ECG Guru - Instructor Resources

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Instructors' Collection ECG of the WEEK, September 29, 2014 ___ Left Anterior Fascicular Block

Mon, 09/29/2014 - 01:39 -- Dawn

This ECG provides an example of LEFT ANTERIOR FASCICULAR BLOCK (LAFB).  It is from an elderly woman for whom we have no other history.

The conduction system below the AV node consists of the Bundle of His, the left bundle branch, and the right bundle branch.  While there is some variation among individuals, most of us have two main fascicles, or branches, of the left bundle.  The ANTERIOR-SUPERIOR fascicle carries the electrical impulse to the anterior wall of the left ventricle, and the POSTERIOR - INFERIOR fascicle carries the impulse to the inferior area of the left ventricle.

Blocks can occur at any level in the conduction system, including left bundle branch block, right bundle branch block, left anterior fascicular block, left posterior block, and bi-fascicular blocks. LAFB can have many causes, including myocardial infarction, cardiomyopathies, fibrosis of the cartilagenous ring, and aortic valve disease.  Left anterior fascicular block is much more common than left posterior fascicular block. Both are also called hemiblocks.

When LAFB is present, the initial septal depolarization forces are still left to right, providing a small initial q wave in Lead I and a small r wave in Lead III.  After septal depolarization is complete, the activation vector moves inferiorly and to the right as the electrical wavefront moves through the left posterior hemifascicle and right bundle branch. The impulse finally makes its way to the left and superiorly via slow conduction through myocardium normally depolarized by the left anterior hemifascicle, which is blocked.  It is because the terminal left ventricular activation moves upward and toward the left that the  inferior leads have negative deflections.

The diagnostic criteria for LAFB are:  LEFT AXIS DEVIATION (QRS axis between -45 degrees and -90 degrees); qR pattern in Lead I; rS pattern in Lead III; delayed activation time evident in Lead aVL - the time from onset of the QRS to the peak of the R wave is 45 ms or more. (This example barely makes that criteria); QRS duration normal or slightly wide, but not 120 ms or more (unless there is also RBBB).  LAFB also causes poor R wave progression in the precordial leads, with late transition and S wave present in V6.

Before deciding on a diagnosis of LAFB, you must rule out previous or acute INFERIOR WALL M.I.  The pathological Q waves that can occur with necrosis can cause a left axis deviation in the frontal plane.  The presence of a small r wave in Lead III rules out pathological Q wave in that lead.  If any fascicular block (hemiblock or bundle branch block) occurs during the course of an M.I., the patient should be watched carefully for progression of the block.  Be prepared to pace if necessary in that situation. 

Thanks to our Consulting Expert, Dr. Ken Grauer, for his editing assistance.

ECG TEACHING VIDEOS - An Important Tool For Teachers and Students Alike

Thu, 09/11/2014 - 23:40 -- Dawn

If you are a teacher, watching a masterful teacher present your topic can help you develop your style, and increase your own knowledge of your subject.  We don't all have the opportunity to attend live classes by the real ECG Gurus of the world, but many of them are now making FREE video lectures available to all of us. Even if you are not an instructor, for many of us, hearing and seeing the presentation is a more effective way to learn than just reading.    

ECG videos are plentiful on the Web.  That being said, we want to be careful who we learn from.  Anyone can publish anything now.  Fortunately, there are some really good teachers out there making videos.  The ECG Guru website would like to recommend two in particular:

Dr. Ken Grauer, MD, is a consulting expert for this website.  Most of you are aware of his website and his excellent print and e-pub publications.  But, he has recently begun making ECG instructional videos, and they are excellent!  Each video is presented in a methodical, organized way, with clear illustrations.  There is something for everyone, from the beginner to the advanced ECG user, including instructors.  To see Dr. Grauer's bio, go to this LINK.  Follow this link to watch his ECG videos.

Dr. Amal Mattu, MD, FACEP, is also well-known to regular readers of the ECG Guru website.  He is an Emergency physician and faculty member at the University of Maryland.  He presents an ECG Video of the Week every week, and they are outstanding!  You will love his conversational style, and his markup illustrations as he progresses through each week's case.  His focus is very clinical and practical, and he manages to be very entertaining as well.  If you are an instructor, you will learn a lot about teaching style from Dr. Mattu.  For his bio, go to this LINK.  Follow this link to his ECG Videos. 

 

ECG Basics: Ventricular Fibrillation Converted With Defibrillation

Sat, 09/06/2014 - 22:48 -- Dawn

A good example of ventricular fibrillation converted by electric defibrillation to what appears to be a sinus rhythm.  There is significant artifact in the post-conversion strip, but the last beat on the strip appears to have a P-QRS-T sequence.

Of course, V Fib presents without pulses, and must be defibrillated as soon as possible.  Best results are achieved by defibrillating a perfused heart, so if there is any delay from onset of V Fib, CPR should be performed to perfuse the heart prior to defibrillation.

Ask The Expert

Fri, 09/05/2014 - 17:23 -- Dawn
Darlene Hutton, RN, BScN, MSN

As a fairly new educator in the telemetry/medical unit or Emergency Department, what steps would you suggest taking in helping new nurses to the unit understand ECG Interpretation?

