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Principles I > Basic EKG > Flashcards

Basic EKG Flashcards

1
Q

where is the SA node located?

A

junction of the superior vena cava and right atrium

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2
Q

what is the SA node inherent rate?

A

60-100 bpm

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3
Q

what is the AV node inherent rate?

A

40-60 bpm

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4
Q

what is the inherent rate of the ventricles/purkinje network?

A

20-40 bpm

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5
Q

what is the AV junction?

A

the conduction pathway between the atria and ventricles

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6
Q

what allows the atria to both contract at once?

A

intratrial pathways from the SA node in the right atrium to the left atrium

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7
Q

what are the phases of the cardiac conduction cycle?

A

-depolarization -repolarization -rest

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8
Q

what activates and completes each cardiac conduction cycle?

A

activated by the automaticity of the heart and completed through electrolyte changes (Na+/K+ ATP pump)

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9
Q

describe depolarization

A

-occurs by cell becoming “positive”, to a point of +30mV -Na+ enters cell, K+ leaves out (more Na+ going in making more positive) -Ca++ enters at slower rate, facilitating a prolonged conduction *electrical firing of the cell *continuous cycle to stimulate each heart beat

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10
Q

describe repolarization

A

-begins with Cl- entrance (making cell more negative) -retruns cell to its resting state (resets) -Na+ pumped back out, K+ begins to return in

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11
Q

how is the cardiac action potential (conduction cycle) depicted in graph form?

A

vertical line (depolarization) followed by a downward slope transition (repolarization)

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12
Q

describe the absolute refractory period

A

-as the cell is repolarizing, period of time where no matter the stimulus, cell can not depolarize again -insures a complete “re-charge” before the next cycle

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13
Q

describe the relative refractory period

A

-cell has completed a portion of the repolarization, but has not completed the process -can depolarize again, but is still more difficult to stimulate *certain stimulus during this time can precipitate the heart to change to lethal dysrhythmias *certain meds can predispose conduction during this period

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14
Q

what may cause dysrhythmias in relation to the relative refractory period?

A

-non pacemaker cells that suddenly discharge on their own similar to the automatic discharge of the SA node -these beats can land during the relative refractory period

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15
Q

what are other causes of dysrhythmias?

A

-may be created by complication with conduction pathway *re-entry rhythms may cause fast repeating beats that often require emergent care to break the cycle -alterations of the pacing sites (failure/impedance vs. hyper excitation) *AMI, drug action, hypoxia, electrolyte imbalance

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16
Q

what are non pacemaker cells that discharge to stimulate a beat called?

A

-ectopic sites or foci

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17
Q

what does the EKG provide?

A

-views the electrical activity of the heart -takes a picture between two electrodes (one lead) -time and voltage are measured

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18
Q

what are the various types of electrodes?

A

-internal (esophageal): pacing probe is placed down throat -epicardial (attached to heart): during open chest -surface (attached to skin)

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19
Q

how is electricity flowing towards a positive lead viewed on the EKG?

A

as an upward or positive line

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20
Q

what are the bipolar leads?

A

-limb leads -looks between the right are, left arm, and left leg -these leads allow to look from both (bipolar) directions -leads I, II, III

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21
Q

what are the unipolar leads?

A

-augmented leads *look b/w a reference point (unipolar) and right and left arms and left foot *leads aVR, aVL, aVF -precordial or chest/V leads *look b/w a reference point and chest lead (AV node)

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22
Q

what is Wilson’s Central Terminal?

A

determines where the heart is, creating a reference point for unipolar leads

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23
Q

what are modified chest leads? (MCL)

A

-modification of bipolar leads to mimic precordial views -used in absence of a 12 lead capable machine -set monitor to lead III (- left shoulder, + left leg); move left shoulder to reference point and move left leg electrode to anatomical points for V1-V6 -each site documented as MCL1 for V1, etc.

