ECG Cards

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dw_ccsf
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159669
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ECG Cards
Updated:
2012-07-06 16:05:22
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ECG ACLS
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ACLS - ECG Review
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  1. 3 Methods of Calculating Heart Rate for this strip:

    Method 1: # of R-R intervals in 6 sec x 10 = ____
    Method 2:
    300 # Large boxes btwn R-R = ____
    Method 3: 1500 # small boxes btwn R-R = ____
    • Method 1:  80 beats per minute (8 intervals)
    • Method 2:  75 beats per minute (4 lg boxes)
    • Method 3:  84 beats per minute  (18 small boxes)
  2. Calculating Heart Rate
    Each Small box = ____ sec
    Each Large box = ____ sec
    • Each Small box = 0.04 sec
    • Each Large box = 0.20 sec
  3. a) Atrial rate is determined between ___ to ___ interval

    b) Ventricular rate is determined between ___ to ___ interval
    a) P-P interval

    b) R-R interval
  4. When is the rhythm considered regular?
    The spacing between R-R and/or P-P is equal throughout the strip
  5. a) What is the hallmark of a sinus rhythm?

    b) What does this indicate?

    c) True or False: A trace with irregular beats can also have a sinus rhythm.
    a) a P-wave is present

    b) SA node is firing to produce a P-wave

    • c) True, it can be irregular sinus rhythm if it still has a p-wave. The description of this tracing is:
    • * Ventricular rate/rhythm: 41-73 bpm, irregular
    • * PR interval: 0.20 sec
    • * QRS interval: 0.12 sec
    • * Identification: Sinus rhythm at 41-73 bpm with a nonconducted PAC
  6. a) What is this waveform?
    b) What are the ECG characteristics?
    a) Coarse V-fib

    • b) Defining ECG Criteria:
    • Rate:       Cannot be determined; no recognizable P, QRS, or T waves. Baseline undulations btwn
    • 150-500/min

    Rhythm:        Indeterminate; pattern of sharp up (peak) and down (trough) deflections

    Amplitude:     Measured from peak-to-trough

    Fine V-Fib:      Peak-to-trough   2 to < 5mm

    Moderate V-Fib:   Peak-to-trough  5 to < 10mm

    Coarse  V-Fib:     Peak-to-trough  10 to <15mm

    Very Coarse V-fib:   Peak-to-trough  >15mm
  7. a) What is this waveform?
    b) What are the ECG characteristics?
    a) Fine V-fib

    • b) Defining ECG Criteria:
    • Rate:       Cannot be determined; no recognizable P, QRS, or T waves. Baseline undulations btwn
    • 150-500/min

    Rhythm:     Indeterminate; pattern of up (peak) and down (trough) deflections

    Amplitude:     Measured from peak-to-trough

    • Fine V-Fib:     Peak-to-trough   2 to < 5mm
    • (rhythm difficult to distinguish from asystole)

    Moderate V-Fib:   Peak-to-trough  5 to < 10mm

    Coarse  V-Fib:   Peak-to-trough  10 to <15mm

    Very Coarse V-fib:   Peak-to-trough  >15mm
  8. a) Any organized rhythm without detectable pulse is ___.
    b) What are the ECG characteristics of this pattern?

    • a) Pulseless Electrical Activity (PEA)
    • b) Defining ECG Criteria:

    •   Rhythm displays organized electrical activity (not VF/pulseless VT)

      Seldom as organized as normal sinus rhythm

      Can be narrow (QRS <0.10 mm) or wide (QRS >0.12 mm); fast (>100 beats/min) or slow(<60 beats/min)

      Most frequently: fast and narrow (noncardiac etiology) or slow and wide (cardiac etiology)
  9. a) What is this waveform?

    b) What are the ECG characteristics?
    • a) Ventricular Asystole
    • b) Defining ECG Criteria:

    • Rate: no ventricular activity seen or ≤6/min; so-called “P-wave asystole” occurs with only atrial impulses present to form P waves

    Rhythm: no ventricular activity seen; or ≤6/min

    PR: cannot be determined; occasionally P wave seen, but by definition R wave must be absent

    QRS complex: no deflections seen that are consistent with a QRS complex
  10. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Sinus Tachycardia (a type of supraventricular tachyarythmia or SVT)

    • b) Defining ECG Criteria:
    • Rate: > 100 beats/min (note: 2.5 boxes per R-R interval, 300/2.5 = 120)
    • Rhythm: sinus
    • PR: usually < 0.20 sec
    • P for every QRS Complex
    • QRS complex: May be normal or wide if there is an underlying abnormality
  11. a) What is this waveform?
    b) What are the ECG characteristics?
    a) Atrial Fibrilation

