HAN 417 Final Exam

When do you start CPR?

after checking for responsiveness, scene safety, breathing, and pulse

immediately if the patient has no pulse and is not breathing

What is the proper compression rate for CPR in adults, children and infants?

100-120 compressions per minute

When do you utilize an AED?

When someone is...

1. Unresponsive

2. Not breathing normally

3. Has no pulse

always turn on the AED before following the prompts

What are the chambers of the heart?

right atrium, right ventricle, left atrium, left ventricle

Valves of the heart and the chambers they separate

- Tricuspid valve: located between the right atrium and right ventricle

- Pulmonary (pulmonic) valve: located between the right ventricle and the pulmonary trunk

- Mitral (bicuspid) valve: located between the left atrium and left ventricle

- aortic valve: located between the left ventricle and the aorta

Toilet Paper My Ass

Atrioventricular valves (AV)

Open when the atria contract and close during ventricular contraction (systole)

Semilunar valves

Open during ventricular contraction and close during ventricular relaxation (diastole)

Layers of the heart and their function

- epicardium: visceral layer of serous pericardium (outside layer of the heart)

- myocardium: cardiac muscle which generates contraction (middle layer of the heart)

- endocardium: lining of the chambers (inside layer of the heart)

What is the function of the heart?

To pump blood around the body

Which parts of the heart does the right coronary artery (RCA) feed?

Right atrium, right ventricle, inferior wall of the left ventricle

Which parts of the heart does the left coronary artery (LCA) feed?

- left anterior descending artery (LAD): anterior wall of the left ventricle, apex of the heart, bundle branches.

- left circumflex artery (LCx): lateral wall of the left ventricle, left atrium, SA node (in some people), and posterior wall of the left ventricle

Which clinical situations should epinephrine be used for?

Cardiac arrest, heart failure, and shock

Which clinical situations should amiodarone be used for?

Ventricular fibrillation and ventricular tachycardia

Which clinical situation should atropine be used for?

Symptomatic bradycardia

Which clinical situation should adenosine be used for?

Supraventricular tachycardia (SVT)

Which clinical situations should diltiazem be used for?

Rapid atrial fibrillation and atrial flutter

Which clinical situations should metoprolol be used for?

Rapid atrial fibrillation and atrial flutter

What does the PR interval represent on an EKG?

The time from the onset of atrial depolarization to ventricular depolarization.

What does the PR segment represent on an EKG?

The normal delay in the AV node

What does the QT interval represent on an EKG?

The total time for the ventricles to depolarize and repolarize

What does the ST interval represent on an EKG?

The ventricular repolarization

What is the path of electrical conduction in the heart?

SA node, AV node, Bundle of His, Purkinje fibers

What is the pacemaker of the heart?

SA node

inherent firing rate of 60-100 impulses per minute

What is the inherent firing rate of the AV node?

40-60 impulses per minute

What is the inherent firing rate of the bundle of branches/purkinje fibers?

30-40 impulses per minute

What does the P-wave represent on an EKG?

- first segment seen on an EKG tracing

- tells us that the SA node is functions properly

- represents atrial depolarization

What does the QRS complex represent on an EKG?

- sec on segment seen on an EKG tracing

- normal means normal ventricular conduction

- represents ventricular depolarization

What does the T-wave represent on an EKG?

- third segment seen on an EKG tracing following the QRS complex

- represents ventricular repolarization

- reflects the heart's recovery phase, and can indicate abnormal cardiac tissues.

What is a positive deflection?

Any waveform above the isoelectric line

What is a negative deflection?

Any waveform below the isoelectric line

What is a biphasic deflection?

A waveform that has both positive AND negative deflections around the isoelectric line.

Which are the bipolar EKG leads?

I, II, and III

Which are the augmented EKG leads?

AVR, aVL, and aVF

Which are the precordial EKG leads?

V1-V6

Timing of small boxes on EKG paper

Each box is 0.04 seconds (40 milliseconds)

used to measure time intervals like the duration of P wave, QRS complex, and T wave

How do you measure the timing of the PR interval and QRS complex using small boxes on an EKG?

- PR interval typically ranges from 3-5 small boxes (0.12-0.20 seconds)

- QRS complex usually lasts between 1 and 3 small boxes (0.04-0.12 seconds)

How do you calculate heart rate on an EKG strip?

- the 300-150-100-75-60-50 method (regular rhythms)

- the 1500 method (more accurate for regular rhythms)

- the 6-second method (irregular rhythms)

The 300-150-100-75-60-50 method

this method is quick and works best for regular rhythm

1. Count the number of large boxes between 2 consecutive R waves

2. Use the following rule based on the number of large boxes between R waves:

- 1 large box= 300 bpm

- 2 large boxes= 150 bpm

- 3 large boxes= 100 bpm ETC

The 1500 method

this method is more precise and works well when you want to calculate the heart rate from a regular rhythm

1. Count the number of small boxes between two consecutive R waves.

2. Use the formula: HR=1500/number of small boxes between R waves.

The 6 second method

this method is useful for irregular rhythms, as it doesn't rely on consistent R-R interval

1. Count the number of R waves (beats) in a 6-second strip

2. Multiply the number of R waves in the 6-second interval by 10 to estimate the heart rate per minute.

What are the characteristics of normal sinus rhythm on an EKG?