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24
Q

describe limb lead placement

A

-each lead labeled for the site (RA- white, LA-black, LL-red, RL-green ) -place on tissue, not bony surface -limb leads can be placed on wrists/ankles or shoulder/flanks **wrong electrode placement alters EKG

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25
Q

describe precordial lead placement

A

V1- 4th intercostal, right sternal border V2- 4 ICS, left sternal border V3- b/w V2 and V4 V4- 5th ICS @ left midclavicular line (MCL) V5- b/w V4 and V6 @ anterior axillary line (AAL) V6- 5th ICS @ midaxillary line (MAL) *under breast tissue

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26
Q

what lead is usually monitored for routine EKG monitoring?

A

II -monitor HR, regularity, conduction patterns

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27
Q

why is lead II good?

A

-views direction of travel of electricity from negative to positive electrode giving positive deflections -view follows normal pathway of heart conduction -looks from 60 degree angle (heart vector 59 degree)

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28
Q

what is diagnostic EKG monitoring used for?

A

-presence and location of AMI -axis deviation -chamber enlargement

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29
Q

what leads look at the septum of the heart?

A

V1 and V2

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30
Q

what leads look at the anterior wall of the heart?

A

V3 and V4

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31
Q

what leads look at the lateral wall of the heart?

A

Lead I, aVL, V5, and V6

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32
Q

what leads look at the inferior wall of the heart?

A

Lead II, III, AVF

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33
Q

what may cause complications with electrodes?

A

-dry adherence glue -diaphoresis -body hair/oils -movement

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34
Q

what might skin prep include with monitoring leads?

A

-wiping skin with alcohol (not with defib pads!!) -tincture of benzoin to increase adherence -shaving hair

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35
Q

what is artifact?

A

ECG deflections caused by factors other than electrical activity of the heart *attempt to eliminate artifact when possible to improve readability and reduce risk of misinterpretation

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36
Q

what are causes of artifact?

A

-muscle tremors -shivering -patient movement -loose electrodes -60 Hz interference (electricity from bovie) -machine malfunction -chest compressions

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37
Q

what axis on the EKG graph represents time?

A

x- axis

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38
Q

what axis on the EKG graph represents voltage?

A

y-axis

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39
Q

what lines are used to measure time on EKG graph?

A

vertical lines (display time increments along the x axis)

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40
Q

what lines are used to measure voltage on EKG graph?

A

horizontal (display voltage increments along y axis)

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41
Q

how fast are EKG machines standardized to run graph paper across a stylus? calibrated at?

A

25 mm/sec; calibrated at 1 mV

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42
Q

with time, one small box equals? 1 large box (5 small)?

A

0,04 sec; 0.2 sec

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43
Q

with voltage, one small box equals? 2 large boxes (10 small)?

A

0.1 mV (1 mm in height); 1 mV

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44
Q

why is time measured?

A

to measure rates and intervals of the EKGs

45
Q

why is voltage measured?

A

to determine the strength and direction of the EKGs

46
Q

what is “size” in the EKG monitor?

A

-scale of the tracing -can be increased to enlarge the entire complex *allows for easier viewing, but may distort features like PR interval or ST elevation *standard calibration is 10mm or 2 large blocks

47
Q

what is “gain” in the EKG monitor?

A

-sensitivity *most new monitors adjust automatically *more sensitivity allows greater reception, but may increase artifact *filter mode (usual mode opposed to monitor mode) filters out artifact

48
Q

what are the five steps of EKG interpretation?

A

1) rate (slow, fast, normal?) 2) rhythm (consistently regular, regularly irregular?) 3) P waves (present? upright? 1 P: 1 QRS?) 4) PR interval (consistent? < .20 sec?) 5)QRS complex (<.12 sec)

49
Q

what is regularly irregular?

A

the irregularity occurs regularly for example a skipped beat after every 3 beats

50
Q

what intervals change with rate?

