EKGs: Overview & the Atria & Tachyarrythmias Flashcards
what leads show you…..
- posterior heart
- lateral heart
- inferior heart
- anterior heart
Posterior Heart: avR
Lateral Heart: I, avL, V5 & V6
Inferior Heart: II, III, avF
Anterior Heart: V1, V2, V3, V4
what is the Rate of the heart? where are areas in the heart which are able to set the rate
4 places
on the EKG: how do you calculate rate? easy and hard way
Rate: Speed at which the heart can beat
SA node: the main pacemaker of the heart: maintains the rate of 60-100 BPM
brady: < 60
tachy: > 100
automaticity foci: areas of the heart which if something happens to the rate pacemakers above will kick in a beat at their own speed
atrium: 60-80
junctional: 40-60
ventricular: 20-40
Rate Calculations
— 300/ (number of peaks of the R waves starting with the first R that starts on the bold lines and then the next R tha t falls on a bold line )
– or read the rate on th ecomputer print out
3 questions to ask when deciding the rhythm of an EKG?
is it sinus or not?
1. is there a P wave before every QRS
2. is there a QRS after every P
3. is the P wave in Lead II going UP?
if yes x3 = sinus rhythm from the SA node
what is sinus arrythmia?
why does it occur
- a SINUS rhythm – from the SA node
- but irregular intervals between each section
occurs - NORMALLY (exaggerated in kids)
- a sympathetic stimulation during inhale
- a parasympathetic stimulation during exhale
- can happen post-MI
if the rhythm is not coming from the SA node (not sinus) –> what are the 4 broad categories it will be called
- irregular rhythms
- escape beats
- premature beats
- tachy-arrythmias
what is normal Axis deviation (degrees?)
- how to determine axis (math way & easy way)
normal deviation of axis: -30 –> 110 degrees
axis determination
Math Way: find the lead where the QRS is equal up and down –isoelectric) should be the avL & then find the axis perpendicular
Easy Way: the thumb method
- left thumb: point the direction of the QRS complex in lead I
- right thumb: point the direction of the QRS complex in lead avF
Length of Time for Intervals
- PR interval
- QRS complex
- QTc interval
conditions of which ther will be abnormal intervals
PR interval: 5 little boxes = .2 seconds
QRS complex: 3 little boxes = .12 seconds
QTc interval: should be 1/2 of the proceeding R-R interval (longer in women slightly)
conditions of abnormal intervals
- 1, 2 &3 heart blocks
- BBB
- long QT
3 types of irregular arrythmias (types of arrythmias)
Irregular Arrythmias = rhytms being made from sites other than the SA node
- wandering pacemaker
- mutlifocal atrial tachycardia
- atrial fibrillation
what is Wandering Pacemaker
what will be seen on EKG & due to what
what do you do for treatment
wandering pacemaker: a type of irregular arrythmia
- result of a battle between the SA node and anotehr atrial etopic foci of automaticity attempting to set the rhythm for the heart
- resulting in 3 various p wave formations on the EKG
- normal
- inverted (from AV travels back)
- P prime (double Pwave) from the etopic trying to set the rhythm
what do you do
- nothing: this is benign
- can monitor pts. with this but no intervention needed
what is Multifocal Atrial Tachycardia?
- what condition is associated with it
- what will you see on EKG that is specific to the WAT
- what is treatment
- think of COPD– most commonly pt. will present with this & have concurring COPD
- multiple foci of automaticity in the atria attempt to make the pace, SA node still attempting too
- see 4+ different P waves
- specifically: see a SPIKEY triangular P wave in lead II
treatment: treat the underlying condition
What is atrial fibrillation
- how with the atrial contractions appear on EKG
- how will ventricular
- a fib = quivering atria because there are SO many etopic foci attempting to pace the heart – no clear winner
- results: a quivering “baseline” with NO clear P wave
Ventricles: QRS will appear normal – the AV node is still properly only allowing some signals to pass down
- ** the intervals between the QRS complexes will have no rhyme or reason – irregular in nature**
what are Esacpe Rhythms? Beats?
- when do they occur
- where can they originate from
Escape rhythms & beats: are triggered when the SA node does not fire – someone needs to step in!
- the beat: a one type trigger from a foci that triggers the beat & then SA node comes back
- the rhythm: the SA node is not coming back, the foci takes over as the pacer
these escape beats are life-saving!!! and necessary!
the beats arise from atrial, junctional or ventricular foci
there is sinuse pause (brief) or sinus arrest (>3 seconds)…. how to differentiate which foci started the following esacpe rhythm?
- atrial
- junctional
- ventricular (prone to what & why)
Atrial: (60-80) might look the same as a normal EKG — only if you had a previous strip to compare to would you notice smaller P waves
Junctional: (40-60) would look much slower & absent P waves
might see the p-wave SLIGHTLY before QRS or slightly after depending on where to foci is in the junction – but because its traveling UP towards atria its gonna be inverted
Ventricular: (20-40) would look very slow with absent P waves & a WIDE QRS
wide QRS: because the foci is in the ventricles –> spreasd from one to the otehr taking time & so they depolarize at slightly different times
ventricular Esacpe rhythm prone to Stokes-Adams Syndrone because it s so slow its not compatable with life
what are irritable beats?
three types?
- premature beats: firing of the etopic foci before the caridac cycle is complete!!!
atrial, junctional and ventricualr beats can do this
premature contractions
reasons for atrial or junctional irritable beats?