    • b) Defining ECG Criteria:
    • *  
Rate:  Wide-ranging ventricular response to atrial rate of 300-400 beats/min
    • *  Rhythm:  Irregular (classic “irregularly irregular”)P waves: Chaotic atrial fibrillatory waves only; Creates disturbed baseline
    • *  PR:  cannot be measured
    • *  QRS complex:  Remains ≤0.10-0.12 sec unless QRS complex distorted by fibrillation/flutter waves or by conduction defects through ventricles
  12. a) What is this waveform?
    
b) What are the ECG characteristics?
    a) Atrial Flutter

    • b) Defining ECG Criteria:

    •   Rate:   
    •     * Atrial rate 220-350 beats/min                 
    •     * Ventricular response = a function of AV node block or conduction of atrial impulses    
    •     * Ventricular response rarely >150-180 beats because of AV node conduction limits
    •   Rhythm: 
    •     * Regular (unlike atrial fibrillation)   
    •     * Ventricular rhythm often regular   
    •     *  Set ratio to atrial rhythm, eg, 2-to-1 or 3-to-1
    •   P waves: 
    • No true P waves seen; Flutter waves in “sawtooth pattern” is classic
    •   PR: cannot be measured
    •   QRS complex:  Remains ≤0.10-0.12 sec unless QRS complex distorted by fibrillation/flutter waves or by conduction defects through ventricles
  13. a) What is this waveform?
    b) ____ phenomenon happens when impulses recycle repeatedly in the AV node because of an abnormal rhythm circuit that allows wave of depolarization to travel in a circle.  What are the 2 kinds?
    
c) What are the ECG characteristics?
    a) Sinus rhythm with a reentry supraventricular tachycardia (SVT)

    b) Reentry phenomenon; Accessory Mediated SVT may include AV nodal reentrant tachycardia or AV reentry tachycardia

    • c) Defining ECG Criteria:
    • Rate:  Exceeds upper limit of sinus tachycardia at rest (>220 bpm), seldom < 150 bpm, often up to 250 bpm
    • Rhythm:  Regular
    • P waves:  Seldom seen because rapid rate causes P wave to be "hidden" in preceding T waves or to be difficult to detect because the origin is low in the atrium
    • QRS:  normal, narrow
  14. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Monomorphic Ventricular Tachycardia (VT)

    • b) Defining ECG Criteria:
    •   Rate:  ventricular rate >100 bpm; typically 120 to 250 bpm
    •   Rhythm:  no atrial activity seen, only regular ventricular
    •   PR:  none
    •   P waves:  seldom seen but present; VT is a form of AV dissociation (which is a definingcharacteristic for wide-complex tachycardias of ventricular origin vs supraventricular tachycardiaswith aberrant conduction)
    •   QRS:  wide and bizarre, “PVC-like” complexes >0.12 sec, with large T wave ofopposite polarity from QRS
  15. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Polymorphic V-Tach

    • b) Defining ECG Criteria:
    •   Rate: ventricular rate >100 bpm; typically 120 to 250
    •   Rhythm:  regular or irregular ventricular, no atrial activity
    •   PR:  nonexistent
    •   P waves: seldom seen but present, VT is a form of AV dissociation
    •   QRS:  marked variation and inconsistency seen in the QRS complexes
  16. a) What is this waveform?
    
b) What are the ECG characteristics?
    • a) Tordades de points: a unique type of Polymorphic VT that occurs in the presence of a long QT interval
    • QRS changes in shape, amplitude, & width and appears to "twist" around the isoelectric line in a "spindle-node" pattern in which ventricular amplitude increases then decreases in a regular pattern (creating the "spindle")
    • A, Start of a "spindle."  Note negative initial deflection and increasing QRS amplitude.
    • B, End of a spindle and start of a "node"
    • C, End of a node and start of the next spindle. Note the positive initial deflection and "spindling" in QRS amplitude

    • b) Defining ECG Criteria:
    •   Atrial Rate: cannot be determinied
    •   Ventricular rate: 150-250 complexes per minute
    •   Rhythm: only irregular ventricular rhythm
    •   PR: Nonexistent
    •   QRS complexes: display classic spindle-node pattern
  17. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Sinus Bradycardia with borderline first-degree AV block

    • b) Defining ECG Criteria:

    •   Rate:  < 60 bpm
    •   Rhythm:  regular sinus
    •   PR:  regular, 0.12 to 0.20 sec
    •   QRS complex:  narrow;  <0.12 sec (often <0.11 sec) in absence of intraventricular conduction defect
  18. a) What is this waveform?
    
