Cardiac Monitoring (Cornelius) Exam 1 Flashcards
Which of the following describes the configuration of bipolar limb leads?
A) One positive electrode and two negative electrodes
B) Two positive electrodes
C) One positive electrode and one negative electrode
D) No electrodes
C) One positive electrode and one negative electrode
Slide 3
Which of the following is a characteristic of augmented limb leads?
A) They use bipolar electrodes.
B) They use unipolar limb leads.
C) They do not require a positive electrode.
D) They measure electrical activity from the chest only.
B) They use unipolar limb leads.
Slide 4
In augmented limb leads, the lead labeled aVR corresponds to the positive electrode placed on the:
A) Left arm
B) Right arm
C) Left leg
D) Right leg
B) Right arm
Slide 4
In augmented limb leads, the lead labeled aVF corresponds to the positive electrode placed on the:
A) Left foot (leg)
B) Right arm
C) Left arm
D) Right foot (leg)
Correct Answer:
A) Left foot (leg)
Slide 4
In augmented limb leads, the lead labeled aVL corresponds to the positive electrode placed on the:
A) Right arm
B) Left arm
C) Right leg
D) Left leg
B) Left arm
Slide 4
Where is V1 placed during precordial lead placement?
A) Left fourth intercostal space at the midclavicular line
B) Right fourth intercostal space at the sternal border
C) Left fifth intercostal space at the midaxillary line
D) Right second intercostal space at the sternal border
B) Right fourth intercostal space at the sternal border
Slide 5
Where is V2 placed during precordial lead placement?
A) Left fourth intercostal space at the sternal border
B) Left fifth intercostal space at the midaxillary line
C) Right fourth intercostal space at the sternal border
D) Left fourth intercostal space at the sternal border
D) Left fourth intercostal space at the sternal border
Slide 5
Where is V3 placed during precordial lead placement?
A) Left fourth intercostal space above V5
B) Midway between V2 and V4 in the fourth rib space
C) Midway between V2 and V4 in the fifth rib space
D) Left fourth intercostal space at the midaxillary line
C) Midway between V2 and V4 in the fifth rib space
Slide 5
Where is V4 placed during precordial lead placement?
A) Left fifth intercostal space at the midclavicular line
B) Left fourth intercostal space at the sternal border
C) Right fourth intercostal space at the sternal border
D) Left fifth intercostal space at the midaxillary line
A) Left fifth intercostal space at the midclavicular line
Slide 5
Where is V6 placed during precordial lead placement?
A) Left fifth intercostal space at the midclavicular line
B) Left fifth intercostal space at the midaxillary line
C) Left fourth intercostal space at the sternal border
D) Right fourth intercostal space at the sternal border
B) Left fifth intercostal space at the midaxillary line
Slide 5
Which lead is most commonly used for continuous EKG monitoring in clinical settings?
A) Lead I
B) Lead II
C) aVR
D) V4
B) Lead II
Cornelius -V1 or V2 may be beneficial or even V5 depending on what’s going on with your patient… multi -lead monitoring will help keep an eye on all the different aspects of the heart.
Slide 6
A 12-lead EKG is useful for identifying which of the following conditions? (Select 3)
A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections
D) Pulmonary embolism
E) Monitoring electrolyte levels
A) Cardiac damage
B) Conduction delays in the heart
C) Cardiac infections
Slide 7
Which leads are primarily used to evaluate the inferior wall of the heart?
A) Lead I, aVL
B) Lead II, Lead III, aVF
C) V1, V2
D) V5, V6
B) Lead II, Lead III, aVF
Slide 8
Which leads primarily monitor the anterior surface of the heart?
A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) V5, V6
C) V3, V4
Slide 8
If you are concerned about septal wall damage, which leads would be most useful for evaluation?
A) V1, V2
B) Lead II, Lead III, aVF
C) V3, V4
D) Lead I, aVL
A) V1, V2
Slide 8
Which leads are most useful for monitoring the high lateral wall of the heart?
(Select 2)
A) V5
B) V6
C) Lead I
D) aVF
E) aVL
C) Lead I
E) aVL
V5 and V6 are lateral but not HIGH lateral
Slide 8
What is the minimum change in contiguous leads that is typically considered significant in evaluating ischemia or infarction?
A) 1 mm
B) 2 mm
C) 3 mm
D) 4 mm
B) 2 mm
Slide 8
When following the “turn signal rule” for bundle branch blocks, an upright QRS complex in V1 at the J point is indicative of which type of bundle branch block?
A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay
B) Right bundle branch block (RBBB)
Slide 9
When following the “turn signal rule” for bundle branch blocks, a downward QRS complex in V1 at the J point is indicative of which type of bundle branch block?
