EKG Workshops
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1
A wave of depolarization traveling
towards a positive EKG electrode
causes a/an ________ deflection on
the EKG tracing
towards a positive EKG electrode
causes a/an ________ deflection on
the EKG tracing
upward
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A wave of depolarization traveling
away from a positive EKG electrode
causes a/an ________ deflection on
the EKG tracin
away from a positive EKG electrode
causes a/an ________ deflection on
the EKG tracin
downward
3
A wave of repolarization traveling towards a positive EKG electrode
causes a/an ________ deflection
on the EKG tracin
causes a/an ________ deflection
on the EKG tracin
downward
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A wave of repolarization traveling away from a positive EKG electrode
causes a/an ________ deflection
on the EKG tracin
causes a/an ________ deflection
on the EKG tracin
upward
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this causes the p wave
atrial depolarization
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this cases the QRS wavw
ventricular depolarozation
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distance (time) from beginning of
P wave to beginning of QRS complex
P wave to beginning of QRS complex
PR interval
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distance (time) from beginning of
QRS complex to end of T wav
QRS complex to end of T wav
QT interval
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distance (time) from end of QRS
complex to end of T wave
(includes the T wave but not the QRS complex)
complex to end of T wave
(includes the T wave but not the QRS complex)
ST interval
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what causes the PR segment
delay of AV node
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plateu phase of evntricular repolarization
ST segment
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entire ventricular repolarization phase
ST interval
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rapid phase of ventricular repolarozation
Twave
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what occurs during the QT interval?
ventricular contraction
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what occurs during the U wave?
repolarzatoom of purkinje fibers
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the vertical axis of an EKG represents voltage and at standard cal is ______
0.1mV
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the horixontal axis of the EKG represents time and at standard cal is _________
0.04 sec
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equation for determining b/min on regular EKG rythms
300/# big blocks
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how do you determine b/min for irregular rythmns
use 3 second markers 
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the 6 limb leads allow determination of axis in this plane
frontal plane
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what are the limbleads of the frontal plane
I,II, III, aVR, aVL, aVF
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what are the chest leads that allow deter,ination of axis in the horizontal plane
V1-6
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fr the limb leads, there are 3 ________ and 3 _________-
bipolar; augmented unipolar
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the bipolar ;limb leads have these electrodes
1 positive and 1 negative
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the augmeted unipolar limb leads have these electrodes
1 positive and 1 compound reference electrode
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which of the limbs is the groundinh lomb where the grounding electrode is placed
rght leg.
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where are the limb leads placed and wgere is the positive node placed? (bipolar)
RA-LA: lead I; LA +
RA-LL: lead 2: LL+
LA-LL : lead 3: LL +
RA-LL: lead 2: LL+
LA-LL : lead 3: LL +
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which are the lateral leads
I and aVL
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which are the inferior leads
II, III, aVF
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how do you quickly determine QRS axis in the frontal plane (what lkeads)
I and aVF, look at positive or negative
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A shift in the electrical axis out of
the normal range is referred to as:
________” in the frontal plan
"_________" in the horizontal plane
the normal range is referred to as:
________” in the frontal plan
"_________" in the horizontal plane
devation
rotation
rotation
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Simply stated, in determining the mean
QRS axis in the horizontal plane:
If the R to S ratio changes from <1 to >1:
After V4 (i.e. V5, V6, or never), then this
is referred to as “______”
At or before V2 (i.e. V1, or V2), then this
is referred to as “_______________on”
After V2 and at or before V4, then the
axis in the horizontal plane is referred to
as “___________
QRS axis in the horizontal plane:
If the R to S ratio changes from <1 to >1:
After V4 (i.e. V5, V6, or never), then this
is referred to as “______”
At or before V2 (i.e. V1, or V2), then this
is referred to as “_______________on”
After V2 and at or before V4, then the
axis in the horizontal plane is referred to
as “___________
leftward axis rotation; rightward axis rotation; normal
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horizontal plane if R to S ratio Starts < 1 and stays < 1, then this is
referred to as
referred to as
leftward acis rotation
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horizontal plane R to S ratio starts >1 and stays > 1 then it is
rightward axis rotation
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horizontal plane if starts >1 ad becomes <1 by V6
refered to as leftward axis rotation
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QRS between -45 and -90 left axis devoation
fascicular block left anterior
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QRS between 90 to 180 right axis deviation
fascicular block left posterior
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Ability of specialized cells to
spontaneously generate electrical
impulses which may then spread
throughout surrounding tissue
spontaneously generate electrical
impulses which may then spread
throughout surrounding tissue
automaticity
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Potential pacemakers within the heart
automaticity foci
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utomaticity foci in the heart
atrial foci , functional fpoci, ventricular foci
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conduction rate atrial foci
60-80 per minte
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conduction rate junctional foci
40-60 per minute
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conduction rate vetricular foci
20-40 per minute
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A protective mechanism whereby an automaticity focus with the next highest inherent rate begins pacing (escapesoverdrive suppression) in the event of a pause or cessation of pacing activity of the previously dominant pacemaker.
