29TH REVIEW CARDIO PART 2 FLASHCARD PPT FOR Q#1 @DR. DJAMINA HANDOJO 5/16/26 transcript

Hi everybody, let's continue with a review cardio part two. Today, Saturday, May the 16th, 2026. Okay, cardio part two, I use the PowerPoint flash card. So, let's talk about EKG. EKG is the graphic study electrical activity of the heart. All right, what should we do before we attach the electrodes? Make sure the patient already rest. Let them go to restroom first. Calm down. Make sure you adjust the room temperature not too cold so they will not shivering.

If the skin sweat dirty, you need to clean the skin with the alcohol wipe, right? Because later you have to attach the electrode and it has to be attached correctly. So, V1, V2, V3, V4, V5 and 6. So, how many wires that we use for EKG? You need six short wires, right? Six short wires and you need four long wires. So, the one that's six short wires that's looking at the heart horizontal. Right? So, actually every electrode is the camera.

You are looking for the blood clot. So, you want to find out where is the blood clot in the heart. So, where you attach V number one at the fourth intercostal right side from the sternum. Okay, you start with V1. So, at the fourth intercostal right side from the sternum. And then your V2 also fourth intercostal, but left side from the sternum. And then go to V4 first and V4 will be the same with your apical pulse is the fifth intercostal left midclavicular line.

So, you attach your V number four at your apical pulse. Then, you attach your V three between V two and V four. After V four, you go to V six, right? After the V three, you go to V six because V six will be at the axilla line. And after you put the axilla line V six, then you know your V five because V five between V four and V six. So, you start with V one, V two, V four, V three, V six, and then V five. Right? So, if the the question ask you put in order how you apply the six electrode V one to V six, you start with V one fourth inter- intercostal right side from sternum, and then V two fourth intercostal left side from the sternum, V four that's your apical pulse fifth intercostal left mid- midclavicular line, and then V three between V two and V four, go to V six that's your axilla line, and then your V five between V four and V six.

And then your four four long wire, you can put one at the right arm, one at the left arm, and then the one the long one at the right leg, and then left leg. Right? You You can also put at the inguinal area, you can put at the chest area left and right. So, those four long wire will give you another six picture, right? AVL looking from the left side on the top, AVR right side on the top, AVR right right, AVF from inferior.

And then you have diagonal on the top that's one, diagonal at the right side that's the number two, and then diagonal the the left side is number three, right? So, you your picture EKG you will have 12 different picture. Right? You have 1 2 3 AVR AVL AVF and then V1 V2 V3 V4 V5 V6. So, 12 different picture, but the one that will easily tell you the problem we looking at the number two. Right? Because the two is the one that diagonal at the uh right side of the heart.

So, six short wires and four long wires. And your apical pulse fifth intercostal left mid-clavicular line. This is for adult, right? For baby usually at the fourth intercostal, but for the adult fifth intercostal left mid-clavicular line. So, again you have six short wires and you have four long wires and you will see complete 12 different pictures. Right? So, the long wire at the right arm left arm and then the N is the ground, so it will not electrocute.

The one that F is the inferior. And then your V1 to V6 MA usually memorize the color, so they can go really fast. They use uh looking at the color. And you have to attach at the correct place because if you put at the wrong place, it will not give you the result that you want. Okay? Normal heart rate 60 to 100. If the boss is the SA node as pace-pacemaker, right? So, what is sinus bradycardia? If you use the word sinus, that means you can see the P QRS and the T.

Right? But bradycardia means the heart rate less than 60. It regular, but less than 60, but you can see the P wave, you can see the QRS, you can see the T. They They don't have problem with atrium and ventricle contraction, but only too slow, usually regular. So this is sinus bradycardia. Okay? Sinus tachycardia, I use the word sinus, that means I can see the P, QRS, and T, but the heart rate more than 100. If somebody drink coffee, exercise, fever, they can have tachycardia, right?

