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EKG Block 1 Flashcards

1
Q

When is an EKG indicated?

A

Syncope
Episodic FADS: fatigue, angina, dizziness, Sob
Palpitations
Transient A-Fib/Flutter neuro events

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2
Q

What are the current speeds through the different areas of the heart?

A

SA/AV- 0.01-0.02m/s
Atria/Ventricles- 1m/s
PF- 2m/s

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3
Q

Define Automaticity

Define Excitability

A

Ability to discharge spontaneously w/out stimulus

Ability to depolarize by stimulus

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4
Q

Define Chronotrophy

Define Inotrophy

Define Dromotrophy

A

Affecting HR

Affecting myocardial contractility

Affecting conductivity

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5
Q

What does a small box on ECG paper mean?

What do the heavy black lines mean?

A

0.1mv in height, .04 seconds in width

5 squares= .5mv, .2 sec

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6
Q

What does the X and Y axis on ECG paper represent?

A 
X= time, 1mm=.04sec 5mm=0.20sec
Y= voltage, 10mm= 1mv (two large boxes)
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7
Q

Define ECG Amplitude

What factors causes it to inc and dec?

A

Height, measured from baseline in milivolts
Inc- hypertrophy
Dec- COPD

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8
Q

What are the parts of a 12 lead ECG?

Which one is typically used for the rhythm strip?

A

Six limb Bipolar- 1, 2, 3, AVR, AVL, AVF
Six Chest Percordial- V1-6

Lead 2

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9
Q

What do leads 1, 2 and 3 measure/record?

Where are leads V1-6 placed?

A

1= RA to LA 2= RA to LL 3= LA to LL

V1= R4IS  V2= L4IS  V3= Between V2 and V4
V4= 5ICSMCL V5= 5ICSAAL V6 5ISMAL
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10
Q

What underlying issues can cause an abnormal QRS complex?

A

HEV FACETIME

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11
Q

What can cause the T wave to be tall/peaked?

A 
Localized= MI
General= hyperkalemia
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12
Q

What can cause the T wave to be inverted?

A

General= pericarditis
Localized= MI
V5, V6, aVL= LVH/BBB
V1/V2= RVH/BBB

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13
Q

What can cause the T wave to be flat?

A

Ischemia
Evolving infarction
Hypokalemia

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14
Q

What can cause the T wave to be elongated/bizarre?

A

Acute cerebral disease

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15
Q

T wave indicates what occurrence?

What does the U wave indicate?

A

T= ventricle repolarization

U= Perkinje fiber repolarization

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16
Q

What is the normal distance of the U wave?

What can cause it to be abnormal?

A

Norm= >1mm best at V3

Over 1mm= abnormal due to Hypo K, Ca, Mg

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17
Q

What does a negative deflection on the U wave indicate?

A

LAD

L main disease

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18
Q

Norms and abnormals of PR segment

A

Normally isoelectric
Depressed- pericarditis
Elevated- atrial infarction

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19
Q

What does the J Point mean?

A

Point where QRS ends and ST segment begins

Describes ST abnormalities (elevated/depressed)

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20
Q

What is the use of the R-R interval?

A

Used to determine Rate and Rhythm

Necessary for determining normal QT

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21
Q

What is the PR Interval?

A

From P wave to beginning of QRS

Measures time taken to travel from SA node/ectopic origin to ventricular muscle fibers

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22
Q

What is the normal duration of the PR interval?

What does a prolonged or shortened interval mean?

A 
Norm= .12-.20 seconds
Pro= AV block, Meds (Adenosine, BBs, CCBs, Digitalis)
Short= low atrial/junctional foci, accelerated passage (WPW Syndrome, Lown-Ganong-Levine)
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23
Q

What does the QT interval include and what does it measure?

A

Beginning of Q to end of T

Measures total ventricular systole time

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24
Q

What factors can change the QT interval?

What is used to measure the corrected QT interval?

