EKG Rhythms Flashcards by Tricia Vantino

What are the 4 major narrow complex tachycardias?

Sinus Tachycardia
Paroxysmal Supraventricular Tachycardia
Atrial Flutter
Atrial Fibrilation

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What are three types of Paroxysmal Supraventricular Tachycardia

AV nodal reentrant Tachycardia (AVNRT): Dual AV nodal pathways like
Wolff Parkinson White
Atrioventricular reentrant tachycardia (AVRT) - “typical” SVT
Multifocal Atrial Tachycardia

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Of the narrow supraventricular tachycardias, which are regular (5)?

Sinus tachycardia,
Atrial tachycardia, or
Atrial flutter with pure 2:1 (or rarely 1:1) conduction,
Atrioventricular nodal reentrant tachycardia (AVNRT) - SVT, and Atrioventricular reentrant tachycardia (AVRT) - WPW
are very regular.

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Of the narrow supraventricular tachycardias, which are irregular (3)?

Atrial fibrillation,
Multifocal atrial tachycardia and Atrial flutter or Atrial tachycardia with variable degrees of atrioventricular (AV) block are irregular.

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How do we determine the rate of EKG via big boxes?

300 / number of big boxes between R-R. only works for regular rhythms

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What is a hallmark of SVT (AVRT) on EKG?

No p waves or retrograde p waves after the QRS

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Hallmark of Multifocal Atrial Tachycardia on EKG?

3 or more morphologically different P waves and Irregular

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What is the wide regular tachycardia?

Monomophric Ventricular Tachycardia

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What are the wide irregular tachycardias?

Polymorphic Ventricular Tachycardia (Tdp)
Ventricular Fibrillation

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EKG for sinus bradycardia
PR interval and QRS

Normal PR Interval and no dropped QRS.

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EKG for 1st Degree AV Block
PR interval and QRS

PR interval - Prolonged greater than 0.2s
No drop in QRS

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EKG for 2nd Degree AV Block Type 1
PR interval and QRS

Progressively longer PR
Dropped QRS

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EKG for 2nd Degree AV Block Type II
PR interval and QRS

PR Constant
Drops QRS

Visible QRS usually widened

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EKG for 3rd Degree AV Block
PR interval and QRS

AV Dissociation - no communication

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What should a normal axis look like? What leads do you look at?

Look at Lead I and aVF.
Are P and QRS both upright?
If aVF is equiphasic, count as up.

if yes, Normal Axis

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What would left axis deviation look like? What leads do you look at? Where do you look to confirm?

Look at Lead I and aVF.

If Lead I is positive and aVF is more negative - it is likely Left Axis Deviation.

Look at Lead II to confirm. If it is equal phasic, it is indeterminate.

If Lead II is more negative, then Left Axis Is Deviated.
If Lead II is positive, it is a normal axis.

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Causes of Left Axis Deviation

Things that alter LV depolarization
-LBBB
-LVH
-LAFB (left anterior fascicular block)

Normal Variant in Obese People

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What would right axis deviation look like? What leads do you look at? Where do you look to confirm?

Look at Lead I and aVF

If Lead I is negative and aVF is positive you have right axis deviation.

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Causes of Right Axis Deviation

-RBBB
-RVH
-LPFB (left posterior fascicular block)
-COPD, PE
-WPW
-Previous Lateral/Ant MI (LV atrophy, can’t conduct)

Can be a normal variation in tall/slender people

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EKG changes for extreme right axis deviation

Both Lead I and aVF downward reflected

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Characteristic EKG changes of Wolf Parkinson White

Delta wave
Short PR interval
QRS greater than 120ms

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Some causes of prolonged QT interval (>500ms)

Anti-Arrthymics
Anti-Biotics
Anti-psyChotics
Anti-Depressants
Anti-Emetics

-Hypo K, Mg, Ca

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Some causes of short QT interval (<460ms)

Hyperkalemia, Hypercalcemia

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Where to look for EKG changes for left atrial enlargement

Lead II and V1

Is lead II p wave biphasic with a sort of dicrotic-looking notch? Then look at V1.

Is V1 a biphasic but mostly negative deflection at the terminal end?

If both yes, it is indicative of left atrial enlargement.

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Causes of left atrial enlargement

Left Heart Failure Cardiomyopathy Mitral Disease

Where to look for EKG changes for right atrial enlargement?

Lead II and V1 Lead II p-wave tal, greater than or equal to 2.5mm. Then look at V1, if initial component is larger than second of p-wave - indicative of RA enlargement

Causes of right atrial enlargement

Pulmonary HTN Tricuspid Disease

Where to look on EKG for LBBB

Look at V5 and V6. Does it have a notched R wave? If yes, could be LBBB Look at V1 and V2. Does it have a rS morphology? Deep (negative) S wave.

Where to look on EKG for RBBB?

First look at V1 and V2 - does it have a rSR' morphology? (bunny ears) Next look at V5 and V6. qRs, Is there a wider, slurred s wave? - if yes to both, RBBB indicated

Where to look for EKG changes indicating LVH

Lead V1 and V2 - Deep S Waves Then V5 and V6 - Tall R Waves

2 causes of LVH

Aortic Stenosis Hypertension

Where to look for EKG indicating RVH

V1 and V2 - Tall R wave V5 and V6 - Deep S wave

Name a cause of RVH

Pulmonary HTN

When assessing for ST depression, where should you first look and what are you looking for?

