Basic EKG Interpretation A Precursor to 12 Lead Interpretation

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Basic EKG InterpretationA Precursor to 12 Lead
Interpretation

• By Darryl Jamison, NREMT-P
• Macon County EMS Training

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Basic Steps of EKG Interpretation

• Rate
• Rhythm
• P waves
• P-R interval
• QRS complexes

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Analyze the Rate

• First step
• Six second method
• R-R intervals

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Analyze the rhythm

• Occasionally irregular
• Regularly irregular
• Irregularly irregular

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Analyze the P waves

• Ask yourself these questions
• Are P waves present?
• Are the P waves regular?
• Is there on P wave for each QRS?
• Are the P waves upright or inverted (compared to
  the QRS?)
• Do all of the P waves look alike?

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Analyze the P-R Interval

• The time necessary for the atria to depolarize
  and the conduction of the impulse to the AV node
• Normal0.12-0.20 seconds
• Should be consistent across the strip

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Analyze the QRS Complex

• Ventricular depolarization
• Ask these questions?
• Do all of the QRS complexes look alike?
• What is the duration of the QRS complex?
• Normal--lt0.12 seconds
• If gt0.12 consider ventricular ectopy.

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Sinus Bradycardia

• Etiologyresults from a slowing in the SA node.
• Increased parasympathetic tone
• Intrinsic disease of the SA node
• Drug effects (digitalis, propanolol, quinidine)

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• SINUS BRADYCARDIA
• Rate--lt60 bpm
• Rhythmregular
• Pacemaker siteSA node
• P wavesupright and normal morphology
• PRI0.12-0.20 seconds and consistent
• QRS0.04-0.12 seconds

Rules of Interpretation
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Sinus Tachycardia

• Etiology
• Exercise
• Fever
• Anxiety
• Hypovolemia
• Anemia
• Pump failure
• Increased sympathetic tone

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• Rate-- gt100
• RhythmRegular
• Pacemaker siteSA node
• P wavesupright and normal in morphology
• PRI0.12-0.20 and constant
• QRS0.04-0.12

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Wandering Pacemaker

• Results from any of the following conditions
• A variant of sinus dysrhythmias
• A normal phenomenon in the very young or the aged
• Ischemic heart disease
• Atrial dilation

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• Rateusually normal
• Rhythm--Slightly irregular
• Pacemakervaries between the SA node, atrial
  tissue, and the AV junction
• P wavesmorphology changes from beat to beat, can
  disappear
• PRIvaries may be less than 0.12 seconds, greater
  than 0.20
• Normal QRS

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PAC's

• Causes
• Use of caffeine, tobacco, or alcohol
• Sympathomimetic drugs
• Ischemic heart disease
• Hypoxia
• Dig toxicity

• Ratedepends on underlying rhythm
• Pacerectopic focus in the atrium
• P wavesoccurs earlier than the next anticipated
  p wave
• PRIusually normal, but can vary depending on
  location
• QRSnormal

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PVC's
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PSVT

• Occurs when rapid atrial depolarization overrides
  the SA node. Can be caused by increased
  automaticity of a single atrial focus or by
  reentry phenomenon at the AV node.
• Etiologystress, overexertion, smoking, or
  ingestion of caffeine.

• Rate150-250
• Rhythmregular
• Paceroutside SA node
• P-waveusually buried within the preceding T wave
• PRInormal
• QRS--normal

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Atrial Flutter

• Caused by rapid atrial reentry circuit and an AV
  node that physiologically cannot conduct all
  impulses through the ventricles.
• Caused by CHF due to atrial dilation. Rarely from
  an MI

• Rateatrial 250-350 vent. Varies with ratio
• Rhythmatrial regular, vent regular unless
  variable conduction
• Flutter waves are present

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Atrial Fibrillation

• Results from multiple areas of reentry within the
  atria or from multiple ectopic foci bombarding an
  AV node that cannot handle the impulses.

• Rateatrial rate from 350-750.
• Irregularly irregular
• Numerous ectopic foci in the atria
• No PRI
• QRS normal

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• Results when the rate of the primary pacemaker,
  usually the SA node, becomes less than that of
  the AV node.

• 40-60 bpm
• AV junction is the pacer site
• P wave may be inverted either before or after
  the QRS
• QRS can be anything

Junctional Rhythm
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Accelerated Junctional

• Results from increased automaticity in the AV
  junction

• 60-100 bpm
• Regular rhythm
• Inverted or absent p waves
• QRS normal

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Junctional Tachycardia

• Results from rapid AV junctional depolarization
  overrides the SA node

• 100-180 bpm
• Regular rhythm
• Same as previous for everything else

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Ventricular Tachycardia

• Three or more PVCs in a row at a rate of greater
  than 100 bpm
• Causesmyocardial ischemia hypoxia acid-base
  disturbances electrolyte imbalances increased
  sympathetic tone idiopathic causes MI

• 100-250 bpm
• Usually regular but can be irregular
• Ventricles is the pacer
• QRS is greater than 0.12

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1st Degree AV Block

• Actually a delay in conduction rather than actual
  block.
• Could have other blocks associated with 1st
  degree, also known as bifascicular blocks which
  is a serious condition.

• Rate depends on underlying
• Normal p waves
• PRI greater than 0.20
• No danger in and of itself, but cannot tell other
  blocks with just a 3 lead. (12 LEAD!!!)

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2nd Degree Type I Wenkebach

• PRI becomes progressively longer until it drops a
  beat, the QRS.
• Ischemia is the most common cause. With increased
  parasympathetic tone and drugs as well.

• Atrial rate is unaffected. Atrial rhythm is
  usually regular.
• Can compromise cardiac output if QRSs are
  dropped often enough.

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Type II
2nd Degree

• Characterized by p waves not associated with QRS.
• Ventricular rate is usually bradycardic.

• Pacemaker insertion is the definitive treatment.

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3rd Degree Block Complete Heart Block

• Complete absence of conduction between the atria
  and ventricles.

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