A

HR, Age, Gender, Autonomic tone

QTc- based on gender and HR

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25
What is the RoT for the QT interval
QT should be <1/2 of RR
26
What is a normal QT inteval for men and women?
M- <420 msec | F- <430
27
What does a prolonged QT interval mean and what can cause it?
``` Delayed repolarization Predisposes to ventricular dysarhythmias Congenital/Rheumatic heart Low K Mg Ca Meds- Levafloxacin, Azithromycin, Zofran, Diflucan, Amiodarone ```
28
What would be considered a prolonged QT interval in men/women? How is it treated?
M- >450 F- > 470 Tx w/ BB
29
What can cause a shortened QT interval?
Hyerkalemia Hypercalcemia Digitalis
30
What are the normal ranges for QRS Complexes, T Wave, PR Interval and QT Interval?
QRS- 1 to <3 boxes, .04-.11 sec T- 2/3 height of R wave PR- 3-5 boxes, .12-0.2 sec QT- <1/2 R-R distance
31
What is the number sequence for determining rate on ECG paper?
300 150 100 75 60 50
32
When is the "6 Second Method" to determine the rate? How is it done?
Useful with bradycardia or irregular rhythms Two consecutive 3 second intervals Count number of R waves Multiply by 10
33
How is a normal Peds ECG different than an adult?
``` +100 bpm Sinus aarythmia Longer QTC Dominant R V1-3 RSR V1 Pattern T-wave inversion V1-3 ```
34
What two events occur and create Tachycardia Cardiomyopathy
Incessant SVT | Uncontrolled ventricular rates
35
How can re-entry tachycardia be terminated?
Vagal maneuver | IV meds
36
How is SVT diagnosed?
12 lead EKG Holter monitor x 24-48hrs Continuous loop recorder x 1mon
37
When/why is Electrophysiologic testing done?
Distinguish between SVT or Ventricular Tachycardia
38
How are SVTs initiated?
Paced pre-mature beats
39
Define Stable Tachycardia
No hemodynamic compromise
40
Define Unstable Tachycardia
Evidence of hemodynamic compromise: | HOTN, Angina, AMS, HF
41
Sinus tachycardia is almost always a response due to ? and never exceeds ? BPM
Stress | 180
42
Define Atrial Tachycardia and what are the two types?
SVTs originating from focal anatomic areas in atria and propogate in centrifugal pattern AVNRT- nodal AVRT- re-entrant
43
Define Paroxysmal Atrial Tachycardia
Rapid firing of irritable atrial focus between 150-220 bpm
44
Define Paroxysmal Junction Tachycardia
Focal tachycardia originating in AV junction at 150-250 bpm
45
Define Junctional Tachycardia
Tachycardia w/out P waves | Negative deflection @ end of leads 2, 3, and aVF= retrograde P wave
46
It is impossible to distinguish Junctional Tachycardia from what other rhythm on ECG?
AVN Re-Entry Tachycardia
47
What are the characteristics of AVNRT
Functional, unidirectional block in AV node leading to retrograde conduction and continuous re-entry circuit 120-220 bpm P waves are inverted/buried Narrow QRS complex unless BBB is present
48
What is the most common SVT and who is it seen in?
AVNRT Young adults Pregnancy/menstrual cycles
49
How is AVNRT treated?
Electrophsiology and catheter ablation
50
Characteristics of AVRT
Anatomic bypass bundle between atria and ventricles w/ no delay Pathway stimulates atria leading to paroxysmal tachycardia
51
AVRT is seen in what cardiac syndromes?
Wolf Parkinson White | LGLS
52
Define Orthodromic AVRT
Most common Impulse travels out of AV node but return to atria through Kent bundle Presents as narrow complex tachycardia
53
Define Antidromic AVRT
Impulse travels from AV to kent bundle to AV node causing wide complex tachycardia
54
What are the characteristics of WPW Syndrome
PR interval <0.12 AV node is bypassed D wave at beginning of QRS causing impulse delivered to myocardium instead of normal conduction route Widened QRS complex Inverted T wave Atria reactivated by ventricles causing rapid, regular tachy in 50-80% of PTs
55
What is WPW Type A pattern and what does it mimic? | What is WPW Type B pattern and what does it mimic?
L sided accessory pathway with tall Rs in V1-3; RVH R sided accessory pathways with tall R and inverted T in inferior leads; LVH
