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ECG > 12 Lead ECG Ch.1-7 > Flashcards

12 Lead ECG Ch.1-7 Flashcards

1
Q

How many electrodes are used in a 12 lead?

What are the 2 types?

A

10 electrodes

There are Limb leads and Precordial Leads

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2
Q

When/Why would you put limb leads on the chest or torso rather than on the limbs where they are meant to be?

A

If the purpose of the ECG is just to determine the Presence (not placement) of ischemic related changes or if the pt is awake and moving a lot the leads would be ok on just the chest.

However, if the purpose is to see all conditions, complications, and the placement of such then the limb leads need to go on the limbs (around the wrists and ankles) and the pt must hold still

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3
Q

What is the color related with each limb lead?

A

RA- White
LA - Black
RL - Green
LL - Red

Right arm Salts the Grass ; Left Arm Peppers the Steak

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4
Q

What are Bipolar limb leads?
What are the 3 bipolar leads called?
What does each one show?

A

Bipolar limb leads use a positive and negative electrode, the negative electrode provides a point for the positive electrode allowing the positive electrode to “see” where this point intersects the heart.

The 3 bipolar limb leads are called Leads I, II, & III

Lead 1 has the positive electrode on the LA and the negative on the RA; this shows the Left side of the heart, looking towards the right

Lead 2 has the positive electrode on the LL and the negative on the RA; this shows the bottom of the heart looking towards the right arm

Lead 3 has the positive electrode on the LL and the negative electrode on the LA; this also shows the bottom of the heart but looking towards the left arm instead of the right

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5
Q

What are Unipolar Limb Leads?

What are the 3 unipolar leads called?

A

They also form a triangle except they use an average of the negative electrode positions which lands in the middle of the chest, this point is called the CT.
The positive electrodes are then placed on the RA, LA, and LL. The positive electrodes look at this CT reference point.

The 3 Unipolar limb leads are: (aV = augmented Voltage)

aVR - Right Arm
aVL - Left Arm
aVF - Left Leg

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6
Q

Which lead types are augmented?

A

Bipolar (I,II,&III) and Unipolar (aVR, aVL,& aVF) ; meaning that the voltage is augmented by a negative electrode to enhance the ability voltage to a level that is readable on an ECG machine

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7
Q

What are Precordial Leads?

Where do the 6 Precordial Leads go?

A

They are the “true chest leads”. These are also unipolar, using only 1 positive electrode and because these leads are so close to the heart they do not need voltage augmentation.

V1 & V2: 4th intercostal space (b/w the 4 and 5 ribs) on
either side of the sternum.
V3 : b/w V2 and V4 on 5th rib or 5th intercostal space
V4: midclavicular 5th intercostal space
V5: 5th intercostal Anterior Axillary Line
V6: 5th intercostal space Mid Axillary Line`

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8
Q

How might you find the 4th intercostal space? (2)

A
  • Count down from the clavicle, the first rib under the clavicle is Rib 2. B/w rib 4 and 5 is the 4th intercostal space
  • Locate the angle of Louis at the bottom of the manubrium where the corresponding rib is rib 2 (at or above the nipple line)
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9
Q

Ideally your pt would be supine for a 12 lead but b/c of intense pain that may be present they may not want to lay supine. What is the next best position for critical pts?

A

Fowler’s Position (sitting up)

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10
Q

What must be done before an ECG reading can be printed?

A

Critical information such as patient age and name must be entered as well as the patient must hold still for at least 10 seconds

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11
Q

What is the 3 Lead Monitor and how is it achieved?
What how many leads are used and which one is omitted?
What is the new name given to the V1-6 positions on a regular 12 lead, when using a 3 lead?

A

A 3 lead monitor can give the info of a 12 lead machine by moving leads around the body while looking via the Lead III setting after looking at I and II separately. It uses 9 total Leads b/c the RL is omitted.

