cardiac, EKG, CXR videos Flashcards
Ninja Nerd EKG Basics: electrical activity generated FROM positive to negative electrode generates what type of deflection on EKG?
negative deflection line
Ninja Nerd EKG Basics: electrical activity generated TO positive FROM negative electrode generates what type of deflection on EKG?
positive deflection line
Ninja Nerd EKG Basics: electrical activity moving from SA node to AV node generates what type of deflection line in Lead II?
positive (upward) deflection line (P wave)
Ninja Nerd EKG Basics: atrial depolarization from SA node to AV node results in what shape in Lead II?
P wave
Ninja Nerd EKG Basics: what does the P wave represent?
atrial depolarization
Ninja Nerd EKG Basics: what happens at AV node and how is it represented on the EKG?
there is a .1 second delay
on the EKG: isoelectric line
we call it PR interval
Ninja Nerd EKG Basics: why is the PR interval very important?
it’s important when looking at heart blocks
first, second, third degree heart blocks get jammed up at AV node
Ninja Nerd EKG Basics: which bundle branch actually depolarizes the ventricular septum?
the LEFT bundle branch
Ninja Nerd EKG Basics: interventricular septum depolarization manifests itself in what way on EKG?
negative deflection called the Q WAVE (but not the pathological kind)
Ninja Nerd EKG Basics: what is the Q wave indicating?
septal depolarization
Armando Hasudungan ACS: Two things characterize acute coronary syndrome
unstable angina
MI: STEMI and NSTEMI
Armando Hasudungan ACS: describe acute coronary syndrome
syndrome in which you have reduction of blood supply to cardiac muscle or loss or total occlusion reducing all blood supply to heart muscle cells
Armando Hasudungan ACS: EKG changes seen over time w/ pts who have suffered a STEMI
onset - 12 hrs: peaked T wave –> ST segment elevation
12-24 hrs: ST segment elevation (and may form pathological Q wave), +/- inverted T-wave
1st wk: pathological Q wave, T wave inversion
wk - mo.s: pathological Q wave (sign of previous MI)
Armando Hasudungan ACS: troponin changes with pt having a STEMI
onset = 2-3 hrs (uptodate) peak = day 2 (video) (24 hrs, PAER)
Armando Hasudungan ACS: CK-MB changes with pt having a STEMI
onset = 3-12 hrs (PAER) peak = ~24-48 hrs (video)
Armando Hasudungan ACS: what percent of EKG’s may be normal in pts in initial stages of unstable angina?
20%
Armando Hasudungan ACS: what area of the heart does the left circumflex artery supply?
lateral wall of the heart
Armando Hasudungan ACS: pathophysiology for a STEMI
complete occlusion of artery b/c of rupture plaque, no blood supply to myocardium, infarction distally which progresses proximally until transmural infarction, possible damage to papillary muscles may result
Armando Hasudungan ACS: what is the definition of a STEMI?
complete occlusion of coronary artery causing an infarction
ST-elevation above J point in 2 contiguous leads
Armando Hasudungan ACS: what is the definition of a NSTEMI?
partial occlusion causing ischemia to tissue proximally
plaque rupture thrombosis, but artery not fully occluded
ST depression below J point
t wave inversion or flattening (sometimes)
Medical Basics EKG for Beginners: what components of the EKG do we consider when we are analyzing an EKG?
rate rhythm intervals - PR, QRS, QT axis ischemia
Medical Basics EKG for Beginners: how many small boxes make up the big boxes in the x axis? how many in the y axis?
5 small boxes x 5 small boxes = 1 big box
Medical Basics EKG for Beginners: what is being measured in the x axis? y axis?
x axis = time
(1 big box = 0.2 seconds)
y axis = voltage
(1 big box = 0.5 mV)
Medical Basics EKG for Beginners: what are we considering when we evaluate the rhythm?
time between R waves, measured by x -axis boxes representing time
Medical Basics EKG for Beginners: which three leads are considered to determine of the axis is normal or abnormal?
I, II, aVR
P waves upright in I, II, inverted in aVR
Medical Basics EKG for Beginners: which lead is negative with a normal axis?
P wave is inverted in aVR lead
Medical Basics EKG for Beginners: what pathologies may cause left axis deviation?
LVH
L anterior fascicular block
inferior MI
Medical Basics EKG for Beginners: what pathologies may cause right axis deviation?
