1 MI Fast Track & EKG Interpretation โดย พว. วินิตย์ หลงละเลิง พยาบาลศาสตรมหาบัณฑิต (การพยาบาลผู้ใหญ่) , Master of Nursing Science Program in Nursing (M.N.S.) วทม. เพศศาสตร์, Master of Science Program in Human Sexuality ผู้ปฏิบัติการพยาบาลขั้นสูง (สาขาการพยาบาลอายุรศาสตร์-ศัลยศาสตร์), Advanced Practiced Nurse (APN) กลุ่มงานการพยาบาล โรงพยาบาลธรรมศาสตร์เฉลิมพระเกียรติ 15 กันยายน 59
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1
MI Fast Track & EKG Interpretation
โดยพว. วนตย หลงละเลง
พยาบาลศาสตรมหาบณฑต (การพยาบาลผใหญ) , Master of Nursing Science Program in Nursing (M.N.S.) วทม. เพศศาสตร, Master of Science Program in Human Sexuality
2. Determine whether the rhythm is regular or irregular.
3. Ensure that there is a P wave before every QRS complex and that
all the P waves are the same shape.
4. Measure the PR interval to determine if they are between 0.12 and 0.20
second.
5. Ensure that a QRS complex follows every P wave.
6. Verify that the QRS complexes are all the same size and shape and
that they measure between 0.04 and 0.10 second.
7. Determine the overall appearance and interpret the rhythm.
(Hebra, J., 1998: 34)
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อตราการเตนของหวใจ (Heart rate)คดค านวณอยางไร?
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กระดาษกราฟ EKGPaper Speed = 25 mm / sec
25 mm (25 ชองเลก ) = 1 sec
1 mm (1 ชองเลก ) = 1 / 25 = 0.04 sec
5 mm (5 ชองเลก = 1 ชองใหญ ) = 0.04 X 5
= 0.2 sec
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การค านวณ Rate
• Rate
1. ใชเทยบบญญตไตรยางศ
2. วธการจ าโดยการประมาณ
3. Six Second Strip
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Rate ใชเทยบบญญตไตรยางศ
ใหนบจ านวนชองระหวาง R-R วาหางกนกชอง
นบชองเลก Rate = 1500/จ านวนชองเลก
นบชองใหญ Rate = 300/จ านวนชองใหญ
0.04 sec = 1 ชองเลก
60 sec = 60/0.04 =1500 ชองเลก
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การค านวณ Heart Rate
= 1500 BPM
จ านวนชองเลก R-R
= 300 BPM
จ านวนชองใหญ R-R
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Rate วธการจ าโดยการประมาณ
• ดจ านวนชวงหางของ R-R วาหางกนกชองใหญ แลว
จ าตวเลข 300,150,100,75,60,50
• ขอจ ากด
ถา R-R Interval ไมตกพอดชองใหญ จะไดคา
Heart Rate โดยประมาณ
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กฎ 300
#จ านวนชองใหญ
อตราเรวของหวใจ (ครง/นาท)
1 300
2 150
3 100
4 75
5 60
6 50
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Rate : Six Second Strip
• ถา Heart rate ชามากหรอเตนไมสม าเสมอ ตองค านวณ
จากชวงเวลาทนานมากขน โดยนบจ านวน QRS
Complex ใน 6 sec วามการบบตวกคร งแลวคณดวย 10
HR =QRS Beat ใน 7 sec x 10
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การแปลผล EKG
Rate จาก SA –Node
60 – 100 Beat/min = Normal Sinus Rhythm (NSR)
< 60 Beat/min = Sinus Bradycardia
> 100 Beat/min = Sinus Tachycardia
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อตราเรวของหวใจ ?
(300 / 6) = 50 ครง/นาท
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อตราเรวของหวใจ ?