A

QT interval changes with rate *PR interval should not change

51
Q

what is a quick way to note for prolonged QT interval?

A

-mark two consecutive R waves -mark half way between *if T wave occurs before the 50% mark, QT is normal; if T wave is on or after the 50% mark, QT is prolonged

52
Q

what is the risk of a prolonged QT interval?

A

R on T phenomenon

53
Q

changes in PR intervals usually indicate what?

A

heart block

54
Q

what is the quickest method to measure rate?

A

count the number of QRS complexes in a 6 second strip and multiply by 10 *always check radial pulse (compare pulse ox to EKG) since an electrical rate may reflect more than the mechanical rate (ex: bigeminy, all beats don’t perfuse)

55
Q

what is the triplicate method of measuring rate?

A

-locate R wave that falls on dark line bordering large box -assign 300, 150, 100, 75, 60, 50 in that order to next six dark lines to the right -number corresponding to dark line at peak of next R wave is rate

56
Q

what is the same and what changes amongst different leads?

A

-intervals will be the same, but may be more easily measured in certain leads -picture/tracing from each lead will be different

57
Q

what is the isoelectric line?

A

electrical tracing when no electrical activity (flat) *ST segment should be parallel to isoelectric line

58
Q

what does the p wave represent?

A

depolarization of the atria

59
Q

what does a normal p wave look like?

A

-upright except in aVR lead -0.06-0.1 sec duration (width) -< or equal to 2.5 mm in height **< or equal to 2.5 mm in width and height

60
Q

what is the PR interval?

A

beginning from the p wave to the beginning of the QRS complex

61
Q

how long is a normal PR interval?

A

0.12-0.2 sec **< or equal to 0.2 sec

62
Q

what does the QRS complex represent?

A

depolarization of the ventricles

63
Q

what components make up the QRS?

A

-Q wave: first downward deflection (septal depolarization) -R wave: positive deflection during ventricular depolarization -S wave: negative deflection following the R wave

64
Q

what is the normal duration of the QRS complex?

A

0.06-0.1 sec **< 0.12 sec

65
Q

what does the ST segment represent?

A

time between depolarization and repolarization of the ventricles *J point= level at which ST segment begins from QRS *should be isoelectric with the baseline

66
Q

what does the T wave represent?

A

ventricular repolarization

67
Q

what can influence T wave changes?

A

-drugs -ischemia -electrolytes

68
Q

describe normal sinus rhythm

A

-60-100 bpm -regular rhythm -P waves present and upright, 1:1 with QRS -PR interval less than 0.2 sec -QRS present, < .12 sec, 1:1 with P wave

69
Q

describe sinus bradycardia

A

only difference from NSR is rate < 60 bpm

70
Q

describe sinus tachycardia

A

only difference from NSR is rate > 100 bpm but < 150 and an abbreviated ST segment (time b/w depolarization and repolarization shorter)

71
Q

when can sinus dysrhythmias commonly be seen?

A
  • vent patients r/t lungs filling and impeding vena cava (HR decrease) then exhale allows blood flow (HR increase)
  • dehydrated younger patients (give fluid)
  • younger patients
72
Q

what is a wandering pacemaker?

A

sinus dysrhythmia where each p wave looks different showing that the electrical impulse is not only originating at the SA node, but also coming from multiple ectopic areas in the atria

*PR and QRS remain intact and normal

73
Q

describe atrial rhythms

A
  • originate outside SA node
  • issue is above the ventricles in atria so QRS comples remains narrow and maintains constant form
74
Q

describe atrial flutter

A
  • rate: variable; may be extremely fast (a-250, v-150)
  • regularity: QRS is regular; P to P is regular
  • P waves: present and upright; multiple P waves per QRS (2:1 conduction or 4:1)
  • PR interval: constant
  • QRS complex: narrow and maintains constant form
75
Q

describe atrial fibrillation

A
  • rate: variable; may be slow or fast (dont rely on monitor, count manual pulse)
  • regularity: very irregular (key identifier)
  • P waves: not visible, may have wavering baseline
  • PR interval: undetermined d/t no true P wave
  • QRS: <.12 sec; same morphology BUT irregular interval
76
Q

describe Supraventricular tachycardia (SVT)

