Module 1: ECG and IABP Monitoring

Question 1

1). What contiguous leads would an inferior wall MI show elevation in?

Answer 1

II, III, AVF

ST elevation is present in leads II, III, and aVF. (Review the following chart for locations of different injury, ischemia, and/or infarcted areas) Location Coronary artery affected 12-lead ECG Anterior LAD V3, V4 Inferior RCA II, III, AVF Lateral LCX I, AVL, V5, V6 Septal LAD V1, V2 Posterior LCX or RCA V1-V4 ST depression, progression of tall R waves

Question 2

2). Which of the following coronary arteries supplies the majority of the circulation to the inferior portion of the heart?

A. Left coronary
B. Left ascending
C. Right coronary
D. Circumflex

Answer 2

The right coronary artery (RCA) supplies the majority of the inferior portion of the heart and some of the posterior portion of the heart. (Review chart provided) Coronary arteries Areas of the heart

Coronary circulation Consists of right and left coronary arteries that arise from the coronary ostia at the aortic root

Left main coronary artery Left anterior descending (LAD) Circumflex (LCX) LAD—supplies the anterior surface of the heart, the anterior 2/3 of the septum and part of the lateral wall

LCX—primarily supplies the lateral wall of the left ventricle

Right coronary artery Supplies the right atrium, right ventricle, and the inferior and posterior walls of the left ventricle

Question 3

3). V1-V6 chest leads are categorized as

A. Bipolar leads
B. Augmented leads
C. Unipolar leads
D. Limb leads

Answer 3

Chest leads, also known as “precordial” or unipolar leads are V1-V6 which views the heart from a horizontal plane. Traditional limb leads, also known as bipolar leads are I, II, and III, which view the heart from a vertical plane. Augmented leads are aVR, aVF, and aVL, which view the heart from a vertical plane. Most common lead used for transport is Lead II.

Question 4

4).Which of the following references can be used to determine ST elevation, ST depression, or QRS duration on the ECG tracing?

A. Delta wave
B. J point
C. Osborne wave
D. Z point

Answer 4

B: The junction point, also known as the J point, is known as the area where the S wave changes direction. The J point can be used to determine ST elevation, ST depression, and/or QRS duration. The delta wave is associated with WPW, the Osborne wave is associated with hypothermia, and the Z point is the reference point when measuring hemodynamic waveforms. Junction between end of QRS and beginning of ST segment where QRS stops and makes a sudden sharp change of direction is called the J point.

Question 5

5). What are the characteristics of a Posterior wall M.I.

Answer 5

C: Posterior MI = R waves increase, ST segment depression (reciprocal changes) present in V1-V4 precordial leads. Development of tall R-waves in the right precordium should be interpreted as evidence of posterior MI.

Question 6

6). ST elevation seen on the ECG tracing can indicate

A. Ischemia
B. Injury
C. Infarction
D. Electrolyte imbalance

Answer 6

B: ST elevation is associated with myocardial injury. ST Changes:

The Three Is:
ST elevation = Injury (acute MI) ST depression = Ischemia Q waves present that measure > 25% the R wave = Infarction (necrosis) First negative deflection seen after the P wave.
- Q wave includes the negative downstroke and return to baseline

Are the Q Waves Significant?

• Acute injury = Q waves with ST elevation Indeterminate = Q waves with ST depression
• Old infarction = Q waves without ST changes ST Measurement Limb Leads-Bipolar
  .
  ST Measurement Limb Leads-Bipolar

—More than 1 mm above (elevation) or below (depression) from the isoelectric line in two or more contiguous leads. Precordial (chest) Leads-Unipolar —More than 2 mm above (elevation) or below (depression) from the isoelectric line in two or more contiguous leads.

Precordial (chest) Leads-Unipolar —More than 2 mm above (elevation) or below (depression) from the isoelectric

Question 7

7). Hyperkalemia >7.0 can exhibit which of the following changes on the ECG tracing?

A. Inverted T waves
B. U waves
C. Tented or peaked T waves
D. Flattened T waves

Answer 7

C: Tented or peaked T waves greater than 5 mm can indicate the presence of hyperkalemia.

Other Changes to Look for on the ECG Peaked/tented T waves > 5 mm: hyperkalemia Flattened T waves/U waves present, which occur just after the T waves are usually smaller in amplitude than the T wave: hypokalemia

Short PRI—may indicate WPW Delta wave = associated with WPW (noted bump in the beginning of the QRS wave). Delta wave is due to early conduction through the accessory pathway.

