ECG rhythms

Scott53813

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Curious in how much detail paramedics must know when it comes to Interpreting/reading ECG. What rhythms must you know? Any good book recommendations?
 

Aprz

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Interpret rhythms and recognize STEMIs. All rhythms.

Normal sinus rhythm, sinus bradycardia, sinus tachycardia, sinus arrhythmia, 1st degree AVB, 2nd degree AVB I & II, 2:1 2nd degree AVB, 3rd degree AVB, junctional escape, junctional tachycardia, ventricular escape, accelerated idioventricular rhythm (AIVR), ventricular tachycardia (VT or vtach), ventricular fibrillation (vfib), asystole, atrial flutter, atrial fibrillation (afib), multi focal atrial tachycardia (MAT), atrial tachycardia, wandering atrial pacemaker (WAP), AV Nodal Reentrant tachycardia (AVNRT, which people will usually call SVT), accessory pathway mediated tachycardia/AV reentrant tachycardia, atrial and/or ventriculcar paced rhythm, supraventricular tachycardia (SVT) when you can't tell which tachycardia it is, pulseless electrical activity (PEA) if is anything other than asystole/vfib/vtach that doesn't have a pulse

Some of those go together. For example, you might say sinus rhythm with a 1st degree AV block.

You should be able to describe features like left bundle branch block, right bundle branch block, intraventricular conduction delay, and premature beats. You might learn how to recognize electrolyte imbalance, particular hyperkalemia being the money maker. Maybe fasicuclar/hemiblocks.

Although taught, I wouldn't say it is necessary to recognize or calculate axis. Once you figure it out, it isn't hard and can be done pretty much instantaneous when looking at the 12-lead. Left ventricular hypertrophy might be a common thing to see and important to recognize for congestive heart failure patients and because it mimics an anterior wall myocardial infarction (looks like a STEMI, but isn't). I feel like other forms of hypertrophy are less important to know or are less commonly see, but might be observed eg right ventricular hypertrophy in an acute or chronic respiratory issue, left atrial enlargement in heart failure or associated with left ventriculcar hypertrophy.

A commonly recommended starter book is Rapid Interpretation of EKGs by Dubin Dale.

After that, I'd recommend The Art of Interpretation: 12-lead ECG by Thomas Garcia.

For practice, Amal Mattu ECG for Emergency Physicians 1 & 2 are good. Don't be fooled by the name. It is easily doable by paramedics. It's a book with a bunch of ECGs that you can interpret, practice without bias, and then look at the back for answers.

There is really no limit to how much a paramedic can learn for 12-leads. I feel like it is one of those things where everything is taught, but few of it is useful or seen. It can be difficult because some of the stuff is very specific, could be useful to know, but rare. Like recognizing fascicular VT (responds to calcium channel blockers, which is usually not what you give to VT patients...), RVOT VT which is adenosine sensitive and will convert, but these things are rare and nobody fault you for not recognizing it I think. Like even all the rhythms you learn, I mostly see the different sinus rhythms, a 1st degree block once a blue moon, atrial fibrillation, and atrial flutter or SVT or VT or vfib once a blue moon. Most of my arrest are asystole or PEA.
 
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Tigger

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Curious in how much detail paramedics must know when it comes to Interpreting/reading ECG. What rhythms must you know? Any good book recommendations?
I think the list of rhythms you must know is probably longer than my memory. However, a solid understanding of what each part of an EKG is telling you from an electrophysiology standpoint will allow you to reason through nearly anything and allow you to an interpret a rhythm. Pattern recognition is great, but it should not be the end goal when learning rhythm interpretation. I found "The Only EKG Book You'll Ever Need" to be useful jumping off point.

The Garcia books are all good.
 

MedicFF

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You know that part we like about being paramedics that allows us to diagnose conditions in the field? We earn that privilege (which nurses don’t have) by having high competency in cardiology knowledge. It’s one of my top professional goals to gain expertise in cardiology. This is an ongoing effort that will never stop.

An ED physician I’ve worked with gave me a book title and said if I spend enough time reading it I would know more cardiology than most doctors. Not sure about that, but I’ve committed to getting through all 900+ pages of “12 Lead ECG: The Art of Interpretation.” You can find it both new and used online, but the wife found me a free PDF copy of the book by digging deep.

It’s written by Tomas Garcia, like Tigger suggested in the previous post.
 

Peak

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You know that part we like about being paramedics that allows us to diagnose conditions in the field? We earn that privilege (which nurses don’t have) by having high competency in cardiology knowledge.
:rolleyes: Your over compensation and Dunning-Kruger are showing.

Curious in how much detail paramedics must know when it comes to Interpreting/reading ECG. What rhythms must you know? Any good book recommendations?
There is certainly a lot of importance in some basic rhythm recognition and morphology presentation. More importantly is a solid understanding of the treatment of a broad category of abnormal cardiac pathologies.

For example it really isn’t all that important to be able to differentiate the many causes of SVT (JET, LGL, WPW, 1:1 flutter, a fib with RVR (at >220 for example), et cetera) in the field. What is more important is to recognize the narrow complex extreme tachycardia and know the pathways for treatment based on the rest of the patient assessment.

For example a narrow complex tachycardia in an unconscious patient without palpable pulses obviously has a very different treatment pathway than a patient who is conscious with a decent BP and 2 minute transport to chest pain center.
 

MedicFF

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Settle down, Peak.

I see how you could get defensive with “interpreting the rhythm” of my statement. It wasn’t in any way meant to devalue nurses and their knowledge/skill. In fact, I learn something new from the great nurses I work with in the ED each shift I’m there. They are all-stars.

