > 0.12 sec) no visible p wave with premature QRS complex PVCs can be unifocal or multifocal With multiple complexes frequency described by name, i.e. bigeminy, trigeminy

Premature Ventricular Contractions (PVCs)

multifocal abnormal complexes have multiple points of origin (complexes are different from each other) unifocal abnormal complexes have one point of origin (complexes are the same)

S in u s B r a d y c a r d ia ( S B )

Caused by depressed automatism in the SA node Clinical causes acute hypoxia, MI, drug intoxications (digoxin), and parasympathetic stimulation Strip has normal cardiac complex, waves, and intervals with a slowed ventricular rate SB is either asymptomatic or symptomatic (meaning CO may or may not be affected from SB) Asymptomatic = slow HR and adequate BP/Sats

Sinus Bradycardia (SB)

Symptomatic bradycardia = CO (BP) is significantly decreased because the ventricular rate is too low Treatment for symptomatic bradycardia is aimed at increasing HR to improve CO

ACLS Intervention Sequence for SB

1. Oxygen 2. Atropine (0.5 mg IV push) may repeat to a total dose of 3 mg, if ineffective 3. Transcutaneous pacer (TCP) 4. Epinephrine 2 10 mcg/min or 5. Dopamine 2 - 10 mcg/kg/min 6. Prepare for transvenous pacer
Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). (2006). Advanced cardiovascular life support provider Advanced manual. Dallas, TX: American Heart Association.

Sinus Arrhythmia
Rhythm is benign to the patient Typically associated with respiration due to fluctuations in vagal tone Rarely associated with underlying pathology Occurs most commonly in young, healthy patients Rate usually increases with inspiration and decreases with expiration Treatment is not usually indicated unless associated with symptomatic bradycardia

Sinus Arrhythmia
Strip is noted to have a HR of 45-100 (box method), sinus p wave, normal QRS/conduction, regularlyirregular rhythm [use 6-sec rule to determine average rate] Non-respiratory form of sinus arrhythmia is present in diseased hearts. It should not be confused with sinus arrest

Sinus Arrest/Sinus Pause

Occurs when SA node fails to function A complete cardiac complex (more than one complex may be missed) is absent from the rhythm Cause is usually associated with increased vagal tone, myocarditis, MI, and digoxin toxicity Usually present in diseased hearts but can occur in healthy hearts

Sinus Arrest/Sinus Pause

Strip has a normal rate (prior to arrest), p waves, QRS complex, and conduction, rhythm is regular other than the arrest/pause Length of pause is not related to the sinus interval Long pauses can contribute to junctional (escape) beats Treatment is aimed at fixing the underlying cause (i.e. MI, dig toxicity) If symptomatic, than atropine may be indicated

Sinus Tachycardia

Results when automatism of SA node increases Manifested by increased HR which increases cardiac workload and oxygen demand (can lead to ischemia) Causes include increased circulating cathecholamines, CHF, hypoxia, PE, fever, pain, stress, agitation ST has a HR of 100-160 bpm, sinus P wave (visualized), normal QRS/conduction Treatment is aimed at identifying and correcting the underlying cause

Atrial Tachycardia (AT/PAT/SVT)

Frequently called paroxysmal atrial tachycardia (PAT) aka: supraventricular tachycardia (SVT) or paroxysmal supraventricular tachycardia (PSVT) Period of very rapid and regular heart beats that begin and end abruptly Results when automatism in the atria is increased The atria form ectopic pacemakers which contribute to overdrive of the sinus rate (SA node) The result is a cardiac rate of 150-250 bpm

Atrial Tachycardia (AT/PAT/SVT)

P wave is partially or completely hidden because of the rapid rate, may be flattened, notched, or masked by T wave QRS complex is normal size AT/PAT/SVT manifest as very fast tachycardias

Atrial Tachycardia (AT/PAT/SVT)

Ventricular rate is so fast, cardiac output is compromised by decreased ventricular filling Frequently occurs in stress syndromes and abuse of caffeine, tobacco, and alcohol Goals for treatment are aimed at rate control

A C L S In te r v e n tio n

Sequence for SVT

Vagal maneuvers Adenosine 6mg, 12 mg, then 12 mg rapid IV push (chase with flush) blockers & diltiazem used with caution in CHF or with pulmonary disease Synchronized cardioversion if unstable SVT
Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). (2006). Advanced cardiovascular life support provider manual. Advanced Dallas, TX: American Heart Association.

