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2-General Anesthesia Exam 2 > ECG Monitoring > Flashcards

ECG Monitoring Flashcards

1
Q

Review practice standards.

A

Slide 2

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2
Q

On a rhythm strip how many seconds is a small box?

A

0.04 seconds

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3
Q

On a rhythm strip how many seconds is a medium (5 small box) box?

A

0.20 seconds

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4
Q

What is the height of the medium box (5 small boxes)?

A

0.5 mV

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5
Q

How many seconds makes a true strip?

A

6 seconds

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6
Q

Interpret rhythm strip image.

A

Slide 6

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7
Q

What are the difference waves that make up an ECG?

A

represent the sequence of depolarization and repolarization of the atria and ventricles

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8
Q

The ECG is recorded at a speed of _______.

A

25 mm/sec

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9
Q

Each small 1-mm square represents ________ in time and _______

A

0.04 sec (40 msec), 0.1 mV in voltage.

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10
Q

Identify the P wave. What does it represent?

A

Represents depolarization of the atria as the electrical impulse moves from the SA node to the atria.

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11
Q

How can the atrial rate be calculated?

A

by determining the time interval between the p waves.

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12
Q

Identify the P wave. What is the normal P wave distance in seconds?

A

Normal 0.08 - 0.10s.

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13
Q

Identify the P-R interval. What occurs in the P-R interval?

A

The period of time from the onset of the P wave to the beginning of the QRS complex. The PR Interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization.

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14
Q

Identify the P-R interval. What is the normal PR interval?

A

Normal 0.12 – 0.20s

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15
Q

Identify the QRS complex. What is occuring during this?

A

Represents ventricular depolarization

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16
Q

Identify the QRS complex. What is the normal length of the QRS complex?

A

Normal 0.06 – 0.10s.

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17
Q

How is the ventricular rate determined?

A

can be calculated by determining the time interval between QRS complexes

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18
Q

What effects the shape of the QRS complex?

A

changes depending on which leads are being viewed.

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19
Q

Identify the ST segment. What is occuring here?

A

The isoelectric period following the QRS complex. This is the time at which the entire ventricle is depolarized.

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20
Q

Identify the T wave. What is occuring here?

A

Represents ventricular repolarization, which is longer in duration than depolarization

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21
Q

What is a U wave? What does it represent?

A

Sometimes a small positive U wave may be seen following the T wave (not shown). This wave represents the last remnants of ventricular repolarization

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22
Q

Identify the QT interval. What is occuring here?

A

Represents the time for both ventricular depolarization and repolarization to occur.

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23
Q

What effect does high heart rates have on the QT interval?

A

ventricular action potentials shorten in duration, which decreases the Q-T interval.

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24
Q

What is true about the Q-T interval in clinical practice?

A

In practice, the Q-T interval is expressed as a “corrected Q-T (QTc)” by taking the Q-T interval and dividing it by the square root of the R-R interval (interval between ventricular depolarizations

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25
Q

What is the correct Q-T (QTC) allow for assessment of?

A

This allows an assessment of the Q-T interval that is independent of heart rate

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26
Q

What is the normal corrected Q-Tc intervals?

A

are less than 0.44 seconds.

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27
Q

What is the J point?

A

denotes the junction of the QRS complex and the ST segment on ECG marking the end of depolarization and beginning of repolarization

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28
Q

Where does repolarization phase start?

A

•at the junction, or j point and continues until the T wave

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29
Q

What is the location of the ST segment?

A

The ST segment is normally at or near the baseline

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30
Q

What are the six steps to rhythm strip interpretation?

A
  1. Is the overall rhythm regular or irregular
  2. What is the atrial and ventricular heart rate (HR)
  3. What is the appearance of the P wave?
  4. Are the P-R intervals of normal duration and are they fixed?
  5. Based upon the response to question four, it can be determined if a relationship exists between the p wave and the adjacent QRS complex
  6. What is the appearance of the QRS complex?
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31
Q

What needs to be determined if the rhythm is irregular?

A

is it due to premature beat(s), a delay in the conduction of impulses, or due to an irregular discharge from the primary pacemaker source?

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32
Q

What needs to be determined about the appearance of the P wave?

A

Assess for the origin of atrial depolarization

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33
Q

The p wave is __________ in lead 2 when it originates from the SA node.

