EKG Technician Review Notes

Appendix A: Key Material

Facilities Where EKGs Are Conducted

Ambulatory care settings:
  - Doctor’s office
  - Urgent care center
  - Freestanding emergency department
  - Occupational health clinic
  - Primary care clinic
  - Cardiology specialty clinic
  - Outpatient surgery center
  - Rehabilitation or physical therapy clinic
Inpatient care settings:
  - Hospital
  - Specialty hospital (e.g., heart hospital or children’s hospital)
  - Long-term care facility
  - Inpatient rehabilitation facility

Qualities of Great EKG Technicians

Acceptance of constructive feedback
Care for personal appearance
Reliable attendance
Attention to detail
Strong communication skills
Acceptance of cultural diversity
Compassion towards patients
Flexibility in approach
Initiative in tasks
Integrity in behavior
Problem-solving ability
Timeliness in activities
Tactfulness in interactions
Understanding of teamwork dynamics

Positive and Negative Nonverbal Communication

Positive nonverbal communication includes:

Standing up straight with arms relaxed
Leaning toward the speaker
Maintaining eye contact
Nodding in agreement or understanding
Offering a handshake or greeting
Taking notes during conversation
Using a cheerful tone of voice
Smiling to convey friendliness

Negative nonverbal communication includes:

Slouching or resting head in hands, indicating disinterest
Leaning back from the speaker, suggesting disengagement
Crossing arms over chest, portraying defensiveness
Avoiding eye contact or looking down, signifying discomfort
Checking the time, indicating frustration
Not acknowledging the other person in conversation
Fidgeting or playing with objects, revealing nervousness
Using an angry tone of voice, implying hostility
Frowning, wincing, or rolling eyes, showing disapproval

Chain of Command in Healthcare Settings

Physicians: Conduct patient examinations, order tests, diagnose conditions, refer patients for additional care, write prescriptions.
Mid-level providers (MLPs): Act under physician supervision performing duties similar to those of physicians (e.g., physician assistants, nurse practitioners).
Staff nurses (RNs, LPNs/LVNs): Provide nursing care as prescribed by physicians.
Other healthcare workers: Assist with check-ins, obtain vital signs, help patients to and from assigned rooms, assist with discharge, prepare areas for incoming patients, and support nursing staff.
EKG Technicians: Perform EKG tests, monitor patients during tests, and assist healthcare workers as required by supervising nurses.
Supervising clinic nurses (RNs or LPNs): Oversee nurses and EKG technicians, providing medical care as directed by physicians and MLPs.
Medical director: Reviews and consults on the medical aspects of patient care, ensuring quality across departments.
Clinical nursing director: Oversees nursing staff and care, managing aides, technicians, and other healthcare personnel.
Executive director or administrator: Handles the non-medical aspects, financial administration, and policy coordination in consultation with medical teams.

Protected Health Information (PHI)

PHI includes any information that can be used to identify an individual, such as:

Name
Postal address
All elements of dates associated with an individual (except year)
Telephone number
Fax number
Email address
URL (website address)
IP address (numerical identifier of a device in a network)
Social security number
Account numbers
Medical record numbers
Health plan beneficiary numbers
Device identifiers and their serial numbers
Vehicle identifiers (e.g., license plate numbers)
Biometric identifiers (e.g., fingerprints, voiceprints)
Full-face photos and comparable images
Any other unique identifiers, codes, or characteristics.

Common Temperature Sites

Oral:
   - Used: Under the tongue
   - Appropriate for: Cooperative and alert patients over 5 years
   - Not appropriate for:
     - Recent smoking, food, or drink intake
     - Coughing
     - Mouth pain
     - Children younger than 5
     - Unconscious or uncooperative patients
Tympanic:
   - Used: Ear
   - Appropriate for: Infants over 6 months, children, adults
   - Not appropriate for: Infants younger than 6 months or patients with excessive earwax buildup
Axillary:
   - Used: Under the arm
   - Appropriate for: Situations where no other method is feasible
   - Not appropriate for: Uncooperative patients (least accurate method)
Temporal:
   - Used: Artery under the skin of the forehead
   - Appropriate for: Infants over 3 months, children, adults
   - Not appropriate for: Infants younger than 3 months

Common Pulse Points

Temporal pulse
Carotid pulse
Apical pulse
Brachial pulse
Radial pulse
Femoral pulse
Popliteal pulse
Pedal pulse (Dorsalis pedis pulse)

Body Positions

Supine Position: Lying on the back.
Fowler's Position: Sitting position inclined at 30 to 90 degrees, commonly used for patients with cardiac or respiratory issues.

