EKG Exam Flashcards

- 2nd degree block: type 2
- some p waves conduct, some don’t
- rhythm regular if conduction ratio is constant; if variable, R-R interval will be irregular
- rate atrial normal; ventricular bradycardic at 1/2, 1/3, or 1/4 of atrial
- p wave upright, uniform, more of these than QRS complexes
- PR interval constant but longer than normal
- QRS normal, 0.12 sec or less
- QT usually normal, less than 1/2 preceding R-R
medications for V.Tach
- amiodarone 150 mg IV over 10 min
- followed by continuous infusion
- if unstable - cardiovert
- torsades de pointes
- mag sulfate 1-2g IV over 5-60 min
what is this rhythm?

asystole
concerns and treatment with complete heart block
- concerns
- hemodynamic compromise
- CHB common PEA
- treatment
- transcutaneous pacing
- atropine - only acts on atria
- dopamine or epi drip - will impact both atria and ventricles
clinical presentation of sinus tachycardia
- depends on underlying cause and individual’s ability to tolerate rapid HR
- may be symptomatic
- hypotension, chest pain, SOB
symptoms of bradycardias
- hypotension
- poor peripheral vascular assessment
- change in mental status
- fatigue, lethargy, dizziness, near syncope
- chest pain
- SOB
relative refractory period
- period of time following absolute refractory period
- heart can respond to strong stimulus, but response will be abnormal
- R on T phenomenon
etiology of PVCs
- hypokalemia, hypomagnesemia
- hypoxia
- bradycardia
- caffeine, ETOH, tobacco
- MI
- dig toxicity
- exercise
morphology of P wave and A:V ration in dysrrhythmia interpretation
- are all P waves the same?
- all coming from same source
- do some look different?
- dramatically different morphologies indicate taking different paths from atria to ventricles
- A:V ratio is 1:1?
- atrial activity = p wave
- ventricular activity = QRS complex

- sinus tachyardia
- rhythm regular
- rate > 100 bpm
- P wave for every QRS; same size and shape
- PR interval normal, 0.10-0.20 sec
- QRS same size and shape; duration normal (0.04-0.12 sec
- QT interval normal (0.36-0.40 sec)
causes of first degree heart block
- cardiomyopathy
- ischemia or injury to AV node
- valvular disorders, digitalis toxicity
- mechanical injury to AV node or junctional tissue
- common in beta blockers
- slows down AV node
treatment for A.fib
- rate control: meds with negative chronotropic and/or negative dromotropic properties to slow conduction speed through AV node
- B-blockers, Ca channel blockers, amiodarone, digoxin
- anticoagulation to prevent clot becoming thrombus
- check with echo
- chronic anticoag therapy (coumadin, prodaxa, xarelto)
- cardioversion
- EP procedures to ablate pathologic tissue
- MAZE procedure to carve up atria to prevent abnormal foci from conducting
PR Interval
- atrial to ventricular conduction time
- time for impulse to travel through atria, through AV node, down to ventricles
- most of delay is located in AV node
etiologies of sinus tachycardia
- non-physiologic conditions
- exercise, caffeine, smoking, alcohol, emotions, pain, anxiety
- physiologic stressors
- hypovolemia, fever, anemia, early sepsis, hypermetabolic states, heart failure, allergic rxn
- medications
- atropine, epi, dopamine, norepi
junctional rhythm overview
- rhythm from AV junction below AV node in bundel of His
- if conduction from SA node disrupted d/t SA or AV node damage, no impulses come down from atria in time
- cells in junctional tissue step in has backup pacemaker to preseve life (junctional “escape” rhythm)
- rate is less than that of SA node (40-60)
- impulse conducted down ventricle but up atria, so P wave is late and inverted - QRS is normal
- P waves can be before, during, or after QRS
- lose atrial kick
parasympathetic stimulation
- occurs through control of vagus nerve
- vagal stimulation slows heart (valsalva maneuver)
- only affects atria (vagal nerve innervates)
- atropine will speed up heart via decreasing vagal suppression
- BUT with heart block, will not conduct down to improve ventricular rate
- atropine lifts vagal suppression and increases HR
causes of second degree heart block: type 2
- worsening ischemia or injury to AV node or junctional tissue
- cardiomyopathy
- valve disease
- digialis toxicity
refractory period
period of time after a cell has depolarized during which it cannot depolarize again
treatment for asystole
- CPR, epi, correct underlying cause
- meds are not rhythm specific and do not improve survival to discharge
- check for DNR
sympathetic stimulation
- catecholamines
- epi, norepi, dopamine
- affects the atria and ventricles
- can give endogenous substances via exogenous methods as code drugs (epi is #1)
- increases HR, conduction velocity, irritability
anticipated interventions for SVT
- treat underlying cause
- valsalva maneuvers
- medications
- push adenosine as close to heart as possible and elevate that extremity - will cause chest pain and anxiety
- synchronized cardioversion if there is a pulse
- synced to R wave to avoid R on T
etiologies of SVT
- stress
- metabolic dx
- medications
- cardiac dx
- anemia
- thyrotoxicosis
- hypoxia
- cardiomyopathy

