 Hi, everyone. I want to welcome you to today's lesson where we will be discussing the electrocardiogram otherwise known as the EKG or the ECG. By now, you know that I'm Leah, either lead in court instructor here at Advanced E-Clinical Training. So in today's lesson, some of the specific things that we will talk about is exactly what is the electrocardiogram? What is the ECG, the EKG? We will be talking about what is your role, specifically in electrocardiogram testing. We will discuss the electrocardiogram itself. We will also talk about how to perform an electrocardiogram. And then at the end of the lesson, we will go over some basic rhythms that you may see while you're in practice. And then also the rhythms that you, these will be the same rhythms that you will need to know for this certification exam. So I'm just going to go ahead here and get started. So what is the EKG? So an electrocardiogram abbreviated, as I said, is either an EKG or an ECG measures the electrical activity of the heartbeat. So with each beat of the heart, an electrical impulse or wave travels through the heart. And this electrical wave causes the heart muscle to squeeze and contract and pump blood from the heart. A normal heartbeat on the EKG will show the rate and rhythm of the contractions in both the upper and the lower chambers of the heart. So why would we, why would we be getting an electrocardiogram on a patient? Why would the provider want to order this? What is the EKG or the electrocardiogram going to show? So the indication for an electrocardiogram would be to determine or detect in a regular heart rhythm, otherwise known as arrhythmias. If a blocked or narrowed artery in the heart, otherwise known as coronary artery disease causes chest pain or a heart attack, the provider would want to get an EKG. Whether you have had a previous heart attack, definitely the provider would want to have an EKG as well. And also to know how well certain heart disease treatments, such as a pacemaker are working for that patient. And definitely an EKG will be ordered if any of the following signs and symptoms, whether it's chest pain, definitely the provider will be ordering an EKG. You can bet that 100% right off the bat. Dizziness, lightheadedness or confusion, heart palpitations, a rapid heartbeat or rapid pulse, shortness of breath or weakness, fatigue or decline in ability to exercise. Or if a patient is having a lot of shortness of breath that's newly onset while performing their activities of daily living. So specifically your role in performing the electrocardiogram would be preparing the patient for the procedure, providing the post procedure assistance to the patient. So that would be helping them to take off the electrodes, to put their shirt back on to help them sit up if needed. And also, of course, to accurately and efficiently perform the test itself also to help identify abnormalities that need immediate intervention. Now, please know that it is not your role to diagnose the patient or to read the electrocardiogram, but what you need to know, what you need to do is to definitely be able to identify certain rhythms that are abnormal that you would need to get the doctor or the provider in immediately. Also maintaining the equipment is super important that it's working properly and then also giving the provider the test results for immediate interpretation after the test is performed. So the EKG itself, the equipment consists of, of course, the EKG machine itself and it's made up of three distinct parts and this includes the electrodes, the lead wires and the main machine. There are 12 lead, the 12 lead ECG placement provides a whole representation by deriving and recording the heart's electrical activity through 12 different perspectives. Even though it is named a 12 lead EKG or ECG, it requires placement of only 10 electrodes on the patient's body. So I know that this sort of can be confusing and it was confusing for me when I first learned about EKGs and like why is it called a 12 lead ECG placement or 12 lead EKG, but there's only 10 electrodes that we connect to the patient's body. So just know that the 12 lead, all that is saying is that that 12 lead is going to show 12 different, I want to say pictures or 12 different perspectives of the heart beating through the heart muscle itself. But again, in this 12 lead ECG, there are only 10 electrodes placed on the patient. So performing the EKG in the implementation phase, of course, you want to place the patient in a sub pine or semi-fowlers position. You want to expose the chest, the ankles and the wrist because that is where the electrodes will be placed. You want to place the electrodes on the inner aspects of the wrists, on the medial aspect of the lower legs and on the chest. You also want to, after all electrodes are in place, connect the lead wires to the machine. You want to press the start button and input any required information, which would most likely be their first and last name, date of birth, the doctor ordering provider who's ordering the test exam itself. Those are mostly the required information that you would enter and make sure that all the leads are represented in the tracing. So if not, you want to determine which electrode has come loose or which electrode is not tracing appropriately, you want to reattach it and then restart the tracing. All recording and other nearby electrical equipment should be properly grounded, and we want to make sure that the electrodes are firmly attached. So this can get a little tricky, especially if patients have oily skin or if they have had lotion on or if they have been diuretic, if they've been sweating, if the