- rate: 60-100 beats per minute (bpm)

- rhythm: regular

- p-waves: normal, upright, before every QRS complex

- PR interval: 0.12-0.20 seconds

- QRS complex: normal, duration of less than 0.12 seconds

What are the characteristics of sinus bradycardia on an EKG?

- rate: less than 60 bpm

- rhythm: regular

- pacemaker site: SA node

- p-waves: upright and normal

- PR interval: normal

- QRS: normal

What are the characteristics of sinus tachycardia on an EKG?

- rate: greater than 100 bpm

- rhythm: regular

- pacemaker site: SA node

- p-waves: upright and normal

- PR interval: normal

- QRS: normal

What are the characteristics of sinus arrhythmia on an EKG?

- rate: 60-100 bpm

- rhythm: irregular

- pacemaker site: SA node

- p-waves: upright and normal

- PR interval: normal

- QRS: normal

What are the characteristics of normal sinus rhythm with sinus arrest on an EKG?

- rate: normal to slow

- rhythm: irregular

- pacemaker site: SA node

- p-waves: upright and normal

- PR interval: normal

- QRS: normal

What is a synchronized cardioversion?

Delivery of a timed electrical shock to reset an abnormal rhythm

True or false- shocks are synchronized with the heart's R-wave during synchronized cardioversion.

True

True or false- once the shock is delivered with a synchronized cardioversion, you must press "sync" again before delivering another shock.

True

What is synchronized cardioversion used for?

Unstable SVT, rapid AFib/Aflutter, and VTach with a pulse

What is defibrillation?

Shocks that are random and DO NOT line up with any specific wave.

if a patient foes into Vfib/VTach cardiac arrest after another intervention (like pacing or cardioversion), a defibrillation should be delivered immediately

What is transcutaneous pacing?

External cardiac pacing

Consists of 2 electrode pads placed anterior-posterior on the patient's chest to conduct electrical impulses through the skin to the heart.

What is transcutaneous pacing used for?

Symptomatic bradycardia and unstable heart blocks

What is the distinguishing feature of wandering atrial pacemaker?

changing P-wave morphologies across the rhythm strip

- P-waves will vary in shape, size, or direction across the rhythm strip as the pacemaker "wanders" between multiple sites.

- 3 or more different P-wave morphologies

What is multi focal atrial tachycardia?

Has the SAME characteristics as wandering atrial pacemaker, just at a rate greater than 100 beats per minute

What is premature atrial contraction?

The premature beat occurs in addition to the regular beat, so when diagnosing the rhythm, you must include both

*normal sinus rhythm with PAC(s)

What is atrial flutter?

- rapid atrial impulses that create a V-shaped waveform with a characteristic "sawtooth" pattern.

- the distinguishing feature is the sawtooth waves between QRS complexes.

What is atrial fibrillation on an EKG strip?

- impulses are so rapid that they cause the atria to quiver, producing irregular, wavy deflection called "fibrillatory waves"

- often described as irregularly irregular

- the distinguishing future is a wavy baseline between irregular QRS complexes, and non-discernable P-waves.

Where do junctional rhythms (general) originate from?

The AV node

Junctional rhythm characteristics

- when the AV junction is functioning as the primary pacemaker, the impulses travel backwards to depolarize the atria.

- due to the short distance between the AV junction and the atria, the PR interval will be short.

inverted p waves in lead II, PR interval is short, QRS complex is normal

Pacemaker cells in junctional rhythms (general)

Have automaticity and have an intrinsic firing rate of 40-60 bpm

In junctional rhythms, P-waves occur in 1 of 3 patterns...

- immediately before the QRS

- immediately after the QRS

- hidden within the QRS

What are premature junctional contractions?

- an early beat that originates in an ectopic pacemaker site in the AV junction.

- both underlying rhythm and the PJC should be identified

normal sinus rhythm with PJC's

What are accelerated junctional rhythms?

- a rhythm that originates in an ectopic site in the AV junction discharging impulses at 60-100 bpm

- "accelerated" denotes a faster rate than a junctional rhythm, but not fast enough to be considered junctional tachycardia

- the distinguishing feature is inverted P-waves in lead II that may appear before, within, or after the QRS complex

What is junctional tachycardia?

- a rhythm that originates in an ectopic site in the AV junction discharging impulses greater than 100 bpm

- distinguishing feature is inverted P-waves in lead II that may appear before, within, or after the QRS complex

Characteristics of Ventricular arrhythmias

- originate from below the bundle of His

- no p-waves

- impulses do not enter the normal conduction pathway

- conduction of impulses is slower as they travel from muscle fiber to muscle fiber

- QRS is wide: >0.12 seconds (3 small boxes)

Characteristics of premature ventricular contractions?

- PVC's are premature

- P-waves are not associated with PVC

- QRS complex is wide

- ST-segment and T-wave are usually in opposite directions

- a pause follows the PVC called compensatory pause

True or false- the premature beat occurs in addition to the regular beat.

