CERTIFIED EKG TECHNICIAN

CERTIFICATION

Thomas Forti R.N.

The EXAM Certified EKG Technician

CET GED and 60 HRs of training 110 Questions (100 Scored)

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

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.

HIPAA Medicinal information needs to be sent

via secure (encrypted) pathways Best way is to personally deliver the

information (Handing the MD the EKG)Not leaving it in a mail box where someone

else could view it. Keep work area clear of patient

information when you walk away

Protected Health information Any information about

Health status Health care services Payment Patient identifiers Social security Hone numbers Address Treatment Assessment Test results Diagnoses Medications

During Direct contact Phone calls Faxes Emails

Anatomy and Physiology 4 Chambers of the Heart

Right and Left AtriaRight and Left Ventricle

Sepal wall separate right from left sides

Three layers of the heartEndocardiumMyocardiumEpicardium

Heart is in a sac calledPericardium AKA Pericardial SacProvided protection and lubrication

Anatomy and Physiology Four Valves of the heart

Tricuspid and Mitral○ Between the atria and

ventriclePulmonary and Aortic

○ Blood exits heartChordae Tendineae

○ Provide support to A-V valves to prevent regurgitation (incompetence)

Anatomy and Physiology Coronary Arteries

Vessels that supply blood to the myocardiumOccur during ventricular diastoleNormal perfusion to body occurs during systoleRCA

○ 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 ventricleCollateral circulation

○ Compensation for loss of O2 in other areas

Conduction System Controls the synchronous, rhythmic contraction

of the heart muscle SA Node

Sinoatrial node60-100 BPMPrimary pacemaker of heartRight AtriaInitiates atria contractionShows as P wave on EKG tracing

Internodal PathwaysTracts that the impulse takes from SA-AV node

Conduction System AV node

Atrioventricular node40-60 BPMConnects Atria to VentricleImpulse pulses here before heading to ventriclesPR interval

Bundle of HisSplits impulse to RBBB and LBBBSits in the Interventricular septum

Purkinje FibersInitiates myocardial contraction20-40 BPM

EKG Theory Measures electrical energy as it travels

through the heart Records as energy over time

Millivolts and Seconds EKG paper has small squares

1mm x 1mm5 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

1ms = 0.001 seconds

EKG Theory EKG paper speed is 25 mm/sec

50mm/sec if rhythm is too fast○ Only change paper speed if ordered by MD

Standard AmplitudeAmplitude is change over a period of time10mm = 1mvGain is used to increase amplitude (size)

Calibration boxAt 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 Refer to user manual and hospital policy

For paper typeCleaning (keypad, wires machine)Daily user testCorrect power supplyBio-engineer will calibrate machine if

needed

EKG Theory Einthoven’s triangle

Willem Einthoven○ Discover everything basic of

EKGs Bi-Polar Leads

I, II, III Unipolar leads

V1-V6Augmented leads

○ avF, avR, avF

Calculating Heart Rates 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 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 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 Wandering baseline

Most common cause is respirationsMove electrodes off torso and onto wrists and

anklesHave patient relax and breath slowly

SeizuresLarge artifactSeizures must be controlled before EKG can be

done Dry Skin

Electrodes might now adhere○ Use Benzoin to promote adhesion○ Abrade the skin

Artifact Wet Skin

Dry skinUse Benzoin to promote adhesion

Cold patientWarm patient with blanketMay have to do EKG with artifact

Dry GelUse new electrodes

Cell PhonesTurn them off, remove and place asideCan look like p waves often like A-flutter

Medical devicesTurn off or move away from EKG patientBe careful in the ER or ICU

Lead Locations 3 Lead

White- Right Shoulder or clavicle areaBlack- left shoulder or clavicle areaRed- Left lower abdomen areaGreen- Right lower abdomen area

5 LeadWhite- right sternum/clavicle areaBlack- Left sternum/clavicle areaRed- Left lower thoracic areaGreen- Right lower thoracic areaBrown- Just below and to the right of

bottom of sternum

Lead Locations Precordial Leads

V1- 4th ICS, Right of SternumV2- 4th ICS, Left of sternumV3- Between V2/V4V4- 5th ICS, midclavicularV5- 5th ICS, between V4/V6V6- 5th ICS, midaxillary

Right precordial leadsReverse V leads

Lead Locations Posterior Leads

V7- Left posterior axillary lineV8- Left midscapular lineV9- left of spine

Stress testLimb electrodes go on torso

Post EKG Check leads for deflection direction Check leads for artifact Check that patient identifiers are on EKG

