ECG Course Level I - EMS Educationems.bcfdmo.com/wp-content/uploads/2019/01/ECG-7... · No P-wave or inverted P-wave or P-wave after the QRS. QRS can be wide or normal width. JR rate

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ECG Course Level I


Units in this Course

• Fundamentals

• Rate

• Regularity

• P-Waves

• Measurements

• Rhythm Interpretation

• Conduction Defects

• STEMI Identification


Rhythm Interpretation Unit• Step-Wise Approach Lesson

• Sinus Rhythms Lesson

• Atrial Rhythms Lesson

• Paced Rhythms Lesson

• Junctional Rhythms Lesson

• AV Blocks Lesson

• Ventricular Rhythms Lesson


Step-Wise Approach


Have a PlanLot’s of ECG analysis plans out there.

Everyone says you NEED one.

We have one for you for this course.

You can choose your own different one later but you should use ours for now.

If you are already experienced at ECG’s, don’t change your plan—but consider ours.


EKG Experts

Paramedic Educator Rob Theriault (rhymes with Ontario where he’s from)

Emergency Medicine Educator Amal Mattu (pronounced muh-2”)—awesome weekly ECG video lessons you should subscribe to (we got you a discount)

Dr. Ken Grauer, Tom Bouthillet at ems12lead.com, Dr. Tom Smith

http://ems12lead.com


EKG Book

Garcia and Holtz is our top pick

We all grew up on Dubin’s

Lot’s of Bob Page fans around


RPM-ABC• “R” Rate and Rhythm• “P” P-waves and Parts • “M” Measure PRI, QRS, QT

• “A” Axis• “B” Bundle Branch Blocks• “C” Changes in ST segment and T wave


For Now…

Just know that you need a plan and…

…our plan is RPM-ABC.

We will deal with the whole plan later because there may be some confusing stuff for you at this point. Stay tuned.


Sinus Rhythms


Requirements

Impulse originates in the SA Node.

That’s it. Nothing further.

Contrast with “Normal Sinus Rhythm”.


How Do You Tell?

P-wave upright in Leads I, II, III, AVL, AVF

P-wave also must be inverted in Lead AVR


Sinus Node P-Waves

Upright in I, II, II, AVL, AVF

Negative in AVR


May Have Other Issues

May have an AV Block

May have a Bundle Branch Block

May have ectopics

All “Sinus” means is that it ORIGINATED in the Sino-Atrial (Sinus) Node


Sinus arrhythmia

Sinus Arrhythmia is a rhythm with variable ventricular rate—irregular but with a pattern that matches the breathing pattern.

No dropped beats.

Sinus P-waves.


Sinus Exit BlockNo dropped beats (remember, we mean QRS’s when we say “beats”)

Sinus P-waves.

From Life in the Fast Lane blog (check it out):

Sino-atrial exit block is due to failed propagation of pacemaker impulses beyond the SA node. The sino-atrial node continues to depolarise normally. However, some of the sinus impulses are “blocked” before they can leave the SA node, leading to intermittent failure of atrial depolarisation (dropped P waves).


aka “Pause”


Normal Sinus Rhythm

Sinus rhythm

Rate is 60 to 99 (100 and over is Tachycardia)

No prolonged PRI—if there were, it would be a Sinus Rhythm with 1st Degree AV Block

No P-waves that don’t conduct to a QRS as in 2nd Degree AV Blocks



Sinus Tachycardia

Sinus rhythm

Rate is 100 or more technically

No prolonged PRI (1st Degree AV Block) or dropped beats (as in 2nd degree AV Block)



Sinus Bradycardia

Sinus rhythm

Rate is less than 60

No prolonged PRI (1st Degree AV Block) or dropped beats (as in 2nd degree AV Block)



SummaryP-wave upright in Leads I, II, III, AVL, AVF

P-wave also must be inverted in Lead AVR

No dropped beats

May have early / ectopic beats or an AV Block or a Bundle Branch Block

May be irregular if sinus _____ (arrhythmia or pause or arrest or exit block)


Atrial Rhythms


Varieties

Atrial Fibrillation

Atrial Flutter

Wandering Atrial Pacemaker

Multifocal Atrial Tachycardia

“SVT”



May have a Bundle Branch Block (wide QRS)

May have accessory pathways (such as Atrial Fib withWPW) (wide QRS)

May have ectopics


Atrial FibrillationNo clearly definable P-waves

“Fibrillatory waves” (coarse or fine)

IRREGULARLY IRREGULAR

Common—ventricular rate is the key

“March it Out”—use “field calipers”



Atrial FlutterNo clearly definable P-waves

“Flutter waves”

REGULAR unless changing ratios

Ratio / ventricular rate is the key

Beware of ventricular rates of about 150




Wandering Atrial PacemakerThree or more different ectopic atrial foci (three or more PAC morphologies)

Rate less than 100.



