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Complex Care > EKG > Flashcards

EKG Flashcards

1
Q

Automaticity

A

any cells in the heart can initiate an impulse

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2
Q

Contractility

A

ability to respond mechanically

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3
Q

Conductivity

A

ability to transmit an impulse

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4
Q

Excitability

A

ability to be electrical stimulated

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5
Q

Electricity in resting state

A

cardiac cells are negative on inside and positive on outside

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6
Q

Depolarization

A

When cells are stimulated by pacemaker and Na moves rapidly to the inside of the cells and K moves to the outside leading to adjacent cells depolarizing

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7
Q

Does electrical activity mean that the heart is mechanically pumping?

A

Hopefully, but not always. EKG looks at electrical conduction but that does not mean the heart is pumping

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8
Q

Why is it important that depolarization is transmitted in a coordinated fashion?

A

Its important that there is contraction at the atrium then contraction and the ventricle to maintain CO and organization

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9
Q

Where does depolarization start?

A

SA node AKA pacemaker

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10
Q

What happens if the SA node fails?

A

The AV node is the backup pacemaker

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11
Q

How fast can the AV node discharge firing?

A

40-60 beats per minute

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12
Q

Where is the SA node located?

A

right atrium

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13
Q

Electrical impulse pathway

A

SA node –> AV node –> bundle of his –> right and left branches –> purkinje fibers

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14
Q

Repolarization

A

Muscles cells will recover and restore electrical charge

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15
Q

Absolute refectory period

A

Period where cardiac muscles cannot be stimulated by any stimuli
Protective mechanism

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16
Q

What is the absolute refractory period on the ECG?

A

beginning of QRS to peak of T wave

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17
Q

Relative refractory period

A

Period where cardiac muscle will respond to a STRONG stimuli
Very vulnerable period
If you shock someone during this phase, you can send them into a lethal rhythm

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18
Q

What is the absolute refractory phase as long as?

A

As long as the contraction phase

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19
Q

Where is the relative refractory phase on an ECG?

A

Peak to the end of the T wave

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20
Q

A change in a waveform is due to

A

change in electrical current or change in a lead

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21
Q

What is an ECG used to evaluate?

A

Heart function, heart rate, ischemia, infarction, chest pain, pacemaker function and medications

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22
Q

Left to right markings represent…

A

time

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23
Q

Verticle marking represent…

A

voltage or energy

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24
Q

Small boxes represent

A

0.04 seconds

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25
Q

Large boxes represent

A

0.20 seconds

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26
Q

Line/dashes at the top of the paper represent

A

3 seconds

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27
Q

An ECG waveform is

A

group of waves that record the electrical signal as it depolarizes that heart muscle cells

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28
Q

P wave represents and looks like

A

arterial depolarization

Small, rounds and before QRS

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29
Q

PR interval is from the.. to the..

A

beginning of P wave to beginning of QRS

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30
Q

Normal PR interval time is

A

0.12 - 0.20

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31
Q

PR interval represents

A

time it takes for the original impulse to leave the SA node and travel through the AV node
Time required for partial depolarization
How well AV node is functioning

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32
Q

What is the atrial kick?

A

the brief delay at AV node that allows atria to empty and contract and it a contributor to the CO

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33
Q

What does the AV node do?

A

it acts as the gatekeeper to limit the ventricular rate

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34
Q

QRS interval is from the.. to the..

A

Beginning of the Q wave to the end of the S wave

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35
Q

Normal QRS time is

A

less that 0.12 seconds

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36
Q

What does the QRS represent?

A

ventricular contraction

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37
Q

ST segment is the

A

time between completion of ventricular contraction and beginning of repolarization

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38
Q

What is the ST segment measured by?

A

Normal = isometric
Elevation due to myocardial injury/infarction (irreversible)
Depressed due to myocardial ischemia (reversible)

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39
Q

T wave represents

A

ventricular repolarization

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40
Q

What does an inverted T wave mean?

A

any condition that interferes with normal repolarization such as ischemia or injury

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41
Q

QT interval is from the .. to the ..

A

beginning of QRS to end of T wave

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42
Q

QT interval represents

A

the total ventricular depolarization and repolarization

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43
Q

QT interval time is

A

0.34-0.43 seconds

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44
Q

What is the isoelectric line?

A

baseline, flat, straight line that connects all the curves

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45
Q

Regular rhythm

A

distance between two QRS complexes does not vary by more than 3 small boxes

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46
Q

Regular irregular rhythm

A

patten is recognized and predicted

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47
Q

Irregular irregular

A

no pattern and no periods of regularity

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48
Q

Steps to read ECG

A
  1. determine if its regular
  2. Calculate HR
  3. Examine P waves
  4. measure PR interval
  5. Measure QRS interval
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49
Q

how to do you calculate the HR by looking at ECG?

