EKG tips and tricks in the ER?

zmansc, ASN, RN · Sep 26, 2014

Rapid Interpretation of EKG by Dale Dubin.... The bible. It will teach you everything you need to know about rhythm strips and 12 lead EKGs.

psu_213, BSN, RN · Sep 26, 2014

One tip in the ED….show it to a doc. Our EKG has the computer interpretation on the top of it. Even if it is entirely normal, we still have to show it to a doc right after it is completed. If it is normal, the doc just has to sign it off--they don't have to actually take the patient and, if they do take the patient, they are under no obligation to see them right away--if it is not a STEMI or other ominous finding of course. Not that basic EKG interpretation is not a valuable skill for the ED nurse, but cover your behind and show that EKG to a doc.

emtb2rn, BSN, RN, EMT-B · Sep 26, 2014

psu_213 brings up a very good point about not relying on the machine's interpretation as it's often not exactly accurate. And know what pacing looks like as some paced rhythms can fool you at a quick glance.

akulahawkRN, ADN, RN, EMT-P · Sep 26, 2014

While I definitely second that recommendation about Dale Dubin's book, don't overlook other EKG resources. EmCrit.org has links to several other resources for learning and interpreting EKGs. Here's a link to the EmCrit page: The Lewis Lead and a course in EKGs with Christopher Watford

The link does describe the Lewis Lead (I've used it occasionally) and Dr. Weingart certainly prefers other resources than Dubin, but then again, he's coming from a different frame of reference than most of the rest of us.

I also like the book by Garcia and Holtz as well... the more you learn, the better you'll become at interpreting the EKG. Eventually you might even disregard the computer interpretation because your own is more accurate.

Guests · Sep 27, 2014

Personally, I don't care for Dubin's book... too many pictures, too few words.

I think Garcia's books are excellent... and I think Ken Grauer's pocket guide is a pretty good down-and-dirty reference after you get the hang of 12-leads.

The real big things to worry about are (a) STEMI, (b) 3rd degree block, and © symptomatic SVT... those are the emergencies. Generally speaking, everything else, confers some time to deal with it.

The biggest thing about a 12-lead in the ER is: Get it into the hands of the attending physician STAT.

If you really want to get the hang of what constitutes a minutes-count emergency, take a look at your LEMSA protocols (that is, what are the medics allowed to treat in the field). By and large, that defines what is a serious emergency (though some LEMSAs are more restrictive than are others).

akulahawkRN, ADN, RN, EMT-P · Sep 28, 2014

Personally, I don't care for Dubin's book... too many pictures, too few words.
I think Garcia's books are excellent... and I think Ken Grauer's pocket guide is a pretty good down-and-dirty reference after you get the hang of 12-leads.
The real big things to worry about are (a) STEMI, (b) 3rd degree block, and © symptomatic SVT... those are the emergencies. Generally speaking, everything else, confers some time to deal with it.
The biggest thing about a 12-lead in the ER is: Get it into the hands of the attending physician STAT.
If you really want to get the hang of what constitutes a minutes-count emergency, take a look at your LEMSA protocols (that is, what are the medics allowed to treat in the field). By and large, that defines what is a serious emergency (though some LEMSAs are more restrictive than are others).

To that "worry list" I would add a 2nd Degree Type II block. Those I worry about because they can progress to a Type 3. Throw in a 2nd Degree Type II and a BBB and I start getting really worried...

Personally, I get worried about heart rates that are slow or fast and are symptomatic... like poor skin perfusion or have some (even minor) mental status changes.

I do suggest that any RN working in the ED become familiar with the local EMS system's cardiac protocols because when you're brought a patient by EMS, you'll have a better idea why they did (or did not) do what they did. The Paramedics go through the same ACLS you do... and they have their own standing orders that may differ (sometimes significantly) from what you do in your ED.

Incidentally that also goes for vascular access. It's easy to assume that Paramedics have the same site restrictions you have. Often they don't. Their VAD orders may effectively state that any peripheral vein is OK, and may define the External Jugular Vein (EJ) as a peripheral site. A very few EMS systems authorize the Paramedics to start subclavian central lines, but if your system allows this, you'll already know about that.

In any event, by going through your LEMSA cardiac protocols, you'll get a pretty good idea what cardiac issues that your area considers emergent and which ones it doesn't. If you have access to your own department's protocols/standing orders when you're at home or otherwise not too busy, become very familiar with those too because that will tell you exactly what your ED considers emergent.

With all the above being said, if your gut tells you to get a 12-lead, get one and get it to a physician. Some machines will attempt their own interpretation and sometimes they'll be right...

alliecatrn10 · Sep 28, 2014

Perfect. These are all incredibly helpful. Thank you!

tarotale · Sep 28, 2014

knowing how to read strips won't be your first worries once you start internship :mask: i transitioned from medsurg to level 1 trauma and i'm few days short of completing internship. ED will rock your world and brain. wish you have good team and charge :)

alliecatrn10 · Sep 28, 2014

To that "worry list" I would add a 2nd Degree Type II block. Those I worry about because they can progress to a Type 3. Throw in a 2nd Degree Type II and a BBB and I start getting really worries...

Ok the answer to this might be obvious and I'm just not thinking it through but what would cause a 2nd degree type 2 block to progress to 3rd degree while they're sitting there in the ED? Don't a good number of people live with a 2nd degree block?

Esme12, ASN, BSN, RN · Sep 28, 2014

Ok the answer to this might be obvious and I'm just not thinking it through but what would cause a 2nd degree type 2 block to progress to 3rd degree while they're sitting there in the ED? Don't a good number of people live with a 2nd degree block?

no....there are people who live with a 1st degree block

As second degree block is a higher form of block and indicates a deeper issue. hey may be "stable" but the rhythm is not.

akulahawkRN, ADN, RN, EMT-P · Sep 28, 2014

Ok the answer to this might be obvious and I'm just not thinking it through but what would cause a 2nd degree type 2 block to progress to 3rd degree while they're sitting there in the ED? Don't a good number of people live with a 2nd degree block?

As Esme has indicated, many people live with a 1st degree block. The higher blocks indicate that more tissue is involved. A 2nd degree type 2 block, where some beats are conducted normally and occasionally one suddenly is dropped means the AV node is starting to have conduction issues. It won't take much for the AV node to stop conducting beats altogether. A BBB (especially new onset) indicates that tissue just below the AV node is no longer viable (ischemia or MI happened) and the other bundle branch is available for conduction of electrical impulses. Fasicular blocks are worrisome in the presence of bundle branch blocks because when that happens, there's only one pathway open... you don't give lidocaine to these patients...

When you see that stuff developing, make sure you have a pacer ready and get the info to a physician. Hopefully it doesn't progress while in your ED.