Multi-focal Atrial Tachycardia

Three or more different ectopic atrial foci (three or more PAC morphologies) (WAP)

Rate 100 or greater.



“SVT”Technically, any tachycardia that originates ABOVE the ventricles is called “supraventricular tachycardia”.

Customarily, we call it “SVT” when it is really AVNRT or AVRT.

Just know that it is a crazy short circuit loop involving the AV Node—its an AV Node issue so you need to reboot the AV Node.

You can read more on the specifics if you want but…don’t get hung up in the weeds.




Paced Rhythms


Varieties

Some watch for native atrial activity and then provide an atrial pacing impulse if the native activity is not present.

Some watch for native ventricular activity and then provide a ventricular pacing impulse if the native activity is not present.

Some do both (pretty common).



Frequently the QRS is wide.

May have ectopics


Examples

Pacemaker SpikesPatients with implanted pacemakers will have “spikes” on their EKG as shown in this short video of AV sequential pacer EKG where one spike causes the p-wave and the second causes the QRS.

http://www.youtube.com/watch?v=pNIssN58G0U

http://www.youtube.com/watch?v=pNIssN58G0U


Junctional Rhythms


Requirements

Impulse originates in the AV Node or AV Junction (we’ll talk about why later)

P-waves may be absent.

P-waves may be inverted.

P-waves may be after the QRS.

QRS may be wide or normal width.



May have a Bundle Branch Block

May have ectopics


Junctional Rhythms

Junctional Escape Rhythm: 40-60 bpm

Accelerated Junctional Rhythm: 60-100 bpm

Junctional Tachycardia: > 100 bpm


What Causes Them?SA Node fails to fire on time—AV Junction pacemakers step in (Junctional “Escape” Rhythm)

Or…AV Junction fires faster than the SA Node



SummaryNo P-wave or inverted P-wave or P-wave after the QRS.

QRS can be wide or normal width.

JR rate is 40-60 but can have accelerated JR or Junctional Tachycardia

REGULAR rhythm—as opposed to Atrial Fib where there are no clear P-waves but the rhythm is irregularly irregular.


Ventricular Rhythms


Types

Ventricular Tachycardia

Polymorphic V-Tach

Torsades de Pointes

Non-sustained V-Tach

Idioventricular Rhythms


V-Tach

Wide (greater than 120 milliseconds)

May have P-waves but they MUST be dissociated

Rate typically 150 or more

May be too fast to generate a pulse


Wide-Complex TachyFour out of five times or more, a WCT is V-Tach

V-Tach may last for a few seconds and revert to a more stable rhythm or it may degrade into V-Fib. V-Tach may last for several minutes or even a few hours.

WCT causes—VT, VT, VT, VT, something with a BBB, something with an Accessory Pathway.


V-Tach vs Other

There are some “rules” out there for determining if a WCT is really V-Tach or not.

They are not sensitive enough to be of any real value to paramedics.

They are not specific enough either.

Simple rule: if it is NOT clearly Sinus Tach with a BBB or AP, then call it V-Tach.


Examples


Polymorphic V-TachMore than one “morphology” (shape).


Torsades de PointesForm of Polymorphic V-Tach

Associated with long QTc

Unstable rhythm that rapidly degrades to VF



Non-Sustained V-TachRun of V-Tach is 4 PVC’s in a row

Non-Sustained V-Tach is up to 30 seconds of V-Tach


Idioventricular Rhythms

Documents

ECG Course Level I - EMS Educationems.bcfdmo.com/wp-content/uploads/2019/01/ECG-7... · No P-wave or inverted P-wave or P-wave after the QRS. QRS can be wide or normal width. JR rate