- superior level junctional rhythm
- upside down P waves before QRS
- PR interval shorter than normal
P wave
atrial depolarization as impulse travels through atria
etiologies of sinus bradycardia
- normal in athletes
- sleep
- vagal stimulation
- increased parasympathetic tone d/t cerebral edema or subdural hematoma
- decreased sympathetic tone d/t SCI
- decreased metabolic rate d/t hypothyroidism or hypothermia
- inferior wall MI
- drugs such as beta blockers, calcium channel blockers, digoxin, antiarrhythmics
PR interval in dysrrhythmia interpretation
- usually between .12-.2 s (120-200 ms)
- how long is it taking impulse to travel from atria through AV node?
- how long is it delayed until getting to ventricle?
clinical presentation of normal sinus rhythm
usually does not cause hemodynamic instability
R on T phenomenon
- PVC falls on preceding initial down slop of T wave
- may cause deterioration into unstable rhythm
- Vf, VT, torsades de pointes
- due to new electrical stimulus during relative refractory period
repolarization
- return of cell’s membrane to resting state
- positive and negative charges return to original positions
- cells must repolarize before depolarizing again
- sodium and calcium move out of cell, potassium back in

- junctional rhythm
- rate 40-60
- rhythm regular
- P wave inverted; immediately before/after QRS or hidden in QRS
- PR interval short - 0.10 sec or less
- QRS normal, 0.12 sec or less
- QT less than 1/2 preceding R-R

- third degree (complete) heart block
- rhythm atria regular; ventricle regular - different
-
rate atrial rate normal; ventriclular rate slower…
- …if junctional focus - 40-60
- …if ventricular focus 20-40
- p wave upright, uniform, more of these than QRS complexes
- PR interval none, no relationship to QRS
- QRS = 0.12 sec if junctional focus; >/= 0.12 if ventricular focus
Purkinje Fibers
- bundle branches terminate in this network branching of fibers
- conduction through Purkinje fibers is extremely rapid
- spreads throughout inner surface of both ventricles
- fibers contain pacemaker cells with inherent rate of 20-40 times/minute
anticipated interventions for normal sinus rhythm
no treatment is usually necessary

- electricity flows from upper right to lower left
- right arm negative; left leg positive
- as electricity flows through heard and down towards left leg
- towards positive lead
- positive ECG deflection
- flow towards negative lead = negative deflection
concerns with V.tach
- response varies
- asymptomatic –> pulseless
- bad CO, bad pumping
- no diastolic filling
- no perfusion of heart b/c no diastole
- why rapid deterioration is imminent - V.fib

- accelerated junctional rhythm
- rate 60-100; > 100 = tachycardia
- P wave same as junctional escape
- PR interval short, if measurable
atrioventricular node
- impulse passes from internodal tracts through AV node to reach ventricles
- located at top of interventricular septum in right atrium near coronary sinus
- cardiac impulse is delayed here to allow for ventricular filling during atrial contraction (atrial kick is 25% of ventricular filling, occurring after diastolic filling)
- acts as gatekeeper by controlling number of atrial impulses reaching ventricles
- normally no more than 180 impulses/minute
- AV node does NOT possess pacemaker cells - surrounding junctional tissue does
overview of supraventricular tachycardia
- fast rhythms originating above ventricles
- atria, junctional tissue, sometimes sinus node
- usually paroxysmal, but may sustain in some cases
- rhythms that cannot be identified as atrial tachycardia, junctional tachycardia, sinus tachycardia, or atrial flutter are all grouped into this classification