56
Orthodromic AVRT in PTs w/ WPW Syndrome looks like ? Antidromic looks like ?
Ortho- SVT, treated as SVT Anti- LVH, treated as LVH
57
What meds are not used in the treatment of Antidromic AVRT in PTs with WPW Syndrome?
ABCD meds- may block AV node and increase HR
58
Characteristics of LGLS
PR Interval <0.12 sec due to James fibres Normal QRS width and normal ventricular conduction through pathway No delta Paroxysmal tachycardia
59
Characteristics of A-Fib
No P wave | Irregularly irregular
60
What is the etiology behind A-Fib
``` PIRATES Pulmonary- OSA, PE, Pneumonia, COPD Rheumatic Dz/Mitral Regurg Alcohol/Anemia Thyrotoxicosis/Toxins E+/endocarditis Sepsis/Sick sinus syndrome ```
61
Define Paroxysmal, Persistent, Permanent and Recurrent A-Fib
Paroxysmal- resolves in 7 days Persistent- Last longer than 7 days Perm- always there and NEVER goes away Recurrent- two or more episodes
62
All A-fib cases must be ?
Anticoagulated
63
How is A-Fib rhythm and rate controlled
Rhythm- cardioversion, antiarrhythmic | Rate- BBs, CCBs
64
A-Fib PTs without HOTN can be given what meds for rate control
``` Esmolol Metoprolol Verapamil Diltiazem Digoxin ```
65
New onset A-Fib in PTs that are good candidates for cardioversion should be anticoagulated with which direct acting PO meds?
Dabigatran Apixaban Rivaroxaban Edoxaban
66
Half of A-Fib cases revert to sinus in ? days What is the fundamental component of management?
3-4days Restore/maintain sinus or allow recurrence/progression to permanent A-Fib
67
All new A-Fib cases get ? procedure prior to conversion?
Transesophageal echo or | Anticoagulate 4wks prior and after procedure
68
What does a Cha2DS2VASc score of 0-1 or 2 mean?
``` 0-2= consider aspirin +2= anticoagulate ```
69
Characteristics of A-Flutter
Atrial rate regular, 250-300 bpm, variable ventricle rate | Characteristics saw tooth pattern
70
What is the etiology behind atrial flutters?
pericardial Dz LAE/RAE Hypoxia Hyper/pothyroid
71
What are the S/Sx of Atrial Flutter
ASx - poor CO
72
How is Atrial Flutter treated?
Control ventricle rate w/ BB/CCB Inc risk of recurrence= catheter ablation as definitive treatment Tx w/ conversion, rate control and antiarrhythmias If persistent, anticoagulate, but is rare
73
What medication can be used IV to attempt to treat atrial flutter?
Ibutilide
74
Atrial flutter should last less than 48hrs or ? needs to be performed?
Transesophageal echocardiogram to r/o clot in L atrial appendage
75
What is the INR limits for Atrial Flutter?
INR of 2-3 w/ Warfarin or | DARE for 4wks prior to minimize stroke
76
Define Ventricular Arrhythmias
Rhythms originating in ventricular myocardium or in His/Purkinje tissues between 150-250 bpm
77
Ventricular arrhythmias includes which ones?
PVCs Non/Sustained ventricular tachycardia Life threatening V-tach
78
# Define Couplet Define Non-Sustained VT Define Sustained VT
Two consecutive PVCs Three or more PVCs +30 seconds
79
What are the etiologies of Ventricular Tachycardia
``` MI Structural heart Dz R on T Irritability, myocardia Drugs E+ disturbances ```
80
How does Ventricular Tachycardia clinically present?
Pulselessness ASx/palpitations Dec CO Syncope
81
Define Paroxysmal V-Tach
Irritable ventricular focus | Consecutive PVC like complexes
82
Define R on T Phenomenon and why it's important
PVCs hit T-wave and causes V-Tach This is why conversions are synchronized to avoid shocking on T-waves
83
How is V-Tach managed in un/stable PTs
Unstable- synchronized conversion w/ 200J Stable- Antiarrhythmia therapy w/ Procainamide, Amiodarone or Lidocaine
84
Define Torsades de Pointes and what causes them
Genetic/medication induced long QT syndrome over 440/460 Hypo Mg, K, Ca
85
How do you treat Torsades de Pointes
Unsynchronized conversion | Magnesium
86
What are the characteristics of Ventricular Fibrillation
Variable wide complex rhythm over 300bpm w/ no P wave
87
