Question 1

A P-R interval of .32 seconds would indicate:

  1. Disturbance in the heart’s conduction pattern
  2. Disturbance in ventricular contraction
  3. Area of ischemia
  4. Electrolyte imbalance


Question 2

A monitor that is worn for 24 hours to evaluate the performance of the heart during routine activities is known as

  1. Resting EGG
  2. Cardiac stress test
  3. Holter monitor
  4. Pacemaker


Question 3

A patient is experiencing chest pain and the physician wishes to determine the cause of the pain during exercise. However the patient is very feeble and cannot perform any exercise. Which of the following would you suggest for this patient?

  1. Cardiopulmonary stress test
  2. Echocardiogram
  3. Persantine Thallium stress test
  4. Holter monitor


Question 4

A patient is showing symptoms of a myocardial infarction, and the physician suspects that the left side (ventricle) of the heart is involved. Which of the following ECG leads will provide the physician with this information?

  1. Leads II, III, and aVF
  2. Leads V1 and V2
  3. Leads I and aVL
  4. Leads V5 and V6


Question 5

Depressed T waves on an EKG tracing represent:

  1. Myocardial injury
  2. Acute hypotension
  3. Myocardial ischemia
  4. Myocardial necrosis


Question 6

Elevated ST segments are indicative of what?

  1. Myocardial ischemia
  2. Certain cardiac medications
  3. Myocardial necrosis
  4. Conduction abnormality


Question 7

Every small square on the horizontal axis of the ECG grid paper represents ________ seconds.

  1. 0.06
  2. 0.04
  3. 0.02
  4. 0.10


Question 8

How many electrophysiologic phases are there in the action potential?

  1. 5
  2. 4
  3. 2
  4. 3


Question 9

In order to obtain a Lead I tracing, the electrode sensors provide:

  1. Right arm (negative): left leg (positive)
  2. Right arm (negative); left arm (positive)
  3. Left arm (negative) : left leg (positive)
  4. Left arm (negative); right arm (positive)


Question 10

In order to obtain a lead III tracing, the ECG sensor makes:

  1. Left leg (positive) Left arm (negative)
  2. Right arm (negative) Left leg (positive)
  3. Left leg (negative) Left arm (positive)
  4. Right arm (negative) Left arm (positive)


Question 11

In the normal conduction system, where does the electrical impulse of the heart originate?

  1. Purkinje fibers
  2. AV node
  3. SA node
  4. Bundle of His


Question 12

In which phase of repolarization is there a slow influx of calcium?

  1. Phase 1
  2. Phase 2
  3. Phase 0
  4. Phase 3


Question 13

Stimulation of the parasympathetic system causes a:

  1. Decreased heart rate
  2. Increased AV conduction
  3. Decreased conduction
  4. Increased contractility


Question 14

The P wave on an ECG tracing represents which of the following:

  1. Ventricular depolarization
  2. Atrial repolarization
  3. Atrial depolarization
  4. Ventricular repolarization


Question 15

The T wave on an ECG tracing represents:

  1. Ventricular repolarization
  2. Atrial depolarization
  3. Atrial repolarization
  4. Ventricular depolarization


Question 16

The ability of a cardiac cell to reach its threshold potential and respond to a stimulus or irritation is called:

  1. Contractility
  2. Conductivity
  3. Automaticity
  4. Excitability


Question 17

The main purpose of a cardiopulmonary stress test is to determine:

  1. Areas of ischemic blood flo
  2. Presence of congenital defects
  3. Presence of electrolyte abnormalities
  4. Criteria for a exercise program


Question 18

The normal P-R interval is:

  1. Usually between .12 and .20 seconds
  2. Less than .10 seconds
  3. Usually greater than .20 seconds
  4. Between .12 and .25 seconds


Question 19

The part of the autonomic nervous system that increases the heart rate is the:

  1. Conduction system
  2. Sympathetic system
  3. Parasympathetic system
  4. Purkinje system


Question 20

The type of electrodes most commonly used are _________________ and should be used ________________.

  1. Disposable, only once
  2. Reusable, more than once
  3. Reusable, after sterilization
  4. Disposable, more than once


Question 21

Two or more waveforms represents a:

  1. Waveform
  2. Interval
  3. Segment
  4. Complex


Question 22

What does the term repolarization mean?

  1. Cardiac cells returning to their resting membrane potential
  2. Contraction of the ventricles
  3. Cardiac cells responding to a trigger
  4. Contraction of the atria


Question 23

When continuous cardiac monitoring is used, what lead is often viewed?

