Review Packet EKG Competency 2016, Lecture notes of Medical Records

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Review Packet

EKG Competency

This packet is a review of the information you will need to know for the proctored EKG

competency test.

Normal Sinus Rhythm Parameters Rhythm: Regular Ventricular Rate: 60 - 100 bpm P Wave: upright, matching, 1: Atrial Rate: 60 - 100 bpm PR Interval: 0.12-0.20 seconds QRS Interval: < 0.10 seconds Etiology None Significance Normal Treatment None

Sinus Bradycardia Parameters Rhythm: Regular Ventricular Rate: < 60 bpm P Wave: upright, matching, 1: Atrial Rate: < 60 bpm PR Interval: 0.12-0.20 seconds QRS Interval: < 0.10 seconds Etiology Normal for trained athletes An MI to the RCA “Reperfusion Rhythm” Elevated ICP Medications (beta-blockers, calcium channel blockers, digitalis) Degenerative diseases, such as sick sinus syndrome Vagal stimulation from vomiting, sleeping, nausea Significance  Normal in healthy adults and athletes  Can be beneficial in injured hearts to allow increased ventricular filling time and decreased myocardial oxygen demands  Some individuals experience a significant decrease in cardiac output (HR x SV = CO) as well as blood pressure Treatment  Treat only if SYMPTOMATIC:

1. IVP Atropine
2. Pacemaker  Temporary transcutaneous or transvenous  Chronic bradycardia may require a permanent pacemaker  Discontinue any bradycardia inducing medications

Sinus Arrhythmia Parameters Rhythm: Irregular Ventricular Rate: any rate P Wave: upright, matching, 1: Atrial Rate: any rate PR Interval: 0.12-0.20 seconds QRS Interval: <0.1 0 seconds Etiology May be seen in young children and elderly Change in vagal tone due to respirations May also be caused by:  Increased ICP  Dig toxicity  Inferior wall MI Significance  None depending on rate  If rate is bradycardic, may decrease cardiac output Treatment  None, unless rate is bradycardic.  If patient is symptomatic with bradycardia: o IVP Atropine o Pacemaker

Paroxysmal Supraventricular Tachycardia (PSVT or SVT) Parameters Rhythm: Regular Ventricular Rate: > 150 bpm P Wave: unable to see Atrial Rate: NA PR Interval: NA QRS Interval: <0.10 seconds Etiology Stress Caffeine Tobacco Alcohol COPD Digitalis Toxicity Significance  Shortens ventricular filling time which can decrease stoke volume which can decrease cardiac output  Increases myocardial oxygen requirements and cardiac workload Treatment If unstable: o Electrical Cardioversion If stable:

1. Sedation
2. Vagal maneuvers
3. IVP Adenosine
4. Rate controlling medication such as a calcium channel blocker (ex. Diltiazem) or a beta blocker.

Atrial Flutter Parameters Rhythm: Regular/Irregular Ventricular Rate: varies P Wave: flutter, sawtooth Atrial Rate: 250 - 35 0 bpm PR Interval: NA QRS Interval: <0.10 seconds Etiology Valvular heart disease Hypertensive heart disease Cardiomyopathy Heart failure Pulmonary disease Pulmonary emboli Post-cardiac surgery Significance  If ventricular rate is rapid: o Ventricular filling time is shortened which can decrease stoke volume which can decrease cardiac output o Myocardial oxygen requirements and cardiac workload are increased  If ventricular rate is slow:  Decrease in cardiac output due to slow heart rate  Stasis of blood in atria can lead to thrombus formation & possible arterial or pulmonary embolism Treatment If patient is stable and the rhythm has been present treatment depends on ventricular rate & patient symptoms:  Amiodarone, Calcium Channel Blockers, Beta Blockers  If unstable: Cardiovert immediately Goal is to restore sinus rhythm!