And then if somebody macho exercise really well, they can have bradycardia. They can live with heart rate maybe only 60 or a little bit below 60, that's still possible. And they they have enough blood go to the brain and the whole body even though the contraction only 60 or less. Not too low though, right? Usually 60 between 55-60, it still makes sense for healthy and strong exercise guy, right? Sport guy. Inotrope, the meaning of inotrope is stronger but slower, right?

So example digoxin. Digoxin can make the heart stronger, that's positive inotrope, but be careful, slower means bradycardia, that's the negative inotrope. So careful with the your digoxin, also your allol allol allol, right? Uh sometimes pril also can have that effect, so be careful, but especially your allol, right? It can make the heart rate slower. So if somebody the heart rate already slow, already under 60, hold your digoxin, hold your allol.

Okay? Uh because inotrope effect means it make the heart stronger but slower. So always listen to apical pulse full 1 minute because sometimes it's irregular, that's why you need to listen to full 1 minute. If the heart rate less than 60, hold your digoxin, hold your all or report to doctor. Okay? Your EKG P Q R S T, your P wave is your ventricle is your atrium contraction, right? Your QRS is the ventricle contraction and your T wave is the ventricle repolarization.

PR interval PR interval between the atrial and ventricular repolarization, right? PR interval And then the rhythm normal heart is regular. So you see this picture. The vertical line telling you how strong is the contraction and the the horizontal line tell you the time, how many millisecond, right? And you can see the P wave, that's the atrium contraction. QRS is the ventricle contraction. The T is the ventricle relaxation.

Your PR interval, that's your atrium contraction and relax, right? So that's your PR interval, only the atrium. And then QRS interval, only the QRS. The QT interval is your QRS until the T finish, right? So your ventricle contract and relax until done, only ventricle, that's your QT interval. And then your PR segment, you can see after the P wave and then before QRS, that segment is PR. Normal PR segment and ST segment, normal should be horizontal line, we call it isoelectric.

So the ST segment, this is this one important, after your QRS and before your T, before the ventricle relax, right? They have a line there, ST segment. Normal is isoelectric, right? When people have heart attack, this ST segment can go up or go down. If it go up, it's already infarction. If the ST infarction, it go down, it's still ischemia injury, right? Ischemia means not enough blood. If nobody help, it will injury, but ischemia and injury still reversible.

Once they already go up, that's already infarction, usually already irreversible because infarction means necrotic. The cell already dead, right? U wave, usually if somebody hypokalemia, they can have U wave, right? So, U wave is another wave after T. Normally only PQRST, right? But if they have another wave, they will call that U PQRSTU, right? But normally who will have U wave? Usually hypokalemia. U hypo, U hypo, right?

Hypokalemia, not hypocalcemia, but hypokalemia, it's potassium. Hypo potassium U wave. All right. So, PR segment, that's the one that after P before QRS. And then your PR interval, that's between your atrium contraction and that PR segment, so that's your PR interval. Whatever only atrium, that's your PR interval. So, atrium contract and relax. And then heart attack, MI, AKG, right? Usually ST can elevate, so we call that STEMI, right?

Not always, but usually a heart attack, they can show as a STEMI means ST elevate myocardial infarction. So, when when blood clot stuck in the coronary artery, the area where they don't receive the blood, the cell around that area can die, right? If the cell already died, that's myocardial infarction. But if the the occlusion only a little bit, the blood still can flow, they can have uh angina pectoris. So if we give them nitroglycerin, it will dilate and finally the pain go away, right?

So angina pectoris, if the chest pain go away after rest or after nitro, once the blood vessel dilate, the clot is okay, it will not occlusion anymore, that's angina pectoris, right? But if we give them nitro sublingual, after vasodilation, it still they have chest pain do not go away, that's usually MI. Because the cell already died, the occlusion is really bad, right? So the vasodilator, the nitro do not help. So if the pain do not go away after nitro or after rest, maybe MI.

But if the pain go away after rest or after the nitro sublingual, that's usually angina pectoris. And you can see that the blood clot can be also the plaque. It make the blood vessel become small. And it can uh occlusion to the blood vessel. And that can cause heart attack, right? Many time the blood clot come from DVT, deep vein thrombosis, right? And if it's uh somebody massage the calf, the thrombus dislodge from the wall, become emboli.