(300 / 1.5) = 200 ครง/นาท
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การแปลผลEKG
•Rhythm
ถา R-R Interval Irregular
Cardiac Dysrhythmia or
Arrhythmia
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The QRS Axis
The QRS axis หมายถงผลรวมของ electrical activity
ของหวใจ
คา axis ทผดปกตอาจบงถง :
หวใจหอง ventricle โต
Conduction blocks เชน hemiblocks
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The QRS Axisคาปกต อยระหวาง
-30° ถง +90°.
left axis deviation (LAD) :
-30° ถง -90°
right axis deviation (RAD) :
+90° ถง +180°
Reading ECG; QRS Axis
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การค านวณ Axis
Predominantly
Positive
Predominantly
Negative
Equiphasic
The Quadrant Approach
1. ด QRS complex ใน leads I and aVF เพอแยกวาเปนpredominantly positive หรอ predominantly negative แลวนามาแปลผลดงตารางดานลาง
The Quadrant Approach2. ถาaxis ทไดคอ LAD, ใหพจารณาท lead II ตอ
ถา QRS ใน lead II เปน predominantly positive LAD นnon-pathologic (axis ปกต).
ถา QRS ใน lead II เปน predominantly negative LAD นpathologic.
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ตวอยางท 1
The Alan E. Lindsay ECG
Learning Center
http://medstat.med.utah.edu/k
w/ecg/
Negative in I, positive in aVF RAD
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ตวอยางท 2
The Alan E. Lindsay ECG
Learning Center
http://medstat.med.utah.edu/k
w/ecg/
Positive in I, negative in aVF Predominantly positive in II
Normal Axis (non-pathologic LAD)
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สรป
P wave : height < 2.5 mm in lead II width < 0.11 s in lead II
PR interval : 0.12 to 0.20 s (3 - 5 small squares)QRS complex :< 0.12 s duration (3 small squares)ST segment :no elevation or depression T wave: สงไมนอยกวา 1/8 ของ R Wave: สงไมมากกวา 2/3 ของ R WaveDuration < 0.16 sec. and height < 5 mm.
เจบหนาอก 15-20 min ไดยาNitrateดขน,ECG STdepress/T-invert,cardiac maker negativeUnstable angina
เจบหนาอกนานกวา20 นาท,ECG ST elevate/new LBBB,cardiac maker positive
Acute Coronary Syndromes
Acute Coronary Syndromes
Non-ST elevation ACSST-elevation MI
Cardiac marker +ve Cardiac marker +ve
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1
2
3
1. IschemiaRepresented by symmetrical T wave inversion(upside down). The definitive leads for ischemia are: I, II, V2 - V6.
2. InjuryAcute damage - look for elevated ST segments. (Pericarditis and cardiac aneurysm can also cause ST elevation; remember to correlate it with the patient.
3. Infarct
Look for significant "patholgic" Q waves. To be significant, a Q wave must be at least one small box wide or one-third the entire QRS height. Remember, to be a Q wave, the initial deflection must be down; even a tiny initial upward deflection makes the apparent Q wave an R wave.
MYOCARDIAL ISCHEMIA AND INFARCTION
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symmetrical T wave inversion
IschemiaRepresented by symmetrical T wave inversion (upside down). Look in leads I, II, V2-V6.
Injury Acute damage -- look for elevated ST segments.
Infarct"Pathologic" Q waves. To be significant, a Q wave
must be at least one small square wide or one-third the entire QRS height.
Myocardial Ischemia & Infarction Pattern
Myocardial Ischemia & Infarction Pattern
Myocardial Ischemia & Infarction Pattern
Myocardial Ischemia & Infarction Pattern
Myocardial Ischemia
Inverted T wave = T wave หวกลบ
Myocardial Ischemia
ST depression = depression of the ST segment level >0.1mV compared with the baseline ST level for at least 1 minute
EKG Criteria- Tall R in V1 (>7mm)(must rule out other causes)- Deep S in V5, V6
- Right axis deviation- Incomplete RBBB pattern in V1(RSR’<0.12 sec)
Right ventricular hypertrophy
Criteria• Tall R in V1 (>7 mm.) (must rule out other
cause)• Deep S in V5,V6
• Right axis deviation.• Incomplete RBBB pattern in V1 (rSR.’< 0.12
sec.)
Hyperkalemia
Tall peak T wave
Loss of p wave
Widen QRS with tall T wave
5.
Hypo and hyperkalemiaST depressionFlat T waveProminent U wave
Pericardial effusion
Pericardial effusion with electrical alternans
The QRS axis alternates between beats
the QRS points in different directions!
due to the heart moving in the effusion.