RVH
L posterior fascicular block
lateral MI
Ninja Nerd EKG Basics: which leads are left-sided leads?
I
aVL
V4-V6
Ninja Nerd EKG Basics: which leads are right-sided leads?
III
aVR
V1-V3
Ninja Nerd EKG Basics: what leads look at the inferior wall of the the heart?
II
III
aVF
Ninja Nerd EKG Basics: what leads look at lateral wall of L ventricle?
I
aVL
V5
V6
Ninja Nerd EKG Basics: what leads look at R ventricle?
aVR
V1
V2
Ninja Nerd EKG Basics: what leads look at anteroseptal area of the heart?
V1-V4
Ninja Nerd EKG Basics: name precordial chest leads and what plane do they report electrical activity from?
V1-V6
Ninja Nerd EKG Basics: what is the cutoff width for deciding if QRS is wide?
> 0.12 seconds = wide
but don’t ignore .10 - .12 seconds
Ninja Nerd MASTER EKG video:
what leads do we consider the P waves for whether the rhythm is normal sinus rhythm?
are P waves upright in leads I and II, and inverted in aVR?
Is every P wave followed by a QRS?
“yes” to both? good!
Ninja Nerd MASTER EKG video:
what are three differentials for NARROW and REGULAR tachycardia?
sinus tach
2:1 atrial flutter
SVT
Ninja Nerd MASTER EKG video:
what are three differentials for NARROW and IRREGULAR tachycardia?
A Fib (MC) variable A flutter (variable block) MAT (multifocal atrial tachycardia)
Ninja Nerd MASTER EKG video:
what are four differentials for WIDE and REGULAR tachycardia?
VTach
SVT w/ BBB
sinus tach w/ BBB
antidromic WPW
Ninja Nerd MASTER EKG video:
what are three differentials for WIDE and IRREGULAR tachycardia?
PMVT = PolyMorphic VTach
AFib w/ WPW
AFib w/ BBB
Ninja Nerd MASTER EKG video:
What’s a J wave?
short positive deflection following the down stroke of the R wave producing a fish hook appearance
this is helpful to differentiating benign early depolarization vs STEMI
Ninja Nerd MASTER EKG video:
What are DDx of ST Elevation? (there are 8 listed by the video)
STEMI
pericarditis
vasospasm
PE
LV aneurysm
LV hypertrophy
L BBB
benign early repolarization
Ninja Nerd MASTER EKG video:
What are DDx of ST Depression?
NSTEMI posterior MI L BBB LVH w/ strain reciprocal changes digoxin toxicity
Ninja Nerd MASTER EKG video:
What are DDx of J Waves?
benign early repolarization
hypothermia
hypercalcemia
Brugada syndrome
Ninja Nerd MASTER EKG video:
what are three types of ST segment DEPRESSION? which one is worse?
downsloping
horizontal
upsloping
horizontal ST depression can be harbinger of ischemia - don’t send this pt home!
(also, the upsloping in V1-V3 with peaked T waves can mean proximal LAD occlusion)
Ninja Nerd MASTER EKG video:
define ST depression
J point/ST segment at least 0.5 mm below isoelectric line in two contiguous leads
Ninja Nerd MASTER EKG video:
four types of T wave abnormalities
T-wave inversion
hyperacute T wave
biphasic T wave
flat T wave
Ninja Nerd MASTER EKG video:
when am I most nervous when I see a particular T wave abnormality and what is it?
t-wave inversion by itself in aVL - this may be a sign of impending inferior wall MI…so keep getting serial EKGs
Ninja Nerd MASTER EKG video:
what are five DDx for T wave inversion?
LVH strain increased ICP PE BBB ischemia
Ninja Nerd MASTER EKG video:
what is an normal variant for for T wave inversion?
it’s not abnormal to have T wave inversion in V1, V2, or lead III
Ninja Nerd MASTER EKG video:
what are two DDx for hyperacute T wave?
vasospasm
early STEMI
Ninja Nerd MASTER EKG video:
what are two DDx for biphasic T wave?
ischemia
hyperkalemia
Ninja Nerd MASTER EKG video:
what are two DDx for flat T wave?
ischemia
hypOkalemia
Ninja Nerd MASTER EKG video:
what are two reasons the QRS wave is widened? What are the other 4 DDx for wide QRS?
