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Medical Diagnosis > Lecture 12 (EKG)-Exam 6 > Flashcards

Lecture 12 (EKG)-Exam 6 Flashcards

1
Q

What are the different wall layers of the heart muscle?

A

Epicardium
* Innermost layer of the pericardium & outer surface of the heart

Endocardium
* Lines the inside chambers of the heart & forms the surface of the valves

Subendocardium
* Layer of the cardiac muscle that becomes ischemic first during an MI

Myocardium
* Muscular tissue of the heart

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2
Q

I think this is low yield but it was under a slide

REVIEW EACH STRUCTURE AND WHAT THEY DO
* Superior & inferior vena cava
* Four chambers
* Pulmonary veins
* Pulmonary artery
* Aorta
* Septum

A
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3
Q

Low yield but under slide

Atrioventricular valves
* What are they? What do they do?

A
  • Tricuspid valve - The tricuspid valve is on the right side of the heart. Itseparates the upper and lower chambers, also known as the right atrium and ventricle. The valve allows deoxygenated blood to flow through both of the chambers. The right ventricle pumps blood to the lungs, where it will be oxygenated.
  • Bicuspid/Mitral valve- The mitral valve islocated between the upper left heart chamber (left atrium) and the lower left heart chamber (left ventricle). Controls blood flow from the atria to the ventricles. A healthy mitral valve keeps your blood moving in the right direction. A leaky valve doesn’t close the way it should, allowing some blood to flow backward into the left atrium
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4
Q

Low yield but under slide

Semilunar valves:
* What are they? What do they do?

A
  • Aortic valve - The aortic valvehelps keep blood flowing in the correct direction through the heart. It separates the heart’s main pumping chamber (left ventricle) and the main artery that supplies oxygen-rich blood to your body (aorta).
  • Pulmonary valve - the pulmonary valve isone of four valves that regulate blood flow in the heart. Controls blood flow out of the ventricles. The valve lies between the lower right heart chamber (right ventricle) and the pulmonary artery
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5
Q

Coronary Arteries:
* What do they supply?
* Where do they originate?
* Vessels run where?
* When blocked, what happens?
* What wall of the heart becomes ichemic first?

A
  • Supplies blood flow to the cardiac muscle
  • Originate from the aorta
  • Vessels run both outside & inside the actual heart muscle
  • When blocked, cardiac muscle cells normally fed by the artery become ischemic
  • This is the beginning of an MI
  • The interior wall of the heart (i.e., subendocardium) or inner most layer becomes ischemic first
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6
Q
  • Left Coronary Artery (LCA): What does it involve?
  • Left Anterior Descending Artery (LAD): What does it supply?
  • Left Circumflex Branch (LCX): What does it supply?
  • Right Coronary Artery (RCA): What does it supply?
A

Left Coronary Artery (LCA)
* Involves almost 2/3 of the heart muscle.

Left Anterior Descending Artery (LAD)
* The LAD supplies blood to the anterior portion of the left ventricle, apical including most of the anterior portion of the septum separating the ventricles.
* Bundle Branch Block, AMI, CHF

Left Circumflex Branch (LCX)
* The LCX supplies blood to the lateral portion and the posterior portion of the left ventricle.

Right Coronary Artery (RCA)
* The RCA supplies blood to the inferior & posterior portion of the left ventricle, as well as the posterior portion of the septum
* The RCA supplies blood to the right ventricle, right atrium, SA & AV nodes (regulates heart rate

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7
Q
A
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8
Q
  • What does ischemia cause?
  • What happens when Severe/complete blockage that last more than a short time?
A
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9
Q
  • Alteration in current blood flow due to ischemia creates what on ECG?
A

ST depression on the ECG

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10
Q

12-Lead ECGs
* portion of the heart is affected by what?
* Look at what?
* What does it help point to?

A
  • portion of the heart is affected by a coronary artery blockage
  • look at the electrical current in the heart from different angles
  • helps point what portion of the heart is affected by a coronary artery blockage creating ischemia andwhat artery is blocked
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11
Q

What is the Blood flow of the CV system?

A
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12
Q

Cardiac Cycle
* What is it?
* Expressed as what?

A
  • Electrical or physical sequence of events that encompasses a full depolarization (CONTRACTION) & repolarization (RELAXATION). Ventricular contraction to ventricular contraction.
  • Expressed as beats per minute (BPM) or your heart rate
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13
Q
  • What is systole?
  • What is diastole?
A
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14
Q
  • Fill in
  • Where does Repolarization of atria happen?
A

Repolarization of atria happens during QRS complex and therefore cannot be evaluated

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15
Q
A
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16
Q

What is stroke volume? What is the normal stroke volume?