Atrial Flutter
A tachydysrhythmia that indicates underlying disease process Atrial rate is usually 250-350, rhythm may be regular or irregular with varying conduction ratios Characterized by saw tooth atrial pattern with a normal QRS complex Multiple areas (foci) in the atria are competing to drive the heart Common diseases include valvular heart disease, right heart failure, MI, and CAD

Atrial Flutter
P- waves are referred to as F-waves due to their flutter pattern Common to refer to A-flutter based on the ratio of Fwaves to ventricular responses Atrial-Ventricular ratio may be in 2:1, 3:1, 4:1, etc. A-flutter has a regular atrial rate, but may be irregular when the conduction ratio changes Goals for treatment are aimed at rhythm conversion and rate control (digoxin, diltiazem, cardioversion)

Atrial Fibrillation (AF/A Fib)

Most common of all dysrhythmia Can occur in healthy or diseased hearts Is either acute or chronic (differentiated at 2 weeks) Common causes include MI, pulmonary embolus, HTN, CAD, and cardiac valvular stenosis Referred to as irregularly irregular F-waves have a fibrillating pattern spaced in an irregular way, are not shaped consistently, or recognizably separate from each other QRS complexes are also spaced irregularly

Atrial Fibrillation (AF/A Fib)

Ventricular rate can vary between very fast and relatively slow heart rates
A-fib w/RVR (Rapid Ventricular Rate) A-fib Bradycardia with A-fib

AF is due to lack of synchronized atrial depolarization, muscle fibers contract & relax without coordination with other fibers Atrial depolarization and mechanical contraction are not organized into an effective pattern Result = decreased atrial kick

Atrial Fibrillation (AF/A Fib)

Loss in atrial kick leads to decreased ventricular filling Decreased ventricular filling = decreased CO (BP) Prolonged AF can cause stasis or pooling blood in the atria (increased risk of thrombus) Goals for treatment are aimed at rhythm conversion, rate control, and anticoagulation when indicated (digoxin, amiodarone, diltiazem, cardioversion, heparin)

Junctional Rhythms
Also called nodal or escape rhythm Foci driving the heart originate from the myocardial junction Atria depolarize in a retrograde fashion (from the junction upward) Result = inverted or absent (buried) P waves on the ECG Ventricle depolarizes in a downward (normal) fashion Result = normal QRS complex JR = inverted/absent P wave with normal QRS

Junctional Rhythms
Intrinsic rate of junction = 40-60 Rhythm is regular Rate is usually 40-60 bpm Three types = junctional rhythm, accelerated junctional rhythm, junctional tachycardia Causes = digoxin toxicity, MI, ischemia, electrolyte imbalance, parasympathetic or sympathetic stimulation, and cardiac myopathy Clinically similar to rate related signs & symptoms

Junctional Rhythms
Junctional Rhythm

Accelerated JR/Junctional Tachycardia

Heart Blocks
Common form of bradyarrhythmia Block refers to an interruption in cardiac conduction (like a road block or detour in traffic) All blocks have different conduction pathways (or detours) measurable on ECG Pathways are impaired or completely disabled Most susceptible areas in the heart are the AV node and the bundle of HIS The more sever the effect, the higher the degree of block

Heart BlocksBBB
Term heart block can refer to a dysrhythmia or damage along the bundles of HIS Bundle of HIS block = bundle branch block BBB cannot be diagnosed from a single monitoring lead (need 12-lead to determine accurately if right/left) On 12 Lead = seen as an extra R wave (jagged R point) on specific leads

A V B lo c k s

Types = first, second (type I and type II), third degree Fairly easy to recognize using consistent landmarks Heart rates are usually normal to slow (often not detected on rate dependent monitoring systems)

AV Blocks First Degree AVB

Normal to slow rate Rhythm is regular (normal RR interval, regular PP interval, regular lengthened PR interval) QRS is normal Only abnormality is prolonged PR interval PR interval > 0.20 sec (5 small boxes) = 1st degree AVB Nonmalignant dysrhythmia (asymptomatic) May precede higher degree block

Second Degree AVB Mobitz I/Wenckebach

Slow to normal rate Cycles through AV node have increasing difficulty Overall rhythm is irregular PR interval gets longer with each QRS cycle, the last PR delay is so long there is no conduction to ventricles and a QRS complex is dropped Identify by Irregular rhythm with variable PR interval Common cause is digoxin toxicity

Second Degree AVB Type II/Mobitz II

Slow to normal rate Regular rhythm, regular RR interval, and regular PP interval, PR interval may be normal/prolonged P:R ratio is greater than 1:1 (more Ps than QRS complexes) Identify by P waves without matching QRS and the PR interval of all conducted P waves equal May progress to third degree readily

Third Degree AVB Complete Heart Block

Rate is slow to normal (often around 40) Life-threatening dysrhythmia (acutely compromises cardiac output) Ventricular activity is regular (R-R interval ) P-P interval is identical and regular (some P waves may be hidden by the QRS or T wave) Atrium & ventricles are functioning independently of each other (no relationship from Ps to QRS complexes) Atrial rate > ventricular rate Identify by regular ventricular rhythm and variable PR intervals

AV BlocksACLS Sequence Intervention

Symptomatic or not? No (report/observe/maintain ABCs) Yesgoals are aimed at fixing rate/conduction 1. Transcutaneous Pacemaker (TCP) (until TVP is available) 2. Atropine 0.5 mg IVP may repeat to total dose of 3 mg 3. Dopamine 2 to 10 mcg/kg/min 4. Epinephrine 2 to 10 mcg/min 5. Prepare for transvenous pacing, treat contributing causes.
Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). (2006). Advanced cardiovascular life support provider manual. Dallas, Advanced TX: American Heart Association.

