EKG review lecture (F) Flashcards
High yield review: murmurs, arrhythmias, & cardiac dz Deck is full
how does WPW present on EKG?
delta wave
what are the 3 holosystolic murmurs?
- MR
- VSD
- TR
MR + S3 sound = ?
worsening CHF
what is the best indicator of prognosis in HF?
S3 on p/e
what are the systolic murmurs?
- AS
- PS
- MVP
what will you hear in MVP?
mid-systolic click
what are the diastolic murmurs?
-AR / PR
-MS / TS
(ARMS = PRTS)
when do w/u systolic murmur?
grade 3-4 only
when do you w/u diastolic murmurs?
ALWAYS
which murmurs are assoc w/ widened pulse pressure?
- AR
- PDA
what is a widened pulse pressure?
- large diff btwn SBP and DBP
- HIGH SBP / LOW DPB
which murmurs are accentuated (made worse) by inspiration?
TR and PS
R sided murmurs
which murmurs are accentuated (made worse) by exhalation?
AR (L sided murmurs)
what murmurs will be seen in pts w/ bicuspid aortic valves?
early dz –> AR
late dz –> AS
which valve is most likely the culprit if Q stem doesn’t mention any hx ?
mitral
what murmur is assoc w/ widened fixed S2?
ASD
which murmur radiates to the axilla?
MR
which murmur radiates to the neck?
AS
which murmur localizes to the 1st R intercostal space and presents w/ thrill @ suprasternal notch?
supravalvular AS
which 2 murmurs get softer w/ squating and louder w/ standing and valsalva?
- HOKUM
2. MVP
what are the most important features of afib?
- irreg irreg
- no pwaves
pt presents to the ER w/ new onset afib. you have no pmHx. what must you suspect as the cause of the afib?
hyperthyroid
what do you do always check w/ new onset afib and an unknown pmHx?
check TSH
besides afib, what is another irreg irreg arrhythmia?
multifocal atrial tachycardia (MAT)
what is MAT assoc w/?
COPD
what does MAT look like on EKG?
- irreg irreg
- variable pwave morphologies >=3
pt presents w/ afib. what is the first Q you ask?
are they stable or unstable?
in a stable pt, how to you tx afib?
- CCB
- BB
- If onset afib >=48hrs ago –> + anticoag (warfarin)
how will an unstable pt w/ afib present?
AMS, low BP, tachy
in an unstable pt, how do you tx afib?
- synced cardioversion (100-200J)
in new onset afib (<48hrs) unstable pts should receive a TTE prior to synced cardioversion (time permitting). if a clot is found, how do you proceed?
- anti-coagulate
2. synched cardiovert
what should you do for an unstable pt presenting w/ new onset afib (<48hrs) when you are unable to do a TTE prior to cardioverting?
start anti-coag prior to synced cardioversion just in case
when do you give adeNosiNe?
-NARROW complex tachy = afib, aflutter, SVT
what causes aflutter?
a re-entrant pathway
how does aflutter present on EKG?
- HR 250-350
- “sawtooth” pattern
- 2:1 AV block
how do you tx aflutter?
same as afib
what is synced cardioversion?
sync to the rhythm –> shock the heart
what is unsynced cardioversion (i.e. defibrillation)?
shocks the heart at random
when do you defibrillate?
only when there is no discernable heart rhythm (vfib and pulseless vtach)
which fast rhythms have wide QRS complexes?
vtach and torsades
which fast rhythms have narrow QRS complexes?
afib, aflutter, SVT
pt is stable but EKG shows vtach. how do you tx the pt?
amiodarone (vtach = Wide. Wide gets aMiodarone)
pt presents in vtach and QRS complex on EKG is short (low amplitude). what should you suspect as the underlying etiology of the arrhythmia?
amyloid dz
what lab do you use to dx amyloid?
congo red stain
what does amyloid look like on congo red stain?
+ apple green birefringence
how do you tx SVT?
- carotid massage/ vagal maneuver
2. adeNosiNe (SVT = Narrow complex)
when is carotid massage C/I?
CAS
what does SVT look like on EKG?
- Narrow QRS complex
- no pwaves
what are the 5Hs of PEA?
- hypovolemia
- hypothermia
- hypoxia
- H+ (acidosis)
- hypo/hyperkalemia
what are the 5Ts of PEA?