What is the etiology behind Ventricular Fibrillation
``` Hypothermia Acid base VT/Torsades, untreated Electrical shock MI infarction/ischemia ```
88
How does Ventricular Fibrillation present clinically
Pulseless | Non-functioning heart causing 50% of deaths w/ CAD
89
Define PEA
Any supraventricular rhythm w/out an effective/detectable pulse caused by the 5 H's and 5 T's that presents as pulseless, non-functioning heart
90
What are the 5 H's of ACLS
``` Hypovolemia Hypoxia H+ excess Hypo/perkalemia Hypothermia ```
91
What are the 5 T's of ACLS
``` Tamponade Toxins Tension Pneumothorax Thrombosis, pulmonary Thrombosis, coronary ```
92
What will a Sinus Block/Sinus arrest look like
Dropped P wave and QRS Unhealthy SA node may temporarily fail to pace for one cycle No P wave
93
Define Sick Sinus Syndrome
Arrhythmic caused by SA node dysfunction w/ unresponsive supraventricular automaticity foci
94
Sick Sinus Syndrome manifests as ? and presents w/ ?
Sinus brady without normal escape mechanisms May present w/ Brady-Tachy Syndrome
95
What is the etiology behind Sick Sinus Syndrome How does it present in clinic?
CADz Presents with palpitations, light headed and syncope
96
Define Pseudo Sick Sinus Syndrome
Athletes w/ resting sinus brady Holster/Pacemaker
97
Define an AV Block
Impacted conduction from atria to ventricles
98
Define First Degree AV Block
Regular rhythm with normal P waves and QRS | PR interval >0.20 sec
99
What is the etiology behind First Degree AV blocks?
Athlete Increases w/ age Medications
100
Define a Second Degree AV Block Mobitz Type 1
Irregular PR interval getting progressively longer until QRS is dropped Normal P wave interval
101
What is the etiology behind a Second Degree Block
Normally ASx | Possible Sx from bradycardia
102
Define Second Degree Heart Block Mobitz Type 2
Prolonged PR interval w/ sudden dropped QRS complexes | Atrial depolarizations are totally blocked
103
What is the etiology behind Second Degree Heart Block Mobitz Type 2
Large MIs Damage to AV node (RCA) Medications
104
How does Second Degree Heart Block Mobitz Type 2 present in clinic and what is the treatment?
Low CO Possible pacemaker
105
Define Third Degree Block
Total block of conduction to ventricles Regular rhythm- 40-60 if junctional 20-40 if ventricular
106
What is the etiology behind 3* Blocks?
Damage to AV node IMI MI at infra-nodal level UNLIKELY from meds
107
How do 3* AV Blocks present
ASx to dec CO | Cannon A waves from valaves closing when chambers are firing
108
How are 3* blocks treated?
Pharmacotherapy | Pacing
109
When do PR intervals increase?
First degree AV block Wenckebach cycles Mobitz w/ QRS drops
110
When do PR intervals decrease? When are PR intervals variable?
WPW Syndrome 3* Block
111
When are there P waves without WRS complexes?
Wenckebach Mobitz 3* block
112
How is unstable bradycardia treated?
1mg Atropine or, Isoproterenol infusion Temporary pacemaker
113
How is stable bradycardia treated?
Remove any medications | Implant pacemaker- especially if Mobitz II and 3* AVB
114
Define BBB
QRS greater than 0.12sec | Recognized by R,R' in specific leads of ECG
115
Define Intraventricular Conduction Delay
QRS between 0.10 - 0.12sec
116
Where do you look on the ECG to find a R BBB and a L BBB?
R- V1, 2 L- V5, 6
117
What etiologies cause R BBB?
``` Atrial Septal Defects Senile Degeneration Ischemic Heart Disease Cardiomyopathy Massive PE RVH Normal Variant ```
118
What characteristics will be seen in ECG paper with a R BBB?
QRS > 0.12 RSR' in V1 or V2 Wide S in V4-6 V1 and V2- ST depression and Inverted T
119
What are the etiological causes of L BBB?
``` Idiopathic degeneration conduction system Dz Ischemic Heart Dz MI New L BBB c/w STEMI Cardiomyopathy Aortic Stenosis HTN/LVH Hyperkalemia Normal Variant (unusual) ```
120
What will be seen on ECG paper during a L BBB?
QRS > 0.12 High voltage S wave V1-2 Tall R wave V5-6, 1 and aVL Slurred notch in any of above V5, V6, 1 and aVL- ST depression and Inverted T
