Welcome back. Today, we're gonna talk about EKG. EKG is a really common diagnostic test. Most of you, if not all of you, will be trained to do this, and we really wanted to kind of walk you through some of the basics around the test itself, some of the technique you need to think about as you start to perform those for the patients that you're working with, and then just a little bit of the science behind them so you better understand why some of your quality assurance activities are so important. So how do we interpret these things and what's the information we're looking for? So let's start with EKG technique, and this is really about what exactly are we looking to accomplish here and how do we create the setup for the test in order to do that? So I'm gonna take you back to the basics. So the EKG, or electrocardiogram, so for those of you that have been through the terminology, electroelectric heart cardiogram tracing, so it's a tracing of the heart electricity, or the rhythm, or the electrical activity of the heart is really what we're doing. So our big fancy terms for this are the record of the depolarization, or stimulation, and repolarization, or recovery potentials generated by the atrium and the ventricle and the myocardium that are associated, so the atrial and ventricular myocardium. And what you're gonna see is what we call a PQRS complex, which is what you see on the right, you're gonna start to see that in your tracing on the EKG. Now our EKGs are in 12 leads, so when you get your tracing, you're gonna see 12 tracings and they're all gonna look a little bit different and I'm gonna explain to you why. But just a really quick, again, you don't need to memorize this and I think it will make more sense as you start to do them. The P portion of the PQRS is the activity in the atria, the QRS portion is the activity in the ventricle, and what we call the T wave is the recovery of the ventricle. So again, the electrical pathway through the heart, and then as I mentioned in our anatomy and physiology section, the contractility follows that. So the reason why this is really important because it gives us an understanding of what's happening with that heart muscle based on what the electrical stimulation or the electrical pathway looks like. So I mentioned this already, the P wave is the atrial depolarization, the QRS is the ventricular activity or depolarization. The STTU complex is the ventricular repolarization, which you could think about as recovery. And then there's something called the J point that sits in between the QRS and the beginning of the ST segment. And again, I just want you aware of the terminology and what part of the heart that they're representing, because that will make sense when it comes to the way that the clinicians that you work with are interpreting it. And I think it just makes you smarter about the tests that you're doing. So a little bit about the actual technique or the way the test is performed. So you've got your EKG paper, which is really just fancy graph paper. And the graphs allow us to look at it kind of based on time. So the recording on the graph paper is divided into these one millimeter squared grid-like boxes. Each box equals 0.04 seconds. And the only reason that's important is because when the computer in the EKG machine, one of the things that will give you is heart rate. And the reason it knows heart rate is because of how many little boxes are between each of the QRS complexes. And it uses that as the math to tell you how many times, how quickly one beat is to the other. And then it does the math to tell you how many beats per minute. So BPM means beats per minute. That's how it gives you the heart rate. In addition, when you look at your graph paper, there's heavier lines. The heavier lines are at the 0.20 seconds. So they're each worth 0.2 seconds. And then we also start to do some measurements around intervals. So RR interval will give you the heart rate. There's something called the PR interval, which is the difference between the P wave and the R wave. There's the interval across the QRS complex. Then there's another interval that we describe as the QT interval. And again, when you start to look at the interpretation of these EKGs, you will see those sorts of terms used when it comes to where there might be concern or where those intervals are either abnormally placed or abnormal timing. So when you go to do an EKG on a patient, I mentioned 12 leads and you don't see 12 leads on here. So part of this is the way we use the leads to measure between each of them. But there's two sets of leads. There's your chest leads, which we term the precordial leads. Because remember, we like to use words that don't make sense. So precordial really means chest. And we put them, there's V1 through V6. And your preceptor will teach you how to do this on a patient. And it will make more sense when you do a few of these. But the idea is you're going to put six leads that basically surround where the heart is on the anterior wall of the patient. And I did map this all out. So you'll kind of see there is an actual standard process and exact placement for these leads. And your preceptor will walk you through this. The second set of leads are what we call the limb or the extremity leads. And those go on the arms and the legs. So there's one on the right and the left. And there's one on the right and the left lower extremity and one on the right and the left upper extremity or arms or legs. And when you get your machine out, you will have a wire with a clip on the end of the wire that clips onto the little sticky electrodes that you put onto the patient. And