Electrocaradiograms
How to read electrocardiograms
Image #6
Important considerations for reading electrocardiograms
- Is the rhythm regular and consistent?
- Is the rate fast, slow, or normal?
- Are P waves present and look the same?:
- Is the PR interval normal and consistent?
- Are the QRS complexes normal and immediately follow the p wave?
- Is the T wave present and normal in appearance?
Common EKGs
Sinus bradycardia (slow heart rate)
Image #65
https://upload.wikimedia.org/wikipedia/commons/7/71/ECG_Sinus_Bradycardia_43_bpm.jpg
PT implications:
- Common to see this rhythm when working with those taking beta-blockers and in the elderly population
- If present, ok to proceed with initiation of activity and continuance of activity,
- Will need to use perceived exertion scale (RPE)to assess tolerance to activity
- Monitor for symptoms of dizziness, lightheadedness, and pallor
Sinus tachycardia (fast heart rate)
Image #66
https://upload.wikimedia.org/wikipedia/commons/1/14/ECG_Sinus_Tachycardia_125_bpm.jpg
PT implications:
- Common to observe this rhythm during exercise
- Pay attention if individual develops headache, dizziness, or lightheadedness with tachycardia
- If these symptoms present, therapist will stop activity and re-assess all vitals
A-fibrillation (A-fib)
Image #67
https://upload.wikimedia.org/wikipedia/commons/6/64/Afib_ecg.jpg
PT implications
- Vital sign monitoring
- Continuous or frequent monitoring of heart rate, blood pressure, and oxygen saturation is essential.
- Pulse may be irregularly irregular, so use auscultation or ECG for accuracy rather than radial pulse alone.
- Be aware that heart rate may be elevated or vary unpredictably.
- Exercise prescription
- Begin with low to moderate intensity activities; avoid high-intensity or sudden exertion early in rehab.
- Use Rate of Perceived Exertion (RPE) rather than heart rate alone due to variability.
- Monitor for signs of exercise intolerance: dizziness, fatigue, palpitations, chest pain, or dyspnea.
A-flutter
Image #68
PT implications
- Vital sign monitoring
- A-flutter often presents with a regular but rapid atrial rate (240–400 bpm); ventricular response may be regular or irregular depending on AV block.
- Carefully monitor heart rate and rhythm, as patients may suddenly shift into more dangerous rhythms (e.g., atrial fibrillation or rapid ventricular response).
- Use ECG or telemetry when possible, especially in acute care settings.
- Exercise intensity and progression
- Initiate with low to moderate intensity aerobic activity.
- Use RPE scales to guide intensity because HR may not accurately reflect exertion, especially if rate-controlled.
- Avoid abrupt changes in activity that could increase sympathetic tone and trigger rhythm instability.
Premature ventricular contraction (PVC)
Image #69
https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/PVC10.JPG/2560px-PVC10.JPG
PT implications
- Singular PVC at rest and exercise: initiate or continue with activity as this can be an anomaly
- Can be caused by stress, caffeine, or idiopathic
- Three or more PVCs in a row at rest or with exercise: do not initiate activity and discontinue exercise as this could lead to fatal heart rhythms
- Monitor for symptoms: heart fluttering, heart pounding, missed heart beats
Ventricular tachycardia
{`Image #70
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PT implications
- Medical emergency and CPR initiated
Ventricular fibrillation
Image #71
https://upload.wikimedia.org/wikipedia/commons/f/f1/Ventricular_fibrillation.png
PT implications
- Medical emergency and CPR initiated
First degree atrioventricular heart block
Image #72
PT implications
- Therapist can initiate and/or continue activity
- No medical management is necessary as condition it typically benign and reversible with exercise, diet, and medication as indicated
Second degree atrioventricular heart block- Mobitz 1
Image #73
https://upload.wikimedia.org/wikipedia/commons/8/88/Second_degree_heart_block.png
PT implications
- Therapist can initiate and/or continue activity
- Typical treatment is medication- atropine- to normalize heart rhythm
Second degree atrioventricular heart block - Mobitz 2
Image #73
https://upload.wikimedia.org/wikipedia/commons/8/88/Second_degree_heart_block.png
PT implication
- Medical emergency as myocardial infarction or pacemaker indicated
Third degree atrioventricular heart block
Image #74
https://upload.wikimedia.org/wikipedia/commons/8/89/Heart_block.png
PT implications
- Medical emergency for pacemaker indicated
Lab values
Lab values can be found at the American Physical Therapy Association (APTA) interpretation guide.