So emboli flow with the blood flow, if it's go to the brain, it will cause stroke, right? If it's stuck in the coronary artery, that's when they have heart attack. If it's stuck in the lung, they can have pulmonary embolism. Right? And normally if somebody heart attack, you can see the ST can elevate. So STEMI is ST elevation MI. Can be plaque also. Plaque is the cholesterol, right? And ST can go down, this is inversion.

Inversion mean the ST go down, not go up. And usually when in in for this this is because ischemia, not enough blood and then injury. Right? And if nobody help, then it will go up. It will be ST elevation after inversion. So, ST depressed or T wave inversion, this is myocardial in ischemia or other condition like pulmonary embolism, it also can show the ST inversion. It go down. Okay? So, ST segment normally should be horizontal.

It should be isoelectric. And this ST segment is after your QRS, before the T wave, right? After the ventricle contract and then before the ventricle relax, there is segment there, ST segment should be normal, should be isoelectric, should be zero. And the meaning of QT interval, that's between the ventricle contract and relax. Okay? So, that's the QT interval. And QRS interval, only the QRS, only the ventricle contract.

So, how long is the contract? That's your QRS interval. U wave, hypokalemia. U hypo, U hypo, right? Hypokalemia usually have U wave. How do we know somebody have history of heart attack? You can see they the Q wave deep. Right? So, we call call that Q wave. Usually people that have heart attack before, we can see from their EKG the Q very deep. We call that Q wave. So, from the EKG we can tell if the patient have history of heart attack.

What is cardiac dysrhythmia? That means irregular with the heart rate, right? So, irregular heart rate, we call that cardiac dysrhythmia. And the medication to make irregular heart rate become regular is your dysrhythmic medication, antiarrhythmic medication. It can make irregular heart rate become regular. And that is uh there are many different type of uh dysrhythmia, but you need to know this. Sinus tachycardia, I can see the PQRST, but the heart rate more than 100.

Sinus bradycardia, I can see the PQRST, but the heart rate less than 60. Right? Supraventricular tachycardia, the ventricle very fast, but the problem is supra, above the ventricle, so it's the atrium problem. Right? SVT, supraventricular tachycardia. The The best medication for SVT is adenosine. Right? Adenosine is the drug of choice for supraventricular tachycardia. And then atrial fibrillation, no P wave, irregular, and no PR.

Right? Atrial fibrillation means your atrium quivering. There is no It cannot pumping, so it's very dangerous for blood clot. Right? So, AFib, there is no P wave, irregular, and I cannot measure the PR. So, know the three thing about AFib. And usually your digoxin is the best medication for AFib, A flutter, and congestive heart failure. Right? Digoxin is the very good medication for AFib, A flutter, and congestive heart failure.

AV block, that means SA node send electric to AV AV AV node, but AV node do not send electric right away to the bundle of His Purkinje fibers. We call that AV block. And AV block can be different degree, maybe the first degree, second degree, or third degree. Right? Usually the first degree only prolong, and then the second degree, they lost one contraction. The the one that third degree, they already lost two contraction, right?

So, that's AV block. Something happened in the AV node. Premature ventricular contraction, so the ventricle come too early. And then possible ventricular tachycardia, the ventricle way too fast. V tach, right? Ventricular tachycardia, very dangerous. Uh the heart rate can be 180, can be more than 180. And then ventricular fibrillation, now usually when they have ventricular fibrillation, the patient will be unconscious, no respiration, and no pulse.

They will need CPR and AED. Right? So, when people ventricular fibrillation, that means that ventricle only quivering, they're not pumping anymore, so they do not do not send the blood to the brain and to the whole body. That's why the patient unconscious, no respiration, and no pulse. They need CPR and AED for ventricular fibrillation. If the heart completely asystole, flat flat line, you only do CPR, right? Even if you attach the AED, AED will just say, "Continue CPR.