A
  • rate: > 150 bpm (not sinus)
  • regularity: regular (not a-fib)
  • P waves: probably not visible d/t rate
  • PR interval: indiscernible d/t rate
  • QRS: narrow complex, <.12 sec (indicates origin of complex is above the ventricle)
77
Q

describe atrial tachycardia

A

*can be considered SVT

  • rate: 180-250 bpm
  • regularity: regular
  • P waves: present but may not be visible
  • PRI: <.20 sec but probably not visible
  • QRS: <.12 sec (narrow complex)
78
Q

describe wandering pacemaker

A

rate: variable
regularity: irregular

P waves: present, 1:1 with QRS; different in origin

PRI: <.20 sec and consistent

QRS: <.12 sec

*morphology of each P wave is different indicating a changing pacer site

79
Q

what is paroxysmal SVT?

A

sudden start and stop of SVT

80
Q

what are junctional rhythms?

A

-characterized by retrograde conduction of the atria

*impulse travels towards the negative electrode, making the P wave inverted (may be late P wave hidden in QRS complex so not visible)

-occurs secondary to an inadequately firing AV node

*inherent rate 40-60 bpm

*accelerated junctional rhythm: 60-100 bpm

*junctional tachycardia >100 bpm

81
Q

describe junctional escape rhythm

A
  • rate: 40-60 bpm
  • regularity: regular QRS
  • P waves: usually present but inverted; may be found after QRS
  • PR interval: variable but <.20 sec
  • QRS: <.12 sec, normal with 1:1 ratio
82
Q

describe ventricular tachycardia

A

rate: usually very fast, always > 100 bpm
regularity: regular

P waves: not present

PRI: undetermined d/t no P waves

QRS: > 0.12 sec, wide symmetrical complexes

83
Q

describe ventricular fibrillation

A

rate: no complete complexes to determine rate
regularity: very irregular chaotic baseline

p wave: none

PRI: N/A

QRS: none

84
Q

describe ventricular escape rhythm

A

AKA idioventricular rhythm; agonal rhythm; dying heart rhythm

  • rate: 20-40 bpm
  • regularity: regular
  • P waves: none visible
  • PRI: N/A
  • QRS: >.12 sec, widely spaced, symmetrical complexes
85
Q

describe sinus rhythm with bigeminy of PVCs

A
  • rate: 60-100 (electrical, mechanical may be 30-50!!)
  • regularity: regularly irregular; PVCs are too early to be regular
  • P waves: present and upright on baseline SR, not visible on PVCs
  • PRI: <.20 sec on baseline sinus rhythm
  • QRS: <.12 sec on baseline; wide complexes (PVCs) with different site of origin
86
Q

what is seen with SR with multifocal PVCs?

A

different ectopic sites indicated by different complexes

87
Q

what is considered a run of V-tach?

A

3 or more PVCs together

88
Q

what are ectopic beats?

A
  • premature beats that come from non-pacemaker sites
  • the individual beat may or may not initiate a mechanical pulse
  • source is determined by the shape of the complex

*p wave=PAC

*wide complex=PVC

*junction= PJC

89
Q

describe ventricular asystole

A
  • rate: QRS= 0 (may have P waves present but still asystole)
  • regularity: N/A
  • P wave: upright, regular
  • PRI: N/A
  • QRS: not present
90
Q

describe pulseless electrical activity (PEA)

A

*no pulse with complexes

  • can be an organized rhythm that does not have a pulse
  • often a slower, wide complex rhythm
91
Q

what are heart blocks?