  1. Lead I
  2. aVF
  3. Lead II
  4. Lead III


Question 24

When obtaining a 12-lead ECG, the correct number of electrodes to use is:

  1. 12
  2. 10
  3. 3
  4. 5


Question 25

Which of the following are characteristics of cardiac cells?

  1. automaticity
  2. excitability
  3. conductivity
  4. contractility


Question 26

Which of the following electrolytes are primarily involved in the cardiac cycle?

  1. Sodium
  2. Calcium
  3. Bicarbonate
  4. Potassium

Question 27

Which of the following electrophysiologic phases represent depolarization?

  1. 1
  2. 2
  3. 3
  4. 0


Question 28

Which of the following is NOT a common use for the 12 lead ECG?

  1. Preoperatively before surgery
  2. Diagnosis of heart disease
  3. To determine cardiac output
  4. To determine when to administer electrical shock


Question 29

Which of the following is counted vertically on the ECG grid paper?

  1. Voltage
  2. Time
  3. Dysrhythmias
  4. Isoelectric line


Question 30

Which of the following is the duration of each large square on ECG paper?

  1. .02 seconds
  2. .20 seconds
  3. .10 seconds
  4. .04 seconds


Question 31

Which of the following is the phase in which a strong stimulus may cause depolarization of cardiac cells?

  1. Relative refractory period
  2. Nonrefractory period
  3. All refractory periods
  4. Absolute refractory period


Question 32

Which of the following leads are considered bipolar leads?

  1. Lead II
  2. aVF
  3. V6
  4. Lead III
  5. Lead I
  6. V1


Question 33

Which of the following leads gives information concerning the lower surface of the heart or the inferior leads?

  1. Lead I
  2. Lead II
  3. Lead III
  4. aVL
  5. aVF


Question 34

Which of the following statements are correct when the cardiac cells are in the resting or polarized state:

  1. In this state, the inside of the cell is negatively charged with Ca+, and the outside is positively charged with Na+.
  2. In this state, the inside and outside of the cell have neutral balance.
  3. In this state, the inside of the cell is positively charged K+, and the outside is negatively charged with Na+.
  4. In this state, the inside of the cell is negatively charged with K+, and the outside is positively charged with Na+.


Question 35

Which of the following statements are true about the U wave of an ECG complex?

  1. U waves follow P waves
  2. U waves become visible only in the presence of electrolyte imbalances or heart disease
  3. U waves represent atrial repolarization
  4. U waves are very visible on an EKG tracing


Question 36

Which of the following uses the center of the heart as the negative reference point?

  1. V1
  2. Lead I
  3. V3
  4. Lead II
  5. V6


Question 37

Which of the following would be a normal duration for a QRS complex?

  1. .12 seconds
  2. .16 seconds
  3. .08 seconds
  4. .20 seconds


Question 38

Which type of ECG testing can be used to evaluate the heart while exercised?

  1. Treadmill stress test
  2. Holter monitor
  3. 12-lead EKG
  4. Echocardiogram


Question 39

Match each chest lead with the correct position.

  1. 4th intercostal space, left of sternum – V2
  2. Midway between V1 and V4 – V3
  3. Fifth intercostal space, midaxillary line – V6
  4. 4th intercostal space, right of sternum – V1
  5. Fifth intercostal space, midclavicular position – V4
  6. Fifth intercostal space, anterior axillary line – V5


Question 40

Using the ECG diagram provided, label the following waves, complexes, segments and intervals

  1. Q wave – 2
  2. T wave – 6
  3. PR Interval – 7
  4. P wave – 1
  5. R wave – 3
  6. ST segment – 9
  7. QRS Complex – 5
  8. QT Interval – 8


Question 41

Place the following components of the conduction pattern in correct order.

  1. Purkenji fibers
  2. AV Node
  3. Bundle of his
  4. SA Node
  5. Right and left bundle branches
  1. D, C, E, A, B
  2. C, D, E, B, A
  3. D, B, C, E, A
  4. B, C, A, E, D


Question 42

Which of the following leads would be required to view continuous ECG monitoring?

