EKG ReviewWFHS Academy of Critical Care and Emergency Medicine 2015

What is the primary pacemaker of the heart?

• SA Node (Sinoatrial Node)

What is the inherent rate of the AV node?

• 40 – 60 bpm

An R wave falls on a bold black line. The subsequent R wave falls on the 2nd subsequent bold black line. What is the rate?

• 150 bpm

Which coronary artery supplies blood to the SA node artery?

• RCA – Right Coronary Artery

Name the (4) valves in the human heart.

• Aortic• Mitral (bicuspid)• Tricuspid• Pulmonic (pulmonary)

Name (3) properties of cardiac muscle tissue.

• Automaticity• Contractility• Irritability (excitability)

Name this dysrhythmia

Ventricular Tachycardia

Name the Waveforms

This is one cardiac cycle. What does this represent from a mechanical standpoint?

1 heart beat, 1 pulse

Name this rhythm

Where is the heart attack?

Acute Inferior MI

ST Elevation in LII, LIII, AVF

Name this artifact

60 Hz AC Interference

Complete the table

SA Node

AV Node

PurkinjeFibers

RA

Junctional Septum

Terminal Bundle Branches

60-100

40 - 60

20 - 40

Pacemaker Location Intrinsic Rate

Describe layers of the heart from inner to outer

Endocardium

Myocardium

Epicardium

What is the other name of the epicardium?

Visceral Pericardium

What is the name of the tough fibrous sac which encloses the heart in the mediastinum?

Parietal Pericardium

Remember, the space called the pericardial space

Name other types of artifact X 60 cycle

Wandering Baseline

Muscle Tremor

Reversed Leads

Pacemaker Spikes

Absolute Heart Block (4th Degree) Caused by Love of the Bottle, should not be confused with reality.

Name the Chest Lead Locations

What is the name of the condition which may require a Rt. Side EKG?Dextrocardia

Limb lead polarities are defined as…

• Bipolar

List the unipolar limb leads

• AVL• AVR• AVF

Which plane is distinguished by the chest leads?

• Horizontal or Transverse

Assign the correct parameters to the objects above

Small Box

Large Box

Times

Voltage

Size

Name the heart blocks

First Degree Heart Block

3rd Degree or Complete Heart Block

Describe a metaphor for depolarization

What is the name of the major intra-atrial pathway of the conduction system?

Regular or Irregular

• Atrial Fibrillation• Atrial Flutter• Ventricular Fibrillation• Ventricular Tachycardia• AVHB Type I• AVHB Type II• 1st Degree HB• Torsade De Pointe

Which Interval would be the most important parameter to check to determine the regularity of a rhythm?

R - R

Lead I

+_

G

Lead II

G_

+

Lead III

_G

+

Lead AVL

+_

_

What is this triangle called?

Einthoven’s Triangle

Name the ectopy

PVC

PAC

PJC PJC

Calculate the heart rate

300 Method 1500

Method6 Second Method

Name the MIAnterior – STEMI – V2 V3 V4

Coronary Arteries

Which major coronary artery branches off the left main and encircles the heart to the left?Circumflex

If the left main coronary artery is occluded, the entire left side of the heart will…DIE!

An occlusion of the LMCA results in a heart attack referred to as a…

Widow Maker

Pacemaker Function

Pacing and sensing wires are implanted in both the atria, and the ventricles. The pacemaker senses the function of each chamber and stimulates (paces) the chamber if needed to cause a contraction.

What principle governs the underlying operation of pacemakers?

The fastest pacemaker will override slower pacemakers

Which valves close during ventricular systole?

• The Mitral Valve (bicuspid) and Tricuspid valve

During ventricular systole, what prevents blood from entering the coronary arteries?

• The flaps of the aortic valve.

Which coronary artery supplies the AV node artery in 90% of the population?

• RCA

Which branch of the LMCA supplies blood to the posterolateral aspect of the left ventricle?

• L Circumflex

Which electrophysiological concept allows for atrial kick?

• Transmission delay in the AV nodeAtrial kick allows the last bit of blood in the atria to be “kicked into” the ventricles.

