Thomas Forti R.N.
The EXAM
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Certified EKG Technician
 CET
GED and 60 HRs of training
 110 Questions (100 Scored)
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 110 minuets Web exam
Score given following the exam
 Don’t spend too much time on one
question
 Try and figure out the answers before
reading the answers
 Eliminate incorrect answer to try and figure
out correct answer
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HIPAA
The Health Insurance Portability and
Accountability Act of 1996
 Patient has right to confidentiality
 Safeguards to ensure that an individual's
health information is used only for
purposes related to treatment, payment,
or healthcare operations
 You are responsible for this when at
work.
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HIPAA
Medicinal information needs to be sent
via secure (encrypted) pathways
 Best way is to personally deliver the
information (Handing the MD the EKG)
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 Not leaving it in a mail box where someone
else could view it.
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Keep work area clear of patient
information when you walk away
Protected Health information
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Any information about
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Health status
Health care services
Payment
Patient identifiers
Social security
Hone numbers
Address
Treatment
Assessment
Test results
Diagnoses
Medications
During
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Direct contact
Phone calls
Faxes
Emails
Anatomy and Physiology
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4 Chambers of the Heart
 Right and Left Atria
 Right and Left Ventricle
Sepal wall separate right from left
sides
 Three layers of the heart
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 Endocardium
 Myocardium
 Epicardium
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Heart is in a sac called
 Pericardium AKA Pericardial Sac
 Provided protection and lubrication
Anatomy and Physiology
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Four Valves of the heart
 Tricuspid and Mitral
○ Between the atria and
ventricle
 Pulmonary and Aortic
○ Blood exits heart
 Chordae Tendineae
○ Provide support to A-V
valves to prevent
regurgitation
(incompetence)
Anatomy and Physiology
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Coronary Arteries
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Vessels that supply blood to the myocardium
Occur during ventricular diastole
Normal perfusion to body occurs during systole
RCA
○ Supply right ventricle and inferior wall of left
ventricle (bottom)
 Left Main Splits to
○ Circumflex
 Supplies blood to posterior (back) and lateral (side)
○ LAD
 Supplies blood to anterior and Left ventricle
 Collateral circulation
○ Compensation for loss of O2 in other areas
Conduction System
Controls the synchronous, rhythmic
contraction of the heart muscle
 SA Node
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Sinoatrial node
60-100 BPM
Primary pacemaker of heart
Right Atria
Initiates atria contraction
Shows as P wave on EKG tracing
Internodal Pathways
 Tracts that the impulse takes from SA-AV node
Conduction System
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AV node
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Atrioventricular node
40-60 BPM
Connects Atria to Ventricle
Impulse pulses here before heading to ventricles
PR interval
Bundle of His
 Splits impulse to RBBB and LBBB
 Sits in the Interventricular septum
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Purkinje Fibers
 Initiates myocardial contraction
 20-40 BPM
EKG Theory
Measures electrical energy as it travels
through the heart
 Records as energy over time
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 Millivolts and Seconds
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EKG paper has small squares
 1mm x 1mm
 5 small boxes = 5mm = 1 large box
Tracings are made by a stylus
 1mm on y axis = 0.1mv
 1mm on x axis = 40ms or 0.04 seconds
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 1ms = 0.001 seconds
EKG Theory
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EKG paper speed is 25 mm/sec
 50mm/sec if rhythm is too fast
○ Only change paper speed if ordered by MD
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Standard Amplitude
 Amplitude is change over a period of time
 10mm = 1mv
 Gain is used to increase amplitude (size)
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Calibration box
 At beginning of lead
○ Speed and amplitude
○ Standard is 10mm tall and 5mm wide
○ Gain of 1 = 10mm, ½ = 5mm, 2 = 20mm
○ 25mm/sec = 5mm, 50mm/sec = 10mm
EKG Theory
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Refer to user manual and hospital policy
 For paper type
 Cleaning (keypad, wires machine)
 Daily user test
 Correct power supply
 Bio-engineer will calibrate machine if
needed
EKG Theory
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Einthoven’s triangle
 Willem Einthoven
○ Discover everything basic of
EKGs
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Bi-Polar Leads
 I, II, III
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Unipolar leads
 V1-V6
 Augmented leads
○ avF, avR, avF
Calculating Heart Rates
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1500 method
 Atria rate- count the P-P interval
○ Small boxes between the P waves
 Ventricle rate- count the R-R interval
○ Small boxes between the R waves
 1500/boxes
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Sequence method
 AKA 300 method
○ Count the large boxes between the R-R waves
and
 300/boxes
○ 300, 150, 100, 75, 60, 50
Calculating Heart Rates
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6 second rule
 Good for estimating rate if R-R intervals are
not regular
 Count QRS complexes in 6 second strip and
multiply by 10
 Marks under tracing indicate 3 seconds
Artifact
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Wandering baseline
 Most common cause is respirations