  1. aVL
  2. Lead I
  3. V2
  4. Lead II
  5. V2
  6. Lead III


Question Answer
EKG inexpensive, noninvasive, and easy to obtain
why do we use EKG chest pain, SOB, dyspnea, weakness, lethargy, and dizziness
What does EKG measure cardiac activity,repolarization and depolarization IT DOES NOT measure force of contraction of the heart
What is repolarization resting…. positive outside of cell
What is depolarization contracting…..negative outside of cell
What is the normal pacemaker of the heart SA node (60-100
2nd pacemaker of heart AV node (40-60)
3rd pacemaker of heart Bundle braches (30-40)
4th pacemaker of heart Purkinje (30-40)
Cardiac electrical pathway SA node, AV node, bundle of HIS, R/L bundle branch, Purkinje Fibers
Nerve fibers within the Atrium Sympathic (speeds HR) and parasympathetic (slows HR) when stimulated
Segment portion of the baseline
Interval contains at least one wave
Rate calculation count the number of large boxes between 2 R waves and then divide that number by 300 OR… memorize 300, 150, 100, 75, 60, 50
5 steps rate, rhythym, p wave, pr interval, QRS complex
To find HR count R’s then x by 10
S below baseline….
Q below baseline… 1st one
R Tallest point
recording techniques for ECGS normally 12 leads, 10 leads are attached
holter monitoring Used to take home and pt tape records when their palpation occurs
Usual electrical setting for defibrillation on adult 200-360 J
Question Answer
What does the ECG measure/record Cardiac electrical activity Repolarization (relaxing) and depolarization (contracting)
When will ECG be indicated Pt complains of chest pain, SOB, dyspnea with palpations, weakness, lathargy, and dizziness
How many seconds does the small squares represent .04 seconds
How many seconds does the large squares represent .2 seconds (5 smaller boxes)
What is the speed 25 mm/sec
What is cardiac electrophysiology basic arrythymia interpretations (why the impulses are doing what they are doing)
Trace the normal cardiac stimulus as it spreads through the atria and ventricles SA nodes, AV nodes, Bundle of HIS, R/L bundle branch, Purkinje fibers
Depolarization contracting When it goes up
Repolarization relexing when it goes down
Normal width of duration for QRS interval .05-.1 seconds
Normal width of duration for PR interval .12-.2 seconds
What is the noraml pace maker of the heart SA node
The rate of the SA node 60-100
Rate of AV node 40-60
rate of Bundle of branches 30-40
rate of Purkinje 30-40
2 nerve fibers within the right atrium that alter the HR when stimulated Parasympathetic and sympathetic
What does the Sympathetic do if stimulated speeds HR
What does the parasympathetic do if stimulated slows HR
Holter monitoring Monitor patient wears and takes home and tape records everything, patient tapes when symptom occurs
echocardiography ultrasound used to see heart and it’s structure in motion (including valves)
Lubb heart sound heard when AV (mytral and tricuspid valves) close (LOUDER because pressure is higher in the left side of the heart)
Dubb heart sound heard when semilunar (pulmonatic and aortic valves) close
Murmur sound heard inbetween lubb and dubb When it’s incompetent AV produces high pitched swooshing….. It is the backflow of blood through the AV into the atrium
Defibrillation setting for ventricular fibrillation energy level of 120-200 J for adults and 2-4 J for children
3 lead system for lead placement White on upper right Smoke over fire(gray over red) clouds over grass (white over green) Brown on ground
Question Answer
P wave represents atrial depolarization (contraction)
QRS complex represents ventricular depolarization and atrial replarization
T wave represents ventricular repolarization
Q wave represents conduction of impulse down the interventricular septum
U wave represents repolarization of bundle of HIS and purkinje fibers
PR interval begining of P wave to begining of QRS (.12-.2 secs)— increase indicates 1st degree heart block
PR segment end of P to beginning of QRS
QRS interval same as QRS complex it is .1 sec or less an increase indicates bundle branch block
ST segment end of S to beginning of T
Question Answer
S1 heart sound sound of AV valves closing
murmur abnormal heart sound
holter monitoring of occasional heart irregularites
voltage represented as vertical axis
P wave atrial contraction
S2 heart sound sound of semilunar valves closing
T wave resting of ventricles
Echocardiogram and cardiac doppler study of heart structures and vlood flow
QRS complex ventricle contraction
Which one would you likely see with acute hypoxia sinus tachycardia
Which rhythym will you see with chronic hypoxia sinus bradycardia
Question Answer
Which of the following criteria applies to third-degree block? There is no relationship between the P waves and the QRS complexes.