Junctional Rhythm Parameters Rhythm: Regular Ventricular Rate: 41 - 60 bpm P Wave: inverted, absent, inverted after QRS Atrial Rate: 41 - 60 PR Interval: <0.12 seconds QRS Interval: <0.1 0 seconds Etiology SA node disease Myocardial infarction Dig toxicity Increase in vagal tone Significance  AV junction not reliable as pacemaker for long periods  The slow rate may cause: o Hypotension o Decrease in Cardiac Output Treatment  Depends on tolerance of slowed heart rate  Identify and treat underlying cause If symptomatic:

1. Atropine IVP
2. Transcutaneous or transvenous pacing

Accelerated Junctional Rhythm Parameters Rhythm: Regular Ventricular Rate: 61 - 100 bpm P Wave: inverted, absent, inverted after QRS Atrial Rate: 61 - 100 bpm PR Interval: <0.12 seconds QRS Interval: <0.10 seconds Etiology Dig toxicity Damage to AV node secondary to Inferior wall MI Heart failure Acute rheumatic fever Valvular heart disease Open heart surgery Myocarditis Significance  Typically well tolerated  For some the loss of normal atrial depolarization can cause a decrease in cardiac output. Treatment  Treatment should be directed at identifying the underlying cause and correcting it.

Premature Junctional Contraction Parameters Rhythm: Usually regular Ventricular Rate: underlying rhythm P Wave: inverted, absent, or inverted after the QRS Atrial Rate: underlying rhythm PR Interval: <0.12 seconds QRS Interval: <0.10 seconds Etiology Alcohol Simulants: o Coffee o Tea o Tobacco Coronary artery disease Digoxin toxicity Inferior wall MI Significance  Unusual in healthy adults  Early sign of digoxin toxicity  May precipitate junctional tachycardia Treatment  Treat underlying cause

Ventricular Fibrillation Parameters Rhythm: Chaotic Ventricular Rate: NA P Wave: NA Atrial Rate: NA PR Interval: NA QRS Interval: NA Etiology Most common cause of death for people with coronary heart disease Most common cause of sudden cardiac death in patients with an acute MI Other causes:  Myocardial Ischemia  Cardiomyopathy  Hypoxia  Cocaine toxicity  Electrolyte imbalance Significance No organ perfusion! Treatment Check for Pulse!  (If there is a pulse, not VF.) If there is no pulse:

1. Defibrillation
2. CPR
3. Drugs:  Epinephrine  Amiodarone

Ventricular Standstill Parameters Rhythm: Atrial Regular Ventricular Rate: NA P Wave: upright, matching Atrial Rate: varies PR Interval: NA QRS Interval: NA Etiology Acidosis Hypoxia Hyperkalemia Hypothermia Drug Overdose

Idioventricular Rhythm Parameters Rhythm: Regular Ventricular Rate: 21 - 40 bpm P Wave: NA Atrial Rate: NA PR Interval: NA QRS Interval: ≥ 0.12 seconds Wide and Bizarre Etiology Disease or injury to the SA node or AV node Medications that can slow or inhibit the SA node or AV node May occur in brief intervals  Advanced heart failure  CHF Significance  Decrease in cardiac output  Commonly precedes asystole  Sign of a “dying heart” Treatment  Goal is to establish a reliable pacemaker and increase the heart rate  Never attempt to obliterate an Idioventricular rhythm with antiarrhythmic drugs  Treat with: o Atropine o Transcutaneous or Transvenous pacemaker o Dopamine for hypotension

Premature Ventricular Contraction Parameters Rhythm: underlying rhythm Ventricular Rate: underlying rhythm P Wave: absent on premature beat Atrial Rate: underlying rhythm PR Interval: none QRS Interval: ≥ 0.12 seconds Etiology Anxiety Excessive caffeine/alcohol intake Drugs CHF Electrolyte imbalance (Hypokalemia, hypomagnesemia) Heart surgery Reperfusion after thrombolytics Significance  PVC’s are very common  Become more frequent as we age  Can precipitate life-threatening arrhythmias Treatment Treat the cause  Medications  Electrolyte replacement  Decrease caffeine consumption

Asystole Parameters Rhythm: NA Ventricular Rate: NA P Wave: NA Atrial Rate: NA PR Interval: NA QRS Interval: NA Etiology Most common cause is MI Hypoxia Hypothermia Drug overdose Acidosis Hyper/Hypokalemia Significance  No cardiac output!!  Poor prognosis despite resuscitative efforts Treatment  Check for Pulse!  Always check another lead to ensure true asystole  If no pulse:

1. Initiate CPR

2. Epinephrine or Vasopressin
3. Temporary pacemaker 4. Find and treat underlying cause