NameDOBMedical record number

Upload EKG Via hospital policy Mount EKG or strip per hospital policy

Hole punch, scan or stick onto mounting paper

Measuring EKG’s 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 Positive

Anything above isoelectric line Negative

Anything below isoelectric line PR segment

Time impulse travels through AV nodeEnd or P to beginning of QRS

ST segmentTime it take for ventricles to repolarizeEnd of QRS to end of T wave

Parts of Waves J Point

Point when ventricles depolarize and ventricle repolarize○ End of QRS

QT intervalTime it takes ventricles to depolarize and

repolarize

Sinus Rhythms P wave resent P wave upright and rounded QRS complex narrow

80-120 milliseconds PR 120-200 milliseconds Regular Sinus Rhythm

Rate 60-100 Sinus Bradycardia

Rate less then 60 Sinus Tachycardia

Rate greater then 100 Sinus Arrhythmia

Rate around 60-100Rhythm is irregular

Atria Rhythms P waves abnormal shaped or absent QRS complexes narrow Atrial Fibrillations

No P waves, No PR interval Rate 60-100 Irregularly irregular

Atrial Fibrillation with Rapid Ventricular No P waves, No PR interval Rate greater then 100 Irregularly irregular

Atrial Flutter P waves = Flutter waves (abnormal P waves) Rate varies Regular

Supraventricular SVT P waves often NOT seen Regular

Premature Atrial Complex PAC 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

P-wave absent or abnormal○ Rate 40-60

Junctional BradycardiaRate less then 40

Accelerated Junctional RhythmRate 60-100

Junctional TachycardiaRate above 100

Ventricle Rhythms QRS complex wide Idioventricular Rhythm

Wide QRS complexesRate 20-40

Ventricular tachycardiaMonomorphic

○ Wide QRS with rate above 120○ Complexes look identical

Polymorphic○ Complexes have different amplitude

Ventricular Rhythms Ventricular Fibrillation

No identifiable waves Asystole

Absence of electrical activity in the heart Premature Ventricular Complex

Wide QRS, absent P wavesR wave opposite direction of T waveNSR with PVCMultifocal PVCs

○ Different shaped PVCs○ Patterns – Bigeminy, Trigemity (every other or 3rd)

Heart Blocks Impulse is delayed or blocked as it travels to the

ventricles 1st degree

PR interval greater then 200 milliseconds 2nd degree type 1

PR interval elongates until dropped QRS complex 2nd degree type 2

PR interval normal if presentDropped QRS complex without warning

3rd degreeComplete 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 Ischemia

ST segment depressionT wave inversion

InjuryST elevation

○ 1mm in limb leads○ 2mm in precordial leads

InfarctionST elevation will return to baselinePathological Q waves developPathological Q waves can indicate MI

Lead Locations for MI

ST segment Morphology Draw line from J point to top of T wave Convex

ST segment is above lineCan be Ischemia STEMI

ConcaveST segment is below lineCan be ischemia but often benign

ST segment sloping

T Wave T wave is peaked T wave is Hyperacute

Hight is greater then ½ the QRS T wave elongates

Cardiac Compromise 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 Ventricular tachycardia

Check Pulse Ventricular fibrillation

Call for help Start CPR Use AED

Asystole Check in 2 leads Call for help Start CPR

Bradycardia Call for help Check Vitals Prepare patient for pacing

Tachycardia Call for help Check vitals Cardioversion

Pacemakers Paced Ventricular Paced Atrial-Ventricular

Patient Care 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 ComplainsPain, 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

procedurePreparation if test isn’t for today

Allow them to ask questions

Patient Care EKG

Allow physician to assess the electrical activity of the heart

Non-invasive, PainlessAround 10 minsWhat the electrodes are forEmpty pockets, relax, lay flat avoid moring

or talking

Patient Care 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 Stress Test

Used to determine how the heart function under increased workload from exercise

Take about 10 minsElectrodes and Blood pressure during testBaseline EKG prior and end of testTest goes until

○ Symptoms occurLightheadedness, dizziness, SOB, Chest pain

○ Target heart rate reached or physician orders test to endPatient not to eat, drink or smoke 3 hours priorContinue normal medication unless instructed by physician to

hold medicationWear clothing and shoes for exercising

Patient Care 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 Telemetry

Continuous monitoring of electrical systemWithin hospitalNotify staff if symptoms occur

Vitals Check Pulse

Adult- RadialChild- Brachial Apex use stethoscope

○ 5th ICS midclavicularPulse 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

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