escape
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Transient escape of an automaticity focus (from overdrive suppression) to generate one beat.
This occurs when there is a pausein pacing activity in the previously
dominant pacemaker.
This occurs when there is a pausein pacing activity in the previously
dominant pacemaker.
escape beat
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Escape of an automaticity focus (from overdrive suppression) with subsequentpacing by that automaticity focus, at its inherent rate.
This occurs when there is a cessation(or arrest) of pacing activity in the
previously dominant pacemaker.
This occurs when there is a cessation(or arrest) of pacing activity in the
previously dominant pacemaker.
escape rhythm
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normal rhythm of the heart
sinus rhyth
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criteria of a sunus rhythm
Each QRS complex is preceded by a P wave.
The P waves must be positive in lead II, and negative in lead aVR
The P waves must be positive in lead II, and negative in lead aVR
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normal sinus rhythm criteria
Sinus rhythm with a heart rate
between 60 and 100 beats per
minute
between 60 and 100 beats per
minute
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Sinus rhythm with a heart rate less than 60 beats per minute
sinus bradycardia
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Sinus rhythm with a heart rate
greater than 100 beats per minute
greater than 100 beats per minute
sinus tachycardia
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Same criteria as sinus rhythm andthere is greater than 0.16 sec.
difference between the shortest and the longest PP intervals within the same EKG tracing
difference between the shortest and the longest PP intervals within the same EKG tracing
sinus arrhythmia
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what is this?
atrial rhythm
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what is this?
junctional rhytm
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what is this?
atrial rhythm
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what is this?
junctional rhytm
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what is this?
junctional rhythm
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(positive in lead aVR and negative in lead II) immediately preceding (PR interval <120 msec) the QRS complex
junctional retrograde p wave
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(buried in the QRS complex or absent due to lack of retrograde AV conduction):
junctional absent p wave
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If the QRS complex is not prolonged (not >120 msec.), ventricular depolarization must have occurred via
the his-purkinje system
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An increase in the tendency for
automaticity foci to spontaneously
generate electrical impulses
automaticity foci to spontaneously
generate electrical impulses
irritability
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Occurs when an irritable automaticity focus spontaneously generates a single electrical impulse prior to the next
expected beat from the dominant
pacemaker
expected beat from the dominant
pacemaker
premature beat
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escape of an automaticity focus (from overdrive suppression) due to failure of the previously dominant pacemaker
escape beats
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irritability of automaticity focus
premature beats
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– every other beat is premature
bigeminy
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every third beat is premature
trigeminy
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every fourth beat is premature
quadrigeminy
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sudden rhytm change
paroxysmal
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Heart rate < 60 beats per minute (bpm)
bradycardia
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Heart rate > 100 bpm
tachycardia
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Rate between 250 and 350 bpm
flutter
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Rate between 350 and 450 bpm
fibrillation
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A “generic” term for any tachycardia originating above the ventricles
supraventricular tachycardia
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Polymorphic ventricular tachycardia (VT) which is preceded by marked prolongation of the QT interval
torsades de pointes
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bradyarrhythmias can de disorders of (x2)
impulse formation or impulse propigation
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Encompasses several SA nodal abnormalities:
Chronotropic incompetence
Sinus pause, arrest or exit block
Bradycardia-tachycardia syndrome:
Paroxysms of atrial tachyarrhythmias
alternating with slow atrial and ventricular
rates
Chronotropic incompetence
Sinus pause, arrest or exit block
Bradycardia-tachycardia syndrome:
Paroxysms of atrial tachyarrhythmias
alternating with slow atrial and ventricular
rates
sick sinus syndrome
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what types of AV blocks can there be
first degree
second degree: type I and II
third degree
second degree: type I and II
third degree
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what needs to be true to have a first degree AV block
1-to-1 ratio of P waves to QRS complexes
PR interval is fixed (consistent)
PR interval exceeds 200 msec
PR interval is fixed (consistent)
PR interval exceeds 200 msec
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what does this show?