- sinus bradycardia
- rhythm regular
- rate < 60 bpm
- P wave for every QRS; all same size and shape
- PR interval normal, 0.10-0.20 sec
- QRS all same size and shape; duration normal - 0.04-0.12 sec
- QT interval normal: 0.36-0.40 sec
causes of asystole
- untreated Vtach or Vfib
- electrocution
- profound electrolyte or acid-base imbalance
- MI

- asystole
- rate none
- rhythm none
- p wave none
- PR interval none
- QRS none
- QT interval none
internodal tracts & Bachman’s bundle
- carry cardiac impulse from SA node
- 3 tracts
- anterior
- middle (Wenkebach)
- posterior (Thorel’s)
- Bachman’s bundle
- interatrial pathway facilitating transmission from the right to left atrium

- normal sinus rhythm originating from SA node
- regular atrial and ventricular rhythm
- 60-100 bpm
- p wave for every QRS; p waves same size and shape
- PR interval normal: 0.10-0.20 sec
- QRS waves same size and shape; duration normal - 0.04-0.12 sec
- QT interval normal: 0.36-0.40 sec
etiologies of atrial fibrillation
- hypoxia
- ischemia/infarction
- electrolyte disturbances
- cardiac surgery
- excessive adrenergic stimulation
- catecholamine surge from stress, surgery
- cardiomyopathy
- CHF
- pericarditis
- alcohol withdrawal
- hyperthyroidism
etiology, causes, and treatment of ventricular escape rhythm
- etiology: failure of SA and AV nodes to pacemake
- causes:
- ischemia, infarction
- severe acid-base disturbances
- cardiomyopathy
- dig toxicity
- treatment
- transcutaneous pacing
- dopamine or epi drip
- DO NOT SUPPRESS VENT ESCAPE RHYTHM
causes of third degree heart block
- untreated digitalis toxicity
- worsening ischemia/injury
- cardiomyopathy
- valvular disease
- mechanical trauma to AV node
QT interval
time from start of depolarization of the ventricles to end of the relative refractory period
beginning of QRS complex to end of T wave
sinoatrial node
- posterior wall of the right atrium
- “natural pacemaker” of the heart
- inrinsic rate of 60-100 times/minute

- mid-level junctional rhythm
- P waves during QRS - drowned out by much bigger QRS
what is pulseless electrical activity?
- any rhythm w/o pulse
- except asystole, VF, VT
- dissociation between the electrical and mechanical functions of heart
- always ask: is there a pulse?
- CPR if no pulse
- large bore IV access (better for circulation)
- epi 1mg IVP q3-5 min
what are PVCs?
- early beats from ventricle
- make ventricular rhythm irregular
- can be in individual complexes, pairs, triplets
- bigeminy, trigeminy, quadrageminy
- unifocal or multifocal
- conduction from cell to cell instead of rapidly across tissue
- precursors to V.tach and V.fib
treatment for VTach
- pulseless - defibrillate
- pulse with serious S/Sx - synchronized cardioversion
- pusle without serious S/Sx - medication trials
treatment of bradycardias
- treated only when symptomatic
- atropine 0.5 mg q3-5 min (total 0.03-0.04 mg/kg)
- transcutaneous pacing as bridge therapy
- dopamine infusion 2-10 ug/kg/min
- epi infusion 2-10 ug/min
- epi and dopamine have more general response if atropine not working
overview of ventricular escape rhythm
- potentially lethal - requires immediate assessment and appropriate intervention
- presentations very from asymptomatic to complete cardiac arrest
- likely to result in decreased CO, decreased perfusion
- discomfort, anxiety, fear

- low-level junctional rhythm
- upside down P waves after QRS
- sort of hidden in T wave
causes of V.fib
- untreated V.tach
- MI
- electrolyte imbalances
- acid-base disturbances
- hypoxia
- cardiac trauma
- electrical shock