A
  • Volume of blood being pumped out of the ventricles in a single beat or contraction.
  • Normal stroke volume is 60 – 130 mL
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17
Q

Cardiac output (CO)
* What is it?
* What is the normal value?
* How do you calulate it?

A
  • Amount of blood pumped by the left ventricle in one minute
  • Normal cardiac output is 4 – 8 L/min
  • Stroke Volume (SV) x Heart Rate (HR) = Cardiac Output (CO)
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18
Q
A
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19
Q

he said FYI

What happens during depolarization?

A
  • Myocardial cells are bathed in electrolyte solution
  • Chemical pumps maintain the concentrations of ions within the cell
  • The cell interior receives stimulus from conduction and become positive
  • Depolarization spreads, causing a mechanical contraction
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20
Q

What happens during repolarization?

A
  • Closing of the sodium & calcium channels
  • Cell interior restores the negative charge
  • Sodium-potassium pump reestablishes proper distribution
  • Refractory period
    * Absolute refractory period
    * Relative refractory period
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21
Q

Know

What is phase 0?

A

Cell depolarizes and begins to contract – QRS Complex

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22
Q

Know

What is phase 1

A

Phase 1: Cell begins to repolarize

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23
Q

know

What is phase 2

A

Phase 2: Na+ and Ca++ enter the cell; K+ flows out – ST Segment to downslope of T wave (absolute refractory)

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24
Q

know

What is phase 3

A

Final phase of repolarization –downslope of T Wave (relative refractory)