b) What are the ECG characteristics?
    a) First-Degree AV Block

    • b) Defining ECG Criteria:
    •   Rate:  1st-degree AV block can be seen with rhythms: sinus bradycardia, sinus tachycardia, or normal sinus mechanism
    •   Rhythm: sinus, regular, both atria and ventricles
    •   PR: prolonged, > 0.20 sec, but does not vary (fixed)
    •   P waves:
    •     * size and shape normal
    •     * every P wave is followed by a QRS complex
    •     * every QRS complex is preceded by P wave
    •   QRS complex:  narrow, < 0.12 sec in absence of intraventricular conduction defect
  19. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Type I Second-Degree AV Block (Mobitz I-Wenckebach)

    • b) Defining ECG Criteria:
    •   Rate:  atrial rate just slightly faster than ventricular (because of dropped conduction); usually within normal range
    •   Rhythm: 
    •     * atrial complexes are regular & ventricular complexs are irregular in timing (because of dropped beats)
    •     * can show regular P waves marching through irregular QRS
    •   PR:  progressive lengthening of PR interval occurs from cycle to cycle; then one P wave is not followed by QRS complex ("dropped beat")
    •   P waves:  size & shape remain normal; occasional P wave not followed by QRS complex ("dropped beat")
    •   QRS complex:  <0.12 sec most often, but a QRS "drops out" periodically
  20. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Type II Second-Degree AV Block (Infranodal; Mobitz II; Non-Wenckebach) - High Block

    • b) Defining ECG Criteria:
    •   Atrial Rate:  usually 60-100 bpm
    •   Ventricular Rate:  by definition (due to blocked impulses) slower than atrial rate
    •   Rhythm:
    •     * Atrial is regular
    •     * Ventricular is irregular (bc of blocked impulses), but was regular until dropped beats
    •     * Ventricular is regular if there is consistent 2:1 or 3:1 block
    •   PR: 
    •     * constant and set
    •     * no progressive prolongation some P waves will not be conducted & therefore not followed by a QRS complex
    •   P waves: 
    •     * typical in size & shape
    •     * by definition some P-waves will not be conducted & therefore not followed by a QRS complex
    •   QRS complex: 
    •     * narrow (<0.12 sec) implies high block relative to AV node
    •     * wide ( 0.12 sec) implies low block relative to AV node
  21. a) What is this waveform?

    b) What are the ECG characteristics?
    a) Type II Second-Degree AV Block (Infranodal; Mobitz II; Non-Wenckebach) - Low Block

    • b) Defining ECG Criteria:
    •   Atrial Rate:  usually 60-100 bpm
    •   Ventricular Rate:  by definition (due to blocked impulses) slower than atrial rate
    •   Rhythm:
    •     * Atrial is regular
    •     * Ventricular may be irregular (bc of blocked impulses) or regular if there is consistent 2:1 or 3:1 block
    •     * In this case: PR-QRS intervals are regular until 2 dropped beats occur
    •   PR: 
    •     * constant and set
    •     * no progressive prolongation some P waves will not be conducted & therefore not followed by a QRS complex
    •   P waves: 
    •     * typical in size & shape
    •     * by definition some P-waves will not be conducted & therefore not followed by a QRS complex
    •   QRS complex: 
    •     * narrow (<0.12 sec) implies high block relative to AV node
    •     * wide ( 0.12 sec) implies low block relative to AV node
  22. a) What is this waveform?
    
b) What are the ECG characteristics?
    • a) Third-Degree AV Block with a junctional escape pacemaker
    • Pathophys: 3-degree block causes atria & ventricles to depolarize independently w/no relationship between the two (AV dissociation)

    • b) Defining ECG Criteria:
    •   Atrial rate: 
    •     * usually 60-100 bpm
    •     * impulses completely independent ("dissociated") from the slower ventricular rate
    •   Ventricular rate:
    •     * depends on rate of ventricular escape beats that arise
    •     * ventricular escape rate slower than atrial rate = 3rd-degree AV block (rate = 20 to 40 bpm)
    •     * ventricular escape rate faster than atrial rate = AV dissociation (rate = 40 to 55 bpm)
    •   Rhythm:  both atrial & ventricular rhythm are regular but independent ("dissociated")
    •   PR: by definition there is no relationship between P wave and R wave
    •   QRS complex:
    •     * narrow (< 0.12 sec) implies high block relative to AV node
  23. Name the reversible causes of cardiac arrest (PEA & Asystole).
    • 5 H's:
    •   Hypovolemia
    •   Hypoxia
    •   Hydrogen ion (acidosis)
    •   Hypo-/hyperkalemia
    •   Hypothermia

    • 5 T's:
    •   Tension pneumothorax
    •   Tamponade, cardiac
    •   Toxins
    •   Thrombosis, pulmonary
    •   Thrombosis, coronary
  24. 1) What do vasopressors do?