 Move electrodes off torso and onto wrists and
ankles
 Have patient relax and breath slowly
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Seizures
 Large artifact
 Seizures must be controlled before EKG can be
done
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Dry Skin
 Electrodes might now adhere
○ Use Benzoin to promote adhesion
○ Abrade the skin
Artifact
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Wet Skin
 Dry skin
 Use Benzoin to promote adhesion
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Cold patient
 Warm patient with blanket
 May have to do EKG with artifact
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Dry Gel
 Use new electrodes
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Cell Phones
 Turn them off, remove and place aside
 Can look like p waves often like A-flutter
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Medical devices
 Turn off or move away from EKG patient
 Be careful in the ER or ICU
Lead Locations
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3 Lead
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White- Right Shoulder or clavicle area
Black- left shoulder or clavicle area
Red- Left lower abdomen area
Green- Right lower abdomen area
5 Lead
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White- right sternum/clavicle area
Black- Left sternum/clavicle area
Red- Left lower thoracic area
Green- Right lower thoracic area
Brown- Just below and to the right of
bottom of sternum
Lead Locations
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Precordial Leads
 V1- 4th ICS, Right of Sternum
 V2- 4th ICS, Left of sternum
 V3- Between V2/V4
 V4- 5th ICS, midclavicular
 V5- 5th ICS, between V4/V6
 V6- 5th ICS, midaxillary
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Right precordial leads
 Reverse V leads
Lead Locations
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Posterior Leads
 V7- Left posterior axillary line
 V8- Left midscapular line
 V9- left of spine
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Stress test
 Limb electrodes go on torso
Post EKG
Check leads for deflection direction
 Check leads for artifact
 Check that patient identifiers are on EKG
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 Name
 DOB
 Medical record number
Upload EKG Via hospital policy
 Mount EKG or strip per hospital policy
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 Hole punch, scan or stick onto mounting paper
Measuring EKG’s
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Know how to be able to measure
 P-P interval
○ Time between Atria contractions
 R-R interval
○ Time between Ventricle contractions
 PR interval
○ Time from SA to ventricles
○ 0.12-0.2 seconds
 QRS
○ Time for ventricles to depolarize
○ 0.06-0.12 seconds
Parts of Waves
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Positive
 Anything above isoelectric line
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Negative
 Anything below isoelectric line
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PR segment
 Time impulse travels through AV node
 End or P to beginning of QRS
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ST segment
 Time it take for ventricles to repolarize
 End of QRS to end of T wave
Parts of Waves
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J Point
 Point when ventricles depolarize and
ventricle repolarize
○ End of QRS
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QT interval
 Time it takes ventricles to depolarize and
repolarize
Sinus Rhythms
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P wave resent
P wave upright and rounded
QRS complex narrow
 80-120 milliseconds
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PR 120-200 milliseconds
Regular Sinus Rhythm
 Rate 60-100
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Sinus Bradycardia
 Rate less then 60
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Sinus Tachycardia
 Rate greater then 100
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Sinus Arrhythmia
 Rate around 60-100
 Rhythm is irregular
Atria Rhythms
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P waves abnormal shaped or absent
QRS complexes narrow
Atrial Fibrillations
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Atrial Fibrillation with Rapid Ventricular
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P waves = Flutter waves (abnormal P waves)
Rate varies
Regular
Supraventricular SVT
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No P waves, No PR interval
Rate greater then 100
Irregularly irregular
Atrial Flutter
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No P waves, No PR interval
Rate 60-100
Irregularly irregular
P waves often NOT seen
Regular
Premature Atrial Complex PAC
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P wave abnormal
QRS follows P wave
NSR with PAC
Junctional Rhythms
Starts at AV node or Bundle of His
 P wave absent or abnormal (inverted)
 QRS narrow or above 120 milliseconds
 Junctional Rhythm
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 P-wave absent or abnormal
○ Rate 40-60
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Junctional Bradycardia
 Rate less then 40
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Accelerated Junctional Rhythm
 Rate 60-100
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Junctional Tachycardia
 Rate above 100
Ventricle Rhythms
QRS complex wide
 Idioventricular Rhythm
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 Wide QRS complexes
 Rate 20-40
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Ventricular tachycardia
 Monomorphic
○ Wide QRS with rate above 120
○ Complexes look identical
 Polymorphic
○ Complexes have different amplitude
Ventricular Rhythms
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Ventricular Fibrillation
 No identifiable waves
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Asystole
 Absence of electrical activity in the heart
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Premature Ventricular Complex
 Wide QRS, absent P waves
 R wave opposite direction of T wave