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25
What is phase 4
Phase 4: Resting phase.
26
Contraction follows what?
follows depolarization and relaxation follows repolarization
27
# know Refractory Periods * What is it? * What are the two period?
It is the period in which the cell is depolarized or in the process or repolarizing and consists of two separate phases: * Absolute refractory period – ventricles have not repolarized enough to enable another depolarization - the QRS complex to the downslope of the T Wave (i.e. systole) * Relative refractory period – some cells have repolarized enough to depolarize again if strong enough stimulus is provided – downslope of T wave
28
SA node: * What is the bpm? * Recieves blood from what? Internodal pathway: * What is this? * Depolarization of what? * Creates what?
Sinoatrial node (SA) * Natural dominant pacemaker, rate 60-100 bpm * Receives  blood from the RCA Internodal Pathway * Electrical path from SA node to AV node * Depolarization of the atria * Creates the contraction of the Atria, known as the P-wave
29
Atrioventricular node (AV) * What is this/what is the bpm? * What happens to the conduction? * Site where what? Atrioventricular bundle (Bundle of His) * Where is it located? * Location of what?
AV node * Secondary pacemaker, rate 40-60 bpm * Conduction delayed to allow atria to empty into the ventricles * Site where the heart blocks occur and if atrial rate is too fast, not all signals will pass  Bundle of His: * Located in the septum * Location of the right and left bundle branches
30
Purkinje fibers * What are they? Both Bundle of His &Purkinje fibers * What do they produce?
Purkinje fibers * Electrical fibers that surround the ventricles & produce the ventricle contraction/depolarization of ventricles, known as the QRS Both Bundle of His &Purkinje fibers * Produce spontaneous action potential if the SA & AV nodes fail, rate 20-40 bpm as a backup measure to ensure blood is continually pumped
31
# He said FYI Conduction pathways that allow current to bypass AV node: * Where are the james fibers? * Where are the mahaim fibers? * The Bundle of Kent enables what?
32
If the SA node is damaged or suppressed, what happens?
If the SA node is damaged or suppressed, other components in the conduction system that can maintain a heart rate and will become the site of origin of the rhythm.
33
What are the different bpm of the pacemarkers?
34
Electrocardiogram * What is it? * What can it be used for? (3)
35
Electrocardiogram - Leads * Three standard limb leads which consist of what? * Which lead is the most helpful? * There are what? * Each lead creates what? * The leads are placed how?
36
Limb leads * known as standard limb leads consist of what? * Which leads view the heart from the front of the body? * leads aVR, aVL and aVF are called what?
* known as standard limb leads consist of Leads I, II and III.  * leads I, II and III view the heart from the front of the body. * leads aVR, aVL and aVF are called augmented limb leads, with only one true pole, other is a combination of information from the other leads
37
Precordial leads * known as what? * Identified as what? * these leads view what?
* known as chest leads * identified as V1, V2, V3, V4, V5 and V6 * these leads view the heart from the front and the left side.
38
Limb leads * Heart emits what? * This electrical activity can be represented by what? * Where is lead 1, 2, 3 placed?
* Heart emits electrical activity with each contraction * This electrical activity can be represented by what we identify as the P, Q, R, S, and T waves on ECG's * Lead I is between to the right and left arms * Lead II is between right arm and left leg * Lead III is between left arm and left leg
39
Augmented Leads * What is avr, avf, acl? * Same locations as what? * What is not needed? * These six leads record electrical activity along a single plane, termed what?
* aVR, faces the heart from the right side, all deflections P, QRS and T are normally negative in this lead. * aVF, augmented left leg lead, oriented to the inferior portion of the heart. * aVL, faces the heart from the left side and is oriented to the anterolateral surface of the left ventricle. * Same locations as leads I, II and III. * No switching of electrodes needed as the ECG recorder does the actual switching and rearranging of electrode designations.  * These six leads record electrical activity along a single plane, termed the frontal plane relative to the heart.
40
For continuous monitoring: * Where does the white, black, red, green leads go? 12 lead: * Where does the white, black, red, green leads go?
For continuous monitoring: * White—right upper chest near shoulder * Black—left upper chest near shoulder * Red—left lower abdomen * Green—right lower abdomen (ground) For 12-lead ECG: * White—right wrist * Black—left wrist * Red—left ankle * Green—right ankle
41
Precordial Leads * Depict the heart in what plane? * Represented as what? * What does Leads V1 and V2 view? * Leads V3 and V4 looks at what? * Leads V5 and V6 view what?
* Depict the heart in the horizontal plane * Represented as V1, V2, V3, V4, V5 and V6 * Leads V1 and V2 view the septum * Leads V3 and V4 look at anterior wall of the left ventricle * Leads V5 and V6 view the lateral wall of the left ventricle
42
Correct and consistent placement of leads is essential to accurate ECG readings * Where does V1,2,3,4,5,6 go on the body?
* V1 -  fourth intercostal space (ICS) to right of the sternum – looks at right ventricle * V2 – fourth ICS to the left of the sternum * V3 – directly between leads V2 and V4 * V4 – fifth ICS at the left midclavicular line * V5 – at level of V4 at left anterior axillary line * V6 – at level of V4 at midaxillary line
43
Contiguous Leads Which leads are lateral, inferior, septal and anterior?
44
# Electrocardiogram – ECG Concepts * ECG baseline is what? What is it also called? * Electrical activity that moves toward a positive electrode will show as what? * Electrical activity that moves in the direction of a negative electrode will show as what?
* ECG baseline is a flat, horizontal line that represents no electrical activity-> Sometimes called the isoelectric line * Electrical activity that moves toward a positive electrode will show as a deflection ABOVE the baseline. * Electrical activity that moves in the direction of a negative electrode will show as a deflection BELOW the baseline.