What is implied by an abnormally prolonged PR interval? Atrioventricular block
Why is the electrical impulse temporarily delayed at the atrioventricular (AV) node? To allow better filling of the ventricles.
Which of the following medications is used to treat sinus bradycardia? Atropine
What term is used to define the ability of certain cardiac cells to depolarize without stimulation? Automaticity
Which of the following ECG abnormalities is most life threatening? Elevated ST segment
Which of the following axis placements represents right-axis deviation? +120
ECG rhythm strip from an adult patient, you notice the following: regular sawtooth-like waves occurring at a rate of 280/min and a regular ventricular rhythm occurring at a rate of about 140/min. the most likely interpretation? Atrial flutter
What is suggested by inverted T waves on the ECGe? Myocardial ischemia
What structure normally paces the healthy heart? Sinoatrial (SA) node
Atrial flutter is considered to be a life-threatening arrhythmi False
Sources for the electrical impulse that triggers cardiac contraction that lie outside the sinoatrial node are referred to as ectopic foci. True
Which of the following is NOT a common characteristic of a premature ventricular complex (PVC)? Narrow QRS
Valvular defects in the heart can be detected with a 12-lead ECG. False
Which of the following is NOT a common cause of ventricular tachycardia? Pericarditis
At what part of the cardiac conduction system does the electrical impulse travel most rapidly? Purkinje fibers
What medication is most useful for the treatment of premature ventricular contractions? Lidocaine
The ECG you are looking at has one P wave for every QRS complex and the PR interval is 0.30 second. What is your interpretation? First-degree heart block
Which of the following waves represents depolarization of the ventricles? QRS wave
What is the width of the normal QRS complex? Not wider than 3 mm
Which of the following waves represents repolarization of the ventricles? T
For which of the following arrhythmias would an electronic pacemaker be indicated? Third-degree block
Your patient has a normal ECG reading. What does this finding tell you about the patient's likelihood of having a myocardial infarction in the immediate future? No predictive value
What is the normal maximum length of the P wave? 3 mm
Which of the following clinical conditions is not associated with tachycardia? Hypothermia
The electrocardiogram (ECG) is primarily used to evaluate the patient with symptoms suggestive of acute myocardial disease. True
What is a possible serious complication associated with atrial fibrillation? Atrial thrombi
What is the normal period of time for the PR interval? Not longer than 0.20 second
What structure serves as the backup pacemaker for the heart? atrioventricular (AV) node
What parameter is measured on the vertical axis of the ECG paper? Voltage
An occasional premature ventricular complex (PVC) is not of major concern. True
What condition is often associated with right-axis deviation? Cor pulmonale
The QRS of an ECG falls on a dark vertical line of the ECG paper. Subsequent QRS complexes fall on every other dark line (10 mm apart). What is the ventricular rate? 150/min
What type of medications may lead to first-degree heart block? ß-blockers
Question Answer
Normal sinus rhythm rate 60-100 Normal complexes
Sinus Bradycardia everything is normal but it’s a slower rate (longer difference between R’s)
PVC (Premature ventricular contraction) an abnormal complex originating in ventricle –wide QRS, –compensatory pause follows
Sinus tachycardia SINUS= normal, rate greater than 100. (exercise, smoking, anxiety, etc) Faster (shorter distance between R’s)
PAC (premature atrial contraction) caused by irritability of atria -early contraction
Sinus arrhythmia rate varies between breathing.. common in children R-R intervals differenitate
Atrial fibrillation Atria depolarized (contracts) at high rate (up to 600/min)… Produces irregular, wavy pattern in place of normal P waves, — baseline is irregular
Atrial flutter Atria simulated about 300 times/min —charc by saw-toothed shape waves
Ventricular tachycardia 3 or more consecutive PVC’s.. HR usually 120-200/min.. LIFE THREATENING… Wide QRS=PVC (heart does not have time to fill up so BP decreases).. P waves are hard to see
Ventricular fibrillation Ventricles do not beat in coordinated fashion… no blood flow… PT unconcious..waves in irregular, CHAOTIC fashion
Asystole flat line Do not shock unless last option do CPR instead
PEA (pulseless electrical activity) no pulse or cardiac output Pattern appears normal… assess with doppler
Acute hypoxia occurs first (tachycardia)
severe hypoxia prolonged time (bradycardia)