The QT interval and U wave
Normally QT interval : Duration < 0.36 sec. (9 mm.)Normally U wave: not seen, Although the U wave, which follow the T wave, has been associated with hypokalemia (which cause its
accentuation) it may be found normally. It is often seen best in the
midprecordial leads (V3 and V4, as above), and it has the same
orientation as the T wave.
6. 7.
Pericarditis (หามให SK เดดขาด)The Knuckle sign in lead aVR
3. P waveรปรางปกตและเหมอนกน น าหนา QRSทกตว และหวตงใน Lead I,II,aVF4. PR, QRS ปกตทงระยะเวลาและรปราง
Normal sinus rhythm
1. ภาวะหวใจเตนชาผดปกต (bradyarrhythmias)
2. ภาวะหวใจเตนเรวผดปกต (tachyarrhythmias)
2.1 Narrow QRS complex tachycardia
2.2 Wide QRS complex tachycardia
การแบงภาวะหวใจเตนผดจงหวะ
Bradyarrhythmias ทส าคญ
- Sinus bradycardia
- Sinus arrhythmia
- Sinus arrest
- Sino- atrial (exit)block
- Atrio -ventricular block : AV block
- AF& SVR
- Atrial flutter
- Junctional rhythm
- Idioventricular rhythm
2.
Sinus Bradycardia
- rate 40-60 ครง/นาท จงหวะการเตนสม าเสมอ
- P wave รปรางปกต น าหนา QRS complex ทกตว
-PR interval, QRS complex, T waveปกต เหมอน normal sinus rhythm พบใน คนปกตทแขงแรง นกกฬา สงอาย โรคหวใจ หรอไดรบยา B-blocker, amiodarone, digitalis
3.
Sinus bradycardia
Sinus tachycardia
Normal sinus rhythm
What is arrhythmia?Arrhythmia literally means “ out of rhythm” and is the term
used to describe a condition where the heart beat has become irregular. Clinically, arrhythmia includes all rhythms of the heart other than its normal sinus rhythm.
• Irregular heart beat
• Excitation from ectopic foci other than the sino-atrialnode causing the heart to contract.
• Disturbance of conduction of excitation.
• Rhythms faster than the regular sinus rhythm and of more than 100 beats/min (tachycardia).
• Rhythms slower than the regular sinus rhythm and of less than 100 beats/min (bradycardia).
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• 1. Direct factors; Ischemic heart disease, Myocardial infarction, Pericarditis, Valvular heart disease (Mitral valve stenosis), Congestive heart failure, Post-op Open heart etc.
• 2. Indirect factors; Electrolyte imbalance, Respiratory acidosis or alkalosis, Metabolic acidosis or alkalosis, Hypoxia, Shock, Hyperthyroidism, Automatic nerverse system abnormalities, Medication, Food, Tea, Coffee, insomnia etc.
Causes of Sinus Arrest• Hypoxia,Myocardial ischemia or infarction,Hyperkalemia,Digitalis toxicity.• Reactions to medications such as Beta-blockers,and Calcium channel blockers.• Carotid sensitivity,or increased vagal tone.
Intervention for Sinus Arrest
• Signs of hemodynamic compromise such as weakness,lightheadedness, dizziness,or syncope.
• If the episodes are transient and no significant signs or symptoms,the patient is observed.
• If hemodynamic compromise is present,IV Atropine may be indicated. If the episodes are frequent and/or prolong(>3 sec.), temporary pacing or insertion of a permanent pacemaker may be warranted.
Sino-atrial (SA) exit block
• เกดเนองจาก SA node สงคลนไฟฟาออกมาชา และในทสดเกดการ block conduction ของคลนไฟฟาท SA junction (บรเวณท SA nodal fiber ตอเชอมกบ intra-atrial tract) SA block แบงไดเปน• - First degree SA block• - Second degree SA block type I (Sinus Wenckebach)• - Second degree SA block type I • - Third-degree SA block
2.
Sino-atrial (SA) exit block• - First degree SA block
• Symtoms: Palpitation (normally not dangerous) but in the patients have heart disease observe the symtom.
• Treatment: Detect of main causes example; exercise, emotional of exciting, insomnia, hyperthyroidism etc.Nursing care- Check pulse and vital sign and Past history.- Detect of factors related to arrhythmia.- Detect of medication the patient have; Aminophylline, Dopamine,Epinephrine etc. if hemodynamic change notify the doctor.