45
Electrocardiogram – ECG Paper * One small box is what is seconds? * One LARGE box, consisting of five small box equals what? * Vertical axis represents what? * Calibration box is printed when?
* One SMALL 1 – mm box equals 0.04 seconds. * One LARGE box, consisting of five small box equals 0.20 seconds. * Vertical axis represents the amplitude. * Calibration box is printed the beginning of 12 Lead ECG's, standard is 10 millimeters per millivolt.
46
# KNOW Intervals * What is normal secs for PR, QRS, QTc?
* PR - 3-5 small boxes or 0.12 – 0.20 seconds. * QRS - 2-3 small boxes or 0.08 – 0.12 seconds. * QTc – 10-11.5 small boxes or 0.35-0.45 (men) and 0.36-0.46 (women)
47
The 6-second Method * Can be used for what? * What do you count?
* Fastest way to measure heart rates * Can be used for regular or irregular rhythms but best for irregular rhythms. * Count the number of QRS complexes in a six second strip.
48
Sequence Method * Can also be used when? * **What is the sequence?** * How do you do it?
* Can only be used when rhythm is regular. * Must memorize the following sequence: 300, 150, 100, 75, 60. * Find an "R" wave on a heavy line and count off 300, 150, 100, 75, 60 for each large box you land on until you reach the next "R" wave.
49
Electrical conduction events on an ECG consist of a series of what?
* Waves * Segments * Intervals * Complexes
50
P wave * What is it? * What is the shape? * What is the normal duration?
* first wave of an ECG complex * represents atrial depolarization * smooth, round, upright shape * normal duration of a P wave is less than 0.11 seconds.
51
What does a notched p wave mean?
wide (enlarged) or biphasic P waves may be seen in increased left/right atrial pressure and left/right atrial dilation
52
* What does the The first 1/3 of the P wave correspond to? Middle? final? * What is biphasic?
* The first 1/3 of the P wave corresponds to right atrial activation, the final 1/3 corresponds to left atrial activation; the middle 1/3 is a combination of the two * If V1 P is biphasic, which part of wave is bigger (1st or 2nd)? If 1st,  consider RAE, If 2nd, consider LAE
53
Inverted P waves * Produced when a P’ wave arises from * Results in what? * May immediately proceed, occurs when? * Associated with dysrhythmias that originate from what?
* Produced when a P’ wave arises from the lower right atrium near the AV node, in the left atria or the AV junction * Results in retrograde depolarization of the atria * May immediately proceed, occur during or follow the QRS complex  * Associated with dysrhythmias that originate from the AV junction
54
PR Interval (PRI) * **What is it?** * Measures what? * What is the normal range? * When does shorter PR happen? Longer? * What does varible PR mean?
* **distance from beginning of P wave to beginning of QRS complex.** * measures time from start of atrial depolarization to start of ventricular depolarization. * **normal range is 0.12 to 0.20 seconds**. * Shorter P’R intervals occur when the impulse originates in the atria close to the AV junction or in the AV junction (Preexcitation) * Longer P’R intervals occur when there is a delay in impulse conduction through the AV node * Variable PR – Wandering atrial pacemaker
55
QRS complex * What does it represent? * Greater than what? * Duration? * Abnormal when? * From beginning of Q wave to what? * What is a normal variant? * Indicates what?
56
QRS complex * Q wave is what? * R wave is what? * S wave is what? * R and S waves represent what?
* Q wave is the first negative deflection and if greater than 0.04 seconds wide or deeper than 1/3 the height * R wave is the first upward deflection * S wave is the downward deflection after the R wave * R and S waves represent depolarization of the right and left ventricles
57
What is this called?
qs wave. Note that q and s waves are utilized with a lower case indicating pathology. Injured regions of the heart may become electrically inactive. Myocardial infarction is the most frequent cause of this.
58
* If there is no R wave, the complex is called what? * If there is no Q wave, the complex is called what? * While there is only one Q wave there can be more what?
* If there is no R wave, the complex is called a QS complex * If there is no Q wave, the complex is called an RS complex  * While there is only one Q wave there can be more than one R and S wave
59
J point * What is it? * Often becomes depressed or elevated with what? * May represent beginning of what? * J point identification will help you to what?
* Where ST segment takes off from the QRS complex * Often becomes depressed or elevated with ischemia and is usually the point to look for * May represent beginning of repolarization * J point identification will help you to determine ST segment changes
60
ST Segment * What is it? * Indicated what? * ST elevation may indicate what? * ST depression may indicate what? * Difference between injury and ischemia is what?
* Straight line connecting end of the QRS complex with beginning of T wave. * Indicates end of ventricular depolarization and start of ventricular repolarization. * ST elevation may indicate myocardial injury or ischemia. * ST depression may indicate myocardial ischemia. * Difference between injury and ischemia is based on time.
61
What is ischemia, injury and infactions?
* Ischemia: Reduction of myocardial oxygen for less than 20 minutes. The damage is reversible. In the electrocardiogram, ischemia produces changes in T wave. * Injury: Persistence of oxygen deficiency (more than 20 min). Damage is still reversible. Injury is characterized by ST-segment abnormalities. * Infarction: Persistence of oxygen deficiency for more than two hours. Damage is irreversible. Infarction is characterized by pathological Q waves on the electrocardiogram.
62
T wave * What is it? * Broader than what? * What is the shape? * Large T waves are associated with what? * Tall pointed T waves may be associated what? * T wave inversion can be secondary to what?