so it's really important that you get these placed in the appropriate places. And those electrodes or those wires all have labels. And it'll say V1, V2, V3, V4, V5, C6, RA, LA, RL, LL. If you put them on the wrong spot, you will end up with a very wrong EKG. That it's not a problem with the patient, it was a problem with your technique. So that's an area for quality assurance to really make sure that number one, you get those leads and those electrodes placed appropriately. But when you go to hook up your wires, you've got them attached appropriately based on the labels on those wires. And then I wanna walk you through a little bit related to what we're trying to do with this. Cause remember when you look at that EKG printout from the machine, or sometimes it's electronic, you'll see it on your computer screen. There literally are 12 different tracings. And when you compare tracing over tracing, they all look a little bit different. The reason they look a little bit different is cause in essence, what we're doing is we're taking a different picture of the heart, looking at different angles. And we're looking at angles of the electrical pathway through the heart. So if I look at that electrical pathway from below the heart, those P waves and the QRS is all gonna be looking a different direction. If I look at it from above the heart, then it's gonna give me a different direction. If I look at it from across the heart, it's gonna give me a different direction. So when the clinicians, you know, the cardiologists, the APPs look at that 12 lead EKG, the way the direction of those P, QRS waves, depending on the lead, give us a lot of information around what's happening with the patient. There's a set of normals, and anytime it deviates from the normal, then we have to understand what's going on. So there's, again, a whole number of things that we look at when we interpret these EKGs, but I wanted you to understand the reason we do 12 is because we're taking basically 12 different snapshots. You can almost think about it as a tree. If I take a picture of the tree from above, all I'm gonna see is the leaves. If I take a picture of the tree from below, all I'm gonna see is the roots. That if I take 12 pictures and then put my pictures all together, I can see all the different parts of the tree from a different perspective. And if there's a part that's abnormal, that portion of my picture is gonna give me a sign or give me evidence that there's abnormality there that I need to look into further. The other thing I will tell you is our EKGs are very good as far as identifying where there might be an abnormality. They're not always that good at telling us what the abnormality is, but think about it as 12 pictures, electrical pictures that we're taking and then putting all of that together to tell us where there might be an abnormality. So a little more information related to kind of the way that our leads are set up. And again, we're looking at the picture at that heart from really from different perspectives to put all of that together. And we have our chest leads, which is our V1 through V6. And when you look on your tracing, you're literally gonna see a V1 through V6. And then when you look at our limb leads, we have different ways that the limb leads measure from one to the next. And that's where we get these lead one, lead two, lead three. And then there's a whole concept around these augmented vectors. So AVR, AVL, and augmented vector foot or AVF. And again, I'm not asking you to be an expert in all these, in fact, I'm not sure that I could completely describe why we call them augmented vectors. But when you look at your 12 lead, you're gonna see all those terms. You're gonna see leads one, two, and three. You're gonna see AVR, AVL, AVF. And as a clinician, when I look at those, I know where to look for abnormalities. And if I see an abnormality in AVR and AVL, that tells me there's a certain part of the heart that is having some issues. And I need to think about what that is and what sorts of other tests to figure out what that might be going on. So they all give us a little bit of evidence that we need to look further. There might be something abnormal. All that being said, the quality of our EKGs are really important. And if you look at that 12 lead, there's a lot of information on there. And if we don't get our leads set up right, or we have any issues with any sort of interference, it's gonna throw off our ability to interpret those and really create some issues. Your job is a really, really important one to make sure that we provide high quality EKGs for our clinicians that ultimately lead to patient care decisions, incredibly important. So things I want you to think about, number one, skin preparation. We gotta make sure we've got, and I'm gonna walk you through these, electrode application, artifact elimination, lead selection, and signal interference precautions. So there's some things you've got to think about in each of these areas. So for your skin preparation, the skin needs to be clean, dry, free of dead skin cells. And in some cases for some of our male patients may need to be shaved. You will have a technique that's applied as be a standard process for your organization. Some organizations use special, it's got a texture tape to it that scratches at the skin to get the dead skin cells off. Others use a liquid preparation. Some may have you go ahead and shave those men that have a fairly hairy chest. Others may, depending on your technology and the type of EKG machine you're using, maybe you end up not having to do as much of that because of the technology is so good within