A

upright

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34
Q

The p wave is __________ in lead 2 when it originates from the A-V node.

A

Inverted

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35
Q

What can be assumed about 1:1 ventricular conduction?

A

present (p waves conduct adjacent QRS complexes) whenever P-R intervals measure out to be the same (are fixed).

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36
Q

What does a narrow QRS complex means?

A

the beat originated above the ventricles (it was supraventricular

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37
Q

What is true about the QRS if it is wide?

A

it originated in the ventricle (e.g. PVC) or above the ventricle (supraventricular with aberrant ventricular conduction – looks like a PVC but is not

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38
Q

Where do junctional rhythms originate?

A

the SA node is not the origin of the electrical activity of the heart – the atrio-ventricular (AV) node is.

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39
Q

What two junctional rhythms will we look at in regard to this course?

A

There are multiple types of junctional rhythms. We will look at two – junctional escape and junctional tachycardia.

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40
Q

What is true regarding the treatment of junctional rhythms?

A

Treatment for either of these junctional rhythms is rarely needed. If either rhythm is noted, assess patient stability and monitor.

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41
Q

Identify the rhythm and if it is regular or irregular.

A

Junctional Escape

  • Rhythm: Regular
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42
Q

What are the typical rates for junctional escape?

A
  • 40-60bpm
  • 60-100bpm (accelerated)
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43
Q

Identify the rhythm. Describe the P waves, PR interval and QRS complex characteristics of this rhythm.

A

Junctional Escape

  • P waves: Inverted before or after QRS or not visible
  • PR Interval: <0.12sec when inverted p is before QRS
  • QRS: 0.04 – 0.10 second
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44
Q

Identify this rhythm. What are causes of this rhythm (9)?

A

Junctional Escape

  • Healthy athlete at rest
  • Related to medications
  • Increased parasympathetic tone
  • Acute inferior wall MI
  • Rheumatic heart disease
  • Post-cardiac surgery
  • Valvular disease
  • SA node disease
  • Hypoxia
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45
Q

What are some medications that can cause this rhythm (3)?

A

Junctional Escape

  • beta blockers
  • calcium channel blockers
  • digitalis toxicity
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46
Q

Identify this rhythm and if it is regular or irregular.

A

Junctional Tachycardia

  • Rhythm: Regular
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47
Q

What is the characteristic rate of this rhythm?

A

Junctional Tachycardia

  • Rate: 101-200bpm
48
Q

Identify this rhythm. Describe the characteristic of the P waves, PR interval and QRS complex with this rhythm.

A

Junctional Tachycardia

  • P waves: Inverted before or after QRS or not visible
  • PR Interval: <0.12sec when inverted p is before QRS
  • QRS: 0.04 – 0.10 second
49
Q

Identify potential causes of this rhythm. (7)

A

Junctional Tachycardia

  • Normal
  • Excessive use of caffeine, alcohol or tobacco
  • CHF
  • Myocardial ischemia or injury
  • Hypokalemia, digitalis toxicity
  • COPD
50
Q

Identify this rhythm and if it is regular or irregular.

A

1st Degree AV Block

  • Regular
  • This rhythm looks very similar to NSR. For every p wave, there is a QRS that follows.
51
Q

When does this rhythm occur?

A

1st Degree AV Block

  • 1st degree AV block occurs when there is a conduction delay in the AV node.
52
Q

Identify this rhythm. What is the key component to identifying this rhythm?

A

1st Degree AV Block

  • The key to identifying this rhythm is the prolonged PR interval. The PR interval for this rhythm is >0.20 second, but not >0.40 second (normal PR interval 0.12-0.20 seconds).
53
Q

What are some causes of this rhythm? (6)

A

1st Degree AV Block

  • Enhanced vagal tone (for example in athletes)
  • Myocarditis
  • Acute MI (especially acute inferior MI)
  • Electrolyte disturbances
  • Medications
54
Q

What are some medications that could cause this rhythm (4)?

A

1st Degree AV Block

  • calcium channel blockers
  • beta blockers
  • cardiac glycosides
  • cholinesterase inhibitors
55
Q

Describe the treatment plan for this rhythm.

A

1st Degree AV Block

  • identifying any underlying electrolyte imbalances and/or medications that may be causing the conduction delay.
56
Q

Does treatment of this rhythm require hospital admission?

