EKG Certification

Bradycardia

Rate: below 60 bpm, P wave: upright, rounded, PR Interval: normal QRS: normal

Normal Sinus Rhythm

Rate: 60-100 bpm, P wave: upright, rounded, PR Interval: normal QRS: normal

Tachycardia

Rate: above 100 bpm, P wave: upright, rounded, PR Interval: normal QRS: normal

Multifocal Atrial Tachycardia (MAT)

At least 3 different P waves, rate over 100

Premature Atrial Contractions (PAC)

Rate: underlying rhythm, with abnormal, ectopic beat

Wandering Atrial Pacemaker (WAP)

At least 3 different P waves, rate 60-100 bpm

Atrial Fibrillation (A Fib)

no P-P rate, irreg R-R rate, no P wave, chaotic line between QRS complexes

Atrial Flutter

F wave rate: 250-350, normal R-R rate, classic "sawtooth" pattern between regular QRS complexes

P wave

Atrial depolarization (contraction)

QRS complex

Ventricular depolarization (contraction)

T wave

Ventricular repolarization

Premature Junctional Complex (PJC)

Rate: underlying rhythm with early ectopic, junctional complexes, inverted or absent P waves

Junctional Escape

Rate: 40-60 bpm, P wave: inverted, absent, or after the QRS, QRS: normal

Accelerated Junctional

Rate: 60-100 bpm, P wave: inverted, absent, or after the QRS, QRS: normal

Junctional Tachycardia

Rate: over 100 bpm, P wave: inverted, absent, or after the QRS, QRS: normal

Supraventricular Tachycardia

Rate: 150-250 bpm, regular rhythm

First-Degree Heart Block

Rate: 60-100 bpm, PR Interval: 0.20 seconds or greater, P wave: normal, QRS: normal

Second-Degree Heart Block, Type I (Mobitz I or Wenckebach)

Regular pattern of prolonging PR Interval (small, medium, long), followed by a dropped QRS complex

Second-Degree Heart Block, Type II (Mobitz II)

All PR Intervals are the same (usually short) and random dropped QRS complexes.

Third-Degree Heart Block

Random PR Intervals and random dropped QRS complexes

Premature Ventricular Complex (PVC)

Rate: underlying rhythm with early, ectopic QRS complex, P wave: normal on normal complexes, absent on ectopic beats, QRS: normal on normal complexes, wide and bizarre on ectopic complexes

Agonal

Rate: less than 20 bpm, P wave: absent, QRS: wide and bizarre

Idioventricular

Rate: 20-40 bpm, P wave: absent, QRS: wide

Accelerated Idioventricular

Rate: 40-100 bpm P wave: absent, QRS: wide

Ventricular Tachycardia

Rate: above 100 bpm, P wave: absent, could be classic "sawtooth", wavy, polymorphic pattern.

Torsade de Pointes

Specific type of polymorphic Ventricular Tachycardia, looks like a party streamer or a sound wave.

Ventricular Fibrillation (V Fib)

No rate, no P wave, no QRS. Just chaotic scribble line.

Asystole

Flat line, no rate.

Sinus Arrest

A pause in the ECG of at least 2 seconds.

Paced Atrial

A spike appears immediately before the P wave, indicating the pacemaker is in the atrium.

Paced Ventricular

A spike appears immediately before the QRS complex, indicating the pacemaker is in the ventricle.

Paced Atrial-Ventricular

Spikes appear before both the P waves and the QRS complexes, indicating the pacemaker is in both the atrium and the ventricle.

Standard Leads

Lead I, Lead II, and Lead III

Precordial Leads

V1, V2, V3, V4, V5, V6

Augmented Leads

aVR, aVL, aVF

1500 Method

Most accurate method to determine heart rate. Count the number of small boxes between any two points. Divide 1500 by that number.

300 Method

Less accurate method to determine heart rate. Count the number of large boxes between any two points. Divide 300 by that number.

Sequence Method

Less accurate method to determine heart rate. Count the number of large boxes in between any two points and count down in a sequence of 300, 150, 100, 75, 60, 50.

6-Second Method

Only method to use for irregular rhythms, and a method to quickly estimate a heart rate. Count the number of whole complexes in six seconds and multiply by 10.

B. "I must not get my monitor wet at any time.

Which of the following statements illustrates the patient understands Holter monitor procedures?
A. "I can take take my monitor off before showering."
B. "I must not get my monitor wet at any time."
C. "I can move the electrodes on my chest if they bother

60-100 BPM

Average adult resting heart rate

12 - 20 minute

Average adult respiration rate

100 - 160 BPM

Average infant resting heart rate

A. "I can wear jeans and boots for my stress test.

Which of the following statements illustrates the need for further patient education?
A. "I can wear jeans and boots for my stress test."
B. "I must not eat for several hours prior to the stress test."
C. "I must notify the doctor of any chest pain during

C. A 54 year-old male with unrelieved chest pain and ST segment elevation

Which of the following patients should not receive a stress test?
A. A 67 year-old female with transient chest pain and a normal EKG
B. A 74 year-old male who has a history of myocardial infarction
C. A 54 year-old male with unrelieved chest pain and ST s

B. Stop the test immediately, let the patient sit, and notify the physician

During a stress test, your patient states that he feels dizzy and nauseous. His heart rate is 98. What should you do?
A. Decrease the treadmill until the dizziness resolves
B. Stop the test immediately, let the patient sit, and notify the physician
C. All

C. Informed consent

After the physician explained the procedure, the patient signed paperwork allowing providers to perform the stress test. This is an example of
A. Tort
B. Negligence
C. Informed consent
D. HIPAA

B. Limb leads are placed on the patient's torso instead of the limbs

What modification to lead placement is made to stress testing?
A. V6 is placed at the 5th intercostal space at the midaxillary line
B. Limb leads are placed on the patient's torso instead of the limbs
C. A limb lead is applied to the right leg to act as a

Manubrium

What is this called?