* Represent ventricular repolarization * Broader then the QRS complex * Simpler and more rounded because repolarization is much slower than ventricular depolarization * Large T waves are associated with myocardial ischemia, injury and infarction * Tall pointed T waves may be associated with hyperkalemia * T wave inversion can be secondary to ischemia, CNS events of just normal finding
63
fill in for t waves
64
U wave: * Always after what? * May what? * May represent what? * May indicate?
* Always after the T wave * May not always be seen * May represent final stage of ventricular depolarization * **May indicate hypokalemia**
65
QT interval * Represents all what? * Includes what? * Considered long if what? * Prolonged QT intervals can lead to what? * What can prolong the QT interval? * Most modern EKG machines will give what?
* Represents all electrical activity of one completed ventricular cycle * Includes the QRS complex, ST segment and the T wave * Considered long if greater than 0.46 seconds * Prolonged QT intervals can lead to ventricular dysrhythmias and sudden cardiac arrest * Medications taken by patients CAN prolong the QT interval * Most modern EKG machines will give you a QTc (corrected) interval for patients heart rate
66
Normal QT intervals is what? Correct QT if rate is what?
* Normal QT intervals is less than or = to half of R-R distance in normal rate * Correct QT if rate is not normal
67
Characteristics of Rhythms * Various rhythms can be determined by what? * ID of the rhythms can help with what? * It is important to be able to identify what? * dentifying that rhythms also have what? * **The single most important concept that you must remember is**
* Various rhythms can be determined by the site that they arise from.  * Identification of the rhythms can help with defining the appropriate treatment that may be needed.   * It is important to be able to identify what is considered a normal rhythm to identify what is abnormal.  * Identifying that rhythms also have a consistent pattern will help with identification.  * The single most important concept that you must remember is above all, you treat the patient, not the monitor. 
68
Normal Sinus Rhythm * What is the HR? * Little variation between what? * What is the normal PR interval?
* Heart rate is between 60-100 beats per minute * Little variation between R-R interval * NORMAL PR interval of 0.12 to 0.20.
69
Normal Sinus Rhythm: * Rate = * Rhythm = * P-wave before each QRS = * P-wave upright/uniform= * PR Interval = * QRS =
* Rate = 60-100 bpm * Rhythm = regular * P-wave before each QRS = YES * P-wave upright/uniform=YES * PR Interval = 0.12-0.20 sec. * QRS = narrow <0.12 sec., similar
70
What is this rhythm?
Normal Sinus Rhythm
71
Sinus Bradycardia * Very low rates can lead to what? * Ectopic pacemakers from the AV node or ventricles may what? * This may be a normal condition in who? * When do you need to treat?
* Very low rates can lead to inadequate cardiac output. * Ectopic pacemakers from the AV node or ventricles may produce escape beats if the rate becomes too slow. * This may be a normal condition in young healthy adults and athletes. * If symptomatic due to the slow heart rate, then may require treatment. 
72
Sinus Bradycardia * Rate = * Rhythm = * P-wave before each QRS = * P-wave upright/uniform = * PR Interval = * QRS =
73
What is the rhythms?
Sinus Bradycardia
74
Sinus Tachycardia * What is the HR? * What is the rhythm? * P wave proceeds every what? * May be caused by what? * Prolonged tachycardia can cause what? * What is the Treatment?
* Heart rate is between 101 and 150 beats per minute * Regular rhythm * P wave proceeds every QRS complex. * May be caused by pain, hypoxia, fever and medications to name a few. * Prolonged tachycardia can cause further ischemia and infarction by increasing the workload of the heart. * Treatment consist of finding the underlying cause.
75
Sinus tachycardia * Rate = * Rhythm = * P-wave before each QRS = * P-wave upright/uniform = * PR Interval = * QRS =
* Rate = 101-150 bpm * Rhythm = regular * P-wave before each QRS = YES * P-wave upright/uniform = YES * PR Interval = 0.12-0.20 sec. * QRS = narrow <0.12 sec., similar
76
What is the rhythm?
Sinus Tachycardia
77
Sinus arrhythmia * What is it? * Variation occurs with what? * Variation occurs when? * Upright P waves precedes what? * What is not required? * Can be what?
* Slight variation in sinus rhythm cycling that usually occurs with breathing. * Variation occurs more with each inspiration. * Upright P waves precede the QRS complexes. * No treatment required. * Can be indicative of WAP (look at morphology of p waves)
78
What rhythm is this? How can you tell?
Sinus arrhythmia * Regular * P-R interval normal * Normal identical P waves * Each P followed by a QRS * Normal QRS * Rate 60-100 beats per minute | normal variability in PP intervals with the respiratory cycle
79
Sinus arrest: * What happens? * Regular rhythm except for what? * Causes can include what? * What can cause this? * May need what?
* SA node fails to initiate an impulse for one cycle for at least 3 seconds then resumes afterwards. * Regular rhythm except for the absent P wave that occurs. * Causes can include ischemia of the SA node as well as an increase vagal tone caused by carotid sinus massage. * Medications such as digitalis can cause this.  * Treatment MAY require a pacemaker.
80
Sinus arrest: * Irreg or reg rhythm? * P wave present before what? * What is ditrubed? * What is the PR interval? * What is normal?
* Rhythm is irregular when it occurs * P wave present before each QRS * P to P wave is disturbed * PR interval is 0.12 to 0.20 * QRS is normal
81
What is this?
sinus arrest
82
Supraventricular Tachycardia * Orignates wherr? * Does not come from what? * What HR does not cause life threatening issues? * What happens to CO? * As the heart rate gets faster, What happens to the P wave * What is the txt? * **What is the origin?**
