EKG Plain and Simple

500 Pages·2011·35.74 MB·English

by  Karen Ellis RN

THIRD EDITION
EKG
Plain and Simple
Karen M. Ellis, RN
Touro Infirmary, New Orleans
Pearson
Boston Columbus Indianapolis New York San Francisco Upper Saddle River
Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto
Delhi Mexico City Sao Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo
Library of Congress Cataloging-in-Publication Data
Ellis, Karen M., author.
EKG plain and simple / Karen M. Ellis, RN, Touro Infirmary, New Orleans.—Third edition.
p. ; cm.
Includes index.
ISBN-13: 978-0-13-237729-4
ISBN-10: 0-13-237729-2
1. Electrocardiography. I. Title.
[DNLM: 1. Electrocardiography. WG 140]
RC683.5.E5E442 2011
616.1'207547—dc22
2010050980
Publisher: Julie Levin Alexander Media Project Managers: Lorena Cerisano and Julita Navarro
Executive Assistant & Supervisor: Regina Bruno Managing Production Editor: Patrick Walsh
Editor-in-Chief: Mark Cohen Production Liaison: Patricia Gutierrez
Executive Editor: Joan Gill Composition: Laserwords Private Limited
Associate Editors: Melissa Kerian and Bronwen Glowacki Production Editor: Erika Jordan/Rebecca Lazure
Editorial Assistant: Mary Ellen Ruitenberg Manufacturing Manager: Alan Fischer
Development Editor: Cathy Wein Creative Director: Christy Mahon
Director of Marketing: David Gesell Art Director: Kristine Carney
Executive Marketing Manager: Katrin Beacom Printer/Binder: Courier/Kendallville
Marketing Specialist: Michael Sirinides Cover Printer: Courier/Kendallville
Senior Media Producer: Amy Peltier Cover/Interior Design: Ilze Lemesis
Notice:The author and the publisher of this volume havetaken care that the information and technical
recommendations contained herein are based on research and expert consultation and are accurate and
compatible with the standards generally accepted at the time of publication. Nevertheless, as new
information becomes available, changes in clinical and technical practices become necessary. The
reader is advised to carefully consult manufacturers’ instructions and information material for all
supplies and equipment before use and to consult with a health care professional as necessary. This
advice is especially important when using new supplies or equipment for clinical purposes. The author
and publisher disclaim all responsibility for any liability, loss, injury, or damage incurred as a
consequence, directly or indirectly,of the use and application of anyof the contents of this volume.
Copyright ©2012, 2007, 2002 by Pearson Education, Inc. Publishing as Pearson, One Lake Street,
Upper Saddle River, New Jersey 07458. All rights reserved.Printed in the United States of America.
This publication is protected by Copyright and permission should be obtained from the publisher prior
to anyprohibited reproduction, storage in a retrieval system, or transmission in any form or by any
means, electronic, mechanical, photocopying, recording, or likewise. For information regarding
permission(s), write to:Rights and Permissions Department, Pearson Education, 1 Lake Street, Upper
Saddle River NJ 07458.
Pearson®is a registered trademark of Pearson plc.
10 9 8 7 6 5
ISBN-10: 0-13-237729-2
www.pearsonhighered.com ISBN-13: 978-0-13-237729-4
Contents
CHAPTER # • CHAPTERTITLE III
Introduction vi Augmented Leads 34
Acknowledgments viii Precordial (Chest) Leads 36
Reviewers ix Continuous Monitoring 37
Electrocardiographic Truths 37
Normal QRS Deflections 38
PART I The Basics
Lead Morphology Practice 41
Chapter Three Notes—To Sum It All Up ... 42
CHAPTER 1
Practice Quiz 42
Coronary Anatomy and Physiology 2
Putting It All Together—Critical Thinking Exercises 43
Introduction 2
Layers of the Heart 3
CHAPTER 4
Heart Chambers 3
Technical Aspects of the EKG 44
Heart Valves 4
Great Vessels 5 Introduction 44
Blood Flow through the Heart 6 Control Features 44
The Cardiac Cycle 6 Electrical Safety 45
Blood Flow through the Systemic Circulation 8 Artifact 46
Coronary Arteries 9 Troubleshooting 47
Heart Cells 9 Artifact Troubleshooting Practice 48
Nervous Control of the Heart 9 Artifact Masquerading as Rhythms 49