A

count number of QRS intervals and multiple by 10

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50
Q

Examine P waves include..

A

Is there any P waves absent or present
Are P waves all the same shape
Is there one P wave for every QRS?

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51
Q

Normal sinus rhythm interpretation

A 
Atrial/Ventricular rate: 60-100 bpm
Rhythm: regular
P wave: 1:1 
PR interval: normal, .12-.20 seconds
QRS complex: normal, less than 0.12 seconds
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52
Q

Sinus bradycardia

A 
Atrial/Ventricular rate: less than 50-60 bpm
Rhythm: regular
P wave: 1:1
PR interval: normal
QRS complex: normal
53
Q

Cause of sinus bradycardia

A

Normal variation in athletes, sleep. Might be associated with a disease like MI, medication, vagal maneuver

54
Q

Treatment for sinus bradycardia

A

ONLY TREAT IF SYMPTOMATIC due to decrease CO which looks like SOB, chest pain, hypotension

  1. Treat underlying cause
  2. maintain airway, assist breathing, give O2
  3. cardiac monitoring and IV access
  4. if adequate perfusion and stable, monitor patinet
  5. If s/s of poor perfusion: All Trained Dogs Eat
55
Q

What does All Trained Dogs Eat in terms of treatment for sinus bradycardia mean?

A

All: atropine
Trained: transcutaneous pacing
Dogs: dopamine
Eat: NE

56
Q

How often and how much atropine should you give?

A

0.5-1.0mg every 3-5 minutes with a max of 3.0mg

57
Q

Sinus tachycardia

A 
Atrial/Ventricular rate: between 100-150 bpm
Rhythm: regular
P wave: 1:1
PR interval: normal
QRS complex: normal
58
Q

Causes of sinus tachycardia

A

CAUSED BY EXTERNAL INFLUENCE

blood loss, fever, anxiety, medications, hypovolemia, ect

59
Q

Treatment for sinus tachycardia

A

TREAT ONLY IF SYMPTOMATIC

  1. maintain airway, assist breathing, give oxygen
  2. IV access
  3. if stable with adequate perfusion, observe
  4. Stable patient may try: diltiazam (CCB) inderal (B blocker), vagal maneuvers
60
Q

What does symptomatic look like due to decrease CO

A

Angina, hypotension, SOB, altered mental status

61
Q

Arterial dysrhythmias

A

Atrial ectopic pace making sites replace that SA node as the pacemaker
Rate of 250-400

62
Q

What keeps all the electrical impulses that the atria are conducting from getting to the ventricles?

A

The AV node

It acts as a gatekeeper and controls how many impulses reach the ventricles

63
Q

major concerns with a flutter and a fib are?

A
  1. thrombi formation due to incomplete emptying of ventricles
  2. Low CO due to loss or partial kick and ventricular rate is too fast or too slow
64
Q

What medication should someone with atrial fib or atrial flutter be on?

A

they should be on anticoagulants because a major risk is clot formation

65
Q

Atrial Flutter rate and discharge

A

Rapid discharge at a single ectopic foci
Rate of 250-400 bpm
Since the AV protection, only some get through

66
Q

Atrial flutter

A 
Atrial/Ventricular rate: Artial rate: 250-250 ventricular rate: 75-150
Rhythm: Regular but can be irregular
P wave: Saw-tooth patter called F waves
PR interval: Not mesurable
QRS complex: normal
67
Q

During atrial flutter what is the ventricular rate if it is controlled?

A

less than 100

68
Q

During atrial flutter what is the ventricular rate if it is uncontrolled?

A

over 100

69
Q

Causes of atrial flutter

A

Rarely normal, usually associated with a disease like cardiomyopathy, coronary artery disease, valvular disease and hypertension

70
Q

Treatment of atrial flutter

A

Unstable: synchronized cardioversion
Stable: looks for a cause because might not need treatment other than treating the cause. Treatment depends on how pt. tolerate the rhythm. May try chemical or electrical cardioversion.
Stable w/ high ventriculuar rate or mildly/moderately symptomatic: slow ventricular rate with medication then use chemical or electrical cardioversion

71
Q

Electrical synchronized cardioversion

A
  1. load amiodarone 150mg slow IVP (over 10 min) before cardioversion
  2. electrical impulse or current delivered to the heart during the R wave which is ventricular depolarization to allow SA node to take over again
    PLACED IN SYNC MODE with pts. R wave
    Done with sedation and analgesics
72
Q

What should you have ready at the bedside before cardioversion?