Continue CPR." Right? Because when AED analyze, they try to sense ventricular fibrillation. If AED sense the ventricular fibrillation, AED will tell you to press the button, right? Before you press the button, make sure clear clear clear clear clear. But if the AED do not sense anything because flat line, the AED will not tell anybody to press the button. It will continue tell you, "Continue CPR. Continue CPR." Right?

And sometimes doctor will purposely hit the chest to make a little bit ventricular fibrillation, so we can charge the patient. All right, with AED. So, this is your atrial fibrillation, no P wave, irregular, no PR. Very dangerous. They have blood clot in the atrium, so they will receive anticoagulant. Know your heparin, Coumadin, Lovenox, Fragmin, apixaban, Xarelto, fondaparinux, right? So many different uh anticoagulant.

But the famous one, make sure you know your heparin and Coumadin. Heparin is IV, subcute, usually in hospital after surgery, we will give them heparin. But if we give heparin IV, we have to check PTT, 35 to 40 second times control, 60 to 70 second, we call that activated PTT. So as long as your PTT 70 second or below, you don't need to report. But if it's above 70, let's say 80 or 90, report because that means the blood is too thin.

They need antidote, protamine sulfate. Right? So if PTT high, report to doctor. Doctor need to order for antidote. And you have to hold your heparin, don't give any more because the patient already overdose. And then Coumadin is PO tablet, right? If I want to send my patient go home, I will uh exchange I will change the heparin to Coumadin. So normally in hospital, we give heparin and Coumadin together for 5 days because Coumadin will start working after 5 days.

So when the Coumadin already start working, we stop the heparin, right? And patient can have Coumadin and and go home with PO, that's easy. But with Coumadin, we have to check PT and INR. So PT is your prothrombin time, INR international normal ratio, right? Normal PT 10 to 12 second, INR 2 to 3. So if it's high, report to doctor because that means the blood too thin. Antidote is vitamin K, phytonadione, AquaMEPHYTON.

Don't eat too much green leafy vegetables or just consistent because green leafy vegetable vegetable have a lot of vitamin K. It can neutralize the Coumadin, right? People prefer Lovenox or Fragmin subcute because if you use Lovenox, this is enoxaparin, right? Lovenox is the same with enoxaparin. It's low molecule heparin. So, many patient prefer Lovenox or Fragmin because you don't need to check PTT or PT/INR, right?

There is no lab that you need to check with Lovenox, Fragmin, or other um anticoagulant. So, only heparin you have to check PTT, Coumadin you have to check PT and INR, and patient do not like it because you poke them. It's painful. All right? Um so, Lovenox is your enoxaparin. It's your low molecule heparin. If somebody toxicity with this enoxaparin, Lovenox, antidote of protamine sulfate because Lovenox enoxaparin is still the heparin class, low molecule heparin.

So, antidote is the same, protamine sulfate. So, please memorize antidote heparin, protamine sulfate. Antidote for Coumadin, that's your phytonadione, Aquamephyton, vitamin K. Stay away not too much green leafy vegetables. Uh atrial fibrillation, I also can use antiarrhythmic drug to make irregular heart rate become regular. And under this class, you have lidocaine. That's the best for VT, ventricular tachycardia. You have flecainide, amiodarone, right?

Adenosine is the drug of choice for SVT, supraventricular tachycardia. Digoxin also your antiarrhythmic drug, right? Including also your allol, your calcium channel blocker. They also antiarrhythmic drug because they can make irregular heart rate become regular. Right? And digoxin is the best for atrial fibrillation, atrial flutter, and congestive heart failure. Remember that, right? Important. Digoxin, you can use This is the best for atrial fibrillation, atrial flutter, and congestive heart failure.

But don't forget digoxin is inotrope effect. It can make your heart slower, but stronger, right? So, you have to listen to apical pulse full 1 minute. If the heart rate less than 60, hold your digoxin. Your olol olol olol also have inotrope effect. And then for AFib, doctor can do cardioversion, right? Cardioversion similar like AED, but this is mini AED, and this is elective means make appointment, right? So, doctor will tell the patient, "Oh, you have atrial fibrillation or atrial flutter.