Sternum

What is this called?

Depressed ST segment

What is this?

Elevated ST segment

What is this?

ST segment Elevation Myocardial Infarction; also known as a classic heart attack

What does STEMI mean?

0.12 - 0.16 seconds

normal PR Interval

0.04 - 0.10 seconds

normal QRS

1. Premature Atrial Complex (PAC)
2. Wandering Atrial Pacemaker (WAP)
3. Multifocal Atrial Tachycardia (MAT)
4. Atrial Fibrillation (A Fib)
5. Atrial Flutter
6. Supraventricular Tachycardia (SVT)

6 dysrhythmias that originate in the ATRIA

60 - 100 bpm

normal rate of the SA node

40 - 60 bpm

normal rate of the AV node

The P wave is inverted, absent, buried, or after the QRS

How do we identify junctional dysrhythmias?

The SA node is not working, so the AV node takes over. It causes the electrical impulse to flow backward and it shows in the absent or inverted P wave.

Why are P waves different in junctional dysrhythmias?

1. Premature Junctional Complex (PJC)
2. Junctional Escape (sometimes just called "Escape Rhythm")
3. Accelerated Junctional
4. Junctional Tachycardia

4 dysrhythmias that originate in the AV junction

True.
They are early complexes that appear in otherwise normal rhythms. It is a premature beat or series of beats before the heart resumes its regular rhythm.

True or False? PAC, PJC, and PVC are technically not rhythms.

If the patient is under 8 years old or if the patient has dextrocardia (organs reversed).

When should you do a right-sided EKG?

Holter monitor

What is this?

Pacemaker

What is this?

During a hospital stay

When is telemetry used?

Place EKG leads on the patient's back

What do you do if the patient has an inferior wall infarction?

Place lead close to the amputation point on the affected limb and place the corresponding lead on the other limb in the same place as the first lead

What do you do if the patient has an amputation?

Pallor (pale)
Diaphoresis (sweating)
Hypotension
Labored, shallow, or slow respiration
Anxiety or confusion
Cyanosis
Lethargy (excessively tired)
Angina (chest pain)
Dizziness
Weakness
Syncope (fainting)

Signs of low cardiac output

D. Surgical

A patient tells the EKG technician he underwent coronary bypass grafting two years ago. This is an example of which of the following type of history?
A. Medical
B. Social
C. Medication
D. Surgical

A. Call for help and begin CPR

While performing a standard 12-lead EKG, a technician notices the patient stops breathing and has no pulse. What should the technician do first?
A. Call for help and begin CPR
B. Assess the patient's respirations
C. Interpret the EKG tracing
D. Defibrilla

First-degree has PR interval of 0.2 or greater
Second-degree, Type I has elongating PR intervals (small, medium, large) followed by a missing QRS, then repeats
Second-degree, Type II has all PR intervals are the same (usually short) followed by random dro

How do you tell the difference between heart blocks?

Irregularity in the EKG caused by factors OTHER than electrical activity in the heart.

What is artifact?

Cell phone interference

What is this type of artifact?

25 mm/second
Only change the speed when ordered by a physician and then remember to set it back immediately after.

What is the typical speed setting for an EKG?

10 mm/mV
Only change the gain when ordered by a physician and then remember to set it back immediately after.

What is the typical gain setting for an EKG?

Add three more leads on the back V7, V8, V9
Keep limb leads where they are.
Leave V1, V2, V3 where they are.
V4 becomes V7
V5 becomes V8
V6 becomes V9
Document new leads on EKG.

Posterior Wall MI lead placement

Wandering baseline artifact

May be caused by a loose electrode; body creams, oils or lotions

Somatic Tremor artifact

Caused by tense muscles or a muscle contraction

Bruce Protocol

Treadmill running at 1.7 mph with 10% incline then every 3 minutes the speed is increased by 0.8 mph and 2% incline increase until exhaustion
Most commonly used stress test protocol

Modified Bruce Protocol

walking at 1.7 mph and 0% for the first 3 minutes than increases in grade
Used in older people and those with cardiac disease

Naughton Protocol

for sicker patients gradual increase in intensity
speed at 2 mph uses 2 min stages

RA Lead (white) to right arm with tab facing upper arm
LA Lead (black) to left arm with tab facing upper arm
RL Lead (green) to right leg with tab facing upper leg
LL Lead (red) to left leg with tab facing upper leg
V1 Lead (red) fourth intercostal space

EKG electrode placement

Usually indicates ischemia, or blockage

What does ST segment depression mean?

When evidence of a significant heart dysrhythmia or STEMI is found.

What is a "positive" stress test or Holter monitor test?

Defibrillation

What is the treatment for Ventricular fibrillation?

CPR, O2, Advanced Life Support, epinephrine, and crash cart ready (do not defibrillate)

What is the treatment for asystole?

Bundle branch block (BBB)

Occurs when the electrical impulse is blocked from traveling down the bundle of His or bundle branches. Results in the ventricles beating at a different rate than the atria.
Shows on the EKG as a slightly wider QRS complex, though not as wide as ventricul