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EKG ReviewWFHS Academy of Critical Care and Emergency Medicine 2015
What is the primary pacemaker of the heart?
• SA Node (Sinoatrial Node)
What is the inherent rate of the AV node?
• 40 – 60 bpm
An R wave falls on a bold black line. The subsequent R wave falls on the 2nd subsequent bold black line. What is the rate?
• 150 bpm
Which coronary artery supplies blood to the SA node artery?
• RCA – Right Coronary Artery
Name the (4) valves in the human heart.
• Aortic• Mitral (bicuspid)• Tricuspid• Pulmonic (pulmonary)
Name (3) properties of cardiac muscle tissue.
• Automaticity• Contractility• Irritability (excitability)
Name this dysrhythmia
Ventricular Tachycardia
Name the Waveforms
This is one cardiac cycle. What does this represent from a mechanical standpoint?
1 heart beat, 1 pulse
Name this rhythm
Where is the heart attack?
Acute Inferior MI
ST Elevation in LII, LIII, AVF
Name this artifact
60 Hz AC Interference
Complete the table
SA Node
AV Node
PurkinjeFibers
RA
Junctional Septum
Terminal Bundle Branches
60-100
40 - 60
20 - 40
Pacemaker Location Intrinsic Rate
Describe layers of the heart from inner to outer
Endocardium
Myocardium
Epicardium
What is the other name of the epicardium?
Visceral Pericardium
What is the name of the tough fibrous sac which encloses the heart in the mediastinum?
Parietal Pericardium
Remember, the space called the pericardial space
Name other types of artifact X 60 cycle
Wandering Baseline
Muscle Tremor
Reversed Leads
Pacemaker Spikes
Absolute Heart Block (4th Degree) Caused by Love of the Bottle, should not be confused with reality.
Name the Chest Lead Locations
What is the name of the condition which may require a Rt. Side EKG?Dextrocardia
Limb lead polarities are defined as…
• Bipolar
List the unipolar limb leads
• AVL• AVR• AVF
Which plane is distinguished by the chest leads?
• Horizontal or Transverse
Assign the correct parameters to the objects above
Small Box
Large Box
Times
Voltage
Size
Name the heart blocks
First Degree Heart Block
3rd Degree or Complete Heart Block
Describe a metaphor for depolarization
What is the name of the major intra-atrial pathway of the conduction system?
Regular or Irregular
• Atrial Fibrillation• Atrial Flutter• Ventricular Fibrillation• Ventricular Tachycardia• AVHB Type I• AVHB Type II• 1st Degree HB• Torsade De Pointe
Which Interval would be the most important parameter to check to determine the regularity of a rhythm?
R - R
Lead I
+_
G
Lead II
G_
+
Lead III
_G
+
Lead AVL
+_
_
What is this triangle called?
Einthoven’s Triangle
Name the ectopy
PVC
PAC
PJC PJC
Calculate the heart rate
300 Method 1500
Method6 Second Method
Name the MIAnterior – STEMI – V2 V3 V4
Coronary Arteries
Which major coronary artery branches off the left main and encircles the heart to the left?Circumflex
If the left main coronary artery is occluded, the entire left side of the heart will…DIE!
An occlusion of the LMCA results in a heart attack referred to as a…
Widow Maker
Pacemaker Function
Pacing and sensing wires are implanted in both the atria, and the ventricles. The pacemaker senses the function of each chamber and stimulates (paces) the chamber if needed to cause a contraction.
What principle governs the underlying operation of pacemakers?
The fastest pacemaker will override slower pacemakers
Which valves close during ventricular systole?
• The Mitral Valve (bicuspid) and Tricuspid valve
During ventricular systole, what prevents blood from entering the coronary arteries?
• The flaps of the aortic valve.
Which coronary artery supplies the AV node artery in 90% of the population?
• RCA
Which branch of the LMCA supplies blood to the posterolateral aspect of the left ventricle?
• L Circumflex
Which electrophysiological concept allows for atrial kick?
• Transmission delay in the AV nodeAtrial kick allows the last bit of blood in the atria to be “kicked into” the ventricles.