* Originates above the ventricles and can be caused by a premature impulse that triggers rapid beats. * Does not come from SA node, but elsewhere in left or right atria or even AV node (i.e Supraventricular) * Rates less than 150 beats per minute rarely causes any life-threatening issues (if short-term). * Cardiac output can be greatly reduced with rates above 150 beats per minute especially if they are sustained for a while as the body will have difficulty compensating for the reduction. * As the heart rate gets faster, the P wave may be obscured by the T wave of the preceding beat.  * Treatment can consist of medications or electrical therapy to slow down the rate.  * Origin would be supraventricular
83
What is this? What are the characterisitics?
Supraventricular Tachycardia * Rate = >150 bpm * Rhythm = regular * P-wave before each QRS = hidden * P-wave upright/uniform = buried * PR Interval = to rapid to see * QRS = narrow <0.12 sec., similar
84
Atrial Fibrillation * No what? * what are the cells doing? * Can be the cause of what? * If stable or unstable what is the txt?
* No organized atrial contraction. * Cells are independently depolarizing that results in a chaotic baseline. * Can be the cause of clots which can lead to strokes. * If stable, then medication for treatment. * If patient becomes unstable may require cardioversion.
85
What is this? What are the characterisitcs?
Atrial Fibrillation * Rate = <100 bpm * Rhythm = irregular * P-wave before each QRS = none definitive * P-wave upright/uniform = none definitive * PR Interval = irregular * QRS = narrow <0.12 sec. * **R-R is irregularly irregular**
86
Atrial Fibrillation with Rapid Ventricular Response/Rate * Rate: * Rhythm * P wave? (2) * PR interval? * QRS:
* Rate = sustained >100 bpm * Rhythm = irregular * P-wave before each QRS = none definitive * P-wave upright/uniform = none definitive * PR Interval = irregular * QRS = narrow <0.12 sec.
87
What is this?
Atrial Fibrillation with Rapid Ventricular Response/Rate
88
Atrial Flutter * What is this? * What is the pattern? * Can be said to be what?
* Impulses from the atrial are rapid and the ventricles are not able to keep up. * Distinctive saw tooth pattern. * Generally, it is regular, constant.  Can be said to be 2:1 conduction, 3:1 conduction depending on the number of waves present. 
89
What is this? What are the characterisitcs?
atrial flutter * * Rate = varies * Rhythm = typically regular * P-wave before each QRS = yes/multiple * P-wave upright/uniform = saw tooth * PR Interval = regular * QRS = narrow & regular
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Premature Junctional complex * **When does this happen?** * What is the rate? * When an impulse is generated in the AV node, it will travel where? * What happens to the p wave? * PRI if present will be what? * What is the QRS?
* **If the SA node fails to function, then the AV junction will take over and fire an impulse. Could be said to be junctional origin.** * The rate is generally between 40-60 beats per minute. * When an impulse is generated in the AV node, it will travel down through the ventricles then back up to the SA node.  * They will have a missing P wave, or it may be inverted.  * PRI if present will be less than 0.12 seconds. * QRS complex is less than 0.11 seconds. 
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What is this?
Premature Junctional complex * note the inverted p waves
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What does AV Junction Rhythms look like?
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Premature Ventricular Complex * What is it? * Has no what? * The QRS complex associated with what? * Can be what? * **Remember to count PVC’s in what?**
* It is a complex that occurs within another one. * Has no P wave and no PR interval. * The QRS complex associated with this premature complex will be greater than 0.12 seconds. * Can be unifocal or multifocal in nature * **Remember to count PVC’s in the total number of beats in a rhythm strip to get the accurate heart rate.**
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Ventricular Rhythms * When does this occur? * QRS are what? P wave? T wave?
* Occurs when the atria, AV junction, or both, are unable to initiate an electrical impulse * QRS are wide (>3 little boxes) and P waves are absent; T waves run in the opposite direction of the R wave
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Idioventricular rhythm * When does this occur? * May result in what? * What happens to the P wave? * What is the rate? * What is the QRS complex?
* Occurs when the SA node and AV node do not send impulses to pace the heart. * May result in the absence of a palpable pulse. * No P wave present nor PR interval * Rate between 20-40 beats per minute * QRS complex is more than 0.12 seconds
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What is this?
Idioventricular rhythm
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Ventricular Tachycardia * Rate? * Identified as such when what happens? * May be what? * Variation in what? * If patient stable, treatment general what?
* Rates that exceeds over 100 beats per minute. * Identified as such when three or more PVC's run together. * May be uniform, with each complex appearing like the one before it.  * Variation in height of QRS complex's seen with electrolyte disorders leading to Torsades de pointes * If patient stable, treatment generally medication, if unstable, then electrical therapy. 
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What is this? What are the characterisitcs?
*Rate = >100 bpm *Rhythm = regular *P-wave before each QRS = hidden by QRS *PR Interval = hidden *QRS = wide >0.12 sec.
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What is the key difference between idioventricular rhythm, accelerated idioventricular rhythm and ventricular tachycardia?
The heart rate
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Ventricular Fibrillation * What type of event? * seen in what type of hearts? * Frequently encountered arrhythmia in who? * No true what? * What are common causes (5)?
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What is this? What are the characteristics?
Ventricular Fibrillation * Rate = none * Rhythm = irregular * P-wave before each QRS = none * P-wave upright/uniform = none * PR Interval = none * QRS = none