A

1st Degree AV Block

  • Typically this arrhythmia does not require hospital admission unless there is an underlying MI
57
Q

Will this rhythm progress to heart block?

A

1st Degree AV Block

  • This arrhythmia does not usually have any significant clinical consequences, and except in very rare circumstances, does not progress to complete heart block.
58
Q

Identify this rhythm. Describe the key characteristics that differentiate it from NSR.

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • There are more p waves than QRS’s
  • The PR interval progressively increases until a p wave appears without a QRS afterwards.
  • Then the cycle begins again.
  • The R to R interval is not regular.
59
Q

What is a way to remember this rhythm?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • “Longer, longer, longer drop is found in Wenkebach”
60
Q

What are some causes of this rhythm?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • Individuals with increased vagal tone (e.g. athletes and small children)
  • Infants and children with structural heart disease (e.g. Tetralogy of Fallot)
  • Individuals who have undergone valvular heart surgery, especially mitral valve
  • MI
  • Medications
61
Q

What is the treatment for unsymptomatic patients with this rhythm?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • Unless the patient with this rhythm is symptomatic, it is unlikely that they will need hospitalization.
  • Typically patients noted to have this rhythm will be referred to a cardiologist on an outpatient basis.
62
Q

What is the treatment for this rhythm if a MI is the suspected underlying cause?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • Patients with suspected underlying myocardial ischemia causing the dysrhythmia should be treated with an appropriate anti-ischemic regimen.
63
Q

What should avoided in a patient with this rhythm?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • AV nodal blocking agents (e.g. beta blockers) should be avoided in these patients.
64
Q

What is the treatment for symptomatic patients with this rhythm?

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • Symptomatic patients may be treated with transcutaneous pacing and/or atropine.
  • Extreme caution should be used in administering atropine if patient is suspected to have myocardial ischemia as ventricular dysrhythmias may occur.
65
Q

What are key components to the differientation of this rhythm with NSR?

A

2nd Degree AV Block/Mobitz Type II

  • The key to identifying this rhythm is the recognition of unexpected nonconducted atrial impulses.
  • Simply put, there are p waves without QRS’s following them.
66
Q

How is this rhythm different from 2nd Degree AV Block/Mobitz Type I?

A

2nd Degree AV Block/Mobitz Type II

  • This is different than Type I because the PR interval is consistent (not longer, longer, longer, drop).
67
Q

What is true about the QRS for this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • This rhythm may have either normal or widened QRS complexes.
68
Q

What are the causes of this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • Most commonly caused by an acute MI (especially anterior or inferior)
  • Medications (e.g. Beta blockers, calcium channel blockers, amiodarone, digoxin)
  • Lyme disease
69
Q

What are some medications that could cause this rhythm? (4)

A

2nd Degree AV Block/Mobitz Type I/Wenkebach

  • Beta blockers
  • calcium channel blockers
  • amiodarone
  • digoxin
70
Q

What are some medication causes of this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • Beta blockers
  • calcium channel blockers
  • amiodarone
  • digoxin
71
Q

What is the pharmacological treatment for this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • Similar to Type I patients, AV nodal medications should be avoided and an anti-ischemic regimen should be initiated if ischemia is suspected.
72
Q

What a mandatory intervention for patients with this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • dysrhythmia whether or not they are symptomatic as this rhythm can rapidly deteriorate into complete heart block.
  • The transcutaneous pacer should be tested to ensure capture.
  • If capture is not able to be achieved, then insertion of a transvenous pacer is indicated.
73
Q

What is an important consult for this rhythm?

A

2nd Degree AV Block/Mobitz Type II

  • An urgent cardiology consult is indicated for patients with symptomatic Type II and asymptomatic patients who are unable to achieve capture with transcutaneous pacing.
74
Q

What is true if you can not distiguish between type I or II AV block?

A

2nd Degree AV Block/Mobitz Type II

  • If it is unclear whether the rhythm is Type I or Type II (e.g. where every other beat is dropped) it is safest to assume a Type II block exists and the patient should be admitted.
75
Q

What is this rhythm?