- ventricular escape rhythm
- rhythm regular
- rate below 40 bpm
- PR interval immeasurable
- QRS greater than .12 sec, uniform morphology
- QT interval difficult to discern from T-wave - less than 1/2 R-R if measurable
anticipated interventions for sinus tachycardia
- beta-blockers, calcium channel blockers
- if HR exceeds 150bpm with serious S/Sx
- tachycardia should be cardioverted
- sinus tachycardia will not respond to cardioversion
- need to treat underlying problem
what type of PVC is this?

couplet - two PVCs in a row (uniform or multiform)
also known as “pair”

- atrial fibrillation
- rhythm: atrial - chaotic; ventricular - irregularly irregular
- rate: atrial 350-700 bpm; ventricular > 100 bpm if uncontrolled; < 100 bpm if controlled
- P waves: fibrillatory waves or “f” waves (coarse or fine)
- PR interval: unable to measure
- QRS: narrow, should be same: 0.04-0.12 sec
why is there a pause after a PAC?
compensatory pause - occurs b/c heart is expecting to go back to underlying rhythm
what is this rhythm?

V-fib
clinical presentation of SVT
- palpitations, angina
- dyspnea, anxiety
- not enough passive diastolic fill time of ventricles
concerns for second degree heart block: type 1
- hemodynamic implications based on HR
- individual symptoms vary
- watch for progression of block
treatments for accelerated junctional rhythms
- remove underlying cause
- control HR
- meds to limit automaticity of junction
- B blockers
- amiodarone
- Ca channel blockers
T wave
ventricular repolarization as ventricules return to resting electrical state
treatment for atrial flutter
- similar to A.fib
- rate control - med with negative chronotropic and/or negative dromotropic properties to slow conduction speed through A/V
- B-adrenergic blockers
- calcium channel blockers
- amiodarone
- digoxin
- anticoagulation - coumadin, prodaxa, xarelto
- often cardioversion
- EP procedures - tissue ablation
- MAZE - carve up atria to prevent abnormal conduction
concerns and treatments for 1st degree heart block
- concerns:
- nothing major
- hemodynamically stable if asymptomatic
- watch for progression to further block
- treatment
- not required
etiologies of junctional rhythms
- infarction, ischemia
- drug toxicity
- digoxin, digitalis, CA channel blockers, beta blockers
causes of 2nd degree heart block: Type 1
- inferior MI
- cardiomyopathies
- digitalis toxicity
- valvular disease
what type of PVC is this?

ventricular bigeminy - ever other beat is a PVC

- first-degree block
- conduction thru SA node delayed, lengthening PR interval
- rhythm regular
- rate underlying rhythm, atrial and ventricular usually same
- P wave sinus, normal, upright
- P interval prolonged, greater than 0.20 sec and constant
- QRS normal, 0.12 sec or less
- QT interval usually normal
treatment for V.fib
- CPR when pulselessness is established
- defibrillate ASAP
- first meds:
- epi 1mg IVP q3-5 min
- antiarrhythmic med - amiodarone
treatment of PVCs
- treat underlying cause
- limited to those with severe Sx
- meds to suppress ventricular ectopy suppress protective vent escape rhythms
- pro-arrhythmic properties
- treatment is cost-benefit anaysis

- PVCs
- rhythm may interrupt underlying rhythm
- rate at any HR and with any underlying rhythm
- P wave may not be present or immediately after; unrelated to PVCs
- PR interval immeasurable
- QRS wide, bizarre, 0.12 sec or longer
- T wave frequently extends in opposite direction of QRS
absolute refractory period
immediately following depolarization - heart cannot respond to another stimulus regardless of stimulus strength
etiologies of PAC’s
- stress, fatigue
- caffeine, alcohol, tobacco
- may be associated with:
- MI, CHF
- infection
- hypoxia
- hypokalemia, hypomagnesemia
- may precede deterioration into A-f or AFc
clinical presentation of complete heart block
- serious and life-threatening
- not tolerated d/t low heart rate (decreased CO)
- hemodyanmic instability
- dyspnea, HF, hypotension, syncope, chest pain
- can progress to ventricular standstill with little/no warning
P wave/QRS complex in dysrrhythmia interpretation
- P wave in front of every QRS complex?
- every QRS complex with a preceding P wave?
- if YES - electrical activity coming from atria
- but NOT necessarily the SA node
- if NO - QRS complex w/o preceding P wave
- electrical activity originated in ventricle