Question Answer
What is an ECG an indirect measurement of the electrical activity within the heart
What do ECG’s not measure pumping ability, abnormalities of cardiac structure, probability of MI
Chief complaint suggestive of ECG chest pain, exert ional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, fainting, palpations, nausea and indigestion in high risk pts
Past medical hx suggestive of ECG hx of heart disease, hx of cardiac surgery
physical exam suggestive of ECG unexplained tachycardia at rest, hypotension, <capillary refill, abnormal heart sounds, pedal edema, cool cyanotic extremities, abnormal heave or lift of pericardium, diaphoresis, JVD, abnormal sensorium, hepatojugular reflex, bilateral insp crackles
*SA Node normally is pacemaker, has greatest automaticity, causes depolarization (60-100bpm)
*AV Node normally acts as back up pacemaker (40-60 bpm)
electrical conduction system of the atria SA node to the 3 internodal atrial conduction tracts leading to AV node and 1 intranodal conduction tract to left atrium (Bachman’s bundle)
Atrioventricular Junction AV Node and bundle of His (.05 second delay)
electrical conduction of the ventricles from bundle of his in AV junction to bundle branches (30-40 bpm) to purkinje network (30-40 bpm)
Systole ventrical contraction
Diastole ventrical relax
atrial kick contraction of the atria (at latter end of systole) just before ventrical contraction-aids in ventrical filling and accounts for 10-20% of CO in healthy person
AV Node delay .05 seconds, delay before passing into bundle of his, allows for complete filling of ventricals before contraction (also protects vents from fast rates)
automaticity cells that have the ability to generate electrical activity spontaneously
pacemaker cells cells w/high degree of automaticity that provide electrical power to heart
myocardial cells contract in response to elec stimuli and pump blood
ectopic impulse impulse originating outside the SA Node
SA Node is stimulated by the sympathetic nervous system, what kinds of things can increase SA Node rate (fight or flight) stress, anxiety, exercise, medication. CHF, hyperthyroidism
what can slow the SA node rate (or stop it) vagal stimulation (parasympathetic), also drugs disease etc
coronary arteries supply 02 and nutrients to heart, arise from descending aorta and branches to coronary vessels
Infarctions blockage of one or more coronary vessels leading to regionalized tissue ischemia and tissue death
MI and ischemia cause what dysrrhythmias and <CO
Hypoxia and ischemia of myocardium causes <PaO2, <HB, <perfusion
how can sympathetic stimulus cause ischemia >workload w/o concurrent blood flow (blocked coronary arteries)
what electrolyte imbalance cause dysrrhythmias potassium, magnesium and calcium are most common
poor cardiac output and HR to slow causes <output, HR to fast vents, not enough time to full so less blood pumping <CO
causes of dysrrhythmias hypoxia, ischemia, sympathetic stimulation, drugs, electrolyte imbalance
acetycholine neurotransmitter of the parasympathetic NS, aka cholinergic, <HR
norepinephrine neurotransmitter of the sympathetic NS, aka adrenergic, >HR, >contractility
alpha and beta adrenergic receptor sites alpha are in blood vessels through out body and B receptor are in heart and lung only
receptor site mnemonic ABCD alpha constrict-beta dilate
heart receptor alpha and B1
lung receptor B2
blood vessel receptor alpha and B2
*4 major characteristics of cardiac cells automaticity, excitability/irritability, conductivity, contractility/rhythmical
action potential electrical charge passing through cell and propagating to other cells (all in one fashion)
polarized resting state
depolarization muscle contraction(loss of negative charge)
re-polarization return to resting state (negative charge returns)
*Pwave (.11 seconds) depolarization of the atria, impulse spreads across atria and triggers atrial contractions
*QRS complex (<.12) impulse spreads to ventricals, triggers ventrical contraction, (depolarization)
T-Wave ventricals returning to resting state
*PRI PR interval, .12-.20, measures time from onset of atrial contraction to onset of vent contraction, aka time for elec impulse to spread through and AV node (3-5 small squares)
short PRI indicates progression of elec impulse is outside normal path
*long PRI indicates delay in conduction or AV block
normal QRS <.12
wide QRS indicates originates in ventricular if supraventricular it has deviated from normal course
narrow QRS normal, supraventricular
ST Segment begins at end of QRS and ends at beginning of Twave, normally flat
*elevated or depressed ST segment depressed ischemia, elevated MI
U-wave follows Twave, may be seen or unseen, final phase of ventrical re-polarization
QT interval from beginning of Q to end of T, should be ½ of R-R
long QT interval >1/2 of R-R (if HR is <80bpm), hypokalemia, hypocacemia, side effect of meds like quinidine
