119 Mod 1 (12-Lead ECG and Lab Values) Flashcards
What is an infarct represented by?
Pathological Q waves
What kind of leads are V1 - V6
precordial (chest)
unipolar
positive electrodes
LVH confirmation _____________ the 12 lead for AMI discrimination
negates
What does the T Wave Represent
Ventricular Repolarization
Accelerated Junctional
inverted P wave
rate 61-100
What are clues of RV involvement
and what are you looking for in v4r
J-point elevation in III is > than II
J-point elevation in V1
J-point depression in V2
v4r - greater than 1 mm j-point elevation
Is the QRS wide or narrow in a hemi block?
can be both wide or narrow
Changes from Benign early repolarization are usually seen in _________ and ________ leads
-anterior
-lateral
What is this secondary control called that a COPD patient might use to breathe?
Hypoxic Drive
When do you run a V4r
EVERY time an ST elevation in INferior Wall (II, III, avf)
Which nervous system slows the heart
Which nervous system speeds the heart up
Slows DOWN the heart - Parasympathetic
Speeds - Sympathetic
My rate is 30bpm. My complexes are regular (they all march out). I have NO P waves and my QRS is >.18s
idioventricular
My underlying rate is 70. My PRI is .22s. I have P, QRS & T waves which all look the same.
Sinus with 1st degree Heart block
Right Coronary Artery wraps around the heart and becomes the _______________________
posterior descending artery
Describe the rhythm of sinus arrhytmia
its irregular it increases with each inspiration and decreases with each expiration
What makes a Q wave physiologic?
< .04 seconds (less than 1 small box)
What lead are we looking at when placing PADs
Lead 2
Anatomically where do V8 and v9 go
(and v7)
v8 - 5th ics mid scapula (L) (under shoulder blade)
v9 - paravertebral border (L) (near spine)
v7 - posterior axillary line (L) (near arm pit)
Elevated serum lactate level is > _______
> 4 mmol
If SVT give
Amiodarone
150mg over 10mins
What does the QT interval represent
The amount of time it takes ventricle to depolarize and repolarize
how much time is between the two heavy lines on a graph
0.20 seconds
if Tachy is regular and monomorphic
stable and wide
give _____
you may give
Adenosine (class I)
6mg, 12mg
Interventions to SPEED up the heart
TCP
Atropine
Epi infusion
Dopamine infusion
What does the S1 sound indicate
closing of the atrioventricular valves.
the start of systolic contraction of both ventricles. closes after blood is pushed out to both the lungs (from RV) to the body (from LV)
What are the DEFIBRILLATION shocks
200j, 300j, 360j
Left Coronary Artery starts as the Left main, then bifurcates into the _________ and the ___________.
-left circumflex
-left anterior descending artery
What does a pathologic wave represent?
Old infarct
What are the top 2 complaints of a woman having a MI
SOB
and
Weakness
what do you do with the energy level if….
you go from a perfusing to a NON perfusing rhythm
never decrease the energy level
from defi to SVT stay at 300
S wave is the negative deflection ___________ the R wave
after
what does AICD mean
Automatic Implantable Cardioverter Defribrillator
INR is a measure of what
Blood clotting
How do you identify pericarditis on an ECG? (3 things - only need 1 to confirm)
-diffuse ST segment elevations
-no reciprocal changes
-PR interval depressions
The left main of the coronary artery branches off to
LCX - left circumflex and LAD - left anterior descending (feeding the lateral anterior wall)
Accelerated Junctional with unifocal PVC’s
PVC - early ventricular, unifocal because they look the same
junctional originates from av junction,
Junctional and hr is 60-100 so it’s accelerated junctional!
Leads II, III, and aVf look at the _______ _______
Inferior wall
Junctional Tachycardia
inverted P wave
rate 101-180
Define Escape
signal above not working, pacemaker below takes over, safety net
is when the SA node slows down or fails and a lower site assumes pacemaking responsibility
Sinus Tach with 1st Degree Block
What BB’s does a hemi block indicate
it specifically indicates LBB
Anterior hemiblock - Pathological left (-30/-90)
and
Posterior -Right Axis (90/180)
What does Nitro and morphine do to the RV
reduce preload
How would you differentiate between junctional focus and ventricular focus in CHB
Junctional focus-QRS complex is less than 0.12 second: rate 40-60 bpm. With ventricular focus, QRS is 0.12 second or more and rate 20-40 bpm.
What is the relationship between sodium and chloride levels?