- wandering atrial pacer
- rate usually 60-100, if over 100 - multiple atrial tachycardia
- rhythm regular or irregular
- P wave 3+ morphologies, A:V ratio 1:1
- PR interval varies on location of ecotpic atrial sites (some may be less than .12sec)
- QRS less than 0.12 sec
- QT interval less than 1/2 preceding R-R interval
regular or irregular HR in dysrrhythmia interpretation
- regular, regularly irregular, or irregularly irregular?
- ex: a.fib is irregularly irregular
- does the abnormality appear on a regular basis or irregular basis?
- pattern in the abnormality or abnormalities?
what type of PVC is this?

ventricular trigeminy - every third beat is a PVC

- ventricular fibrillation
- rate immeasurable
- rhythm chaotic
- p wave chaotic, no AV ratio
- PR interval immeasurable
- QRS absent
- QT interval absent
- will NEVER be a perfusing rhythm
atrial fibrillation overview
- chaotic electrical activity originating from irritable atrial tissue
- cause atrial muscle to quiver ineffectively, losing atrial kick
- only some of atrial impulse conduct thru AV junctional tissue thru ventricular conduction system
- CO can be compromised by 5-30%
- gatekeeping fxn of AV node important
- only lets the strongest of the 300+ atrial impulses thru/minute
etiology of normal sinus rhythm
normal pacemaker rate

- 2nd degree heart block: type 1 (Wenckebach)
- rhythm irregular
- rate atrial normal; ventricular slower b/c not all beats conduct
- P wave upright, uniform, some now followed by QRS
- PR interval progressively longer until no conduction
- QRS normal, 0.12 sec or less
- QT usually normal, less than 1/2 preceeding R-R
causes of PEA

depolarization
- electrical excitation across the myocardial cell membrane
- spreads from cell to cell through conduction system and muscle cells
- sodium and calcium move into cell, potasssium out
- provides stimulus for ocntraction

- sinus arrhythmia - from SA node irregularly in relation to respiration
- variations in breathing d/t fluctuations in parasympathetic vagal tone
- rhythm irregular
- rate speeds up during inspiration, slows during expiration
- P wave for every QRS, same size and shape
- PR interval normal, 0.10-0.20 sec
- QRS same size and shape; normal duration (0.04-0.12 sec)
what is this rhythm?

V-tach

- supraventricular tachycardia (SVT)
- rhythm may be regular
- rate 150-250 bpm
- p wave usually hidden in preceding T wave
- PR interval immeasurable d/t hidden P waves
- QRS narrow, less than 0.12, all the same
overview of atrioventricular conductiondisorders (aka blocks)
- delay through bundle of His = PR interval
- time to allow atria to complete contract and impart “kick” in pressurizing ventricles to prepare (stretch) them for power of stroke contraction (Starling’s Law)
- problems arise when conduction through AV node is slowed (1st), delayed to prevention (2nd T1), intermittent (2nd T2), completely blocked (3rd)
- reaches a point where more passive filling of RA won’t impact CO (too much delay)
- dysfxn, fewer ventricular complexes, fewer ventricular contractions, negative impact on CO
conduction system of the heart

QRS interval in dysrrhythmia interpretation
- less than .12 s (120 ms)
- QT normally less than 1/2 of proceeding R-R interval
concerns and treatments with 2nd degree heart block: type 2
- concerns
- bradycardia common
- often progresses to complete heart block
- treatment
- transcutaneous pacing
QRS wave
- ventricular depolarization as impulse travels through both ventricles
- width of QRS wave indicates intraventricular conduction time
etiologies of atrial flutter
- after open heart surgery
- MI
- mitral or tricuspid valvular disease
- PE
- chronic atrial flutter d/t organic heart dx
- ischemia
EKG
graphic recording of the electrical current produced by depolarization and repolarization of the heart
overview of third degree (complete) heart block
- total block at AV node, so no conduction of SA node impulses through AV node
- atria and ventricles dissociated from each other
- funtion independently, using intrinsic mechanisms to pace themselves
causes of ventricular tachycardia
- MI, CHF, cardiomyopathy
- electrolyte disturbances
- acid-base disturbances
- R on T
- direct stimulation of myocardium
- profound hypokalemia
isoelectric line
- EKG machine’s stylus producing a straight line on the paper when unconnected from the patient’s electrodes
- all electrical forces are equal
- also asystole - no electrical activity
- flow towards positive electrode = upright waveform
- flow towards negative electrode = downward waveform