Chapter One Notes—To Sum It All Up ... 10 Artifact in Three Leads Monitored Simultaneously 51
Practice Quiz 11 Is It Real or Is It Artifact? 52
Putting It All Together—Critical Thinking Exercises 12 Real or Artifact:How to Tell the Difference 53
Chapter Four Notes—To Sum It All Up ... 53
CHAPTER 2 Practice Quiz 53
Electrophysiology 13 Putting It All Together—Critical Thinking Exercises 54
Introduction 13
Depolarization and Repolarization 13 CHAPTER 5
The Action Potential 14 Calculating Heart Rate 55
Refractory Periods 15
Introduction 55
EKG Waves and Complexes 15
Methods for Calculating Heart Rate 55
Waves and Complexes Identification Practice 16
Regularity-Based Heart Rate Calculation 57
QRS Nomenclature 18
Regularity Types 57
QRS Nomenclature Practice 19
Practice Strips:Regularity of Rhythms 59
Cardiac Conduction System 19
Kind of Heart Rate to Calculate for Different Types of
Cardiac Cells 20
Regularity 60
Inherent (Escape) Rates of the Pacemaker Cells 20
Practice Strips:Calculating Heart Rate 62
Conduction Variations 21
Chapter Five Notes—To Sum It All Up ... 64
EKG Paper 24
Practice Quiz 65
Intervals 25
Putting It All Together—Critical Thinking Exercises 65
Intervals Practice 27
Chapter Two Notes—To Sum It All Up ... 30
CHAPTER 6
Practice Quiz 31
Putting It All Together—Critical Thinking Exercises 32 How to Interpret a Rhythm Strip 66
Introduction 66
CHAPTER 3
The Five Steps to Rhythm Interpretation 66
Lead Morphology and Placement 33
The Five Steps Practice 67
Introduction 33 Chapter Six Notes—To Sum It All Up ... 69
Bipolar Leads 34 Practice Quiz 70
III
IV CONTENTS
CHAPTER 7 Idioventricular Rhythm (IVR) 129
Rhythms Originating in the Sinus Node 71 Accelerated Idioventricular Rhythm (AIVR) 130
Ventricular Tachycardia (V-tach) 131
Introduction 71
Wolff-Parkinson-White Syndrome (WPW) 132
The Word on Sinus Rhythms 71
Torsades de Pointes 133
Sinus Rhythm 72
Ventricular Fibrillation (V-fib) 134
Sinus Bradycardia 73
Asystole 135
Sinus Tachycardia 75
Pacemaker Rhythm 136
Sinus Arrhythmia 76
Practice Strips:Ventricular Rhythms 137
Sinus Arrest 77
Chapter Ten Notes—To Sum it All Up ... 145
Sinus Block (Also Called Sinus Exit Block) 78
Practice Quiz 146
Practice Strips:Sinus Rhythms 79
Putting It All Together—Critical Thinking Exercises 147
Chapter Seven Notes—To Sum It All Up ... 87
Practice Quiz 88
CHAPTER 11
Putting It All Together—Critical Thinking Exercises 88
AV Blocks 148
CHAPTER 8 Introduction 148
Rhythms Originating in the Atria 90 Degrees of AV Block 148
The Word on AV Blocks 150
Introduction 90
First-Degree AV Block 150
The Word on Atrial Rhythms 90
Mobitz I Second-Degree AV Block (Wenckebach) 151
Wandering Atrial Pacemaker/Multifocal Atrial Tachycardia 91
Mobitz II Second-Degree AV Block 152
Premature Atrial Complexes (PACs) 93
2:1 AV Block 153
Paroxysmal Atrial Tachycardia (PAT) 95
Third-Degree AV Block (Complete Heart Block) 154
Atrial Flutter 96
Practice Strips:AV Blocks 156
Atrial Fibrillation 97
Chapter Eleven Notes—To Sum It All Up ... 164
Supraventricular Tachycardia (SVT) 99
Practice Quiz 165
Practice Strips:Atrial Rhythms 100
Putting It All Together—Critical Thinking Exercises 166
Chapter Eight Notes—To Sum It All Up ... 108
Practice Quiz 109
CHAPTER 12
Putting It All Together—Critical Thinking Exercises 109
Rhythm Practice Strips 167
CHAPTER 9 Introduction 167
Rhythms Originating in the AV Junction 111 Rhythm Summary Sheets 168
Rhythms for Practice 178
Introduction 111
The Word on Junctional Rhythms 112
Part II Advanced Concepts
Premature Junctional Complexes (PJCs) 112
Junctional Bradycardia 113
CHAPTER 13
Junctional Rhythm 114
Accelerated Junctional Rhythm 115 How to Interpret a 12-Lead EKG 264
Junctional Tachycardia 116
Introduction 264
Practice Strips:Junctional Rhythms 116
The Six Steps to 12-Lead EKG Interpretation 264
Chapter Nine Notes—To Sum It All Up ... 121
Axis Determination 265
Practice Quiz 122
Axis Practice EKGs 267
Putting It All Together—Critical Thinking Exercises 122
Bundle Branch Blocks 270
BBB Practice 278
CHAPTER 10
Ventricular Hypertrophy 288
Rhythms Originating in the Ventricles 124
Hypertrophy Practice 291