Let's make appointment." So, when the patient come, doctor will give general anesthetic. The patient will sleep, right? And then doctor will charge the patient with 50 joules. And hopefully the AFib the atrial fibrillation or atrial flutter will go away, right? But if it's still there, if it's still glitched, then you can increase the fibrillation. Max is 200 joules. So, this is cardioversion, right? Basically, what we do is we stop the heart, and hopefully when the heart start again, there is no more glitched, right?

Because this atrial fibrillation atrial flutter is like glitched to the heart. All right, the same concept. If your cell phone problem, if your laptop glitched, you turn it off, right? So, this is also the same. We turn it off the Turn off the heart, and hopefully when it start over, no more glitched. So, this cardioversion not the same with AED because AED you found the patient unconscious, no respiration, and no pulse, right?

That's the one that you do CPR, and then you tell somebody go call 911 and go get AED, right? So when AED come, you attach and then the first thing to do is turn it on, right? Turn it on. And then the AED will analyze, right? If If AED analyze and can find can sense the ventricular tachyca- ventricular fibrillation, right? V fib. Ventricular fibrillation, then AED will say press the button. Before you press, make sure clear clear clear clear clear, right?

And when you press the button, we start with 200 joules. If no result, the patient still the same, you can increase to 300 joules. This is in hospital, right? This is in hospital, it will increase to 300 joules and then the max is 360 joules. That's it. That's the max maximum, right? You cannot increase more because then it will be burn the skin. Because don't forget this is the electric, very strong. So the unit is joules.

Okay? 200 300 360 joules. The max is 360 joules. So patient already unconscious, no respiration and no pulse. This is when we use CPR and AED automated external defib- defibrillator. Atrial flutter, you will see sawtooth pattern. So memorize that word, sawtooth pattern. That's atrial fibrillation. Usually we not really worry about the blood clots, so doctor can give anticoagulant or not, that's okay. But we will give antiarrhythmic and digoxin is the best.

And doctor can do cardioversion also and ablation. Ablation means use the certain radio frequency wave. Right? Ablation. This is not the heart surgery, but only from outside. Try to fix the heart with the certain wave. And then V tach, ventricular tachycardia, the ventricle QRS QRS QRS really fast. And then ventricular fibrillation, that's the the one that patient unconscious, no respiration, and no pulse, right? Don't forget your CPR.

If you by yourself or two people, for adult, it's 30 compression and two back with the air, right? Two air, right? So, 30 compression and two with the ambu bag. That's the ratio. But if I ask you the rate, it's also always 100 to 120 times per minute, right? The rate for baby, the rate for adult is the same. The rate is 100 to 120. The ratio, if adult, I don't care one rescuer rescue or two rescuer, 32. But for the children and baby, if you by yourself, 32, but if there is two people, then 152.

Because baby and the child respiration faster than adult. For baby and and and child, you press 4 cm deep, that's 1 1/2 to 2 in deep. And for the adult, 5 cm, right? That's about 2 to 2 and 1/2 in. Where you put your hand placement for adult and for child, half lower breastbone, right? Half lower breastbone. Do not press the xiphoid process because it can fracture. For the baby, you use your two finger in between the nipple of the baby, right?

So, two finger, and you can do your CPR in between that two nipple. And if two people rescuer, then you can turn the baby, and you use your two thumb, right? You hold the baby and circle the thorax area, and then use your two thumb to give the compression. So, if this is for baby or child to rescuer 15 compression and then two respiration because they breathe faster than adult. PVC is the ventricular contraction come to early.

And if too many PVC that's dangerous, right? Ventricular tachycardia all you see is QRS QRS QRS and then ventricular fibrillation is already you cannot see QRS or P. It's already messed up but there is still something, right? It's not totally flatline. All right, so I will stop here and we'll continue uh the disease later at the part three cardio. Thank you.