Steps to attaining all views with just a 3 lead machine:

  • Record Leads I, II, III using the lead-select switch on
    the ECG Monitor
  • Leave the monitor lead-select switch set to Lead III
  • Detach the LL (red) electrode wire and place it on the
    V1-V6 positions, and record the tracing
  • Trim the resulting strip to a three-second strip
  • Return the LL to the V1/MCL-1 position

The usual V1-6 positions are called MCL1-6 when viewed with a 3 lead machine.
MCL = Modified Chest Left leads (left b/c its LL lead that moves)

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12
Q

GO OVER HOW 3 LEAD MONITORS AUGMENT FREQUENCY REPONSE AND WHAT THAT CHANGES ON PAGE 9

A

GO OVER HOW 3 LEAD MONITORS AUGMENT FREQUENCY REPONSE AND WHAT THAT CHANGES ON PAGE 9

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13
Q

What is the difference in size and printouts of in hospital vs out of hospital ECG machines?

A

In-Hospital:
- Print on 8-1/2” x 11” sheets and have 3 rows of 4 columns on top and 3 rows on the bottom showing Lead II and V2/V5 or V1/V6

Out-of-Hostpital:
- Print on smaller sheets, 90-100mm and only show the top three rows in 4 columns

*Some machines only show one column of the top three rows one at a time for 2.5 seconds

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14
Q

What leads are shown in columns 1-4 on the top 3 rows of the ECG?

A

Column1: Leads I, II, III (the bipolar leads)
Column2: Leads aVR, aVL, aVF (the unipolar
augmented leads)
Column3: V1, V2, V3
Column4: V4, V5, V6

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15
Q

Which is more accurate, the lead measurements or the interval measurements (at the top of the strip) and why?

A

The interval measurements are more accurate b/c they tell you the precise number of intervals using voltage,

the lead measurements are what is drawn out on the graphing and the thickness of the lines may make it difficult to read precisely what the time and voltage is.

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16
Q

If a machine is giving you a readout in milliseconds, how do you convert that to seconds?

A

You take the decimal and move it 3 spaces to the left

160ms = .160sec

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17
Q

How is voltage measured related to boxes on an ecg paper?

A

1 small box upwards from the isoelectric line is 1 millimeter or mm.

10mm = 1 millivolt or mv

so 1 mv is equal to 2 large boxes, this is usually seen at the beginning of each readout as a stand alone partial rectangle known as the CALIBRATION SPIKE that is exactly 2 large box or 1 mv above the isoelectric line

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18
Q

What is R Wave Progression?

What is the Transition Zone?

A

R Wave Progression is referring to how the positively deflected R wave on the V leads should continually get more positive when looking from V1 to V6. It should start out most negative in V1 and end at most positive in V6 with V6 having the tallest R wave.
(V1 having the smallest R and V6 having the largest)

The Transition Zone is between Leads V3 ad V4 where the overall R wave should go from being predominantly negative to predominately positive
(that is to say that the R wave should go from being mostly below the isoelectric line to mostly above it)

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19
Q

What is Axis?

How much of the generated impulses actually travel from start to finish in the heart?

A

Axis is the general direction of electrical impulses as they travel through the heart.

Only about 10% of the started impulses travel in one primary direction completely. 90% cancel each other out

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20
Q

What is the hexaxial system?

A

It is a pie chart of the degrees of the angles viewed in the heart by leads I, II, II, aVL, aVR, & aVF

LOOK ON PAGE 21 TO SEE IT

Roughly put if you draw a circle and put a right angle in it from center going down and to the right, the right point is 0 degrees and the bottom line is 90.

Starting with the aVL at -30 moving clockwise you have:

  • aVL at -30 degrees
  • lead I at 0 degrees
  • Lead II at 60 degrees
  • aVF at 90 degrees
  • Lead III at 120 degrees
  • aVR at 210 degrees

Use the angle of the line that would be generated by leads I, II, III in Einthoven’s triangle and place that on the associated angled line in the hexaxial system

Like wise take aVR, aVL, aVF looking at the CT and place the angle of those lines in the hexaxial system

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21
Q

How do you determine if an axis is negative or positive by looking at an ECG reading?

A

In each lead (I, II, III) take the amount of the QRS that is BELOW the iso and SUBTRACT that from the amount above. If that number is positive then it is positive and if it is negative then it is negative.

