ECG Success Exercises in ECG Interpretation

286 Pages·2008·39.58 MB·English

00Jones ECG (F)-FM 5/3/07 12:43 PM Page i
UNIT TWO
ECG Success
Exercises in ECG Interpretation
00Jones ECG (F)-FM 5/3/07 12:44 PM Page iii
ECG Success
Exercises in ECG Interpretation
Shirley A. Jones, MS Ed, MHA, EMT-P
Emergency Medical Services Educator
Arrhythmia Instructor
Riverview Hospital
Noblesville, Indiana
Basic Life Support Instructor
American Heart Association
Advanced Cardiac Life Support Instructor
American Heart Association
00Jones ECG (F)-FM 5/21/07 4:53 PM Page iv
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2008 by F. A. Davis Company
Copyright © 2008 by F. A. Davis Company. All rights reserved. This product is protected by copyright.
No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, or otherwise, without written permission
from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor:Lisa B. Deitch
Project Editor:Ilysa Richman, Padraic J. Maroney
Director of Content Development: DarleneD. Pedersen
Art and Design Manager:Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recommended
treatments and drug therapies undergo changes. The author(s) and publisher have done everything
possible to make this book accurate, up to date, and in accord with accepted standards at the time of
publication. The author(s), editors, and publisher are not responsible for errors or omissions or for
consequences from application of the book, and make no warranty, expressed or implied, in regard to
the contents of the book. Any practice described in this book should be applied by the reader in accor-
dance with professional standards of care used in regard to the unique circumstances that may apply
in each situation. The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering any drug.
Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Jones, Shirley A.
ECG success : exercises in ECG interpretation / Shirley A. Jones.
p. ; cm.
ISBN-13: 978-0-8036-1577-9
ISBN-10: 0-8036-1577-9
1. Electrocardiography—Interpretation—Problems, exercises, etc. I. Title.
[DNLM: 1. Electrocardiography—methods—Problems and Exercises. 2. Arrhythmia—diagnosis—
Problems and Exercises. WG 18.2 J76e 2007]
RC683.5.E5J575 2007
616.1’2075470076—dc22 2007017019
Authorization to photocopy items for internal or personal use, or the internal or personal use of spe-
cific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Cen-
ter (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to
CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a
photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of
the Transactional Reporting Service is: 8036-1577-07 0 (cid:2)$.10.
00Jones ECG (F)-FM 5/3/07 12:44 PM Page v
Dedication
To the memory of my father George Francis Jones
who was and still is my hero in life. And, to my sis-
ter Virginia Kelleher, MD, for all her love and sup-
port. Also to my best buddies who have always given
me unconditional love, Zachary, Chelsea, Little
Zachary, Darby, Spirit, and Francis.
Shirley A. Jones
v
00Jones ECG (F)-FM 5/3/07 12:44 PM Page vii
Preface
No one is born knowing how to read ECG strips. We artificial pacemaker rhythm. The section ends with a
learn to do many things in a lifetime, and nearly all of chapter on myocardial infarction and the 12-lead ECG.
them get better with practice. If you’re planning to use The chapter practice strips will warm you up for
this book, ECG isn’t completely new to you––you have Unit Three, the working core of the book. You’ll find
a good idea of what’s involved in generating and inter- four test chapters with a total of 300 strips and the
preting a tracing. answers given at the end of each chapter so you can
ECG Success covers all the information you will check your work. In case you’re hungry for more, the
need––anatomy and physiology, practice, and case sce- two chapters in Unit Four comprise eleven real-life case
narios, and relevant emergency care––to help you feel studies, followed by multiple-choice questions and
competent and in control, whether the situation illustrated by more ECG strips. Four appendices round
involves an emergency or just a nonthreatening ECG. out the book: Healthcare Provider Guidelines for Car-
This book has staying power. You will find its content diopulmonary Resuscitation, Advanced Cardiac Life
useful across a spectrum of situations, from classroom Support Protocols, Emergency Medications, and Emer-
study through clinical experience and later in actual gency Medical Skills.