A) Left bundle branch block (LBBB)
B) Right bundle branch block (RBBB)
C) Left posterior fascicular block
D) Nonspecific intraventricular conduction delay
A) Left bundle branch block (LBBB)
Slide 10
Which of the following EKG characteristics is indicative of right atrial hypertrophy (RAH)?
A) Notched P wave in lead V1
B) Initial component of the P wave larger in V1
C) M-shaped P wave in lead II
D) Inverted T wave in limb leads
B) Initial component of the P wave larger in V1
Slide 11
A P wave height greater than how many millimeters in any limb lead suggests right atrial hypertrophy (RAH)?
A) 1.5 mm
B) 2.0 mm
C) 2.5 mm
D) 3.0 mm
C) 2.5 mm
slide 11
Which component of the P wave in lead V1 is larger in left atrial hypertrophy LAH?
A) Initial component
B) Terminal component
C) Entire P wave
D) QRS complex
B) Terminal component of diphasic P in V1 larger
Slide 12
P-waves for lead II and Lead VI are shown below. What would be indicated by this EKG waveform?
A) Notched P wave in lead V1
B) Right atrial hypertrophy
C) M-shaped P wave in lead II
D) Bi-atrial enlargement
Bi-atrial enlargement
Slide12
Right ventricular hypertrophy (RVH) is characterized by smaller R waves and more depolarization toward which lead?
A) V6
B) Lead II
C) V1
D) aVR
C) V1
Cornelius - *Be mindful of your QRS changes for V1, especially if you have RVH, and when we start worrying about patients with concentric hypertrophy, *
Slide 13
Which precordial lead shows a large R wave that is indicative of left ventricular hypertrophy?
A) V1
B) V3
C) V5
D) V6
C) V5
Slide 14
Which of the following EKG characteristics is indicative of left ventricular hypertrophy (LVH)?
A) Small R wave in V5
B) Large S wave in V1
C) Small S wave in V1
D) R wave progression through V1-V3
B) Large S wave in V1
Slide 14
What is the combined depth of the S wave in V1 and the height of the R wave in V5 used to diagnose LVH?
A) 25 mm
B) 30 mm
C) 35 mm
D) 40 mm
C) 35 mm
Slide 14
Which of the following EKG findings is most indicative of myocardial ischemia?
A) Elevated ST segment
B) Inverted, symmetrical T wave
C) Deep Q waves
D) Peaked T waves
B) Inverted, symmetrical T wave
Starts with reduced supply of O2 from the coronary arteries
Slide 15
What EKG finding is most indicative of an acute myocardial “acute injury”?
A) Inverted T waves
B) ST segment elevation
C) Deep Q waves
D) Widened QRS complex
B) ST segment elevation
Slide 16
Which EKG finding is most indicative of a past myocardial infarction (Transmural)?
A) ST segment elevation
B) Inverted T waves
C) Deep, significant Q waves
D) Shortened PR interval
C) Deep, significant Q waves
Slide 17
For a Q wave to be considered significant and indicate an old infarction, it must be at least how wide?
A) 0.5 mm
B) 1 mm
C) 2 mm
D) 1.5 mm
B) 1 mm
Slide 17
What other criteria, in addition to being at least 1 mm wide, must be met for a Q wave to signify an old infarction?
A) Must be at least 1/3 the height of the QRS complex
B) Must be present in all precordial leads
C) Must be present in only one lead
D) Must be present only in limb leads
A) Must be at least 1/3 the height of the QRS complex
and 2 related leads
slide 17
What is the primary indication for the use of an artificial cardiac pacemaker?
A) Treatment of ventricular fibrillation
B) Correction of disturbances
C) Management of hypertrophic cardiomyopathy
D) Prevention of atrial fibrillation
B) Correction of disturbances in cardiac impulse conduction
Elderly….SSS
Anti-bradycardic treatment
Slide 19
Which of the following are components of an artificial cardiac pacemaker? (Select 2)
A) Pulse generator
B) Electrode leads
C) Defibrillator paddles
D) Electrode generator
A) Pulse generator
B) Electrode leads
Slide 19
Which of the following is not an example of an artificial cardiac pacemaker?
A) Transthoracic pacemaker
B) Transvenous pacemaker
C) Transverse pacemaker
D) Transcutaneous pacemaker
C) Transverse pacemaker
Slide 19
What is the primary function of the generator in a pacemaker system?
A) To detect heart rate
B) To transmit electrical impulses
C) To provide energy and electrical circuits
D) To monitor pacemaker battery life
C) To provide energy and electrical circuits
Slide 20
Which part of the pacemaker is the insulated wire that connects the generator to the heart?
A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire
B) Lead
Slide 20
Which part of the pacemaker that comes into contact with the actual heart?
A) Electrode
B) Lead
C) Pulse generator
D) Grounding wire
A) Electrode
Cornelius - that’s where the energy is actually gonna be exposed to the heart itself, the lead goes down to the electrode from the generator and then the electrodes actually contacts the heart.
