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# UPH- Dr. Jose G. Tamayo Medical University UPH- Dr. Jose G.

## Tamayo Medical University

Sto.Nio, Bian, Laguna Sto.Nio, Bian, Laguna

## ECG ARRHYTHMIA RECOGNITION

OBJECTIVES Describe normal conduction system of the heart State criteria for performing an EKG/ECG Identify basic normal EKG/ECG waveforms Identify arrhythmias and blocks Describe treatment options for these basic arrhythmias To recognize an acute myocardial infarction on a 12-lead ECG.

## Impulse Conduction & the ECG

Sinoatrial node AV node

Bundle of His
Bundle Branches Purkinje fibers

The PQRST

## Pacemakers of the Heart

SA Node - Dominant pacemaker with an intrinsic rate of 60 - 100 beats/minute. AV Node - Back-up pacemaker with an intrinsic rate of 40 - 60 beats/minute. Ventricular cells - Back-up pacemaker with an intrinsic rate of 20 - 45 bpm.

## The ECG Paper

Horizontally
One small box - 0.04 s One large box - 0.20 s

Vertically
One large box - 0.5 mV

## The ECG Paper (cont)

3 sec

3 sec

Every 3 seconds (15 large boxes) is marked by a vertical line. This helps when calculating the heart rate. NOTE: the following strips are not marked but all are 6 seconds long.

Rhythm Analysis

## Step 1: Step 2: Step 3: Step 4: Step 5: Step 6:

Calculate rate. Determine regularity. Assess the P waves. Determine PR interval. Determine QRS duration. Evaluate Twave

3 sec 3 sec

## Count the # of R waves in a 6 second rhythm strip, then multiply by 10.

Interpretation? 9 x 10 = 90 bpm

## Step 1: Calculate Rate

B. SEQUENCE METHOD

R wave

Identify an R wave that falls on the marker of a big block Count the # of large boxes to the next R wave. If the second R wave is 1 large box away the rate is 300, 2 boxes - 150, 3 boxes - 100, 4 boxes - 75, etc. (cont)

## Step 1: Calculate Rate

3 1 1 0 5 0 7 6 5 0 0 0 5 0 0

Remember the sequence: 300, 150, 100, 75, 60, 50, 43, 37 Count the number of big blocks to the next R wave
Approx. 1 box less than 100 Interpretation? = 95 bpm

## Step 1: Calculate Rate C. 1500 METHOD

First, identify two consecutive P waves on the rhythm strip. Next, select identical points in each wave, and count the number of small squares between the points. Then divide 1,500 by the number of small squares counted (because 1,500 small squares equal to 1 minute) to get the rate.

## Step 1: Calculate Rate

D. 300 METHOD
First, identify two consecutive P waves on the rhythm strip. Next, select identical points in each wave, and count the number of big squares between the points. Then divide 300 by the number of big squares counted (because 300 big squares equal to 1 minute) to get the rate.

## Step 2: Determine regularity

R R

Look at the R-R distances (using a caliper or markings on a pen or paper). To determine if the ventricular rhythm is regular or irregular, measure the distance between 2 consecutive R-R intervals and compare that distance with the other R-r intervals. For atrial rhythm, measure the distance between 2 consecutive P-P intervals.

Interpretation: Regular
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## Step 3: Assess the P waves

Are there P waves? Do the P waves all look alike? Do the P waves occur at a regular rate? Is there one P wave before each QRS?

## Step 4: Determine PR interval

Does the duration of the PR interval fall within limits, 0.12 to 0.20 second ( or 3 to 5 small boxes)? Is the PR interval constant?

## Step 5: QRS duration

Does the duration of the QRS complex fall within normal limits, 0.60 to 0.10 seconds? Are all QRS complexes the same size and shape? Does a QRS complex appear after every P wave?

## Interpretation? 0.08 seconds

Step 6: Evaluate T Wave Represent ventricular muscle repolarization (when the cells regain a negative charge; also called the resting state). It follows the QRS complex and is usually the same direction as the QRS complex.