Anatomical Terms Related to the Chest

Clavicle (collarbone)
Sternum (breastbone)
Thorax (chest area)
Axilla (armpit)
Mediastinum (area between the lungs)

Anatomical Terms of Location and Direction

Superior: Toward the head
Inferior: Away from the head
Anterior or ventral: Front of the body
Posterior or dorsal: Back of the body
Lateral: Away from the midline
Medial: Toward the midline
Proximal: Closer to the torso
Distal: Further from the torso
Intercostal: Between the ribs

Anatomical Lines of Reference

Posterior axillary line
Midaxillary line
Anterior axillary line
Midline
Midclavicular line

Location of the Heart

Base of heart: Top portion where major blood vessels attach.
Apex of heart: Bottom, pointed end of the heart.

Components of Blood

Formed Elements: Erythrocytes (red blood cells), leukocytes (white blood cells), thrombocytes (platelets).
Plasma: Composed of 91% water and 9% dissolved substances (proteins, gases, hormones, clotting factors, nutrients).

Types of Blood Vessels

Arteries: Carry blood away from the heart.
Arterioles: Smaller branches of arteries.
Capillaries: Microscopic vessels where exchange occurs.
Venules: Small vessels that collect blood from capillaries.
Veins: Carry blood back to the heart.

The Respiratory System

Major components:
  - Bronchi
  - Bronchioles
  - Trachea
  - Larynx
  - Pharynx
  - Alveoli
  - Diaphragm

Divisions of the Nervous System

Autonomic Nervous System: Controls involuntary actions like heartbeat and breathing.
- Sympathetic Nervous System: Increases heart rate and respiration (fight-or-flight).
- Parasympathetic Nervous System: Decreases heart rate and promotes recovery.
Somatic Nervous System: Controls voluntary actions.
Central Nervous System: Comprises the brain and spinal cord.
Peripheral Nervous System: Comprises nerves that extend to all body parts.

Layers of the Heart

Epicardium: Outer layer.
Myocardium: Muscle layer responsible for contracting.
Endocardium: Inner layer lining the heart chambers.

Major Blood Vessels Entering and Leaving the Heart

Right pulmonary artery
Left pulmonary artery
Aorta
Superior vena cava
Inferior vena cava
Coronary arteries
Right pulmonary veins
Left pulmonary veins

Coronary Arteries

Right coronary artery
Left coronary artery
Circumflex coronary artery
Left anterior descending artery (LAD)

Valves of the Heart

Bicuspid (Mitral) valve: Between left atrium and ventricle.
Tricuspid valve: Between right atrium and ventricle.
Aortic semilunar valve: Between left ventricle and aorta.
Pulmonary semilunar valve: Between right ventricle and pulmonary artery.

Circulation Types

Pulmonary Circulation: Movement of blood from the right side of the heart to the lungs and back to the left side.
Systemic Circulation: Movement of blood from the left side of the heart to the rest of the body and back to the right side.

Pathophysiology: Plaque Buildup

Plaque: Accumulation in artery walls can lead to obstruction.
Ischemia: Reduced blood flow due to narrowed arteries, which can result in myocardial infarction (heart attack).

Signs and Symptoms of Myocardial Infarction

Feelings of impending doom
Decreased level of consciousness
Diaphoresis (sweating)
Pain radiating to the arm
Chest pain or pressure
Neck or jaw pain
Dyspnea (shortness of breath)
Weakness
Nausea (with or without vomiting)

Cardiomyopathy Types and Symptoms

Normal Heart: Healthy cardiac structure.
Cardiomyopathy Signs and Symptoms:
  - Dyspnea (difficulty breathing)
  - Orthopnea (difficulty breathing when lying flat)
  - Edema (swelling) in lower extremities
  - Weakness
  - Fatigue

Signs and Symptoms of Right-Sided Congestive Heart Failure

Liver congestion
Edema in lower extremities
Spleen congestion
Ascites (fluid buildup in the abdominal cavity)

Signs and Symptoms of Left-Sided Congestive Heart Failure

Productive cough with frothy white sputum
Dyspnea/Orthopnea
Tachycardia (rapid heartbeat)
Neck vein distention

Heart Valve Disease

Normal blood flow: No obstruction.
Regurgitation: Blood leaks backward due to damaged valves.