121
Left BBB confounds ECG interpretation for what three things?
Ischemia/infarction Ventricular hypertrophy ST/T wave changes
122
What does the R Coronary Artery supply? What does the L Coronary Artery supply?
Posterior division of L BB and AV node R BB and Anterior division of L BB
123
What are the 4 Fascicular Blocks
Acute MI (LAD) HTN Aortic stenosis Dilated cardiomyopathy
124
Where will an Anterior Fascicular Block be seen on ECG paper?
Q1, S3, 2, and aVF | Normal/slightly wide QRS
125
Where will a Posterior Fascicular Block be seen on ECG paper?
S1Q3- S in L1, Q in L3 Right axis deviation Normal/slightly widened QRS
126
Why are posterior fascicular blocks rare?
Usually dual blood supply
127
Define Axis
Direction of movement of depolarization that spreads through heart to stimulate the myocradium
128
What part of the heart beat identifies contraction of the myocardium?
QRS
129
Which way does the QRS point on ECG paper?
Down and L due to L ventricle wall thickness
130
Which two leads are the key ones for determining the axis?
1 and aVF
131
Which wax does the axis point during hypertrophy and MIs?
Hypertrophy- towards trophied side MI- away from side w/ infarct
132
What are the causes of L Axis Deviation
``` LVH Inf MI L Ant Fasc. Block L BBB Paced Rhythm WPW Syndrome ```
133
What are the causes of R Axis Deviation?
``` RVH Lateral MI L Post Fasc Block Acute Lung Dz (PE) COPD ```
134
What are the causes of Extreme R Axis Deviation?
V-Tach | Hyperkalemia
135
What is the next step after identifying an axis deviation for better localization?
Find next best isoelectric lead Vector is 90* from lead Known quadrant allows axis vector determination
136
Define Horizontal Axis
R Wave Progression | Determined w/ precordial leads
137
Define Horizontal Zone of Transition
How deflection moves across precordial leads
138
What are the normals seen in Horizontal Zone of Transistion?
Norm= negative in V1 Transition= + in V6 Normal zone= V2-4
139
What are the causes of poor R Wave progression? What needs to be checked here for operator error?
Anterior Infarction RVH Chronic Lung Dz Obesity *Check for lead reversal
140
Define Acute Coronary Syndrome
Spectrum from unstable angina to NSTEMI
141
Define Angina
Chest pain from ischemia
142
Define Ischemia
Lack of O2 to myocardial muscle
143
Define Unstable Angina
Partial clot that can occur without case and last 15-20min Poor response to Nitro Dx on 1st episode
144
Define Stable Angina
Predictable, usually w/ activity or stress | Dx only after work up for angina
145
Define Variant/Printzmetal Angina
Chest pain from a coronary artery spasm that can occur at rest/night in a non-atherosclerotic vessel Thought to be caused by an endothelial dysfunction
146
Define Infarct
Cellular death and necrosis leading to permanent loss of myocardium and function
147
Define NSTEMI
AKA Non-Q wave MI Difficult to distinguish from unstable MI w/out assessing markers Markers= NSTEMI No Markers= Unstable angina
148
Acute Coronary Syndrome has a 50% or higher prevalence in what three areas?
NSTEMI 65y/o Men
149
What T wave changes will be seen with ischemia/infarction?
Peaked w/ hyperacute Inverted w/ ischemia, infarct or injury
150
What ST changes will be seen with ischemia/infarction?
Depressed w/ ischemia | Elevated w/ injury/infarct
151
What Q wave changes will be seen with ischemia/infarction?
Start appearing w/ ischemia, injury, or infarct | Remain permanent if infarct occurs
152
What U wave changes will be seen with ischemia/infarction?
Seen on leads w/ pathological Q Waves Exercise stress test can cause inversions
153
How do you measure for ST Segment Deviations?
Locate J point Move 1.5 small boxes to R Measure from baseline to isoelectric point
154
Define ST Depression
Represents sub-endothelial myocardial ischemia Can be reversible and not necessarily associated w/ injury but can be a dire warning sign Associated w/ T wave inversion
155
Define ST Elevation