TECHNICAL ASPECT OF ECG RECORDING 3 Areas of Consideration in Taking ECGs The ECG Machine The Patient The ECG Tracing

## The ECG Machine

Know your ECG machine Voltage: 110 or 220? Wheres the on/off switch? Stylus or thermal printer? Settings: manual or automatic? How do you load ECG paper?

## The ECG Machine

Parts ECG recorder/printer ECG cables, bulbs, and clamps/straps Power cord, Battery (?)

Operator Console
o How does it work?
1. Start/stop key 2. 1 mV Standardization key 3. Sensitivity keys/knob 5, 10, or 20 mm/mV 4. Speed setting key 25 mm/s or 50 mm/s 5. Lead key/knob I, II,III AVR, AVL, AVF V1, V2, V3, V4, V5, V6

Preparing for 12-lead ECG Gather all needed supplies. Explain the procedure to the patient. Answer the patients questions. Ask the patient to lie in a supine position in the center of the bed with his arms at his sides. Ensure privacy. Drape the patient for comfort.

B. Precordial Leads V1 4th intercostals space, right sternal border V2 4th intercostals space, left sternal border V3 Equidistant between V2 and V4 V4 5th intercostals space, Left midclavicualr line V5 Over the fifth intercostals space at the left anterior axillary V6 Over the fifth intercostals space at the left midaxillary

C. Right Precordial Lead Placement Evaluates only the left ventricle V1R- Fourth intercostal Space (ICS), left sternal border V2R- Fourth ICS, right sternal border V3R- Haftway between, V2R and V4R V4R- Fifth ICS, rigth midclavicular line V5R- Fifth ICS, rigth anterior axillary line V6R- Fifth ICS, right midaxillary line

Placing the Leads D. Posterior Lead Placement Used to assess the posterior side of the heart Posterior electrodes V7, V8, an V9 are placed same horizontal level as the V6 lead at the fifth intercostal space. V7 placed at posterior axillary line V8 halfway between leads V7 and V9 V9 paraspinal line

Recording the ECG 1. Plug the cord of the ECG machine. 2. Turn on the machine. 3. Enter the patients identification data. 4. Place all the electrodes on the patient. 5. Make sure all leads are securely attached 6. Make sure that the ECG paper speed selector is set to standard 25 mm per second

## Recording the ECG

7. Instruct the patient to relax, lie still, breath normally, and refrain from talking during the recording. 8. Start recording the ECG. 9. Observe quality of tracing. 10.Turn off the machine 11. Remove the electrodes and clean the patients skin.

Make sure the printout shows pertinent data, including: Patients name Age/Gender Patients room number Date Time Doctors name

Keep in mind these important facts about ECG recordings: Theyre legal documents. They belong in the patients chart. They must be saved for future reference and comparison with baseline strips.

## 60-100 bpm Regular Normal 0.12 - 0.20 s 0.04 - 0.12 s

Normal Sinus Rhythm The electrical impulse is formed in the SA node and conducted normally. This is the normal rhythm of the heart; other rhythms that do not conduct via the typical pathway are called arrhythmias.

## 1. Sinus Bradycardia 2. Sinus Tachycardia

Rate less than 60 beats per minute Rhythm regular Impulses originating in the sinus node Usually occurs as the normal response to a reduced demand for blood flow.

Causes: Conditions that increases vagal stimulation/ decrease sympathetic stimulation Carotid massage Deep relaxation Sleep Valsalvas manuever Drugs

If the patient is aymptomatic and V/S are stable, no treatment. Continue to observe patients heart rhythm and monitor the progression and duration of bradycardia. Evaluate patients tolerance for rhythm at rest and with activity. Review the patients drug regimen. If the patient is symptomatic, identify and treat the underlying cause.
- Drugs - Transcutaneous pacemaker - Permanent pacemaker

Sinus Tachycardia
Accelerated SA node firing. Sinus rate above 100 bpm. Normal response to exercise or stimulation of the SNS. Causes: Cardiac conditions Non-cardiac condition Drugs Normal Body response

## Nursing Interventions (Sinus Tachycardia)

No treatment is needed if the patient is asymptomatic. Correct the underlying cause. Check LOC Provide patient with a calm environment. Assess for S/S of angina and heart failure. If the patient has cardiac ischemia, give drug to slow the heart rate. - beta-adrenergic blockers - Calcium Channel blockers Monitor intake and output, along with daily weight. Check the patients medication history. avoid substances that can trigger tachycardia.