R-prime a QRS complex that has a second positive deflection, the first is the R, the second is R-prime
S-prime second S wave in QRS
normal mean axis between 0 and 90 degrees
Right axis deviation right vent is enlarged
Left axis deviation left vent is enlarged
S&S of dysrrhythmias chest pain, dyspnea, fine crackles, palpations, pale cool skin, dizziness/syncope, sense of impending doom, low BP-<90systolic, <LOC
interpreting dysrrhythmias can be accomplished in 3 levels 1ventrical response (abnormal conduction), 2 categorize based on origin, 3 electro-physiology (pathway of conduction disturbance)
how is ventrical response determined QRS complexes and pulse strength (to fast/slow, irritability, lethal, absent)
categories of origin are atrial, junctional, ventricular
electrophysiology of dysrrhythmias ectopic beat/rhythm, escape beats/rhythms, AV block, bundle branch block
*bradycardia rate <60
*tachycardia rate >100
irregular rhythms may be random or in patterns, ectopic beat, escape beat, second degree AV block, atrial Fib, sinus dysrrhythmias
*evaluate Pwave positive, round, <.10, <2.5 mm tall, all should look alike
*odd shaped Pwaves are indicative of atrial enlargement
*more than one Pwave may indicative of atrial flutter (Pwaves look alike), atrial fib (Pwaves don’t look alike), 2nd or 3rd degree heart block
*evaluating PR interval norm .12-.20 seconds, >.20 is possible heart block (delayed AV node)
*evaluating QRS norm <.12, wide w/bundle branch block, ectopic beat in vent (PVC’s), ventrical dysrrhythmias (vtach, idioventricular rhythm or premature ventricular complex), 3rd degree heart block
*evaluating ST segment norm is isoelectric(flat), elevated is myocardial injury, depressed is ischemia
cases of right axis deviation left vent infarction, rt vent hypertrophy, COPD, pulm emboli, normal in infants,
causes of left axis deviation rt vent infarction, left vent hypertrophy, abdominal obesity, ascites, or ab tumor, pregnancy
*evaluating the Qwave norm is <.04 and less than 1/3 amplitude of R, greater than 1/3 R is pathologic, indicative of new or old MI
*Right atrium enlargement is seen in pts chronic pulm hypertension (as with COPD)
*Right atrium enlargement is diagnosed by rt deviation of Pwave, tall Pwave or prominent or negative Pwave
*cor pulmonale (rt atrium enlargement) shifts axis how to the right
*absolute bradycardia <60 bpm w/no problems to pt (athlete)
*relative bradycardia <60 bpm not tolerated well by pt, pts with compromised cardiac function may cause hypotension, syncope, <CO, CHF or shock
transient bradycardia may be caused by >vagal tone from carotid massage, manipulation of tubes, suctioning, valsalva maneuver
long term bradycardia can be caused by damage to SA node by MI
disease states that cause bradycardia hypothyroidism, hypothermia, hyperkalemia, meds
*sinus tachycardia 100-150 BPM with SA node as pacemaker, most often caused by fever, pain, hypoxemia, hypovelemia, hypotension, sepsis, heart failure and suctioning
*respiratory meds that cause sinus tachycardia methylxanthines (phosphodiesterase inhibitors) and B agonist
evaluating sinus dysrrhythmias usually benign, everything is normal except rhythm, rhythm will be off (space between the R-R)
what is paroxysmal atrial tachycardia 160-240 bpm, ectopic foci in the atrium takes over as pacemaker, sudden onset and ending, may cause hypotension, CHF, or ischemic episode, or recent/pre existing MI
danger of PAT (paroxysmal atrial tachycardia) >myocardial O2 demand but pump is ineffective because of rate, especially dangerous in pt with bad heart
Pt complaint with PAT light headed, palpations, possible fainting
causes of PAT stress, mitral valve disease, rheumatic heart disease, digitalis toxicity, alcohol, caffeine or nicotine
evaluating PAT rate 160-240 bpm, rhythm normal, Pwave abnormalities-hidden in QRS or if before QRS it appears pointed, can combine with Twave, PRI is usually not measurable
*atrial flutter pattern on ECG strip is caused by rapid firing of ectopic foci, sawtooth Pwave with normal QRS
*F-waves flutter waves, caused by rapid contractions of atria upon stimulation by re-entry or accelerated automaticity
atrial flutter reduces CO how reducing atrial kick
mural thrombi thrombi that form along the atrial walls (stagnated blood) during atrial flutter, migration may cause emboli
atrial flutter usually resolves how deteriorates to atrial Fib or spontaneously returns to normal
caused of atrial flutter valvular heart disease, MI, hypertension, cardiomyopathy, myocarditis and pericarditis
evaluating atrial flutter rate 180-400, rhythm is regular, Pwave is sawtooth can be 2:1, 3:1 etc, PRI not measurable (to many Pwave), QRS is normal <.12 sec
Atrial Fibrillation quivering of the atrials caused by multiple ectopic beats, causes complete loss of atrial pumping ability and increased risk of mural thrombi and emboli