Wide QRS: BBB present, TCA overdose Prolonged QT interval = TCA overdose

The QT Interval can be quickly assessed by using the R-R interval. QT interval measuring >½ of one R-R interval is prolonged until proven otherwise. Salvador Dali’s Mustache = Look for the “DIG DIP,” presenting as ST depression; may indicate digitalis toxicity

Diffuse ST elevation across the entire ECG in conjuction with PR segment depression—suspectsuspect pericarditis/infection presenting with H/O fever or pericardial friction rub is noted Electrical alternans = suspect pericardial effusion/cardiac tamponde (amplitude of the R wave changes across the ECG “small, large, small”)

Question 8

8). What are the characteristics of an Anterior wall MI?

Answer 8

B: ST elevation present in V3, V4, Lead I, and aVL indicative of an anterior wall MI. 12-lead ECG Interpretation Review Remember LISA!

Lateral wall MI = I, AVL, V5, V6
Inferior wall MI = II, III, AVF
Septal MI = V1, V2
Anterior MI = V3, V4

Question 9

9). Which of the following is characteristic of the 12-lead ECG for a patient with a history of WPW?

A. J point
B. Delta wave
C. Osborne wave
D. Q wave

Answer 9

B: The delta wave is due to early conduction through the accessory pathway.

Question 10

10). What are the characteristics of a complete heart block?

Answer 10

D: Complete AVB, also known as AV disassociation, and third-degree heart block. ECG characteristics include no constant PRI or P wave. With every QRS, R-R interval will be regular, and the P waves will consistently march out.

Question 11

11). ST depression can indicate all of the following, except

A. Ischemia
B. Old injury
C. Acute injury
D. Digitalis toxicity

Answer 11

C: Acute injury is indicated by the presence of ST elevation. Ischemia, old infarction, and digitalis toxicity can present with ST depression.

Question 12

12). Q waves present with ST elevation can indicate

A. Acute ischemia
B. Acute injury
C. Old infarction
D. Right ventricular MI

Answer 12

B: Q waves present with ST elevation can indicate that an acute myocardial injury is occurring.

• Q Wave with ST Depression or T Wave Inversion: Indeterminant
• Q Wave Without ST Changes: Old Injury/Infarction.

Question 13

13). What are the characteristics of a 100% paced rhythm?

Answer 13

A: 100% paced rhythm with ventricular spikes present before the QRS.

Question 14

14). What are the characteristics of an Inferior wall MI

Answer 14

C: Inferior wall MI presents with ST elevation in leads II, III, and aVF.

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Question 15

15). What are the characteristics of Polymorphic Ventricular Tachycardia?

Answer 15

B: Polymorphic ventricular tachycardia, formerly known as Torsade’s de pointes, is a French word meaning “twisting of the points” and can occur with or without a pulse.

Question 16

16). Your patient is exhibiting ST elevation in leads II, III, and AVF. ST depression is noted in V1-V3. Which of the following may prove hazardous?

A. Isotonic fluid bolus
B. Heparin
C. GII/BIIIa inhibitors
D. Nitroglycerin

Answer 16

D: Patients presenting with an inferior wall MI may also have a right ventricular MI present which would affect filling pressures. Medications that decrease preload are not recommended, unless the patient has been managed with IV fluids prior to administration. Diagnosis of a right ventricular myocardial infarction (RVMI) can be done by obtaining a right-sided 12-lead ECG. The presence of ST elevation in RV4 is a highly sensitive marker for right ventricular involvement.

Question 17

17). Describe the characteristics of an Anterolateral MI?

Answer 17

B: Anteroseptal MI presents with ST elevation in precordial leads V1-V4.

Question 18

18). In which sequence does blood flow through the heart valves?

