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Page 1: EKG for ACLS

AMANDA HOOPER2008-2009

EKG for ACLS

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Let’s start with some basics…

V1: right 4th intercostal space

V2: left 4th intercostal space

V3: halfway between V2 and V4

V4: left 5th intercostal space, mid-clavicular line

V5: horizontal to V4, anterior axillary line

V6: horizontal to V5, mid-axillar line

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Conduction System of the Heart Sinus node is the pacemaker

of the heart, the dominant center of automaticity.

Generates continuous regular depolarization stimuli at a rate of 60-100 bpm

There are other potential pacemakers that can take over if SA node fails, and they have different intrinsic rates. These are in the atria, AV junction, and the ventricles.

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EKG Paper

EKG machine moves at 25 mm/sec, each small box is 1 mm

Small boxes represent 0.04 sec

Large boxes represent 0.2 sec

Five large boxes equal one second

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EKG Waves and Intervals

P wave: the sequential activation (depolarization) of the right and left atria

QRS complex: right and left ventricular depolarization (normally the ventricles are activated simultaneously)

ST-T wave: ventricular repolarization PR interval: time interval from onset of atrial depolarization (P

wave) to onset of ventricular depolarization (QRS complex) QRS duration: duration of ventricular muscle depolarization QT interval: duration of ventricular depolarization and repolarization

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Systematic Approach to ECG Interpretation

RateRhythmAxisIntervalsHypertrophyInfarct (QRST Changes)

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Determining Rate R-R interval is ventricular rate p-p interval is atrial rate. Usually the same but not always

Several ways to do this… 1) Count down the number of large boxes: 300, 150, 100, 75, 60,

50, .... Ex: this one is between 150 and 100, closer to 150 so we might say ~130-140

bpm 2) Count the number of large boxes and divide by 300

Ex: 300/2 = 150 but it is a little slower than that so we might say ~130-140 bpm

3) Count the number of small boxes between beats and divide into 1500 Ex: 1500/11 = 136 bpm

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Analyzing A Rhythm Strip

Is the rhythm regular?

What is the rate?Is the QRS complex

narrow or wide?Are P waves

present?Are P waves

related to the QRS complexes?

What is the PR interval ?

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Intervals PR interval

From the onset of atrial depolarization to the onset of ventricular depolarization

Normal between 0.12 and 0.20 sec—so should be less than a large box

QRS interval: Time it takes for ventricular

depolarization to occur Normal is 0.10 sec or less—so

should be less than half of a large box

QT interval From the beginning of ventricular

depolarization to the end of ventricular repolarization

Normal is les than half of a R-R interval (can’t always rely on this if rate is very tachycardic)

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Atrial Flutter with 2:1 AV Block

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Aflutter With Carotid Massage

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Supraventricular Tachycardia (SVT)

Supraventricular rhythms start by definition at or above the AV node. If the QRS is narrow in all leads, you can almost be guaranteed the rhythm is supraventricular.

Sinus rhythm, atrial fibrillation, atrial flutter, junctional/nodal rhythms, and PSVT

PSVT is a reentry rhythm

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SVT

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Myocardial Infarction

Look for QRST changes in each lead Note each lead where Q waves are foundLook for R wave progression—transition

normally occurs between V2 and V4Look at ST segments and note depression or

elevation Look for T wave inversion

Q waves or T wave inversion may be a normal finding in leads III, aVF, aVL, aVR, and V1

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Basic Lead Groupings

Inferior leads: II, III, aVFLateral (left-sided) leads: V4 to V6 and I, aVLSeptal leads: V1, V2Anterior leads: V2 to V4

Right coronary artery: SA node, IV septum, inferior heart, +/- posterior heart

Left coronary artery: LAD- anterior heart Left circumflex- lateral heart

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12 EKG with Acute MI

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Anteroseptal MI

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Inferior MI with RV Infarction

From: Heart Disease 6th Edition. Braunwald E, Zipes D, and Libby P. 2001