patient is wet. Also, if the patient has a lot of hair on their chest or their arms or their legs, so you want to really make sure that the electrodes are firmly attached. So, you know, if it's not any emergent situation and you have the time, I would always like to take an alcohol pad and just kind of clean the skin where I was going to place the electrode that way. It kind of gets off the lotion or any sweat or any oil on the skin. And then if the patient is hairy, then you want to take a razor and just, you know, shade that just one small area where the electrode will be placed. So here is, we're going to talk in the next couple of slides about exactly the lead placement. So again, in this 12th lead EKG, there are only 10 electrodes that we will be placing. So I like to start first with the limb placement. So the white lead goes on to the right arm. The black lead goes on to the left arm. The red lead goes on to the left leg. And then the green lead goes on to the right leg. So the green lead and the red lead on this picture here. It's placed up a little bit higher, like it looks like on the groin or the hip area. Those leads actually need to come down a little bit further on the leg or on the ankle. A good way to remember how to do this is if you, a little rhyme or nomogram that I used to like to remember for this is, so the white lead is on the right shoulder. So it's, and then the green lead is on the right leg. So you want to remember snow over grass and then the left. So the snow over grass is the white over the green. So snow over grass. And then the black lead is on the left arm. The red lead is on the left leg and then smoke over fire. So that's a good way to remember where the limb leads are placed at least. So moving on. So of course, you know, we said this is a, even though it's a 12 lead, there are 10 electrodes that need to be placed on the previous slide. We talked about four of those. So there are six more that we need to talk about. So there's V1, V2, V3, V4 and V5. So as you can see here on this photo that there, V1 needs to be placed on the right sternal edge. So we know the sternum is the bone that goes in the center of our chest. So V1, you want to go to the right sternal edge, the fourth intercostal space. So what does that mean exactly? So it would be, you know, your collarbone and then there's rib number one, rib number two, rib number three, rib number four. So between rib number four and rib number five is V1, but it's placed on the right sternal edge. V2, you want to place on the fourth intercostal space in the same intercostal space, but on the left sternal edge. So as you can see here, it's on the opposite side as V2. Then V3 is midway between leads four, midway between V2 and V4. The fifth intercostal space or the mid collocular space, you want to place lead four. The left interior axillary line is where you want to place V5, and then the left mid axillary line, you want to place V6. Moving on to the electrocardiograph paper itself. So this paper is the paper that is going to be fed out from the EKG machine itself, and this is where the waves or the electrical impulses from the electrocardiogram will be graphed. And so I just wanted to make you aware of what this is exactly. So this paper can be displayed in a graph or dot matrix format with vertical and horizontal lines or dots at one millimeter interval. So the vertical axis, so we know vertical means up and down, represents gain or amplitude, and the horizontal axis displays time. So horizontal meaning this way. So each small vertical square represents 0.1 millivolts, and each horizontal square represents 0.04 seconds. I'm sorry about my typo there. So large squares are identified by darker lines and include five small boxes horizontally and vertically. So we can see here that this is a larger square with the darker borders, the darker and thicker borders, and then this is the small square. And you can see there are five squares that make up the horizontal axis of a larger box. So what are these waveforms and intervals and segments that we have been discussing? So each waveform, interval and segment has significant meaning on the EKG. The medical assistant is not expected to diagnose conditions, as I said before, but you must have an awareness of obvious normal versus abnormal tracings. So your role is to monitor the tracing as it's being recorded to ensure that the leaves were connected properly and that artifacts are not appearing. So what are artifacts? So different when we talk about artifacts, meaning that each waveform on the EKG paper should be straight across and should be easily seen. There should be no fluctuation, no scribbly lines, I should say. So let me move myself up here so you're able to see this just a little bit better. So here is the electrocardiogram. Here is the heartbeat. So this is the electrical heartbeats of the heart muscle, the electrical impulse. And so there are, we talked about PQRST and then here is the U wave. There's not always a U wave, but PQRST, PQRST. So the P wave represents atrial depolarization or contraction. So here is the P wave that we can see here. The QRS wave is, begins at the end of the P wave and the beginning of the T wave. So QRS and that represents the ventricular depolarization or contraction. We have the T wave. That's here. And that represents ventricular repolarization or relaxation. We have the U wave. And I, like I said before, that this is not always visible, but it represents the repolarization of the bundle of his and the purkinje fibers. So the PR interval, now we're talking about an interval. So the interval is the space between where the P wave ends and the