BBB
hyperkalemia
(also: VTach WPW paced rhythm meds (TCA))
Ninja Nerd MASTER EKG video:
what does it mean if a biphasic T wave is seen in V2 to V3? ESPECIALLY if it is positive deflection followed by negative deflection!
sign of proximal LAD occlusion
“Wellens-A criteria”
Ninja Nerd MASTER EKG video:
what does it mean if a biphasic T wave is negatively deflected then positively deflected?
think HYPERKALEMIA, and check the potassium
Ninja Nerd MASTER EKG video:
what are three DDx for peaked T waves?
hyperkalemia
hypermagnesemia
ischemia
Ninja Nerd MASTER EKG video:
what are De-Winters T-waves and why do they concern us?
De-Winters T-waves are signs of ischemia….they are STEMI equivalent, peaked T waves in V1 to V3 area, plus upsloping ST depression….get scared for proximal LAD occlusion
CXR:
four initial checks when looking at a CXR?
RIPE R = rotation I = inspiration P = projection E = exposure
(not the TB RIPE)
CXR: what is the systematic way to move through a CXR?
ABCDE A = airway B = breathing C = cardiology D = diaphragm E = everything else (bones, fxs, lytic lesions, etc.)
Ninja Nerd MASTER EKG video:
define T wave inversion
a depression that is at least 1mm or greater below the isoelectric line
CXR: first items to check when reviewing CXR
pt name DOB date of XR where XR taken see if pt has any previous XRays
CXR: how many posterior ribs should you be able to count on a good quality CXR?
posterior: 9
CXR: how many anterior ribs should you be able to count on a good quality CXR?
anterior: 5-6
CXR: what medical sign of the heart needs to be carefully considered with seen in an AP film?
AP film will make heart look slightly larger than it is
CXR: what medical findings may cause the trachea to deviate to the RIGHT?
pleural effusion
LEFT pneumothorax
RIGHT collapsed lung
CXR: at what level of the thoracic vertebrae is the carina?
T4/5
CXR: what topographical landmark on the anterior chest is at the level of the carina?
sternal angle (angle of Louis)
CXR: the four zones of the lungs are:
apical
upper
middle
lower
CXR: how do you determine if the heart is enlarged on the CXR?
make sure the width of the heart is not more than 50% of the width of the thoracic window
CXR: Is it normal to see air under the diaphragm?
yes, you may see air under the left side of the diaphragm b/c air is in the fundus of the stomach
CXR: elements to remember when reading CXR to your attending
confirm pt, DOB, date of XRay RIPE ABCDE say what you see review positive findings
Ninja Nerd MASTER EKG video:
what is a pathological Q wave (three criteria)?
1) >0.04 seconds (“very wide”), ORRRRR
2) >2 mm in depth (from isoelectric line), ORRRR
3) >25% of QRS complex height
Ninja Nerd MASTER EKG video:
LEFT BBB:
in V1-V2, what do you see (according to Ninja Nerd)?
or V5-V6, what do you see (according to Ninja Nerd)?
V1-V2 –> deep big S wave (maybe even a little biphid shape)
V5-V6 –> the ‘M’ shape
Ninja Nerd MASTER EKG video:
RIGHT BBB:
in V1-V2, what do you see (according to Ninja Nerd)?
in V5-V6, what do you see (according to Ninja Nerd)?
V1-V2 –> R-S-R’ pattern
V5-V6 –> super wide S wave, slurred even
Ninja Nerd MASTER EKG video:
where should you NEVER see Q waves? What if you do? What does that mean?
V1-V3
seeing Q waves in V1-V3 = pathological Q waves
Ninja Nerd MASTER EKG video:
why do we care about pathological Q waves (in other words, what are four DDx for pathological Q waves)?
MI (old or new)
PE
LBBB
LVH
Ninja Nerd MASTER EKG video:
what is the primary concern for low voltage QRS wave?
pericardial effusion is the big concern (esp if there is increased HR and SOB)
(think about reasons why the conduction is not getting through to the electrodes)
Ninja Nerd MASTER EKG video:
what are two DDx for poor R wave progression (as you go from V1 to V6)?
in other words “what might a poorly progressive R wave mean”?
anterior MI
RVH with strain
Ninja Nerd MASTER EKG video:
what is a dominant R wave?
it’s a big R-wave in V1, V2, or V3 (R waves are supposed to be small in these leads, and definitely shouldn’t be greater than the S waves!)
