AAA PA: Lab & Diagnostic Testing > Module 2b: Electrocardiogram > Flashcards

Module 2b: Electrocardiogram Flashcards

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1
Q

What key factors contribute to cardiac output?

A
  • Stroke volume: EDV - ESV
    • Preload: LVEDP (more get in, more squeeze out)
    • Afterload: Systemic vascular resistance (SVR) & resistance from valve
    • Contractility: force of contraction (inc squeeze)
  • Heart Rate:
    • Exercise/rest
      (Tools to improve cardiac output)
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2
Q

What are chronotropic, dromotropic, ionotropic, and lusitropic?

A
  • Chronotropic: Rate, SA Node, S: faster, P: slower
  • Dromotropic: conduction velocity, CCC/myocytes/AV node, S: faster, P: slower
  • Ionotropic: contractility, ventricle, S: stronger (P: not sig)
  • Lusitropic: relaxation, ventricle, S: faster, (P: not sig)
    (S: sympathetic, P: parasympathetic)
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3
Q

What are the components of the myocyte action potential?

A
  • Phase 0: Na+ open, depolarization (reach threshold potential of -70mV)
  • Phase 1: Na+ close, K+ begin repolarization (op to +20mV)
  • Phase 2: Ca2+ open, maintain polarization
  • Phase 3: Ca2+ close, K+ repolarize (pump K+ in & Na+ & Ca2+ out)
  • Phase 4: leak channels maintain polarization (-90mV)
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4
Q

What are the pacemaker potentials of the CCS?

A
  • SA: 60-100bpm (bradycardia <, > tachycardia)
  • Junction rhythm: 40-60bpm
    • AV Node & Bundle of His
  • Ventricular rhythm: 20-40bpm
    • Originating distal bundle of His
      (Fibrinous connective tissue)
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5
Q

What are the relative conduction rates of the heart?

A
  • Atrial/ventricular myocytes: 0.5m/sec
  • Internodal pathway & Bauchman bundle: 2m/sec
  • AV node: 0.05m/sec
  • Bundle of His, RBB, LBB, LP Fascicle, LAF 3m/sec
  • Purkinje fibers: 4m/sec
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6
Q

What are the cardiac vectors?

A
  • Created by myocyte depolarization
  • Leads pick up millions of myocytes depolarization (not originate from CCS (not enough myocytes), most from ventricles)
  • Vector away from lead: Negative reflection
  • Vector across the lead: Positive & negative reflections
  • Vector toward the lead: Positive reflection
  • 4 Large vectors: 2 atria & 2 ventricles (more like 2: atrial (P) & ventricular (QRS) depolarization)
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7
Q

What are the limb leads?

A
  • White on right, smoke over fire
  • “Three-view”
  • (RA -> LA) I: right to left
  • (RA -> LL) II: down toward left
  • (LA -> LL) III: down toward right
    Routine monitoring
    (Bipolar, only worry about positive = direction of vector)
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8
Q

What are the augmented vector leads?

A

Computer generated
- aVR: superior & right
- aVL: superior & left
- aVF: inferior
(unipolar, + points toward direction of vector)

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9
Q

What is the hexaxial system?

A

0: starts at + lead I
+60: II
+90: aVF
+120: III
180: negative pole of lead I
-150: aVR
-30: aVL

Normal: +30-+60
- Skewed by LV hypertrophy: more +30 or 0

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10
Q

What are the Precordial leads?

A
  • V1: right of sternum, 4th intercostal space
  • V2: left of sternum, 4th intercostal space
  • V3: between V2 & V4
  • V4: 5th intercostal space, mid clavicular
  • V5: anterior axillary (level w/ V4)
  • V6: mid axillary (level w/ V5)
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11
Q

What are the general views of the heart?

A
  • Inferior wall: III, aVF, II
  • Septal wall: V1, V2
  • Anterior wall: V3, V4
  • Lateral wall: V5, V6, I
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12
Q

What are the important aspects of the ECG paper?

A
  • Small block: 0.04 sec
  • Big block: 0.2 sec (5 = 1 sec)
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13
Q

What are the components of an ECG complex?

A
  • Baseline
  • P wave
  • PRI
  • PR segment
  • QRS complex
  • ST segment
  • T wave
  • QT interval
  • TP interval
  • U wave
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14
Q

What is the baseline?

A

A line from one TP segment to the next

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15
Q

What is the P wave?

A
  • Atria depolarization
  • Duration: 0.08-0.11sec
  • Axis: 0-75* downward & to the left
    (Tp: repolarization, opposite direction, usually not seen b/c during QRS)
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16
Q

What is the PR segment?

A
  • Exists
    (Depolarization through AV node, His bundles, bundle branches, & Purkinje)
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17
Q

What is the PR interval?