- what will they look like?
what is bigeminy and trigeminy?
atrial and junctional beats: will be a result of sympathetic stimulation think caffeine, stress, etc.
look like…
-atrial: look like normal P wave, just early (on top of the T wave of previous)
-junctional: can be missing or inverted (just coming way early)
bigeminy: the regular pattern of 1 normal beat, 1 premature
trigeminy: the regular pattern of 1 nomral, 2 premature
bi & trigeminy can be atrial or junctional beats
reasons for ventricular irritable beats?
- what will they look like
- what are they an indication of?
- if 3+ or 6+/min = what
ventricular irritable beats (PVCs) = HYPOXIC CONDITIONS think MI or hypoxia!!!!
- these are not good, you will see a widened QRS complex
- because they’re far from the SA node –> you wont see any impact on the SA node – it will pause and then conitnue its own work - wont reset
3+ PVCs or 6+/min = ventricualr tachycardia!!! emergency
what is Barlow Syndrome?
defect in which the heart valves (cordae tendinae) are too low – sit on top of a ventricualr foci
every closure triggers a foci to signal & sends PVCs
benign condition
R on T Phenomenon
when a PVC falls ONTOP of a T wave – triggers a ventricular fibrillation & can be life threatening
emergency conditions — get pacer pads, O2 and K ready
what are tachyarrythmias?
groups based one?
what do they impact?
- type of tachyarrythmia which come on SUDDENLY & at fast rates
- tachyarrythmias will impact the ventricles!!!
- paroxysmal : 150-250
- flutter: 250-300
- filbrillation: 350-450
paryoxsmal atrial tachycardia
- two causes
- what will you see on EKG
- what is the rate
rate: 150-250 and impacting ventricles
- these are tachyarrythmias which occur due to 2 conditions
- 1. congenital (rare) because of a cresent of cells within the atra which SUDDEN spike rate up
- 2. digoxin: seein a 2:1 block
what will you see?
- will not be able to differentiate the P from the T wave since theyre so close together
paroxymsal junctional tachycardia
- what is it
- what will it look like on EKG
- sudden, rapid (150-250) beating impacting the ventricles
- this is from a juntional foci of automaticity –> so there will be missing p wave, or inverted p waves
what is AVnRT? what is it a type of
- what is happening physiologically
- what is the treatment
- a process of a 2 pathways in the AV node- fast and slow which creates probelms with sending the electrical signal
- the ventrciles depolarize then the atria as a result of the two way pathway
- a type of SVT
Treatment
- vagal maneuvers– scare or throw ice to get them out of the rhythm
- give adenosine to reset rhythm
- CCB or BB can be used
paroxysmal ventricaulr tachycardia
- what is it a sing of
- what does it look like
- waht do you do
- HYPOXIA – THIS IS V TACH!!!
- need to shock pt out of this
can be unifocal (ischemia) ot multifocla(think drug or electrolyte)
what is atrial flutter
- rate, what it impacts
- why its happening
- appearance on EKG
- treatment
Atrial Flutter: rate of 250-250, impacting ventricles!!!!
- irritable foci in the atria are triggering this fast beat and its making its way to the ventricles
EKG: see saw-tooth pattern and messed up (SHARP) QRS complexes (2:1 or 3:1 patteren)
_ CLOT FORMATION BECAUSE BLOOD ISNT MOVING
Treatment: need to get them out of a flutter
- control the AV node & whats getting to ventriclrs via meds
- cardioversion shocking
- clot prone – treat with meds or surgery to ablate and stop the flutter
what is ventricular flutter
- rate, why it happens
- what do you see on EKG
- what do you do
250-350 pacing due to a single irritable ventricualr foci
- this is HYPOXIA EMERGECNNY– absluoutely no o2 to the heart or blow flow to body
- faster than vtach, can lead to vfib
- there will be a pattern of just waves
- need to cardiovert and shock
Torsade des pointes
- what is it, how is it different than vflutter
- what do you treat with
- what do you NOT treat with
- there are TWO foci in the ventricles competeing to set pace (250-350)
- ribbon like pattern
treatment
-Mg
- K
- cardiovert (paced shock)
DO NOT GIVE PROCANAMIDE!!!!!!! This will send them to vfib and theyre basically dead
what is atrial fibrillation
- what is occuring
- what are they at risk for
- what will EKG look like
- what do you treat with
atrial fibrillation: 350-450
- multiple foci in the atria trying to control the rhythm
- most commonly the LEFT ATRIUM
- - high risk of clots!!!
- the AV node still is a bouncer: only some pacers get through
- the quiver baseline with irregular QRS spacing
treatmnet
- anticoag to reduce stroke
- antiarrythmia or DC
- BB or CCB to slow AV node!!!
what is ventricular fibrillation
- what is the reason
- EKG
- treatment
multiple foci firing in ventricle at 350-450 rate
- essentailly dead and no rhythm ryme or reason – all waves look different
treatment: CPR and DEFIBRILLATION – SHOCK!!!
what is WPW
- type of what
- what is key charactersitc on EKG
- what can we NOT give them
- what can we give them
wolf-parkinson white syndrome
- extra fast pathwy from atria to ventricels = Kent bundle
- but acts as bypass –> so you get a DElTA wave inn QRS complex as it sneaks in to depolarize
CANNOT GIVE CCB OR BB because then all will go through the kent and cause vfib
can give procanamide to long the QT and allow time for signal
