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EKG > Nersi EKG Guide > Flashcards

Nersi EKG Guide Flashcards

1
Q

What leads are involved in an inferior MI?

A

II, III, aVF

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2
Q

What leads are involved in an anterior MI?

A

V1, V2 and V3

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3
Q

What leads are involved in a posterior MI?

A

inversions of V1 and V2

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4
Q

What leads show the left side of the heart?

A

I, aVL, V4 V5 and V6

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5
Q

What leads show the right side of the heart?

A

aVR and V1

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6
Q

In what leads can a biphasic p wave be normal? How about a negative p wave?

A

III and V1 - biphasic

aVR - negative

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7
Q

A normal p wave is shorter than what? If it’s taller, what’s the likely diagnosis?

A

less than 0.25 mV - two and a half small boxes

right atrial hypertrophy if taller

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8
Q

How wide is a normal p wave?

A

.12 s or three small boxes

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9
Q

How long is a normal PR interval?

A

0.12 s to 0.20 s (3-5 small boxes)

not usually bigger than 1 big box

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10
Q

What should happen to the R wave as you progress through the precordial leads?

A

should get taller - R wave progression (while the S wave gets smaller)

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11
Q

Where is the normal transition point in the precordial leads?

A

V3 or V4 (this is where the R and S waves are roughly equal)

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12
Q

How long is a normal QRS interval?

A

0.12 s or less

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13
Q

The QT interval is generally less than ___ of the R-R interval.

A

half

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14
Q

The axis is normal if the QRS complex is positive in what two leads?

A

I and aVF

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15
Q

If the QRS is positive in 1 but negative in aVF, what’s the axis?

A

left deviation

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16
Q

If the axis is right deviated, what will the QRS be in 1 and aVF?

A

negative in 1

positive in aVF

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17
Q

What’s another way to tell axis?

A

look for the isoelectric QRS and then go 90 degrees from there

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18
Q

When can you say an axis is indeterminate?

A

when the QRS is isoelectric in multiple leads

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19
Q

What leads do we look at for atrial enlargmetn?

A

II and V1

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20
Q

What will the P look like in II for RAE?

A

the first part becomes asymmetrically taller and sooner, so there will be a small hump at the end

but it stays about the same width

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21
Q

What will the P look like in V1 for RAE?

A

biphasic, with a taller upward peak first

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22
Q

What will the p look like in II for LAE?

A

wider with a taller hump at the end (instead of at the beginning like in RAE)

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23
Q

What will the P lok like in V1 for LAE?

A

biphasic with a deeper trough at the end

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24
Q

What will happen in the precordial leads with right ventricular hypertrophy?

A

you’ll lose the normal R wave progression, such that the QRS complex is more positive on the right (V1) and less positive on the left (V6), which is the opposite of what these leads normally show

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25
Q

What are the sokolow-lyon criteria for LVH?

A

Height of S in V1 or V2 plus height of R in V5 or V6 total >35 mmHg

OR

If the R wave in aVL is at least 11 mmHg, that’s LVH

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26
Q

What are the cornell criteria for LVH?

A

add the height of S in V3 and R in aVL. if this is greater than 28 mmHg in men or 20 mmHG in women, LVH

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27
Q

With severe ventricular hypertrophy, particularly as it becomes severe, there can be repolarization abnormalities such that you get asymmetric ST segment depression with a slope, as well as T wave inversion. What leads does this commonly occur in for RVH?LVH? What’s this called?

A

V1 and V2 for RVH
V5 and V6 for LVH

called a ventricular strain pattern

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28
Q

How are grade II AV nodal blocks described (both type I and II)?

A

in terms of how many beats there are until the QRS is dropped. If there are three beats and then the fourth QRS is dropped, it’s a 4:3 second degree block

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29
Q

Which grade II block has the PR interval that gradually widens?

A

type I - Wenchebach

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30
Q

What will the QRS look like with a bundle branch block?

A

the ventricles won’t fire quite in synch, so you get an R-S-R’ pattern

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31
Q

Where will you see the RSR’ with a right BBB?

A

V1 and V2

and you’ll see a large S in V5 and V6

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32
Q

Where will you see the RSR’ pattern with a left BBB?

A

V5 and V6, but also I and aVL

however - note that the RSR’ in LBBB isn’t quite as distinct as in the RBBB and may appear as a notched. widened R wave

(and a large S in V1 and V2)

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33
Q

What other scary looking thing can happen in the same leads as the RSR’ with BBB?

A

ST segment depression and T wave inversion

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34
Q

What will the QRS look like in an incomplete bundle branch block?

A

the RSR’ is evident, but the QRS isn’t prolonged

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35
Q

If the QRS is prolonged, but there is no RSR’, what’s that called?

A

nonspecific intraventricular conduction delay

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36
Q

True or false: do left fascicular blocks prolong the QRS?