    2) Why are vasopressors used during cardiac arrest?
    1) They vasoconstrict blood vessels

    2) Vasopressors optimize cardiac output & blood pressure; evidence that use of vasopressors favors initial resuscitation with ROSC (return of spontaneous circulation)
  25. 1) What Vasopressors are given during cardiac arrest?

    2) What is the difference between them?

    3) Which one is better?
    • 1) Vasopressors given during cardiac arrest:
    •   Epinephrine: 1 mg IV/IO (repeat q 3-5 min)
    •   Vasopressin: 1 dose of 40 units IV/IO (may replace either first or second dose of epinephrine)

    • 2) Epinephrine stimulates adrenergic receptors, causing vasoconstriction.
    • Vasopressin stimulates non adrenergic peripheral  receptors

    3) The efficacy of Vasopressin is no different from Epinephrine in cardiac arrest.
  26. What do you do if there is a continuing need for a vasopressor after the dose of Vasopressin has been administered during cardiac arrest?
    Administer Epinephrine every 3-5 minutes after the dose of Vasopressin if there is a continuing need for a vasopressor.
  27. Do any of the antiarrhythmic drugs given routinely during cardiac arrest increase survival to hospital discharge?
    No, however, Amiodarone has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.
  28. What are the 3 antiarrythmic agents that may be given during cardiac arrest?
    1. Amiodarone

    2. Lidocaine

    3. Magnesium Sulfate
  29. A. What is the treatment for Cardiac Arrest?

    B. What do you do if there is Asystole or PEA?

    C. What do you do there is VF or VT (no pulse)?
    • A:
    • 1) Shout for help/ Activate Emergency Response
    • 2) Start CPR
    • 2) Give O2
    • 3) Attach monitor/defibrillator

    • B: This indicates no shockable rhythm
    • 1) CPR 2 min (30 compressions)
    • 2) IV/IO access
    • 3) Epinephrine q 3-5 min
    • 4) Consider advanced airway
    • 5) If still not shockable -> CPR 2 min & treat reversible causes;  If shockable, go to C.

    • C: These are shockable rhythms
    • 1) SHOCK
    • 2) CPR 2 min
    •      * IV/IO access
    • 3) SHOCK (if VF/VT)
    • 4) CPR 2 min
    •      * Epinephrine 1 mg q 3-5 min (or Vasopressin 40 units)
    •      * Consider advanced airway, capnography
    • 5 SHOCK (if VF/VT)
    • 6) CPR 2 min
    •      * Amiodarone 1st dose: 300 mg bolus
    •      * Treat reversible causes
    • 7) If VF/VT continues: SHOCK -> CPR -> Epi -> SHOCK -> CPR -> Amiodarone 2nd dose 150 mg
  30. A. What is the treatment for Post-Cardiac Arrest?  (after return of spontaneous circulation - ROSC)
    • 1. Optimize ventilation & oxygenation
    •   Maintain O2 sat 94%
    •   Consider advanced airway & waveform capnography
    •   Do not hyperventilate (10-12 breaths/min)

    • 2. Treat hypotension (SBP < 90 mmHg)
    •   IV/IO bolus (1-2 L NS or LR; 4C if induce hypothermia)
    •   Vasopressor infusion
    •      -  Epinephrine IV 0.1-0.5 mcg/kg/min
    •      -  Dopamine IV 5-10 mcg/kg/min
    •      -  Norepinephrine IV 0.1-0.5 mcg/kg/min

    • 3. Follows commands: No = Induce hypothermia
    • Follows commands: Yes = Coronary reperfusion with PCI (percutaneous coronary intervention) bc likely STEMI

    4. Institute glycemic control & advanced critical care
  31. A. When does Bradycardia require treatment?

    B. What is the treatment for Bradycardia (with pulse)?
    • A. If signs and symptoms include:
    •   Hypotension (BP < 50)
    •   Acutely altered mental status
    •   Signs of shock
    •   Ischemic chest discomfort
    •   Acute heart failure

    • B. Treatment includes:
    •   Identify & treat underlying cause
    •      - Maintain patent airway
    •      - O2 (if hypoxemic)
    •      - Cardiac monitor to i.d. rhythm; monitor blood pressure & oximetry
    •      - IV access
    •      - 12-Lead ECG if available; don't delay therapy
    • (if symptoms occur):
    •   Atropine IV (1st dose 0.5 mg; repeat q 3-5min; MAX 3 mg)