What are the (2) branches of the left bundle branch called?

• Left Posterior Fascicle• Left Anterior Fascicle

Ectopic beats generated secondary to irritability fall into these categories

• Premature Atrial Beats• Premature Junctional Beats• Premature Ventricular Beats

How many internodal pathways exist?

• What are their names?

3

1. Anterior2. Medial3. Posterior

Which nodes do they connect?

SA and AV

If an abnormal pathway exists between atria and ventricles, which dysrhythmias may result?

1. Atrial Flutter2. Supraventricular Tachycardia3. WPW, LGL

What is the standard size calibration box representing amplitude?

• 10 mm tall (Y) x 5 mm wide (X)

How is standard gain defined?

• 10 mm per 1 mV

What is the purpose of Wilson’s Central Terminal?

• Creates a reference point for 6 of the 12 leads• Is the “0” end for the 9 unipolar leads• Creates positive end of unipolar leads

What is the rate of the above rhythm using the 1500 method?

Which type of rhythms are best rate calculated by this method?

Tachycard-as and regular rhythms

The sequence method

• Complete the sequence• 300• 150• 100• 75• 60• 50

What is the rate of the rhythm below?

6 second rule

• What is the rate…

When can it be used?

Any rhythm

Let’s Review Anatomy

That looks funny!

Ambulatory Monitoring

How do you verify the accuracy and validity of your EKG recording?

Where is the DAMAGE?

What’s on the opposite side?

Name Me!!!!!!!!

Polymorphic VT

Ventricular Tachycardia

Torsade De Pointes

Supraventricular Tachycardia

Atrial Fibrillation

Name Me Tooooooo!

Complete Heart Block

Complete Heart Block

2nd Degree AVHB Type I

Wenckebach

Atrial Flutter

What makes us alike? Which One does

not belong?

We are all 2nd degree HB Type II except for the 3rd degree imposter

What to do? The patient refuses to give consent because…

Does not understand why the consent form is required?

Explain the legal requirement of an informed consent and refer to MD if needed.

Pt. Does not understand the procedure.

Notify MD, provide brochure while pt. is waiting for MD to explain procedure.

Pt. is illiterate and cannot sign name.

Need witness, *family member, mark with an X, witness signs, you sign,

Pt. is unable to sign because does not have glasses.

Get the glasses – have pt. sign to best of ability and get a witness *family member, you sign.

Exercise Electrocardiography SAFETY Preparing for Emergencies

• Inform pt. how they may feel during test. Mild fatigue, increased HR, sweat, increased RR

• Explain need to report S/S, CP, dizziness, weakness or extreme fatigue

• Instruct to stop exercise with pain, extreme fatigue• MD must be present during entire procedure• Crash Cart available• Observe, monitor, report any S/S to MD

Name (3) things the patient should avoid at least (3) hours prior to Exercise EKG

•ALCOHOL•Caffeine• Tobacco

What is another name for Exercise Electrocardiography?

Stress Test,Stress EKG

True or False

• As a multi-skilled healthcare provider, you are responsible for reporting the results of exercise electrocardiography to the patient and referring any questions to the MD.

• FALSE – The MD reports results

Ambulatory Monitoring

• How long does ambulatory monitoring take?• 24 – 48 hours• Name one specific type of ambulatory monitor• Holter Monitor• How many leads are attached?• 3-5 depending on type• What S/S should be recorded in the patient’s diary?• CP, Indigestion, Dizziness

Ambulatory Monitoring

• What are the most common types?• Continuous• Intermittent

When does the intermittent system record?

When the patient has S/S they press “record”

During continuous recording, the patient may be asked to press a button to mark the tracing whenever a symptom is noted. What is this mark called?

“event marker”

Is it possible to record a 12 lead Holter?

YEP!

FYI Some ambulatory monitors are “voice activated”.

Ambulatory MonitoringLead Placement (General)

Electrodes (leads) need to be placed according to manufacturer.

Name Me

Pacemaker 1st Degree HB

Wandering Baseline (a-fib)

ANTERIOR MI

Multiform PVCs