A

False - even thought the depolarization would have to travel longer through the anatomotic loop, it happens so quickly that you don’t get widening.

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37
Q

FOr a left anterior fascicular block, the axis becomes deviated____

A

leftward

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38
Q

For a left posterior fascicular block, the axis becomes deviated___

A

rightward

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39
Q

If the R-R intervals are not consistent, but all the P waves are upright, where is the arrhythmia coming from?

A

has to be from the atria because anything originating below the atria will spread backwards and cause a negative p wave

40
Q

Why do atrial arrhythmias have narrow complexes?

A

because conduction through the AV node and the ventricular bundles is normal

41
Q

Describe what a PAC looks like.

A

the P wave looks different from other P waves

the P and QRS will come earlier than would be expected based on the other R-R

the QRS and T are followed by a relative pause

42
Q

If several repeated beats from an ectopic atrial focus occur after a PAC, what is this called?

A

paroxysmal atrial tachycardia (PAT)

43
Q

Parosyxmal atrial tachycardia in a normal heart usually has a 1;1 conduction, but PAT in what context have have multiple p waves per QRS and why?

A

when on digoxin because it blocks AV node conduction

44
Q

What do you call it when there are 3 or more p wave morphologies?

A

wandering atrial pacemaker

45
Q

What do you call it if there is a wandering atrial pacemaker and the rate is over 100 bpm?

A

multifocal atrial tachycardia

46
Q

What differentiates wandering atrial pacemaker from atrial fibrillation?

A

the p waves may look different from each other, but there are always distinguishable p waves

47
Q

What are the two varieties of atrial re-entrant arrhythmia?

A

atrial fibrilation

atrial flutter

48
Q

How do you describe an atrial flutter?

A

by how many flutter waves there are per QRS complex, liked 3:1

49
Q

Besides not having clearly discernible P waves, how does atrial fibrillation differ from flutter?

A

Flutter still sends depolarization down to the ventricles in a regular fashion

fibrillation doesn’t, so you get an irregularly irregualr rhythm

50
Q

Where do junctional arrhythmias arise form?

A

the AV junction

51
Q

Do junctional arrhythmias have narrow or wide complexes?

A

narrow

52
Q

So junctional arrhythmias and atrial arrhythmias are both examples of what?

A

supraventricular arrhythmias, or wide complex arrhythmias

53
Q

How are junctional arrhythmias distinguished from atrial arrhythmias?

A

junctional rhythms don’t have normal p waves - can have retrograde - or upside down- p waves

54
Q

The AV junction can create an early depolarization wave, called what?

A

premature junctional beats (basically the AV version of PACs)

55
Q

If there are multiple rapid junctional beats in a row that begin suddenly, this is called…

A

paroxysmal junctional tachycardia

56
Q

What’s the tip-off that you’re looking at an escape rhythm?

A

you’ll have a beat that fires later than expected based on th eprevious R-R intervals, which is in contrast to premature beats

57
Q

What would be the rate of an atrial escape?

A

60-80 bpm

58
Q

What would be the rate of a junctional escap?

A

40-60

59
Q

Ventricular escape rhythms are more commonly called what?

A

idioventricular rhythms

60
Q

What is the typical rate for an idioventricular rhythm?

A

20-50 bpm

61
Q

if an idioventricular rhythm is occurring faster than 50 bpm, what is this called?

A

accelerated idioventricular rhythm (often occurs with MI or after the myocardium is reperfusd in a cath lab)

62
Q

Usually PVCs will occur in isolation, but if they alternate between 1 normal beat and 1 PVC, what’s this called? How about 2 normals to 1 pvc?

A

bigeminy

trigeminy

63
Q

If there are two PVCs in a row, followed by a normal beat, what is this called?

A

a couplet

64
Q

How about three PVCs in a row followed by a normal beat?

A

a triplet

65
Q

If you have more than three PVCs in a row….

A

ventricular tachycardia

66
Q

If the ventricular tachycardia lasts more than 30 seconds…

A

sustained ventricular tachycardia (if it runs for less, it’s non-sustained vtach)

67
Q

What do you call it if the ventricular tachycardia is PVCs occurring at regular intervals with very similar heights and widths?

A

monomorphic ventricular tachycardia

68
Q

If the QRS complexes of the vtach do not resemble each other, what is this called? What’s a good example?

A

polymorphic ventricular tachycardia

torsades de pointes

69
Q

If an EKG has a series of irregular, chaotic, dissimilar waves with none of the identifiable morphologies of a normal beat, what is this….

A

ventricular fibrillation

70
Q

What is the typical EKG sequence of events in an MI?

