Pulmonary Disease Management

Chapter 17: Interpreting the Echocardiogram

I. Interpreting the Echocardiogram
1. The Electrocardiogram
2. Electrophysiology
3. Basic ECG Waves
4. Axis Evaluation
5. Steps to Follow
6. Normal Sinus Rhythm
7. Sinus Tachycardia
8. Sinus Bradycardia
9. First-Degree Heart Block
10. Second-Degree Heart Block
11. Third-Degree Heart Block
12. Atrial Flutter
13. Atrial Fibrillation
14. Premature Ventricular Contractions
15. Ventricular Tachycardia
16. Ventricular Fibrillation Basic ECG Waves
• Atrial depolarization is seen as the P wave.
• Ventricular depolarization is seen as the QRS
The Electrocardiogram complex.
• An ECG is a popular tool because it is inexpensive, • The normal QRS complex is not wider than 3 mm (0.12
noninvasive, and easy to obtain. second).
• Often used to assess the patient suspected of having • The wave of ventricular repolarization is seen as the T
an acute myocardial infarction. wave.
• Also used as a health screening tool in patient over age • The PR interval is the time from the start of atrial
40 years. contraction to the start of ventricular contraction
• It cannot predict future heart attacks or detect structural (normally not >0.20 second).
defects (e.g., valve stenosis) • Long PR intervals = heart block
• ST segment = the time from the end ventricular
Electrophysiology
depolarization to the start of ventricular repolarization
• Normally, cardiac cells are polarized with the positive (normally isoelectric)
charge on the outside.
• Elevated or depressed ST segments = ischemia
• When stimulated, cardiac cells depolarize as sodium
rushes insides the cells.
• Depolarization causes the muscle cells to contract
momentarily.
• Repolarization reestablishes the electrical imbalance
across the cell membrane.
• Three different types of cardiac cells are present in the
heart
1. Pacemaker cells (e.g., sinoatrial node)
2. Specialized rapidly conducting tissue (e.g.,
Purkinje fibers)
3. Atrial and Ventricular muscle cells
⎯ All these cells have the ability to spontaneously
depolarize (automaticity) Axis Evaluation
• Normally, the mean axis is between 0 and +90
degrees.
• Right-axis deviation (+90 to +180 degrees) is
consistent with right ventricular hypertrophy.
• Left-axis deviation (0 to -90 degrees) is consistent with
left ventricular hypertrophy.

Steps to Follow
The Impulse-Conducting System
• This system is responsible for initiating the heartbeat
and controlling the heart rate.
• Normally, the SA node has the greatest degree of
automaticity and paces of the heart.
• The AV node serves as a back-up pacemaker when
the SA node fails
• After leaving the AV node, the impulse travels through
the bundle of HIS, bundle branches and Purkinje fibers.
1. Identify the atrial and ventricular rates; normally they
are the same and 60 to 100/min.
2. Measure the PR interval; normally this is <0.20 second.
3. Evaluate the QRS complex; it should be no longer than
0.12 second.
4. Evaluate the T wave; normally it should be upright and
rounded; inversion = ischemia
5. Evaluate the ST segment; normally it is flat; elevation
or depression = ischemia
6. Assess the RR interval to evaluate the regularity of the
rhythm.
7. Identify the mean QRS axis by finding the lead with the
most voltage; if this lead has a positive QRS complex
the axis is very close to where this lead is labeled on
the hexaxial reference circle.
Normal Sinus Rhythm
• Has an upright P wave that is identical throughout the
strip
• The PR interval is <0.20 second.
• The QRS complexes are identical and no longer than
0.12 second.
• The ST segment is flat.
• The RR interval is regular, and the heart rate is 60 to
100/min.
Sinus Tachycardia
• Recognized when the heart rate exceeds 100/min at
rest
• Each QRS complex is preceded by a P wave.
• A common finding in patients with acute illness and
may be caused by pain, anxiety, fever, hypovolemia,
and hypoxemia.
• It may also be caused by certain medications such as
bronchodilators.
Sinus Bradycardia
• Heart rate is less than 60/min.
• Each QRS is preceded by a P wave.
• PR interval and QRS complex are normal.
• Of concern only when it causes clinical problems such
hypotension and syncope
• Atropine is an effective treatment.
First-Degree Heart Block
• The PR interval exceeds 0.20 second.
• Each QRS complex is preceded by a P wave.
• Cardiac impulse is delayed in passing through the AV
node or bundle of His.
• Typically, the RR intervals are regular.
• May occur after an MI or with the use of beta-blockers
• Treatment may not be needed.
Second-Degree Heart Block
• Comes in two types
1. Type I (Wenckebach or Mobitz type 1) block;
recognized when PR interval gets
progressively longer until one does not pass
on to the ventricles.
2. Type II (Mobitz type II) is less common but
occurs with more serious problems such as
an MI.
• Treatment of type I not usually needed.
• Treatment of type II often needed and includes
medications such as atropine and possibly a
pacemaker.
Third-Degree Heart Block
• Occurs when the conduction system between the atria
and ventricles is completely blocked
• The atria and ventricles are paced independently and
there is no relationship between the P waves and the
QRS complexes.
• The PP intervals and RR intervals are regular.
• Treatment includes medications to speed up the heart
and a placement of a pacemaker.
Atrial Flutter
• Represents rapid depolarization of the atria from an
ectopic focus (250 to 350/min)
• Causes a characteristic sawtooth pattern; numerous P
waves are present for each QRS
• Caused by a wide variety of disorders such as
rheumatic heart disease, coronary heart disease, renal
failure, stress, and hypoxemia
• Treated with medications and cardioversion
Atrial Fibrillation
• Results when the atrial muscle quivers in an erratic
pattern; no true P waves are seen
• The ventricular rate may be slow and irregular.
• Atrial fibrillation causes cardiac output to drop and may
lead to thrombi in the atria due to blood stagnation.
• Cardioversion is used as treatment in most cases.
Premature Ventricular Contractions
• Occurs when ectopic beats originate in the ventricles
• PVCs are commonly the result of hypoxia, electrolyte
imbalances, and acid-base disorders.
• QRS complex is wide and has no preceding P wave.
• Frequent PVCs call for treatment of the underlying
cause (lidocaine offers temporary solution in some
cases).

Ventricular Tachycardia
• Represent a run of three or more PVCs
• Easy to recognize as a series of wide QRS complexes
with no preceding P wave
• Ventricular rate is usually 100 to 250/min.
• VT represents a serious arrhythmia that often
progresses to V fib if untreated.
• Treatment includes cardioversion and medications.

Ventricular Fibrillation
• Represents the most life-threatening arrhythmia
• Defined as erratic quivering of the ventricular muscle
mass
• Causes cardiac output to drop to zero
• The ECG show grossly irregular fluctuations with a
zigzag pattern.
• Treatment includes cardioversion, CPR, oxygen, and
antiarrhythmic medications.