Ninja Nerd MASTER EKG video:
what are three DDx for dominant R waves in V1-V3 AND there is ST depression and upright T waves?
I’m most nervous for POSTERIOR MI, but make sure to r/o:
RBBB
and RVH
Ninja Nerd MASTER EKG video:
there are nine DDx for prolonged QT…how many can you name?
antiarrythmics antibiotics antipsychotics antidepressants antiemetics
ischemia
hypokalemia
hypomagnesemia
hypocalcemia
Ninja Nerd MASTER EKG video:
what are four DDx for left axis deviation?
L BBB
LVH
inferior MI
hyperkalemia
Ninja Nerd MASTER EKG video:
what are four DDx for right axis deviation?
R BBB
RVH
anterior MI
VTach
Ninja Nerd MASTER EKG video: what are three DDx for EXTREME right axis deviation?
extreme RVH
VTach
severe obesity
Ninja Nerd MASTER EKG video:
How do we define ST segment elevation?
1 mm of elevation from isoelectric line in any two contiguous leads except V2 or V3, where it’s 2 mm of elevation
Ninja Nerd MASTER EKG video:
How do we define ST segment depression?
if the J point is >= 0.5 mm below isoelectric line in any two contiguous leads
Ninja Nerd MASTER EKG video:
what benign condition may be present if we see ST segment elevation (ST-E) and a J wave on the EKG?
benign early repolarization (add the proper leads to the question) (??)
Ninja Nerd MASTER EKG video:
In which conditions do you see a J wave?
benign early repolarization
hypothermia
hyperkalemia
Brugada syndrome
Ninja Nerd MASTER EKG video:
where are t wave inversions seen as a normal variant?
V1
V2
III
Ninja Nerd MASTER EKG video:
how many mm below the isoelectric line have to be T wave inversions to meet criteria of T wave inversion
1 mm
What is Wellens A criteria? Why is this important?
V2/V3 biphasic T waves beginning with a positive deflection followed by a negative deflection
don’t know why it’s important
Ninja Nerd MASTER EKG video:
what does R wave progression mean?
progressively increasing amplitude of R waves from V1-V6
Ninja Nerd MASTER EKG video:
what might you be concerned about if you note a dominant R wave (where the R wave is > than S wave) in V1-V3?
posterior MI
RBBB
RVH
Ninja Nerd MASTER EKG video:
What is another name for a J wave?
Osborn wave
Strong Med Lesson 3:
Three ways to assess technical quality of CXR in terms of rotation
1) crooked pt?
2) ensure lung apices are visible above clavicles
3) ensure vertebral spinous processes bisect the distance b/w the medial ends of the clavicles
Strong Med Lesson 3:
one way to assess technical quality of CXR in terms of adequate inspiration
make sure 9-10 posterior ribs are visible
Strong Med Lesson 3:
one way to assess technical quality of CXR in terms of exposure/penetration
identify thoracic vertebrae
Strong Med Lesson 3:
what are three consequences of inadequate inspiration
long volume appears falsely low
lung markings are falsely prominent, giving false appearance of pulm edema
cardiac silhouette/mediastinum appear falsely enlarged
Strong Med Lesson 3:
what are two consequences of a crooked pt/film
costophrenic angles are not visible
gastric air bubble, or intraperitoneal free air, not visible
Strong Med Lesson 1:
What determines SHADOW?
density
thickness
duration of exposure
Strong Med Lesson 1:
short exposures are______
UNDERexposed, too bright
Strong Med Lesson 1:
long exposures are ____
OVERexposed, too dark
Strong Med:
which three factors determine exposure?
duration of exposure
energy of photons
source-to-image distance
Strong Med:
name the fissures, whether visible on xray or not:
R Lung L Lung
horizontal oblique
oblique
Mr Johnson:
what if you cannot see pleural lines on CXR?
nothing, it’s normal
Strong Med:
what two characteristics of tissue determine brightness of shadow?
density and thickness
Strong Med:
what are four aspects of a systematic approach?
1 - the less-experienced clinicians need a system
2 - the system should include all aspects of a CXR
3 - the system should be logical and/or easy to remember
4 - always start with the eval of the CXR technical quality
Strong Med:
what bones are visible on CXR?
ribs
clavicles
vertebral bodies
sternum
Strong Med:
what features of the cardiac structures are visible on CXR?