- tamponade
- tension pneumo
- tablets/toxins (drugs)
- thrombus (coronary)
- thrombus (PE)
how do you tx PEA?
- CPR
- EPI/vasopressin
- correct underlying cause (5Hs and 5Ts)
what do you never do to tx PEA?
cardiovert
how do you tx vfib and pulseless vtach?
CPR + defibrillation
how much time does one small box = on EKG?
0.04 sec
how much time does one big box = on EKG?
0.2 sec
how do you tell 1st degree heart block from 2nd and 3rd degree?
1st degree = no dropped beats
what does 1st degree block look like on EKG?
- prolonged PR int > 0.2 sec (i.e. >1 big box)
- PR = stable length
- NO dropped beats
what are the 2 types of 2nd degree heart block?
type 1 = mobitz 1 = wenkebach
type 2 = mobitz 2
what does mobitz type 1 look like on EKG?
“longer longer longer drop. then you have a wenkebach”
what does mobitz type 2 look like on EKG?
- fixed prolonged PR int
- randomly dropped beats
what is 3rd degree heart block?
complete dissociation of atria and ventricles
what does 3rd degree heart block look like on EKG?
- if Ps and Qs don’t agree, then you’ve got a 3rd degree”
- will not have a pwave for every QRS complex
what is the def of sinus rhythm?
every QRS complex is preceded by a pwave
how do you tx 1st degree heart block
1st degree - generally asymp and won’t tx
how do you tx mobitz 1 heart block?
Generally won’t need to tx. If you do,
- atropine
- synced cardioversion (unstable)
how do you tx mobitz 2 and 3rd degree heart block?
acute presentation: 1. atropine 2. synced cardioversion chronic mobitz 2 and 3rd degree: permanent pacemaker
what class of drugs do you avoid in heart block?
BB
what does R vent hypertrophy look like on EKG?
+R axis deviation (lead 1: QRS -, avF: QRS +)
+R wave in V1 >7mm (>1.4 big boxes)
+/- wide S wave lead 1, V5, V6
what 2 things cause axis deviation?
- BBB
2. vent. hypertrophy
what are 5 causes of R axis deviation?
- cor pulmonale
- dextrocardia
- RBBB
- COPD
- PE
what does L vent hypertrophy look like on EKG?
-R wave in avL >=12mm (>= 2.4 big boxes)
^very specific finding
what is LBBB associated w/?
- MI
2. L axis deviation (lead 1: QRS +, avF: QRS -)
what is seen on EKG in NSTEMI?
- non-specific changes
- might see ST depression
how do you dx NSTEMI?
-labs = troponin and CK-MB
what is seen on EKG in STEMI?
> =1-2mm ST elevation in 2+ contig leads
how long will the ST elevations last after a STEMI?
up to 4 weeks
what is the dx if ST elevation >4wks after a STEMI?
ventricular aneurysm
which leads show ST elevations in lateral STEMIs?
lead 1, avL, v5, v6
which leads show ST elevations in inferior STEMIs?
leads 2, 3, avF
which leads show ST elevations in septal STEMIs?
v1, v2
which leads show ST elevations in anterior (apical) STEMIs?
v3, v4
which leads show ST elevations in posterior STEMIs?
+ leads 7-9
+/- lead 2, 3, avF
what will nL vs R vs L axis deviation look like?
nL –> 1 up, avF up
R –> 1 down, avF up
L –> 1 up, avF down
what does pericarditis look like on EKG?
+diffuse ST elevations (all leads elevated except avF)
+/- PR depression (pathognomonic when present)
+/- electrical alternans (if effusion present)
if untreated, pericarditis can develop into what?
pericarditis –> pericardial effusion –> cardiac tamponade
what is Beck’s triad?
- the triad of s/s seen in cardiac tamponade
1. hypotension, 2. JVD, 3. muffled/distant heart sounds
electrical alternans is seen in what two conditions?
- cardiac tamponade
2. pericarditis w/ large pericardial effusion
what do peaked twaves mean?
high K
what does low K look like on EKG?
- flattened/inverted T waves
- u waves
what does torsades de pointes look like on EKG?
twisted ribbon
how do you tx torsades?
Mg