Rhythm #2

Rhythm #3

## Interpretation? Sinus Tachycardia

ATRIAL ARRHYTHMIAS

## Impulse originate from either in the atria, outside the SA node.

- They arise from either a single ectopic focus or from multiple atrial foci that supersede the SA node as pacemaker for one or more beats. Causes: - Enhanced automaticity in atrial tissue - Heart Failure - Acute respiratory failure

## Premature Atrial Contractions

Digoxin toxicity - Drugs that prolonged period SA node ( Quinidine and Procainamide)
-

NURSING INTERVENTIONS Usually, no treatment is needed if the patient has no symptoms. If the patient has symptoms, treatment may focus On eliminating or controlling trigger factors.

## Premature Atrial Contractions

May be treated with drugs that prolong the Atrial refractory period. ( beta-adrenergic blockers or Calcium Channel Blockers). Patient teaching

Atrial Flutter

A supraventricluar tachycardia No P waves. Instead flutter waves (note sawtooth pattern) are formed at a rate of 250 - 350 bpm. Originates in a single atrial focus Results from a reentry circuit and possibly increased automaticity.

NURSING INTERVENTION (Atrial Flutter) If the patient is hemodynamically unstable, prepare for immediate synchronized cardioversion. Administer a beta-adrenergic blocker ( metoprolol), or calcium channel Blocker (diltiazem) to control the ventricular rate if the patient has normal heart function. In patients with impaired heart function, use digoxin or amiodarone. Monitor the patient closely for evidence of low cardiac output

Atrial Fibrillation

Chaotic, asynchronous, electrical activity in atrial tissue Results from firing of multiple impulses from numerous ectopic pacemakers in the atria. Absence of P wave Irregularly irregular ventricular response.

Atrial Fibrillation
Origin: Right or left atrium Rate: 400 BPM Characteristic: Random, chaotic rhtym; atria quiver, associated with irregular rhythm P wave: absent QRS: Normal morphology Irregular irregular RR interval

Atrial Fibrillation
Causes: nicotine, caffeine, or alcohol Drugs, such as aminophylline and digoxin Certain diseases Endogenous catecholamine released during exercise NURSING INTERVENTIONS Intervention aim to control the ventricular rate, establish anticoagulation,a nd restore and maintian

NURSING INTERVENTIONS
Intervention aim to control the ventricular rate, establish anticoagulation, and restore and maintain a sinus rhythm. Treatment typically includes drug therapy to control the ventricular response or a combination of electrical cardioversion. Monitor carefully patients rhythm, heart rate, and blood pressure. In stable patients, beta-adrenergic blockers and calcium channel blockers are given. Patients with reduced ventricular function typically received digoxin.

## Wandering Atrial Pacemaker

Arrhythmia that results when the site of impulse formation shifts from SA node to another area above the ventricles- the Atria or AV junctional tissue. Occurs because of increased parasympathetic influences on the SA node or AV junction.

## Nursing Intervention (Wandering Atrial Pacemaker)

Usually, no treatment is needed for asymptomatic patients. If the patient is symptomatic, however, his medications should be reviewed and the underlying cause investigated and treated. Monitor the patients heart rhythm and assess for signs of hemodynamic instability, such as hypotension and changes in mental status.

Junctional Rhythm
Junctional rhythm occurs when the AV node, instead of the sinus node, becomes the pacemaker of the heart. When the sinus node slows (eg, from increased vagal tone) or when the impulse cannot be conducted through the AV node (eg, because of complete heart block).

## Nursing Interventions (Junctional Rhythm)

Treatment involves identification and correction of the underlying causes. If the patient is hemodynamically unstable, start continous ECG monitoring. Make sure the patient has a patent venous access. If the patient is symptomatic, you may give atropine. Keep emergency equipment readily available. You may need to prepare for a temporary (transcutaneous or transvenous) or permanent pacemaker insertion. Monitor patients serum digoxin and electrolyte levels.