Q wave starts. So the PR interval starts at the beginning of the P wave and ends at the beginning of the Q wave. So this represents, this interval represents the time it takes for the beginning of the atrial depolarization to the beginning of the ventricular repolarization. Next, we have the QC interval. And the QT interval starts at the beginning of the Q wave and ends at the beginning of the T wave. And this represents the time from the beginning of the ventricular depolarization to the end of ventricular repolarization. Last week, we have the ST segment. And the ST segment starts at the end of the S wave and ends at the beginning of the T wave. And this represents the time from the end of ventricular depolarization to the beginning of ventricular repolarization. So spend some time looking at this graph here to know what the P wave is, the Q or S wave, the T wave and the U wave. Those are the waves and their cells. And then the intervals, the PR interval, the QT interval and the ST segment. So here are some of the basic cardiac rhythms that you will need to know for the certification exam. But also for, I want you to familiarize yourself with so you know what a normal heart rhythm looks like versus what a abnormal heart rhythm looks like. Now again, it is not in your scope of practice to diagnose the patient or to even identify what these rhythms are specifically, but you need to know what looks normal and what is not normal. So here is a nice normal sinus rhythm. So this is what the EKG will look like for somebody who is healthy, who has a healthy heart, has a normal healthy heart rhythm with no arrhythmias. And we can see that it is, here's one heartbeat, two, three, four, five, six, seven. So this, you want to count the number of heart beats and times that by 10. So this, that will give you the patient's heart rate. So one, two, three, four, five, six, seven times 10 is 70. So we know this person's heart rate is 70. And we know that's a normal heart rate, right? Because a normal heart rate is between 60 and 100 for a normal person. So regular, like we said here, a regular rhythm at a rate of 60 to 100 beats per minute. Each QRS complex is preceded by a normal P wave. So what that means is here is the P wave that we saw. Here is the QRS complex. And then here's the T. So P, QR, ST. There's all the P waves are right before the QRS. Each normal P wave access. The P waves are upright in leads one and two. And the P wave, PR interval remains constant. So this P wave looks normal for each one of these heart beats. So here is sinus tachycardia. So this is an EKG rhythm for somebody who is tachycardic. And we know that tachycardic means that a person has a heart rate greater than 100 beats per minute. So how do we know that? Again, we count each one of these electrical heart beats. One, two, three, four, five, six, seven, eight, nine, 10. So we know this person is about 100 or more. So we're going to call this sinus tachycardia. But we can see that it's sinus, meaning that it's normal. There's a P wave for each QRS wave, even though this is a higher heart rate. Sinus bradycardia. So I know that you're all starting to probably see a pattern here. So the first rhythm we looked at was nice and normal. The second one we looked at was there were a lot of PQRS. There were a lot of electrical impulses because that person is tachycardic. Now this rhythm here is bradycardic. So this means that this patient has a heart rate less than 60 beats per minute. One, two, three times that by 10 is 30. But the rhythm is regular. There is regular meaning there is a P wave for each QRS and T wave, a P wave for each QRS and a T wave. That's how we know that the rhythm is regular. So what's a sinus arrest? So sinus arrest occurs when there's a sudden absence of electrical activity initiated by the SA notes. So this results in a pause in electrical activity seen on the tracing. Now, just because you see this, so you see the PQRS and then where is the PQRST? There's none here, right? So that means there's a absence of electrical activity. This doesn't mean necessarily that your patient is in cardiac arrest. It just means that they could go into cardiac arrest. This is definitely a warning sign here. And this is something you want to let the provider know about immediately. They could be in heart block, they could be about to cardiac arrest. So this is something that is very serious and that the provider should know about immediately. So again, here in these patterns of these rhythms that we're looking at, you're beginning to see what normal looks like, what a fast heart rate looks like, what a slow heart rate what looks like and what a heart rate looks like when it ceases to produce electrical activity. Now, just because you're looking at this cardiac rhythm or you're looking at this rhythm, and I said this doesn't necessarily mean that your cardiac, that your patient could be in cardiac arrest, but that's what they could very well be. So you're looking at this rhythm, but you're also looking at the patient. Don't ever, ever forget that. You always want to look at the patient and see like what is the patient doing? Are they breathing? Are they difficult to arouse? Are they uptended? Are they responding to your questions? So always look at the patient, but this is definitely something to be concerned about. Here's another one, atrial flutter. So what you can see here is this definitely looks different than normal sinus rhythm. It looks different than the sinus tachycardia or sinus radiocardia. So what this is is a narrow complex tachycardia. So this is basically when the atria of the heart is firing a bunch of electrical pulses at