2.
Supraventricular tachycardia (SVT)
HR > 150 /min
Paroxysmal Supraventricular tachycardia
HR. 161-240 bpm.
3.
• Management of SVT - Conversion SVT to NSR
• Depend on hemodynamic• Unstable
- Electrical cardioversion (state with 50-100 J Biphasic)- Adenosine
• The impulse of SA node is irregular. Sinus arrhythmia meets all the criteria as described under normal sinus rhythm, except for the variation in rate, often associated with the respiratory cycles. It is commonly seen in the young. The PR intervals are constant, but the RR intervals are continually changing.
Sinus arrhythmia
Premature Atrial Contraction(PAC)
5.
Premature Atrial Contraction (PAC)
NSR with PAC’s
• May occur because of emotional stress,CHF,Myocardial ischemia or injury,mental and physical fatigue,atrial enlargement,digitalis toxicity,hypokalemia,hypomagnesemia,hyperthyroidism,and excessive intake of caffeine,tobacco,or alcohol.
Causes of PACs
• Do not require treatment if they are not frequent.• Frequent PACs are treated by correcting the underline cause.• If needed,frequent PACs may be treated with beta-blockers,calcium
• Paroxysmal A-fib has been associated with excessive alcohol consumption.(Holiday heart syndrome)
Intervention for A-fib• Same treatment as patient who has Atrial flutter. Accept
(cardioversion 120-200 J Biphasic) or (200 J mono)
• Should receive anti-coagulant
Tachycardia Algorithm.
Junctional escape rhythm
– การกด SA node เปนผลให AV node ปลอยกระแสไฟฟาดวยอตรา 40-60 ครง/นาท (ไมพบ p-wave นา).
หวใจเตนผดจงหวะ : คาจากดความ
• Premature Junctional Complexes
• Junctional Escape Beats/Rhythm (40-60 bpm)
• Accelerated Junctional Rhythm (60-100 bpm)
• Junctional Tachycardia• ( >100 bpm)
Junctional Rhythm
Idioventricular rhythm
Junctional rhythm rate 40-60 bpm
rate 20-40 bpm
Junctional rhythm
Accelerated junctional rhythm
Junctional escape rhythm
Intraventricular Conduction Disturbances
1.Right Bundle Branch block (RBBB)2. Left Bundle Branch block (LBBB)
Bundle branch block refer to an interference with
conduction in either the right bundle branch or the left
bundle branch . The left bundle branch is very short and
branches early into an anterior and a posterior division.
The right bundle branch, on the other hand, continues
almost to the apex of the right ventricle before branching.
RIGHT BUNDLE-BRANCH BLOCK
1. QRS interval 0.12 sec. or Greater
2. Wide deep S wave present in leads I, aVL, V5 and V 6
3. RSR’ in lead V1, V2
LEFT BUNDLE BRANCH BLOCK
1. QRS complex > 0.12 sec. or Greater
2. Wide deep S wave in leads V1 and V2, wide R wave in V5 and V6
3. Left axis deviation
Right Bundle Branch Block
(RBBB):
Left Bundle Branch Block
(LBBB)
Atrioventricular Conduction Disturbances
AV nodal blocks - a conduction block within the AV node (or occasionally in the bundle of His) that impairs impulse conduction from the atria to the ventricles.
หวใจเตนผดจงหวะ : ค าจ ากดความ
First-degree AV nodal block
the conduction velocity is slowed so that the P-R interval is increased to > 0.2 seconds.
Can be caused by enhanced vagal tone, digitalis, beta-blockers, CCBs, or ischemic damage.
• TdP is French for “ Twisting of the points” which decribes the QRS that changes in shape,amptitude,and width and appears to “twist” around the isoelectric line.
• TdP is a type of polymorphic VT associated with a prolonged QT interval.• TdP has a ventricular rate typically between 200 to 250 beats/min.
Nurses very important because your caring the patient total 24 hours. Your freedom from continuous tiring visual monitoring and presentation of valuable diagnostic data assists medical staff. Nurses monitor patients’ ECGs ,early recognition of arrhythmia aids early treatment. your are responsible of life. You must have knowledge for identifying abnormalities of ECG and for my patients.