If the number is about the same then it is considered to be EQUIPHASIC

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22
Q

What should a normal axis show in leads I, III, III?

A

Positive QRS complex for all three views

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23
Q

What would a PHYSIOLOGICAL LEFT Axis Deviation show in leads I, II, and III?

What would a PATHOLOGICAL LEFT Axis Deviation show in leads I, II, and III?

Which is worse?

A

PHYSIOLOGICAL LEFT Axis Deviation would show a Positive QRS in lead I, a Positive or Equiphasic QRS in lead II, and a Negative QRS in Lead III

PATHOLOGICAL LEFT Axis Deviation would show a Positive QRS in lead I, and a Negative QRS in lead II and Lead III. (usually turns left greater than -40 deg)

A PHYSIOLOGICAL LEFT Axis Deviation is considered a normal variant and can occur from things like obesity. However, a PATHOLOGICAL LEFT Axis Deviation indicates that something more serious is wrong

***As noticed Lead I will always be Pos and Lead III will always be negative in a Left Axis Deviation, so when Lead III is negative assume a Left Axis Deviation and then look at Lead II to determine if it is Physio or Patho

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24
Q

What would RIGHT AXIS DEVIATION QRSs look like in leads I, II, & III?

A

***Right Axis Deviation is normal in kids, but not adults

Right Axis Deviation will be the opposite of Left, so:

  • Lead I QRS will be Negative
  • Lead II can be Pos, Neg, or Equiphasic/Iso
  • Lead III will be Positive
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25
Q

What is EXTREME RIGHT AXIS DEVIATION (>180degrees) and what is it a sign of?

A

It is when Leads I, II, & III all have a negative deflection and it is indicative of the impulse heading towards the right shoulder and that the impulse is starting in the Ventricles

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26
Q

What does an axis deviation indicate?

A

A Hemiblock

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27
Q

What is a Hemiblock?

A

A block of one of the 2 fascicles of the Left Bundle Branch (Anterior or Posterior Hemifascicle)

28
Q

How many bundle branches and fascicles are there?

A

There is a Right Bundle Branch (RBB) and a Left Bundle Branch (LBB). The LBB has 2 separate Fascicles called Anterior and Posterior Hemifascicles.

Between the Anterior and Posterior Hemifascicles of the LBB and the singular RBB, they create a TRIFASCULAR System

These 3 different pathways of the Trifascular system are the 3 ways that impulses can travel to the ventricles

29
Q

What is indicated by an axis deviation and therefore an hemiblock?

A

It is a precursor for a heart block.

Determining axis is about 98% of detecting hemiblock

30
Q

What axis indicates an Anterior Hemiblock?

A

A PATHological Left Deviation of -40 to -90 degrees

As seen on an ECG by a Pos. QRS in lead I and a Neg. QRS in leads II & III

(additional clues are a small Q wave in I, and a small R wave in III) opposite in Post)

31
Q

What axis indicates a Posterior Hemiblock?

A

A Right Axis of 90 to 180 degrees

As seen on an ECG by a Neg. QRS in Lead I and a Pos. QRS in Lead III

(Lead II can be anything, the main thing is that a neg lead I and pos lead III immediately means a right shift)

(additional clues are a small R wave in I, and a small Q wave in III) opposite in Ant)

32
Q

What arteries supply the Left Anterior Hemifascicle?

Left Posterior Hemifascicle?

A

Left Anterior Hemifascicle is supplied by:
- Left Anterior Descending (LAD) branch of the Left Coronary Artery

Left Posterior Hemifascicles supplies by:
- Right coronary Artery and the Circumflex
(the post is thicker and therefore needs a redundant supply)

** the fascicular system is made up of living breathing Cardiac Conduction Cells (CCS) that need a constant supply of blood

33
Q

How do the appearances of the Ant and Post Left Hemifascicles differ?

Which one is more commonly blocked?

Which one blocked is worse?