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Asystole * What is happening to the heart? * Considered what?
* Heart is not contracting and no signs of electrical activity * Considered a non-shockable rhythm. (DO CPR)
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What is this? What are the characterisitcs?
Asystole * Rate = 0 * Rhythm = none * P-wave before each QRS = none * P-wave upright/uniform = none * PR Interval = none * QRS = none
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Pulseless Electrical Activity * What is it? * What is it caused by? (5) * Rhythm with no what? * What is the treatment?
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Patients rhythm but no pulse?
Pulseless Electrical Activity * NO PULSE * Any narrow complex rhythm without a pulse
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Heart Blocks * Heart blocks occur where? * AV node is known as what? * Heart blocks are broken into four types, what are they?
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First Degree Heart Block * What is the PRI? * Considered what? * txt?
* A constant PRI that exceeds 0.20 seconds  * Considered the least serious type of block but is often the first indication of damage in the AV node. * Rarely treated in a prehospital setting unless associated with symptomatic bradycardia.
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What heart block is this? What are characteristics?
First Degree Heart Block * Rate = <100 bpm (commonly bradycardic) * Rhythm = regular * P for every QRS = YES * QRS for every P = YES * P-wave upright/uniform = YES *** PR Interval = >0.20 sec**. * QRS = narrow <0.12 sec., similar
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2nd Degree Heart Block Type 1 * Also known as what? * occurs when? * Prevents what? * What are the causes?
* Also known as Mobitz type I second-degree block or Wenckebach. * Occurs when an interruption in impulse conduction occurs within the AV node, bundle of His, or His-Purkinje system. * Prevents the impulse from proceeding to the ventricles and generating a QRS complex. * Causes can include AMI,  increased vagal tone,  electrolyte  imbalances as well as Digoxin toxicity. 
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What heart block is this? What are the characterisitcs?
2nd Degree Heart Block Type 1 * Rate = <60 bpm * Rhythm = regular * P for every QRS = YES * QRS for every P = NO * **PR Interval Consistent = constantly prolonging** * QRS narrow/wide = narrow
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2nd Degree Heart Block Type 2 * Also called what? * What is it it? * Causes can be what/ * What are sxs? * What is txt?
* Also called Mobitz Type 2 * Several impulses are not able to continue through. * Causes can include AMI.  * Symptoms that may appear are dizziness, fatigue, dyspnea, syncope.  * Treatment is usually required which may consist of cardiac pacing. 
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What heart block is this? What are the characteristics?
2nd Degree Heart Block Type 2 * Rate = <60 bpm * Rhythm = regular * P for every QRS = YES * QRS for every P = NO * PR Interval Consistent = regular * QRS narrow/wide = narrow
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3rd Degree Heart Block * Known as what? * What happens? * What initates an impulse for conduction? * When presents with symptoms due to the heart block, may require what? * **If present the origin can be said to be what?**
* Known as complete heart block. * Supraventricular impulses are not able to pass to the ventricles. * Secondary pacemaker initiates an impulse for conduction.  * When presents with symptoms due to the heart block, may require treatment with medication and/or external cardiac pacing.  * If present the origin can be said to be ventricular.
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What is this? What are the characteristics?
3rd degree heart block * Rate = <60 bpm * Rhythm = regular * P for every QRS = NO * QRS for every P = NO * PR Interval Consistent = NO * QRS narrow/wide = varies
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What heart block is this?
3rd degree heart block | P and QRS are doing their own thing
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What heart block is this?
2nd degree heart block, type one | widening PQ intervals until QRS is dropped
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What is this?
Junctional | no p wave
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What is this?
Pre mature atrial
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What is this?
Idioventricular rhythm
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What is this?
idioventricular rhythm (IVR)
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Multifocal PVCs
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V-tach
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What is this?
V-tach
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V. fib
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what is the The 5-step approach?
1.What is the heart rate (fast or slow?) 2.What is the heart rhythm (regular or irregular) 3.Determine the intervals (PR interval, QT interval, QRS interval, etc.…) 4.What is the axis? 5.Determine the segments & waves 
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What do you find HR on 12 lead/
on 12 leads, you can count the number of QRS complexes in lead II at bottom and multiply by 10
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What can you use for regulat rhythms?
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What should you do with Step 2: What is the rhythm?
* Regular vs irregular * Measure the distance between the R waves. * Considered regular when the distance between the R waves is the same. 
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What are the Common electrolytes that can affect the intervals?
* Potassium * Calcium
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Benefits of Potassium (K+) * prevents what? * Allows for what? * Protects what? * Slows or speeds up heart rate?
* Prevents action potential from being too short (QT interval)  * Allows for organized fast heart rates  * Protects from excitability * Slows the heart rate in vagal conditions