A
  • Delay of AV node
    (Impulse initiation, atrial depolarization, atrial repolarization , AV node stimulation, His bundle stimulation, bundle branch & Purkinje system stimulation)
  • Can be too short or too long
    (>0.20 first-degree AV block)
  • Duration: 0.11-0.20sec
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18
Q

What is the QRS complex?

A
  • Ventricular depolarization
  • 0.06-0.11sec
  • (-30 to +105, downward & to the left)
  • Q: benign or indicate dead myocardial tissue
    • significant: 0.03 sec or wider or height => 1/3 height of R wave
    • insig: common I, aVL, V6 (septal innervation)
  • Intrinsicoid deflection (beginning of QRS to downward R): elevated = thicker myocardium
    • Upper limit pericordials R = 0.035sec, L = 0.045sec
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19
Q

What is the ST segment?

A
  • beginning = J point
  • usually: baseline
  • normal elevation: 1mm or up to 3mm in R pericordials in some pts (L ventricular hypertrophy or early repolarization pattern)
  • Any elevation in symptomatic pt should be considered significant & representative of myocardial injury/infarction until proven otherwise
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20
Q

What is the T wave?

A
  • Ventricular repolarization
  • Should be asymmetric
  • Symmetric usually sign of pathology
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21
Q

What is the QT interval?

A
  • All events of ventricular systole
  • Prolonged: harbinger arrhythmias esp torsades de pointes
  • Should be < 1/2 preceding RR interval
  • QTc: (corrected for HR; inverse relationship)
    • QTc = QT + 1.75 (ventricular rate - 60)
    • Normal: 0.410sec
    • Prolonged: >0.419sec
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22
Q

What is the U wave?

A
  • Unknown events
  • Same direction as T
  • May indicate hypokalemia
  • CANNOT have hyperkalemia w/ U wave
  • Can lead to longer-than-accurate QT interval
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23
Q

What is the R-R interval?

A
  • Distance between identical points (usually the peaks)
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24
Q

What is the P-P interval?