practice. As you page through this book you’ll find some
Pattern recognition lies at the heart of ECG inter- special features to guide you. In Units One and Two,
pretation. This skill develops with experience, gained frequent Clinical Tips provide valuable information on
through repetition and variety. You need to see the how an arrhythmia can affect the patient. Hints on
same patterns over and over again, but you also need rhythm interpretation appear throughout the first prac-
to see as great a diversity as possible. In ECG Success tice strip chapter.
you’ll find more than 550 ECG tracings. I couldn’t have written this book without building
The book is organized into four units. First, two up a track record of my own ECG successes. The secret:
introductory chapters review the background informa- I had a good instructor who was patient and explained
tion you need for working with ECG. Chapter One dis- everything in detail. She kept emphasizing that we
cusses heart anatomy and physiology, including had to follow every step when analyzing a rhythm;
biomechanics and electrophysiology. Chapter Two gives shortcuts are dangerous because you can miss critical
you the basics of ECG: limb and chest leads, electrode details on the rhythm strip. Then we had to practice,
placement, cable connections, components of a tracing, practice, practice. That repetition, combined with
rhythm strip analysis, and more. careful attention to every step, was the real key to my
In Unit Two, seven chapters explain and illustrate success.
the different types of rhythm, some dangerous, others Take your time now, and use ECG Success to
merely troublesome, and a few even normal. Each of improve your skills. Once you run into a genuine
these chapters gives you a group of nine practice strips emergency you will have only minutes, or less, to inter-
to analyze, with the answers given at the end of the pret the ECG correctly and ensure the right treatment
chapter. All types of arrhythmias are discussed and for the patient.
illustrated: sinus, atrial, junctional, and ventricular;
atrioventricular and bundle branch blocks; artifact; and Shirley A. Jones
vii
00Jones ECG (F)-FM 5/21/07 4:53 PM Page ix
Consultants
Dawn McKay, RN, MSN, CCRN Carmen J. Petrin, MS, APRN, BC
Critical Care Instructor Nurse Practioner
Assistant Professor of Nursing New England Heart Institute at
Liberty University Catholic Medical Center
Lynchburg, Virginia Manchester, New Hampshire
Basic Life Support Instructor, Former Critical Care Educator
American Heart Association Catholic Medical Center
Advanced Cardiac Life Support Instructor, American Manchester, New Hampshire
Heart Association Basic Life Support Instructor,
Trauma Nursing Core Course Instructor, Emergency American Heart Association
Nurses Association Advanced Cardiac Life Support Instructor,
Fundamental Critical Care Support Instructor, Society American Heart Association
of Critical Care Medicine Pediatric Advanced Life Support Instructor,
American Heart Association
National Advanced Cardiac Life Support
Faculty, American Heart Association
Pediatric Advanced Life Support Training
Center Faculty, American Heart Association
Basic Life Support Training Center
Faculty, American Heart Association
Shirley A. Jones has worked in the field of emergency medical services for more than 30 years. She received her Master of Science in Educa-
tion and her Master of Health Administration degrees from Indiana University. She has been awarded five first-place honors in tri-state and
state-wide advanced life support competitions, served on the faculty of national conferences, and won honors from the Medical Writers Asso-
ciation for two textbooks. She is an accomplished writer and educator in the fields of electrocardiology and pharmacological and mechanical
therapy. She welcomes the comments, criticisms, and ideas of readers for the improvement of future editions.
