April 2012 CE

Site code # 107200E-1212

Cardiac Reivew – Rhythm Strips and 12 Lead EKG’s

Packet by Sharon Hopkins, RN, BSN, EMT-P

To view on the Advocate Condell website visit: www.advocatehealth.com/condell/body.cfm?id=422

Date of CE presentation: April 2012 Topic: Cardiac Review – Rhythm Strips and 12 Lead EKG’s Behavioral Objectives: Upon successful completion of this module, the EMS provider will be able to:

1. Differentiate stable from unstable patients. 2. List criteria of the 2nd degree Type I, Type II and 3rd degree heart blocks. 3. Identify a variety of cardiac rhythms. 4. Identify ST elevation when presented with a variety of 12 lead EKG’s. 5. Describe treatment for the Acute Coronary Syndrome patient. 6. Given a rhythm, appropriately identify the rhythm and state treatment per Region X SOP’s. 7. Demonstrate placement of electrodes for obtaining a 12 lead EKG. 8. Successfully complete the post quiz with a score of 80% or better. Bibliography:

� Region X Advanced Life Support Standard Operating Procedures February 1, 2012

� Aehlert, B. ECG’s Made Easy 4th Edition. Elsevier. 2011. � American Heart Association. STEMI Professional Provider Manual. 2008. � Atwood, S., Stanton, C., Storey-Davenport, J. Introduction to Basic

Cardiac Dysrhythmia 3rd Edition. MosbyJems. 2003. � Beasley, B. Understanding EKGs – A Practical Approach 3rd Edition.

Brady. 2012. � Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices

Third Edition. Brady. 2009. � Limmer, D., O’Keefe, M. Emergency Care 12th Edition. Brady. 2012. � Page, B. 12 Lead ECG for Acute and Critical Care Providers. Brady. 2005. � Phalen, T., Aehlert, B. The 12 Lead ECG in Acute Coronary Syndromes

2nd Edition. Elsevier. 2006.

Stable patient

� Condition not expected to deteriorate � Perfusion supports adequate level of consciousness

� Patient able to understand and obey commands � Evaluate level of consciousness � Evaluate blood pressure

Unstable patient

� Patient condition may be changing/deteriorating � Altered level of consciousness � Blood pressure less than 90 systolic

� This is abnormal for the patient � Not adequate to maintain perfusion to the vital organs

Cardiac Conduction System

Criteria for Heart Blocks First Degree Heart Block Regular rhythm Rate dependent on underlying rhythm PR interval >0.20 seconds QRS complex <0.12 seconds Not a true rhythm; a condition of a rhythm Symptoms dependent on the underlying rhythm

Second Degree Heart block Type I – Wenckebach Atrial rhythm regular (P to P); ventricular rhythm irregular (dropped QRS) PR interval progressively lengthening until dropped QRS QRS complex <0.12 seconds Patients usually tolerate the slowed heart rate and are not symptomatic Considered a normal rhythm for some people Second Degree Heart Block Type II – Classical Atrial rhythm regular (P to P); ventricular rhythm regular (usually slow) PR interval (when present) – 0.12 – 0.20 seconds More P waves than QRS QRS complex <0.12 seconds Symptomatic usually due to the slow heart rate Consider the presence of an AMI until proven otherwise Third Degree Heart Block - Complete Atrial rate regular (P to P); ventricular rate based on pacemaker site P waves have no relationship with the QRS; no consistent PR intervals QRS complex < 0.12 seconds Often see the P waves marching through the QRS complex providing the different configurations noted sometimes form QRS to QRS Steps to Identify Cardiac Rhythms � Rhythm regular or irregular

� Can be off 2-3 little boxes � Overall rate � P waves and PR intervals (n=<0.20 sec) � QRS complex < 0.12 sec � Interpretation? � How is your patient doing/tolerating it?

Identify the Following Rhythms 1.

2.

3.

4.

5.

6.

7.

8.

9.

Cardiac Blood Flow Coronary Blood Flow

Correlation of Coronary Arteries and Areas of Myocardium Supplied

EKG Complex Wave Forms ST Segment Evolution

Views From the 12 Lead Perspective

Ischemia – ST depression

Injury – ST elevation

Infarct – Q wave development

12 Lead Electrode Placement 12 Lead EKG Practice #1

#2

#3

#4

#5

#6

#7

Identifying BBB

� Don’t always see “notching” � Important – QRS is widened (>0.20 sec) � Atrial activity (i.e.: P wave) precedes QRS � RBBB

� RSR’ pattern in V1 � End of QRS is a positive deflection

� LBBB � QS pattern in V1

� End of QRS is a negative deflection Can think of using your turn signal in the car to determine right from left bundle branch blocks: To make a right turn, you lift the turn signal up so get a positive deflection in V1. To make a left turn, you pull the turn signal down and get a negative deflection in V1. File: CE, EMS; CE Packets; 2012; April; Cardiac Review