HR in dysrrhythmia interpretation
- normal = 60-100
- origin likely from SA node
- dramatic changes in HR without changes in SV will change CO

- ventricular tachycardia
- rate 140-250 bpm
- rhythm regular
- p wave no discernable p waves
- QRS >0.12 sec, morphology can be identical or vary
-
QT interval usually immeasurable
- subcategory of VT called polymorphic, prolonged QT, ventricular tachycardia b/c of QT of underlying rhythm
- can be brief/nonsustained (30 sec or less) or sustained (>30 sec)
what type of PVC is this?

triplet - three PVCs in a row (uniform or multiform)

- premature atrial contractions
- impulse from atria that is earlier than next expected sinus beat d/t irritable, ectopic focus in atrial tissue
- rhythm underlying may be regular, overall irregular d/t PAC
- rate of underlying rhythm
- P wave different morphology from SA node p wave; may be hidden in preceding T wave
- PR interval between .10 and .20 seconds - different fro the ectopic beat
- QRS narrow, same, less than .12 sec
- QT interval less than 1/2 preceding R-R
overview of second degree heart block: type 1
- aka Wenckebach
- SA node impulses progressively delayed until one impulse is not conducted
- then cycle repeats
- longer, longer, longer drop. Now I know my Wenkebach
six questions for dysrrhythmias interpretation
- HR: fast, slow, normal?
- regular or irregular?
- morphology of p waves and A:V ratio
- PR interval
- QRS measurement
- P wave for every QRS?
- QRS after every P wave?
treatments for second degree heart block: type 1
- based on symptoms of bradycardia
- transcutaneous pacing
- atropine
- dopamine or epi drip
- permanent pacemaker may be indicated if Wenckebach persists
polarized
- resting cell’s electrical charges are balanced
- cell is ready for action
atrial rhythms - overview
- result of electrical impulse originating from atrial tissue that is NOT SA node - ectopic impulse
- occurs when atrial rate faster than sinus rate and overrides SA node to generate depolarization
- unusual P waves - notched, flattened, peaked or biphasic
- d/t slower, atypical impulse conduction thru atria
- impulse travels thru AV junctional tissue and ventricular conduction pathways terminating in Purkinje fibers
- supraventricular rhythms create narrow (normal) QRS wave - no problem in ventricle
etiologies of accelerated junctional rhythms
- usually transient
- enhanced autorhythmicity of junction
- digitalis or theophylline toxicity
- catecholamien surge from stress, stimulants
- acid base imbalances
digitalis
- increases contractility of heart indirectly by actingon AV node to make it less irritable and slow conduction
- allows for more ventricular filling
- rate control in A.fib
- things to check
- therapeutic levels - narrow therapeutic range (renally cleared)
- apical HR
Bundle of His and Bundle branches
- divides into right and left Bundle branches which descends on either side of interventricular septum
- left bundle branch divides into 2 fascicles (anterior and posterior)
- conduction speed in left bundle is faster than right
- Bundle of His is a pacemaker site with inherent rate of 40-60 times/minute
what type of PVC is this?

ventricular quadrigeminy - every fourth beat is a PVC
basic electrophysiology of EKG
- electrocardiography cannot detect mechanical performance of the heart
- beware of pulseless electrical activity (PEA)
- aka electromechanical dissociation
- expert level dysrhythmia interpretation does not replace expert level patient assessment
concerns with atrial fibrillation
- most common dysrhythmia - patients can live with it chronically
- rate control
- prevent clot formation
- loss of CO from atrial kick

- atrial flutter
- rhythm atrial regular, ventricular variable (depends on A:V)
- rate atrial 250-400, ventricular variable
- P wave fast “saw tooth” or “picket fence” flutter waves that are uniform; AV ratio can be fixed w/ regular ventricular rhythm or variable
- PR interval immeasurable
- QRS duration less tahn 0.12 sec, identical morphology
- QT interval less than 1/2 preceding R-R interval (normal)