Introduction 124 Miscellaneous Effects 297
The Word on Ventricular Rhythms 125 Chapter Thirteen Notes—To Sum It All Up ... 299
Premature Ventricular Complexes (PVCs) 125 Practice Quiz 299
Agonal Rhythm (Dying Heart) 128 Putting It All Together—Critical Thinking Exercises 300
CONTENTS V
CHAPTER 14 Pacemaker Malfunctions Practice 373
Myocardial Infarction 301 Therapeutic Hypothermia (TH) 376
Chapter Sixteen Notes—To Sum It All Up ... 377
Introduction 302
Practice Quiz 378
Symptoms of MI 302
Putting It All Together—Critical Thinking Exercises 378
The Three Is of Infarction 303
ST Segment 304
CHAPTER 17
T Wave 305
Diagnostic Electrocardiography 380
QRS Complexes 305
R Wave Progression and Transition 305 Introduction 380
Evolution of a STEMI 306 Stress Testing 380
Determining the Age of an MI 306 Stress Test Assessment Practice 387
Walls of the Left Ventricle 307 Holter Monitoring 395
Myocardial Infarction Locations 309 Event Monitoring 396
Infarction Squares 310 Chapter Seventeen Notes—To Sum It All Up ... 397
MI Pictorials 311 Practice Quiz 398
Myocardial Infarction Algorithm 318 Putting It All Together—Critical Thinking Exercises 398
Right Ventricular Infarction 318
CHAPTER 18
Conditions That Can Mimic an MI 320
Putting It All Together: Critical Thinking
MI Practice 322
Scenarios 401
EKG Complications of MI 330
Treatment of MI 330 Introduction 401
Chapter Fourteen Notes—To Sum It All Up ... 331 Scenario A:Mr.Johnson 401
Practice Quiz 332 Scenario B:Ms.Capitano 405
Putting It All Together—Critical Thinking Exercises 333 Scenario C:Mr.Farley 406
Scenario D:Mr.Lew 408
CHAPTER 15
Scenario E:Mrs.Epstein 410
12-Lead EKG Practice 336 Scenario F:Mr.Calico 412
Scenario G:Mrs.Taylor 415
Introduction 336
Scenario H:Mr.Foster 415
12-Lead EKG Interpretation in a Nutshell 337
Scenario I:Mr.Frye 418
12-Lead EKG Interpretation Checklist 338
Scenario J:Mrs.Terry 419
Practice EKGS 339
CHAPTER 16 Appendix: Answers to Chapter Skills Practice
Medications and Electrical Therapy 360 Questions, End-of-Chapter Practice Quizzes, and
Critical Thinking Exercise Questions 423
Introduction 360
Medications 360 Glossary 467
Electrical Therapy 366 Glossary of Abbreviations 475
DDD versus VVI Practice 370 Index 477
VI PART # • PART TITLE Introduction
Welcome to the third edition of EKG Plain and Simple. We’ve pulled out all the stops
this time. There are lots of changes from the last edition.
More stuff. Better stuff. Not meaning to sound like a TV commercial, but we’ve
got better stuff this edition.
Opening scenarios. Short opening scenarios show the clinical importance of that
chapter’s information.
Chapter Checkup. This new feature pops in at each chapter’s halfway mark and
asks a few pertinent questions to assess your understanding of the material. It can help
you decide if you’re ready to move ahead in the chapter or if you need to stop and
review first.
Fewer chapters. Condensed from 19 chapters to 18, this edition simplifies EKG
even more by combining information in a logical manner.
Study notes at the end of each chapter. This pulls together all of each chapter’s
important points in one place and makes studying easier. This is also available for
download/printing off the student website.
More practice strips. More strips in each rhythms chapter and 250 in Chapter 12
make learning rhythm interpretation easier.
More tables, new photos, and better art.We’ve improved the art and added photo-
graphs of real-life situations, full color, and more tables so the book is more user-friendly
and more visually appealing.
More clinical information on rhythms, heart attack symptoms, and treatment.
This helps you see the whole person, not just the EKG.
More clinical anecdotes sprinkled throughout. The material makes more sense
when it’s shown in the context of a real-life situation. And it helps answer the question,
“OK, I know what the rhythm/EKG shows; now what do I do with this information?”
Critical Thinking Exercises. Each chapter has exercises that might include case
scenarios, diagrams to label, or other exercises that challenge you to put what you
learned into practice.