the machine. So you will have a standard work for your organization and make sure you understand what that is. In addition, we gotta worry about artifact. So on the right is an EKG and you see how that baseline and that baseline is really this line right here. If you can see it, it's kind of all over the place. That is artifact. So that baseline needs to be a nice straight line. If you look at row E and F, that line is pretty straight. But if you look at G and A, they're all over the place. We would describe that as artifact. So EKG artifact is electrocardiographic alterations not related to cardiac electrical activity. So that's the goal here is we wanna remove anything out of that EKG that's not related to the patient's heart. So things that can cause artifact are motion. So if the patient is moving, and one of the things that should be part of your standard work is that you have a patient that's resting supine or laying flat and calm and slowly breathing. And so you just want very calm, very quiet, no extra movement. And so you just wanna make sure that you've got a very calm patient and you've eliminated any additional movement around the patient, in the room, that kind of thing. In addition to that, there's a few other things where we can have artifact or signal issues. So I mentioned the motion. So supine, lay flat, relax patient. It's very important to have effective skin preparation so we have good adherence between the electrode, the sticky tape, and the chest wall. We need to assure that the lead effective is adhesion. So I mentioned the stickiness. We wanna make sure we have good sticking of our leads. And then finally, maximize the distance from electrical cords and outlets. Some of our exam rooms are kind of small. And one of the things, especially with some of our older EKG machines, they can pick up electrical stimulus from other things. So if you're seeing any of that, make sure that your EKG machine is not close to a plug on the wall or there's not any issues related to plugs around the patient or electrical outlets around the patients that might be adding to some of that electrical artifact that's not related to the patient's own heart. And then the last piece I wanted to cover with this is just cardiac monitors. And we will actually walk you through this again in the diagnostic module, but I think it's always helpful to hear more than once. So what I just described to you is called a 12-lead EKG. It's a single EKG, single shot in time, if you will, that shows the patient's electrical activity at that moment. Now we have the ability to put basically walking EKGs on people. We call them Holter monitors or event monitors. Holters mean that they're going to wear that for 24 to 48 hours. Likely in your role, you will learn to put these on and put them on the patients in the office, let them go home, and then they bring the equipment back. Typically it's not 12 leads. Typically it's three leads or five leads, depending on the monitor. And you will prep the patient just as you do for your 12-lead EKG. You will put those on and then the patient will have a little pack that they wear for the next full 24 to 48 hours. So the goal is that we monitor that heart rhythm for a long period of time. For those patients that we need more than 24 to 48 hours of data, we may put them on an extended monitor. We call those event monitors. And there's several different types of those. And we'll give you some more details when we get into the diagnostic modules. But oftentimes those are meant to be worn anywhere from 14 up to 28 days. Sometimes they're a patch. Sometimes they're still those different leads with a little pack. There's just multiple things on the market now. And so you'll have very standard approaches within your organization. But I want you to be aware, it's really the same concept is that 12-lead EKG, usually less leads, but it's something that the patient wears continuously for a period of time that monitors the electrical activity. In this case, the rhythm of that patient to look for any abnormalities with that. This next two slides, and we will provide this as a handout as part of your toolkit, but basically walks you through those different types of monitors. And so I mentioned the patches. ZO is a type of a patch. Patients can wear these anywhere from three to seven or seven to 14 days. Some of them have something called MCOT, which allows for actual transmitting of the information in real time. So they have cellular capabilities. And then the different companies provide different, they have different names for their equipment. Again, your organization will have specific types of equipment that you use, specific vendors, specific names, but we wanted to provide you the resources just to kind of have a reference guide and give you a visualization of what these look like. So you can see in this case, these are actually sticky patches. They're really easy to put on. It makes your job easy related to these different monitors. So there's a couple different options. And again, just go back to your preceptor, your supervisor, and find out what types your organization uses. And then they will provide you the standard work as far as how to apply these to the patients and when to apply them based on the orders that your providers put in and for the patients that they're caring for. And that wraps up our module on EKGs and monitors. So again, if you have any questions, start with your preceptor, but you're welcome to reach out to the academy at academyatmedaxiom.com. And thank you for your time today.

EKG basics

electrocardiogram

diagnostic test

12-lead EKGs

cardiac monitors