When sodium decreases, chloride levels decrease - vice versa
What is the drug dose of Atropine
when do you give
1mg
Brady
Limb leads look at the ____________
Precordial (Chest) leads look at the ___________
Frontal plane
Horizontal plane
Explain depolarization vs Contraction
Depolarization = electrical activity only
Contraction = mechanical squeeze of the heart
Accelerated Junctional
Can’t see the p waves so it’s junctional and the hr is 80
60-100 accelerated
40-60 junctional escape
100-180 junctional tachy
For 15 lead where do you move
V4
V5
V6
v4 - v4r
v5 - v8 - mid scapular line (L)
v6 - v9 - let pariveteral border (near spine)
What are two interventions that start or squeeze the heart
start - epi
squeeze - defib
1 and avL, V5 and V6 looks at what part of the heart
Lateral Wall
+ electrode is at the left arm (1, avL)
left lateral chest ( v5, v6)
What parts of conduction does the Sympathetic influence
The atria
(i.e., the SA node, the intraatrial, and internodal pathways, and the AV junction)
and the ventricles
What is the drug dose of Epinephirine
when do you give
1:10,000 cardiac
1mg
Code
If you have elevation in II III and avF where might you see reciprocal change
I, avL, v leads
What is ejection fraction
% of blood pumped out by the left ventricle, compared to how much it holds (usually 70-75%)
BBB with QRS 170ms, ejection fraction can’t be more than 50% (chf or MI) can compensate
normal hematocrit levels
Male: 45%-52%
Female: 37-48%
What are two ways to find the isoelectric line
- use the T-P segment
- use the end of the calibration mark
What are the rules/guidelines of a Second Degree Type II
Impulses are blocked at the AV node so some P waves stand alone. P-R is constant and NORMAL
P waves are present but there are dropped QRS’s because the impulse is blocked
How can you identify Wellen’s syndrome?
Inverted or biphasic T-waves (usually in V2 and V3)
V Tach
3rd Degree Block
atrial contractions are ‘normal’
but no electrical conduction is conveyed to the ventricles. The ventricles then generate
their own signal through an ‘escape mechanism’ from a focus somewhere within the
ventricle.
Where is the ST segment
Between the J- point and the beginning of the T wave
How do you find ST elevation
Find the j point, find the t-p segment as your isoelectric line, and compare (move over 1 small box)
Pain from pericarditis (does/does not) radiate.
Does not
What fires during the PR interval?
The atria, AV node, bundle of His, bundle branches, and Purkinje system all fire.
if electrical current flows toward the positive electrode with deflection be upright or downward
upright
How do you confirm RBBB after turnsignal in V1
(with qrs over 120 & supra rhythm)
look at I and/or V6 for:
S wave, slurring, cupping
When should you do a 12 lead on a woman (top 2 reasons)
- weakness
- SOB
Define Starlings Law
the bigger the stretch the bigger the squeeze
What the augmented leads
avr avL avf
Where would you see a U wave?
The U wave is a small, flat wave seen after the T wave and before the next P wave.
For Brady what is the quick treatment atde
All
Trained
Dogs
Eat
Atropine
TCP
Dopamine
Epinephrine
Limb leads look at the heart from a __________ plane
frontal
SVT (no P waves seen)
What is the drug dose of Amiodarone
when do you give
300mg
2nd dose
150mg
Code
Treatment for Hydrogen Ion (Acidosis)
Sodium BiCarb
airway management
CPR
My rate is 30bpm. My complexes have a ‘normal’ morphology of P, QRS & T waves that all look the same. I am a regular rhythm.
Sinus Brady
Depression in aVr is indicative of _________
Pericarditis
With ROSC how should you position patient
Elevate head 30 degrees
In what part/stage of patient assessment do you recheck the interventions you have performed on your patient?
Re-Assessment
Define Supraventricular Rhythms
Rates over 150, narrow QRS
V-Tach
wide, bizarre QRS
Your coronary arteries fed when the ventricle ______________.
relaxes
Explain where the negatives and positives in Einhovens Triangle
The positive electrode looks at the ____________
negative electrode
When you find a block, hemi block what do you do next
PUT Pads on them to DEFIB or PACE
Creatinine levels
0.6-1.2 mg/dL
What class intervention is TCP according to ACLS
Class I
What are interventions to SLOW the heart
Synchronized Cardioversion
Defib
Adenosine
Diltiazem
Beta-Blockers (lol)
Lidocaine
Mag Sulfate
Idioventricular
Obtain v8 and v9 when
v1- v4 show st depression (two or more anatomically contiguous)
SVT
hr 160-250
cant see P waves so fast
vagal then cardiovert
A hemi block is also known as a
Fascicular Block
What are 2 requirements of BBB
Widened QRS 120ms (QRS 0.120s)
and
Supraventricular Rhythm (sinus, atrial, junctional)
look in V1 (turn signal: up or down)
When do you look for Posterior MI
when v1-v4 show ST depression (any two or more anatomically contiguous) or story is convincing
Low blood sodium is called ____________
Hyponatremia
What are the rates of Junctional Rhythms
and difference between junc brady and idiovent
Junctional Tachy Over 100
Accel Junctional 60 -100
Junctional (Escape) 40-60
Junctional Brady Below 40 (narrow QRS)
(idioventricular = wide QRS over 0.120s, below 40)
Define Absolute refractory period
heart cannot fire, not ready,
has not reached halfway up t-wave
Define Polarization
When electrical charges are balanced and ready for discharge
avR T wave inversion is _______, in v1 and v2 it is ________ and other leads its a sign of _________
normal (because of how leads are)
a normal variant
a sign of ischemia
What are 2 ways to find the isoelectric line?