A

The Anterior is long and thin whereas the Posterior is Thicker (note that is why it needs more blood supply)

B/c the Anterior is thinner it is more commonly blocked but it is worse to have the Posterior be blocked. When the Anterior is blocked the Pt can usually tolerate it without symptoms and requires no treatment. When a person is having a Myocardial Infarction, a Post hemiblock should be assumed.

34
Q

What are the 3 big clinical significances of a Hemiblock?

A
  • 4x higher mortality rate if a hemiblock is present during an AMI
  • If a pt has another heart block along with a hemiblock they have very high chances of turning into a complete heart block
  • When an AMI is present it can indicate proximal artery occlusion
35
Q

LOOK BACK AT THE RAPID AXIS AND HEMIBLOCK CHART ON PG 27 TO SEE HOW AXIS, LEAD I-III, AND HEMIBLOCKS ALL FIT TOGETHER

A

LOOK BACK AT THE RAPID AXIS AND HEMIBLOCK CHART ON PG 27 TO SEE HOW AXIS, LEAD I-III, AND HEMIBLOCKS ALL FIT TOGETHER

36
Q

Is it important for paramedics to know the exact angle of the axis?

A

NO, only which category or broad range it fits into to allow us to know if it is within normal range(0-90), Physiological left (0 to -40), Pathological left (-40 to -90), right (90 to 180), or extreme right (>180)

37
Q

What is Syncytium?

Why does a Bundle Branch Block mess up Syncytium?

A

Syncytium is the feature of the ventricles or the atrium that produces simultaneous depolarization.

Bundle Branches are made of Cardiac Conduction Cells that conduct impulses much faster than regular myocardial cells.

When there is a BBB in one of the 3 Hemifascicles that prevent impulses from reaching one or more of the ventricles then the myocardial cells much start producing an impulse for depolarization but this is much slower than Cardiac Conduction Cells

This slower depolarization is what causes the Wide QRS complex associated with a bundle branch block which is a conduction issue

38
Q

What lead is best used to see a Bundle Branch Block?

A

MCL-1 aka V1 ; this view looks across the ventricles so it can see both bundle branches

(to see MCL-1 take the red electrode or LL lead and place it on the 4th intercostal to the right of the sternum left in lead III view)

39
Q

What is the turn signal criteria and what is it used for?

A

It is used to diagnose a bunch branch block

First find a supraventricular complex (one with a P wave) and has a wide QRS. Find a circle the J point, draw a line backwards toward the beginning of the complex. Shade in the triangle, if the arrowhead points UP its a RIGHT BUNDLE BRANCH block, if the arrow points DOWN its a LEFT BUNDLE BRANCH block.

40
Q

What needs to be blocked in order to have a BIFASCICULAR block and why is recognizing one so important?

A

If you have an RBBB and one of the 2 Hemifascicles blocked then you have a BIFASCICULAR block. OR if you have a complete LBBB where both Hemifascicles are blocked you can also have a BIFASCICULAR block.
(Essentially any combo of blocks that blocks 2 of the 3 fascicles)

When you have a BIFASCICULAR block such drugs as Lidocaine, Procainamide, Amiodarone, and sometimes even Morphine will further slow down the conduction through the ventricles resulting in a drug induced complete heart block or maybe even asystole.

41
Q

How does BBBs affect Hemodynamics?

What is Ejection Fraction?

A

Since the ventricles are firing out of sync with a BBB, the preload will be reduced. Also since the contraction will be much slower it will squeeze less hard; if the QRS is greater than 0.17 sec it will cause an EJECTION FRACTION of less than 50%. When this happens using something like Nitro you may have a severe drop in blood pressure.

Ejection Fraction is one measure of left ventricular effectiveness and the normal range is between 60-75%.

42
Q

What do you need to determine a pts risk for complete heart block?

What can be seen that is going to be indicative of a high risk for Heart Block and a contraindication for drugs like Lidocaine, Procainamide, Amiodarone, and sometimes even Morphine?

A

A 12-lead or a 4-lead baseline (I, II, III, & MCL-1)

If a Intraventricular Heart Block (either a hemiblock or a BBB) appears or is implied twice in an ECG (such as a 1st degree heart block with a hemiblock or a bifascicular block) the patient is at High Risk For COMPLETE HEART BLOCK.