Vital signs
- Temperature: 97℉ - 99.6℉
- High value indicates fever
- Resting heart rate: 60-100 beats per minute
- Below 60 indicates bradycardia
- Above 100 indicates tachycardia
- Respiration: 12- 20 breaths per minute
- Below 12 indicates respiratory depression
- Above 20 indicates hyperventilation
- Blood pressure: 120/80
- See Chapter 2.1
- Oxygen saturation (O2 sats) 90%-100%
- Below 90% indicates possible need for supplemental oxygen
Hematological - Complete blood count
- Hemoglobin: responsible for transporting oxygen via red blood cells
- Male: 14-18
- Female: 12-16
- Below normal values indicates anemia which increases the risk for blood transfusion
- Above normal value indicates polycythemia which increases the risk for clogging of capillaries
- Hematocrit: ratio of red blood cells to total volume of blood
- Male: 42%-52%
- Female: 37%-47%
- Below normal values indicates anemia which increases the risk for blood transfusion or need for fluids
- Above normal value indicates polycythemia which increases the risk for clogging of capillaries
- Platelets: clot forming components of blood
- 150,000-400,000 mm3
- Below 150,000 mm3 indicates thrombocytopenia which increases risk for hemorrhage, bleeding from gums, heavy menstrual bleeding, or blood in uring or stools
- Above 400,000 mm3 indicates thrombocytosis which increases risk for DVT development
- 150,000-400,000 mm3
- White blood count: important in immune response to infectious processes
- 5,000 - 10,000 mm3
- Below 5,000 mm3 indicates leukopenia which increases the risk for recurrent infections
- Above 10,000 mm3 indicates leukocytosis which increases the risk for inflammation, immune system, or bone marrow disease
- 5,000 - 10,000 mm3
- Red blood count: cells that carry oxygen from lungs to tissue and are produced within the bone marrow
- Male: 4.7-6.1
- Female: 4.2-5.4
- Below normal values indicates anemia which increases the risk for blood transfusion
- Above normal value indicates polycythemia which increases the risk for myocardial infarction and stroke
- INR (international normalized ratio): the specific blood test used to measure the time it takes for blood to form a blood clot
- 0.8 – 1.2: normal range of person non on anticoagulants
- Too Low (< 2.0): Blood may clot too easily → risk of thrombosis, stroke, or embolism.
- Too High (> 3.0–3.5): Blood is too thin → increased risk of bleeding, especially dangerous in falls or with trauma.
- 0.8 – 1.2: normal range of person non on anticoagulants
Liver panel
- Albumin: protein that assists with moving small molecules such as bilirubin, progesterone, and calcium through body
- 3-5.5
- Lab value that indicates nutritional status in last 12-18 days
- Below 3 indicates malnutrition
- Will need to increase overall protein intake
- Above 55 indicates chronic kidney disease
- 3-5.5
- Pre-albumin: protein that assists with moving small molecules such as bilirubin, progesterone, and calcium through the body.
- 15-36
- Lab value that indicates nutritional status in last 1.9 days
- This is the preferred lab value for nutritional status
- Below 15 indicates malnutrition
- Will need to increase overall protein intake
- Above 36 indicates chronic kidney disease
- Lab value that indicates nutritional status in last 1.9 days
- 15-36
Renal function
- Blood urea nitrogen (BUN): Measures the metabolic function of the kidney and excretory function of the kidney
- 10-20
- Below 10 indicates hepatic disease or issues with liver absorption
- Above 20 indicates high protein diet, burns- over body covering large surface area due to increased metabolism occurring, septic shock
- 10-20
- Creatine kinase: Involved in the supply of energy for muscular contraction
- Male: 0.6-1.2
- Female: 0.5-1.1
- Below normal decreased muscle mass, debilitation
- Above normal renal disease, rhabdomyolysis, endocrine dysfunction
Cardiac lab values
- Troponin:
- Lab value indicates suspected acute coronary ischemic disease
- Troponin T: < 0.1
- Troponin: < 0.03
- Above normal: myocardial injury or myocardial infarction
- Lab value indicates suspected acute coronary ischemic disease
Arterial blood gases- see further explanation in later chapter 3.3
- pH: 7.35- 7.45
- Partial pressure of carbon dioxide (PaC02): 32-45
- Bicarbonate (HCO3): 22-26
Lipid panel
- Low density lipoprotein (LDL - bad cholesterol):
- Create plaques and occlusions in blood vessels
- Normal <100
- Low level indicates decreased protein malabsorption, severe burns
- High levels indicates liver or kidney disease
- High density lipoprotein (HDL- good cholesterol):
- Helps to remove excess cholesterol deposits
- Normal: >60 mg/dL
- Below 35 mg/dL indicates increased risk for cardiovascular disease
- Triglycerides:
- Produced in liver and transport fatty tissue
- Desirable <150
- Above 150 is hypertrilglyceridemia indicates increased risk for hypothyroidism, myocardial infarction, or cardiovascular disease
- No specific value- hypotriglyceridemia indicates increased risk for malnutrition
- Total cholesterol:
- Main lipid associated with cardiovascular disease
- <200
- 200 or higher hypercholesterolemia indicates increased risk for cardiovascular disease
- No specific value- hypocholesterolemia indicates increased risk for malnutrition
- <200
- Main lipid associated with cardiovascular disease
Ankle brachial index (ABI)
- Procedure in which the systolic blood pressure is taken from the brachial artery (brachial) and dorsal pedis and posterior tibialis arteries (ankle) to assess if peripheral arterial disease is present
- Ratio of ankle blood pressure over brachial blood pressure
- Summary of Results:
- 1.4 and above:
- indicates calcification and vessel hardening
- 0.9-1.3:
- Normal no disease present
- 0.51-0.89
- Venous insufficiency indicated
- Lower extremity compression indicated
- Venous insufficiency indicated
- 0.5 and below:
- Arterial insufficiency indicated
- Lower extremity compression contraindicated
- Arterial insufficiency indicated
- 1.4 and above:
- Summary of Results:
- Ratio of ankle blood pressure over brachial blood pressure