A
  • also known as AV blocks or atrioventricular delays
  • occurs d/t a slowed or blocked conduction of electrical current from the SA node through the AV junction to the ventricles
  • classified as first degree, second degree (type I/Wenckebach or type II/classical), and third degree
92
Q

what elements need to be identified in order to classify the heart block?

A
  • determine the PRI
  • determine the P:P and QRS:QRS timing
93
Q

describe a first degree heart block

A

**PR interval: constant, but > .20 sec (1 big box)

  • rate: 60-100
  • regularity: regular
  • p waves: present, upright, 1:1 with QRS
  • QRS: <.12 sec, normal
94
Q

describe second degree, type I (Wenckebach) heart block

A

rate: variable, commonly slow (60-100)

**regularity: QRS irregular

P waves: present, upright; *multiple p waves per QRS BUT p-p constant

PR interval: *widening PRI, before resetting (cyclic)

QRS: <.12 sec, conducts only behind portion of p waves

95
Q

describe second degree, type II (classical) heart block

A

rate: variable, usually slow
regularity: *QRS and P waves are regular

P waves: present, upright; multiple p waves per QRS

PR interval: constant for last p wave, <.20 sec

QRS: narrow complex, conduction only to last p wave

96
Q

describe third degree heart block

A
  • complete block
  • characterized by complete dissociation b/w P and QRS complexes
    rate: QRS rate slow (20-40); P rate 60-100
    regularity: P:P regular; QRS:QRS regular; P:QRS very irregular

P waves: present, upright, multiple P waves per QRS

PRI: variable at each measurement

QRS: usually wide and evenly spaced far apart

97
Q

describe pacer rhythms

A

-pacers can be for atria, ventricles, or both

*look for pacer spikes

*ventricular pacer always creates a wide complex rhythm

*cant determine ischemia on a 12 lead when paced

98
Q

how are magnets used with pacers?

A

-defibrillators can be disabled by placing a magnet directly over the AICD unit until it beeps

*re-activate unit with the magnet again

*re-activation may set the unit to a “default” mode rather than previous programming

-pacing settings can be changed to “non sensing” with a magnet

**recommendation is to have rep disable and reactivate pre-op and post-op

99
Q

what are the categories of each letter in the pacer type?

A

I. chambers paced

II. chamber(s) sensed

III. response to sensing

IV. programmability, rate modulation

V. antitachyarrythmia function (AICD or not?)

ex: VOO= ventricle paced with no chamber sensing
ex: DA= dual chambers paced, atria sensed

100
Q

what EKG changes are seen with pericarditis?

A

elevated, concave ST segment

101
Q

what EKG changes are seen with hyperkalemia?

A
  • tall, peaked T waves (> 1/3 ht. QRS)
  • wide, flat P waves
  • widening QRS
  • disappearing ST segment
  • merging QRS
102
Q

what EKG changes are seen with hypokalemia?

A
  • U wave
  • depressed ST segment
  • flattening T waves
  • widening QRS
103
Q

What EKG changes are seen with hypercalcemia?

A

short QT intervals

104
Q

what EKG changes are seen with hypocalcemia?

A

prolonged QT intervals

105
Q

what EKG changes are seen with digitalis effect?

A
  • depressed “scooped” ST segment
  • flat, inverted, or biphasic T waves
  • short QT intervals
106
Q

what is seen with Wolff-Parkinson-White?

A
  • more of a gradual incline with an upstroke of the QRS rather than a sharp upstroke
  • upstroke is curved (delta wave) compared to downstroke of QRS
107
Q

what can determine if elevated T wave is d/t hyperkalemia or AMI?

A

elevated T waves are noted throughout entrie EKG in all leads in hyperkalemia

108
Q

with cardioversion of SVT, what should be checked?

A

-in synchronized mode

109
Q

if monitoring an EKG and see ST elevation, what should you check?

A

check the red lead, if placed high on the chest, you will see false ST elevation

Principles I (18 decks)

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