ix
00Jones ECG (F)-FM 5/21/07 4:53 PM Page xi
Reviewers
Lori Baker, RN Jeff Chianfagna, BS, MA, PA Patricia Richards, RN, MSN, CCRN
Surgical Nurse Educator Clinical Physician Assistant and Faculty, Nursing Department
Lions Gate Hospital Academic Instructor/Faculty Central Maine Community College
North Vancouver, Canada Pace Lenox Hill Hospital Physician Auburn, Maine
Assistant Program
Carole Berube, MA, MSN, RN New York, New York Catherine Richmond, RN, BSN, MSN
Professor Emerita in Nursing Professor, Nursing
Bristol Community College Nancy Edge, RN, BSN SUNY Alfred State College
Fall River, Massachusetts Clinical Educator, Cardiac Surgery Alfred, New York
Vancouver General Hospital
Daryl Boucher, MSN, RN Vancouver, Canada Robert Spears, MPAS, PA-C
Flight Nurse/Nursing and Allied Assistant Professor
Health Faculty Linda Latham, RN, BSN, MA The University of Findlay
Aroustook Medical Center/Northern Lead Instructor Findlay, Ohio
Maine Community College Forsyth Technical Community
Presque Isle, Maine College Walt Stoy, PhD
Winston-Salem, North Carolina Director of Education
Carmen Carpenter, RN, MS, CMA Center for Emergency Medicine
Department Chair, Allied Health Cindy Light, RN, MSN, CEN Pittsburgh, Pennsylvania
Sciences and Medical Assisting Nursing Instructor
South University Baker University School of Nursing Debbie Sullivan, PhD, PA-C
West Palm Beach, Florida Topeka, Kansas Assistant Professor/PA Program
Faculty/Interim Director
Barbara Chamberlain, Dawn McKay, RN, MSN, CCRN Midwestern University
MSN, APRN, BC Assistant Professor Glendale, Arizona
Critical Care Clinical Nurse Liberty University
Specialist Lynchburg, Virginia Rita Tomasewski, MSN, ARCNP
Kennedy Health System Cardiovascular Clinical Nurse
Turnersville, New Jersey Susan Moore, PhD, RN Specialist
Professor of Nursing St. Francis Health Center
Pam Chambers, MPH, PA-C New Hampshire Community Topeka, Kansas
Associate Professor, Physician Technical College
Assistant Program Manchester, New Hampshire Marilyn Turner, RN, CMA
Des Moines University Medical Assisting Program Director
Des Moines, Iowa Deborah Opacic, EdD, PA-C Ogeechee Technical College
Professor, Clinical Educator Statesboro, Georgia
Julie Chew, RN, MS, PhD Duquesne University
Clinical Educator Pittsburgh, Pennsylvania
Sacred Heart Medical Center
Eugene, Oregon
xi
00Jones ECG (F)-FM 5/3/07 12:44 PM Page xiii
Contents
Heart Structure and Rhythms and
UNIT ONE UNIT TWO
Electrical Activity Their Analysis
Chapter 1: ANATOMY AND PHYSIOLOGY Chapter 3: SINOATRIAL NODE ARRHYTHMIAS 20
OF THE HEART 2 Normal Sinus Rhythm (NSR) 20
Overview 2 Sinus Bradycardia 21
Anatomy of the Heart 2 Sinus Tachycardia 21
Layers of the Heart 2 Sinus Arrhythmia 22
Heart Valves 2 Sinus Pause (Sinus Arrest) 22
Heart Chambers and Great Vessels 3 Sinoatrial (SA) Block 23
Coronary Vessel Circulation 3 ECG Practice Strips 23
Anatomy of the Answers to Chapter 3
Cardiovascular System 4 ECG Practice Strips 26
Blood Vessel Structures 4 Chapter 4: ATRIAL ARRHYTHMIAS 28
Arterial Circulation 4 Wandering Atrial Pacemaker
Venous Circulation 5 (WAP) 28
Physiology of the Heart 5 Multifocal Atrial Tachycardia
Mechanical Physiology 5 (MAT) 29
Electrophysiology 6 Premature Atrial Contraction
(PAC) 29
Chapter 2: THE ELECTROCARDIOGRAM 9
Atrial Tachycardia 30
Overview 9
Supraventricular Tachycardia
Limb Leads 10
(SVT) 30
Standard Chest Leads 10
Paroxysmal Supraventricular
Cable Connections 11
Tachycardia (PSVT) 31
