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ONTARIO. QUIT. BASE HOSPITAL GROUP. ADVANCED ASSESSMENT ECG INTERPRETATION. 2007 Ontario Base Hospital Group. ADVANCED ASSESSMENT ECG INTERPRETATION. AUTHOR Tim Dodd, AEMCA, ACP Hamilton Base Hospital References – Emergency Medicine. REVIEWERS/CONTRIBUTORS Al Santos A-EMCA, ACP

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ONTARIO

QUIT

BASE HOSPITAL GROUP

ADVANCED ASSESSMENTECG INTERPRETATION

2007 Ontario Base Hospital Group


ADVANCED ASSESSMENTECG INTERPRETATION

AUTHOR

Tim Dodd, AEMCA, ACP

Hamilton Base Hospital

References – Emergency Medicine

REVIEWERS/CONTRIBUTORS

Al Santos A-EMCA, ACP

Donna L. Smith AEMCA, ACP

Hamilton Base Hospital

2007 Ontario Base Hospital Group


Lecture overview

Anatomy review

Electrical impulse conduction

ECG paper constants

Limb placements

Heart rate determination

Steps to rhythm strip analyzes

ECG interpretations!

Lecture Overview


Objectives

To gain a basic knowledge of cardiac electrophysiology

To understand the representations of the cardiac cycle on the ECG

To master techniques used for learning the characteristics of the different dysrhythmias

To learn measurement and count techniques essential for dysrhythmia interpretation

Objectives


Lead placement and ecg view

Our cardiac monitors have the ability to display ECG rhythms

In manual mode it is possible to capture various leads or “views” of the electrical activity

No matter which view is being displayed, the underlying rhythm does NOT change

Lead Placement and ECG “View”


Bipolar leads or limb leads i ii iii

Bipolar Leads or Limb Leads (I,II,III)


Limb leads

Einthoven’s triangle is composed of the standard (bipolar) limb leads:

Lead I: negative pole is right arm & positive is left arm

Lead II: negative pole is right arm & positive left leg

Lead III: negative pole is left arm & positive left leg

Limb Leads


Lead placement and views
Lead Placement and Views (bipolar) limb leads:

Lead I

Negative

Positive

Ground


Lead placement and views1
Lead Placement and Views (bipolar) limb leads:

Ground

Negative

Lead II

Positive


Lead placement and views2
Lead Placement and Views (bipolar) limb leads:

Negative

Ground

Lead III

Positive


Bipolar leads i ii iii
BiPolar Leads I, II & III (bipolar) limb leads:

Lead I

Lead III

Lead II


Limb leads1

Lead I (bipolar) limb leads:

-

+

Right Arm

Left Arm

-

-

Lead II

Lead III

+

+

Left Leg

Limb Leads


Cardiac monitoring and lead placement

Cardiac Monitoring and (bipolar) limb leads:Lead Placement


V (Brown): Place to Right of sternum at the 4 (bipolar) limb leads:th intercostal Space

5 Lead Electrode Placement

LA (Black): Place near left mid-clavicular line, directly below the clavicle

RA (White): Place near right mid-clavicular line, directly below the clavicle.

LL (Red):Place between 6th & 7th intercostal Space on left mid-clavicular line

RL (Green): Place between 6th and 7th intercostal Space on right mid-clavicular line


12 lead electrode placement
12 Lead Electrode Placement (bipolar) limb leads:


Lead groups
Lead Groups (bipolar) limb leads:

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

Limb Leads

Chest Leads


Inferior wall

II, III and aVF (bipolar) limb leads:

Left Leg

Inferior Wall

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Inferior wall1
Inferior Wall (bipolar) limb leads:

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

Inferior Wall


Septal wall

V1, V2 (bipolar) limb leads:

Along sternal borders

Septal Wall

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Septal wall1
Septal Wall (bipolar) limb leads:

  • V1,V2

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Anterior wall

V3 and V4 (bipolar) limb leads:

Left anterior chest

Anterior Wall

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Anterior wall1
Anterior Wall (bipolar) limb leads:

  • V3 and V4

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Lateral wall high

I and aVL (bipolar) limb leads:

Left Arm

Lateral Wall - High

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Lateral wall low

V5 and V6 (bipolar) limb leads:

Left lateral chest

Lateral Wall - Low

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Lateral wall

I, aVL, V5 and V6 (bipolar) limb leads:

Lateral Wall

Lateral Wall

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6


Cardiac conduction

Cardiac (bipolar) limb leads:Conduction


Cardiac conduction1

Essentially 2 pumps (bipolar) limb leads:

Atria

Ventricles

Must operate in unison and in order

Three Primary Pacemakers

Sinoatrial Node

Atrio-Ventricular Junction

Purkinje System

Cardiac Conduction


Electromechanics

Resting cells: negative interior, positive exterior (bipolar) limb leads:

Changes in this resting state cause depolarization and repolarization

Electromechanics


Electrical flow

Towards negative electrode: (bipolar) limb leads:downward deflection on paper

Towards positive electrode:

upward deflection on paper

As energy travels away from this axis amplitude on the ECG decreases

Electrical Flow


Ecg view and electrical flow

Lead II offers the best “view” (bipolar) limb leads:

The normal electrical axis travels the 11-5 o’clock vector which is 59 degrees

Lead II is at 60 degrees

ECG “View”and Electrical Flow


S ino a trial node

Contraction of the Atria (bipolar) limb leads:

Normally depolarizes 60-80 times/min.

Can depolarize up to 300 times/min.

Follows special pathways –

- IntraAtrial:

Anterior, Middle, Posterior Internodal Tracts

SinoAtrial Node


A trio v entricular node

Pauses depolarization to allow ventricular filling (bipolar) limb leads:

Capable of depolarizing 40-60 times/min. (in the absence of the SA Node input)

AtrioVentricularNode


Ventricular pathways

Bundle of His (bipolar) limb leads:

Left and Right Bundle Branches

Left bundle gives rise to anterior and posterior fascicles

Ends at the Purkinje fibers

Inherent depolarization rate < 40/min.

Ventricular Pathways


Conduction pathways
Conduction Pathways (bipolar) limb leads:


Pathway structure relationship
Pathway – structure relationship (bipolar) limb leads:

Slide courtesy of York BH


Ecg paper

Horizontal lines: (bipolar) limb leads: distance in millimeters and time in seconds

Vertical lines: voltage (amplitude) in millimeters

Uses the Metric system

Is very good for accuracy

ECG Paper


Ecg paper1

Light vertical lines are 0.04 second (1 mm) apart (bipolar) limb leads:

Dark vertical lines are 0.20 second (5 mm) apart

5 dark squares is 1 second

ECG Paper


Cardiac conduction2
Cardiac Conduction (bipolar) limb leads:


Cardiac conduction p wave
Cardiac Conduction: (bipolar) limb leads:P Wave

P Wave: Atrial Impulse

.04 - .08 Seconds


Cardiac conduction pr interval
Cardiac Conduction: (bipolar) limb leads:PR Interval

P Wave .04 - .08 Sec.

PRI .12-.20 Sec.


Cardiac conduction qrs complex
Cardiac Conduction: (bipolar) limb leads:QRS Complex

P Wave .04 - .08 Sec.

PRI .12 - .20 Sec.

QRS .06 - .12 Sec.


Analyzing a rhythm strip

Analyzing a (bipolar) limb leads:Rhythm Strip


Dysrhythmia interpretation 5 step approach

Step 1: What is the rate? (bipolar) limb leads:

Step 2: Is the rhythm regular or irregular?

Step 3: Is the P wave normal?

Step 4: P-R Interval/relationship?

Step 5: Normal QRS complex?