A. Tricuspid, pulmonic, mitral, aortic
B. Tricuspid, mitral, pulmonic, aortic
C. Tricuspid, aortic, mitral, pulmonic
D. Mitral, pulmonic, tricuspid, aortic

Answer 18

A: Remember “Toilet Paper My A_ _” for direction of blood flow through the valves. (Review chart for heart anatomy)
Anatomy of the Heart - Area of location Definition:
* Pericardium Double-walled fibrous sac surrounding the heart
-Heart chambers Four chambers divided by septum
-Heart Contains three layers: Epicardium—thin, outermost layer Myocardium—thick, muscular middle layer Endocardium—thin, innermost layer
- AV valves Located between atria and ventricles
*Open as a result of lower ventricular pressures and close as a result of higher ventricular pressures
*Tricuspid—located between the right atrium and right ventricle
*Mitral (bicuspid)—located between the left atrium and left ventricle
*Semilunar valves Located between the ventricles and the great arteries
*Pulmonic—separates the right ventricle from the pulmonary artery
*Aortic—separates the left ventricle from the aorta Valve order

T-P-M-A (remember Toilet Paper My A . . .) Tricuspid, pulmonic, mitral, aortic

Question 19

19). What condition is associated with peaked T-waves on an ECG?

Answer 19

B: Hyperkalemia presents with peaked or tented T waves on the ECG. Serum lab values usually greater than 7.0 when ECG changes are present.

Question 20

20). Describe A-fibrillation with ST-Elevation?

Answer 20

D: Atrial fibrillation with ST elevation. R-R intervals are irregularly irregular with no obvious P waves present.

Question 21

21). The ECG may show peaked P waves, flattened/slurred Ts, and appearance of U waves, which may indicate

A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hyperchloremia

Answer 21

B: Hypokalemia may show peaked P waves, flattened/slurred T waves, and the presence of U waves. T wave and U wave may present as a biphasic wave.

Question 22

22). Describe A-fib with a LB3?

Answer 22

B: Atrial fibrillation with bundle branch block. R-R intervals are irregularly irregular with no discernable P waves present.

Question 23

23). Inferior wall MI is caused by an occlusion of which coronary artery?

A. LAD
B. RCA
C. Circumflex
D. Inferior vena cava

Answer 23

B: Right coronary artery.

Question 24

24). Describe an ECG Anteroseptal-lateral MI?

Answer 24

A: Anteroseptal-lateral wall MI. ST elevation is present in leads I, aVL, V5, V6 for lateral wall; V1, V2 for septal and V3, V4 for anterior wall. Reciprocal changes (ST depression) is present in the inferior leads (II, III, and aVF).

Question 25

25). Describe the ECG of Second degree AVB/Mobitz Type I?

Answer 25

C: Second-degree AVB, Mobitz II, also called Type II. PR interval is constant and there are more P waves present than QRS complexes. R-R interval is regular because there is a 2:1 conduction that remains constant. P waves march out.

Question 26

26). On 12-lead ECG, posterior wall MIs manifest as

A. ST elevation in II, III, AVF
B. ST depression in II, III, AVF
C.ST depression in V1-V4 with abnormally tall R waves
D.ST elevation in V1-V4 with abnormally tall R waves

Answer 26

C: Posterior wall MI. Note the progression of abnormal tall R waves and ST depression in precordial chest leads V1-V4.

Question 27

27). Describe a ECG showing an Inferior-lateral wall MI?

Answer 27

B: Inferolateral wall MI. ST elevation present in the inferior leads II, III, aVF, and V5, V6 for the lateral leads. Recipricol changes (ST depression) present in leads I and aVL.

Question 28

28). Described what asystole with pacer spike?

Answer 28

A: Asystole with pacer spikes present representing failure to capture.

Question 29

29). Describe what a Lateral wall MI looks like on an ECG?

Answer 29

B: Lateral wall MI. ST elevation present in lateral leads I and aVL with recipricol changes (ST depression) in the inferior leads II, III, and aVF.

Question 30

30). ST elevation in leads I, aVL, V5, and V6 are indicative of injury to which area of the heart?

A. Inferior
B. Lateral
C. Anterior
D. Posterior

Answer 30

B: Lateral wall MI

Question 31

31). A patient with a history of tricyclic antidepressant overdose can exhibit which of the following on the ECG tracing?

A. Short PR interval
B. Peaked or tented T waves
C. Prolonged QT interval
D. Prolonged PR interval

Answer 31

C: Prolonged Q-T interval and/or widened QRS > 0.12 seconds.

.

Question 32

32). Describe the ECG findings of Atrial Flutter with ST depression.

Answer 32

C: Atrial flutter with ST depression. Note the “flutter” waves and regular R-R intervals.

Question 33

33). Describe an ECG for complete heart block.

Answer 33

Complete AVB. If unable to determine rhythm, assess the continuous strip, which is usually provided at the bottom of the 12-lead ECG as lead II. The R-R interval is regular, and there is no constant PR interval and the P waves march out.