True

when diagnosing the rhythm, you must include both

What is idioventricular rhythm?

- a very slow rhythm originating in the ventricles at a rate of 30-40 bpm

- rhythm appears regular, but does not have P waves

- non-measurable PR interval

- QRS is wide, ST segment and T wave are in opposite direction of the QRS complex

- usually a continuous terminal rhythm but may occur intermittently

very difficult to resuscitate, usually progresses to asystole

What is agonal rhythm?

When the rhythm becomes irregular, slower, and QRS' begin to widen and deteriorate into indistinguishable waveforms.

What is an accelerated idioventricular rhythm?

- discharges impulses at a rate of 50-120 bpm

- looks the SAME as IVR and VTach, just differentiated by HR.

What is ventricular tachycardia on a strip?

- originates from an ectopic site in the ventricles discharging impulses at a rate of 140-250 bpm

- has the same appearance as IVR and AIVR, but is differentiated by HR.

Monomorphic VTach

- QRS complexes have the same morphology

- the most common form if VTach

- occurs as a continuous rhythm or intermittent runs of 3 or more consecutive ventricular beats.

Polymorphic VTach

QRS complexes have different morphologies in the same lead.

What is Torsades de Pointes?

- a type of polymorphic VTach

- distinguishing characteristic is QRS complexes "twist" around the isoeletric line.

What is ventricular fibrillation on a strip?

- rhythm originating in multiple site in the ventricles characterized by erratic electrical activity which takes over control of the heart.

- the ventricular muscle quivers instead of contracting, producing wavy irregular deflections with no discernible waves or complexes.

- once VF occurs, there is no cardiac output, peripheral pulses, or blood pressure

always considered symptomatic

What is coarse VFib?

VFib with large deflections

What is fine VFib?

VFib with small deflections

What is asystole?

- there is no ventricular activity and thus no QRS complexes, basically a straight line

- there still may be atrial activity presenting in the form of a P-wave

- may be represented as a straight line/"flatline" or P-waves absent of QRS complexes

What is pulseless electrical activity?

- clinical situation where there is organized electrical activity seen on the monitor, but there is no palpable pulse

- you may observe NSR on the monitor, but if there is no pulse, this is PEA

- causes and treatment are the same as asystole

What are AV blocks (general)?

- a group of rhythms that originates in the sinus node and will have normal p-waves

- "AV block"- used to describe rhythms in which there is a delay or block in the conduction of impulses from the atria to the ventricles.

What are the classifications of AV blocks?

- 1st degree AV block

- 2nd degree type I AV block

- 2nd degree type II AV block

- 3rd degree AV block

What are 1st degree AV blocks?

- the impulse is delayed more than normal at the AV node before being conducted to the ventricles

- although the impulse is delayed, they are still conducted to the ventricles.

- this delay results in a PR interval that is greater than 0.2 seconds.

- underlying rhythm should be identified with block.

What is 2nd degree, type I (mobitz I) AV block?

- each impulse has increasing difficulty passing through the AV node

- eventually the impulse cannot pass through the AV node so there is no impulse conducted to the ventricles

reflected on the EKG by p-waves that occur in regular intervals and PR intervals that progressively get longer and longer until an impulse is not conducted to the ventricles

What is 2nd degree, type II (mobitz II) AV block?

- P-P is ALWAYS regular

- R-R is regular until non-conducted beat

- if the location is at the bundle of His, the QRS duration will be normal

- if the location is at the level of the bundle branches the QRS duration will be wide

What is a 3rd degree AV block?

complete heart block

- atria and ventricles beat independently of each other (different pacemakers)

- atria is typically paced at 60-100 bpm

- ventricles are typically paced at 40-60 bpm, sometimes less

if the p's and q's dont agree= type 3/complete AV

What color is the Right arm (RA) bipolar lead?

White

placed on right arm

"White on the right"

What color is the Right leg (RL) bipolar lead?

Green

placed on right leg

"Clouds over grass"

What color is the left arm (LA) bipolar lead?

Black

placed on left arm

"Smoke over fire"

What color is the left leg (LL) bipolar lead?

Red

placed on left leg

"Smoke over fire"

What color is the V1 precordial lead?

Red

placed at 4th ICS, right of the sternum

What color is the V2 precordial lead?

Yellow

placed at 4th ICS, left of the sternum

What color is the V3 precordial lead?

Green

placed between V2 and V4

What color is the V4 precordial lead?

Blue

placed at 5th ICS, midclavicular line

What color is the V5 precordial lead?

Orange

placed at anterior axillary line, horizontal to V4

What color is the V6 precordial lead?

Purple

placed at the mid-axillary line, horizontal to V4 and V5

What is the pneumonic for precordial lead colors?

Ride

Your

Green

Bike

On

Pavement

What is the format of a 12-lead?

- top left box: patient information

- middle box: measurements

- right box: analysis

How does a 12-lead print?

Prints 2.5 seconds of leads I, II, and III, then switches to augmented and precordial leads

What are contiguous leads?

Defined as a group of leads on an EKG that reflect the same anatomical area

What is the J-point?

Where the QRS complex and the ST segment meet