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7/31/2019 Advanced ECGs for MLAs
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Advanced ECGs for MLAs
Cathie Cousins, RN, BScN, CCN(C)
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May 13, 2006 Cathie Cousins,RN BScN CCN(C) 2
Objectives
1. To review Basic Concepts for the 12-Lead ECG
To discuss the following on the 12-Lead ECG2. Bradycardia
3. Tachycardia
4. Ventricular Ectopy
5. ST and T wave changes
6. Pacemakers
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1. Basic Concepts
The heart is a pump with an electricalconduction system
2 basic types of cardiac cells in the heart
Myocardial cells or muscle cells
Specialized cells of the conduction system orpacemaker cells
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Electrical Axes and Vectors
Each of the 12 leads on the ECG has a different
pattern because each lead views the hearts
electrical axis from a different position
Atrial and ventricular depolarization and
repolarization generate an electric current
known as an electrical axis or vector (differentfrom the axis of a lead)
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Average of all the ventricular vectorspoints to the left and downward
Knowing the electrical axis of the heartenables us to determine the normal
pattern of each lead and the cause for
altered patterns in each lead
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Rate
Both the atrial and ventricular rates should bemeasured
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The Grid Method for Rate
Uses the distance between 2 sequentialcomplexes on the ECG
Each small square represents 0.04 seconds
- 1500 small squares in 1 minute- 300 large squares in 1 minute
Count the large squares between P waves for
atrial rate and R waves for ventricular rate
300 number of large squares = number of
beats/min
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Quick Tips 300 5 large squares = 60 bpm
5 or > large squares per minute = Bradycardia
300 3 large squares = 100 bpm
3 or > large squares per minute = Tachycardia
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May 13, 2006 Cathie Cousins,RN BScN CCN(C) 13
2. Bradycardia
Bradycardia is a heart rate < 60/min
Bradycardia can be due a slow sinus rate, theorigin of the rhythm or an AV block:
- Sinus Bradycardia
- Junctional Rhythm
- Idioventricular Rhythm
- 2 AV Block Type I- 2 AV Block Type II
- 3 AV Block
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Sinus Bradycardia
Sinus node is pacing at a rate < 60/min
P wave, QRS normal
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Junctional Rhythm
Sinus node and atria fail to pace the heart.
AV junction paces at 40-60/min
No P wave or PR interval < 0.12, QRS normal
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Idioventricular Rhythm
Sinus node, atria, and AV junction fail to pace.
Ectopic pacemaker in the ventricles paces at
20-40/min
No P wave, QRS wide, ST & T waves oftenabnormal
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AV Blocks
2 Type I and 2Type II AV Blocks, sinus nodepaces the heart
Not ever P wave results in QRS,
QRS normal or wide
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3 AV Block, sinus node paces the heart
P waves do not result in QRSAV junction paces, QRS normal
Ventricles pace, QRS wide
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3. Tachycardia
Tachycardia is a heart rate > 100/min
Tachycardia can be due to:
- Sinus Tachycardia
- Supraventricular Tachycardia
- Ventricular Tachycardia
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Sinus Tachycardia
Sinus node is pacing at a rate > 100/min
P wave, QRS normal
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Superventricular Tachycardia
Ectopic focus in atria or AV junction paces the heart
or Abnormal conduction thru AV node
or Accessory pathway
P wave or no P wave, QRS narrow or wide,
rate > 150/min
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Ventricular Tachycardia
Ectopic pacemaker in ventricles paces the heart
No P wave, QRS wide and bizarre
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4. Premature Ventricular Contractions
QRS Duration
QRS duration - depolarization of right and leftventricles, from the endocardium to epicardium
Normal QRS duration - 0.06-0.10 sec
QRS duration > 0.10 sec, a conduction delayexists in the bundle branches, Purkinjie networkor ventricular myocardium, or ventricular ectopicconduction exists
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PVCs, premature ventricular complexes:
the premature beat originates in an ectopic
focus in one ventricle, it depolarizes that
ventricle, then the other
No P wave, QRS wide & bizarre, ST often
abnormal, T wave often opposite the rhythm
Multifocal PVCs come from more than oneectopic focus, each foci has a different shape
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1 PVC = a PVC
2 PVCs = couplet
3 PVCs = triplet
4 PVCs = ventricular tachycardia
Every 2nd
PVC = bigeminy Every 3rd PVC = trigeminy
Bigeminy or trigeminy can refer to any ectopic
beat so clarify -
eg. bigeminal PVCs or bigeminal PACs, etc.