 NSR with PVC
 Multifocal PVCs
○ Different shaped PVCs
○ Patterns – Bigeminy, Trigemity (every other or 3rd)
Heart Blocks
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Impulse is delayed or blocked as it travels to
the ventricles
1st degree
 PR interval greater then 200 milliseconds
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2nd degree type 1
 PR interval elongates until dropped QRS complex
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2nd degree type 2
 PR interval normal if present
 Dropped QRS complex without warning
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3rd degree
 Complete lack of association between the atria and
ventricles
○ P waves present at normal rate
○ QRS waves at rate of Junctional rate or idioventricle
 Could be wide or narrow
Injury
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Ischemia
 ST segment depression
 T wave inversion
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Injury
 ST elevation
○ 1mm in limb leads
○ 2mm in precordial leads
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Infarction
 ST elevation will return to baseline
 Pathological Q waves develop
 Pathological Q waves can indicate MI
Lead Locations for MI
ST segment Morphology
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Draw line from J point to top of T wave
Convex
 ST segment is above line
 Can be Ischemia STEMI
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Concave
 ST segment is below line
 Can be ischemia but often benign
ST segment sloping
T Wave
T wave is peaked
 T wave is Hyperacute
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 Hight is greater then ½ the QRS
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T wave elongates
Cardiac Compromise
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Tachy or brady
Pallor
Diaphoresis
Decrease in BP
Breathing problems
Anxiety or confusion
Cyanosis
Chest pain or tightness
Back, arm, jaw pain
Nausea and vomiting
Lightheadedness
Weakness
Syncope
Left-threating arrhythmias
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Ventricular tachycardia
 Check Pulse
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Ventricular fibrillation
 Call for help
 Start CPR
 Use AED
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Asystole
 Check in 2 leads
 Call for help
 Start CPR
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Bradycardia
 Call for help
 Check Vitals
 Prepare patient for pacing
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Tachycardia
 Call for help
 Check vitals
 Cardioversion
Pacemakers
Paced Ventricular
 Paced Atrial-Ventricular
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Patient Care
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Responsible for knowing patients
 Medical History
○ Smoking, alcohol, drugs, stress, exercise, nutrition, work
environment, family history, marital status, children
○ Past medical conditions
 Stroke, MI, Aneurysm, murmurs, PE, DVTs, Heart failure,
hypertension, COPD, CHF
○ Current Complains
 Pain, SOB, Edema, Palpitations, Fainting, Weakness
 Surgical History
○ What, when, complications (more details if cardiac)
 Medication List (also allergies)
○ Currently taking and recently stopped (last month or 2)
○ Include OTC medications, birth control, erectile dysfunction
Patient Care
Explain procedures fully with easy to
understand terms
 Explain purpose, length, steps of
procedure
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 Preparation if test isn’t for today
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Allow them to ask questions
Patient Care
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EKG
 Allow physician to assess the electrical
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activity of the heart
Non-invasive, Painless
Around 10 mins
What the electrodes are for
Empty pockets, relax, lay flat avoid moring
or talking
Patient Care
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Holter
 Monitors activity for 24-72 hours
 Instruct patient to bathe rior to appointment
○ Pt can not remove electrodes or get device wet during time
 Loose fitting clothing to help prevent artifact
 Notify if irritation occurs from electrodes
 Normal daily activity
○ Including work exercise and sleep
 Journal with date time and duration of any symptoms
○ Lightheadedness, palpations, chest pain, SOB
○ Note when medications taken, physical activity and sleeping
 Patient to call physician office if electrodes fall off
○ Electrodes get replaced by Tech NOT patient
○ Batteries get changed by Tech NOT patient
○ Electrodes get moved by Tech
 Call 911 for serious symptoms
Patient Care
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Stress Test
 Used to determine how the heart function under
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increased workload from exercise
Take about 10 mins
Electrodes and Blood pressure during test
Baseline EKG prior and end of test
Test goes until
○ Symptoms occur
 Lightheadedness, dizziness, SOB, Chest pain
○ Target heart rate reached or physician orders test to end
 Patient not to eat, drink or smoke 3 hours prior
 Continue normal medication unless instructed by
physician to hold medication
 Wear clothing and shoes for exercising
Patient Care
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Stress Test
 Monitor for
○ Vital Sings
○ Arrhythmias
○ Cardiopulmonary compromise
○ Heart rate
 Complications
○ Most common is hypotension and arrhythmias
○ Stop and let patient rest
○ Lay patient down
○ Report change to physician
Patient Care
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Telemetry
 Continuous monitoring of electrical system
 Within hospital
 Notify staff if symptoms occur
Vitals
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Check Pulse
 Adult- Radial
 Child- Brachial
 Apex use stethoscope
○ 5th ICS midclavicular
 Pulse oximeter
○ Used to determine amount of oxygen in blood
○ Normal is above 95%
○ Cant read if: cold hands, colored nails,
edema, fake nails
Vitals
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms
Rhythms