Question 34

34). What changes in the ECG would a patient presenting with an inferior wall MI most likely have?

A.ST depression in leads II, III, and aVF
B.ST elevation in leads I, aVL, V5, and V6
C.ST elevation in leads II, III, and aVF
D. ST depression in leads V1 and V2

Answer 34

C: ST elevation (injury) in leads II, III, and aVF.

Question 35

35). Normal K+ lab value is

A. 3. 0-4.0
B. 3.5-4.5
C. 4.0-5.0
D. >5.5

Answer 35

B: Normal serum potassium range is 3.5-4.5, but it can go as high as 5.5 and can still be considered within normal range.

Question 36

36). Describe Atrial Tachycardia on an ECG.

Answer 36

Atrial tachycardia, also known as supraventricular tachycardia (SVT). The R-R interval is regular, and the P wave, which is not visible on the ECG tracing, is most likely buried within the T wave. Heart rate is greater than 160 beats per minute.

Question 37

37). Describe what Idioventricular rhythm looks like on an ECG.

Answer 37

Idioventricular rhythm (IVR) is defined as a ventricular rate of 20-40, wide QRS > 0.12 seconds and no P waves are present. Accelerated idioventricular rhythm (AIVR) is defined as a ventricular rate of forty to sixty beats per minute, wide QRS > 0.12 seconds and no P waves are present. The QRS duration is measured from the beginning of the QRS to the J point. Normal range is 0.04-0.12 seconds.

Question 38

38). Diagnosis of a right ventricular MI includes

A.Right-sided 12-lead ECG with ST elevation in V4
B.Right-sided 12-lead ECG with ST depression in V2-V4
C.Left-sided 12-lead ECG with ST elevation in V1-V4
D.Left-sided 12-lead ECG with ST depression in V1-V2

Answer 38

A: Highly sensitive marker for the presence of right ventricular infarction (RVI) is the presence of ST elevation in right-sided V4 lead.

Question 39

39). Describe Ventricular Tachycardia on an ECG.

Answer 39

Ventricular tachycardia (VT). The R-R interval is regular with a wide QRS constant pattern.

Question 40

40). Describe a Second Degree AVB type I.

Answer 40

Second-degree AVB, type I, which is also known as Mobitz I or Wenckebach. The R-R interval is irregular because there is a dropped QRS complex. The P-R interval lengthens until it drops a beat.

Question 41

41). Your IABP begins to purge during ascent. The triggering mechanism for this function was initiated as a result of which gas law?

A. Boyle’s law
B. Gay-Lussac’s law
C. Charles’s law
D. Henry’s law

Answer 41

A: Boyle’s law is the expansion (ascent) or contraction (descent) of gas. Other equipment that can be affected by this law include ETT cuff, which may increase in size with ascent.

Question 42

42). The balloon has dislodged when treating your IABP patient. Which is the most common site that will be affected?

A. Right radial
B. Left radial
C. Right femoral
D. Left femoral

Answer 42

B: Left radial artery is the most common site. The distal tip of the balloon is placed in the descending aorta to displace blood both in the cephalad and distal direction to the balloon. The proximal end of the balloon is positioned just above the renal arteries.

                             IABP Dislodgment 

Distal displacement Proximal displacement

Left radial artery Renal arteries

Decrease/absent pulse Decrease/absent urine output

Question 43

43). During transport you note rust-colored “flakes” in the IABP tubing. This indicates

A. Helium tank degredation
B. IABP pump failure/lubricant leak
C. Helium oxidation
D. Balloon rupture

Answer 43

D: Balloon rupture

Question 44

44). Describe what an early inflation looks like on a IABP timing strip.

Answer 44

Early inflation. Locate dicrotic notch (DN). Draw an imaginary line from the DN to the inflation point (IP). If the inflation point is 2 mm or more from the dicrotic notch, it indicates early inflation. The precise timing of balloon inflation and deflation is essential to achieve the hemodynamic effects that increase coronary blood flow and decrease the workload of the heart. The arterial pressure waveform is always used to set and assess the timing. Timing is done based on the shape of the waveform and the relationship of the landmarks. Timing should always be assessed in a 1:2 assist ratio so that a comparison of the assisted and unassisted landmarks can be made.