More scenarios in the final chapter. Chapter 18 is an entire chapter of scenarios
that require you to analyze the situation and decide on the rhythm or EKG, the normal
treatment, and the expected outcome of that treatment. The added scenarios ensure that
modern-day clinical issues are represented (and there are some doozies!).
MyHealthProfessionsKit This is an exciting addition that
includes videos, animations, diagrams, scenarios, games, and practice tests—all certain
to help you fine-tune your understanding of the book’s material.
Instructor Resources.At MyHealthProfessionsKit, instructors can download chap-
ter synopses, outlines, objectives, frequently asked questions, suggested class activities,
and critical thinking questions. Also included is a test bank that allows instructors to
generate customized exams and quizzes. There is also an updated comprehensive turn-
key lecture package in a clicker-friendly PowerPoint®format.
The book starts, as before, with the basics in Part I. First is a little coronary anatomy
and physiology, then EKG waves and complexes, lead morphology, and rhythms.
You’ll learn what the rhythm is, how to calculate the heart rate, and what the adverse
effects and treatments are. There are critical thinking exercises and lots of practice
strips to perfect your interpretation skills.
VI
INTRODUCTION VII
Part II covers 12-lead EKG interpretation. You’ll learn what’s normal on a 12-lead
and what’s pathological. Axis, hypertrophy, bundle branch blocks, hemiblocks,
myocardial infarction, and pacemakers are just a few topics covered in Part II.
Again there are lots of critical thinking exercises and an entire chapter of 12-leads
for practice.
This third edition of EKG Plain and Simple is written in the same conversational
style as the previous editions. Who wants to study some dry, boring textbook?
So turn the page and prepare to learn some good stuff.Á
Karen Ellis
VIII PART # • PART TITLE Acknowledgments
The following people have been instrumental in their contributions to this effort and I’d
like to thank them all:
Lehman Ellis, my husband, who bar none has the best smirk I’ve ever seen, and
who always saves the day when my computer—or anything else—messes up. I love
you, booboo.
My sons Jason, Mark, and Matthew; my daughter-in-law Lauren; and my
soon-to-be daughter-in-law Myshel, for being so wonderful and so funny. They have
my sense of humor, I keep telling them. To which their reply is “Wait—you think
you’re funny?”
ICU staff at Touro Infirmary, who are always on the lookout for good strips and
EKGs for me, and who ask my opinion every now and then so I feel like I’m useful.
Special shout-out to Terry Lafauci, Kathryn Rives, Holly Gab, Kristen Cannon, Erin
Blaum, Becky Rohner, Lacey Sanders, Kimla Bell, Chris Sones, Toni Doyle, Jill
Comeaux, Tanya Doucette, Jill Prattini, and Betty Bennet.
Former Emergency Department tech (and new nurse) Patrick Frye, a fellow
EKG geek, for asking me disturbingly insightful questions that send me skulking off to
do more research. And for being the only one I know who, like me, gets positively
giddy at the sight of a really cool EKG.
Emergency Department nurses at Touro Infirmary, for tolerating with
good humor my frequent meddling. Special shout-out to Ron Pelas, Paul Over-
land, Paul Garner, Samantha Santiago, Margaret Pentek, Lisa Mitchell, Lisa
Grush, Brian Baudoin, Casey Saavedra, Amy Shepherd, Kelly Krieger, and Christine
Troxlair.
Telemetry techs Karen Nix, Roxie Doskey, and Leola Bates, for finding cool
strips.
My editors Melissa Kerian and Cathy Wein, whose advice and suggestions were
always perfect, and whose respect for an author’s autonomy has constantly amazed me.
Melissa is my anchor—she’s been with me for a while and is always reassuring and
helpful. Cathy is a new addition to our team and her contribution has been invaluable.
Conference calls with Melissa and Cathy have yielded a bounty of ideas and logistical
suggestions. The teamwork has been exceptional.
Mark Cohen, formerly my editor but now a “big cheese,” for still being there for
me with support and guidanceÁand just a little bit of cheerleading.
Karen
VIII
Reviewers
Travis Fox, EMT-P Melyssa Munch, CPI, CMA
University of Antelope Valley Star Career Academy
Palmdale, California Brick, New Jersey
Scott C. Jones, MBA, EMT-P Auburne Overton, MHA, RPSGT
Victor Valley College Mercy College of Health Sciences
Victorville, California Des Moines, Iowa
Dean C. Meenach,AAS, RN, BSN, CEN, CCRN, EMT-P Krista T. Rodgers, BS, RMA
Mineral Area College Miller-Motte Technical College
Park Hills, Missouri Charleston, South Carolina
IX