V2 and V3 - ST Depression 0.5mm or more All other leads >1mm Horizontal and/or Down-Sloping ST Depression in two contiguous leads

What morphology of ST depression is less indicative of ischemia?

An upsloping ST depression

ST depression and T wave inversion can be indicative of?

If trops positive - NSTEMI If trops negative - Unstable Angina Digoxin Toxicity, Hypokalemia

Which is more concerning: ST Elevation with a concave or Convex morphology

Convex

What amount of elevation is concerning for ST Elevation in all leads? Is there an exception?

New ST elevation at the J point in two contiguous leads of 0.1mV in all leads EXCEPT V2 and V3. V2 and V3: greater than or equal to 0.2mV in men 40 years old or more greater than or equal to 0.25mV in men less than 40 greater than or equal to 0.15mV in women

Causes of ST elevations

STEMI Pericarditis Hyperkalemia

How can you differentiate between Pericarditits and STEMI

Pericarditis usually has a concave ST elevation shape and more diffuse across almost all leads

What is the difference between Atrial Tachycardia and Multifocal Atrial Tachycardia?

AT: 3 or more consecutive PACs coming from a single atrial focus, having identical, NON-SINUS, P-wave morphology MAT: 3 or more consecutive different morphologies P waves

MAT most commonly occurs in patients with?

chronic lung disease

Longer runs, or chronic, atrial tachycardias are usually treated with?

Antiarrhythmics or Ablations

An isolated posterior MI is treated as a STEMI. What would you see on a regular 12 lead EKG that would make you want to investigate and consider a posterior 12 lead?

ST depression in Anterior leads (V1-V2) may indicate the presence of a posterior MI

When assessing for R wave progression, what direction of the chest leads do you expect the R wave to go from smaller to larger?

V1 smallest -> V5-6 biggest

What leads do you review for R wave progression?

Precordial / Chest Leads

As the R wave gets bigger, what happens to the S wave?

As R wave gets bigger, S wave gets smaller

What are the characteristics of an Accelerated Idioventricular Rhythm?

3+ consecutive ventricular beats that are faster than regular intrinsic ventricular beats >40bpm, but slower the vTach which is >100

1st degree AV Block has a PR interval greater than?

0.2s or 200ms

What is the difference in PR interval between 2nd-degree type II and 3rd-degree AV block?

2nd degree type II has a consistent PR interval The atrial rate is always faster than the ventricular rate in 3rd degree

Your potassium is ~5.5 or greater; what EKG findings could you see?

QRS > 0.20, no visible p waves, Peaked T wave in MORE THAN ONE LEAD.

Your potassium is less than ~2.7; what ekg changes could you see?

Prominent U wave due to delayed ventricular repolarization. Small or inverted T-wave may or may not be visible.

What are some ECG changes that could occur with hypermagnesemia - Mag > 10

Delayed intraventricular conduction, prolonged QT interval, first-degree heart block, Can progress to worsening blocks

ECG findings with hypomagnesemia Mg<1.0

Prolongation of QT and PR intervals

With what electrolyte disturbance would you see an Osborn or J wave? What condition can also produce J waves?

Hypercalcemia - send troponins AND a calcium level. Hypothermia

What ECG changes can you see with hypercalcemia?

Shortening the ST segment corresponds to shortening or QT. Osborn Wave / J wave

T waves usually have a gradual ascending limb and a steeper descending limb. What electrolyte disturbance may cause a reverse of this, steep ascending and gradual descending?

Hypercalcemia

Atrial Flutter is commonly a macro-reentrant tachycardia, what does that mean?

Develops a circuit within the RA where the impulses keep firing at the AV node.

What is Sick Sinus Syndrome? How does it manifest? How is it treated?

Irreversible dysfunction of SA node. Idiopathic, "normal" wear of the heart. Manifests as SB, sinus arrest, SA block, tachybrady syndrome Tx: Permanent Pacemaker

Normal T wave morphology. How should the ascending and descending parts of the wave look?

Upstroke should be slower and downstroke should drop / be steeper. Think rollercoaster

In a normal EKG, the T wave is always upright in what leads?

Leads I, II, V3-V6 And inverted in aVR (if it's not, we have some sort of pathology going on)

T waves may be flipped in what leads as a normal variant

V1 and V2 (maybe V3)

What is the normal degree range for the QRS axis

-30 to 90 degrees

If you're having extreme right axis deviation, that means electrical activation is originating from?

The ventricles. Bad news, bears.

Causes of extreme right axis deviation

VT Accelerated Idioventricular Rhythm (death of primary pacer cells) Massive MIs Severe RVH Hyperkalemia

What is an incomplete Right BBB or LBBB?

It meets the morphology criteria, but it is within normal QRS duration. Less than 0.12s.

In a LBBB, which ventricle depolarizes first?

Right Ventricle, then Left Ventricle

What is the most common intraventricular conduction defect?

Left Anterior Fascicular Block (LAFB)

What do you expect to see on an EKG with a patient with a Left Anterior Fascicular Block?

Left Axis Deviation rS complexes in II, III, aVF qR complexes in I and/or aVL