-Use the TP segment
-Use the end of calibration mark
If STABLE narrow Tachy
how do you treat
(and if wide)
IV, 12lead
Vagal Maneuvers (blow into
Give Adenosine 6/12
(if wide give amiodarone 150mg)
INR for pt on warfarin
3 sec
What is the normal range for potassium (K+)
3.5-5.0 mEq/L
As a PTs INR increases, what risk also increases?
Bleeding
What is the number 1 cause of upright avR
Limb lead reversal (check leads)
Where does blood flow through the heart
Superior/Inferior VC -> R Atria -> Tricuspid valve -> R Ventricle -> Pulmonary artery ->
Lungs ->
Pulmonary veins -> L Atria -> Mitral valve -> L Ventricle -> Aorta
What are the anatomical locations of
V1 - V6
V1 - 4th intercostal (r) strernum
V2 - 4th intercostal (L) strernum
V3 - (between v2 v4)
V4 - 5th intercostal, mid clavicular
V5 - 5th inter, anterior axillary line
V6 - 5th inter, Mid Axillary line
How do you treat PEA
CPR - compressions
IV/IO access
1mg Epinephrine (0.1mg/mL) IVP every 3/5 mins
ETT and Capno
Second Degree Type II
What are the 3 Inherent rates of the conduction system
SA Node 60-100 bpm
AV Junction 40-60 bpm
Ventricles 20-40 bpm
Where is the negative electrode with
augmented unipolar leads
computer average central terminus middle
avr
avL
avf
AHA definition of a STEMI
> or equal to 1mm ST elevation in 2 or more anatomically contiguous leads
Left Anterior descending artery feeds the (3 things):
-anterior septal wall
-anterior left ventricular wall
-apex
What is the treatment sequence for BRADYCARDIA
Atropine 1mg every (q) 3-5mins max of 3mg
TCP (pacing) start at 80bpm
DO NOT DELAY PACING FOR IV
Dopamine Infusion or Epi
What two requirements have to be met in order to have a bundle branch block on an ECG?
Wide QRS
and
Supraventricular Rhythm
Where anatomically is v5r, v6r placed
v5r - 5th ics anterior axillary (right)
v6r - 5th ics mid axillary (right)
Which leads look at the INFERIOR wall of the heart?
II, III, and aVF
How can you identify hypokalemia on an ECG?
-ST depression
-prominent U-wave
what is the drug dose of cardizem
when do you give
afib or aflutter
(0.25 then 0.35)
Which leads look at the LATERAL wall of the heart?
I, aVL, V5, and V6
Atrial Fibrillation (controlled) with 2 unifocal PVC’s
V Tach 100J
The baseline is a straight line drawn between the _____ of one complex to the _____ of the succeeding complex.
TP segment–TP segment
What is happening during a
QRS
Ventricle Depolarization
how many small boxes is a 6 second strip
150
Low creatinine levels suggest _______ and/or ________ disease
Heart and/or liver
What are the bi-polar leads
I II III
What causes Left Ventricular Hypertrophy?
chronic hypertension
what do you do with the energy level if….
you go from a NON perfusing to a perfusing rhythm
you may start at a lower energy setting
Junctional Escape
What are two reasons for ST depression
- Ischemia
- reciprocal change
What lead is the positive lead in aVr?
right arm +
What is the dose for Dopamine
What is the dose for Epinephrine
Dopamine
5-20mcg/kg/min
Epinephrine
2-10mcg/min
Dopamine can be added to Epi or used alone
In avR where is the positive electrode?
Right shoulder
R wave is the _____ _______________________ in the QRS complex
1st positive deflection
When an arrhythmia is irregular, you should determine the heart rate by counting the number of R waves divided by
10
What is happening during a
T Wave
Ventricle repolarization
Sinus with PAC
early atrial activity
early p wave looks different
What are the 6 H’s
also known as
Hypovolemia
Hypoxia
Hydrogen Ions (Acidosis)
Hypo and Hyper Kalemia
Hypothermia
probable causes
Where is the ST segment?
B/w J-point and beginning of the T wave
Steps for Pacing
- Pads on
- Limb leads on
- Set pace to 80 for adults
- Increase mA until electrical capture achieved
- Then palpate femoral pulse and increase until mechanical capture
- Then add 10% to final setting
- Patient codes, turn pacing off
Pathological left axis comes with ____________ hemiblock
anterior