A

3rd Degree AV Block/Complete Heart Block

  • This is a very significant dysrhythmia and should be identified by the caregiver immediately.
76
Q

What are the characteristics of this rhythm? (5)

A

3rd Degree AV Block/Complete Heart Block

  • In 3rd degree heart block, there is a complete dissociation of the atria and ventricle.
  • Thus, there are more p waves than QRS’s.
  • Also, the p waves are in no way related to the QRS’s.
  • The PR interval varies greatly (e.g. no pattern, but not regular).
  • The QRS complexes may appear normal or wide.
77
Q

What are some causes of this rhythm? (4)

A

3rd Degree AV Block/Complete Heart Block

  • Acute MI
  • Overdose of medications
  • Cardiomyopathy
  • Metabolic disturbances (e.g. severe hyperkalemia
78
Q

What are some medications that cause this rhythm?

A

3rd Degree AV Block/Complete Heart Block

  • •Overdose of medications (e.g. procainamide, beta blockers, amiodarone, calcium channel blockers, digoxin, etc.)
79
Q

What are the immediate steps that must be taken with this rhythm?

A

3nd Degree AV Block/Complete Heart Block

  • Immediately upon recognition of this dysrhythmia ensure the patient is receiving oxygen prn and has a patent IV.
  • Take regular blood pressures and maintain continuous cardiac monitoring.
80
Q

What should not be given with this rhythm?

A

3rd Degree AV Block/Complete Heart Block

  • AV nodal medications should be withheld and anti-ischemic therapy should be initiated when appropriate.
81
Q

What needs to be applied to the patient with this rhythm?

A

3rd Degree AV Block/Complete Heart Block

  • Transcutaneous pacing pads should be applied to the patient and tested
  • If capture cannot be achieved with transcutaneous pacing, a transvenous pacemaker should be inserted
82
Q

What is the consult that needs to be done for this 3rd degree/complete heart block ?

A

3rd Degree AV Block/Complete Heart Block

  • A cardiology consult is indicated for all patients with this dysrhythmia.
83
Q

What are some side effects of giving atropine to this rhythm?

A

3rd Degree AV Block/Complete Heart Block

  • Hemodynamically unstable patients may be treated with atropine, but if the rhythm is a wide complex escape rhythm the atropine is likely to be unsuccessful.
  • Similarly, if atropine is administered to a patient with a suspected MI, increased ventricular irritability may occur, leading to ventricular arrhythmias.
84
Q

What needs to happen to patients with this rhythm following stabilization?

A

3rd Degree AV Block/Complete Heart Block

arrangements should be made for permanent pacemaker insertion.

85
Q

Name this rhythm:

A. Normal sinus rhythm with multifocal PVC’s

B.Normal sinus rhythm with unifocal PVC’s

C.Normal sinus rhythm with PAC’s

D.Normal sinus rhythm with PJC’s

A

ANS: Normal sinus rhythm with multifocal PVC’s (A)

86
Q

Name this rhythm:

A. Normal sinus rhythm with unifocal couplet PVC’s

B.Normal sinus rhythm with multifocal PVC’s

C.Normal sinus rhythm with paced beats (from a pacemaker)

D.Sinus bradycardia with PVC’s

A

ANS: Normal sinus rhythm with unifocal couplet PVC’s (A)

87
Q

Name this rhythm

A.1st Degree AV Block

B.2nd Degree AV Block, Type I (Wenkebach)

C.2nd Degree AV Block, Type II

D. 3rd Degree AV Block / Complete Heart Block

A

B. 2nd Degree AV Block, Type I (Wenkebach)

88
Q

Name this rhythm

A.1st Degree AV Block

B.2nd Degree AV Block, Type I (Wenckebach)

C.2nd Degree AV Block, Type II

D.3rd Degree AV Block / Complete Heart Block

A

D. 3rd Degree AV Block / Complete Heart Block

89
Q

What is Pulseless electrical activity characterized by?

A
  • patient unresponsiveness and a lack of palpable pulses in the presence of organized electrical activity.
90
Q

What is the cause of PEA?

A
  • PEA is caused by the inability of cardiac muscle to generate sufficient force in response to electrical depolarization.
91
Q

What is the treatment for PEAs?

A
  • Patients in PEA should be treated as per the ACLS algorithm, with a focus on identifying the underlying cause(s) of the PEA.
92
Q

What is a way to remember causes for PEA?