What are the (2) branches of the left bundle branch called?
• Left Posterior Fascicle• Left Anterior Fascicle
Ectopic beats generated secondary to irritability fall into these categories
• Premature Atrial Beats• Premature Junctional Beats• Premature Ventricular Beats
How many internodal pathways exist?
• What are their names?
3
1. Anterior2. Medial3. Posterior
Which nodes do they connect?
SA and AV
If an abnormal pathway exists between atria and ventricles, which dysrhythmias may result?
1. Atrial Flutter2. Supraventricular Tachycardia3. WPW, LGL
What is the standard size calibration box representing amplitude?
• 10 mm tall (Y) x 5 mm wide (X)
How is standard gain defined?
• 10 mm per 1 mV
What is the purpose of Wilson’s Central Terminal?
• Creates a reference point for 6 of the 12 leads• Is the “0” end for the 9 unipolar leads• Creates positive end of unipolar leads
What is the rate of the above rhythm using the 1500 method?
Which type of rhythms are best rate calculated by this method?
Tachycard-as and regular rhythms
The sequence method
• Complete the sequence• 300• 150• 100• 75• 60• 50
What is the rate of the rhythm below?
6 second rule
• What is the rate…
When can it be used?
Any rhythm
Let’s Review Anatomy
That looks funny!
Ambulatory Monitoring
How do you verify the accuracy and validity of your EKG recording?
Where is the DAMAGE?
What’s on the opposite side?
Name Me!!!!!!!!
Polymorphic VT
Ventricular Tachycardia
Torsade De Pointes
Supraventricular Tachycardia
Atrial Fibrillation
Name Me Tooooooo!
Complete Heart Block
Complete Heart Block
2nd Degree AVHB Type I
Wenckebach
Atrial Flutter
What makes us alike? Which One does
not belong?
We are all 2nd degree HB Type II except for the 3rd degree imposter
What to do? The patient refuses to give consent because…
Does not understand why the consent form is required?
Explain the legal requirement of an informed consent and refer to MD if needed.
Pt. Does not understand the procedure.
Notify MD, provide brochure while pt. is waiting for MD to explain procedure.
Pt. is illiterate and cannot sign name.
Need witness, *family member, mark with an X, witness signs, you sign,
Pt. is unable to sign because does not have glasses.
Get the glasses – have pt. sign to best of ability and get a witness *family member, you sign.
Exercise Electrocardiography SAFETY Preparing for Emergencies
• Inform pt. how they may feel during test. Mild fatigue, increased HR, sweat, increased RR
• Explain need to report S/S, CP, dizziness, weakness or extreme fatigue
• Instruct to stop exercise with pain, extreme fatigue• MD must be present during entire procedure• Crash Cart available• Observe, monitor, report any S/S to MD
Name (3) things the patient should avoid at least (3) hours prior to Exercise EKG
•ALCOHOL•Caffeine• Tobacco
What is another name for Exercise Electrocardiography?
Stress Test,Stress EKG
True or False
• As a multi-skilled healthcare provider, you are responsible for reporting the results of exercise electrocardiography to the patient and referring any questions to the MD.
• FALSE – The MD reports results
Ambulatory Monitoring
• How long does ambulatory monitoring take?• 24 – 48 hours• Name one specific type of ambulatory monitor• Holter Monitor• How many leads are attached?• 3-5 depending on type• What S/S should be recorded in the patient’s diary?• CP, Indigestion, Dizziness
Ambulatory Monitoring
• What are the most common types?• Continuous• Intermittent
When does the intermittent system record?
When the patient has S/S they press “record”
During continuous recording, the patient may be asked to press a button to mark the tracing whenever a symptom is noted. What is this mark called?
“event marker”
Is it possible to record a 12 lead Holter?
YEP!
FYI Some ambulatory monitors are “voice activated”.
Ambulatory MonitoringLead Placement (General)
Electrodes (leads) need to be placed according to manufacturer.
Name Me
Pacemaker 1st Degree HB
Wandering Baseline (a-fib)
ANTERIOR MI
Multiform PVCs