A
  • Distance b/w two identical points on one P wave & the next
  • Helpful for rhythm abnormalities
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25
What is the sequence for approximating rate?
- 1 block: 300bpm - 2 blocks: 150bpm - 3 blocks: 100bpm - 4 blocks: 75bpm - 5 blocks: 60 bpm - 6 blocks: 50 bpm
26
What are the fundamentals of ECG rhythm analysis?
General: 1. Fast or slow? 2. Regular or irregular (irregular or regular)? P Waves 3. Present? (atrial or supraventricular) 4. Same? (same pacemaker) 5. Each QRS have a P wave? (AV nodal block) 6. PRI constant? (wandering atrial pacemaker or multifocal atrial tachycardia, PAC) QRS Complexes 7. P waves & QRS associated w/ one another? 8. Narrow or wide? 9. Grouped? 10. Dropped?
27
What is a normal sinus rhythm?
- Rate: 60-100bpm - Regularity: regular - P wave: present - P:QRS 1:1 - PRI: normal - QRS width: normal - Grouping: none - Dropped: none
28
What is a sinus arrhythmia?
(NSR but regularity) - Rate: 60-100bpm - Regularity: **varies with respiration** - P wave: present - P:QRS 1:1 - PRI: normal - QRS width: normal - Grouping: none - Dropped: none
29
What is Sinus bradycardia?
(NSR but rate) **- Rate: <60 bpm** - Regularity: regular - P wave: present - P:QRS 1:1 - PRI: normal *to slightly prolonged* - QRS width: normal *to slightly prolonged* - Grouping: none - Dropped: none (Athlete, vagal stimulation, medications)
30
What is sinus tachycardia?
(NSR but rate) **- Rate: >100bpm** - Regularity: regular - P wave: present - P:QRS 1:1 - PRI: normal *to slightly shortened* - QRS width: normal *to slightly shortened* - Grouping: none - Dropped: none (med, exercise, hypoxemia, hypovolemia, hemorrhage, & acidosis)
31
What is sinus pause/arrest?
- Rate: **varies** - Regularity: **irregular** - P wave: present *except in areas of pause/arrest* - P:QRS 1:1 - PRI: normal - QRS width: normal - Grouping: none - Dropped: **Yes** (Longer pause, not multiple of normal P-P interval, no sinus pacemaker working)
32
What is the sinoatrial block?
- Rate: **varies** - Regularity: **irregular** - P wave: present *except in areas of dropped beats* - P:QRS 1:1 - PRI: normal - QRS width: normal - Grouping: none - Dropped: **yes** (Some multiple of P-P interval, nonconducted beat from normal pacemaker)
33
What is a premature atrial contraction (PAC)?
- Rate: **depends on underlying rate** - Regularity: **irregular** - P wave: present *in PAC may be different shape* - P:QRS 1:1 - PRI: normal *varies in PAC* - QRS width: normal - Grouping: **sometimes** - Dropped: none (some other pacemaker cell fires faster than SA node, underlying rhythm disturbed & not proceed at same pace. Non compensatory pause less than 2x underlying normal P-P interval)
34
What is an ectopic atrial tachycardia?
- Rate: **100-180bpm** - Regularity: regular - P wave: **morphology of ectopic focus is different** - P:QRS 1:1 - PRI: **ectopic focus has a different interval** - QRS width: normal *but can be aberrant at times* - Grouping: none - Dropped: none (ectopic atrial pacemaker)
35
What is a wandering atrial pacemaker?
- Rate: **<100bpm** - Regularity: **irregularly irregular** - P wave: **at least 3 different morphologies** - P:QRS 1:1 - PRI: **variable depending on focus** - QRS width: normal - Grouping: none - Dropped: none (multiple atrial pacemakers each firing at its own pace)
36
What is a multifocal atrial tachycardia (MAT)?
- Rate: **>100bpm** - Regularity: **irregularly irregular** - P wave: **at least 3 different morphologies** - P:QRS 1:1 - PRI: **variable** - QRS width: normal - Grouping: none - Dropped: none (Tachycardic WAP)
37
What are the rhythm rules of atrial fibrillation?
- Rate: Variable - Rhythm: irregularly irregular (most common) - P-wave: none - PRI: none - P:QRS: None - QRS: normal - Grouping: none - Dropped: none
38
What are the rhythm rules of atrial flutter?
- Rate: Atrial: 250-350bpm, Ventricular: 125-175bpm - Rhythm: regular, may be variable - P-wave: saw-tooth "F waves" - PRI: Variable - P:QRS: varies, most common 2:1 - QRS width: normal - Grouping: none - Dropped: none - Reentrant tachycardia - Consistent pattern b/w P waves & QRS - should be able to determine rate for both
39
What is supraventricular tachycardia?
- General, broad term for any rapid arrhythmia originating above the ventricles - Sinus tachycardia - A-fib (when rate >100) - A-flutter (when rate >100) - Multifocal Atrial Tachycardia Reentrant - Atrioventricular reentrant tachycardia (AVRT): orthodromic & antidromic - Atrioventricular node reentrant tachycardia (AVNRT): typical/common & atypical/uncommon - Very hard to determine exact nature of rhythm when rapid = "SVT" or "PSVT" (Paroxysmal - episodic)
40
What determines if a patient in SVT is stable or unstable?
- AMS - Chest pain - SOB - Hypotension - Signs of shock - Heart failure
41
What is an AVRT?
- Atrioventricular reentrant tachycardia - Through bundle of kent 1) WPW x = AVRT - WPW & Bundle of Kent put at high risk of AVRT 2) P-wave absent (or upside down) 3) "SVT" or "PSVT" 4) 140-280 BPM 5) Initiation (PAC) - Orthodromic: Anterograde through AV & retrograde through Kent, narrow QRS b/c normal depolarization ventricles - Antidromic: retrograde AV & anterograde through Kent, Wide QRS (Looks like V tach)
42
What is a WPW?
- Wolff-Parkinson-White 1) PRI shortened 2) Elongated Q upslope "Delta wave" (Sinus rhythm)
43
What is AVNRT?