Slide 20
What is the difference between unipolar and bipolar electrodes in pacemaker systems?
A) Unipolar electrodes provide lower sensitivity to electromagnetic interference (EMI)
B) Unipolar electrodes are used for temporary pacing, and bipolar electrodes are permanent
C) Bipolar electrodes use the heart as a ground, while unipolar does not
D) Unipolar electrodes use more energy, and bipolar electrodes use less energy
D) Unipolar electrodes use more energy, and bipolar electrodes use less energy
Unipolar electrodes - neg electrode in chamber; positive electrode (grounding)
More sensitive to Electromagnetic interference (EMI)
Bipolar electrodes - both electrodes in chamber being paced
Slide 20
True or False
Bipolar electrodes are the most common pacemaker
True
Slide 20
Which of the following best describes a multipolar pacemaker system?
A) A system with multiple generators in one device
B) A system with one lead and multiple electrodes in different chambers
C) A pacemaker that uses external grounding for pacing
D) A pacemaker system designed for short-term use only
B) A system with one lead and multiple electrodes in different chambers
Cornelius - *You may also see that you use multiple electrodes. So for instance sometimes we’ll see leads that will go across the septum. So you may have like biatrial electrodes or you may have biventricular electrodes. *
Slide 20
What does Roman numeral I in the pacemaker code represent?
A) Chamber(s) paced
B) Chamber(s) sensed
C) Response to sensing
D) Rate modulation
A) Chamber(s) paced
Cornelius - you may have an atrial pacemaker, you may have a ventricular pacemaker, or you may have dual AV pacemakers, or you may have no pacers, not programmed at all.
Slide 21
What does Roman numeral II in the pacemaker code represent?
A) Multisite pacing
B) Chamber(s) sensed
C) Chamber(s) paced
D) Response to sensing
B) Chamber(s) sensed
Cornelius - *instead of it being a non -demand device, it’s actually on demand…it pays attention to see what the patient’s heart rate is, and then it determines its response.
Especially with ventricular pacemakers, where it’s just set for a default rate at a round number like 60, 70, or 80. So, if you’re looking at somebody and you see that they’ve got a big, wide QRS and it’s kind of that clock regular rate of like 60, 70, or 80, be very suspicious that they may have a pacemaker, even if you don’t see pacer spikes.
*
Slide 21
What does Roman numeral III in the pacemaker code represent?
A) Chamber(s) paced
B) Multisite pacing
C) Response to sensing
D) Rate modulation
C) Response to sensing
Cornelius - *What this means is that everything can be programmed differently depending on the device.
I - Inhibit - Sometimes there’s nothing done differently when it senses. If you have an inhibit, the pacemaker senses that there’s a traditional or a spontaneous depolarization, it will not activate, so the pacemaker doesn’t do anything.
T - Trigger - You may have a patient that falls outside of the set parameters, maybe they become bradycardic, so then the device will trigger.
D - Dual - You may have dual, which means it’s capable of doing both. The dual is the most common that you’re going to see as far as like response to sensing
Slide 21
What does Roman numeral IV in the pacemaker code represent?
A) Rate modulation
B) Chamber(s) paced
C) Multisite pacing
D) Chamber(s) sensed
A) Rate modulation
Cornelius - Rate modulation may mean that it is able to adapt a little bit.
That’s not very common. Usually, if you see that, it’s more in response to like overdrive pacing.
Slide 21
What does Roman numeral V in the pacemaker code represent?
A) Chamber(s) sensed
B) Response to sensing
C) Multisite pacing
D) Rate modulation
C) Multisite pacing
Cornelius - The last one is if you have multiple locations where it’s able to pace. So is it like by atrial, by ventricular, or is it both atria and ventricular
Slide 21
What happens when a pacemaker is inhibited?
A) The pacemaker discharges if intrinsic activity is sensed.
B) The pacemaker discharges regardless of intrinsic activity.
C) The pacemaker does not discharge if intrinsic activity is sensed.
D) The pacemaker paces at a default rate.
C) The pacemaker does not discharge if intrinsic activity is sensed.
Slide 22
Which setting allows a pacemaker to discharge only during testing of the device?
A) Inhibited
B) Triggered
C) Rate modulation
D) Multisite pacing
B) Triggered
Cornelius - They may be inhibiting/triggering to demonstrate that it’s able to pace. They use medications to alter the heart rate.
You may also see that they will increase the patient’s heart rate just to prove that they can do it and they have good capture
Slide 22
What factors can influence rate modulation in a pacemaker?