caused of A Fib same as a-flutter plus hyperthyroidism, pulm diseases and congenital heart diseases
evaluating for A-Fib rate can be as high as 400bpm, rhythm is irregular irregular, Pwave is chaotic and irregular, PRI is unmeasurable, QRS <.12
PVC ectopic beat originating in ventrical, can occur in normal or diseased heart
common causes of PVC’s anxiety, caffeine, alcohol, tobacco and meds. Also seen in pts with HX of MI, heart disease, acidosis, electrolyte imbalance, CHF, and hypoxia
when are PVC’s dangerous multiple PVC’s in less than 1 minute (indicates irritable vent area), couplets (2in a row), salvos (3 in a row), or R on T phenomenon
Salvos 3 PVC’s in a row, also known as a run of Vtach
R on T phenomenon PVC’s occur during Twave of preceding beat, can cause PVC’s to turn into Vtach (when it happens Vtach QRS wave looks more rounded)
evaluating for PVC’s rate is underlying, rhythm is regular, Pwave is not associated with PVC (others are normal), PRI not measurable (others are norm), QRS norm except with PVC>.12 abnormal look and premature, Twave is opposite direction of PVC (PVC up Twave down)
All PVC’s are followed by what compensatory pause (because they are premature)
Ventricular Tachycardia run of 5 or more PVC’s, looks like a series of wide QRS’s w/no Pwave, tombstones or fireman hats
*what causes Vtach hypoxic heart, as with severe myocardial ischemia
evaluating Vtach rate 140-300 bpm, rhythm is regular, no Pwave with PVC, no PTI with PVC, wide QRS
Ventricular Fibrillation chaotic unorganized ventrical activity, wavy irregular pattern, no QRS, no rate, rhythm, Pwave or PRI
Asystole cardiac standstill-flatline-no pulse, dead
PEA pulseless electrical activity, rare and usually follows an event like tension pneumo, cardiac trauma, severe electrolyte imbalance or acid-base disturbance
PEA rhythm any rhythm that does not produce a pulse except Vtach, Vfib and asystole
most common AV Heart block causes meds like digitalis, damage from MI
1st degree AV heart block (mildest) prolonged PRI >.20 second delay at AV node
1st degree AV heart block causes meds (digitalis), >vagal tone, hyperkalemia, myocarditis, and degenerative disease
evaluating for 1st degree heart block rate normal, rhythm regular, Pwave normal, PRI prolonged (>.20), QRS norm at <.12
Second degree AV Block Type 1, aka Mobitz 1 aka Wenkebach (intermediate block) PRI gets long each beat until QRS is dropped, same causes as type 1
2nd degree AV Block type 2 aka Mobitz type 2 rare and serious, many Pwaves with out QRS, PRI can be normal or prolonged, but is always constant
evaluating 2nd degree mobitz 2 rate varies but ventrical is always less than atrial, rhythm is regular regular or regular irregular, Pwave looks normal but no QRS follows some.PRI is norm or long but all look alike, QRS <.12
causes of 2nd degree heart block type 2 damaged bundle branch fallowing an MI or degenerative disease
3rd degree block most extreme and dangerous heart block. Conduction problem is in bundle of his (narrow QRS) or in bundled branches (wide QRS), complete block, no conduction atria and ventricals
causes of 3rd degree heart blocks inferior MI, increased vagal tone, myocarditis, digitalis toxicity, may be permanent condition following MI or degenerative disease
evaluating 3rd degree heart block rate <60, rhythm is regular, Pwave is normal but not always followed by QRS, PRI varies many with no relationship to QRS, QRS is usually wide but can also be normal
idoventricular rhythm normal pacemaker is not setting pace, trials norm but ventrical wave is irritable ectopic beat, looks like slow wide bizarre QRS, with brady, leads to rapid heart failure, (looks like row of slow moving PVC’s)
accelerated idoventricular rhythm variation of idoventricular but rate is 60-100
evaluating idioventricular rhythm rate 30-40, rhythm is regular, Pwave is absent, PRI none, QRS >.12
Junctional rhythm area of AV junction assumes pacemaker
causes of junctional rhythm AV node damage, electrolyte disturbance, digitalis toxicity, heart failure, valve disease, rheumatic fever
evaluating junctional rhythm rate 40-60, accelerated 60-100, junctional tachycardia >100, rhythm is reg, Pwave is absent, inverted or short, can be befor or after QRS, PRI if present is short, QRS <.12
Pwave following QRS is what junctional rhythm, shows retrograde conduction (up), and will be inverted (looks like ST segment is dipped)
If Pwave appears befor QRS in junctional rythm Pwave is not responsible for QRS if PRI is less than .12
deviation of the ST segment up or down suggests what abnormal myocardial perfussion and oxygenation (due to hyperkalemia), cardiac ischemia but no perminant damage
COPD causes what kind of axis deviation hyperinflation rotates heart & causes R axis deviation.
Cor pulmonale (R vent enlargement) causes what kind of deviation R axis deviation