 

Today's Expert is Darlene Hutton, RN, BScN, MSN

Darlene Hutton has worked in CCU, ICU, PACU, and Emergency as a bedside nurse, educator, and manager. She is currently working as a Clinical Research Manager at Rouge Valley Metabolic Research Associates in Toronto. Darlene also is an Educational Consultant providing workshops, seminars, and conferences on such topics as ECG Interpretation, Dysrhythmia Interpretation, Acute Coronary Syndromes and Cardiology Drugs. She is also an ACLS Course Director and runs courses throughout the province. Her company, QRS Educational Services, founded 18 years ago, provides education to nurses and other health care professionals throughout Canada. She is also the Department Head for Emergency Preparedness in the O.R. in the American College of Plastic Surgical Nursing journal.

 Darlene@qrseducation.com

(905) 706-3301     www.qrs-education.com     www.facebook.com/qrs.educationservices


ANSWER:

As an independent educator for the past 20 years, I have had the incredible pleasure of spending time with novice to expert nurses in their respective field from a variety of different hospital settings.  My response to this question comes from what I have learned from each of these individuals over the past 2 decades.

We know that the “expert” practitioner is sometimes not the best educator because of their own challenges in bringing the information to a basic level of understanding.  What makes an educator invaluable is their ability to bring the most advanced concepts to the level of understanding for the individual and tailor the education to that level.

A novice nurse entering into one of these units will likely have had some courses in rhythm interpretation as a basic entry level requirement.  However, I find that many of these nurses have not had adequate preparation time in being able to apply a systematic approach to assessing the 12 Lead ECG. When working in these types of units, promptly assessing the ECG is essential to ensure there is no time delay in notifying the physician of anything urgent.

I apply a step-wise approach in ensuring that the basics are understood before moving on to the more intricate aspects of the ECG.

The basics that I assess are:

1. Ensure the nurse understands what the P, QRS, and ST represent and their significance, if abnormal. Most importantly, I ask them to point out examples of ST elevation and depression on various ECGs.  You would be surprised at how many people do not know this very core concept and before discussing treatment management and complications, this basic concept needs to be well understood. If you only have 30 minutes to spend with a nurse on this particular day, this would be the priority, in my opinion.

2. The next step would then be to assess their knowledge and discuss what’s happening with ST elevation/depression, including the treatment strategies. This can be achieved in 30 minutes to an hour.

3. Third: anticipated complications. I can’t tell you how often I hear nurses want to give a saline bolus to a hypotensive patient experiencing an anterior wall MI.  They do not understand the pathophysiology and their actions will subsequently worsen the situation.  Apart from cardiac arrest occurring with any MI, I expect that everyone understands the ‘expected’ complications associated with the inferior and anterior wall MI. For this, I keep it very simple so retention of information remains. “The heart is comprised of 2 pumps. If the right pump fails and backs up, what will you notice? Will the chest be wet or dry? (about 1/3 of the group will say wet, which is incorrect). If the left pump fails and backs up (such as in an anterior MI), where does it back up to? Will the chest be wet or dry?” By keeping it simple, the concepts are easier to understand and retain.

4. In many of the hospitals, there is an annual recertification of the ECG basics and this is another opportunity as an educator to assist those who may be struggling. 

5. I also provide staff with reference tools so they can help themselves learn at their own pace. On my educational website: www.qrs-education.com , there are reference links and tips under the QRS Tips tab as well as our manual which you can read about in the Products page. This manual has taken the complex concepts to a more manageable level. I also promote Dawn’s website (www.ecgguru.com ) as another invaluable tool. Two examples of interactive links are:  www.practicalclinicalskills.com  and www.skillsstat.com 

I hope this has helped. Thank you.

Darlene Hutton

President, QRS Educational Services

www.qrs-education.com  

 

 IF YOU HAVE A TEACHING QUESTION FOR OUR EXPERTS, PLEASE EMAIL TO INFO@ECGGURU.COM

 

THE MOST COMFORTABLE SHIRT YOU WILL EVER WEAR

Wed, 01/15/2014 - 20:55 -- Dawn

THIS WILL BE YOUR FAVORITE SHIRT!

This is not an ordinary tee shirt.  It is made of the smoothest, most comfortable lightweight fabric, which is moisture-wicking and has a sun-protective UPF of 30.  And, it is wearable art, featuring the work of ALYSSA BEAN.  If you work in a cath lab, and wear lead aprons all day, you will love the feel of this shirt. The fabric keeps you warm in cold environments and cool in warm temperatures.  It is great for sports, boating, beach, and layering.

The ECG Guru is committed to providing high-quality resources for ECG instructors and students FREE of CHARGE and FREE of COPYRIGHT.  We do rack up some expenses keeping the website going.  We came up with the idea of fund raising while also providing a product that we know our members and visitors will LOVE. 

Go to the STORE to learn more about this shirt.

Broken Heart

Click to open: 
Heart Art, Broken Heart, Heart Leaf Illustration

Looking for an illustration for your presentation or packets?

Photograph by Alyssa Bean.  May be used free of charge and free of copyright in instructional setting.  Please contact the artist at Dawn.ECGGuru@gmail.com for any commercial use.

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