``` Represents acute transmural myocardial injury and appears in areas of necrosis M= >2mm W= >1.5mm Or >1mm in 2 or more contigous leads Occurs w/out necrosis in variant angina ```
156
What are the four types of ST morphologies?
Concave- less concerning Up Slope Horizontal Convex
157
What are the 3 evolving phases of change on an ECG during a MI?
Hyper/Early Acute Evolved Acute Chronic/Stabilized
158
What events occur during the Hyper/Early Acute phase of changes of a MI?
T waves increase and widen over area of injury ST goes from concave to straight to convex up Proceeds clinical Sxs
159
What events occur during the Evolved Acute phase of changes of a MI?
ST segments regress T waves invert Q waves develop after 1-2hrs
160
What events occur during the Chronic/Stable phase of changes of a MI?
ST returns to base line or slightly elevated after 2wks Early perfusion therapy helps accelerate changes Obtain new baseline ECG
161
What medications are considered in a sinus bradycardia DDx?
``` BB CCB Antiarryhythmics Digoxin Lithium ```
162
S/Sxs of sinud bradycardia?
``` If PT can compensate/ASx= athlete AMS Blurred vision Angina Cool/clammy skin Adeventitious lungs Dizz HOTN S3 heart sound Syncope ```
163
Define a Wandering Atrial Pacemaker
Site shifts between SA, atria and AV nodes 3 different p-wave morphologies HR below 100bpm
164
What is the etiology of Wandering Atrial Pacemaker?
``` Idiopathic Vagal tone Dig toxicity Inflammed atrium VHD ```
165
Define Multifocal Atrial Tachycardia
Sped up version of WAP | Common in PTs w/ COPD
166
What characteristics about MAT are different that WAP?
SA node doesn't pace 3 or more different shaped P-waves +100bpm Irregular P-r, R-R and P-P intervals
167
What is the etiology behind MAT?
Sever pulmonary Dz (COPD/Pneumonia) Hypoxia CHF
168
How does MAT manifest?
Palpitations SOB Chest pain Lightheaded/syncope
169
What are the etiological causes of escape beats/rhythms
Dec automaticity- sinus node suppression, AMI, rheumatic disease, respiratory failure Automaticity focus transiently escapes overdrive suppression- caffeine, adrenaline, digitalis, hyper thyroid, stretch
170
How do frequent pauses/escape beats clincially manifest?
Normally ASx HOTN Light headed/syncope
171
How does an atrial escape beat look on ECG?
Upright P wave | Occurs in healthy people related to sinus node suppression by meds, MI or respiratory failure
172
How does a ventricular escape beat look on ECG?
Widened QRS
173
How does a junctional escape beat look on ECG?
Inverted/absent P wave
174
What causes junctional escape beats?
``` Caffeine Nicotine ETOH/withdrawl Digitalis Hypoxia Sinus node ischemia Heart valve Dz Myocarditis ```
175
What causes ventricular escape beats?
Failed SA and AV pacing | Heart failure
176
# Define Bigeminy What is it associated with?
Irritable focus (atria/venticle) that couple to the end of a normal cycle Hypoxia
177
What causes a run of PVCs
Irritable venticular focus fires spontaneous impulses
178
What criteria makes non-sustained V-Tach?
3 or more PVCs
179
# Define R on T phenomenon What does this definition justify in medical treatments?
PVC falls on a T wave and can cause deadly arrhythmia Non-emergent conversions are synchronized to avoid T waves
180
What factors make the heart vulnerable to R on T Phenomenons?
Hypoxia | Hypokalemia
181
A normal P wave is seen inverted on which lead?
aVR
182
What heart issues is AKA the "Holiday Heart"
A-Fib
183
What are the intrinsic conduction rates?
``` SA Node 60 Atrial cells- 55 AV node- 45 His bundle- 40 Bundle branch- 40 Purkinje- 35 Myocardial- 30 ```
184
The hearts BPMs are altered by ? and the m/s of conduction are altered by ?
Autonomic stimulus Meds
185
How fast does ECG paper move? What does that mean calibrated?
22mm/sec 10mm=1mv
186
How is HCM manageed?
ECG and holter monitor No vigorous activities Verapamil or BBs Consider implant pacemaker

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