Dysrhythmia Interpretation: 5 Step Approach


Step 1- Rate (bipolar) limb leads:

Method 1

Count the number of R waves for a six second interval and multiply by ten.

6 sec

3sec

3 sec

(can be used for regular & irregular)


Step 1 - Rate (bipolar) limb leads:

Method 2: Count the number of 5mm squares and divide into 300 (or memorize)

300

150

100

75

60

50

43

37

33

30 … slow


Step 1 rate

RATE: (bipolar) limb leads:

Tachycardia exists if the rate is greater than 100 beats/min.

Bradycardia exists if the rate is less than 60 beats/min.

Step 1 - Rate


Step 2 rhythm

RHYTHM: (bipolar) limb leads:

Determine if the ventricular rhythm is regular or irregular (pattern to irreg.?)

R-R intervals should measure the same

P-P intervals should also measure the same

Step 2 - Rhythm


Step 2 - Rhythm (bipolar) limb leads:

REGULAR

IRREGULAR


Irregularly Irregular (bipolar) limb leads:

STEP 2 - Rhythm Example


Step 3 is the p wave normal

Identify and examine P waves: (bipolar) limb leads:

Present?

Appearance?

Consistency?

Relation to QRS?

STEP 3 – Is the P Wave Normal


Normal (bipolar) limb leads:

Normal

P wave with no QRS complex

STEP 3 - Is the P Wave Normal

Same Shape

Associated with a QRS Complex?


Consistent PRI of <.20 secs is normal, (bipolar) limb leads:

lengthened or variant PRI’s could indicate an AV block

STEP 4 –

PR Interval/Relationship


STEP FIVE –QRS DURATION (bipolar) limb leads:

  • A narrow QRS complex (< 0.12), indicates the impulse has followed the normal conduction pathway

  • A widened QRS complex (> 0.12), may indicate the impulse was generated somewhere in the ventricles


Remember

Use a systematic approach (bipolar) limb leads:

Go through all the steps

Take your time!

Compare with your characteristics list

Interpret the dysrhythmia

REMEMBER!!!


Questions

QUESTIONS? (bipolar) limb leads:


Let s have some fun

Let’s Have Some Fun! (bipolar) limb leads:


Sinus mechanisms

Sinus Mechanisms (bipolar) limb leads:


Sinus node

Normal Sinus Rhythm (NSR) (bipolar) limb leads:

Sinus Bradycardia

Sinus Tachycardia

Sinus Arrhythmia

Sinus Arrest/Pause

Sinoatrial Exit Block

Sinus Node


Normal sinus rhythm nsr

Rate: (bipolar) limb leads: 60-100 beats/min

Rhythm: regular

P waves: uniform, + (upright) in lead II, one precedes each QRS complex

PR interval: 0.12 - 0.20 seconds and constant

QRS duration: < 0.12 sec

Normal Sinus Rhythm (NSR)


Normal sinus rhythm nsr1
Normal Sinus Rhythm (NSR) (bipolar) limb leads:


Sinus bradycardia

Rate: (bipolar) limb leads: less than 60 beats/min

Rhythm: regular

P waves: uniform in appearance, upright and one precedes each QRS complex

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Sinus Bradycardia


Sinus bradycardia1
Sinus Bradycardia (bipolar) limb leads:


Sinus tachycardia

Rate: (bipolar) limb leads:greater than 100-150 beats/min

Rhythm: regular

P waves: uniform, upright, one precedes each QRS

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Sinus Tachycardia


Sinus tachycardia1
Sinus Tachycardia (bipolar) limb leads:


Enough of sinus

ENOUGH OF SINUS (bipolar) limb leads:


Sinus arrhythmia

Rate: (bipolar) limb leads: 60-100 beats/min

Rhythm:irregular

P waves: uniform in appearance, upright, one precedes each QRS

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Sinus Arrhythmia


Sinus arrhythmia1
Sinus Arrhythmia (bipolar) limb leads:


Sinus arrest pause

Rate: (bipolar) limb leads:usually normal but varies due to the arrest

Rhythm:irregular; the arrest is of undetermined length

P waves: uniform in appearance, upright, one precedes each QRS

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Sinus Arrest/Pause


Sinus arrest pause1
Sinus Arrest/Pause (bipolar) limb leads:


Sinoatrial exit block

Rate: (bipolar) limb leads:varies due to the pause

Rhythm:irregular; each pause is the same as the distance between two other P-P intervals

P waves: uniform in appearance, upright, one precedes each QRS

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Sinoatrial Exit Block


Sinoatrial exit block1
Sinoatrial Exit Block (bipolar) limb leads:


Atrial dysrhythmias

Atrial Dysrhythmias (bipolar) limb leads:


Atrial dysrhythmias1

Premature Atrial Complexes (PACs) (bipolar) limb leads:

Wandering Atrial Pacemaker (WAP)

Supraventricular Tachycardia (SVT)

Wolff-Parkinson-White Syndrome (WPW)

Atrial Flutter

Atrial Fibrillation (A-Fib)

Atrial Dysrhythmias


Premature atrial complexes pacs

Rate: (bipolar) limb leads:depends on underlying rhythm

Rhythm:regular with premature beats

P waves:premature (earlier than expected) and may differ in shape from sinus P waves

PR interval: 0.12 - 0.20 sec and constant

QRS duration: < 0.12 sec

Note: Ectopic complex

Premature Atrial Complexes (PACs)


Premature atrial complexes pacs1
Premature Atrial Complexes (PACs) (bipolar) limb leads:


Wandering atrial pacemaker wap

Rate: (bipolar) limb leads: usually 60-100 beats/min;if greater than 100 beats/min, it’s termed multifocal atrial tachycardia

Rhythm:may be normal or irregular due to shift in ectopic atrial locations

P waves:size, shape and direction change (3 or more different P waves)

PR interval:may be normal or variable

QRS duration: < 0.12 sec

Wandering Atrial Pacemaker (WAP)


Wandering atrial pacemaker wap1
Wandering Atrial Pacemaker (WAP) (bipolar) limb leads:


Supraventricular tachycardia svt psvt

Rate: (bipolar) limb leads:120-250 beats/min

Rhythm: regular

P waves:not present

PR interval:not measurable

QRS duration: < 0.12 sec

Note: PSVT is an SVT

that starts/ends suddenly

Supraventricular Tachycardia (SVT/PSVT)


Supraventricular tachycardia svt
Supraventricular Tachycardia (SVT) (bipolar) limb leads:


Wolff parkinson white syndrome wpw

Rate: (bipolar) limb leads: usually 60-100 beats/min (can be associated with runs/episodes of A-Fib)

Rhythm: regular

P waves: uniform in appearance, upright, one precedes each QRS

PR interval: 0.12 - 0.20 sec and constant

QRS duration:usually > 0.12 sec; slurred upstroke of the QRS complex (delta wave)

Wolff-Parkinson-White Syndrome (WPW)



Atrial flutter

Rate: (bipolar) limb leads:atrial rate 250-450 beats/min; ventricular rate will not usually exceed 180 beats/min

Rhythm:atrial regular; ventricular regular or irregular

P waves:saw-toothed “flutter” waves

PR interval:not measurable

QRS duration: < 0.12 sec

Atrial Flutter


Atrial flutter1
Atrial Flutter (bipolar) limb leads:


Atrial fibrillation a fib

Rate: (bipolar) limb leads:variable

Rhythm:irregularly irregular

P waves:no identifiable P waves

PR interval:not measurable

QRS duration: < 0.12 sec

Atrial Fibrillation (A-fib)


Atrial fibrillation a fib1
Atrial Fibrillation (A-fib) (bipolar) limb leads:


Junctional rhythms

Junctional Rhythms (bipolar) limb leads:


Junctional rhythms1

Premature Junctional Complex (PJC) (bipolar) limb leads:

Junctional Rhythm

Accelerated Junctional Rhythm

Junctional Tachycardia

Junctional Rhythms


Premature junctional complexes pjc

Rate: (bipolar) limb leads: usually normal but depends on the underlying rhythm

Rhythm:regular with premature beats

P waves:may occur before, during or after the QRS (inverted if visible)

PR interval:if P visible, < or = to 0.12 sec

QRS duration: < 0.12 sec

Note: Ectopic complex

Premature Junctional Complexes (PJC)



Junctional rhythm

Rate: (bipolar) limb leads:40-60 beats/min

Rhythm: regular

P waves:not present or may occur before, during or after the QRS (inverted if present)

PR interval:not measurable, but if present usually < or = to 0.12 sec

QRS duration: < 0.12 sec

Junctional Rhythm


Junctional rhythm1
Junctional Rhythm (bipolar) limb leads:


Junctional rhythm2
Junctional Rhythm (bipolar) limb leads:


Accelerated junctional rhythm

Rate: (bipolar) limb leads:61-100 beats/min

Rhythm: regular

P waves:not present or may occur before, during or after the QRS (inverted if present; may be notched or S waved)

PR interval:not measurable, but if present usually < or = to 0.12 sec

QRS duration: < 0.12 sec

Accelerated Junctional Rhythm


Accelerated junctional rhythm1
Accelerated Junctional Rhythm (bipolar) limb leads:


Junctional tachycardia

Rate: (bipolar) limb leads:101-180 beats/min

Rhythm: regular

P waves:not present or may occur before, during or after the QRS (inverted if present)

PR interval:not measurable, but if present usually < or = to 0.12 sec

QRS duration: < 0.12 sec

Junctional Tachycardia


Junctional tachycardia1
Junctional Tachycardia (bipolar) limb leads:


Ventricular rhythms

Ventricular Rhythms (bipolar) limb leads:


Ventricular rhythms1

Premature Ventricular Complexes (PVC's) (bipolar) limb leads:

Idioventricular Rhythm

Ventricular Tachycardia (VT)

Torsades de Pointes (TdP)

Ventricular Fibrillation (VF)

Asystole

Ventricular Rhythms


Premature ventricular complexes pvc s

Rate: (bipolar) limb leads:depends on underlying rhythm

Rhythm:regular with premature beats

P waves:absent

PR interval:none

QRS duration:> 0.12 sec, wide and bizarre!

Note: Ectopic complex

Premature Ventricular Complexes (PVC's)


Premature ventricular complexes pvc s1
Premature Ventricular Complexes (PVC's) (bipolar) limb leads:

Note – Complexes not Contractions


Pvc s

Uniformed/Multiformed (bipolar) limb leads:

Couplets/Salvos/Runs

Bigeminy/Trigeminy/Quadrageminy

PVC’s


Uniformed pvc s
Uniformed PVC’s (bipolar) limb leads:


R on t phenomena
R on T Phenomena (bipolar) limb leads:


Multiformed pvc s
Multiformed PVC’s (bipolar) limb leads:


Pvc couplets
PVC Couplets (bipolar) limb leads:


Pvc salvos and runs
PVC Salvos and Runs (bipolar) limb leads:


Bigeminy pvc s
Bigeminy PVC’s (bipolar) limb leads:


Trigeminy pvc s
Trigeminy PVC’s (bipolar) limb leads:


Quadrageminy pvc s
Quadrageminy PVC’s (bipolar) limb leads:


Ventricular escape beats

Rate: (bipolar) limb leads:depends on underlying rhythm

Rhythm:regular with late beats; occurs after the next expected sinus beat

P waves:absent

PR interval:none

QRS duration:> 0.12 sec. wide and bizarre

Note: Ectopic complex

Ventricular Escape Beats


Ventricular escape beats1
Ventricular Escape Beats (bipolar) limb leads:


Idioventricular rhythm

Rate: (bipolar) limb leads:20-40 beats/min

Rhythm: regular

P waves:absent

PR interval:none

QRS duration:> 0.12 sec

Note: “Wide and Slow, (Oh No!) it’s Idio”

Idioventricular Rhythm


Idioventricular rhythm1
Idioventricular Rhythm (bipolar) limb leads:


Ventricular tachycardia vt

Rate: (bipolar) limb leads:101-250 beats/min

Rhythm: regular

P waves:absent

PR interval:none

QRS duration:> 0.12 sec. often difficult to differentiate between QRS and T wave

Note: Monomorphic - same shape

and amplitude

Ventricular Tachycardia (VT)


Ventricular tachycardia vt1
Ventricular Tachycardia (VT) (bipolar) limb leads:


V tach
V Tach (bipolar) limb leads:


Torsades de pointes tdep

Rate: (bipolar) limb leads:150-300 beats/min

Rhythm:regular or irregular

P waves:none

PR interval:none

QRS duration:> 0.12 sec. gradual alteration in amplitude and direction of the QRS complexes

Torsades de Pointes (TdeP)


Torsades de pointes tdep1
Torsades de Pointes (TdeP) (bipolar) limb leads:


Ventricular fibrillation vf

Rate: (bipolar) limb leads:CNO as no discernible complexes

Rhythm:rapid and chaotic

P waves:none

PR interval:none

QRS duration:none

Note: Fine vs. coarse?

Ventricular Fibrillation (VF)


Ventricular fibrillation vf1
Ventricular Fibrillation (VF) (bipolar) limb leads:


Ventricular fibrillation vf2
Ventricular Fibrillation (VF) (bipolar) limb leads:



Asystole cardiac standstill

Rate: (bipolar) limb leads:none

Rhythm:none

P waves:none

PR interval:not measurable

QRS duration:absent

Asystole (Cardiac Standstill)


Asystole cardiac standstill1
Asystole (bipolar) limb leads: (Cardiac Standstill)


Asystole the mother of all bradycardias
Asystole (bipolar) limb leads:The Mother of all Bradycardias


Questions1

QUESTIONS? (bipolar) limb leads:


Atrioventricular av blocks

AtrioVentricular (AV) Blocks (bipolar) limb leads:


Atrioventricular av blocks1

First-degree AV block (bipolar) limb leads:

Second-degree AV block, type I (Wenckebach or Mobitz I)

Second-degree AV block, type II (Mobitz II)

Third-degree AV block (Complete AV Block)

Atrioventricular (AV) Blocks


First degree av block

Rate: (bipolar) limb leads:depends on underlying rhythm (usually regular)

Rhythm: regular

P waves: normal in size and shape

PR interval:> 0.20 sec but constant

QRS duration: < 0.12 sec

First-degree AV block


First degree av block1
First-degree AV block (bipolar) limb leads:


2 nd degree av block type i wenckebach mobitz type i

Rate: (bipolar) limb leads:atrial rate > ventricular rate

Rhythm:atrial reg.; ventricular irreg.

P waves: normal in size and shape

PR interval:lengthens with each cycle until a P appears with no QRS complex

QRS duration:< 0.12 sec(Periodically dropped QRS complex!)

2nd Degree AV block Type I (Wenckebach/Mobitz Type I)


2 nd degree av block type i wenckebach mobitz type i1
2 (bipolar) limb leads:nd Degree AV block Type I (Wenckebach/Mobitz Type I)


2 nd degree av block type ii mobitz type ii

Rate: (bipolar) limb leads:atrial rate > the ventricular rate

Rhythm:atrial reg.; ventricular irreg.