- Atrioventricular Node Reentrant Tachycardia 1) Two different types "typical" - 90% 2) P-wave absent (or upside down) 3) 140-280 BPM 4) QRS <= 0.12 sec 5) Initiation: ectopic early beat (PAC)
44
What is important to note about sinus tachycardia?
- Normal physiological NOT pathological - Search for extracardial problems
45
What are the rhythm rules for junctional rhythm?
- Rate: 40-60 bpm - Regularity: regular - P-wave: Variable (none, anterograde, retrograde) - P:QRS: None, or 1:1 if ante/retrograde - PRI: none, short, retrograde - QRS width: normal - Grouping: none - Dropped: none
46
What are the rhythm rules for accelerated junctional rhythm?
- Rate: 60-100 bpm - Regularity: regular - P-wave: Variable (none, anterograde, retrograde) - P:QRS: None, or 1:1 if ante/retrograde - PRI: none, short, retrograde - QRS width: normal - Grouping: none - Dropped: none
47
What are the rhythm rules of premature junctional contraction (PJC)?
- Rate: depends on underlying rhythm - Regularity: irregular - P-wave: Variable (none, anterograde, retrograde) - P:QRS: None, or 1:1 if ante/retrograde - PRI: none, short, retrograde - QRS width: normal - Grouping: none (can occur) - Dropped: none
48
What are the rhythm rules for junctional escape beat?
- Rate: depends underlying rhythm - Regularity: irregular - P-wave: Variable (none, anterograde, retrograde) - P:QRS: None, or 1:1 if ante/retrograde - PRI: none, short, retrograde - QRS width: normal - Grouping: none - Dropped: yes
49
What are rhythm rules for premature ventricular contraction?
Rate: depends on underlying rhythm Regularity: irregular P wave: absent on PVC P:QRS: no P on PVC PRI: None QRS: Wide (>=12sec), bizarre Grouping: usually not present Dropped: none - *Compensatory pause, not affect SA node & rate is maintained*
50
What are the classifications of PVCs?
- Unifocal: all look same - Multifocal: two different appearances - Just one: "underlying rhythm w/ PVCs" - Bigeminy: every other beat - Trigeminy: every 3rd beat - Quadgeminy: every 4th beat - Couplet: PVCs happen together, group of 2 *May precede larger event or may be irritated cell (stress, caffeine, etc)*
51
Why are ventricular rhythms concerning?
- Preload effected b/c ventricle not have enough time to fill by gravity and atrial kick is lost (PVC, VT)
52
What are the rhythm rules of ventricular escape beats?
- Rate: depends on underlying rhythm - Regularity: irregular - P wave: none in PVC - P:QRS: none in PVC - PRI: none QRS: Wide (>=12sec), bizarre Grouping: usually not present Dropped: none - *Non-compensatory b/c normal pace maker did not fire, will rest to new timing cycle, maybe different rate*
53
What are the rhythm rules of idioventricular rhythm?
- Rate: 20-40 - Regularity: regular - P wave: none - P:QRS: none - PRI: none QRS: Wide (>=12sec), bizarre Grouping: none Dropped: none
54
What are the rhythm rules for accelerated idioventricular rhythm?
- Rate: 40-100 - Regularity: regular - P wave: none - P:QRS: none - PRI: none QRS: Wide (>=12sec), bizarre Grouping: none Dropped: none
55
What are the rhythm rules for ventricular tachycardia?
- Rate: 100-200 - Regularity: regular - P wave: Dissociated atrial rate - P:QRS: variable - PRI: none QRS: Wide (>=12sec), bizarre Grouping: none Dropped: none
56
What causes V Tach? What is the concern?
Causes - Reentrant (most common) - Triggered activity (electrolyte or md imbalance) - Ischemic heart dz, inc MI - LV dysfunction - Prolonged QT Concern - Untreated -> ventricular fibrillation -> asystole
57
What is a wide QRS complex?
- V Tach unless evidence of the contrary - May not be able to tell apart from an SVT so assume the worst - WCT when hemodynamically unstable treated as VT, but hemodynamically does not indicate if it is VT
58
What are the categories of VT?
- Morphology: monomorphic, polymorphic, torsades des points - Duration: sustained: >30sec; not sustained: 3 beats-<30sec
59
What may identify a VT?
- dozens of rules b/c look different depending on origin - AV dissociation: ventricular pace (reentrant) & underlying SA w/ p waves - Fusion & capture beats - Brugada's sign: R-S bottom >0.10 sec - Josephson's sign: notch near low point of S - Total QRS >=0.16 sec - Age >35 - Previous MI or ischemic Heart dz - Cardiomyopathy - Family Hx sudden cardiac death
60
What are the rhythm rules of Torsade de Pointes?
- Rate: 200-250 - Regularity: Irregular - P wave: None - P:QRS: None - PRI: none - QRS: variable - Grouping: variable sinusoidal pattern - Dropped: none - *Most common polymorphic VT (which themselves are very rare). Caused by genetics & meds. "Twisting of the point" that if sustained will quickly lead to V fib*
61
What are the rhythm rules of ventricular flutter?
- Rate: 200-300bpm - Regularity: regular - P wave: none - P:QRS: none - PRI: none - QRS: Wide (>=12sec), bizarre - Grouping: none - Dropped: none - *Tx same as VT*
62
What are the rhythm rules of ventricular fibrillation?
- Rate: indeterminate - Regularity: Chaotic rhythm - P wave: none - P:QRS: none - PRI: none - QRS: none - Grouping: none - Dropped: no beats at all - *If the monitor looks like this but the patient looks fine it is artifact because a lead has fallen off. It is not VFib*
63
What is asystole?
- Absence of any electrical activity on the ECG - Always want to confirm in second lead - Ability to convert pt to sustainable rhythm once in asystole very low - Do not shock, all cells already depolarized. May cause harm.
AAA PA: Lab & Diagnostic Testing
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