Ventricular Dysrhythmia
Ventricular dysrhythmia compromise cardiac output (almost always) Frequent precursor to cardiopulmonary arrest Dysrhythmia are either ventricular or supraventricular, ventricular identified by widened QRS Ventricular dysrhythmia originate from the ventricle

Ventricular Tachycardia (VTach/VT)

VT = run of three or more consecutive PVCs Life-threatening May occur with or without pulses (CO) Rate is usually 100-220 bpm/Rhythm & regular P waves are not visualized QRS complexes are very wide (>0.12 sec) Causes include MI, ischemia, acidosis, electrolyte imbalance

V-TachACLS Intervention Sequence

Pulse
Without pulse: (code) With pulse: 1. Shock followed by 5 cycles 1. Oxygen CPR 2. Establish IV access 2. Shock, when IV access 3. Amiodarone 150 mg IV available give vasopressor over 10 minutes, repeat to (during CPR): Epinephrine 1mg max dose of 2.2 g/24 hours IVP (q 3-5min) or Vasopressin 40 Prepare for synchronized units IV single dose 1 time in cardioversion. If unstable perform immediately after IV place of 1st or 2nd dose of access. Epinephrine Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). 3. Give 5 cycles of CPR between (2006). Advanced cardiovascular life support provider manual. Dallas, TX: American Heart Association. shocks. 4. Amiodarone or lidocaine consider Magnesium

Ventricular Fibrillation (V-Fib/VF)

One of four types of cardiac arrest (asystole, pulseless VT, and PEA are others) Most disorganized rhythm (cardiac cells depolarize independently) Myocardium has quivering muscle activity producing no cardiac output (pulse) Irregular wavy baseline with no organized pattern

V-fibACLS Sequence Intervention

Definitive therapy for VF is defibrillation ABCD (code) 1. Shock followed by 5 cycles CPR 2. Shock, when IV access available give vasopressor (during CPR): Epinephrine 1mg IVP (q 3-5min) or Vasopressin 40 units IV single dose 1 time in place of 1st or 2nd dose of Epinephrine 3. Give 5 cycles of CPR between shocks. 4. Amiodarone or lidocaine, consider Magnesium
Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). (2006). Advanced cardiovascular life support provider manual. Dallas, TX: American Heart Association.

Idioventricular Rhythms
Slow, regular rhythm with wide ventricular complexes Absent P waves Rate = 40 or less Originates from ventricles Assume VT with all wide complex tachycardias until proven otherwise Treat based on symptoms

Ventricular Asystole
Translated without contractions Completely without electrical activity No waves or complexes (may see P waves without QRS) AKA: cardiac or ventricular standstill Causes = MI, ischemia, hypokalemia, digoxin toxicity, prolonged sinus arrest, complete heart block, prolonged hypoxia

AsystoleACLS Sequence Intervention

ABCD of CPR Call code (5 cycles of CPR) Check rhythm with defibrillator Vasopressor, Epinephrine 1 mg IV q 3-5 minutes or Vasopressin 40 U IV to replace 1st or 2nd dose of Epinephrine Consider Atropine 1 mg IV q 3-5 minutes up to 3 doses Check rhythm q 5 cycles of CPR Consider ending code
Field, J.M., Gonzales, L., & Hazinski, M. F. (Eds.). (2006). Advanced cardiovascular life support provider manual. Dallas, TX: American Heart Association.

Where have we been?

Cardiac anatomy & physiology ECG basics
Waveforms Measurement Normal values

ECG Interpretation
Atrial Arrhythmia Junctional Arrhythmia Heart Block Ventricular Arrhythmia

Interventions

Pediatric Intervals
The 6 month old infant
PR interval 0.09 0.14 sec QRS interval 0.03 0.08 sec Heart Rate 110 160/minute

The 2 year old child

PR interval 0.10 0.15 sec QRS interval 0.03 0.08 sec Heart Rate 90 140/minute

The 6 year old child

PR interval 0.12 0.18 sec QRS interval 0.04 0.09 sec Heart Rate 75 100/minute