A

suction, intubation tray, crash cart

73
Q

If patient is stable with atrial dysrhythmias without clots

A

synchronized cardioversion and/or chemical cardioversion

74
Q

If patient is stable with atrial dysrhythmias with clots

A

Anticoagulate with heparin, warfarin, or lovenox before cardioversion and send home. Check TEE again in 4-6 weeks then cardioversion

75
Q

If patient is unstable with atrial dysrhythmias with or without clots

A

immediate cardioversion, no amiodarone prior to

76
Q

Patient with chronic a.fib or a.fluter with be on..

A

anticoagulant therapy indefinitely

77
Q

What is another lifelong therapy option for a patient with atrial flutter?

A

radioactive ablation

78
Q

Atrial fibrillation electrical site

A

Rapid discharge of multiple atrial ectopic foci with a rate of more than 400 per minute
Atria is twitching/fibrilating because they can’t contract effectively

79
Q

Atrial fibrillation

A 
Atrial/Ventricular rate: Atrial rate: 350-600 Ventricular rate: 100-150
Rhythm: irregularly irregular 
P wave: fibrillary f-waves
PR interval: Not measurable
QRS complex: normal
80
Q

Causes of a.fib

A

Same as a flutter

Can be d/t high alcohol intake, COPD, cardiac valve disease or CHF

81
Q

Treatment for a.fib

A

same as a flutter

82
Q

First degree AV block can be a…

A

precursor to other blocks

83
Q

Frist degree AV block

A

Atrial/Ventricular rate: normal, regular
Rhythm: regular
P wave: normal 1:1
PR interval: constant more than .20 seconds
QRS complex: normal

84
Q

Causes of a first degree block

A

lesion along the conduction pathway like calcification or necrosis, MI, myocarditis, medications like digoxin, CCB, B-blockers and frequently seen in athletes and children

85
Q

Treatment for first degree block

A
  1. monitor patient for tolerance
  2. monitor for progression to 2nd degree
  3. no treatment if patient is tolerating rhythm or has been present for a long time and rarely causes anything negative
86
Q

Second degree AV block type 1

A

Atrial/Ventricular rate: Normal/slower due to dropped QRS
Rhythm: regularly irregular
P wave:
PR interval: progressively lengthens until QRS not conducted
QRS complex: normal or wide, dropped with nonconductor P wave

87
Q

Second degree AV block type 1 PR interval

A

cyclic progressive lengthen or PR interval until atrial impulse is not conducted and QRS complex is dropped

88
Q

Second degree AV block type 1 causes

A

ischemia

89
Q

Second degree AV block type 1 treatment

A
  1. monitor patient for tolerance
  2. monitor for progression to 3rd degree
  3. no treatment if pt. is tolerating it
  4. if symptomatic atropine or temporary pacemaker
90
Q

Second degree AV block type 2

A

Atrial/Ventricular rate: normal/normla but slower due to dropped beat
Rhythm: irregular
P wave:
PR interval: constant, normal or prolonged
QRS complex: normal or wide with dropped QRS

91
Q

Second degree AV block type 2 causes

A

ischemia or heart disease

92
Q

Second degree AV block type 2 treatment:

A
  1. atropine but sometimes can increase demand on heart

2. pacemaker may be required

93
Q

Third degree block also known as

A

complete heart block where the atria and ventricles beat independently and are not communicating with each other. No impulses get through AV node

94
Q

Third degree block

A

Atrial/Ventricular rate: may or may not be normal/may or may not be normal. Vent and atria are synchronous and uncoordinated
Rhythm: Generally regular
P wave: normal
PR interval: not measured, changes randomly
QRS complex: normal or wide

95
Q

Third degree block causes

A

ischemia and heart disease

96
Q

Third degree block treatment

A
  1. symptomatic SB algorithm

2. early pacemaker

97
Q

First degree block shortened

A

constant prolonged PR, always P for each QRS

98
Q

Second degree block type 1 shortened

A

Progressively prolonged PR until a dropped QRS

99
Q

Second degree block type 2 shortened

A

Constant prolonged PR and dropped QRS

100
Q

Premature ventricular contraction in general

A

ectopic foci in ventricle cases an impulse to start a contraction before the next sinus impulse
QRS wave takes longer to conduct and is wide, bizarre and typically does not have a P wave

101
Q

Premature ventricular contraction

A

Atrial/Ventricular rate: may occur at any rate and with any basic rhythm
Rhythm: irregular due to early beats
P wave: typically none
PR interval: not present before PVC
QRS complex: wide and bizarre, more than 0.12 seconds

102
Q

Do you treat PVC?

A

Everyone has PVC but you only treat for certain scenarios or if the patient has symptoms

103
Q

What scenarios do you treat a PVC?