RIGHT:
ascending aorta
R pulm artery
R atrium
LEFT: aortic arch window L pulm artery L atrium L ventricle descending aorta
Strong Med:
what are the ABCDEF’s of the systematic approach?
A = airways B = bones & soft tissue C = cardiac silhouette and mediastinum D = diaphragm & gastric bubble E = effusions (i.e. pleural) F = fields (lung) and findings (lines, tubes, devices)
Strong Med Lesson 6:
what size of pneumothorax is classified as “small”?
2 cm
Strong Med Lesson 6:
define the deep sulcus sign
a very pronounced costophrenic angle/sulcus
Strong Med Lesson 6:
What is subcutaneous air?
subcutaneous = tissue beneath skin emphysema = "trapped air"
air that leaks from chest cavity, often found in chest, neck, face; it travels along the fascia
Strong Med Lesson 6:
describe how pleural effusion looks on CXR?
blunting of posterior costophrenic angle on lateral view
fluid may track up the pleura
Strong Med Lesson 6:
define subpulmonic effusion
fluid accumulation b/w lung base and diaphragm which does not track up the pleura, does not blunt costophrenic angle
Strong Med Lesson 6:
describe how subpulmonic effusions appear
1 - diaphragm appears to peak more lateral than normal
2 - diaphragm appears more horizontal than normal
3 - on L: abnormally large distance b/w gastric bubble and lung base
4 - on R: abnormally high horizontal fissure
Strong Med Lesson 5:
how do you recognize R ventricular enlargement on lateral CXR?
the R ventricle fills the retrosternal space
Strong Med Lesson 5:
define double density sign
enlarged L atrium stretching over the R atrium
Strong Med Lesson 5:
what usually causes the splaying of the carinal angle?
lymphadenopathy
Strong Med Lesson 5:
what is an “increased AP diameter”
COPD barrel chest
Strong Med Lesson 5:
what are two signs of pericardial effusion?
water bottle sign
oreo cookie sign
Strong Med Lesson 5:
what size defines a widened mediastinum?
> 8 cm
Strong Med 5:
what usually causes widened mediastinum?
technical errors, sign of a suboptimal CXR
three of them are:
rotation
poor inspiratory effort
AP view
Strong Med Lesson 5:
what usually causes widened mediastinum?
technical errors, sign of a suboptimal CXR
three of them are:
rotation
poor inspiratory effort
AP view
Strong Med Lesson 5:
what are three causes of hilar enlargement?
maliignancy
infection
other
Strong Med Lesson 5:
name the four regions of the mediastinum?
anterior
superior
middle
posterior
Strong Med Lesson 4:
what are three causes that a trachea is deviated in the opposite direction?
pleural effusion
large mass
pneumothorax
Strong Med Lesson 4:
what are three causes that a trachea is pulled in the ipsilateral direction?
collapsed lung (atelectasis)
lobectomy/pneumonectomy
fibrosis
Strong Med Lesson 4:
define a cervical rib
an extra rib that arises from the 7th cervical vertebrae
Strong Med Lesson 4:
what can result from a cervical rib
cervical ribs can cause thoracic outlet syndrome
Strong Med Lesson 6:
how do loculated pleural effusions look?
found in unusual locations that defy gravity
won’t shift when pt lays in lat decubitus position
Strong Med Lesson 5:
what is the hilum overlay sign?
if pulmonary vessels are visible THROUGH a mass, then
the mass is not in the hilum
(a hilar mass would obscure the pulmonary vessels)
Strong Med Lesson 7
what are four reasons for “reduced lung volume” on CXR?
poor inspiratory effort
suboptimal timed exposure
restrictive lung disease
subpulmonic effusions
Strong Med Lesson 7:
what are two categories of diffuse lung opacities?
alveolar opacities (aka "airspace opacities") interstitial opacities
Strong Med Lesson 7:
what is one reason for cardiogenic pulm edema (causing alveolar opacities)?
any cause of congestive heart failure
Strong Med Lesson 7:
what are two reasons for NON-cardiogenic pulm edema (causing alveolar opacities)?
acute lung injury (ALI)
acute resp distress syndrome (ARDS)
Strong Med Lesson 7:
what are two causes of alveolar opacities without edema?
multilobar pneumonia
diffuse alveolar hemorrhage
Strong Med Lesson 7:
what are three types of interstitial opacities?
reticular
nodular
reticulonodular