Signs and Symptoms of Heart Valve Disease

Cough
Chest pain
Abdominal swelling
Palpitations
Weight gain
Lower extremity edema
Weakness

Signs and Symptoms of Pulmonary Embolism

Sense of unease
Cyanosis (blue or gray skin color)
Dyspnea
Chest pain

Signs and Symptoms of CVA (Stroke)

Dizziness
Sudden severe headache
Confusion
Vision changes
Facial droop
Dysphagia (difficulty swallowing)
Hemiparesis (weakness on one side)
Hemiplegia (paralysis on one side)

Signs and Symptoms of Hypertension

Headache
Dizziness
Fatigue
Blurred vision
Nosebleed
Nausea

12-Lead EKG Tracing

Standard speed is 25.0 mm/s
Normal frequency of 40 Hz

Lead Types

Limb Leads: Bipolar leads including:
  - Lead I
  - Lead II
  - Lead III
Augmented Limb Leads:
  - aVF
  - aVL
  - aVR
Precordial Leads (Chest Leads):
- V1, V2, V3, V4, V5, V6

Areas of the Heart Examined by Each Lead

V1 and V2: Anteroseptal wall
V3 and V4: Anterior wall
V5: Lateral wall
aVF: Inferior wall

Electrode Placement for 3-Lead Applications

Right Arm (RA): Under right clavicle at right midclavicular line.
Left Arm (LA): Under left clavicle at left midclavicular line.
Left Leg (LL): Left lower torso.

Electrode Placement for 5-Lead Applications

Include RA, LA, and LL placements as above.
V1: Fourth intercostal space to the right of the sternum.

Electrode Placement for 12-Lead Applications

Place electrodes across mentioned areas including:
  - RA
  - LA
  - LL
  - V1 to V6 as detailed above.

EKG Tracings and Measurement Methods

At 25 mm/s and 50 mm/s, standard gain is 10 mm/mV.
Heart rate measured using:
  1. 6-Second Method: Good for both regular and irregular rhythms.
  2. Large Block Method: Fast calculations START 300, reduce by the count of large blocks.
  3. Small Block Method: Count small blocks between R waves and calculate heart rate using the equation: $ext{Heart Rate} = \frac{1500}{ ext{Number of Small Blocks}}$ .

EKG Complex Measurements

PR Interval: Measured from the beginning of the P wave to the beginning of the QRS complex.
QRS Complex: Indicates ventricular depolarization; duration measured as less than 0.12 s.
ST Segment: Elevation or depression indicates pathophysiological findings that need monitoring.
Abnormalities in these intervals can indicate rhythm disturbances or cardiac compromise.

Common Cardiac Rhythms and Their Indicators

All identified cardiac rhythms are crucial for assessment:

Normal Sinus Rhythm: 60-100 bpm with regular P waves.
Sinus Tachycardia: Heart rate exceeds 100 bpm; P waves normal.
Sinus Bradycardia: Heart rate below 60 bpm; stable but low rate.
Atrial Fibrillation: Irregular rhythm with absent P waves; requires monitoring.

Heart Block Classifications

First-Degree Block: PR interval > 0.20 s; mostly benign.
Second-Degree Block (Mobitz Type I): Progressively longer PR interval until a beat is dropped.
Second-Degree Block (Mobitz Type II): Consistent PR interval with dropped QRS complexes.
Third-Degree Block: No relationship between P waves and QRS complexes; potentially lethal.

Pacemakers and Cardiac Devices

Atrial Pacing: Spike before P wave indicates pacing.
Ventricular Pacing: Spike preceding QRS complex.
Dual Chamber Pacing: Spikes correspond to both atrial and ventricular pacing, indicating synchronous function.
Failure to Sense: Lack of relationship between pacemaker activity and patient rhythm.
Failure to Capture: Pacemaker spikes that do not generate electrical activity.

ST Segment Changes and Their Implications

Elevation of ST Segment: > 1 mm above isolectric line indicates acute injury.
Depression of ST Segment: > 2 mm below baseline can signify ischemia.

Critical EKG Changes to Report Immediately

Ventricular tachycardia and fibrillation are both life-threatening.
New-onset dysrhythmias require instant clinical attention.