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Hypokalemia – Patient findings: * What are the serum levels? * What are causes? * What are the sxs? * What is teh diagnostic on ECG? * What drug can affect? * What electrolyte can cause the sam ECG characteristics?
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Hyperkalemia (irritates cardiac cell wall) * What are mild cases?
Mild cases (< 6.5 mEq/L)  * Tall tented “peaked” T waves with a narrow base (QTc is still normal)  * Leads II, III, V2 and V4  * Normal P waves 
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Hyperkalemia (irritates cardiac cell wall) * What are Moderate cases?
Moderate cases (< 8 mEq/L)  * QRS widens  * Broad S wave in V leads  * Left axis deviation  * ST segment is gone, contiguous with the  “peaked” T wave  * P wave changes, starts to go 
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What are the K levels with these ECG findings?
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Hypercalcemia * What are the causes? * What happens on ECG? Hypocalcemia: * What are the causes * What happens on ECG?
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What does this show in terms of calcium levels?
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axis * Cardiac axis refers to waht? * Depolarization starts where? * Axis deviation refers to what? * Pathology that affects the conduction pathway of the heart will therefore affect what? * Anatomical problems would be what? * Pathological problems would include what?
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Axis * Normal axis is what? * Impulses going toward a positive electrode will make what? * As it goes away from the electrode, it makes what?
  * Normal axis is downward and toward the left which has upright complexes in Leads I, II, III. * Impulses going toward a positive electrode will make a positive deflection.  * As it goes away from the electrode, it makes a negative deflection.  ## Footnote It is not sensitive nor specific to any particular diagnosis.....it is used along with other information to determine what is happening in the heart. 
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Determining the AXIS * Run which leads? * Leads must be where? * Look at what?
* Run Leads I, II, and III * Leads must be on the limbs. * Look at the net QRS deflection in each lead (Does it go up, down, or halfway?)
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Axis Deviation angles * What is normal? * RAD? * LAD? * Extreme axis deviation?
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Figure out the axis
Method to determine the QRS Axis using QRS complexes in leads I and aVF.  * Positive QRS in leads I and aVF = normal QRS axis * Positive QRS in lead I and negative in lead aVF = left axis deviation.  * Negative QRS in lead I and positive in lead aVF = right axis deviation.  * Negative QRS in leads I and aVF = extreme right axis deviation. 
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WHAT IS THE AXIS
Normal
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What is the axis?
LAD
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What is the axis
RAD
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What is the axis
Extreme
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Physiological Left Axis Deviation * What are the causes?
* Normal variant in adults * Common in obesity and athletes (LVH) * Lead II can show upward or halfway deflection * Lead III is down
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Pathological Left Axis Deviation * What type of process? * What block is present? * Patients are 4 times more likely to what?
* Disease process * Hemiblock - not found on Lead II (almost a 3rd degree HB) * Suggests anterior hemiblock * Patients are 4 times more likely to arrest with a hemiblock and “chest pain” * Proximal occlusion until proven otherwise ## Footnote * A hemiblock is an intraventricular heart block that is a risk factor for complete heart block.  * A hemiblock can not be found on a Lead II rhtyhm strip.  * Besides being a heart block, it puts the patient at risk for sudden cardiac death syndrome * In the setting of a patient with an AMI and the patient has a hemiblock, or any other conduction disorder, they are presumed to have a proximal occlusion until proven otherwise. 
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Right Axis Deviation * What is it? * What is the assoicated with? * Very high mortality with what?
## Footnote Caused by: *  Pulmonary hypertension * Massive pulmonary embolism * Right ventricular hypertrophy * Posterior hemiblock in the patient with acute chest pain * Lead II could be any deflection, while Lead I is up and Lead III is down.  * Right axis deviation, very high mortality with an AMI.  * Serious problem involving two cornorary arteries. 
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Extreme right Axis Deviation * Usually what? * What are th leads in?
* Indeterminate axis * Usually ventricular in origin * Down in all three leads, I, II and III.  ## Footnote * Obvious indicator of ventricular originating beats * VT doesn’t always have an extreme right axis, but if it does, it is considered diagnostic. 
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Fascicular blocks (Hemiblock) * Occurs when? * Diagnosed by looking for left or right axis deviation, explain?
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Hemiblock take aways * may stimulate what? * Most common cause/ * Above all...
* May stimulate or conceal signs of an MI or ventricular hypertrophy. * Most common cause is CAD followed by hypertension. * Above all..treat the patient, not the monitor. 
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Determine the segments & waves  * Identify what? * What is the goal?
* Identify the waves (P-QRS-T) * Identify the segments (PR segment, ST segment) * Goal is to identify what is abnormal and how does it relate to overall EKG and how does it affect the patient. * Sick or not sick

Medical Diagnosis (16 decks)

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