one time. At the ventric, from the right atrium to the left atrium. So instead of fall, instead of going boom, boom, boom, it's going boom, boom, boom, boom, but it's all over the place. There's no regular rhythm to it. So how do we know it looks like a flutter? So you can see this sawtooth pattern of the inverted flutter wave. So it just looks like this is fluttering here, right? These are fluttering P waves, but there's always a QRS, QRS, QRS. You have these fluttering P waves. So this is atrial flutter. This is also a rhythm that you need to be concerned about. A lot of people have atrial flutter. Sometimes they've had some patients say they don't even know that they can't even feel it. They have no symptoms. Other patients do. Some patients can feel a fluttering actually in their chest. They can feel heart palpitations. They could be short of breath. Other people don't feel anything at all. So it again is patient specific. So that's why you always have to look at your patients and say, you know, how are you feeling? You know, do you feel that? But this is a rhythm that is concerning. So you definitely want to let the provider know about immediately. Here is atrial fibrillation. So atrial fibrillation and atrial or a flutter are very, very similar. So again, this is an irregularly irregular rhythm. So this is coming from the atrium of the heart instead of the electrical activity being nice and with a normal rhythm like boom, boom, boom. It's all over the place. And again, your patients, some patients can feel this. They can feel the fluttering in their chest. They feel heart palpitations. They feel short of breath. They feel tired. Other patients, they don't feel it at all. They're in atrial fibrillation. So again, that's why it's always important to look at your patients. But when you're performing the actual electrocardiogram and you see a rhythm like this, I want to let the provider know immediately. The thing about a fib and atrial flutter is that these rhythms put their patient at risk for blood clots, at risk for stroke, at risk for PEs. And so this is something to be concerned about and let the provider know. But you can see in this atrial fibrillation, there's a QRS, QRS, QRS with these P waves are very irregular and there is not a QRS for each one of these P waves. So it's very similar to the atrial flutter that we talked about on the previous slide. It just looks not as pretty as I say for the A flutter. Asystole, this is a problem. A systole is a very, very big problem because it's referred to as a flat line or represents the cessation of electrical and mechanical activity of the heart. Your patient is in cardiac arrest. You need to call for help and start CPR immediately. This is a problem. Your patient is in cardiac arrest. Again, if this happens, look at your patient first. Make sure that what you're seeing is corresponding to what is happening with the patient, but this is a problem. They are not responding. They aren't full cardiac arrest. So you call for help. Don't ever leave the patient alone and you begin CPR. V-thib or ventricular fibrillation. Again, this heart rhythm is a big problem. It's chaotic. Your regular deflections. There's no identifying P-waves, QRS complexes or T-waves. There's a heart rate, but this person is in V-thib and they are going to cardiac arrest almost immediately unless they are defibrillated. But you as a CCMA won't ever defibrillate a patient, but if you see this rhythm and it's corresponding to your patient who's probably not responding at this point, you need to call for help immediately. And again, you need to start CPR, especially if they don't have a heart. If they have no pulse, you want to start CPR, chest compressions. If they have a pulse, you definitely want to just start with a rescue breathing with an ambu bag. But always call for help, but this is a big problem. Another one I wanted to just discuss here is premature ventricular contractions or PVCs. So you can see that there is a P-wave, a QRS, T, P-Q-R-S-T, P-Q-R-S-T, P-Q-R-S. And then what happened here? It's a P-Q-R-S-T, but it's premature because it's not following the same pattern as the other P-Q-R-S-T waves. It's premature. It's coming up quick. And so that's why we call those premature ventricular contractions or PVCs. So a lot of people have PVCs and they don't know that they have it. Again, some people don't have any symptoms or have indication that this is happening. Some people have occasional fluttering in their chest or heart palpitations, most likely. But this could lead to a dangerous heart rhythm, if not caught. But if you do see this while you're performing the EKG, this is not an emergent situation, but you definitely need to let the provider know. And that's the end of this presentation. I just wanted to make you aware that the rhythms that we looked at were only a handful of rhythms. There are many, many, many more. And if you plan to go on to become a physician's assistant or a nurse practitioner or a doctor, you or even a nurse, you will see more rhythms and get training on those rhythms. They're more complex. But for this stage of the game and for your role that you're currently training for, you only need to know the rhythms that we just discussed. And certainly you will need to know those for the certification exam. I thank you all for following along here with me. And please reach out to me if you have any questions or concerns. You know that you can do that at any time by email or you can schedule office hours with me. If you need any clarification, I'm happy to spend the time with you to provide that. So thank you once again and I will see you all again real soon.