My point was that yes, it’s imperative paramedics fully commit to ongoing study in ECG interpretation. Because we are allowed to diagnose and treat in the field based on our interpretation, we are obliged to reach high proficiency in that area. Notice I used the word privilege, and not a right to diagnose. My statement that paramedics can diagnose while nurses cannot was meant to further implore paramedics to respect that privilege, lest it be taken away.

My mother was a nurse for over 30 years and was one of my major influences in entering this field. There is no skewed perspective of nursing on my part, but thanks for the concern. Also, the Dunning-Kruger reference was funny the first five times I saw it on this forum. Now, it’s played out.

All in good fun and respect😎

Hope you are enjoying a tasty beverage on this Labor Day if off duty or fine overtime pay if on.
 

Tigger

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If you really want to test your mettle, Marriott’s Challenging ECGs is what you want. Can be tough to find but is on amazon at a reasonable price right now. I’ve seen it sell for up to 180 at certain points but I think it’s pretty irreplaceable.
 

akflightmedic

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As an ER RN, I diagnose and implement treatments and protocols...long before the docs see the patient. I legit can have line, labs, EKG, and several medications on board based on my "not diagnosing"...you know, much of what I do in the ER is not all that different than being a Paramedic except I now get paid way more and have way better working conditions. So yeh MedicFF, you are off course since it seems your only reference point for that position (all in good fun) is your mom.

Additionally, that is what we do up front. And then throughout the course of the patient's stay, we are constantly nudging, suggesting, collaborating, learning from the providers. Myself and my colleagues are often asked "what do you think?" by the providers. We even have providers whom we can guide down a very specific course of treatment or testing based on our "non-diagnosis".

Just saying, you do not know until you know. I myself have been surprised at the level of autonomy, the driving force I have with patient care, and the overall freedom of doing quite a bit...all from a "non-diagnosis".

FYI, (only cause you may not know me), I am not some new medic who made the leap and is now drinking the kool aid. I have been a Paramedic since 1994, worked in many different systems, (also a FF), have been a flight medic, have worked internationally, instructed, and many other things. I too once held an opinion very similar to what you stated....and I was wrong.
 
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Akulahawk

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I've been an RN for about 5 years now. Like a few here, I'm an ED RN. I have an amazing amount of autonomy, though where I work, we're not protocol-heavy as some other places. That being said, when someone comes in and they've not been seen by a provider yet, I'll get a bunch of stuff rolling ahead of time. Like Peak and akflightmedic, the providers do lean on me and my RN colleagues a LOT. I can easily nudge a provider down a very specific treatment path just by how I present the patient to them. The providers I work with do trust me sufficiently that very often they'll put in an order for exactly what I'm asking for, just because they know that I know what I'm looking for (and at) and I'm not going to "ask" for something inappropriate.

ED providers do learn a LOT from us "non-diagnostic" nurses because we do see those patients a heck of a lot more than they do and they know that we do pick up on some (sometimes very much so) subtle indicators that something is askew. Other providers (like social workers) can sometimes make their decisions based on information us nurses do get and pass along.

Also, you'd be amazed at the number of times I'll have to notify the provider that the "system" has fired off an alert for something and "we" knew about whatever "it" was long ago and it's already addressed (or in some cases, dismissed) but I still have to formally notify the provider.

What's the true deal? Nurses do diagnose. We don't "medically" diagnose, but that doesn't mean that we don't go through the process. Same goes for Paramedics. If you're not a Physician/PA/NP, guess what? You don't medically diagnose because that's not your job. It doesn't mean you can't go through the diagnostic process and come up with whatever your "evaluation" of a given problem is...
 

MedicFF

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Akflightmedic, I've read a lot of your posts. Dig the extensive background in and out of medicine. You are definitely not a new paramedic. I am, and I'm learning plenty from reading on this forum.

Your post is right on. Again, I think my statement got misinterpreted. It was all about promoting ongoing, self-directed learning and proficiency, especially when there is a lot of "field independence" to lose. It was not at all a slight to what nurses are or aren't capable of. When I made that statement, it was from the vantage point that Akulahawk talked about, how nurses don't "medically diagnose" on the books. As he says, I do agree that paramedics don't either. So let's get all that out of the way.

I work part-time in the ED in addition to working out in the field. I am side by side with upwards of a dozen nurses every shift. I learn as much or more from them as I do the docs. I'm lucky to work with some amazing people that are team members and team leaders, knowledgable, skilled, open-minded, and most importantly, down to earth. Like both of you say (Peak, you three!), nurses in the ED do a hell of a lot of nudging, brainstorming, and critical thinking. It's not the case everywhere, but I'm glad the ED I work at is a culture where the docs have humility and know the nurses can, in many cases, have the smartest and most valuable thoughts in the room.

A busy ED environment, which it sounds like we all work in, requires this team culture that values contributions of all its members. Or else, things fall through the cracks, and we can't let that happen.
 

mgr22

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This talk of diagnosing reminds me of a late-'90s change in the EMS curriculum (not sure if it was national or local) that encouraged EMTs to describe injuries instead of naming them. For example, an obvious L femur fx might be called "a severely angulated deformity of the upper left leg." That approach lasted a few years, then was largely ignored. I think the intent was to restrict diagnosing to doctors. Not sure why, although I'd certainly expect an MD to have a much broader perspective than a medic or a nurse.

My dictionary says "diagnose" means "to analyze the nature or cause of." Based on that, I'd say It's pretty hard for anyone who assesses patients to stop before diagnosing them.
 

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