P waves: normal in size and shape

PR interval:within normal limits or slightly prolonged but constant

QRS duration:< 0.12 sec (Periodically dropped QRS complex!)

2nd Degree AV block Type II (Mobitz Type II)


2 nd degree av block type ii mobitz type ii1
2 (bipolar) limb leads:nd Degree AV block Type II (Mobitz Type II)


3 rd degree av block complete av block

Rate: (bipolar) limb leads:atrial rate is > ventricular rate

Rhythm:atrial reg.; ventricular reg. (P waves plot through)

P waves: normal in size and shape

PR interval:no relationship (independent)

QRS duration:narrow or wide depending on location of pacemaker

3rd Degree AV block (Complete AV Block)


3 rd degree av block complete av block1
3 (bipolar) limb leads:rd Degree AV block (Complete AV Block)


3 rd degree av block
3 (bipolar) limb leads:rd Degree AV block


Pacemaker rhythms

Pacemaker Rhythms (bipolar) limb leads:


Cardiac pacemakers

Definition (bipolar) limb leads:

Delivers artificial stimulus to heart

Causes depolarization and contraction

Uses

Bradyarrhythmias

Asystole

Tachyarrhythmias (overdrive pacing)

Cardiac Pacemakers


Cardiac pacemakers1

Fixed (bipolar) limb leads:

Fires at constant rate

Can discharge on T-wave

Very rare

Demand

Senses patient’s rhythm

Fires only if no activity sensed after preset interval (escape interval)

Cardiac Pacemakers


Cardiac pacemakers2
Cardiac Pacemakers (bipolar) limb leads:


Cardiac pacemakers3

Demand Pacemaker Types (bipolar) limb leads:

Atrial

Fires atria

Atria fire ventricles

Requires intact AV conduction

Ventricular

Fires ventricles

Cardiac Pacemakers


Cardiac pacemakers4

Demand Pacemaker Types (bipolar) limb leads:

Atrial Synchronous

Senses atria

Fires ventricles

AV Sequential

Two electrodes

Fires atria/ventricles in sequence

Cardiac Pacemakers


Cardiac pacemakers5

Special Considerations (bipolar) limb leads:

Pacemaker does NOT affect treatment of cardiac arrest

Do NOT defibrillate directly over pacemaker generator

Pacemakers may keep AEDs from advising shock

Cardiac Pacemakers


Atrial pacemaker single chamber
Atrial Pacemaker (bipolar) limb leads:(Single Chamber)

pacemaker

  • Capture?


Ventricular pacemaker single chamber
Ventricular Pacemaker (bipolar) limb leads: (Single Chamber)

pacemaker


Dual paced rhythm
Dual Paced Rhythm (bipolar) limb leads:

pacemaker


Special notes

Special Notes (bipolar) limb leads:


S t elevation

S-T elevation is not significant without a 12 lead interpretation

Should not be reported!

S-T Elevation


S t elevation1

Monitors filter rhythms and show you what they think it should

ST elevation is common on Pts. who show no elevation on 12 Lead

S-T Elevation


Artifact should


60 cycle interference

60 cycle artifact (noise) should

Problem solve causes

Electromagnetic emanations:

i.e. TV’s, electric motors, fluorescent lights

60 Cycle Interference



Aberrancy bundle branch block

12 Lead ECG required to diagnose BBB (Left or right BBB?) should

Describe widened QRS (>0.12 sec) as “aberrant” unless using 12 lead

AberrancyBundle Branch Block


Aberrancy bundle branch block1
Aberrancy shouldBundle Branch Block


Pulseless electrical activity pea

The absence of a detectable pulse and blood pressure should

Presence of electrical activity of the heart as evidenced by ECG rhythm, but not VF or VT

Pulseless Electrical Activity(PEA)

= 0/0 mmHg

+


Practice practice practice use it or lose it

Practice shouldPracticePracticeUSE IT OR LOSE IT!!!!


ONTARIO should

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