Rhythm #4

## Rate? Regularity? P waves? PR interval?

QRS duration?

70 bpm occasionally irreg. 2/7 different contour 0.14 s (except 2/7) 0.08 s

## Interpretation? NSR w Premature Atrial Contractions

Rhythm #5 Rhythm #5

QRS duration?

## Interpretation? Atrial Fibrillation

Rhythm #6 Rhythm #6

0.06 s

## Interpretation? Atrial Flutter

Ventricular Arrhythmias

## Rate? Regularity? P waves? PR interval? QRS duration?

60 bpm occasionally irreg. none for 7th QRS 0.14 s 0.08 s (7th wide)

## Premature Ventricular Contractions

Ectopic beats that originate in the ventricles and occur earlier than expected. May occur singly, in pairs (couplets), or in clusters. May also appear in patterns, such as bigeminy or trigeminy. May be uniform in appearance or multiform.

## Premature Ventricular Contractions

When an impulse originates in a ventricle, conduction through the ventricles will be inefficient and the QRS will be wide and bizarre.

Ventricular Conduction

Normal
Signal moves rapidly through the ventricles

Abnormal
Signal moves slowly through the ventricles

## Nursing Interventions (Premature Ventricular Contractions)

If the patient are infrequent and the patient has normal heart function and is asymptomatic, just observe the patient. Patient with PVCs accompanied by serious problem should have continuous ECG monitoring and emergency equipment readily available. Make sure the patient has a patent venous access. Prepare to give drugs that suppress ventricular irritability - Lidocaine - Procainamide - Amiodarone

Ventricular Tachycardia
Three or more PVCs in a row with a ventricular rate above 100 bpm. May be monomorphic or polymorphic. It occurs when an ectopic focus or foci fire repetitively and the ventricle takes control as the pacemaker. Monomorphic VT

Ventricular Tachycardia
no normal looking QRS complexes Rate: > 100 beats per minute and usually not faster than 220 beats per minute Rhythm: usually regular but may be irregular P waves: in rapid VT the p waves are usually not recognizable. At slower ventricular rates, p waves may be recognized and may represent normal atrial depolarization from sinus node at a rate slower than VT, but electrical activities do not affect one another QRS, ST segment, Twave: The width of the QRS is 0.12 second or greater The QRS morphology is often bizarre, with notching

## Polymorphic Ventricular Tachycardia

The blue line shows the characteristic "twist" around the isoelectric baseline Torsades de Pointes

## Nursing Interventions (V-tach)

Start continuous ECG monitoring Make sure the patient has a patent venous access. Treatment depends on the patients clinical status. Carefully assess the patient for LOC, the presence of spontaneous, effective respirations, and palpable carotid pulse. Patient with pulse VT required immediate defibrillation and CPR. For clinically stable patient, amiodarone and possible synchronized cardioversion are given.

Ventricular Fibrillation
This life-threatening arrhythmia is marked by rapid, disorganized depolarizations of the ventricles and a disruption in the normal flow of electrical impulses through the cardiac conduction system. The ventricles quiver rather than contract. As a result, they fail to pump blood, and cardiac output falls to zero. If fibrillation continues, it eventually leads to ventricular asystole( or standstill), and death quickly follows. On the ECG strip, ventricular activity appears as fibrillatory waves with no recognizable pattern.

Ventricular Fibrillation

No normal looking QRS Rate: VF rate is very rapid and usually too organized to count. Rhythm: irregular. Electrical waveforms vary in size and shape. There are no QRS complexes. ST segments, P waves, and T waves are absent as well.

## Nursing Interventions (V-fib)

Start prompt treatment following health care facility. Start CPR. To preserve the oxygen supply, CPR must be performed until the defibrillator arrives. Defibrillate the patient immediately . If the first two attempt at defibrillation fail, consider giving epinephrine. Establish an airway and ventilate the patient. Consider giving antiarrhythmic drugs.

Asystole Asystole is ventricular standstill. The patient is completely unresponsive, with no electrical activity in the heart and no cardiac output. This arrhythmia results most often from a prolonged period of cardiac arrest without effective resuscitation.

Asystole

Rhythm # 7