    • (if atropine ineffective):
    •   Transcutaneous pacing
    • or
    •   Dopamine IV (2-10 mcg/kg/min)
    • or
    •   Epinephrine IV (2-10 mcg/kg/min)

    • Then:
    •   Consider expert consultation or transvenous pacing
  32. What is the treatment for Tachycardia (with pulse) and signs and symptoms include:
        - Hypotension (BP < 50)
        - Acutely altered mental status
        - Signs of shock
        - Ischemic chest discomfort
        - Acute heart failure
    • 1) Identify & treat underlying cause:   
    •     - Maintain patent airway    
    •     - O2 (if hypoxemic)   
    •     - Cardiac monitor to i.d. rhythm; monitor blood pressure & oximetry

    • 2) GIVE:  Synchronized Cardioversion, initial doses:    
    • - Narrow reg: 50-100 J    
    • - Narrow irregular: 120-200 J biphasic or 200 J monophasic   
    • - Wide regular: 100 J    
    • - Wide irregular: defibrillation dose (NOT synchronized)
  33. What is the treatment for Tachycardia (with pulse) and signs and symptoms DO NOT include:
        - Hypotension (BP < 50)
        - Acutely altered mental status
        - Signs of shock
         - Ischemic chest discomfort
        - Acute heart failure
    • 1) Identify & treat underlying cause:
    •      - Maintain patent airway
    •      - O2 (if hypoxemic)
    •      - Cardiac monitor to i.d. rhythm; monitor blood pressure & oximetry

    • 2) If no sxs, but QRS is wide (>0.12 sec)
    • GIVE:
    •      - IV access & 12-lead ECG
    •      - consider Adenosine IV only if regular & monomorphic (1st dose 150 mg over 10 min; repeat if VT; follow w/maintenance 1 mg/min for 1st 6 hrs)
    •      - consider Antiarrhythmic drug:
    •             * Procainamide IV (20-50mg/min; Maintenance 1-4 mg)
    •             * Amiodarone IV (150 mg over 10 min; Maintenance 1 mg/min for 1st 6 hrs)
    •             * Sotalol IV (100 mg or 1.5 mg/kg over 5 min)

    • 3) If no sxs, but QRS is NOT wide (<0.12 sec)
    • GIVE:
    •       - IV access & 12-lead ECG
    •      - Vagal maneuvers
    •      - consider Adenosine IV only if regular (1st dose 6 mg rapid IV push; follow w/ NS flush; 2nd dose 12 mg)
    •      - B-Blocker or Calcium channel blocker
    •      - consider expert consultation
  34. What is the inital dose of atropine for a patient with sinus bradycardia, HR=42, BP=80/60?
    0.5 mg
  35. A patient is in PEA tachycardia, 2 shocks & 1 dose of epinephrine have been given.  What is the drug/dose to anticipate to administer?
    Amiodarone 300 mg
  36. a) What is this waveform?
    b) What are the ECG characteristics?
    a) Complete AV block with a ventricular escape pacemaker

    • b)
    • QRS: wide, 0.12 to 0.14 sec
    •     * wide ( > 0.12 sec) implies low block relative to AV node
  37. What is the ED treatment for ischemia or infarction?
    1) if O2 sat < 94%, start O2 at 4 L/min, titrate

    2) Aspirin 160 to 325 mg (if not given by EMS)

    3) Nitroglycerin sublingual or spray

    4) Morpine IV if discomfort not relieved by nitroglycerin
  38. What is the EMS assessment, care, & hospital prep for symptoms suggestive of ischemia or infarction?
    1) Monitor, support ABCs. Be prepared to give CPR & defibrillation.

    2) Admin aspirin and consider O2, nitroglycerin, & morphine if needed

    • 3) Obtain 12 lead ECG;  if ST elevation:
    •      * Notify receiving hospital w/transmission or interpretaion
    •      * Note time of onset & 1st medical contact

    4) Notified hospital should mobilize hospital resources to respond to STEMI

    5) If considering prehospital fibrinolysis, use fibrinolytic checklist
  39. What is the concurrent ED assessment (<10 min) for symptoms suggestive of ischemia or infarction?
    1) Check VS; evaluate O2 sat

    2) Establish IV access

    3) Perform brief, targeted history, physical exam

    4) Review/complete fibrinolytic checklist; check contraindications

    5) Obtain initial cardiac marker levels, initial electrolyte & coagulation studies

    6) Obtain portable chest x-ray (<30 min)

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