A
  1. occurs frequently (more than 6 times/minute)
  2. Occur on every other beat (bigeminy)
  3. Strike on a T wave of preceding beat
  4. Originate from more than 1 focus (multifocal)
  5. Occur in consecutive fashion (couplet, triplet)
  6. occur after an MI (treat for 24 hours)
104
Q

PVC causes

A

with or without cardiac disease. Most common cause is hypoxia, can be due to caffeine intake or ventricular irritability

105
Q

Treatment for PVC

A
  1. look for a cause, might be benign
  2. monitor for tolerance
  3. consider amiodarone slow IVP
106
Q

Ventricular tachycardia in general is

A

A run of 3 or more PVCs with a rate greater than 100 bmp

Orriginates from a very irritable ectopic foci in vent at 150-250 bmp

107
Q

Ventricular tachycardia

A 
Atrial/Ventricular rate: not measurable/vent 150-250bmp
Rhythm: regular
P wave: no present 
PR interval: no measurable 
QRS complex: wide and bizarre
108
Q

VT monomorphic

A

all QRS are the same

109
Q

VT polymorphic

A

QRS complexes change shape/twisting

110
Q

VT causes

A

with or without cardiac disease

Associated with cardiomyopathy, electrolyte imbalance like low K, proarrythmic medication or congenital long QT syndrome

111
Q

VT treatment with pulse

A

Medically manage with IV< O2, labs, 12 lead ECG, echo, cardiology consult, load with amiodarone and prepare for immediate cardioversion

112
Q

VT without pulse

A

treated same as V-fib, defibrillate

113
Q

Treatment of pulseless VT/V-fib

A
  1. BLS/CRP, O2, attach monitor/defibrillator
  2. Give CPR for 2 mins
  3. Give 1 shock when defibrillator is available
  4. Resume CPR, 5 cycles
  5. Give 1 shock
  6. Resume CPR, 5 cycles
  7. When IV/IO is available give vasopressor (EPI) during CPR
  8. Give 1 shock
  9. Resume CPR, 5 cycles
  10. consider anti arrhythmic like amiodarone or lidocaine, consider Mg
  11. repeat above sequence
114
Q

Ventricular fibrillation in general

A

Ventricles are fibrillating, no effective CO or contractions
Always fatal unless treated
most common cause of cardiac arrest
V-fib tends to convert to asystole

115
Q

Ventricular fibrillation rate, rhythm and waveforms

A

unable to identify due to rapid disorganized activity

116
Q

Causes of V-fib

A

heart disease, ischemia or infarction

117
Q

V-fib treatment

A

CPR, defibrillation with sync off

118
Q

Concept of defibrillation

A

shock tries to depolarize and have the natural pacemaker take back over

119
Q

Defibrillation nursing responsibilities

A
  1. Patient safety: no water or metal surfaces
  2. Apply pads: cardiac sandwich
  3. Make sure personnel are not directly or indirectly touching patient
  4. Ensure synch switch is off!
120
Q

Implantable cardioverter defibrillator

A

Surgically implanted generator that can sense intrinsic electrical activity and deliver an electrical impulse

121
Q

What patient can have a ICD

A

survived a VT or VF or sudden cardiac death
Experienced syncope with VT/VF
At high risk for VT/VF after cardiac surgery and cannot tolerate medications or ablation

122
Q

Pulseless electrical activity

A

absence of detectable pulse despite evidence of electrical activity
Usually caused vey clinical states that can by reversed if caught early
Any organized rhythm w/o pulse is PEA
Condition more than rhythm

123
Q

Causes of PEA

A
  1. Hypovolemia
  2. Hypoxia
  3. Acidosis
  4. hypo/hyper K
  5. Hypoglycemia
  6. Hypothermia
  7. Tablets/Toxins
  8. Tamponade
  9. Tension pneumothorax
  10. Thrombosis
124
Q

Treatment PEA

A

P-E begin BLS
P - search for Probable cause, Push fluids
E - Epi 1 mg IVP every 3-5 minutes, or vasopressin 40 units IVP
Cannot shock these patients

125
Q

Asystole

A

Total absence of electrical activity or CO

126
Q

Asystole treatment

A
  1. look for cause - Hs and Ts, CPR, early intubation
  2. Epi
    DO NOT SHOCK THESE PATIENTS: interferes with natural pacemaker recovery
127
Q

Asystole on ECG

A

just a flat line

128
Q

CO is

A

HR x SV

Volume of blood that the head pumps per minute

129
Q

What is the s/s of decreased CO

A

SOB, hypotension, angina, altered mental status

Complex Care (22 decks)

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