A

T wave changes (hyperacute T waves first, then later inversions) = ischemia

J point elevation (where the ST segment begins at baseline and then slopes upward such that the ST segment is indiscernible from the T wave)

ST elevation (where the J point is 1 mm above the baseline in two or more contiguous leads) = injury

pathologic Q waves = completed infarct

71
Q

Define pathologic Q waves

A

a Q wave with width greater than 1 little box and height greater than 2 little boxes
or
greater than 1/3 the entire QRS

present in 2 or more contiguous leads

72
Q

In what lead do we not care about q waves?

A

aVR - per usual

73
Q

How do th ST depressions of ventricular strain differ from that of an NSTEMI?

A

with strain, the t wave inversions are assymetric - gradually downslping ST segments ending in a T wave that rapidly rises

while the NSTEMI ST depressions show more symmetric T waves and flattened ST segments, not downsloping

74
Q

What are reciprocal changes?

A

they are essentially opposite findings in the leads opposite from the infarct - so tall R waves instead of Q waves, ST depression instead of ST elevation

75
Q

Why do pre-excitation syndromes typically have shortened PR intervals?

A

because they are usually due to an accessory pathway that conducts more quickly than the relatively slow AV node

76
Q

What is the main example of a pre-excitation syndrome?

A

Wolf-Parkinson-White (with the bundle of Kent)

77
Q

Describe the EKG findings of WPW.

A
  1. short PR interval
  2. delta wave (up-swoop of the early QRS complex)
  3. widened QRS (because of the Delta wave, but the rest of the QRS will appear normal)
78
Q

Describe the accessory pathway in Lown-Ganong-Levine syndrome.

A

James fibers that connect the atria directly to the bundle of His, bypassing the AV node

79
Q

Describe the EKG changes in LGL.

A

the only finding is a short PR interval because the QRS won’t be widened at all

80
Q

What will digoxin do to the heart at normal therapeutic levels?

A
  1. gradual downsloping of the R wave at the end of the QRS complex
  2. can be accompanied by ST depressions and T wave inversions
81
Q

What will digoxin toxicity look like on EKG?

A
  1. the downsloping of the R wave and possible ST dep/T inv as above
  2. sinus bradycardia
  3. loss of sinuns rhythm altogether
  4. AV nodal blocks
  5. can also be tachyarrhythmic with PACs, PVCs, PAT, etc.
82
Q

What electrolyte issue will potentiate digoxin toxicity?

A

hypokalemia, because low K will cause further inhibition fo the Na-K ATPase that is already inhibited by dig

83
Q

What EKG change can be seen with hypercalcemia?

A

shortened QT segment (less than 0.35 s)

84
Q

What EKG change can be seen with hypocalcemia?

A

QT interval prolongation (greater than 0.45s)

85
Q

What other electrolyte abnormality can lead to prolonged QT?

A

hypomagnesemia

86
Q

What is the earliest finding in hyperkalemia?

A

peaked T waves - tall, narrow and symmetric (unlike hyperacute T waves) occurring in all leads

87
Q

What will happen with worsening hyperkalemia?

A

The P waves will flatten, PR interval lengthens and the QRS widens

may widen so much that you get a sinusoidal pattern, which is a precursor to ventricular fibrillation

88
Q

What EKG change happens with hypokalemia?

A

T waves flatten

as it worsens, you can get a second positive wave after the T wave, called a U wave

89
Q

What other electrolyte abnormalities/pathologies can also have a U wave?

A

hypercalcemia
hyperthyroidism
dig toxicity
LVH

90
Q

What can happen on the EKG with hypothermia?

A

bradycardia (as metabolism slows)
tremors - background noise from shivering
irregular rate

OSBORN WAVE, which is a sudden, narrow, positive wave immediately after the QRS complex, starting at the J point - these can also be called J waves. Look like a camel hump (sometimes hard to distinguish from a bundle branch block)

91
Q

What can you see on EKG with a pulmonary embolism?

A
  1. evidence of RVH and a strain pattern
  2. right bundle branch block
  3. sinus tachycardia!!!

S1Q3T3: large S in I, large Q in III and occasionally an inverted T in lead III
(T waves may also invert in the more right-sided precordial leads - V1 through V4)

92
Q

What will happen on EKG in pericarditis?

A

DIFFUSE ST elevations

93
Q

What will happen on EKG if a pericardial effusion develops?

A
  1. voltage may be decreased (due to dampened signal)
  2. Electrical alternans (alternating large and small amplitude QRS complexes) as the depolarization axis points in different directions as the heart bounces around in the fluid
94
Q

What is the tip-off that you’re looking at a paced rhythm?

A

there will be a very narrow spike (called a pacer spike) that looks like a vertical line just prior to the P wave (if the PM is in the atrium) or before the QRS (if the PM is in the ventricle)

95
Q

What will the QRS look like if there is a pacemaker in the ventricle?

A

It will be wide (because the right ventricle will not fire before the left) - thus resembling a left BBB

can also cause ST elevations in the anterior leads (much like a LBBB)

EKG (2 decks)

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