                   IABP terminology 

Terminology Definition

PAEDP Patient aortic end diastolic pressure—this is the patient’s unassisted diastole (DIA)

PSP Peak systolic pressure—this is the patient’s unassisted systole

PDP/DA Peak diastolic pressure or diastolic augmentation—this is the pressure generated in the aorta as the result of
inflation

BAEDP Balloon aortic end diastolic pressure—this is the lowest pressure produced by deflation of the IAB; this is assisted
diastole (ADIA)

APSP Assisted peak systolic pressure—this systole follows balloon deflation and should reflect the decrease in LV work

DN Dicrotic notch—closure of the aortic valve

Question 45

45). The primary trigger used for most IABP operations is the

A. A-line
B. PA catheter
C. EKG
D. CVP catheter

Answer 45

C: Inflation and deflation are synchronized with the patient’s cardiac cycle. Most common is the ECG using the R wave. Mainly balloon inflation is set automatically to start in the middle of the T wave and to deflate prior to the ending QRS complex. The arterial waveform can be used when tachyarrhythmias, cardiac pacemaker function, and poor ECG signals may cause difficulties in obtaining synchronization when the ECG mode is used.

Question 46

46). Inadvertent migration of the IAB may cause which of the following, except

A. Loss of renal perfusion
B. Loss of flow to subclavian artery
C. Loss of flow to the carotid vein
D. Loss of flow to the renal arteries

Answer 46

C: From the insertion site (usually the femoral artery), if the balloon is too distal to the aorta, occlusion of the brachiocephalic artery, left carotid artery, or left subclavian artery may occur. Balloon is positioned in the descending aorta, 2-4 cm below the level of the aortic arch, just distal to the left subclavian artery (radio-opaque distal tip of the balloon should be seen at the level of the second or third intercostal space on the chest x-ray). From the insertion site, if the balloon is too proximal (below the renal artery), the celiac, superior mesenteric, or renal arteries may be obstructed. Proximal end of the balloon should be positioned above the renal artery from the insertion site.

Question 47

47). When timing the IABP, inflation should initiate in synchronization with

A. ECG-P wave
B. Anacrotic notch of the A-line
C. Beginning systole
D.Dicrotic notch indicated on the A-line pressure wave

Answer 47

D: It is important that the inflation of the IAB occurs at the onset of ventricular diastole, noted on the dicrotic notch on the arterial waveform. Deflation of the balloon should occur at the end of diastole just prior to the onset of ventricular systole. Balloon synchronization starts usually at a beat ratio of 1:2. This ratio facilitates comparison between the patient’s own ventricular beats and augmented beats to determine ideal IABP timing.

                                       IABP 

Balloon inflation => Balloon deflation

Inflates at the onset of ventricular diastole => Deflates just prior to the onset of ventricular systole

Increases diastolic pressure => Increases perfusion to the coronary circulation => Increases systemic perfusion

Question 48

48). Describe late deflation on a IABP timing strip.

Answer 48

B: Late deflation. If ADIA (assisted diastole > DIA (unassisted diastole) = Late Deflation ADIA < DIA = Normal timing

Question 49

49). Which of the following is the most potentially harmful timing error?

A. Early deflation
B. Early inflation
C. Late deflation
D. None of the above is potentially harmful

Answer 49

C: Late deflation. Timing errors can cause decrease in arterial pressures, decrease in cardiac output, decrease in ejection fraction, increase in heart rate, increase in pulmonary artery diastolic pressures, and increase in capillary wedge pressures.

• Left Ventricular Assisted Device (LVAD) Criteria:
  
  • Patient must be a heart transplant candidate
  • Patient must demonstrate reversible end-stage organ disease
• Body surface area must be large enough to contain the device
• Meets the New York Heart Association Class IV hear failure criteria
• Patient has hemodynamic deterioration criteria:
• CI < 2.0
• Either a MAP < 65 mmHg or PAWP/PAD > 18 mmHg, or
• Life-threatening arrhythmias non-responsive to medical treatment, or
• Patient needs support of two positive inotropes, or
• Patient has an IABP placed
• Demonstrates the ability to manage the device or has a support person at all times

Question 50

50). During transport you experience a complete IABP failure. You should

A. Withdraw the IABP to 10 cm
B.Cycle the balloon manually timing with EKG visually
C.Cycle the balloon manually timing with the A-line visually
D.Cycle the balloon manually every thirty minutes regardless of timing

Answer 50

D: Cycle the balloon manually every thirty minutes regarding of timing when managing IABP failure.