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5a. ST Segments
ST segment = end of ventricular repolarization +
early part of ventricular repolarization
ST segment normally isoelectric
Ischemic + injured myocardial cells altered
membrane potentials, this allows a current toflow as seen in ST elevation + depression
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Measuring ST Segments
ST measurement = vertical difference betweenthe isoelectric line + end of QRS complex, the
J point
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ST Segment Elevation
ST segment elevation = >1 mm (>0.1 mV) abovebaseline after the J point
ST segment elevation due to severe injury
temporary until ischemia resolved or injuredheart tissue heals or dies
ST segments elevate in leads facing the injury
ST segments depress in leads opposite(reciprocal ) leads
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Types of ST Elevation in AMI
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Oth C C f
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Other Common Causes ofST Segment Elevation
Coronary artery vasospasm
Acute pericarditis
Ventricular aneursym
Hyperkalemia
Non-specific ST-T wave changes
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ST Segment Depression
ST segment depression = > 1 mm below
baseline after the J point
ST segment depression due to severe ischemia
temporary until ischemia resolved or heart tissueheals
ST segments depress in leads facing the
ischemia
ST segments elevate in opposite (reciprocal)
leads
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Types of ST Depression in AMI
Different types of
ST depression in AMI:
- downsloping
- horizontal
- upsloping
Oth C C f
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Other Common Causes of
ST Segment Depression
Left and right ventricular hypertrophy
Left and right bundle branch block Digitalis in therapeutic and toxic doses
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Acute MI Facing Leads Opposite Leads
Anterior
Septal V1-V2 None
Anterior V3-V4 None
Lateral I, aVL, & V5 or V6 II, III, & aVF
Inferior II, III, & aVF I & aVL
Posterior V7,V8, V9 on 18 lead V1-V4Right Ventricle V4R, V5R, V6R on 18 lead None
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5b. T waves
A T wave represents ventricular depolarization
T waves normally upright, rounded, and slightly
asymmetrical. Normally negative in aVR.
Normally 1/8 to 2/3 the height of the QRS
complex
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Abnormal T Waves in AMI
Normal Heart -
positive T wave
Subendocardial
Ischemia -
symmetrically
positive tall,
peaked T wave
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Subepicardial
Ischemia -symmetrically
negative deep T wave
Late phases in AMI -
deeply inverted
T waves with
abnormal Q waves
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6. Pacemakers
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The 3 Functions of Pacing
1. Sensing the ability of the pacemaker torecognize the patients intrinsic heartbeat
2. Pacing the pacemaker produces a stimuluseither when the sensing circuit does not detectan intrinsic heartbeat or at a predeterminedtime interval
3. Capturing the depolarization of themyocardium in response to pacing
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Pacemaker Codes
I Chamber(s) paced
II Chamber(s) sensed
III Response to sensing
IV Programmable function(s)
V Antitachyarrhythmia function(s)
Pacing Leads Sites Permanent
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Pacing Leads Sites - Permanent
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Pacing Leads Sites - Temporary
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Pacemaker Sites - Temporary
Transcutaneous
External Pacing
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Pacemaker Strip 1
1. Sensing
2. Pacing
3. Capturing
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Pacemaker Strip 2
1. Sensing2. Pacing
3. Capturing
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Thank You
Remember: It is the team that assists the
patient in achieving wellness.
Thank you and enjoy the exciting world of
12 Lead ECGs.