A

H & T’s

93
Q

What are the H’s that can lead to pulseless electrical activity?

A
  • Hypovolemia
  • Hypoxia
  • Hydrogen Ion (Acidosis)
  • Hypo-/Hyperkalemia
  • Hypoglycemia
  • Hypothermia
94
Q

What are the T’s that cause PEA?

A
  • Toxins
  • Tamponade, cardiac
  • Tension Pneumothorax
  • Thrombosis (coronary or pulmonary)
  • Trauma (hypovolemia, increased ICP)
95
Q

What is this rhythm? What type of form is it?

A

Torsades de Pointe

  • This arrhythmia is a specific form of ventricular tachycardia with distinct characteristics.
96
Q

What is the hallmark characteristics of this rhythm?

A

Torsades de Pointe

  • The hallmark of this arrhythmia is rapid, polymorphic ventricular tachycardia twisting around an isoelectric baseline.
97
Q

When does this rhythm usually occur?

A

Torsades de Pointe

  • This is very often seen to occur in patients with a prolonged QT interval and who then prematurely conduct a beat (R on T phenomenon).
98
Q

What are the two types of causes of this rhythm?

A

Torsades de Pointe

  • Congenital prolonged QT syndromes
  • Acquired prolonged QT syndromes
99
Q

What are some aquired prolonged QT causes of this rhythm?

A

Torsades de Pointe

  • Medications
  • Cardiac conditions (e.g. MI, complete heart block)
  • Intracranial disorders (e.g. subarachnoid hemorrhage, stroke)
  • Nutritional disorders (e.g. anorexia, starvation, celiac disease
100
Q

What are the short term treatment for this rhythm?

A

Torsades de Pointe

  • Defibrillation
  • Discontinue the offending medication (if known)
  • Magnesium is the drug of choice for suppressing and terminating this arrhythmia.
101
Q

What is true regarding torsades de pointe?

A

•Although Torsades is often self limiting, it can degenerate into V Fib.

102
Q

What is the MOA of magnesium and torsades de pointe?

A

•This is achieved by decreasing the influx of calcium.

103
Q

What is the recommended magnesium dose for torsades de pointe?

A
  • Magnesium can be given at 1-2 gm IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes.
  • Alternatively, a continuous infusion can be started at a rate of 3-10 mg/min. Magnesium is effective even in patients with normal magnesium levels.
104
Q

Identify the electrolyte abnormality here. What are the characteristics? (4)

A

Hypokalemia

  • U Wave (Early Sign)
  • T wave flattened and widened
  • T wave inversion
  • ST depression
105
Q

What is an early rhythmic sign of this electrolyte abnormality?

A

Hypokalemia

  • U Waves
106
Q

What are rhythms usually associated with this electrolyte disturbances?

A

Hypokalemia

  • PVC’s, atrial or nodal tachycardia, ventricular tachycardia, ventricular fibrillation
107
Q

What T wave changes associated with hyperkalemia?

A
  • T waves narrowed and peaked
  • Early sign (K+ of 6-7mEq/L)
108
Q

What are some atrial changes associated with hyperkalemia?

A
  • P wave flattens and widens (Intra-atrial block)
  • PR prolongs then P wave disappears
109
Q

What ventricular changes are associated with hyperkalemia?

A
  • Followed by ventricular changes (K+ of 8-9mEq/L)
  • QRS widens (intra-ventricular block)
110
Q

What is the rhythm commonly seen with hyperkalemia?

A

SB → 1◦ AV Block → Junctional → Idioventricular → Asystole

111
Q

What is the treatment of hyperkalemia?

A
  • Reverse membrane effects with calcium
  • Transfer extracellular potassium into cells
  • Remove K+ from body
112
Q

What are some medications that transfer extracellular potassium into cells?

A

D10W, Sodium bicarbonate, beta-2 agonists

113
Q

What are some medications that can help remove K+ from body?

A

Proximal or loop diuretics, binding resins, HD

114
Q

What are some ECG characteristics of hypocalemia?

A
  • Long QT interval
  • ST segment elongation
  • Lowering and inversion of T wave (1/3 of cases
115
Q

What are the ECG characteristics of hypercalcemia?

A
  • Short QT interval
  • ST segment narrowing
  • Enhances early ventricular repolarization

2-General Anesthesia Exam 2 (11 decks)

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