Also when this is present there is contraindication for drugs like Lidocaine, Procainamide, Amiodarone, and sometimes even Morphine because they will further slow the conduction impulse

43
Q

What are the 3 types of Bifascicular blocks?

A
  • Anterior Hemiblock + RBBB
  • Posterior Hemiblock + LBBB
  • LBBB
44
Q

_____ _____ is a life-threatening condition and should be correctly identified, recorded, and terminated before continuing assessment of the 12 lead for other problems

A

Ventricular Tachycardia

45
Q

What is the first and easiest way you should look at/for on an ECG to verify presence of VT?

A

An Extreme Right Axis Deviation (ERAD) with a Positive V1 or MCL-1

(Negative deflections in I, II, & III but a Positive in VI)

***A seconday way is if there is if there is Right Axis Deviation with a Negative V1 or MCL-1

46
Q

LOOK AT PG 64 TO SEE MORPHOLOGY OF QRS IN VT LOOKING AT V1 WHEN IT IS POSITIVE OR NEGATIVE

A

LOOK AT PG 64 TO SEE MORPHOLOGY OF QRS IN VT LOOKING AT V1 WHEN IT IS POSITIVE OR NEGATIVE

47
Q

Apart from looking at the morphology indications on V1 what lead is a more reliable source of morphology clues to indicate VT?

A

V6, any predominantly negative complex in Lead V6 suggests VT

48
Q

What is Concordance Criteria and what does it indicate? What can be some contraindications for this indication?

A

Concordance means all the same, So Concordance Criteria references that in VT all the Precordial Leads (V1-V6) should all be either positive or negative.

  • When there is Negative Concordance that suggests
    VT you must look to see if the rhythms are possibly
    atrial b/c a LBBB may be in negative concordance
    but that does not mean its VT
  • Positive Concordance may indicate either VT or
    WPW (Wolf-Parkinson-White Syndrome). To rule out
    WPW look for the Delta Wave that slurs on the initial
    upstroke toward the P wave.
49
Q

What are the 3 big measurements that indicate VT?

A
  • A Positive QRS in V1 that is >0.14sec
  • A Negative QRS in V1 that is >0.16sec
  • The RS interval (From the tip of the R to the tip of the S) which MEASURES the ventricular activation time, and if it is more than 0.1sec it is VT
50
Q

What are the 3 big AV dissociation clues that point to VT?

A
  • Cannon A Waves (Pressure Waves that shoot up
    through the Jugular Veins at irregular intervals b/c the
    atria are contracting when the ventricles are not
    prepared to receive, sending that pressure
    backwards into the Jugular Veins)
  • P waves out of place and isolated
  • Different S1 (first heart sound)
51
Q

What are 2 critical questions to ask in a History that will help identify VT?

A
  • Have you had a previous hart attack?

- Did you have tachycardia starting after your heart attack?

52
Q

Ventricular Tachycardia (VT) is usually VERY REGULAR, what is one rhythm that looks like VT but is not and is seen looking similar to VT but is Irregular?

A

Atrial Fibrillation

Remember VT is REGULAR and AFib is IRREGULAR

53
Q

What are Capture or Fusion beats?

A

They are narrow complex beats occurring within a sustained VT Rhythm. Occasionally the atria conduct a beat normally that catches the ventricles at just the right moment to squeeze in an atrial conducted beat.

This is a sign of AV dissociation however and indicates VT

54
Q

What is the list of 7 easy steps to identify and establish VT from SVT?

A
  • ERAD and a Positive V1 or MCL-1
  • QRS morphology in V1 or MCL-1
  • QRS morphology in V6 or MCL-6
  • ERAD and Negative V1 or MCL-1
  • Concordance in V1-V6 (up or down)
  • RS Interval >0.1sec in any V Lead
  • QRS >0.14sec if up OR >0.16sec if down in V1 or MCL-1
55
Q

How does blood enter the coronary arteries and how does it get back to the heart?