Electrode Placement Using a
Atrial Flutter 31
Three-wire Cable 11
Atrial Fibrillation 32
Electrode Placement Using
Wolff-Parkinson-White (WPW)
a Five-wire Cable 12
Syndrome 32
Modified Chest Leads 12
ECG Practice Strips 33
The Right-sided 12-Lead ECG 12
Answers to Chapter 4
The 15-Lead ECG 13
ECG Practice Strips 36
Recording of the ECG 13
Components of an ECG Tracing 14 Chapter 5: JUNCTIONAL ARRHYTHMIAS 37
Methods for Calculating Junctional Rhythm 37
Heart Rate 14 Accelerated Junctional
Rhythm Strip Analysis 16 Rhythm 38
Instructions for Analyzing ECG Junctional Tachycardia 38
Practice and Test Strips 16 Junctional Escape Beat 38
xiii
00Jones ECG (F)-FM 5/3/07 12:44 PM Page xiv
xiv Contents
Premature Junctional Artificial Pacemaker Rhythm 64
Contraction (PJC) 39 Single-chamber Pacemaker
ECG Practice Strips 39 Rhythm––Atrial 65
Answers to Chapter 5 Single-chamber Pacemaker
ECG Practice Strips 42 Rhythm––Ventricular 65
Dual-chamber Pacemaker
Chapter 6: VENTRICULAR ARRHYTHMIAS 44
Rhythm––Atrial and
Idioventricular Rhythm 44
Ventricular 65
Accelerated Idioventricular
Pacemaker Malfunctions 65
Rhythm 45
Failure to Capture 66
Premature Ventricular Contraction
Failure to Sense 66
(PVC) 45
Oversensing 66
Premature Ventricular Contraction:
ECG Practice Strips 67
Uniform 46
Answers to Chapter 8
Premature Ventricular Contraction:
ECG Practice Strips 70
Multiform 46
Premature Ventricular Contraction: Chapter 9: ARTIFACT 71
Ventricular Bigeminy 46 Loose Electrical Connection 71
Premature Ventricular Contraction: Variation with Respiration 71
Ventricular Trigeminy 46 60-cycle Interference 72
Premature Ventricular Contraction: Muscle Artifact 72
Ventricular Quadrigeminy 47 ECG Practice Strips 72
Premature Ventricular Answers to Chapter 9
Contraction: Couplets 47 ECG Practice Strips 75
Premature Ventricular Contraction: R
Chapter 10: THE 12-LEAD ECG AND ACUTE
on T Phenomenon 47
MYOCARDIAL INFARCTION 77
Premature Contraction: Interpolated
Troubleshooting ECG Problems 77
PVC 48
R Wave Progression 78
Ventricular Tachycardia (VT):
Electrical Axis Deviation 78
Monomorphic 48
Ischemia, Injury, and Infarction 78
Ventricular Tachycardia (VT):
Progression of an Acute Myocardial
Polymorphic 49
Infarction 79
Torsade de Pointes 49
ST Segment Elevation and
Ventricular Fibrillation (VF) 50
Depression 79
Pulseless Electrical Activity (PEA) 50
The Normal 12-lead ECG 80
Asystole 51
Anterior Myocardial Infarction 80
ECG Practice Strips 51
Inferior Myocardial Infarction 80
Answers to Chapter 6
Lateral Myocardial Infarction 81
ECG Practice Strips 54
Septal Myocardial Infarction 81
Chapter 7: ATRIOVENTRICULAR AND Posterior Myocardial Infarction 82
BUNDLE BRANCH BLOCKS 56 Left Bundle Branch Block 82
First-degree AV Block 56 Right Bundle Branch Block 82
Second-degree AV Block: Type I
(Mobitz I or Wenckebach) 57 ECG Practice Tests
UNIT THREE
Second-degree AV Block: Type II
(Mobitz II) 57 Chapter 11: ECG PRACTICE TEST ONE 86
Third-degree AV Block 58 Test Strip Section One 86
Bundle Branch Block (BBB) 58 Answers to Practice Test One 115
ECG Practice Strips 59
Chapter 12: ECG PRACTICE TEST TWO 122
Answers to Chapter 7
Test Strip Section Two 122
ECG Practice Strips 62
Answers to Practice Test Two 147
Chapter 8: ARTIFICIAL CARDIAC PACEMAKERS 63
Chapter 13: ECG PRACTICE TEST THREE 154
Artificial Pacemaker 63
Test Strip Section Three 154
Pacemaker Modes 64
Answers to Practice Test Three 179
Understanding Pacemaker Codes 64