first degree AV block
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Grouped beats
Groups or clusters of QRS complexes separated by “missed” single beats
Two P waves for every QRS complex, without groups or clusters of beats
All PR intervals will be the same (fixed/consistent)
Groups or clusters of QRS complexes separated by “missed” single beats
Two P waves for every QRS complex, without groups or clusters of beats
All PR intervals will be the same (fixed/consistent)
type I second degree AV block
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There are more P waves than QRS complexes
All P waves that immediately precede QRS complexes have equal PR intervals
At times, there may be a fixed ratio of P waves to QRS complexes (e.g. 2-to-1*, 3-to-1, or 4-to-1, etc.)
All P waves that immediately precede QRS complexes have equal PR intervals
At times, there may be a fixed ratio of P waves to QRS complexes (e.g. 2-to-1*, 3-to-1, or 4-to-1, etc.)
type II second degree AV blocj
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Slowing of the previously dominant pacemaker, with subsequent junctional or ventricular escape rhythm
default AV dissocociation
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Acceleration of a latent pacemaker which usurps control of the ventricles
usurpation av dissociation
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QRS duration > 120 msec.
Criteria for RBBB are not met
Criteria for LBBB are not met
Criteria for RBBB are not met
Criteria for LBBB are not met
nonspecific intraventricular conduction defect (nonspecific IVCD)
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how do you determine if its a left ventricular hypertrophy? (x2)
V2 or V6 s is greater than 35mm
-only can use this method if individual is oilder than 40
-only can use this method if individual is oilder than 40
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what does the T wave look like in a Left ventricular hypertrophy (left chest leads)
inverted T wave (asymetrcal)
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what 3 criteria strongly suggest rught ventricular hypertropy?
Right axis deviation (> 110°)
(for our test, simply use RAD or extreme RAD)
R/S > 1 in lead V1
Deep S waves in lead V5 or V6
(for our test, simply use RAD or extreme RAD)
R/S > 1 in lead V1
Deep S waves in lead V5 or V6
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what must be present in early repolarization St elevations
Distribution: Diffuse (usually)
Reciprocal ST depression: Absent
ST segment shape: Concave upwards
PR depression: Absent
Reciprocal ST depression: Absent
ST segment shape: Concave upwards
PR depression: Absent
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clinical significance early repolarization ST elevation
Asymptomatic; usually an incidental
finding on a routine EKG; often present in
young males
finding on a routine EKG; often present in
young males
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what is required fir acute pericarditis ST elivation
Distribution: Diffuse (usually)
Reciprocal ST depression: Absent
ST segment shape: Concave upwards
PR depression: Present (in leads that have
ST elevation)
Reciprocal ST depression: Absent
ST segment shape: Concave upwards
PR depression: Present (in leads that have
ST elevation)
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clinical cause of acute pericarditis ST elivation
gradual onset of sharp,
pleuritic chest discomfort, which is often
relieved or improved by sitting up;
sometimes preceded or accompanied by
fever or other flu-like symptoms
pleuritic chest discomfort, which is often
relieved or improved by sitting up;
sometimes preceded or accompanied by
fever or other flu-like symptoms
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what is required for acute MI St elevation
Distribution: Regional (vascular)
Reciprocal ST depression: Present (if MI
involves inferior or high lateral wall)
ST segment shape: Not as reliable
Concave down (if “textbook” case)
PR depression: Absent
Reciprocal ST depression: Present (if MI
involves inferior or high lateral wall)
ST segment shape: Not as reliable
Concave down (if “textbook” case)
PR depression: Absent
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clinical cause of acute MI St elevation
(usually) Sudden onset of non-
sharp, non-pleuritic chest discomfort or
dyspnea; sometimes accompanied by
nausea, vomiting, and/or diaphoresis
sharp, non-pleuritic chest discomfort or
dyspnea; sometimes accompanied by
nausea, vomiting, and/or diaphoresis
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what can cause deep symmetrically inverted T waves
non st elevation MI (acute or recent, myocardial ischemia, ICH
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what can cause significant Q waves
age indeterminate or a previous MI
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what signifies a significant Q wave
a q wave greater than 1mm wide; a q wave 1/3 QRS amplitude
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Always order______________-sided chest
leads when there is evidence of
an acute inferior wall MI on the
standard 12-lead EKG!
leads when there is evidence of
an acute inferior wall MI on the
standard 12-lead EKG!
right