A

The coronary arteries branch off the aorta just above the leaflets of the aortic valve. During Systole he pressure opens the aortic valve while closing the openings to the coronary arteries to protect them from the high pressure surge during contraction. Once Diastole starts the aortic valve closes and the coronary arteries open again allowing backflow from the Aortic Arch to flow into them. After this oxygenated blood has done its job it gets back to the right atrium via coronary sinus and the Great Cardiac Vein

56
Q

The Right Coronary Artery (RCA) and Posterior Descending Coronary Artery (PDCA) Supplies?

A 
Right Coronary Artery (RCA) Supplies:
- Inferior wall of the Left Ventricle
- Right Ventricle
- SA Node in 50% of people
- AV Node in 90% of people
(Reduction in supply of last two can cause bradycardia, or heart conduction delays)

After the RCA branches off into the Posterior Descending Coronary Artery it supplies:

  • Posterior wall of the Left Ventricle
  • Posterior Fascicle of the LBB
57
Q

The Left Coronary Artery is separated in two major branches, the:
Left Anterior Descending Branch (LAD) and the Left Circumflex Artery (LCA)(Which wraps around to the back of the heart)

What do they supply?

A

Left Anterior Descending Branch (LAD) supplies:
- 40% of the Left Ventricular Mass
- Anterior and Septal Walls of the Left Ventricle
- Bundle of His and both Bundle Branches (through the
intraventricular septal perforator artery)

Left Circumflex Artery (LCA) supplies:

  • Lateral wall of the left ventricle
  • SA node in 45% of people
  • AV node in 10% of people
  • Posterior wall of left ventricle
58
Q

What is the “Widow Maker”?

A

It is the Left Anterior Descending Artery (LAD) b/c most sudden death AMIs result from a proximal occlusion of the LAD

59
Q

What are the 2 risk factor categories for an AMI?

A

Modifiable: hypertension, obesity, stress, drugs, alcohol, etc

Non-Modifiable: Age, Gender, Family History, etc

60
Q

What is Atherosclerosis and how is it formed?

What is angina Pectoris?

A

Atherosclerosis is the narrowing of an artery lumen caused by the build of Low-Density-Lipoproteins(LDLs) sticking between or under layers of the arterial wall.

Angina Pectoris is chest pain that is caused by an increase in demand for oxygen but it is unable to be provided b/c of the atherosclerosis of the coronary arteries

61
Q

Explain how Clot formation in a Coronary Artery can come about and how it causes an AMI?

A

As the plaque builds up and hardens in Atherosclerosis, it is prone to rupturing and when that happens the plaque that breaks off damages the intimal layer of the blood vessel causing damage.

After the damage the normal clotting process occurs creating a clot that occludes the confined space of an artery creating an Acute Myocardial Infarction

62
Q

What are 2 drugs that can be given before getting to the hospital where Fibrinolytics and a cardiac cath lab can eliminate the clot?

Which one can you give without much risk but which must be given only once 3 criteria indicating AMI are present?

A
  • Aspirin (anticoagulant that acts on platelets) which can
    be given without much risk.
  • Heparin (anticoagulant that slows the chemical cascade
    that leads to fibrin production) is reserved for a diagnosed evolving AMI done by:
  • history of present illness
  • physical exam
  • 12 lead suggesting AMI
63
Q

What are the 5 main areas of assessment on a physical exam?

A
  • Look for JVD
  • Auscultate Heart Sounds
  • Palpate the Chest
  • Palpate the Abdomen (for epigastric discomfort)
  • Look for Peripheral Edema

LOOK AT PGS 81-82 FOR MORE DETAILS ON WHAT EXACTLY TO LOOK FOR

64
Q

How fast should a 12 lead be started on a Pt with cardiac problems, especially if an MI is suspected?

A

The AHA suggests within 10 minutes of PT contact

65
Q

What is a good mnemonic for quick pharm treatment of a AMI pt?

A

“MONA greets the MI Patient”

Morphine
Oxygen
Nitro
Aspirin

Some services also give antiemetics

ECG (2 decks)

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