COPD dysrhythmias Tachycardia, Multifocal atrial tachycardia, ventricle ectopic beats are most common (from hypoxemia & meds) & worsen at night due to hypoxemia.
Calculating EKG HR Between R-R, add lg boxes at .20 each and sm boxes at .04 then divide into 60. 2lg + 3sm is 60/.2+.2+.04+.04+.04 equals 60/.52 is a HR of 115
Prolonged QRS .12-.10 causes R or L bundle branch block, IVCD or L anterior or posterior fascicular block.
QRS >.12 Complete RBBB or LBBB (3rd degree block), IVCD, or PVC’S (v-tach & pacemakers)
IVCD intraventricular conduction delay.
Sick sinus syndrome disturbance of SA node causing marked variable in rhythm – cycles of brady and tachy.
Atrial tachy Series of 3 or more PAC’s (includes PAT-paroxysmal atrial tach)
Atrial flutter rate according to Karol’s handout 250-350
A Fib Uncoordinated atrial depolarization’s
Junctional escape Rhythms Inverted or no p-wave, AV node rhythm of 40-60
AV block Conduction block w/in AV node (sometimes bundle of his)
1st degree block PRI >.20, caused by increased vagal tone, digitalis, beta- blockers, calcium channel blockers or ischemia damage.
2nd degree AV block slow conduction at AV node so some don’t get through. Ventricle rhythm is < atrial rhythm.
2nd degree Type 1 (wenkebach) AV node block. PRI it elongates then drops QRS – most often seen in sleeping pt with high vagal tone (rarely is pacing indicated)
3rd degree complete block, but escape rhythms cause QRS but they originate in AV node, bundle of his or vent region. No synchrony between Pwaves & QRS atrial rhythm can be normal, but vent will be 30-40
SVT most often caused by reentry currents in atria or from vent to atria. Rate 140-250
VPB (Ventricular premature beats) Wide QRS, caused by eptopic foci in ventricle.
V Tach Caused by aberrant vent automatically or intra-ventricular reentry, can be sustained or paroxysmal (short run) wide QRS 100-200 bpm.
V Flutter vent depolarizes >200/min
V Fib Uncoordinated vent depolarization’s
The 3 types of heart cells are pacemaker (automaticity), conducting (conduct electricity), and myocardial cells ( contract in response to electricity)
where is the greatest degree of of automaticity SA node-thus the pacemaker
what is the back up pacemaker AV junction
blocked coronary artery causes what ischemia and infarction leads to dysrrhythmias and <QT
what does the QRS reflect on ECG electrical activity of the ventricals
during depolarization what happens in the myocardial cells K- moves out and NA+ and CA+ moves in
during re-polarization what happens in the myocardial cells K- moves back inside and NA+ and CA+ move to the outside
isoelectric flat (no positive of negative charge)
normal ECG has how many leads 12, 6 limb (vertical plane) and 6 chest (horizontal plane)
what are the 6 limb leads I, II, III, aVR, aVL, aVF
bipolar leads leads I, II, and III, voltage is measured as a difference in between two electrodes
augmented leads leads aVR, aVL, aVF are augmented by the machine because they are unipolar
frontal plane vertical plane of the limb leads, measures up-down, right-left etc.
what are the chest leads V1-V6
where are V1 and V2 located 4th intercostal space V1 on the left and V2 on the right
where is V6 located 5th intercostal in the midaxillary line (mid axillary would be if you cut body in half from top down, so mid axillary is under armpit) V3, V4 and V5 are located in between V2 and V6
depressed ST ischemia
elevated ST infarction, greater the height-greater the damage
elevated T ischemia (usually seen with depressed ST
significant increase in Q wave (.04) is indicative of what infarction
ECG’s are useful for assessing what impact of lung disease on heart, severity of infarction, heart rhythm, never pick pumping ability or QT
what clinical findings suggest the need for ECG’s orthopnea and syncope
what is the normal intrinsic rate of primary pacemaker 60-100
what is the normal intrinsic rate of secondary pacemaker 60-80
what does P wave represent atrial depolarization
what does QRS represent ventrical depolarization
what does T wave represent ventrical re-polarization
normal PR interval .20
normal QRS <.12
QRS is equally spaced with 3 large boxes between, whats the rate 100 (300/3 is 100)
QRS is equally spaced with 4 large boxes between, whats the rate 75 (300/4 is 75)
prolonged PR interval AV block
acute infarction looks like what on ECG elevated ST segment
difference between fibrillate and flutter flutter you can count and fibrillation is a quiver-chaotic, Ventrical fib and flutter originate low in the heart, so no QRS as with atrial fib and flutter (they have a QRS)
must know ID these strips and how to treat including meds brady, sinus tach, PVC, fine and course VFib, asystol, depressed ST and elevated ST
1 small box on strip .04 seconds
1 large box on strip .20 seconds
calculating bpm add the large boxes between R waves and devide into 300 so 300/3 is 100 bpm