(Select all that apply-4)
A) Motion
B) Intrinsic atrial depolarization
C) Vibration
D) Heart rate only
E) Minute ventilation
F) Right ventricular pressure
G) Left ventricular pressure
A) Motion
C) Vibration
E) Minute ventilation
F) Right ventricular pressure
Cornelius - modulation is like an artifact setting, they may be able to use that to determine the patient’s heart rate actually hasn’t increased and its just artifact. You can separate out the real QRS complexes from the artifact. You may see that there’s some modulation settings in there where they’re able to kind of tailor that for the patient.
Slide 22
Which condition is multisite pacing most commonly used for?
A) Atrial fibrillation
B) Cardiomyopathies
C) Bradycardia
D) AV block
B) Cardiomyopathies
Cornelius - The biggest thing we’re seeing with as far as multisite pacing is gonna be ventricular pacers for people with like horrible dilated cardiomyopathies.
You will occasionally see it for AFib, but Bi -V is the most common one that we do see.
Slide 22
What type of pacemaker is represented by an atrial impulse followed by a ventricular pacer spike and QRS complex? (B in the picture)
A) Atrial sequential pacemaker
B) Ventricular pacemaker
C) Atrioventricular sequential pacemaker
D) Dual chamber pacemaker
Correct Answer: B) Ventricular pacemaker
Cornelius - the atria is still working normally on its own, but the ventricles aren’t working. So you see that pacer spike and then the big QRS complex that follows it.
Slide 23
Which pacemaker type generates both atrial and ventricular spikes followed by corresponding depolarizations? (C in the picture)
A) Single chamber pacemaker
B) Ventricular sequential pacemaker
C) Atrioventricular sequential pacemaker
D) Atrial sequential pacemaker
C) Atrioventricular (AV) sequential pacemaker
Cornelius - there’s an atrial spike and then the atrial impulse is the atria depolarized. And then you have a ventricular spike and then a ventricular depolarization.
Slide 23
Which of the following are important considerations for perioperative care of patients with pacemakers? (Select 3)
A) Turn off the pacemaker during surgery
B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively
D) Turn the filter off on the cardiac monitor
E) Use monopolar electrocautery near the pacemaker
F) Place a magnet on the patients chest over the heart
B) Ensure the grounding pad is placed distant from the pacemaker
C) Interrogate the pacemaker pre- and post-operatively - NOT routinely done anymore or required
D) Turn the filter off on the cardiac monitor - there’s usually a pacer setting on the cardiac monitor…be familiar with whatever the kind of functionality of your monitor is. Some do it automatically. Some you have to do it manually
Slide 24
True or False
Monopolor Cautery is safe to use with patients with cardiac pacemakers
FALSE
Bipolar Cautery is safer to use with cardiac pacemakers
Cornelius - you want to try and avoid putting the grounding pad anywhere near it. You also want to try and avoid using monopolar electroconrading anywhere near the device if possible
Slide 24
What might happen if you place a magnet on an older pacemaker device?
A) It will deactivate the pacemaker
B) It will change the pacemaker to a non-demand mode
C) It will increase the heart rate to 100 bpm
D) It will trigger defibrillation
B) It will change the pacemaker to a non-demand mode
Cornelius - Historically putting a magnet on a device would put it into a non -demand mode So it would just go to a regular rate of 60 70 or 80 depending on what the backup programming was for.** Some newer devices don’t do that**, so just be very cautious
Slide 24
What chambers are paced with a BiV pacemaker?
A) Right atrium and both ventricles
B) Left atrium and both ventricles
C) Both atria only
D) Both ventricles only
A) Right atrium and both ventricles *(trans-septal) *
C - *one lead that goes into the right atrium and then you’ll have a lead that goes into each ventricle…it goes through the septum *
Slide 25
What is the purpose of BiV pacing in pacemakers?
A) Increase heart rate
B) Improve RV-LV activation time
C) Reduce atrial fibrillation
D) Provide electrical shocks during arrhythmias
B) Improve RV-LV activation time
C - to increase the patient’s cardiac resynchronization (CRT), so the right and left ventricle are working and increasing EF % and improving CO.
Historically these people have bad cardiomyopathy and as a result of that the impulses are delayed as they transmit. They’re pretty dependent on pacemakers…somebody that can’t go without having their pacemaker on. Putting then in non -demand mode is probably fine for them because they’re gonna default to something that’s adequate, but be very cautious about turning these devices off or manipulating them
Slide 25
Which of the following methods is NOT used to provide anesthesia for pacemaker placement?
A) Cervical plexus block
B) Sedation
C) Topical
D) Local infiltration
E) Periclavicular block
F) General Anesthesia
C) Topical
C- You can put the patient under general anesthesia… but a lot of times, because they’re so sick, we do sedation and a local. Sometimes we’ll a periclavicular block. Sometimes we’ll do like a cervical plexus block .It really just depends on where they’re putting the device in the surgeon may just infiltrate with local
Slide 25